April 30, 2021

Dateline West Memphis, Arkansas –

And he’s on the road again… roughly three years after the last time I did the cross country drive. I seem to do them when I am in turmoil. Disconnecting from my usual life and patterns and driving for hours seems to help me recenter in some way. At least this time, I’m not in acute grief over the death of a partner, but I do figure I’m grieving in some rather odd ways – mainly connected to the ongoing saga of Covid that’s defined all of our lives over the last fifteen months. It’s led to lots of little deaths. Deaths of plans, deaths of certainties, deaths of possibilities. And then for me, there’s been the very real deaths that I’ve had to help people through – children grieving parents, parents grieving children, spouses grieving and adjusting to widowhood – as there are now 576,000 empty chairs at the American table and some of those are for my patients and their connections.

The vaccine has been a game changer, of course. My patients, many cooped up for over a year, are able to venture out some without being panicked and families are able to gather together for the first time in a while. Even with that, the legacy of mental health conditions that have been left behind is enormous and I’m only just beginning to unpack that particular box. A large part of my day is spent working through grief and depression and anxiety left in Covid’s wake as that’s now the major thing affecting my patients’ health, far more than their blood pressure or their diabetes. I feel a bit inadequate to the task but I usually muddle through somehow.

I finished up my usual work day around one thirty this afternoon, ran by the accountant to drop off my tax paperwork so I can get my refund, and then headed home to pack. I like to travel and can usually pack pretty quickly and get supplies for anything from snowstorm to desert heat into a single suitcase (one of the things one learns growing up in Seattle when the weather can do anything over the course of a weekend). Suitcases packed, trusty laptop in its bag, I kissed the kitties good by, threw things in the car and headed out. I’m making this trip up as I go along. I have nearly a week to get to Seattle and a continent full of possible routes. We’ll see where I end up.

I decided Northwest was as good a direction as any so took I-22 out of town past all the Walker County towns I know and love from VA house calls, and then on beyond into Mississippi. After Tupelo, which seem s to have little reason for existing other than housing Elvis Presley’s birth place (will he be remembered in another few decades, after the boomers are gone?), I was driving into a glorious sunset straight out of Gone With the Wind for an hour or so as Mississippi gave way to Tennessee. I figured Memphis was far enough and stopped in the West suburbs, on the Arkansas side of the Mississippi for the night. With the crossing of the river, I guess I am officially in the West again. Can’t say much about Memphis. The famous civic pyramid seems to have become a Bass Pro Shop and it was too dark by the time I got to the bridge to see anything of Mud Island.

Tomorrow, I’ll either head west towards Little Rock and Fort Smith or north towards St Louis. We’ll see what I feel like after breakfast. Twenty three years ago, on our drive across country from Sacramento to Birmingham to start our new life, Steve and I stopped for the night in Fort Smith. It was Halloween weekend and, while in the motel room we turned on the TV and a local commercial blared for an Evangelical church’s Harvest Festival party, an alternative to demonic Halloween. Biblically correct costumes were encouraged. Steve looked at me, rolled his eyes, and announced that he wanted to stay an extra day so he could show up as Jezebel. (He would have too, if I had let him, but we had a van full of furniture to meet in Birmingham and could not afford the extra time).

My stops for gas and Dr. Pepper show that masks appear to be unknown here in the heartland. I’m trusting in my vaccinated status and I’m still wearing one when going indoors. And keeping my hands washed and sanitized. And keeping a wide berth. It’s not over until its over.

April 28, 2021

It’s April 28th again. Another year past and now Tommy has been gone for three years. I thought about going out to Parrish to put some flowers on his grave but other life chores intervened. I don’t think he minds. He was never one for fuss and ceremony and ritual unless it involved children and socializing them into the mysteries of the grown up world. Valentines? Anniversaries? Forget about it – he had no patience for the Hallmark holidays. I once made the mistake of bringing him roses at work on our anniversary. He was not amused and let me know just what he thought of that gesture and my lack of imagination for executing it in no uncertain terms. But, if a child or group of children of his acquaintance had something special that needed celebrating, he was all over that. While packing up the house this last year and moving, I found his stash of all purpose child gifts. They’re being used appropriately over time.

Tommy and I didn’t talk about death much. I think there were two reasons for that. The first was the shadow of Steve that hung over our lives. As Steve was dead, he was both omnipresent and unknowable to Tommy. They never met (well – I did figure out later that Tommy had probably waited on Steve and I at the Eastwood Olive Garden a couple of times after we first moved to Birmingham but neither Tommy or I had any real memories of it). Talk of death with Tommy would, of course, rope Steve into the conversation and that was a subject best left in the past. The second was that Tommy had far too much living to do and way to many plans to let a little nuisance such as death get in his way. Even during that last hospitalization, he was working on wig designs and plots for his summer shows and trying to figure out how to go back to school again for yet another degree (he was interested in seminary with an eye on a concentration in church music and hymnody. I found a few sketches for an idea for a musical setting of the Latin Mass in his papers. That would have been an interesting – and massive project). The one time I remember asking Tommy about what he would want in terms of arrangements should he die, he looked at me and said ‘You’ll have to figure it out, I won’t be here’ and went back to whatever he was working on.

Tommy’s relatively quick decline and unexpected death was very different from my experience with Steve. With Steve, we had roughly two years from the time we learned he was seriously ill with his pulmonary fibrosis until his death. We both knew it was coming, made some basic arrangements and then, basically never revisited the subject until it actually happened. There was no need. We lived our lives around his living, not his dying and those two years were some of the best times we had in our thirteen years together. Steve let go of the rat race of trying to be successful and make money and buried himself in his art and his garden and his love of the little things in life and was pretty much at peace, possibly for the first time in his life. He had not had an easy existence as a younger man. He came out as a gay man in high school at age fourteen. That’s not an uncommon story these days, but that was 1962 and his attitude from the beginning was to defy the world and anyone in it who would not accept him for exactly who he was. He spent his 20s and 30s in Los Angeles, part of the avant garde set around West Hollywood and Studio City, where he knew everyone and went to all the parties of the demimonde in the late 60s and 70s. He had all sorts of stories. The 80s and HIV destroyed his life and decimated his social circle and friendships, causing him to flee North to the Sacramento area to become his mother’s caregiver after she was diagnosed with cancer and where we met.

