August 4, 2020

Social Distancing – High School Style

And he’s back in the salt mines on regular hours and attempting to pick up where he left off a few weeks ago. The first few days back at work are always about emptying inboxes – physical and electronic. I learned long ago that if I’m going to take time off, I need to take a minimum of two weeks. If I only take a week, my colleagues will just let things pile up in a corner for when I get back. At two weeks, they will deal with what they can in my absence so at least the immediate patient need piles aren’t as bad as they might be. Two days in and I’ve pretty much tidied it all away or have a plan to deal with it over the next week or so. The major undone task is putting together some zoom lectures on aging for my usual church sponsored adult enrichment course that will take place the next few weeks. I have all the material so it won’t take that long. I just need to sit down and do it.

And it’s time to dive back into the accidental plague diaries. Alabama continues to be in a surge. The number of Covid inpatients at UAB is roughly double what it was late March – May as the infections that ticked up with the opening up of the state in June turned into serious infections and hospitalizations in July and will turn into a spike in deaths in August, just in time for us to open up the schools. I come from a land where schools didn’t start back until Labor Day, but here in the Deep South, they tend to begin mid-August. From what I can tell, the departments of education in the southern states, like most other governmental entities, rather than grappling with the problems posed by the corona virus, are simply passing the buck further and further down the chain of command and leaving things up to individual school districts. There are a number of school districts in my metropolitan area and they all seem to be completely at sea as to what they should be doing in regards to in person learning, distance learning, after school activities, safety of teachers and staff. Each one seems to be taking a different tack and sailing off a different edge of the earth. New emails come out daily causing parents to be more and more confused and completely unsure about what is actually going to happen as schools gear up over the next few weeks. The largest entity, Jefferson County schools, decided today that they will have no in person classes for the first nine weeks of the semesters. The teachers will report to school and conduct classes remotely. How that’s supposed to work for students without laptops or how a teacher is supposed to effectively teach twenty five kids via Zoom was not explained. Some of the rural Georgia districts started back this week and the first day of school pictures beginning to circulate on social media do not look promising. They show teenagers being teenagers in the halls with no social distancing and only a rare mask. Covid-19 spread in 3…2…1…

I see the country as a whole beginning to have a major surge this fall, far worse than we are seeing now as all those young people mix and mingle and carry each others microbes home. Add to that the fact that high school football programs (a near religion in this part of the world) are going great guns and Friday Night Lights will soon be here and we’re going to have even more issues. I’m not overly worried about the kids. The data suggests that the vast majority will not get seriously ill (although vast majority doesn’t mean all and some previously healthy children and teens will die). I’m much more worried about the teachers and staff who have dedicated their lives to nurturing our young and who are already horribly undervalued. When they have to choose between their calling and their mortality, what will they choose? What happens if a significant portion of the teachers in this country quit because it’s just too dangerous for them to be around crowds of young people? Do we redesign schools to be smaller and less centralized? Do we make more education home dependent? What happens in those families that can only make it economically if all the adults work, sometimes at multiple jobs? Families are likely to start doubling up and becoming more multigenerational in order to have an adult in the home for child rearing and supervision. When that adult is a grandparent or great grandparent, what does that mean in terms of their risk for corona virus infection? I don’t have answers for any of this, but it’s the sort of thing that keeps me up at night.

It fascinates me that the basic attitude of our governmental institutions is towards the pandemic is one of ‘if we pretend it isn’t there, somehow it will go away’. Nature doesn’t work like that viral illness can’t be swayed by op-ed columns or mean tweets, or 30 second campaign commercials. It only obeys the laws of biology, chemistry and physics, but we seem somehow determined to shunt aside the findings of science for feelings or wishful thinking. We can keep doing that, but as long as we keep doing that, things are not going to be ‘normal’. No one is immune to the virus and we don’t know what protects some of us and keeps us from getting ill or what causes some of us to end up for weeks in the ICU despite no previous health history. There are tantalizing clues and the scientists are working overtime, but I’m not sure the politicians are actually listening. My handy dandy corona virus counter says we’re at 4.77 million cases in the US as of this afternoon. That’s 1.45% of the population. It’s likely an undercount as so many young people are asymptomatic. Let’s say we’ve missed half of them so 2.9% of the population has been infected to date. At this point, we are somewhere north of 155,000 deaths. (That’s roughly three Vietnam Wars). If we continue to do a whole lot of nothing to stop the disease and it continues until we reach herd immunity (roughly 80% infection rate), we’re looking at about four and a half million deaths and who knows how many chronically ill or disabled. That’s roughly fifty percent higher than the number of US military casualties in all of the wars and actions we have ever fought over the last two hundred and fifty years. Or the population of the entire San Francisco Bay area if you want something a little less military.

We can’t have normal unless we grow up and do what is required to bring things under control. Have a real lockdown. Develop a testing system that can rapidly identify the infected. Trace those whom the infected have come into contact with. Put the good of society ahead of our own personal convenience. That’s what works. Until that happens, we’re going to continue to have disasters – both major and minor and whole sectors of the economy, those that depend on groups of people being able to get together, just won’t be able to function normally. Most people I know are being pretty good about doing the things we can do as individuals – wear our masks (I’ve got a great source if you want some fashionable ones), wash our hands, don’t get too close, don’t go out if you don’t have to. But that only goes so far. We need those other things as well and I’m pretty sure we won’t get them before next January at the earliest.

I’m a bit of a Debbie Downer tonight and this post seems a bit repetitive of other things I’ve put up. Now that I’ve had my decompress time and am back on usual schedule, I’m willing to do some research and burrow into some more interesting tangents so if anyone wants me to wax rhapsodic on something in the accidental plague diaries, let me know. You can always send me a message if you don’t want to post it publicly.

