I got run over by a steam roller on Sunday evening, and then it backed up and ran over me again a few times on Monday and Tuesday. I am, of course, speaking metaphorically as the steam roller is whatever the latest viral syndrome is that’s felled me and I’m now on my fourth day in bed. I am starting to feel more human and am planning on returning to the land of the living (and work) on Friday assuming I do not backslide. This is the fourth virus to wreak havoc on my finely attuned internal systems since New Year’s and I am getting awfully tired of getting over something, feeling normal for a week or so and then sinking back into hacking cough, collywobbles, and fuzzy thinking. I think this one has been influenza A from symptomatology (although I haven’t been formally tested – not much to do one way or another besides wait it out) but I have been in touch with my doctor and have friends available should I collapse in a puddle on the floor. Haven’t quite gotten to that point but there were a few moments on Monday night… the last time I felt so ill was my initial covid infection three years ago.

As I’m mainly lying around feeling sorry for myself, I’ve had more than enough time to watch bad television, do some reading. work a bit on new writing projects (not sure I’m doing my best work on these. I will definitely reread before submitting as I don’t want to come across as a complete lunatic), and catching up on the news. I have kept my promise to myself to avoid TV news but that doesn’t mean I don’t fall down rabbit holes of reportage and analysis of the chaos emanating form DC these days. When I last wrote one of these pieces, the immediate reduction of indirect costs on NIH grants had just been announced, roiling academic health centers nation wide. The attorneys general of the blue states banded together and got a court injunction blocking this, but it only covers the blue states that sued. Steve Marshall, our current attorney general is sort of a Ken Paxton manque best known for suing to protect monuments glorifying the confederacy from removal, keeping innocent men on death row (before executing them with nitrogen gas), refusing to acknowledge the legitimacy of the Biden presidency, and pushing hard to end DACA. He’s unlikely to go to bat against anything for which Trump and the Muskrats push.

We do have one public servant who seems to understand the major catastrophe significant reductions to NIH funding could unleash on UAB, Birmingham, and the state of Alabama, senator Katie Britt. I may not agree with her politics but she strikes me as being reasonably intelligent regarding realpolitik. She appears to be working behind closed doors on potential solutions. I doubt she’ll get very far. As far as our other senator goes, the less said about him, the better. Scrolling through comments on political articles (and weeding out the obvious bots and trolls), those who appear to be in favor of DOGE actions appear to have little understanding of how any government processes work and certainly seem to think that national budgets are akin to family budgets worked out at the kitchen table. News flash: they aren’t.

DOGE, of dubious legality and certainly staffed with people who would not be able to get positions of governmental power in ordinary times (Elon Musk himself is limited by his open admission to freely using psychoactive drugs), is acting as if it is working on a hostile takeover of a failing business. The purpose of a business, in a capitalist society, is to make profit for the owners of business. This is not the purpose of a national government. A national government is there to protect the citizenry and create conditions under which they can thrive. The US hasn’t been doing a very good job of this latter in recent decades (which is why we are where we are) but axing large portions of the government is unlikely to improve anything for anyone.

The constitution was not written by stupid people. They set up the system of checks and balances to make sure that the executive and legislative were responsive to the people through the mechanism of elections. If the people don’t like what you’re doing, out you go with the next election cycle. The allocation of funding was very deliberately given to the legislative, not the executive and we have a chance every two years to change the composition of the legislature. One has to wonder why there are not howls of execration form both house and senate at the usurpation of their constitutional duties. Especially as the Republicans have a fairly slim majority. Are they all scurrying around in backrooms saving their own special slices of pork or are they secretly in favor of a dismantling of bureaucracy? Quite frankly, the federal government is overdue for a major audit but I’d feel much better if it were being undertaken by apolitical forensic accountants and not by a ketamine addicted billionaire with multiple conflicts of interest backed up by some grad students with no qualifications other than computer skills.

If the opposition truly wants to oppose, the first thing to do would be to drive a wedge between Trump and Musk. Musk’s power derives solely from what Trump grants to him. There isn’t room in the oval office for two megalomaniacal egos. A constant messaging that Trump isn’t really in charge (and yesterday’s press conference gives plenty of fuel for that fire) should provoke him to shove Musk out of the spotlight PDQ. The fact that such a thing isn’t happening to any great extent again makes me wonder what’s really going on in the back rooms of DC. Whatever it is, they and theirs will be the first to be protected. Those of us outside of those charmed circles better hang on. The weather’s going to get rougher.

And the hits keep on coming. I did a certain amount of predicting a while ago that the new administration was likely to do something that would upset the delicate financial ecosystem that allows our academic health centers to exist and that axe fell late yesterday. The National Institutes of Health are savagely cutting back what is known as indirect costs from the various rates that are carefully worked out based on the nature of the research involved and the expense of supporting the labs and other things necessary to make sure that it is done properly, safely, and ethically. NIH is now imposing a maximum 15% in indirect costs to be paid to universities and other institutions rather than current rates which usually run 20-50% depending on exactly what is being studied and how.

I have mentioned before that UAB is the state’s largest employer with 28,000 employees across undergraduate programs, schools of medicine, nursing, and other health professions, and a robust research program that received about 400 million from NIH last year. (It’s somewhere around #25 on the list of top universities for research funding). A draconian cut like this is going to lead to something like 75 million less coming in to university coffers starting immediately. I’ve been around academia a long time. I know what comes next. Those at the top of the food chain circle the wagons in self protection and the pain gets forced down to more rank and file individuals. Secretarial/administrative support? Gone. Fewer custodians. Less food service. Deferred maintenance projects get canceled and facilities continue to deteriorate. And then the ripple effects when hundreds, if not thousands of ex-University employees no longer buy houses, patronize restaurants shop in local stores and otherwise contribute to the economy. It’s way too early to know what the actual effects are going to be but my guess is they’re not going to be pretty. And this is going to play out in every community supported by a university with an academic health center nationwide. It took many decades to create them and the miracles they are able to produce. They can easily be severely damaged if not destroyed very quickly. I know we’re not supposed to draw Nazi parallels due to Godwin’s law but I often think of the University of Vienna. In the late 19th and early 20th centuries, it was the pinnacle of medical learning in the world. Nothing in the US could compare. After the Anschluss, the new regime fired all the Jewish faculty – to this day, the institution has never been able to rebuild what it once had. The destruction that World War II unleashed on Europe was what allowed American universities to enter the void and grow and flourish.