Between the two of them, I had nearly thirty years of partnership/marriage whatever term you want to use for it. I wrote a sermon a few years back, before the Obergefell decision, on the word marriage as applied to gay couples and how our inexact language uses a single word in law for two radically different constructs -a civil contract that defines a family unit in the eyes of the state and a sacred covenant that defines a union in the eyes of a church. The pro gay marriage forces were fighting for the contract. The anti gay marriage forces were fighting to protect the covenant. They’re still talking at each other rather than to each other so I don’t believe for a moment that this particular war is at an end. I miss the coupled state, having been out of it now for three years, but I don’t know if I want to do the work necessary to get back in to one.

Keeping a gay male relationship alive and solid is difficult. There aren’t a lot of supports and foundations for it within either gay culture or straight culture. One believes that you should be free to find the next hot thing, the other believes that you’re intruding on sacred ground in some sort of burlesque. This requires two men in union with each other to have to pour enormous resources in terms of emotional energy into the relationship and to be willing to make sacrifices to their socialized roles for the good of the unit. It’s very hard. I have nothing but admiration for my friends who have managed to do it over the years because I know just how much work they have to do behind closed doors and nothing but sympathy for my other friends who can’t overcome all of the obstacles and make it work over time. I’m never going to say never in regards to a potential third husband, but I have no plans to start looking in the near future. There’s a number of hoops any potential candidate would have to jump through and I know I’m not going to just settle to have someone in my life. Maybe I’m a victim of Mona’s Law from Tales of the City as defined by Armistead Maupin – you can have a hot lover, a hot job, and a hot apartment but you can’t have all three at once. I’ve got the job and housing covered so the third might be asking a little too much of the universe at the moment. If I do find someone, going back to Mouse and Tales of the City, I just would like someone with whom I could buy a Christmas tree.

Sleep well, both Steve and Tommy, and know that I am forever richer and better for having been yours.

April 25, 2021

Those of my generation will get it

I still feel like I’m running on empty. Fortunately, only five more days until I get my time off and can hopefully recharge the batteries. One of the major reasons I decided to turn this into a road trip was a chance to simply disconnect from my usual world for a while. The nature of my job and career is such that there are lots and lots of people out there who rely on me for succor and counsel and empathy. I have a lot to give but every one of those encounters leads me to give away a bit of my self and my energy and eventually, the well starts to feel like it’s running dry. A couple of weeks without feeling like everyone wants a piece and I will hopefully start feeling a little more in balance.

Tonight is the Oscars. I’m not watching. This pandemic year as upended my usual moviegoing habits and I’ve seen none of the films up for the big awards. There are a few that are on my radar and which I should catch streaming on one service or another eventually. The theaters are starting to open up again but I don’t think I’ll feel comfortable going in to sit among strangers with my overpriced bucket of popcorn and soft drink for a while longer yet. I’ve been watching more long form television than film recently – that seems to be where all the good writers have drifted to and it comes in easily digestible chunks between work projects, writing projects and keeping things up on the home front in the evenings. There are plenty of older films out there to keep me going when I truly want a movie (or when MNM needs something to review for her column). Will I be able to go to the movies again? I’m sure I will but I can’t imagine feeling safe prior to the fall and even that is going to depend on what happens with Covid numbers and with all of the ramifications of the never ending politics of vaccines.

The big hotspot at the moment in Covidland is India, likely driven by variants which are more highly infectious, although the authorities are still trying to figure out why cases, beaten back over the winter and early spring, started to skyrocket over the last few weeks. There’s so much that we still don’t know about this disease, its pathology, and its epidemiology. Apparently, last month was election season in India with Prime Minister Modi and other politicians addressing huge crowds. Per usual, the virus exploited a change in human behavior patterns to its advantage. There is one variant in India that has the health authorities concerned. It has changes in spike proteins allowing it to bind more tightly to human host cells making it significantly more infectious. If this variant combines with the ones originating in Britain that make it more transmissible person to person, we may have cause for alarm. I have a trip planned for India in the spring of 2022. I shall, as always, be cautious.

This week marks the third anniversary of Tommy’s death. I know it’s time to move on (and in a lot of ways I have) but the whole pandemic nature of our lives keeps me cocooned away from the world when I’m not at work. I’m getting better about going out than I was a few months ago, but seeing people socially still seems a bit awkward and forced. It’s as if the usual rules of etiquette have been put in suspense and we’re all feeling our way together into some new patterns of being with others that are not of ones immediate family circle. Handshakes and hugs are still pretty verboten. Subjects to talk about are somewhat limited when no one has done much over the last year. I feel like I need to take a lesson from Eliza Doolittle and stick to two subjects – the weather and everyone’s health. So if you hear me asking about a new straw hat that should have come to me, you’ll know the reason. I’ve been told the next of the Zoom theater projects is Pygmalion with me as Colonel Pickering so I may be picking up a few Shavian epigrams honestly in coming months.

