January 20, 2022

It’s opening night! Opening night! It’s Virginia Samford’s latest show… will it flop or will it go? And now that all the theater people are busy singing along in their heads, time to launch into another long post in the age of omicron chronicles. I haven’t really written much about my latest theatrical venture, Dolly Parton’s 9 to 5: The Musical. I’ve had reasons for that. The first is that I’ve been a bit ambivalent about doing a large cast musical at this stage of the pandemic. The show was planned and I was cast before anyone had ever heard of the omicron variant and there has been grumbling in some quarters that the show should have been cancelled or postponed due to potential risks. I understand that thinking and I have certainly thought that way myself. I was somewhat relieved when I developed my mild breakthrough case when I did as it was over and my quarantine was up before I was really needed for rehearsals. My part, while integral, is small in terms of stage time and technical need so I really didn’t come into the show until late in the rehearsal process.

Part of the problem with writing these Accidental Plague Diaries is that some who read them have confused me with some sort of expert in virology and epidemiology. I’m not. I have a well trained mind and a breadth of knowledge, but I’m as human as the next person, bewildered by all of the conflicting information flying around the world through the system of tubes known as the internet and my writings are my way of trying to sift through it all and make some coherent sense out of what’s happening to our world. Like all humans, I have my biases, my short sightedness, my choices and lack thereof. Unfortunately, a lot of my friends seem to forget that and want to anoint me as some sort of Covid oracle, all seeing and certainly perfect in knowing just what to do when faced with the unknowable. Sorry… I don’t know that guy. Like everyone else, I’m trying to work out the risk benefit of various activities and how to stay safe myself and keep those around me safe as well. That’s the world we’re going to be living in for the foreseeable future.

Living in a world that does not have live music/theater performance is, to me, a world that’s devoid of life. Theater is as much of a calling as medicine or the priesthood, and it’s probably no accident that it developed, in the Western Tradition, out of religious rituals in Ancient Greece. Those of us with the calling, which includes all of us on and backstage at 9 to 5, are compelled to make this sort of art. In the height of the pandemic, we adapted to various on line versions of theater but we need to tell our stories in real time to live people. The audience gives us life as we give life to the audience, the one mirroring the other. If you don’t have that calling, or if your risk/benefit calculus is different than mine, I can understand not wanting to perform or attend a show at the moment and I support your decision. We’re all vaccinated, rehearsed in masks until dress rehearsal and, being actors and singers, know what to do to keep our bodies healthy and away from infection. Just as I trust my colleagues in medicine to look out for me as I look out for them, I trust my colleagues in theater.

When I accepted the part of Tinsworthy, the deus ex machina who appears late in the second act to make sure the plot comes out right and to reward the heroes and punish the villains, I figured I was just getting involved in a light piece of fluff that wouldn’t be too taxing. They added a second role for me in the first act as a corpse so I’d have something to do. It’s actually the more technically difficult thing for me. It’s not easy to lay motionless under a sheet on stage for ten minutes on stage while slapstick comedy is going on all around you. There is a verb in theater parlance ‘to corpse’ which means to crack up inappropriately on stage in front of an audience. Having now played a corpse, I understand completely where it comes from. I had seen a previous production of the show at the same theater ten years ago, but I remember very little about it other than it was innocuous fun. Tommy and I came in during tech and helped fix something. It may have been wigs, it may have been props. I can’t remember now what it was.

VST’s Current Production of 9 to 5 – I’m not in this scene

Having now spent some time with the show, it’s resonating in a very different way and this production is digging at some of the deeper themes under the surface. In this age of Covid and the Great Resignation, where we are grappling with whether we should Live to Work or Work to Live and our whole relationship with the workplace being rapidly redefined, this parable of feminism turning the tables on masculine corporate culture has a bite that it didn’t a decade ago. In many ways, our whole cultural moment is a tug of war between a masculine individualist ethos and a feminine cooperative one. That’s certainly been true in the social approach to the pandemic. One side is firmly on the side of individual choice and a belittling of precaution as fear mongering while the other side is about caring for all and trying to set up systems to protect families and friends and the vulnerable. I’m of the opinion the show sends the correct message and that’s resonating on an unconscious level with the audience. Theater goers tend to belong to social classes more in sync with the feminine approach.

I’ve worked with most of the principals multiple times on various projects so it’s old home week backstage. Everyone is bringing their A game and there’s not a weak link in the bunch with everyone having a couple of stand out moments. To me, though, the real stars are the young folk in the ensemble who are in constant movement throughout the show. The staging is cinematic with a lot of dance transitions and I don’t see how they can do all of that for more than two hours. I can’t and couldn’t even when I was their age. I’d have fallen over from exhaustion half way through the first act. They don’t get anywhere near the credit they deserve and I privileged to appear on stage with them. I can’t even really sing the chorus parts. Most modern musicals are written with all of the male vocal arrangements for rock tenor and the tessitura is just too high for this bass baritone. I have the choice of screeching falsetto or singing down the octave. Fortunately, the only musical number I’m in is the finale and it’s not that difficult.

When you’re in the audience at a well produced musical, you’re watching just one facet of a complicated, well-oiled machine that starts ticking a couple of hours before the house lights go down. For everyone you see on stage, there’s someone else backstage you don’t see and it’s a whole other show there in the wings and the dressing rooms. This show is full of mass quick changes, rolling set pieces. and choreographed furniture, all of which has to be done to set musical cues. The offstage show in the wings is often more fascinating than what’s actually on stage. We’ve got most of the kinks worked out and the only person who missed an entrance tonight was Dolly Parton herself due to a technical glitch with a video cue. The amount of complicated team work and absolute trust one must have in ones cast and crewmates puts any team sport to shame. To me, it’s a lot more absorbing that sportsball. But there’s that masculine/feminine dichotomy again.

So, the show is good. It’s selling well so if you’re in the Birmingham area and want to see it, get your tickets now. I’m looking forward to the next three weekends. And yes, we wear our masks in our dressing rooms, keep our hands washed and sanitized and have our vaccines.

January 16, 2022

And the hits just keep coming. Omicron cases continue to mount both locally and nationally and we’re over 150,000 people hospitalized nationally with Covid. From what I can tell, that number includes incidental cases in people hospitalized with other things so it may not represent the true state of what is bedeviling the health system. All I know is that the numbers at UAB have gone up enough to send us back into surge emergency mode with housestaff being pulled from their regular rotations to manage Covid and the call going out for volunteers from the faculty to staff additional care teams. I volunteered last surge (and was fortunately never called up – I’m not sure how useful I would have been not having done acute inpatient care since the last millennium) and will likely volunteer again this surge. Again, I hope it doesn’t come down to me but if it does, I will cheerfully and willingly do what I can.

