September 19, 2020

The Notorious RBG is gone. It’s not often that elderly women become pop culture icons, but once in a while, one breaks through and is embraced by all ages as a symbol of the strength and wisdom of the elder. Or maybe it’s a testament to the very human need to believe in endurance, no matter what life throws at each of us and those few work and live their full best lives into their eighties and beyond, come to embody that hope for continued relevance as time continues to march on and on and on. It’s been marching across my face recently. I looked in the mirror this morning when I got up and was not happy with the cross of Christopher Walken’s Headless Horseman and Christopher Lloyd’s Doc Brown that looked back at me.

One of the curses of being a well trained geriatrician is hearing news about the health of aging public figures and being able to draw far more conclusions about life span than most. I’ve got a good deal more data to work with than the average American. I wasn’t in the least surprised by RBG’s death. I had hoped she would hang on a while longer but frankly, I was surprised she made it as long as she did given what I was able to glean from news reports about her overall health. As much as I admired her and her jurisprudence over many years, I was never able to cast her in my mind as this tiny, but towering figure holding dark forces at bay and I doubt she ever conceived of herself that way either. She used her keen mind and her wit and her knowledge to make the law serve as many people as possible, rather than serve the few and bludgeon the many, and she was well aware that some of her opinions were going to be in the minority. She never fussed, she never went to the media trying to rally the court of public opinion. She simply dissented with vigor and well honed argument knowing full well that her dissents and their legal reasoning might help form the basis of a win sometime in the future.

The biggest problem with the American political system at the moment is the American preoccupation with instant gratification. We want results and we want them now. The system wasn’t built that way and by, trying to force it into that mold, it’s been made into a constant two party slugfest with one side constantly trying to score a TKO and proclaim victory. There’s lots of things that have gone into this devolution. The rise of 24 hour news and news cycles, consolidation of media outlets, politicians playing to the camera rather than to the public, the expense of campaigning requiring constant fundraising etc. etc. RBG knew this all to well and avoided it. Her best friend on and off the court for years was Justice Scalia. Despite their diametrically opposed judicial philosophies, they bonded over their love of the arts, especially opera. The two of them may have lived in different idealogical worlds but they inhabited the same cultural sphere as Americans and it strikes me that we need to start doing more of that as a people, get out of our confirmatory bias echo chambers and spend more time together in common space. Of course that’s been made a tad more difficult due to our old friend Covid-19.

And here’s where I cleverly segue to tonight’s accidental plague diary. which is about an event scheduled for November 10th. On that day, the Trump administration will argue California v Texas in front of the Supreme Court. For those of you who have forgotten, this is a case brought by a number of conservative states claiming that the Affordable Care Act is fundamentally flawed from a constitutional point of view and that the entire law must be declared unconstitutional and therefore, null and void. It is highly unlikely that RBG’s seat will be filled in seven weeks no matter what happens, so only eight justices will hear the arguments with a decision likely rendered in the late spring before the court retires for the summer.

What happens if the ACA is found unconstitutional? The most important thing in regards to Covid-19 is the provision about pre-existing conditions. Since the ACA was passed in 2010, it has been illegal for health insurance to discriminate against you based on your past health history. If this goes away again, then pretty much anyone who was infected with Covid-19 will become uninsureable. No insurance underwriter in their right mind is going to allow someone to purchase their product who has been infected by a disease that causes significant changes to nearly every organ system and for which the possible long term sequelae are essentially unknown. That’s roughly 7 million people so far and growing rapidly. And given that the attempts to limit its spread on any sort of a national level are sorely lacking, we may get to that mythical herd immunity at some point, but only after the numbers of those infected are in the tens of millions.

How do we change things for the better? We do this by using the system the way it was designed to work. It’s a slow, laborious process which requires a lot of labor, patience, and willingness to accept defeat, learn from it and move on. We have to let go of the idea that a single election or a single figure is going to either save or condemn us. We have to be willing to understand and play the long game. As Tip O’Neill famously said, all politics is local. If you want to see change, join the local chapter of your preferred political party. Volunteer to be a precinct chair. Be willing to do a lot of thankless work in terms of door knocking, get out the vote campaigns, learning to compromise while crafting platform positions. When you lose an election, take a day off to mourn, then start working on the next one. That’s how it works. The national parties bubble up from the grassroots. The work that has come to fruition in conservative circles over the last decade is the result of this kind of work starting in the early 1970s. It took them nearly fifty years to get where they wanted. If you want something different in the future, go to work now. Of course, you can always tear the entire system down in some sort of revolutionary action but movements like that are often either hijacked or take on a life of their own and you end up somewhere very different from where you intended so I can’t say I recommend that course of action.

Quiet weekend here at the condo. Me and the kitties reading, writing, and watching bad television. I feel a need to burst out of here next weekend. Maybe I will. If I do, you’ll hear about it.

September 16, 2020

Orange Beach AL after the storm

It’s hurricane season again. Sally (not to be confused with my sister-in-law) has been busy battering the Alabama coast line and is slowly making its way northeast into Georgia and points beyond. Here in Birmingham, about 200 miles from the coast, we only got a few of the outer bands which brought lovely cool temperatures, some wind and a smattering of rain. Nothing to cause any difficulties here. Friends on the gulf coast have been checking in and everyone seems OK but there’s been a lot of flooding and wind damage in the beach towns. My guest suite is currently unoccupied if someone needs respite for a few days. There are four more storms lined up out in the Atlantic so we may get something worse in the days to come. Fires in the west, flooding in the south, pestilence everywhere. Just another week in the life of 2020.

Jefferson County, home to Birmingham and the most populous in Alabama, has generally posted somewhere between 70-130 new cases of Covid-19 daily over the last month or so. Yesterday, they posted over 1,000 new cases. The number is so out of line with where things have been that I assume it’s a data anomaly due to a data dump or an adjustment in the statistics. Either that or we’re seeing the result of people getting a little too friendly with each other at their Labor Day picnics and barbeques a few weeks ago. Time will tell. The numbers at UAB hospital have remained relatively steady. Far more than we would like, but low enough for the system to handle without buckling.
The medical residents are back on their usual rotations and I have had a flock of new interns rotating through my UAB Geriatrics Clinic over the course of the last month or so. Residency is hard enough and I can’t begin to imagine what it must be like with the added stresses of duty on Covid-19 wards and the shut down of a lot of the ways that young people like and need to blow off steam after grueling weeks. Our rotation is pretty easy for them compared to others that they have to do and we try to give them a chance to explore some of the more interesting things that geriatrics has to offer in the hopes that it might rub off a little and one of them might be willing to make it a career choice. We occasionally succeed but we need a lot more of them to look our way. We are really down on clinical faculty and it’s very difficult to find new ones and entice them to Birmingham. One of my best tools has been taking them out on my rural house calls with the VA, but those remain in abeyance due to Covid-19 risks. Hopefully I’ll be out in the field again after the first of the year. Telemedicine is useful but it doesn’t give you the real picture of what’s going on.

