And he’s back… home that is. Not much to say about the end of my quick trip to Seattle. I did my usual Q and A on elder health concerns for the residents of my father’s senior living community. It was well attended and allowed me to practice my standup medical advice skills which I have been honing for decades. They laughed. I went into it expecting a bunch of questions on health politics surrounding DHHS and Kennedy and vaccines but didn’t get a one. Popular topics this time were fall prevention, dementia prevention, and the side effects of various medications. This was followed by a family dinner for all the members of the immediate family (everyone is doing well and getting along fine – the nieces have both turned into capable young women. The elder is in year two of teaching science at Garfield High School in Seattle and the younger, having just finished college, is on a job hunt for something beyond barista). Got a good night’s sleep, left early this morning, battled the usual zoo at Sea-Tac International airport and got home without significant incident. The kitties were a little miffed at my absence at first but they have now joined me on the bed so I think they have gotten over it.

Time to launch into the third and final installment of my essay on options in senior living andd some of what is going on with them. In the first two parts we covered aging in place and adaptation of one’s usual residence and then community based options. This one is going to discuss institutional options. By institutional options, I refer to the various types of senior housing communities operated as businesses with the specific mission of helping individuals cope with the issues and problems of aging. There are two major types – those which provide skilled nursing care and those that do not.

We’ll start with those who do not provide skilled care. As they are, in general, ineligible to receive federal health dollars through either the Medicare or the Medicaid programs, they are not regulated by the types of federal law that cover health care, hospitals, home health agencies, hospices, and all of the other pieces of the health system that can bill the Center for Medicare and Medicaid Services (CMS). Some states do allow for Medicaid funds to be spent on these institutions (Alabama is not one of them) but in general, these funds are additional state funds placed into their Medicaid program and not federal. There are three basic types – independent living facilities (ILF), assisted living facilities (ALF), and specialty care (dementia) living facilities (SCALF). These terminologies may vary state to state as their regulation is at the state and not at the national level.

Senior communities can consist of one type, or multiple types colocated. The different types may be in different buildings or wings or services may be brought up under an individual in the same dwelling changing the environment and supports without the person having to move. They generally are not paid for with public funds and therefore entering and residing in one usually depends on private pay from savings or family resources. Medicare is not an option. Long term care insurance will generally pay for this sort of living but the amount it will pay will depend entirely on the insurance contract and may or may not cover the total cost. As I mentioned earlier, long term care insurance is now difficult to find as the market prove actuarially unsound over the last three or four decades.

Independent Living usually consists of apartments or sometimes clusters of small garden homes. Residents are expected to support themselves in the same way they would in the general community. There are often community amenities available such as congregate dining should they choose not to shop and cook routinely. There may be a certain amount of on site health care, recreational activities and organized events. Many residents still drive and have no issues accessing the world so these communities are often built in somewhat isolated suburban locations. Depending on location and amenities, costs can vary from about 2500-6000 a month. Some communities require a buy in as if one were purchasing a condo or coop but a certain percentage is refunded at move out. These communities are usually beyond the financial reach of lower socioeconomic groups. There has been a move to develop some lower priced models, often by converting older motels, but there’s not a lot of money in the low end so development has been sluggish. There are a few communities owned and operated by charitable groups with social mission with alternative funding streams that allows them to keep prices down. These communities usually have very long waiting lists and may have restrictions on who is eligible for residency. A lot of the nicer ones are owned by either regional or national coprorations on a for profit model. If a particular community becomes unprofitable, it can be suddenly closed, just like any other business.

Assisted living facilities are for those who cannot live completely independently without daily attention from another adult who can assist with basic tasks of living such as bathing safely, dressing, getting to meals, or safely handling medications. In general, the living spaces are significantly smaller than ILF spaces and are designed more for the convenience of the staff than for the resident. Meals are usually prepared and served in a dining room but residents can have a small fridge and microwave for snacks. They’re not dissimilar from college dorms of my generation. In general, one must be ablebodied enough to help oneself to exit the building in an emergency and must have enough cognitive capacity to understand their medications, even if they are being given by staff in a med pass. Keeping your own medications, even Tylenol, requires a physician order. Most residents need assistive devices such as walkers but can walk some. The staff in these facilities are generally not medically trained. They are expected to cook, clean, help residents get around, help with bathing and personal care but not to help with medical issues although there may be the ability to do simple monitoring such as checking of blood pressure or blood sugar. Residents are free to come and go as they please. Most don’t have the ability to drive but if they want to go out, it’s their business although the facility usually requires residents to sign in and out so they know where people are. Costs vary but are generally in the 4000-7000 a month range.

Specialty Care Assisted Living looks a lot like regular assisted living but there’s one major difference. To qualify for SCALF, your cognition must be such that you cannot handle your own needs due to confusion. Therefore, these are locked units and the staff is legally allowed to prevent you from leaving for your own safety. Families can take people out but they must be signed out and there may be rules on how long they can be absent. All medications are handled by staff for safety. Staff must prevent physical relationships from developing between residents due to the inability to consent. Most residents are ambulatory and well designed facilities are usually circular with interior courts and gardens to allow people to wander. They are generally significantly more expensive than regular assisted living due to higher staffing needs starting around 5000 a month and I have seen some has high as 10000.

Skilled Nursing Facilities (SNF) or nursing homes are a completely different type of facility. As they are eligible for CMMS payments, they must adhere to a myriad of federal rules and regulations. It’s been estimated that there are more federal rules and regulations regarding long term care than there are on nuclear power and commercial aviation. All of these rules pretty much guarantee that all the SNFs in the country run roughly the same – in theory. As one who reviews medicolegal records on a consultantcy basis (those donations to Birmingham theatre have to come from somewhere…), I have seen all sorts of interesting things happen in the name of profit. SNFs are for those who require daily assistance for medical basis that nursing must address. In general, to be eligible for admission, you need to be missing three of your basic activities of daily living (bathing, dressing, grooming, ambulating, transferring, toileting, and feeding). They are, in general, designed and run along hospital lines as that’s more or less what the rules require. There are some which try to create a more homey environment but they are a minority.

Medicare pays for admission to skilled nursing in limited circumstances, generally following a hospitalization for illness or injury where some additional rehab and support will help with recovery. Most are eligible for a twenty day stay (which can be extended with additional copays in limited circumstances). Anyone who requires a longer stay is going to need to pay with either private pay or with long term care insurance. Costs are usually 5000-8000 a month. In states where Medicaid does not pay for ALF or SCALF, those without funds who qualify for Medicaid and do not have adequate community support to remain at home with be placed at SNF, even if they would do well at a lower level of care. Federal rules require that those resident in a SNF get a medical visit on a monthly basis from a physician or an NP. (These days it’s usually the latter). There are also rules requiring medication review from pharmacists, especially for psychoactive medications.

The actual nursing care at SNF is rarely provided by an RN. Usually there’s only one RN in the facility (on day shift) and their role is mainly administrative as much of the federal paperwork requires completion by an RN. The nurses on the floor are LPNs (LVNs in some states) who are responsible for meds and certain skilled treatments. The vast majority of the hands on care is done by nursing assistants – jobs which are heavy physical labor and low wage and consequently high turnover. The pandemic, which led to roughly 20% of the workforce in clinical healthcare leaving the field, has hit SNFs particulary hard. About 98% of SNFs nationwide are now understaffed. Rules are being changed as no one can meet the old metrics. In much of the country nursing assistant jobs have long been held by new immigrants. This population is rapidly being withdrawn from the workforce.