Elon and his flying monkeys (although I prefer Elon and the Muskrats even if it does sound like a minor British Invasion band) continue to rampage across the federal landscape. I am not adverse to budget cuts and fiscal discipline. I am fine with a light being shown into the darker recesses of federal agencies and pointing out that maybe tax dollars should not be appropriated for certain expenditures. But there is a right way and a wrong way to go about this. The constitution was carefully constructed to prevent the consolidation of power in any one branch or individual through the system of checks and balances. It makes for an unwieldy system with a lot of stalemates but that’s intentional and why it’s been able to function for the last 235 years or so. It requires are politics to be measured, to rely on negotiation, and to approach some sort of consensus before big changes which can cause societal upheaval are put into play. The abandonment of the power of the purse by congress to a ketamine addled narcissistic billionaire longing for the apartheid of his youth and a bunch of grad school tech nerds who have basically been granted license to do whatever they feel like is a recipe for disaster.

Finding something you don’t agree with for ideological reasons in the federal budget does not mean fraud. If congress appropriated funds, it is not fraud by any definition. The administration is free to go to congress and propose a bill which will eliminate any program or department they so choose and, if congress passes it, so be it. Congress knows, however, that the passage of bills that cut things is difficult and usually unpopular with the voting public which is likely why they are letting this happen. They can sit there and say ‘It wasn’t me – my hands are clean’. But, as there are no checks on what is happening, there’s going to be throwing a lot of babies out with the bathwater. Shutting down USAID is going to hurt American farmers and manufacturers, lead to hundreds of thousands starving in the poorer quarters of the world and likely lead to more and more epidemic disease which, with modern transportation, will be more than happy to hitch rides back to the US. (Not to mention it’s illegal. As USAID was created by congressional statute, it requires an act of congress to shut it down).

Trump’s latest bit of self-aggrandizement was to fire the Kennedy Center Board and to appoint himself its new head. (Again, illegal, the Kennedy Center is not part of the executive branch and the board doesn’t work for him in any capacity – cue the lawsuits in 3…2…1…) It’s easy to be facetious and speculate as to whether Mel Gibson or Kid Rock will be up for a Kennedy Center honor next year or wonder when the Kennedy Center production of Dreamgirls starring Laura Osnes is likely to open but there’s another thread of totalitarianism here. When the state declares what is or is not art, culture stultifies. Think of all of the dreary statuary in the Eastern Bloc from the last century or the truly bad paintings of mid 20th Century Germany after the Nazis tried to suppress modern art as ‘degenerate’. Art is not supposed to glorify the status quo. It’s supposed to hold a mirror up to who we are and reflect us warts and all and make us want to be better and to move forward. It needs to experiment. It needs to shock. It needs to foment anger. Major leaps forward are often reviled in their time – the original reception of Stravinsky’s The Rite of Spring, for example. Then, thought and people and culture catch up. I don’t know what Trump’s definition of ‘golden age of American Art’ is but I’m pretty sure it’s quite different from mine.

Speaking of envelope pushing art, the Virginia Samford Theatre opened a new production of Stephen Sondheim’s Assassins this week. I went to opening night on Thursday (I’m on the board so I figured I should show up). I’ve known the show for more than thirty years, read it, seen clips, listened to various cast albums, but this was the first time I had a chance to see a full staged production. For those who do not worship at the altar of the god Sondheim, the show is a vaudeville telling the stories of various presidential assassins from the famous (John Wilkes Booth, Lee Harvey Oswald) to the more obscure would bes like (Sam Byck who tried to kill Nixon by flying a 747 into the White House and Giuseppe Zangara who failed to shoot FDR (but did manage to kill the mayor of Chicago)). I’m not advocating an assassination by any means – we have enough troubles – but the underlying message of the show is that there is a dark side to America which creates outcasts and misfits who see their only hope of redemption as one vainglorious act. Late in the show, the assassins all sing a song ‘Another National Anthem’ which lays all of this bear and, in this particular political moment, the lyrics cut deep. The show is absolutely terrific so, if you’re in the greater Birmingham area, don’t miss it.

Not everything is bad. I seem to have fixed whatever it was that was making Edward the polter-cat unhappy. He has not peed in the bed the last few days. And there was much rejoicing (other than in the frozen land of Nador).

The weird idea that captured my brain at some strange hour last night: are we actually living in the zombie apocalypse? Hear me out… we assume, based on The Walking Dead and George Romero, that some sort of killer virus will turn most of our friends and neighbors into a ravening horde of deteriorating animate carcasses. But what if it’s more subtle than that and proceeds more slowly?

One of the ideas I have been playing with in regards to new book essay subjects is that we all have long covid. Over the last five years, the vast majority of us have had at least one infection and many of us have had two or three. Personally, I have had two of which I am aware. It’s possible I had a third one in there that was subclinical but I really don’t know. As the disease is so new, we still have only the vaguest ideas regarding long term effects of infection. It’s a vascular disease. It infiltrates any tissue with high amounts of capillary blood flow. Lungs, of course, have a huge amount, so this is why it tended to cause pulmonary problems and why we think of it, erroneously, as a respiratory disease, but cardiac, renal and central nervous system issues are also well documented.

There are rare cases of serious brain issues such as demyelination following covid infection. Most of the brain issues described are of the ‘brain fog’ variety. Memory not working quite as well as it should along with feelings of mild confusion or somnolence. But there are some other interesting things that are coming to light. Population studies have shown small, but measurable declines in cognitive function post covid. We aren’t thinking quite as well as a species as we were. The objective declines aren’t huge, but even small changes in an organ as complex as the human brain may have significant effect in aggregate. I’ve seen studies showing that traffic accident rates are up, people are more likely to be irritable and have explosive anger outbursts, and there is a decline in empathic social skills after covid infection.

