Pakistan faces a 'silent epidemic': 300,000 premature infants develop retinopathy annually, urgent call for nationwide screening program

The Shock of 300,000: When Lives Are Saved, Eyes Fade Away

The number 300,000 rang out like a thunderclap in the Al-Shifa Trust Eye Hospital auditorium on Tuesday. It is not a dry statistic about an infectious disease, but the number of premature infants in Pakistan developing retinopathy of prematurity (ROP) each year. I have tracked these numbers for years, witnessing how global health systems grapple with a cruel paradox: the more premature infants we save, the more potential victims we create of a preventable disease.

When I worked in Busan, I witnessed how South Korea built a comprehensive newborn screening system, from metabolic to hearing screening. But in Pakistan, the story is unfolding differently. Leading ophthalmologists at Al-Shifa Trust, one of the country's largest eye hospitals, have just issued a shocking warning: the nation is facing a 'silent epidemic' of retinopathy in premature infants. They urge the government to immediately enact a mandatory nationwide screening policy, before thousands of children fall into permanent blindness that is entirely preventable.

The Big Picture: From Intensive Care to Risk of Blindness

To understand the severity of the problem, we must look at the overall picture of neonatal healthcare in Pakistan. This South Asian nation records approximately 1 million premature births each year – a massive figure reflecting both population scale and healthcare system challenges. Among these, according to estimates from Al-Shifa Trust experts, up to 300,000 develop varying degrees of retinopathy.

Retinopathy of prematurity (ROP) is a dangerous disease that directly attacks the retina – the light-sensitive tissue at the back of the eye. In premature infants, retinal blood vessel development is disrupted due to premature birth, leading to abnormal growth. These vessels can grow in wrong directions, causing bleeding, scarring, and in severe cases, retinal detachment – leading to permanent blindness.

The concerning aspect is that Pakistan's ROP incidence rate is estimated at 30% – at the high end of global estimates. In developed countries, this rate typically ranges from 10-20% among premature infants. This disparity is not coincidental. It reflects a painful reality about the quality of care in Pakistan's neonatal intensive care units (NICUs), particularly regarding oxygen management.

The Paradox of Life: When Medical Progress Creates New Challenges

At the core of the issue lies a paradox few recognize. Over the past two decades, Pakistan has made significant progress in improving survival rates for premature infants. Advances in respiratory care, infection control, and nutrition have given extremely premature infants – as young as 28-32 weeks gestational age – a better chance of survival than ever before.

But this very success creates a new challenge. Surviving premature infants are the highest-risk population for developing ROP. Previously, many extremely premature infants might not have survived, meaning the ROP burden was not as visible. Today, as more infants survive, the number needing ROP screening and treatment grows exponentially.

This is a classic 'second-generation health problem' – an inevitable consequence of medical development. Developed countries went through this phase in the 1980s-1990s, when they had to build comprehensive ROP screening programs to cope with the 'wave' of surviving premature infants. Pakistan is at the early stage of this transition, and the question is whether they will learn from those who came before.

Deep Analysis: The Gap in the Screening System

When I carefully analyze the Al-Shifa Trust doctors' recommendation, I notice a serious gap in Pakistan's health system. The call for 'mandatory screening' – while entirely correct and aligned with World Health Organization (WHO) recommendations – is not accompanied by a specific implementation plan.

According to WHO guidelines, all premature infants under 32 weeks gestational age or weighing under 1,500 grams should undergo eye screening within 4-6 weeks after birth. This screening must be performed by ophthalmologists specially trained in ROP, using specialized equipment such as indirect ophthalmoscopes or retinal cameras.

But the question arises: does Pakistan have the resources to do this? With approximately 1 million premature births annually, and assuming a significant proportion meet screening criteria, the health system would need to handle a massive workload. Meanwhile, the number of ophthalmologists in Pakistan – estimated at around 2,000 for a population of over 240 million – is completely insufficient to meet this demand.

The Bottleneck of Workforce and Infrastructure: A Difficult Equation for the Government

The concentration of resources at major hospitals like Al-Shifa Trust creates another paradox. Although this hospital has a top-tier specialist team and modern facilities, its operational scope is limited to a few major cities. Meanwhile, most premature infants in rural areas – where 60% of the population lives – have virtually no access to specialized screening services.

This is a structural problem that cannot be solved overnight. In South Korea, where I lived and worked, the ROP screening system was built on a network of public health centers and general hospitals, with close coordination between obstetrics, pediatrics, and ophthalmology departments. Pakistan, with its fragmented health system and devolution to provincial governments under the 18th Amendment, will face enormous challenges in building a unified national program.

Furthermore, the 'brain drain' in the health sector is worsening the situation. Many well-trained Pakistani ophthalmologists and neonatologists are attracted by better salaries and working conditions in Gulf states, the United Kingdom, or other developed countries. This makes the domestic workforce even scarcer.

Contrarian View: Where Could I Be Wrong?

Before reaching final conclusions, I must re-examine my arguments. Is the 300,000 ROP cases per year figure truly accurate? The estimation methodology is not publicly disclosed, and if based on data from a single hospital like Al-Shifa Trust, there could be significant deviation from national reality.