Appropriate mask for mask deniers

I’m getting a little tired of video evidence of ‘anti-maskers’ or ‘mask deniers’ or whatever they’re calling themselves these days. It’s a piece of cloth on your face, you wear coverings on most of the rest of your body without incident. It’s not chain mail or barbed wire but the amount of carrying on that seems to go on with some people for political reasons strikes me as being completely out of proportion with what is being asked. Perhaps if people would stop posting video of ordinary people behaving badly in Target or Wal-Mart, there would be less self aggrandizement and less monkey see, monkey do. Do me a favor and don’t send me a copy of the latest ignoramus in high dudgeon over being asked by society to do something relatively simple to help other people and society as a whole.
I was reading Andy Slavitt’s notes the other day. (If you haven’t heard of him, he was the head of the Center for Medicare and Medicaid Services under Obama and he’s a fierce defender of science in public health). He’s become a significant critic of the Trump administration’s response to Covid-19 and does a routine deep dive into the science which he puts out on Twitter and on his podcast. He did some modelling based on what is known about the Ro (infectiousness of the virus in a naive population) and Re (infectiousness of the virus in a population taking steps to control the pandemic) and came up with a rather startling figure. Every 1% of the US population that refuses to mask will result in an extra 10,000 deaths from Covid-19 over the next year. So, if 30% are anti-maskers, there will be an additional 300,000 deaths in this country that doing something as simple as universal masking when out and about would have prevented. I highly recommend following him and reading his notes. They are literate, easily understood by the lay public, and point out the real issues. He also is incredibly experienced in how public health and governance work together.

There is an old saying that the one who saves one life, saves the world entire. Encouraging an additional percentage to mask up spares 10,000 lives. That’s got to be more than the world, perhaps the galaxy, or at least our quadrant. I just don’t understand the complete lack of empathy that our culture seems to have bred into a considerable percentage that leads people not to want to do something so simple to help others. It just doesn’t compute. The ultimate message of almost every religious tradition is one of caring for the stranger as you would care for your own so I don’t see how people who profess to follow any sort of spiritual life would have any qualms about not only masking up, but assisting their neighbor in doing the same. I guess it just shows how poisoned some religious traditions have become in a lust for secular power. Until we all take this seriously, I and my coreligionists in our church choir will continue to meet by Zoom and discuss how we can have a safe community sing/rehearsal in the church parking lot where we can be masked, socially distance, and out of doors.

Enough of that rant. Time to switch over to a different part of the brain. I have a couple of new movie columns to finish up. If you have films you want Mrs. Norman Maine to tackle in the coming months, she’s taking nominations.

September 13, 2020

Sunday, sweet Sunday with too much to do. I don’t think that’s quite what Oscar Hammerstein II wrote but it does make a certain amount of sense. I haven’t quite figured out how my ‘To Do’ list gets longer and longer when I’m spending most of my time out of work by myself but that seems to be the way of the world these days. Probably has something to do with the fact that there are just a lot of days when I don’t feel like accomplishing much so things of low priority simply get carried over week to week to be joined by an ever growing list of somewhat higher priority items. And, as we’ve all gotten more facile with Zoom meetings and the like, things that were more or less in abeyance for some months are steadily creeping back into my life. Like 7 am QA committee meetings…

So where are we today with the Accidental Plague Diaries? We’re just about to hit 200,000 deaths in the USA (that’s 50,000 Benghazis or 67 9/11s for those who are keeping track) and there’s not a lot of evidence that we’re going to be turning a corner anytime soon. Locally, the college spike in Tuscaloosa seems to have been stemmed somewhat by the city having closed the local bars and their numbers are trending down. The numbers here at UAB have remained relatively low due to a great deal of vigilance on behalf of the administration. Out of curiosity, I looked up the current demographics for my patient population. The mortality rate for those in nursing homes is 25%. Long term morbidity is unknown. The mortality rate for those of an age and illness burden which could place them in nursing homes but who live in the community is somewhat lower but there is disagreement among authorities as to what it is. Those living in the community are far less susceptible than those in group living, probably due to the success of isolation measures leading to far less exposure. My take home from all of this is that the simple tried and true measures for pandemic control are working when they are being allowed to work. The fact that a significant part of the population is being talked into ignoring these basic public health measures for political reasons means that our lives of discomfort are going to continue far longer than we want. It’s one of those the building is only as strong as its weakest stone sort of situations.

One thing that’s bringing me hope is the stirrings of life in the local performing arts community. There have been some safely produced out of doors entertainments, some work towards small scale indoor socially distanced pieces, and a lot of work at figuring out how to adapt Zoom and other videoconferencing platforms to the requirements of theatrical and musical performance. Large scale musical endeavors don’t work due to the lags in sound inherent in the software but that doesn’t mean there aren’t other things that can be done and, as brighter minds than mine enter the fray, I think there will be more and more technical improvements with time. I’m currently working on an ‘The Importance of Being Earnest’ with a group mainly based in South Carolina and that’ s something positive the pandemic is wrought. When working on line, you can pull your cast, and your audience, from anywhere. And I think I’ve figured out how to pass hand props across state lines. I don’t believe it’s a violation of the Mann Act.

Santa Fe Opera

The hardest part of getting live performances back on track is not going to be able to figure out how to keep cast/crew/musicians safe, it’s going to be how to keep audience safe from each other and how to make audience comfortable attending live performance in enclosed space. Our theaters, concert halls, recital rooms, and all the rest, are not designed for social distancing, actually the opposite and that is the Gordian knot of a problem that must be solved before live entertainment returns in full. Do we retrofit existing venues? How? Do we build new ones that will allow for appropriate social distancing? Do we take a page from the Santa Fe Opera and make performance spaces indoor/outdoor?

