“My Covid test was positive”. I’ve been fielding that message multiple times a day over the last couple of weeks. As most of my patients are over the age of 75, their risk for complications and hospitalizations is higher but we’ve been pretty luck so far. Few have been sick enough to need the emergency department and no one has yet needed an ICU bed. It won’t last. I know I’ll lose one of my charges eventually. In the meantime, I and my staff run through our script of how to cope with the virus at home, when to call us, when to head for the emergency room, and we send in the Paxlovid prescription to their local pharmacy. A month or so ago we were getting about one call a week, now it’s ten to twenty so we can tell we’re in a surge even if the media isn’t really covering it.

If you look at the national numbers, the death rate is up about 50% over last month (from about 300 a day to about 450 a day), hospitalizations are up about about 30% from roughly 30,000 to 40,000, and test positivity has crept back up over the 10% mark to about 12%. There’s no particular hot spot when you look at the map, it’s going up pretty uniformly everywhere. If I had to guess why, it’s because it’s roughly three weeks after Thanksgiving and, if you’ll remember our usual pattern, hospitalizations rise two to four weeks after a behavior change. I imagine, going forward into the indefinite future, that the holidays with the travel and gatherings that accompany them, will translate into Covid season and we will tend to see peaks in December and early January for some time.

There is good news. Even though the numbers are up, they aren’t going up to the point that the health care system can’t handle them and we aren’t seeing gurneys parked in tents in the parking lot this year. And, with luck, we won’t be for some time as the pandemic continues to evolve into an endemic phase – a disease that remains part of our environmental landscape but which no longer seems to be ripping our social fabric apart. There have been issues with children’s hospitals and emergency rooms as the tridemic of Covid, influenza, and respiratory syncytial virus have been making the rounds among the younger set. Fortunately, as all students of pediatrics quickly learn, the vast majority of children are pretty indestructible and get better on their own so long term morbidity and mortality have been quite low in that population.

Those who are bearing the brunt currently are the elders, especially those over the age of 75, my population. The vast majority of deaths are within this group and are mainly in those with preexisting chronic illnesses of various stripes. If you’re vaccinated, in reasonable health and under 70, you need not be overly concerned by Covid infection, at least in its current evolutionary form. Mind you it could continue to mutate into something quite different over time, but you need not panic today. Of course, you may want to consider your potential place in an infection chain that could put your parents or grandparents at risk. This is why all my teams continue to mask for clinical encounters.

Personally, I have had two shots, three boosters, and two infections so I figure my immune system is about as primed as it’s ever going to get. I’ll test before getting on an airplane to fly to the British Isles in a couple of weeks. And I continue to keep a mask in my pocket for any situation where I feel things might be a bit dicey. Costco on Saturday afternoon comes to mind… Is the pandemic over? Not really, but we’ve moved out of the acute phase and are settling into a more chronic phase. And it’s not nearly as interesting to write about; although some of the usual suspects continue to provide bang head into the wall moments such as the governor of Florida’s recent announcement that he is calling a grand jury to investigate the CDC for providing ‘misinformation’ about Covid vaccines. Interesting that he feels a need to act there but not against those who were recommending injections of bleach, iodine gargles, or horse deworming paste…

As Covid continues to simmer in this more chronic phase, it’s becoming far less interesting to write about then it was in the past so I’m likely to leave the subject other than the occasional update. I will, of course, return to it with my usual zealotry if there are either major developments in its natural history such as new mutations or late complication syndromes with major implications for public health. It also means that the Accidental Plague Diaries is likely to end in book form after Volume III. And that’s just as well.

It’s giving me some time to actually participate in holiday stuff this year. This week is choral week. Multiple rehearsals for Handel’s Messiah cumulating in one glorious performance on Saturday evening with the Alabama Symphony Orchestra at Alys Stephens Center. I’m also adding to the bass section of Eastlake United Methodist Church choir for their Lessons in Carols and my usual Unitarian Universalist Church of Birmingham is using me for the basso profundo part of ‘You’re A Mean One, Mr. Grinch’ for this Sunday’s service. The UUCB repertoire of anthems is nothing, if not eclectic. Next week is relax week. Pretty much everything on my list with a deadline is done by the 20th. Perhaps I’ll finally get my tree decorated then. I did get it out of the box and up in its place but I haven’t gotten the ornaments on it yet. Part of that is deliberate. With the new cat in the house, I wanted to have it be part of the usual environment before covering it with shiny fragile things and having Binx decide he needs to take a swan dive into it from the piano.

Volume II of The Accidental Plague Diaries seems to be slowly but steadily selling. It and the first volume together make a lovely holiday gift to the readers in your life (hint hint…) I took a set to my dentist’s office last week for the staff. (Due to bad British teeth genes on both sides, I spend a lot of time at the dentist and I’m quite friendly with the staff there). I ended up having to go again this morning as my current temporary crown decided to pop off and go exploring the other side of my mouth a couple of days ago. The receptionist told me she read half of volume one while getting her oil changed and found it hard to put down. Another acquaintance later today told me she was trying to read it during a boring meeting and kept breaking into laughter at inappropriate moments and that she had no idea that the pandemic could be funny. And there you have it. TAPD – providing a little entertainment one reader at a time.

Ava Kofman wrote an article on the for profit hospice industry that appeared in the December 5th issue of The New Yorker magazine. It’s a meticulously researched article detailing some of the more egregious abuses of the Medicare system for hospice payments looking at dishonest recruitment and billing practices, damage done to patients, families and the reputation of the program, and scores of shady hospice programs existing at mail drop addresses. It’s caused a bit of an explosion in the world of palliative care and geriatric medicine. Not because of the immoral and illegal acts documented – every one of us who works in the biz has our own stories – but because of the connecting of the dots to show how the shift of what was a not for profit sector to a for profit sector has pushed even good actors into bad deeds in order to serve the insatiable corporate hunger for profit.

The article begins by detailing some of the shenanigans which went on in southern Alabama after a locally run hospice chain, Hospice South was acquired by Beverly Enterprises, a large national for profit conglomerate, under its AseraCare hospice label. Ultimately, employees at the Monroeville office, appalled at corporate practices, turned whistleblowers leading to a massive DOJ lawsuit which underwent a number of twists and turns over the next decade or so. I’ll let those who are interested read the article. It can be found at the following link. https://www.propublica.org/…/hospice-healthcare….

