We’re into full rehearsal mode on Into the Woods and multiple fifteen hour days this week between work and rehearsal obligations are making me feel every one of my sixty-one years. Fortunately, I have only about fifteen minutes of stage time in a two and a half hour show so I have reasonable down time in rehearsal and can nod off when necessary and recharge for the next bit. It’s also fortunate that it’s not a dance show – just some movement in the big numbers that’s not beyond my limited dance skills. I have long joked that I am a graduate of the Terri Schiavo School of the Dance but, as I age, I’m starting to think it’s more Stephen Hawking. I’ve got a three day weekend and I’m pretty caught up with work stuff so I should be able to take a little down time so I can conserve my energy for next week.

I had a call with my publisher last night. The books continue to sell slowly but consistently. For some reason, copies are moving in Germany at the moment. I have no idea why. I’m still trying to figure out a way to do some no budget PR and see if I can raise their profile a bit. I’m using my social media, working my few connections and seeing if I can get those who cover LGBTQ writing to consider including it in their recommendations as I do talk about my two same sex marriages in them. Maybe I can get Moms For Liberty to try to ban them from Florida classrooms. If that were to happen, then I’ll know I’ve arrived.

Steve (my publisher, not late husband #1) has an idea for a new book using my original proposal of writing about the intersection of the aging Baby Boom and the health and senior care segments of society. His thoughts are not what I originally envisioned but it may be a more practical and quicker project as he has outlined it. I’m going to mull it over some and do some noodling around with ideas over the next few weeks. I’ll then likely post something and ask for some thoughts and feedback. More details to come as it becomes clearer in my mind. The Accidental Plague Diaries would never have been written without the comments and conversations people had with me about the material as I was writing them so I’ve come to trust all of you out there to help steer me in the right direction.

Making a brief detour into Covid, the numbers keep going up and it’s having real practical consequences. UAB was completely out of bed and emergency department capacity on Wednesday of this week. Was it due to Covid? That’s unclear as without the emergency to subsidize the collection and publication of data, it’s hard to really get a handle on things. It certainly seems to be due to respiratory illness in general. Influenza, Covid and RSV are all heavy hitters at the moment. RSV seems to have peaked and be tapering off, but the other two are definitely continuing to ascend. There is some evidence that the JN.1 variant of omicron which has rapidly become the dominant strain, is more infectious than other omicron strains, binding tighter to the ACE receptors of cells. I haven’t been able to find much about whether this is translating into increased virulence.

On the good news front, those who have kept up with their Covid boosters (which is a distinct minority) are much less likely to catch the disease this go round. (If you’re vaccinated and boosted, you generally have to be in close proximity with an infected person for something like six hours for transmission to occur. It’s much less than that for the unvaccinated). You are also about 70% less likely to develop long Covid after a case. So I continue to suggest that you keep up with those shots, especially if you are aging (like I am) or have significant chronic disease burden or immune deficiency. But I don’t argue the point. In the words of the hosts of keyboard warriors out there, ‘Do Your Own Research’. I just hope you do it at sites with actual science and not with sites full of propaganda masquerading as science. This lengthening time of exposure to transmit which seems to be a benefit of vaccinated populations means that you’re relatively well protected in normal social situations and activities which rarely last more than two to three hours. It’s best to be wary of close colleagues and might be reasonable to continue masking on long plane flights.

I haven’t written a movie column in quite some time. I’m trying to figure out why. Some of it has been lack of time and energy with all of the other things happening in life, but it’s more than that. Mrs. Norman Maine seems to awaken and go dormant on her own cycle. I can feel her stirring in the back of my brain so something may be forthcoming relatively soon. She’ll just have to explain her absence. It will have to be something other than cryogenic freezing this time as I can only use that once.

I don’t have to be at rehearsal until 11:30 tomorrow morning. I plan on sleeping in. The cats may have other ideas. If they’re too insistent too early, they will receive a free flying lesson.

Back to the grind tomorrow. It’s been a nice two weeks off but I have been told I have to start showing up again if I expect that nice direct deposit into my checking account next month. I have heard of this mythical state called ‘retirement’ where deposits show up without having to set alarms and get yourself out of bed but I’m starting to think that it’s some sort of fantasy. And so, because I still have a mortgage and other bills, showing up at the job remains a necessity. I am not looking forward to the next few days as I clean out all of the accumulated detritus from in boxes, both physical and electronic. At least next weekend is a three day one courtesy of MLK so I shouldn’t fall too far behind too quickly.

The end portion of the New York trip was uneventful. I thoroughly enjoyed ‘Merrily We Roll Along’ with Jonathan Groff and Daniel Radcliffe. (Lindsay Mendez, the third lead was out but her understudy was sensational so I didn’t miss her). The show was well directed, finding the right balance between heart and bite, with a talented ensemble. I did have a few quibbles. I wanted a bit more from the physical production at Broadway prices (although a coup de theatre involving stars at the end of the show was lovely). The reduced orchestrations should have been jettisoned in favor of the originals. I will never agree with the jettisoning of the high school graduation bookends and the swap out of ‘Rich and Happy’ for ‘That Frank’ at the top of the show. I’m hoping the Sondheim estate eventually changes its mind on that one. The Hills of Tomorrow, the high school graduation song dropped when the high school scenes were dropped, is the musical foundation of the score as originally conceived. And every song that Franklin Shepard writes during the show is basically the same general structure and melodic line underscoring how as he sells out, his ability to create goes with it.

Merrily is a show that has always spoken to me because of my age. I was 19 when the show premiered in 1982 and really laying down my musical theater understanding as an undergraduate when the show opened…and closed. In fact, I was taking a course in American Musical Theater that quarter and the show and its failure were frequent topics of conversation. The original cast were the same age as I. I didn’t know any of them personally, but Liz Callaway had gone to high school with a friend and word would trickle through the grapevine about what was going on with the troubled production.