Maybe I’ll watch Hamilton again…

July 31, 2020

The straight line winds are blowing, the rains are descending and I remain in the same quasi-torpor I’ve been in for the last few days. I’ve kept myself pretty much quarantined in the condo just in case I came into contact with the novel corona virus on the trip to Seattle and back. So far, so good. I feel fine other than a general sense of lassitude and need for daytime napping during my staycation week. I have accomplished a few constructive things. I sorted my whole CD collection and got it stowed, got the laundry done, and made some progress on some writing projects. It’s the little things…

We’re trending upwards by about 1,000 cases a day in the state and 150 cases a day in the county over the last week. We’re not Florida or Texas but we’re nowhere near as large or as populous and we don’t have the same urban density which is why I think we’re relatively protected around here but there’s no end in sight for the upward trends so back into the accidental plague diaries I go. I long to write about something else but until our society develops the political will to do what must be done to bring the pandemic under control, we’re going to be stuck in the current situation. I read somewhere that the US economy contracted by something over 30% last quarter. This compares to 6% with the recession of 2008 and 16% with the Great Depression. There’s a world of hurt still to come.

I was trying to decide what to write about today but everything that came to mind seemed to horribly depressing and I am trying to keep my own personal spirits up after a particularly downbeat couple of days, dominated by the death of two old friends (neither related to Covid-19) and a local scandal involving another old friend, also a geriatrician, who was arrested on salacious charges. This wouldn’t have been much of an issue but when you googled his name, my UAB promotional picture came up so people were sharing the story around social media with my picture attached which was not a particularly good feeling. I’ve pretty much been home so no one has been staring in the street and I have sicced the UAB IT department on the issue.

The big contretemps locally is over the issue of getting the kids back to school. There is a very vocal minority pushing for the schools to open normally in August with full in person instruction. There is a less vocal majority who are concerned about all of the issues that opening up will bring to the fore. Running the schools is not an easy business. There are federal, state, and local mandates regarding instruction and subjects and credit hours. There are negotiations with teachers and employees unions. There are the fixed costs of maintaining the physical plants. There are the special needs children and educational programs. There are the extracurricular activities such as sports and music and theater that are often the only way to maintain older children’s interest in education. I can’t even begin to imagine how you balance all of that in normal times without the stresses of a pandemic, especially in a state like ours which works on a starvation budget at best. One local school district sent out a memo noting that the budget allowed for only one bottle of hand sanitizer and one box of sanitary wipes per classroom to last the entire school year.

There are times when I wish my life had allowed for children of my own, but this is not one of them. I can’t imagine the kinds of decisions that parents and families who rely on public schools are trying to navigate at the moment. The lack of central leadership means that every school district is trying to work it all out for itself. I’m not particularly worried about the children of America. They appear to be resilient and relatively unaffected by Covid-19 but what happens when they start coming home to parents and grandparents and great grandparents? The at risk populations in this country are much more likely to live in multigenerational households, not isolated nuclear family units and I can see another surge in October and November as those people become exposed through school children and sicken. What are we planning to do if children end up orphaned? What happens if the teachers and their unions go on strike due to unsafe working conditions? Is the federal government going to send in their newly constituted riot police to force them into work at gunpoint? (I’m being ridiculous there, but a lot of what I would have considered ridiculous things a few years ago have come to pass recently.)

Vincent Price in the Masque of the Red Death

Large segments of our society still seem to be living in denial that Covid-19 is a serious problem. Yes, the percentage death rate is relatively low when compared to a viral illness like Ebola but it’s still a good deal higher than the flu. (We’re at about five times dead in six months what the flu kills annually). We still don’t know what the long term sequelae of those who recover from serious cases are likely to be. The numbers will keep going up until there is a coordinated federal response of some sort. And yet, the Senate appears incapable of acting due to partisan bickering on a federal level and the executive branch appears to be continuing to try and reenact Poe’s The Masque of the Red Death (without remembering how the story ends). I need to see if the Roger Corman/Vincent Price film adaptation is on one of the streaming services. It’s been years since I’ve seen it and it strikes me as being perhaps the best metaphor for our times.

I go back to work on Monday. I’m not looking forward to climbing back in to the pressure cooker, but needs must, especially with two mortgages to pay until someone buys my house. My fashion masks are all washed, I have plenty of hand sanitizer, and, if the rain stops, I’ll spend as much time as I can out of doors.

July 27, 2020

“View of Chattanooga, Tennessee from Lookout Mountain”

And I have returned from the Pacific Northwest back to my own domicile where the weather is hot and sticky, the condo is deliciously cool due to the recent replacement of the HVAC and where I am once again being pretty much ignored by both of my cats. My friend Holly house sat while I was gone, at least in part to get some peace and quiet away from her busy family life – perhaps the cats are disappointed that I am not her. Both Oliver and Anastasia did not even bother to appear for several hours after I came back, and even then it was only to yowl about supper.

The rest of the trip was relatively uneventful. Family time, naps on the couch, socially distanced visits with old friends followed by another gauntlet of airports and planes in the time of Covid. With the number of flights greatly curtailed, nothing was crowded and I didn’t feel especially endangered as mask usage was consistent throughout the process. But one never knows, does one. The only minor issue was finding, on arriving back in Atlanta, that I had somehow left the rear driver’s side window down all week and it had rained so I had to swamp out the back seat before exiting the economy parking lot. There was nothing of value in the car so it wasn’t a major issue but I have no idea how I managed to do that. I suppose it was better than the time Steve and I went off for a three day weekend leaving the oven on…

I decided not to make a beeline home. I was tired so I spent the night in Atlanta in yet another one of those ubiquitous Hampton Inns. (I now have something north of 600,000 Hilton Points and, of course, nowhere to go to spend them). The next day, rather than making the usual beeline down I-20, I decided to take a more leisurely and scenic route up through Chattanooga. Now I have driven through Chattanooga about 100 times over the last couple of decades but I’ve never stopped. As it was a sunny day, I decided to take the drive up Lookout Mountain for the view. Most things were closed or full of unmasked tourists so I did not see Rock City or visit Ruby Falls, but I did have a nice masked and socially distanced walk among the lovely houses on top of the mountain looking out over the Tennessee river valley spread below. After that, I came on home.

Back to the accidental plague diaries: In the nine days I’ve been away, the number of Covid-19 cases in the county is up about 2,000, the number in the state is up about 13,000, and the number nationally is up about a half million. It took several months to generate those numbers at the start of the pandemic, now it’s taking just over a week and, with continued uncontrolled spread, it will start speeding up more and more as that’s what exponential numbers do. Now that it has become so firmly entrenched in more conservative states, the administration appears to finally be waking up to the very real public health concerns but their track record to date at putting politics and ideology before good public health practices doesn’t give me a lot of confidence that we’ll be making headway soon.

