I’ve been looking at the photos of various protests of lockdown orders happening around the country, from waves of people looking like they’re about to storm the beaches of Orange County to angry yahoos overly armed marching on the Michigan capitol building and trying to figure out the various motivations behind these ‘spontaneous’ actions. It’s pretty clear that big money from the usual ‘conservative’ sources is ginning them up and providing logistical support and communications infrastructure. Most of these demonstrations aren’t terribly large when you consider the population as a whole and are being amplified by a media eager for something to provide content and sensationalism and ratings.

Personally, I stopped watching televised news and information programming years ago. Between the rise of Fox and the sale of CNN to Time Warner with it’s transformation from a legitimate journalistic enterprise to infotainment,there’s no cogent analysis or impartial drilling down to facts any more. It’s all dumbed down to some sort of hyperpartisan sports competition cast in terms of which side is winning and it’s not very helpful in understanding what’s going on. Not to mention the sensationalistic punditry that’s designed specifically to engage a viewers emotions. My first prescription for older people with high blood pressure for years is to limit themselves to one half hour newscast of choice daily. That’s enough to keep you up to date. Everything else if filler and is just going to raise your catecholamine levels. Those who actually listen to that advice, a distinct minority, often don’t need further pharmaceutical intervention.

The militia type folks parading around with their AK-47s aren’t especially scary to me, just sad. I see a lot of young men raised on a media image that a major societal transformation would resemble a combination of Mad Max, The Walking Dead, and Fallout Video Games. What did they get instead? People staying home, bonding with their families, working on their gardens, and learning home baking techniques. I think they’re having a major cognitive disconnect. If it ever comes down to shooting (which it probably will somewhere at some point), it’s going to go about as well for them as the second act of Les Miserables when they go up against trained military and law enforcement. I doubt any of the provocateurs has given much thought to such things as intel and logistics.

The much scarier thought to me than untrained hobbyists with assault weapons is the quiet agenda that seems to be playing out at the highest levels of the government and business communiities, the one that seems to have decided that certain classes of people are expendable for the greater good. It’s the sort of thinking we’ve seen before in other societies and even our own (HIV anyone?), Moves are being put in place to hide what’s going on in senior living communities in Florida, in midwest agricultural plants staffed mainly by immigrants, in communities of color in large cities, in the homeless population. It’s a very slippery slope and very easy to begin casting that net wider and wider, especially if there’s positive reinforcement. What do I mean my that? Fewer nursing home residents means fewer Medicaid long term care dollars are needed relieving strained state budgets. A need to keep essential businesses open gives an opportunity to reduce ‘bureacracy’, in terms of worker safety protections, environmental regulations, and allows for union busting. A shrinking of ‘problem’ communities reduces a demand for social services. There’s a word for the merging of the needs of the state with the needs of the business elite, one that encompasses the use of symbols of patriotism, and holds up an idyllic and virtuous people as clean, while those that are ‘other’ are classified as diseased, and it’s not a pretty one.

No matter what the gestalt of the moment is, the virus isn’t beaten. It’s not going away, and it’s continuing to spread. Lockdowns have slowed things but until there’s widespread testing, an effective medical regimen, or a vaccine, there’s no other real weapon against it. We can give them up and try to return to a semblance of normal but doing so will kill a lot of people. What I suspect will happen is we will open up some, more people will die, but we’re just not going to hear much about it. The majority of those who do die will not be reported on by the media who, on a corporate level, have the same vested interest in opening things back up as every other big business. Personally, I’ll keep going to work – it’s my ethical and moral responsibility and I will follow the directives of my employers on staff and patient safety. They have made prudent decisions so far and I trust them to continue doing that. Other than that, even though I’m as ready to bust out of here as everyone else, I’ll continue to stay home. I have books to read, Netflix to binge, jigsaw puzzles to do, walks to take, food to eat, and I’m still trying to move over the course of the next month while using appropriate sanitation and social distancing.

Be safe, be well, wash y’alls hands

The accidental plague diaries need to go tangential tonight, not because Covid 19 has been beaten, or even been beaten back much (despite politicians hankering for everything to open up). The US cases broke one million today and the number of dead broke 58,000, essentially exactly the same as the number of Vietnam War casualties. It’s for selfish reasons. When my emotions go into turmoil, long term readers know I start writing stream of conciousness in order to process and those who are interested come along for the ride and those who aren’t stop reading and keep scrolling to the next cat video or political meme.

I know what the cause is this time around. It’s not work stress (although there’s plenty of that), It’s not isolation cabin fever (going to work regularly has helped keep that from settling in). It’s the date. Two years ago today, in the wee hours of the morning, I got one of those phone calls you don’t want to get. Tommy, who had been finally beginning to recover from serious heart problems after six weeks in the hospital, unexpectedly died in the night. I had steeled myself for the possibility of his death over the preceding weeks given the seriousness of his previously undiagnosed heart issues, but he fought back valiantly, full of plans for the future. The last time I saw him alive, he was making notes on wigs for Beauty and the Beast which was coming up that June. I hadn’t expected it that night, thinking that if he was going to die, that there would be a steady downhill course and time to prepare. It was not to be.

So, April 28th is now to me, a day of unrealness, of having to tell his family, of quickly having to make funeral and burial arrangements, and of having to begin contemplating aging alone, rather than with a loving, enthusiastic, exasperating and unconventional partner in crime. I know the date will lose it’s meaning eventually from experience. I always remember Steve’s birthday and our anniversary when they roll around every year, but I often don’t remember his death day until several days after it’s past. It’s lost its meaning with time as his illness and death recedes in my mind in favor of our years of heatlh and adventure. i know the same thing will happen with Tommy with time; it’s just a little too early.

I think this was my 7th weekend in isolation. It followed the same pattern as most of the others. Catching up on work undone from the week. Doing some writing. A couple of long walks through the neighborhood. A little more sorting of decades worth of accumulated possessions in preparation for the move. I did add a couple of constructive moments to the usual – getting together with Holly McClendon who’s acting as my moving coordinator (I can take no time off from work prior to June for various reasons so someone else has to deal with all the little niggling details) and having Debbie Wiatrak take a look at the new space together with her artistic daughter and giving me some ideas on colors. I think I’ve made final selections. Bolder than the pastels in this house, but not quite as wild as the range of colors Tommy chose for the old one. I have to come up with a name for the new place. I’ve named all my houses. The first thing that came to mind was Covid Corners but I’m not sure that’s the best idea.

