Covid cases continue to inch up, but they are flattening a bit so maybe the current surge won’t be as bad as feared. Numbers continue to be above where they were a month or so ago but they aren’t increasing terribly rapidly on either the national or the local levels. Fingers remain crossed. Of course, it’s not the only viral illness in the headlines at the moment. Monkey pox continues to spread fairly rapidly with something over 5.000 cases reported in the US to the CDC over the last month or so. It’s a very different disease than Covid and, as it spreads through interpersonal contact rather than being airborne, it’s nowhere near as equal opportunity as Covid has been. It will also be easier to contain should we choose to make good public health choices.

As monkey pox is spread person to person, isolating individuals infectious with the disease is enough to interrupt transmission chains. Contact tracing and self imposed quarantines would do a lot of keep it from spreading but that presumes the existence of a robust public health system to do the tracing and check up on the isolation. Unfortunately, Covid and its political fall out has done a bit of a number of public health measures. The mere mention of quarantines or the privacy concerns of contact tracing has been enough to rile up some political groups into attacking public health officers pushing good people out of those roles and leaving the system a bit threadbare. We’re fortunate that monkey pox, while temporarily disfiguring and painful, is not that dangerous a disease. There have been no deaths to date in the US and only one in Europe, a Spanish man with significant immune system problems. There is an effective vaccine, which is becoming more available to at risk populations and so far vaccine misinformation spreading through the darker corners of social media has been pretty minimal. If you are over fifty, you’re pretty well protected by your small pox vaccinations from your childhood and you need not worry a whole lot.

I’d like to stop writing about viral epidemics. There’s so much more to life than those but they do remain an overriding concern for those of us in health care. The damage to the healthcare system and public health infrastructure over the last few years is incalculable and I do worry sometimes about a truly dangerous virus such as Ebola or Marburg getting lose these days and the havoc that could cause before American society is willing to pull its collective head out of its collective rectum regarding such issues. I am hoping that the current surge fizzles out over the fall, that things remain relatively calm with the availability of the new omicron specific booster in a few months and that I might be able to wind down these Accidental Plague Diaries after three years. Will I find something else to write about? Almost certainly but I wonder if I’ll still be able to create as much quality material as quickly without the seismic shifts in society and health care as fuel.

It’s Friday night. I toyed with the idea of taking myself out to the movies and then decided against it. It’s not a pandemic thing. It’s a lack of energy thing. I’ve been very sedentary and solitary these past few weeks. Those of you who know me well know that there’s been a little bit of domestic drama around here, one that I might write about eventually, but now is not the time. Sorry to vaguebook with that but I am cautious in terms of dragging other people into these writings in ways that may not reflect kindly on them. Oliver the cat is keeping me company, sleeping next to me on the bed when not yowling for more kitty treats. He has been joined by a new little brother – Binx, a gift from a friend. Binx arrived yesterday and is still very much in hiding at being in a new environment. I have barely seen him. As long as he knows where to find the food and water and where the litter box is, I’ll let him come out and join the party in his own good time. And so Oliver and I are enjoying old episodes of 30 Rock on Netflix, as I work my way through some neglected work projects and a glass of Pinot Grigio.

I’m working my way through the first galley proofs of The Accidental Plague Diaries Volume II – tentatively subtitled Vaccines and Variants or some such. It should be out in about six weeks for all of you who have been keeping a space for it on your library shelves. I’m not going to push this one like I did the first, just put it out there and see what happens. I will be available for readings and signings should your group want to schedule one and am willing to travel reasonable distances for such events. I used to travel a lot for work, but most of that has dried up the last few years. Even pre-pandemic, my job was switching away from academic pursuits into more routine clinical work and the lecturing and conferences and such that I used to attend somewhat regularly were drying up. I doubt they’ll be back in the way that they were in the past moving forward for any of us. The clinical demands on those of us left to prop the system up are such that finding the time off to head off somewhere for a week is becoming more and more difficult. Plus the budgets for paying for such expenses have been significantly reduced. Plus we’re all used to attending meetings on zoom and we’re just all doing that now more and more.

When Tommy and I were first together, in the early 2000s, he was the chief nursing officer for the local Federally Qualified Health Center and responsible for a number of federal grants. I was still working with a number of organizations that met in DC routinely. That first couple of years, one or the other or both of us was in DC every other month or so. We would usually add a day on and take a bit of a break together – favorite destinations being Meskerem Ethiopian restaurant in Adams Morgan, shopping at Dupont Circle and Sunday Service at All Souls Unitarian Church. I haven’t been back to DC for well over a decade now. I assume it’s about the same but the images of January 6th still cast a bit of a pall over the sights for me. Perhaps someday again I’ll walk the halls of the National Gallery and the Air and Space Museum. Maybe I’ll even have someone to share it with.

A decade before Tommy, I had a lot of meetings in Bethesda at NIH with the Cardiovascular Health Study. I had to fly from Sacramento to National Airport about once a quarter, grab the Metro out to Bethesda, collapse for the night, attend meetings all the next day, go out to dinner with people and collapse a second night, and fly back on the third day. It was always a bit surreal as the trips were so quick and basically indoors the whole time. The work was interesting, being a group review of medical records to determine whether deaths were related to cardiovascular disease or not for study purposes. We were the group that discovered things like squiring sublingual nifedipine into patients in the ER was actually killing them. I enjoyed the big research phase of my career but I was also smart enough to know that it was never going to be my true calling. You have to have a real fire in your belly for grantsmanship to lead that life and I didn’t. I much preferred to actually doctor real humans face to face and so ultimately, due to my internal philosophy and various happenstances of life, the research faded away. It means I’ll never be a department chair or a dean but I can live with that.

What I’m having difficulty living with is a society that is willing to turn selfishness into an exalted virtue and which down plays humanitarian impulses into some sort of weakness. Do others a favor. Wash your hands. Don’t spread disease. Get your shots.

Onward and upward. That’s the name of the game as we continue to head into the BA 5 omicron surge that has drawn a collective shrug and a yawn from American society. Unless your livelihood depends upon a functioning health care system or involves public health planning, you too are likely to be spending most of your time worrying about the economic shocks caused by the pandemic which have led to spiking prices for basic necessities such as food and fuel and the disruptions in supply chains which made everything take much longer for delivery than we are used to waiting. I and my colleagues are all waiting on tenterhooks waiting to see where this one is going to end up. We know how rickety the system has become over the last six months and it won’t take all that much stress for significant collapses to start manifesting themselves.

I see the little ones every day. Short staffing of delivery drivers so that medical equipment or home oxygen doesn’t show up when it’s supposed to. Not enough nursing aids in skilled nursing facilities so patients aren’t changed as often and start getting diaper rashes and skin breakdown they hadn’t had in the past. Delays of weeks to months in getting specialty appointments, even for urgent conditions. Empty bins in the house call supply room where the things we use routinely like phlebotomy equipment remains on perpetual backorder. Insurance policies redoing their terms and refusing to cover routine lab work or adding multiple convoluted steps of prior authorization. Agencies desperate for cash flow stooping to ethically questionable methods of recruiting new patients . Patients and their families, frustrated with a system that isn’t serving their needs turning to patient advocates and other mediators who reach out with reasonable requests but whom you can’t satisfy with your resources at hand.