What’s most irksome about all of this is how absolutely unnecessary this all is. Even at this late date, the pandemic could be controlled and well on its way to eradication in four to six weeks. It would be painful and politically difficult but could be done. We are the richest society this planet has ever produced. We can do or have anything pretty much as long as we align our political and economic systems to make it so. What would we need to do? First, a real lockdown of at least a month. We haven’t had one other than some jurisdictions in the Northeast and the SF Bay area. It would have to be nationwide, no exceptions, everybody home, no travel other than trade goods, no one on the street or gathering anywhere for any reasons and that would have to be enforced. Second, use of that time to make and distribute accurate point of service testing so that as people coming out of lockdown can be tested and we can gather an understanding of where the virus is being transmitted in real time. Third, contact tracing of carriers with enforced quarantines until the transmission chains are broken. Of course, to do this, the government would have to take on the economic calamities that will resort from more lockdowns and we haven’t been the best at that so far, especially when compared with the rest of the developed world. But that’s why the rest of the world is beginning to open up and we’re in a continued upward trajectory.

I can’t help but wonder if my little jaunt to Seattle, which I felt was absolutely necessary for both my mental health and my family, wasn’t in its own way contributing to the problem. I’m pretty good at my masks and social distancing (although the staff at my father’s senior living facility was miffed when we removed our masks on the patio of his building to drink our coffee, even though we were outdoors and a good ten feet apart). But that’s me, always over thinking and taking on more weltschmerz than I really need to. I have a full week before I go back to work, so I’m spending it pretty much in self imposed quarantine in my condo to make sure I didn’t pick it up on the trip. So here I am, puttering around with a list of little projects to keep me busy this week.

If I do go out, you all know the litany.

Wear your mask,

Take your sanitizer with you,

Keep your hands washed…

July 22, 2020

Statues covered with face masks in Seattle’s Fremont neighborhood, April 26, 2020. (Matt M. McKnight/Crosscut)

As promised yesterday, time to head back into the Accidental Plague Diaries. Here, in Seattle, the first US epicenter back in those distant days of this past February, the population saw how quickly and silently Covid-19 can spread and they take the potential dangers seriously. In my wanderings around town, I’ve seen excellent adherence to masking and social distancing by the general population and, from what I can tell from the data available to me, transmission in Seattle proper is way down. The rest of the state… not quite so good. I assume that’s a combination of rural population politics combined with substandard living conditions for agricultural workers on the other side of the Cascades.

The question I keep getting asked by family and friends is some variant on what’s coming next or what is the new normal going to look like. Now, I have no degree in futurology or futurism or future studies or whatever it may be called (I’m not sure if there’s even a higher education program in such things outside of one of the more obscure for profit colleges where they send you a PDF file diploma in exchange for a tuition check). So you’ll have to bear with me as I attempt to answer this. I may be right, I may be hopelessly wrong but it’s what I see from where I stand in mid-July of this benighted year. I’m not going to go into everything that I see trending, but will stick within those areas where I have a certain amount of expertise.

Healthcare: The healthcare system was going to enter a system of intense strain in about a decade, even without the presence of pandemic illness due to the demographics of American society. The aging of the boom, its wish to remain forever young, and its demands that the health system provide quick fixes to the complex issues of aging were going to tax the system and that process has just been sped up considerably and shown where the cracks are about a decade ahead of schedule. Some things that I think are here to stay: more and more primary care will be moved away from office visits to virtual visits, especially for the management of chronic illness. People will get one or two appointments a year in the office and others will be on-line, checking through a list of potential issues, looking for problems. More and more of these routine visits will also be devolved from physicians to Nurse Practitioners and Physician Assistants. Access to specialty care is likely to move back towards a more gatekeeper mechanism requiring referrals and more workup through primary care before a specialty appointment can be kept as the system continues to try and limit face to face contacts for the protection of both patients and health care providers. There will also likely be more rapid development of house call programs, home health will expand its service lines, and the home hospital model is likely to gain additional interest in an attempt to keep ill people who can be handled in a situation other than the hospital setting out of a place where the sick congregate and they are more likely to become infected. Hospitals will continue to work to separate out Covid services physically from other parts of hospital care leading to something akin to the old TB pavilions and sanitariums of a century ago.

Aging: There is going to be more and more push for housing appropriate for multi-generational families as older people will be more and more loathe to enter senior communities where they may be cut off from interacting with their grand children and great grandchildren. As more people work from home, there will be other adults in the home to assist an elder and I think we’ll continue to see the collapse of the nuclear family as an ideal for the extended family. Elders are also going to want to be more connected to community and looking for senior housing integrated into urban areas rather than separated in suburban areas where they are trapped if they cannot drive. Older people, understanding their vulnerabilities, are going to be among the last to return to full social interactions which is going to have a huge impact on such things as audiences for performing arts events and dining patterns. There’s going to be a huge demand for services that can clean and disinfect in various ways so that they feel more secure in their environments.

Fashion: I am not Miranda Priestly and I have no training in this, but I know enough about the history of costume to know that historical events are reflected in clothing trends. As more and more work is decentralized and more and more jobs are done at home, there is going to be a decline in formal business apparel for clothes that will look smart and professional, but will also be comfortable and appropriate for other household tasks. I think the necktie will likely disappear as it’s a vector for disease transmission (they aren’t washed enough). As more clothes are bought online, they will be designed and cut to fit relatively well for various body types to minimize returns.

Real estate: As there will be fewer opportunities to socialize, people are going to want to know their neighbors more and socialize on the street. Older neighborhoods which were designed for that with sidewalks and front porches, will become more desirable and newer neighborhoods designed strictly around the automobile less so. There is also likely to be a renewed interest in living in central cities versus far flung suburbs. Commercial real estate is going to be in trouble as more and more businesses realize they can work perfectly efficiently without so much office space. There will be far fewer commuters and businesses that rely on heavy commute traffic will suffer.