I watched the on line Sondheim 90th birthday concert last evening. I had tried to watch it on Sunday but the technical glitches that led to the delay in broadcast meant that I fell asleep about the time it started so I had to wait until Monday after work. Such electronic gatherings may be the future of theater in the short term. I hope not because so much of theater depends on the connection between performer and audience and you just don’t get that in an electronic medium (and why I really don’t like watching theatrical performance on film – it always feels like something is missing.) It was worth the delay and I’m glad I was able to see it. Sondheim’s music has been so much the soundtrack of my entire adult life that any celebration, or new interpretation of the canon always brings me joy. But it was mixed with sorrow, especially Brandon Uranowitz’s performance of ‘With So Little To Be Sure Of’. It’s a song that’s always been dear to my heart and one that always come to mind when I think of my losses. To hear it performed so well when I was preparing myself emotionally for the anniversary of Tommy’s passing hit me and I must confess I cried for a couple of minutes. But the song also applies to this entire moment we’re all going through: “Crazy business this, this life we live in. Can’t complain about the time we’re given. With so little to be sure of in this world…”

I, of course, am not the only person to lose a loved one. There’s a lot of that going around at the moment. Each unique individual loss, whether its Covid or something more mundane, leaves a hole in the tapestry of life and the edges start to unravel. Only a combination of time and other people knit it back up. We all have time at the moment but there’s a dearth of other people. It took a small army of friends, family , and colleagues to get me through my losses with dinners, coffee dates, phone calls, post rehearsal chats, and all the rest of that and I feel so for those who lose someone at this moment of history who can’t draw on those resources in the same way. No gathering at a wake or funeral to share memories and tell outrageous stories, no losing oneself in a crowd reminding oneself that life goes on, no getting down and playing with groups of children as a reminder of the cycles and continuity of the process of life. If you have lost someone recently or know someone who has, my heart goes out.

I’ll try to go back to something a bit more health and science related in the next entry but I needed to get some of this off my brain. If anyone has a particular subject you’d like me to explore, let me know.

In the meantime, be well, be safe, wash your hands.

My handy Corona Virus counter shows we’re closing in on three million cases world wide (doubtless a huge undercount for both political and logistical reasons), one million cases in the USA and just over six thousand cases here in Alabama. The greater Birmingham area remains relatively virus free due to the local population continuing to adhere to social distancing requirements. The state hotspots are Mobile (likely due to proximity to New Orleans) and the Georgia/Alabama border area around Auburn. I have no need to travel to either of those places. I haven’t been much of anywere other than work in the last six and a half weeks. I’m still working on the same tank of gas I put in the car in early March.

There is still a population out there who want to believe, mainly for idealogical reasons, that Covid 19 is no worse than the flu and isn’t worth all the fuss. As a point of comparison, we are currently at just over 51,000 death in the US from the disease (again, likely an undercount due to inconsistent reporting methodologies and spotty testing) and, at current trends, will hit 60,000 by the middle of next week. This means the disease will have killed more Americans in eight weeks than were killed in eight years of misadventure in the Vietnam War. Every one of those deaths was someone’s child, someone’s parent, someone’s colleague, someone’s friend. The ripple effects are going to be enormous and long lasting as we’re still in an upward trajectory.

Some are advocating opening up and herd immunity. Herd immunity happens when enough of a susceptible population is immune to a disease process so that a communicable disease cannot get established and transmitted. It’s what protects the small portion of the population that cannot be vaccinated for medical reasons from common infectious diseases. Enough people are vaccinated to keep it from ever reaching those vulnerable ones. Herd immunity has been studied and is one of the more basic concepts in epidemiology. It is easy to calculate, based on a simple formula which depends on the transmissability of the disease. In simplest form, if an infected person is capable of transmitting the disease to two people, 1/2 or 50% of the population must be immune to achieve herd immunity. If it’s three people, 2/3 or 67%, four people, 3/4 or 75%. The more transmissable, the higher the percentage must be. The transmissability of Covid 19 is hotly debated and is somewhere between 2.2 and 5.7 meaning between 55% and 82% of the population must be immune to achieve herd immunity. In the US, with a population of roughly 320 million, that’s between 172 million and 256 million infections that need to happen. How many excess deaths would that cause? It’s unclear as there seem to be significant numbers of subclinical cases – people who have the disease but never know it. The percentage of asymptomatic cases is unknown and spot studies have shown everything from 5 to 80% which is too wide a spread to be of much use. What is clearer is the mortality rate for symptomatic cases which seems to be about 3.5%. This leaves us with a low of 35 million to a high of 243 million clinical cases to achieve herd immunity and 1,170,000 to 8,270,000 deaths.

It may or may not be possible to save those individuals but the longer we can delay their becoming ill through social distancing and flattening the curve, the greater the chance of developing a vaccine or coming up with medications which, if not cure, can at least lessen the damage the disease causes. Then there are the issues of the health system. It cannot cope with tens of millions of cases at once but it can begin to cope with lower numbers over a longer period of time. We’ve been relatively blessed in Alabama with not a lot of our health care workers becoming ill and stocks of PPE lasting. That’s not true for the country as a whole. I saw somewhere that it’s estimated that 10,000 US health care workers have caught the disease on the job to date. By contrast, in forty years of HIV care, fewer than fifty US health care workers have contracted that disease on the job.

I see the crowds rallying at statehouses, riled up by politicans and economic forces that do not have their best interests at heart and I don’t understand. We all want it to be like it was. I miss getting together with friends, having rehearsal, going out to dinner but I know that as a responsible citizen and member of society, not to mention a health professional caring for a very vulnerable population, that that has to be put on hold for a while. Even if lock down orders are lifted, it’s not going to go back to 2019 behavior patterns the next day. People have learned a lot these last few weeks and are going to be much more cautious in their choices. They’re going to have the freedom to not do things as well as to do things and the economy is going to remain in trouble, driven as it is by consumer spending. There is no way to get through this process without economic disruption whether that’s by shutting things down or by doing nothing and letting a significant portion of the population suffer and die all at once bringing down the health system with it (and the health system is nearing 18% of GDP). And, quite frankly, if those are the choices, I’m happy to take the former.

