Now officially celebrating 31 days, one full month of bronchial inflammation! Everything has cleared up other than the occasional coughing fit which produces reactive airway wheeze and a feeling of impending status asthmaticus which resolves itself in a minute or two. I figure I have about a week to ten days to go until that finally subsides but as long as everything else is holding together, I’ll put up with it. I am most happy about the return of my singing voice which suddenly came back on Sunday evening after having been missing in action for over four weeks. I hadn’t realized how much I had missed it until some bass sonority started rolling out of me when I sang along to the radio. I don’t know just what nasty little virus this was, but I hope my immune system does its job going forward and keeps it from ever returning. It was heinous.

I took this past weekend off from usual pursuits. Instead, Patti Steelman and I road tripped it over to Atlanta on Friday afternoon for an overnight at the W hotel. After checking in and a visit to a not very good vegan restaurant at Ponce City Market (atmosphere 7, food 4) we headed off to the Cobb Energy Center to see Verdi’s Macbetto at the opera. (I’m going to cling to theatrical supersition here and not use the English version of the Scottish Play’s name). Patti is now a regular theater buddy but I doubt I shall ever get her to really appreciate opera. But she does tolerate it. And I gave her some homework so she had some background on Verdi and his approach to the material before we went. I had listened to this one before but had never seen a production so it was nice to tick it off of my life list.. Michael Mayes, Baritone played the title role. Many long years ago he sang the role of Valentin in a production of Faust for which I was in the chorus. He was handsome, supremely talented, affable, and an all around good ol’ boy – which befits someone who hails from Cut n Shoot Texas. Now he sings dramatic heavy roles in all of the great opera houses of the world (De Rocher in Dead Man Walking, Sweeney in Sweeney Todd, Alberich in The RIng Cycle etc.) I made journeys to Atlanta opera to see him in the first two roles. Haven’t had the courage to take on the full Ring Cycle yet. He and Tommy, in particular really got on well. They were both scions of the rural working class and saw the world in the same way. The opera was quite good. Atlanta has come way up in the world over the last few decades and is now a top ten company like Houston, Seattle, San Francisco, and Santa Fe.

On Saturday, Patti and I headed back to I-20 and continued east another three hours or so to Columbia, South Carolina where we met up with one of my favorite partners in crime, Frank Thompson. Patti and Frank had gotten to know each other on social media but had yet to meet in real life so we had a very pleasant long late lunch/early dinner, before we had cocktails (none for Frank before a show – there’s a very long story there involving a performance of Cabaret some years ago) and headed out to the small suburb of Chapin to see Chapin Theater Company’s production of Chicago, in which Frank was continuing his journey through all of the roles originated by Jerry Orbach by essaying Billy Flynn. It was done in a small black box space, making it all very in your face which served the material well and I ended up enjoying it immensely. Or was that the cocktails? More cocktails post show and then to bed to enjoy the time change before getting up for the long drive back.

I pretty much divorced myself from news and politics during my weekend away, but, when returned, I found that 1) measles continues to spread with the government drop shipping budesonide and vitamin A into the affected area rather than vaccinations. 2) tuberculosis is starting to surge in Africa with the collapse of surveillance and treatment programs that were run by USAID. 3) right wing thinkers are pushing the narrative that it is our manifest destiny to invade and occupy Canada. 4) the stock market is in free fall 5) the president is selling cars on the south lawn 6) that the rhetoric is being put in place to dismantle Social Security, Medicare, and Medicaid using a makers and takers dynamic in which only those who are productive and make society go truly deserve government benefits. The takers who depend on government largesse to survive are simply second class citizens whose needs and wants need not be considered. Honestly, I am seeing American society as an oversize Jenga game. The current administration keeps knocking blocks out and eventually the whole thing is going to collapse on all of our heads.

Anyone who can do simple math (and I don’t think this includes most politicians of either party) can understand that the government has been in deficit spending for decades. We can have long arguments about what this actually means but those who try to reduce it to some sort of upscaled kitchen table family budget are way oversimplifying things. If we wish to reduce the deficit spending, there are two choices: increase revenue or reduce expenditures. Increasing revenue (taxes) has been anathema to Republicans since Reagan and they remain slavishly devoted to the idea of supply side economics despite nearly fifty years of failing to do what they constantly promise. The administration is desperate to extend the tax cuts it passed for the wealthy in 2017 during Trump’s previous term. This will skyrocket deficit spending. The only way to offset this is to cut trillions from federal spending.

If you look at federal spending, there are only three areas in which trillions of dollars in savings can be achieved. The Department of Defense, Medicare/Medicaid, and Social Security. Elon and the Muskrats can take a wrecking ball to the entire federal bureaucracy, fire everyone and close every program and office and it will only reduce federal expenditures by about 4%. Everything that’s going on right now is pretty much waste fraud and abuse theater and has nothing to do with any sort of logical plan to save money. Cutting where the real money is is fraught with political difficulty. Elon’s public statements show that he is ready to ride in and pull down the temple but those who actually have to face voters for reelection don’t seem to be quite so sure.

