December 3, 2020

Stress Testing in an Engineering Lab

I was going to write my next update in these Accidental Plague Diaries tomorrow but I woke up this morning with a feeling that I better write today and generally, when I have one of those moments, there’s something in the recesses of my brain trying to burst out and the best thing that I can do is just start typing away until my limbic system (or is it my frontal lobe?) says enough, you’re done and generally I feel a bit better in general. I don’t feel bad today. I’ve been a bit lazy the last couple of days. I’ve made starts on my next round of home projects but I haven’t put in the hours and hours that they’re going to need. Instead, I have spent time in reading junk novels, doing a jigsaw puzzle with far too many monochrome pieces, and assembling the holiday gift basket for my family in Seattle and hauling it off to the UPS store for shipping.

I think the thing that has me screaming inside is the incredible escalation of Covid numbers over the last few weeks which has been met by a collective shrug by our government and with society as a whole as the latest shenanigans of various Republican lawyers try to overturn the presidential election without a shred of objective evidence and the financial chicanery of the presidential fund raising apparatus, busy fleecing the flock with The Grift of the MAGA, push other stories off of the front pages. We are now at 14 million cases of Covid. There were 9 million at Halloween, less than 5 weeks ago which means we are adding 1 million cases a week. We now have over 100,000 people hospitalized nationally which is more or less the inflection point for national systemic strain and that number is going up. Roughly 2800 people died yesterday alone. That’s more than were killed at the World Trade Center on 9/11. In two days, we are losing more citizens than China, with its 1.3 billion people, has lost since the beginning of the pandemic. Their official total death toll since last December is fewer than 5,000.

Indian elementary school in the time of Covid

I expect these numbers, which are horrific, are going to take a sharp increase over December as we have yet to see the impact of the Thanksgiving holidays. Cases caught over the holiday weekend won’t start showing up in hospitals for another two or three weeks; just in time for everyone to start gathering for Christmas, New Years, and other end of the year festivals. The level of societal denial that’s going on at the moment is breathtaking. I woke this morning to news that one of our ritzier suburbs is planning on a huge holiday party/dance for the middle schoolers at a local country club. Just what in heaven makes people think putting 500 tweens in a ballroom midwinter bouncing around to the latest hits is a good idea? I understand parents wanting to provide some normal socialization but these are not normal times. A recent study from India (which has a different culture so you can’t just generalize) which involved hundreds of thousands of cases and contract tracing showed that the major vector of spread was schools. Children are walking petri dishes for viral illness. They always have been. It’s part of the necessary process of developing a healthy body. Put them together in enclosed space, and then have them mingle with children’s normal behaviors and they’re going to trade germs like crazy and then carry them back home.

We’ve reached the point where Covid is becoming a significant stress test on our societal systems. I view it sort of like when structural engineers test models in wind tunnels to determine what sorts of architecture can withstand a category 5 hurricane. We’re putting societal infrastructure, which has been deliberately hollowed out by various decisions over the last fifty years, out there and subjecting it to a simultaneous 8 on the Richter scale earthquake, F-5 tornado, and wildfire storm. It’s no wonder things aren’t doing so well.

The piece of society I am the most familiar with is the healthcare system. What was once the most advanced health culture and the envy of the world in the decades following World War II was changed from a system whose goal was improving American lives to an industry whose goal was improving American businesses bottom lines, executive compensation, and stock profits. It wasn’t deliberate, no one person or thing orchestrated it, but starting in the mid-70s, the sector was taken over by business minds focused on the manufacture of health as measured in data points and the system was stripped of excess capacity in order to make it lean and mean. Physicians and others skilled in healing lost control of the system to those with skills in accountancy, marketing, and data management. This has all coincided with my career in medicine (I having entered the training in 1984) and its been both fascinating and nerve wracking to watch all of this happen. With the stress of Covid out of control, we don’t have hospital capacity, we don’t have staff capacity, decisions are made based on financial risks to institutions, we continue to lose smaller and rural hospitals, especially in states which refused the Medicaid expansion for political reasons (many of these the same states in which the infection is spreading like wildfire as the same political trends push the population to ignore sound public health advice). My generation of physicians is getting pummeled and fed up and will likely begin retiring at a relatively young age. I don’t see many of us working into our 80s in the way that an earlier generation did. And we aren’t going to have a new generation to replace us as the system pushes graduates into specialties of high remuneration rather than of societal need. We haven’t been able to attract a single fellow for training in geriatrics at UAB for three years.
The hollowed out educational system is hurting. Teachers were having to make do with significant funding cuts as back as far as the Reagan era and with salaries so low that many work second jobs to make ends meet. The move from having teachers teach to manage data metrics and preparing students for standardized tests which came from the No Child Left Behind act, caused another huge issue. Now teachers are being asked to work two full time jobs. As in person classroom teachers and as on line teachers to students whose families have opted to keep their children out of the classroom due to Covid risks. It can’t be borne and the older generation will retire and the younger generation will burn out. The lack of leadership from the current administration’s Department of Education, run by someone whose sole qualification was donating huge amounts of money to right wing causes, is just the icing on the cake.

What can I say about our government? On the federal level, the executive branch decided to politicize a worldwide pandemic into an us vs them exercise, spending months feeding misinformation to the public about risk, public health measures, and basic scientific laws. When the pandemic blossomed out of control, which was inevitable in the face of this attitude, they simply ignored it, kicking responsibility to the states with the results that more conservative states, following federal example, chose to act as if nothing was happening and poured even more gasoline on the fire. State governments, with the exception of a few large rich states such as California and New York do not have the resources to deal with world problems. It is the role of federal government. Things may begin to change on January 20th but that’s still seven weeks away. In the meantime, at current trends, another 7 or 8 million people will get sick and another 350,000 will die.

So keep up the good fight, wear your mask, wash your hands, social distance and stay out of crowds.

November 30, 2020

And the long holiday weekend is over. All of the people who traveled against CDC advice have traveled again to get themselves back home and the numbers continue to mount. I canceled my personal travel plans when the numbers really began to skyrocket in early November. I’m fairly savvy and could have made the trip to Seattle and back safely but the odds for such things are tipping away and don’t look good to me until numbers start decreasing again and I don’t think we’re going to see that until Spring given that the weather will drive us all back indoors. We’re having an unseasonable cold snap here in Alabama at the moment with a light dusting of snow here in Birmingham. This is not conducive to outdoor activity. I was going to take a walk earlier but the weather was really too ugly.