If we look at the worldwide statistics for the pandemic since the spread of the BA 4 and BA 5 omicron variants (BA 5 has vastly outcompeted BA 4 which is now a mere blip on the radar screen), case numbers and hospitalizations have increased about 40% since the end of June. Hospitalizations have doubled in Europe. Japan is having one of its most rapid rates of increase since the pandemic began. Domestically, we’ve got about 45,000 people in the hospital and we’re losing something over 400 a day. On the good news front, the number of people requiring ICU care in the hospital is not going up rapidly, even though this variant is highly infectious and the case report data is totally inadequate due to the prevalence of unreported home testing. But, given the lag time between case spread, hospitalization, ICU care, and death, it’s going to be another month or so before we really know what the current wave is going to look like.

The majority of hospitalizations at this point are in older adults (age 70+). Vaccination remains highly protective against BA 5 and every other strain to date. If you’re over 70 and unvaccinated, make your will; you’re the demographic most likely to leave the hospital as a celestial discharge. Fortunately, nationwide, 92% of adults in this age group have had their shots and 65% have had at least one booster. My recommendation at this point is that, if you’re over fifty, you go get that second booster now. Those under fifty aren’t yet eligible for a second booster unless they have an immunocompromising condition. The feds are waiting on the in process development of a rejiggered booster with specific omicron protection which is expected to be cleared for production and administration in the fall, opening that up to everyone. I have a feeling that this will be the new normal. A covid booster once or twice a year along with our annual flu shots. Some enterprising big pharma corporation is, I’m sure, working out away to do both shots from the same vial. New Flovid! Just a little jab’ll do ya! I can see the commercials now.

I didn’t sleep well last night so I’m having more difficulties than usual maintaining a train of thought. I’m pretty sure that’s most of the covid news I needed to cover. I’m trying to ignore the political news at the moment as it just makes me nauseous. I’m sure there’s some new pop culture social trend story out there but the last thing I noticed was J Lo and Ben Affleck getting married and I had to wonder if we’d gone back to the 1990s. Cue Peter Allen singing Everything Old is New Again. That song conjures up three very specific things for me. One is the Bob Fosse film All That Jazz where Ann Reinking and Erzsebet Foldi do a dance number in the living room to it to the amusement of Roy Scheider. All That Jazz came out my senior year of high school and I remember that I saw it at the Broadway theater on Capitol Hill in Seattle (now a drug store although they did preserve the neon marquee). I was at that impressionable seventeen year old stage of deep feelings and quests for meaning and I found the film brilliant but also shocking in the rather blunt nihilism of its final act. I knew who Fosse was, of course, but I hadn’t quite morphed into the theater kid I was to become over the next few years so I was able to distance myself a bit from some of the negativity. If I had seen it about three years later, I would have been devastated. The second is Hugh Jackman playing Peter Allen in The Boy From Oz on Broadway. The Bio musical which used his song catalogue to tell his story wasn’t an especially good show. Shoehorning existing songs into a book never works as well as the creators hope. But Hugh Jackman gave one of the most amazing performances I have ever seen on a stage. He wasn’t yet ‘Hugh Jackman’. The first X-men movie had just come out and Wolverine wasn’t yet the pop culture icon he would become. I went with Tommy and my cousin Jenny and all three of us were entranced by Jackman’s effortless charm and ability to hold an audience in the palm of his hand for two and a half hours.

The third involves a piano bar. Back in the 1990s, Steve and I began to travel with a gay travel group, Atlantis Events, which basically rented out Club Med type properties for a week for a LGBTQ clientele. Since those days, they have grown and now are best known for their huge cruises, but those hadn’t yet begun when the two of us would go off to what amounted to Summer Camp for gay men on the beaches of Mexico. Instead of arts and crafts, it was lazy days in the ocean and pool with an open bar. There were horses to ride (I’m a pretty good rider. Steve was not. I still remember him screaming as his mount decided half way down the beach that he preferred his paddock and took off at a lope the wrong way and Steve had no idea how to rein him in). And, instead of songs around the campfire, we had piano bar. Our pianist and song leader, Wayne Moore remains one of my favorite people and amongst the Broadway standards and medleys, he would do a killer version of Everything Old is New Again. One night at piano bar, Wayne launched into ‘One’ from A Chorus Line and a half dozen campers, all of whom had danced at one time or another with the original production on Broadway or on tour, got up and did the original choreography on the patio. I did not join them. (Although I did a fabulous lip synch Evita on that same trip…).

As we’re deep in musical theater land, I suppose I better sign off with so long, farewell, auf wiedersehen, adieu – go wash your hands and vaccinate un peu.

Virus here, virus there, virus virus everywhere… And it’s not just coronaviruses making the headlines anymore. Although Covid-19 and the continuing pandemic makes for the most concern to the greatest number, there are other disturbing trends out there. Today, there was a confirmed case of wild polio in New York, this follows on cases in the UK. This follows hard upon the exponential spread of monkeypox which, while not the disaster Covid-19 has been, is definitely out of control and spreading quickly. What worries me about these news stories is that they come on the heels of willful political attempts to attack and disable the public health infrastructure as being against ‘freedom’. Right wing groups are bringing court cases and lobbying state legislatures to gut public health laws that prevent gatherings in a public health emergency as being against freedom of worship, prevent contact tracing as being antiprivacy, and mandating face coverings or other sanitation measures as being undemocratic or some such. The current attempts to march back to the nonexistent good old days of seventy years ago by undoing social legislation in either the legislative arena or the court system is going to bring back other sights and trends that we all thought were firmly in the past. I’m assuming those who are behind the anti-public health campaigns will finally be satisfied when we return to rows of children in iron lungs from poliovirus or dead and disabled children from rapid spread of measles encephalitis.

A case or two of polio is not yet cause for immediate concern, but if it gets into a rabidly antivaccine or antipublic health community of some sort, whether left or right wing, we could be in for a world of hurt. Monkeypox is a bit of a different story. it’s definitely seeded in the US and Western Europe. The antipublic health press is trying to cast it as a sort of ‘wages of sin’ disease due to its early appearance in gay male populations, much in the same way that the early HIV epidemic was brought to public attention. Monkeypox is not a sexually transmitted infection. It is transmitted by close contact, which could, I suppose, include sex, but it could just as easily run through the very heterosexual crowd at a spring break type pool party, or a crowded dance floor, or a cheering throng after a football game. If you’re over fifty, you need not worry too much about monkeypox. The US regularly vaccinated for smallpox up through 1972 and the generations born prior to that point lined up for vaccines without a good deal of complaining or bias (their parental generations having grown up in a time when epidemic disease carried off quite a few young and healthy people). Smallpox vaccine cross reacts with the monkeypox virus and creates a relative immunity to infection or serious clinical symptoms.

For the most part, monkeypox doesn’t make people sick enough to require hospital treatment, it gives fever, body aches and all those other delightful viral symptoms along with the blistering pockmarks that characterize this family of viral infections. It clears up and goes away on its own within a couple of weeks but you feel like hell while that is happening. If you’re symptomatic with it, you’re infectious so stay home. There is a vaccine against monkeypox but it is in relatively short supply. It doesn’t do any good to get the vaccine after you develop the disease, you have to have had it before hand. I suppose the biggest issue with it as it starts to spread more and more into the general population is that it’s going to knock even more people out of the work force for a while which is already spread too thin. And the continued slow collapse of the health care system and access to health care as the insurance companies try to recoup their covid losses by jacking rates (most plans are expecting to post about a 10% increase this next year) pushing more and more people off the rolls which isn’t going to do anyone much good.