Reading it carried me back in my career. I first became a hospice medical director in 2001 with Odyssey Hospice here in Birmingham. Odyssey was bought and sold numerous times. It’s current descendent is Kindred Hospice. In 2003, I became the medical director of Hospice South, that was looking to expand into the Birmingham market. It was, small, it was scrappy, and the people who were running the local office and were wanting me to take over the medical end of things, were determined to do things the right way. I accepted the contract and was in place when the agency opened its doors. A year or so later, Hospice South was sold to AseraCare and rebranded. We kept the same staff but we could all feel the corporate pressure to cut corners and to meet admission quotas that weren’t remotely feasible. I refused to do things in any way but the ethical and right way clinically and I and the Birmingham staff pushed back. Ultimately, AseraCare responded by closing the office rather than reduce its profit margin.

I’m in an interesting position when it comes to contract work. As a full time employee and faculty member of UAB, I can take external contracts but they are not made with me as an individual, they are rather made with UAB as an institution. Basically, an external agency can rent a piece of my time from UAB for a price. I don’t set that price, UAB does. I don’t see the money, it’s paid to UAB which uses complicated formulas to determine how much of my time and salary can be defrayed. I am therefore never actually an employee of a hospice or home health agency or case management program that uses my services and they therefore have no real power over me and my clinical decision making.

As the various senior service agencies that used to want my clinical expertise have transitioned to more and more for profit corporate models, I have been edged out. Because of my decades of experience in clinical geriatrics, UAB sets my rates on the high end of the market. The agencies want someone they can get cheaper. They just need a licensed MD and any one will do. I’ve seen more and more medical directors of questionable credentials in play in recent years. They also want people whom they can directly employ and force to toe a line in terms of clinical decision making that will best profit the company. Me with my insulation through UAB has always had the freedom to do the right and ethical thing and the bean counters in the back office haven’t really been able to do much about it other than wave the occasional empty threat in my direction. This is probably why my last hospice medical direction contract ended in mid-2020 and no one has been interested in picking me up since.

To really understand what’s going on here, we have to look back a bit at what hospice is and isn’t. Hospice as a concept was invented by Dame Cicely Saunders, an RN in the UK in the early1960s to treat all the sources of pain in terminal cancer patients – physical, social, and spiritual. She came to the US in 1963 and gave a lecture at Yale medical school outlining her ideas and philosophies which came to be regarded as the founding of the hospice movement in the US. Hospice was slow to catch on, mainly being debated in academic circles until, in 1969, when Elizabeth Kubler-Ross published her seminal treatise ‘On Death and Dying’. This turbocharged thinking about the dying process and symptom relief and changed the cultural conversations. By 1974, Medicare had established demonstration programs in hospice care. It became more widespread with federal funds becoming available and with Joint Commission standards for hospices being developed. It became a permanent part of the Medicare A program in 1985.

Hospice, as originally developed, was a specific program for managing the needs of the actively dying in an interdisciplinary manner. It was presumed that those enrolled would, in general, live no longer than six months, and that a holistic model of care would ease their passage, assist their friends and family, and provide an alternative to fruitless acute care. It was predominantly administered through small agencies run as not for profits, often with religious or public health entity affiliation. Then things started to change. Hospice came on the scene just as the corporatization of American medicine began to take off in all sectors. Its relatively low overheads and steady sources of payment through Medicare started to make them acquisition targets.

Clinically, things were changing as well. The rise of hospice coincided with the HIV epidemic with a lot of previously robust young people requiring terminal care. Hospice learned how to manage medical issues far beyond cancer and it became clear that hospice could provide benefit to many sorts of end stage illnesses – cardiac disease, pulmonary disease, renal disease, dementia. Guidelines were developed on a national level to help hospices and clinicians determine who was appropriate for hospice services and who was not. But here’s where we start to run into clinical problems. Human beings never fit into the nice neat categories that administrators create. At the same time, the enormous increase in the very aged in their late 80s and 90s were overwhelming the systems we have to provide care to the frail elder. Physicians and families would start to wonder why the robust sixty five year old with lung cancer who was still getting out every day and driving to the mall would qualify while the ninety five year old who could not get herself out of bed without assistance but who was suffering from nothing more than the infirmity of age could not. And hospice is an all or nothing program. You’re either in and qualifying for its benefits and assistance (but you give up your acute care treatments under Medicare in exchange) or you’re out and all that is taken away.

In states like Alabama where senior services are practically non-existent, hospice is one of the few mechanisms available to deliver appropriate palliative care for the aged and everyone who works in medicine is aware of that. There’s a push by patients and families and community physicians to qualify marginal people so there’s enough assistance to allow them to stay home comfortably. But then that leads to people being admitted and staying on hospice for years and, if they stabilize because of the extra medical attention, then they have to be discharged for failure to decline, starting up a cycle of decline and readmittance to hospice and discharge when they stabilize again. When relatively easy care patients who are stable appear on the hospice roles, profits go up as they are less resource intense. In a for profit environment, this pushes the system to seek out more of these type of patients and, in unethical hospices, some of the more egregious issues mentioned in the article start to happen. I had one just a few months ago. One of my VA patients, healthy but slightly confused and living in assisted living, was all of a sudden admitted to a hospice without my knowledge. He had no medical problem which would have qualified him. We found out that a hospice marketer was trolling the halls of the facility and having people sign for promises of more help then the usual staff could give them but without real explanations of what they were signing for. We called the hospice suggesting they disenroll him as he wasn’t qualified. They refused. We then called the Medicare fraud hotline. He was rapidly disenrolled the next week.

I always try to do right by patients and balance all of the competing interests – their personal wishes, their family needs, the economic pressures of insurance, Medicare and other payors, my abilities as a physician and a human. It’s just becoming harder and harder to do so as the fault lines uncovered by the pandemic become more and more rigid. How much longer can I keep this up? I don’t know. I’ve made a pledge not to retire during calendar 2023. I haven’t said anything about calendar 2024.