I still believe very strongly that a society is strongest when it is a society of ‘we’ rather than a society of ‘me’. And I think that’s the major issue underlying most of what’s causing our fractures in our various social institutions. For the last fifty or so years, the US has been on a course favoring the individual over the collective, the private over the public, the have over the have not. It’s metastasized into all of our social institutions. Politics has tilted in favor of money and corporate profit over public good. Religion has found the prosperity gospel which conflates economic success with piety (despite Balzac’s dictum ‘Behind every great fortune is a crime’.). The educational system has been tilted towards economic success for the individual and away from personal fulfillment or even societal needs. The result has been a hollow and brittle sphere, unable to meet the challenges the pandemic has forced upon us.

We are now two years into this thing and the richest society this globe has ever produced still cannot vaccinate its population, provide real time testing and tracking of cases, guarantee adequate health care for the sick, or provide clear and concise information to its population on how to stay well and what the individual can do to combat the pandemic. These problems are not unique to the US but they are a bit more pronounced here than they are in other countries and societies; and I don’t see any of them being solved at any time in the near future. The structural issues run too deep and many of the wounds have been left to fester far too long.

Why are we here? It’s easy to point the finger at the former president and his administration, but that’s a symptom of underlying disease and, while it might feel nice to use an easy scapegoat, his recent treatment by his followers for even suggesting that vaccination might be a good idea shows that our problems stretch far beyond what goes on at Mar a Lago. We have an entire political party that decided last year that vaccine denialism, and posturing against public health measures was good politics. And people died. These positions remain. And people are still dying. When there’s a change in administration form Democrat to Republican, it’s become political orthodoxy to undo public health measures, as we are witnessing in Virginia where the recently elected Republican governor, as his first acts, is issuing executive orders to undo mask and vaccination mandates. The judiciary has jumped into this as well with the Supreme Court using some rather peculiar logic to undo OSHA’s demand that all large workplaces have vaccine mandates (or a test/mask alternative for those who refuse vaccines). The irony of watching a set of masked and vaccinated judges whose workplace requires vaccination ruling that the coronavirus is not a workplace hazard as it exists outside the workplace was not lost on anyone with more than a few functional brain cells.

These politics, like all of our politics, are driven by money. There’s a lot of right wing dark money pouring into various groups keeping all of these sentiments ginned up. When the sources are traced, it runs back to all of the usual suspects, mainly extreme right wing billionaires who have been playing a very long game of trying to undo all of the regulatory progress of the 20th century which stands between them and maximum profits. I presume that the Scaifes and the Adelsons and the Kochs of the world have some sort of plan in place to protect their assets once society has devolved to the point when the population can no longer afford the goods and services that they sell. Or maybe they’re content with Louis XV’s philosophy of ‘Apres moi le deluge’. The professional classes have tacitly supported this agenda as it’s been good for their 401K balances but I’m not sure how much longer that’s going to last. Economists like Piketty, who is probably the most important thinker in the field of the last fifty years, have been sending up smoke signals for years that Western Civilization is built on an economic house of cards.

Cassandra of Troy

I have always identified with Cassandra, ever since I first learned the stories of the Trojan War. The prophetess with the ability to see the truth and the curse of never having anyone believe her predictions. As I look around at the world today, I feel like I am a member of the Divine Family of Cassandra Like Oracles. (I should be able to make that into a cute acronym, but I don’t have the energy). I went into Geriatrics in part because my reading of demographic charts prepared in the 1950s and 1960s, before I was even born, alerted me to the needs of the population and how I would never want for people who could use my skill set. For the last thirty years I have discussed demographic changes and the needs for medical care with several generations of healthcare administrators, generally getting nowhere. I’ve spoken about the likelihood of a viral pandemic and the changes that would need to be brought to bear in eldercare since the mid 1990s, mainly to yawns. There’s a part of me that’s getting tired of fighting the good fight and that wants to retire into a hole and say ‘You figure it out, I’m done’ but I know I’m not going to do that quite yet.

I figure I can muster up enough energy for a few more years of crazy town, at least if it can be done along with those things which renew my internal energy sources – theater and travel. But I really wish our society would understand just how much deep damage they are doing to their healthcare system and the people in it. The political refusal to expand the health care system so that the whole population is covered is both disgusting and hugely problematic in the face of a viral pandemic without seeming end. The emphasis on profit in health care rather than outcomes is going to continue to drive workers out of the sector, especially under high stress conditions. Nursing, in particular, is in bad trouble and it’s going to take some years to replace the skilled nurses who have retired or who have been lost to stress, illness, or death. The aging boom, with their demands for instant satisfaction from all things in life, are going to be in for a rude awakening over the next few years when they can’t get everything they want from healthcare when they want it as the system has been too damaged to deliver. Most of my older patients are very good at following basic public health measures, but their children… Perhaps I should suggest a few trips out to the woodshed…

In the meantime, you all know what to do. Get those vaccines and boosters. They work. Keep your hands clean. Wear your mask (N-95 or KN-95 if possible as long as omicron is rampant). Watch your distance when you can.

January 12, 2022

Omicron! Omicron! Never before have the numbers been more… More people in the hospital than at the peak of the pandemic a year ago just as vaccinations were starting to come on line. Three quarters of a million new cases daily in the US alone. The local case positivity rate is well over 10% (it needs to be under 5% to consider spread in the community under any sort of control). The death rate continues to inch up and is now at about 1700 deaths daily (from under a thousand a few months ago). Everywhere you turn, it’s a plethora of bad news.

What does all of this mean? It means omicron is much more infectious than previous strains and much easier to contract through casual contact than the previous circulating variants. Given this ease and rapidity of spread, omicron’s R0 (estimated number of individuals an infectious person can spread disease to) is about 7. The original strains of Covid were closer to 2-3. With one person in 440 in the country being diagnosed daily, that’s 1.6% of the population a week or 7.2% of the population in a month. No matter how you slice it, it’s everywhere and unless you’re a hermit, you’ve got a good chance of encountering it if you are in contact with anyone outside of your home. Fortunately, we’re two years into pandemic life and we should all know what to do as a society. First and foremost, vaccines work. They’re not perfect at preventing infection but they are working very very well at keeping people out of the hospital and the morgue. Unvaccinated individuals are somewhere between 13 and 17 times as likely to require hospitalization and are about 20 times as likely to die as vaccinated individuals. Vaccinated individuals that require hospitalization tend to be those over 65 and those with significant other disease processes. If you are a non-elder, relatively healthy, and are vaccinated (and boosted), you’re somewhat more likely to die in a traffic accident than from Covid.

