Like everyone else I know with formal medical training, I have been watching the events unfolding in Washington DC over the last few days with increasing puzzlement. Absolutely nothing that’s happening makes any sense from either a personal or a public health perspective. There are those that claim that the president’s recent diagnosis with Covid-19 was some sort of elaborate ruse but that seems exceedingly unlikely with the thick and fast news of multiple collateral diagnoses within the executive orbit. Then there was the very real evidence from yesterday. I have more than thirty years experience at sizing up aging adults and determining whether they are sick or not in the first thirty seconds of walking into the room and beginning to converse with them. It’s dozens of little cues from behavior to body posture to the look in their eyes that allow you to either tense up and prepare to send them immediately to the emergency department or relax and let them tell their story while you leisurely ponder differential diagnoses in your head. The man I saw walk up the stairs to the South Portico of the White House yesterday evening was sick.

His walking into the White House, a crowded workplace, with full blown Covid-19 while blithely removing his mask told me everything I need to know about the situation. I don’t think this there’s any sort of sinister cabal going on. I think we’re in full blown the inmates are running the asylum mode as anyone with either the knowledge or ability to deal appropriately with highly communicable infectious disease has either been purged or silenced. The virus will therefore continue to keep leaping around the executive branch and I expect the vast majority of those with easy access to the White House will likely be positive by the end of the week. Will any of them die? That remains to be seen. Likely not many but some are likely to become incredibly ill and others are likely to have permanent health complications.

There’s been a lot of posting about karma and schadenfreude (a word most American’s had to look up) over the last couple of days. As much as I detest the politics and policies coming out of this administration, it is made up of human beings and one thing that my religious tradition of Unitarian Universalism teaching me is that every human life has dignity and worth so I cannot wish ill on any of them. I can only say that when you go swimming in a lagoon posted ‘Danger: No swimming. Alligators’ don’t be surprised if you come back to shore missing a limb. Actions have consequences and people who take certain imbecilic actions better be prepared to live with the consequences of those actions.

Will the president recover uneventfully? Will he get worse? Will he be well enough for his next scheduled debate appearance? I can’t answer these questions. All I can say is that by all objective evidence available to me he’s sick, possibly seriously ill, and the puffery coming out of his medical team makes no sense from either a diagnostic or a treatment perspective so there’s really no way for me to have any sort of informed opinion. Things will happen as they will; hang on – the wild rollercoaster of the last few days isn’t likely to slow down for a while. In the meantime, there will be more and more blather of the uninformed, opining on the unintended consequences of the actions of the uncaring. It’s all making me a bit tired so I have gone to bed relatively early.

All I can say is that at this juncture in history, I’m glad I live in a smaller city with a relatively informed population with a high percentage of folk employed in health services. In Birmingham proper, most people are pretty good at social distancing, wearing their masks and not doing anything too crazy. This has kept our caseload relatively constant and allowed the local hospitals not to get too overloaded. I do my part and have given up much that I love for the greater good. Watching those to whom much has been given in terms of money and power blithely wander through life as if those were any sort of protections against the way the world actually works makes me a bit sick. As I have said, actions have consequences. I just hope that my positive actions in favor of protecting people I don’t know lead ultimately to positive consequences in my life. I’m a past master at delayed gratification. I can wait a while longer to find out.

I’m trying to process the events of the last 24 hours or so. In my ongoing saga of chronicling my peculiar take on the effect of Covid-19 on my life and American society, we may have reached an inflection point. I can’t say that I am the least bit surprised that the President has caught the virus. His very public behaviors over the last six months more or less made that inevitable but I’m a bit surprised at the rapidity of change from he’s fine, to he has significant symptoms, to he’s being airlifted to Walter Reed. None of us has reliable data on his health and speculation, while intriguing, is not especially useful. I’ve compared the White House’s response to the novel corona virus to Poe’s The Masque of the Red Death a number of times over the period that I’ve been writing these accidental plague diaries. I have a feeling that midnight has struck and that Prince Prospero and his guests are going to pay the price of believing that wealth and privilege somehow insulate one from science and fact. You can believe in virology and epidemiology or, you can pooh-pooh them for political reasons, but that doesn’t make the science any less true. Viruses have no political allegiance. They simply exist to propagate themselves from one host to the next.