There are three enormous issues colliding regarding institutional long term care. The first is demographic. The Boomers are on the cusp of turning 80 and that’s generally the time at which a signifcant portion of the population cannot be adequately supported in usual home environments and starts looking for alternative arrangements. There are nowhere enough ILF, ALF, SCALF, and SNF beds available for the projected needs of the next twenty years and there’s been no significant push to develop new communities in any number. These are pretty much all for profit and the profits just aren’t there in the way that they were. I don’t see this changing much in the next few years unless there’s some sort of incentives put in place at either federal or state level but rhe current federal administration is unlikely to undertake any new housing programs and state budgets are strapped to the gills with those they are already tasked with caring for on Medicaid rolls. The cynical part of my brain wonders if the dismantling of public health is in part deliberate to reduce the number of elderly with chronic illness and I’ve seen a number of essays discussing a coming necocracy for all but the obscenely wealthy.

The second is cultural. The general design of senior living communities was put in place starting in the 1970s for the needs of the aging World War II and Silent Generations. Their social patterns and ideas of pleasurable activities are very different from those of the Boom. The newly minted octogenarians are not going to be content with shuffleboard and bingo and I haven’t seen a lot of radical reassessment of how senior communities are going to adapt to changing demands. Even the architecture of such communities may need to be rethought but I don’t see a lot of the owners, whose corporate structures often flow up to venture capital firms, being willing to expend enormous sums on reconfiguring living space.

The third is economic. There are all sort of poison pills within the Big Beautiful Bill of this spring which will trigger significant cuts to Medicare and Medicaid going forward. Downturns in the economy due to shortsighted economic policies are likely to prevent any new dollars being pushed towards ong term care. Communities which can’t be profit centers, especially in more rural areas, are likely to close. This will be exacerbated by a worsening of the staffing problems mentioned above. We’ve lost about 20% of the workforce in the last five years. Recent polls suggest that 50% of the remaining workforce in clinical healthcare is thinking about leaving their jobs due to the strains and cuts happening within the system. I’m one of them.

I have no solutions to these problems. All I can do is identify them. I’ve put in my 35 years in geriatrics and it’s going to be up to a younger generation to figure out what’s next.

Dateline – Seattle, Washington

I don’t have much to add to the travelogue today as there’s not a lot going on at Aljoya at Thornton Place today. I had a bit of a sleep in, a couple of good meals, a meeting with my editor/publisher which confirmed what I had suspected, and time to catch up on some backlog of work progress notes. Not too shabby for a sunny Saturday in Seattle. Therefore I’ll continue on with the discussion of senior housing issues begun yesterday. And try to ignore the fact that a top White House official called for the social ruination of anyone not in step with Charlie Kirk’s political views and a major daytime talk show host advocated with the state sanctioned murder of the entire homeless population. I can’t think why anyone would be disturbed by such public pronouncements.

Yesterday, I discussed the first, and perhaps the most popular option regarding housing and aging, so called aging in place where an individual continues to occupy the same life space they did when they were younger but accomodations are made for the physical and cognitive changes that accompany aging. This option is not practical for everyone so today we’ll explore community based solutions to senior housing and some of the issues involved. The third and last piece of the discussion will appear maybe tomorrow and maybe later in the week depending on how I feel and will discuss institutional housing and the issues that arise when considering those options.

Community based senior housing encompasses a wide range of options and practices which happen when an elder leaves the home of their mature adulthood to live elsewhere but does not enter a formal institution such as a nursing home or assisted living facility. Most of these options depend on family structures, cultural norms, and financial resources and I don’t specifically advocate one over every other. Every person and every life pattern is individual and must be thought about as a fresh problem to be solved. Anyone who thinks that one size fits all rules or solutions are going to work has no experience with the real world.

Living with family is probably the most common of these practices. Either the elders move in with the kids and grandkids or other younger family members or the various family generations make agreements to move together to new housing which can better accomodate multiple generations. This is hardly a new model. It’s the way most families worked prior to the 1950s and multigenerational families in the same dwelling remains the norm in most of the world. The US model of the nuclear family is an exception, not the general rule when looking at family structures globally. A new US variant on this is the tiny house phenomenon, sometimes referred to as a ‘granny pod’ in which a small prefab home is placed on the same property as another family member’s home allowing both independence and proximity when help is needed. Having the kids move in with the elder is more akin to the adaptations made with aging in place. All of these allow for mutual support. Elders can help with household chores or childcare to the best of their abilities while knowing that family with (hopefully) their best interests at heart are around and can assist with what they need and the whole family unit can adapt to change together.

There are a host of issues when adult children who have been independent and parents get back together again in a shared household. Traditions may have evolved or changed. There may be subtle (and not so subtle) pushes to assert dominance over a family system. There are problems with role reversal when it becomes necessary for the children to parent the parent, particularly when ti comes to curtailing activities which may be beyond their capabilities due to change. The one that causes the most friction is driving. We don’t have a lot of markers of independent adulthood in our society. The driver’s license is one of the most important and a lot of our identity (especially for men) is bound up with the idea that we are free to go anywhere at anytime and that usually requires a car. Even when we don’t do it, the thought that we could sustains us and cutting that off is traumatic.

In these sort of family arrangements, finances, if any are involved, are usually a private matter worked out in the family and there is no regulation of these arrangements by the state short of zoning and building codes when doing things like remodeling for a mother in law apartment in the basement or installing a tiny home on the property. There is one more model that usually depends on private financial arrangements and that is cohousing. This has never really been that popular in this country but, with more and more single people in the aging Boom generation it’s starting to catch on.

In cohousing, a group of like minded individuals make the decision to live together as chosen family. These relationships are not blessed by the state and if they are to be recognized legally or for matters of health care decisions, powers of attorney will be required. Sometimes a large dwelling with many bedrooms is purchased or rented and shared, sometimes a number of smaller dwellings in close proximity are used, often with a certain amount of communal facilities which may include communal laundry or kitchen. Elders live together in mutual support, share in the finacial burdens and the everyday aggravations of chores and home maintenance, and functional communal living is achieved. Sometimes the best intentions founder in acrimony. Anyone who wants to explore this sort of arrangement should enter into it with eyes open and legal contracts regarding rights and responsibilities in place. I am aware of a number of these communities working well on the west coast or in larger cities. They may be regarded with suspicion by the neighbors in smaller towns. It also bears researching both local and state law. There are laws in some jurisdictions that require any home that houses three or more unrelated senior adults be licensed as a senior care facility. All of the successful ventures of this type of which I am aware are headed and run by women. It likely has something to do with the socialization of the genders in earlier generations.

If you are not of mind or finances to purchase, there are various rental options available to seniors. Just like any other adult, they can rent an apartment or a home on the open market. In terms of making decisions regarding a rental, they should be similar to the ones made when assessing a home for its potential to be age friendly. Are there stairs or steps? Where is it located? Can I pursue my usual life from it if I no longer drive? Is it in a community where neighbors will help each other? There are rental properties being developed specifically limited to older (usually defined as over 55) renters. These usually have bathrooms that are suitable for the physical needs of aging. They may or may not have an office staffed with someone knowledgeable in local elder services who can assist when there are problems. Some buildings and communities participate in what is known as Section 8. This is a federal program which provides subsidies to allow the building owner to rent to elders on fixed incomes to rent for far below market value. One must apply and be qualified for the program based on income and assets. Section 8 rental units vary from the decrepit to the spartan to the adequate. It usually depends on who owns the building and their motivations for participating in the program. In general, the best communities are owned and run by charitable organizations with a mission to do social good and have funding streams outside of the rents.

There are, especially in rural areas, individuals with large homes who may open them up as a senior boarding home. These usually come with a bedroom and meals and are, in general, much cheaper than institutional senior living. They exist in a bit of a legal gray zone depending on state and local law but most, if they are non-exploitative, will be allowed to continue as the state knows quite well that if they were to close them down, that most of the residents would be compelled to enter nursing homes at great expense to state Medicaid. I am aware of a number of these in the greater Birmingham area which do very well with family style care but they are usually due to the labors of a central figure who works 24/7/365 and if anything happens to that person, things rapidly deteriorate.