So back to the continuing saga of Covid-19. We’re definitely into another surge. Numbers in our local hospitals are going up quickly both in general beds and in ICUs. They aren’t at the heights of last winter but they’re about five times what they were a month ago. More and more people are going out sick and on quarantine making it difficult to cover duty rosters given the short staffing that exists everywhere. We have four faculty out in my division having come down with it this past week. Several of the nurses I depend on are out. The consensus from friends who have gotten sick is that the BA 5 strain currently marching across the land is making even the vaccinated and boosted very ill for about three days and overly fatigued and washed out for another week after that. And BA 5 is so good at evading immunity, whether it’s from vaccine or prior infection, that you can get reinfected in as early as four weeks from your last bout.

I had a call with my editor this evening. The book version of Volume II of these Accidental Plague Diaries is coming together and we are in schedule for it to come out some time in September. And we’re discussing a possible Volume III. When I began these writings, I had no idea what they were becoming and, when it was clear that Volume I was a book, I was pretty sure it was going to be a one off as the pandemic would slowly dissipate with the introduction of the vaccine in early 2021. As we all know, between politics and biology, that’s not what happened and I continue to churn out these essays. I’m not sure what they are. Personal ruminations? Political analysis with a health care bent? My hope for them is that someone will pick up a copy in fifty years, read it, and have a better understanding of just what was going on in American society and how it changed because of Covid.

We are changing. I’m not sure that any of us has been able to grasp yet what those changes are and how they are going to continue to manifest themselves over the course of the next decade or so. Just like the flu epidemic of 1918-19 created the conditions that allowed for the Roaring 20s and the Depression and War that followed, Covid is creating the conditions for something different. Some fear that that difference is going to be Civil War of some sort. I’m more optimistic than that. I’m still hoping that it’s going to continue to teach us new ways to be that may be healthier in the long run. The discovery that many jobs can be done from home or in a hybrid home/office dichotomy is, I believe healthy in the long run, allowing for better balances between work and personal life. The simplification of wardrobe and dress due to zoom calls replacing face to face meetings is healthy as it frees up purchasing power for other things. The need for parents to have become more and more aware of their children’s educational needs is healthy. I don’t think it’s always manifesting in healthy ways as certain groups of parents try to push their personal religious moralities on everyone but at least they’re not abdicating parental responsibilities to the education system in quite the same way.

I think I’ll end this evenings musings with an anecdote about a previous viral pandemic. This one is from 1968 and was what was known as the Hong Kong flu as it was caused by an influenza strain that first appeared in that city. I caught the Hong Kong flu that winter. I was six years old and in first grade and it laid me low. I think I was out of school for about two weeks. I don’t remember a lot of the gory details other than I was having difficulty keeping anything down, upchucking even the ginger ale and saltine crackers that were my mothers mainstay for her children with upset stomachs. I came down from my sickbed one evening to the family dinner table to find that my mother had made sloppy joes. These were my favorite and I was exceedingly upset that I would not be able to partake. My brother, who was a baby, wasn’t eating them either as he was still on baby food and my sister, then a toddler, was wearing more of hers than she was eating. I finally demanded that I have one too. My mother was concerned that if I ate one, it would just come right back up but I didn’t care. So she made me one and I ate it. And it stayed down. It was the only thing that stayed down all week. I think it was sheer will power.

Masks on, hands washed, get boosted, and eat your sloppy joes.

And the numbers continue to rise. The number of inpatients with Covid at the Birmingham VA has quadrupled over the last two weeks. I haven’t seen the numbers for UAB hospital, but scuttlebutt is that they’re on the way up as well. Test positivity rate has climbed from about 5% to 30% here in Alabama and, at last count, 22 of the athletes here for the World Games have tested positive, although none has required hospitalization. The numbers are equally bleak on the national level. There are well over 100,000 new diagnoses daily, 40,000 people are in the hospital, and the national death rate, which was down around 200 a few weeks ago, has more than doubled. The BA 5 wave is definitely here (and the BA 2.75 wave is hot on its heels. It’ll be interesting to see which of those two outcompetes the other over the next month or so).

Will it be as bad as the omicron wave of this past winter? Unlikely as there is still lingering community immunity from those cases. Natural immunity seems to be in the four to eight month range so it is starting to fall off somewhat and the current BA strains are quite resourceful at getting around the immune system so I don’t trust that particular defensive line to hold a whole lot longer. Then there are the vaccinations. I would strongly suggest anyone eligible for a second booster go get it as vaccination remains our best bet to keep hospital and mortality numbers down. Death rates continue to run six to seven times as high in the unvaccinated population. The health care system is on somewhat shaky ground, as anyone who works in it or who has tried to use it recently can attest, and another out of control wave that shoots the number of patients requiring hospitalization back to extremely high levels may be enough to start bringing some of it crashing down.

I know you’re all tired of this mess. I’m just as tired as you are but the virus isn’t. It’s too simple an organism to have emotional states. It’s just going to keep on searching for hosts and replicating and mutating. That’s it’s only aim and mission. There are a few things we can all do besides getting vaccinated. We can make sure that public spaces are properly ventilated. We can mask up indoors and outdoors in crowds. We can properly quarantine if we get sick to help break transmission chains. We can pretend that we give a good god damn about each other. I know that’s unfashionable these days but cooperation is the only way through all of this and it’s going to have to be on a global scale as there isn’t a human on the planet that’s not at risk.

Am I going to turn myself into a hermit again? Wasn’t planning on it. Like everyone else, I’m doing my risk/benefit calculations regarding activities and public mingling. I’m still eating out some, but I look at table spacing and ventilation and how crowded the dining area is. I go to live theater as I tend to trust that the type of people who comprise theater audiences are likely vaccinated and making the same sort of calculations I’m making. I’m not going to the movies very often, and when I do, sit away from others. I continue to mask up at work when around patients. I fully expect to be reinfected at some point. I don’t know that it’s possible to completely avoid it. I’m going to trust to two boosters, some lingering natural immunity from January and my fairly solid constitution to keep me from becoming too ill.

Where do we go with live theater as the pandemic grinds on? Both of the large companies in town lost performances in June to Covid in the cast despite significant precautions. Smaller companies locally also had to cancel or reschedule shows due to illness in key roles. And this was when numbers were down prior to the new omicron BA surge that’s now taking shape. Backstage areas are cramped and require a lot of hanging out together for entrances. Dressing rooms and lobbies are often in older buildings that are inadequately ventilated and companies don’t have the money necessary to upgrade. There are newer performance spaces for hire that are built with better safety measures in place but they’re beyond the budget of most production companies. Even Broadway continues to have significant issues with show cancellations or unscheduled understudy appearances with Covid spreading backstage.