Shutting society down was a necessity early in the pandemic to mitigate spread as we had no weapons to fight back. We’re not in that position any more thanks to vaccines which remain the best thing we’ve got to save health and lives. (There are monoclonal antibodies and antivirals as well, but they are nowhere near as effective). Western society has made the decision – no more shut downs. We should probably keep them on the table, but neither our government nor our populace is going to go for them without a hellacious fight. So we’re going to have to rely on other mitigation measures. What else have we got other than vaccines? The same things I’ve been talking about for months and months. Masks (and this is the time to break out the N-95s you’ve been saving), hand washing, and appropriate social distancing. If we would all do those three simple things, we’d be in a much better position, but alas, if my recent trips to work are any indication, the population of Alabama is more or less over those basics as well.

Flatten the curve is so 2020 but it’s really necessary at the moment. Even though omicron appears to be less virulent, and the breakthrough cases in vaccinated individuals don’t require the intense inpatient therapy that those stricken early in the pandemic needed, the absolute number of people becoming infected is creating a huge influx of folk needing at least some hospital care. The numbers of Covid inpatients at UAB, which had been down around a couple dozen a few months ago, are now over 200 and everyone is battening down the hatches as hospitalizations lag diagnoses by about two weeks so it’s going to get a lot worse before it gets better. So everyone, get those vaccines to keep yourselves out of the hospital and reduce the burdens on the health care system. Local vaccination rates have gone up but the state as a whole still remains about 45% unvaccinated. In the last two years, given all of the strains on health care, and they have been many, roughly 20% of the healthcare workforce have left their jobs. I haven’t seen numbers on how many of those were rehired elsewhere in the healthcare system but every hospital system I know of is having difficulty fielding nursing, provider, and other ancillary staff due to resignations and individuals being out sick themselves. (And the messaging about isolation/quarantine by health care workers is all over the map – get it together CDC…)

We’re getting close to a fairly catastrophic failure of inpatient care. That doesn’t mean that hospital buildings are going to collapse a la Surfside condominiums or hand out closed signs, it just means that they will not be able to provide the services we depend upon them to do as part of the infrastructure of society. Those wounded in a car accident or a fall won’t be able to be treated and will die of their accidental injuries. Patients will not get cancer treatment. There will be no one to deal with the sudden heart attack or stroke where precious minutes can count. Covid related deaths without covid infection. And once the infrastructure is shattered, it’s going to take a lot more time and money to rebuild than we as a society have been willing to invest in social services for some decades. The US health system, ranked #37 nationally between Slovenia and Costa Rica for outcomes, will plummet down the international scales . We may continue to delude ourselves about exceptionalism in American medicine but I fear we’re going to be exceptional going forward for all the wrong reasons.

A lot of what happens next is out of the hands of any of us as individuals. Society as a whole is going to have to decide how things progress. The problem with that is we’re living in two distinct societies currently, red and blue for want of a better shorthand. Red society, with its disdain for expertise, basic public health measures, vaccinations, and anything that resembles a ‘mandate’ will continue to place great strain on the medical system and continue to put the chronically ill, and those who cannot be vaccinated, including their younger children, in the path of potential harm. Blue society, with its acceptance of vaccination, social norms of masking, distancing, and willingness to isolate in case of breakthrough infection, will be able to resume a certain normalcy in social interactions and activities, even in the face of omicron. But we don’t live in purely blue and red communities, we’re all living in a mosaic of various shades of purple where the choices of both sides are likely to affect what happens to you as an individual. I’m afraid that until we get some strong leadership from the center that can appeal to both sides (is that even possible these days?) we’re going to be doomed to dealing with pandemic issues for some time to come.

In the meantime, there are a few things y’all can do and you know what they are. Get those vaccines and boosters. Wear an N-95 mask at least until omicron has started to die down. Keep those hands clean. Think about your distancing when inside with others. Do your socializing outside as much as possible. Try not to be a link in the infection chain… Yeah, I got it but to my knowledge by isolating for five days and masking up since, I haven’t spread it to anyone else.

January 8, 2022

I continue to mend after my little omicron adventure of the last few days. I only had one really bad day. After that, it’s just been a bad cold and I’ve had those every few years throughout my adult life so I know how to deal with that. Thank you all for the offers of chore work, telephone companionship, and deliveries of chicken soup to my balcony via drone but I am surviving just fine thanks to Uber Eats, a number of good books, Netflix, Xbox, and Oliver the noisy cat who insists on occupying the bed with me and yowling every few minutes for no particular reason. If he keeps that up, he’s going to learn how to fly. I remain under quarantine through the weekend. My five days are up as of Monday morning but my being cleared for work will be up to UAB and Birmingham VA employee health departments. I haven’t had a fever for days and my cough is much improved so I don’t think they’ll hold me out much longer than that. if they do, I guess I have some more time to try and escape the asylum in ‘Call of Cthulhu’. I’m quite good at solving the puzzle pieces of video games but have much more difficulty with the action sequences as I wasn’t born with a controller in my hands the way younger generations are.

This enforced time out has given me a good deal of time to think about where we are as we enter year three of pandemic life. Will it be the last year? I have no idea. The speed with which omicron is taking advantage of the social habits of the Western World to propagate itself suggests that it may burn through the pool of possible hosts rapidly and therefore recede due to that favored mythical phrase of ‘herd immunity’. Of course, we have no idea what novel mutations are percolating out there in the background. Some new Greek letter may be on all of our lips by Valentine’s day with a whole new set of problems in terms of transmissibility, virulence, or symptomatology. We’re all learning the meaning of that old curse ‘may you live in interesting times’ together.