Modern theater audiences seem to have caught up with the backwards structure of the show and so that aspect no longer seems to be giving actors, directors, or viewers much difficulty. Perhaps the audience of 1981 wasn’t as able to deal with that and found it confusing. There’s also the issue of college age actors playing jaded middle aged types. Young actors can play young and they can usually play age. They have grave difficulty with middle age, however, and most college productions I have seen over the years of any work which relies on characters in their 40s and 50s flounders because of this. The second act of the cumulating with the three leads meeting on a roof top and singing their paean to youthful optimism, ‘Our Time’, makes me cry every time no matter what age the performers as it taps into my personal youth and all of the possibilities and how time and experience shaped and moved me in unpredictable ways, closing some doors, opening others, but making me, as a mature adult, someone young me would likely not recognize.

The drive back to Birmingham from New York was much less eventful than the drive up. The weather was fine and we were out of holiday traffic so nothing terribly untoward happened on the road to Columbia SC to drop off Frank or on the further back to Birmingham. I was back in plenty of time for my first staging rehearsal for ‘Into the Woods’. I don’t have a lot to do in the show (fine by me – I like small parts – you get to spend time creating with a group of talented people but you don’t have to tear your hair out trying to retain copious amounts of dialogue or come off stage at the end of the night feeling thoroughly drained) so I’m working out how I can maximize my material for best effect. Upstaging fellow performers is unfair but trying to steal a scene from them so they have to bring their A game and you all get better because of it is not.

Time for a spot of tea and a good book and early to bed so I’m well rested for the gazillion and one minor problems that have accumulated in my clinics in my absence.

Dateline – New York, New York –

The trip up North is about to tie up loose ends and I hit the road back to the Southland tomorrow. But the time off from work still has nearly a week to run. I’m not due back until Monday the 8th. Which is just as well, as I may need a couple of days to recuperate from the city that never sleeps. Personally, I’ve been alternating between sleeping a lot and adding a nap days with run around and do it all days. So far so good. But on those run around days I’m starting to feel my age. Perhaps if I colored my hair…

What has happened since I last checked in? I had a day of Sondheim with Josh Groban in Sweeney Todd for the matinee (Annaleigh Ashford was out but Jenna de Waal was fabulous and I can’t say I’m sorry for that.). It remains one of my favorite pieces of theater and it was great to hear and see it in a Broadway size house with the full orchestrations. Groban sings it beautifully – not the scariest and most imposing of Sweeney’s but he has settled into the role nicely and he and Jenna had great chemistry in their scenes together. My only complaint with the supporting cast was the Toby who was, to my mind, too old for the role and they had to transpose keys way down for them. In group stuff where changing the key would have been tougher, he was singing down the octave. I particularly liked the foppish turn from Beadle Bamford (whose name I do not remember and I’m too lazy to get up and go check the playbill). There are plans afoot for another theater weekend this spring and, if so, I’ll come back and check it out with Aaron Tveit and Sutton Foster who take over next month.

For the evening show, I went to Here We Are, Sondheim’s last work which is receiving an Off Broadway production at The Shed at Hudson Yards. Hudson Yards had not yet opened when I was last in New York so this was my first trip over to that part of the west side. It was lovely at night, all dolled up for Christmas with fairy lights everywhere. The Shed is devoted to modern and avant-garde works of all kinds and it was an appropriate venue. The theater, reached by ascending many escalators, is a large black box which can be configured for just about anything. The show was in 3/4 on a thrust stage. It’s based on a couple of Luis Bunuel films and is an ensemble piece with a sterling cast of eleven including Denis O’Hare, Bobby Canavale, Steven Pasquale, Micaela Diamond, and David Hyde-Pierce. In the first act, a group of idle rich bourgeoisie have difficulty finding brunch. In the second, they’re trapped inside an opulent room in a mansion while the end of the world may or may not be ending outside. The show is quirky, erudite, unexpected at times and only Sondheim and David Ives could possibly have written it. The score is most reminiscent of Sunday with riffs and melodic lines that build and recombine. It feels unfinished. Which it was as he was still working on it when he died.

New Years Eve and New Years Day were off from theater as I had no intention of being anywhere near Times Square and the theater district for that madhouse. The younger members of the extended party went down to the Battery for the fireworks over the harbor. The old folk stayed home and did a puzzle depicting Times Square. It remains unfinished but progress has been made. To celebrate the new year, I and Frank Thompson and Ginny Stahlman Crooks spent the latter evening at Marie’s Crisis singing show tunes. Frank brought the house down with Trouble (and that crowd knew the backup lines) and Ginny had a big diva moment with If He Walked Into My Life. We have been told to come back… and bring more friends.

I’ve been a bit melancholy the last few days. Some of it is New Year and the thoughts of what’s past and what’s to come and feeling a bit unmoored. Will this year bring retirement? Are the finances in place to allow that to happen? How to I replace the void of not working on a multi volume social history of the pandemic? As the world returns to normal, what should that mean for me? There’s also been a ton of memories, good and bad, flooding in of me, of Steve, of Tommy, and how we all intertwine in New York and with theater over the course of the last forty years. I know that when I get back, when work is in full force, and when I’m in rehearsal for Into the Woods that should all take care of itself. In the meantime, it’s off this evening to the last of the trifecta of Sondheim with Merrily We Roll Along with Daniel Radcliffe and Jonathan Groff.