Just because it’s one of my favorite film costumes ever

I had Hope, the Red Prius, serviced and detailed this weekend, making sure she was ready to drive 6,000 or so miles the next few weeks. The folks at Hoover Toyota told me that all was well so, if the pistons fall out in the middle of South Dakota, you know whom I will be calling on the Gods of the Lakota to strike down in vengeance. I’ve downloaded some decent books to the audible account and I’ve mapped out at least four different routes. Having driven across the country a half dozen times, I’ve seen a good deal of it so which one I take is likely to depend on weather patterns, snow reports, and my mood of the morning after downing a caramel macchiato from the closest Starbucks. Now I just have to pack a few necessities (travel was easier before my dependence on CPAP which takes up a third of a suitcase) and find my decent sunglasses. Yes, I will write my usual travelogues. I need something to write with them: family stories? Covid updates? Discussions of aging and health topics? A bit of all three? I generally don’t know what I’m going to write when I sit down to bang on the keys and produce these musings but I do take requests and often a comment or something someone says to me will inspire a topic.

The weather is lovely – get out and enjoy it, as I did this afternoon with Opera Shots in the Opera Birmingham Parking Lot. The next one is Sunday May 16th at Collins Bar downtown. That block of 2nd Avenue North will be closed so get a drink from Andrew J. Collins and enjoy some good singing. I’m planning on returning from the road that day and whether I turn up or not will depend on when I get back to town. Enjoy your martini, but remember to social distance and keep your mask on around people you don’t know. And grab some Opera Birmingham branded hand sanitizer while you’re there.

April 21, 2021

Drive In Covid Vaccine Clinic

I’m back to normal. Or as normal as I ever get. I think I was born under an eccentric star and have been just a bit off kilter ever since. A number of long deep sleeps and a few naps have restored my equilibrium somewhat and I am back in my usual physical space of feeling just a little bit aged but with the ability to power through usual work days with some left over to expend on a project or two at night. With the book more or less done and nothing much theatrical coming up in the near future, that means the bins of family papers, photographs, old theater programs, and other ephemera that have been staring at me from the front hallway since January must be tackled. It will give me the excuse of scanning in a few more pieces of visual memorabilia to share with my stories I suppose.

My Facebook timeline is a plethora of vaccine selfies as the full opening up of appointments for everyone over the age of sixteen has been accomplished. This means by Memorial Day, a significant portion of the healthy population will have received vaccine and by the Fourth of July, most of those wanting to be vaccinated will have finished their six weeks of marinating and will be good to go. I’m hopeful that means that the pandemic will be under reasonable control by fall and we can resume most normal activities. There are two things that are going to hold this back.

The first is the significant portion of the population that is still holding on to political ideas about the virus and vaccination that are making them avoid getting their shots. If it was a small minority, it would be pretty immaterial as that misunderstood concept of herd immunity would take over and protect society from significantly spreading coronavirus anyway. But it’s not a small minority. Polls suggest it’s more like 30% of the population and that’s a large enough group to prevent eradication of the pandemic. It’s also a big enough group to keep trading virus back and forth setting up new strains which could potentially become more lethal or which will slip by the vaccination rendering that immunity useless. The second is the usual American ideas of exceptionalism keeping us from understanding that this is not a uniquely American problem.

This is a global pandemic. It’s everywhere from the concrete canyons of Manhattan to the jungles of the Amazon to the plains of central Asia. And we live in an interconnected world. Given modern travel technology, most of us are capable of reaching pretty much anywhere on the planet within 24-48 hours and our microbes come along for the ride when we board that Airbus A-320. To truly beat the pandemic, it has to be forced back not just here but everywhere. That means getting out billions of doses of vaccine, many to much poorer countries with sketchier transportation networks and governmental institutions. I wouldn’t want to be the guy in charge of figuring out how to get vaccine to the population of Somalia. With more stable leadership now in place, we can come together with other advanced countries and help with a world wide concerted effort but it’s still going to take a bit of time, energy, and money.

While the pandemic is coming under control domestically (and Alabama still looks pretty good number wise at the moment), it’s still been inching back up around here with cases up about 10% over two weeks ago. Mind you the absolute number looks pretty good, about a tenth of what it was at the peak of the winter surge in January, but any uptick is worrisome. It’s probably the result of spring break, the governor’s letting the mask mandate expire, and a general movement of people back into public space as vaccines take hold. Anecdotally, most of the people being admitted currently are young/middle aged and the mortality rate isn’t quite as high, but a number of them remain extremely ill so please, everyone, don’t fall of the horse right before the finish line. Keep up those good habits until six weeks after your initial vaccination and beyond to protect your neighbors who are behind you in the line.

The world picture is not so good. There were more new cases of Covid world wide last week than in any week since the beginning of the pandemic. Numbers are pushing upward in Brazil, India, and Southern Africa due to more infectious (and in some cases more lethal) variants. They will get here eventually. It’s inevitable. But, with luck, we’ll have enough vaccine out there to keep them from getting a significant foothold in the population and our reinvigorated public health institutions will be able to identify and isolate them quickly, as should have been done last year.

I had a recurring dream with all my weekend napping. I reenrolled at Stanford and decided to start anew on my college career. But I was trying to do it with my nearly sixty year old brain and I was floundering and failing and having a fairly rotten time. None of my classes was meeting where it was supposed to. The layout of the campus kept changing. The bursar’s office was dunning me for tuition bills for courses I was pretty sure I hadn’t taken (History of Roman chariot racing? Advanced Bioplar disorder?) After the third time I found myself back in the same general milieu, I woke up wondering what my subconscious was trying to tell me. Was it a Groundhog Day phenomenon born of this incessant pause in living patterns? Had I sniffed a madeleine before falling asleep and was I trying to recover lost youth? Perhaps my brain knows that I’m approaching a crossroads of some sort and is warning me not to take the same old road but veer onto some other path in the yellow wood.

Seven more work days until I have a chance to try and clear the brain and the plague diary morphs at least in part into a travel diary for a while. In the meantime. Wash your hands. Wear your mask indoors around people you don’t know. Stay out of the mosh pit until at least six weeks after your initial vaccine.

