I didn’t sleep well last night. I woke up around 3 AM and I knew it would be one of those nights when I wouldn’t be nodding off again. I should have gotten up and been productive and written something then, but I was weary so I lay in bed taking in another episode of the final season of Ozark while fretting about various work related things. The good news out of all of this is that I’ve been dragging around all day and I should have no difficulty getting a good night’s sleep tonight. I usually sleep relatively well and without the aid of soporifics or other aids so the occasional bad night is, I assume, another price I get to pay for kicking around in this body for a few decades longer than I ever intended, or even thought possible.

I’m of the HIV generation. I was a college student in the San Francisco Bay area in the early 1980s, and the first whispers of something seriously wrong started to reach campus toward the end of my sophomore year. My crazy schedule of double science major during the day and theater nerd at night probably saved my life as it kept me from getting into too much trouble. All the same, by the time I finished college and moved on into medical school the HIV epidemic was firmly established due to the powers that be of that time having no interest in diseases that seemed to be contained to marginalized groups, and so it ended wiping out so many of the men who could have been my mentors and teachers and exemplars .My reaction to this was to remain firmly closeted during my medical school years and to assume I’d probably be dead before the age of 35. I eventually wised up and came out and, obviously, I’m still on the right side of the dirt, at least as of this writing. I’m not to sure of any or our life expectancies these days… too many unknowns.

One of the things that’s kept me interested in our societal response to the Covid epidemic is the obvious parallels between our flawed responses to HIV and our flawed responses to Covid. In both cases, proper public health responses to epidemic infectious diseases were hijacked by political considerations and many thousands of people died needlessly. Eventually, science won out in the HIV epidemic and it has, for the most part, become a manageable chronic disease. We’re still adjusting to the Covid pandemic and it’s unclear where that’s heading next. Case rates are ticking up nationally, especially in the Northeast, but the mortality rate is remaining mercifully low. Is it a new phase where it’s becoming less virulent? The effect of widespread natural and vaccine immunity? Are we just not yet seeing the mortality from the current increase of cases as that usually isn’t apparent for a month or two? Then there’s a number of new omicron variants popping up, especially in South Africa, where omicron initially originated. It’s unclear if any of these is going to be a particularly bad actor but initial reports suggest no worse than the original omicron strain.

The big news this week is, of course, the leaked Supreme Court opinion which scuttles Roe v Wade. Chief Justice Roberts has acknowledged its veracity. There’s a lot of running around and beating of chests in shock and surprise. I am neither. The movement conservative forces in this country, playing a long game of many decades, have telegraphed every move well in advance with great fanfare and publicity. Why be surprised when they do exactly what they’ve told you they’re going to do. I am more than a little Susan Collins concerned about what comes next. In the opinion is legal language which sets up the repeal of Obergefell (gay marriage), Lawrence (striking down sodomy statutes), Griswold (allowing contraception), and even Loving (interracial marriage). I expect the current conservative bloc on the court will start looking for cases which will let the rest of the dominoes fall.

Without legal protections, people like me will become vulnerable to the state. I am planning on remaining in Alabama, at least through active retirement years, but I don’t know if it will be possible if the state is allowed to legally harass and subjugate my marginalized community. I’ve been out too long to go back to my closeted life of the late 70s and early 80s. At the same time, LGBTQ citizens of Alabama live life normally somewhere between stages 3 and 4 on the scale of the ten stages of genocide and if we start sliding toward stage 5 or 6 or beyond, it might behoove me to get out before something really bad takes place. And I’m too much of a realist to think things like ‘it can’t happen here’.

If more liberal individuals want to have the ship of state come about, they’re going to have to stop sniping at each other and start doing the hard work of organizing. It means going to precinct meetings and putting in the work as committee chairs and running for local offices, prepared to lose, but getting an alternative vision before the voting public. It’s going to take a unified front on social and political issues that’s going to require compromise and which can’t be beholden to various idealogical purity tests. It’s going to mean building a network of interlocking activist agencies willing to cooperate rather than spending their time in never ending turf wars over issues and funding. It’s going to mean developing a certain intellectual rigor in liberal philosophies and ideals and training thinkers to write clearly and cogently about policies and positions in a way that will capture broad public interest. Politics in this country works from the bottom up, not the top down.

This kind of work can be done. Ask my generation of the LGBTQ community and those a few years older than I. When the US government condemned us to early death from HIV, we fought back and built the various HIV service organizations and LGBTQ advocacy groups that continue to be a focal point of our community. It wasn’t easy but it was an emergency and needed to be done and there was no white knight coming to the rescue. No white knight is going to stop the Supremes either. Time to roll up the sleeves and get to work. Just get your booster before you go out and do it.

Tommy left us four years ago today. Obviously, he’s been on my mind as I’ve dragged myself through one of my usual work days. It wasn’t an especially hard day, one of my VA house call days in Sumiton and Jasper, but I still was feeling a bit beat down by the world. I suppose it’s normal to feel like this on an anniversary of this type but I have this negative reaction to emotions. They’re messy uncontrollable things that make it difficult to get things done with speed and efficiency. VA house calls are more about a previous loss, that of Steve. I was in the middle of one, talking about the mundane details of diabetes management with a lovely elderly African American vet and his wife, when I got the call that Steve had suddenly collapsed and died at home. There’s this little piece of me that always equates my walking into a patient’s home in the role of VA physician with circumstances of sorrow and loss. Perhaps that’s why I’m so comfortable talking about uncomfortable subjects when I make these house calls. I’ve been there.

Last night, in my role as board president of Opera Birmingham, I attended the final dress rehearsal of our current production of La Boheme. It’s the first time we’ve been able to mount a fully staged opera in a couple of years. Cendrillon, the last one scheduled, was cancelled half way through staging rehearsals in March 2020 when the world shut down. The exigencies and uncertainties of pandemic life made going into this production, less than a sure thing so the decision was made to scale it way down. We moved to a smaller house, arranged to share a physical production with several other small opera companies, and pared the cast down to the seven principals and an ensemble of twelve and a reduced, but full orchestra. The result was stunning. The smaller house puts the audience in immediate touch with the performers, allowing them to draw you into their world. The set proportions were those of Parisian attics, and not garrets the size of a suburban McMansions. And the singers and orchestra entwined together to bring through the true emotions of the piece. Note to self. Sitting through Act IV and Mimi’s death scene of the eve of the anniversary of one’s own loss is not recommended. It plays Friday night and Sunday matinee at the Day theater this weekend. Don’t miss it. I’ll be there again Friday night.