Dateline: New York, New York

I know that I have been in radio silence the last few days; something in my brain has been telling me just unplug and live in the moment so I’ve not been doing the usual travel journal thing. Besides which, I’ve made any number of trips to Manhattan over the years and have likely exhausted my supply of New York City anecdotes. It’s been 36 years since my first trip – on the occasion for interviewing with some New York based residency programs. The one of which I liked was Cornell; and I ranked it highly but knew they would never take me. A cursory glance at their class statistics over the previous decade showed that they had only taken two residents from schools west of the Mississippi over the last ten years and I was pretty certain I was not going to be the third one, having been a somewhat indifferent medical student. No one at the University of Washington School of Medicine expected much out of me. But I was still the first member of my class to be appointed to a medical school faculty. The joys of tying oneself to underserved subject areas.

Christmas Day was pretty quiet. I slept in. Gave the kitties their Christmas treats (although they much prefer knocking pens off a table and chasing them around the room to any patent cat toy I’ve ever brought home). Spent the afternoon with my friend Holly and her family to get in a little of children showing off their Christmas gifts time. I do enjoy borrowing other peoples children occasionally. I suppose it’s why I continue to teach Sunday School at church. Also, being the one teacher without children in the program, I’m good at shaming the congreagation into volunteer jobs that need to be done.

On Boxing Day, Bill McMullen picked me up in his SUV and together we pointed the car towards points east and headed off into the rain. Traffic was light. Even Atlanta was freely moving. And we stopped in Columbia, South Carolina to pick up Frank Thompson continuing to dive up I-20 until it met I-95 where we made a left and headed to the North, spending the night in some wide spot in the road in Southern Virginia which had a Hampton Inn. We got up the next morning for the 7-8 hours of remaining drive time – and pulled into Manhattan nearly eleven hours later. The vile weather and holiday traffic combined to make the drive north one hell of a slog. But we made it and made it to our curtain time with five minutes to spare.

We were joined at the Belasco theater by David Pohler, Stephen Crooks Felis and Ginny Stahlman Crooks, reuniting six of the Alabama Seven from London (Kathy McMullen due to arrive the next day). The first show was ‘How to Dance in Ohio’ which is a musical, based on a true story, about a group of young people on the autism spectrum getting ready for a spring formal as part of social skills therapy). I had heard some mixed things about the show going in but was keeping an open mind. I ended up loving it. The subtext of the show is that people should be allowed to communicate their own stories in their own way, not through the lens of someone else’s worldview. And as the autistic characters are all played by performers who are themselves on the spectrum, there is a connection and an energy there that could not be replicated with better trained actors. The show has Heart that cannot be faked. I am hoping good word of mouth keeps them going for a while.

The next morning, I was up early, had breakfast with a friend at The Harvard Club in midtown and then wandered over through Times Square which was relatively quiet in the gray and the mist as the costumed characters don’t show up until about 10:30. I had nothing else on the schedule so I ran over to Lincoln Center and joined Frank for the family matinee of The Magic Flute. It’s the Julie Taymor production with the amazing puppeteering. Tommy and I had seen it on simulcast at the movies years ago but it was the first time for me to see it live. We were the first and second slaves in the Opera Birmingham production about a decade ago. I remember some of my chorus music but I can’t say that the plot makes any more sense in English than it does in the original German.

Lunch and some more wandering and then David and I went on to the evening show of the revival of Spamalot. It’s a show that requires a half dozen expert farceurs. They have them in the current cast. There’s not a wasted moment and every line of the script has been mined for jokes. And how can you hate a show that ends with an audience sing a long to ‘Always Look on the Bright Side of Life’. I then broke one of my cardinal life rules about never driving in Manhattan by taking Bill’s car up to Hamilton Heights where David lives and the parking is free. I am proud to see that I made it up the whole length of the island from 20th street to 145th street without crashing the car or needing a Xanax. But I did collapse on returning back to the condo.

I slept for quite some time and did very little today. Until it was time for everyone to gather for dinner, having been joined by the McMullen junior generation (Tricia McMullen, Trevor McMullen and Lee Hedgepeth). Lovely Mexican dinner right off of Times Square with Darrien Hess as our waitperson). David and I then opted for Harmony as our show for the evening. Barry Manilow’s score is pretty darn good (except for that one obvious steal from ‘Ragtime’) and it’s expertly performed (and wonderful to see local theater kind Kate Wesler in her Broadway debut). The show has some inconsistencies of tone and relies a bit too much on a memory play narrator at times. It mines some of the same ground as ‘Cabaret’ but comes at it from a different angle. The design is pretty great. They’re finally figuring out what they can do with projections to add to a concept rather than detract.

I’ve been away from most of my Covid news sources but one thing I have heard is that morbidity and mortality numbers are continuing to increase as the JN. 1 variant continues to spread rapidly. It’s up to about 50% of cases since first being identified several months ago. And deaths are up to abou 2000 a week. They were under 400 a week prior to Thanksgiving. Wash your hands! Wear a mask where appropriate! Get your shots!

And so we reach another Christmastide. I’m not ready for it. Between work and rehearsal/performance obligations I’ve just not had the energy to do some of the things I had every intention of doing this year like put up a Christmas tree. I do have tomorrow morning free so I suppose I could schlepp down to the basement storeroom and pull decorations out. It’s not that I don’t have a choice of six trees down there. If I do put one up, I think I’ll put up Tommy’s Teddy Bear tree. The Teddy Bear was his symbol and he had quite the collection. Our traditional souvenir from our travels together was a Teddy Bear representing the city/country/region. He worked out a way to get them to sit on a Christmas tree and – voila. It’s actually a fairly quick assembly and looks impressive. Or maybe I’ll just download a photo of a tree and print it and stick it on the front window with Scotch tape. At least, if I do it, I will be liturgically correct. Christmas decorations are supposed to be put up on Christmas Eve and taken down on Epiphany.