April 17, 2021

I’ve been exhausted this week. Tired to the point of forgetting to set my alarm yesterday and waking up twenty minutes after I should have been at work. I did prove that I can be in a patient room within fifteen minutes of opening my eyes in the morning and I was able to get my schedule back on track but I haven’t done anything like that in years. Usually, on the mornings when I don’t have to get up, I wake up within about twenty minutes of my usual alarm time and then, when I realize I can sleep in, I roll over and go back to sleep for a while longer. The weariness this week, however, has been bone deep. I figure it’s due to the one two punch of Pirates of Penzance being over and having finished the book and gotten it out to my first group of beta readers. I have little on my schedule the next few weeks other than usual work things so I’m going to listen to my body and try to unwind.

We passed three million Covid deaths world wide this weekend. The US total continues to inch up as well and is now at 567,000. It’s not racing upwards as badly as it could, likely because new cases are more likely to occur in healthier and younger individuals, older populations being more likely to have received vaccines at this point, but it’s still on the upswing. It wouldn’t be so bad if the US character regarding health care weren’t out in full force. We’ve more or less decided as a society to allow the vaccine to do all the heavy lifting for us so we can all get back to our usual lives. And the current administration has done a phenomenal job of getting the vaccine out. Half of US adults have now had at least one dose and somewhere between three and five million jabs are happening daily.

US culture has always had a quick fix mentality when it comes to health care. People come to us, as healers, expecting a pill or a shot will take care of whatever ails them. While this may be true of common infectious diseases of the young, it’s certainly not true of the disease processes of aging and body neglect such as diabetes or atherosclerosis. Successful treatment of these generally requires lifestyle modification, prudence and moderation in regards to such things as diet, exercise, and sleep, and a willingness to partner with us for the long haul. Most Americans have difficulties with these concepts. Successful primary care physicians, like myself, have to figure out where the boundaries are between what we can control and help with and what are the responsibilities of patients and their family systems. Those who don’t negotiate that tightrope successfully generally don’t do well with ambulatory care. It’s difficult and most doctors who work with inpatients have, at best, a limited understanding of it. Unfortunately, it’s the inpatient docs that have political clout and the ear of administration.

It takes roughly six weeks from the first shot, no matter which version you get, until you develop full immunity. (Shot one, then shot two three or four weeks later, then two more weeks until full immunity develops for Pfizer and Moderna – Six weeks after the single shot for Johnson and Johnson). Six weeks ago, we were in early March and vaccine was just beginning to become more widely available after having been reserved for health care workers and at risk seniors. The people given vaccine the first week of March have only just become fully immune. Everyone who has received them after that isn’t there yet and we’ve only really opened up the vaccine lines to all comers in the last week or so. We’re not going to have significant population immunity until Memorial Day. This is why it’s so important to continue to wear masks indoors with other people and keep up the social distancing. We’ve still got a ways to go.

The vaccine isn’t 100% effective. There have been roughly 5,800 covid cases in the US in individuals who were previously vaccinated. When you divide that out over the 125 million of us who have been shot up so far, that’s a very small number. The majority of the cases have been mild but 78 of those 5,800 died of the disease. Don’t let all those good habits built up over the last year go to waste yet. It’s going to take a combination of the vaccine and proper social behavior to restore things back to a semblance of normal, not just vaccine alone. There are very few quick fixes in medicine outside of antibiotics and some surgeries.
Sometimes, though, the fixes are unique and idiosyncratic and dependent on the individual. I learned long ago never to argue with success when it came to my patients. Some years ago, an elderly man came to see me. He had an obvious dementia to which he and his family were somewhat oblivious (even when the family had taken him for his drivers license renewal and the examiners insisted on a road test and the first thing he did was drive the car into the dumpster, none of them was willing to admit that perhaps his mentation had changed in his ninety years). When I asked him why he had come to see me, he told me it was because someone had replaced his nose with a metal valve and he was afraid that when he slept at night, someone was going to close it off and then he would die. I sympathized with his plight and asked him how he might prevent that. ‘Oh, I have a sure fire way’ he said. ‘Before I go to bed, I wrap a plastic bag around my head and then rubber band a washcloth over that. Then I put two scoops of vanilla ice cream on the washcloth, put on a stocking cap and go to bed. Works like a charm’. I was a bit taken aback – the only follow up question I could think of to ask was ‘Does it have to be vanilla? Will other flavors work as well?’. He was so pleased with himself, that I let him and his family work all of that out… including the laundry.

Today was Prince Philip’s funeral; he missed completing his hundredth year by only a few months. Her Majesty looked very small and frail and alone. I expect her to go on for a few more years but its likely that her public schedule will be greatly reduced. My cousins, the Earl of Snowdon and Lady Sarah Chatto were amongst the cortege, looking decidedly middle aged. I guess that means none of us is young anymore. I wonder what will happen when the Queen dies? She’s been on the throne for nearly 70 years. Few are left with adult memories of life under any other monarch. I expect the institution of the monarchy will survive. It’s one of the things that makes Britain Britain.

April 13, 2021

Steve and I circa 1993 – not in the birthday shirt

It’s the other side of the weekend. That means it’s Steve’s birthday today. He’d be 73 were he still here, likely running around making art and stirring up trouble wherever he could. That means it was twenty years ago this evening that we had his last birthday party. He loved birthday parties as much as he hated actually growing older. We invited over the few friends we had managed to make since moving to Birmingham – mainly church people as a combination of culture shock and his illness had somewhat limited our socializing over the previous few years. He wore our birthday shirt. It was a shirt he had bought me for my birthday some ten years before. He gave it to me, then decided he really liked it and declared he was taking it back. I wrapped it up and gave it to him for Christmas, he wrapped it and gave it to me for my next birthday and so on. I think it was wrapped and unwrapped more than a dozen times over the years and was a standing joke between us until the end.

