By Kathleen Nelson
Sunday, January 11, 2004
Of the 40 million people affected by blindness worldwide, two-thirds are women. If the gender-related causes of the disease aren't better addressed, the number of blind around the world could double in 25 years.
(WOMENSENEWS)--A World Health Organization initiative, Vision 2020, has set the goal of eliminating avoidable blindness by the year 2020. But with women representing two-thirds of the 40 million people around the world with impaired sight, some doubt that such a goal is feasible unless health officials concentrate on improving women's access to treatment.
"Without a gender-sensitive approach, we will not succeed in reaching our targets," says PaulCourtright, co-director of the Kilimanjaro Centre for Community Ophthalmology, which operates from Tumaini University in Tanzania. "In the developing world, women utilize fewer health services compared to men."
Courtright authored a review of 70 blindness surveys covering the 20-year period between 1980 and 2000. Published in the journal Ophthalmic Epidemiology in 2001, the review analyzes why women are so disproportionately affected by blindness.
The review points out that cataract--a clouding of the eye's lens that afflicts 25 million people around the world--can be cured by a surgery. While fairly routine in industrialized nations, the procedure is less common for people in other parts of the world, especially women.
Courtright says that few women come to the Department of Ophthalmology at Kilimanjaro Christian Medical Centre Hospital in Moshi, Tanzania, for cataract surgery. Those who do often arrive totally blind or with a form of the disease that is more advanced than it is for the men who come in with the condition.
Cost and availability are only part of the problem, he says. "Probably, most important, women do not have decision-making authority or access to financial resources within the household." Cultural barriers, he adds, may prevent women from traveling beyond their communities and accessing hospital services.
The number of ophthalmologists is not enough to meet the needs in Africa, Courtright notes, yet he argues that a more important issue is planning and management.
"To eliminate avoidable blindness we must create a 'bridge' between communities and hospitals and make sure that gender considerations are central in the planning and implementation process."
Gender-related blindness is slowly being recognized as a health issue worthy of educational, research and political investment.
Courtright's analysis, for instance, publicized the startling fact that two-thirds of the world's blind are women, not only in developing countries but in industrialized countries as well. He was asked by the Geneva-based World Health Organization to produce a fact sheet on gender and blindness and is working with the global public-health organization to promote initiatives to prevent blinding eye diseases in women.
In industrialized countries, two-thirds of women are blind because vision loss attends aging and in these parts of the world, women live longer.
The problems of gender inequity in the developing world and women's age-related blindness in industrialized countries are not easy problems to address, say health advocates, particularly in the absence of any significant public-health initiatives.
"Vision loss is a major fear for the public, often second only to fear of cancer or death," says Ilene Gipson, a senior scientist at The Schepens Eye Research Institute, an affiliate of Harvard Medical School in Boston. "The last message most of us remember is that you should eat carrots--and there hasn't been much since."
To change that, the Women's Eye Health Task Force at The Schepens Eye Research Institute, last November convened an international conference on women and blindness that is now trying to raise public awareness about the problem among women and their doctors.
In the United States, more than 1 million people are blind, including 700,000 women. Among this population, age-related macular degeneration is the leading cause of untreatable vision loss. It occurs when the macula--the center of the eye's light-sensitive retina--deteriorates and sufferers develop a blind spot in the middle of their field of vision that grows larger with time.
In the developing-world countries of Africa and Asia, trachoma, a bacterial infection of the surface of the eye that causes scarring and blinding, is easily spread by hands, clothing or flies exposed to discharge from the eyes or nose of someone who is infected. Women, who spend more time in domestic settings where these sources of infection exist, acquire it more than men. About 2 million people are blind from trachoma; it is the world's leading cause of preventable blindness.
Throughout the world, efforts to prevent, cure, or at least delay the progression of eye diseases need to stepped up, according to Courtright and Gipson. Cataract, trachoma, or refractive errors such as near- and farsightedness are the leading causes of visual impairment and blindness globally. The conditions can either be prevented by changing behavior--improving hygiene in the case of trachoma--or by providing curative services for cataract and refractive errors. Glaucoma and some other sight-threatening afflictions are linked to potentially modifiable behaviors.
In industrialized countries, screening every five years for those over 50 and more often for those with diabetes or a history of eye disease, as well as protecting eyes from ultraviolet light can help. Quitting smoking delays development of cataracts and age-related macular degeneration.
Type 2 diabetes, which is closely tied to obesity, often results in diabetic retinopathy, or retinal damage. Avoiding becoming overweight, or if diabetic, maintaining control of insulin levels may help delay vision problems.
Nutrition also plays an important role. Simply instructing everyone at risk of age-related macular degeneration to take daily supplements of vitamins B, C, beta carotene and zinc would prevent vision loss in more than 300,000 U.S. citizens, according to a study in the November issue of the Archives of Ophthalmology.
Hormones also contribute to women's eye disease and they are more difficult to control than nutrition or behavior change. Women who use hormone replacement suffer more from a disease called dry eye syndrome, in which the eye doesn't produce enough tears for proper lubrication.
Debra A. Schaumberg, an epidemiologist and assistant professor of medicine and ophthalmology at Harvard Medical School, authored the first large-scale study on the risk of dry eye among women who use hormone replacement therapy, published in November 2001 by The Journal of the American Medical Association.
"Our study showed that women who used estrogen alone (versus never having used any hormone replacement) had about a 70 percent increased risk of dry eye," says Schaumberg. Women who used combination of estrogen plus progesterone/progestins had about a 30 percent increased risk of the disease.
Longer durations of hormone-replacement therapy create a greater likelihood of dry eye. Reading, driving, and other daily life activities are more difficult with dry, irritated eyes. If the disease goes untreated, according to Schaumberg, women have increased risk of infections and even permanent eye damage.
More than 3.2 million women in the United States aged 50 and older experience moderate to severe dry eye, Schaumberg reported in another study published in the August 2003 issue of the American Journal of Ophthalmology. Millions more may have less severe forms of the condition, she says, and notes that dryness and irritation are not a normal part of aging.
Kathleen Nelson writes about medicine and health policy for general and specialist audiences.
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