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| EDITORIAL |
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| Year : 1997 | Volume
: 45
| Issue : 4 | Page : 201-202 |
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What role do epidemiology and public health have in dealing with blindness in India?
L Dandona
Correspondence Address:
L Dandona
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 9567013 
How to cite this article:
Dandona L. What role do epidemiology and public health have in dealing with blindness in India?. Indian J Ophthalmol 1997;45:201-2 |
A question that must be asked before trying to address the substance of this editorial is: what is a worthwhile role for us as ophthalmologists, doctors, and responsible citizens of our country? This is not meant to be a "sound-good" question like the rhetoric of many politicians nor is it meant to be an expression of naivete as some might interpret. This is a fundamental question as to what is an ideal mindset with which we should do what we do, whatever our profession may be, such that we could contribute to the forward movement of our society. If we examine the roots of our own rich culture[1] or the thoughts of some remarkable thinkers in other cultures,[2],[3] we may realise that this contribution to forward movement of society need not be some unique single revelation, which the majority of us are unlikely to get; rather it is the mindset which would enable us to see the inter-connectedness of the various aspects of creation in our everyday life. If this sounds too abstract, consider the following real situation related to eye care in our country which would probably make this apparently abstract issue to be of more practical significance than most "practical" things we do.
The majority of us provide eye care with good intentions to the patients who come to us or even those we reach out to in "camps". However, do we ask the question why is it that in spite of our good intentions blindness in India continues unabated? It might perhaps be that we are not paying enough attention to the inter-connectedness of the various issues that would enable us to reduce blindness. Then, one might ask how do we get to understand these inter-connected issues that would reduce blindness? One approach, often used in our country, is to form hasty impressions based on sketchy and disorganised information in order to "do something" when we are pushed into a corner. Another, the preferred approach as it seems to have worked in other parts of the world, would be to invest in obtaining reliable and organised information about the various aspects of blindness in our country and the reality of people's life within which blindness occurs. This is where the role of epidemiology and public health comes in.
Epidemiology, simply put, is the study of how common diseases are, who gets them, and why some people get them and others do not. It would seem to be common sense that such basic information is necessary for any effective planning to improve the health of a country. The fact remains that reliable epidemiologic information regarding the various aspects of blindness in India is quite scanty. The word "reliable" here is of significance because doing a so called "survey of blindness" in a population without adequate methodology, which has been the case in our country more often than not, is not the kind of information which will help us reduce blindness. What is needed are population-based studies which have clear objectives, and equally clear methodology acceptable by current international standards that would enable answers to be obtained in an objective manner to the questions that are being addressed. What is a population-based study, and why should one bother about it instead of getting information from patients coming to our hospitals or clinics which would be simpler? The majority of people with visual impairment in India do not have access to eye care, and if we base our planning to reduce blindness on the few that come to us, we are likely not to address the issues related to blindness of the majority as these would be different from those that are able to come to us. Therefore, we need studies which evaluate the various aspects of blindness in a representative sample of the whole population under consideration. Such studies are referred to as population-based studies, and an important element in their methodology is that the chosen sample should closely reflect the population being studied, and the sample size should be large enough to answer with confidence the questions that are being asked. Well-designed population-based studies are expensive, but so is the loss of productivity and the socioeconomic burden due to the continuing high rate of blindness. Initial investment has to be made to obtain reliable population-based information about the magnitude and causes of blindness and low vision, risk factors for eye diseases, how people's quality of life is affected by visual impairment, and what barriers to eye care are perceived by the people.[4] This, if planned well, is likely to be cost-effective in the long run by enabling formulation of strategies that would reduce the socioeconomic burden of blindness in India. Such studies obviously cannot be done by ophthalmologists alone; also needed are epidemiologists, biostatisticians, sociologists, anthropologists, and economists. It might be pointed out that such qualified personnel are not easily available in India. This precisely is what needs to be changed if we have to have effective eye care or health care in general. Initial investment and attitudinal change in policy would be necessary, which in the long-term is likely to save more than it costs. We have to plan for the future by investing wisely to prevent disease and disability along with dealing with the problem at hand, instead of always playing "catch-up" with health care problems after they occur as we do now.
The understanding of inter-connectedness has to be the basis of effective public health policy which puts together the principles of epidemiology, medical sciences, social sciences, economics, and ethics to bring about practical improvement in the health of society. We break up health care into separate segments to understand the details and be good in one narrow area. This is all well and good in today's era of expanding knowledge. However, what is not well and good is if we forget that this need for micros-pecialisation has to go hand-in-hand with a macro-perspective which keeps the needs of the whole society in mind. Epidemiology and public health, if properly done, play the role of bringing in this societal perspective. Perhaps, many of us ophthalmic surgeons are turned off by epidemiology and public health which are perceived to be fuzzy areas never providing concrete answers as readily as restoration of vision after taking out a cataract. The reasons for this may partly be the lackadaisical and theoretical way in which we are exposed to epidemiology and public health during our medical training, and partly the mostly ineffective public health policy in our country which does not have a concrete ideological basis. Whatever the reasons may be, are we to continue to complain about an ineffective health care system for the majority in our country without doing anything to change it, an approach usually taken by cynics trying to find excuses, or are we willing to do something about it? If we continue not to consider this as our own problem and do something about it, the imbalance in our country's health care will continue to increase. Continuing imbalance in any society is not sustainable as human history has shown, for example, our country's independence from colonial rule as well as the French and Russian revolutions. It comes back again to the issue of seeing the inter-connectedness and acting such that our society moves forward and not backward. In our profession, this can be done by seeing basic sciences, clinical sciences, epidemiology and public health as different dimensions of the same issue, that is, improving the health of society as a whole and not just the privileged few. Together, these different areas of medicine and health care may be able to achieve this goal, but inadequate attention to one or more of these areas would result in continuing failure. In practical terms, this means that more "real" emphasis and investment, as opposed to lip-service, are needed to develop quality epidemiology and public health expertise in India if blindness is to be effectively reduced. This may mean some painful rethinking by senior academicians and policy makers amongst us. But then some pain may not be bad, as this would be for a worthwhile gain, that is, reduction of blindness in India.
| References | |  |
| 1. | Easwaran E. The Bhagvad Gita for Daily Living. Petaluma, USA: Nilgiri Press; 1975.  |
| 2. | Thoreau HD. Walden and Civil Disobedience. New York: Penguin Books; 1983. First published in 1849. |
| 3. | Tolstoy L. What Then Must We Do? Bideford, UK: Green Books; 1991. First published in 1886. |
| 4. | Dandona R, Dandona L, Naduvilath TJ, Nanda A, McCarty CA. Design of a population-based study of visual impairment in India: the Andhra Pradesh Eye Disease Study. Indian J Ophthalmol 1997;45:251-57. |
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