Robert Neiderman
Internship, Spring 2005
It is well documented that poor children suffer academically. Many reasons have been put forth: inadequate schools and teacher in poor urban or rural areas, lack of family support at home, lack of pleasure reading at home, social pressure, and others. Another factor must be added to this list. Children growing up poor have more obstacles to good vision than their wealthier counterparts. Problems of nutrition and healthcare often prohibit proper development of the eyes, or allow vision-related health problems to take root. Without good vision, learning suffers. The early years of a child’s education are important, as they set the groundwork for the rest of his or her academic life. This in turn often leads to crime, unemployment, or other social ills associated with poverty. The fight against poverty must include comprehensive health care, including full vision care.
It is estimated that about one-fifth of the world’s population lives in poverty. Poverty can be defined as a state in which the fundamental commodity needs are unable to be met by an individual or household. These basic needs include nutrition, shelter, sanitation, and health care. (Dasgupta, 1993). For statistical purposes, we usually determine a poverty line, with those earning income below being poor, those above being not poor. The poverty line in the United States represents the income equal to three times the minimum food requirements of each member of a household. In other words, we assume that one third of income is used to buy food. This allows for distribution among members of a household, providing greater accuracy. In 1995, for example, the poverty threshold of an American family of four was $15,569, but it was $7,763 for an individual, and $31,280 for a family of nine. (Littman, 1998).
Poverty bites the young more shrewdly than adults. The rate of Americans under age 18 living in poverty is twice that of those over 18. They make up 40% of the American poor. Worse still, one in four Americans under the age of six live in a poor household. (Littman, 1998). This is largely due to the limited opportunities for employment available to children and teenagers. Family size plays a statistical role as well, since poor families tend to be larger than middle or upper class families.
Since the ability to provide food is an integral part in any measure of poverty, nutrition becomes an obvious area of life adversely affected by poverty. With the exception of extremely poor areas hit by famine and drought, people do not simply starve. The problem is most often malnourishment or undernourishment. In effect, the poor tend to eat too little food or, especially in the case of poor young Americans, junk food. Eating too little, or too little of the right foods, leaves one short of vital nutrients. Diets in most poor countries are often unbalanced. One might not be getting the adequate amount of vitamin A, iron, iodine, etc, even if protein needs are met, for example. (Dasgupta, 1993).
Not meeting these nutritional needs can lead to severe hardships. Low birth weight, growth stunting, and susceptibility to illness are common results of malnutrition during the early stages of life. Insufficient calcium leads to weak bones, and ultimately to osteoporosis. Too little vitamins lead to scurvy, rickets, and a host of other diseases. Lack of iodine in childhood reduces brain development. A study has shown that iodine-deficient individuals score an average of 13.5 points lower in IQ tests. (Behrman, 2005).
In areas of abject poverty, such as rural areas in less developed parts of the world, malnutrition can be severe. Even areas not routinely hit by famine show widespread hunger if there is not an even distribution of sufficient wealth. The nation of Bangladesh, bordering India to the East, has among the highest rates of malnutrition in the world. The prevalence of stunted growth among Bangladeshi children between the ages of 6 months and 59 months was 55% in 1999. Underweight children in the same age group numbered 61% in 1999. (Hossain, 2005). From this extreme, we can see the harm that growing up poor does to children.
Nearly any nutritional deficiency affects the eyes in some way. The B vitamins are important to organs associated with vision, such as nerve tissue and skin. Vitamin C helps to maintain cellular structure, as well as strengthen the immune system against infection. (Dowaliby, 1981). As it relates to vision, malnutrition is most troubling when it comes to vitamin A deficiency. Vitamin A deficiency in children can permanently damage eyesight, even causing blindness. (Gilbert, 2001). This is found even in moderately developed countries. A national survey in South Africa found that one in three children were vitamin A deficient. This was especially prevalent in the poorer rural areas. Also found were higher than average rates of xerophthalmia, (thickening and dryness of the conjunctiva), corneal xerosis (dryness of the cornea), night blindness, and keratomalacia (corneal softening and scarring), all caused by vitamin A deficiency. (Witten, 2004). Xerophthalmia is usually followed by blindness. (IEF, 2005).
Another result of poverty is inadequate medical care. In countries lacking universal health care, such as the United States or underdeveloped countries, trips to the doctor can be prohibitively expensive. In depressed or rural areas, routine medical care becomes a luxury few can afford. Many exotic diseases are considered exotic because they have been eradicated in fully industrialized nations by vaccination, proper treatment, or simply sanitation. Bubonic plague is relatively common in parts of Asia, but plague deaths in the United States are almost unheard of in the last hundred years, despite a persisting presence in the western part of the country. (Scott, 2004). Such diseases have become illnesses of the poor, both poor countries and poor citizens of developing nations. Some of these affect vision directly.
Trachoma is a bacterial infection caused by unsanitary drinking water. Common in Africa, it is the leading infectious cause of preventable blindness, affecting nearly 500 million people. Trachoma causes inflammation and formation of granules on the conjunctiva. Antibiotics can treat the infection, but proper sanitary and hygienic practices are necessary to prevent the spread of the disease. Onchocerciasis, commonly known as river blindness, is the world’s second-leading infectious cause of blindness. Parasitic worms are transmitted by the black fly, spreading the disease, characterized by nodular swelling of the skin and lesions of the eyes. It is estimated that 18 million people suffer from river blindness. Trachoma and river blindness usually result in total blindness. Where vision remains, it is compromised. (Keller, 2004).
