January 23, 2021

Bernie is Everywhere

It’s only been three days since the last one of these entries but it seems like several months have gone by in the interim. Something seems to have happened to my perception of time. It feels normal in the immediate here and now but once something slips into the past, it’s as if there’s a great acceleration. Perhaps its the dizzying pace of events as the country reels from political and public health upheavals. Perhaps this is what happens when you age. My patients have always talked about time moving so quickly in their later years. It’s just that if feels like the inauguration was three months ago rather than three days ago. Or maybe it’s the rapid proliferation of 10,000 Bernie Sanders mittens memes…

With a new administration in place. things are beginning to change for the better in terms of the federal response to the corona virus pandemic. The administration has released its plan for bringing the plague under control and its a common sense compendium of tried and true public health measures, most of which should have been in place last spring. It has taken the availability of vaccines into account and there are now federal plans to utilize the national guard and other elements of the government to get vaccine out as quickly as it can be manufactured.

Locally, we here in Alabama are stymied by shortages in vaccine supply. The Alabama Department of Public Health who controls all distribution in the state has gotten its act together and is getting vaccine out to various points to begin vaccinating those over age 75, however, the complete lack of federal coordination has kept vaccine from flowing into the state to meet demand. Vaccinators often don’t know when they are going to get a shipment until a few hours before it arrives which makes setting up schedules and notifying patients a wee bit difficult. There are plans for several mass vaccination sites in the greater Birmingham area and the logistics are in place but they can’t open them up until there is a supply that can be counted on for both first and second shots.

In the meantime, numbers continue to mushroom. There is some evidence that we have peaked and we may be on the downward side of the hump caused by holiday gatherings and travel from Halloween through New Years. Numbers in the hospital locally are down slightly. The percentage of positive tests is decreasing somewhat (but is still more than double the five percent which is thought to be the level at which we can consider the pandemic under control in a particular area). Anthony Fauci has finally been allowed to share his expertise with the public untrammelled and is now responsive only to science and not to politics and his expression of delight at being able to at long last speak unvarnished truth and swing the CDC and other health organizations toward protecting the public rather than protecting the optics of the White House has been rather refreshing. The next big issue is the spreading of the UK variant which is significantly more contagious than the original strains. If this isn’t slowed, we may barely get a rest from this peak before a whole other surge begins later this spring.

Cabaret – Virginia Samford Theater – January 2020 with Celeste Burnum and Chris Sams

Tonight was the one year anniversary of the opening of the Virginia Samford Theater’s production of Cabaret, the last live stage show I was part of during the ‘before’ times. The cast gathered on zoom to toast each other and watch an archival video of a performance together. I don’t like watching myself in such things – stage perforrmances depend so much on the interaction of the actors with the audience that you always feel removed on both sides of the equation when it’s on screen. However, it was fun to see everyone and to reminisce and to comment on how appropriate that piece was to the political times we have been living in recently. When the local theater world opens back up, we’re going to lobby for the theater to revive that production. One year later and I’ve just started rehearsal on another theater project, a zoom theater version of Tartuffe in which I am playing Orgon. Now there’s another play that’s perfectly in synch with the current political times despite being four hundred years old. That’s what makes great art, something born out of turbulent times that helps a future generation understand the turbulent times in which it finds itself.

Bad times, pandemic disease, political unrest, religious schism – no society is immune from such things. We like to think of ourselves as privileged individuals living in the finest civilization the world has produced, an apogee of comfort and enlightenment. I’m pretty sure the Ancient Sumerians, the Imperial Romans, Tudor British, 18th century French, and all the others felt the same way about themselves and their societies in their day. I think it’s part of the human condition to believe it can’t happen here until it does.

I have no idea how the new administration is going to go about solving the myriad problems in American society that our failed response to the corona virus has exposed. I don’t know what the opposition to President Biden and the Democratic party has planned in terms of response. All I can say is that there’s going to be no linking arms around the campfire and singing Kumbyah. We’re a long way from controlling this pandemic and we must all continue to be vigilant, vaccinated or not. Hundreds of thousands have died, hundreds of thousands more are likely to die but we can each do our own small part to protect each other. You all know what to do. Stay home, wash your hands, wear your masks and social distance.

January 20, 2021

Inauguration Day: The center holds, the Republic stands, and we can all go to bed this evening, no matter what our political leanings, knowing that there are stable individuals controlling the levers of power. What does this portend for the future, especially for those corona virus related public health issues in which I am most interested? I can’t say that I know. I am hoping that we will begin to see a unified national response, rather tha a piecemeal local one dependent on the whims of politics. I’m hoping those in charge bring the resources of the federal government to bear on the vaccination effort and that extant vaccines get into willing arms as quickly as possible. Most of all, I’m hopeful that policies will be crafted that will tilt the balance away from the side of profit back towards the side of people.

I have no idea how successful any of these shall be in either the short or the long term. particularly this last onel The economic powers that be which shield capital from the depradations of the people with needs are strong and entrenched and neither political party has really taken them on in some decades due to the great costs of maintaining the current apparatus of elective office, particulary the cost of campaigning in the media age. Lofty promises have been made, but results have been few and far between since the mid 1970s when the earnings of corporations began to outstrip the earnings of workers – and those curves have diverged further and further from each other over nearly five decades. That’s a lot of societal repair.

I’ve been talking a bit about the Big Lie regarding the truth of who won the election, the idea of it having been stolen by the Democrats from the Republicans still having currency in some circles despite essentially no evidence to corroberate this belief and plenty of evidence that the Democrats took both the popular and electoral voted fair and square. There is, however, an even bigger lie that’s been promulgated for decades. The one that the collapse of earning power by Blue Collar and rural Americans is due to a theft of resources by those below them on the social scale, whether by undercutting them in the job market or through governmental benefit, rather than to a redistribution of wealth to those above them on the social scale through corporate consolidation, multinationalism, and redistribution of economic resources outside of the US. This has fed the deep divisions in our country and they are likely beyond the ability of any one administration to repair.

There is one thing that gives me a great deal of hope and that was on display at the Inauguration in the person of Amanda Gorman with her brilliant reading of her poem ‘The Hill We Climb’. This young black woman, full of poise and meaningful words, captured our current moment perfectly and, to me, is emblamatic of the rise of the Millennials and Generation Z to power. She joins the Florida high school students whose work and commitment helped take down the untouchable NRA, the youthful climate change activists, and the committed young people I work with in medicine who are facing the challenges of Covid-19 head on. It’s a generation who clearly sees where the old forms and ways of doing things are broken and who are unafraid of speaking truth to power and moving forward.