Performing Arts: I think there will be a decentralization of music-theater away from NYC and other cultural capitals and an increased recognition that good art doesn’t depend on the imprimatur of particular critics or branding. Smaller, more facile companies that are willing to take radical steps to envision new ways of bringing content to a public starved for entertainment will do better than large, overhead heavy traditional companies that really only know one way of doing things. Ultimately, I think we’re going to get some exceptional artistic works from this period from creatives who use all of this societal uncertainty to springboard to something new. It’s always worked that way. The financial structures underpinning the arts in this country are in trouble (and have been for years) so we’re going to have to decide as a society what we want to do about that.

It’s going to change. Be prepared. Change is neither right or wrong, it just is. It’s what allows us to move forward a society to something better. It’s scary and painful and no one likes to give up the familiar – inertia is a powerful force – but ultimately the choice is to either grab hold of it and go along for the ride or resist it and let it grind you into the past. I’m doing my best to do the former, although I find it as difficult as everyone else does. In the meantime, I’ll continue to do the three basic things that we can all do to curb the pandemic.

Wear a mask.

Keep my distance.

Wash my hands.

July 21, 2020

The Saunders Clan heading out to the low tide line

Dateline – Seattle, Washington:We interrupt the accidental plague diaries for an afternoon of travel journaling. Believe me, I would much rather be writing about new and interesting places or people, the rehearsal process for a new show or any of the hundred and one things I would write about in these columns pre-coronavirus. But, as someone much brighter than I once said, write what you know and modern life over the last four months has been pretty much a lurch from one uncertainty to another due to the advance of Covid-19 and, being a physician who is still gainfully employed, it’s impact on myself as an individual, the collective of my friends, family and society, and the world at large became something I could help clarify to others as I attempted to work it all out for myself.

Anyway, I am enjoying my first time off in many months and a trip to be with the family in Seattle. I’m not making my usual rounds as I’m trying to adhere to social distancing, mask use, and all those other little rules of the moment. I have no particular wish to be part of one of those human interest stories that read something like ‘Fourteen family members sickened after welcome home feast’. I’ve been welcomed into my brother’s immediate family bubble, but with everyone else, it’s been distance and masks. Fortunately the weather has been lovely so we have been able to gather outside for the most part. I’ve met friends and family for walks on the beach, glasses of wine in lawn chairs in the yard, coffee on terraces and while it’s a little awkward as everyone tries to determine correct etiquette, even among those who have known each other for forty or fifty years, it all works out in the end.

Today was a bit melancholy, the entire American branch of the Saunders clan gathered at my uncle’s house at Magnolia bluff to bid formal goodbye to my mother. As you may recall, my mother died rather unexpectedly in late January. She had had a serious genetic dementia for some years and was non-communicative and unable to function the last few years of her life. She just didn’t wake up one morning. We wonder if possibly she may have been an early Covid-19 victim as she had had a bit of a cough the week before her death and the disease was spreading silently in the Seattle area at the time. No one thought to look for it then so there is no way of knowing. We had planned a memorial for her in early April here in Seattle, but that was cancelled by the spreading pandemic, so we decided to have a private family gathering to scatter her ashes at the same place as her sister.

The house on Magnolia Bluff

When my uncle’s parents died in the 1960s, he took the money he inherited from the sale of their house and bought an undeveloped lot at the base of Magnolia bluff on Puget Sound. Just off shore from the lot was a boulder sitting on the sea bed, a glacial erratic placed there at the end of the last ice age by the retreating glaciers that carved the Sound and its landscape. It may have an official name, but my generation, children at the time, dubbed it Turtle Rock due to it’s resemblance to the shell of a turtle breaking the surface of the waters at high tide. Not much happened at the Turtle Rock property for 25 years or so other than scrambling down the bluff for beach walks or blackberrying in the summer.

Turtle Rock and Magnolia Bluff

Around 1990, my aunt and uncle built a house on the property. It took some doing as the city had forgotten there was an undeveloped lot still on that road and the permitting process was a bit of a chore. He is an expert on Japanese culture and policy and she was an artist with an interest in Asian art forms and the house they built took both Japanese and Northwest design elements and has become quite the gathering place for the clan over time. My aunt died of breast cancer in 2012 and, after her cremation, was scattered at Turtle Rock at the July low tide that summer. We took my mother to join her this morning, eight years to the day later. The group consisting of myself, my uncle, my brother and his family, my sister and her SO, and my two cousins and families who are in town, made our way down the bluff to the tide flats, went wading past the herons, the geoducks, the moon snails, and a mildly curious bald eagle, armed with the ashes, flowers, and a few words of remembrance. It was quite nice. I think she would approve. My father was not up to the climb up and down the hill so watched from the balcony. I haven’t made any specific requests regarding my remains when I die other than cremation. I shan’t be around to either approve or disapprove but I won’t be upset if I end up at Turtle Rock as well.

Saying goodbye

Talking with various cousins, I kept getting the same question. What do you think comes next. So that will be the subject of the next edition of the Accidental Plague Diaries. Stay tuned to this space for my thoughts on that.

July 19, 2020

Travel in the age of Covid-19

I’m sitting on the living room couch at my brother’s house, a couple of tuckered out dogs napping at my feet listening to him practice some sort of stadium rock riffs on his electric guitar. It’s nice to be around some family after months and months of social distancing and more evenings and weekends alone than I care to contemplate. Time once again to pick up the laptop, let the fingers race over the keys vomiting out whatever words are built up in my brain and put forward another entry in the Accidental Plague Diaries. I suppose this one should be about the challenges of long distance travel in this Covid-19 era. I do all my air travel on Delta these days due to my location in the Southeast and my researches into the responses of airlines to the needs of the corona virus era suggested to me that there was no real need to change that as their protocols were about as good as you could get given the configurations of airplanes and airports. As, in some ways, I was more concerned about time in airports than the plane itself, I decided to drive over to Atlanta on Friday night and spend the night in an airport area hotel, ensuring myself minimal airport time and no need to make a plane change at one of the hubs. I have all my points through Hilton properties and Hampton Inn has been my go to for years. I took advantage of the on line check in and check out through my phone app together with downloading a digital key so I didn’t have to linger in a lobby. The room was clean, I wiped off surfaces before I touched them and hope for the best.