There are those who are descending down the black holes of various conspiracy theories regarding Covid-19, now that it has reached the highest offices in the land. It’s a little silly. The current group of politicians in power in DC haven’t been able to run the government with all of the tools at their disposal. Imagining them running some sort of shadowy network of interconnected outrageous plots out of a Ian Fleming or Robert Ludlam defies belief. Anyone who has ever been a corporate project manager can tell you that human beings in groups just aren’t capable of such Byzantine and opaque maneuverings without the whole thing crashing down because someone wanted to binge watch the latest season of Schitt’s Creek rather than do their portion of the assignment.

The Ancient Greeks would have loved the current situation in the capital. President Trump very much fits their mold of the leader who rises too high, too fast in mockery of the gods and it ultimately undone by his own nature and character flaws. The rapid fire revelations about his tax and financial status, the economic collapse of his campaign, and now the illness, likely linked to the stubborn refusal of him and his followers to obey even the simplest precepts of public health measures to prevent viral transmission. We don’t know what the next act of the drama is going to play like. I know what I would write if I were creating a drama of hubris, but it’s not up to me.

I’ve tried to leave politics out of these diaries for the most part. When it comes to Covid-19, politics is immaterial as the virus is completely apolitical and I feel very strongly that what I’ve been able to learn about the disease and how it affects our lives is a subject that should be of interest to the entire spectrum of opinions. It sneaks in occasionally because the US response to the virus has been allowed to become politicized at nearly every step of the process of pandemic response. We are the weaker for it, hundreds of thousands are dead and, within a month or so, it will move from the fourth worst mass casualty event in American history to the third, surpassing World War II. (If it kills more than 600,000 eventually, it will surpass the Civil War, leaving it only behind the Flu Pandemic of 1918.) Would the impact have been lessened with a less political response? It’s tough to say but we probably wouldn’t be having a mask war in society and adherence to things like masking and social distancing would probably be much greater and our casualty rates would likely be more in line with those in Western Europe.

I hope I live long enough to be able to read the definitive history of the Trump presidency that some Barbara Tuchman of the future will write sometime after 2030, when enough time will have passed for us all to be able to get some perspective on what we are living through. I also have the feeling that this particular moment in history is going to inspire some great artistic works. Trump, himself, is too big a character for traditional film or stage. He is an operatic figure and I think only a grand opera in the Verdi tradition can totally explore his psychology and motivations. (Ricky Ian Gordon – here’s your potential masterwork…) The Black Death gave us the Italian Renaissance. What is Covid-19 going to give us?I too will be checking my news feeds in the morning for the next chapter.

In the meantime, you all know the drill.

Wash your hands.

Wear your masks.

Keep six feet apart.

And it’s another evening of feeling a bit like Neville, my favorite Gashlycrumb Tiny with whom I have always identified. I should be celebrating as the sale of the old house closed yesterday but there’s not a lot of joy in life and society and I really don’t have anyone much to rejoice with once I leave work these days. I did get to meet the new owners of 4334 Clairmont Avenue South at the closing yesterday morning. (I knew who they were through some mutual friends but had not yet had the pleasure of meeting them). They seem sympatico with what Tommy and my ideas for the house were had life turned out differently and we had stayed there for a few decades as originally planned. Their plan for the much needed kitchen remodel was pretty much exactly what we had intended so I feel the house is in good hands and I wish them much joy in the years to come.

Not much exciting going on in my new abode other than a few lessons learned in regards to the production of Zoom theater. The Kelly Green plastic tablecloths from Party City ($1.49 apiece or a roll of 100 feet for $10) make an acceptable green screen for inserting virtual backgrounds, but if you cut them too long and they hand too low, your cats will love batting at them and trying to pull them down at inopportune moments. Those projects are taking up a little time and creative energy but I still have more hours to fill so I bought myself the unlimited access Rosetta Stone language plan and am going back over all the basic languages I have learned over the years for some additional ear training and grammar. I’ve started with French, which I learned as a child and is still fairly intact when I need it but I have to use it routinely to have it come with any fluency.