The Baby Boom is not going to relinquish social, economic, and political power easily or gracefully but time is coming for them. Demographically, somewhere around 15% of the generation will have died by 2030. They will then die off rapidly over the next two decades, roughly 40% in the 2030s and another 40% in the 2040s. A few will linger on with the last American boomer passing away around 2080 at the ripe old age of 115. There will be a wholesale changing of the guard in society over the next twenty years and from what I have seen, the kids are alright and we’re in pretty good hands going forward.

We’re now at 400,000 deaths in the US from Covid-19, most of whom would not have needed to die had this virus arose at another point in modern US history but, as it coincided with an administration with minimal interest in the commonweal, an accidental plague it did become and we all have to live with the consequences of that and whatever part we played in allowing it to happen. Our fascination with infotainment over real news and analysis, our wish for quick solutions, our unwillingness to endure discomfort for the sake of others – all of these helped the virus establish itself here in ways that have cost real lives and untold suffering. Now we have the chance to make some different choices but it remains to be seen if we, as a society, will be willing to do that. I hope we can.

In the meantime, I’ll still be here. Watching, writing, trying to interpret the course of events in ways that help me make sense of this crazy world we find ourselves in. I’ll continue to follow my particular mantra, one which I have been imparting to medical students for decades: the world is saved one patient at a time. I have hope that the plague will recede enough that other things in my life will get back on track but I am content for the moment with my work, my thoughts, and a little recreation on the side.

Here’s to new beginnings, but in the meantime you know what to do. Wash your hands, wear your mask, social distance, and stay out of indoor crowds. May your vaccine arrive soon should you choose it.

January 18, 2020

Liberty Leading the People. 1830. Oil on canvas, 260 x 325 cm.

It’s MLK day and things are relatively quiet. I’ve learned to steel myself in recent weeks before opening my news feeds to see what’s happened over the last day or so. I was quite relieved to read through my digests this morning to find that all of the threatened nonsense for the long weekend vowed by those responsible for the violation of the Capitol has not come to pass. There have been some rather desulatory state level demonstrations, but nothing to compare with what came before. Whether it’s because the riot at the Capitol has finally shocked American society out of its complaisance about extremism or because those forces are simply biding their time until we are all looking the other way to organize and strike again I do not know. I simply know, due to my study of historical patterns, that the Big Lie of a stolen election, Trumpism, and the bizzareness known as Q-Anon aren’t going away any time soon and will continue to influence our politics for a while to come.

Martin Luther King Jr. had a dream. I was a toddler when he gave that famous speech and I’ve heard it and its message my entire life. I’ve done my best to live up to the ideals of that dream and to see that my part of the world does as well. I’m human and imperfect so I haven’t always succeeded but I have kept slowly pushing to be a better accomplice for equality and justice and I know that’s going to be a life long challenge. I’m a white male of the professional class, one whose parents believed in education and in books, so I’ve had certain systemic advantages through life. Being openly gay has been a disadvantage but it’s also helped me see inherent biases and to recognize that correcting those biases aren’t any sort of personal attack on me and mine. I think a lot of the support for the toxic brew of white nationalism, evangelical christianity, and populist sloganeering that’s in vogue comes from people who haven’t been able to understand this, that changing society to allow broader anticipation isn’t about tearing down what is, but rather about adding to and strengthening to allow others to contribute their inherent gifts. It takes tesserae of all shapes, colors and sizes to create a moasic.

When it comes to history and the understanding of social structures and movements, I’ve always been of the opinion that the underpinnings are economic in nature. Who has the money? Where does it flow? Who gets to adjust those flows in terms of taxation and economic policy? We’re living in a time of extreme wealth. The amount of money our current titans of industry control would make the Roman Emperors blush. And the pandemic has hastened the concentration of wealth into fewer and fewer hands as the economic fallout has hit small business far harder than large. When I read about fortunes in the billions, I wonder how one even begins to spend that sort of money? For the most part, it isn’t spent, it’s simply concentrated and the various net worth lists become a sort of score card in the great game of amassing a fortune. Honore de Balzac once wrote ‘Behind every great fortune is a crime’. I wonder if that continues to hold true.

Revolutions of 1848

We’re living in a time, not unlike that of the Industrial Revolution, when a small number of wealthy set national economic policies for their benefit to the detriment of those who actually generated the wealth. In the battle of people vs profits, profits were coming out ahead until about 1848 when various revolutionary reform movements began both in Europe and in the Americas. The pushback, which continued over the next eighty some years eventually led to fair working hours, the abolition of child labor, the idea of the pension, workplace safety laws, the existence of the weekend, and a thousand and one other things that we take for granted. People were finally valued over profits and the resulting policies led to the post World War II world with which we’re all familiar. However, capital and profit always fight back and, since the 1950s, bit by bit, profit has been renegotiating the social contract in its favor. Pensions became 401Ks forcing the middle classes to favor economic policies that were pro-capital and market economy. Recepients of social largesse were recast as moochers and thieves. Public investment in infrastructure was curtailed (compare public buildings and spaces in this country with those in any other developed nation to see where that’s left us).

When a stress such as the corona virus hits a society where the balance is tilted towards profit and away from people, you get what we have seen over the last year. An unwillingness to do the sorts of hard shutdowns necessary to control spread. A lack of response of the government to the people regarding the economic pain and anxiety of even partial shut downs. A public infrastructure eroded by neglect that cannot deliver tools such as PPE or vaccine efficiently. A general sense that 400,000 deaths to date is some sort of bearable collateral damage. A general message of we’re all on our own and good luck to you. Will that start to change this next week with a change of administration? I don’t know. The politics may change but the underlying economics will remain the same without some significant heavy lifting in all three branches of government and I’m uncertain that they’re prepared to do that.

In late January, 2020, a resident of San Jose by the name of Patricia Dowd, a woman the same age as I, developed flu like symptoms. Like most of us, she thought it was no big deal and stayed home treating herself. She died suddenly in her home on February 6, 2020. She was the first known US vicitim of Covid-19. 400,000 more have followed her since then. It only took us five weeks to go from 300,000 to 400,000 and thanks to holiday gatherings, the pace continues to accelerate. We will be at nearly 500,000 deaths on the first anniversary of her passing, more than we lost in four years of World War II and approaching the number lost in four years of the Civil War. We’re well on track for Covid-19 to become the worst mass casualty event in American history. I have hope that we will turn the corner this spring. Vaccines should become more available. They don’t necessarily prevent spread but they definitely prevent the serious forms of the disease that require hospitalization. There is an opportunity, with a new administration, to change the type and tone of public discourse. Better weather will allow more socialization outdoors which is considerably safer.