We haven’t run the numbers for a while. Anecdotally, I keep hearing of friends succumbing to Covid infections but no one seems to be getting particularly ill. Inpatient numbers at UAB have dropped to single digits since the pandemic first hit the Birmingham area in the spring of 2020, despite significant changes in behavior patterns regarding indoor gatherings. Maybe we’re kind of through this thing. Maybe we’re just enjoying a lull. As the virus is continuing to rocket around the world through all sorts of populations with all sorts of behaviors, anything is possible. Mutation marches on. We’re at something over 81 million documented infections in the US. This amounts to roughly 25% of the population. A recent cross sectional study of the population looking at antibody prevalence suggested that exposure is much higher than this, maybe closer to 60% of the population having had an infection. This would mean that the number of subclinical cases that were never tested for is enormous.

If 60% of the population has at least some natural immunity and roughly 66% of the population is vaccinated, the virus may be having a harder and harder time breaking through and forming effective transmission chains. Maybe not. I think we all tend to forget just how new this disease is and how little we really know about its natural history. Even at this low rate, we’re losing between 600 and 700 people a day to the disease and we’re something over 991,000 total deaths. This will put us over the million death mark sometime in mid May. This means that three of every thousand Americans who were alive in January of 2020 has died of Covid in the interim. Covid has been the third leading cause of death for the last two years, lagging only cancer and heart disease. And this is only the deaths. I care for a number of people who caught serious Covid, were hospitalized, some for a very long time, and who are now gravely incapacitated with multiple health issues. But they aren’t dead, just drowning in medical debt and unable to work.

I don’t think we have any idea yet about the ripple effects on survivors. The hundreds of thousands of new widows and widowers. The children who lost a parent, or both. The parents who had to bury their previously healthy adult children. The burdens of caregiving, for what might be years, on those left chronically ill. Then there’s the ripple effects on social and economic institutions. Entire industries and sectors of the economy are in precarious shape. The one I’m dealing with the most is the long term care industry. I know of no nursing home that’s not short staffed. The extra work piled on those left behind to cover for missing coworkers is burning them out leading more to quit and a vicious cycle rolls on. The short staffing is leading to basic needs of dependent people not being attended to promptly, corners being cut, and declining health outcomes which in turn is pushing people out of the nursing home back into the hospital with a preventable acute illness, using up precious resources and putting additional strains on exhausted medical staffs. Add in the aging of the Baby Boom and a perfect storm is brewing with which the health system and American society is not yet prepared to cope.

I got a notice that the book was short listed for the Grand Prize for the Eric Hoffer Book Awards, which only about 1/20 entrants makes, so someone somewhere has been reading it. I have a reading and signing at the Opera Birmingham office on May 7th if you haven’t yet obtained a copy. I’m busy reading and editing volume 2 to try and stay vaguely on schedule. It would be nice to win something prestigious but I’m not holding my breath. I didn’t write it for awards or sales, but rather to help myself cope with a rapidly changing world and putting it down on paper helped me make sense of the madness swirling around.

I was going to write a treatise on medications and deprescribing, but I’m too tired. Next time perhaps. In the meantime, the best vaccine is one in the arm. I got my second booster on Tuesday. I didn’t feel to horrible afterwards. And keep those hands washed.

Barbra Streisand turns 80 today. If that doesn’t make me feel old, nothing will. By coincidence, it’s also the opening night of the first Broadway production of Funny Girl since the original launched Ms. Streisand to superstardom two thirds of a century ago. I’m sure that all means something on a cosmic level, but I can’t begin to tell you what. As a gay man, I got the diva appreciation gene but not so much the diva worship gene. I don’t make pilgrimages or overspend on concert tickets or set up little shrines in my domicile as some do. I’ve often wondered where the relationship between gay men and larger than life female entertainers comes from? I imagine it’s that many of these entertainers enter a persona of womanhood that occupies a traditional dominant male space of commanding attention, and does so with affectations that are easy to mimic, giving birth to thousands of bad drag acts. Those few times I have done classic drag, I have done it as MissClairol Channing. Carol Channing is easy for me to do. We’re roughly the same size and shape, she’s got a distinctive voice I can imitate, and a little of her goes a very long way meaning I’m not asked to drag her out terribly often. She will not be making an appearance at my birthday this year – and my Birmingham friends have all let out a collective sigh of relief.

Tonight feels like a free association night. There’s not much going on in covidland. I’m still waiting for the other shoe to drop now that we’re more or less pretending the pandemic is over. The virus will use our changed behaviors and how that’s all going to play out is anybody’s guess. As long as it doesn’t send another major surge through the healthcare system. It’s gotten awfully rickety and I’m thinking it’s not going to take a whole lot more for it to become nonviable. In some ways, it already is. The waits for appointments and elective procedures aren’t going down. they’re actually going up locally. The mass of retirements and departures from the sector is ratcheting down the number of services available and the timeliness of those services. There are a few common referrals I make where I can find no provider with an opening for four months, either inside of or outside of the UAB network.

Personally, gross exhaustion has been setting in from the UAB piece of my job. For various reasons, UAB Geriatrics Clinic can only offer about half the appointment slots we were able to offer pre-pandemic. We still have roughly the same number of patients. We are still trying to squeeze in new patients who desperately need our counsel and advice. We haven’t had much luck replacing departing providers. The aging Baby Boomers, having had a couple of years to contemplate themselves without major interruptions have decided they don’t like bodily change and are banging on the doors. Everyone has gotten a chance to experiment with patient portal e-mail systems, quite like them, and send in messages about every little thing. The administrative heads of health systems have had two years to dream up all sorts of projects using the big data capabilities of electronic health records are requiring more and more inputs. All of this is falling squarely on the shoulders of me and the other providers in our clinical system. Then throw in a maternity leave and a prolonged vacation before pouring in the blender and hitting frappe. Whine over. Things will get better.