The next morning, drive through Starbucks, park at the Atlanta airport in the economy lot, and mask in place, enter the terminal. I am pleased to say that no matter what the idiot governor of Georgia may be up to, masking at the airport was universal with the exception of people eating in the food court. (I did not stop). The airport was nowhere near as busy as usual so maintaining distance was not difficult, and I was able to get my bottle of Purell through security without a fuss so sanitize after ever new activity wasn’t an issue. The plane was about 60% full. Middle seats weren’t sold except to family groups traveling together, people stayed masked and there was minimal traffic in the aisles. I wedged myself in my seat per usual, put on a movie, promptly fell asleep, and woke up somewhere over Nebraska in time for a bottle of water, some cheez-its and some cookies in a baggie which was all the food and beverage service. More movies, which did not put me to sleep this time, and a lovely view of Mount Rainier as we flew past and I was descending into Sea-Tac airport. Again, universal masking, a quick trip through baggage claim and off to meet my brother who was picking me up.

My biggest take away from the whole experience is how we have to do a whole new set of risk benefit calculations with everyday activity that we just aren’t used to and for which we are operating off of imperfect data. We’ve all been very used to doing this around life since we were children. Busy street? Wait for the light and the corner or, as there’s no one coming, jaywalk to cut a couple minutes off of time. Dark underpass at a late hour? Not a problem – I’m with three friends. We don’t even think much about those calculations, especially if we’re white males. We’ve been acculturated to them over decades of life experience and we don’t even think about them most of the time. Now we have a whole new set of risks to think about in a pandemic world and little conventional wisdom on which to fall back. Am I far enough away from that person in this elevator? Is the need for my being able to interact with my family worth the risk of this plane flight? Can I hold it long enough not to need to use this public restroom? We’ll get better at making these calculations with time and additional data points.

The same thing is going on at a macro level with society. Is the need to educate and socialize our children worth the risk of opening up public schools in the usual model? Can we accomplish the same sorts of business or academic productivity without commuting into offices daily? Is it safe to stand in line with strangers? Is it safe to go indoors with them in large groups? If not now, when? What needs to happen to restore public confidence in these sorts of activities? The criminal neglect of these basic questions evidenced by the lack of interest by current federal and state administrations is why we remain mired in a sort of stasis. We’re holding at a crossroads: either we allow the virus to spread unchecked and accept the consequences in excess mortality and morbidity (although what that latter is remains pretty much unknown) or we get serious about bringing it under control in the way most of the rest of the world has done. To do that, we will need a real lockdown – no travel, no leaving your domicile other than medial emergency or a once a week run for groceries monitored by the authorities, an enforced curfew and quarantine, and prohibition of gatherings, mandatory masking, a robust testing system, and contact tracing until we can thoroughly identify and isolate carriers. It’s going to be a politically hard sell but that’s what works. I didn’t make the rules. It’s just how viral pandemics work and how you can beat them. I’m afraid we’re going to be stuck in stasis until we make up our societal minds about which way we really want to go. Neither choice is pleasant. The virus doesn’t care.

In the meantime, wash your hands, wear your mask, maintain social distancing (which I am doing as much as I can, even with members of my family).

July 15, 2020

Ask and ye shall receive – Kim Kardashian is selling face masks…

I got a text from an old friend a couple of days ago. She’s a nurse anaesthetist in Houston these days. In it she said that her 290 bed hospital is completely full. 160 of the patients are Covid patients. Every single ICU bed has a Covid patient in it. It was 10 AM and she had already been called to six Code Blue situations and she was frazzled and exhausted. And that’s just the beginning of the surge in Houston area hospitals. There’s a very predictable pattern happening in hot spots. Cases begin to rise with higher percentages of positive tests. About three weeks later, hospitals begin to fill up. Three weeks after that, the deaths begin to skyrocket. The end of July and beginning of August are going to be brutal for Texas, Arizona, Florida, and the other states following their general curves.

Numbers are arcing up in Alabama as well. As we don’t have the large dense urban centers, our absolute numbers are far fewer but the trends are the same. UAB hospital now has over 100 Covid inpatients (we were at about sixty a month ago). The other hospitals in town are also seeing a rise. It’s seeping into the long term care facilities and senior communities and starting to spread among those vulnerable populations. Our governor, never one to rock the boat, or even to be visible the majority of the time, emerged today for a press conference and announced a mandatory statewide mask order. I suppose it’s better late than never but it would have been helpful before the numbers really started to spike. Of course this has led to the inevitable backlash among those who have been conditioned by certain media outlets to regard anything that impinges on their sense of entitlement as a threat. I wonder what a future generation is going to make of the great mask wars of the summer of 2020. Perhaps we need to enlist the help of the Kardashians running a PR campaign to make masks the must have fashion accessory of the season.

You can try to get past the Walmart bouncer without a mask, but I don’t think you’ll succeed…

The longer a significant portion of the population refuses to believe in Covid and its dangers and flouts good public health policy, the longer we’re all going to have to put up with it. Every time I see some grinning idiot wandering into a store or take out counter without one, I kind of want to hit them up the side of the head and say ‘You, yes you are the reason I can’t take my planned trip out of the country this fall or go to a rehearsal or performance or be with my friends’. Then I think better of it as I’m getting to the age where if I get knocked down by a neanderthal, I could break a hip. It’s not that we haven’t know for well over a century how to cope with a pandemic. It’s really quite simple. Determine who is sick or a carrier (testing), and break chains of transmission (masking, quarantine, and contact tracing). It’s really that simple. But for a disease that spreads rapidly and for which the whole country is at risk due to lack of immunity. large scale public health programs need to be put in place. It requires a full core press federal response so that appropriate resources can be called up and put into place. Unfortunately, decades of starving public health programs as unimportant, political marginalization of science and expertise, and leadership at the very top that is completely disinterested in anything other than corporate profit have made this essentially impossible and I really don’t see much progress prior to this next spring and even that is likely to depend on the political winds.

I sent the collected accidental plague diaries to the editor I’ve been working with to determine if I’m actually writing a book with these pieces. It’s about 50,000 words now since I published the first one in early March. He thinks that it actually dovetails with my original thought for a book about the stresses that were going to be brought to bear on the health system by the aging of the Baby Boom. Covid is just hyper accelerating those processes in some unusual ways. I was expecting the cracks and problems to begin showing in the late 2020s and really becoming a serious issue in the 2030s. Looks like I missed the mark by a decade. I’m still not sure how to put all this randomness together in a coherent whole but I liked what he had to say so I’m going to ruminate on it a couple of weeks. If I get the pieces in order in my mind, then I should be able to write fairly quickly and might have something by next year. Got to use all those non-rehearsal hours for something other than perfecting my Civilization VI game.