In the meantime, you all know what to do, vaccinated or not: Wear your mask, wash your hands, social distance, and avoid crowded indoor spaces.

January 15, 2021

I haven’t been able to write for a few days. I don’t often get writers block but every time I sat down to compose something this week I would stare at the keyboard for a while and then find an excuse to do something else. I’m not sure if it’s delayed shock and a need to process last week, a creeping sense of hopeless futility when looking at public health statistics around Covid-19, or just a feeling that I’ve run out of things to say about this peculiar moment in time that we all occupy, when the political and the medical are interlaced in such a unique way. I finally decided this evening that I’m just going to start typing and see what comes out. Sometimes the result is a relatively good piece, sometimes it’s a hopeless jumble massively in need of a rewrite. We shall see.

On the political front, we are just a few days from a change in administration. I, like most of my fellow countrymen, am waiting with bated breath to see if another shoe is going to drop in Washington DC. The most perfunctory look at the rhetoric spewing forth from the extreme right wing suggests that the contretemps at the Capitol last week was not the end and that there are forces out there spoiling for a fight. Will there be more violence in DC this weekend or around next week’s inaugural? I can’t even begin to predict. If you’d told me at Christmas I’d be writing about an invasion of the Capitol building with very real physical threats to Congress within a couple of weeks, I would have assumed you were telling a rather cruel joke. Will action spread from the nation’s capital to state capitals? There’s some suggestion that’s possible. Let’s just say I don’t think anyone will be caught unawares. The possibility of surprise is long gone.

The biggest problem to come out of all this is the continued embrace of the Big Lie – that the election was stolen and illegitimate – by a majority of the Republican Party. There isn’t a shred of evidence that this is true (and a great deal of evidence that it is not) but as long as this farcical notion remains in the air, it’s going to hang over the Biden administration and hamstring it. Politicians, who should know better but who have cynical reasons for continuing the lie for their personal short term political gain, look like they’re not willing to take down The Big Lie for the good of the country and that’s going to continue to be a huge problem going forward the next few years and will likely hamper public health responses and economic recovery. If the federal government is viewed as illegitimate in certain quarters, the motivation for cooperation for the betterment of society is lacking and that’s going to include the response to the corona virus.

We’re at 23.5 million cases of Covid-19 in the country today according to the Johns Hopkins Corona Virus counter. We will surpass 400,000 US deaths sometime between now and the inaugural. If that number were a city, it would be 48th in population in the US, between Tulsa and Tampa. The winter surge, fueled by holiday travel and gatherings, has shown no significant signs of slowing down either locally or nationally. The local hospitals are full. The staff are burnt out. I hear stories of horrible conditions from friends in California. Hospitalizations from Christmas should be starting to peak in another week, from New Years a week after that. Maybe by mid February we’ll start to see better trends.

The vaccines, while off to an encouraging start last month, are bogged down in the same lack of competent federal leadership morass that has taken down pretty much every step of our public health response to the corona virus pandemic every step of the way over the past year. Distribution remains problematic. Some of that is the logistics of transporting and storing a product that requires sepcialized temperature regulation and which has a very limited shelf life. (It must be administrered within six hours of being drawn out of the stored vial). This has led to a lot of head into wall banging in my VA house call program as so many of those patients live in remote rural areas and are not easily transported to a vaccination center. We’re going to have to figure out how to courier doses off to any number of rural homes from Birmingham under a hard time gun. And we can’t just go house to house. Each recipient is going to have to be monitored for a minimum of fifteen minutes after administration and, given the frailty of the population, thirty minutes is a better idea. Draw up in pharmacy + get to nurse + nurse driving to far far away + nurse administering and monitoring adds up to a number of hours and we won’t realistically be able to guarantee more than two or three in a day to fit it in that six hour window. Then we have to account for weather, road delays, the occasional flat tire, and chattering families, starved for company, who don’t want to let the nurse head off to the next stop.

US numbers

I am deluged daily with calls, texts, DMs, emails, and taps on my shoulder in the grocery store asking about when so and so can get a Covid-19 vaccine. I have only one answer. I don’t know. All Covid-19 vaccine in Alabama is under the purview of the state department of public health. They have broken the population down into a number of groups. The first, called 1a, included health care providers and residents in congregate senior facilities. They’ve made significant progress in getting those vaccines out there. Group 1b, which includes first responders like police and those with significant chronic health conditions and those over age 75 will be eligible as of this coming week. The state and counties have set up hotlines for people to call to set up vaccination appointments. Those hotlines fielded over a million calls in a week and haven’t been easy to get through on. The last thing I saw was that all appointment slots were full and they were working on a waiting list.

The lack of coherent federal leadership means that pretty much every state is doing their own thing at the moment. Some are prioritizing community dwelling elderly, some are prioritizing those in occupations with more potential exposure such as store clerks and teachers. The CDC has issues guidelines, but not mandates and, from what I can tell, no one is paying a lot of attention to them. There was agreement that health care providers and congregate living seniors needed to go first but, after that, it’s devolving into a free for all. Add to that the so called ‘warp speed’ program of the executive branch that seems incapable of accounting for vaccine, where it is and how best to get it out there and we get announcements like the one this afternoon where they admitted their highly touted reserve supply which was going to be released to make up for shortages doesn’t actually exist.

How the adenovirus vaccine delivers DNA to a cell

There is one encouraging bit of news on the vaccine front. A vaccine candidate from Johnson and Johnson is starting to show some encouraging preliminary results. It is not an mRNA vaccine like the currently circulaing Pfizer and Moderna products. It uses a modified virus, one which cannot make humans ill, to transport DNA that encodes for the spike proteins of the corona virus into human cells. The cell then makes and expresses these proteins. The immune system recognizes these as foreign and gears up against them, protecting the person if and when the corona virus shows up later as the immune system already knows to knock anything expressing those proteins out. The adenovirus that carries the DNA is much hardier than the mRNA transport system of the current vaccines so it can be stored in a standard refrigerator and, best of all, it’s a single shot regimen. Data from trials is expected to be presented to the FDA in late January or early Februray.