I’m going to have an after dinner brandy and watch some bad TV. Stay tuned for part 3 – institutional care.

Dateline – Seattle, Washington

I’m up here on a quick jaunt to see the family and check up on my father in his 93rd year making sure that he and his life are in sync with each other. Many decades of experience in geriatric medicine has taught me that the majority of problems occur when an elder has changed, either physically or cognitively, enough so that the life they have designed for themselves no longer fits. Most of what I do is getting the person and the life back together and in sync with each other. Sometimes that involves providing the individual with adaptations. Sometimes that involves changing the contours of living in such a way that the elder can continue to succeed. It’s a constantly evolving dance, with ever more intricate moves as time goes on. My parents, having made good decisions some fifteen years ago, have managed to do relatively well with minimal intervention. As I no longer live within 2500 miles, I have to do most of my work through gentle, well timed suggestions. I know all to well what happens when people and families try to create stasis. It never ends well.

I’ve been promising to write a significant essay on elder housing and what may be coming in the time of Trump. I’ll start on it tonight but I am unlikely to complete all of my ideas in this particular missive. I’ve got a lot to say and we’ll see where it goes. My belly is full of Hispanic Heritage month buffet dinner at my father’s senior living community where I am in residence for the nexxt few days. As it was accompanied by a large margarita and I had to get up at 3:30 AM local time to catch my flight, I am likely to conk out long before I get all of this down. Not to mention that I do feel compelled to comment on some of the political developments of the last few days as I feel they are of some significance.

We’ll start with that. I never met Charlie Kirk. I paid very little attention to Charlie Kirk when he was alive other than to know that he was a figure in the alt-right movement who seemed to relish in being a provocateur and a sort of slick styled enfant terrible who would do what was necessary for clicks, likes, exposure, and networking. The Sufi poet Rumi is credited with coming up with the following dictum about speech – before speaking, ask if it is true, if it is necessary, and if it is kind. I try to follow that with my public speech (which consists mainly of these writings these days – I’m imperfect and have violated this rule on a number of occasions but I always carry it with me). I’ll let you make up your own mind as to whether Mr. Kirk adhered to such rules of civilized discourse.

What I find fascinating is not so much his assassination. I find that incredibly sad – especially as the film clips of his shooting will haunt his friends and family for the rest of their lives. But rather the national response to his assassination. Right wing powers in this country are busy with his apotheosis – flags lowered, bills to allow him to lie in state at the Capitol, a social media led purge of anyone who dares to not show proper respect for his death. To my knowledge, he has done nothing in service to this country that would make such honors appropriate. He held no public office. He created no major policy. He is most famous for being willing to speak ideas against mainstream cultural thought but from what I could tell, they were almost always from a place of the arrogance of youth without a balancing of the humility which comes with maturity.

The fact that all of this has developed so rapidly, eclipsing the annual rememberance of 9/11 (and if any ordinary civilians should have been accorded the honor of a state funeral, the passengers of flight 93 or the members of the NYPD and NYFD would have been deserving), makes me think that the MAGA movement has been preparing for and in need of a martyr for some time. Given the number of guns in our society, the amount of mental health issues among young men, and the shredding of our mental health care system over the last four decades, it was only a matter of time until something happened which would fit the bill. The fallout is continuing. The early attempts to pin the shooting on radical leftist ideology aren’t passing the sniff test so it will be interesting to see how long this lasts on the cultural radar and what both sides of our divide learn from it when the next sociopolitical figure is killed. It will happen.

Back to elder housing. The first thing to understand about aging is that aging is change. And it’s change that our own brains do not understand. Our bodies and our brains grow, mature, and change together during our first quarter century. We are very different people at 5, 10, 15, 20, 25. And society recognizes this. We don’t send young people of vastly different ages to the same educational institutions. We give people different limits and privileges as they mature. A younger teen may be limited in terms of their exploration of their world by what’s available by bicycle and public transportation but once they have a driver’s license, their world opens up in new ways. The college or military experience may completely reshape how a young person thinks about the world. Sometime in our mid to late 20s, however, our brain finishes its developmental cycle. It’s done. We become the mature adult we were destined to be and we no longer make the impulsive decisions we might have made just a few years earlier. And our brain continues to hold that self image and the body we have at that time of our lives becomes what it considers to be the adullt norm and we build our neurologic autopilot around that healthy young adult body. We will consider ourselves that person the rest of our lives. As the decades march on, we still feel like that internally and we watch the physical changes in the mirror going ‘What’s happening?’ and our brain doesn’t really understand them.

As we are Cro-Magnons and as, from an evolutionary point of view, they had to live long enough for the tribe to continue i.e. becoming a successful grandparent, our bodies needed to last into our forties. And that they do. There are not a lot of things tht go wrong prior to the age of fifty. Everything more or less works as designed. In pre-civilization times, very few individuals made it much past forty or so so there has been no evolutionary pressure to get rid of problems that occur after that age. Six thousand years of civilization is not enough time to change who or what we are at the biological level. These days, however, with a modicum of common sense, most of us will make it into our 60s, 70s, 80s, and beyond.

When we hit our 70s and 80s, if we’ve been in reasonable health,, our brains autopilot settings still try to get us to work our bodies as if they are some fifty years younger than they are. We’ll do things the way we’ve always done them but changes in our musculoskeletal system and neurologic systems keep us from completing those tasks in the usual ways. This is where things start to get messy. The first option in regards to aging is called aging in place which means living in your same house and doing things the way you always have. Most people, when asked, prefer this over other options. There are a number of issues that come up with this, especially over the age of 80 that need to be considered.

First: as the realtors say, location location location. Everyone, if they live long enough, is likely to lose the ability to drive. It may be a mobility problem – arthritic joints that don’t allow you to operate pedals or turn your head to check blind spots. It may be vision – I can already tell that my night vision is changing. It may be cognition where you can operate the car fine but you cannot react to all of the other idiots the state granted a drivers license. Key questions to ask are: if I cannot drive, how will I get food/shopping? How will I be able to keep medical appointments? How will I socialize? If I live in a more rural setting, how quickly can I expect help to arrive in an emergency? If I live in an isolated home, can I protect myself?

Closely related to this is the design of the house. Many homes built a few years ago are split level or have sunken living rooms or other changes in height requiring stairs. Stairs are difficult to negotiate as one ages and should not be attempted without the use of another point of balance such as a handrail. The leading preventable cause of death for elders is a bad fall with a broken bone or a head injury. I am forever going on about the need for appropriate light in stairwells, sturdy hand rails, and understanding that things such as trays or laundry baskets that require two hands to carry should not be taken up or down stairs. And don’t get me started on ladders. I lose a patient every holiday season or two from falling off a ladder while hanging decorations on the outside of the house. Don’t do it if you’re over 70.

If you make it into your 80s or 90s, you will still likely be able to walk but not without additional points of balance constantly. This usually requires a walker and occasionally a wheelchair. Are doors and halls wide enough in your home to accomodate this? Is the bathroom designed in such a way that you can bathe without stepping up and into a tub? Are there enough points of balance to be able to get up and down from the commode? And the toiletpaper holder doesn’t count. It wasn’t designed to support your weight.

Most of us live in pairs and age in pairs. This is a good thing. Long term couples often become symbiotic organisms with one life being lived in two bodies. We can get quite creative in designing life patterns around a couple with different strengths and weaknesses. Something that we do not discuss in our culture, however, is that one of the pair is likely to outlive the other. What happens when that piece of your life isn’t available? Will that shared living space still function for you? It’s always best to open these discussions when everyone is hale and hearty and not at 3 am in an Emergency Room. In the Baby Boom generation, many of the women are aging alone. Divorce, childlessness or estrangement, widowhood. Society has never taken kindly to an abundance of older women. See witch hunts.