Where are we with the accidental plague diaries? One million dead world wide, 200,000 dead in the USA and a significant portion of the population still refusing the most basic public health precautions through some sort of misguided political allegiance that I just don’t understand. I did not watch the presidential debate last night. I prefer not to torture myself after hours. From the continuous comments on my Facebook feed, it seems it turned out pretty much as expected and the inability of the federal government to handle a crisis in any sort of measured or logical way was on full display.

I haven’t come up with a new or interesting angle on Covid-19 to write about this evening. That’s been the thing I’ve been most worried about since I started writing these missives more than six months ago. How can I make this one subject fresh and impart fresh insights without getting awfully repetitive. I think I generally do a good job but there are times, like this evening, when the pandemic has dropped to a dull roar out there in the world and I can’t think of much of anything to say about it without going down a path I’ve trod before. New things are published routinely and there are constantly shifting battles and skirmishes between the population and the microbe so that’s unlikely to last. The thing I’m looking for is what’s going to happen later this fall in response to the outbreaks traceable to college and university reopenings? For the most part, the students won’t be overly effected but what’s going to happen to the populations of college towns and institutions in close proximity to colleges such as hospitals and elder care centers? There’s a well recognized pattern. Population behavior changes. Case numbers reflect that change three or four weeks later. Mortality statistics reflect that change another month or so after that. We’re about a month in to fall quarter. Cases are rising in places like Utah driven by University exposures. What happens a month from now? What happens when flu starts circulating? I am keeping my fingers crossed on flu season. As a goodly percentage of the population are being careful about viral exposure, this will interrupt seasonal flu transmission as well as Covid-19 and hopefully keep the flu season on the lighter end.

I haven’t told a story for a while so I’ll end up this evening with one. This one goes back to the summer I was 22. I had graduated from Stanford and was to start medical school in the fall. As a graduation present, my parents gave me a plane ticket to Europe, a second class Eurail pass, a knapsack and some traveler’s checks (remember those?) and told me to go have fun. I had never been off the continent before and was uncertain when I would be again so I was determined to see as much as I could squeeze into my eight weeks as I could. (Fourteen countries by the time I arrived back in the US, exhausted and fifteen pounds lighter from all the walking and cheap eats). About a third of the way through my jaunt, I had taken the train from Paris to the French Riviera and then, after a day or two, onwards into Italy. One Sunday in July, after touring Rome for most of the previous few days, I realized I had a relatively free day as I still had not made it to the Vatican museums and they were not open on Sundays so I decided to take the train down to Naples and visit Pompeii. I caught the first train of the morning. Five minutes after we were to depart, there was an unintelligible Italian address over the PA. Much groaning and everyone detrained and headed over to the second train of the morning and reseated themselves. (I hadn’t a clue what had been said but I could follow the crowd.) Forty minutes later, the same thing happened and the swelling number of irate Naples bound passengers detrained again to board the third train of the morning. This one actually departed and off we went around the bay.

I arrived in Naples later than I had anticipated, toured the museum and then boarded the local train that headed to Pompeii. I made a mistake with this train and ended up getting off one stop too early. (Apparently the stop labeled Pompeii was not the stop for the ruins) and I headed down the road thinking I was in one place when I was, in fact, in quite another. When I realized my mistake, I thought, oh well, and, having taken orienteering in Boy Scouts, that I should be able to get where I needed to go by wandering down the country lanes as long as I kept Vesuvius on my left. Off I went and after about half a mile, passed an Italian farm house where a huge extended Italian family were having Sunday dinner in the courtyard. They leapt up excitedly at the strange young tall blond and obviously lost young man wandering past their compound and soon, I was being dragged in and invited to share the meal. They spoke not a word of English and I not a word of Italian past Prego but we finally found some common ground in French and were able to roughly communicate for an hour while I was offered several sorts of pasta and what I think was veal. I thanked them for their hospitality and departed with one of the sons who looked to be about fifteen who escorted me to the right road towards the entrance to the ruins.