Let’s look at the law of unintended consequences as applied to Medicaid, the most vulnerable of these buckets of money as it is for ‘the poors’ and therefore must be going to the undeserving poor and meet the rather malleable definition of waste fraud and abuse that’s currently being bandied about. As I mentioned in a previous essay, Medicaid is the public funding mechanism by which we provide custodial care (nursing home placement) to those who have become unable to care for themselves due to age, infirmity, or bad luck. Somewhere around half the dollars in the long term care industry originate in the program and it is one of the most expensive line items in the general funds of many states. Why? More older people who are living longer. And for the most part, the Baby Boom hasn’t yet aged into their custodial care years so these expenditures are going to increase mightily over the next couple of decades, and then come back down as the Boom enters its die off in the later 2030s and 2040s.

Let us say we take an axe to Medicaid and that pot of money with which we have been paying to maintain this population shrinks while the population itself is increasing. A number of nursing homes, most of which are corporate owned under venture capital firms, will simply close as unprofitable, causing huge strains on the ones that remain. If the federal government is not providing dollars anymore, what is the state to do? I suppose it can abandon frail elderly people on railroad sidings and downtown parks but that doesn’t look good on the nightly news. It will look for alternate revenue sources. Thirty of the fifty states (Alabama is not one of them) have what are called filial duty laws. These are laws that state that if a parent is aged or infirm, it is the legal obligation of the children to provide for their parents needs and that the state can use the legal system to enforce this duty. This means that the state can seize assets, garnish wages, sell off property of the children to meet the nursing home bills of the parents which are no longer being covered by federal Medicaid dollars. The public hasn’t figured this one out yet but when the state takes your kid’s college fund to pay for your mother’s dementia care, you might have certain visceral reactions to that.

I have no idea how this is all going to work out. There are now calls from both sides of the aisle to leave Medicaid, Medicare and Social Security sacrosanct. Fine. But if they do, those extended tax cuts for the wealthy are going to skyrocket the debt making all of the chaos that’s currently being sown moot. I’m not a politician. I’m not an economist. I’m just a professor of geriatric medicine pointing out that when you make changes in complex systems, there are ripple effects and the more complex the system, the more titanic those effects may end up being.

Here endeth the rant. Gotta write some patient progress notes.

Day twenty-six. Down to just an occasional coughing fit reminiscent of a bronchial orangutan. With luck I’ll be through it all by the end of the weekend and can start afresh this next week. In the meantime, I’m still trying to get plenty of sleep and not over extend myself. I’m not doing a lot outside of work other than writing – on those evenings when I don’t feel too draggy. Writing these missives, movie reviews, work progress notes, and stuff my publisher wants keeps my brain active but at times I can only do so much before I stare blankly at the screen without anything more to say. I look at the prodigious and well reasoned output of someone like Heather Cox Richardson and I wonder how she can possibly do it. Maybe if I was a trained historian with an encyclopedic knowledge of US history – which I am not.

In terms of the areas in which I do have training and expertise, not much has changed this week. Measles continues to spread. Covid and flu numbers remain high (but down from what they were earlier this winter). The bird flu continues to lay waste to factory farming – don’t expect the price of eggs to come down in the near future. It’s difficult to tell what’s happening on the international front given the severing of ties between the US and WHO and the muzzling of CDC but there are rumors of a new respiratory virus in China and a filovirus in Africa. Who knows if either of these will get out and start wreaking havoc.

In politics, POTUS used his bully pulpit to hurl personal invective, insults, and both misinformation and disinformation to a joint session of congress. But that’s neither new or surprising. The Secretary of the VA announced that he will cut the VA’s workforce by 83,000 jobs (about 20% of the total). What that will mean for services or for what I do within the VA who knows? I assume they’ll simply remove the house call program wholesale nationally as being inefficient. It’s been a dream of the right wing to privatize VA services and monetize them for corporate profit for decades so that’s likely the short term set of moves. Veterans around here tend to skew pro-Republican and may be a bit surprised to find their benefits curtailed as time goes on.

I hear about various other things in my readings and internet wanderings but I can’t always tell what is true and what is hyperbolic rumor. Both left and right are so busy lobbing verbal grenades and propagandistic memes at each other that it isn’t always possible to decipher what is actually going on and I try my best to stay relatively objective when it comes to politics and to comment on policy and not on personality. While I’m on the blue team, I don’t think that means all red team ideas are automatically wrong or backwards and that all blue team ideas are delivered from the gods on stone tablets. It’s much more nuanced than that. I’m a firm believer in shades of gray.

Much of the current dysfunction can be traced back thirty or forty years to the ascendancy of the Baby Boom (then known as the Yuppies) who gravitated to centers of power in coastal cities and began to discount anyone who did not do the same or share their values – flyover country. As the center of the country, both geographically and economically, hollowed out through policies aimed to bolster the more monied classes, those left behind, became more and more desperate for a voice. The modern Republican party, especially Trump, gave them that but has done so mainly by funneling impulses into destruction and hardening of partisan lines, rather than in compromise, dialogue and cooperation, traits necessary for functional society.