That’s the hardest thing about losing your partner. You lose the person with whom you’ve built a history of hundreds of private jokes and pet moments. You want to say ‘do you remember when…’ but the only person that could possibly answer that with a yes is just no longer there. I suppose, in part, that’s one of the things that’s spurred me into writing these pieces over the last few years. I want to keep remembering when and this is one way to get those stories out to a new audience that might appreciate a few of them. Most of my Birmingham friends never met Steve. He became ill about a year after we arrived and before we had had a chance to create much of a social circle and he was gone before I returned to the world of the performing arts that I had left for medicine so many years prior.

I suppose the second week of April is always going to be a bit of a difficult time, as long as I live, due to the proximity of Steve and Tommy’s birthdays. Note to self. Try not to plan anything too emotionally involving for that week going forward. Fortunately The Pirates of Penzance is not Ibsen or Arthur Miller. And it is now over, to be replaced eventually with whatever the next theatrical project shall be. There’s nothing on the horizon yet; I’m not worried. Something’s bound to come along for the summer as things continue to open up. Perhaps this is the summer to revive Shakespeare in the Park. I’ve only done that once and, as much as I enjoyed it, outdoor theater in Birmingham in August is not overly pleasant for either cast or audience due to certain climate peculiarities.

I still have great hopes for summer, despite today’s not so good news about the Johnson and Johnson vaccine. A couple of things everyone should keep in mind. 1) Correlation is not causation. Just because two things happen together in time does not mean that they are linked. 2) The number of reported cases of clotting is very small (six out of seven million doses of vaccine administered). All the case reports involved women between 18 and 48 and the background incidence of significant clots in women of that age isn’t all that different. Women are more prone to clots than men as estrogens are thrombotic in nature. About 0.3% of users of oral contraceptives develop clots because of this. Other risk factors include smoking and being sedentary and we know nothing about how any of these may play into this cluster of cases.

If you’ve received the Johnson and Johnson vaccine, don’t panic, even if you’re a woman under fifty. The chance of you having a problem is about the same as being struck by lightning this next year. If you were scheduled to get it and your appointment has been canceled, don’t panic. There’s plenty of Pfizer and Moderna in the pipeline to make up the short fall and the system has figured out how to get vaccine into people in record numbers over the last month with between four and five million shots happening daily. My biggest fear in all of this is that the media, who long ago abandoned in depth reportage and nuance for sensationalism and click bait, will write a lot of misleading headlines that will push people on the fence away from vaccination and, if we’re going to return to a sense of normalcy, we need as many people immune as possible, whether from immunization or from having had the disease (something I wouldn’t wish on anyone – even mild cases seem to have significant issues with cardiac and nervous system inflammation that have unknown long term consequences).

Alabama may have abandoned its mask mandate, but the city of Birmingham has not. We were doing really well the last few weeks with one of the lowest levels of transmission in the country (only Arkansas had better numbers) and it will be interesting to see if the dropping of the mask mandate by the state will start leading to an increase around the end of the month. I’m still wearing mine. I’ve gotten used to the thing, other than when trying to march and sing at the same time. The British variant has, as predicted, now become the predominant strain in this country which is a problem given that it’s significantly more transmissable than the original strains. The patterns in high transmission states such as Michigan show that it is spreading rapidly in young, unvaccinated populations. The majority of those folk, being healthy, will weather the storm but there are more and more thirty and forty somethings being admitted to hospitals in dire straights with no prior significant health history. These are people who don’t need to die if we will continue to toe the line just a while longer.

Wear your mask in public, even if no one else does. It sets a good example. Keep your hands washed. Get your vaccine.

April 10, 2021

Tommy and I as pirates in another lifetime

Today is Tommy’s birthday. He would be 56 today if he were still living. Perhaps it’s fitting that I spent the day performing for his beloved Opera Birmingham in the inaugural performances of a shortened outdoor romp in the park version of The Pirates of Penzance. He was with me today. I could feel him running around the ampitheater, redecorating the set, supervising the front of house staff, and turning up in the pirate chorus. Gilbert and Sullivan weren’t really to his musical taste but he was all in on any project he had a hand in, whether he personally liked the material or not. He would even have appreciated the weather, with last night’s thunderstorms dissipating by about nine this morning and everything sunny and relatively cool by show time. Other than some minor bobbles with my police choreography in the second show (marching and singing in a mask is enough to make anyone tired), I personally felt it went well and the audience was more than appreciative to at long last attend a live music/theater entertainment conceived to be Covid caution compliant for both performers and spectators.

Many of the patrons were older and therefore have had their vaccines for some weeks and are now venturing out after a year of confinement. The state’s mandatory mask order expired as of yesterday (and our governor is not renewing it but is also not standing in the way of any local ordinances or business decisions) but the city of Birmingham’s remains on the books for a while longer and the audience was compliant with masks and social distancing without complaint. Local numbers have been trending up again the last few weeks, mainly among younger unvaccinated folks. Jefferson County cases, which over the last two weeks had trended down from 80 to about 30 new cases a day, suddenly spiked at the end of last week to over 100 again, likely the result of spring break. Hopefully, it’s a momentary spike and will immediately trend down again. Total US cases keep going up – we’re over 31 million now with more than 561,000 deaths. Only about 60,000 more to go until Covid surpasses the Civil War in terms of death toll and that took four years. On a more modern scale, the number of dead just surpassed the population of Albuquerque to become the 32nd largest city in the country.

I’ve been casting about for a medical topic to write about and it hit me yesterday when one of my patient’s brought in some new patent ‘brain food’ they’ve been taking to stave off the memory loss of aging. I always ask that people bring me the bottles of such things so I can scan the ingredients and determine if there’s anything in them that might interfere with other medications or might cause unpleasant side effects. Most of them are vitamin and mineral supplements (not harmful for the most part, but often not necessary) with various herbs added (potentially problematic depending on the blend and strength). As a physician with a relatively holistic approach to health, especially with the aging (most older people understand their bodies quite well, having lived in them a long time and know what to do to keep them well balanced), I never discourage people from doing what they think is best for themselves, I just try to give them any information I have based in science so that they can make educated choices.