I had a lovely (if somewhat warm) afternoon wandering through Pompeii, and as the sun was going down, headed off to the correct train station to take the train back to Naples. When I arrived in Naples, I was hungry again so I found a little seafood restaurant right on the harbor where they were frying up the catch of the day so I ordered the special (which contained mussels, octopi, seahorses, a couple of kinds of fish and who knows what else) and a bottle of the house wine. It was lovely watching the sun set into the Mediterranean and I kept eating and drinking and then I suddenly realized I had finished off the entire bottle of wine by myself and it was starting to hit. I stumbled to the train station to get a seat on the overnight back to Rome, found myself with a few hours to kill before boarding, and promptly lay down on the floor of the train station and sort of passed out until I was roused by a not overly friendly carabinieri. I was able to get to my feet, produce my ticket to the train, and stumble in the right general direction so I managed to avoid a trip to the drunk tank, get on the train, and more or less pass out again until it pulled up to the station in Rome. By that time I had sobered up, taken a couple of aspirin, had a cup of coffee and headed off to see the Vatican thoroughly hung over. I quite enjoyed the Vatican other than the Sistine chapel. Every time I tilted my head back to look at the ceiling, it would make the headache worse. The moral of the story. Don’t visit buildings with famous painted ceilings when you’re hung over.

Today, I was either a slug or a sloth or perhaps some sort of hybrid. It took me something over three hours after waking up to actually get out of bed and I’ve had two additional cat naps so far and I may be heading for a third. I think my lizard brain has permanently switched from hypervigilance in the face of danger to a state of chronic play dead and conserve energy for further perils to come. I sometimes really do feel like I’m slowly being ground to fine powder between the Scylla of Covid-19 and the Charybdis of Social Isolation and have to remind myself that no matter how horrible things seem to be, I have a roof over my head, food in the pantry, a job that continues to pay me, and a large supportive circle of friends who remain part of my life even if we can’t be together in the usual ways.

I started these posts two and a half years ago in the face of personal tragedy as a way to help myself puzzle out thoughts and feelings and reinvent myself for a new phase of life. I assumed they wouldn’t be of much interest to anyone but I quickly got a response and a loyal readership, especially to my anecdotes about some of the odd things that have happened throughout the course of my life. I started to write those as it was dawning on me that I had aged into being an elder in the traditional sense. The elders are those with the life experience to understand the human condition and to translate it into forms palatable for consumption, originally around the campfire, and then later on in poetry, prose and song that could transfer collective wisdom generation to generation. They are the story tellers. My stories, without Tommy in my life, no longer had a home and were going to die with me if I didn’t start telling them in some form and this seemed as good a way as any to send them out into the world.

I assumed that these posts would revolve around the areas of my life in which new stories might arise… theatrical endeavors, travel, encounters with new and interesting people. But six months ago, all that changed as the whole world shifted and I started to write more and more about Covid-19 and its effects on the health care system, my personal life, and the world at large. And thus, the Accidental Plague Diaries were born. It just happened. I didn’t set out to do it. When I first started my Covid-19 posts, I assumed that the institutions that have saved us from serious trouble with infectious disease in the past would swing into action and that the whole thing would likely be over in six months or so, at least in terms of writing. Now, I can clearly see my own naivete. There is no clear end in sight at this point – and my posts on the subject are now at book length.