158. It’s just a number, much like any other three digit number. But it’s one that’s going to make a huge difference over the next few decades. It’s the number of medical residents that opted for advanced training in geriatrics this next year. It’s far lower than the nearly 250 from last year (fewer than a hundred of whom were graduates of US medical schools). It’s lower than it’s been for some years leaving the vast majority of training positions (something over 400 nationwide) unfilled. More than half of the training programs across the country have no fellows coming in 2023. This lack of trainees means less hands to do the work. Less people coming up the ranks to provide the specialized clinical care that complicated older people need. And less visibility of the specialty in the health care system making it even harder to attract young physicians our direction.

2023 will see roughly 3.4 million US residents pass from age 64 to 65 and enter their senior years. (There were about 4.25 million babies born in 1958 and roughly 80% of them remain alive). Half of those, at current trends, will be alive in 2043 at the age of 85 or 1.7 million. And these figures remain roughly the same for all of the cohorts five years either way. So, we’re producing roughly one geriatrician for every 10,000 new senior citizens. Even the best and most efficient physicians have difficulty caring for panels of patients much over 2,500 and that’s for a young and healthy population. If numbers like this continue, specialized senior care in this country will collapse. It’s inevitable.

I’ve been fighting the good fight and telling anyone who will listen (and it hasn’t been many) for years about what demographics is going to do to the health system and what sort of things need to happen in order to make geriatrics a more attractive career choice to young physicians. Very little of that work has been done. It doesn’t generate revenue or headlines. And here we are. A rapidly aging population of Baby Boomers, a significant population of Silent Generation in their 80s and 90s still in good health but in need of assistance to maintain that, and a health system reeling from the strains of the pandemic that’s unable to change its entrenched models with any kind of alacrity. A healthcare workforce so burnt out by the last few years that more and more are pursuing early retirement.

I’ve devoted more than thirty years of my life to the pursuit of excellence in clinical geriatrics. I’ve taken care of thousands of patients, trained hundreds of residents, dozens of fellows, lectured to crowds of five and five hundred, and tried to follow the dictum of you save the world one patient at a time. I knew it was an underserved specialty which ranked very low in the hierarchy of medicine when I entered it. In my early years of high energy, I naively thought that I and my generation would change all of that somehow. We didn’t any more than the generation before me or the generation after me has been able to. Usually, when confronted with concrete evidence of how little difference we’ve made like the 158 this year, I shrug it off and move on to the next problem to be solved.

This year, however, it feels different. Maybe it’s my rapidly rushing towards my senior years myself. I keep getting patients with major issues who are younger than I am which is enough to make me feel old and to remind me that we are promised nothing. Maybe it’s the departure of colleagues which has accelerated in the post pandemic era (we had eighteen geriatrics faculty a decade ago – we’re now down to eight). Maybe it’s my continued perusals of demographic charts and constant adjusting to the rapid swings of Medicare policies as the Center for Medicare and Medicaid Services constantly adjusts to both clinical and financial realities. I’m feeling like my major life’s work hasn’t mattered. It’s mattered to individual patients and families, but not in the grand scheme of having made a difference to the world going forward.

But then maybe I’m just hangry because I skipped lunch. Perhaps some chicken masaman can restore my equanimity. At the very least it might give me the energy to haul out the holly and put some Christmas decorations up. But then again, it might just put me into a post prandial torpor and I’ll lie there on the bed watching Netflix and cuddling with the cats. Binx the ghost cat has decided he likes being up on the bed with me and Oliver. He’s even snuggled up a few times and allowed me to pet him. Progress is being made.

If you see my father, wish him a happy 90th. I think he’s a bit bemused by entering his tenth decade as I am from entering my seventh. He remains in good health and does the three things required to maintain it at his age – eat, sleep, and move. And mainly stays away from the one thing that must be avoided, visiting the floor. These days we should probably add handwashing and appropriate vaccinations to the list.

And another long Thanksgiving weekend draws to a close. I’m lying here in bed losing a battle against napping. Perhaps it’s Oliver tucked up against me snoring away. Binx, the ghost cat, will sometimes get up on the bed with us as well but he still won’t come near me and if I make any motion in his direction, he immediately hightails it under the bed for the next quarter of an hour. It’s an improvement over hiding in the fireplace or under the shelves in the guest closet all day I suppose. Someday he may figure out I mean him no harm and am the source of all kitty treats. In the meantime, cat behavior is simply what it is.

Nothing too outrageous happened over my off days. I had two Thanksgiving meals, one with Tommy’s family and one with friends, stuffing myself to the gills and making eating on Friday entirely unnecessary. Good food, good conversation, good company. What more could one want? The rest of the weekend was spent in a combination of torpor, household tasks such as prepping all of my mail out copies of Volume II for a trip to the post office this next week. I also got the family Christmas shopping done so I could put together the traditional gift basket for shipping to Seattle. I have become the dotty old uncle that gives everyone a book. It solves a number of problems when shopping for family whom I do not see all that often: there’s a fairly infinite selection, it’s unlikely to be duplicative, and they’re easy to wrap. This last is not necessarily the least. Wrapping has never been my strong suit. Both Steve and Tommy were quite skilled and could make packages worthy of high end store windows. (Steve’s first career was as the window display designer for the Sears in Santa Monica back in the 1960s). Mine come out lumpy, uneven and dog eared, no matter how hard I try. I did, however learn a few tricks from Tommy regarding the construction of gift baskets. Three bookstores and done. And I made it through my Christmas shopping safe from Whamageddon and Mariah Carey.

I had my first reading today from Volume II at East Lake United Methodist Church as a benefit for their theater program, The Belltower Players (so called as the church building has a rather massive belfry that can be seen from all over that part of town). I’ve been a friend of the church for some years. Someone, I can no longer remember who, suggested I audition for Scrooge in their production of A Christmas Carol some years ago and I’ve been popping in and out ever since, most recently with The Hallelujah Girls this last fall and I am directing Dearly Departed there in January and February of this coming year. The audience was mainly friends so I didn’t have to sell myself, just read and let my words of a year or two ago speak for me. They were very receptive. I’m still amazed at how something I dashed off one evening with minimal thought causes someone to have an emotional response months or years after the fact. Let’s face it, I’m still surprised that these books exist as I had no intention of writing them. If anyone would like to arrange a reading/signing with me as a benefit or just because you’d like to see me appear at your local bookstore, slip into my DMs. I also strongly encourage those of you who want to read this new book to order it through your local bookstore and ask when you order, if they’d get another copy or two and put it on one of their display shelves.