I have a local chiropractor I trust to whom I refer as they can sometimes be more helpful for low back pain than allopathic medicine. I also refer to an accupuncutrist/herbalist locally. There’s a local complementary medicine clinic run by a well trained doctor who works well with the anxious and somatisizers and who is smart enough to refer back to me when he recognizes some real pathology. I don’t see any of these as being any sort of problem for the right patient. So much of medicine is getting people to tap into their own body understanding and wellness that these are just additional tools to do that.

I’m not as fond of the pills. Actual herbs and extracts used in traditional ways are fine but the lumping of a lot of things together, slapping a pretty label on it and advertising it all over late night television is something else. The manufacturers of such products who had long run riot selling pretty much anything in a bottle, were brought to heel by the Dietary Supplement and Health Education Act of 1994. This piece of legislation allows these products to be classified legally as nutritional supplements and therefore exempts them from regulation by the FDA as drugs. In return, they are not allowed to be promoted as a cure for any sort of disease and the labels are, in theory, supposed to match what’s actually in the bottle. (Multiple studies of proprietary studies show that about 1/3 do not contain what’s listed on the label and another 1/3 contain active ingredients which are not listed. A 2013 study of supplements found over 750 varieties that contained unlisted pharmaceutical drugs which should be FDA regulated). That’s why the ads always say things like ‘not intended to cure any disease’ and they are sold for vaguely defined conditions such as ‘wellness’ or ‘more energy’. I gently try to steer people away from them.

At the same time, I do recognize the desperation people feel when faced with serious illness in themselves or a loved one. I’ve felt it myself when confronted with two husbands critically ill with conditions for which I could offer nothing other than love and presence. If I thought there was healing magic in a bottle available, I would have raced out and gotten it, no matter the obstacles. My training, however, makes me understand that miracles are rarely obtained in capsule form. This wasn’t always the case. A couple of generations ago, in the depths of World War II, brilliant minds finally figured out what Alexander Fleming’s orange mold penicillium was actually good for. When applied to injured battlefield troops, it prevented the wound infections and septic shock that had always killed the majority of soldiers and the antibiotic era was born. After the war was over and there was enough of the new wonder drug left over for the civilian population, previously fatal infections were beaten back. Mix this with an intact infrastructure (the only one in the Western World after World War II) and the idea of American exceptionalism in medicine was born and, in the immediate post war years, was absolutely true.

The idea that miracles can be found in pills took full root in American culture and to this day, everyone wants a quick fix two week course of something. While this model works fine for acute infectious disease in the young, it’s not so helpful for the usual chronic diseases of the elderly. The best thing for these is primary prevention, keeping them from ever setting up shop in the first place and this usually requires an understanding of good health habits and a willingness to partake of them routinely. Most would rather do what they want when they want and then demand a fix from the doctor when things have broken down enough to require serious intervention and repair. This does not sit very well with the baby boom in particular. They’re going to be livid in another decade when they finally figure out that neither I nor any other physician in the country has a copy of Ponce de Leon’s map tattooed on our hineys and we can’t turn back time. (Sorry Cher).

If you knew Tommy, give him a thought today. And have some carrot cake in his honor.

April 7, 2021

I heard about another physician suicide this morning. It wasn’t someone I had ever met. I knew who he was from some of his postings in a group for gay male physicians. He was quick with a quip, had a nice sense of humor and was posting his usual bad jokes up until the day he died. It made me wonder just what the mental health cost of this past year is really going to be, especially in medicine. UAB gives us a little survey once a month to check up on our mental health. I have no idea what they do with the data they’re collecting, but no one has ever called me concerned from the chairs office so I figure they aren’t overly interested as long as I keep showing up for work routinely and vaguely on time. (I could be a bit earlier in the mornings, but ‘not a morning person’ doesn’t even begin to cover it as anyone who has ever scheduled a 7 AM meeting with me can attest).

I’m not suicidal and am unlikely to ever be. All of the bad that’s happened in my life, both personally and professionally has given me a rather deep well of resilience that I can draw on. I’ve been through the fire, survived and it’s going to take more than a viral pandemic and a societal shut down to really disturb my equanimity. I’m also of an age where I know I’m looking at the end game of my career. I don’t know how much longer I’ll continue working. It’s going to depend on a number of factors that are in constant motion but I don know I have no intention of being in my eighties and tottering around the office older than my geriatric patients. (I’m starting to get a few patients within a few years of me. That’s scary enough).

I am worried about my younger colleagues. They are giving up their 20s and early 30s to the educational treadmill, being forced into significant debt, and emerging into a health system that no longer truly values what a physician is. The corporatization of healthcare and change over into a health industry that has changed its goals from service and social mission to the manufacture of encounters and hospitalizations for the purposes of profit, regarding the physician as just one more cog in the machine. The system recognizes that the physician is necessary – laws dictate that nothing happens in the system without a physician’s order – but not so necessary that he or she cannot be replaced with a less expensive adjunct such as a physician’s assistant or second guessed by sophisticated algorithms contained within information systems. More and more, physicians in their patient advocacy role, are going to be slowly ground down by the implacable demands of the business side of the health care industry.

Covid has exposed a lot of the problems in the system for physicians. During the shut down, when patients did not want to enter health facilities for fear of exposure, falling revenue streams led to cuts in salaries just as they were being asked to step up to the plate and bring their A game to societal needs. The psychic strain on younger physicians caring for deathly ill Covid patients, many young and with whom they could identify, added additional burdens. The current cadre of young physicians is too young to remember the HIV epidemic. I was in the thick of it and sat at the bedside of a lot of young men in the late 80s and early 90s and held their hands as they died as there was no one else who would do it so those of my generation have experiences we can draw on that the younger ones don’t. The acute shortages of staff and the abrupt rise of telemedicine are leading hospitals to experiment with new ways of providing care that don’t necessarily depend on patient and physician in a one on one setting. Better information systems is leading to outsourcing of services to cheaper labor markets as in all other industries.