If you look at the areas of the brain most affected by Covid, there are two that stand out. The first is the hippocampus, which is basically a memory control/switching center. It is one of the areas of the brain most damaged by Alzheimer’s disease leading to the characteristic memory loss displayed by those who have it. The feelings of brain fog may be coming by mild dysfunction here. The second is a portion of the brain known as the anterior cingulate cortex. This portion of the brain has multiple higher functions in regards to integration of memory and behavior including decision making, recognition of error, and emotional regulation. Perhaps most of our brains have been infected with a virus which has subtly changed them so that we are more likely to feel like we are in the right (even when we are not), that our beliefs are the true ones, that others are to be discounted (decreasing empathy), and that anger is the appropriate emotional response to challenge and conflict. Perhaps the politics of the moment are being driven by biology and we can no longer hang together as a species as well as we once did due to brand new physiologic change. The things I think about in the wee hours…

Covid continues to spread. I’ve had a number of patients and friends with it. There’s an estimated 500,000 new infections a day in the US according to some sources so you’re likely to run into it. I’m not worried about covid these days. I’m well vaccinated and relatively healthy and should recover quickly. I’m worried about long covid and losing health and function. The rough chances for long covid per infection are about 10% if unvaccinated and about 2-3% if vaccinated. This is why I get my boosters. With so much of the public health infrastructure down while the new administration rips out the fake crisis of DEI root and stem (and how we’re supposed to be able to tailor public health programs to various populations without being able to parse them, I don’t know), I can’t find the information on covid as easily as I once did. But I still look. It’s even harder to find decent information on H5N1 bird flu which is apparently undergoing a certain amount of mutation as it spreads through dairy herds. (Price of milk skyrocketing in 3…2…1… and I wouldn’t dream of indulging in the current fashion for raw milk). Will it become our next pandemic? Who knows. If it does, I guess the Accidental Plague Diaries will crank up again.

On the Accidental Political Diary front, the big bombshell of the last twenty-four hours or so was the president and the prime minister of Israel lobbing out the idea of the USA taking over the Gaza strip and redeveloping it into some sort of Dubai on the Mediterranean. I’m paying little attention to this, coming out of the mouth of a man who bankrupted a casino in Atlantic City. His ability to develop twenty five miles of coastline half a world away is minimal at best. It’s simply the latest outrage distraction to keep press and people focused away from the fact that his administration has repeatedly flouted the constitution and the rule of law since installation and that neither congress, the opposition, or the courts, seems terribly interested in bringing it to heel. I have to assume that Elon Musk now has compromised pretty much every governmental data system in DC allowing who knows what malicious actors entry, and has installed back door code everywhere which will allow him and his minions to continue fiddling about even if they are given the bums rush. If you’ve ever paid taxes, gotten a direct deposit from the government, received social security or Medicare benefits, figure all your personal and banking data has been exposed. I’m hoping that in a pool of 340 million, mine won’t float to the surface when a bunch of Belarusian hackers start siphoning all of our assets away.

I’m supposed to be writing reflections on events of five years ago tonight. I’m not. I’m trying to work up the courage to try and figure out where Edward the polter-cat peed on the floor (likely as a message to me of some sort) as I can smell it and I better clean it up before it soaks into carpet or flooring. Bad kitty.

“Optimistic Nihilism” – that’s the philosophy one of my dearest friends is urging us all to develop as the USA continues to rapidly unravel around us in ragged streamers of red, white, and blue. We’ve been having some discussions as to just what it means and what should be included but it more or less boils down to remembering to enjoy the little things and the good in the world as politics, economy, healthcare, and society all dance off into an oblivion created by what could best be described as a coup in the nation’s capital; unprecedented things are happening through extra-legal and downright illegal mechanisms, one after another like a well oiled machine while those responsible for the checks and balances are either unwilling or unable to mount even a tepid verbal response. So, for today, my optimistic nihilism was grateful for spring like weather, a weekend of music making, an impromptu party at one of my favorite restaurants, and getting through a whole day without a new viral symptom of some kind.

I hadn’t pegged Elon Musk to be quite as dangerous as he is but, as I put the story together, the new cabinet picks have allowed him and a cadre of engineering grad students to march into the OPM (Office of Personnel Management – basically HR for the entire federal government) and the Department of the Treasury and access their central data bases and computer systems. So, a foreign born billionaire who seems more interested in salving his ego through enriching himself into the stratosphere, who is unelected, unvetted, unconfirmed now has carte blanche to pull your social security records, your Medicare files, and your tax returns. The close association with Peter Thiel suggests that we’re going to have some big data set analysis on the scale of Cambridge Analytica. It wouldn’t be that hard for them to parse the population into as many slice and dice pigeonholes as they see fit. And what if they start to manipulate the data. Sorry all of you transgendered individuals who we have easily identified by changes in gender markers on government documents. We’ve decided you no longer deserve Social Security. Push the button and the data’s all gone. And good luck trying to fight to get anything restored from the outside when the entire system’s hostile. The people of San Francisco are supporting leftist policies. Let’s just prevent the treasury from sending any sort of disbursement to any California zip code. If what’s going on now isn’t giving you the heebee-jeebies, all I can say is you have a lack of imagination as to where this could go.

On top of this, after nearly two hundred years of peaceful coexistence, Trump has picked a fight with Canada, our closest ally, and is busy proving on an hourly basis that he has no understanding of what a tariff is or how they actually work. He’s also sent Marco Rubio off to Panama to threaten their sovereignty over some half baked idea to try and take the Panama Canal back. Then, on the public health front, there’s a measles outbreak in Texas, the biggest TB outbreak ever in Kansas, avian flu H5N1 is continuing to spread to various farm herds and bird populations leading to mass culling and a sharp rise in the price plus a shortage of eggs. It’s still not effectively spreading human to human but with the taking of a significant portion of NIH and CDC off line this past week, it’s not the easiest thing to tease out. But I’m sure if Robert Kennedy Jr. is confirmed next week as Secretary of Health and Human Services, these problems will all take care of themselves. And for even more good health news, there’s been an outbreak of Ebola in Uganda and of Marburg in Tanzania. The policy in the past has always been to fight diseases like this (and the filoviruses are some of the nastiest diseases on the planet) over there so they never have a chance to come over here. The wide swaths of destruction in the Foreign Policy arena including the illegal disbandment of USAID is likely to prevent that sort of maneuver moving forward.