Everywhere I go, when I see people whom I haven’t seen for a while, they bring up my writing and how it has helped them make sense of a non-sensical world and how they are grateful for the combination of trying to stick to fact and trying to navigate a centrist position through the hysterical hyperbole that informs reporting on the subject on both sides of the political spectrum. I don’t know what to say. I’m immensely gratified that people like these essays but I hope they realize that I am as lost and confused in modern life as they are and that sitting down a couple of times a week to let my fingers dance over the keyboard is more about educating myself than other people. If I can find the words for difficult concepts that others can understand, then I know I’ve gotten things straight in my mind. And if I can get it together in my head, then I can pull it together to make it through the next day, the next week, the next month…

We’re now at seven million cases of Covid-19 in the US. We were at six million only three and a half weeks ago so we are in no way getting the pandemic under control. It’s now the third highest cause of death in the country (superseded only by cancer and heart disease). The long term effects on those who recover remain completely unknown. There are tantalizing glimpses of why it is so serious in some people and essentially asymptomatic in others. If those could be figured out, we might be able to figure out protections for the more susceptible and let the unsusceptible get on with life but we’re a long way from clear understanding. Life is beginning to return to pre-Covid norms in other parts of the world (but reporting in US media is spotty as it becomes more and more concerned with election politics) but those areas have robust public health programs not undermined by politics with authority to implement tried and true public health measures.

There’s a piece of me that wonders if part of the predicament we find ourselves in comes from the Boom generation’s refusal to accept elderhood. I’ve written before about how Boomers refuse to consider themselves as old, even though the leading edge is now in their 70s. I use the Cher scale at work. Cher was born in 1946, the first year of the Boom. I have my med students rate patient age based on Cher – Cher + 3 years, Cher – 2 years to help them understand just what a demographic watershed that year has proved to be. Part of the reason that the Boom has always felt young is that the generation above them, the Silent Generation, has smashed all actuarial tables in terms of living long healthy lives. Many of the cohort now in their 80s and early 90s remain with us and in quite good shape. The Boom, having always had stable elders to look up to, thinks of themselves as young in part because of that generation who have always been old to them. (Old is always fifteen years older than you are).

There is a lot of speculation as to why the Silent Generation have lived such a long, healthy life. The one that I think is the truth is known as the semi-starved rat hypothesis. This is a phenomenon first noted in rats, but replicated over time in many other species including primates. If you take the young of a species and calorie restrict them, it extends their life span. The Silent Generation was young during the Depression/World War II years. They didn’t starve but weren’t able to glut either. The long lived Silent Generation have helped keep the Boom from embracing their own aging and mortality and, as the Boom have been the political and economic power generation of the last thirty years, they haven’t developed a generational empathy for aging. What does this have to do with Covid-19? If the Boom can’t be old, then they can’t be in danger from things that happen to old people and therefore those things need not be worried about and policies that might help older people aren’t as important. This is being played out in very real threats to the ACA and Medicare which a shift in the makeup of the Supreme Court is not likely to help.

That’s enough for this evening. Going to go back to working on transforming my dining room into a movie studio for Zoom theater projects and have some left over Chicken Korma.

It’s one of those evenings when I’m in a French existentialist mood. Everything’s terrible and nothing I can do or say can make it any better. Time to break out a beret, a black T-shirt, and an unfiltered Gauloise and yammer on about the futility of modern living. But that sort of thing generally doesn’t last with me. I have a deep seated optimism by nature that no matter how bad things seem to get, human beings eventually get their act together and start responding to their better selves. The question just becomes how low can we go before that kicks in or whether it will kick in quickly enough to save us from our worst impulses. I don’t know the answer to these things. I may have to take a sabbatical from my usual diet of political news for sanity’s sake. I don’t watch any of it on television, I’m not that much of a masochist, but I do read relatively extensively on politics, especially as it intersects with health policy so that I have some clue as to how to begin positioning the little corners of health care for which I have some responsibility to weather the storms of administrative and financial craziness that have become all to frequent recently.

I’m not sure what’s put me in such a dreary mood. Nothing too horrible has happened at work. In fact most things are ticking along. There have been some hiccups with expanding the VA house call program into the Huntsville area but nothing that can’t be overcome with some training and attention to staff. UAB is functioning relatively normally in the outpatient arena. Perhaps it’s a side effect of my annual flu shot which I received earlier today. They generally don’t bother me but one never really knows how the central nervous system is affected by the state of one’s physical health. You are living inside of it and are usually the last one to notice anything different. One of the problems with being alone after so many years of coupledom is there’s no one who can look at me at home and tell me when I’m a bit off and my personal barometer may just not be the most accurate. I’m hoping a cocktail, some left over chicken masaman, and some reading of Sondheim studies before a decent night’s sleep will take care of the issue.

