Italy takes care of blind citizens, but more can be done

Blind people in Italy are entitled to a pension, special allowances and free education, but bureaucracy often hampers rather than helps, advocates for the blind say.

ByMichela Cimberle

Italy has a history of state care for the blind and visually impaired that reaches back to the years following the end of World War II.

Looking into Italian eye care policy on the support of blind and visually impaired people, we encounter innumerable laws and amendments, many of which date back almost 50 years. Before this time, little was done by the Italian government. Blindness was regarded as a personal or family problem, and its social implications were entirely overlooked.

Although many of the changes in the past 50 years were due to the growing social conscience of the newly born Italian republican state and society, much of the credit should be given to the indefatigable faith and restless campaigning of the Italian Blind Union (Unione Italiana Ciechi, UIC). Since its founding in 1920, the association has fought to secure equal opportunity and full participation in society for those it represents, and has continually encouraged the government to develop standards appropriate to the needs of blind people in the fields of education, work, health services and social welfare.

A short history

In 1954, a law decreed for the first time the right of blind people to receive financial support for their disability. A monthly disability pension was assigned both to the totally blind and to the visually impaired with residual visual acuity of less than 20/200 as part of the state provisions for persons with disabilities. This is in the spirit of article 38 of the Italian Constitution, which says that “Every citizen who is unable to work and devoid of the necessary means to survive has the right to maintenance and social assistance.”

The disability pension could be obtained on condition that the applicant could demonstrate insufficient personal or family income. In the years that followed, this restriction was partly relaxed: income limits were modified and only referred to the applicant him- or herself. However, the visual acuity condition was toughened to 20/400.

An important step was taken in 1968, when an additional assistance allowance was granted to the blind in recognition of their inability to independently manage everyday tasks and of their need for assistance when walking outside home. This allowance was not income-related. Between 1980 and 1990, thanks to the efforts of the UIC, this allowance was extended, with an increased amount, to blind people under 18 years of age. At the same time, those under 18 with less severe visual impairment were granted a special allowance to cover their attendance at rehabilitation centers.

Enrico Bisante, MD, is a fellow at the school of ophthalmology in one of the main research centers in the field of blindness and visual impairment in Italy, the University “la Sapienza” in Rome. In his opinion, “Italy has progressively become more sensitive to social needs, equal opportunities and human rights. However, much is still to be done. The current legislation is fairly supportive and exhaustive, but there are weak points that need to be improved. First of all, blind or visually impaired people are not always given the proper information concerning their rights. Bureaucracy often hampers procedures, and the health authorities, with ophthalmologists in the front line, are not themselves sufficiently informed or, for that matter, especially helpful. Secondly, the definition of legal blindness needs to be revised. The partially blind are those who more often suffer from inadequate, unfair support.

“Finally,” he continued, “more attention should be given to the problems of blind children and babies and their families. At present, I believe that the law is not adequate to their needs.”

Applying for benefits

The family doctor is the first link of the chain when blind or visually impaired people in Italy want to claim health care and social benefits according to their rights. The family doctor writes the initial certificate and applies to the proper authorities for examination of the case. A special commission (a so-called “commission for the blind”) is appointed by the local health department to evaluate the degree of visual deficiency of the applicant. A medical-legal specialist presides over the commission, and the applicant has the right to be represented by a medical specialist of his or her own choice.

of his or her own choice. “The primary role attributed to the medical-legal specialist is of undeniable importance,” said Flavio Alessio, MD, who has often worked in this capacity. “We represent the link between the two worlds of medicine and law and can offer multi-disciplinary competence. Of equal importance, however, is the presence of at least two ophthalmologists, one of which is appointed by the health department and one by the UIC, which is entitled to appoint a representative.”

Luigi Ballardin, president of the UIC in Ravenna, one of the most important regions of Northern Italy, said, “We make sure that our representative should be an ophthalmologist of certified experience. Without a specialist on the commission, evaluations can only be generic and sometimes unfair.”