In terms of judging risk, not just from Covid but from all other activities of life, I apply the car test. If, as an American, you get into a car with any regularity, your chance of dying as a result of a car accident in any given year is 0.02%. It’s pretty low so the risk benefit calculation to most of us is pretty easy so we all get into our cars without thinking about it. Now let’s compare that to the risk of death from Covid which seems to be somewhere between 0.6% and 2% for all comers and is even higher for my gender and age group. In other words, about 100 times as dangerous as driving. That starts to give me pause. When evaluating risk, if it’s less risky then driving (flying, being struck by lightning, being attacked by a shark at the beach), I never worry about it. If it’s orders of magnitude more risky, it gives me pause. Seattle will still be there in a few months and hopefully, when spring comes, risks will start descending as human activity again starts to move outdoors, and, with luck, we have a vaccine that should provide at least partial protection and an executive administration guided by science rather than by political whims.

I don’t have much new to report on the vaccine front. The Moderna mRNA vaccine I wrote about in the last few entries was presented to the FDA for an emergency use authorization so we should hear about approvals for it and Pfizer’s similar vaccine in the next few weeks. There are still a lot of questions about distribution to be answered. The last thing I saw was that the federal government was going to distribute it to the states based on population and then let the states decide for themselves how to allocate it from there. While this fits in with the administration’s passing the buck and every state for itself strategies, I don’t think this is the wisest of ideas as it gives no flexibility to distribute vaccine based on hot spots or needs. The Dakotas, for instance, are in serious trouble but with their relatively small population, vaccine just isn’t going to get there.

The hot off the presses news from today is that Scott Atlas MD, the Stanford radiologist with no epidemiological or virology experience who was appointed to be a senior adviser to the president’s Covid task force has resigned. Good! His blase laissez-faire attitude toward prevention have likely cost thousands of people their lives. As I still have an active California medical license (I kept it because for years I assumed I would go back – that’s not going to happen and I now keep it out of habit), I seriously thought about calling up the Medical Board of California and filing a complaint against him for endangerment. I am counting the days until January 20th when, with a little luck, decisions on the national level will once again be based in sound science and public health. We’re at 13.5 million cases in the US as we head into December. A month ago we were at 9 million. One third of all Covid cases since the beginning of the pandemic have happened in the last month.

I have this week off. My Christmas preparations are pretty much complete so I have to find something else to fill the time. The next big thing on my to do list is to go through the bins of ephemera that came out of the house in the move. I’m a pack rat. I keep letters, theater programs, photographs, news clippings: anything that I think I might like to look at again. I used to be very good about scrapbooking it all but that kind of fell by the wayside with Tommy as he, unlike Steve, had no interest in that kind of sentimentality. Now I have what feels like a few metric tons that I have to go through and decide what to save and what to discard. I’ve been putting this chore off for a while because its going to cause me to go through a lot of memories of togetherness at a time when I’m isolated and alone. It would be easier to do with someone so I could reminisce and tell the stories but that’s not really possible at the moment. I’ll probably dance around it for another day or two and then just sit down and start. That’s my usual modus operandi. If I find anything terribly interesting, I may scan it in and share it with y’all. Pictures of a time when I had a hair color…

Stay safe, stay well, and be careful out there.

November 26, 2020

Happy Thanksgiving everyone. Time for another essay length post about life, the universe and everything. I haven’t the vaguest idea what I’m actually going to cover today – sometimes my best creations fashion themselves by my turning my conscious mind off and just letting the fingers fly across the keyboard. It is turkey day. No turkey here. I was hardly going to cook a turkey for one for dinner. I do have a few goodies in the fridge for later along with a bottle of wine for our family zoom hour coming up later this evening. Family stretched across four time zones and alcohol will either end up in hilarity or disaster. Knowing my people the way I do, it will almost certainly be the former.
As much as I kvetch while writing these missives, I really do have a good deal to be thankful for. I have a roof over my head. I don’t need to worry about where my next meal is coming from. I remain gainfully employed with a regular paycheck. My needs are all met. I can satisfy most of my wants. The two that I cannot, theater and travel, are denied to pretty much everyone at the moment so I can’t whine about it too much. Covid will continue to run our lives for a while longer but eventually we will adapt to a world wherein it exists and we will all figure out how to do those sorts of things in manners which allow us to be safe.

There’s a couple of new wrinkles on the vaccine front that I’ve learned about in the four days since writing the last one of these diaries (which shows just how quickly things are moving). The first is that there is another vaccine that has emerged with a successful track record. This one, from Astra-Zeneca and the Jenner Vaccine Institute at Oxford University, is very different from the two mRNA vaccines I discussed previously. It is a live virus vaccine and, because of this, it does not have to be kept at super cold temperatures for shipment and storage. It is stable at room temperatures for some time making it easier to distribute, especially to parts of the world that have less developed infrastructure. It is also, due to funding promises from various sources, likely to be a good deal cheaper than the mRNA vaccines.

This vaccine has its roots in the Ebola and MERS (Middle East Respiratory Syndrome) outbreaks of the last decade. Knowing that there would eventually be a world wide pandemic of something, scientists at the Jenner Vaccine Institute decided that what was needed was a vaccine that could be easily modified for any particular disease that came down the pike. They took a cold virus (an adenovirus to be specific) from chimpanzees, modified it slightly to make in uninfectious to humans, and then started to work out ways that it could be a messenger and drop any particular engineered payload to human cells, allowing the immune system to activate against it. They were quite far along with their ideas when Covid hit and were able to pivot to using the spike proteins of the coronavirus as the target, more or less completing ten years worth of work in less than ten months. The original trials of dosing of this vaccine weren’t especially promising, 50% protection rather than the 95% of the mRNA vaccines until there was a happy accident and, by error, one of the test cohorts got only a half dose in their initial shot of a two shot series. Those individuals showed 90% protection. No one’s quite sure why but the studies are being hurriedly looked at and replicated.

