December 16, 2021

The fragile truce we’ve had with Covid the last few months appears to be unravelling rapidly with the advance of omicron. It’s gone from being barely a whisper in the US to a significant player in less than a week. It’s prevalence in terms of genetic testing has grown from 0.4% of tests to 2.9% of tests since the weekend. That’s a seven fold increase. The math I’ve seen is that omicron is roughly three times as infectious as delta (which in itself was about twice as infectious as the original wild type virus). Given our old friend exponential math, we’ll see it everywhere by Christmas weekend. The first positive omicron test in Alabama turned up today in West Alabama. We’ve known it was here – it was just a matter of when it would be tested for.

Those of you who follow theater news like I do are aware of a large number of cancellations on Broadway and in the West End of performances due to positive covid tests in the various companies. A lot of angry ticket holders are blaming the performers or the front of house staff or the management but some of that is entirely unwarranted. In an attempt to keep both company members and audiences safe, professional theaters are testing their employees rigorously and routinely. If every employer in the country were doing the same thing, we’d find a lot more positives due to heightened testing and every other industry would be as prone to cancellation and shut down as live performance. It’s going to get worse before it gets better and I can see both theater districts having to go on pause again which is going to cause a lot of continued financial hardship for a lot of people. My trip to England is still on as of this writing but with the situation in the UK changing rapidly day by day, anything could happen over the next week and a half. I’m not spending a lot of time worrying about it. If it seems unwise, I simply won’t get on the plane when departure time arrives.

Michigan, Western Pennsylvania, the West Slope of Colorado, and other hot spots continue to have large numbers of ill individuals and buckling health systems, overburdened by predominantly unvaccinated individuals needing care. I still think where the spread is strongest is related to climate. Delta spread in the Deep South, Texas and Florida this summer as the heat chased people inside in search of air conditioning. It’s spreading in new places this winter where the cold is chasing people inside in search of heat. Maybe covid will end up chasing all of us somewhere in search of a Goldilocks climate of not too hot and not too cold. Unfortunately, I don’t think all 330 million of us will fit in San Diego.

I am quite concerned regarding the slow collapse of health care infrastructure that continues. The hospitals that are over burdened at this point aren’t in the same position as they were at the beginning of the pandemic when the issue was inadequate supplies and physical room to care for patients. Now, the biggest issue is inadequate staffing. There aren’t enough nurses and other trained staff to take care of the critically ill. Nearly two years of incredible work related stress, societal disrespect, inadequate compensation, and downright danger have led to health care workers reevaluating their lives and looking at alternative paths. I read somewhere that a significant portion of recent nursing school graduates have left the profession and the older generation is retiring. Some of the middle folk are finding it easier to make better money through per diem or travel arrangements rather than stay in their old jobs. The desperate need for individuals in caring professions is leading to some improvements in wages and working conditions, but the wholesale realignments are creating havoc in all sorts of ways.

The one that affects me the most is the elder care industry. I’m weird as a geriatrician. I do almost no nursing home work. (I was able to carve out a career caring for people disabled enough to live in nursing homes who live in the community instead – when I entered the field decades ago, no one was doing that kind of work so everything was wide open for me). That doesn’t mean I don’t interdigitate with what goes on in institutional care. Over the last few decades, nursing homes and other senior living facilities transitioned from not for profit to for profit institutions, mainly owned by large corporate interests. The business model relied on a large workforce of predominantly women, often women of color, who had limited options. Pay was low, working conditions arduous, and short staffing and rapid turnover par for the course.

Large group of female nurses working together

Over the last two years, this population of women has had a chance to restructure their lives. Some have died. Some have needed to leave the work force to care for children wen schools and daycares closed. Some have moved up the ladder to better nursing jobs as they have rapidly become available. Some have figured out ways to thrive economically without a slave wage job being part of the equation. I know of no senior living facility that is not short staffed and begging for employees with few applicants. Fewer on the floor employees is starting to lead to a rise in not so good outcomes in senior living residents and I expect we’ll see increased fall rates, medication errors, nutrition issues without someone to take the time to one on one feed the most frail, and the like. The agencies that provide senior services in the home such as bathing and light housework are even worse off. Especially in rural areas, there are no employees to be had and the demand is going up as covid begins to create a new class of chronically disabled and as the Baby Boom continues its inexorable march into old age.

I am fielding daily complaints from families about the inadequacy of services for the aging in the current environment. I have no solutions. All I can do is listen. Lack of good home health services is going to damage the already frail early warning system of a senior falling off of their balance point at home even more. This is going to lead to more elders being found with much more serious disease and in need of a hospital when an early intervention might have taken care of the problem at home. This will compound with all of the individuals who have had to have care delayed due to inadequate health resources as the local system is overwhelmed with covid needs or who avoid the health system for fear of contagion in the emergency department or waiting room (a not unrealistic fear).

Sometimes I feel like the little plastic man on skates in the kids game ‘Don’t Break The Ice’. I see block after block knocked out and I’m just waiting for the wrong one to fall causing the entire field to collapse in on itself. I’m not worried about me personally – I’m in a position to survive the worst and could consider stepping out of health care at almost any point. I’m scared for the families I’ve been working with for decades – many of limited means. I have people I’ve been caring for since the last millennium – in their 70s then, in their 90s now – and sometimes I have their children or even their grandchildren. I’ve pledged the majority of my working life to them and I want to be able to see them through. But I can’t work miracles and I have no power to offset the macroeconomic forces wreaking havoc on us all.

UAB doesn’t want me to retire anytime soon. They’re continuing to work on an endowed chair for me which would keep me coming in a while longer. If any of you has a spare half a million or so hanging around, I’ll be happy to put you in touch with the development officer responsible. If you don’t, do something for an exhausted health care provider, get your vaccines including your booster. That’s free.

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