If you are aging alone and want to age in place, you are likely to need another adult in your life on a regular basis to help cope with everything life can throw at you. If you have family or close friends who can fill this role, great. What if you don’t? American society has been very loath to expend public dollars on elder caregiving in the home and for the most part it is not financed through public programs and depends entirely on your personal financial resources. There are some exceptions. Certain states have made Medicaid dollars available for these kinds of services to prevent an elder from being institutionalized at a much higher cost to the state. The VA has programs for veterans. There are some other programs for specail populations. If you have long term care insurance, it may pay for these kinds of services. I do not expect these services to expand in the next decade or so. There are too many aging adults to make it attractive for public entities to take on new programs or benefits. If anything, they will contract given the way in which the Trump administration is approaching health and social services in general.

If aging in place is your choice, I suggest the following happen with your retirement and later life planning. A consultation with an elder law attorney for will and estate planning. If you have significant assets, a financial counselor/manager to make sure your income streams can meet your life demands. And lastly, a professional geriatric care manager who can sit down with you and family and help you think through the thousand and one things in your life that may need to adjust as your body changes. At the age of 63 with a planned retirement age of 65, I’m putting all of this together for myself. I’m not immune to the slings and arrows of outrageous fortune. If you don’t already have long term care insurance, you’re probably out of luck. Most companies have withdrawn from that market as it’s actuarially unsound. People are living far longer and needing many more months of benefits than the initial calculations predicted.

This has gone on long enough. I’ll write more tomorrow or the next day regarding other types of options in senior housing.

I went to a very fancy party Friday night, a black tie gala raising funds for UAB’s arts programs. Hors d’Oeuvres and wine, a concert by Wilson Philllips, steak dinner at sumptuously decorated tables placed on the stage of the Sirote theater. More wine. It left me with a sort of a glow all weekend. A huge shout out to Rita Polonus Cowell for the invitation and Patti Steelman for asking me to be her plus one. Through various stealth maneuvers, my Birmingham theatre buds of the last few decades have come into their own and now run most of UAB’s performing arts programs. Here’s looking at you J. Heath Mixon, Kimberly Kirklin, Chuck Evans, and Dane Peterson. Keep building on success.

I always feel a little bit guilty when I take part in the ritual of a gala party. There is so much need and want int the world that being surrounded by lavish accoutrements feels like a waste on some levels. But I suppose the difference between someone like me and a denizen of Mar a Lago or the new ‘Rose Garden Club’ at the White House is that I know that such occasions are special and to be savored and packed away into the coffers of reminiscence to be brought out again in the future when a positive memory is needed. They are not an entitlement that I should or would be surrounded by on a daily basis. Besides which, I refuse to spend the money on hair plugs, botox, jaw enhancement and other cosmetic procedures to give myself the super strange android look that has become de rigueur amongst the uber wealthy, particularly on the right side of the aisle.

Listening to Wilson Phillips (part of the sound track of my late adolesence – they had their heyday when I was in medical school and residency) allowed me to open up the above mentioned coffers and think over other special occasions, savored from my past. My brother had a Beach Boys fixation as a preteen and the greatest hits of Brian Wilson (father of Carnie and Wendy Wilson) were constantly emenating from our shared bedroom. In the winter of 1987, when I fell for a man for the first time (this was a couple of years before Steve), we had some magical times together in New York City and, as a treat, he took me to Michael’s Pub to hear the Mamas and the Papas. This was a reconstituted group John Phillips was still leading it using his original arrangements and harmonies but the other three were Mackenzie Phillips singing Michelle’s part, Scott Mackenzie singing Denny Doherty’s part and Spanky McFarland (of Spanky and Our Gang) singing Mama Cass’ part. Mackenzie Phillips, at that time in one of her many bouts of recovery, sat next to me at the bar between sets making a big deal of drinking her Perrier with a twist of lemon. I think we exchanged a few pleasantries but I can’t remember what they were about. She was very petite which surprised me. I got to meet Chynna Phillips briefly at the dinner and told her my life was coming around in circles again. She was amused.

I’ve been asked to write about what’s going on in senior housing and what the trends may look like moving into both the near future and the distant future what with cuts to social assistance programs, health insurance, and the impact of demographics on Medicare, Medicaid and long term care. I am much too tired to take that on this evening. I’ll mull it over the next couple of days and maybe something will spring forth full grown like Athena from the brain sometime this next week. I should also have a much better idea as to what’s coming next in my writing life after this next week. My publisher is back in the saddle. We had a call tonight discussing a number of topics and we’re going to meet for a couple of hours this next weekend while I am in Seattle visiting the family.

My current car book is Matthew Hongoltz-Hetling’s chronicle of the experiment in the early years of this century to create a utopian Libertarian community in Grafton, New Hampshire. Entitled ‘A Libertarian Walks into a Bear’ it’s one of those novelistic/journalistic treatises that examines the social politics of an American community, similar to John Berendt’s Midnight in the Garden of Good and Evil. A number of Libertarian (the political philosophy that government should have no role in telling individuals what they should or should not do or how they should treat their property) activists moved to the small town of Grafton, took over the wheels of local power, removed regulations and city services, and the whole thing came undone when it ran into the reality of the local bear population. I am drawing a great many parallels to how DHHS and Joseph Ladopo in Florida are dealing with vaccines. Ladopo has basically taken the position that bodily autonomy is an inalienable right and that the government has no power to force an individual to inject something into their body nor does it have the power to supersede the wishes of parents when it comes to their children. (Funny how this inalienable right does not seem to apply to female reproductive services).

The wholesale spreading of misinformation, quackery, and general foolishness regarding Covid vaccines has now come to taint the very concept of vaccination (which we have been doing since the late 18th century). An NBC poll released recently showed that roughly 1/3 of Republican voters now feel that all vaccines should be made optional if not banned outright. Visit any cemetary that dates back before World War II and look at the number of headstones placed for children. They virtually vanish by the 1950s. That is what vaccination has done. Allowed tens of millions of American children to navigate the biologic hazards of childhood and reach maturity. Life expectancy for Americans in 1900 was in the mid 40s. Not because folk were dying of old age in their 40s, but because so many infants and children died of what are now preventable diseases. If you made it through the treacherous gamut of measles, diphtheria, whooping cough and all the rest, you would generally make it somewhere between 50 and 75. People didn’t start achieving their 80s in good health with any regularity until after 1950. And that’s what’s coming next for all of us. Somewhere between eight and nine thousand American celebrating their 80th birthday every day for the next twenty years. OK Boomer.

The problem with pure Libertarianism is that it completely falls apart the minute you have a society larger than about a hundred people. Under Libertarian principles of absolute rights, the government cannot tell me that I cannot set a fire on my land to clear brush anytime I so choose. But what if I choose to do so in high summer when there’s a windstorm, virtually guaranteeing that the fire will spread beyond my property and burn my neighbors’ houses down. Government exists to help us balance our individual rights with the individual rights of others. If a third of Republican voters stop vaccinating their children, I guarantee that the pestilences of the past will return and within a decade we’ll have kids in iron lungs. Public health law is not just about you. It’s about us, all of us, who have to somehow get along together and coexist. Unfortunately, one of our great political parties has pretty much decided that coexistence is for pussies and only dominance matters.

Then we have the debacle of the Savannah, Georgia Hyundai plant. Georgia spent millions in incentives to land an enormous facility to help produce electric vehicles and batteries. The plant is not yet finished and is a complicated build requiring a lot of proprietary high tech and Hyundai had a number of South Korean nationals on the property assisting with the build so that the plant could become operational and hire the locals for the jobs that would be generated. A would be politican, Tori Branum, who decided to out MAGA MAGA called ICE about all the illegal aliens working at the plant. ICE conducted an enormous raid, slapped nearly 500 South Koreans in chains and carted them off. In the past, if visas and work papers weren’t properly in place, there would have been some back channel phone calls and things would have been addressed. Now, we have an international incident with one of our closest allies, a major manufacturer wondering if their investment is safe, and probably every other multinational making fresh decisions about where to site industry in coming years. But, from what I read on the hellscape of X, MAGA has no conception of how badly they have shot themselves in the foot with this one. Ideology above all. It never ends well. Just ask the bears of New Hampshire.