Tomorrow starts a new week – I’m sure it’s going to have additional lovely surprises waiting for us. But optimistic nihilism will win the day. I’ll have fond memories of my Scottish grandmother as I eat my oatmeal in the morning. I’ll try to make a major difference in a patient’s life by tweaking the healthcare system just enough to make something work better for them. I’m supposed to have dinner with Tommy’s mother and brother. Coming up on seven years since I lost him. That somehow doesn’t seem quite possible. That means I’m approaching seven years since I began these writings which have become many things to many people, even though they started out as sort of private therapy to fulfill my role of elder shaman storyteller of some sort. I don’t know where these writings are going. I’m feeling the compulsion to write to help myself stay afloat in the same sea of existential dread many of us are feeling. But what should I be writing about. In some ways, this last two weeks feels a bit like the second and third weeks of March, 2020 when everything changed. I don’t have the knowledge depth to analyze current happenings in the way I did then so I doubt I’m heading into The Accidental Political Diaries, but one never knows does one.

I have a ton of writing to do outside of these essays for books of various stripes. I’m behind, but I have no performance obligations for the next few months so that may help me catch up. Not this weekend, though for I had to put on my tuxedo, tuck my choral book under my arm, and spend a number of hours in the choral balcony at The Alys Stephens Center for the Masterworks concert. The chorus hasn’t been used yet this season so this concert was built around us – an eight part Schubert piece for the men and string orchestra – a long Debussy piece for the women and full orchestra, and finishing up with Borodin’s Polovtsian Dance’s from Prince Igor to give the audience a little something to sing along with and a big presto fortissimo ending designed to bring them to their feet.

I really don’t want to go to work tomorrow.

Another day, another round of poorly phrased and thought out and thoroughly muddled executive orders that have ping ponged back and forth all day between seeming to pause funding for such vital programs as Medicaid, Head Start, SNAP, WIC and the like and then are said to exclude the more politically popular programs that support individuals. At the same time, state governments report that they cannot access the federal websites that allow them to actually track that payments have been received. I am assuming the obfuscation and shockwaves of chaos through federal and state bureaucracy are deliberate and are as much a part of the message as any actual end results. a lot of things will work themselves out over the next few weeks. In the meantime, those who depend on stable federal funding for housing, health care, food and the like will just have to remain on tenterhooks.

Are you able to live independently as a senior due to reduced rent granted through Section 8 housing? The rent differential may be paid, it may not. If not, the owner of your building might put it to more profitable use. Do you depend on meals on wheels because you can no longer shop or cook? The grants coming to your area agency on aging which are dispersed to cover the costs of food, preparation, and distribution might or might not be in place. Is a clinical trial providing you with life saving medicine under a federal grant? Sorry, will that be Mastercard or Visa? Do you get your HIV medications with aid from the Ryan White act? That’s too entwined with LGBTQ+ issues to be allowed. I don’t know if any or all of these will actually continue but I’m not holding my breath for the current administration to do the right thing by anyone.

The new regime is unleashing forces that they probably don’t understand and are unlikely to be able to control. Wishful thinking and fervent belief do not contravene the laws of biology, physics and economics. I don’t know what the end game is. There are a few suggestions floating around out there. One is that there is a concerted push to put society under such strain that it becomes inevitable that street violence breaks out on either the right or the left and that becomes the excuse to activate the military, declare martial law and suspend the constitution. Another is that it’s an attempt to pretty much undo the bureaucratic state as built since World War II and return to government as it existed pre-FDR where basically there were no safety nets and you were on your own. A side effect of this is going to be to rigidly restore a social caste system where anyone not a cis heterosexual Christian European heritage male is relegated to other status and social rules and norms will strongly enforce this. An acquaintance was attacked by a gang of white folk at a rural gas station today for having a rainbow sticker on his car. The large dog in his car made sure he was unharmed but it’s behavior that’s going to become more and more common. As a gay man who lived as an adult through the 80s, I’m used to that sort of thing and have always maintained a certain sense of alertness, even in supposedly safe spaces but the younger generation doesn’t have the life experience to really understand the dangers that are coming.

I’m rather disgusted by both political parties. On the one side, there is an inexcusable amount of silence and lack of pushback. Where is the DNC in terms of being on air and in print explaining exactly what each of these new orders is going to mean in the lives of average Americans? Why are they not challenging and making the administration own every harmful decision? I’ve seen some tweets from AOC and a couple of other muted responses from individuals but very little from the party as a whole. And it’s not like they haven’t had access to the Project 2025 handbook for a couple of years and had time to prepare for what was obviously coming. If they thought ‘Oh, they’ll never actually do that’, more fool them. On the other, there is a systems of checks and balances to keep the three branches of government from supposedly ever devolving into a unitary executive (which the founders would have regarded as tyranny). One of the chief means for the legislative to check the executive is in the power of the purse. The Republican majority have apparently rolled over and offered that particular one up to the executive without so much as a boop on the nose. I also wonder a great deal about the adults in the room on the R side who have spent the last forty years choosing party over country and wondering if they actually approve of current actions when the television cameras are off (I’m looking at you Mitch McConnell) or if they’re quietly going to slink off to their country manses and enjoy what remains of their declining years.

I’ve been told there’s an email in my VA work email inbox telling me that if I resign my position before February 6th, I will be paid through the end of the fiscal year (September 30th). I’m planning on ignoring it. I’ve got work to do taking care of a vulnerable veteran population that may have some of the rugs pulled out from under them. I won’t be in the least bit surprised, however, if sometime after February 6th, some officious administration official demands my removal. I’ve been critical of the present regime’s policies in person and in print far too long; the first volume of my The Accidental Plague Diaries is a blow by blow encounter of the failures of the first Trump administration’s failures with the pandemic. The VA was never part of my retirement planning, it’s gravy so I don’t really care that much what happens. I’ll stay until I reach my planned retirement date or until I am asked to do something by the federal government that breaches my professional ethics or personal moral code. On that day, I will make my fond farewells and, given the enormous shortage of geriatricians, good luck to the VA in finding and hiring a replacement.