I’m going to put on my prognosticator’s hat again for a bit and see if I can read the tea leaves as to what may be coming over the next year or two. There are a number of trends that seem quite salient to me and I’m curious to see if any of my assumptions are going to come out the way I’m thinking. The first is, of course, the course of the disease. I think we’re going to continue to see successive waves of variants for another year or two. Some will be relatively minor in scope, others will dominate headlines for several months. I don’t think we can escape this due to the continued inability of governments to get their populations properly vaccinated. In Western societies, politics stands in the way. In Developing Nations, it’s economics. It doesn’t really matter what the issue is but as long as there are significant portions of humanity that remain unvaccinated, there will be a pool in which the coronavirus can circulate and mutate and spring up again. And it will continue to happen. The flu virus has never really gone away. We’ve adapted to it and live with it and get flu shots and accept a certain amount of death. Covid will be here to stay in a similar way but it’s numbers will remain significantly higher than flu for quite some time as it’s so new and our immune systems are still working out exactly how to combat it. We can, of course, get our act together and get all eight billion of us vaccinated and boosted routinely but under what authority? We live in a global society, but not under global governance and that mismatch give the virus the advantage.

I think the biggest change for those of us here in the good old USA is going to be having to adjust to not getting what we want when we want it. In order to feed our society of consumerist instant gratification, we made a lot of changes to how things work over the last half century or so. We took our communal resources out of the public commons and long term planning and infrastructure and instead put them in private hands allowing certain segments of the population to get rich; they did this by creating a marketplace in which you could get pretty much anything at any time making consumerism the heart and soul of the economy. Of course, the side effect of this was an over abundance of retail, a shift of jobs and economy away from manufacturing to service and a general downward drift of purchasing power in most jobs. Manufacturing was outsourced to countries with lower wage scales. Service jobs, be they in retail, health care, hospitality, or any other sector, had stagnant wages with business models built on minimums that could not keep up with inflation or the cost of living. Low end retail thrived while middle class retail with higher quality goods designed to last longer struggled. We became a society of disposability. This spilled over from the commercial business place into sectors of the economy that, in most societies, are not viewed as being places of profit or privatization. Prisons became private for profit institutions. Public education was undermined by the charter school movement and other privatization mechanisms. Health care went from being a system that provided for the nation’s health to an industry that provided for the profits of the owners of the industry. The military became more and more dependent on private contractors . Things may have looked fine on the surface, but underneath the society had been hollowed out. The traditional rural/small town societies dependent on a major manufacturer or an extractive industry such as mining or logging started to feel the negative effects of all of this first and have understood for more than a generation that the system does not work for people like them and has no interest in working for people like them. They’ve been ripe for a demagogue to follow for years.

The pandemic has exposed all of this to those of us who still lived and worked in the bubble of function that existed in upper middle class urban USA. Now it’s not people in fly over land whose lives aren’t working and whom the system can’t help. It’s the people next door. It’s the people on whom we depend for groceries, for transportation, for health care, for assistance in child rearing who aren’t there where we’re used to having them quietly go about their tasks that allow our lives to be comfortable and seamless. As Covid either directly or indirectly takes significant parts of the work force down, there will be empty shelves. You won’t be able to count on your child’s school operating normally. You take your car in for repair and it will be three weeks rather than the usual 48 hours. We don’t like this and there’s going to be a lot of demands to speak to the manager but the manager isn’t going to be able to help.

I’m seeing this a lot currently in elder care. I know of no agency that provides direct hands on service to older adults that’s been able to field a full complement of staff in recent months. People have quit or retired. People are constantly out with Covid or quarantine because of a family member with Covid. People have moved up the career ladder to better paying jobs and the usual individuals who take lower end jobs (immigrants) aren’t available due to Covid and recent immigration policies. Everyday, my office gets a couple of calls from a patient or family complaining that the home health nurse hasn’t been or the therapist has cut visits, or that the time allotted by staff has been cut, or someone simply hasn’t shown up. They want a referral to an new agency that won’t have these problems. Sorry. Such an animal doesn’t exist. Nursing homes are running on reduced staffs. There will be poorer outcomes because of this. People will die who might not have otherwise, victims of the pandemic who never caught Covid. We as a society made the decision years ago to run these industries on low wages and poor working conditions. Now we must pay the price for those choices.

Need to travel? You may or may not be able to due to the availability of flight crew. Want a clean hotel room? Don’t depend on there actually being maid service available. Interested in going out to eat? The dining room may or may not have any waitstaff available. It’s going to take years for all of this to be sorted out. Unfortunately, we’re not a people with the patience to wait years and we’re going to do a lot of yelling at authority stating something must be done to fix this. Those who promise the biggest and quickest fixes, whether they have any ability to deliver on those promises, are likely to get the most traction politically going forward. Those who tell the truth about conditions and suggest that the way forward is through cooperation and restoring public spending are going to have an uphill battle (even though that’s going to be our way out of this mess).

From where I sit, there’s only one way for any of us to move forward through the next few years. We’re going to have to become more communal. We’re going to have to band together in our tribes and families of choice and care for each other. We won’t be able to go it alone in our little nuclear family enclaves heading for the store whenever we need something. We’re going to need to bring back a culture of watching out for each other, lending a hand, giving a little of our excess to those without and not being afraid to ask for or take a little when we need something from someone else. Nothing else is going to work.

In the meantime: Get your vaccines and boosters. Wash your hands. Keep your distance. Wear your masks. We’re all in this together.

January 6, 2021

Bad Andy

Well, my luck finally ran out. Two years after the emergence of the novel coronavirus in China and one year after the politics of our moment came to a head in Washington DC, one of the little buggers slipped past my defenses and did what it’s designed to do – replicated in my tissues and provoking an immune response in my body that has made me feel less than well. I had noticed itchy eyes on Tuesday evening and, when I woke up on Wednesday morning, I had a runny nose and a chest cough that had not been there the night before. Being a responsible citizen, I did not go in to work but rather figured out how to see my patients via video while I ran around and got my Covid testing done. I figured it might be Covid or it might be the usual cold virus I get in January. It was a standard joke for years – Andy has bronchitis – must be time for the January opera… I started feeling worse and worse as the afternoon went on and by 4 PM I knew this was no ordinary cold so I was not surprised when my test came back positive. By 7 PM it hurt to move, the cough was worse and there was a bit of a temp. I put on bad TV, bundled up and went to bed.