The left also refuses to unify, generally splintering itself over purity tests of one kind or another which diminishes their power or ability to accomplish things on a national scale. The ostracism of Al Franken over a poor taste joke was a huge strategic blunder. The inability to understand the history of the Palestinian conflict. I read a news article about the cancellation of a student production of Stephen Sondheim’s Assassins at Northwestern last week. I assumed it was due to right wing complaints of the glorification of presidential assassins and the message this could send about the current administration. No, it was due to left wing complaints about the use of the N word in a song lyric, placed their deliberately due to historical conflict and to make the audience feel uncomfortable. If we on the left cannot accept the more uncomfortable parts of our past, how can we accept those on the right to honor such ideals?

What’s someone of the center left to do? I work to educate younger LGBTQ people about the realities of the experiences of my generation so that they don’t have to go through the same things. I try to stay informed, while using my brains to try and stay out of the weeds of propaganda. I use my talents to create things that can help people see problems – in healthcare, in society, in aging – in new ways. I don’t have the answers to most of what’s facing us but somebody out there does. Maybe I can be a spark to help light a fire.

At last, after three weeks of hell, I have turned the corner and am on the mend. I still have the occasional chest death rattle and cough like a kudu with pertussis but it’s only about once every ninety minutes or so and I didn’t wake up once last night. I’m still feeling a bit tired and under the weather but I’m hoping it all clears up over the weekend and I can meet next week with full gusto. Fortunately, next week is a light one as both of my full VA days are devoted to classes that I don’t really need, especially the one about defending myself against attackers armed with fresh fruit, or is it pointed sticks?

The world continues to go to hell in the proverbial handbasket, at least here in the USA. I could not bring myself to watch the attempted mob shakedown of Zelenskyy in the oval office, reading about it was bad enough. The right wing was busy chortling about Trump’s masterful diplomatic skills. My take was a couple of thugs who had a petulant temper tantrum when they didn’t get what they wanted. But it might all have been Trump’s understanding of the presidency as some sort of reality TV show where he performs for the cameras and I’m sure he felt it all made for exciting television. Governance brought to you by Real Housewives…

So now that the executive branch is all in for Russia (with the Republicans in congress acting as a cheerleading squad from the sidelines – just don’t let Mitch or Lindsay form the top of the pyramid), I’ll have to assume that our traditional alliances are pretty much on life support. If I were the EU I would not only offer immediate admission to the Ukraine, but I’d throw in Canada and Mexico as well, walling us off in a major time out until our toddler tantrums are done. I am putting off making my major travel plans for the year as I can see the diplomatic wars escalating over the next few months and a US passport may not be as welcome as it was a few months ago. If nothing else, I expect I’ll be socked with some very expensive visas going forward.

It is definitely time to revive Politically Incorrect Cabaret. I’ve got a venue that’s willing to host it going forward and I am in possession of the company’s few assets. I just feel that I’m the wrong age. My generation is on their way out. Dealing with this political moment and the aftermath is going to be a task for the millennials and gen z. So come on, one of you theater kids out there in the greater Birmingham area has to have an interest in Weimar Berlin style cabaret forms, street theater, political satire, and holding that mirror up to society. People assume that PIC is/was an anti-Republican thing. It’s not. It’s a way of using theater to expose the problems in the power structure, no matter which party may be in charge. (Heck, we did a whole show lampooning the Democrats a few years ago). And we never did a number or a sketch about Trump. If you think you and your friends are the right people to pick up the torch, let me know. And now a chorus of Do You Hear the People Sing?

For the first time ever, a state has eliminated previously granted civil rights. The legislature of the state of Iowa passed a law to remove gender identity from the list of innate human characteristics that is protected by anti-discrimination law. So if you live in Dubuque, you are now free to refuse to hire, provide services to, or rent to Caitlin Jenner. The vitriol and cruelty being unleashed against transgender Americans by current political forces reminds me a good deal of the sort of behaviors that led to public lynchings and I won’t be surprised if they start to occur. They’re a tiny minority with zip political power and we’re starting to see denial of state documents such as passports due to ‘incorrect’ gender markers, organized campaigns against their participation in public life and there are moves afoot to force medical detransitioning which would be exceptionally cruel. This was, of course, all begun ‘because of the children’ but the proscriptions are rapidly moving out of pediatric medical treatment to all medical treatment of gender dysphoria. And so many of the proposed laws are so vague and broad that all sorts of things will be caught up in them. No stage depictions of a character in gender inappropriate clothing would get rid of most of the Shakespeare comedies and even Charley’s Aunt, delighting audiences since 1892. (When you’re looking at banning things the Victorian’s didn’t have a problem with, maybe you’re the problem…) Heck, even Les Miserables would be out as Eponine dresses as a boy in order to cross the barricade.