I’ve been through professional periods like this before. The difference this time around is the pandemic having created a whole new set of complications – for patients, for providers, for health care systems, for society. There hasn’t been a lot of fat in the system for a long time due to the economic structures of for profit health care that have been slowly put in place over the time of my professional career, but the pandemic took the last little bits and a good portion of the muscle and skeleton as well so it’s all we little neurons can do to keep the system upright from day to day. I’ve started to think that every day I go to work, and I come out at the end of the day feeling like I haven’t left a patient in the lurch is a successful day and should be celebrated.

My performance life is going to rev up again starting next week with rehearsals beginning for the symphony next week and for The Merry Widow the week following. I have a bit of trepidation about putting that back in on top of the work stresses of the moment but I know that those sort of commitments create what I call good stress in my life rather than bad stress. Besides, I’m going to be on staycation during most of the symphony rehearsal period so it shouldn’t be a problem. And I’m only doing ensemble in The Merry Widow so I’m thinking I’ll be able to handle that without too much difficulty.

I’ve got the first 40% or so of the second volume of these Accidental Plague Diaries edited. It should be fully edited by the first of June at the current pace and I should be on schedule for an early fall completion. It’s been interesting rereading things from a year ago. It reminds me of how fast and how thoroughly our society has changed over the last few years, too fast for us to really understand what all has actually happened and what all it means. And that’s why I keep writing. Even if the pandemic were over (and I don’t believe that for a minute), the ripple effects are just beginning and are going to cause vast changes over the next decade or so. I don’t see these writings going to ten volumes (no one would read them, unless they’re the sort of person who thinks Robert Jordan’s Wheel of Time needed to be a bit longer) but I won’t be surprised if there’s a volume 3 in 2023. I won’t make that decision for another year and it will depend on all sorts of things that I cannot predict at this point.

It’s coming up on the 4th anniversary of Tommy’s death so I’ve been reflecting back on him a bit this week. He’s still very much present in my life. Clothes he wore still hang in my closet. I’ve been sorting bins of miscellaneous paper and finding notes of his from various projects, theatrical and otherwise. I haven’t noticed his physical presence, but my house guest swears he’s heard him in the kitchen a time or two. (It’s probably just the cat). If he is hanging around the condo, the kitchen is the most likely place for him to be. I’m sure he’s not very happy with the way I’ve arranged it but he’s likely to approve of the new refrigerator and dishwasher as both of the ones that came with the condo decided to give up the ghost recently. I bought his favorite kind of fridge. I didn’t get his favorite brand of dishwasher as I always had trouble with the adjustable racks myself and broke more than a few of them over the years. If the new dishwasher has issues, then I’ll know Tommy’s in the kitchen and won’t rest until I get a Bosch.

IT’S NOT OVER! If I had the budget, I’d like to hire a skywriter to write it in large letters in the sky over the capitol dome. Do we even have skywriting planes any more? I haven’t seen one in years and years. I suppose the chemicals they used to create the stable clouds are bad for us, like so much else in modern life, and they have gone the way of the dodo. I think small planes towing large banners remains a thing so I suppose I could do that but it doesn’t have quite the same impact. Then there’s the Goodyear Blimp. I’ve always wanted a blimp or a zeppelin ride but I was born in the wrong decade for that to be of high likelihood. I love the images of the elegance of between the wars travel with slim people in suits and hats sitting in elegant art deco lounges on ocean liners or the Orient Express. I’m sure the actual experience was nowhere near as refined and sophisticated as the image but wedging myself into a seat on a plane between two overweight people in faded T-shirts, cutoffs and flip flops is getting a bit old.

And why do I say it’s not over? Society is tired of pandemic life after two plus years and the political system as more or less abandoned all restrictions in the name of public health. One of the last bastions to fall, being the lifting of masking requirements on public transport by a judge in Florida earlier this week. If you actually read her opinion, that she was determined to find fault with the administration’s rule and just needed to come up with some specious legal reasoning to allow it. (Three guesses as to which president appointed her and what her family and social connections are…). Her opinion depends on a new reading of a 1940s public health law which permits the executive to exert necessary ‘sanitation’ measures by saying that the definition of sanitation refers only to something like a cleanser, and not to the much broader definition of sanitation in public health parlance, referring to any measure that prevents the spread of infectious disease which the drafters of that law were obviously referring to. Ah well, a few more people die due to preventable infection. What’s that to people who feel inconvenienced by a bit of cloth on their faces.

At the same time as this, over the last two weeks, new infections in the US are up about 40% from their low last month. These increases aren’t distributed evenly and are concentrated mainly in New England and the Northeast. There are a few other hot spots here and there but outside these areas things are pretty calm. They are being driven primarily by newer strains of omicron. It’s certainly not spreading at the astronomical rate it did this past winter (likely because it’s running into the walls of the vaccinated and the previously infected) and it hasn’t put huge strains on the health system yet, but it’s early days still. We shall see what we shall see.

We tend to be a bit myopic in this country and not pay much attention to what’s happening outside of our borders but, for those keeping score at home, Shanghai is in complete lockdown to try and contain omicron which has caused so much illness that their hospital and public health systems are basically non functional. This is likely due to China’s not pushing and prioritizing vaccination in their older population leaving a highly vulnerable group under protected and now dealing with heavy morbidity. Shanghai is the third largest city in the world. (By comparison, the largest US city, New York, is only about a third of the population and is ranked #45 in the world in population). If you look elsewhere, there are reports of new omicron sublineages emerging in South Africa, deaths in the United Kingdom are actually a bit higher than they were at the peak of omicron and cases in Canada are going up similar to what’s happening in New England, likely due to trans-border traffic. Keeping all of this in mind, I think it’s fine to enjoy the lull we’re currently having but we must all be mindful that our peace may be more fragile than we think.