So there now appears to be a bit of a three way horse race to see who can first get an FDA emergency use authorization and then get their product out. I’m thinking Moderna is likely to be the winner here. It comes down to money. The Pfizer vaccine is backed primarily by Germany and the Astra-Zeneca is backed primarily by England while the Moderna is American. It doesn’t hurt that Moncef Slaoui, the vaccine guru behind ‘Operation Warp Speed’ was on the board of Moderna and was reaping benefits from the company until Elizabeth Warren pointed it out and pushed for him to divest. I have a feeling that a number of individuals well connected to Moderna are going to make a killing over the next six months and there will be a lot of mutual back scratching along with the congratulations. Societal upheaval and disaster has always created new wealth – like Procter and Gamble moving from local Cincinnati company to international powerhouse on the strength of contracts to supply the Union Army with soap and candles. Perhaps Honore de Balzac had it best with his quote ‘Behind every great fortune is a crime’.

Numbers are continuing to skyrocket everywhere and will continue to do so while we have rules and regulations governed more by politics and judicial fiat than by sound public health principles. We’re just lucky that the mortality is as low as it is. If this were SARS (and technically Covid is SARS-2) with its 15% mortality rate, we’d have nearly two million dead at this point in the pandemic and our social and health institutions might be close to a state of collapse. Y’all know what to do. Wash your hands, wear your mask, social distance, stay out of crowded buildings if you don’t have to be there. I hate to think what the numbers are going to look like at Christmas given the widespread flouting of these simple rules that continues to go on. I’m tired of hearing about people I know and love falling ill or losing loved ones.

November 22, 2020

An illustration picture shows vials with Covid-19 Vaccine stickers attached and syringes with the logo of US pharmaceutical company Pfizer and German partner BioNTech, on November 17, 2020. (Photo by JUSTIN TALLIS / AFP) (Photo by JUSTIN TALLIS/AFP via Getty Images)

And the first weekend of my time away from work draws to a close. I really can’t consider it much of a vacation as doing interesting things outside of my usual patterns is somewhat unwise at the moment. I can’t really think of it as a staycation either as that tends to imply a certain amount of business with life and a need to retreat to the comforts of home and I’ve been spending far too much time there over the last nine months. We’ll just have to think of it as time off work and time to get some of those projects that always fall to the bottom of my ‘to do’ list ticked off. The first one was entitled ‘Haul Out the Holly’ and I accomplished it today together with my friend Holly (how seasonal) and her daughter Naomi. We got all the bins of Christmas out of storage and half the decor is up. I seem to have guessed about right in terms of what I kept and what I let go in the downsizing although half a Christmas tree has gone missing and had to be replaced with a quick run to Home Depot. The trees and all should be finished in the next couple of days. I know it’s a bit early but I decided that if there was ever a year to be early with the holiday decorations, 2020 was it. And I may keep them up through Valentines.

An old high school friend with whom I have recently been in communication (the positive joys of social media) asked me my thoughts on the Covid-19 vaccines that have been in the news recently and what may come of them. I am not an immunologist or a virologist, just a poor geriatrician trying to make sense of this brave new world along with the rest of you but I have been seeking out information where I can. So, this evening’s entry in the Accidental Plague Diaries can be called something like ‘When Can I Get My Shot’. The basic answer is ‘I don’t know’. There are something like 100 vaccine candidates out there being worked on world wide. There are a couple of motivations. The first is the beneficence of being able to protect us form the virus. The second is the potential of enormous sums of money to be made by successful products. Given the politics and sociology of this moment, I don’t think we’re going to see the kind of gestures made in the past such as the discoverers of insulin refusing to patent or take recompense or, more recently, Jonas Salk’s not wanting to profit off the polio vaccine.

For a vaccine or any other pharmaceutical to come to market, there’s basically a three step process. First, you have to show that the drug or vaccine does what you think it does in a test tube or cell culture. Second, you have to show that in an animal model and provide data that it’s safe for humans. Third, you have to present data on human trials showing efficacy and safety and then you can get approval. The incredible need for a vaccine in this particular case has allowed a certain fast tracking over this system and a very rapid development of phase three human trials. Two different vaccines have completed a phase three trial and showed roughly 90-95% efficacy in preventing Covid-19 with minimal side effects.The first is a vaccine from Pfizer in association with a small German biotech company BioNTech. Despite certain politicians touting it as an American solution, it was developed in Germany with German money. The vaccine works by using mRNA (synthetic messenger RNA) targeted to encode a piece of the RNA the virus uses to manufacture its proteins. This idea is relatively new and has only been in use in the lab for about fifteen years so these vaccines are not the same as older virus vaccines like flu or measles which actually use the viral proteins themselves to confer immunity. The mRNA is injected into your muscle tissue where it is taken up by muscle cells and the muscle cells use this mRNA to make the viral proteins. Your immune system recognizes these as foreign and gears up antibodies to them. Therefore, if you run into the actual virus later, your immune system is primed to take it out before it can ever establish itself in your body. It’s a nifty little idea and, as you’re not actually shooting foreign proteins into someone, you’re less likely to have negative reactions.

The hitch is that mRNA is not a very stable molecule. In order for it not to degrade or transform into something that would cause your cells to start making the wrong protein, it has to be kept very, very cold (-70 degrees C). This is a good deal colder than your average freezer. Therefore, in order to be able to distribute the vaccine, you have to have a cold chain in place that can ensure the vaccine stays at a super low temperature from the time and place of manufacture to its end destination where it is defrosted just in time to be used. This can be done. The Shingrix shingles vaccine requires similar cold temperatures and has been safely distributed for some years. (There were shortages early on due to manufacturing capabilities but they have been worked out and it’s now easy to receive at most major pharmacies).

The Moderna vaccine, which is an American product, Moderna being based in Massachusetts, is also an mRNA vaccine which works in essentially the same way as the Pfizer/BioNTech does. Moderna’s big selling point is that their formulation is more shelf stable and does not require quite as cold a temperature and will last longer at room temperature than the other product. Mind you, neither product has yet obtained FDA approval. Pfizer has filed for an Emergency Use Authorization that will allow them to circumvent much of the usual red tape. Moderna is expected to follow suit within the next couple of weeks. Once the EUA is granted, it will be legal for them to manufacture, distribute and administer the products. When will that be? I’m going to trust that there are still scientists at the FDA who will know how to interpret the data and will make decisions based on that rather than on drug company press releases (the source of the vast majority of the news coverage on these products.) I have a healthy skepticism of drug company press releases. Go back a century or so and you’ll find lovely ads for ‘Heroin – the new sedative for cough’. I’m sure the makers of thalidomide had great things to say about their product when it was released. In more recent years, you can ask me about my experiences with the Merck Corporation and Vioxx next time you see me. The chances are good that there will be something available in the next few months but we’ll have to see what happens when it’s released to a general, rather than a study population. And then there’s all the issues as to who should get it and how quickly.