I am taking my first journey since Covid his this weekend when I head to Seattle to see my family. It’s my first time off and the first time I will have been able to see them since last November. Those of you in the greater Seattle area, if you want to get together for walks around Greenlake or the Arboretum or along the Burke-Gilman Trail, let me know. Most of the things I usually do in when I’m up that way just aren’t a good idea at the moment due to infection control principles. I’ll be staying at my brother’s house in Wedgwood. I have no real agenda other than family time – probably a number of very long naps as the grind of work in this era has been getting to me. I’m not looking forward to flying in the age of Covid but it was either that or nine days of driving round trip. Watch this space for my impressions. Believe me, I much prefer to write travel diaries than plague diaries.

Keep those hands washed and sanitized.

Wear your mask when out and about.

Stay home as much as you can.

July 11, 2020

Line forming for Virus of the Caribbean

We’re up over 70,000 new diagnoses daily in this country, more than 130,000 are dead, hospitals in multiple states are running out of ICU beds, and Walt Disney World decides it’s a great time to reopen. Must be time for another entry in the Accidental Plague Diaries. I’m in a bit better mood than i was when I wrote my last missive. That was a low point. I’m not sure what refreshed my soul. Maybe my once a month trip to Target for supplies (100% masks on patrons and employees), maybe having appointments with a couple of my favorite patients over the last few days, maybe memories of Tommy and Steve. Today would have been mine and Tommy’s sixth legal anniversary. We didn’t use the date as we’d been together for nearly twelve years when we did get married. That was simply a formality for taxes and insurance.

Tommy and Andy go to criminal court

Prior to the Obergefell decision of 2015, marriage laws were something of a patchwork in this country but the Windsor decision of 2013 decreed that, at least for federal purposes, a legal marriage in any state would be recognized by the federal government. Tommy and I looked at our taxes and things and decided that marriage would be advantageous. We decided that we didn’t want a wedding. We were a decade or more too late for that and there was the issue of Alabama dragging its feet for state purposes so we decided, on our next trip to Seattle to visit the family, we would do the deed. I contacted my old friend Kanti Carolyn Ramamurti, an attorney in Seattle and she put us in touch with a judge who was willing to marry us so one July afternoon, we trekked down to the King County Criminal Court in Redmond along with my father, brother, and cousin Jenny for witnesses and said our ‘I dos’ in front of the power vested by the state of Washington right after she was done with the Grand Theft Auto case that dragged on a bit longer than anyone expected. That was followed by a dinner for family and friends in my sister’s back yard. Tommy felt that even that was too much hoopla but I expect he secretly enjoyed it. On the flight back to Alabama, our marriage dissolved and reformed several times depending on which state we were flying over and was not recognized when we returned home, but we were able to file a joint tax return that year and a year later, with Obergefell, remained married no matter what the flight path.

Our marriage was, of course, cut short by Tommy’s untimely death four years later but it was valid and made a huge difference in our lives in regards to dealing with various institutions. It allowed me to put him on my benefits without question, it helped at tax time, it announced to the world we weren’t giving up on each other (although everybody had already figured that one out), and it changed how we related to each other in some subtle but real ways. We both knew that leaving each other would now require a lot more than packing a suitcase and walking out the door and there was more strength to the bond when we had our fights (and believe me, we had some doozies). Most importantly, I think, was we understood that we were riding a wave of societal change forward. We had no idea where it was going to lead us, but we knew that there would be no turning back and that things would always be different.

I think one of the fundamental flaws of American culture, and I wonder if it’s descended from the Boomer ideal of how the media depiction of America prevalent in their childhood – the Leave it to Beaver and Sally, Dick and Jane world of perfection and safety – is some sort of quintessence that must be recaptured at all costs, is its rose colored nostalgia that causes people to look backwards rather than forwards. When applied to the current time of Covid-19, we all run around talking about things getting back to normal or things being all over. Honestly, we have no way of knowing if that is going to be possible and, even if the virus were to fall silent tomorrow, we wouldn’t be able to go back to where we were last fall. There’s been too much radical change to allow that. It’s the old You Can’t Go Home Again phenomenon.

I’m hoping that some of our brighter thinkers (and I do not count myself among that group) can start giving us ways to start thinking about moving forward to what can be rather than pining for what is no longer and can help us redirect our energies in that way. Our education system, for instance, was borrowed from Prussia in the mid 19th century and was designed to create an obeisant proletariat of workers and soldiers. Regimented, full of an unwritten curriculum of obedience to authority, subject to the tyranny of the clock (hungry? too bad – you can’t eat until the bell rings). We no longer live in that world. Perhaps this can be a time where we can take the underpinnings of the system and reinvent something for who we are in the 21st century, nearly 200 years later. We are the wealthiest society that the planet has ever produced and where does an enormous amount of our treasure go? Defense systems far above and beyond what are needed. Can some of that be redirected? Our health system is tied to employment due to mid 20th century historical accident. What are the possibilities there?

Follies girls and their ghosts – Original Broadway Cast

Living in the past with backwards thinking is toxic and corrosive and will set you up for failure. Being the show queen that I am, and having been primed with several viewings of Hamilton, I went to my CD collection and to the Sondheim rack where I tend to find a lot of life’s answers. I put on the Original Cast Album of Follies, a show that is about the dangers of living in the past, trying to stop time, and refusing to recognize that either you or the world has changed. That title is a double edged sword. It may be about the ghosts of the between the wars young adults and their mature 1970s selves but the same phenomenon is happening today, especially with the boom. How many Boomer icons in their 70s and 80s are trying to project the same image they have for the last fifty years? In my job, I see so many people in their 70s to whom I have to break it that their disease processes are chronic and not curable due to the ravages of time who simply refuse to accept it. Our two candidates for president are 74 and 77. Could this be the moment that we can move forward with a cultural reset and where younger artists with a new way of looking at the world get their chance to lead us in new directions?