And so the great state of Florida has decided against any vaccine mandates of any kind in either children or adults. What will happen? To figure that out, we need to travel back in time to December of 2014. At that time a person, never identified but presumed to have been in recent contact with a measles outbreak in the Phillipines, visited Disneyland, the so called happiest place on earth. That one person led to a chain of events that led to 131 cases in California, cases in six other US states, Mexico, and 159 sickened in a religious community in Canada. It was stamped out in April of 2015 through vigorous contact tracing and vaccination.

Florida is a state full of tourist attractions from Disney to Universal to the beaches to multiple cruise ship ports. All of these provide wonderful opportunities for strange biomes to meet and mingle and for highly contagious viruses to spread. We are already undervaccinated in this country due to the politicization of vaccine policy. In addition, the current administration is gleefully destroying public health infrastructure in the name of making America healthy again or some such. A significant drop in vaccine rates in a state, especially one like Florida where many come and go, will simply lead to higher and higher chances of epidemic infectious diseases that have been pretty much eliminated throughout our lifetimes again coming to the fore. It’s no longer going to be a question of if but rather of when. Perhaps Florida will be able to repurpose Alligator Alcatraz for children in iron lungs as that is where this is headed.

There’s a whole branch of mathematics and statistics that devotes itself to the prediction of events based on various probabilities. I wish I knew more about it as it would be useful information to have about now. However, given that this sort of research is likely politically verboten these days, don’t expect anyone to do the calculations. It’s the same folk who disprove conspiracy theories with mathematics. Elaborate conspiracies depend on tens of thousands of people holding silence. Human nature tells us that this never happens. Somebody always talks – pillow talk, an inadvertant slip while intoxicated, a deathbed confession. The larger the number of people that need to be involved, the less length of time a secret can be kept. Which is why I don’t buy into 9/11 was an inside job. With all of the people that would have had to be involved in rigging the towers and preparing the cover story, that secret couldn’t have been kept more than about three years.

Covid is still out there and is still a danger. Not like it was four or five years ago thanks to a combination of vaccines and natural immunity and viral mutation. But it can still make your life extremely unpleasant through long covid symptoms and it’s still killing people routinely. Am I going to continue to get Covid boosters? Yes. Those that are up to date in vaccinations are about 50% less likely to become infected and, if infected are about 70% less likely to require the ICU or die from the infection. They are also about 50-60% less likely to develop long covid symptoms after an infection. That’s good enough for me. I’ll let you make your own call. Most of us have opted not to continue vaccination. Only about 15% of the population got last year’s booster.

I’m about to launch back into an update of my Covid writings from 2020-2022. I haven’t yet figured out completely how to slant it. We’re sitting in a very different place culturally than we were when we were in the thick of the pandemic. There’s a piece of me that feels it needs to focus on lessons learned and how to be more prepared for the next pandemic which is becoming pretty inevitable with the current administration’s health policy. If Russia or China or India really wants to knock us off the world stage, sending some lethal viruses over should do the trick. Our society won’t be able to respond – other than with horse paste and injectable bleach.

I’ve had a request to write about what’s happening with senior housing given current cultural trends. I’ll try to gather my thoughts on that and maybe get to it later this weekend. My weekend is starting with a black tie gala. I hope it’s not the ball on the eve of the battle.

I never know which of these missives from the deeper recesses of my mind are going to strike home and which are going to receive a collective yawn. I’ll write something that I think is brilliant. I have all of my metaphors just right, the parallel constructions are spot on, and I think I’ve made some major cathartic conclusion. Crickets. Then there’s something like my last piece which I thought was a semicoherent drivel. People are still discussing it a week later and it’s been shared all over the place. This is why I don’t spend too much time thinking about what I write and just let it flow. Usually the less thought, the more it seems to touch at something deep within readers. Nor do I know what the current writings are really about or what they might become. My publisher is surfacing this next week after a prolonged absence and we will begin discussing possibilities.

The bad news continues to creep in through every available enntrance. I spent the long weekend trying to avoid both television and written news reports to give myself a break but even then people would mention something in passing or I would be in a public place with the inevitable television attuned to one of the more conservative news channels barking twaddle and tommyrot into the air. I am, however, like Sally Brown, determined to continue to support my new philosophy of optimistic nihilism so I have decided it’s time to look for silver linings in all of this. There have to be a few.

Let’s start with Robert Kennedy Jr., DHHS, and the MAHA movement. There’s a lot of focus on vaccine denialism, destruction of confidence in public health institutions, hobbling of the CDC, the FDA, and other federal programs which have helped us stay away from things that can kill us at young ages without us having to think too much about it. But there are some nuggets of positivity which should be encouraged. And perhaps the first way to guide resisters back to science based thinking is to accept those ideas which make a certain amount of sense. A refocusing of society on proper nutrition and whole foods isn’t a bad idea at all. And the federal government is the correct entity to make better foodstuffs available to all, help eliminate inner city food deserts and through subsity and distribution, make a more wholesome diet easier to achieve. Another idea that is percolating up through the MAHA ranks is an elimination of direct to consumer perscription pharmaceutical advertising. I’m all for this. It should never have been allowed in the first place. We believe, in our culture, that there should be a magical cure for everything available in pill form and that eternal good health is the baseline and anyone not enjoying that is somehow being shortchanged by someone or something who can be blamed. Sorry, life remains a 100% fatal disease. Good health is just the slowest way to die.

Is there a silver lining in the tariffs and economic mayhem? Perhaps this will begin to curb American’s addiciton to cheap disposable consumer goods. We all have far more in our houses than we need and many of us spill over into storage spaces full of things we haven’t touched in years. A trend toward fewer possessions of higher quality would not necessarily be bad for us, our society, or the planet. People are also starting to become more interested in the macroeconomics of the economy as well as the microeconomics of the household. The more of us that get that, the more likely we’ll elect representatives who will help manage the economy for the advantage of ordinary Americans, rather than the current shoveling of all wealth to the top as quickly as possible.

The attempts to federalize law enforcement through calling out the National Guard for unnecessary reasons, the overreach of ICE, and the general attempts to stifle dissent to unpopular policies are having some effect. There has been a general increase in understanding of the constitution, especially the 6th amendment with its requirement that defendents be given their rights. Jeannine Pirro has now been foiled by grand juries seven times in the last month who declined to indict charges she brought. In the previous decade there were only eleven cases where a grand jury did not indict on a federal prosecutor’s evidence nationwide. It’s also worken up a portion of the Democratic party and they are actually starting to do political opposition work rather than try to just protect their campaign funding.

I’m sure there are others but I can’t think of them right now. I’m too tired. I’ve been immersed in a couple of legal cases which I have to have reviewed by the middle of the month. One of them is fairly straight forward. The other had 8,000 pages and they just sent me another 4,000 last week. It’s going to take awhile. At least, with nothing theatrical, I should be able to plow through it all. It just all has to be done by the first of October when I go into vacation mode for two weeks.

Another day, another hosepipe of bad news heading our direction. Stories of the day include another mass shooting of children, this time during a school mass in Minnesota. The right wing has seized upon the fact that the mentally ill perpetrator was trans and are banging the alarm bells to round up and incarcerate the dangerous trans folk before they can kill more of our children. So I did a little research. There have been about four and a half thousand shootings with more than one victim over the last decade in the US and of those, fewer than ten were committed by trans identified individuals. There never seems to be any discussion of how we have hollowed out the mental health system of this country systematically over the last fifty years, how we allow pretty much anyone to purchase firearms that have no purpose other than as weapons of war and mass killing, and how there are now more guns in the country in private hands than there are people. That combination pretty much ensures we will continue to have mass shootings until we as a society make demands that the gun lobby cannot overcome. Of course, the perpatrator posted for weeks on the internet about their intentions but as the DHS office in charge of monitoring domestic terrorism was turned over to a 22 year old intern who promptly fired 80% of the staff and instructed the remaining 20% to focus on ICE/Border issues, no one was paying attention.

