• Current Perspective

    Understanding and Addressing Disparities in Eye Care

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    Stephen D. McLeod, MD

    By Stephen D. McLeod, MD, CEO


    Not long after the COVID-19 pandemic took hold in the United States, it became clear that infection risk and disease severity varied substantially across demographic groups and that within minority populations, socioeconomic determinants were strongly associated with outcomes.1 A highly contagious novel respiratory virus should not play favorites, but the data were clear: Black and Hispanic individuals were far more likely to test positive for SARS-CoV-2 infection than were White individuals, and measures of socioeconomic duress were strongly associated with mor­tality rates in Asian American and Hispanic patients.

    These findings underscore that health is far more than mere biology, and that an understanding of those nonbiolog­ical and unevenly experienced factors that bear upon health outcomes is vital. And, of course, failure to recognize and address these factors is what results in the selectively poorer outcomes that define health disparities. This is a key concept: the way to address health disparities is not through diligently delivering equivalent care to all individuals regardless of cir­cumstance but through recognizing where circumstances call for adjustment to achieve an equitable outcome.

    The movement to tackle this issue of health inequity seri­ously, as a matter of principle and public health, has gathered momentum across all of medicine. Recognizing this, late in 2020 the Academy established a Task Force on Disparities in Eye Care, encompassing five sub-task forces focusing on specific aspects, including access to care, health literacy, and workforce diversity. This remarkable group of volunteer experts, chaired by Paul Lee, MD, JD, was charged with conducting a compre­hensive literature review to understand the current state in vision and eye care and to identify areas for future research.

    A series of papers produced by this monumental effort will soon be published in the Ophthalmology family of journals, and these works will help to guide this important discussion toward a real impact on patient outcomes. There is a great deal to learn from each of these major papers. The authors acknowledge that socioeconomic data are often incomplete and that research involving race and ethnicity is often hindered by inconsistent criteria describing ill-defined categories that lack sound biological or social definition. Nevertheless, broadly speaking, these studies document that among the general population, individuals from racial and ethnic minority groups have higher rates of visual impair­ment and blindness, with some older estimates suggesting rates nearly three times higher in Black individuals than in White individuals, and that socioeconomic and insurance status amplify these discrepancies.

    We now recognize that it is rarely genetic elements clus­tering reliably by racial category that are responsible for such disparities, but rather the environmental conditions that tend to accompany these categories. These social determinants of health have also been explored in the literature and examined in this initial review from the Academy’s task force. Numer­ous studies have confirmed the association between low income, unemployment, and educational level with the risk of blindness and visual im­pairment. Moreover, insurance status is also a factor, with a lack of health insurance as a risk factor for reduced utilization of health care services and low vision.

    This initial survey provides a wealth of information—as well as highlighting areas that require far more work to truly understand the drivers of poor and inequitable vision health care outcomes. The obvious question follows: what is to be done immediately and going forward? This is, of course, the ultimate object of the exercise, and some key remedial concepts are introduced in the series of task force papers. Our goal as a profession must be to go beyond simply acknowledging the current state and to diligently pursue those strategies that measurably close the gap and advance outcomes for all. Oph­thalmology has a long history of leadership in medicine, and with thanks to all the task force members for their tremen­dous work, the Academy is committed to leading here, too.

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    1 Magesh S et al. JAMA Netw Open. 2021;4(11):e2134147.