If no vaccine is found, ultimately we’re all going to be tested by fire and get Covid just as our ancestors all got small pox. The majority of us will survive, life, society and civilization will go on, just different. How different? I don’t know. There are tantalizing clues in studing the pandemics of the past and their effect on society (The plague of Justinian effectively ending the Roman Empire in the west and leading to the development of Byzantine society, the black death of Medieval Europe allowing for the Renaissance, Reformation and modern world, even the Spanish Flu effectively helping end World War I). Unfortunately, I left my crystal ball in an old handbag at the left luggage counter of Victoria Station some years ago so my prognostication abilities for the current pandemic are, shall we say, limited.

Be safe, be well, wash your hands.

And back to the accidental plague diaries I go. The local numbers for metro Birmingham are flattening. UAB and the Birmingham VA have weathered the storm without a major disaster and now the conversation has shifted to how to start thinking about opening things up again while keeping both patients and staff safe. The people at the top calling the shots in both institutions seem to be making cautious and wise decisions with the ability to backtrack if necessary so we’ll see how it goes. I have to give kudos to our governor as well. She has not jumped on the bandwagon of Trumpist conservative Republican southern governors who are running around trying to force things open prematurely for political reasons. She came out today and stated lifting her closure orders is going to be done based on recommendations from scientists, epidemiologists and the department of public health. From what I can tell, the rather odd laundry list of things opening soon in neighboring states has more to do with moving people off of unemployment programs for tax and political reasons than it has to do with any sort of orderly transition based on societal need. Nail salons? Massage studios?

I have a feeling when patient care opens up on an outpatient basis for a return to face to face visits, there are going to be some major changes in patterns of who comes in and when and why. I think video calls are here to stay. There are still a lot of technical glitches but those are going to get worked out over the next few months. It will probably work fine for some sorts of routine follow up but not for everything (and I still have no idea how to do a decent physical via telemedicine. Nothing looks right to me on screen. The VA has been using a lot of telemedicine to get specialty care to rural areas and is way ahead of the curve so I may be doing some of my rural house calls via nurse carried iPad or some such in the not too distant future. Something else I’ve notice is that my hypochondriacs (every doctor has a collection of people that are always ‘sick’ or have new symptoms that must be addressed or are worried about this or that) have gone dormant. When I’ve called them up asking them how they’re doing, they’ve all been fine and stable and without complaints (for the first time in a decade or more). I haven’t quite decided why this is. They may have finally realized what sick really is and have started to understand that they really are relatively well or they may be so scared of visiting a health facility for fear of coming into contact with an infected person, that they’re going to be well unless something is actually seriously wrong. I have a feeling doctor/patient dynamics are going to come out on the other side of the Covid 19 crisis somewhat changed and maybe, with people less interested in accessing health services they don’t really need, those changes may be for the better.

I attended a virtual cocktail party this evening via Zoom. A bunch of folk from the opera chorus got together, each with his or her glass of wine or cocktail. ( I was enjoying a peach hard cider I bought on a whim on my last grocery run). No one has quite figured out the etiquette of virtual gatherings yet but it was good to see everyone, even in a Brady Bunch gathering of squares on my laptop. There’s something not right with my laptops and zoom. On one I can get video and no audio and on the other I can get audio and no video. I settled for the video and also dialed in on my phone for the audio portion. A little clunky but it ended up working. Fortunately, I’ve had some practice with on line social life, even before video was even possible. When Steve was sick and I had a couple of years when I couldn’t really leave the house much other than for work, most of my connections were through email and chat boards and some of the friends I made that way have remained friends for lo these twenty years. (You know who you are.) Just another one of my life experiences that seems to have readied me for this particular moment in history.

There’s a new Facebook group that’s sprung up in the last month for gay male doctors. I don’t know why there wasn’t one before but apparently, given the current social conditions, the time was right, and it’s now up to nearly 5,000 members. The majority are American but there are a few European, Australian, Middle Eastern, and South African thrown in. Despite a tendency of the well built and good looking to throw in some pictures more appropriate for Tinder, it’s interesting to see how much has changed in the last couple of generations. When I was in medical training, there was no one out in medicine. I take that back, there were a few openly gay men in HIV medicine which at the time was in its infancy. Everyone else was pretty strictly closeted whether student, resident, or faculty. I understood the lesson, if I wanted to be successful in medicine, I had to be closeted and play the part society expected. Therefore, no real dating or bonding or getting to know my tribe. I also had no role models for how to live an authentic life in my chosen profession. It wasn’t until I met Steve in 1989 and he let me know in no uncertain terms that if we were going to be together, the closet was not an option, that I came out. Steve came out in the early 60s while still in high school, pre Stonewall and had fought for respect and recognition his whole adult life and he wasn’t going to retreat one step.

The late 80s and early 90s and the cultural changes associated, spurred in part by the AIDS crisis, led to a weakening of some of the barriers and traditions in the medical field and more people started to come out and demand to be recognized. By the time I finished my training, there were one or two out residents in every class and a few of the faculty began to publicly acknowledge what everyone had suspected for years. UAB, being in Alabama, was somewhat lagging when I came here in the late 90s. To my knowledge, I was the first member of the medical faculty recruited as an out individual (everyone else having been closeted until after they got the job), I don’t think they quite knew what to do with me and Steve but they wanted me and my skill set so I got the job. Someone made the right decision for here I sit, 22 years, two husbands, and thousands of patients later. As I look at all the eager young faces in the gay physician Facebook group, internists, pediatricians, radiologists, surgeons, pathologists and so many more, I’ve come to the conclusion that enduring some of what I endured was OK. My generation broke the glass walls and that’s allowing there generation to flourish. They may not recognize the work that was done or the sacrifices that were made but the results make it all worth while. A new generation gets to live up to their full potential and not ghettoized into stereotypical roles.

And so, as Samuel Pepys would say, to bed…

Stay well, stay safe, and wash yo damn hands…

And back to the accidental plague diaries I go. We’re up to about 730,000 cases in the US, 4,300 in the state of Alabama and greater Birmingham is leveling off between 1000-1200 due to our early adoption of shut downs and social distancing. Unfortunately, a certain class of corporate masters seem to have decided that an increased mortality rate is worth it as long as their next quarter profit margins increase and they are getting their minions to agitate for opening things up prematurely. All that’s going to do is cause some flare ups. Fortunately, Alabama is not yet among the states where a Trump rally sans Trump is happening on the steps of the state house. I see pictures of those people rushing and roaring at buildings or at Alex Jones who seems to have been strapped in a barcalounger on top of an SUV, and all I can think of is the zombie hordes in The Walking Dead.