The second one is that the government continues to insist on opening more and more detention centers for undocumented residents, going so far as to repurpose the Japanese American internment camp at Fort Bliss in Texas, site of one of the more shameful incidents in 20th century American history, for a new life and purpose. Meanwhile, in Florida, Alligator Alcatraz is to be closed after having been in existence for less than two months at a loss to the Florida tax payers of a quarter billion dollars, revealing just what a grift and performative exercise this whole thing is. Especially after it was revealed that ICE detained and questioned a working fire crew battling the Bear Gulch blaze in Washington because there’s nothing more dangerous to the homeland than an active group of firefighters trying to control a forest fire that’s been raging for some weeks. The ICE goons keep going after soft targets as it might actually strain them or put them in some danger to actually go after known gang members. On a closer to home and tangential note, a dispute is boiling up between a local municipality and a Hispanic focused grocery store that certainly has a colorful stench surrounding it.

Then there is the insanity in the health system. The head of DHHS, the esteemed Robert F. Kennedy Jr. announced that he can diagnose children as having ‘inflammation’ and mitochondrial challenges’ just by looking at them and that this is what public health needs to focus on. I’ve been in clinical medicine for more than forty years now and WTF is ‘mitochondrial challenge’? There’s a new piece of quackery that arises every few years to entice the gullible to buy expensive supplements to fix the basic problems of human existence like physical and psychic discomfort and somatization and body changes of aging and I guess this is just the latest. At least there will be Covid shots availble this fall but the indications are being ratcheted way down. You’ll need to be over 65 or have a medical condition which will make you more susceptible to infection to fit the new criteria. (Pro Tip – most pharmacies will allow you to self attest to the ‘more susceptible to infection’ category). The senior leadership at the CDC is exiting rapidly following the twisting of science to try to validate political positions rather than rationally seeing where the science leads. Demetre Daskalakis, one of the best minds regarding public health and infectious disease released a scathing resignation letter pointing out just what is wrong with RFKs handling of our health systems. Of course the right wing is piling on with the usual invective because 1. He’s openly gay. 2. He has a funny name and therefore can’t be a real American and 3. He dared use the phrase ‘pregnant persons’. I’ll let you look it up and read it on your own time. I can’t help but wonder what Bill Cassidy, who was the deciding vote to confirm RFK and is a physician thinks of his basic betrayal of basic medical ethics.

After seeing a bit of this weeks cringey cabinet meeting in which sycophantic phrases were bandied about like so many shuttlecocks in a game of existential badminton, I can’t help but wonder who is really calling the shots in DC. The president appears to be barely coherent. The cabinet appear to be about to go all Night of the Long Knives on each other. And yet the orders keep rolling on our completely reshaping society and how we interact with each other. Somebody somewhere is making sure this happens. And it’s not Elon Musk. He and Peter Thiel are probably playing around with the huge data set that contains all three hundred million plus social security numbers tied to all of our other personal data which DOGE uploaded to the cloud and which is now being used by who knows whom for who knows what purposes. That particular move will make it very easy to start putting Big Brother is Watching You in place for us all.

The administration seems to be intent on securing DC with sympathetic individuals. National Guard units from red states have been called up to ‘combat crime’ but they’re all stationed around the Mall and other low crime tourist areas where they are easily seen and photographed and they have been put to work doing the jobs normally done by federal employees that were axed in the DOGE purge such as clearing litter, spreading mulch, and basic repair work. And now the administration has taken over Union Station from Amtrak. I can’t help but wonder if this is a plan to secure the city from anyone coming in to remove the current administration should they decide to stay, no matter the outcome of coming elections. At least the airports are not within DC proper and will be a little harder to claim. I looked up the top states for violent crime rates – The top 5 are New Mexico, Alaska, Arkansas, Louisiana, Tennessee. Four of those five are solidly red states. The administration appears to be going after Illinois next. It’s number thirty on the list. (Alabama is number eighteen).

Then there’s the economic meltdown from the craziness of Trump’s tariffs. The removal of the de minimis exemption for packages has pretty much paused most of the world’s postal systems from shipping anything to the US as the rules are completely unclear and changing from day to day. If you enjoy ordering things from international retailers, forget it. It ain’t happening. Not to mention all of the small businesses that rely on small lot shipments internationally to stay afloat. Gone. The administration appears to want to remove us from the global economy which has allowed us to grow and sustained us for the last century. I suppose we can become a hermit kingdom and international pariah. It’s worked out so well for North Korea.

There are some glimmers of hope. Pope Leo and the Catholic Conference of Bishops have come out swinging for gun control after this week’s shooting. A few of the Democratic governors, most notably Newsom and Pritzker, have started to understand how to battle the administration in the political arena. Pretty much every special election in the last few months has shown a ten to twenty point swing towards the democrats due to the extreme unpopularity of the majority of the policies descending from the White House. But we’ve still got over a year until the midterm election. It’s going to be a very long year.

Two musings in a row. That’s not something that happens too often these days. I guess I’m having to do some decompression or cleansing of the system or jetting out of the drains or whatever metaphor strikes your fancy and, as it’s my page and my writing, you all get to travel along with me if you so choose. Or you can scroll on by. Free will is still a thing. At least until the current administration shuts it down for being unpatriotic. I kid – they aren’t really going to come after anyone for their thoughts. But they seem to be dead serious about making sure we all understand that expressing our thoughts in certain ways is a good way to bring the full power of the US government down on individuals in sometimes a spectacularly cruel fashion – to demonstrate the consequences of not adhering to the party line in terms of history, science, culture, politics, economics, health, and dozens of other things where truth and fact are now regarded as so many political commodities and easily replaced.

Today I have been thinking about death. I last directed a musical in 2012 – 42nd Street for the Gardendale Arts Council – the budget was low but I was able to cajole a number of talented people into performing and on the artistic staff so the end result was actually pretty good. I had a number of high school and college age kids in the ensemble tapping up a storm. Two of them, Brandon and Angelicca, both died this week in their late 20s/early 30s. I can still see them as young people, grinning after a successful performance, not knowing or suspecting that their lives would be cut short not that many years later. This of course has got me thinking about other friends who died young – in traffic accidents, of suicide, murdered, of particulary nasty cancers. Because of theater, I tend to hang out with and have a lot of younger friends who should be outliving me and whenever one goes, I mourn the loss of the talent, and the light they brought to the world. Their creativity. Their humor.

I’m of an age now when my peer group are now all grandparents and starting to leave through the usual natural causes of aging organs or the cumulative effect of bad life choices. I’m well aware I’ll board the train myself one of these days. I’m not planning on it happening for a while but I am preparing for it. In my profession I’ve seen the thousand and one disasters that happen when there has been no preparation so I urge you, if you’re an aging adult, get that will updated, prepare an advance directive. Look around your living space and think about what needs to happen if you don’t have the ability to easily navigate stairs. Or if your memory isn’t quite what it once was. Or if you lose your ability to drive safely. I’ve thought through all of these possibilities for my life and have plans in place but most of us don’t because the inevitability of aging, debility and death remain the ultimate taboo in our society.

