March 20, 2022

I haven’t written for a few days. Sorry about that, those of you who seem to hang on my every word. As the world is opening up and at least entering a breather, if not a true post-pandemic phase yet (I’m still expecting at least one more ugly surprise waiting for us), my schedule is starting to pile up and look more like it once did pre pandemic with my having to keep careful notes to make sure I am in the right place at the right time on the right day. I get more than 90% of it correct but I occasionally find myself heading for a meeting an hour early, or forgetting about that zoom call I should have been on twenty minutes ago. At least I’m not currently in rehearsal for anything. As that stands, that’s not going to happen until late April or early May with the first two projects lined up being Beethoven’s Ninth with the Alabama Symphony Orchestra (no I’m not singing the baritone solo – no one wants to hear that. I’ll be one of the cast of thousands in the choral balcony) and a role in a bucket list musical that I think I can announce but I haven’t fully cleared it yet with the production so I better keep mum in public forum for just a little while longer.

I had hoped to get away for awhile in late April and turn these missives back into a travel diary for a week or two but that is not to be. Outpatient geriatrics is becoming more and more short staffed with only two doctors and one nurse practitioner there more than once a week and, in late April, the other physician needs to visit her family on the other side of the planet and the nurse practitioner will be out on maternity leave. Yours truly will be pretty much last one standing so heading out of town just wasn’t in the cards for a functional clinic system. We’ve been through periods like this in the past but have always managed to claw our way back to adequate staffing so we can spell each other after a few months of hell. I’m not so certain about what’s going to happen this time. The number of qualified individuals looking for jobs in geriatric medicine is cratering just as the demand is starting to go into overdrive from the aging baby boom. I just don’t know where we’re going to get a new generation of providers from. This situation is not unique to UAB. It’s nationwide. It’s easily fixed by aligning some economic incentives such as loan forgiveness and salary structure in such a way for people to self select into the specialty but there’s been no motion from the powers that be to do anything of the sort. And they wonder why I’m contemplating retirement….

I can’t say I’m in despair regarding the future of clinical geriatrics. Concerned, yes. Despairing, no. Those of us who choose to practice in this way tend to be committed and resourceful individuals used to thinking on our feet and problem solving way outside of the box as the clinical issues dumped in our laps on a routine basis are not often amenable to textbook answers and yet we still have to come up with some sort of solutions. Someone once asked me to define geriatric medicine and my answer was ‘creative solutions to unsolvable problems’. I think I came up with that in the early 90s and have found it to remain true all of these years. What I am expecting is increased demand will start to spread to those in society with loud voices and the economic power to make those voices heard and that’s when things will begin to change for the better. I found out many years ago that the best way to get what you needed for geriatrics clinical programs was to take care of the chancellor’s mother in law.

There is, however, a great deal of despair abreast in the land and it’s about to get worse and it’s fueling a deadly pandemic that’s been traveling in tandem with Covid and which has largely fallen off the public radar screen and that is hospitalization and death due to the maladaptive coping mechanism of substance use. Most people don’t wake up one day and think ‘geez, I’d like to become an addict – it sounds like fun’. Instead, social situations and pressures create unhealthy stresses and toxic life events and there becomes a psychological need to escape – and, when there’s not a physical means of escape, there’s always drugs and alcohol. They buy at least a temporary and fleeting time away from the pressures and problems of the world. Unfortunately, they carry a lot of bad life choice baggage along with them.

In the two years since the start of the pandemic, deaths in the US related to alcohol have risen by about 25% over what they were at baseline. The lack of diversions of lockdown and the economic worries of lack of income and the stress of jobs that put people in harms way are probably all contributors. Some of this was mitigated by the various programs that paid extra federal dollars to individuals and prevented eviction for nonpayment of rent, but all of these programs are set to expire, along with the federal dollars that have paid for Covid care in the uninsured. Those on the lower rungs of society are about to be significantly squeezed by all of this and, if they do get sick, are going to be out of luck regarding medical care. This is going to set up social conditions ripe for new variants to percolate to the surface and spread and, if there’s one thing the history of infectious disease has taught us, it never remains contained in ‘those people’ while ‘we people’ are immune. It always spreads.