Then there’s the medical front. The Texas measles outbreak continues to mushroom. At least one ill person, of course, got on an airplane so there should be additional pockets of infecton popping up shortly. There has not been one word out of the usually loquacious governor and attorney general of Texas regarding this particular issue. Word has come down from on high that staff at the CDC are prohibited from collaborating, coauthoring papers or doing any other professional work with anyone at WHO. Preventing the sharing of scientific knowledge has never been a winning strategy for any society ever so I’m not sure what the powers that be think they’re going to gain from this decision. And, the destruction of USAID has taken out the TB control programs which prevent its spread. The program not only protected the US, it was also the backbone of the global harm reduction program. We can hope the EU will step into the gap but there’s no guarantees. I wonder what global corporation is investing in new TB sanitariums?

There are other disasters in the offing. We’re two weeks from defaulting on the national debt with a congress that’s completely out of control and which has abdicated a number of its constitutionally mandated duties. Elon and the muskrats took a chainsaw to NOAA and the National Weather Service. Sure, there are private weather forecasting services, but where do you think they get the data that goes into their models. Be prepared for far less accurate warnings of tornadoes, hurricanes, tsunamis and the like. Twenty-six months to go until I can hide under a rock, if I can make it that long. In the meantime, I have to get back to my other writing projects now that I have a bit more stamina.

I am now on day eighteen of the cold virus from hell. While the snot factory has reduced production somewhat over the last few days, it hasn’t quite gotten to the point of going out of business sale and I am still blowing my nose and hawking up pieces of lung far more frequently than is comfortable. I don’t feel that bad. Just a bit tired. I’m just really really over feeling under the weather. It will be three weeks on Sunday and that’s about two weeks too long. I keep hoping each morning when I open my eyes that I’ll check out my body and I’ll feel that finally this is the day that I’ve turned the corner. No such luck so far. Hope springs eternal.

Not much happened on the rest of my brief visit to Seattle. I spent most of my time visiting with family, writing, and watching bad TV. Not much of import happened other than my sister producing a very good family dinner of linguini with clams at her house on Sunday night. Would have been better with a good glass of wine but I’m avoiding alcohol at the moment other than the medicinal amounts in NyQuil so as not to exacerbate anything. Monday was devoted to the return trip and, for the first time in five years, Sea-Tac airport was not a complete zoo when I stepped off the light rail to check in for my flight back to the southland. Bag drop and security lines were both properly staffed and functioned as designed. I was gobsmacked.

Fortunately both this week and next week are relatively light weeks at work so I should get in enough rest time outside of work to shake this puppy for once and for all. And once I do, I plan on nailing this particular virus in a lead coffin and tossing it overboard several miles offshore in the Gulf of (insert your preferred geographical term here) as I never want to see it again. It should also give me the time to tackle the next major domestic chore – the taxes. And I’m still trying to catch up on the writing assignments due to my publisher. I have clawed my way forward on some, but I’m still a few weeks behind on the schedule as it exists in my head.

So what’s going on in the world? The House of Representatives passed a resolution to allow a ‘Big Beautiful Budget Bill’ which will be stuffed with tax cuts for those with more money than they can possibly spend and draconian cuts to those with the least. I wrote a bit about what the proposed Medicaid cuts will do if made law last time I wrote one of these essays. None of that is off the table as only one Republican, Thomas Massie, found the spine to stand up and say that this sort of gutting of services is wrong and not who we are. It’s not law yet. It will have to pass the house still as a budget, requiring the Republican party to go on record as specifically voting to take a meat cleaver to Medicaid (and a lot of their constituents are going to be shocked when they find out that’s what pays for their kids and mom in the nursing home and very little of it is going to fictitious Cadillac driving welfare queens in some far off big city). One can hope that the Senate will hold the line some but I’m not sure about anything these days when it comes to members off congress which makes me wonder what hold to the powers that be have on them (and what sort of data have Elon and the muskrats been vacuuming out of various archives that they don’t wish to have publicized).

I’ve always loved Charles Dickens’ A Christmas Carol and find Ebenezer Scrooge a fascinating character. When we first meet him, he’s a miser, a misanthrope and a thoroughly odious human being whom we later learn through the visits of the ghosts was not always that way, but was self created due to fear, generational trauma, and bad choices. At the end, he is the same person, only returned to who and what he should have been had he made different choices earlier in life and if he had not been as badly scarred as he was by others. I got to play him once in a production that used most of the original Dickensian language. It was interesting figuring out all of those psychological underpinnings. The story is a cultural touchstone as we identify with the redemptive arc. If Scrooge remained the man we first meet, no one would have read the piece after about 1845,

The current Republican party is perfectly embodying Scrooge in his counting house on Christmas Eve. It’s mistreating the workers of the nation, begrudging them every little pleasure, feeling that they are not worth the pittance they are being paid. It has no interest in supporting a more charitable view of the world when it comes calling looking for a donation. In it’s withholding of social services and health care, it is fulfilling Scrooge’s axiom ‘If they would rather die, they had better do it and decrease the surplus population’. Unfortunately, I don’t see the ghosts of Teddy Roosevelt, FDR, and Lyndon Johnson visiting the leadership in the depths of the night to give them moral clarity. It’s going to take things causing pain to the professional and upper classes before there’s likely to be much shift. Or a complete blowout in the 2026 midterms.

