New Challenges for VISION 2020

Over the past six years of its existence, VISION 2020 has gained a prominent role in many countries in shaping the public health agenda for eye care services. Its launch on 18 February 1999 was an important milestone in the collaborative effort of WHO with a group of dedicated non-governmental organizations to establish a global coalition of those working in the field of visual health. At the time of its launch, the agenda of VISION 2020 was determined by the most prominent needs and known interventions available to control the major causes of blindness. Blindness due to cataract was seen as the main global challenge and addressed the many millions of people needlessly suffering from visual impairment caused by a treatable disease. Infectious diseases such as trachoma and onchocerciasis followed on the list and their elimination was shown to be achievable through known interventions and poverty alleviation. Children's eye health was recognized to require special attention as preservation of their sight has a direct impact on their entire life. It was also acknowledged that people with various less-easily treatable eye diseases, as well as with significant refractive errors, would benefit from widely available adequate refraction and in some cases from low vision services. Considering that the greatest need was in less-developed countries and underserved communities, the VISION 2020 agenda has targeted mostly countries in Africa and some parts of Asia. When the World Health Assembly adopted the Resolution on Elimination of Avoidable Blindness in 2003, the agenda of VISION 2020 acquired a truly political and global dimension.

Six years after the launch of VISION 2020, it is now a fitting time for a midterm review of its accomplishments and impact. In the light of new information on the magnitude and causes of blindness, it is also a suitable opportunity to assess global trends in the pattern of visual impairment and identify the most appropriate responses VISION 2020 should adopt in its working agenda.

As we have witnessed over the last three decades, the threat posed to people by infectious diseases is gradually diminishing, due partly to the developmental progress achieved in many countries and partly to the implementation of known and successfully tested interventions for their prevention and treatment. This has been recorded in the case of trachoma and onchocerciasis in addition to other infectious external eye conditions. Thanks to broad international alliances, these infectious eye conditions are already successfully controlled in many countries, and every year there is significant progress towards their elimination as a public health problem. Being driven by its successes, this process must continue. However, the ever-increasing number of cases of chronic eye diseases, such as diabetic retinopathy, glaucoma, and age-related macular degeneration, demands adequate attention. The global trends indicate that chronic diseases related to aging will join cataract at the top of the priority list for interventions in the field of public health eye care. Due to the increased lifespan, cataract is likely to remain a leading cause of blindness. In many countries, although the interventions needed to cure blindness due to cataract are known, measures for providing them to the poor and those living in rural areas and other underprivileged population groups have not yet materialized. In the cases of diabetic retinopathy and glaucoma, the control measures are more elusive. The complexity of these conditions, which is imbedded in both the currently available means for their early diagnosis and the complicated long-term treatment protocols, poses a demanding task for health care systems. While early detection and control of glaucoma is mostly in the hands of eye health care providers, the management of diabetes and its manifestation in various organs is truly a multidisciplinary task. Its recognition as a priority eye condition on the working agenda of VISION 2020 requires us to build a broadening coalition of health care providers to develop sound national strategies for diabetes control, thereby also addressing the issue of prevention of sight loss due to this disease. Budgetary implications are substantial, and the strengthening of primary and secondary care in this respect is a principal objective. Tertiary state-of-the-art institutions providing complex vitreoretinal surgical services will not be sufficient to meet all the needs of a nationwide diabetic retinopathy control program. Its success will be determined by having a population that is well informed about health risks in diabetes and that follows the guidelines for prevention of visual impairment. Health care systems will need to secure enough resources to screen and treat diabetic retinopathy.

The incidence and distribution of avoidable visual impairment in children very much depends on geographical location and socioeconomic development. As socioeconomic development in the middle income countries of Latin America, Asia and the eastern part of Europe accelerates, improved neonatological services allow for more successful care of prematurely born children. Control of retinopathy of prematurity is only likely if this development comes with access to skilled pediatric ophthalmologic services. The key factor is appropriate organization of eye care services and competent eye health care providers working along with other specialists such as neonatologists and pediatricians.

Care for individuals with refractive errors as well as the wider availability and promotion of low vision services will remain important. The latter are also a solution for many eye conditions that cannot currently be prevented or treated by existing methods or for which the visual acuity gained through treatment can be further improved by suitable optical aids and appropriate rehabilitation. The need for more refraction and low vision services, which would be both available to and affordable by patients, is still to be recognized in many countries.

The current trends in the global pattern of blindness broaden the agenda of VISION 2020 for health care planners in developing as well as in more economically successful countries. Further success in the control of avoidable visual impairment will be conditioned by new knowledge gained through research. “Knowledge heals” and its lack is manifested in the epidemiologic pattern of blindness. The missing knowledge has several facets, suggesting that further scientific efforts need to focus on operational, epidemiological as well as fundamental research. Even in the case of cataract, for which cost-effective interventions are already known, additional operational research is required to make these interventions more widely available and affordable. In the case of other conditions such as glaucoma, age-related macular degeneration and diabetic retinopathy, more needs to be known about their pathophysiology to control their impact on vision. In this respect, research—both fundamental and applied—is a crucial element of the global initiative for the elimination of avoidable blindness.