In the meantime, the numbers don’t look good. Those of you who have been reading these little essays of mine for a while may remember I wrote up a table of how many days it took for a million cases to occur in the US. We passed 12 million yesterday. Just six days after we passed 11 million. Which was only seven days after we passed 10 million. For those who run around saying things like ‘I’m not worried, It’s only a 1% mortality rate’ think about what that means. There are roughly 200,000 cases diagnosed daily at the moment. That means 2,000 people have been told they are going to die. The problem is we don’t know which 2,000. So we’re having between four and five 9/11s a week in terms of mortality alone, and that doesn’t even begin to touch what the morbidity both short and long term might be. Those of us who work in health care are tired. We know that the numbers today means the hospitalizations will be skyrocketing in four to six weeks, just in time for Christmas. What’s going to make a difference in terms of life and death for many is going to be the number of functional acute care nurses and other staff that are going to be available. If they’re sick or burned out, we gots nuttin’.

If you’re going to have Thanksgiving with the family, set up card tables on the lawn. (or in the carport if it’s raining…) And wash your hands. And wear your mask. And check on your health care worker friends and neighbors.

November 18, 2020

I’m sad this evening. It’s all related to Covid of course, how could it not be? The number of US deaths passed one quarter million today. That’s 250,000 families that were intact in February and which are now irretrievably broken. Widows without spouses, children without parents, parents without children. And none of it had to be. Given the nature of the beast we were always going to lose some but with good leadership and public health practices, our losses should be lower by an order of magnitude. As I read through my Covid related news feeds, I’m reading about North Dakota, now the hot spot for the disease not just in the country, but in the entire world. one out of a thousand people there has died of Covid since the beginning of the pandemic. South Dakota, just across the border isn’t faring much better and their seemingly delusional governor is busy running tourist ads to try and get people to come visit. They are completely out of hospital beds in Oklahoma. New York City schools are shutting again. Lockdowns are taking shape on the West Coast.

The current surge, which is much worse than either the initial outbreak of the spring or the higher numbers of July/August, is absolutely predictable. The sages in the epidemiology/virology community stated what would happen quite succinctly and matter of factly this summer if the country did not take things seriously and mask up, social distance, and cancel significant gatherings of people. What did America do? It turned the wearing of masks into some sort of star bellied Sneetches political statement to delineate in and out groups. It sent its children back to school and its young people back to college where they engaged in the behaviors that young people are want to do. It couldn’t live without its motorcycle rallies, its football games, its nights out at the restaurant. It would not exert political leadership to make it economically possible for Americans to choose to take care of each other. With no other source of income, everyone had to go back to whatever work they could find, risks be damned. I’ve worked very hard to be careful but I’m human. I’ve slipped a few times and done things that might have put myself or others at risk. I want my old life back just as much as everyone else.

The virus, of course, cares nothing for any of this. It simply takes advantage of the opportunities afforded to it by human behavior and, with a third of the population convinced that Covid is likely a hoax and certainly not a threat, there’s really no way to contain spread in the population as a whole and you get what we have now which is pretty much uncontained community spread everywhere. I think the saddest story I read this week was from a nurse in South Dakota on the Covid wards who, when calling families of patients who were about to be intubated and like to die and would they like a chance to say goodbye to their loved one was told over and over again that that wouldn’t be necessary as the virus was a hoax. The next call, was of course, to tell them that their loved one had died and the cognitive dissonance that must be causing I can’t even begin to imagine. I have heard that families have come in demanding that death certificates must be changed. It can’t possibly be Covid. It must be pneumonia, flu, an undiagnosed cancer but not Covid because it doesn’t exist.

On a personal note, I’m sad that I won’t be able to see my family as I had planned. After much discussion and reflection, I’ve come to the conclusion that it’s best not to go to Seattle at the moment. Washington state is heading back to mandatory quarantining of out of state visitors (and I can’t take the time for a two week quarantine before seeing anyone at the moment). There’s the heightened chance of exposure through travel and the risks that potentially poses to my soon to be 88 year old father. What I’m going to do with my time off I’m not sure now. I am going to go down to storage and haul out Christmas this next week. As Mame says, ‘We need a little Christmas, right this very minute’. And it will give me the time to figure out which of my multitudinous decorations will work in this new space and which should be rehomed. Then I have to tackle boxes of ephemera and sort out pictures and mementos.

I’m sad for my patients, who were just starting to feel safe coming out of their cocoons who have to go right back into an isolated existence. I’m sad for their families who are often stuck outside of a window or glass door. I’m especially sad for the demented ones who don’t understand what’s happening and why routines have been so disrupted. They need touch and laughter and small children to stay anchored and present in the world and these basic needs are denied them. I try to be a bright spot in their day when they visit me either in person or via video conference but it takes a lot of energy to be that role I’ve perfected for myself over the last three decades.

I’m sad for my colleagues who were, earlier in the fall, starting to feel human again as the pressures of Covid were letting up some on the system and old patterns and schedules were starting to fall back into place. They haven’t recovered and here they’re being asked to gird up their loins and prepare for worse yet. It’s taking a major toll on mental health. I can see it and feel it. People are snappier, less tolerant of minor snafus, more likely to pick fights over turf or disagreements in treatment plans. I know when I get like that, it’s time for a vacation and I schedule one post haste but there’s not enough of us to handle what is happening as some retire, some burn out, and some fall ill. I’m not worried about UAB but nationwide, one fifth of hospitals are at or over capacity as of today and the numbers show no signs of trending down.

I made a deal with myself after Tommy’s death that the way I was going to cope with life was to schedule one thing a month that I could look forward to. A vacation, a long weekend away, a theatrical project. Something that would nurture my soul. I was doing pretty well until March when the world fell apart for me as well as for everyone else. I’ve had little to look forward to and I look out at the horizon and still see a long stretch of months where my usuals still won’t be possible. I have to figure out something to take their place. I just haven’t been able to do so as of yet.

