The COVID-19 pandemic has not affected everyone equally. The headlines have been broadcasting that there are serious disparities in how the pandemic is affecting people of color. A Perspective in the New England Journal of Medicine stated that “The Covid-19 pandemic has exposed the magnitude of U.S. health inequities — which the World Health Organization defines as “avoidable, unfair, or remediable differences” in health. It has also highlighted structural racism — institutions, practices, mores, and policies that differentially allocate resources and opportunities to increase inequity among racial groups. Covid-19 mortality rates are more than twice as high in Black, Latinx, and Indigenous populations as in White populations.[i].”
Disparities in income in the US are evident. On average White Americans earn 137% more income than Hispanic Americans and 170% more income than African Americans.[ii] Income, or rather a lack of, is also associated with increased rates of severe vision loss, defined as being blind or having serious difficulty seeing even with glasses.[iii] All of the factors contributing to poor outcomes from COVID-19, and all the ways in which income leads to increased prevalence of vision loss are known as “Social Determinants of Health.” The Centers for Disease Control defines Social Determinants of Health as “conditions in environments in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.[iv]”
Racial disparities in prevalence of glaucoma
The prevalence of glaucoma in the US overall is about 2%.[v] However, among adults over 80 the prevalence is about 12% for African Americans, 8% for White Americans.v On top of this, African Americans are three times more likely to have glaucoma,[vi] five times more likely to have unilateral blindness[vii] and twice as likely to have bilateral blindness from glaucoma compared to White Americans.[viii] Looking at these statistics through the lens of disparities in health outcomes, income inequality and social determinants of health, we have to question how we can do better as a society to improve access to and outcomes from glaucoma care.
The SIGHT Program
In response to the disparities in glaucoma, and eye health outcomes and the numerous barriers to equitable eye care, the National Academy of Science, Engineering and Medicine issued a call for action in 2016, stating that “coordinated efforts are needed to expand public health capacities that recognize improved eye health as an important population health outcome to achieve better health equity.[ix]”
In a grant from the U.S. Centers for Disease Control and Prevention to the University of Michigan Kellogg Eye Center, we are testing the Screening and Intervention for Glaucoma and Eye Health through Telemedicine (SIGHT) Program. We anticipate that this programme may enable us to detect a higher prevalence of glaucoma than the 2% prevalence seen in the larger US population. The SIGHT Program embeds a telemedicine-based glaucoma screening programme in trusted community clinics with a long history of providing primary care to underserved populations. We offer to fit participants with low-cost glasses as an incentive to participate in glaucoma and eye health screening. If people screen positive for eye disease, we provide support to help them get scheduled with an affordable eye care provider. As we continue to enroll participants in this programme over the next three years, we will gain a better understanding of how best to reach populations at high risk for glaucoma-related blindness.
[i] Berkowitz SA, Cene CW, Chatterjee A. Covid-19 and Health Equity — Time to Think Big. NEJM 2020; 383:e76
[ii] Median household income in the United States in 2019, by race or ethnic group. https://www.statista.com/statistics/233324/median-household-income-in-the-united-states-by-race-or-ethnic-group/ Accessed 2/25/21
[iii] Kirtland KA, Saaddine JB, Geiss LS, et al. Geographic Disparity of Severe Vision Loss — United States, 2009–2013. Morbidity and Mortality Weekly May 22, 2015 / 64(19);513-517
[iv] Social Determinants of Health. https://health.gov/healthypeople/objectives-and-data/social-determinants-health Accessed 2/25/21.
[v] NEI 2010 U.S. Age-Specific Prevalence Rates for Glaucoma by Age and Race/Ethnicity. http://www.nei.nih.gov/eyedata/glaucoma.asp
[vi] Friedman DS. Prevalence of Open-Angle Glaucoma among Adults in the United States. Arch Ophthalmol 2004;122:532–8.
[vii] Sommer A, Tielsch JM, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Engl J Med 1991;325:1412–7.
[viii] Tielsch JM, Sommer A, Katz J, et al. Socioeconomic Status and Visual Impairment Among Urban Americans. Arch Ophthalmol 1991;109:637–41.
[ix] National Academy of Science. Making Eye Health a Population Health Imperative: Vision for Tomorrow. 2016.