I’m thinking that our sclerotic, if not downright fossilized social institutions are cracking under the strain of Covid and that may not necessarily be a bad thing, as long as the energy is channeled in positive directions. If it goes negative… well let’s just hope we avoid 1793 France or 1918 Russia.

Time to change the CD. Switching from Follies to Merrily We Roll Along, a caustic look at where the Boomers went wrong in middle age. Seems somewhat fitting, doesn’t it. I am allowed to criticize the Boomers, I am one, although at the very tail end of the generation.

In the meantime, wash your hands, wear your mask, and stay home when you can.

July 7, 2020

Thunderstorms over Birmingham

I came home from work this evening about 5:30, sat down on the couch, and found myself incapable of moving for about two hours. That’s become a fairly common pattern. About twice a week I get in from the day, feeling pretty normal, and then like someone stuck a pin into my balloon, I feel drained of all energy and can’t do much besides stare out the window (thunderstorms and rain today) and wait for my faculties to return. I assume it’s my personal physiologic reaction to the never ending Covid stress that we’re all living in. At least those of us who work in health care and are paying attention are living in. A significant portion of the population seems to be running around as if nothing has changed and that we aren’t living in a very different world than we were living in last year.

The local counts continue to rise. My hospital has over 90 inpatients with Covid (we were running 60-70 at the height of the early pandemic in March/April) and we’ve increased by over 50% in a week and a half. The numbers in surrounding Southern states are absolutely appalling with more than 10,000 cases a day becoming the norm in Florida and Texas with their large populations and relatively dense cities. The stories are spreading among medical professionals of overfull ICUs, patients being sent to other cities or even out of state for treatment, absolute exhaustion on the part of medical personnel, shortages of protective equipment and all the other logistical nightmares that have been reported in New York and elsewhere in the world. There hasn’t been much reportage on this – the powers that be (and the media that decides what we will hear and what we will not hear is very much part of that) has decided that a narrative of economic recovery is more important than one of personal safety. People have lost out to profits in our late stage capitalism enterprise.

There’s a lot of speculation as to why the death toll has not spiked in the same way as case numbers. Some may be due to changes in testing, some may be due to a shift in infections away from older populations who are taking greater precautions to younger populations who are not and that those younger populations are less likely to become seriously ill. (It is true that younger people in general, as they have healthier bodies with less chronic disease burden are less likely to be seriously affected but this malevolent disease that we do not yet fully understand makes a certain percentage of young and healthy people with no appreciable health problems deathly ill and appears to leave those that survive with chronic issues that may take months or years to resolve, if ever). But no matter what, every single infection is conceivably preventable with proper public health measures that we as a society are completely unwilling to take.

This spring’s lockdown was never about eradicating the virus and returning to normalcy. It was about buying time for the government and the public health system to put appropriate programs in place that would curb the spread over time so that we would eventually all be able to return to a semblance of normal. Most of the developed Asian countries and soon, the European Union, have done this and are heading back to normal economies and societal function. Our dysfunctional federal government has adopted a strategy of ‘live with it’ and pushed public health measures back to the states. The states, already cash strapped and unable to mount national responses are dealing in myriad different ways, most of which are unsuccessful and pushing down to the county and city level. The population, which needs strong leadership in an emergency and which will be able to pull together if clearly shown what the problem is and a road towards a solution, gets multiple conflicting messages and tunes out and goes to the mall with dinner at Applebees to follow. The end result in my life is a constant low level of exhaustion with no end in sight and no ability to take part in the activities I’ve always used to rejuvenate myself and I end up staring out the window for hours.

We’ve got some huge societal dilemmas coming up over the next year or so which are independent of current partisan politics or who occupies the White House. The first is the question of education. The vast majority of American families depend economically on two incomes which requires both parents to work. This means schools must be open and in loco parentis during usual business hours. Children gathered together in groups are highly unlikely to keep social distancing, proper hygiene or masks in place. The majority of veteran teachers are of an age to be in a higher risk group. If we send kids to school, how do we keep them safe? How do we keep teachers and staff safe? If Covid starts to spread in a school do we shut it down? What to do with everyone for quarantine periods? When veteran teachers decide to put their health ahead of their careers and take early retirement, how do we replace that lost experience? How do we deal with the extracurriculars which are sometimes the only things that will keep at risk kids in school? In higher education, where on line education is a little more feasible in certain subjects, what do you do with practicums like chemistry labs? What do we do about federal policies about students on visas not allowing them to remain in the country if their classes are on line? (A move that is going to decimate graduate and research programs nationwide – the US University system is one of the shining jewels in our culture and I can’t think of anything that could be done to destroy it more quickly than this particular piece of idiocy. Destroy the universities because of their perceived ‘liberalism’ and we will rapidly fall behind the rest of the world in science and innovation. It’s happened before. Look what happened to the research institutions of central Europe after the Nazis rose to power. They never fully recovered.)

I’ve certainly considered early retirement myself as it’s become clear that neither my state or federal government cares much about the safety of me and my colleagues or the stress that we’re being put through at the moment. If they did, they’d be paying more attention to the public health system (as underfunded as it is) and a little less attention to the chamber of commerce. If I were a few years older, I likely would, but in looking at all my options, I plan to keep soldiering on for a few years more. I’ll continue to hold up my little corner of the health care system and hope that things get better and maybe, just maybe the cavalry will eventually show up and give me and mine a little respite. I’m being a little unfair. Part of my job is with the Birmingham VA and they are bending over backwards to protect clinical staff as much as they can. I’m not high enough up the food chain to know what really happens in the C suite but they really are trying their best in a crazy and ever changing situation. Not every experienced health care provider is going to want to continue to work under these conditions. How do we replace them? We’ve been importing doctors to the US for years as US medical schools haven’t been able to produce enough to meet demand. If we become more cut off from the rest of the world and unfriendly to immigrants, where are we going to get people to replace them?