This begs the question of what do I write next? The Accidental Plague Diaries are drawing to a close with the receding of the pandemic in public and social consciousness. The pandemic isn’t over, but the wrenching social changes and huge impacts on health care that marked the last few years have levelled out giving me a lot less to write about on the Covid front. Mind you, we could have a huge resurgence this winter, there could be a new mutation that does something highly unpleasant, or there might be a socio-political development that sends things spinning in a new direction but unless any of these things are overwhelming, I’m pretty much done. There are 790 pages published, an unknown number in Volume III, and when you have over 1,000 pages devoted to anything, you’re just getting repetitive.

I am in the habit of writing 2500-3000 words a week so I think I need to keep that up as a form of self discipline. Do I return to the book on the impact of the Baby Boom on the health care system? (That seems a bit redundant as most of what I was going to say in it came out in The Accidental Plague Diaries in one form or another). Do I take my Mrs. Norman Maine film reviews (sadly neglected these last few months) and edit them into a cohesive whole? Do I try my hand at a work of fiction? If I do, should I write a genre piece (murder mystery? fantasy? romance?) or something more general. My fiction prose tends to be lightly satirical, similar in style to Patrick Dennis or Armistead Maupin, but what would be the subject? Senior living? The social constructs of greater Birmingham? Academic health centers and their internal politics?

There are several things I did not do this weekend despite good intentions. I have not yet broken out the holiday decorations or decided how much of them I’m going to use. I put them all up at Christmas 2020 so I know how to make them work in the condo but the process of hauling all those boxes and bins out of the basement storage and getting things arranged just strikes me as exhausting at the moment. I also have not completed my CME for the year and that must be done before Christmas or the powers that be will come after me with a stick. I know what I need to do to finish them up. I just have to make myself do it. Likely a long dull Saturday afternoon sometime. In the meantime, you all know the drill. Get your booster, wash your hands, complete your licensure requirements.

Backup singer for The Eagles… Not something I’d ever expect to have on my resume, but there you have it. I’ve known about last night’s gig for a couple of months but those of us in the Opera Birmingham chorus who participated all signed non-disclosure agreements and were forbidden to talk about it until after the fact. So now I can sit down and write about and ruminate on what it was like to be part of a major touring concert show. A couple of things to get out of the way: no, I didn’t meet Don Henley or Vince Gill (singing Glenn Frey’s vocals), yes I was paid (medico-legal work pays much better), no I didn’t get to keep the choir robe but I do have my laminated backstage pass on a lanyard as a souvenir.

The Eagles current tour has a big production number at the end of the first act in which Don Henley sings ‘The Last Resort’ which, as the number builds, requires a full string orchestra and a back up choir. It’s a good deal cheaper for the tour to hire these locally at each stop than to pay for thirty instrumentalists and twenty-four singers for several months, not to mention feed and house them. Opera Birmingham got a call from the tour back in September asking if we could provide the chorus. A chance to sing with The Eagles? Getting Opera Birmingham’s name and people in front of an audience of nearly 20,000 at The Legacy Arena? It was a no-brainer and we quickly signed up. Last evening, many of the chorus regulars gathered at the opera offices for a quick rehearsal (eight bars of I-IV-V-I chords on ‘AH’ isn’t difficult to learn) and then caravanned over to the arena.

We were met there by a tour functionary who gave us backstage passes and marshalled us into a large greenroom, later joined by the members of the string orchestra (mainly players from the Alabama Symphony Orchestra) to wait until our cue. We couldn’t see a lot, but when the concert started about 90 minutes later, we could certainly hear it, even if it was a bit muffled by various doors and drapes. About forty-five minutes into the set, the strings were lined up and marched out to their places . We followed about twenty minutes later, dressed in gold choir robes supplied by the tour, winding our way through the bowels of the arena, past the various dressing rooms, craft services stations, wardrobe, make-up, engineering departments and the like. Eventually we came to a loading dock type area full of enormous road cases and foot lockers and a lot of technical types and then were funneled into a backstage area and onto a set of rising platforms.

Hurry up and wait and stand waiting for cue. At the right moments, the platforms with the chorus and the strings rose up behind the band and a dozen cameras started photographing us and projecting us on the huge Jumbotron screen that formed the backdrop. Number reaches climax. We sing our ‘AH’. Number ends. Pandemonium in the house and standing ovation as the audience has recognized locals blown up to forty feet high on screen. Acknowledgement of our contribution from Don Henley and we are lowered back into the depths of the backstage area. Shed robe, collect souvenir merch and we are done.

It was rather an incredible experience and full of firsts. First time to perform for an arena sized audience. First time to perform with an internationally known act. First time appearing larger than life on a Jumbotron screen. Also, as president of the Opera Board of Directors, I am very grateful to have had an opportunity to get the organization in front of a whole new audience, many of whom may not have realized that Birmingham has a professional opera company. We probably reached more new people last night than in the previous few years combined.

The tour was taking standard Covid precautions seriously. Masks on unless actively eating or drinking or on stage. No going backstage into areas you didn’t need to be in. No hanging out with the tour crew other than those responsible for corralling the chorus and orchestra (and after multiple stops, they have it down to a science). A tour like this is a multi-million dollar extravaganza and Covid among the artists would be disastrous.

Generationally, I am in the sweet spot for The Eagles. I was born in 1962. We form our musical tastes generally between ages 12 and 25 (1974-1987 for me). Their Greatest Hits album (the blue one with the bird skull) came out just as I was really discovering pop music. Hotel California came out my freshman year of high school and The Long Run came out my senior year of high school. Their music is very much interwoven with my adolescence and coming of age. Pretty much any of their songs can quickly take me back to a memory of the 70s or early 80s. I’m trying to imagine going back in time and trying to explain to teenage Andy that one day, he would be onstage with that band singing back up vocals before 20,000 people. Teenage Andy would have assumed serious mental illness and looked for the nearest exit. Funny how some of the threads of events and people come and go in the tapestry of our lives.

