Pakistan: 300,000 Premature Infants a Year Face Preventable Blindness — Why Still No National Screening?

At an eye clinic in Rawalpindi, doctors at Al-Shifa Trust Eye Hospital are used to examining the retinas of premature babies weighing less than 1.5kg. The babies cannot complain, cannot say they are slowly losing their sight. But through the ophthalmoscope, the image of abnormal new blood vessels growing across the retina is a silent indictment. This is retinopathy of prematurity – ROP. Each year, Pakistan records roughly one million premature births. According to ophthalmologists, 300,000 of these infants develop ROP to varying degrees. It is a quiet public-health emergency hidden inside a country of more than 240 million people. The number is alarming, but the bigger issue is how to read it. ROP is a potentially blinding disease, yet it is also preventable if screening happens at the right time. It is treatable if caught before retinal detachment. Pakistan, however, has no mandatory national screening programme. I have always looked for the point where a success creates a new kind of failure. ROP is exactly that point. For decades, developing countries focused on reducing neonatal mortality. Pakistan has made real progress in intensive neonatal care; extremely premature infants now have a better chance of survival. But survival created a new population: babies with immature retinas who are vulnerable to oxygen and the stress of treatment. The 30% ROP incidence reported by Pakistani doctors is higher than the 10–20% seen in developed countries. If accurate, it suggests a serious problem with oxygen management in neonatal intensive care units. Uncontrolled oxygen supplementation is the single most important modifiable risk factor for ROP. Premature babies in Pakistan may receive high-flow oxygen without continuous saturation monitoring, or oxygen may be adjusted by feeling rather than by protocol. The Express Tribune quotes ophthalmologists urging the government to adopt mandatory nationwide screening. Their message is clear: do not let the silence of statistics hide a humanitarian disaster unfolding inside hospitals. But an advocacy campaign cannot stand on moral outrage alone. Policymakers will ask: where does 300,000 come from? How many of these children truly need treatment? What will a national screening programme cost? This is where critical data thinking becomes essential. When a number becomes an advocacy tool, it can be rounded, inflated, or taken out of context. The number 300,000 sounds terrifying, but globally only about 5–10% of ROP cases progress to the threshold requiring surgical intervention. Most mild ROP regresses spontaneously with proper monitoring. Applying that rate, the true number of Pakistani infants requiring laser or anti-VEGF injection might be 15,000–30,000 per year. That lower number does not make the problem smaller; it still overwhelms the capacity of any single eye hospital in Pakistan. What worries me is not the choice of number. What worries me is how the health system responds. Al-Shifa Trust, a private charitable eye hospital, is cited as the main source of data. That means even data about childhood blindness is not in the hands of the public health system. If the state does not own the data, it is very difficult for the state to build an evidence-based intervention programme. A national ROP screening programme is not just an administrative decree. It requires a complete chain of care: premature infants must be examined at 4–6 weeks of age; doctors must have indirect ophthalmoscopy skills; hospitals must have laser or intravitreal injection capacity; and families must be able to return for scheduled follow-up visits. If one link in this chain breaks, the whole programme collapses. In Pakistan, the weakest link is human resources. There are roughly 2,000 ophthalmologists for the entire country. Neonatologists, who see premature babies every day, are often not trained enough in ROP to perform initial screening. The workforce shortage is a bigger barrier than budget. International health organisations have suggested task-shifting: training nurses or refraction technicians to take retinal images and sending them to a central reading centre through telemedicine. This model works in India and parts of Latin America, but it requires an integrated health-data system that Pakistan lacks. Pakistan’s story is also one of fragmented governance. After the 18th Amendment, health policy was devolved to four provinces. A mandatory national screening order would need to be approved and funded by four separate provincial governments. Punjab may be ready, but Balochistan, a sparsely populated province, may not have a single ophthalmologist in many rural districts. The problem cannot wait for every province to become ready. Every year of delay means thousands of children will move permanently into darkness. Advocacy around ROP in Pakistan remains far too weak. This is one of the few media reports raising the alarm. There are no stories about a specific child losing sight, no images of a mother crying in the operating theatre, no celebrity ambassador. Emotionally, the story is almost invisible. That is why, even though the statistics have appeared in the English-language press, the Pakistani public has not generated enough pressure to force a government response. A common mistake in health advocacy is believing that if the number is large enough, policy will automatically change. In the real world, health budgets are allocated according to political priority, not according to the tragedy of the disease. A child blinded by ROP has no voice. Parents are often poor and poorly educated. This is a problem of the powerless, and in Pakistan’s political system, the powerless are usually left behind. I remember a fundamental principle of data analysis: never confuse correlation with causation. The rise in ROP cases may not mean the disease is becoming more severe; it might simply mean neonatologists are paying more attention and referring more babies for eye examination. Without baseline data from previous years, we cannot confirm whether an ROP epidemic is actually growing over time. The 300,000 may be just the tip of an iceberg that has accumulated for years but was never recorded. Yet questioning the accuracy of data does not mean denying the problem. A responsible analyst must read statistics with skepticism while also listening to the stories behind them. The right question is not “300,000 or 30,000?” but “are we ready to face even the lowest estimate?” If not, then arguing about the number is just a way to postpone responsibility. Pakistan needs a national epidemiological survey on ROP, led by the Ministry of Health, with the participation of Al-Shifa Trust, medical universities and the World Health Organization. The survey would answer three fundamental questions: how many babies actually have ROP, how many progress to treatment threshold, and which provinces carry the highest burden. Only then can the government decide how much to invest and where to prioritise. Meanwhile, ophthalmologists should not wait for a top-down policy. They can start by building an internal case-reporting network among the major maternity hospitals in Karachi, Lahore and Islamabad. If every neonatal intensive care unit makes an eye appointment before discharge, thousands of babies can still be saved even without a national law. This bottom-up approach is often the most effective when the government remains slow. The lesson from Pakistan is painful but extremely valuable for other developing countries, including Vietnam. Vietnam is improving neonatal care, and the survival rate of premature babies is rising. That means the population at risk of ROP will also rise unless we prepare in advance. The cost of an indirect ophthalmoscope is far lower than the cost of raising and educating a visually impaired child for eighteen years. Economically, there is no reason to delay. This story is not really about Pakistan. It is about how human beings respond to a threat that has no noisy symptoms. ROP does not cause fever, does not cause coughing, does not make the baby cry more than usual. It silently steals the sight of a child just as doctors celebrate saving the child’s life. And because it is silent, we can easily pretend it is not there. The data on ROP is telling us something very clear: if we do not act now, today’s generation of premature infants will become the generation of blind adults in the next three decades. The truth does not need to be shouted. It only needs to be read with sober eyes, and turned into policy before it is too late.