I have more or less finished the work year. Everything is wrapped up for the VA until the second week of January. I still have a few things to deal with for UAB. I volunteered to do the call for the long holiday weekend so all of my colleagues with children and family obligations wouldn’t have that hanging over their heads. I’m also behind on progress notes and am steadily working my way through the backlog. They should all be done by Monday morning. Which is a good thing, as I am heading out for NYC on Tuesday. I have a Christmas Eve service to sing at church tomorrow late afternoon and I have a couple of ideas for Christmas day that I’m kicking around. Although there’s a part of me that sort of wants to hibernate. The loss of Tommy has fundamentally altered my relationship to the holidays as our marathon of holiday shows/church pageant/Messiah/family Christmas/annual open house was so much a part of who we were as a couple. It took the two of us to pull all of that off as we could support each other/cajole each other/fight with each other and give each other the energy necessary to cross the finish line. Alone, I just can’t do it.

Of course, the pandemic has completely upended my being able to lay down any new traditions for my single state. And retirement is going to do yet another major shift. I’m thinking that ultimately, some sort of travel at the holidays might end up being the best solution. Perhaps an exploration of the Christmasmarkts of Eastern Europe – or escaping the cold altogether with something in the Southern hemisphere. The pandemic is not exactly over, but it’s certainly in a very different place in terms of our societal relationship with the virus which is why I’m not writing about it nearly as much as I once did.

(The exotic Christmas Market of Cullman, Alabama, about an hour up the road)

Speaking of the pandemic, for those who do not follow public health news, the numbers continue to increase – both in terms of hospitalizations and in terms of presence of virus in wastewater samples. We have a new variant, still omicron, known as JN.1 which appears to spread more rapidly than some of the other omicrons we’ve had as it is more efficiently transmitted and clings tighter to the ACE receptor molecule once it enters the body. It will be the dominant strain by New Years. Does this mean much of anything? In theory, because of the tighter binding, long Covid symptoms might become more frequent but there’s no real way to know in advance. The booster that came out this past fall seems to be quite effective so, if you haven’t gotten it yet (and something like 85% of adults have not), you might give yourself a Christmas present down at your local CVS.

This will be my first trip to New York since the pandemic. I was last there in 2018. And it’s also my first trip during holiday season since 2004. I have a little bit of trepidation in going as I am well aware of how many people you have to share too little space with. I will pack a few masks. I’m not that worried about Covid as neither of the two cases I have had has been particularly severe. But urban America is having a banner year for all sorts of other respiratory viruses as we’re all making up for the lost time of the last few years and busily trading our biomes with each other. And I have a long tradition of getting one in January which usually morphs into bronchitis with a cough like a seal for six weeks. And I would rather not deliver my most famous line as ‘The closer to the family bark bark bark the closer to the wine’.

American cultural Christmas developed during a time when there was usually at least one and often more than one adults in the home who could do the baking and the decorating and the corralling of the overexcited children. Now, when most adults must work outside the home to survive, doing all of that stuff has to happen in many fewer hours. And no one can keep up. We’re fed these images of perfect holiday season through Hallmark movies and other cultural tropes and then we look around at our lives and feel inadequate as it doesn’t measure up. Perhaps its time for us to reevaluate the expectations for a new millennium.

As I’ve grown older, my favorite part of the holidays is Christmas Eve service. I’m not explicitly Christian so it really doesn’t have anything to do with Jesus, but rather the much earlier mythos of light and hope springing from darkness and how each new child, no matter how low they are on the social pecking order at birth, has the potential to be a savior in some way as they mature. And we celebrate this hope with music and traditional carols that have been sung generation after generation and singing those songs, at least for me, helps me feel connected and part of a much bigger story than I can ever comprehend. Angels We Have Heard On High dates to the 12th century. That’s nearly a millennium of ordinary people belting out ‘Gloria in Excelsis Deo’ together – and I find magic in the community of choral singing. We need to do more of it.

It’s coming to the end of another Advent weekend and I am moving towards being caught up with life. Not completely… that will never happen… but I am at least done with everything that has to be finished before the next, and last work week for the year begins in the morning. I am hoping that the tendency of people not to want to go to the doctor continues as I feel in need of some R and R. I am going to get that starting on the 22nd when I can hang up my shingle until January the 8th. I am headed for NYC for a good bit of it- the gang who went to London for New Year’s last year is hitting another cultural capital this year- so if you’re NYC based and want to get together sometime between the 27th and the 3rd, drop me a line. I have made a deliberate decision to do minimal advance planning and scheduling and just let that week happen. Maybe I’ll see some shows. Maybe I’ll sleep fourteen hours a day and read a couple of good books. Maybe I’ll have them lock me in the Metropolitan Museum after hours so I can have a ‘From the Mixed Up Files of Mrs. Basil E. Frankweiler’ moment.

Seven Santas closed this afternoon with the matinee performance and another project has been put to bed. I really quite enjoyed this one. There’s something therapeutic about screaming in another actors face or going from despair to uncontrolled rage to sardonic laughter in about three minutes. Given the triggers written into the script for my character, Red, putting the show to bed is about as apt a metaphor as I could come up with. I’ll miss my other six Santas and Mrs. Claus as it was very much an ensemble show with each of us being an integral part of the structure and staging. All eight of us got along exceedingly well and had a blast working together to create the rather depraved humor of the piece. I won’t have too long to mourn theatrically, however, as my first rehearsal for Into The Woods is tomorrow evening. I finally received the full cast list and it’s very definitely split into the old guard, people with whom I’ve worked many times over the years, and the young uns who are up and coming and whom I am looking forward to getting to know better.