It’s a long weekend. I have writing projects I need to get going on, legal cases that need reviewing, and I need to take down Christmas so I can reinstall my primitive green screen studio in the dining room. Next up: Tartuffe from the same people that brought you The Importance of Being Earnest in December. It’ll be your chance to see me in a 17th century wig.

The vaccine is getting out there, albeit slowly. There promises to be a more robust federal response on the public health front starting in less than a week. The weather will begin to warm so people won’t be as tempted to gather inside. It will get better. I have to keep telling myself that. In the meantime, vaccinated or not, you all know what to do: Wash your hands, wear your mask, social distance, and stay out of crowded indoor spaces. This is particularly important these next few weeks as the pesky British strain that’s more contagious appears to be starting to spread in this country and your local health care provider really doesn’t need the pace of people falling ill to accelerate.

January 10, 2021

And now it is Sunday afternoon. It’s cold in Birmingham, but the sun is out and it’s beckoning me to get outside and take a walk or do something else semi-outdoorsy. Yet here I sit, interior life roiling while I bang out another one of these essays that I have come to call the Accidental Plague Diaries. I’m still rattled by the surreal events of this past Wednesday and, as more and more information comes to light regarding just what happened on the grounds of the Capitol, I become more and more worried that this particular putsch was not the end of something, but rather the beginning of something.

For the most part, I’ve held my tongue on politics over the last ten months, other than the ways in which they intersect with health policy. I don’t especially believe in the vituperative name calling and attacking of personality that much of modern political discourse has devolved into. I believe in attacking misguided policies and problematic social trends. It’s never possible to truly understand the complexities, judgments, and motivations of an individual without knowing them intimately. It is, however, possible, to understand the actions of large groups of people through a study of sociology, economics, and political science. Le plus ce change, le plus c’est la meme chose. I’ve spent years writing political satire for The Politically Incorrect Cabaret. When doing that, I have a couple of rules I try to adhere to. Always punch up, never down. Punching down isn’t satire, it’s cruelty. Make fun of power and postions of power and the roles of power, not directly at the humans who inhabit them. It’s one of the reasons I have not ever been able to satirize the current president. It’s not possible to separate the person from the power and that’s one of the things that has made him so dangerous to our political norms.

There’s a lot swirling out there on the interwebs about the more violent elements behind Wednesday’s insurrection planning additional actions over the next week or so leading up to the inauguration. Whether there is any truth to these rumors, I do not know and will assume that the Secret Service, as a proud group of professionals, will do their duty to keep things safe for all involved and we will have no more paramilitaries stalking the halls of government buildings looking for politicians of opposing beliefs to capture and summarily execute. But do not color me shocked if violence rears up again next week.

The highest levels of government in this country have been lying perpetually for the last four years. Usually it’s been about little things that are easily disproven but, without shame, they shrug it off and move on to the next set of alternative facts. This has conditioned all of us, on both sides of the political spectrum to shrug off lies as par for the political discourse these days. Unfortunately, its also allowed a big lie, the lie that the 2020 election was stolen, to move forward unchecked. There is not one shred of evidence, other than the usual one or two vote errors that turn up when things are looked at with a microscope, that this is true but it became the underlying motivation for last week’s actions. The lie is still out there. It’s still motivating a substantial portion of the population. It’s still ascribed to by a significant number of national political figures for whatever cynical motives of money or power they may have. It no longer requires Trump for life and it’s going to hover over the Biden administration. The ironic thing, of course, is that there was a stolen presidential election in 2000 where everything hung on the state of Florida. All forensic recounts done show that Gore won the state and should have been awarded the electoral votes but the Supreme Court’s intervention tipped things the other way. The losers graciously accepted and there was some protest but no violence. One wonders where we would be today had we had a Gore vs a Bush presidency in the early part of this century. The current big lie about a stolen election is unlikely to slink off into the sunset in the same way and will probably motivate much of what is to come in both congress and the executive branch.

And this is my biggest fear. This is all happening in the middle of a worsening pandemic that has dropped right off the front pages. The numbers keep going up. Alabama is diagnosing roughly 5,000 new cases daily, the country is adding a million new cases every five days or so and the number of dead on a daily basis is now well over 4,000. This isn’t going away and, in order to start improving these numbers, its going to require an enormous amount of leadership from the incoming administration combined with logistics and resources to make sure vaccines are distributed, hospital pressures are relieved, and appropriate equipment and personnel are in the right place at the right time. If the Biden team has to spend all of its time shoring up political support and defending itself against the big lie, they aren’t going to have the energy and the resources to put into fighting the pandemic the way that they should. It means that the disease will keep on racing through the country, felling tens of thousands who don’t otherwise have to die. And it means that all of my brothers and sisters in health care who have been savaged physically and psychologically by the pandemic will have been written off by society as so much collateral damage, sacrifices on the altar of big lie politics.

A couple of personal stories that have come to my attention recently. In one, a good friend, whose family remains in Southern California, is worried about her grandmother. Grandma has had a fall and has some facial fractures and a subdural hematoma. She was taken to the ER and seen there. She needs neurosurgery to drain her subdural but the hospital is out of the supplies needed to treat her in the OR. Calls to every other hospital in the region reveal no space. She has been sent home to recover on her own the best she can. The family described the ER as a war zone with gurneys everywhere and tents over parking lots to accomodate the dying. She may become a victim of Covid without ever contracting the disease. In the second, a rising star of regional theater, who ran one of the most successful theaters in the Southeast known for its innovative productions, was exposed last year for a long history of racially insensitive and descriminatory actions. He was ostracized, the theater was shut down (more from pandemic related finanical issues than anything else), and he, despite being a gay man from a performing arts background, decided to begin marketing himself on social media as a radical right wing figure and quickly became a darling of Trump circles. There are unconfirmed reports that he was one of those in the Capitol last week. The morals of these stories? Don’t think it can’t happen here or that Americans are exceptional. Our health system is buckling due to years of neglect and moving of its goals away from health to the making of money and it can’t cope with the stresses of the pandemic. If you’re feeling alone and disenfranchised and helpless in life, it’s easy to be caught up in a different pattern if that one gives you positive reinforcement and validation.

I’m hoping the new work week gives me something more positive to write about. In the meantime you all know the drill, vaccinated or not: Wash your hands, wear your mask, social distance.