I hadn’t really thought that my job as a physician was going to turn into part call center employee and part tech support. We’re trying to transfer visits to video conferencing software as much as we can. You haven’t lived until you’ve tried to get a ninety year old to download and connect over a video app when neither their cognition nor hearing is what it once was. “I’m sorry you’re having trouble hearing me. Let me use my opera voice”. “No, you need the app store”. “No, don’t open the app, it will run in the background. I’m going to send you a text”. “No, you don’t text me back. You see that link in the text? Just select it”. “No, we can’t do this through Facebook” “Is your daughter there?” “Could you give her the phone? Maybe she can help you.” “Can you turn the camera around? The breakfast table doesn’t help me.” “Yes, I’ll look at your legs but lets not point the camera up your dress.” And on it goes. Every time I successfully complete a video visit, I feel like I’ve won a small victory.

I was somewhat constructive today. I went down to the storage space and retrieved all of the remaining wigs that I could find and put them in the studio so everything would be together when Red Mountain Theater Company comes to pack it all up and take it away this next week. I’m furnishing out the wig room in their new theater complex for them and they’re going to name it after Tommy. Once the studio is empty, I’ll have a staging area for my dejunking of the house. I’m hiring Holly McClendon, Tommy’s wig assistant to be my move coordinator and help make this all go well. As a military wife, she’s moved her family multiple times and knows how to make it all work. I also met the contractor at the new condo and went over all of the minor repairs that need to be done prior to moving and he’s going to get started on them this next week. We both agreed that the bathrooms ultimately will need some updating but that’s a problem for another day. They’re perfectly functional for now. I’m starting to think about colors for the paint job. I keep changing my mind about them. One of my friends has volunteered to come over with her decorator daughter and kibitz next week.

Someone brought up in a comment on a previous plague diary entry that most of the doctors of his acquaintance were quite conservative in their politics and I am not and wondering why that was. First of all, I’m not that far left. I’m a bit left of center for the Pacific Coast. This, of course, makes me somewhere to the left of Vladimir Lenin in the state of Alabama. Second, not all doctors are the same. We’re as varied as any other profession. How the education works is as follows. In order to get into medical school in this country, there are a number of requirements in terms of college level science classes plus the MCAT entry exam. This tends to push most premedical students into majors like biology or chemistry. (I actually majored in both – more fool I). In the 60s and 70s, top grades in science and high scores were all that was necessary and the system churned out great clinicians who were not terribly well rounded people and often had problems with the humanistic aspects of medicine. There was a shift in the 80s (when I was a med student) to trying to admit people who had something else going for them making them a more well rounded person in addition to just grades and test scores. For me, it was my technical theater background. My medical school class included a professional kayaker, a modern dance major,and a table dancer from one of the more notorious bars in Fairbanks. Of course, the education hadn’t changed and most of us round pegs were being pounded into the same danged square holes and were pretty miserable. Everyone gets pretty much exactly the same education over four years.

In your fourth year of medical school, you apply for a residency position. This will determine your specialty. They range from three years for most primary care specialties such as family practice and internal medicine up to six or seven years for the more technical surgical specialties such as cardiac surgery or plastic surgery. Your education will be very different and the demands on you will vary widely depending on what you select. The number of residency slots per specialty is fixed at each institution and the choice of which one to apply for is up to the student so for certain specialties with limited slots and the possibility of a very lucrative career on the far side, there is enormous competition (dermatology, ophthalmology) while others go begging due to lots of slots and low prestige and reimbursement (family practice). I chose internal medicine because I didn’t know what I wanted to be when I grew up. The same process happens again after residency for fellowship (subspecialty training) anything from another additional one to four years depending on what you’re learning. For me, it was two years of geriatric medicine. It’s the second least popular specialty in the country. The least popular is geriatric psychiatry.

Why is that? Because everything about medical training is about diagnosis and cure. In geriatrics, we don’t worry so much about that as we do about how people function and feel. That’s antithetical to the medical mind and makes a lot of doctors very uncomfortable. All of this is a long way of saying that medical trainees start early in their careers to sort themselves depending on interest, drives, and personality types. Surgeons tend to be technicians. They’re good with their hands and they want easily identified problems with cut and dried solutions. Medical subspecialists are problem solvers. They like the puzzle of diagnosis. Primary care docs are nurturers. They want to know their patients as people and recognize that 90% of the issues that bring patients into a primary care office are things that doctors don’t have answers for but the good ones develop strategies that help people anyway. The closer a doc is to the lives his or her patients live, especially if the patients belong to marginalized communities, the more likely they are to understand the downside of what actually goes on in our society and the more likely he or she will advocate for policies or programs that will help the people who entrust their lives to him or her, which in American politics, mean they move left. The technicians, being very removed from the life of their patients and only really encountering them in the artificial world of the hospital, tend to look at the world through the lens of business and personal pocketbook issues.

There’s one huge trend that is pushing these dynamics more and more and that is the influence of women in medicine. Women in this country did not start to go to medical school in any number until the 1970s. There were a few who went earlier (my grandmother graduated from medical school in 1926 – the only woman in her class). One thing I noticed about these pioneers when I started to meet them in the 1980s, fifteen or twenty years into their careers, was that they had to degender themselves to succeed. The feminine had to give way to the asexual. By the time my generation came along, their were enough women in medicine that this was no longer true but there were still some interesting trends. Women were self segregating, for the most part in primary care disciplines. I guess they speak to their nurturing instincts. They are also more flexible in regards to such issues as job sharing and time off which is important when dealing with childbirth and family life. To this day, the surgical specialties still remain heavily masculine but it is changing slowly. A few years ago the scales tipped and there are now more women than men in medical education in this country. I can easily see the entire profession becoming female dominated over the next fifty years and that just might be a good thing.

Enough for tonight. Be well. Be safe. And wash your hands. Holmes and Semmelweis were right.

And just like that, it’s April 15th. In an ordinary year, people would be pounding their heads into their laptops trying to make TurboTax spit out comprehensible numbers and a refund. This is not an ordinary year, however, and taxes aren’t due to July. I actually had everything complete and to my accountant in early February this year, figuring that a late March or early April refund would help fill my coffers for moving expenses. More fool I. I called my accountant late last week and he, like every other CPA is snowed under with stimulus program havoc. Routine tax returns will just have to wait. He’s done my taxes since I moved here during the last millennium so I trust him to do what he knows how to do.