By 9 AM this morning, I could tell I was on the mend. I still feel like I’ve been hit by a truck, but it’s nowhere near as bad as yesterday. I’m on quarantine until Monday so I’m more or less just sitting around and slowly working my way through some long neglected projects – ten minutes work, thirty minutes rest. That’s what I can muster at the moment. I don’t need anything. I had Uber Eats deliver a quantity of soup and Thai curries from Surin yesterday so I have plenty of food in the house (it doesn’t taste right but I can taste it) and I am quite capable of taking care of myself so everyone can relax. I do understand how people, not as adept at reading body signals and what they mean, are pouring into the ED with this one. I’m assuming I have omicron and even a mild case feels dreadful in those initial stages. Tylenol and Dayquil/Nyquil are keeping the worst at bay.

So how did I get it, I’m assuming I ran across it in New Orleans this past week. The interesting thing being that David has not gotten sick and our potential exposures were essentially identical. I’m guessing that my nearly 60 year old immune system is just not quite as up to the task as his much younger one. There’s a part of me that, of course, it kicking myself. Years ago Domino’s Pizza ran an add campaign with the character Bad Andy and he always comes to mind when I try to second guess myself and my decisions. Was I bad for taking a vacation during a pandemic? I don’t think so. I needed it for mental health reasons. Did I do everything I could do to protect myself? Pretty much and the fact that David isn’t sick suggests we did a dang good job. Omicron is so widespread and so transmissible that I’m just one of about 550,000 new diagnoses yesterday in the US and, given the nature of my job, I could just as easily have picked it up staying here at home so I refuse to believe it’s some sort of karmic punishment.

In some ways, the timing isn’t horrible. I didn’t get sick in some hotel room in some strange city. (I’ve done that before – it’s really unpleasant). Because I was supposed to have been in Europe, this week at work was planned around jet lag and is very light so I won’t have too much trouble keeping things running from home. Major rehearsals for 9 to 5 don’t begin for me until next week when I’ll be through quarantine. The only thing that remains to be seen is whether I will have any long covid type symptoms but, given the fact that I am rallying fairly rapidly over the last twenty-four hours, I think that’s unlikely. All hail vaccinations and boosters. I read a column by some pundit recently where the major thesis was we can’t live in a world where we all need to get another booster every six months. Oh yes we can. If we can get to the moon and create a device in our pocket that is phone/camera/library we can certainly create programs and policies that can get every person on the planet vaccinated and vaccinated repeatedly. What stops us is economics and politics. Rich countries don’t want to help poor countries and rich people don’t want to help poor people. The problem is that we now live in a global society and viruses, because of their very nature, will continue to be a global problem as long as there are populations in which they can continue to circulate and mutate.

The recent Covid numbers are fascinating. The number of cases has skyrocketed in recent weeks thanks to omicron’s extreme infectiousness. Everyday, records for numbers of cases are shattered. Hospitalizations are up because of the rapidity of spread but the proportion of cases requiring hospitalization is way down. If it weren’t spreading so fast, the health system could handle things but the combination of exponential case growth plus short staffing due to health care workers being out on quarantine is putting a huge strain on everything and everyone. The death rate hasn’t increased that much. It’s been running steady between about 1000 and 1300 a day nationwide since the beginning of the Delta wave and it has stayed there, even as omicron has snowballed. If omicron were to cause severe mortality, we should be starting to see that in the numbers about now but it’s just not there. I think the moral of the story is that vaccinations and boosters are working.

I’ve been wondering what to do regarding these writings going forward. Those who have read ‘The Accidental Plague Diaries’ keep asking me if there is going to be a volume two covering 2021. I have demurred. I don’t like repeating myself when it comes to creative work but there has been enough interesting stuff going on to keep my brain and typing fingers busy over the last year so I suppose it’s time to pull out everything I’ve written and look at it. And perhaps my personal experience of infection is the inflection point which makes a natural cut point for a new volume. Must think about this over the next few days. I’ll have time in quarantine with my Thai food, my Nyquil, my yowling cat at my side, and my lines to be learned for 9 to 5.

The litany remains the same: wash your hands. Get your vaccinations and your booster. Wear your mask indoors with others. Keep your distance.

January 4, 2022

Well, the New Orleans trip wound down with a trip to the Mardi Gras museum (much fun was had dressing up in old Mardi Gras costumes), dinner with old friends Catherine Pate and James R Hood, some gallery hopping, and a trip to Uptown where I finally bought an Alex Beard original at his new gallery space on Magazine street. David Pohler‘s flight was delayed a day in all of the catastrophes that have become air travel in the age of Omicron but he finally made it home this evening. I once again split the drive due to the possibility of ice on the roads following snowfall in the Birmingham area on Monday and spent an uneventful night in Meridian, Mississippi before ambling in this afternoon around lunch time. The trip wasn’t London as planned, but it was definitely enjoyable and I’ll have to take some more weekends in New Orleans this next year, especially if more exotic travel remains off the table for reasons of Covid. The London trip is still on (it is paid for) and alternative dates are being looked at in late February and early March. We shall see what happens. The UK is generally not a garden spot at that time of year and it won’t have the enticements of the holidays, but it’s still London. With luck Omicron will have calmed down enough by then for things such as theater to have regained their normal footing. I’m not going to spend a lot of time worrying about it one way or another.

With David Pohler and Catherine Pate

Where are we with Omicron? It’s everywhere and spreading like wildfire. The number of people in the hospital at UAB is back up to a covid census of over 100 and we’re moving on up to over a half million new diagnoses in the US alone on a daily basis. There is some good news in all of the doom and gloom if you look at the numbers closely. First, vaccines work. They are very good at keeping people who catch omicron out of the hospital and from dying (the general death rate is up less than 10% despite the soaring number of cases). A recent study from NIH suggests that in 2021, without vaccines, the death toll from Covid would have been something in excess of 1.5 million rather than the 400,000 or so it was. While the number is horrific, it does mean there are more than a million people alive today in the US who would not have been without vaccines. Booster shots are working. They seem to be between 50 and 80% effective in preventing infection with an exposure. There is new data just emerging from Israel suggesting that a second booster might also be beneficial in the frail or very elderly but there has been no CDC guidance on this as of yet. Second, masks work. If two people meet and are correctly masked, transmission is cut by about 50-65%. If they’re both wearing N-95 masks, it’s cut by about 97%. Third, hand washing and sanitizing works (and we’ve known that since the early 19th century although it took years for both the medical establishment and the general public to accept it). There’s a reason for my litany.