We officially passed 200,000 Covid-19 deaths in the USA today. That could easily double again in the next few months. If only those who led our country would approach matters of public health with the speed and gusto they are approaching the prospect of filling a vacant Supreme Court seat. SCOTUS will still be there after the first of the year. Another 100,000 Americans or so may not be. It’s become painfully clear that the powers that be consider all of us not of their class expendable. Couple this with economic imbalance of the type that led to the French Revolution and I fear sometimes we may really all be dancing on the edge of the abyss. And then I decide, no, it’s not that bad and start trying to figure out when I can next go to Seattle to see my family.

The Politically Incorrect Cabaret is talking about doing some on-line content, perhaps some things from the archives edited together with some new stuff. On line theater techniques would allow us to pull in some members who have since moved away. The Ansager would be happy to come out and play. I don’t mind monologuing it but one thing I have discovered is that I cannot sing or learn music well in isolation. Too much of my ability to learn music comes from being surrounded by sound of either accompanist or other singers and without all those subtle cues, I get lost in terms of either rhythm or pitch (often both) and the resulting product is terrible. I also am terribly self conscious when I sing solo. I can do it in character when it’s not me but I have a dreadful time when it’s Andy up there exposed. It’s why I hate recital singing and won’t sing for church outside of choral work. Give me a character and a situation in a theatrical piece where I can work it out in my head as to just why I’m singing and I can do it no problem (except when the part was written for lyric baritone and I have to cheat as a bass-baritone who has gotten lower with age for all those above the staff notes).

People have asked why we haven’t done more Politically Incorrect Cabarets during the Trump era. It’s because out current political moment is nigh on impossible to satirize. No matter what I could possibly dream up, reality will top it next week. Think of all the things that would have been unthinkable five years ago that have become normalized in terms of political ideology and discourse. Politically Incorrect was born, in part, out of a theatrical moment in March of 2003. At that time, as the drums of war were leading up to the invasion of Iraq, performing artists around the world decided to make an antiwar statement and on 3/3/03, theater companies around the world did performances of Aristophanes’ Lysistrata as a message. Some were readings, some semi-staged, some fully staged. I was part of the Birmingham production put on by the Birmingham Peace Project and it was my first appearance as an actor on a Birmingham stage outside of a church show. There is some thought that maybe Birmingham needs a Zoom version of Lysistrata as a reminder. I was the narrator that held that original production together. Tommy was one of the soldiers and I still remember him coming up the aisle with his balloon phallus fully inflated. Fortunately or unfortunately, I don’t think any pictures recorded that particular moment.

I think the thing I’m the most scared of at the moment is the opacity of information regarding Covid-19. The combination of lack of interest from the federal government with the strict control of information that flows from federal sources such as the CDC and the FDA (which is the prerogative of the executive branch – they are all executive agencies) makes it difficult to know where to turn for well sourced science regarding spread, responses, impact of morbidity over time and the like. When the CDC recommendations flop back and forth in a rather ham fisted way, one can only surmise that non-scientists are calling the shots for political expediency. If the political system tries to hide the true extent of the virus and what it’s doing to the population, we’re going to have a world of hurt. I am not a conspiracy theorist. Anyone who has ever been a project manager knows that you can’t keep a dozen people on task and not talking about what they’re working on. You can’t have nefarious complicated cabals of tens of thousands without somebody somewhere accidentally spilling the beans. For this reason alone, truth will always eventually out and if the public ever decides that their loved ones died because the government decided they were expendable or acceptable collateral damage, there’s going to be hell to pay.

Usually, by the time I finish one of these and I’ve been in a funky mood, I’ve straightened my head out a bit. Not so much this evening. Anastasia kitty has decided to snuggle so I’ll finish this up and go back to my reading for a bit followed by my Schitt’s Creek binge watch marathon.

You know the litany:

Stay in when you can.

Wear your mask.

Wash your hands.

It’s that simple.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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