January 8, 2020

It’s another one of those sit bolt upright at 3:45 AM sort of nights with the head spinning full of half baked anxieties and bad dreams. When that happens, I never get back to sleep again so I might as well grab the laptop, start writing and see what comes of it. In my REM state just beofre I woke, I was having my cognitive faculties checked by some unidentifiable power with one of the standard mental status questions and I had just been asked to name as many words as I could that started with the letter ‘O’. Option, occidental, orthostasis, omicron… and then I was awake and aware.

I assume I’m processing all of the very bad news of the past few days in my own peculiar way. I deliberately did not watch the live news broadcasts of the Capitol takeover as I have come to the conclusion that televised news is in general bad for my underlying anxiety levels. Instead I read analysis, reportage and opinion later, all of which was accompanied by plenty of well composed still photos of what went on. I’m sure you’ve seen them to and for each of us, there is probably one that is the punch in the gut. For me, it was the one of a man flouting the Confederate flag through the rotunda, something that never happened during four years of Civil War. A close second was a trampled American flag replaced on a stand by a Trump 2020 flag. The semiotics of flags is interesting. How we put so much meaning into scraps of colored cloth and how they come to hold our most cherished dreams or deepest fears and even the briefest glimpse of a universally recognized one in visual media, such as the Nazi banner, can immediately change our whole worldview. The last show I did before the shut down, Cabaret, immediately shifts in the audience’s perceptions with the appearance of a small swastika near the end of the first act. One of these days I need to read a good book on vexillology if anyone has a reccomendation.

We may all be distracted by political theater but the corona virus is not going away and continues to pose an imminent threat to the stability of the health system. We’re now topping 4,000 deaths daily in this country (that’s 30% higher than 9/11 and 40% higher than Pearl Harbor on a daily basis). Our local hospital systems are inundated with beds going into waiting areas and some people, who require monitoring but are not in imminent danger, being shuffled into close by hotel rooms. There hasn’t been a day in the last two weeks when I haven’t heard of a friend being diagnosed. Fortunately the majority are young and healthy and seem to be recovering without major incident but I am also receiving daily calls from friends about grandparents, great aunts, and other cherished elders who are not doing well.

My major thought of the day is that the corona virus and our politics are fundamentally the same. Something invades the body or the body politic and quietly goes about its business unseen and ignored until all of a sudden it bursts forth in a reign of havoc. On the micro level, the virus enters the body, generally through the respiratory tract. It’s a simple organism, a protein capsule containing its basic genetic information that allow it to create the proteins of which it consists. It’s so simple that it uses RNA rather than the more involved DNA for its genetic code and doesn’t have the cellular machinery to even replicated itself. Instead, it’s spike proteins attach to host cells, it injects its RNA into those cells and uses the host’s own mechanisms for its replication. One successful viral attachment can lead to that cell releasing thousands of copies of that virus which then go on to attach to other cells and repeat the process many times over. Eventually, the hosts immune system is going to notice the rising tide of invaders and react and the symptoms of disease appear. The devestating consequences of Covid-19 are often the result of an over action of the immune system resulting in inflammatory changes which can lead to organ failure and death.

In the same way, one virally infected individual can enter a social group, appear to be healthy, have no signs or symptoms of disease but shed virus easily to others through close contact and respiratory droplets. If the asymptomatic period is prolonged, the contacts then go on about their business, never realizing they have been exposed and carry it on to others. This coronavirus is infectious but not as infectious as a lot of other common human viruses so it’s quite dependent on human behaviors of congregation to propagate. Transmissibility can be curbed through simple measures such as social distancing and mask wearing. When we refuse to adhere to these simple public health measures, the virus, having no brain or thought, simply takes advantage of our own conscious choices that benefit it. The result of the spread is more and more sick people and, with the traditional gatherings for holidays, the numbers have soared quickly. Our country’s immune system against disease, health care, is becoming overwhelmed and may start to react in ways due to the pressures put upon it that may ultimately end up being damaging, a sort of institutional auto immune process. We’re just very lucky that Covid-19 has a relatively low mortality rate. If the mortality rate were the same as its very close cousin SARS, we’d be counting the dead in the multi-millions currently.

On the political front, there have been inoculums of misinformation, disinformation, and fantasy injected into public discourse. They’ve bred in the darker corners of social media such as 4 chan and 8 chan and Free Republic and seem to be combinations of regurgitated talking points from the Protocols of the Elders of Zion, Mein Kampf, and The Camp of the Saints. They have, through widespread social media, entered the minds of those who understand on some basic level that the political system is no longer responsive to the people, but to wealthy donors who fund campaigns. Those ideas have churned quietly in the dark for years, fertilized by a media ecosystem who understood that they could be mobilized politically, amd have been used by political, economic and religious leaders as a base upon which to amass power and wealth without actually understanding or wanting to do much of anything about the conditions stoking the grievances. The body politic is now fully infected, the show down at the Capitol yesterday was just a symptom that cannot be ignored. The responses I see from many in power are like those of most American’s to disease. Let’s just go down to the urgent care clinic and get a pill and everything will be normal again. I don’t think that sort of magical thinking is going to help in the situation we find ourselves in. The latest polls show that half of rank and file Republicans are convinced that Wednesday’s events are some sort of false flag George Soros/antifa plot. The usual corners of the conservative media ecosphere are bubbling with ‘this is just the beginning’ rhetoric. We’re going to see more. And what of the immune response? Power protecting itself from those without? Will it be proportional or will we develop a severe civic autoimmune disease worse than the original infection? I don’t know. I couldn’t have imagined the events of this year a year ago so I have no idea where we’re headed.

What can I do? I can get my second Covid shot later today. I’ll take whatever after effects it may give. I feel it’s my civic and professional duty to do anything in my power to keep the disease from spreading and to set an example. The serious side effects such as anaphylaxis rates among the beta test group of health care professionals and long term care residents that have been vaccinated so far appears to be about 11 in one million and, as far as I know, no one has died. The current death toll from Covid in the US is about one in fifty. I’ll take my chances with the vaccine.

In the meantime, you all know the mantra. Even if you’re vaccinated: Wash your hands, wear your mask, social distance.