Sorry to be Debbie Downer this evening but some days are just like that. In the meantime you all know the drill: wear your mask, wash your hands, social distance, avoid close crowds.

November 14, 2020

Today’s ‘Million MAGA March’

It’s the second Saturday in November, not quite two weeks after the election. Neo-Nazis are busy marching in DC, we have an administration that refuses a gracious concession despite a major defeat, and Covid marches on at disastrous levels. In the last week alone 1 out of 378 Americans tested positive for Covid. Since the beginning of the pandemic 9 months ago, roughly 1 out of 31 Americans has tested positive. We’re at something over 250,000 deaths. For those of you still hoping for ‘herd immunity’ which will require roughly 2/3 to 3/4 of Americans to test positive, basic math tells us 5 to 6 million will die.

I opened up my Facebook feed yesterday and started to scroll through. The first four posts were all related to serious Covid problems. A friend mourning the death of a parent from Covid earlier than afternoon, another friend celebrating release from the hospital but still requiring home oxygen, a friend bemoaning a positive test that day which will require two weeks quarantining off work with concomitant loss of income, a friend two weeks out of the hospital who still doesn’t have the strength to do much besides rest up. I can’t help but wonder how much longer I can keep avoiding it. I’m not stupid and don’t take unnecessary risks and have clamped way down on my activities but I still march into hospital buildings every work day that are full of the ill and I don’t believe for a minute that everyone in them is negative, no matter how much checking of temperatures they do at entry.
I have a lot to say about what’s about to happen to the health system in certain parts of the country, but I think I’ll save that for the next entry.

Me as Rudolph and Jan Hunter as Dolly in 2018

I’m tired of writing about doom and gloom. I want to write about positive things today and there are a few positive things going on as a result of the pandemic that should be celebrated. A few nights ago, I came home really grouchy and I’ve learned over the years that there’s no better cure for that then to put on a Jerry Herman show, so I put on the Carol Channing 90s revival of Hello, Dolly! (I like this one because it includes a bunch of the dance music and the tempi are quicker than usual which gives it even more energy). It got me thinking about the times I’ve done the show in the past. There are a number of speeches in the show, usually monologues that break the fourth wall and which are straight out of the Thornton Wilder source material that are important. Wilder really understood how to dig down to the essence of humanity in American culture in Our Town, The Skin of Our Teeth, and The Matchmaker and remind us of what’s truly important. “Money, pardon the expression, is like manure. It’s not worth a thing unless it’s spread around, encouraging young things to grow”. “For years I had not shed one tear nor had I been filled with the wonderful hope that something or other would turn out well. And so I decided to rejoin the human race”. “Even if I have to dig ditches for the rest of my life, I’ll be a ditch digger who once had a wonderful day”. I think it’s these moments and the deep humanity of the characters that make it one of my favorite shows despite the gooey trappings.

So what is the good? Personally, keeping these posts up has helped me continue to hone my writing and has given me the discipline to write these essays a couple of times a week as a record of how at least one person has been affected and reacted to the pandemic and it has allowed me to explore a number of topics in epidemiology, sociology, and psychology that I might not otherwise have encountered. It’s given me an excuse to be in touch with old friends that I might not otherwise have communicated with. It’s made me withdraw from some of my over scheduling, a coping device I’ve used for years to run away from having to face emotions, and made me actually confront and process some of the things that have happened to me over the years.

I see a lot of good as I look around me at society. People are learning to cook again. I should join their ranks (and I’m actually not a bad cook, I just had the luxury of a trained chef in my kitchen for fifteen years) but I’ve just never been terribly interested in cooking for one. When things open up and I can have people over for dinner, I’ll break out some of my favored recipes from years past. I’ve seen a lot of people return to long neglected hobbies and crafts. People are sewing, knitting, painting, building and expressing themselves practically and creatively. Items created in 2020 with love and care will come down through the generations in the future with a story attached, much in the way that we prize great grandmothers shawl or the chest great grandfather made. Performers are becoming more and more creative in how they use new technologies or how they gather an audience. I have been to drive in performances, bring your own lawn chair to a parking lot performances, and seen people on Zoom or other streaming platforms actively creating new entertainment hybrids between stage and film.

We’ve got a long way to go and given current trends, things are going to get a whole lot worse before they get better. States which are rejecting public health science for political reasons are going to continue to fuel the spread nationally. Can that be fixed? I hope so but it’s going to take a lot of work and a lot of education, and a removal of those media vectors that propagate disinformation. We’ll see what happens. As I’ve said repeatedly, viruses don’t care about your politics, only that your behaviors allow it to spread. I’ll keep trying to do my small part to reduce the spread by (everyone all together now…) washing my hands, wearing a mask, and minimizing my time indoors with crowds of other people.

Stay well.

November 10, 2020

Hi, my name is Andrew and I have Covid fatigue. There, I said it. I’ve been writing these Accidental Plague Diaries for eight months now and I’m tired. I’m tired of otherwise intelligent people ignoring science for political purposes. I’m tired of a government allowing ordinary citizens to suffer and die from a predictable infectious disease that can be mitigated by tried and true public health methods. I’m tired of working in a health system that’s under incredible pressures between the needs of Covid patients and the needs of everyone else. I’m tired of giving up a much of what I find pleasurable in life for the greater good to see hordes of people out and about just not giving a damn about what their behavior means to others. Tired, tired, tired… I know it was all getting to me this past weekend when I kept falling asleep most of the time. I didn’t have much on my docket so any time I sat down on the couch with a book, I nodded off yet again. It reminded me of how I would feel when I would come home from college for vacations and sleep 12-14 hours a day for two weeks, recuperating from the quarter just past and resetting for the quarter to come.

So where are we now? We’ve passed 10 million cases in the USA and for the last week, have been averaging over 100,000 cases daily. At current trends, we’ll be up to 11 million before Thanksgiving week. Hospitalizations are up by about 75% over the last month with some of the smaller Midwest states completely out of hospital and ICU beds. The death rate is up 15% over last week. All of this has been pushed off the front pages by the political news of the last week in the aftermath of the election. The way things are going, I won’t be surprised if we end up with a presidency in the White House and a presidency in Avignon trading barbs at each other for the next four years. Actually, the whole saga is unfolding exactly as those who read the political currents closely predicted it would some months ago with a Democratic victory and a lot of Republican sound and fury without much substance behind it.