I think we’re going to see a democratization of theater in this country over the next decade. Theatrical success will not be limited to a few dozen early 20th century theaters within walking distance of Times Square. As bright minds solve more and more technical problems allowing anyone to access theater performance from anywhere and allowing a theater company anywhere in the country access to a potential international audience, things are going to change. Research has shown that release of a filmed or taped theatrical performance does not diminish audience demand for the live product, it increases it. As more people have a chance to see what it is, more and more people want the chance to experience it live. Innovative companies, authors, performers, who use this pandemic enforced hiatus to create content suitable to the needs and interests of today, cultivate audiences, and move towards something new and different are likely to be well positioned with a huge demand when things open up again. And successful theater will be able to be accessed by those whose household budgets do not allow for the average $150/seat price tag for Broadway.

As usual, everything comes down to Sondheim… You keep moving on…

September 9, 2020

Why they have ‘Watch Your Wake’ signs posted in busy boat channels…

I’m feeling a bit unmoored tonight, adrift among the uncertainties of modern life. Hopefully, some egotistical rich person with no cares for the little people will not come roaring by and swamp my small craft in his wake. If the events of this past weekend with the Lake Travis flotilla were not the perfect metaphor for our current sociopolitical ‘greed is good’ vulture capitalism, I don’t know what else could be. I should be careful about such idle wishes; these days anything outlandish is usually topped within the week. It’s one of the reasons why I am finding it so much more difficult to write political satire than I have in the past. How can I possibly top reality?

As I dig into this entry in the Accidental Plague Diaries, of which there have been somewhere between fifty and sixty entries since I started writing them six months ago, we’re about to hit another milestone: 200,000 US deaths. The toll around here is lighter. About 2,500 deaths in Alabama, 17,000 cases in the county, and 125,000 cases in the state but we’re a small, mostly small town/rural state. Pretty much everyday I hear about a case affecting someone of my acquaintance. They are sick, a family member is sick, a good friend is deathly ill. I’ve lost a few friends, others are recovering. My experience is probably pretty typical.

I was as naive as most of the rest of us back in February and early March, trusting that the structures of the federal government and the world renowned institutions such as the CDC would swing into action. That we would get regular informed updates backed up by data synthesized by brilliant minds and that government agencies at all levels would start working together to make sure the pandemic would be contained before it could become a serious problem. As the spring advanced and it became abundantly clear that our significantly dysfunctional government either would not or could not do anything of the kind, I retreated into a shell made up partly of disbelief, partly of morbid humor, and partly of focus on the very real problems that had to be solved quickly to make the health systems to which I owe responsibility responsive to the needs of patients in an unusual time.

The news that’s been breaking over the last day or so of the absolute proof of incompetence and malignancy at the highest levels of governance in response to the emerging pandemic, which has more or less been sat upon and kept under wraps for the purposes of journalistic profit through book contracts and media appearances, is making me by turns furiously angry and incredibly sad. Angry at the fact that people with the means to get information out that could potentially sway public opinion and action, chose their personal profit over public good and sad that the system we live under has become so corrupt that hundreds of thousands of people will end up giving their lives so that a very few can continue to pretend that the world isn’t changing around them.

I’ve always been more of an incrementalist by nature when it comes to change. When I started reading philosophy and sociology in high school, I was most attracted to the Fabian socialists of the late 19th and early 20th century who believed in a slow, natural evolution to a more just society. I’m starting to think I’ve been wrong for most of the last few decades and that maybe it is time to pull a whole lot of rotted structures down completely and begin again. It’s become a lot easier for me to see how the Jacobins and Trotskyites of the world were able to move forward as quickly and decisively as they did at their particular historical moments. I think we’re racing towards a similar inflection point and it’s going to be here faster than any of us can believe. Steve, who was very much a child of the 60s and described himself as a communist when he was asked what his political philosophy was, would have been very much in his element if he were here today. I think Tommy was seeing where we were headed fairly clearly before his death and was planning on coping with it by ignoring it and throwing himself into his work.

And that’s what I am likely to be doing as well – there are patients to care for, systems of health care that remain imperfect to which I can contribute a few innovative ideas. I have people to mentor, theater groups to support through a very tough time, friends to counsel. I’m not able to fix the problems of the country, much less the world, I can only, like Voltaire writes, cultivate my garden without regret for yesterday or hope for tomorrow. I don’t like that sentiment. I’m a big believer in hope. The idea that things will get better is what motivates me to get up in the morning and throw myself back into the fray.

Dorothea Puente being escorted back to Sacramento for trial after having fled to Los Angeles

A relatively morbid story from my past has been running through my head the last few days. I have no idea why it’s popped up but it’s not going away and that usually means something. It took place in the fall of 1988, about six months after I had moved from Seattle to Sacramento for my residency. I was at a bit of a low point. Internship is hard. I was trying to deal with my sexuality and had not yet come out. I was in the midst of a disastrous off again on again relationship that was deteriorating. (I met Steve about three months after this and started to put my life back together then.) I was driving home to my apartment in midtown Sacramento after a long on call shift at the Kaiser hospital in the North part of town. As I turned up F street from 12th, I ran into a huge phalanx of police cars, lights flashing blocking the traffic. I detoured around wondering what in the heck was going on but was too tired to do anything but go home and drop into bed. In the next morning’s paper, the headline read multiple bodies found buried in the backyard of a boarding house at 15th and F streets. (I lived at 16th and H so it was only a couple of blocks away). Eventually it all came out that Dorothea Puente, who operated a boarding house at the address, had been murdering her tenants, burying them in the back yard and cashing their social security checks for years. It’s not often that you live a few blocks away from a little old lady serial killer and she was the talk of the town for the next few months. Steve bought a T-shirt with a cartoon of her in her trademark red coat holding a shovel standing in front of the house with the legend ‘Sacramento: I Dig It’ on it. He had it for years and loved wearing it on out of town vacations. I may still have it buried in a box somewhere.

Why is that one floating to the surface? Is the connection death? Is it the duplicity of the monster hidden behind a benign surface? Is it fear of aging into being a vulnerable elder? Am I getting some sort of weird vibe from one of my new neighbors? I don’t know. Maybe I’ll figure it out, maybe I won’t. In the meantime, it’s time for a nightcap, Netflix and bed.