On the public health front, there are a few things of note. The measles outbreak in West Texas continues to grow with the first child now dead. (The first measles death in the US in ten years). More are likely to die. A number of people have asked if they should get a MMR booster. If you have had the disease or the two shot MMR booster, you carry life long immunity and you should not need to do anything. There is one caveat: if your two MMR shots were between 1957 and 1968 (when they reformulated the vaccine), there is a chance that your immunity may be low and a booster might be advisable. (I had a booster in the 1990s when I was in an area of an outbreak so I know I’m OK). A number of people are asking me if they should bring their vaccinations up to date given the new administration. I have no idea what will happen to vaccine availability going forward so it’s not a bad idea. Ask your doctor. I’m caught up with everything other than RSV so I’ll go get that sometime after I stop coughing up my bronchial tree.

The H5N1 bird flu continues to be of concern. It continues to spread through poultry flocks and dairy herds (don’t expect the price of eggs to come down in the near future). There are some strains in Wyoming that are showing mutations that will make it easier to spread in humans increasing the likelihood of pandemic spread at some point. We’re not there yet and there’s no reason to panic. There’s just two things to keep in mind. First, H5N1 has a mortality rate in humans of up to 50%. (Coin flip whether you live or die if you get it). If that sort of mortality were to happen in healthy working populations, we could no longer function as a society. Second, the current administration is busy destroying all of the tools we would need in order to identify and contain a rapidly spreading virus before it becomes pandemic. In a lot of ways, we’re in a worse position now than we were five years ago when Covid began to spread.

As I start to read some of the reasoning behind MAHA (Make America Healthy Again), it reads very similar to the social hygiene/eugenics movements of the last century, the attempt to prevent lesser humans (however you want to define that) from reproducing and taking from societal resources. The belief is that those resources should be reserved solely for the industrious and the deserving. I can see a wish for a doomsday pandemic to sweep through and clear out ‘the dead wood’ so that the healthy trees can flourish in the aftermath. It’s a dangerous philosophy with so many slippery slopes that I really don’t feel like going into it at the moment. All I can do is implore those of you with differing political opinions to please think carefully about what you are supporting and where it leads. There are many, many exemplars through history and not one of them ends well.

In the meantime, I filed my five bullet points, haven’t received a termination notice, and I’m going to continue to provide the best care I can to a population that’s frail and vulnerable and just as deserving of the fruits of society as any other.

Dateline – Seattle, Washington

Today was an uneventful travel day. I had to get up at a god forsaken hour for an early morning flight but every line, transfer, flight, and piece of public transportation functioned as designed and I was deposited at my father’s place after some eleven hours of totally benign travel. This is just as well as I am on day thirteen of the current viral infection. It is slowly improving. I don’t feel all that bad, just tired. The noise my bronchial tree is making is changing somewhat. It has morphed from seal with croup to walrus with diphtheria. I’m not sure if it’s much of an improvement. As I have to speak in the morning, I’m taking large quantities of Mucinex and cough suppressant. At least the laryngitis is better and I have a voice today when I did not yesterday or the day before. Fortunately, I will have a microphone and I won’t be asked to sing any of my answers to questions in geriatric medicine.

Paterfamilias looks fairly robust for 92 years of age and I am detecting nothing of serious concern as I cast my jaundiced eye over his form and function. I can breathe easier for the next six months or so. Haven’t seen anyone else in the family yet. They all know where I am and how long I’ll be here and I assume they’ll pop up when they can. Can’t say much about Seattle. It’s raining and rather dreary, which is pretty typical for February. I’m not planning on doing a lot of running around this weekend, just keeping family company and working on some writing.

As I was listening to the dinner conversations of the other silent generation residents of my father’s senior community, the big topic were the latest moves of the current administration, and their feelings of helplessness regarding the negative effects coming for society. These are people with living memories of the Depression and World War II who know what bad is and they all sense bad returning like we have not seen since those times. The Boom and younger generations have no real living memories of serious societal turmoil (with the possible exception of a few years in the late sixties) so they are still not completely understanding where all this can lead. If I have one piece of advice for today, listen to your oldest family members and have them tell you how and where they are drawing parallels.

When I started to comment on our political moment last month with the change of administration, I plainly stated that I am not and cannot write the kind of pieces I wrote during the pandemic as I don’t know the world of politics and socio-economics as well as I know the world of medicine and public health. I’m trying to stay within the borders of subjects I know something about and not be another deranged keyboard warrior opining on things of which I know little. I strongly recommend reading Heather Cox Richardson for a good regular placement of modern politics in historical context. But, there are things I do know a bit about in regards to health, medicine, senior care, and their ilk so I will try to stay in my lane.

