April 28, 2022

Tommy left us four years ago today. Obviously, he’s been on my mind as I’ve dragged myself through one of my usual work days. It wasn’t an especially hard day, one of my VA house call days in Sumiton and Jasper, but I still was feeling a bit beat down by the world. I suppose it’s normal to feel like this on an anniversary of this type but I have this negative reaction to emotions. They’re messy uncontrollable things that make it difficult to get things done with speed and efficiency. VA house calls are more about a previous loss, that of Steve. I was in the middle of one, talking about the mundane details of diabetes management with a lovely elderly African American vet and his wife, when I got the call that Steve had suddenly collapsed and died at home. There’s this little piece of me that always equates my walking into a patient’s home in the role of VA physician with circumstances of sorrow and loss. Perhaps that’s why I’m so comfortable talking about uncomfortable subjects when I make these house calls. I’ve been there.

Last night, in my role as board president of Opera Birmingham, I attended the final dress rehearsal of our current production of La Boheme. It’s the first time we’ve been able to mount a fully staged opera in a couple of years. Cendrillon, the last one scheduled, was cancelled half way through staging rehearsals in March 2020 when the world shut down. The exigencies and uncertainties of pandemic life made going into this production, less than a sure thing so the decision was made to scale it way down. We moved to a smaller house, arranged to share a physical production with several other small opera companies, and pared the cast down to the seven principals and an ensemble of twelve and a reduced, but full orchestra. The result was stunning. The smaller house puts the audience in immediate touch with the performers, allowing them to draw you into their world. The set proportions were those of Parisian attics, and not garrets the size of a suburban McMansions. And the singers and orchestra entwined together to bring through the true emotions of the piece. Note to self. Sitting through Act IV and Mimi’s death scene of the eve of the anniversary of one’s own loss is not recommended. It plays Friday night and Sunday matinee at the Day theater this weekend. Don’t miss it. I’ll be there again Friday night.

We haven’t run the numbers for a while. Anecdotally, I keep hearing of friends succumbing to Covid infections but no one seems to be getting particularly ill. Inpatient numbers at UAB have dropped to single digits since the pandemic first hit the Birmingham area in the spring of 2020, despite significant changes in behavior patterns regarding indoor gatherings. Maybe we’re kind of through this thing. Maybe we’re just enjoying a lull. As the virus is continuing to rocket around the world through all sorts of populations with all sorts of behaviors, anything is possible. Mutation marches on. We’re at something over 81 million documented infections in the US. This amounts to roughly 25% of the population. A recent cross sectional study of the population looking at antibody prevalence suggested that exposure is much higher than this, maybe closer to 60% of the population having had an infection. This would mean that the number of subclinical cases that were never tested for is enormous.

If 60% of the population has at least some natural immunity and roughly 66% of the population is vaccinated, the virus may be having a harder and harder time breaking through and forming effective transmission chains. Maybe not. I think we all tend to forget just how new this disease is and how little we really know about its natural history. Even at this low rate, we’re losing between 600 and 700 people a day to the disease and we’re something over 991,000 total deaths. This will put us over the million death mark sometime in mid May. This means that three of every thousand Americans who were alive in January of 2020 has died of Covid in the interim. Covid has been the third leading cause of death for the last two years, lagging only cancer and heart disease. And this is only the deaths. I care for a number of people who caught serious Covid, were hospitalized, some for a very long time, and who are now gravely incapacitated with multiple health issues. But they aren’t dead, just drowning in medical debt and unable to work.

I don’t think we have any idea yet about the ripple effects on survivors. The hundreds of thousands of new widows and widowers. The children who lost a parent, or both. The parents who had to bury their previously healthy adult children. The burdens of caregiving, for what might be years, on those left chronically ill. Then there’s the ripple effects on social and economic institutions. Entire industries and sectors of the economy are in precarious shape. The one I’m dealing with the most is the long term care industry. I know of no nursing home that’s not short staffed. The extra work piled on those left behind to cover for missing coworkers is burning them out leading more to quit and a vicious cycle rolls on. The short staffing is leading to basic needs of dependent people not being attended to promptly, corners being cut, and declining health outcomes which in turn is pushing people out of the nursing home back into the hospital with a preventable acute illness, using up precious resources and putting additional strains on exhausted medical staffs. Add in the aging of the Baby Boom and a perfect storm is brewing with which the health system and American society is not yet prepared to cope.

I got a notice that the book was short listed for the Grand Prize for the Eric Hoffer Book Awards, which only about 1/20 entrants makes, so someone somewhere has been reading it. I have a reading and signing at the Opera Birmingham office on May 7th if you haven’t yet obtained a copy. I’m busy reading and editing volume 2 to try and stay vaguely on schedule. It would be nice to win something prestigious but I’m not holding my breath. I didn’t write it for awards or sales, but rather to help myself cope with a rapidly changing world and putting it down on paper helped me make sense of the madness swirling around.

I was going to write a treatise on medications and deprescribing, but I’m too tired. Next time perhaps. In the meantime, the best vaccine is one in the arm. I got my second booster on Tuesday. I didn’t feel to horrible afterwards. And keep those hands washed.

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