I’ve been racking my brain to try and think of an amusing anecdote from my past to tell. People always seem to enjoy those. The problem is that over the last four years of writing these posts, I’ve told the majority of my really good cocktail chatter tales. But here’s a brief one involving Steve and the very beginnings of my professional career. It was brought to mind as I have been dealing with caterers this week. If you go into any sort of professional position, especially in academic life, one of the skills you must develop is negotiating a hotel ballroom full of people with a glass of wine in one hand and a plate full of nibbles in the other. When I finished my internal medicine residency and transitioned into my geriatric medicine fellowship, I was invited by my department chair to give a brief presentation at a gathering of the Northern California chapter of the American College of Physicians meeting that was taking place in Monterey. As I was speaking briefly, I would get an expenses paid weekend, some exposure, and a little notch in my anemic academic CV. At this point, Steve and I had never been to Monterey so he tagged along (he bought a copy of Steinbeck’s Cannery Row for company as he had no intention of sitting through the medical programs).

One thing that had to be understood about Steve is that he was the exact opposite of a foodie. If we went out to eat, he would always order the same thing and he had a huge aversion to seafood of any stripe. If he even smelled fish, he would grab my arm before we were seated and lead me out until we could find a dining establishment that smelled more like steak and potatoes. Finned fish, shellfish – it didn’t matter. If it lived in the water, he wouldn’t eat it. So anyway, here we are in Monterey, a town known for its seafood history, in a large downtown hotel and it’s the opening night reception. Plastic tumblers of wine (not for Steve who was sober in AA for thirty years when he died), chafing dishes with various hot hors d’oeuvres, people greeting colleagues they hadn’t seen for a while. I was chatting with a friend from residency when Steve came over, his little plastic plate piled high. ‘I’ve just discovered this stuff called calamari’ he said. ‘It’s delicious’ as he popped another piece in his mouth. Our mutual friend, who knew about his seafood aversion, looked at him and said ‘Do you know what calamari is?’ He admitted he didn’t and she made the mistake of telling him. He spat it out, let out a shriek and made a beeline for the door. I had the good taste not to refer to the incident the rest of the weekend.

It’s late and it’s bedtime. What should you do about masking in the light of what’s going on? It’s never wrong to wear one, no matter what others may say. I wear one at work when I’m in clinical areas and on house calls. I judge other indoor spaces by the number of people, the kind of people and the amount of ventilation. Study after study shows that one of the best ways we can control Covid is by adjusting ventilatory standards in public indoor space. It’s one of the reasons why I’m hosting my birthday party where I am. It’s a large open very high ceiling area with plenty of appropriate ventilation. And wash your hands. And have some calamari (it was always my and Tommy’s favorite starter when eating out).

I’m still battling fairly consistent fatigue. It’s not bad enough to keep me from meeting any of my usual obligations but, when I get to the weekend and some free time, all I want to do is sleep. It remains unclear to me if this is a stress response (work is particularly hellacious at the moment due to significant understaffing coupled with increased demands on clinical geriatrics), my version of ‘long Covid’, or the fact that I’m older than I ever intended to be by several decades and my body is simply starting to require more down time. It might be all of these together I suppose. Anyway, I slept for ten hours last night and am retiring early tonight as I have to get up for church in the morning in order to sing with the choir and those high Es won’t even begin to come out without rest, relaxation, and hydration.

The Unitarian church, having been founded in opposition to the Trinitarian belief of God the Father, God the Son and God the Holy Spirit, doesn’t celebrate Easter in the usual way. We have what is known as the flower communion created by Rev. Norbert Capek nearly a century ago. The congregation arrives with flowers which are gathered and then, during the service we choose and depart with a different blossom – the flowers symbolize spring and renewal and they are all different just as we all are different, coming with us and departing with another member of the beloved community. It, like other religious rituals, comes around every year and the older I get, the more I recognize the importance of ritual and tradition in all of our lives. The world changes fast. As we age, our abilities to absorb and reorder ourselves for those changes decreases. The part of culture and religion that is unchanging becomes more and more of a touchstone, an anchor point in a world that is more and more unfamiliar. If I feel like this at sixty, I can just imagine what I’ll feel like in another generation when I’m eighty, should I live so long.

Most of the planning is done for my sixtieth birthday bash, which I’m regarding as a party I’m giving as a thank you for all of my local friends who have helped me weather the last few years of loss and pain and pandemic. Invitations are going out this week. Should you be local and not receive one and you’re really interested in attending, message me privately and I’ll get you the particulars. I haven’t given a significant party since Tommy and my last open house at the end of 2017 and it feels strange to put one together without his input. I don’t have his culinary skills to fall back on so I’m going with professional catering and I hope he’ll forgive me. I’ve picked a venue with space to spread out and good air circulation and I’ll keep my fingers crossed that Covid keeps its head down for the next month.

I’ve heard through the grapevine of a number of friends catching Covid over the last week or so. No one has been particularly ill and it’s mainly been picked up on positive home tests without PCR confirmation so it’s hard to say what’s going on. At the moment, the US is flying blind. The federal government’s payment for Covid testing for the uninsured has lapsed keeping large segments of the population away from testing. The large testing centers have closed. Exhausted health departments aren’t doing the contact tracing or surveillance they have been doing in the past. We really can’t trust the data being reported into the central data banks regarding numbers of positive tests to accurately reflect what’s going on out there the way we could a few months ago. What do we know? Numbers are creeping up in New England thanks to omicron variants spreading in the major cities. It does not appear to be enough to have a serious impact on hospitalizations. As a heavily vaccinated region, it may not get much of a hold on the population as a whole following the major spike of the initial omicron wave.

The local numbers here in Alabama are quite low. UAB hospital is holding steady at roughly ten inpatients with no one on a ventilator, giving the ICU teams a much needed break and allowing the system to open up for long delayed elective procedures. Given the prevalence of home testing, with no good way to actually collect that data, we may need to look for other numbers to help us make sense of the world. The first is the percent positivity rate of the PCR tests that are collected in hospitals and clinics and testing centers. If fewer than 5% (1/20) of those tests is positive for Covid, than, per WHO definitions, the disease is under reasonable control and spread in the community is limited. That number isn’t generally reported but it’s out there. I’ll see what I can find. The other major marker is wastewater surveillance which I think I have mentioned before. As all our bodily wastes, which will include virus, go through the same sewer systems, testing at water treatment plants for the amount of virus coming down the pipes is a pretty good marker for how sick the community is. This methodology is inconsistent across the US and can’t really be counted on for national planning.