The great shut down of 2020 is, of course, playing financial havoc in more ways than just accountants trying to figure out the byzantine rules of hastily passed small business loan assistance programs. And, as money makes the world go round, the lack of it flowing through the system as everyone retrenches for a more sedentary and less consumerist life, is shaking the powers that be. Conservative ‘grass roots’ protests against shut downs and social distancing are sprouting up. The most visible one today was in Michigan at the state capital in Lansing. Of course what most of the media reports are leaving out is that these are orchestrated by the usual big money conservative families with an agenda – the Lansing rally was paid for by groups tied to the DeVos family of Amway and Secretary of Education fame. i don’t think there’s been much protest on the right wing in decades that hasn’t been paid for by some deep pocket. There are, of course, some economic winners in all of this. The Ravensburger jigsaw puzzle company is having it’s best year in all 138 years of its existence. If you can’t find a jigsaw and are close to me, I have a few I’m willing to give away as I downsize.

The numbers of cases keep going up. There’s some interesting social epidemiological trends happening with fifty states responding in fifty different ways due to a lack of organized central leadership. The one I was most interested in today was South Dakota, a relatively small state population wise, where cases have increased nearly ten fold over the last ten days from about 100 to nearly 1,000. The culprit? The conservative governor’s steadfast refusal to employ any social distancing or shut down orders of any kind. I imagine we’ve only seen the tip of the iceberg there. The pattern will be similar in a lot of rural America. A population that have been fed a diet of misinformation about how it’s a coastal city problem, or no worse than the flu, a hollowing out of health infrastructure through politics and neglect, a hollowing out of community life through the destruction of small agriculture and manufacturing, and the great equalizer – the one large institution where everyone in town meets together day after day. Wal-Mart – the only place left to shop. And we won’t hear about most of the deaths in small town and rural America as it’s outside the ken of most media figures and therefore not really real to them or worthy of much interest.
Tonight’s subject seems to be money. There’s an odd thing going on which at first seems counterintuitive but, on closer examination, makes perfect sense given that we’re operating in a health care industry and not in a health care system. Just at the time that doctors, nurses and other health care workers are being called upon to put themselves in harms way and sacrifice much, including possibly their lives, for the good of American society, they are being faced with pay cuts of 10, 20 and I have even heard some reports of 50%. Why on the one hand are they being lauded as heroes and on the other hand being punished? It’s because health care is big business and it’s a for profit business in most of the sector. Covid 19 is keeping people with other illnesses away from the health care system as they start to realize that whatever is going on with them is not so serious as to risk exposure in a crowded emergency room or urgent care clinic. Visits are plummeting. Doctors are wisely keeping those with chronic illnesses out of hospitals and large clinic buildings where sick people congregate. Outpatient volumes are down 50-75% nationwide and hospital bed occupancy is also way down – to free up more front line staff for Covid cases, and to keep ill people away from active cases as much as possible. Those who are coming in with Covid are, of course, sicker than snot but the numbers are small compared to the numbers of patients that usually show up over the course of the average workday. Without elective surgeries, lab tests, routine check ups and monitoring of diabetes, hypertension, administering of chemo and all the thousand and one other things that happen every day in usual volume, collections are way, way down. If a business isn’t bringing any money in, expenses have to be trimmed. I’m not personally alarmed as I’m a pretty cheap date and I work in a specialty where we all support each other and are socialistic about such things as compensation. It’s going to be different for the young ‘uns, who gave up their youth and put themselves in a huge amount of debt to complete their educations and now won’t be able to manage the loan payments, the mortgage and the kids college fund. The days of the rich doctor were over before I ever entered the profession and primary care and cognitive specialties have never paid terribly well and have had a terrible time recruiting students over the last few decades. That’s going to become harder than ever and I think a number of mid career physicians, when this dies down, are going to look at these trends and get out and do something else with their lives. I’ll keep at what I’m doing. Too old to change.

Speaking of money, as of today I have two mortgages, at least until I sell the house. I am now the proud owner of the new condo as of 2 PM this afternoon. The next couple of weeks will be spent getting it ready for move in and then I’ll figure out some way to actually execute a move in a time of social distancing and corona virus. I’d consider taking some pictures and posting them but it’s all a rather dreary off white color scheme and I think I’ll wait until I get it painted. I don’t think I’m going to go quite for the wild palette Tommy used in the old house, but it’s going to have color and reflect my rather eccentric personality. My favorite type of style is Regency/Empire but, of course, I don’t have much in the way of furniture that actually fits that. Someday. And I can’t go too far that direction in a mid-90s condo block. It would look a bit silly.

I had another topic I was going to tackle tonight, but it’s late and I need to get some sleep before solving the problems of Walker County veterans tomorrow. I’ll take it on in a later entry in the accidental plague diaries.

Be well, be safe, and wash your hands.

And on the other side of yet another socially isolated weekend, it’s time for the next installment in the accidental plague diaries. The date today bookends the date at the start of the weekend. Friday, the 10th was Tommy’s birthday and today, the 13th was Steve’s. If Steve had lived, he would be 72 years old today. I have a hard time envisioning a septuagenarian Steve and I don’t think he would have enjoyed that age much. Perhaps it’s best he left the party a bit early. If someone had told my younger self that by the age of 55 I would be widowed twice and living in Birmingham, Alabama I would inquire just what drugs they were ingesting at the time. Funny how life turns out sometimes.

The Corona Virus caseload locally continues to remain relatively steady meaning that the health system has been able to absorb it and cope with the needs of the ill. From what I can tell, even the more rural areas are starting to understand that they are not immune and are beginning to take social distancing more seriously and doing such things as drive up church where everyone stays in their cars in the parking lot with the pastor on the porch with a PA system. Whatever it takes. When you’re in the more rural parts of the state, there’s not a lot of wi-fi and zoom conferencing available. A decade or so ago, when I was working with the mine workers in rural West Virginia and one of the nurses was having data base problems, she called into tech support (in Minneapolis if I recall correctly) and the tech just wanted her to go down to the local Starbucks and hop on the wi-fi. She had to educate him as to just how rural the hollers of West Virginia actually are and Starbucks would be a three hour trip to Charleston.

I now have a proper video conferencing station set up at my UAB clinic office so I can connect face to face with patients and families with smart phones. It’s not the same as being in the same room, but it’s better than trying to hazard guesses about certain things over the telephone. Now I just have to get the over 80 set to trust smart phone capabilities. Most of them are still tied to their land lines. I’ve considered finally leaving my land line behind when I move to the condo. The problem is that it’s the only thing loud enough to wake me up at night when I’m on call. The cell phone just doesn’t do it. Perhaps if I find a nice klaxon ring tone for it. Tommy was always an early adopter of new technology. He got an iPhone about a year before I made the switch. He would get the latest and the greatest, I would watch him use it for a while, then he would trade up and I would get his old one having finally figured it out. It worked as a system.