The right wing has been sending us down a path of isolationism for the last few years with their chants of build a wall etc. etc. The business community understands that, in this day of global economies and multinational corporations, that this has been relatively silly rhetoric that keeps the masses distracted while their pockets are picked. However, our complete failure to respond appropriately to the pandemic may lead the rest of the world to wall us off anyway, at least until we’re no longer seen as dangerous. Be careful for what you wish, for you may get it. I see advertisements for inexpensive international travel cropping up for late fall or winter and I can’t help but think that will never happen. We think it’s bad now. What happens when the usual flu season coincides with the pandemic with no adequate responses in place? I wouldn’t plan that trip to Paris quite yet.

Usually I’m relatively optimistic in these, my accidental plague diaries. I’m feeling pessimistic this evening. Maybe it was that two hours of staring out the window at the rain. Maybe it’s the life circumstance to have to go through this alone. Maybe the Smoothie King lunch I drank isn’t agreeing.

Wash your hands. Wear your mask. Use common sense.

July 4, 2020

High above the Rhine at the Neiderwald – Rudisheim and Bingen – one year ago

I dream a lot. Generally, they’re gone within an hour or so of getting up and getting on with the day unless I take a moment to jot them down. I’ve dream journaled off and on over the years, mainly off but I’m wondered if I should take it up again to try and make sense of all the insanity in the world today. If dreams are the ways our subconscious processes information, maybe it’s time to pay a bit more attention to them. I have a dream journal on my nightstand that Tommy gave me years ago. He inscribed it ‘Andy – For your dreams… Good or bad always remember you are in my heart. Take solace there! -Tommy’. Little things like that from the past are what allow me to keep going on the days when it all seems to be too much.

The dreams this last week have all been about travel. They’ve been somewhat variations on the actors nightmare or typical school dreams. One was about my trying to pack for an important trip and not being able to find the things I need which led to my being late to the airport, missing the flight etc. etc. One was about being in a foreign country where I did not speak the language and being lost in a crumbling palace of some sort. Then came the realization that I owned it and would never be able to afford the repairs. A third involved being trapped on a train with a lot of unpleasant people – sort of a Murder on the Orient Express without the murder.

I’m assuming I’m having travel dreams because I’m moving on. The immediate stresses of the move are over, I’m settling in and now I have to figure out who the new me is going forward. The new me was going to be defined by my two great interests outside of my professional career – music/theater and travel. Neither one of those things are currently possible and so there’s a huge void that has yet to be filled and I don’t know yet how to make those adjustments. I have projects to work on and the job gives me direction and purpose and uses up an enormous amount of energy given all the strains on health care that must be absorbed. I know it will all work itself out eventually and that patience and delayed gratification are called for (again). Still, I think I’m allowed to think back to last Fourth of July when I was floating down the Rhine and wondering when that such experiences will be possible again.

Social distancing – only for the little people

The local virus numbers are increasing as they are all across the South East. Alabama is adding a thousand new cases a day which is high for our state but only a tenth of what’s happening in Florida and Texas. I put that down to our lack of large cities. Birmingham is our largest but it’s quite small compared to the megalopolises of Atlanta or Houston or Jacksonville and, with smaller and less dense populations, we can keep numbers down, at least within our communities which will take things seriously. Alabama is not immune to the anti-mask idiocy that’s sweeping the land. It appears to be limited to communities of privilege who feel that they should be allowed to live their lives on their terms and that society is to cater to them rather than they are to cater to society. Communities of color and social outsider status who understand the importance of taking care of each other are much more likely to think of others as well as themselves. Americans seem to have forgotten that the unit of survival in human social evolution isn’t the individual or the family, it’s the tribe. We have effectively split ourselves into two tribes, eyeing each other with mutual suspicion and an unwillingness to reach out to help and that is leading to our country falling far behind the rest of the world when confronting a global threat. Those on the other side of the divide may get their dream of a wall, but it’s going to be built by the rest of the world to keep us in unless we start figuring out how to pull together, rather than apart.

Phillipa Soo in Hamilton

Like most of the rest of the theater world, I subscribed to Disney+ in order to watch the filmed version of the original production of Hamilton which is streaming for a brief time. I was fortunate enough to see the original production on Broadway (but with a different cast) a couple years ago (and those who want my reactions to that can scroll back to the fall of 2018 on the blog). Generally I don’t care for filmed versions of stage works as film and stage are such different mediums and what works for one is dull in the other. This version, as filmed by original director Thomas Kail, does as good a job as can be done to capture the energy, talent and sheer genius of the work. The addition of judicious close ups, heightening of the theatrical lighting, and the clarity of the sound allowing every word to be heard make this one a winner. Hamilton became a phenomenon in 2015-16, the end of the Obama era and now, only about five years later, watching it makes it so clear how much our civic life has changed over a very short time. I also picked up much more clearly on a couple of themes. First, while the show is called Hamilton and Alexander is the central character, the narrator, and our way into the show and our perspective comes entirely through Aaron Burr, the ultimate outsider among our critical founding fathers and the one whom we don’t remember on the coinage or the postage stamps. Second, the ultimate theme of the show, which became crystal clear in the filming, and in Phillipa Soo’s performance as Eliza Schuyler Hamilton, is that the most important thing in history is who gets to tell the story and control the narrative. For centuries, we have been taught a specific American narrative of progress and superiority and Hamilton gently reminds us that this isn’t necessarily the truth, the whole truth and nothing but the truth.

That has been my great revelation of the last few years. Telling the story is perhaps our most important function as humans. As I’ve realized this, it’s permeated all the various areas of my life. I succeed as a physician when I allow patients and families to tell their story. If I am patient and listen, there’s usually a nugget of information in their that will allow me to crack the case and figure out how I can actually help. I started writing these posts a few years ago when I came to the realization that I had a lot of stories to tell and, without Tommy, really no one to tell them to and I figured it was time to send them out into the world to see if they could touch anyone else. Its evolution into a plague diary was completely accidental and simply my attempt to trying to make sense of a crazy time in modern world history. Storytelling is, of course, essential to the whole nature of theater. I find I can do things in character that I could/would never do in my own persona.

Where do I go from here? No one knows the answer to that question. We think we do. We make our plans and then life interferes and off we go on a tangent. I’m sure something will make sense eventually and I’ll start down that road and then, as in the words of Robert Frost, way leads on to way and that has made all the difference. In the meantime, I’ll soldier on in the trenches of health care, keep up some writing, try to stay connected to the other parts of my life as best as I can, and the story goes on.