January 6, 2021

Perhaps the most appropriate epiphany for today

Happy Epiphany! And perhaps, in the nation’s capital, another epiphany of sorts is taking place in which leaders who have tolerated inexcusable behavior for short term political gain are finally having their eyes opened to the consequences of indulging the segment of the population who have abandoned reason, the rule of law, and other bedrock principles of our constitutional republic. I will leave it to others much better versed in the ins and outs of politics to opine on the events of today, which are still unfolding and time will tell if this was a storming of the Bastille or a manning of the barricades of the June Rebellion as portrayed in Les Miserables. Hopefully, those on the right side of the aisle are being reminded of the story of Frankenstein’s monster and those on the left that fulfilling a corporatist agenda at the expense of the people may not be the best way to govern going forward.

I am most concerned about today’s events in regards to the trickle down to issues of public health, something I do know a bit about. Covid numbers continue to skyrocket, both locally and nationally. US cases, which crossed the 20 million line on New Year’s day are now well above 21 million and the number of dead in the country is nearly 360,000. There are few hospital beds to be had anywhere in North Central Alabama as ward after ward is transformed from its usual purpose into a Covid unit. My inpatient brothers and sisters are absolutely exhausted and the onslaught shows no signs of slowing. On a more personal note, I have a panel of roughly 175 house call patients I take care of, mainly elderly and chronically ill. Five of them died over New Year’s weekend alone.

Inside the Capitol earlier today

What effect is the chaos in the capital/capitol going to have on the already inadequate federal response to the corona virus? Well, given that the government has pretty much under responded at every step of the game since a year ago this month, it may not be much. The biggest issue I see is federal resources and attention, that should be going towards saving the citizenry may get sucked up in the political maelstrom and that with uncertainty at the top, bureacracies will tread water rather than take action leading to futher delays in vaccine delivery, or allocation of needed safety equipment and personnel. There’s also the issue of the news cycle and the media/culture’s collective attention span of hours to days. Protracted problems will push Covid-19 news off the front pages and if it isn’t talked about much over the next two weeks, we’ll have a certain amount of societal amnesia while the cases increase, the medical system buckles further, and the death toll rises.

The pictures out of DC this afternoon show a lot of people from all over the country bunched very close together and generally unmasked. At the end of the day, they’ll board their charter busses and head back off whence they came having done a lot of intermingling of their germs. I wonder if the new more highly infectious UK variant is in the crowd and will use this day of problematic behavior to quickly pop up here, there and everywhere over the next few weeks. Most of the left wing protests of this past year, which had equally large crowds , tended to encourage social distancing and mask wearing and, to my knowledge, no major outbreaks of Covid-19 were ever traced to them. That was not true of Sturgis and is unlikely to be true of this event.

Outside the Capitol earlier today

What does all this mean? I don’t know. As I write this, things are still going on at the Capitol but we’re just a few minutes away from a 6 PM Eastern Time curfew. Hopefully things will be more orderly tomorrow and our politicians will start to think themselves out of the pickle they have placed themselves in with their conniving and dealmaking and refusals of holding to account of the last few years. I keep returning to an essay Masha Gessen wrote in the New York Review which was published on November 10, 2016 called “Autocracy: Rules for Survival”. Ms Gessen, a refugee from Russia who has seen it all knew what was coming and laid it all out. Listen to your friends who are recent immigrants from more autocratic regimes. They’ll tell you how to approach this sort of political turmoil. We Americans have little experience of it but that doesn’t mean it’s new to the world.

Before pouring myself a stiff drink and deliberately not turning on the news (I’ll be able to learn what I need to know without pundits yelling in my face), I’d like to take a moment to celebrate some of the things that are right with the world. We’ve made it into a new year (and those who thought that a mere turning of a calendar page was going to reinvent the world were deluded) but it’s nice to know that 2020 is behind us. There’s a lot of creative energy bubbling up in arts communities as people get over the shellshock of lockdowns and quarantines and start experimenting with new forms of expression. The Ratatouille musical that grew out of amateurs on TikTok adding on to each other’s creations helped point the way to what theater can be in isolation and raised $1.5 million for The Actors Fund. I have a couple of projects coming up – a reading of A Midsummer Night’s Dream in which I am essaying Bottom (fortunately my asses ears arrived from Amazon yesterday) and a full Zoom production of Tartuffe in which I am Orgon, being done by the same people who did The Importance of Being Earnest this past fall.

Do not despair. We aren’t in a civil war yet. Live, laugh, love – just be sure to do it with hand hygiene, masks, social distancing, and not crowding into indoor space.

January 3, 2021

And we’re off into the new year, ending up a holiday weekend with the slog of regular work weeks lined up for the next few months. The US celebrated New Year’s day by surpassing 20 million documented Covid-19 infections. We hit 10 million cases this past November 9th meaning it took us only 52 days or less than 8 weeks to double the case load. And it doesn’t look like things are going to slow down anytime soon. We have yet to see the full surge in cases related to Christmas. Those won’t peak for another week or so. I wrote a good deal about numbers in the last one of these posts so we’re going to skip those for now. They were mindnumbingly bad then and they remain that way now.

The most interesting trend to watch over the next few weeks (other than the not especially entertaining circus in Washington DC) is going to be how vaccine roll outs proceed with the holidays out of the way and a significant number of first responders and health workers having received their shots. The federal government, with the current administration’s laissez faire attitude towards matters of public health, has devolved responsibilities to states without a lot of guidance and the states are doing about as well as you might expect – from lines of octagenarians camped out overnight in Florida to officials sneaking their friends and family into vaccination sites in Tennessee. Alabama is actually doing a decent job from what I can tell. The only thing I can fault them on is not communicating clearly with the public as to when vaccine will be available for community dwelling people at risk, but I’m pretty sure that’s because they don’t know themselves about how many vaccines will be available on what schedule and they want to be sure that whatever system they put in place is going to work as advertised and not fail under the weight of poor planning.

There’s been a minor skirmish in the gay community over gay health care providers who received their vaccinations and then immediately took off for Puerto Vallarta for a circuit party full of bronzed bodies dancing on the beach with lots of unmasked/lack of social distancing selfies popping up on social media. It reached a height of surreal when, on New Year’s Eve, a party boat full of guys capsized off the coast leading to the need for a water rescue. No one was physically hurt from what I can tell (although some puffed up egos were likely badly bruised). No reports on if the guys on shore sang ‘There’s Got To Be A Morning After’ in four part harmony while this was taking place. The basic issues seem to be two: a flaunting of privilege and the possibility of adding to case loads in a poorer community/country whose health system is straining under the number of cases already present. While I absolutely understand the need for gay professionals working in the relatively homophobic environment of medicine to go let off steam with the tribe, and have done so myself, the timing of this event appears to be, how shall we put it, poor.