The first baby boomers turn 80 in just over four months. I refer to the 80s with my patients as the uncertain 80s. Most people – if they have had good fortune, good genes, good health care, and good choices, make it into their 80s relatively independent and unscathed. However, most people do not make it into their 90s in the same shape. The 80s is when most of our bodies and minds will fail. The policies being put into place by this administration are gutting health services for the aging. The current model of long term care/nursing home is going to become economically unsustainable very rapidly. As people on the lower 4/5 of the socioeconomic ladder age, given current trends, they’re likely to start plunging into poverty and ultimately homelessness which will lead to death. Their bodies won’t be able to hold up to those kinds of stresses.

But this seems to be ultimate goal of the current administration, a supplantation of our current reverence for life with a sort of necro-state designed to rapidly lower the population (other than those in the very top tier who don’t have to worry about a doubling of grocery or energy prices or a raising of rents out of reach of the younger generation). HHS is in the process of introducing rules to prevent the FDA from regulating the claims (and likely the ingredients) of patent medicines taking us back to the good old days of the 1890s when the American public poisoned itself at enormous rates. An inability to afford basic necessities will push more and more people onto the street where new laws against vagrancy will sweep them up into camps rife with disease (you didn’t really think all of these new camps would be reserved strictly for immigrants did you? They will be kept full with as many classes of undesirables as necessary to keep the contract money flowing). The federalization of law enforcement and the steps toward militarizing the national guard against the population of Democratic leaning cities does not bode well for anyone. We aren’t in a shooting civil war yet but the chess pieces are being moved into place. And then there’s Covid – with a recent pandemic that’s being erased from public consciousness for political reasons. It’s a virus that we still don’t completely understand and which likely will have significant long term effects on the population. But we’re highly unlikely to be allowed to study what they are as that would contradict the official narrative.

Put this all together and I see a couple of things coming. First, life expectancy in this country, already significantly lower than most other developed nations, is going to start moving down. The Boom and Generation X, who have aged seeing parent figures age successfully into their 80s and 90s are going to have difficulties matching this and are going to be livid that the quasi-immortality they have been promising themselves for decades will not be theirs for the taking. More and more young people, already being hammered by economic changes, student loans, and other such things that prevent them from maturing into such usual milestones as homeownership and parenthood, are going to be asked to help take care of aging family as there won’t be other options, adding further economic strains to family units.

While at times it’s lonely being responsible solely for myself in my aging state, I am thankful that I know enough about how all this works to prevent myself from being a significant burden as I complete my life cycle. But I’m not planning on closing that circle for a few years yet. I’ve got a few more things to do. Like finish all of Dickens’ novels – Read Little Dorrit last month. Four more to go.

It’s not quite a week post Shakespeare and I’m still trying to put my life rhythms back together. Sleep patterns are adjusting, stress level has gone down a bit, some things that have been sitting on the ‘to do’ list for a while have been stricken off. My big chore for the weekend is to get my final decision in regarding my fall trip. I have it down to two options and I’ve promised myself I will have a decision made by Sunday. I still haven’t come up with a decent travel companion with similar tastes, bucket list and finances. Some day… Or I strike it rich and start treating friends.

As I’ve come back to the surface and I’m starting to pay attention to the world outside of my condo, office and the theater, it looks like we’ve all stumbled into more of the Upside Down than I would have thought possible a few months ago. In the last few days I’ve seen mouthpieces for the administration opine that we should have taken Hitler’s side in World War II, that McCarthyism was a good thing and should be reestablished, and that the key to future success is the deportation of all non-native born Americans. Considering that pushback against these senitments has been muted at best and certainly there’s been none coming from the party in power, I can only assume that we’ve pretty much arrived at full blown fascism. There’s nothing I can do about it, just circle the wagons around me and the people whom I care about and hang on as things will get worse and there’s no white knight coming to the rescue.

Since I last paid major attention to politics, the president of the US has had private conversations with Putin (on American soil no less) where his aides were obviously distressed by the nature of the talks (pity there was not someone in a tree). The leaders on NATO dropped everything and raced to DC along with Zelenskyy to shore up support against Russian aggression. The secretary of defense keeps firing top military officers who insist on speaking truth rather than the lies he wants to hear. The Supreme Court continues to hand down decisions designed to speed up the conversion of government from tripartite to unitary executive. We’re busy opening concentration camps with cute names suitable for T-shirts and other merchandising opportunities. The Department of Health continues to suppress public health data.. All signs point to a sledgehammer about to be taken to the Smithsonian to rid it of degnerate history exhibits. And the FBI is being weaponized to attack Trump’s personal enemies. It’s enough to make anyone turn to drink and I have no idea how to parse it in such a way that I can even begin to wrap my brain around it.

On the Covid front, cases and hospitalizations continue to climb, especially in the West and Southwest. What few CDC numbers I can still find plus wastewater studies confirm this. Why this should be is unclear. It looks like we’re settling into a bimodal distribution with peaks in late summer and in midwinter. The peaks are likely related to human behavior and more extremes in temperature, whether cold or hot, pushing us indoors for either heat or AC and into closer proximity to our fellow beings. It’s still around locally. A local theater lost its star for the majority of the run of a cabaret show due to a covid infection last week. I haven’t been sick in some months following my winter from hell. It’s been nice to have felt normal for a while. This is probably a sign that I’ll come down with something next week. What likely saves me is the nature of my job which requires me to wash and sanitize my hands a dozen or so times a day which is going to reduce my environmental exposure.

I’m trying to figure out what I should write next. The posts about the state of all of our lives I’ve been writing for the last six months or so don’t lend themselves to much of anything other than Substack and I’m starting to think I need to embark on a project with a more definite goal in mind. Is there anything within my usual purview that people want to read about? Both of my vacation options come with some significant down time where I can possibly break the back on a new project of some sort. Perhaps a play in iambic pentameter. I tried that once. It was not a successful experiment. The juices just aren’t flowing at the moment.

Perhaps Richard II took more out of me than I quite understand given all of the various production disasters which I have detailed in previous missives. Anyone who wishes to judge my ides for themselves can do so at the following link: https://www.youtube.com/watch?v=00gvaegg120 – I have no idea if I managed to pull off even half of what I was going for. Maybe, maybe not. If you skim through it and like it, Yay. If you skim through it and hate it, tell me. I’m an adult, I can take it. You don’t improve without constructive criticism.

In lieu of my usual musings, I present the following. One of my Richard II cast used his experiences working on the show as part of a school project and, as part of that, asked me some questions. Here they are with my answers.

Can you give me a brief explanation of who you are and what your theater experience is like?

I’m a well-educated, highly imaginative man who has always tried to balance my right and left-brain lives in some way. I excelled in the hard sciences in high school and college and there was a family tradition of medical education that pushed me toward becoming a physician. I also always had a healthy interest in the humanities, reading voraciously and taking classes in history, sociology, literature, philosophy, and religion. At the age of sixteen, my high school built a new arts building with a theatre (we had never had one before). I had never done theater as a child but had been taken to live performance since I was old enough to sit still and had always enjoyed it. Something clicked, however, when I walked into that space and looked at things like the fly system. I wanted to learn how to use it to create. So, I signed up for technical theater and learned the basic elements of design, stage craft, and production. I found my niche as a stage manager and was later encouraged to try directing. I directed my first show, a one act, at the end of my senior year of high school.

When I went to college, I found there was a tradition of dorm theater. My freshman year, we decided to do a dorm production of You Can’t Take It With You. As I was the only one with directing experience, I got the job. The end result was reasonable It was seen by some upperclassmen prominent in campus theater who decided I had talent and was taken under their wing and I moved up the ranks in campus theater as both stage manager and director. Later, in medical school, I continued to stage manage and direct in community theater circles. It all came to an end when I hit residency and every fourth night on call.

I was away from theater for the next fifteen years building my medical career. In my early forties, after some life reverses, I felt a need to rebalance and decided to return to my old passion. I was encouraged this time to try performing. I had never considered myself a performer but figured what the heck and made the leap. Amazingly, I kept getting cast. Over the last two decades I’ve performed in over eighty productions in Birmingham and am occasionally given the chance to direct.