Visual deficiency is evaluated using a percentage system, according to officially set guidelines. Special tables, listing all forms of visual impairment and vision-impairing disorders, attribute a certain number of marks for each item, and the sum gives the final percentage of disability for each case. For example, binocular blindness is given the maximum score of 100 marks, while monocular blindness is attributed 30 marks. Non-congenital glaucoma can be assessed from a minimum of 11 to a maximum of 20 marks, cataract or keratoconus 5 marks, entropion 1 to 10 marks.

“As quite a number of patients present with more than one complaint, the percentage of certified invalidity is given by the sum of the single items,” Dr. Alessio explained. “Different percentages of disability entitle one to different benefits. A 45% disability, for example, entitles the applicant to preferential access to employment. In Italy, all public and private enterprises must reserve, by law, a certain number of job appointments for the disabled. A 66% disability entitles one to free medical treatment.”

With a rating of 74% disability or higher, the applicant is entitled to financial benefits, Dr. Alessio said.

UIC members believe that some of the evaluation criteria of the invalidity tables need to be revised.

“While a visual acuity of 20/400 in both eyes is evaluated as 80% disability, the same visual acuity of 20/400 in only one eye with visual acuity less than 20/400 in the fellow eye is considered as 100% disability,” said Dr. Ballardin. “Less than 20/400 might mean 20/600, which doesn’t make such a large difference.”

Inequity in treatment

Both blind people and those with 20/400 visual impairment are entitled to a disability pension. Income limits for eligibility have been fixed at US$12,000 per year, counting only the applicant’s personal income. The pension amounts to about US$2600 a month.

Additional assistance is given to totally blind persons, independent of income. Since 1988, this has been extended to those under 18. This monthly amount is US$6300. The Defense Ministry also assigns a certain number of young army conscripts to give free assistance to this category of people.

The 20/400 visually impaired are excluded from this allowance. By law, they are considered sufficiently independent to cope with everyday tasks including preparing food, taking medications, keeping themselves and their homes clean, walking along the street, shopping and using transport.

“This point of the law needs further discussion,” according to Dr. Bisante. “These patients need almost as much assistance as the 100% blind in their daily lives. Their visual acuity allows them only to distinguish light from dark, or the mere shadow of a near object. They are in fact incapable of real independence and are very much in danger of injuring themselves both at home and outside. In many ways, their condition is psychologically more difficult than total blindness, as they are expected to do more and to do it better, thanks to what little eyesight they possess. This inevitably generates feelings of inadequacy, impotence and lack of self-respect.”

Only a small monthly allowance of US$50 is given to this category instead of the assistance allowance.

Support for the underaged

Infancy, childhood and adolescence are difficult stages of human life. A disability deeply affects the growing process of individuals at these ages, interfering with all aspects of social life and hindering normal development of the sense of self and personal identity.

sense of self and personal identity. “For the infant, the eyes are the first source of information concerning the surrounding world,” said Rossella Apolloni, MD, a lecturer and researcher at Rome University. “They allow the functional coordination of all sensory stimulation and their connection with data from previous experience. Consequently, eyesight is a very important means of integration between perceptive, cognitive and motor systems. Severe visual impairments hinder this process of integration. It has, however, been demonstrated that appropriate stimulation of the other perceptive channels — touch, hearing, smell — compensates for visual deficiency and promotes the normal development of the infant’s physical, emotional and cognitive functions.”

Loving parents, who are aware of possible problems and have been properly assisted in learning how to help their visually impaired child grow, are irreplaceable in the physical and psychological development of these children.

“Parents need more support, both psychological and financial, and more information and advice from experts,” Dr. Apolloni said. “Even the earliest upbringing of a visually impaired child cannot be improvised,” she said.