Neither you nor I can do anything about or fix any of this. Circle your wagons. Shelter those you can. Take care of yourself. Work closely with those who believe as you do to be ready to advocate for change when the winds shift, as they always do.

We’re three days in to the new administration and I’m already feeling like things fall apart, the center does not hold. I’m not surprised. Those now in power have spent the last four years carefully contriving a slate of ideas which were then word smithed into executive orders designed to rapidly destabilize and then hopefully undo the modern bureaucratic nation state that has been slowly built after World War II. The speed at which these have been released is deliberate in that it prevents any sort of organized response as there is too much too fast for most of us to actually comprehend what is happening and what the consequences will likely be. (See Naomi Klein’s The Shock Doctrine). There is much more to come. It’s no secret. It was all laid out on paper in the Project 2025 manifesto from The Heritage Foundation. All of those who claimed that that would never happen conveniently forgot the first rule of dealing with authoritarians. Believe what they tell you the first time.

I don’t plan on turning these continuing essays into some sort of play by play of the second Trump administration as I really don’t have the background or connections in politics and political thought that I do in health care. I will address those policies which have bearing on health or elder / aging issues as I feel like I have some expertise in those areas. Believe me, I would rather write about my travels, amusing anecdotes, and the vagaries of pop culture but there are other things currently foremost in my mind. And I’ve also got a heck of a lot of writing to do on new editions of The Accidental Plague Diaries and side projects flowing from these. The goal is roughly 1500-2000 words a day over the next couple of months… if I can keep Edward the polter-cat from walking across my keyboard every few minutes. He’s currently curled up at my side and Binx is curled up at my feet, I’ll take it.

There are two of the recent flurry of executive orders that are causing significant issues in my little corner of the health world. The first is the one which places an absolute moratorium on federal hiring for ninety days (with no exceptions as of yet). The federal department for which I work is the Department of Veteran’s Affairs which includes the Veteran’s Health Administration which flows down through multiple layers of bureaucracy to the Birmingham VA Medical Center and to its Geriatrics and Extended Care service line of which the Home Based Primary Care program (VA house calls) is one. UAB has assigned a significant portion of my time to this program for the last dozen years or so. I enjoy it. It’s not difficult work for me but, because I do the rural areas outside of metro Birmingham, its very time consuming with lots of travel time involved. Because of a lack of physicians with my skill set, I cover about twice as many veterans as I should given the national guidelines regarding patient load. We were going to solve this problem with a nurse practitioner who actually lives in my northwest territory. The process to get her hired was arduous and took well over a year. She was due to get her final hire letter today. Her job offer was rescinded by the hiring freeze.

The VA health system has a fairly high turn over. Federal pay scales are usually lower than comparable community jobs. People can move upwards in the federal system relatively easily once initially hired. It needs to hire 40,000 people a year just to keep up with the natural attrition rate. The rapid departure of the workforce from clinical healthcare roles with the pandemic (about 20% of the national workforce in those positions left between 2020 and 2024) hit the VA as much as anyone else. This had led to an additional deficit. Federal hiring rules make the approval of new positions a bit of a chore. It’s not like you can stick a ‘Help Wanted’ sign in the window. On Monday, January 20th, there were about 8,000 new VA employees nationally who had been offered jobs but had not yet received final contracts. The hiring freeze has forced every one of those offers to be rescinded and it is unclear if any of these positions will be reopened for these candidates after the initial ninety days passes. In many cases, these are people who moved to new cities to begin new jobs, bought houses, uprooted families trusting to the good faith of the US government who have been left with nothing.

The VA is an integral part of the US medical training system. Many VAs have close affiliations with medical schools (as is the case between the Birmingham VA and UAB Heersink School of Medicine). The VA funds an enormous number of the training slots for interns, residents and fellows in medicine and in all sorts of allied health programs. They get the benefit of good trainees who will help with veteran health for relatively bargain prices. The academic year begins July 1 which means that now (January) is the time that people interview for these positions. The current hiring freeze, by not exempting health profession trainees (which has always been done in the past) means that there is no guarantee that there will be any support for these positions this next year. Residency programs are going to have to scramble and, if I were on the interview trail, I would certainly think twice about choosing any program with a significant VA component. The aging of the Vietnam Vet cohort is putting significant strains on VA health services and policies that prevent hiring, in a time when there are distinct shortages of qualified health providers, strikes me as, at the very least, counter productive.

Another executive order that was put into effect yesterday, interrupts the normal functions of the top federal health institutions including the National Institutes of Health, the Center for Disease Control, and the Food and Drug Administration. They are prohibited from communicating with the public. The routine gatherings to review research at NIH have been suspended. For the first time since 1961, the CDC will not be issuing its Morbidity and Mortality World Report (MMWR) which has long been the way in which our fractured public health system learns about troubling trends in health and the pieces can be put together to stop disease spread before it becomes worse. The administration has been close mouthed as to their reasoning behind these decisions but its fairly clear to me that particular political views regarding infectious disease, vaccination, and related topics are going to be injected into the scientific method. Science explains how our complicated world works. You can pass laws based in belief but that won’t change how it works and preventing scientific investigation just means you’d rather be in the dark – Plato’s cave analogy comes to mind. There may be very real economic consequences if the NIH is no longer able to fund in the way that it has. UAB is the state of Alabama’s largest employer. Something over 400 million of its revenue comes from NIH grants (it’s in the top 1% of institutions that receive grants). Significant reductions will lead to significant layoffs and brain drain – a state like Alabama won’t be able to make up for federal cuts. Wealthy states like California or Massachusetts can.

I don’t know where all this is going but I don’t like the road signs.