In choosing what to right about today, I had a lot of options – Elon and the muskrats continued stomping through the bureaucracy without seeming rhyme or reason which seems to have led to the firing of park rangers, those who manage the nuclear arsenal, and a rather large number of recent veterans as the Biden administration had prioritized the hiring of veterans into federal positions so a large percentage of those still in their probationary period are of this type. The continued fallout on academic health centers of the lowering of indirect costs. (I will have to correct myself here – I had calculated that the hole blown in the UAB budget was $75 million a year. I was wrong, it’s only $70 million). The continued destruction of the post war European order. The annual freak show at CPAC. But I’ve decided to discuss Medicaid and how the dominoes are likely to fall if the proposed budget which calls for up to $880 billion dollars in cuts to Medicaid. I’m not exactly sure how this is supposed to work given that the 2024 federal contribution to Medicaid was about $620 billion dollars. I assume it’s some sort of multi-year reduction but the actual numbers are still quite nebulous.

What is Medicaid and why is it first up on the chopping block? As I alluded to in my last essay, the big money in federal expenditures is in health, defense, and social security. Medicaid is likely the most politically palatable to dismember because, as he says in his best Anna Delvy, it’s for the poors. Medicaid cuts are unlikely to affect the major donors to political campaigns or their nearest and dearest. When the US, through historical accident, created an employment based health care system post World War II, it led to some significant populations being excluded, the post employed and the unemployable. Twenty years later, congress passed Lyndon Johnson’s great society programs including Medicare (giving the post employed access to health care for treatment of their acute illnesses) and Medicaid (giving children, the impoverished, and the chronically ill – all poor populations) – access to health care for both acute and chronic issues.

Medicare was created as solely a federal program. It’s morphed a lot over sixty years but in its pure form, it was designed to be federally funded (with contributions from individual beneficiaries) and the same nation wide. Medicaid was not. It was created as a joint federal state program with both state and federal dollars flowing into it. It is therefore different in every state in terms of its benefits and ability to qualify and range of programs that it covers. Wealthy states such as California and New York have many more options under Medicaid that a poor state such as Alabama. The creation of Obamacare in 2010 led to an expansion of Medicaid eligibility under federal law to create a mechanism and funding to better cover the working uninsured. Politics of the time kept it from being a mandate and every state was free to participate as they saw fit. Most did. Some poorer Republican dominated states such as Alabama did not and their programs remain similar to what they were in the last century.

Medicaid is about 9% of the federal budget and about 19% of total health spending. About 27% of the population is a Medicaid beneficiary. Massive cuts would likely start with rolling back of the Obamacare expansions which allowed people of low, but not poverty level incomes to participate, removing millions of the working class and their families from access to health insurance. Some may be able to return to employer sponsored insurance (but it’s becoming more and more unaffordable). Others might be able to find a plan on the exchanges assuming they aren’t blown up. A lot will return to the ranks of the uninsured.

Medicaid and the related Children’s Health Insurance Program (CHIP) covers 60% of American children. If large numbers of children are removed from coverage and easy access to health care, there will be more sick children. As healthy adults come from healthy children, the disease burden on the population as a whole will rise. More children will die of preventable causes. Life expectancy will fall. We already have the highest child and maternal mortality rates in the developed world (in some parts of the US, worse than sub-Saharan Africa) and are life expectancy is significantly lower than Europe. Life expectancy is currently about 78. In 1900 it was 47. I doubt it will drop that low again but we could quite easily dip back into the low 70s are high 60s where we were when Medicare and Medicaid came into being.

Medicaid is the largest payor of long term care services. Medicare, as it is designed to get people over an acute illness, does not cover long term care or nursing home stays, other than in limited form as part of a recovery plan. Roughly six of every ten dollars going to long term care facilities in this country is from either federal or state Medicaid funding. It’s one of the biggest expenditures to state discretionary spending. In most states somewhere between 20-25% of discretionary spending flows to Medicaid long term care and total Medicaid is 35-40% of discretionary spending. The demographic changes of the aging boom have led health economists to predict roughly a 70% increase in these dollar figures over the next decade. The math isn’t mathing very well.

So we slash the beneficiaries or the reimbursements to make the math math again. I mentioned sicker children and populations above. What about long term care? The pandemic has done a number of nursing homes and other long term care institutions in this country. They can’t find good trained staff willing to accept low salaries and grueling jobs. Many have been bought up by corporate interests as profit centers and, if they cease to bring in profits, will be closed or downsized. If your plan for a carefree retirement is placing mom in a senior community and have someone else look out for her, you might need to rethink that as there simply may not be places extant to provide such care. This means taking in ones elders, a difficult task in a culture which prizes the nuclear family over the extended family model, and likely removal of adults from the paid work force to stay home and look after granny and keep her from falling or running over the neighbor’s mailbox with the car again.

The most chilling thing I have been seeing as I look through thought pieces from those who approve of the current administration’s policies is the rise of rhetoric discussing those not capable of contributing to the economic success of the country through paid work.. Words such as parasitical and takers appear constantly. I find this disturbing. The holocaust did not begin with the gas chambers of Auschwitz-Birkenau. It began with the decision of the German state to humanely remove the chronically ill, the mentally and physically infirm, those with birth defects, those who required significant assistance in maintaining their own bodies, all done in the name of economic necessity and humanitarian goals. Will be start down that path? I don’t know but if we do, I will not be part of it.