Over the last century or so, long before the pandemic took shape, live theater in the US began to morph from a populist art form accessible to pretty much anyone to an expensive hobby, confined mainly to the professional and upper classes. Movies and television took over mass audiences and theater stars and authors, once familiar from variety shows, and talk shows, and other pop culture organs were gradually relegated to a small group of cognoscenti. Productions that gained national attention, tended to do so based on spectacle, becoming elaborate theme park type attractions, rather than on superior artistic expression. When I was a child, everyone knew who Richard Rodgers, Mary Martin, Ethel Merman, and Jerome Robbins were. If you’re not a theater person, you might not know the names Duncan Sheikh, Gavin Creel, Jerry Zaks, and Sutton Foster.

At the same time, public funding for theater to keep it accessible to the population as a whole more or less dried up. Most advanced countries have strong support for art and culture. Not the US where everything is supposed to sink or swim on its own in the marketplace. There is some private philanthropic support, but it’s not broad based and is usually disinclined to support nontraditional ways of presenting theater. The beauty of theater is its temporary nature. Every performance becomes a cooperative venture between production and audience, never to be repeated. It truly serves as the mirror of society in ways that film or television cannot but to really do so, it needs to grow and evolve along with society and each generation needs to revisit the texts and the scores and use them in new ways to enlighten and illuminate. Reinterpretations may not always be successful, but they give theater life and vitality. To me, there’s room for both a classic production of a classic work and a radical rethinking and both give us something. The classic allows us to see and better understand the past. The rethinking allows us to better see ourselves and how we have changed, for good or ill.

So how do we make all of this work in a time where gathering together indoors is possibly dangerous, both for performers and for audience? A couple of things come to mind. One, public funding for retrofitting of theater buildings with better ventilation systems, for any place of public gathering as a matter of fact. It needs to be part of the continuing work to improve infrastructure. When climate permits, more outdoor performance. Long before there was electric light and smoke machines, there were ampitheaters with engaged and attentive audiences. It may require training performers to project and audiences to listen and not rely on amplification but I don’t have a problem with that. We need to culturally normalize good theater as existing outside of the Broadway spectacles and their touring versions coming soon to a civic barn near you. Good theater does not require top notch production values and million dollar sets and costumes. It requires performers that can cast the spell which gets the audience to suspend their disbelief for a couple of hours. Time and again I have found that I have enjoyed a small scale local production of something far more than a national tour but the public has been trained that unless it has a high ticket price and the imprimatur of Broadway in the advertising, it’s not a worthy endeavor.

Theater will survive, it always has, because the people who create it are passionate about the work and the people who feel uplifted by the connection that only live performance can make will seek it out, whether it be in a Broadway house or a church basement. We just all need to be prepared to do our part for society in order for it to continue in its current forms… get vaccinated, provide the financial support to production companies to forge ahead, lobby for societal support for infrastructure improvements, be prepared to explore new venues and ways of presentation in this moment of change. We live in interesting times.

It’s 7-11 and no Slurpee… Do they even have 7-11 stores anymore? I haven’t seen one in years but they may be a West Coast thing. They certainly aren’t here in Alabama. We have our own versions such as Kangaroo Mart and the ubiquitous Family Dollar and Dollar General stores. But 7-11 is always going to mean something a bit different to me. It was my and Tommy’s legal anniversary. It’s not the date we celebrated as our anniversary (that was October 27th, the day of our first date) but the day, some eleven years later that we stood in front of the judge at the King County criminal court, right after the grand theft auto trial, and said our ‘I dos’ and emerged with a legal document declaring us husband and husband. It was a year before Obergefell so same sex marriage hadn’t yet arrived in Alabama but it was after Windsor so the federal government was recognizing a valid state marriage for tax and other purposes so Tommy and I decided on one of our trips to Seattle to visit family, to tie the knot for mutual protection as Washington had recently legalized same sex marriage. I got hold of an old high school friend who put us in touch with a judge and the pieces fell into place. We knew we didn’t want a wedding… we’d been together too long so a simple courtroom ceremony with a couple of witnesses and a family dinner to follow was about right. Tommy has now been dead longer than our legal marriage lasted, cut short by his untimely demise.

Covid numbers continue to increase across the country, fueled by the fast spread of omicron BA 5. It’s more contagious than prior, more apt to elude immunity, and even outdoor events are becoming super spreaders. The hospital numbers are beginning to increase in New York City and other urban areas so I expect death numbers to begin going up as well. Should we be concerned? I don’t know that I can completely answer that. Most people are coming down with mild disease and recovering with minimal difficulty but I don’t know that things will remain that way. And then there’s the prospect of long covid.

If you do much reading regarding COVID and its symptoms these days, you eventually run into the terms ‘Long Covid’ or ‘Post Covid Syndrome’ being applied to people still experiencing symptoms of the disease months after the acute infection or, in some cases, having entirely new symptoms and problems that can be traced back to an initial COVID infection of some months previously. It appears to be an issue in all sorts of people and can occur whether the initial infection was mild or life-threatening.

It’s a tricky issue to study. How do we make determinations about chronic disease with an infectious agent that’s only been present in human beings for less than three years? How do we even define which cases fit a definition of Long Covid when neither the CDC or the WHO, or any other major public health body, has standardized any sort of definition for what constitutes the disease and what does not? Enough data has been coming in over the second year and into the third of the pandemic to suggest that Long Covid is a real entity. It’s not at all clear what causes it.

One theory is that in some people, the immune system is ineffective at fully clearing the virus from the body, and that there are small pockets of viral load hidden within various internal organs which are continuing to infect cells and creating new symptoms. Another theory is that there is a cross-reactivity between the immune system and normal tissue. The virus stimulates the immune system to attack normal body tissues and cells in an autoimmune response creating the symptoms. Either is possible and we’ll likely eventually figure it out but who knows at this point?

How many people have Long Covid? No one knows as no one can even agree on what it is. The UK has put out studies estimating that about 3% of those who catch and recover from the disease will have long term sequelae. Some groups in the USA have suggested that this is a gross undercount and that upwards of 25-30% may have some sort of long term issues. This means that somewhere between two and 20 million Americans currently have Long Covid. What sort of treatments and supports they might need now and in months to come are anybody’s guess. Most large health systems, especially those with an academic component, have established specialty Post-Covid Clinics for long term monitoring and symptomatic therapy. As they collect and publish data over the next few years, we’re going to learn a lot more.

What tissues are involved? Well, the angiotensin converting enzyme (ACE) receptors which act as the doorway to the cell for the virus (it’s the thing in the cell wall that the spike protein is able to grab onto and anchor down) are found throughout the body. They are especially prevalent in the heart and vascular system. One of the more common groups of blood pressure medicines, the ACE inhibitors like lisinopril and enalapril also work through these proteins. It’s thought that the propensity of the virus to induce clotting may be somehow related to this concentration in the vasculature. The big issue here is the heart, which has the highest concentrations of ACE receptors. Data coming out of the VA suggests that prior COVID infection is a significant risk factor for later heart and cardiovascular complications with rates of stroke, heart attack, inflammation of the heart muscle, and arrhythmias all much higher in those who had infection versus those who did not. Serious infections requiring hospitalization or ICU stay increased risks of heart issues astronomically after recovery with rates four or five times those of control populations. Exactly what mechanisms are involved aren’t known as of yet.