It would never have occured to me to try and book such a trip at this moment. I’ve been leery of even heading for Gulf Shores or Pensacola currently due to the wild spread of Covid in the area. I’m not sure that I would go for the next month or two, even though I will be fully vaccinated. I miss travelling, I really do. Long trips to new places or even weekends in New Orleans or Savannah or at the beach but I’m doing my best to be part of the solution and to set a good example. Full disclosure: I have put down a deposit for a trip to Europe next fall as I am very hopeful that with a new administration and new approaches to public health policy, we’re going to be in a much better position by summer. I am, however, setting it up in such a way that I can walk away from it up to the day before if things are not going well with Covid and making the trip would be irresponsible on my part.

A lot of people tell me that these essays are helping them understand Covid, our health system’s response and what’s going on in society. I’m glad to be of service and pleased that these writings, which I took on to help me understand all of this, have found an audience (and are in the process of being made into a book. I hope a few of you will consider a purchase when it is finished). Of course, this does make me a bit of a role model and that’s always a hard position to be in. I get it at work all the time. New patients and their families come in saying things like ‘we’ve heard so many good things about you’ and that leaves me with the sinking feeling that I have to live up to a reputation that I may or may not deserve. I’ve always been of the philosophy of do the best you can one patient at a time and let the chips fall where they may. Because so many of my patients have been ignored or over treated by the health system in general, I can usually make them feel better simply by listening and helping them unlock their own inner powers of wellness and I guess that’s what gets circulated in the community. There are days when I walk into work and I’m tired and cranky and would rather be anywhere else but I put on my physician role and after fifteen minutes or so, I’m Dr. D again and ready to heal what little bit I can.

This is what makes Covid so difficult for me. There’s very little I can do other than watch and wait and treat some symptoms. Viral illness is like that. I have been trying to push a little harder on good health habits as it appears that those with well balanced health, even of advanced age, are far less likely to develop complicated and serious disease. So I encourage more exercise and a well balanced diet and talk about supplements where there is some evidence that there might be benefit and help get people off excess medication which might harm them in the long run and go over the basic mantras of avoiding viral disease like hand hygiene, masking and social distancing. I’ve watched my loved ones die of disease processes I could do nothing about, despite all of my training and intellect. I do my best to keep myself from having to be in a similar position with my patients. I know how to have those ‘there’s nothing more that I or the health care system can do’ conversations with patients and families but it never gets any easier. At least with Steve and with Tommy, I was able to sit by their bedsides and hold hands. I can’t imagine the pain of having to say goodbye via a borrowed iPad and FaceTime. So please, all of you, be role models in your own right. You know what to do. The more people who do the correct things, the faster this all comes under control. It’s been studied. When the privileged are seen flouting rules, the public assumes the rules need not be kept and we end up in situations like the one we find ourselves in. It’s hard, but it’s the right thing to do.

December 30, 2020

I was going to write the next one of the Accidental Plague Diaries tomorrow and reflect on New Year’s Eve and the end of 2020 but the news that’s been pouring in all day locally has been such that I am compelled to let me fingers dance across the keyboard an evening early while I try to wrap my head around it. We’re going up in proverbial flames and I feel like I have a cracked and ancient squirt gun with which to beat them back.

Let’s start with UAB, my home institution. I try to be circumspect in what I say about work but sometimes the word does have to get out. Six months ago, at the summer peak, UAB hospital had about 100 inpatients with a Covid diagnosis, then, as the pandemic came under control, this dropped to about 65 inpatients at a time. With the current surge, fueled by Thanksgiving travel and spread from domestic contacts, UAB has much larger numbers with even higher numbers expected throughout the next few months. We’re a strong and resilient institution with some of the best facilities and personnel on the planet but there’s only so much we can do. Nursing school faculty and students have been pressed into service. I’m on the volunteer list to be called in despite the fact that I haven’t practiced inpatient medicine since the last millenium and don’t even know how to work the inpatient charting system. However, it’s my duty and my call as a physician to be part of the team if they need me.

For most of my time during the pandemic, I’ve been able to help buck my patients up through lockdowns and quarantines and I was relieved that relatively few of them became ill. I had a few here and there who did. Some were miserable and recovered. Some were barely affected. A few were hospitalized. Two or three died. This past few weeks, it has been different. I’ve been fielding calls about diagnoses in my long term patients three or four times a day. I lost four over the holiday weekend. I know of about ten scattered around various regional hospitals. There’s not much of anything I can do for them other than wait. I’m not much of a one for prayer in general but I think a great deal about them and their families and what they are going through. My patients have mainly been at home. They’re pretty compliant with masks and other basic safety measures. Almost all of them have gotten ill at home because of a younger family member coming into the house who hadn’t been as vigilant.

In the state of Alabama, there were slightly over 5,000 new cases of Covid diagnosed today per the Department of Public Health. This was out of just over 7,000 tests administered for a positivity rate of 71%. This means that pretty much only symptomatic people were being tested and we have not been able to even begin testing asymptomatic carriers to tell where the disease is spreading. Today may be an aberration, but the rolling average for the last week is 41% which is still horrific. In order for a pandemic to be controlled, positivity rate needs to be routinely and reliably under 5% and when it’s over 10% most public health authorities state it’s time to take drastic measures. I haven’t heard a peep out of the governor or ADPH recently and I doubt most of the rest of the public has either. With this kind of wide spread, the numbers of acutely ill are going to keep increasing to the point where the health system simply can’t handle it, but flatten the curve is so April. We’ve moved on.

But wait, we have a weapon, a vaccine! Alabama has been allocated 128,000 doses in its initial shipments. There are 300,000 Alabamians in the highest priority group (health care workers and long term care facility residents). More vaccine is promised but we’ve still got a major distribution problem. As of today, only 20,354 vaccines have been administered since the first Pfizer vaccines became available on December 14th. That’s only about 1,200 vaccines a day. At that rate we’ll have the first priority group done around Labor Day. From what I can tell, vaccines are getting to the state from manufacturing plants but, as the federal government has basically abandoned its role in further distribution to the state level, which has neither the expertise nor the systems to take on so mammoth a project, things are, shall we say, slow to roll out. The holidays, of course, aren’t helping. There are those who say it can’t be done any faster. To them, I point to the fact that in 1947, New York City was able to vaccinate all 5 million of its residents for small pox in about a month. It can be done, but without effective leadership it’s like recruiting a thousand volunteers to your search and rescue operation and then not supplying them with maps and just telling them to look where they feel like.