And this month’s viral crud remains the gift that keeps on giving. I thought I was over it on Saturday, but it came roaring back on Sunday evening, this time settling in my lungs, bringing a cough that makes me sound like a seal with the croup, and grossly interrupting my ability to sleep as enormous quantities of phlegm have been coming up the last few nights. It seems to have quieted a little tonight and I hope it’s under control by Friday when I have to get on a plane and head for Seattle. Traveling when under the weather is no fun. I have just swallowed a large dose of NyQuil and I hope it begins to work its magic over the next hour or so. If this essay degenerates into something along the lines of hhhrjjfhriet, it’s either Edward the polter-cat walking across the keyboard or it’s my brain sinking into a world of soporifics and antitussives.

There’s been so much yelling and screaming about the budget across social media in recent days, so I decided to do some looking at the budget for the most recently completed year 10/23-9/24 to see if I could find some real numbers. Total expenditures for the year were $6.1 trillion dollars. They fall into a couple of basic buckets: social security payments ($1.3 trillion). Medicare payments ($839 billion). Defense spending ($805 billion). Interest on the national debt ($659 billion). Federal contributions to Medicaid payments ($616 billion). Income security (SNAP, SSI, Unemployment etc) ($448 billion). Veteran affairs ($301 billion). Other mandatory spending ($217 billion) and other discretionary spending (pretty much everything we regard the federal government as doing ($917 billion). Elon and the muskrats are pretty much only galumphing through this last category but it only accounts for about 15% of total outlays so pretty much everything they’re up to is ‘fraud theater’ and will make minimal impact on federal spending. We could fire every single person who receives a federal paycheck and we would save maybe 25 billion, the size of the civilian payroll, which is about 4% of the total budget. It’s not where the big money is. The size of the federal bureaucracy is actually somewhat smaller than it was forty or fifty years ago and that’s with a significant increase in population.

The only way to really reduce expenditures is going to be slashing social security, health programs (Medicare/Medicaid/Veteran’s Affairs) , and Department of Defense. Social security is the biggest bucket. Much is being made of millions of improper payments being made (although most of the evidence for this seems to come from the muskrats inability to read federal spreadsheets). There are not 20 million centenarians currently receiving social security benefits, but something under 10,000 which is in line with current census statistics. Cutting existing benefits will be met by howls of outrage from all quarters. They can attempt to cut future benefits by raising the age at which people can collect. Or they can reduce the size of the population which can collect by ensuring that life expectancy declines.

This may be the ultimate playbook here. Life expectancy isn’t particularly great in the US these days, especially as compared to other advanced countries (It’s about 78 where most of Europe is over 82). But it’s not an even distribution. Some subpopulations live much shorter lives than others. Our current elders, mainly the silent generation born during the time of the Depression and World War II, are blowing actuarial tables out of the water. There’s a lot of thought that this is due to what is known as the semi-starved rat phenomenon. It was originally described in rats but has been observed in all sorts of species since. If you calorie restrict the young, you extend life span (likely due to the creation of efficiencies of metabolism). As a generation, they were unable to glut as children and that has led to many of them living healthy lives into their late 80s and 90s. Younger generations aren’t likely to get that kick. The longer the life, the more social security payments. Therefore, choosing policies that prevent people from living healthy into their later decades leads to improved financial balances. The war on smoking, for instance, which took the percentage of adult smokers from about 65% to 15% over the last sixty years has created a much larger elder population leading to increased costs to social security and health programs.

So are we trying to create a two tiered society, a sort of split between the gentry who are given access to health care and long life and the mob who will be accorded a Hobbesian existence – nasty, brutish and short? I wouldn’t put that past the minds that are conceiving of some of our current excesses. Our current health care industry mess, which consumes 18% of our GDP, with the major funder being the federal government, is a beast. No other country spends more than 11% of GDP and the majority get better results than we do and do it without significant costs to their citizenry. We have a problem. The biggest issue is our inability to come to grips with the difference between acute and chronic disease. When Medicare was put in place, sixty years ago (at a cost of $2 billion – about $12 billion in current dollars), it was designed to allow the post employed access to health care for their acute health needs – infectious disease, injuries and the like. There was no particular thought as to the management of chronic disease. People died of these issues and did not survive to develop and require long term treatment and repeat hospitalization for such issues as congestive heart disease, chronic kidney disease, diabetes, and chronic obstructive pulmonary disease.

We now have the abilities to keep a significant population alive with long term expensive treatments. This is not only the elder population but also children born with significant special needs, people with major genetic anomalies, and people with sheer bad luck who become majorly disabled due to misadventure. The prevalence of significant disability in the population has increased over the last sixty years from about 2% to 13% and supporting that population costs a lot of money in terms of medical care, housing, and other maintenance. I’m not advocating any particular policies here, just pointing out what is. If we take Alabama as an exemplar, last years general fund spending was roughly 14 billion. One dollar in seven went to Medicaid long term care spending. This is not atypical for most states where somewhere between 12 and 18% of state discretionary funds are spent on long term care. And, in general federal matching funds are four times what the state spends.

