August 17, 2021

I set a new record today on my rural house calls run. 310 road miles and seven driving hours. Due to some staff issues, I ended up having to do all the driving myself to Guntersville, Fort Payne, Henegar and Section. I was a wee bit fried by the time I got back to Birmingham. Notes will need to be written tomorrow as I am in no shape to battle the VA computer system this evening. I suppose today explains why there aren’t more rural house call programs in place. The VA can afford to run a program at a loss as long as it helps the system as a whole. Veterans enrolled in our program have somewhere between 60 and 75 percent fewer hospital days per year than age/morbidity matched controls who are not. It doesn’t take too many non-existent ED visits or ICU stays to free up enough dollars to pay for house calls. It doesn’t happen a lot in other systems for two reasons. First, in most systems inpatient and outpatient sectors are siloed from each other financially so there’s no way to calculate cost savings between the two realms. Second, there are a dearth of providers out there who feel comfortable and really understand how to provide care in the home environment. One of today’s patients was just out of a community hospital in Northeast Alabama and, per the family, it went from being relatively quite last week to a zoo over the weekend due to the impact of Covid patients.

The local news regarding Covid keeps getting worse and worse. Yesterday, there were two ICU beds available statewide. Today, there are a couple dozen more ICU patients in hospitals than there are staff to man those beds and the numbers aren’t even beginning to slow down. UAB’s inpatient census ticked up another couple dozen overnight. There are more than double the number of hospitalized children than there were at the peak of the surge last winter. Local school districts have only been in session for a few days and already the notices of exposures at school are flying thick and fast. We’re not quite at the level of Florida where one Tampa Bay school district had over 5,000 students out on quarantine but I won’t be shocked if we get there. The death rates are still relatively low, but that’s a lagging indicator and won’t really start increasing for another week or two.

There’s been a lot of grumbling among physicians and other healthcare workers of my acquaintance about having to take care of the willfully unvaccinated as they have deliberately put themselves in harms way and are not only requiring intense resources, but are also drawing away resources from patients with other conditions. While I get the emotional impulses fueling this (those working in health care are all exhausted after eighteen months of this with no end in sight), I can’t agree with it. My ethical compass dictates that I help patients, no matter the cause of their discomfort or illness. If we start drawing those sorts of lines, where do we stop? Do we stop treating lung disease in smokers? Liver disease in alcoholics? Injuries in those at fault in motor vehicle accidents? Heart disease and diabetes in the overweight? You can make all of the ‘right’ choices and you’re still eventually going to have something go wrong in your body and I don’t think any of us has the moral authority to sit in judgement in that way. So the health system is really not empowered to make people get vaccinated. The government really isn’t either in a free society. We believe in letting autonomous adults choose for themselves rightly or wrongly about all sorts of things. There are some carve outs for public health purposes, but with the highly polarized politics of the moment, I don’t see much of anyone in the governmental arena demanding anything from the entire population.

So what will increase vaccination rates? The thing that has always changed American behavior over the years – capitalism. Free market forces have already figured out that letting individuals with a potentially deadly infectious disease into your place of business may not be the world’s best strategy for economic growth. In addition, if your employees become either chronically or terminally ill, given our peculiar employment based health insurance system, Wall Street is going to stop wanting to pay for things which are largely preventable. Private enterprise is going to put more and more rules in place. They will, of course, be challenged in court, but with the packing of the courts in recent years with judges siding with corporate interests over the interests of the individual, I figure the right wing may find itself hoist on its own petard.

I had a meeting this weekend to start thinking about a possible new version of The Politically Incorrect Cabaret for the fall. Some ideas were bandied about but we were left at the end with the understanding that we had no knowledge of where society would be in a few months, in terms of either attending or comprehending satirical entertainment so we ultimately decided to see how things develop over the next few weeks before making any firm decisions. If I were writing the show this week, in addition to Covid, I would also be writing about Afghanistan and the situation there. The end game is incredibly sad, but was also inevitable as any student of land wars in Central Asia will attest. The final withdrawal has been a botch (but the administration assumed they would have weeks to plan and execute it, not just a few days) and my heart goes out to the Westernized urban populations of Kabul and Kandahar and other cities, especially the young who grew up in a relatively liberal atmosphere who are going to be pushed into a repressive medieval society not of their devising. But I can’t really think of ways to make either of these topics funny, even with the cutting humor I usually bring to the PIC that makes people laugh somewhat uncomfortably. Ah well, a problem for another day.

Litany in the meantime – In my best Ansager outrageous accent – Vash yer hends! Kip yer mesks ovuh yer nose unt yer mouth! Don’t git toooo close. Vaaahks!