It’s Friday, the sun is sinking in the West and so we say goodbye to another work week, the last full one before the holiday season begins in earnest. I only have to work a half week next week but I did volunteer to take the clinical call for the long weekend so that those with families and kids wouldn’t have to. I don’t have particular plans for the long weekend. I’ll probably keep up my tradition of doing my Christmas shopping on Saturday during the Alabama/Auburn game when the majority of the population is glued to the television set and the stores are relatively empty. Shopping shouldn’t be difficult. I’ve evolved into that eccentric old uncle that gives everyone books. It just becomes a game of finding just the right title for just the right person.

New books were always one of my favorite things to find under the Christmas tree when I was small. The first Christmas I can remember is the one when I was three (Christmas 1965 for those of you keeping score at home) and there were picture books for me which held more interest than the Tonka bulldozer or the blocks, but maybe not as much as the Viewmaster. I still have a few of my childhood picture books, and many of the good editions of the children’s classics that my father read to me over the years, some of which had been my parents and even my grandparents as children. Reading remains a fundamental pleasure and I try to get through a book or two a month when I have the time and I make it a point to either read or listen to one of the great works of world literature every year that I missed along the way. Recent choices have been Madame Bovary, Anna Karenina, Moby Dick, Barnaby Rudge, and The Mayor of Casterbridge. Next up is Martin Chuzzlewit. I plan to get through all of Dicken’s major works before I die, including the ones that no one ever reads anymore.

Work has been pretty steady without a lot of pandemic issues. There remain a good deal of tangential problems however including short staffed senior care agencies, mental issues in patients and families, worsening disease from delayed care, and general administrative oddness. The biggest problem has been the loss of physician faculty from the UAB geriatrics section. We are down roughly 50% over the last decade and trying to run a similar clinical footprint on half the people is becoming more and more difficult. I don’t know where we’re supposed to get new faculty as no one in US medicine goes into the field. I’ve written extensively in the past as to the reasons why this has happened so I’m not going to repeat them all again. Let us just say there are days where I feel content with work and other days when retirement cannot come soon enough.

The VA system has made a conscious decision to reallocate resources to programs designed to keep veterans out of custodial care and out of emergency rooms so the house call program is gaining rapidly in prestige and finances. We may be able to meet my goal of expanding to a point where every veteran in North Central Alabama who lives within the Birmingham VA catchment area can access house calls within the next two years. I was thinking it would take a decade. I’ll be thrilled if we get the whole thing up and running, taking in the whole territory with strategically placed teams of case management nurses and ancillary services. The biggest obstacle will be in finding qualified and quality team members who are resourceful and motivated to work in the unique niche of home based primary care. It’s very different than working on a ward or in an office. When you enter someone’s home, you’re not the one in charge and you have to respect that shift in power dynamic and learn how to get patients and families working together with you in partnership to improve health and function.

I am getting a new boss at UAB, the new chief of the UAB Division of Gerontology, Geriatrics, and Palliative Care arrives the week after Thanksgiving. He is coming into academic senior care at an, as they say, interesting time. I’ll help him the best I can. I have no idea what his goals or priorities are going to be. I’ll just try to give him the history of the last twenty-five years and let him know what has worked and what has not and why and see what he runs with. It’s hardly the first time I’ve gone through a change in leadership. I’m just glad it’s not me. It’s a very difficult time in medicine and navigating it is not for everyone. I’ll just remain in my own little clinical world saving society one patient at a time. It’s all I can really do.

What’s up with Covid? Well, the pandemic remains unfinished. Cases in Los Angeles are up 50% over two weeks ago. (Thank you Omicron variants BQ 1 and BQ 1.1 which are becoming dominant there). It doesn’t appear that hospitalizations are going up at that same rate but it’s early times yet and hospitalizations are a lagging indicator, usually going up about three weeks after the case rates start going up so we should have a better picture in mid-December. Meanwhile, in New York, the current production of Little Shop of Horrors had to all off a recent performance at intermission as key cast members got sick during the first act and there weren’t enough understudies and swings available to continue. I suppose they could have pulled an Audrey out of the audience. If she had been able to belt out ‘Suddenly Seymour’ without rehearsal, it would have been a real Shirley Maclaine moment.

I’m off to a wedding tomorrow. It’s my first one since the ‘before times’. One of the advantages of my performing arts life is that it keeps a lot of younger people in my social circle so I do still get to go to an occasional wedding and not just have to satisfy myself with pictures of my peers new grandchildren. I’m not sure if wedding etiquette has changed to conform to new social realities in a more virally conscious world. I guess I’ll find out tomorrow. If nothing else, it will give me the excuse of breaking out some fancier clothes. That may help my mood. Time to go put on some Jerry Herman and sing along to ‘Put On Your Sunday Clothes’ from Hello, Dolly!

Another weekend comes to an end with me only having accomplished about half of what I had set out to do. Some of that is due to the never ending stream of electronic health record progress notes I have to write. They take about 15-20 minutes apiece and are therefore impossible to complete during a clinic visit when my attention is supposed to be on patients and their families., leading to a backlog to be finished up over the weekend. This usually takes four to five hours leading to a major dint in my free time. Some is due to my needing to nap every time I sit down and stop moving for more than fifteen minutes. Some of that is due to various social obligations. I’m very good at saying yes to things. Trouble is that means I actually have to follow through sometime down the line.

I’m starting to prep for the show I’m directing after the first of the year, Dearly Departed. It’s another one of those southern fried comedies. It’s darker than the Hope/Jones/Wooten variety, less raunchy than those of Del Shores, and is a favorite of community theaters due to its easy technical requirements and strong characters with a preponderance of female roles. It’s been many decades since I last directed a straight play and we’ll have to see if I remember what I’m doing. I’ve got a visual concept in mind, a way in which I want to approach things thematically, some decent actors on board. I should be OK.