September 5, 2020

John Snow removing the handle of the Broad Street Pump – 1854

It’s another exciting Saturday Evening chez Andy. I sat out on my terrace after dinner and watched the sun go down in a flurry of lavender and tangerine while sipping a warm weather concoction I just invented with a tumbler full of ice, limeade, ginger ale, and a generous dollop of gin. Not quite watching the sun set over the rift valley in Eastern Africa, especially as the only nearby wildlife were my two obnoxious cats complaining that they hadn’t yet had their evening kitty treats. The yowls of felis domesticis cannot be interchanged with the roaring of the big cats of the Savannah in any way, shape or form.

Going to be a quiet long weekend. I don’t feel like going anywhere and rubbing elbows with crowds as I am still taking Covid-19 seriously and don’t want to be the one that brings it into the UAB and Birmingham VA clinical geriatrics programs. I do get out some but I try to do it at non-peak times and I’m still not really comfortable going into indoor spaces I don’t have to be in when they are filled with a lot of other people I don’t know. I’m fine with small group/outdoor socializing but nothing much has presented itself recently. I do have a dinner with Tommy’s family coming up on Monday and it will be good to catch up with them.

What to say for the accidental plague diaries this evening? I’m just perplexed at the number of highly educated and supposedly rational people out there who seem determined to throw out centuries of careful study of epidemic disease, microbiology and virology in favor of politically expedient puffery. The tried and true mechanisms for dealing with pandemics weren’t invented out of whole cloth. They come from a series of brilliant minds – giants standing on the shoulders of giants, to get us to the point where the deadliest of diseases can be corralled through time honored principles. As recently as a decade ago, Ebola, a much more deadly disease than Covid was contained with US CDC leadership and beaten back. The number of US fatalities – two.

The Broad Street Pump Today

Now we are approaching 200,000 American fatalities and, at current trends, that’s expected to have doubled before the end of the year and will easily top 500,000 by inauguration day when there may be a political class in this country that relies on evidence and rationality rather than feeling and expediency. The journey of knowledge of microbiology is a long one, beginning in the 1640s with the invention of the microscope by Kircher, later perfected and popularized in the 1670s by Anton van Leeuwenhoek. Their discovery of a plethora of living things, previously invisible to the human eye led to a revolution in the understanding of the mechanisms of disease. By 1700, physicians were beginning to postulate that some of these newly discovered micro-organisms were responsible for infectious disease, but it wasn’t proven until experiments done by Agostino Bassi around 1810. Once the germ theory of disease took hold, Holmes and Semmelweis demonstrated how unwashed hands caused puerperal fever in OB wards in 1843 and John Snow traced a cholera outbreak in London to the handle of the Broad Street pump in 1854.

By the late Victorian period, the need for hygiene in medicine and society was well recognized and various social campaigns began to modernize sewer systems, provide for indoor plumbing, and create aseptic nursing and surgery in health care settings. The result? Life expectancy sky rocketed as more and more of us were able to avoid what were previously common infectious diseases. In 1900, life expectancy in the USA was 42 years. Today, it’s 79 years (and we’re low on the international totem pole – in most of Western Europe it’s well over 80 years). The biggest contributor to that? Your ability to access a flush toilet and sink for hand washing pretty much anywhere you go.

Microbes are everywhere

The brains of the late 19th and early 20th centuries recognized the importance of public health measures, the importance of understanding the epidemiology of disease, and the importance of educating the populace in good health habits like regular bathing and giving average people the ability to do so. They gifted us with our much longer life spans and, unfortunately, took away our general fear of epidemic disease. As we live in a culture where there hasn’t been much of serious epidemic striking the general population in several generations, we collectively forgot the lessons of the past and haven’t adequately funded the institutions needed to protect us en masse. Nature doesn’t care. Let down your guard and cease your vigilance and she’s always there with her rules which have nothing to do with our political, economic, or sociologic structures.

More of us are going to die. As we drift towards some sort of mythic herd immunity, we’ll do it at the expense of hundreds of thousands, if not millions of individuals that didn’t have to die at this time. We have no way of knowing what the long term morbidity will be in addition. A recent study showed that something over a third of college athletes that developed Covid-19 and recovered have residual myocarditis (inflammation of the heart muscle). If that continues, will that lead to a weakening of heart tissue and early onset congestive heart failure twenty or thirty years from now when they should be in the prime of life? Will it interfere with their cardiac conduction system greatly raising their change of sudden cardiac death in the future? No one knows. We’ll be studying and learning from this virus and its effects of decades, likely the rest of my personal life span.

The one thing we can all do is follow the playbook that’s been around for the last couple of hundred years for dealing with epidemic disease. Good hygiene, isolate, and break transmission chains – in this case wearing a mask to contain aerosol and droplet transmission. There’s an old saying that when you save one life, you save the world entire. Doing the basics will do that many times over.

September 1, 2020

Nick Saban and Black Lives Matter in Tuscaloosa

It was the best of times, it was the worst of times. Somebody else once used that as the opening of their story and it struck me as being the perfect opening of this installment of The Accidental Plague Diaries. I don’t know about anyone else but I keep being whipsawed back and forth between extreme highs and lows with what’s going on in the world today. Something happens to make me think I still live in a country full of generous and compassionate people and then something else comes along an hour later which makes me feel like Thomas Hobbes was not only right, but he’s also busy directing events from the next world. The truth is, as always, somewhere in the middle of extremes but it’s not always easy to see when your brain is being asked to absorb far more than it has the capacity to parse on a daily basis.