There are a few studies out of Europe that suggest that we are not the only ones having difficulty figuring out what’s going on in real time. Studies there are showing an uncoupling of the data curves of testing from the data curves of reported illness as not all tests are being done quickly and reported to the authorities the way that they were being as recently as January when omicron reached its peak. Our current valley and more than two years of battle has left us somewhat spent and taking advantage of the lull. However, one must always remember that the virus never takes a break and simply exploits changes in human behavior in its inexorable need to replicate. I shan’t be in the least bit surprised at another surge coming up and that it will surprise it when it does come as we simply haven’t been looking for it, now being distracted with domestic politics and the situation in Ukraine.

If I am reading the tea leaves right, we’re about five years away from a major collapse in the health care system. Now that Covid is improving to the point that older populations are getting out and about more, the aging lead edge of the baby boom, now in their mid 70s, is reevaluating its health needs and trying to turn to geriatrics to make sure they age with eternal youth. (It doesn’t work, but my newer patients seem to think that I am Miracle Max and I’m just hiding some perfect concoction of turmeric, mineral supplements, biotin, blood pressure medication, and memory enhancers somewhere in my files and that if they just keep pushing, I’ll give them the secret – sorry Ponce de Leon did not leave me the map). They are about to be joined by their younger brothers and sisters clamoring for help from an exhausted group of health care providers, many of whom have left the profession leaving more work for those left behind. On top of that, the commercial insurers, who took a bath on Covid, are looking for ways to replenish their coffers and are ratcheting down on payments and fighting against even basic testing and medications – denials and prior authorizations and calls to adenoidal individuals at call centers with no medical training other than a script are way up and that just adds more and more time and busy work to our day. It now takes me about 6-8 hours on the weekend to catch up from my average work week. It used to take about 2. It’s going to continue to drive people away from primary care disciplines. Just another gift of the pandemic to our post pandemic world.

Enough kvetching. Time to end this and put on an old episode of Supernatural as I fall asleep. Be careful out there. I’ve gone back to masking in crowded stores. It doesn’t hurt me and it may help. Have an appointment for my second booster coming up as well. I figure it won’t hurt and it might help.

t’s what I call birthday week again. Yesterday would have been Tommy’s 57th birthday and Wednesday will be what would have been Steve’s 74th. It’s a bit hard to wrap my head around that latter one. I have enormous difficulties imagining a septuagenarian Steve. He was a pure early baby boomer, always conceiving of himself as young, even into his fifties when I lost him. He would have fought the infirmities and indignities of age every step of the way and I imagine by this time the bills for hair treatment, botox, teeth whitening, and various other youthening procedures would have been relatively exorbitant. Tommy was much more philosophical about the aging process, given his burden of various diseases due to bad genetics and bad luck long before his early departure. He did spend a small fortune at the hair salon every few months to stay strawberry blond but other than that he just let the chips fall where they might.

Having been a student of aging and watching the psychological battles of thousands of people from a number of different generations over the years, I just let my body do what it’s going to do. I don’t color my hair (I figure I’ve earned the white), do botox, expend large amounts on various facial creams or the like. I try to keep my weight under control (sometimes difficult to do on an erratic diet due to my erratic hours), shower routinely and occasionally put a little cheap moisturizer on my face. That’s it. It seems to have worked so far. I haven’t had a surgery since my tonsillectomy at age three, rarely become seriously ill, and my aches and pains are pretty controlled with judicious use of Tylenol. I know I’ll have to have my knees done eventually. They let me know that every time I climb stairs, but they’re not bad enough to have to think about that prior to retirement when I’ll have time to cope with such things.

Why are we so afraid to grow old in our culture? Our youth obsession is fed by our capitalistic society. Everything revolves around the advertising dollar and advertising is a science that’s been studied fervently for well over a century. One of the things that’s well known is that it’s not possible to brand or sway a consumer over the age of thirty five by advertising. Older brains are too savvy to fall for the ploys and the glitz and the glamor. Therefore, general advertisers really aren’t terribly interested in attracting much of anyone over forty. This makes our pop culture skew young and explains why when you’re fifty or sixty, you can’t find a movie or new music that speaks to you. As television has migrated away from advertising based networks to subscription based streaming, there’s less need to grab a younger audience, just to grab a paying audience and older people have disposable income for Netflix so television over the last decade or so has created the well written well acted dramas and comedies leaving the movies the purview of super heroes and special effects that entice teens and twenty somethings.

I suppose as we go hurtling through the space-time continuum to our inevitable destination of mortality, we have difficulty coming to grips with our non-existence. This chafes at the Western mind. Ever since Rene Descartes posited Cartesian dualism – life of the body and life of the mind separate but parallel – we’ve built our culture around the cult of the individual. The most fundamental building block of our economics, politics, and social arrangements is that we are all different, unique individuals and the self is the most important thing in our lives. Anything that threatens the self is anathema and the annihilation of self posed by death, combined with our very linear thinking about time, means we tend to become more and more frightened thinking about the end of the journey. It’s also why Alzheimer’s is so feared. We recognize it as obliteration of the self while still leaving the body alive. That’s too scary a prospect for most of us to contemplate.

Personally, Alzheimer’s and dementia doesn’t scare me. If we just approach it as a regression backwards through the stages of development, we recognize that most of the misery is caused by trying to make a person who no longer has a functional adult brain still lead a functional adult life. At the beginning of the life cycle, we’re very good at matching development with environment. One does not send a five year old, a ten year old, and a fifteen year old out into the same world, we tailor it to needs. If we do that for the demented, constantly fitting the world around them to their needs and abilities, they are quite capable of being happy and contented. We’re just horrible at doing that, both as a medical system and as a society. It’s one of the first things I start to evaluate when I get a new patient with cognitive problems. My mother had a genetic dementia. As such diseases are autosomal dominant, I have a fifty percent chance of carrying it. Fortunately, it doesn’t start showing up until about age 75 so I have plenty of time. I’m leaving strict instructions to my family to help my environment and abilities match. Give me someplace with my books and my music and a cat to cuddle and dessert with every meal and I’ll be fine. I am much more scared of diseases such as ALS which leave an intact mind in a completely nonfunctional body. To me, that’s the definition of hell. Over the years, I’ve met a number of people with what is know as locked in syndrome. It’s a condition where a serious stroke leaves the thinking and feeling part of the brain intact but destroys all motor function. They can’t use their bodies, often can’t communicate, and usually end up spending years in nursing facilities as their care is too burdensome for home. I’d likely have a psychotic break internally if it happened to me.