I’ve been watching the hubris of Elon Musk with great interest the last few days. I can’t figure out if he spent $44 billion to acquire Twitter because he wanted to shut it down, if he believes his own propaganda that as an obscenely rich person, he must be smarter than everyone else and every decision he makes must be genius by definition, or if he just stumbled clueless into a business of which he really knows nothing and is trying to figure it out under a very bright spotlight. He obviously did not study the history of the rise and fall of other tech giants such as Yahoo! to see how easy it is to completely muck things up with bone headed decisions and he seems to have the usual right wing misunderstanding of free speech. Free speech means that the government cannot punish you for expressing unpopular or political opinions. Free speech does not mean that every opinion should be given equal weight, especially when some of those opinions are based on misinformation, faulty reasoning, or are pure propaganda. The speed at which Twitter is collapsing makes me think we’re hitting Tumblr 2: Electric Twitterloo territory.

A corollary to the above is the story of Eli Lilly. Musk’s idiotic idea of handing out verified status to pretty much anyone who was willing to fork over eight bucks without actually back checking led to someone posing as the official Eli Lilly account and then tweeting out that their insulin products would be free in the future. It was retweeted and run all the way round the internet in a few hours before it was taken down but not before it tanked Eli Lilly’s stock and sparked a healthy debate as to what Big Pharma in general has been doing with drug prices in general in recent decades. When insulin was first invented and patented in 1923, the inventors refused to profit from it under the belief that the lives that would be saved were more important than their personal enrichment. So why is a drug that was gifted to the world and will be a century old in just a few months costing patients hundreds of dollars monthly? Interesting question. While insulin itself is not under patent, delivery systems, additives, ways of modifying it so as to change its absorbability or distribution in the body are.

Insulin isn’t the only drug where these kinds of games are played. The drug colchicine, used in the treatment of gout, and around since the time of the ancient Egyptians, used to be exceedingly cheap. The trouble was, that the drug was so old that there had never been any real scientific study of its effectiveness. The FDA was going to take it off the market as unproven until a drug company stepped in, did some studies, and showed it worked as expected. The FDA then allowed the company to exert patent rights over colchicine and it is now their exclusive and proprietary property. What was pennies is now many dollars. The common asthma drug, albuterol, had a similar fate. It was generic and cheap for quite some time. When chlorofluorocarbons were banned as aerosol propellants due to the destruction of ozone a few decades ago, that covered albuterol inhalers. The propellant in the cannister had to be changed. As the delivery system was now ‘different’, it allowed pharmaceutical companies to reclaim exclusive rights and it went from cheap generic to expensive brand only overnight.

Covid numbers, both locally and nationally, remain about the same. That’s not necessarily the same with international numbers. There’s been a significant increase in China with their autocratic government imposing more lockdowns and restrictions to bring things back under control. As several of the important industrial cities are included, this means that we will likely continue to have issues with the supply chain of manufactured goods for the foreseeable future. If you need to replace any of your consumer electronics, do it now. My next out of the country trip, coming up in about six weeks, is to the UK. They’re numbers remain relatively low so hopefully there won’t be any serious issues with that trip coming off, having already been delayed by a year.

Time for me to get up from my writings, get dressed, and head out to the next social obligation. A fundraiser for a local theater advertised as a sneaker ball. Dress formally but wear sneakers. I think I can handle that. I’m also wearing hand sanitizer and have a mask in my back pocket should I not like the ventilation available at the venue.

It’s the day after the midterms. And the result is… the country is as divided today as it was yesterday. It may be a while before we know who controls congress due to any number of close races and need for runoffs, but it looks like the gap will be narrow between red and blue, no matter which way the pendulum eventually swings. It’s not the result that the partisans on both sides were exulting about, all in their own ways, these past few weeks, but it’s what we’ve got and what we have to use to move forward.

How will this impact what comes next when it comes to the pandemic? It’s tough to say. A lot will depend on how well the current administration can maneuver with a narrowly divided legislative branch. A smart president and cabinet can use that dynamic to benefit their agenda but it needs to be done carefully and with a certain amount of finesse and I’m not sure the Biden administration possesses those skills. I might be surprised. They may be able to push through some legislation that will strengthen the health care sector, public health programs and future pandemic response. Then again, they may decide that’s all yesterdays news and go for actions that will appeal to the more current kitchen table economic issues that have bedeviled them over the last six months or so.

I was relieved that the party that seems to be most wedded to a philosophy of selfishness and greed rather than to one of cooperation and altruism did not win in a blow out. Given the current economic conditions, that should have easily been the case, but the fact that the big win failed to materialize suggests that the American voting public is more interested in governmental solutions to big problems than in destroying government’s ability to respond to big problems. The more contested states that have been on the fence between R and D seem to be moving a little closer to D in their voting patterns. Have they noted the general prosperity of the more liberal parts of the country as compared to the more conservative? Did the death of a million or so voters over the last two and a half years, more conservatives than liberals due to to vaccine denialism change the balance of power just enough? Is the public sick of obnoxious bloviators with minimal intelligence representing the country in congress and in the media? Who knows. I’ll let the political scientists sort through all of that.

In viral news, the numbers for Covid remain relatively stable. We’re still at about 300 deaths a day. 30,000 people remain hospitalized, roughly 10% of them in intensive care. It’s still not possible to completely parse out whom is hospitalized for Covid (the infection being the major reason they are ill) versus whom is hospitalized with Covid (they test positive but the real pathology putting them in the hospital is either only tangentially related or unrelated). I haven’t been able to find any recent numbers on what percentage of hospitalized are unvaccinated vs vaccinated vs vaccinated and boosted. The common sense conclusions that are emerging with the most recent data are that vaccines are very good at preventing serious disease and reduce the chance of prolonged illness or long Covid significantly. Vaccine immunity, however, isn’t forever and tends to wane somewhere around six months after the shot so booster shots remain a good idea and will likely become annual. The mRNA technology allows them to be relatively easily adjusted for new circulating strains. Natural immunity from infection also appears to wane after six or eight months so its possible to get reinfected a couple of times a year. (It was roughly eight months between my two bouts this past year and I had had a booster shot in between). It’s also becoming clear that Paxlovid, when used shortly after symptoms appear in older adults, is very good at reducing symptoms, duration of the infection, and development of long Covid. It doesn’t seem to help younger people with more boisterous native immune systems much.