Studies out of Europe show that the patterns of Long Covid vary significantly by sex and age. Women, especially younger women, seem to be at highest risk. Some of that may be due to women’s more frequent seeking of health care and encounters with the health care system leading to higher levels of reporting but there’s also some thought that the immune systems of women of reproductive age, being somewhat more active so as to protect the potential fetus, might be working slightly differently when they encounter the virus. Younger people of both sexes are more likely to report altered taste and smell over prolonged time than older people, while older people are more likely to have GI effects.

In about 40% of people, Long Covid presents as a relapse several months after the initial infection has been cleared. They may be well for three or four months and then start to have fatigue and other significant issues that may limit activity. These kinds of symptoms aren’t unique to Covid. Other viruses can cause post-viral symptoms, including the closely related SARS and MERS, but even more common things like the flu can do it, too.

What does all this mean? It means the coronavirus is not a great thing to have in your body and should, therefore, be avoided. If you do get it, you want it to be the mildest case possible. A case that puts you in the hospital may have unpleasant side effects down the road. How can you ensure that? Get your vaccine and your boosters. It’s by far the best weapon we’ve got to keep people as hale and hearty as they can be.

Interesting times in Covidland. Omicron variant BA5 tends to be the major variant spreading in the US. BA 4, which was spreading along with it, has rapidly been outcompeted and looks like it’s on its way out. There’s a new sublineage, omicron BA 2.75 which has spread rapidly in India, especially around Mumbai and which has a number of new mutations on the spike protein that may allow it to get around both natural and vaccine induced immunity but it’s hard to tell as India doesn’t have the infrastructure for surveillance testing that exists in the first world so numbers are incomplete. BA 2.75 hasn’t his the US yet, but with travel having picked up to record levels following two years of the world having been cooped up, it will get here eventually and we’ll see what it does.

There’s about 100,000 new cases of Covid reported in the US daily to public health authorities. Given that the majority of testing is now home testing, this is likely only a small fraction of the total number of cases happening per day which is likely closer to 1,000,000. While this seems like a shockingly high number, at the peak of the original omicron wave six months ago, we were up as high as 4,000,000 new cases daily so we’re still well under that number. It does mean, however, that every time I open my social media accounts, four or five more friends are displaying pictures of their positive test results and cancelling out their lives for a week. Fortunately, hospitalizations and deaths remain relatively low, although up about 30% from a couple of weeks ago and they could start taking off again like a rocket at any time. Deaths, which had dropped as low as about 150 a day at the nadir are now between 350 and 400 a day in the USA and are continuing to slowly trend up.

What does all this mean for practical purposes? We’re not out of the woods yet even though Covid news has, for the most part, fallen off the front pages and things are in flux and not in the right direction. My advice? Get your second booster if you’re at higher risk (over 50, chronic health issues, immune system issues), put the mask back on in crowded indoor situations, especially if they’re not well ventilated, and keep those hands clean. Stuff I’ve been harping on for a couple of years now. Should you cancel that party or skip that trip or forego that outing? I think that depends on your individual risk tolerance. If you or someone you spend time with is of significant risk, take some basic precautions and keep an eye on the reporting, even if it has fallen to the back of the national news section, underneath the feature article on fifty fun things to do with styrofoam.

Today is the opening of the 2022 World Games here in lil ol Birmingham. We have a new football stadium downtown, home of the USFL Birmingham Stallions and also used by the UAB Blazers during college season. (See, I do know something about sportsball…) Tonight it’s being used for the World Game Opening Ceremonies. As it was over 100 degrees this afternoon, and projected to still be in the 90s this evening, plus humid, plus no wind, I can think of a lot of places I would rather be than an open stadium so I did not attend the festivities. The World Games appear to be the international championships for events not sanctioned by the IOC and not part of the Olympics but which world class athletes still participate in and more than a hundred countries have shown up for Archery, Ballroom dancing, Rock Climbing, Sumo Wrestling, and Rhythmic Gymnastics amongst others. Many are Olympic medalists in IOC sanctioned events. Other than the weather, there’s a bit of a party spirit in town but I’m being curmudgeonly and staying in my HVAC cooled condo and hoping that traffic isn’t too bad in the morning when I have to go into work. (UAB is the site of the athlete’s village, the dorms having been given over to them and my clinic is a block away from some of the bigger ones).

I’m just hoping that everyone enjoys themselves without spreading too many microbes and sharing too much of their international biomes with us locals. I don’t have too much going on currently so if I got sick and had to go out on quarantine, it wouldn’t cause too many problems other than mucking up my clinical schedules for a few weeks. But I really don’t want to see Birmingham get an international black eye. It doesn’t have the best reputation internationally due to events and attitudes of decades past and it would be nice for others to see beyond that to this small dynamic city that I’ve called home for two dozen years now. I never thought I’d move here. When I did, I never thought I would stay. And I certainly never thought I would become as firmly integrated into the city as I have with fingers in a dozen different civic pies with friends and acquaintances amidst the arts, the medical, the activist, and the business communities.

Birmingham frustrates me. It has so much to offer and so much that holds it back. It’s a very pretty small city with its rolling hills and streams and lush vegetation but it has a summer climate that this poor west coast boy finds relatively intolerable. (Visit spring or fall). It has great wealth and dire poverty. It has a burgeoning arts scene and an indifferent local population to that talent. It has dozens of squabbling suburbs that refuse to cooperate with the central city without understanding that they could not exist without that energy and those amenities. It has the most amazing restaurants. It has an incredible system of mountain parks. It has a political culture that resembles two armed camps in a sort of sullen detente. It has monuments to tolerance and nasty levels of bigotry which often sneaks up on you from a surprising source. Why my life should have been reordered at age 36 to push me here remains one of the great mysteries. It has been the site of my greatest heartaches and the site of my greatest triumphs. Perhaps with all of my personal inherent contradictions and paradoxes it was inevitable that we would be drawn together. Perhaps, in a very real way, I am Birmingham and will remain so.

And it’s another new month. This time, we enter the second half of 2022, the second sequel of 2020. I don’t think any of us expected, when we entered the new decade two and a half years ago, that we were going to enter an era of time compression and continuation. I know that I have a difficult time keeping my sense of time about these last few years straight in my head. In some ways, things feel like they have moved quickly and changed radically and in others, I feel like we’re still in the midst of 2020 or maybe early 2021. It’s another long weekend – happy Fourth of July to all those who celebrate. We’ve made it for 246 years. Maybe we’ll make it a few more. I read somewhere that the average life span of an empire is 250 years. On that scale, I suppose we’re about due for a fall but we really haven’t been an empire since 1776. That didn’t really start to happen until some sixty or seventy years later with the westward expansion and the Mexican American war. And there are others who would use the Spanish American war, fifty years after that as the start of our imperium.