Respiratory illness is definitely continuing to spread locally. There’s been some Covid, but most of it is the crud. I continue to search for good information on what Covid is actually doing these days but the usual fragmentation of public health information that happens when the federal government is not involved in an active emergency situation stymies any easy digesting of the numbers. There’s also the overlay of antivaccine movement noise that tries to interpret issues in ways that favor their worldview whether that’s what the data actually say or not and you have to try to sift through that as well. Hospitalizations and deaths, while up, are not anywhere near where they have been in the past. But as I start to think about it, these are not the most useful metrics for this phase of the disease. Much more useful would be numbers that allow us to track Long Covid or post Covid complications with clotting or heart or neurologic issues in relatively young people that may have enormous bearings on total morbidity and mortality for society as time goes on. No one seems to be counting and reporting any of that in any sort of systematic way. No one can even agree on what Long Covid is and is not.

There are a couple of local physicians whom have set themselves up as specialists in Long Covid and vaccine injury. I imagine there are a few in every community who are seizing on this business opportunity. From what I can tell, they are preying on desperate people with promises based on therapies with no scientific data to back them. And selling all sorts of supplements out of their offices to boot. There’s an old saying in medicine. The A students become medical school faculty, the B students become good doctors, and the C students become millionaires. I was a B. I would not have become med school faculty i I had not chosen a field that was enormously underserved. If you come to me with signs and symptoms of Long Covid, I’m going to tell you what we know (not much), what we don’t know (a lot), and figure out a treatment plan with some rationale that will interdigitate with your other disease processes and who you are. I’m not referring you to a self styled specialist who seems to be motivated by profit.

There was a long article in today’s Washington Post (which I posted elsewhere) about one of the dirty little secrets of American health care – the Assisted Living industry. There are three basic levels of residential senior care – independent where you live as you please but where the community may offer services such as communal dining and housekeeping – assisted where you have staff to help you with things you cannot do for yourself safely such as bathe when you are wobbly on your feet (it gets subdivided in most states into regular and dementia/memory care) – and skilled nursing which provides those who need regular nursing attendance to care for their own bodies or who have major issues such as catheters and feeding tubes.

Most people assume that all of these are licensed and regulated in the same way. They are not. Skilled nursing, as it can be paid for with federal dollars (mainly through a state Medicaid program although Medicare does step in in certain limited situations to help someone get over the hump after illness or injury) is subject to intense federal regulation, similar to that which polices hospitals. There are more rules and regulations on skilled nursing facilities than practically any other industry in the country (including commercial aviation and nuclear power) and the feds have significant powers over a SNF in terms of fines and licensure. They don’t always exert those powers, but that’s another story. The up side is that there are regulatory teeth and the facilities and their operators understand this. The down side is that the RN is more likely to be doing paperwork to ensure better audit scores than actually providing any meaningful patient care.

Assisted living, however, is not regulated at all at the federal level as no federal dollars flow into them. (A state Medicaid program can pay for assisted living if it so chooses, but there are no requirements. This does not happen in Alabama.) It’s entirely up to the states. And the industry lobbies long and hard to prevent federal regulation and to keep state regulation cursory at best. ALF regulation is actually pretty good in Alabama. It’s one of the best states for oversight. As there are minimal public funds going into them, they are pretty much entirely private pay and generally attract the upper classes on the socioeconomic scale. The lower ones handle their elders at home as a fee of $5000-7500 a month is beyond their means.

What do you get for these costs? You will be told, especially for the demented, that you will get 24/7 supervisory care to prevent accident or wandering or any of the other major behavioral issues that make dementia patients difficult at home. They represent a safe alternative to being at home and getting into mischief when a broken brain makes an older adult do things that they believe are entirely correct (they often still think of themselves as healthy vibrant adults not in need of supervision) but which families and the world in general may look upon askance. There are promises of frequent checks, trained staff, nutritious meals etc. And there’s the money that goes into the furnishings in the public areas to instill a sense of security in families.

The Post article takes a deep dive into the thousands of patients that wander away from Assisted Living every year and the hundreds that have died from exposure or other misadventure as they cannot find their way back due to the disorientation that often accompanies dementia. It then goes into the consequences of these events (not much) and how they come to occur (understaffing, under trained staff, an emphasis on collection of monthly fees over actually providing care). And, as the federal government is not involved, when something goes drastically wrong, the legal remedies are somewhat limited. And in many cases, a clause limiting to binding arbitration is part of the admission documents.

I do a little medical legal work on the side. It’s how I get the money I give to local theater companies so don’t judge me too harshly. Doing this sort of thing has allowed me to peek behind the curtain when something has gone wrong and see how the long term care industry operates. It used to be a not for profit sector but no longer. It’s now mainly corporate chains hiding behind cozy local names with multiple interlocking companies used to shield each other from trouble. One company owns the building and another employs the nursing staff and a third runs the kitchen etc. A dogged plaintiff’s lawyer can cut through all of it but it can take years and most families aren’t cut out for the process. But when they are, you can finally get the budget sheets for the kitchen and find out that the allocation for meals per resident is just over four dollars a day. (That’s not the norm – that was something that came up in a case of adult failure to thrive and weight loss where the resident kept complaining to the family about the quality of the food.)

I encourage everyone to seek out the article and read it. Because the issues highlighted are about to get much, much worse with the aging of the Baby Boom. They have yet to really hit the dementia belt but that’s going to change within the next five years. What will those pressures bring? Federal regulation? Unlikely without federal dollars being involved. Improved state regulation? Industry trade groups will be able to outspend concerned citizens at every level. Probably just more sad stories and a decline in the number of existing beds if corporate America feels that the sector is going to become unprofitable. And then there’s the continued issue of lack of staffing. That’s not likely to improve anytime in the near future, especially with the current negative feelings towards immigration. Nursing aide is often the first step on the ladder for new immigrant women.