Omicron is so infectious that I fully expect to catch it sometime this go round. I take what I consider are common sense precautions but unless you fully lock down with no contact with the outside world, there’s little you’ll be able to do to avoid contact with the disease. Fortunately, it appears to be less problematic than earlier variants. One of the things I wish we would get a better handle on in our health statistic reporting is a breaking down of Covid hospitalizations into a category of hospitalization from Covid (the infection is the primary reason for the acute illness) and a category of hospitalization with Covid (the infection is incidental to the reasons for the hospitalization). Unfortunately, there doesn’t appear to be much good data on this on a national level (although several health systems have run the numbers and it looks like a significant percentage of omicron hospitalizations are persons with incidental Covid infections. That’s one of my pet peeves at the moment. With all of the money we have in this society, how can we be so bad at testing and contact tracing. There are whole states that appear to be throwing all of that out the window for political reasons. And don’t get me started on the lack of tests… Every pharmacy I have passed all week has said ‘sold out of covid tests’. They aren’t that hard to manufacture and the government has been throwing money at the sector. Congress is auditing as there’s a significant mismatch between the funding authorization and what’s appearing on the street. What a surprise.

With the new year, I’ve been thinking a lot about what’s next. It’s that time of year for everyone to get their prognostications in order and do their best Madame Cleo. All I can say is that, given the way the last few years have gone, everyone is going to be dead wrong. The car has jumped the tracks and all we can do it hang on and see where it’s going to come to rest. I’m not terribly hopeful about this next year as it’s an election year and one of our two great political parties has spent the entire last year remaking itself into the image of the former president as they believe that’s what’s going to give them an electoral advantage. Nearly 50% of the Republican congress people who were sworn in in January 2017, the beginning of the Trump era, are no longer in office. The party has purged itself of perceived enemies, trading in Adam Kinzingers on Marjorie Taylor Greenes.

I think we’re a long way from open hostilities/Civil War, but we’re not that far away from the rules of the game being changed to make it more difficult for an opposition party to be effective once the other party has captured the castle. I have no idea what’s going to happen in next November’s political elections – there’s a lot that could affect it one way or another over the next ten months – pandemic issues, economic gains and losses, minor or major scandals, gerrymandering. Anyone who tells you that this or that is going to be the defining factor is lying through their teeth. There’s way too much in play for anyone to know. I’ll support which ever party supports, regulation of unfettered capitalism, public health, education, and improving lives of average people. In the meantime, get those vaccines and boosters, wear your mask indoors, and keep your hands washed.

January 1, 2022

Dateline: New Orleans, Louisiana

Happy New Year! Or maybe happy 2021 is continuing! Or maybe it’s ‘you didn’t know 2020 was going to be a trilogy’. I feel like we’re all trapped in stasis or a strange time loop what with Covid case numbers back up to what they were a year ago and beyond. As I’ve said previously, I really don’t know how to interpret the huge increase as the hospitalization/death rates are significantly trailing a year ago and it’s still not quite clear what that is or what that might represent. Changes in human behavior? Vaccine prevalence? Viral strain mutations? I just hope that 2022 brings a little more sanity to our politics when it comes to matters of public health, but I’m not going to spend a lot of time holding my breath.

The time off in New Orleans continues to go well. Yesterday began with jazz brunch at The Court of Two Sisters. Large buffet with a little big of everything along with a couple of mimosas. Fully sated and then some, we walked it off and decided to take a cemetery tour and pay our respects to Marie Laveau and her current neighbors. Then it was New Years Eve. For reasons known only to the Hilton Corporation, a flyer was shoved under our door asking us to consider participating in the taping of the Dick Clark’s Rockin New Years Eve, the Central Time Zone segment coming from NOLA with Billy Porter as host and entertainment. I suspect David’s mojo was the reason. This is the man who wandered into a Tonight Show taping and ended up singing a duet with Jimmy Fallon. Both of us being Billy Porter fans and not having much else scheduled, we decided to be extras as it would give us some free food and drink and give us a front row seat to the midnight fireworks. So we wandered the couple of blocks from the Hilton Riverside to the Louis Armstrong, a floating party barge tricked out to vaguely resemble a Mississippi paddle wheeler, and up to the open air top deck where we dutifully applauded and cheered on cue for five hours of promo spots and New Years Eve countdown. Then battling the thousands of others who came down to the river to watch the fireworks.

Today, we had breakfast at Brennan’s (no bananas foster, but the most gorgeous croque madame I’ve ever run across). We went up to the garden district to look over the mansions, and took a look at Audubon and City Parks. Then, after more cocktails (there’s a theme there – but it is New Orleans), we went to see the national tour of Hadestown which is here this week. Lovely show which I have wanted to see for some years. Excellent cast and production so get tickets if it comes your way. Now it’s feet up time with the hoots of victorious Baylor fans echoing in the streets waving green and yellow, while dejected Ole Miss fans in red and navy blue are walking dejectedly back to their hotel rooms.

I know how they feel. Both tribes. I’m not sure whether to celebrate 2021 or mourn it. I survived (as did all of you who are reading this). I can’t help but think we all deserve some sort of participation trophy at the very least. While 2020 gave me life experience and time for reflection, 2021 gave me a book inspired by all that. And 2022 may give me another one. 2021 also allowed me to sate my travel bug and kept me gainfully employed. At the same time, it brought us a political division in a realm of public health that is having very real consequences in morbidity and mortality and I can’t help but mourn that. I mourn all those we lost and with those left behind. Hundreds of thousands without parents, without spouses, without siblings, without that one friend that helps them hold life together. I mourn the damage done and yet to come to country and society when good politics trumps good policy. I mourn the emptiness of organized religions who put materialism and private benefit over the needs of community. I stand with the thousands of my health care colleagues whose abilities to cope are shot due to a system overburdened by the willfully ignorant.

Not much to do but one foot in front of the other, one day at a time, one keystroke after another, one piece of music on the stand.

December 30, 2021

Dateline: New Orleans, Louisiana

It is late December and New Orleans has been hovering in the low 80s, dropping to the mid 70s at night, weather more appropriate to June than to nearly January. It has done what I had hoped regarding Covid precautions, more and more activity, dining, drinking, and all the other things one does in the Big Easy has been moved out of doors. Between that and the city mandate for masking indoors and the checking of vaccination status at the door of establishments, I figure it’s about as safe as anywhere as the tidal wave of the omicron variant washes over the US. David Pohler was supposed to be my roommate on the aborted London trip, so, as we both had the time off and we hadn’t seen each other for a while, I arranged for him to come down south for a few days from New York so we could have at least some semblance of a getaway. Despite having grown up on the Panhandle of Florida and years in Alabama, he had never been to NOLA and it’s been fun rediscovering the city through fresh eyes.