What inspired your production of Richard II?

Bell Tower Players, with whom I have worked off and on for a decade, is the only community theater locally that routinely does the classics. They have done a few Shakespeare plays in the past and a few years ago, decided to do Shakespeare in the summer and asked me to direct. My first production with them was A Midsummer Night’s Dream and last year we did The Merry Wives of Windsor. I wanted to challenge the group and move out of the comedies and didn’t think we were ready for any of the great tragedies so I decided that one of the history plays might be appropriate. I chose Richard II as I thought it would be castable out of our usual group and because it’s a particular favorite of mine in terms of its themes.

The play was chosen nearly a year ago and, as politics in the US progressed through that time, I began to think more and more about the themes of the play and how the major one that I wanted to highlight was that of power – how it is used, abused, and misused and how it can destroy an individual and ultimately a system of government. As I kept thinking about this, I decided that it would be interesting to highlight the parallels between Richard’s world and our own. Various ideas occurred to me and one of them was that the play was a memory play taking place in Richard’s mind as he awaits his inevitable death in his cell at the end. The technical limitations of our space and budget made me throw that out but I was intrigued of the idea of the jail setting and my original idea morphed into that of a political prison and more and more pieces fell into place as I continued to study the play.

I took ideas from varying sources such as Man of La Mancha, The Kiss of the Spiderwoman, Bent, the TV series Oz and scrambled them all together in my mind. I developed the idea of making the prison a temporary holding cell that has been thrown together, that it was a church basement to tie it closer to the audience’s actual experience, and came up with the idea of the color palette for the costumes to get the audience to subtly reflect on the meanings of the colors in various cultures. Then it was a matter of translating the action of the play into the milieu of the setting. What takes the place of throwing down gages? What does a tournament look like? How would a gardener show up to talk about plants?

Why do you believe community theater is important?

There are two words there. Community and Theater. I think the former is the most important. Community theaters are for the forming of a community, whether it be the show family created for each project or the group of people who find a theatrical home and return for production after production in some capacity. The theater is the team project. The thing that cannot be created by any one individual, but which requires everyone to do their part. Sometimes the smallest pieces become staggeringly important like with scissors. The pin is the most vital component. They are the training grounds where young people can get their first experience before moving on to more professional settings. They are the place of refuge for those who enjoy performing or creating but whose lives and life patterns preclude them from aspiring higher up the ladder. They can showcase incredible talents that will never be seen on Broadway and who deserve to share their gifts with the world. I see a lot of attitude among some in our area that they believe themselves too good to work on a small, low budget community theater show. I believe you’re never too good and that if the project is right for you, you can do smaller projects and mentor and inspire and raise the general quality of the art being produced.

How has being a part of community theater personally impacted you?

My adventures in community theater have taught me an enormous amount about human beings and human nature that has come in handy with my day job in medicine. It has helped me become a better and more creative problem solver. It has taught me communication skills that no class would be able to. I am definitely a more fulfilled, richer, and possibly more interesting person for all the things I’ve done.

What has been some challenges you’ve faced with Richard II?

I believe very strongly that good theater requires a cast to be an ensemble. That they learn to be comfortable with each other. To support each other. To work together as a unit. That way, when things go sideways, and they always do, they can handle it as a group and keep the show moving forward with minimal disruptions. With Richard II, I had a cast of sixteen, ranging in age from 19 to 86. Some had had decades of experience on stage. Some were complete novices. I had to figure out how to get them working together, to help them craft performances that balanced each other, and to keep them from being so scared of the language. As I say repeatedly, Shakespeare wasn’t writing Shakespeare. He was writing popular entertainments, and we need to approach it in that way to make sure it’s of interest to a modern audience. If everyone were to stand centerstage and declaim each speech in measured cadence, the audience would be asleep in twenty minutes. It has to be interesting. It has to be understood by the audience (which is more about intention and the actor understanding exactly what he or she is doing with what motivation) than it is about every word being perfect. We do these plays four hundred years later as Shakespeare was not only a brilliant poet, but also a keen observer of the human condition. It’s that latter which makes the plays still relatable and why we continue to enjoy them.

This particular production also had some major production issues. The lighting system died so I made the decision that we would simply use the work lights. As a concept, I didn’t hate it as that’s the kind of lighting this prison space would have had, but it meant we lost all control over using lights to help tell the story or to isolate particular areas of the stage that could have made it easier for the audience to follow some of the changes in setting in the Richard story. The costumer ending up in the ER twice in two weeks put costumes behind and I wasn’t able to refine some of the choices the way I might have otherwise. There were also significant difficulties with certain actors abilities to learn and retain their lines. One of them I planned for, the others I did not.

What about challenges with other productions?

I wrote, starred in, and helped produce a show called Politically Incorrect Cabaret that went through a dozen editions over fifteen years. We took it to venues in five states throughout the Southeast. The stories of that show are legion including unheated venues in below freezing weather, unairconditioned venues when it was over a hundred. Drunk tech crews (and one time a drunk cast member). Collapsing floors. Performing without a tech rehearsal. A power outage with the show done by candlelight and flashlights. I’m amazed that some of those actually made it on stage. But it’s semi-improv nature allowed us to get away with a lot.

I’ve had costumes disintegrate on stage, set pieces lowered on my head, falls off of platforms, a skid across the stage on my backside when a fellow cast member got a little over exuberant with a planned shove, been stuck on stage with a twelve year old when someone missed an entrance leading to five minutes of improv, missed cues, reordered lines, broken and missing props. It’s all part of what makes live theater so special.

I learned long ago to make Geoffrey Rush in Shakespeare in Love my spirit animal when it comes to theater.

What do you hope the audience takes away from Richard II?

I want them to leave the production thinking about something differently. Whether it is a different thought about our political moment, a new way of thinking about the possibilities of Shakespeare, or an increased respect for what Bell Tower Players and the performers are capable of achieving.

Can you share a story where you’ve witnessed the power of community theater positively impact another person?

I’ve seen a number of the young people with whom I have done community theater in the Birmingham area go on to professional careers. Perhaps the most famous is Jordan Fisher who will always be twelve-year-old Chulalongkorn in The King and I to me. Others I’ve worked with have gone on to national tours, Broadway, television, and national ad campaigns. I celebrate each and every one of them for their successes. Some get jealous. I don’t. I’m where I need to be.

Nearly twenty years ago, I played Mayor Shinn. The girl who played my younger daughter, eleven at the time, was just beginning in community theater. She went off, got her training and came back to town as a young adult and sixteen years later, I again played her father in Into the Woods in which she was a magical Cinderella.

What do you think about the health benefits (mental health or otherwise) of community theater, especially as a doctor?

Working in theater requires keeping ones mental faculties in shape and a certain level of self-discipline. It stimulates creativity, helps with memory, and often comes with a certain amount of aerobic exercise, especially when performing in a musical. A lot of stage performers continue to perform into their eighties as their training, and their performance regimens keep them in tip top shape.

As a geriatrician, when I find out that my patients have some sort of background in performance or music, I encourage them to pursue it on some level. It helps them tie in to pleasant experiences, encourages social connection and there is research that shows that both physical and cognitive abilities improve

What is your hope for the future of community theater?

That it will be seen to be as much a part of a healthy civic community as a sports team or an educational system, or recreational opportunities. The arts are as deserving of public funding as other aspects of civic life and should not be relegated to the whims of private funding or thought of as being less than other things we willingly fund like sports stadiums. Theater, more than any other art form, is the mirror of society as it exists as a collaboration between the performers and the audience. No two performances are ever exactly the same as no two audiences are ever exactly the same so the energy in the room is never duplicated. A film is always exactly the same. A play or musical is constantly reinterpreted for new audiences with new experiences and new historical context. It can always reflect both our better selves and those parts of ourselves we would rather not see.