I’ve often thought that we’d be better off as a society if we had formal death education. Classes in school or in community institutions where there was frank discussion about mortality, the causes and mechanisms of death, what kinds of medical care can help serious disease and which simply prolong the inevitable, the importance of wills, powers of attorney, and advance directives, and other such subjects. The problem is that death is probably even a bigger taboo than sex in American culture and we all know what sorts of wars are propagated by sex education in the schools and elsewhere. The cultural battles over death education would probably touch off fighting in the streets. Speaking of sex education, the governor of Alabama signed bills this past week stipulating felony charges against those who try to provide medical care to trans children and major threats against anyone who tries to bring discussion of gender or sexuality into elementary classrooms. The bills are badly worded and vague and will be tied up in court for some time. They are so vague that I suppose I, as a concerned citizen, could lodge a complaint that Sally, DIck and Jane should be banned as there are clear gender roles present in the material and such things are not to be discussed. Sally, Dick and Jane need to be retired for all sorts of reasons but it does go to show how piling on the conservative bandwagon is not the best of ideas.

Trans issues are being used as a wedge to open up anti LGBTQ sentiments again. Three steps forward, two steps back. I really resent the ‘grooming’ language that has all of a sudden become ubiquitous when it comes to issues of gender and sexuality and the education of children. Kids are curious creatures. They’re going to start making assumptions about such things whether you want them to or not and often at earlier ages than you might think. You can either give them correct information or don’t and let them pick it up haphazardly from peers or the internet (and every ten year old has hacks to get around parental filters and controls). I don’t groom kids. I’ll answer questions appropriately and honestly. None of my LGBTQ friends grooms kids. We don’t want to or need to. Those kids who understand that we are their tribe seek us out of their own accord when the time comes, usually in later adolescence. As for the parents of trans and non conforming kids. They aren’t trying to push an agenda on anyone. They’re frightened to death that a cruel and misunderstanding world will push their children into misery, addiction, and suicide and they’re doing everything in their power to prevent that. Being told by the state that that’s abusive is unconscionable.

I have no idea why I wrote about this tonight or where this all came from. I was going to write about BA 2 and Covid numbers but they remain low and I hope everyone is enjoying a bit of a pandemic respite. I’m not certain it’s going to last. But get out and enjoy spring weather while you can. Just keep your hands washed and pay attention to local transmission rates and put your mask back on if they start going up. (This has already happened in Philadelphia – other large cities my need to follow suit. We shall see).

And merrily we roll along as if the pandemic is definitely in the rear view mirror. I am not so sanguine. BA2 continues to spread in this country. It hasn’t caused a trend upward yet in cases or deaths (which still remain mercifully low) but the pace of decline has slowed over the last few weeks which could mean a new equilibrium or it could mean it’s just about to start back up again. Time will tell. I was reading today about yet another omicron variant that’s been identified and that’s spreading rapidly in the UK. This one, known as XE, has genetic material from both the original omicron and the BA2 or stealth strain. So far, there’s no reportage that morbidity or mortality is higher from it but there is some evidence that it is much more contagious and spreads even faster than the original omicron – and that one went from a few hundred cases in South Africa to the highest levels yet seen worldwide in a matter of weeks. Be prepared to fasten your seat belts, or at least put your masks back on.

What’s been preoccupying my mind this week as I march through my daily round of clinical geriatrics problems to be solved (this weeks include a man whose friends keep sneaking large quantities of vodka into his assisted living, a family who is majorly unhappy about surgical complications from five years ago with which I was not at all involved, a daughter demanding a letter certifying her mother, who is bed bound, is safe to be left alone all day so she can get Adult Protective Services off her back, and a schizophrenic who has destroyed all the appliances in his house) is what comes next. We may actually be at the point where Covid slides from pandemic into endemic mode, always there in the background like the flu but not enough to cause major social disruption.

I wish I knew. I don’t think we yet know exactly what social disruptions have been set in motion or where they’re going to end up. The flu pandemic of 1918 helped lead to a rapid closure of World War I and the disastrous Treaty of Versailles in Europe while, in the US, it helped create the social conditions that led to the demise of the Victorian way of thinking toward what we would consider a more modern way of viewing the world. The societies of the Titanic and The Great Gatsby were only about a decade apart but everything changed in that decade. I think we’re in the middle of a very similar social transformation but, because we’re all stuck in the middle of it, we can’t really see it or understand it in any sort of objective way. It may not be clear for years yet.

I’m toying in my head with this idea that there’s some sort of fundamental connections between various pieces of our social turmoil, kind of like the unified field theory of physics that explains the failures of our politics and social institutions and Eastern European unrest and horrible public health responses. I’m not quite smart enough to see them all or draw all of the parallels that need to be drawn, not being the Kwizatz Haderach, but there’s something there and I think the stressed of the pandemic are making it more and more visible. Perhaps the simplest way of thinking about it is the failure of the neoliberal globalization of capitalism which has been the grand design of the Western democracies over the last couple of generations. I think the pandemic has exposed the extreme inequalities that have been brought to bear, both domestically and internationally by our current economic system.

We’ve been able to paper things over with the traditional bread and circuses but over the last two years, it’s become very clear that when faced with an external threat which was equal opportunity, that that did not come with equal consequences and there wasn’t a lot of attempt to level the playing field. Wealthy populations were able to cocoon and isolate themselves with aid of modern technology until vaccines became widely available and still have managed to figure out a functional life with fewer social contacts. Poorer populations had to do go out and do the jobs that allowed wealthy populations to maintain this existence, and died. Meanwhile, the poorest populations internationally couldn’t even get vaccine for months and months and months. The system we’ve built which puts profit at the top of Maslow’s hierarchy of needs as created a totally dysfunctional society which no longer serves its denizens, only the profit motive. And this rapacious hunger is leading to climate change, conflicts over resources, tribalism, a lack of empathy and caring, and a steering of religion away from its ancient function of bringing people together to separating us from them through a myriad of rules. Perhaps this is how civilizations fall and its just time for Western Civilization to go the way of the Minoans, the Romans, and the Mayans.