In the meantime, I am not trying to discourage anyone form using Assisted Living if it’s the appropriate solution to their family’s needs. But Caveat Emptor. Don’t make your decisions based on marketing materials and floral displays in the dining area. Ask around. I’m happy to give my impressions of local senior living communities. I’ve been in most of them, know many hard working and dedicated people who work in them, and listen to what patients and their families have to say about their experiences.

I should be writing this week’s incomplete progress notes but I really don’t feel like diving down that rabbit hole on this dreary gray afternoon and so I have the television playing old episodes of CSI Miami in the background and I’m playing catch up on various household things that have been neglected the last three weeks as my spare energies have been channeled into learning the six minute monologue and 45 minute scene that comprise my piece of Seven Santas. I am proud to say that I have forced all of those words into my brain and that they mainly come out at the right time and in the right order on stage. There are a couple of lines that I seem to drop routinely and I have no idea why I have such a block against them but my castmates have figured out which ones they are and there are plans in place to keep things on track when I screw up. We officially opened last night. The audience seemed to enjoy it. Although I’m not sure it’s the sort of play you enjoy as much as take in and cogitate on as it’s got some very astute political and sociological points to make in the trappings of mordant black comedy. Two more performances this weekend and three next, and then it’s on to Into the Woods, the next project in the queue.

We’re in that lull period of the work year which lasts from roughly Thanksgiving through MLK day. People have way too much on their plates so they tend not to schedule routine physician visits and all of those problems that generally require them to send multiple portal messages magically go on hiatus while there are other things to occupy the waking hours. Things take off like a rocket again in January, however, when the out of town kids come to visit the parents for the holidays and realize what has been covered up or minimized and they then start pushing their elders in to deal with the cognitive and physical changes that the out of towners recognize more than the in towners as the delta of chronic disease is big enough between visits to declare itself. I have two more work weeks, then two weeks off. I’ve taken the post Christmas holiday period the last two years so I probably won’t be able to take it next year. It will be someone else’s turn. Unless I retire in the interim.

Covid numbers continue to go up. Hospitalizations have been going up by about 10% every ten days or so throughout the fall. It’s not high enough to cause significant impacts on the system, but it is high enough to raise eyebrows on those who make it their business to follow public health trends. All of the deaths I’ve heard about the last few months have been anecdotal. They’ve all been relatively young and healthy people. I’m probably hearing about them because of this so it’s a skewed sample. I haven’t seen any scientifically sound data suggesting that mortality rates for serious infection have shifted significantly since the beginning of omicron two years ago.

There have been a couple of things of note. First, the CDC has a new nifty little tool that summarizes the wastewater surveillance results by region. It’s available at https://covid.cdc.gov/covid-data-tracker/… and it’s a handy way of seeing what trends have been over the last few weeks and months. Second, immunization numbers for the most recent booster are pretty abysmal with fewer than 20% of adults having taken advantage of it. Some of that is messaging. Some of that is the end of the emergency and the federal government stepping out of distribution. Some of that is the residual follow out of the vaccine wars and a certain level of skepticism. And the third, and perhaps most important, data is coming out confirming that with every subsequent Covid infection, chances of developing long Covid symptoms increases, to the point that it rises to about 35% chance after a fourth infection. That’s enough to keep me heading off to the pharmacy for boosters as they become available. I have seen enough of long Covid to know that it’s not something I want.

I’m off to NYC for New Years. I plan to avoid Times Square on the evening of the 31st. That might have been fun at twenty or twenty five, but at sixty, it just seems nightmarish. It will be my first trip back since the pandemic. I haven’t decided what theater I will attend. I’m pretty caught up after two weeks in London this past year. The thing I would most like to see, the revival of Merrily We Roll Along, is priced astronomically so it’s pretty much out. I’ll make it up as I go along. The one thing I can say about theater is that it’s usually possible to get a single seat to even the most sold out show. You just can’t get two together. The gang that went to London last year is doing a different cultural capital together this year. Should be fun. And we’ve worked out how to do it on a budget… other than theatre tickets…

I think a nap before call time is in order. The cats have the right idea.

I have a rare night off from rehearsal. I’m starting to feel pretty good about Seven Santas. The monologue is solid and the lines for the big complicated scene are mostly coming out where and when they are supposed to. We have one more week before a paying audience so I can relax a bit. I find that if I run my part in my head when I first wake up in the morning and again at least once during the day, it serves to keep it sitting in the part of the brain where I can access it appropriately. I just have to make a couple of simple props tomorrow sometime and then I think all the other pieces are in place. My five pound tin of Danish butter cookies came in. No, I’m not eating them all at once but I do have to eat about a dozen each run. This show may cause me to put my Covid weight back on.

Speaking of Covid, as we all know, it has not yet gone away. I haven’t looked at the numbers for a bit as they are no longer gathered and parsed in an easily digestible format as they were during the pandemic emergency. From what I have been able to find, there are a couple of things going on. First, ER visits and hospitalizations have gone up about 10% this past week over where they were. It’s probably due to the change in weather and behavior that accompanies as we enter the traditional cold and flu season. It’s a bit early for Thanksgiving travel to have had much of an impact. Covid numbers are way up in Nursing Homes, likely due to the reduction in precautions and the weakened immune systems of those who reside there. As far as mortality, for the month of November, Covid was responsible for about 2.5% of deaths. This is way down from peak pandemic numbers but still alarmingly high.