On the good news front is a news story out of Tuscaloosa where there was a Black Lives Matter march. BLM marches aren’t uncommon these days (I’ve been in a few myself as I strongly support the concept of racial equity and reassessing social structures that prevent it from happening) but what made this one special is the figure spearheading the march, Alabama football coach Nick Saban. Those not of Alabama may not get the import of that image, but college football is a religion in these parts and Saban is a major deity in the pantheon, ranking only slightly below the legendary Bear Bryant (and a couple of more national championships in the bag and he’ll likely dethrone Bryant from the peak of Olympus). I spend a lot of time in small town and rural Alabama due to the part of my job that runs through the VA where I am medical director for their rural house call program. University of Alabama football fandom is one of the few things that’s common to pretty much every household I enter, no matter where it may fall on the socio-economic scale and what political beliefs the inhabitants may hold. The fervency with which they follow the Crimson Tide is usually inversely proportional to the actual likelihood of having ever attended an institution of higher learning. The sight of this divine being, praised by rural Alabama culture, not just supporting, but leading a group disdained by rural Alabama culture (thanks to a steady diet of Fox News) has set up an enormous cognitive dissonance. It will be interesting to see how it actually plays out. I can’t think of a better way to get the people of this region to actually start considering what BLM actually stands for and means.

Department of Idiot Memes

Moving on from a high to a low… I have a number of friends on the opposite side of the political spectrum from myself and I make it a point to read things written by people of widely divergent views. I swore off televised news years ago but I try to read a good deal of political news and commentary and try to find the nuggets of fact and truth within the spin. Monday I was greeted by a few of my more conservative friends passing around the ridiculous idea that only 6% of Covid-19 deaths were actually due to Covid-19. In tracking down where that insane idea had come from, I found that it was a gross misinterpretation of some data published by the CDC where they stated that only 6% of the death certificates filed had Covid-19 as the sole cause of death. All the others mentioned things like respiratory failure, heart disease, etc. etc. The people promulgating this idea that those 94% of death certificates are part of some sort of grand conspiracy theory don’t know how death certificates actually work. If the certifying physician is doing them correctly, there should almost always be several contributing causes of death and often a cascade of events documented that leads to death. Very few natural cause deaths are completely cut and dried. Rejecting death certificates with other causes would be akin to saying that someone who was involved in a serious car crash, and died later at the hospital of cardiac arrest solely died of cardiac disease and that the accident had nothing to do with the death. Most of realize that this is a) ridiculous and b) would prevent us from getting good public health data on motor vehicle accidents that can be used to keep us all safer. The need of a certain segment of the population to continue to deny the pandemic for political and economic reasons of their own drives me mad. And in the end, you can believe what you want, but the virus will remain the virus, do what the virus does, and all your philosophical arguments will come to naught for the virus doesn’t care.

I posted an article earlier today from a somewhat obscure source on some work done by a group using a supercomputer to sequence the genome of the virus and therefore reverse engineer what it’s actually up to. They came up with some rather surprising conclusions about how the virus is acting in relationship to the angiotensin renin system and the angiotensin converting enzyme (which seems to be how the virus attaches to human cells and infects them) suggesting that what is happening is an overproduction of the protein bradykinin, an inflammatory product and that this is what ultimately tends to cause the pathologies. If this is true, and there is a lot of work yet to do to prove or disprove this hypothesis, it may help come up with some better targeted therapies.
I’m not sure what to make of the reportage on vaccine development. The FDA and the CDC have been so heavily politicized in recent months that I don’t completely trust the information coming out of them and the FDA seems to be ready to approve anything that will ‘help more than it hurts’ whether there is sound science behind it or not. That strikes me as a recipe for either grand failure (after all, we could construe an injection of normal saline as helping more than it hurts) or utter disaster as something improperly tested is widely distributed and only later found to have a major negative effect. Given my reading of political tea leaves, the FDA is likely to release or at least announce a vaccine the last week of October, just as we head to the voting booths. Even if something is available, I have a feeling that there’s going to be some major distribution issues and I won’t be in the least bit surprised to start reading news stories of corruption and profiteering in the supply chain.

In the meantime, you know the drill. Wash your hands, wear your mask, stay out of crowds.

August 29, 2020

Life is settling down into a new normal. I can’t say I like it but it is what it is and must be dealt with. Corona virus has profoundly altered so many things that even the mundane day to day existence of my life just feels very different from what it felt six months ago. I look at the numbers and trends here locally and nationally and there is guarded cause for optimism – the trends are down, likely due to better adherence to mask wearing and social distancing in public leading to broken transmission chains and a decline in the infection rate. Will they remain down with the spikes beginning to arise in schools and on college campuses? Time alone will tell.

What are the changes? On the University side of my job, which revolves mainly around outpatient ambulatory clinics, the amount of time I need to spend outside of actual clinical hours dealing with patient needs has roughly doubled. A four hour clinic session used to create about one to two hours of out of clinic work (paperwork, charting, phone calls, emails, patient messages etc.) and now it generates three to four. I think Covid is directly responsible. People no longer save up their questions for their next visit to the doctor. They’re uncertain about life and want some certitude in at least the area of their health and are much more likely to make multiple calls or send multiple emails, each of which must be dealt with individually by me or my staff. In order to ensure safety and isolation, our bar for enlisting home health services for patients is a good deal lower. We’d rather have a professional go in who understands infection control than have patients go out and rub shoulders with multiple individuals that may not. Each of those referrals generates a mountain of paperwork, required by Medicare for documentation, so that the Center for Medicare and Medicaid services knows for what it is paying. On the VA side of the job, I’m managing all my house call teams from my bunker in a VA out building. This saves many hours of car trips to such exciting destinations as Holly Pond and Nauvoo but sitting there staring at a computer screen for hours on end, whether it’s with patients and families or with federal systems stressed by Covid makes me cross eyed after a few hours. We’re also using this period for program building and over the next six months my patient panel will increase by 50-100% as we create new teams based out of Huntsville.

I just know that when I come home in the evening after my usual ten hour work day, I sit on the couch and just zone out for an hour or so. That’s not something I ever used to do in the past. My usual pattern was grab dinner and head for rehearsal and not get home until sometime between 9-10 pm and I would feel perfectly energetic for a few more hours and be able to get the necessary chores done. I can’t imagine doing that right now. The tiredness is probably a stress response, my limbic system and primitive brain reflexes making me store up energy to fight the omnipresent danger later. I’d rather go to rehearsal. I even miss technicals. I have a few major projects to do around the condo over the next few months but I’ve had a hard time getting started on any of them. They don’t need to be done on any particular calendar. I do keep lists of minor tasks that need to be done and do get a bunch of them done on a weekend and can make a great show of crossing them off the list. I’m waiting for the cats to applaud. So far they haven’t.