So what am I doing for my long weekend? Very little. I’m caught up with immediate work tasks and with book editing on Volume 2 of the Accidental Plague Diaries. I’m therefore treating myself to some naps and some television and a couple of films. I’m just about finished with the last two mega episodes of Stranger Things, a series I have quite enjoyed mainly as I remember the 80s fondly and the Duffer Brothers have got the period details right. I’m about ten years older than our fictional protagonists. While they are in middle school and just entering high school in the mid 80s, I was in late college and in med school so my interests were a bit different than theirs but I was still aware enough of pop culture to absorb all of the media images and trends. You lay down the patterns of your life between roughly ages 10 and 25. Whatever you were watching, whatever you were playing, whatever you were listening to in that period is what informs your adult life ever after. After 25 or so, you’re interest in pop culture drops off quickly and it’s pretty much gone by 35, left to a new generation to reorder that aspect of our world. For me, that key period is mid 70s to mid/late 80s. To this day, ABBA and disco classics and 80s movies evoke a certain nostalgia nothing else does. As the early Boomers are starting to enter the middle old years and will edge into the dementia belt in about another five, I wonder how nursing facilities and dementia day programs are going to retool for the radically different generation that’s going to shortly need their services. It will be interesting to watch from a professional point of view.

The Covid numbers continue to march upwards. The CDC is now recommending indoor masking again for much of the country. From what I can tell, no one is paying much attention. I was one of the few masked on my Costco run today. I’ve decided I’m going to retrain myself to mask indoors in public again. I’m not worried about me in the least between two boosters and native immunity from my previous omicron infection but I do feel like I should lead by example. I’m keeping tabs on various health websites to try and figure out what’s going on but, as society as more or less moved on, the quality of data out there just isn’t as good as it was. The one good thing is that hospitalizations don’t seem to be zooming up at all. I hope it stays that way.

The airline industry seems to be a complete disaster due to understaffing, Covid absences, and lack of air traffic controllers. I suppose this is what we all get from deregulating the airlines fifty years ago and letting them all work as for profit companies rather than as public services. Everything is always going to focus on next quarter’s balance sheet rather than what people actually need in regards to travel. I am glad that I did not book a major vacation this summer given some of the horror stories I’ve heard back from friends. I’ll look and see if the budget can support something this fall and I do have my long delayed trip to London at New Year’s. I did book a round trip ticket to Seattle for mid August to go see my family for a couple of days but I did it on Delta, not on a discount airline. The initial fares I was encountering were nearly $1800 from BHM to SEA but by driving to ATL and flying directly in and out of there, I was able to reduce it significantly. I also have some date flexibility so if flights are canceled and/or rerouted, I shouldn’t have too much trouble. Famous last words…

I’ve been getting a lot of complaints from friends about the health system in general over the last couple of months, mainly regarding delays in care and difficulties in getting appointments in a timely fashion. Some of this is warranted. Some of this is not. American consumers are used to same day service with a smile and do not like to be told that they will have to wait. This has been one of the main arguments used against adopting more socialized models of health care rather than our crazy backwards employment driven system (that exists nowhere else in the world as no other population would put up with it). ‘You’ll have to wait’ has always been anathema to us, whether it’s for an MRI scan or for an oil change or for a McDonald’s burger. The delays in the health world, just as frustrating to me as to everyone else, are due to a host of reasons in our late pandemic world. The first is short staffing. An enormous number of physicians, nurses and other providers of services used the pandemic as an excuse to leave the health professions. In addition, the relatively low salaries that systems have been used to offering support staff aren’t attracting new hires. (We’ve been looking for a lead nurse for my clinic for a year now…) Nursing, in particular, has been rocked by the migration of nurses away from staff jobs to temp and travel jobs which pay better and which short staffed institutions are forced to rely upon. There are supply chain issues in healthcare as there are everywhere else. Not a day goes by without a notice of shortfalls in some pharmaceutical or contrast material or the inability to get some part to keep some machine in proper repair.

Then there’s the rapid aging of the population, many of whom delayed care for this and that the last few years. The sheer numbers of the boom means that disease case loads, especially in the chronic diseases that start to strike significantly in the 70s, are way way up and there just aren’t the numbers of specialists available to handle these increases – and the medical education system is not designed to pump out more doctors quickly. It took me thirteen years of higher education to become what I am. I figure I have somewhere between two and seven more years of full time working life left, depending on health – physical, mental and financial. That’s enough time for me to train up three or four clones but we can’t find much of anyone interested in dedicating their career to geriatrics. Over the last five years, we’ve lost eight clinical faculty to retirement, other job opportunities, or spousal needs. We gained two during that same period so we’ve got a significant net deficit which is really affecting how all of our clinical programs run.

There’s not too much for me to write about Covid currently as I continue these Accidental Plague Diaries. That could change at any time. It’s not over and I’m pretty sure it has one or two more nasty surprises to throw at us before it fades away. So, I’m thinking I’ll probably be writing more about the cracks in our various institutions that have widened under the strain of the pandemic and its inherent social changes. I don’t think we have a good understanding of all that yet and I’m trying to educate myself on it, at least as it applies to the health care system where the order of the day seems to be stamp out today’s fire today and stamp out tomorrow’s fire tomorrow. I would love to have a work day where I didn’t feel like the whole system could come crashing down overnight (or over a long weekend). If it does, I’m pretty resourceful and I’ll take care of my patients the best I can. My focus for this year is trying to catch up on preventive measures that fell by the wayside over the last few years and which might be helpful.

If anyone has a particular topic you’d like me to think about and maybe tackle, drop me a line. All reasonable requests entertained. In the meantime, the mask is in the back pocket, the sanitizer is on every desk I use and in the car, and I muddle through one day at a time.

Omicron continues. The BA 4 and 5 variants of omicron are swiftly becoming the dominant strains in the US as they have elsewhere in the world. The good news is that they are not that different from the initial omicron strain which first appeared around last Thanksgiving and immunity from either natural infection or vaccination appears to be holding, at least for serious disease. It’s difficult to interpret the numbers these days due to so many tests not being reported to health authorities as they are done at home but we do still get reasonable data from hospitals and, at the moment, the number of patients requiring hospital care for Covid and its complications continues to remain mercifully low. Still, we’re at about 32,000 hospitalized nationwide (well below the hundreds of thousands during previous surges) and the numbers have been trending up by between five and ten percent a week over the last month ago. We’re also still having between three and four hundred deaths a day nationally, or the number of people killed on 9/11 every two weeks.

The vaccines seem to be working relatively well. You’re about forty times more likely to be hospitalized if you’re unvaccinated. Those with two boosters have about 1/4 the hospitalization rate of those with one booster. The biggest issue is that immunity from vaccines does not appear to be long lasting and starts to wane after six months or so. This is particularly important in older people and in those with immune compromise. There is, therefore, a lot of debate about what to do next. Should there be another round of boosters in the fall? Both Pfizer and Moderna have been retooling their vaccines to offer better omicron coverage and the preliminary results of studies on these new formulations look promising. The FDA is in the process of discussing whether another booster should be made available in the fall and if it should be changed for better omicron coverage. The final decisions aren’t out yet but it looks like the answers are yes and yes. It may be that we are going to be getting Covid boosters once or twice a year for a while. The flip side of this is modelling what is likely to happen should we not make new boosters available and the short answer to that is a few hundred thousand more people dead.