We’re now in the third wave of Covid cases in the US. The first wave having happened in March and April when the disease first began to spread and the second having happened around July. This one is bigger and more widespread than the first two. Fewer people seem to be dying as the health system has learned how to save lives but more and more people are getting sick with unknown future sequelae. My brothers and sisters in health care were running on nervous energy and adrenaline and on the combined fear and hope of the unknown for the first wave. They received the second wave with grace, having more or less learned what they needed to do. However, they’re tired. They’ve been doing this for eight months without respite and the numbers are climbing again and I’m really afraid we’re going to start seeing some of them crumble. Those older than I are researching their retirement options. Those younger are looking at career paths that aren’t quite so stressful. Those my age are plodding forward one day at a time. We have a healthcare provider shortage, especially of skilled RNs in this country. We’ve imported them in the past. The current administration has shut that down.

I’m really worried that we’re going to see some major fractures in the health system over the next few months, just in time for the holidays. Large University systems like UAB will be fine. They have all sorts of resources they can draw on. I’m worried about community hospitals in more out of the way locations and with much smaller systems behind them and much less of a talent pool from which to draw. These have already been heavily stressed by the general changes in health care over the last few decades, and greatly exacerbated by the political refusal of Medicaid expansion funds tied to Obamacare. I’ve spent a lot of my career serving patients in rural poverty, going into their homes, learning the way they think and how they relate to health care culturally and I hate to think of the richest nation ever failing some of its citizens in so basic a manner.

Speaking of Obamacare, the Trump administration, together with a coalition of a number of Republican state Attorneys General was before the Supreme Court today arguing in California v Texas that Obamacare should be completely invalidated for nothing says I care for my citizens like stripping 20 million of them of health insurance during a pandemic and stripping all 350 million of them of protection against discrimination for preexisting conditions when we’re facing a disease with unknown long standing repercussions. I wouldn’t count on the conservative majority throwing the whole thing out, though. There were some remarks from the bench from some surprising sources that suggest it won’t happen. But we will see what we will see.

Rant over. I’m still tired. I should move on to a constructive project but I think I’ll finish my package of Oreos and turn on Netflix instead.

November 6, 2020

My mother c 1954

Today would have been my mother’s 88th birthday and it’s the first one she’s no longer here for. I miss her, but I’ve missed her for years. As dementia stole her faculties over a long, slow, painful period, she became less and less present and able to be the touchstone of my life that she had been. I love my father deeply, but, I am definitely my mothers child in so many ways. I inherited from her my somewhat British sensibility, my love of words, my Puckish sense of humor, and enjoyment of a good single malt scotch. She taught me to love literature for its own sake; encouraged me to read widely and deeply and with a sense of inquiry (although she was somewhat taken aback when she found me ensconced in Kurt Vonnegut at age ten); taught me how to choose words carefully and how to put them together into cogent ideas; and how to hold ones head high and move serenely through life no matter the obstacles. The vagaries of life that led her, the child of British emigres, brought up in San Francisco society in an era where women wore hats and gloves downtown and married men of good families and prospects, to venture afield and meet and marry my father never cease to amaze me. Wherever her energy is these days, I hope she’s happy and contentedly smiling down on her successful descendants and their collaterals.

Back to the Accidental Plague Diaries: Covid news has been knocked off the front pages by presidential politics this week but that doesn’t mean it’s over by a long shot. I’ve seen a few of my more conservative friends post some silly memes suggesting that it will now just all go away. I’m afraid that’s not happening. Both Wednesday and Thursday of this week, there were more than 100,000 cases reported in the US. (I won’t be surprised if that proves true for today as well when final numbers are tallied.) The numbers locally are skyrocketing. I can tell by watching my Facebook feed as well as by looking at the various case counters constantly updated on line in real time. I have had five or six friends post that they have been diagnosed this week. Two have been hospitalized. Neither is serious enough to require ICU care at this time but it’s early days. I’ve had four long term patients admitted to the hospital with Covid this week. One has died. For most of this year it’s been running about one a week so that’s a four fold increase, although the sample size is too small to make a statistical inference. As it has been proven time and again, the sequence goes behavior change leads to increases cases some weeks later leads to increased hospitalizations some weeks after that leads to deaths some weeks after that. I am assuming this huge wave that we just seem to be rolling into is coming from the opening up of various social institutions over the last few months, schools being chief amongst them. If the usual patterns prevail, we’re just going into the case spike now. The hospital spike should arrive just in time for the holiday season and we’ll start seeing a significant increase in the death rate for Christmas and New Years. So, unless you want to gift someone with premature death this year, keep up the usual: masks, hand hygiene, social distancing, avoiding of crowd situations.

The presidential election, while not yet complete due to the enormous numbers of absentee and mail in ballots, looks to be pretty much a done deal and there will be a new administration as of January 20th. What is that going to mean for Covid? That’s a little hard to prognosticate but I suspect a few things will happen. There will be some restoration to executive agencies such as the CDC and FDA of principles of science in decision making rather than principles of politics and wishful thinking. Congress retains the power of the purse and while the House is likely to appropriate money for public health measures, the politics of the Senate are far less certain and it remains in dispute which party will even be in control. All eyes will go to Georgia between now and its run off election slated for January 5th. With luck, Stacey Abrams will be allowed to do what she knows how to do. I will repeat my mantra. Black Women should be in charge of everything in this country. They know how to get things done. I also suspect that there will be some new federal initiatives put in place to make it easier for states to cooperate regionally for better pandemic control. I am not hopeful that there will be any sort of magic bullet vaccine. We’ll get one in the next year or so and it will help some but it will be like the Flu Shot. It certainly helps reduce morbidity and mortality but it’s no cure all.

The thing I am most afraid of in terms of thinking through what’s coming over the next few years in regards to Covid is the unknown long term consequences of the disease. As it becomes more and more clear that this is not a respiratory virus, but a vascular virus with damage to multiple organ systems, there may be all sorts of ugly little surprises awaiting those who have recovered. I won’t be in the least surprised if in a decade or so, there are significant cardiac, renal, or neurological late complications that surface in those who were infected. What they will be and what they will mean for health, function, and life expectancy are entirely unknown. But every time I read of a young healthy theater friend who has been diagnosed and is recuperating at home, I can’t help but wonder what happens next. A change in administration may lead to more of an emphasis on people and less on profit but I’m not holding my breath.