So far so good on the personal Covid front. My surveillance testing has been negative. I haven’t had a repeat of the feeling rotten of last weekend which I am fairly certain could be traced to something I ate. As I wander through my life at UAB, I’ve noticed that about 1/3 of the population wears their masks below their noses, completely defeating the purpose so I figure it’s only a matter of time, especially as I have to keep closeting myself up in my too small exam rooms with demented people who have child like or toddler brains and who won’t keep masks on for love nor money. I’ll continue to trust in providence and the fact that the majority of demented tend not to hang out in sports bars.
I’m not completely sure what to make of the social battles over the opening of schools and universities. Not a day goes by currently when I don’t hear about a younger friend from theater circles or the college aged child of a peer being diagnosed at school. They’ve all been fine and should recover without major incident (although the long term effects remain obscure and potentially dangerous). The smaller schools seem to be doing better than the larger ones, although they have smaller problems to solve. UAB itself seems to be doing well and has policies in place that are well thought out and there haven’t been any major clusters or super spreader events that I’ve been aware of. Down the road in Tuscaloosa, it’s been a different matter but the culture of the institution is not the same. UAB is an urban, mainly commuter campus while Tuscaloosa is an isolated traditional campus in a small college town. The biggest question is going to be the effect of the football season. The SEC has not cancelled (big money I expect) although the stadia are supposed to be socially distanced in seating. I just don’t see how that’s supposed to work and will not be in the least surprised if one of the early match ups turns into a super spreading event.

The debate over whether schools should be in person or on line continues. I don’t know all the answers here. I just think that the administrators of educational institutions have been put in an impossible position due to the political failures of six months ago that allowed the virus to become so firmly entrenched. They have so many constituencies that they must try to satisfy. The needs of students, the needs of parents, the needs of faculty and staff, mandates on education from the local, state, and federal level, the rules of accrediting bodies, the needs of donors in the case of private institutions. It’s a nigh impossible task to please all of these disparate viewpoints and I like to think that the majority of educational administrators are trying to do their best with inadequate resources in a highly stressful time. Of course, I also feel that some I have read about are complete bone heads, but that’s just me.

I did get my creative juices going this week by writing some parody Christmas Carol lyrics for a friend’s choral group. I’m hoping ‘Walkin’ in a Covid Wonderland’ and ‘Have Yourself a Covid Little Christmas’ will be heard in heavy rotation on the radio this yuletide. If anyone else needs some quick satire, you know where to find me. In the meantime, I’m going to finish my hard pineapple cider, and put on a movie. MNM needs to write some more columns.

Wear your mask, wash your hands, keep your distance. It’s really that simple.

August 23, 2020

I haven’t felt well this weekend so I’ve spent most of it in bed, bingeing on Netflix, and babying my stomach with ginger ale and ramen. No fever, no respiratory symptoms so I doubt it’s Covid, just one of the usual cruds that we all tend to pick up now and again. I figure one more good night’s sleep and I should be ready to face next week. I put off most of my to do list this weekend other than the few things I had to get done – the only one that remains is writing the talk I’m giving to the church adult education program this next week on the impact of Alzheimer’s on caregivers and family systems. I have most of it in my head but I will need to get an outline down on paper in order to not sound like a complete idiot Tuesday evening when I fire up my Zoom camera. With a quiet weekend, I’ve done some catching up on my coronavirus reading, leafing through articles on treatments, promising and not so promising, vaccine development, and current epidemiological trends. After doing that for a few hours, I usually emerge with a combination of anger that the adults in our society who were in a position to do something about all of this thoroughly abdicated their responsibilities because it’s hard stuff, and sadness at the difficulties that we will all continue to bear until the adults in the room decide that the lives of ordinary people are at least equal in importance to the wealth of the few.

The latest round of news stories over the opening of colleges and universities cements this. It’s become pretty clear that the money flowing through academia is more important than the lives and safety of faculty, staff, and students in a lot of cases. (My university, UAB, appears to be trying to do things correctly but I cannot say that of all institutions of higher learning…) And there seems to be a societal tendency to blame the students for misbehaving when they simply act like college students. Young adults in their late teens and early 20s do not have fully developed frontal lobes and are not yet capable of fully understanding the consequences of their actions. Humans have known this for millennia (it’s why frat boys think lighting the couch on fire and tossing it off the roof is a great idea). You don’t get all those neural connections until age 25 or so. College students aren’t capable of making the choices we’re trying to force on them and the adults that should be making those choices are pushing them off on young people and then blaming them when they aren’t made in the wisest fashion. It’s just one of the hundred and one ways in which mature generations are shafting the future out of selfish motives.

I’ve written before that I believe this is an unintended consequence of social attitudes put in place in the 30s and 40s. From October of 1929 with the Wall Street crash until August of 1945 with the end of World War II, America went through a whole lot of bad – more than fifteen years worth. The new parents of the late 40s and early 50s, determined that their children would not know bad in that way, created a society that coddled and protected their offspring and this privileged generation, growing up in a Disneyfied Sally, Dick and Jane world, were imbued with a sense of entitlement to the good life that has followed them through their life cycles. These kids, now in their late 60s and early 70s, run the majority of our social institutions and don’t seem to be able to act when bad has come again. The magical thinking emanating from various high government offices has reached epidemic proportions and while abdicating responsibility is a choice, it does little to help society cope or move forward. Those in the upper reaches of society also seem to have little care for younger generations who are now adult and need to be brought into decision making capacities, dismissing rising young leaders out of hand.

The Covid trends locally and nationally have been positive over the last few weeks. The reopening of schools may change that, but there is no way to tell for a few weeks. There’s a significant lag between a change in society and the trend in cases and then another lag before it’s reflected in morbidity and mortality statistics. I’ll keep my fingers crossed that numbers will continue to inch down, but I don’t have a good feeling about what’s to come at all. I’m going to continue to do my part with my quasi-hermit existence. It’s all I can really do. At least I have some creative outlets coming up. The Henry IV Part 2 I had a cameo in is up and I’ve been asked to do a major role in Tartuffe in a similar format. As performing artists start exploring the capabilities of on line and other mediums, I have one piece of advice both for artists and audiences. Don’t go into projects trying to recreate what was. That’s just going to provoke nostalgia and feelings of sadness. Go into them determined to forge something new, something we haven’t seen before. In the words of Sondhiem, Move On…

Speaking of Sondheim, I was cleaning out a drawer and found the letters I have received from him over the years, including my favorite one. Back in the early days of the internet and list serves, I devised a number of puzzles around his songs and shows, some of which I sent to him. He solved most of them easily other than one. And when I sent him the solution his note back was ‘I could shoot myself, but I won’t’. I thought I’d put this puzzle here and let’s see if any of my friends can best Sondheim…There are three groups of Sondheim song titles below. In each group, song titles are missing. Fill in the gaps with song titles that complete the pattern. (There is more than one possible solution).