Both Tommy and Steve had political views that were predicated on the flaws in modern society. Steve liked to agitate and always called himself a Gay Communist for the shock value. Shortly after I joined the faculty at UC Davis, I was invited to some sort of fancy cocktail party honoring some political figure (I’ve forgotten whom) and Steve marched up to the then Dean of the Med School and said ‘Hi, I’m Steve. I’m a Gay Communist. What are you going to do about it?’. It was not one of his finer moments. Steve, as a kid who had grown up near the studios in Hollywood, was very savvy about appearance and media. In the late 80s, when California was chafing under a Republican governor and considering a bunch of anti-gay legislation, pushed as a reaction to HIV, he would turn up at all the protests at the Capitol dressed in a three piece suit and looking quite dapper. He could be well spoken when he wanted and he usually ended up on the evening news as ‘Gay Activist’. Tommy, for the most part, absented himself from politics as he felt that the whole system was corrupt and, with his nursing work among the poorest of the poor, that it had nothing much to offer the have nots so he wasn’t going to engage until it did. Personally, I’m more hopeful than either of them. The system is flawed but is capable of responding to fixes if people are willing to put the work in. The current conservative ascendancy is the culmination of sixty years of movement conservatism and a lot of grunt work at the local level that showed little result for decades. The left generally doesn’t seem to have the patience to do what’s going to be necessary to right the ship.

Several people have asked me over the years if I would be interested in going into politics. My answer has always been not just no, but hell no. I have far too many skeletons in my closet and I’m not that interested in compromising my core beliefs for campaign donations. I’m also not a particularly good equivocator. Someone once said that politics is just show biz for the unattractive. I’m not especially good looking, but I’m OK for regional stage so I’ll continue to do my performing in the world of musical comedy and let others perform for the cameras of C-Span. Not that I’d mind being a political adviser of some sort. As the Baby Boom continues to age and demand more and more of society and the health system to help them cope, there may be a role for me in retirement for something of that stripe, but I’ll gladly remain an eminence grise.

It’s late. Time for bed. One more work day to get through this week, then four more weeks before I get some time off.

I took the weekend off. I haven’t done that for some months. I am now staring at a pile of work that should have been done and will have to be squeezed in this next week but I’m not feeling in the least bit guilty. Well, maybe just a little bit guilty, but not enough to really worry about. My Anglo-Scot heritage gives me that Puritan work ethic that makes me feel all uncomfortable when I’m not doing something constructive with my time. I might have been better off with a heritage that’s more about work to live than live to work but we can’t do much about the genetic lottery that predicates where and when we are born and to whom. Perhaps my mantra for my next decade should be something along the lines of ‘you don’t have to finish that today’.

I used my weekend off to drive to Columbia, South Carolina to visit an old friend who relocated there a decade or so ago and whom I try to visit a couple of times a year. He was one of the first true friends I made in Birmingham theater when I turned my hand to performing twenty years ago and we shared the stage many times in various projects. Our favorite thing to do together were the various incarnations of Politically Incorrect Cabaret as we’re both highly verbal people and we have the ability to sling improv zingers and repartee back and forth at each other without missing a beat. We had several good meals together; I got to see some of the Columbia theater people I’ve gotten to know through him and the zoom projects we all worked on together during the worst of the shutdown; and I got to see him perform in a very silly production of the stage version of Clue. (Basically the mid-80s film with ending A adapted for theater – not a great drama by any sense of the imagination but the director and cast took advantage of the more ludicrous aspects and went for broke so it ended up being highly enjoyable). Back to the grind in the morning.

The pandemic is winding down in the minds of American society and American governance. It’s not over. The omicron BA2 variant has spiked in both Europe and Asia and is causing significant increases in caseloads. It’s now more than 50% of cases domestically so it’s going to start spiking here shortly as well. What will that look like? Nobody really knows but there’s a few things that we can conjecture. One, the omicron wave was so steep and fast (with more than 800,000 cases daily at its peak) that a significant portion of the US population was infected. BA2 is a subvariant of omicron which means that there’s significant natural immunity circulating. Two, vaccination rates ticked up during omicron and while they aren’t what they should be, they’re better than they were. We’re at 2/3 of the US population fully vaccinated. Alabama is far worse with only 1/2 fully vaccinated. But, if you start breaking the numbers down further you find that there are populations that are pretty much fully vaccinated and other populations where vaccination is uncommon.

This suggests that the BA2 wave is likely to be highly uneven across the country, hitting different communities with very different rates of infection and morbidity/mortality. Urban populations which have high levels of vaccination and which omicron tore through are likely to have somewhat limited issues while willfully unvaccinated populations in isolation may have very severe outbreaks if they managed to escape much omicron earlier this year. We shall see what we shall see. At this point, if you are vaccinated and boosted (and a second booster won’t hurt…), you’re probably not at significant risk of major disease. But there are populations (the extremely elderly, immunocompromised individuals, seriously obese/diabetic) who will continue to sicken and die needlessly without a certain amount of public health vigilance. The problem is, we’re in the process of dismantling all of the systems we’ve put in place over the last couple of years. They’re expensive; federal dollars are drying up and a quarrelsome congress isn’t in the mood to keep up the largesse; there’s a general feeling of it’s over. Tracking officials are being let go or reassigned. Reportage systems are no longer being operated on a daily basis making data more suspect or incomplete. The distribution of home tests without a means of tracking the results means that lots of cases aren’t even being caught by the authorities.

I wonder if we’ve learned anything from the last two years? Covid is here to stay. It’s no longer novel as we’re moving into a third year with it and it’s human nature to always want to move on to something new. Are we going to banish it to history books and medical research papers no one reads? We can, but if we do, we’ll continue to lose susceptible people. Are we willing to categorize them as acceptable losses? Collateral damage in our need to move ahead to the next thing in life? The poison of distrust in science is now part of our national landscape. When the next virus comes through, one potentially more contagious and more deadly than Covid, the antivaxxers of the future will have social attitudes and infrastructure on which to build which will make containing something like a filovirus much more difficult than it otherwise need be.