Yesterday was Easter Sunday. The Deep South was wracked with thunderstorms and tornadoes and it was a very good day to stay indoors under a blanket with a book and the Xbox. Birmingham proper was fine, just a lot of noise, flash and torrential rains that led to some spot flooding (including the basement of the theater where I do most of my work). There were some tornadoes in more outlying areas but, at last report, no one in Alabama was killed. Mississippi wasn’t so lucky. More storms are due to come through tonight. I was in need of some comfort food and in digging through the freezer, I found a bag of Tommy’s famous chili left over from out last big holiday open house. I thawed it out and had it for Easter dinner – it had lost none of its heat for being in the freezer for a couple of years and, per usual, I had to cut it with a bunch of sour cream in order to be able to eat it. Tommy cared immensely for people. He didn’t always show it and could be a little rough around the edges but he did and the way he showed it best was in cooking for them. He always took great pride in our parties where he basically made everything on the table himself from scratch.

As I’ve been haunted by the ghosts of husbands past this weekend and it has coincided with Easter, I’ve been doing a lot of pondering of life and death. You can’t open social media without seeing a story of some promising life cut short by Covid 19 and we’re all trapped in a miasma of worry wondering whether we or those we love will be next. What do I think about death? I’ve been around long enough and seen enough people die to not be frightened of it. I don’t have any intentions of dying myself in the near future as I don’t think I’m done yet and I’ve barely scratched the surface of my bucket list but, if my number comes up I won’t be able to complain too much. I’ve had an interesting life and accomplished a lot more than most with the time I have been allotted so far. If I do get carried off by Covid 19, I have one request. Whomever puts my obituary together is to call out a certain US president and a certain Alabama governor by name and suggest that my premature demise was unnecessary and directly linked to their inability to follow proper public health protocols in a timely fashion.

Matter is essentially indestructible, just transformable. The matter that makes up our bodies was forged in stars billions of years ago and billions of miles away. We are, literally, made of stardust. We’re allowed to borrow it for a time and then we return it back to the universe where it is recycled in unknowable cosmic plans. What happens to our self, our consciousness, our soul? Frankly, I have no idea, only that whatever it is it’s the same for everyone. The dichotomous afterlife so popular in certain religious traditions makes no sense to me. Each new baby brings light and hope and salvation and, no matter what circumstance or bad choices may bring, that original promise remains buried within so as we all enter the world in the same way, I think we must leave in the same way as well. I do hope to see both Steve and Tommy again after. It’ll be interesting to see what they’ve made of each other and what they’ll think of what I’ve done with the remainder of my life.

Stay well. Stay home. Wash your hands.

I should have written a long post last night, but I was feeling a bit down. It was Tommy‘s birthday (he would be 55 today were he still here) and of course that took me back to memories of his last birthday that we spent together. He was in the CCU recovering from a line infection so he could have cardiac stents placed in what would ultimately be a fruitless attempt to preserve his cardiac function, and by extension his life. Tommy hated what he called Hallmark holidays and didn’t like his birthday commemorated (and heaven forbid if I should give him a birthday present – he eagerly accepted presents on all non-holidays however – part of his contrarian nature). I did ask him that day if he would like anything for his birthday, and he surprised my by saying yes. He really wanted some carrot cake from Continental Bakery (Carole Griffin – he worked for you there at some point in the 90s). So off I went for a small one for dessert that night. I don’t think the nurses were terribly happy as it wasn’t on his diet plan but he had let them know early on that he was going to eat as he pleased, diet be damned. Last year on his birthday, I decided to keep up the tradition and went and got myself a carrot cake. This year, with my trying to minimize community contact, I didn’t go. I did do my once every three week grocery run and while my local Piggly Wiggly didn’t have carrot cake, they had a package of carrot cake Oreos so I bought that instead. I don’t think Tommy would mind, he’d probably find it funny.

This week in April is always a bit hard. Steve’s birthday is this coming Monday. What is it about me and Aires men? I suppose to continue the pattern, if I have a third husband, his birthday will have to be April 7th (and he’ll have to have a first name he doesn’t use and alliterative middle and last names he does. Jon Steven Spivey, Louie Tommy Thompson Jr. ) That may be a tall order. Steve, in contrast, loved birthday presents, the more the better. He also loved parties, especially if he was the center of attention. Tommy loved parties because he loved to see everyone at once and he loved to feed people. Cooking was an innate part of his nurturing instincts. It certainly rubbed off on me, especially about thirty pounds of excess avoirdupois I put on during our time together, which I have been slowly taking off now that I can go back to eating like a thin person.

Enough of my maudlin moment. Time to get back to the accidental plague diaries. Another work week has ended. UAB and the Birmingham VA continue to handle Corona Virus cases without too much difficulty but I am concerned about a few weeks from now when small town Alabama that has not been embracing social distancing starts to manifest infections. A few people of my acquaintance have been infected and recovered. One has died. Most of us have remained healthy to date due to the Birmingham area’s early embracing of shut downs. It helps when the major economic engine of the community is a major research university with a huge medical school. I’ve got the new work patterns down pretty well and we’re holding the geriatrics program together through telephonic work, home health agencies, and creative problem solving.

I checked my official counter – today we surpassed 500,000 cases in the USA (almost certainly a huge undercount as testing remains spotty), 3,000 cases in Alabama and we’re creeping up on 1,000 cases in Metro Birmingham. Despite indifferent political leadership, the medical community has rallied, pooled information, pooled resources and, even in the greater New York area, seems to be plowing forward with what must be done. Of course the pundit class, that thrives on the 24 hour news cycle, has grown weary of social distancing, quarantine and isolation and wants this all to be over so they can move on to the next sensation which will distract us all and make their advertisers happy. Unfortunately, viruses have no interest in human concerns, their only concern being viral propagation and cannot be reasoned with, bribed, or otherwise made to do human bidding. There is a well known series of steps necessary to bring pandemic illness under control but, from what I can see, no one’s that interested in following those stages as it’s difficult to sensationalize or monetize. But, until we start accepting this biologic reality, we’re going to have trouble.