Locally, the viral news isn’t about Covid. Numbers here are relatively low. The Birmingham VA, which still issues reports on numbers, is down to three inpatients and seven staff out with infections. Two months ago it was about five times this. We’re having a major influenza outbreak instead. Both influenza A and B are circulating in high levels locally and causing a lot of misery. It’s a bit weird. Generally flu season in Alabama, due to its southern clime, is January-February, not late October-early November. We’ve also been having unseasonably warm temperatures with afternoons going up to the high 70s and low 80s. At least the humidity is gone. The numbers are high enough that it’s drained the local pharmacies of their supplies of flu antivirals – it’s difficult to find a dose of Tamiflu anywhere in the metro area. At least I’m not hearing about significant upticks in hospitalizations and/or deaths yet.

Why are the numbers so high? The prevailing theory is that the last two and a half years of reduced viral transmission due to masking and social distancing, having more or less come to an end, has led to more people coming into contact with more microbes than they have for a while. As everyone has had less respiratory illness due to these same factors, immune systems may not be as revved up as they usually are and that is making people more susceptible, especially among younger school age populations who then carry it home to parent and grandparents. Hopefully, it will burn itself out shortly. In the meantime, this would be a really good year not to skip your annual flu shot.

I have finished editing the print proof copy of Volume II of these Accidental Plague Diaries. The changes are in at the publisher and I can announce a street date as soon as those last few typos are corrected. It should be by the end of next week. I think I have one more volume in me, covering the age of omicron, to come out in 2023 and then I think it’s time to lay this particular project aside. Of course we’re only one mutation away from the pandemic careening into some new form that will require additional study and understanding, but I’m hoping it doesn’t come to that.

So, if I’m going to reduce my plague writings, where and how do I direct my focus to a new writing project? Do I keep up these writings and see if they morph into something unexpected? Do I see if I can actually write some sustained fiction worth reading? Do I go back to the original book about the aging of the Baby Boom and wrestle with it? (Most of what would have gone into that has appeared in some form in The Accidental Plague Diaries over the years so it strikes me that that would just be repeating myself). Do I write a play? Maybe two? I don’t know the answers to any of these questions. I’ll leave it up to coincidence and serendipity. They’ve been my guiding stars for years.

Some things I do know. Clean hands are good for you. Masks never hurt. Covid shots and boosters are a really good idea. It’s a good time to be gentle with each other; we’ve been through a lot and we’re all hurting from our experiences, each in our own way. Perhaps the greatest thing you can do in life is tell the story.

And Volume II of these Accidental Plague Diaries is now a reality. Well, at least I finally have a proof copy in my hands and am busy plowing through it looking for egregious mistakes and typos before unleashing it on an unsuspecting world. I’ll let everyone know when there’s a formal release date. Should be in about two weeks, just in time for your holiday shopping (hint… hint…). It’s really odd reading over things that happened a year or so ago and having them feel like ancient history, especially when I realize that I’m in the midst of writing the end of Volume III. I’m pretty sure I know where the cut point for that is going to come. Will there be a Volume IV? I certainly hope not.

So where are we with the pandemic? It’s still very much with us. The numbers of ill and dead remain relatively consistent with about 40,000 new cases and something over 300 deaths reported daily nationwide. It’s the new normal that we as a society have decided is acceptable. Will these numbers go up as we head into later fall and winter? It remains to be seen. The underlying strains remain omicron but we’re transitioning from the BA 4 and 5 variants that were prevalent this summer to BQ 1 and BQ 1.1 which were unknown a month or so ago and are now responsible for about 35% of US infections. They appear to be as easily transmissible as other omicron lineages but there are also a couple of nasty surprises. Preliminary data suggests that they are quite good at evading the immune system’s natural responses so natural immunity from prior infection isn’t as good as it has been (the jury is still out on vaccine mediated immunity). BQ 1.1 also appears to evade Evushield, the drug given to the severely immunocompromised in whom vaccines are ineffective. Paxlovid still seems to be working.

Those at risk appear to be the elderly, especially those over the age of 75 or so (watch out Cher) and the seriously chronically ill. These tend to be somewhat hidden populations in our youth oriented society so morbidity and mortality in these ranks don’t always penetrate public consciousness the way that they should. Vaccines remain the best weapon we have so go get that booster you’ve been putting off. The new bivalent with specific effectiveness against omicron is going begging. Once the money congress has appropriated for it which has made the vaccines free to the public runs out at the end of the year, we’ll see even less likelihood of people going out and getting it.

The pandemic isn’t over. I’m not even certain it will be over within my lifetime, but the acute phase seems to be drawing to a close and we’re settling in to a new chronic phase where it’s just there in the background of life. I can live with that but I live with it with one eye open and a conscious desire to know what’s going on. As it becomes less and less of a headline generating, all encompassing topic, most aren’t going to take the time and trouble to really know what the issues are or what’s really going on. Especially in this day and age of infotainment and corporate ownership of media where everything is about revenues and clicks rather than about keeping the public informed. Here in Birmingham, we no longer have a daily newspaper. There is a web presence, but that eliminates dissemination of news to populations who are either too poor to own devices or who are of an age that they don’t feel the need to learn new technologies. And that latter is the group most at risk from Covid. The disappearance of print is one of the things that has pushed susceptible populations into the clutches of the 24 hour news channels with their partisan focus and their reliance on hyperbolic opinion over fact.

All of this worries me, not so much about Covid, which is reaching some sort of equilibrium, but about the natural history of the next pandemic. And there will be a next one and chances are it will be much nastier than what we have seen to date. There are now eight billion human beings on the planet (about three times the number that existed when I was born). This means humans are pushed into new habitats and into contact with new environments and their microbes. Add to that modern transportation and something highly transmissible and highly fatal is going to enter modern urbanized society eventually – and we have laid a social groundwork of distrust of public health measures, division into us and them where bad things and diseases are only a problem of the them, and a rejection of expertise for personal feeling and belief, no matter how outrageous those may be. If something with a ten or twenty percent mortality rate gets lose, we’ll be lucky if Western Civilization doesn’t come crashing down.