The current rapidly spreading variant is known as BA 2.86. It’s still from the omicron lineage. There hasn’t been a major shift requiring a new Greek letter for a couple of years now. It has the same general profile in terms of infectivity and symptoms. It’s numbers, however, are accelerating rapidly in wastewater sampling and other epidemiological measures, having tripled in prevalence over the last few weeks, suggesting it’s pretty good at out competing earlier omicron strains. The recent booster, which was formulated against the later omicron variants out there, appears to be covering it and other currently circulating variants relatively well so it remains a good idea to stay current on vaccinations.

The thing that’s really spreading at the moment is RSV (respiratory syncytial virus). Pediatric hospitals are inundated nationwide. It’s quite a nasty disease in young children. In most adults, it’s a bad chest cold (unless you have serious underlying immune issues or pulmonary disease). This is the first fall in four years that the majority of the population has been living in relatively normal patterns. This means we have four years worth of young children who were not exposed to most circulating viruses as we tried to keep them free of Covid who are now running into RSV and other such things and so a large population is getting them all at once. The good news is there is an RSV vaccine. If you’re a healthy adult, it won’t hurt you to get jabbed, but I don’t think you need to race out and get one. Most everyone I know has had the sniffles recently. It’s the same thing. You’re just running into what was always there and the viruses are making up for lost time in terms of spread. There are also a few running around locally that are causing some nasty diarrhea. Avoid those. Do you need to mask up? If you want but the most important thing you can do is keep those hands washed.

I try to read or (audio listen to) at least one literary classic every six months or so that I missed along the way. I also have a goal to make sure I read all of Dickens’ novels before I check out so my current car book is Martin Chuzzlewit. I knew the title, but really knew nothing about the book other than it was not one of his more successful novels from the height of his fame. And I’m wondering why more of us don’t read it. It’s really quite good and I am enjoying it a good deal more than some of his more famous titles. I assume the reason it is not as well thought of this side of the pond is due to it’s nasty satirical look at America and American society of the 1840s. The chapters involving young Martin’s adventures in New York, full of Dickensian side characters worshipping at the altars of land speculation and profit, are so incisive that they could be about our society of some 175 years later. Donald Trump would fit right into the story. He even has an appropriately Dickensian name. Next up for me is Ken Follett’s most recent sequel to The Pillars of the Earth taking fictional Kingsbridge up to the Industrial Revolution. I enjoy soapy historical fiction but I wish Ken would either learn how to write a sex scene or would just leave them out. His are painful to get through.

Today is my father’s 91st birthday. I had the good fortune to be able to see him in the flesh last week. He continues to do quite well for his age, stumping around independently with his stick and his scooter for longer distances. I hope I got some of the good pieces of his genome along with the bad British teeth genes that put me in the dentist chair far more often than I would like. Raise a glass and give him a toast this weekend. I know I shall.

It’s something after midnight, Birmingham time, and I’m sitting in the departure lounge of the Seattle airport waiting for my red eye flight back to Atlanta – at which point I get the wonderful job of driving for three hours on next to no sleep in order to get home. The combination of short staffing at work and a show in rehearsal have made leaving town for anything other than the briefest periods a tricky business so this particular Seattle trip was just a bit over 48 hours. It was long enough to catch up with the family, have Thanksgiving dinner with as many of the tribe as were in town, and get the holiday shopping done for everyone so that I could get it wrapped and leave it behind me and not have to worry about shipping it later. I have become the dotty old uncle that gives everyone a book. The younger generation are now fully adult and I’m not around enough to know their wants and needs and books have always held a place of high esteem in my family. I suppose in another five to ten years, the next generation will start to arrive and I can switch back to educational toys. I only have one hard and fast rule. I don’t provide anything that makes noise. I leave it to parents to make that mistake.

Tommy’s great nieces and nephews are still children but I don’t see them all that often so they get age appropriate books as well. Which means I have to sit down every year and try to remember their approximate ages so I’m not giving a copy of ‘Harold and the Purple Crayon’ to the fifteen year old. With them, I tend to go with classics that I enjoyed in my childhood or with those kids reference books full of facts that ten year olds love like the amount of poop the average elephant generates in a year. I don’t know that it will ever get me a nomination for great uncle of the year, but I probably have a better relationship than Scrooge and his nephew Fred pre ghostly visitations.

I did put some work in on my lines for Birmingham Festival Theatre’s production of Seven Santas which is slated to open on December 8th. I have the monologue more or less down. I know my lines for the scene work, but not firmly, and I probably won’t be able to fully get them into my body until we’re actually doing that very long and complicated scene on its feet, off book, every night this next week. I tend to polish my performances organically and I have to have the sound of others voices and my blocking and other people to react to in order for everything to fall into place the way it’s supposed to. Tickets are for sale on line for all six performances if you really want to hear me curse routinely and get violent with Mrs. Claus.

I’ve been thinking a lot about the rather hopeless situation in the Middle East. The news has been appalling from all quarters and, unfortunately, people are oversimplifying matters and leaping to postures of virtue signaling without having any real understanding of what’s going on or why. I am no expert in Arab/Israeli relations but I have been around long enough to know that Hamas, which leads the Palestinians in Gaza, is a terrorist organization (their actions on October 7th certainly proved that if nothing else). On the other hand, Bibi Netanyahu’s governmental policies towards the Palestinians have also been outrageous for years. American Muslims are not responsible for Hamas and American Jews are not responsible for the depredations of settlement so the uptick in Antisemitism and Islamophobia are heinous and show how much we have abandoned critical thinking for Tik-Tok video propaganda. Whose side am I on? I am on the side of life, of the innocent who suffer on both sides for decisions they have no voice in, and I wish my Jewish and my Muslim friends nothing but peace.