It’s the day after the inauguration. The parties are over. The champagne flutes put away. The streets are clear. And twenty six executive orders, twelve memoranda, and four proclamations were issued from the White House making it clear that the regime has changed. Some are performative. Some are clearly illegal. Some are unconstitutional (unless the Supreme Court decides to continue to throw stare decisis out with yesterday’s slops). The overall pattern appears to be to try and repudiate Biden era policies, promote somewhat fanciful ideas developed mainly as counternarratives to the conventional, and punish transgender individuals and immigrants simply for existing. Will this pace continue? Will there be more and more unwelcome announcements such as the pardoning of the violent felons among the January 6th rioters? Almost certainly.

Masha Gessen, the Russian-American journalist who has documented sociological trends in Russia for years under the rising Putin autocracy, understood the turning point that the first election of Mr. Trump represented and the parallels between what had happened in Russia and what was happening in the USA. Her essay, ‘Autocracy – Rules for Survival’ was published in November 2016 shortly after the election and I go back and reread it every year or so when the news feels particularly dire. It’s a reminder of what those of us who do not agree with the autocratic turn the country is taking, must do to maintain and not be seduced into complacency. If you haven’t read it, it’s easily available on line.

One of the more performative executive orders, the one placing a moratorium of ninety days on all federal hiring, is causing a major headache in my life. The federal hiring system is byzantine beyond belief and getting timely hires onboarded is a challenge. I have needed a nurse practitioner to help with my rural VA house calls for some time. Over a year ago, we identified the right candidate have gone under, over, and around multiple bureaucratic hurdles and her formal letter of offer was due to come out next week. Of course everything is now on moratorium. I am not happy. There may be some ways around the blockade regarding emergent patient care issues but the way forward has not yet become clear. Just one more thing that’s pushing me towards the exits as soon as is practical.

There has been one major change on the domestic front. Ghost cat Edward appears to have undergone a personality transplant of some sort. This past Friday evening, about 11 PM, he emerged from hiding, stalked into my bedroom, leapt on the bed, settled himself in my lad and began to immediately demand pets and snuggles. Ever since, he has become a pest, leaping on me when I’m trying to work, attacking my laptop while I’m typing, investigating my dinner plate. I’ve decided I had simply mischaracterized him. He’s not a ghost cat, he’s a poltergeist cat. Binx seems to be as puzzled as I at the rapid change in behavior and I have no idea what has triggered it. I’m thinking perhaps Edward has been observing Binx or that they have been communicating in whatever ways cats do and Edward has finally learned how to be a cat. He seems to be getting better at it. He’s figured out he needs to keep his claws sheathed when making demands unless he wants free flying lessons. It’s sort of funny watching the two cats together. Binx is relatively large and Edward is quite small, about five pounds, all black with gold eyes and seems to have stepped out of T. S. Eliot’s Mr. Mistoffeles poem.

The New Orleans comedy play reading I was part of this past weekend went quite well with relatively little rehearsal commitment. My part wasn’t difficult and I did figure out how to get most of my laughs. I had a number of very talented castmates and I found that the project was a bit of a master class in improving comic timing. I have a symphony concert in two weeks and then that completes the music/theater career for a while. It’s OK. I have to put a bunch of time and energy into writing. I’m working on a fifth anniversary edition of The Accidental Plague Diaries with commentary from present self back to past self plus trying to complete sections of the new book on Covid change, tentatively entitled The Fourth Horseman. With luck, the back will be broken on all of that by mid April.

The weather is weird. We are in the midst of a hard freeze but have had no snow, but there have been blizzard conditions several hundred miles south of us on the gulf beaches. Go figure. I don’t have any outdoor activity planned for the next few weeks so it can do what it wants out there.

Now is the winter of our viral crud made glorious summer by improving health. This last week has been a bit of a trial. I had last Thursday off and was feeling a bit tired so I went to bed early to wake up to an underwhelming inch and a half of snow on Friday morning. UAB took pity on us and decided we could do our clinical work for the day from home via telehealth. This may be the last time that this is possible. Medicare has been paying for video visits as if they are in person visits under emergency legislation which is set to expire in March unless renewed by congress. Given what I have seen of the new congress and the incoming administration, I doubt prompt attention to the nation’s laws is terribly high up on their list of priorities. It will remove a valuable tool and convenience for frail older people who need a check up but who have a difficult time getting in to the office. (And our house call program has about a nine month waiting list). Of course, I can still do video visits (and likely will as it will be the right thing to do in certain situations). It just means there will be no Medicare reimbursement and the bean counters that run health systems tend to take a very dim view of any activity that does not contribute to the health of the next quarter’s balance sheet.

I was still feeling fatigued so I walked out on the terrace on Friday morning, said something along the line of ‘yep – snow’ and went back inside to get my work done and take a nap. I had nothing specific planned over the weekend so I continued to sleep a lot as I just wasn’t feeling well. I couldn’t put my finger on it. Some body and joint aches but no real respiratory complaints, no fever, no sweats, vital signs all normal other than some mild tachycardia. I decided winter crud viral syndrome. It got worse on Monday and Tuesday. Still no specific symptoms other than fatigue increasing to exhaustion. Those were both fourteen hour days between work and rehearsal but I powered through as I am want to do. Wednesday was excruciating and I finished my work up around 4 PM and came home and fell into bed, too tired to read, write, pay attention to the TV, game, or even sleep. I finally did get to sleep about midnight and when I woke up this morning, success! That feeling that you’ve broken the back on something and your body systems are restoring themselves to normal. I am happy to say that I expect to be fully recovered by the end of the week (when I have to make a stage appearance on Sunday) but that I am continuing to curtail activities so I can sleep as much as possible. I have found that sleep does me much better than all of the various nostrums pushed upon the unwell by consumer culture (although I do have a bit of a fondness for the DayQuil/NyQuil combination).