The new variant that was first discovered in England has seeded in this country with case reports from both California and Colorado. Fortunately, it doesn’t appear to cause any worse clinical disease and is as susceptible to the vaccine as prior strains but it is more transmissable. The most recent figures from England suggest that it is 56% more transmissable than the usual. This doesn’t seem like much. For instance, measles is about 1200% more transmissable than Covid, but our brains, which are wired for nice linear math, don’t really get what exponential numbers do until we’re being overwhelmed by them. Let us say I have a population of 100 people with Covid and, for sake of argument and easy math, the disease has a transmissability of 1.0 (its R0 figure) meaning each person can tansmit the disease to one other person. Let us say then that they are no longer infectious so our original cohort of 100 infects 100 more who then infect 100 more and so on. At the end of ten cycles of this, there will be ten infected cohorts or a total of 1,000 infected people. If we up the R0 to 1.56, which is the difference between the two strains, our initial cohort infects not 100 people, but 156 people. These 156 then infect 1.56 times as many or 243. After ten cycles of this, you don’t end up with 1,000 infected people, but rather 15,000 infeccted people. This new strain is not good news and, as we have decided to abandon most mitigation strategies for the holidays, watch out.

I think that’s enough math for this evening. The more I consider this, the more I just want to pour myself another eggnog and bury my head under the pillow.

December 27, 2020

A quiet Christmas chez Andy

The US Covid-19 case counter passed 19 million this morning. It passed 18 million last Tuesday, was at 17 million on the 17th of this month, 13 million at the end of November, and 9 million at Halloween. That’s 10 million cases and more than 50% of the total in less than two months and the numbers show no signs of slowing down. Dr. Fauci, whom I tend to trust on the subject of pandemic disease, was opining early today that things are likely to get worse and worse through the rest of the winter. So how about the mortality rate? We’re at 332,000 deaths. The population of the US in 2019 was estimated to be 328,000,000 so we’re now over 1/1000 of the citizenry dead in less than a year. I have my personal feelings about a federal government that’s presided over the death of a significant portion of its people with what seems, currently, to be a collective yawn but I’ll let you draw your own conclusions.

Maybe I’m using the wrong words here, because the federal government seems to have not presided over much of anything when it comes to either the Covid-19 pandemic or the necessary responses to it, devolving responsibility down to states and regions and, at times, pitting them against each other for political advantage. The end result is a disease that’s totally out of control due to a lack of unified vision and messaging to the American people. Many of my friends are counting down the 24 days left until there’s a change of administration but I’m not holding out a lot of hope for major changes in policy to make themselves felt at ground level much before late spring or summer. We’ve got a few hurdles to make it over before the inauguration – the special Senate election in Georgia on the 5th and the congressional certification of the electoral college vote on the 6th come to mind. Anything could happen with either one of those given the complete abandonment of public service for private gain and short term political advantage by various clowns in Washington DC.

Whether the Christmas and New Years holidays will have similar spreading effects to Thanksgiving remain to be seen. The travel statistics from airports and the like suggest it’s going to be about as bad. The publicity around the fall surge may have caused people to take additional precautions which may mitigate caseload later on, or maybe not. My Christmas was a quiet day with the cats. I didn’t mind it. In looking through my social media feed at pictures of friends gathered by the tree in their immediate family groups, I was actually struck by the thought that this might be just what American Christmas has needed for a while. The amount of weight that has been put on this one holiday over the centuries is more than it can bear and maybe it’s time to start stripping some of it away.

Me having my American Christmas

What is American Christmas? It’s the Nordic/Germanic Jul Solstice celebration with greenery and lights and feasting. It’s the Roman winter solstice celebration of December 25th to which the Christian nativity story was tied. It’s the adaptation of the Dutch feast of St Nicholas that came to New Amsterdam, later New York, and morphed into Santa Claus. It’s the Second Great Awakening’s reaction against rollicking festivities with its images of still and silent nights of snow. It’s the commercialization of the American mercantile world of the late 19th and early 20th century realizing that they could turn it into a consumer free for all. No wonder we all go into it with expectations so high and a vague feeling of disappointment when it’s all over. Tommy and I used to refer to the Christmas season as our annual marathon: decorate house – check, rehearse and sing The Messiah with the symphony – check, prepare wigs and makeup for Red Mountain’s Christmas Spectacular – check, produce and direct the annual children’s Holiday pageant for the church – check, prepare dinner and gifts for family – check, host Holiday open house for several hundred – check. It’s no wonder we rarely went out on New Year’s Eve; we were usually asleep by ten. I miss the results of those times, but not the onslaught and the endless lists and the staying up to all hours. But we did have good times together, whether it was making costumes for the kids, assembly line baking hundreds of Christmas cookies, making enough chili for a small army. I made myself his cider and eggnog this year. I have his chili recipe somewhere but, as it makes somewhere between eight and ten gallons, I haven’t broken it out until I can figure out a way to reduce it somewhat.

The vaccine continues its march across the land with roughly a million Americans, mainly health care workers and long term care residents having received either the Pfizer or the Moderna to date. I think there’s this fallacious idea running around that once we get vaccinated the pandemic will be over. That’s not true. It’s going to take a long time to distribute vaccine to over 300 million, there are huge inequities in the system which will make it difficult for some populations to access it, even if the supplies are plentiful, and there’s politicization of the vaccine, although that seems to be waning somewhat as people are getting vaccinated without major ill effects. Be prepared to wear your masks until summer.

I read a great analogy earlier this week as to why we should care about the disease and its death toll. The author compared Covid-19 to a catastrophic weather event. If a hurricane was bearing down on Houston or Miami, would we not board things up and evacuate? It’s only going to kill 1/1,000 people so let’s just go about our lives as if everything’s normal. It’s a great way of seeing how idiotic the laissez faire arguments that emerge from some quarters actually are. 1/1,000 is where we are today and the curve is still trending up. We could easily be 2/1,000 or 3/1,000 by next summer. There are only three mass casualty events in American history greater at this point: World War II at 418,500, The Civil War at 618,200 and the 1918 Flu Epidemic at 675,000. We’ll have no problems passing World War II in another month or two and I won’t be in the least bit surprised if we have a new record by summer.