Regular eye exams would reveal symptoms early enough to treat. Medicine can stop many diseases before any irreversible damage is done. Sadly, those in poverty-stricken areas of the globe do not have access to the necessary services. In developed countries like the United States, it is more common to find vision problems the result of untreated genetic or environmental conditions than of infectious disease.
When resources are scarce, whether in a society wracked by calamity or poverty, needs perceived as less vital are put aside for the more basic requirements of living. Long before anyone goes hungry, he or she neglects some other aspect of life. In places like the US, financial hardship causes people to drive old rusting cars a little while longer, or put off getting new clothes for another year. Very often, the time between eye exams stretches from one or two years to four or more. In that time, many sight-damaging conditions may develop. For example, 4 out of 5 blind people have conditions for which there are treatments easily available in developed countries. The poorest of the poor, even in America, sometimes never get more than a rudimentary vision screening from their school nurses. Regular, comprehensive eye exams are an important part of overall health care, and can detect many eye diseases and conditions before they permanently compromise vision (Vision, 2005).
Glaucoma is characterized by increased intraocular pressure, resulting in progressive damage to the peripheral retina. Caused by a failure of the aqueous humor to drain sufficiently into the Canal of Schlemm, glaucoma is a leading cause of blindness in the United States. It is a particularly biting coincidence that African Americans have a statistically higher risk of developing glaucoma, considering the higher proportion of minorities among the American poor. Other risk factors include family history, diabetes, or extreme myopia. Glaucoma is progressive, and can be treated if caught early enough. There is no cure, however, and any vision lost is irretrievable. Since vision loss begins at the periphery, most glaucoma sufferers don’t notice the disease until it is fairly well progressed. Comprehensive eye exams, including tonometry and/or retinal photography can detect glaucoma well before a patient can. (Vision, 2005).
The most common eye condition to be found during an exam, and the easiest to treat, is refractive error. Myopia, hyperopia, astigmatism, and presbyopia all fall under this category. Most children are hyperopic early on, as the globes of their eyes are too short relative to the refractive media. As they age, hyperopia decreases, ultimately leading to either emmetropia or even myopia, as their eyes grow longer. Myopia and astigmatism are common among children as well. Any competent doctor can diagnose refractive errors and prescribe the necessary eyeglasses (rarely contacts for preteens), but first the patient must come in for an exam.
A myopic child will simply not be able to see well at a distance. Likewise, an astigmatic child will have blurry vision. His or her world is an unclear place, and the child adapts to not being able to see well. Of much greater concern is hyperopia, and the danger of accommodative esotropia. Accommodation, the ability to increase plus power for near vision, diminishes with age. This is why those over 40 develop presbyopia and need reading help. A hyperope’s eyes require additional plus power to focus at a distance. Hyperopes can overcome some of their refractive error through accommodating. Since a child’s ability to accommodate is so great, he or she can neutralize large amounts of hyperopia by creating the necessary plus power. The problem is that accommodation is tied to convergence of the eyes, being activated by the same cranial nerve, CN3. So, the child forms a clear image on the retina, but produces double vision due to one eye turning inward. To prevent confusion, the brain suppresses vision from one eye, usually the weaker of the two. Over time amblyopia, or blindness in an uninjured eye, can result. The simple correction for accommodative esotropia, if caught early enough, is to wear plus lenses and bifocals to relax all accommodation at distance and near. If not treated very early, the amblyopic eye will not regain sight, and the sighted eye will require a strong correction. (Dowaliby, 1981).
Hyperopia is not the only cause of strabismus. Imbalances of the extraocular muscles cause the eyes to hold unequal fixations, and this can also result in amblyopia. Muscular strabismus can be treated through eye exercises and, when all else fails, surgery. (Dowaliby, 1981). Unfortunately for the poor, this requires frequent doctor visits and expenditures.
Whatever the cause of a child’s visual impairment, schoolwork suffers. Studies show that 80% of a child’s learning in the early grades is obtained visually. Failure to see the chalkboard and reading difficulty are obvious ways education suffers. It is estimated that 70% of the 2 million students who have problems reading suffer from visual impairments. (McCaskill Poor, 2002).
Visual problems are also linked to daydreaming and behavior problems. Frustration and embarrassment caused by difficulty in the classroom are common reasons for students to misbehave. Often to avoid ridicule, a student acts up in class rather than struggle to participate. The same pattern can be seen with other hindrances to learning, such as hearing impairment and cognitive disabilities. (Dowaliby, 1981).
Such problems in the early grades are compounded as the child gets older. If the student’s academic performance is poor enough, he or she will have to repeat the grade. This often results in social problems, which in turn hamper scholastic progress. If the child is promoted to the next grade, the work gets harder, and usually builds upon knowledge gained in previous grades. A student who squeaks by to the fourth grade, yet reads on a first or second grade level, will not likely do well. Nor will a student who is bad at arithmetic do well in algebra should he advance. Children of poor families who do not get regular eye exams will compound the problem with continued, possibly worsening vision problems. 25% of students K-6 have visual impairments. (McCaskill Child’s, 2002).
Many of society’s ills are connected to poverty by way of inadequate education. Numerous social programs deal with eradicating poverty and helping the poor make better lives for themselves. One very important way society can and must help the poor is through comprehensive health care, with special attention paid to vision care. A good education is vital to rising above the social conditions of the lowest classes. Such an education is nearly impossible for students with untreated visual impairments. A doctor can correct nearly all such impairments, from blindness to simple refractive error, and the worst of these must be diagnosed early. If we agree that combating poverty is in the best interest of American and global society, than we must provide regular, comprehensive vision care to those who cannot provide it for themselves.
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