August 24, 2021

Another day, another slops bucket full of bad news. The seven day average of new cases in Alabama is back up over 4,000 cases a day for the first time since the peak of the winter surge in January. US deaths are back up over 1,000 a day. Statewide, we have about 60 more ICU patients than staffing. The nursing shortage is becoming more and more acute with hospitals frantically looking for and paying top dollar to anyone with a nursing license who is willing to work. (I’ve heard of signing bonuses in excess of $30,000). Birmingham itself remains relatively resilient as medicine is its major service industry so we have a lot of capacity in terms of both physical plants and staffing but, if the models that have cases doubling again between now and Labor Day hold true, even we will be treating people in parking garages and tents.

The local scuttlebutt passed around physician to physician is multiple stories of young healthy people 20-50, who went from the sniffles to full fledged Covid pneumonitis within a few days and are now fighting for their lives in the various ICUs around town. Nearly all unvaccinated, either for reasons of politics or inertia, they are the ordinary and everyday people that make up the background of our lives. A kindergarten teacher, a school bus driver, a fast food worker, an apparel store clerk. A tired workforce of nurses, therapists, physicians, pharmacists, unit clerks, custodians, dietary workers, and all the other people that make up the modern hospital trudge in for their shifts, hope to win small battles, and lock down the anguish when they lose and another once vital young person is no longer here. One of the things I hear bandied about is the idea of why should we worry, it kills less than 1%. (Actually, the total death toll to date is closer to 2% but as the elderly with much higher death rates have gotten vaccinated, the number is starting to fall…) It may be only 1% but for the people that love each victim, it’s a 100% loss. It’s easy to write off other people’s lives in the abstract, but a much tougher proposition in the concrete when it’s someone in whom you have emotional investment.

I read somewhere once about the shopping cart test. The way to tell if someone has empathy or consideration outside of themselves is to watch what they do with the shopping cart in the grocery store parking lot once they’ve loaded their purchases into their car. The empathic person returns the cart to the cart corral. It’s an easy thing to do, requires little effort on the part of the shopper, but does mean that they have to go out of their way a little bit to make someone else’s life easier. The non-empathic person leaves the cart to fend for itself, uncaring that they’ve created more work for the person whose job it is to round the carts up and return them to the front of the store for the next go round. And there’s the issue. Currently we’ve developed a society that not only doesn’t return its shopping carts, but also runs over them a few times with their SUV on the way out of the parking lot.

This innate selfishness shows up in a lot of different ways. Perhaps the most obvious is the forty plus year march to privatize and monetize the public sector which has left our governmental buildings and general infrastructure something of a shambles. Compare the public/governmental buildings of the US built over the last forty years to those built in almost any other developed country in terms of architecture, artistry, use of open space, and pleasant environment. I see it most clearly in the VA part of my job. The buildings and offices we work in, as they have had to be constructed on limited budgets, are functional but not necessarily inviting or inspiring of confidence. Today was an election day locally for mayoral, city council and school board candidates. All I could think of was the pictures of people waiting in lines hours long to vote in some precincts during the last national election and just what care was taken to design a system to allow that as, in my neighborhood, there would be a riot and a rush on city hall by people ‘that matter’ if such a thing were to happen.

I got wind today of a bill making its way through congress. The pandemic has ripped the blinders off our national government exposing something that I have been shouting from rooftops for the last thirty years. The departure of nurses, nurses aids, and other direct care providers from the health care industry is leaving a huge gap in available care for vulnerable and aging adults, just as the baby boom is starting into its years of infirmity. Anyone who has looked at a demographic chart for the US created after 1960 has known this would happen, it’s just a couple of years ahead of schedule due to the stresses of the pandemic. The bill in question would mandate a minimum wage of $15 an hour for any person involved in direct care for an elderly or otherwise vulnerable adult. This would include nurses aids, home health aides, sitters, therapy assistants, housekeeping assistants. Any one of the lower level positions that has to lay on hands in some way. The theory is that if the wages are improved, more people will flock to these jobs. I don’t think it’s going to be quite so simple. The nursing home and home health industries have structured themselves over decades around low wages for these sorts of positions (usually in the $8-10 an hour range) and mandating huge increases are going to put enormous strains on the corporate structures behind these companies. We’ve allowed this sector to move from not for profit to for profit and, if they can’t make a profit, these companies will simply cease to offer these services. Driving eldercare into bankruptcy just as the baby boom is going to require it doesn’t strike me as sound social policy. How to balance this? Quite frankly, I don’t know. These are issues that have been predictable and discussed in geriatrics/gerontology quarters for well over half a century. Society, with its focus on youth, hasn’t wanted to pay attention. They may be forced into it sooner than even I had thought. I was expecting the 2030s to be the decade of eldercare quandaries – looks like I was off by a few years.

The book is coming! Those of you who have signed up for more information at should be getting an email from the publisher today. It should be live on Amazon in about a week and you can get your local bookseller to order it for you from Ingram as of this weekend. Early word of mouth from various reviewers etc. has been positive (and most of you saw my note from Stephen Sondheim regarding my theatrical Easter Egg in the chapter titles). Even though I have been delivering advance copies for a week, it still doesn’t quite feel real. I’ve decided the moment it becomes real is when I spot a copy someplace unexpected in the wild, one that I had no hand in getting there. For those of you who have read/are reading it – if you like it, tell people. Gotta sell a few…

In the meantime, you all know the drill. Wash your hands, stay distant in crowds, wear your mask indoors in public, get your vaccine.

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