A dear friend of mine and sometime writing partner wrote a musical many years ago called ‘Abraham’s Land’. In its initial conception, it was a fable in which an IDF soldier, Yitzak (Isaac) and a Palestinian student Ismail (Ishmael), end up swapping places and each of them learns important lessons about the other side. Over the years, she has rewritten and revised it and with each subsequent draft, as the situation between the Israelis and the Palestinians has become more fraught, the material has become more complex and darker. It finally received a production a year or two ago (delayed by Covid) and I thought that she and her collaborators, Jewish and Palestinian alike, had succeeded in holding up a mirror to both the region and to our attitudes toward the conflicts creating a balanced look at all of the heartbreak. If Equity will allow it, it would be a good time to get the pro-shot Video of the show out there. Sometimes the arts are what we need to show us our true selves. Of course, the hyperpartisans on both sides would likely object to the humanization of the ‘enemy’ but isn’t the first role of religion welcoming the stranger and offering hospitality? It’s the first step in making a perceived enemy into a friend.

They’ve opened the boarding door. Time to get on the plane, wedge myself into my corner, and try to snooze for a bit so that I have some energy for unwritten progress notes and a rehearsal tomorrow.

Rosalynn Carter died today at the age of 96, shortly after entering hospice care. She is survived by her husband of 77 years, Jimmy. Given Jimmy’s 99 years and devotion to her, I won’t be in the least surprised if he boards his train in the very near future. I’ve learned a lot about humans in my thirty plus years in geriatrics and one of them is that elderly men who choose not to survive the death of their long time spouse often don’t. I was in high school during the Carter presidency. He wasn’t held in particularly high regard in the social circles of Seattle through which I moved as a teenager. He was somewhat naive as a politician on the national stage. But for decade after decade both halves of the couple have served as shining exemplars of humble service to humanity. I doubt we will ever see as good an ex-president again. The temptations of world wide celebrity and highly paid speaking tours and multi-million dollar book deals are just too great.

Jimmy was a World War II vet. There aren’t a lot of them left. To have been 17 in 1945, one must have been born in 1928 because math so in 2023, you turned 95. Given that life expectancy for men is mid 70s, the surviving World War II vets are the outliers. I have a few on my VA house call panel. You don’t get to be that age if you haven’t taken care of yourself and made good life choices so they tend to be healthier than my Vietnam era vets who often didn’t. We’re reaching the tipping point which happens for all historical epochs where World War II is passing from living adult human memory. In another decade or so there will only be child memories of the events left in some very aged people and then, another ten or so years later, there will be no living human memory left of the Anschluss, Pearl Harbor, Dresden, the Holocaust, Stalingrad or any of the other moments that seared public consciousness in the late 30s and early 40s of the last century.

This process, which has always happened, turning real memories of real events into history and myth and legend, will continue on throughout the 21st century as each of the tumultuous decades of the 20th century recedes further and further into the past. ‘Happy Days’, the TV series for young people of the 70s which was a nostalgic look at adolescence a couple of decades earlier, will have its 50th anniversary in a couple of months. The lead edge of the Baby Boom is just a couple of years shy of turning 80. It won’t be all that much longer until the Summer of Love and Woodstock fade out of living adult memory as well. And I suspect the Boom is going to rage, rage against the dying of the light. They remain trapped in their thinking of themselves as the younger generation. And they tend to internalize the outliers as norms. I can’t tell you how many times I’ve had to explain to patients in their 70s and their normal symptoms of aging are not related to disease. They always have a story about someone ten or twenty years older than they who doesn’t have their issues and they’re upset as they think they are entitled to the same good fortune. They don’t seem to realize that these people they hear about, often through media reports, are extreme outliers and that’s why they generate media interest to begin with.

I just passed the half way point of my 62nd year this past week. And I can tell that I am not the same being either physically or cognitively that I was a couple of decades ago. I don’t fuss about it for the most part. There’s not a lot I can do about the aging process. Anyone who thinks that a geriatrician has some sort of elixir of youth needs a psychiatrist. I can’t fix my aging problems any more than I can fix those of my patients. What I can do is sort out the things that have helpful interventions from those that don’t. I also seem to spend a lot of time adjusting to my ever changing body and continually making new friends with it as it decides to pursue new and unusual patterns brought on by time. Geriatric medicine really boils down to a couple of essential principles. How to keep people on their feet without falling over, how to keep people from poisoning themselves with medications they may not need, and how to keep people eating and dealing appropriately with the waste products of metabolism. The general health system does very badly with most of these so we geriatricians have carved out a niche area which no one else really wants to fill.

My biggest aging challenge at the moment involved my memorization skills. I used to be able to memorize enormous amounts of information relatively quickly but that skill seems to have subsided some with age. I can still learn things but it takes longer and requires more perseverance on my part than it used to. The play I am currently rehearsing, Seven Santas, is a bit of a challenge. I have a monologue (not overly long and it’s coming – I can now do it with just my cheat sheet (first letter of each word) and without script but I’m not quite at the point of being able to it completely off book. (I have one more week). What’s defeating me is the 40 minute scene where are Seven Santas and Mrs. Claus are busy having knock down drag outs at one wild AA meeting and where I have a hundred lines and very few in the form of direct dialogue. Have one more week to get that down as well. There are a couple of cross country plane flights in there in which I can work on lines – if I can stay awake.

The third book is out and orderable. You can get it on Amazon or any of the big national retailers through their on line presence. But I always find it more fun to ask your local bookstore to order it for you. They can always then order a couple of extra copies for store display. I will do some signings in the next few months but not before the holidays. I’ve got too much going on. If you want me to sign copies for holiday gifts or other such things, I am happy to do it, just slide into my DMs or give me a call and we can make arrangements.

Three more work days before a couple of days off. And then twelve days before Seven Santas are unleashed on an unsuspecting public.