The tech gurus capturing zoom filming for The Importance of Being Earnest. That’s me in the top left corner of the main screen

My spate of online endeavors is coming to an end. The Politically Incorrect Cabaret video ‘October Surprise’ is out. I finished filming my bits for the South Carolina production of The Importance of Being Earnest tonight (due out December 9th). A story telling program for UAB’s Arts in Medicine for which I talked about how I have developed my resilience over the years bowed yesterday and is supposed to be available on YouTube soon (I’ll post a link when available). I can take down my green screen and pack away my makeshift studio this weekend until the next project comes my way. There’s always something. Maybe I can pull some theater friends together for cocktails and impromptu Zoom play readings over the next month or two. In the meantime, I have a number of projects around here begging for attention.

Stay safe. Be well.

November 2, 2020

Tomorrow we’ll be far away

Tomorrow is the judgement day

Tomorrow we’ll discover

What our God in Heaven has in store

One more dawn

One more day

One day more

All the theater people who read these little essays of mine are busy singing that particular quote in their heads, if not aloud, frightening the neighbors, nearby pets, and passers by out on the street. All I can say about tomorrow is that I have done what I personally can do about the current state of the country and, as of tomorrow, we will have the government that we deserve as a people. Our current government has made it abundantly clear what they stand for over the last four years and if we choose to retain it, we will all be responsible for the consequences. If we choose to change it, we will all be responsible for forging a new path. I plan on taking a news/social media hiatus tomorrow evening and curling up with a good book. I’ll know the outcome soon enough and will live with the results like everyone else.

So where are we with the accidental plague diaries? Tired. Cases are increasing again locally and in the hospital. I’ve had three long term patients test positive since Friday. They are all, so far, doing well, but with the age and general physiologic condition of my folks, they are not out of the woods by a long shot. Despite the ominous signs, Alabama is doing better than a number of other places around the country. A quick skim of the headlines on my newsfeeds this morning revealed a lack of ICU beds in the midwest, the need for a fourth mobile morgue unit in El Paso, and a study tracing roughly 30,000 cases over the last month to infections spread by the President’s rallies. Someone was complaining today about how the virus keeps changing making it difficult to know how to react. This is fallacious. Viruses do not change their behavior. They don’t have central nervous systems, brains, emotion, reasoning, or anything else we might wish to anthropomorphize them with. What changes is our behavior and that is what determines how and where the virus can spread.

The significant uptick in cases over the last couple of weeks probably relates to back to school behavior, Covid fatigue which leads to people relaxing their guard and being more likely to head off to a restaurant or a small informal party, and colder weather starting to push more people indoors. These are all trends that started some weeks ago and it takes a while for the change in behavior to lead to a rise in cases. The rise in hospitalizations comes next. We’re already seeing it in some places and I am really worried about where we may end up over the next few months. We’ve got the equipment and the hospital beds. We’re running out of staff. There’s 168 hours in a week which means you need four full time shifts of workers to staff acute care beds. As nurses and other staff are getting burnt out, sick themselves, or are otherwise not able to handle the rigors of Covid related hospital and ICU work, we’re going to run out of bodies to keep the system going. Nurse staffing companies are offering huge bonuses to travel RNs at the moment due to demand (causing some regular hospital RNs to quit their jobs for the better dollars of the travel/PRN life) but even these inducements aren’t going to work forever. In the past, we imported a lot of nurses but the current administration’s crackdown on immigration plus Covid related travel restrictions are going to keep that from being a solution. 1700 health care providers dead so far. And the chief cause of death among active duty peace officers this year – you guessed it – Covid 19, not guns.

Number of geriatricians produced per year 1995-2010. Couldn’t find the data for the last decade

My little corner of health care is pretty stable at the moment but I have to wonder sometimes for how long. We’ve been trying to find some new geriatrics faculty for years but have had little luck. It’s a deeply unpopular specialty among American medical school graduates as it’s non-procedure oriented and not especially lucrative. It does not lend itself to being taught and understood in the standard four week rotation given to medical students and residents as the specialty is longitudinal and it requires months or years to understand how interventions actually work with patients and families. It requires a lot of creative, right brain thinking which physicians, selected for their ability to analyze and work with scientific rigor, feel very uncomfortable with. Doctors want answers. There aren’t a lot of them in geriatric medicine and you have to be able to look patients and families squarely in the eye sometimes and say ‘There is no science on this subject’ or ‘We have no data about this’ or simply ‘I don’t know’. I think the late fall, early winter are going to be hellacious when it comes to Covid cases. I just hope it’s not so bad that the health care system starts to fail in any appreciable ways. I think it may do so in certain localities where the number of ill people simply overwhelm the ability of the system to cope. I think we’ve got enough resources and resilience locally that it won’t be us but one never knows, does one. The one saving grace is that the protective behaviors against Covid will also be protective against other viral respiratory illnesses including flu so hopefully it will be a light flu season.

After much discussion, my family has canceled our usual Thanksgiving gathering. Too risky with octogenarian seniors, college students coming home from school and bringing buddies with them, travel exposures and the like. I am still going to go to Seattle in late November to see the family but probably after the holiday rush. My father’s 88th birthday is the Tuesday after Thanksgiving and so I will make that the centerpiece of my trip, that way I can travel on less crowded days making it safer for me and for him. We are having a family zoom on Thanksgiving night. I don’t know what I’ll do for dinner yet. I’m not wedded to Turkey. Steve and I, on our first Thanksgiving together more than thirty years ago, had Lasagna at a Swiss Restaurant in Mexico City so maybe it should be Lasagna in commemoration. I have a few weeks to think about it.