If we are willing to blow up our health care industry and replace it with a true not for profit health care system, we could go a long way towards getting rid of budget deficits for the next century or so. It won’t happen. Far too many of our oligarchs are getting way too wealthy off of the system as is and they have no interest in disturbing their profit centers. We will, therefore continue to have an unwieldy, under performing system that will aggravate everyone who either works within it or tries to use it. No one is happy. Our new secretary of HHS has a couple of good ideas (removing direct to consumer prescription drug advertising, really looking at the nutritional content of manufactured foods) and a whole lot of bad ones. (Work camps for children and adolescents with mental health issues, trashing of vaccine therapy). I just hope that we aren’t going to enter a time of culling of the population by refusing to be kind to our friends and neighbors, allowing them the tools they need to live.

A big thank you to all of you who have checked in on me and my health. I am happy to report that all systems seem to have been restored to original factory settings and that I am at usual baseline, other than feeling a bit tired and washed out. I’m hoping that will resolve over the course of the weekend (I have nothing more strenuous scheduled than plunking down in a theatre seat). The polter-cat appears to be upset about my going back to work yesterday. While I was home sick, he used the litter box faithfully; yesterday, he peed on the bedroom rug while I was at work. We’re going to have to have a serious talk about his toilet habits and how they are not the best way to call attention to himself.

I figure it’s time for an update on the world of viral disease. I’m busy writing commentary on my original pandemic essays from the vantage point of five years later and it’s interesting to revisit those times in depth. How all that is going to be released to the world is still being worked on but in the meantime, I trudge through my world of five years ago recalling events, emotional states, predictions and plans, and try to make coherent self of past self with present self. It’s not as easy as you might think as that whole period has a sort of unreality attached to it given all of the wrenching changes that happened faster than any of us were able to process them. We’re about three weeks away from the fifth anniversary of the beginning of the shut down. Sometimes it feels like last year. Sometimes it feels like last century.

In terms of current impacts of viral disease, I (and many others) are living proof that this is the worst cold and flu season in about fifteen years. Doctors offices, urgent cares and emergency departments are flooded. I can’t feel good statistics regarding morbidity and mortality of influenza, covid, RSV, human metapneumovirus, and the other critters making the rounds as the current administration has taken an axe to the reporting systems. The anecdotal evidence being gossiped about on backlines by health professionals is that it’s not good. If you are at serious risk from respiratory illness, I’d consider staying home as much as possible the next few weeks and for goodness sakes keep your hands washed. The utility of masking is debatable as it is currently not universal but it never hurts.

H5N1 bird flu continues to rip through poultry flocks requiring significant culling (and a major shortage of eggs) and also through dairy herds. There was a news report of dead bald eagles just north of us which was likely due to spread in the wild. It does not appear to have made significant inroads into humans yet and there’s still no solid evidence of human to human transmission but, once again, the reporting systems are down and if it does begin to spread in the population, it may take some time for anyone to realize it. At that point, it’s likely to be game over in terms of early containment. Given it’s high mortality rate, that’s one you really will want to mask up and stay home for, no matter what the federal government may say.

Elon and the muskrats continue to show that they haven’t a clue what they’re actually doing. On Thursday, they fired the entire contingent of federal employees responsible for the US nuclear stockpile until someone pointed out what a disaster that could become so they rapidly tried to undo it on Friday. Over at the Justice Department, they’re apparently playing Squid Games with the prosecutors until someone is left standing who is willing to violate both ethics and law to get the results they want in dealing with the corruption of NYC mayor Eric Adams. Meanwhile various Trumpanzees are trying to impeach any judge who won’t give a pass to the various illegal and unconstitutional executive orders that keep flowing off the Resolute Desk. Transgendered people are being erased both as persons and from history when the T and the Q were removed from Stonewall National Monument in the West Village leading to protests and the entire LGBTQ community is being removed from the programming at the Kennedy Center. Just another week under the current administration.

I, as an employee of the VA, received a memo from Doug Collins, the new secretary of Veterans Affairs, that pride flags are now banned on all VA property including in private offices and personal desks. I hadn’t ever considered having one at my desk before. There will be one there when I return this next week and I have more than a few things up my sleeve. The VA doesn’t know me very well if they think I will docilely comply with immoral and unconstitutional (first amendment) orders. I’m not worried about me at all. They can’t easily replace me (and they know it). There are probably about 200 people in the country with my skill set and very few of them are going to be interested in relocating to the Birmingham Alabama VA. And it things get testy, I have the option of retiring any day. (I met with my financial people yesterday and all systems are go – it’ll just take a phone call and I can leave medicine behind). I’m also shoring up the security on my accounts. The checking account is out there as that’s where deposits happen, but I don’t keep that much money there and the federal data systems don’t have the numbers of my other accounts easily accessible.

I’m off to a matinee of What the Constitution Means to Me in a couple of hours. Not much theater for me for a couple of months but I’m starting to think about Richard II that I’m to direct this summer. There’s going to be a lot of political commentary in how I do it that Shakespeare hadn’t considered but I think he’d be a fan. He was a bit of an iconoclast and anti-establishment type himself. All great artists are. I’m hardly a great artist but I do understand the role of the artist in difficult times.

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.