No big plans for the weekend. Nowhere to go. My usual distractions of rehearsal and performance are on indefinite hiatus. It does look like the condo sale will close next week as scheduled and I will have possession by the end of next week. I still haven’t figured out how I’m supposed to move while we’re shut down and in isolation. In the meantime, I am slowly dejunking the house, finding some rather surprising things tucked away in corners. As I’ve only been here four years, there hasn’t been too much time for accumulation but there’s still moments of ‘what the hell is this and why do I own it’. I think a lot of the odder things are the result of Tommy’s late night on line shopping addiction. He would order the oddest things at 3 AM. There were a lot of times when he would show me his latest gadget when all I could think was ‘garage sale in five years’. But it kept him happy… Wherever he is now, I hope he’s just as happy.

Stay well.

I apologize for no long post last night. I’ve tried to be disciplined and keep these up every other evening but last night I felt like a balloon after all the air has been let out of it and I crawled into bed by 9 and slept through until the alarm went off at 7 this morning. I feel fine. I think my brain just needed some off time from the toxic stew of life stresses that we’re all marinating in at the moment. At least the new work patterns are becoming slightly predictable and I’ve been able to stay on top of the crises in three different systems: UAB Geriatrics Clinic, Birmingham VA Home Based Primary Care and Comfort Care Hospice. One day, one patient, one problem at a time – although my phone continues to ding regularly with incoming texts from whichever two sites I’m not currently at.

An anecdote from my very distant past involving a balloon. I must have been three or four at the time. My parents gave me a red balloon, fairly strong and sturdy and rubberized that had a cat face on it. I don’t remember where we got it or why and it had no magical properties, unlike the one in the fabulous French short film by Albert Lamorisse. I was playing with it in the alley behind my house when my friend Jay came out of his house across the way and told me it would be great fun to pop it. Jay was a couple years older than I was so I looked up to him as an experienced man of five or six and said sure, that should be fun. He couldn’t find a rock that would puncture it but finally found a stick and convinced me to poke a hole in the balloon. If it had exploded with a satisfying bang, I might have enjoyed the noise – all boys love blowing things up but instead it slowly leaked air and involuted and started to shrink away. My three year old brain hadn’t considered the possibility that my toy might do that and become less usable and fun. I took my wounded balloon inside to my mother who, to her credit, didn’t laugh at me but rather took it as a chance to teach me a lesson in actions have consequences and some decisions, once made, cannot be undone. I kept what remained of that balloon in my room for quite a while as a reminder to be careful with what I chose – and as a reminder to not always follow someone based on seniority. (I’ve taken that last lesson very much too heart and had major problems arise from it at times, but I think I’m happier bucking the system when I know I’m right rather than going along to get along.) It was probably also my introduction to the second law of thermodynamics although I didn’t figure that out until years later.

The number of Facebook friend requests I’m getting and my blog readership are going up astronomically since I’ve started into what I’m calling my plague diaries. Quite frankly, I’d much rather still be doing travel diaries but one writes about what one knows and journaling comes out of the mundane and minutia of everyday life and all of our everyday lives have become about Covid 19 whether we want them to be or not. I did a podcast recording a couple of weeks ago (https://audioboom.com/posts/7547581-season-3-episode-6-one-doctor-s-life-in-the-time-of-coronavirus) where we talk a bit about this blog. Yes, the title is a nod to Douglas Adams. It’s been years since I’ve read his books, but his wonky sense of humor has always appealed to me and it’s very similar to my own. If you doubt me, read the movie columns. Of course, when Mr. Adams was my age, he’d been dead for nearly a decade so he accomplished a lot more with his writings than I have with my own.

In my last long post, I explored – briefly – why the US has health insurance tied to employment while such a system happened nowhere else in the industrialized world. Tonight I want to say a few words about another aspect of the US health care system that’s unique and which causes us a significant amount of trouble. I’m not passing judgment on why this is or the ethics or social trends behind it, I’m just going to lay it out there.

The vast majority of world health systems, especially those of the developed world, are morbidity driven health systems. The aim of the systems is to keep their populations well. They understand that health is much cheaper for a system than disease and resources are deployed to try to keep the majority of the population as healthy as possible. Healthy adults come from healthy children come from healthy infants come from healthy parents so they put enormous resources into making sure all of their population has access to care, that primary care is funded and available, that there is adequate prenatal and child care, that pediatric care will not stress a family unit, and preventive services that will keep people from falling into ill health by catching disease early are easy to come by. What’s the result? Their populations have higher life expectancies than we do, their systems cost much less (usually 9-11% of GDP while ours is something over 17% of GDP), and no one in their populations worries about medical bills and the possibility of bankruptcy from a health condition is so alien as to be unfathomable.

On the contrast, the US health care system is a mortality based system. We worry about why people die and do everything we can to prevent that occurrence. A death is considered a failure of the system to provide adequate care in some way (and our legal system is always looking to find someone at fault). We view life as linear with death as an endpoint and, if our health system is applied properly, we should never actually reach that spot. There are some generational differences in these ideas but it is most clearly seen in the early Boomers, those now in their early 70s who still view themselves as being forever young. There’s a line from a film which paraphrased is something like ‘How can I be old? I was at Woodstock!’

This cultural need to prevent death leads us to pour huge resources into individuals who are obviously in a dying process. For most people, death is a process – a very quick process for some (almost instantaneous in some cases) and a very slow process for others. Most health professionals know when someone is in that process but we are taught from early in our training how not to take away hope and the ethics of doing everything in our power to preserve life if that is the wish of a patient and family. But, deep inside, we often recognize when the continued treatments are doing no good. The specialty of palliative care which has arisen over the last few decades is capitalizing on this mismatch and showing that there is another way of not being aggressive with treatments during the dying process and they have shown scientifically that, in a lot of cases, people actually live longer with just having their symptoms treated rather than trying to cure the incurable underlying disease process.

Other systems look at us somewhat amused, ‘Those crazy Americans – they see death rates ticking up from cardiac disease and put everyone on aspirin, everyone on a statin, train more cardiologists. And then the cancer rates start to go up so more cancer centers, new chemo regimens, new biologic tumor annihilators. And now it’s an increase in dementia so more work on new drugs to prevent it (so far unsuccessful). Don’t they realize that the numbers always add up to 100% and all you can do is move people from one category to another?’ The problem is, we really don’t when it comes to how our health system actually operates. I am fond of reminding Medicare insurance executives of the fact that everybody dies in meetings when they’re touting how wonderful their product is at keeping people alive. It has not endeared me to them but I don’t mind.