October 30, 2020

Hurricane Zeta ambled through town in the wee hours of the morning. We’re a few hundred miles from the coast so it did not have hurricane force winds by the time it passed through Birmingham but it was still enough to cause limbs and trees down all over town with massive power outages. I lost power briefly around 2:30 AM and would normally have slept through it but the restoration some minutes later caused things to go slightly haywire in my personal electrical grid. The smoke detector outside my bedroom began to speak to me in an overly chipper electronic voice demanding I get up and poke its reset button. While I was up, I noted that power was on in certain circuits but not in others. I had lights in the dining room, but no outlet power and no lights in the hall, refrigerator or wi-fi. Flipping the circuit breakers did nothing to rectify the situation and by now I was thoroughly awake and disgruntled so I went back to bed with a book to wait until morning when I could talk to building maintenance. I found out from them the whole building was a crazy quilt of circuitry that wasn’t quite right. For instance, the lights and doors of the elevators were operating, but the cable motors were not. There’s something odd about how the grid and the building interconnect that causes it to happen if there’s an incomplete interruption. I went off to work figuring it would work itself out while I was away and by the time I crawled back in about 7:30 PM after a very long day, it all seemed to be back to normal. It’s been 30 years since I’ve lived in a multi-unit building and I’ve never lived in one of this size so it’s something new everyday.

Returning to the Accidental Plague Diaries, today marks the day that the US surpassed 9 million cases of Covid-19. This got me interested in the mathematics of big numbers when it comes to Covid so I went back and looked up the other seven figure anniversaries that have happened so far this year and constructed this little table:

0 cases – 1/19/2020 (the first US case was reported 1/20/2020)

1 million cases – 4/28/2020 (99 days later)

2 million cases – 6/11/2020 (44 days later)

3 million cases – 7/8/2020 (28 days later)

4 million cases – 7/24/2020 (16 days later)

5 million cases – 8/10/2020 (17 days later)

6 million cases – 8/31/2020 (21 days later)

7 million cases – 9/25/2020 (25 days later)

8 million cases – 10/16/2020 (21 days later)

9 million cases – 10/30/2020 (14 days later)

The next data point will take us to 8 figures and a whole new order of magnitude and will probably happen sometime a week or so after the election given current trends.

South Korea, an early hot spot, had its first case of Covid-19 on the same date as the US. To date, they have had roughly 26,000 cases and about 450 deaths. They are, of course, a smaller country with roughly 1/7 of our population. If we multiply these numbers by seven, we get 182,000 cases and 3,150 deaths. Compare this to our 9,000.000 cases and 225,000 deaths to date. Our fate wasn’t inevitable. It’s the product of deliberate decision making on both the governmental and individual level.

As a society, we have all become conditioned to quick and convenient services and results. We have little patience for the slow pace and rhythms of the natural world. We want our needs met instantly with same day service, fast food, drive through convenience and all the other things we have constructed to allow us to live over scheduled busy lives. Given what I do for a living, I run into this all the time. When my patients become acutely ill in their 70s and 80s, we can usually get them over the hump and get their physiologic processes on track so that they can begin healing and restorative care. As the boom has begun to enter that age group, they expect their recoveries to take no more than a few days at best. That’s all they can allow for it in their lives. Nature doesn’t work that way. A body in that age group generally needs roughly 4-7 days of recuperation for every day of acute illness so four days in the hospital may equal a month before things are back to normal. Patients and their families get angry at me all the time as I gently explain that this is the way it works and no amount of money or social position or wanting it to be different is going to change that.

Why do we do this? Aside from our infatuation with instant results, I think it has to do with brain development. Our brains are growing and changing and maturing until our mid 20s. At that point, they’re done and we have our fully developed adult brain that will guide us the rest of our lives. When we’re younger than that and our brain is changing as our bodies change, we’re used to looking in the mirror and seeing someone different look back at us as our physical and cognitive/emotional selves mature together. Then that second one comes to a halt but the physical keeps on going and changing in ways that most of us would rather it not. So by the time you’re my age, you’re looking in the mirror and seeing an unfamiliar older person look back and you’re wondering ‘What happened?’

Those of us with a little education and access to health care can keep our bodies in pretty decent shape with minimal fuss until late 70s or early 80s these days and all the time, that same brain that still conceives of itself as 25, maybe 30, is rattling around inside and not really understanding that the physiology has changed. On an evolutionary scale, when most of us were dead by mid 40s at the latest, this wasn’t a big problem, but in the last few generations when aging has become equal opportunity, we’re creating huge numbers of people with a cognitive dissonance between mind and body. And as this is a new phenomenon, there isn’t a huge amount of accumulated common wisdom to have been passed down generation to generation about what it means and how to cope with being a healthy eighty year old and what you should worry about and what you shouldn’t The lead edge of the boom turns 80 in just five short years. It’s going to be awfully interesting in my professional world when that happens.

This lack of understanding of natural processes is, of course, playing out in our response to Covid-19. We want everything to stay the same, the way we’re used to it being. We want a quick fix. Slow methodical fixes that require significant behavior change and long periods of time just aren’t in our cultural DNA. Therefore, we want to get back to our restaurants and our parties and our football games and our school events. I’m human. I do too but I also know that the virus exploits our inability to maintain good habits and uses that to spread and every time it spreads, there’s a good chance that someone is going to become seriously ill or die.

It keeps hitting close to home. There hasn’t been a day in the last week or so where someone hasn’t reached out to me with a story about an ill friend or family member, looking for advice or support. I do what I can but there remain no magic bullet treatments. The one thing that seems to be happening is that there are fewer catastrophic cases, probably as more and more cases are happening among younger, hardier populations. I’m getting tired. I have a lot of energy to help but I’m not an infinite well and my usual restoratives have fallen victim to the pandemic. I am counting the days until I get some time off. This isn’t the flu. It’s much deadlier and the chronic health issues of those who are seriously ill but survive remain unknown. It takes out perfectly healthy young people.

We can all help bring it under control with a few relatively easy behavior changes:

-hand washing

-mask wearing

-social distancing

-staying out of crowds

and then on the societal level

-ventilating public spaces

-contact tracing


None of these is perfect, but when used together, you get South Korea.

There’s a lovely metaphorical model based on Swiss Cheese which shows why this works. If we don’t do these things, the virus is going to exploit our behaviors and behavior leads to rise in infections (going on now) leads to rise in hospitalizations (happening in many states – there are no hospital beds available in many Midwest communities) leads to a rise in deaths with a few week lag between each step. 10 million will become 20 million will become 30 million. Wearing your mask today ensures that someone else will be here for Christmas.