Clinical reality shows that not all 300,000 ROP cases require treatment. Most mild ROP cases can regress spontaneously without intervention. Only about 5-10% of ROP cases progress to severe stages requiring treatment. This means the actual number needing medical intervention might be only 15,000-30,000 cases per year – still a very large number, but significantly different from 300,000.

However, even with this more conservative figure, the problem remains highly serious. 'Thousands of children needing surgery' – as the article mentions – is a large enough number to demand urgent government intervention. And more importantly, the difference between 300,000 and 30,000 does not change the nature of the problem: Pakistan lacks a national ROP screening system, and thousands of children are suffering avoidable consequences.

The Cost of Inaction: The Overlooked Economic Equation

One of the biggest omissions in the article is the lack of attention to the economic dimension of the problem. The cost of preventing ROP blindness is actually not too high when compared to the long-term burden it creates.

Let's do a simple calculation. The cost of a single eye screening examination using an indirect ophthalmoscope in Pakistan might be only $5-10. With 1 million premature infants annually, the cost of screening all would be approximately $5-10 million per year – not a small figure but entirely within the capacity of the national health budget.

Meanwhile, the treatment cost for a severe ROP case can reach $500-2,000 per eye, depending on the treatment method (laser or anti-VEGF injection). But if left untreated, a blind child will bear lifetime costs: special education, medical care, lost productivity – estimated at $10,000-30,000 per case in developing countries.

In other words, every dollar spent on screening could save $10-20 in long-term costs. This is one of the highest economic-efficiency health investments any government can make. But the issue is not just money – it's about policy priorities and implementation capacity.

The Role of International Organizations and the Private Sector

In a context where Pakistan's government faces many competing priorities – from polio eradication to reducing maternal mortality – the role of international organizations and the private sector becomes particularly important.

International NGOs such as SightSavers, the Fred Hollows Foundation, or WHO and UNICEF programs could play a pivotal role in providing technical and financial support for a national ROP screening program. WHO's VISION 2026 initiative – the goal of eliminating preventable blindness by 2026 – is a suitable framework that Pakistan could leverage.

Additionally, private sector participation is crucial. Pharmaceutical companies producing anti-VEGF drugs like bevacizumab (Avastin) – a low-cost, highly effective treatment for ROP – could provide drugs at preferential prices for public health programs. Medical device manufacturers could also contribute by providing retinal cameras at reasonable costs.

However, it must be emphasized that the role of international organizations and the private sector is supplementary. Primary responsibility still rests with Pakistan's government – specifically the Ministry of Health and provincial governments – in developing and implementing policy.

Proposed Solutions: A Three-Phase Action Roadmap

Based on my experience tracking public health programs in South Korea and other Asian countries, I propose a three-phase action roadmap for Pakistan:

Phase 1 (0-12 months): Building the Foundation – Enact mandatory ROP screening policy at public hospitals in major cities (Karachi, Lahore, Islamabad, Peshawar, Quetta). Train teams of ophthalmologists and technicians in ROP screening techniques. Establish referral systems between obstetrics, pediatrics, and ophthalmology departments.

Phase 2 (12-36 months): Expanding Coverage – Deploy the program at provincial and district hospitals. Train an additional 500-1,000 doctors and technicians. Build a national ROP database for monitoring and evaluation.

Phase 3 (36-60 months): Sustaining – Integrate ROP screening into existing maternal and child health programs. Mobilize resources from national budget and international donors. Conduct independent evaluation and adjust the program based on results.

A key element in this strategy is 'task-shifting' – training neonatologists and technicians to perform basic ROP screening, reducing the burden on specialized ophthalmologists. This model has proven effective in India and several African countries where specialized human resources are also very limited.

A Story from the Football Field: Lessons on Preparation and Systems

I often compare health systems to football teams. A good team not only has outstanding stars but also a smoothly operating tactical system with coordinated play between lines. Al-Shifa Trust can be seen as a 'striker star' – but they alone cannot win the match against blindness.

Pakistan needs to build a solid 'defensive system' – that is the screening network at hospitals nationwide. It needs a 'midfield' – that is a well-trained team of neonatologists and technicians. And it needs a 'coaching staff' – that is the government with its role in policy planning and resource allocation.

In football, a team lacking preparation will pay the price with goals conceded. In public health, lack of preparation will pay the price with the eyes of thousands of children.

Conclusion: The Time to Act Is Now

The story of retinopathy in premature infants in Pakistan is not a pessimistic one. On the contrary, it is one of the most effective health intervention opportunities a developing country can undertake. ROP is entirely preventable if screened and treated in time.

But time waits for no one. Each year of delay means thousands of children will enter life with permanent darkness. Each year of delay means the economic and social burden will continue to compound.

The doctors at Al-Shifa Trust have spoken. International organizations are ready to help. The private sector can contribute. The only missing piece is political will and determination to act from Pakistan's government.

Will policymakers in Islamabad listen to the voices from the medical community? Will they see the bigger picture – that investing in ROP screening today will save billions of rupees for the health budget in the future? Will they have the courage to make the right decision, even when facing political pressures and tight budgets?

The answers to these questions will determine the fate of thousands of Pakistani children – children who deserve the chance to see sunlight, their parents' faces, and the colorful world around them.