I expect the alcohol death rate to start going up again this summer as social stresses increase. How that’s most going to affect the general population is more drunk drivers on the road and we all know that they don’t only hurt themselves when there’s an accident. Traffic fatalities were up about 12% in 2021 over 2020. I haven’t seen any breakdown as to which percentage were alcohol or drug related but I have a sneaking suspicion it’s a cofactor. There’s always been something sort of bohemian romantic about drinking ones self to death. I don’t advise it. Anyone who’s in medicine can tell you that a death from liver failure is highly unpleasant and not something you wish to experience before you go.

The drug overdose epidemic continues unabated as well. Pre pandemic, the number was about 70,000 a year (which was extremely high when compared to a generation prior when it was about a third of that number) and it’s now topping 100,000 a year. And that number is rising astronomically despite the prevalence of naloxone, the opioid overdose anecdote being widely available. I cannot even write a prescription for an opioid in the VA system for anyone unless there’s a prescription for naloxone in the prior year. It’s a much lower number than Covid deaths but as these deaths are mainly young and healthy people, the number of potential years of life lost are similar, if not greater. There are any number of experiments that show that people (and other species) shy away from drugs as long as they have enriched, fulfilling lives without an over abundance of stressors. Unfortunately, we live in a society that tolerates the perfect conditions for creating addiction in certain subgroups.

It’s no accident that the current wave of drug use, triggered by Purdue pharmaceuticals outrageous peddling of OxyContin inappropriately in the late 90s and early 2000s, took shape in Appalachia. Appalachia, as a region, has an economy mainly based in extractive industries, such as coal, and some heavy manufacturing. With a globalized economy, and improved technology, the union jobs that supported the population and society collapsed leaving a hollowed out husk of mining towns that the young and energetic had to flee in order to have a future. The mining industry, in particular, with its company towns and health care, turned the population on to the power of the pill back in the 20s and 30s. The backbreaking labor of manual coal mining left the men with orthopedic issues and chronic pain which required meds for them to be able to continue their work underground. Their women were always anxious about their husbands, brothers, sons coming back up alive and were routinely prescribed sedatives so they could get through their days without being crippled by anxiety. Fast forward a few generations and a population with incredible economic stressors who have been socialized to believe in the power of the pill meets OxyContin and voila… When the medical system realized the extent of the opioid crisis and began to ratchet down the supply, the population turned to other sources and heroin use surged. And then some drug lord came up with the great idea of cutting the heroin with various fentanyl related compounds, many of which are deadly in very small quantities and the overdoses came thick and fast, spreading out from Appalachia through other small towns and inner cities and then creeping tentacles into suburbs and into the house down the block. And then came the pandemic…

People in these sorts of desperate straits long for an easy solution. They’re ripe for an autocrat who will tell them that they have the answers and a road to salvation. Most of DC, living inside the beltway and knowing no one and nothing of these people and towns and ways of life, have ignored them and their needs for decades but one populist presidential candidate a few years back got it and fashioned a message for them and they have responded with fealty that has completely changed the face of our political system in just a few short years. I have no ideas where it’s going but such political movements eventually gain their own momentum and no one can completely control where they end up. Just ask Maximilian Robespierre or Leon Trotsky.

The CDC is still pretty gung ho on the current state of Covid infections and there are no local requirements or suggestions for masking. I’m still wearing mine at work due to the number of immunocompromised who enter my clinical workspaces. I pick and choose about where to wear it indoors currently but if I see the numbers start to tick up (and given trends in Asia and Europe, I think it will happen) I’ll be back to masking everywhere. Stay safe. Get your booster. And wash your hands.

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