I had predicted, decades ago, that the late 2020s and early 2030s were going to be rough time for American medicine. This was based on demography and the aging of the baby boom. In 2030 we hit peak age with the older boomers in the early 80s and even the youngest over 65. I had not forseen Covid and its effects on American healthcare which seem to have accelerated the negative trends so that we are in the midst of this transitional time now, a decade ahead of schedule. I can tell it has hit because the demands on me as a clinician by patients and families are accelerating. The high levels of anxiety and depression engendered by the last year are starting to manifest in somatic ways and with people in constant need of reassurance. The paperwork load, with all of the transfer to telephonic and video conference services has doubled. People, now that they are vaccinated, are paying attention to body signals again in heightened ways and developing weird symptoms which need to be evaluated and followed up on. When this is in an older person, there’s always the question of whether something is a normal phenomenon falling within the ever broadening bell curve or an unusual presentation of something which could be disastrous if missed.

One of the reasons I like being a geriatrician is that so much of our work is team based and I don’t always have to rely just on myself to stay on top of everything that could be wrong with my patients. I’m human. I miss things all the time, but with competent nurses and social workers and pharmacists and therapists also looking at the picture, the missing puzzle piece is usually noticed by someone and we can work together to craft a care plan that will ultimately help. When something goes awry, I often second guess myself and wonder what I could have missed or what I should have done differently. When I was in residency and Steve and I were first together, I had a case like that where my patient died and I was kicking myself at home that evening assuming I had blown it in some way. The next day, at work, I opened up my backpack to find a rubber skull in it with a word balloon coming out of its mouth in Steve’s writing saying ‘Dr. Andy, why you kill me?’. That was Steve.

Set load in – Avondale Ampitheater

Quick switch of subjects. Pirates of Penzance has sold out. We had a spacing rehearsal in the ampitheater this evening and the show is going to work well. We are all now nervously watching weather reports as another storm/tornado front is due in the next couple of days. As long as it passes before Saturday at 2 PM we should be OK. We may have to do our dress rehearsals with umbrellas and gum boots. I must say this was one of the easiest parts I’ve ever had to learn as the majority of my lyrics are variations of ‘Tarataratara’ I had those down at the first rehearsal.

Covid numbers are not looking good. We added more than 450,000 new cases last week in the US and the British variant has become dominant. It takes roughly six weeks between your first jab and maximal immunity setting in so all of the people who have been vaccinated in the last month are still somewhat susceptible and those begining their series now won’t be good to go until June. Therefore, it remains imperative to keep up all those good habits. Wear your mask, wash your hands, keep your distance, even if you’ve had your vaccine.

April 3, 2021

here’s a weird disconnect going on in my head at the moment. There’s the part of me that is starting to believe that the pandemic is nearing an end, that things will continue to open up, that the US of four million vaccines administered a day and a rapid fall in cases from the highs of December and January will continue into a golden summer of everything is all right. Then there’s the part of me that actually looks at the data that the media is downplaying. The numbers of cases are roughly the same as they were during last summer’s second surge; it just seems much lower coming after the huge numbers of this past winter. Mortality hasn’t surged the way it has in the past. I assume this is because more cases are in younger and healthier people as vaccine has been distributed more widely among the elderly and the chronically ill but I really don’t know.

There are worrying trends from elsewhere around the globe. France and Italy are both going back into lockdown in certain areas due to spikes in cases. Brazil, thanks to the Covid denialism rampant in their executive branch, has a heatlh system on the verge of total collapse. More and more variants keep cropping up as large pools of unvaccinated individuals keep propogating virus giving it a chance to mutate and a number of the variants appear to be more infectious than the original. None of them has yet proved to be more lethal but it’s a definite possibility that will happen. As long as a more lethal strain remains covered by the current vaccines, we will be OK.

Alabama’s mask mandate expires on Friday and our governor will not renew it. I’m going to keep wearing mine, mandate or not, as it’s still the right thing to do until the vast majority of the population has been able to be vaccinated. At the rate we’re going, that shouldn’t take a whole lot longer. I don’t know what we’re supposed to do about the portion of the population disinterested in being vaccinated for whatever reason. If it were a very small percentage of the population, it wouldn’t matter as herd immunity would protect the group as a whole, but if it remains the current 30% or so, that falls apart and all we have is a significant population which can keep reintroducing virus variants into the population at large.

Gaiety or gloom, which should I focus on? On both? On neither? I’d prefer the former but I’ve been around too long to ever let the latter go unattended. Bad things are just part and parcel of the world at large and ignoring them doesn’t make them go away. The gaiety side at the moment includes the CDC statement from late this week that it is safe for fully vaccinated individuals to travel domestically. I can now take my planned trip to Seattle free of guilt. I’m still thinking of driving and making it a two week road trip but haven’t completely made up my mind. I have Delta credits from plane fares for trips canceled by the pandemic which I could use instead. Other happy things include Pirates of Penzance which is coming together quite nicely. Masks make it hard to sing and Covid safety protocols make the staging odd at best but we’ve made it through six weeks together with no one getting sick. I can’t say I’ll look forward to rehearsing again in a parking garage, especially in an Alabama spring. Rehearsals have had ambient temps anywhere from the high 30s to the low 80s.

Penelope at her loom

I was part of a Zoom play reading tonight of a play retelling the story of Odysseus from Penelope’s point of view, playing one of the vile suitors who eventually gets his comeuppance once Odysseus returns to Ithaca after his twenty year absence. I’m hoping that some of this kind of work, that allows a cast to be gathered from around the country, continues once the pandemic is past. It allows performers to experiment in some new ways which are rather freeing. The first half of the Tartuffe I filmed has dropped if you’ve ever wanted to see me in a baroque wig. I rather enjoy classical theater and I hope I get to do some more of it as live performance begins to open up again.