Dr. Apolloni said that in her opinion, not much is done at present by the state to guarantee support for parents of visually impaired children. Again, she said, the distinction between total blindness and severe (20/400) visual impairment penalizes many infants and infants’ families who have the same needs but fewer rights. “It is mandatory that an emendation of the current law extend the right for assistance allowance to all visually impaired children,” she said.

Improvements in education

In the field of education for the blind and visually impaired, much has changed over the past 50 years. In the 1950s and 1960s, visually impaired children lived most of their time away from the family. From infant school age to middle school, they were educated in special boarding institutes, often far from the family home. There, they could take advantage of specialized and sometimes very advanced educational programs, growing up together with other children with the same problem and developing a reassuring, but deceptive, feeling of “normality.” The ensuing impact when they encountered the outside world and non-blind people was often traumatic and difficult.

Student protests in 1968 produced dramatic changes. The whole concept of special school and boarding school was questioned and rejected. A new trend emerged: the disabled, among them the blind, were to be integrated into ordinary schools.

“Nowadays, Italian blind students are given all the necessary support by the state so that they can study and grow up among other children without discrimination,” Mr. Ballardin said. “These children are subsidized for the entire duration of their studies, from infant school to university. Government funds are also allocated to provide schools and universities with the learning aids needed by the visually impaired, from books in Braille to the latest technology.

A weak point, of not inconsiderable importance, is the insufficient number of specialized teachers involved in the education of blind students, Mr. Ballardin noted.

“The average school day of a disabled child is spent with his or her schoolmates, attending the same classes and sharing the same tasks,” Mr. Ballardin said. “Up to the age of 14, however, some hours should be spent one-on-one, or in small groups, with a ‘support teacher,’ who is supposed to be trained in special education and therefore able to work with the child using specific skills determined by his or her disability. Unfortunately, very few Italian teachers are properly trained for special education, and even fewer for the education of the blind.”

The GISI group

Among ophthalmologic scientific societies, GISI, the Italian study group for the visually impaired, is dedicated to patients with severe visual loss. “Not the totally blind, but those who can still benefit from rehabilitation,” said Prof. Enrico Gandolfo, MD, temporary president of the association.

GISI promotes scientific research in the field of low vision. It acts as a link among Italian centers that specialize in the field and is an important meeting point for those who participate in the rehabilitation and integration of the visually impaired (ophthalmologists, psychologists, social workers, etc.).

“Together with the UIC, our group has obtained the allocation of an annual US$2,500 fund,” Prof. Gandolfo said. “The money is distributed on a regional basis, to centers that propose projects dealing with prevention or rehabilitation for the visually impaired.”

GISI and UIC aim for recognition of the visually impaired with vision worse than 20/200 but better than 20/400.

“These patients are not recognized as legally blind, and have no right to benefits,” Prof. Gandolfo said. “We are working at creating better awareness and greater knowledge of this particular problem among our colleagues. At the same time, we are trying to change government policies.”

For Your Information:

Enrico Bisante, MD, and Rossella Apolloni, MD, can be reached at Università “la Sapienza,”Viale Policlinico, 00100 Roma, Italy; +(39) 06-490296; fax: +(39) 06-8606280.

Prof. Enrico Gandolfo, MD, can be reached at Clinica Oculistica, Piazzale Ospedali Civili 1, 25123 Brescia, Italy; +(39) 030-394452; fax: +(39) 030-3388190; e-mail: gandolfo@mafter.cci.unibs.it.

Luigi Ballardin can be reached at Unione Italiana Ciechi, Sezione Provinciale di Ravenna, Via Tombesi dall’Ova 4, 48100 Ravenna, Italy; +(39) 30-0544-33622; fax: +(39) 30-0544-34762; e-mail: Uicra@uiciechi.it.

Flavio Alessio, MD, can be reached at his private practice, V. le Venezia 14, 36061 Bassano del Grappa (VI), Italy; +(39) 0424-52510; fax: +(39) 0424-52511.