First Group


It Takes Two

I Never Do Anything Twice


Another Hundred People


Chrysanthemum Tea

Middle Group

Jet Song

Comedy Tonight


On The Steps Of The Palace

The Sun Won’t Set


Last Group

Some People


Send In The Clowns


Another National Anthem


Something Just Broke

Getting Married Today

Y’all can work on that. I’m going back to the Sunday Times Crossword. I got the solfege theme today but I’m still having trouble with it…

August 18, 2020

Traditional Move In Day

It’s another long post evening. It shouldn’t be. Ten hour work day followed by an hour plus zoom lecture for my church’s adult education program and I really should be curled up in a tight little ball watching some bad film for a a new column, but my mind is racing a dozen different ways so I’ll start typing and we’ll see what comes out this time. I’d like to write about some new theatrical project but there’s not a lot going on there. I do have a small part in an on-line zoom theater production of Henry IV part 2 based out of Columbia, SC (thank you Thurston Howell III and Charlie Goodrich) and I have been asked to do one of the leads in Tartuffe in a future zoom theater production later in the fall but there’s not a lot you can write about sitting at your dining room table waiting to turn on the camera on your cue and deliver your lines before turning your camera off again as your character exits. Classic theater is the way to go at the moment. No rights to pay. Usually constructed that the language is the most important element. Often a collection of French scenes that makes it easy to follow when the cast is a collection of little boxes winking on and off.

The local Covid-19 numbers are falling. This is good news. It remains to be seen what back to school is going to do to them. The news from elsewhere is not good. Both UNC and Notre Dame, which went back this past week with in person instruction, have shut again after flare ups. UAB is in the midst of move in. There is a brand new private student apartment/dorm development across the street from my academic office. I walked past it this morning on my way to the VA and watched move in day for a moment. Lots of excited young people and boxes doing what young people have always done. I doubt there’s going to be a lot of social distancing or mask wearing. I doubt I would have at eighteen or twenty.

The men of Gypsy – Virginia Samford Theater – Summer 2017 Left to Right: Kyle Bass, Lewis Armstrong, Benji Burford, Me, David Strickland, Hal McIntosh, Howard Green

I’m both sad and mad that it’s quite likely their chance to explore the joys of youth and higher education might just be jerked to a halt in a couple of weeks; it didn’t have to be that way. If this country had listened to those who know how to handle pandemic viral illness instead of to politicians with personal agendas, there’s no reason why we couldn’t be in the same position as most of the rest of the civilized world. Cautiously opening up and returning to normal life patterns and prepared to stomp out pockets of disease which are quickly and easily detected. It’s all heightened by the loss of my friend Hal McIntosh to Covid yesterday. Hal, known to generations of high schoolers as Mr. Mac, was one of the legendary theater teachers in town and a stalwart member of the theater community as a director and a performer. There are twelve of fifteen of us character guys of a certain age in town that get all the juicy old guy roles in various productions and I knew Hal from his work long before I actually got to know him. We didn’t do a show together until 2017 when I finally got to spend some time with him. (The character men in Gypsy all have about one scene each, and them two hours in the dressing room until curtain call). He was lovely and kind gracious and knowledgeable and dammit, he should still be here for another decade or two gracing the stage and encouraging the younger set to do their best and always improve. I’m very afraid he’s not going to be the last of the local theater community to exit stage left over the coming months. If your life hasn’t been touched by this disease yet, just wait, it will be. It’s too widespread and the numbers are too high for it to pass you by. The average American has a circle of acquaintance of roughly 5,0000 people. At current rates, thirty people you know are likely to die before it’s all over and hundreds more will have serious health problems, likely permanently.

My lecture tonight was on death, dying and advance directives – not the most light hearted of subjects but I have figured out ways to make even the most lugubrious of geriatric related topics interesting over the years. I first began public speaking in the early 1990s and it didn’t take me long to realize that having a certain patter and willingness to tell jokes and drop one liners when discussing relatively heavy subject matter kept people engaged, helped them remember what you wanted them to remember, and made them not want to slit their wrists after a talk on their upcoming infirmities and indignities that we all age into eventually. I picked a bit of it up by watching good lecturers in medical school. a bit from Monty Python and Saturday Night Live, and a bit from my own idiosyncratic background and early theater experiences. I’ve had a few people suggest I need to come up with some sort of one man show/comedic monologue about all the craziness of geriatric medicine and how it intertwines with the rest of my life. I could probably write it but I’d need a lot of help making it into a theatrical piece.

I did tell one story tonight. It was about death, at least tangentially. There is an odd quirk in Alabama law. You are not allowed to authorize your own cremation. Cremation is only allowed if your surviving next of kin allows it. (I’ve been told it was crafted by the funeral industry to allow for more burials – and it works. Alabama is the state with the lowest rate of cremation. I don’t know if that’s true or not, so none of my funeral director friends come after me with a brick…) Twenty years ago when Steve died, we had had plenty of time to prepare. He was sick for two years. He had gone down to a local funeral home and made pre-need arrangements. He told me he had handled it so I didn’t think anything of it. He was on hospice when he died, so hospice handled the transfer to the funeral home and I went down the next day to see them and to make arrangements for the cremation he wanted. When I got there, the very nice young man told me he was sorry, but they could not possibly cremate Steve. There must be a release from legal next of kin. Despite our 13 years together, I didn’t count (It was 2001, legal marriage was still a pipe dream). I held it together and calmly said that was nice, but his parents were dead, he had no children, and he was estranged from his siblings and I had no means of contacting them. What did he want to do about that? We sparred for a few moments, then he got a twinkle in his eye and said ‘I have an idea’. He went off and made some calls, coming back to me in a few minutes. He suggested we transfer Steve to the low cost mortuary across town where they didn’t ask too many questions. I consented, Steve was moved and off I went to mortuary number two. There, the mortician, who reminded me a bit of a pawn shop counter person, basically said ‘We’ll keep him for three days, if no one comes to complain, we’ll cremate him” wink wink, nudge nudge, say no more…

Steve was duly cremated, I received the cremains – what happened next is another story that I’ve already written up at least once. If you haven’t read it, I’ll try to find it and link to it.

