Ophthalmology faces years-long changes from COVID-19
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We ophthalmologists and our colleague epidemiologists from all over the world will be studying the COVID-19 pandemic for decades and, if the 1918-1919 influenza pandemic and the mid-1300s bubonic plague pandemic are examples, centuries from now.
As I mentioned in a previous commentary, my favorite site to learn what is happening around the world in this pandemic is worldometers.info. The cover story in this issue is focused on our colleagues in Europe, and we all appreciate their early and honest reporting. I have learned much from the European experience. I may ramble a little in this commentary, and to be direct, I am not making any political or judgmental comments. The thoughts I express are my own, and the future may prove me wrong on some or all of them.
If I look at the COVID-19 experience in the key EU countries of Germany, the United Kingdom (the Brexit transition is not complete), France, Italy and Spain, they together have reported approximately 3,400 confirmed cases and 400 deaths per million population as of May 8. When I look at their case volume curves, they spike up for 4 to 6 weeks to a maximum and then decline toward zero over 8 to 12 weeks. I do not see any significant “flattening of the curve” as I look at their data. In some countries and some regions, the general hospitals were severely challenged at the case volume peak.
We in the United States entered this pandemic later than Europe, and in most states and cities, including my home in Minneapolis, schools and nonessential businesses were closed and strong shelter at home with social distancing and masking protocols were enacted. As I look at the case curves for the United States at www.worldometers.info/coronavirus/country/us/, to me there is definitely more evidence of a “flattened” case volume curve in the U.S. than in Europe, especially when looking at the 7-day moving averages. The U.S. and Canada as of May 8, are currently at just under 3,000 confirmed cases and 200 deaths per million population. In only a few of the largest U.S. cities has the volume of severe cases overwhelmed the hospital system. While reporting reliability is likely different everywhere, this “flattening of the curve” looks to me like it will extend the duration of the COVID-19 pandemic in America. I do not see the 4 to 6 weeks up and 8 to 12 weeks down pattern reported by our European colleagues.
In the end, it looks to me like the U.S. will have the highest number of cases and deaths per million in the world, and the longest duration of social and economic impact. The poster boys of pandemic management are our Asian friends. China, South Korea, Taiwan, Singapore and Hong Kong are reporting an amazing 1,030 cases and only 3 deaths per million population, and their economies and health care systems, including elective eye surgery, are already recovering. Perhaps the most interesting experiment is in the Nordic countries, where Denmark, Norway and Finland managed COVID-19 differently from Sweden, the latter opting for a more laissez-faire approach to business, educational and social interaction. In the first three Nordic countries, the cases and deaths per million to date are about 1600 and 60, whereas in Sweden they are currently reporting 2,400 and 300, favoring stricter social distancing, but the economic and social impact in Sweden has been much less.
A few other thoughts. In the hardest-hit countries and cities, ophthalmologists were called on to assist their colleagues in managing the very sick in this pandemic, even serving on acute care wards in general hospitals. We can all be proud of the fact that our colleagues, when called, responded and served their countries as physicians first. This was not required in my city, and we ophthalmologists in Minneapolis have continued to only manage eye care emergencies as needed. The busiest subspecialty in our field for the 7 weeks between March 16 and April 8 has been retina, as these colleagues were called on to provide ongoing intravitreal injections and manage more sight-threatening emergencies such as retinal detachment and trauma.
Now we face the next great challenge: going back to work in a changed world and pursuing economic recovery. According to the European Commission, Europe is expected to experience an 8% decline in gross domestic product (GDP) in 2020 and at least 10% unemployment. In the U.S., our GDP was down 4.8% in the first quarter and is projected to be down 17.6% in the second quarter. A 17.6% single quarter decline in U.S. GDP last occurred during the Great Depression. This definitely qualifies as a recession and, if prolonged, could evolve into a depression. Predictions by the Federal Reserve Bank of Atlanta suggest GDP will fall at least 5.6% for the full 2020 year, and unemployment in the U.S. recently reached 14.7%. In Minnesota, we entered 2020 with more than $2.43 billion in state cash reserves, but as a state, we will exit the biennium with a deficit of more than $2.34 billion, for a $4.77 billion swing.
Economic stimulus is unprecedented worldwide, but it is possible we will transition from a severe global recession to something resembling a depression that could last 18 to 24 months. In April, our five clinics at Minnesota Eye Consultants were at 21% and our ASCs at 6% of projected pre-COVID-19 case volume. In May, we were getting back to work, with elective surgery beginning again May 11 in Minnesota. We will be much slower with reduced patient volume per hour in both the clinic and OR as we screen incoming patients, maintain social distancing, utilize personal protective equipment for patients, providers and all staff, and clean rooms and equipment carefully between cases. We will have to work much longer hours to see the same number of patients in a day, week or month. I expect us to be challenged for an extended period of time, and patient care will be different, maybe forever.
We also can expect several more surprises in the months to come. For example, many senior ophthalmologists may never return to work, simply choosing to retire. I estimate this could reduce the number of practicing ophthalmologists in the U.S. by 5% to 10%. COVID-19, along with influenza, could recur in the late fall or winter, resulting in a second slowdown or even shutdown of our practices, just as we are recovering from the current crisis. Such an event would be devastating to most of us.
Education will change and is already changing. The first virtual meeting of the American Society of Cataract and Refractive Surgery was held May 16 and 17, and I took the weekend off to Zoom in and participate. Several friends in Europe have optimistically closed emails to me with, “ See you at ESCRS in Amsterdam in October.” I looked into flights, and even if I felt comfortable flying to Amsterdam in October, today there are no flights available to book. I have gotten flights for the American Academy of Ophthalmology meeting in Las Vegas, Nov. 12 to 17, and for Hawaiian Eye, Jan. 16 to 22, 2021, and both airfares and hotels are less costly than pre-COVID-19, something positive for a change. But I expect both meetings to be smaller than in previous years. I am hoping Kiawah Eye happens Sept. 11 to 13 and OSN New York Oct. 16 to 18, but I again expect smaller meetings than last year with mostly local participants.
I am planning my first commercial flight since February in July from Minneapolis to California for a board of directors meeting. I plan to be wearing an N95 mask in the transport sedan, at the airports on both ends of my trip and while on the airplane. I have yet to learn how to eat and drink with an N95 mask in place, and I am not certain a meal or drink would even be served. The “winds of change” are blowing around the world!
As Louis Pasteur stated in one of my favorite quotes: “Fortune favors the prepared mind.” We will do our best at Ocular Surgery News to help you as we share this journey to a still uncertain destination.
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