I picked him up at the airport yesterday and then we had the obligatory walk through the Vieux Carre with lunch at The Gumbo Shop on St Peter (one of my favorites). After some more exploring, we signed up for Brian Webber‘s Haunted AF French Quarter tour. David had never met Brian (although he does know his daughter Rosie Webber having served as her dresser on one of the stops of the tour of The Gentleman’s Guide to Love and Murder she was on). Brian and I go way back… He was my antagonist in one of the early versions of Politically Incorrect Cabaret playing Judge Roy Moore. I still have the prop version of The Ten Commandments Monument we had built for that show. Brian is a showman and gives a great ghost tour through the French Quarter at night. Highly recommended. After the tour, we sat around chatting with Brian and other tour guides until the wee hours of the morning and imbibed perhaps more wine than we should have. We did make it back to the hotel.

Today, we slept in, had a nice greasy breakfast at Mother’s restaurant, stopped by Harrah’s casino and promptly lost $20 to a one armed bandit. Then we boarded a bus and headed out into bayou country for a swamp tour and some alligator sightings. Plenty of gators, egrets, a cuddly raccoon, an osprey, and other assorted flora and fauna. My parents spent a year in the bayou back before I was born in a little place at the end of the road in St. Bernard Parish called Hopedale, Louisiana. It’s where my father conducted his PhD research on estuaries. I don’t think it’s changed much in sixty some years given their stories of their time there. On return, dinner at Cafe Malpaso and then some bar hopping. I, being old, retired early leaving David to continue bar hopping until the wee hours should he so choose. He’s young. He can still do that sort of thing.

This is kid cases in one state, but all the curves are looking like this one…

I must confess, being in vacation mode, that I have not been paying full attention to what’s going on with Covid over the last few days. The raw numbers are astronomical with raw counts of nearly 400,000 cases daily being reported nationwide. This is much higher than at the peak of the wave last winter when the pandemic was at its worst and hospitals were jammed and vaccine roll out was painfully slow. In Alabama, the number of cases has increased by 500% in the last two weeks, but the total number is still below where we were as prevalence was very low locally prior to the omicron onslaught. While the number of cases are proliferating to an extreme extent, the hospitalization rate has not gone up substantially, only by about 15% nationally. There are, of course, huge variations from place to place with some health systems buckling, and others well below the numbers they were battling during the peak of the delta wave. The death rate has remained relatively flat at about 1200 per day nationally.

What’s going on. We know that the hospitalization and death rates are lagging indicators – have they just not caught up yet with the number of diagnoses? Is the omicron variant, as prevalent as its becoming, less virulent? Is the improvement in vaccination rates nationally having a mitigating effect? It’s really too soon to know. It could be any of these or some combination of all of the above. The worst case scenario is we will see rapid escalation of hospitalizations starting in about two weeks and deaths about two weeks after that. If that doesn’t happen, then perhaps a combination of behavior change, vaccination, and viral evolution is happening making the disease less virulent. If so, I think we need to change our thinking about it away from number of cases and diagnoses to worrying about serious cases requiring hospitalization and what can be done to prevent this. All of the data, no matter how you look at it, does suggest one thing. Vaccination works and we all need to be vaxxed and boosted, not just for ourselves, but for our society and each other. As someone much smarter than I once said, we must all hang together or we shall hang separately.

December 28, 2021

Dateline: Hattiesburg, Mississippi

It has been a very strange 36 hours, feeling something akin to some of my work shifts during residency – accomplished long before the rules on resident work hours went into effect. I got up yesterday morning in Seattle, had breakfast with my father, and then took the light rail in to SeaTac airport. I had heard about cancellations and delays but I figured I would be fairly safe from them as I was flying a Delta flight to Atlanta and, as that is where most of their crews are based, they would likely prioritize ATL bound flights. I added an extra hour to the usual two hours prior to flight time I allow for clearing security and possible other unforeseen issues. The light rail, which stops four blocks from my father’s place, is a direct shot into the airport and takes roughly an hour so I got a 10 am train so as to arrive at the airport at 11 am for my 2 pm flight.

On arrival, the Departure hall was a zoo. Lines snaking everywhere with little rhyme or reason and obviously far too few ticketing agents and baggage handlers for the volume of passengers travelling. Omicron case quarantines combined with the snow and ice in the area had led to a perfect storm. I did finally locate the correct line, checked my bag, cleared security and settled down to kill 90 minutes or so at the gate. About 1 pm, the ‘flight delayed’ notifications began to come in. We got 7 of them between 1 and 5:30 when the flight finally boarded. Then we sat at the gate for nearly two hours as they searched for a new copilot. The constant delays had led to the assigned copilot timing out from having too many on duty hours. They did find one, but he was in the air when located so it took a while for his previous flight to land, for him to make his way to our plane, and then to do all the necessary checks. We did finally take to the skies around 7:30 or so, five and a half hours late, arriving at ATL at 2:30 AM. I have no idea how long I was wedged in my Comfort + (Ha!) seat but it was long enough to watch Casino Royale, Quantum of Solace and Skyfall back to back. There were no flights to Birmingham at that ridiculous hour so I rebooked for the first available flight in the morning at 8:30. Five and a half hours was not enough time to leave the airport, get to a hotel, get some sleep, and get back, so the floor of the D terminal it was for some restless sleep. It’s not my first time sleeping on an airport floor and I doubt it will be my last. Fortunately, it only seems to happen about once a decade or so, so I can live with it.

The morning flight to Birmingham was without incident, the bag made the transfer, and I arrived in Birmingham at breakfast time, somewhat bleary eyed and disheveled but in one piece. First stop was Bogue’s diner for a large greasy breakfast as I had not had a meal in 24 hours, domestic air travel no longer believing in feeding the passengers, even when they’re trapped on the plane for three or four extra hours. One thing I will say, despite all the issues involved, I did not see one single instance of bad behavior or abuse of an airline employee by a frazzled passenger.