In other news, the holiday play that I was in the process of rehearsing has been put on ice until next holiday season. It’s one that requires more rehearsal than this company can give it so, as we’re all used to putting things off these days, it’s been decided that that is the best course of action. There have been unexpected good things that have come out of this decision, the first being that I’m going to direct Dearly Departed for The Belltower Players at Eastlake Methodist. Auditions are next weekend, rehearsals start January 9th and it goes up late February if you’re interested. The second is that it frees up my schedule to sing The Messiah with the Alabama Symphony Orchestra on December 17th. So that settles my music-theater life for the next few months. Assuming the pandemic doesn’t have other plans…

The midterm elections are in a few days. Figure out your Tuesday schedule and get out and vote. We only make progress when we do it together. When half to two thirds of the population checks out, minority policies and opinions prevail. Just wash your hands before and after you go to the polls. And consider masking if your polling place isn’t particularly well ventilated.

It’s All Saints Day, following hard upon Halloween, with All Souls Day coming up the stretch and Guy Fawkes Day taking the pole position. There really are a few too many notable occasions crowded into this week. Perhaps a few could be shifted to August which is notable as being the month without any significant holidays of any type. To me, of course, this week marks the anniversary of my arrival in Birmingham with Steve, Patrick the cat, and a 1994 Acura Integra stuffed with boxes and baggage as the vanguard of our household relocation; the moving van was a day or two behind. We hadn’t quite closed on the house so after we dodged the crowds of trick or treaters driving up Clairmont Avenue (never knowing that years later we would own one of those houses), we checked into the Crestwood Holiday Inn which was our base of operations while we got the furniture into the new house, got the utilities transferred over, opened the bank accounts, and all of the other annoying little details a cross country move entails.

That was two dozen years ago. I was thirty-six, licking my wounds after the ignominious end of the clinical geriatrics program at UC Davis into which I had poured seven years of my life and energy, figuring I would be here in the deep south for maybe five years before moving on somewhere more propitious. Boy was I wrong and I had absolutely no idea the twists and turns that life was about to take. I feel like I’m at a somewhat similar crossroads now. I’m transitioning into the final arc of my professional career and I can’t yet see how that’s going to turn out or what it’s going to entail. Will it be mainly clinical? Will it be more creative than that and be more about programmatic development? Will factors outside my control force me to reduce my usual days of racing from pillar to post, trying to get all of the tasks completed and the deadlines met? I haven’t a clue.

Three years ago this week, I was recovering from the usual wild ride of putting together an edition of The Politically Incorrect Cabaret. I had additional performances on the books: The Messiah and The Mozart Requiem with the Alabama Symphony Orchestra and Chorus, Cendrillon with Opera Birmingham, Herr Schultz in Cabaret and a small part in 1776 with Virginia Samford Theater and talk of a production of The Gin Game. Only a few of those came to fruition because, four months later, the world as we knew it shut down. The writings that I had been doing to entertain myself and my friends morphed into these Accidental Plague Diaries documenting, from my own unique point of view what was happening, and continues to happen to our world.

I’m starting to think it’s about time to put these writings to rest. Not because the pandemic is over, but because we believe the pandemic is over and our choices and behaviors echo that belief, no matter what science and fact tells us. I’ve spent too much of my life in geriatric medicine, calling out like Cassandra about the weaknesses in the American health system as it has to deal with a rising and inexorable tide of aging Baby Boomers, to want to remain a lone voice in the wilderness, preaching to my audience of one. I’d like to write about other things. History, art, music, social science, but not necessarily seen through the lens of Covid.

I’ve spent a lot of time poring over numbers, trying to reduce some rather complicated epidemiologic concepts to easily digestible morsels, looking at mortality, morbidity, case rates, the exponential math of spread and the like. Where are we now? Deaths remain relatively flat and stubbornly in the range of 300-400 daily. This multiplies out to somewhere between 100,000 and 150,000 annually. This is far below the 375,000 deaths in 2020 (about 10% of all deaths) and 460,000 deaths in 2021 (about 14% of all deaths). But it’s still about five times the annual death rate for influenza and high enough that this disease, absolutely unknown three years ago, looks to be the third leading cause of death 2020-2022, behind heart disease and cancer, and will be fifth or sixth going forward assuming there are no further surges (and that’s not a great assumption to make).

Modern science and the new mRNA technology allowed us to develop effective vaccines in records time. The first shots were going into arms less than a year after the virus was first detected in Wuhan. Despite widespread availability, the most recent booster has been greeted by a collective yawn by the American population. Fewer than ten percent of eligible adults have received the bivalent booster engineered to be more effective against the omicron variant. Is this how the pandemic ends? Not with a bang but with a whimper of apathy? I’m planning on getting every new booster as it becomes available. The virus has proven itself to have way too many nasty effects with unknown and unknowable long term effects waiting to surprise us later on. Most people aren’t as most people, who have had a combination of original vaccines and boosters and natural infection have enough of an immune response that when they have gotten the disease recently, they aren’t all that sick. Unfortunately, it may not remain that way as both natural and artificial immunity wanes fairly rapidly with time.

The antiscience antivaccine crowd aren’t apathetic. They’re still out there trading their conspiracy theories in the darker corners of social media, popping to the surface occasionally. A large contingent descended on the Greenwich Village annual Halloween parade this past weekend. A week from today, we go to the polls. One political party has repudiated this type of thinking, one has embraced it. Whichever one wins is likely to determine our continued pandemic responses going forward. Like every election, we’ll get the result we deserve.

I went to a reception earlier this evening at the UAB President’s mansion. I hadn’t been there in twenty four years, the only other time I was invited was to the party welcoming new faculty the fall I arrived in Alabama. This was to celebrate the creation of an endowed chair in LGBTQ health equity in the School of Public Health. I warranted an invitation as I had contributed to the necessary fund raising. As I stood nursing my drink on the terrace, I thought back two dozen years. It wasn’t that long ago but celebrating such a post would have been inconceivable back then. We couldn’t even get an equal protection clause into UAB policy at that point. Time marches on, things change, and the arc of history slowly and painfully bends towards moral right.