I’m trying to think of an amusing anecdote or other fun and pithy thing to write about as I finish this entry in the Accidental Plague Diaries up but nothing is coming to mind. Maybe I should do a few more columns on basic geriatric medicine. Perhaps I should go through my experiences and write down all of the weird little things from my past that I haven’t yet shared and start ticking through them. I’ll take suggestions from the floor.

On a not unrelated note, the book manuscript I have drawn from these Accidental Plague Diaries is finally finished. I need a few early readers to browse the manuscript and give me some feedback before its final polish. To be one of them you must be 1) Local to me in Birmingham so I can deliver you a copy. 2) Willing to read it relatively quickly (it need not be cover to cover – skimming is allowed). 3) Be willing to discuss the answers to a few simple questions with me. If this is you, drop me a message.

March 30, 2021

Numbers from Detroit showing the uptick happening in recent weeks

The news from Covid land is decidedly mixed. I wish it wasn’t. I wish I could say that we are definitely on a downhill slide and that this was all going to be over soon, but it’s just not yet possible to do that. The big push for vaccinations is certainly helping. Most of my patients have been able to at least begin their series and there have been many heartwarming stories from them of finally being able to leave their homes unafraid, reunions with children and grandchildren, and the picking up of social activities for those who have been locked down in congregate living facilities. But it’s still a minority of the population that’s been able to access vaccines to date. It gets better all the time thanks to the efforts of the current administration but it’s going to be a while before everyone who could benefit receives the shot in their deltoid of choice.

On the negative side, the numbers are not looking good. The numbers of cases and the numbers of deaths have both been steadily rising over the last few weeks. I think it’s too soon to say we’re definitely in another surge but it cannot be completely ruled out. What;s driving it? Likely a combination of factors: spring break, a general feeling of that we’re getting towards the finish line so we can relax, governors in more conservative states relaxing mask mandates and other public health measures due to political pressure, the spread of the new variants. The problems with this initial rise over the last couple of weeks is that these might represent the early stages of exponential numbers and, within a month, if they continue to rise in that way, we may be right back where we were in January.

The scuttlebutt among those of us in health care that work the Covid wards is that there’s a bit of a sea change in whom they are seeing. As the elders get their vaccines, the people who are arriving sick as snot requiring ICU care are skewing younger and younger. People in their 30s and 40s who are otherwise healthy devolving from cold symptoms to nonfunctional respiratory systems in a matter of days. We still have a ways to go and it’s too soon to put away your masks and your good habits developed over this last year of pain and loneliness. It’s going to be some months yet before vaccine can really roll out to the younger adult population and, while the chances of any one individual in that group getting extremely ill isn’t great, the vast population means that the absolute number at risk remains high and all of those illnesses and deaths remain preventable.

I’m not sure what to make of the current dissection of the response to Covid by the previous administration that’s occupying the press. Anyone with some knowledge of epidemiology and infectious disease isn’t in the least surprised by the current spate of breathless revelations. Those basic facts were there to be seen by those that looked – from the deliberate hiding and downplaying of deaths in the state of Florida at the behest of the governor to the toadying at the highest levels of the CDC to the political whims of the previous president. I don’t feel any particular sympathy to any of the public figures currently being caught with their pants down over previous Covid responses. They all knew truth. They all chose not to speak it for whatever reason at the time.

One of the chief probllems at the moment remains the language we use to continue our framing and understanding of what is going on with Covid and public health. We use terms such as war and battle. This anthropomorphizes the virus and we then start to presume that it has feeling and thought and strategy. It doesn’t. It’s just a virus, doing exactly what nature designed it to do – spread. It’s spread doesn’t depend on it’s behavior. It has none. It’s spread depends entirely on our behavior. The current rise is likely caught up in our decisions and our choices as individuals and as a society.

This leaves me, of course, as an educated individual both in the ways of humans and the ways of viruses in something of a quandry. I too wish to be free of the proscriptions of the last year and I am fully vaccinated. I have allowed myself a bit more leeway in terms of socialization with other vaccinated folk and I’m not overly concerned about socially distanced outdoor activity (witness my participation in the covid compliant concert staging of highlights of Pirates of Penzance) but I’m not willing to doff my mask, yell ‘Whee’ and dive into a mosh pit. I want to be a good guardian of society and particularly my patients. At the same time, the subtle cues of society are all those of ‘get back to normal’ for both economic and social reasons. it’s not normal yet. It may be more normal than a year ago but it’s not two years ago and if we don’t keep vigilant, it isn’t going to be. I wish our governor, who is allowing our mask mandate to expire a week from Friday, would continue to push it for just a few more months but she won’t for political reasons and I get that. I’m going to keep mine at hand. I’ve gotten used to them. Besides, I have collected quite a few that are fashion accessories.

The second edit on the book edition of these ‘The Accidental Plague Diaries’ is nearly complete. Next stop proofing and then it will be a manuscript worthy of reading. I feel like Little Red Riding Hood – excited and scared that something written originally strictly for myself and friends will soon face a readership who doesn’t know me or how my mind works or where all these strange ideas come from. It will go out there and sink or swim on its own merits I suppose. I have these fantasies of it catching someone’s attention and being nominated for a Pulitzer and then I come back to reality and recognize that if I sell more than 20 copies outside of my immediate circle of acquaintance, it will be a success. My sister has come up with some wonderful concepts for cover art which might sell a few if it ever makes it into a bookstore.

I return to the field with my VA housecalls starting next week. It will be interesting to see what messages of the current administration and public health policy will have penetrated rural Alabama. Until then, keep the mask, keep the hand hygiene, keep the distance.