This issue of morbidity vs mortality is going to play out during the current pandemic. I don’t know how yet but it will be interesting to keep comparing the response in other countries to what we have here. I remain afraid that we’re still in early days with this thing, no matter how tired we all may be of our disrupted lives.

Stay well.

Last time I wrote an entry in the plague diaries, it was the end of the work week. This time, it’s the end of the weekend. Was it an exciting and action packed weekend? Hardly, those are in abeyance for the duration but I had a few minor triumphs. In the harsh light of day, I decided the cat hair on the rug was not a lived in, but a sloven look so I broke out the vacuum cleaner and the duster and cleaned the main floor of the house. I also finished sorting the DVD collection for discards and entered all the ones I’m keeping into an app database so I’ll know what I’ve got next time I look for a physical copy of something. I played three very long games of Civilization VI on the Xbox and lost every time to my AI opponents. I read a dozen chapters in the book my sister gave me for Christmas (a zombie apocalypse in Seattle told from the point of view of a tame crow and the pets left behind). I took two long neighborhood walks. And I ‘attended’ on line church with a sermon on the non-canonical gospels entitled ‘The Heretic in the Pulpit’ – let it not be said that we UUs have no sense of humor.

On one of my walks I encountered my old friend Angela Forbus Pruitt and we called a few pleasantries to each other across the street. While we were talking I had a brain flash about what to write this evening. One of the themes I’ve seen as friends have been posting about Corona Virus is the common fear of being stranded without health insurance due to job loss. We are the only advanced society that ties health care and employment together. As most of us grow up in this system, it seems normal to us while most of the rest of the world considers it bizarre. How did we get here and why do we do it?

To answer that question, we have to go back to the 1920s and 30s. In the 1920s, the average American family spent a greater portion of their wealth on cosmetics than on health care. For the most part, you didn’t access the system. Doctoring was done by mom or granny and the vast majority of illnesses were handled at home. The doctors, almost exclusively men, were mainly general practitioners who were part of a community that supported them in a symbiotic relationship: this is where all the stories about paying the doctor in chickens came from. If the doctor had an office, it was often part of his home and he spent most of his time making the rounds in the donkey cart or the model T calling on the sick at home, providing advice and succor as he could. There were hospitals, but they were small and generally used for a few specific purposes: surgery, separation of those who might be dangerous to the greater community (the asylum and sanitarium), teaching, and as a carer of last resort for those without intact family structures who were medically ill. They were owned predominantly by public or religious institutions with a charitable mission to provide care for the ill and were non profit in nature.

Health insurance, as we understand it, was invented in 1929 in Dallas, Texas. Baylor University had constructed a large new hospital and was having difficulty filling the beds. The vice president for health services at Baylor, Justin Kimball, had connections with the Dallas school teachers union and hit upon a plan. If the teachers would pay Baylor a fifty cents a month, they would then be eligible, should they require hospital treatment, to enter Baylor’s hospital free of charge for up to twenty one days. This ensured Baylor a steady stream of income, and a steady stream of patients over the next decade or so.

This original plan morphed over time, as it grew, into Blue Cross: an amalgam of local plans which over the next couple of decades, grew into the organization that those of my generation all remember from my childhood. Blue Shield, which eventually merged with it, had a different origin. It came from a banding together of workers in the logging and mining camps of the Pacific Northwest into fraternal organizations that paid doctors fees if one of their number became ill. Blue Cross and Blue Shield grew piecemeal throughout the 1930s due to the state of the economy.

In the early 1940s, with the United States now at war, many of the heavy construction jobs, especially in the shipyards and airplace factories were taken by women as the men were fighting overseas (the days of Rosie the Riveter). It didn’t take long for the titans of industry to figure out that if these women fell ill, or if their children fell ill, they could not come to work and productivity would be hindered. It started to become the smart business decision for a company to begin thinking about the health of its employees and their families. The leader among the heavy industry types was Charles Kaiser, head of Kaiser alumnium. He led the way in making sure his employees had access to good and timely health care and that the bills would be paid.

In the latter half of the 1940s, after the end of the war and the return of the men to the workforce, heavy industry faced another problem. While the economy was gearing up to meet fifteen years of pent up US consumer demand, not to mention helping the rest of the world rebuild shattered infrastructure, there were still laws on the books left over from the Great Depression, which controlled wages – it wasn’t possible for company A to offer more money than company B for the same job. Corporate America found something else to make up the gap – the benefits package which did not fall under these rules. Health insurance, as it had already taken root in heavy industry quickly became a carrot for getting employees to sign on the dotted line. By the late 1940s, industrial American lobbied congress to change to tax code so that it became advantageous to the owners of industry to offer a health benefit and, before anyone knew it or thought about the consequences, employer tied health insurance was born.

Through the 1950s and 60s, the system worked relatively well. Hospitals were not for profit by both custom and law. Physicians were small independent businesses. There wasn’t much money in the health sector of the economy and, as employment was relatively easy to get in the booming post war economy, everyone was happy. Things started to change with the introduction of Medicare and Medicaid in 1965. They were created to give populations who were not employed or employable access to the health care system – Medicare for the elderly and disabled and Medicaid for the impoverished. But what ended up happening, was a sudden influx of federal dollars into the health care system. Money always catches the eye of the businessperson and this was no exception.

It was Charles Kaiser who went to his old friend Richard Nixon in 1973 and persuaded him to sign a piece of legislation known as the HMO (Health Maintenance Organization) Act. It was in order for him to spin off his health organization into a free standing company (Kaiser Permanente). The unintended consequence was that the language of the act made health care, up to then a not for profit enterprise, into a for profit business. Wall Street took notice and corporate America arrived in health care starting in the late 1970s, determined to remake medicine into a business, one that manufactured hospitalizations and patient encounters, and using the same business principles that had served it well in other sectors of the economy. By the mid 1980s, the field of medicine was very different as we evolved from a health care system, whose goal was to heal the sick and injured, to a health care industry whose goal is to create profit for the owners of industry. These trends have continued over the last four decades (coinciding with my time in medicine – I entered medical school in 1984) and now there is an enormous stress on the system wrought by Covid 19. What will the ultimate outcome be? I don’t know, but I don’t think the health system will look the same or operate the same when we emerge on the other side.

And there you have it. More than you ever wanted to know about the history of American health insurance in seven paragraphs.

Stay well.