So – if you want to be cremated in Alabama, make sure your family knows it. Your word, even in a will or final instruction’s isn’t good enough. Personally, I’m going to take Tommy’s approach. When I asked him about his preferences, he said ‘I won’t be here, you’ll have to figure it out’ and refused to return to the subject. I trust my family to figure it out – conservation of mass and energy will return my physical being to the cosmos no matter what they do.

August 14, 2020

Time to head back into the thickets of the Accidental Plague Diaries. I have no idea what I should write about this evening but that’s never stopped me before. Since my last entry, Alabama has easily crested 100,000 cases of Covid-19, the US death toll has climbed to nearly 170,000 and the world watches aghast as we prepare to send students back to school at all levels with community transmission still at unacceptably high rates. There is somewhat good news on this front. The percentage positive rate of tests in Alabama over the last week has come down from double digits and locally, the number of people in the hospital with Covid-19 has started to drop from a peak a few weeks ago. If these trends continue, the health care system is going to get a little breathing room. Any bump in numbers from back to school won’t occur for about three to four weeks.

I didn’t lose too many of my long term patients to Covid early in the pandemic, but I’m starting to lose more now. Three or four in the last two weeks. Some had been ill for some time, some were relatively newly diagnosed. I suspect that in pretty much all of the cases, a family member or friend brought it into the home after being out and about a bit more cavalier with their masking and social distancing due to summer weather and the wish for good times. When the grandkids and great grandkids head back to school, I expect I’ll see another uptick. I’ve also had friends lose spouses, parents, grandparents, and siblings recently. It’s not over until it’s over.

I’ve accepted an offer on the house and the real estate wheels are churning along and everything should be over and done with by the first of October. One more month of double mortgage payments… If the contract stands, it’s going to a family with young children where both parents work from home. Tommy would like that. He adored kids and working with them. I think the happiest I ever saw him was when he was teaching and leading his beloved children’s choir. Steve adored being the wicked uncle to children and leading them into mischief and then vanishing before there could be any consequences. There are days when I think I’ve missed out not having children, but then I realize that the unit of survival is the tribe, not the individual, and my role is to ease the burdens of the older generation and their nurturers so that they have time and energy to give to their children and grandchildren and I feel a bit better about my choices.

Covid and its roiling of health care finances has hit how my job works. The hospice I have medical directed for for many years and UAB are parting ways. Fortunately, it is happening at the same time that the VA part of my job is working diligently to expand the rural house call program to a new population centered in Huntsville so it’s all going to come out in the wash. Most of the house call work is still being handled through video conferencing but plans are afoot to get back into the field later in the fall. I will probably ultimately be doing a mix of field work and call work. I hadn’t planned on working in a call center late in my career but nothing ever stays the same in life, no matter what. As long as I can cobble together enough funding to keep my bills paid, I’m happy. I’m only about twenty months away from instituting the first part of my retirement plan. I am vested in the University of California pension system from my years there and it stops accruing when I turn sixty so I’ll officially become retired faculty from there when I hit that birthday and start drawing a pension. When I was young, I was sure I would flame out and be dead by thirty five. Now I’m becoming an old age pensioner.

I was industrious this evening after I made my dinner. I washed all of my face masks, got the iron out, blew the dust off of it, and gave them all a good steam ironing for disinfecting and dewrinkling purposes. Rodgers and Hammerstein is good music to iron to in case you were wondering. The weekend has a few chores lined up. I have to get my office supplies organized (currently they’re thrown in a closet). I bought some shelving to help with that which I need to assemble. Tommy and I bought a lot of do it yourself assembly furnishings and shelves over the years and we would sit in the living room trying to insert tab A into slot B with screwdrivers and rubber mallets kvetching at each other that he wasn’t doing his part right. I guess I’ll have to complain bitterly to the cats when something doesn’t want to fit this go round. I also have a couple of lectures to write for community education programs and there’s a dozen and a half progress notes from this week calling my name.

Now that the initial shock of the Covid world has worn off, I’m puzzling out how to keep myself motivated. Over the last couple of years, since Tommy’s untimely death, I’ve done it by having about one thing a month to look forward to: a trip somewhere, a show to rehearse and perform, a special concert. All those self rewards are now on indefinite hold and I haven’t figured out how to replace them yet. The effects of Covid on my job plus the craziness of moving have kept me sufficiently distracted in recent months, for the most part, but it’s unclear to me, now that things are settling down into new routine, what should come next. I have a few more projects to accomplish around the house, several of which will take some time, but those feel like obligations, not rewards. Maybe I’ll do a little weekend road tripping this fall, depending on what happens to the Covid numbers once the school impact becomes clear and once all the Sturgis motorcyclists make their way home and spread whatever they’ve picked up.

I’ve always been one to cope, pick myself up after reverses, and keep chugging along. It’s been present since I was very small. My parents tell a story about a camping trip we took when I was three or four (I remember the trip, but not this incident – I know my age as my sister had not yet joined the family and she was born shortly after my fifth birthday). My parents were very outdoorsy types in Washington State so we did a lot of backpacking and car camping when I was a child. My parents and I had gone up into the mountains where we had put up the tent and were enjoying the sights and smells of the Pacific Northwest woods. Next to our campsite was a large tree with some invitingly low branches and I wanted to climb it. My parents said no, it wasn’t going to be a good climb for someone of my size. (I was a tiny child). I wheedled and cajoled and put forth all my best reasoned post toddler arguments. Eventually I was told ‘Fine, but if you fall, don’t come crying to us’. So I climbed up, and sure enough I fell. It wasn’t a big enough fall to really hurt me but it knocked the wind out of me. My parents watched to see what I would do. I picked myself up, bit my lip, and uttered not a sound. I had been told the consequences and I accepted them. I’m still that way.

Go ahead and climb your trees everyone but, if you fall out, deal with the pain and shock you were warned about.