Locally, the issue continues to be rapid spread among small populations with close contact. At least three shows in local theaters had to shut down and cancel performances in recent weeks once it got into the cast and crew. Fortunately, all of my performances, since the original omicron wave, were Covid free. I’m also performance free for a while. Taking my usual rehearsal time to finish up Volume 2 of these Accidental Plague Diaries for publication and then trying to take stock of my theatrical life and see what I can do to simplify. I’m responsible for two quasi-defunct production companies, a storage space full of theatrical paraphernalia, presidency of the opera board, a couple of other theater boards, and helping with a few capital campaigns. It also seems to be spreading in the main VA hospital with about 3% of the workforce out on quarantine this week. My VA job is peripheral to the hospital so I rarely go in and haven’t come into contact with anyone sick to my knowledge. I thoroughly expect to get reinfected at some time… but not today.

I taught an undergraduate class on the biology of aging and aging research opportunities via zoom yesterday. I hate teaching on line. I guess it’s my stage performance heart. I need to connect with my audience and read them and know when and how to time my jokes and when to get serious and when they’re into what I’m saying and when they’re falling asleep and checking their phones they think they’re successfully hiding in their laps. When they’re all just in little tiles a la The Brady Bunch titles, none of that works. I just have to start talking and hope that at least one point will trigger each of them in some way. They were all rising juniors planning on pursuing medical school and health care careers. It got me thinking back on me at that age. I was at Stanford. Ronald Reagan was president (first term) and I was vaguely thinking of a bench science research career in some sort of toxicology. It’s not where I ended up but the longer I live, the more I learn that life’s about the journeys and not the destinations.

I don’t necessarily have the fondest memories of my classes my junior year of college. It was the year I battled p-chem, quantum physics, group theory, and vertebrate anatomy. My MCAT was in the middle of it. This was long before computer terminals and on line testing so I took mine with several hundred other premeds using pencil, paper and a fill in the bubble form. Due to inopportune scheduling, my MCAT was at the same time as the second tech of ‘Hello, Dolly!’ which I was assistant directing for the big student theater group. Fortunately, the testing classroom was in the building next door to the theater so I was able to run over during all the breaks, check in, and then run back and settled down to the next section of the test. I can’t say it was ideal test taking conditions, but it seems to have worked as I did reasonably well on my MCAT and managed to make it into medical school about eight months later.

Most of my friends and colleagues have been preoccupied with distressing political news this past week, be it heinous supreme court decisions, testimony in the January 6th hearings, or prognostications regarding the midterm elections coming up in the fall. I refuse to go into a funk. Don’t like what politics is doing? Go out there and get to work and change it. The current conservative surge has been fifty years in the making and has succeeding due to a fundamental understanding of how our system works. It’s a winner take all system with judiciary as the referees. Want a different result, get out there and do the dirty work in the trenches of precinct politics. Volunteer for candidates of choice. Help build institutions that will produce trained minds that are qualified for the judiciary that will view the world as you do. Sniping at each other, edging others out for not holding quite the same views or being as idealogically pure as you, ginning up division on identity lines are all recipes for ultimate failure in the zero sum game of American politics where with 50.001% of the vote, you take it all. If you lose, you mourn for a day or so, then you have to roll up your sleeves, get out there and get to work. It’s the only thing that has ever succeeded.

There’s left over Chinese in the fridge and I’m hungry. Gonna stop now and eat. But wash my hands first.

Another work week over. This one punctuated by the collapse of Roe vs. Wade in the official release of the Supreme Court’s vote and opinion in the Dobbs case. This is where we are: a political system in which the minority party is busy dismantling the election apparatus in plain sight and a judicial system where the supreme arbiters are hell bent on imposing the world views of a particular religious minority on the majority. I can’t fix any of it so I’m not going to let any of it ruin my life. It will be interesting, however, to see what happens when there is no longer the unifying force of ‘overturn Roe’ keeping all of the disparate groups and agendas on the conservative side of the political agenda pulling together. Will they now start turning on each other over finer points of theology and doctrine? Will the money behind them whip them into a frenzy over a new target? (If this is what’s next, I’m likely to have a large bullseye on my back). Time will tell.

My friends in the local emergency departments are reporting a sharp uptick in people with Covid related illness over the last week. Most are not ill enough to require hospital support and are sent home with comfort meds and prescriptions for antivirals if warranted but the number of inpatients are creeping back up again. The bigger issue for the health system currently isn’t the patients but the workforce. When one of us catches it, we’re out for five to ten days on quarantine and as the case numbers climb, the number of nurses and doctors and therapists and pharmacists and housekeepers and billing clerks going out climbs putting additional burdens on those who remain to close the gaps. It’s leading to more and more erosions of care. There isn’t a specialty service I’ve called with a referral this past month that doesn’t have a six to twelve week waiting list for appointments. If I pull in favors and it’s urgent, I can sometimes get that down to a couple of weeks but forget getting someone in the next day or by the end of the week. Anyone I think’s emergent generally has to go to the ER if I’m going to have a prayer of getting it looked at in a timely fashion. It’s not a great use of ER resources but my hands are tied and my first responsibility is to the needs of my patients.

We’re seeing this play out in another industry, travel. I’m very glad that I decided to forego booking a significant vacation this summer (a combination of needing new kitchen appliances and expenses around the 60th birthday bash took care of that). The news from the front lines of travel, especially by air, is shall we say, chaotic at least and its a world wide phenomenon. It’s driven by a couple of things. The first is an inadequate workforce and understaffing (this one sounds familiar). The rapid fall off in travel in 2020 due to the pandemic led to the airlines hemorrhaging money and, like any for profit business they did what they could to shore themselves up. They offered early retirements and buyouts to senior staff to save on salaries and trimmed their work force. Now, everyone wants to travel again and the airlines just don’t have the flight crews – and it’s not like they can create a pilot from a willing applicant with a couple of weekend seminars, an on line training course and a couple of YouTube videos. Then there’s the lifting of the universal masking mandate on transport. Masking only really works properly when everyone does it and, in the airline industry, it helped keep the chances of flight crew getting ill and out on quarantine lower. Without it, the pilots and cabin crew are more likely to get sick, go out on quarantine and there you have it, not enough on the duty roster for all the scheduled flights to take off. The same thing is happening in medicine, just replace flight with elective surgery or MRI scan with contrast or rheumatology appointment.

The piece of the health system that looks like it’s going to collapse the first is the long term care industry. By the latest numbers, 98% of nursing homes and long term care facilities are understaffed and 73% are in the red as they have to spend additional dollars on agency staff to make up for additional employees coupled with inflation in food and energy costs. The pandemic also has made families rethink when to use group living for elders and a lot of the patients who would have been relatively easy care as their needs are fewer are being kept at home making the per capita acuity of those that remain higher, and therefore more expensive. In the middle of the last century, long term care was mainly a not for profit sector with the nursing home generally reserved only for those who could not be cared for at home by family and often subsidized by either a governmental or religious entity. As the industry was transformed with advances in medicine into more of a step down hospital role, and with more certainty of payments with the introduction of Medicaid for the indigent, for profit corporate entities began to buy up nursing homes as revenue generators and put processes in place to allow for economies of scale. For profit operators aren’t going to want to carry chronically money losing businesses on their books and I foresee a rash of closures coming over the next few years.