I got home, took a nap, did a few domestic chores, repacked the luggage, and around 5 pm headed off for part 2 of my winter vacation. I had booked the time off for London so, if it wasn’t happening, I was still going to do something so my friend David and I who were going to be roommates in London are instead going to be roommates in New Orleans. Chosen because the weather report suggests unseasonably warm weather this week meaning we can eat and drink out of doors and there are lots of interesting things to do which don’t require hanging out in a crowd on Bourbon street and because he has never been.

The rapid rise in omicron in the US (here’s looking at you Hugh Jackman and Sutton Foster) and the extreme transmissibility of the virus suggests two alternatives. One, complete isolation until the wave is passed (not possible for me given my job and obligations) or two, live life while vaccinated, boosted, and not being stupid and that’s the course I have chosen. I may get the virus in all of this wandering through airports and such but I’ve been pretty good at avoiding it so far. I wash and sanitize my hands, wear my mask indoors, and took every vaccination as soon as it became available and I’m trusting in that.

As I’m still slightly bleary eyed, I decided the wisest course was to not do the whole BHM to NOLA drive in one fell swoop which is why I’m passing the evening in one of Hattiesburg’s finer interstate exit hotels. I’ll pick up David tomorrow at the NOLA airport (he’s flying in from NYC) and then we’ll have some fun. I am looking forward to a hurricane or two on the patio at Pat O’Brien’s. I am, of course, watching the Covid numbers with some alarm (nationally, they are climbing back to where they were a year ago prior to the vaccine being widely available) but I’m thinking absolute case numbers may be the wrong metric. A significant number of infections in the vaccinated are minor. I think we need to concentrate on the number of serious illness cases and how and where they cluster and make decisions based on that data. They’re not the easiest numbers to find so I’m hoping one of the epidemiology blogs I read will give me some hard numbers that I can chase down and determine what they mean for practical purposes.

December 26, 2021

Snow in Seattle

Dateline: Seattle, Washington

Happy Boxing Day everyone. I think it’s still celebrated in the UK, mainly with after Christmas sales in the larger retail establishments. A friend tells a story about a couple of elderly ladies at Harrod’s on Boxing Day getting into it over a tea cozy or an egg cuddler or some such leading to a knock down drag out that would make a Wal-Mart proud. Sad to say, it will be a few more months before I can do any shopping at Harrod’s. Not that there’s much there I need but it’s always fun wander the Food Halls. On one of my last trips to London, I and a friend went to Harvey Nick’s (it was during the original run of Absolutely Fabulous – Don’t Judge) and had lunch in the top floor restaurant. As we were waiting for our check, I looked over at the cashier and a pair of women were settling their bill and they were dead ringers for Patsy and Edina. Cell phone cameras were not yet a thing -if they had been, I would have taken a picture.

The clan gathered
The six of my generation

The American branch of the Saunders clan gathered at various houses yesterday for presents, Christmas cheer and our traditional feast. We almost had a full complement with 16 of the 19 members present and accounted for including all six of my generation being under the same roof for the first time in fifteen or so years. Usually either I or my cousin Jack who resides in Connecticut is missing. The other four are all Seattle based and easy to get together. My maternal grandparents John and Alison Saunders were British emigres who arrived in the 1930s and settled in San Francisco. Their two daughters, Alison and Margery, both ended up in Seattle as both of their husbands ended up on faculty at the University of Washington. The two families lived blocks apart so the three Duxburys and the three Hellmanns of my generation grew up in a tumble together and my first cousins on that side are more like siblings in some ways. I am the eldest of the gang and Jack brings up the rear eight years later. We are all accomplished each in our own way and I am delighted to say that I truly like my family, as well as love them. In all of my work with families over the years, I have found that this is not always the norm, but we all get along famously well. My generation now also includes four spouses, most of whom have been present for decades and there are now seven members of the junior generation rapidly growing up ranging from age eleven to twenty-two – a mix of first and second cousins. And, in another decade, I imagine there will be another generation still. That’s the way the world tends to work.

It snowed last night. It’s a good thing it held off until then as Seattle roads can become impassable in a snowfall and Seattle drivers immediately jettison all rules of the road and common sense as flakes start to fall. My uncle’s house, the usual site of gatherings these days, is down a steep and winding lane at he base of Magnolia Bluff and it would have been quite interesting trying to ferry everyone down there if the snow had begun yesterday afternoon. But it did not and I woke up this morning to three inches covering everything in a blanket of white and six busses stalled on the hill in front of my hotel. Fortunately, it’s only five blocks to my father’s from where I am staying and I was able to nimbly work my way around stalled busses and bewildered drivers. As I write this, it’s still falling. Fortunately, I am only three blocks from the light rail station with direct service to the airport so I’m not worried about departing tomorrow. I wouldn’t trust car based transportation. As far as I know, I’m still good regarding my flights home tomorrow and nothing has yet been canceled. If something goes wrong, I’ll manage.

Other than family festivities, it’s been a quiet weekend. I’ve deliberately done nothing much the last couple of days. I haven’t been giving myself enough down time recently and I’m trying to listen to my body and my psyche and make sure I’m properly renewed. This does mean that there are a couple of work projects that I haven’t finished up yet that need to be done before the end of the year. I’ll get to them…. I’ll get to them…

There’s not a lot to report on the covid front. The news media has switched to heart warming stories of family reunification, holiday cheer, and best of the year lists like they do every year around this time. They’ll be back to gloom and doom soon enough. What I have been able to glean is that omicron is causing significant disruptions mainly due to vast numbers of workers needing to be in quarantine more than being caused by significant illness burden. The parts of the country where hospitals are being inundated (currently centered on Cleveland and the upper midwest) the cases are still mainly due to delta variant marching through unvaccinated populations. Of course, the omicron wave is still too new for us to really know what hospitalization and death patterns are actually going to be. The best thing you can do to combat the virus, both personally and socially, is get vaccinated and boosted. It remains the only real weapon we’ve got as we live in a society that can’t really be locked down as we refuse to use public money to support ordinary people without huge political battles.

The fact that somewhere between a quarter and a third of the population flatly refuses vaccination also doesn’t help. At this point, I’m pretty much done with someone who’s refusal is due to political or ersatz religious beliefs. I think we’ve seen a great example of the irrationality with the blowback against former president Trump for his remarks in favor of vaccination this past week. It also shows that the current fascist movement in the country, usually referred to as Trumpism, is very much independent of the man. He may have helped let the genie out of the bottle but it was never really about him. It’s antecedents are much older dating back to before the founding the country when some groups assumed an inherent superiority over others. Choose life. Choose health. Get vaccinated.