I don’t know what it was. I was thinking, when I was feeling at my worst yesterday evening, that it was some sort of karmic retribution for my writings and that I had Long Covid without a preceding Covid infection. No. Probably some no name winter virus that my immune system really really didn’t like and which caused a major flare in my prostacyclins, prostaglandins, and interleukins. For anyone who was around me this week, don’t worry too much. The time I would have been infectious was when I was fatigued but not yet symptomatic – Friday, Saturday, and Sunday and I spent most of that time in the condo by myself. The cats might have some concern, but the community at large need not. Speaking of cats, Edward the ghost cat continues his tutelage under Binx in how to be a cat and is much more present, even willing to be in the same room as me for a few minutes. He’s also now vocalizing normally. He wouldn’t utter a sound when he first arrived. I’m taking this as progress.

My original plan for this past weekend was to do a bunch of writing on new book project. That didn’t happen. (Sorry, Steve). I have another long weekend this weekend with minimal things scheduled so maybe I’ll be able to hack out a few essays starting tomorrow now that I’m no longer feeling like I’ve been run over a London bus and dragged through Piccadilly Circus. The next one I’m launching into is on the failure of the health care system to provide even the most basic services to patients and how this relates to the changes wrought by the pandemic – covering such topics as why you can’t get a primary care physician, why when you need to see a doctor, you usually only get a nurse practitioner (nothing against them – I respect the ones I work with a whole lot), why it can take six months or more to get an urgent appointment with a specialist, why treatment plans are often delayed, and why you can’t get your usual medication in a timely fashion at an appropriate price. If anyone would like to chime in below with an anecdote, I’m all ears.

The fractures in the system are not going to get better in the near future. Given the philosophies of the individuals being nominated by the incoming administration to key positions, they will almost certainly get worse. The pandemic is a huge contributor (and one that was not foreseen – although given how the world operates, it should have been anticipated better). Demography is another enormous piece of the puzzle. And that one has been modeled and discussed for half a century without anyone in the US health system being willing to make the adaptations needed as it would bring no short term profits. Other pieces of our socio-political makeup are also involved. So what can we all do to cope with this?

Dr. Duxbury”s Rules for Thriving in a Collapsing Health Care System:

1. Choose your parents carefully. You are what your genes make you.

2. Remember all the things your mother taught you – eat right, go out and get your exercise, not too much TV

3. Don’t fall down. If your balance isn’t what it used to be, admit you’ve hit your patriarch/matriarch stage and get out your staff. Not only will it help you balance, you can use it to wallop those who annoy you.

4. Treat medications with respect. They are controlled doses of poison.

5. Don’t develop too many bad habits. You know what they are. On the other hand, complete abstinence from all of life’s pleasures is also probably not the best idea. Moderation.

6. Health care is a partnership between patient and provider. Find someone who will partner with you. You’re the one who lives in that body and you will always know it better than anyone else ever can.

7. The range of ‘normal’, especially as you get older, is huge. Don’t get fixated on numbers or on what you hear about the experiences of others.

8.More is often not better – not everything needs to be tested, scanned, measured and for gods sake, if one pill is good, four is never a good idea.

9. No one should be making decisions regarding your health other than yourself or your legal representative and your provider. No other decision maker belongs in that room. And don’t insert yourself in other’s decisions

10. Trust to sheer dumb luck.

Maybe I can shorten those down somewhat for another T-shirt… Maybe a ten commandments motif

Not even ten days into the new year and already it feels like the wheels are coming off of the bus. There was a brief reprieve today with the measured and elegiac state funeral for former president Jimmy Carter. President Biden granted all federal employees the day off today in remembrance of Mr. Carter and, as Thursday is one of my VA days, I got an unexpected day away from work. I spent it relaxing with some friends, a thing I don’t get to do all that often these days. Tomorrow, however, we will return to the president elect being sentenced for felonious conduct, the city of Los Angeles going up in smoke, Republican congress critters falling all over themselves as they try to prefile bills making the plans laid out in the Heritage Foundation’s Project 2025 a political reality, a terrible winter cold and flu season with the hints of a new pandemic on the horizon, and the promise of up to six inches of snow overnight in the greater Birmingham area. (I will still be expected to slide down the hill and into work – no patients will show up…)

The golden hills of California have burned regularly with wildfire for millennia. The entire ecosystem evolved around the rejuvenative properties of fire clearing away underbrush. Various conifer trees require the high heat of fire to burst open their cones so the new seeds can scatter. The hills will survive, with or without the sound of music or fire sirens. Up through the early 20th century, societies understood the power of nature and adapted dwelling and planning around the way in which the local eco system worked. (The 18th and 19th century neighborhoods in NOLA, for instance, were the ones that did not flood during Katrina). In the 20th century, with the rise of real estate as a major economic commodity, rather than just the creation of human habitation, all of that went out the window as developers threw up houses and other buildings anywhere and everywhere a buck could be made. Now, a century later, the bill is coming due with coastal erosion, sea level rise, stronger hurricanes, excessive rain events, and stronger winds that can whip up firestorms and mother nature, stressed by climate change, doesn’t really care where you built your house. She’s gonna do what she’s gonna do.

This is the third catastrophic California wildfire which has marched through an urban area and destroyed the lives of multiple friends and acquaintances. The other two were the Oakland Hills fire of 1991 and the Santa Rosa fire of 2017. I was a Californian for fourteen years so I have a lot of ties to the state. My life was in Northern California so I have no special love for Los Angeles (Steve did – he grew up in the San Fernando Valley) but I cannot help but grieve for the thousands upon thousands of little deaths of culture, of community, and familiarity that any disaster of this magnitude brings. The best book I read this past year was Stephen Markley’s The Deluge, a sprawling novel of near future United States history as the current economic, climatic, and political forces continue to play out unabated. One of the major set pieces of the novel is a massive wildfire, nicknamed ‘El Diablo’ that nearly destroys Los Angeles. The conditions that produce and progress of the fire in the book is being eerily replayed on the nightly news. Markley’s largely pessimistic novel is a painful read but as time moves on, it looks like he read the tea leaves correctly. I was so impressed with The Deluge that I read Markley’s earlier novel, Ohio, a few months ago. This one is an examination of the millennials of small town America as they enter middle age and the dreadful things that happen to them as America has not lived up to her promises for the younger generations. The audio book is very good.