Closing nursing homes are going to run into smack dab into several other trends which are pushing the opposite direction. The first is the continued aging of the Baby Boom generation, that huge cohort of individuals that’s just starting to age into the chronologic band where long term care becomes necessary for a portion of the population. The lead edge is 76 this year. They’ll be 80 in four short years and with that, the number who will not be able to care for themselves due to physical and or cognitive decline will start to increase exponentially. The second is the financial strain that Medicaid places on state budgets. Medicare, which is a federal program and solely consists of federal dollars, does not pay for long term care. It will pay for brief stints in a nursing home for rehabilitative purposes to recover from illness or injury if certain conditions are met. If you require a permanent stay, you are on your own (unless you have private long term care insurance – a product that as now near impossible to obtain as it’s actuarially unsound). If you have either exhausted or cleverly hidden your assets from the state, than Medicaid, a joint federal/state program steps in to pay the bill to maintain you.

We don’t tend to think much of nursing home residents as they are a hidden population from society. You don’t see them walking down the street or out to dinner or at the football game but there are about one and a half million nationwide. Roughly 40-50% of a state’s total Medicaid budget flows to nursing homes annually. Medicaid is about 20% of the average state’s general fund spending so nursing homes take about one dollar in ten of a state’s discretionary spending. If nursing homes start to close, there’s going to be an enormous financial pressure on states to try and get out of future nursing home payments as most state budgets are pretty cash strapped. There’s not going to be a lot of push for the public sector to step in with new beds. I think there’s going to be pressure instead to get families to step up and house and nurse their own elders as in times past. There will likely be promise for new pots of public money to provide assistive services to make that more successful but the reality is likely to mirror the deinstitutionalization of the mentally ill some years ago. The mental hospitals were closed but the promised community based programs and funds that were to replace them somehow never materialized.

If you’re in my peer group and contemplating retirement and the unknown country of age and infirmity, it’s a good idea to sit down and make some plans and talk to the kids now. The old models aren’t likely to last. It’s one of the reasons I made my decision a couple of years ago to downsize to this condo. It’s a space I can age in with minimal supports. Take it from the geriatrician. Your golden years are coming, like it or not. Unless, of course, you skip your vaccines, expose yourself to sick people and don’t wash your hands.

Today is Juneteenth. And all good wishes to my African American friends and colleagues who are celebrating today. Both UAB and the VA are observing the holiday so I have a three day weekend and I used the first part of mine to sleep in after the excitement of the show this past week. I would like to use the rest of today to laze around, but unwritten progress notes, a lecture to prepare, and the usual unending supply of household projects and performing arts organizations requiring assistance in terms of planning will keep me busy until sometime in the evening.

Covid has been on the back burner the last few weeks while other life areas have taken precedence but I was jolted back to reality after receiving an email this morning about a potential exposure. I’m not worried. I’ve had both shots, both boosters, and natural immunity to omicron following my bout six months ago. I was feeling a little blah yesterday so I stayed home from a planned outing and went to bed early. I’m fine this morning. Hopefully noting will sneak up on me over the course of the day. It’s just a reminder that as much as the culture at large is moving on to a post pandemic mindset, we’re not completely out of this thing. I hadn’t looked for a bit so I checked the numbers. On a national level, they’re still rising but not at the rate they were a month ago, having flattened a bit over the last two weeks. The current hotspots are in the Rocky Mountain states and in Appalachia. Why that should be is anybody’s guess. Perhaps the virus is hitching a ride as people are escaping the sweltering summer heat to the relative coolness of mountain towns. Alabama numbers are similar. A general slow increase, but without a significant rise in hospitalizations or deaths. But it’s hard to say what’s really going on locally – the reported cases are those from testing done in hospitals or pharmacies or public health departments. Home tests have no convenient way to be included in the totals in this state. And most of the people of my acquaintance who have gotten sick recently have all been diagnosed with home testing.

The other big development is the approval of Covid vaccinations for children under the age of 5. The number of parents planning on getting their children a vaccine is distressingly small, likely due to the collapse of trust in expertise that politics has engendered over the last half dozen years or so. Actually, it’s been brewing a lot longer than that but that’s a subject for discussion another day. Katelyn Jetelina, who goes by the moniker YLE (Your Local Epidemiologist) has put together a very nice one pager on the vaccine for young kids based solely on the science and I highly recommend searching that out if you have children in that age group and questions. Her writings on Covid, while occasionally over my head as I am not a trained epidemiologist, are a great way to keep up on the latest regarding the pandemic and the science driving the response at institutions such as the WHO and the CDC. I find her a much better source than many of the more usual mainstream media writings which tend to over simplify or try to find some sort of clickbait angle to use.

Most of this past week, when not at work, was spent on the fundraising cabaret show, Little Black Dresses and Bowties. It was a Broadway Backwards or Miscast type revue where we all got to sing songs we would never be allowed to in the context of a real production as we would be the wrong gender or type for the role. With that in mind, we were somewhat genderqueer in our costume choices. I was the MC so I did a bit of a riff on my traditional garb as the MC of Politically Incorrect Cabaret – tail coat, white tie and vest (but without a shirt) for the top and pleather hot pants, fish nets and pumps with three inch heels below. The show was a success. I’ve gotten more compliments on my legs this past week (thank you Peloton and enjoying a good walk) and it has helped with coming out of my omigod I’m sixty funk. I did a lot of age jokes in my MC patter for the show as I’m pretty good at poking fun at myself. One I didn’t make, and should of, was that if I fell off those damned heels, I would have to yell out ‘Is there another doctor in the house?’.

It was one of the fastest turn arounds I’ve had in stage performance. Half an hour with the pianist on Sunday to figure out tempi and style. Meet and greet with the rest of the cast Tuesday evening and first band rehearsal and figure out some basic staging. The band was a standard jazz combo of keyboards, bass and drums and Sebastian Black, Lee Wright and Joe Cooley worked amazingly well together. Tech/dress Wednesday to iron out light cues and any other bobbles. Run Thursday-Saturday. We all had a great time as did the audiences and have decided that it should perhaps become an annual event. If it does, I’ll get smart and wear those pumps around the house for a few days prior to rehearsals. I’ll just have to come up with women’s up tempo Broadway numbers that I can sing. ‘Don’t Tell Mama’ was a good choice. Perhaps ‘Dance Ten, Looks Three’ for next year.

I have noting booked on my performance calendar at this time. I’m not worried about it. Sumer is a slow season for music-theater and something will eventually turn up. It always does. The venue we did this last show in would be perfect for Politically Incorrect Cabaret so perhaps it’s time to come up with another edition of that. If so, I think it’s time for a bit of a reboot. After nearly 20 years, those of us who survive from the original crew are getting a bit long in the tooth and I think I need to find some thirty somethings with an interest in political satire and street theater and cabaret forms and let them run with it. So, if you’re one of my local theater friends and you have any interest in this, drop me a line. The bigger theaters in town have announced their line ups for next season. I, of course, immediately scan them looking for parts I might be appropriate for. Not a lot has turned up so far. Choices seem to be trending female and young. I suppose I could get out one of Tommy’s wigs and put my pumps back on and audition for Truvy in Steel Magnolias, but I doubt I’d fit in with the rest of the cast – unless we’re all men and I just don’t see this particular company doing that. Oh well, any time I don’t use on theater projects can be used getting the next volume of The Accidental Plague Diaries ready for publication. We’re still shooting for September.