The next few days should be rather interesting for political junkies. President elect Trump receives his sentence tomorrow for being found guilty of felony crimes involving the falsification of business records. Most people convicted of 34 felonies would be looking at some serious jail time but most aren’t as well connected or ten days away from walking again into the White House. I suspect Judge Merchan will end the whole affair with an admission of guilt and then a general discharge so that the whole thing can be swept under the rug. It won’t be long before the propagandists begin completely rewriting the story making Trump a hero-martyr. The way in which the propaganda machine is busy trying to turn January 6, 2021 into something other than what it was is truly a marvel to behold. I saw some piece where the pundit was describing it as a bunch of patriotic American grandmothers giving themselves a self guided tour of the Capitol. DO NOT let them gull you into disbelieving what you actually experienced. Following this, the Jack Smith report on the federal cases involving election interference and mishandling of classified documents are expected to be released as early as this coming Sunday. There are reporters all over the country salivating at what little nuggets of information might be contained therein. I’m sure we’ll hear all about it.

On a lighter note, I have a new theatrical project next week. It’s a readers theatre piece for Cahaba Theatre Group entitled Finding the Absent Crescent by Gina Pauratore. This means that we don’t have to learn our lines, but we still have to give a performance, even with the books in front of us. It has one glorious performance at 2:30 PM Sunday the 19th at the Clubhouse on Highland (a venue near and dear to my heart – we did a number of the later Politically Incorrect Cabarets there). The play is a Southern Fried Comedy with a Creole flair. Eccentric family, check. Funeral brings them together under high stress conditions, check. It’s not as mordant as the plays of Del Shores and not as sit com as the Hope Jones Wooten oeuvre which has replaced Neil Simon as the community theater comedy staple. It reminds me a bit of Dearly Departed which I directed for Bell Tower players a couple of years ago. I play a ghostly grandfather who bookends the show. Two weeks later, I have an Alabama Symphony Orchestra concert where the men are singing Schubert, the women, Debussy and everyone joins up for Borodin’s Polovtsian Dances (best known as the source material for the musical Kismet – Stranger in Paradise and He’s in Love are prominent in the piece we’re singing). And that’s it for a while. Something else will turn up, it always does. In the meantime, I have to buckle down to various writing assignments which will become my next book and a few other things. Fortunately, I write very quickly and do some of my best work under the pressure of deadline so something should have form by summer.

I just looked out my window. There is no snow and minimal clouds. So I opened my NOAA weather app (something that will cease to exist if Elon Musk has his way) and there’s a wall of snow just starting to cross the state line from Mississippi to Alabama. Things may be very different in the morning.

Dateline – London, England

It is midnight local time. I have three hours remaining before I have to start on the return journey. 3 AM is not my favorite time of day but when you have a 6 AM flight to Copenhagen prior to coming back across the pond, needs must. Especially when you have paid a tour company to deal with things like airport transfers so you don’t have to do so. Therefore, this is the last entry in the current travelogue. So far there are no solid travel plans for 2025 in the offing other than a quick jaunt to Seattle to check up on my now 92 year old father but I’m sure that will change based on whims, opportunities, and various geopolitical situations.

Today was a lovely sunny day, cold but clear. Perfect walking weather so Frank Thompson and I began the day with a long amble from the hotel in Fitzrovia to Knightsbridge for a pilgrimage to Harrods. Harrods is a lovely institution, bursting with luxury goods that us mere mortals cannot possibly afford and coiffed and manicured shop assistants that can tell I do not belong to the moneyed classes and am not about to drop $8,000 on an Armani suit for $350,000 on a golden piano shaped like a solar disc. Harrods exists for us ordinary folk to gawk at, for corporate expense accounts to order hampers, and for the world’s rich who have London residences to have their staff shop for them.

On the way, we passed Hyde Park barracks and the memorial plaque to my Great Great Uncle Matthew Fontaine Maury Meiklejohn who was killed on the spot in an act of heroism back in 1913. I’ve recounted that story before so if you want more details, you can check his Wikipedia Page. As he died some fifty years before I was born, I never met him. Just another oddball family connection of which I have many, as do most of you if you go digging around in your family history.

Next it was off to Southwark to see The Massive Tragedy of Madame Bovary, a hysterical farcical adaptation of Flaubert in which four very skilled comic actors send up 19th century fiction, mores, and everything else they can get their hands on. I haven’t laughed so hard in a theater in some time. I enjoy a good Theater of the Ridiculous presentation and this one reminded me a lot of Medea: The Musical that was a huge hit in the SF Bay Area in the 90s. (Sara James – it’s a perfect THEATRE DOWNTOWN show – I bought a copy of the script which you can peruse). This was followed by a walk up to the Thames near Tower Bridge for dinner at The Ivy (the one at Tower Bridge, not the one in Los Angeles for those of you who might be confused) where I had shepherd’s pie. I asked the waiter if I might have it peppered with actual shepherd on top. He looked confused. I don’t think Sondheim was his first language.

After dinner, next door to The Bridge Theatre for their stupendous production of Guys and Dolls. I had seen it before a year and a half ago when I was in London with Vickie Rozell and the ASO Chorus for our concert at Southward Cathedral and I was eager to revisit it. It’s closing soon (to be replaced by a revival of Richard II starring Jonathan Bailey – get those tickets now after the success of Wicked) so I’m glad I was in time to catch it once more before it goes off to theatrical heaven (it’s unlikely to be brought to the US for various logistical and financial reasons.) It really is one of the best productions of a classic American musical I have ever seen with the immersive staging in the round, the constantly moving levels of the set, the three hundred standees on the floor becoming part of the action as the crowds of Times Square. Even though I knew exactly what to expect, it made me cry tears of emotional joy a couple of times. Frank, Kathy McMullen, and Bill McMullen had not seen it before (in fact Kathy had never seen a production of Guys and Dolls before and didn’t even know the plot going in) and they were all thoroughly blown away. It definitely ended London theater week on a high note.

I’m not bothering to go to bed. I shall just watch TV or something until I have to drag my suitcase downstairs. There’s no point. I can sleep on the plane.