Sorry to be a bit of a gloomy gus this evening but I’m feeling a bit worn down by life. The weekend helped but wasn’t long enough. Five weeks to go until I get a bit of a longer break. And in the meantime, I have social events to plan, work to do, a second volume of The Accidental Plague Diaries to edit, promotional events for the first volume (it’s up for some more awards) but one thing I don’t have is a show to perform in this spring as the one I had been cast in has been cancelled. Ah well… time to look and see if there’s another opportunity out there. In the meantime – wash the hands, get your vaccines, and keep a mask in your pocket and stick it on correctly when appropriate.

The wind is howling outside the window as the stormfront from the west continues to march on Birmingham. It’s not here yet and, from my study of the weather map, it won’t hit for another hour or two but we’ve been under a tornado watch for the last few hours and I’m prepared to move into the master bath if anything starts to look too serious out there. The condo building is a large concrete fortress, but I’m not terribly worried as long as I’m away from any of the picture windows. I imagine there’s a metaphor to be drawn between such weather fronts and the coronavirus, but I’m much too tired to sit down and work it all out tonight. The general fatigue of the last few weeks continues. I did actually get my request in for time off in May and I’m hoping that, as the idea of respite sinks into my subconscious, it will alleviate somewhat – but I’m not holding my breath.

The news from covidland this week remains something of a mixed bag. The most important thing was yesterday’s announcement of the FDA approving a second booster shot for those fifty and over or those younger with immunocompromise. The FDA didn’t recommend it, they just approved it and so the messaging from both the government and the media has been somewhat confusing, at best. And this has been a constant bone of contention between me and the current administration – make your messaging about public health measures absolutely clear, consistent, and understandable by the general population. The Biden administration hasn’t done a whole lot better than the Trump administration in this regard. So what does the science say? It’s also somewhat unclear. The data that everyone is looking at is out of a very large study in Israel but there are some flaws with it. It wasn’t a randomized controlled trial, it was done in a self selected group of individuals concerned about their health and more likely to be proactive in various ways against Covid infection. Therefore, we are left with the question of whether the reduced risk of infection was actually due to a second booster shot or due to a set of improved health behaviors. The data doesn’t allow us to really distinguish.

Therefore, what we’re left with is a conclusion that a second booster shot may indeed be beneficial (although there is data from other smaller studies that show additional boosters give diminishing returns in terms of protection) but it’s not completely proven. The good news is there is no evidence that an additional booster is harmful in any way. I’m over fifty; I’ve had a case of omicron; I’m planning on getting a booster this weekend or next. Everyone is going to have to start doing their own risk/benefit calculations about what’s right for them. Ultimately, what’s going to be the most useful is rejiggering of the mRNA vaccines to make them more effective against new variants and, when that happens, we’ll probably all need an annual or biennial booster, something like a flu shot.

I ran into an interesting predicament today while dealing with some community elder health issues. There is only one population group guaranteed the right of health care by judicial fiat in American society. Prisoners. It’s usually not the best health care but it must be provided. One of the side effects of lock ’em up mentality is an aging prison population who must be provided with health care which gets more and more complex and expensive as they age. if they become bedridden or demented, they aren’t usually much of a threat to society but until they are released, they must receive health care from the Department of Corrections at public expense. Covid has caused some huge issues with this. Aging prisoners who developed Covid were hospitalized to protect other inmates and, those that recovered, were often too sick to return to hospital infirmary wards due to their acute needs for oxygen or wound care. They have been occupying hospital beds for months as the prisons can’t handle them, nursing homes don’t want them and hospitals have nowhere to send them.

This weekend, in one local town that shall remain nameless, the hospital decided enough was enough and discharged a number of long hospitalized prisoners back to the custody of the local prison, calling ambulances for transport. When they arrived at the prison, the staff refused to accept them and the ambulances returned to the hospital where the medical staff refused to admit them. A full third of the city’s ambulance fleet was tied up all day in the stalemate and unavailable for any other calls. What was the resolution? A judge was rousted out on the weekend to change their sentences to ‘time served’ to keep them from having to go back to prison and the social services staff was busy calling every nursing home in a fifty mile radius to see if they could be admitted anywhere so that the ambulances could go back in service. My source didn’t know the end of the story so I can’t relay it.

This is emblematic of the hidden problems that are currently shaking the American health system to the core. A large new chronically ill population combined with the normal aging issues of the huge Baby Boom generation combined with the great resignation combined with the grossly inefficient system we’ve allowed to continue for decade after decade is going to lead to more and more incidents of this kind. I have absolutely no solutions to any of this. All I can do is point a spotlight at some of the more ludicrous aspects. Why is it allowed to continue? Money. It’s always money. More and more private equity is moving into the health care center and they have one motive and one motive only. Profit. If a crazy quilt system that doesn’t serve the population’s needs allows the dollars to keep flowing, they will lobby congress long and hard to prevent any sort of reform.

I’ve been listening to the audiobook of Dune in the car this past week. I’ve read it several times before, but not since college. The politics of Arrakis, Giedi Prime, Caladan, Corrino and the rest, all culminating in ‘The Spice Must Flow’ seem eerily prescient and appropriate to our current moment. It’s just that we’re living in a system where the cash must flow. In the meantime, consider a booster, keep your hands washed, and remember we’re not exactly out of the woods quite yet.

It’s Friday. I’ve had a couple of glasses of wine so pretty much anything might come out of brain and on to the page this evening. I was going to do something highly constructive but I continue to feel tired and burnt out so I’m allowing myself an evening off from absolutely everything other than getting this written. The notes of the week, the legal case review, the sorting of the bin of miscellaneous papers, the study of the song for voice lesson this next week, the movie review column, and the planning of various social events can all wait for tomorrow or Sunday. I’ll lie here on the bed with Oliver the cat purring beside me and just let stream of consciousness take over.

The news on the Covid front continues to be reasonable if not exactly good. Local numbers have dropped back to where they were a year ago before the Delta and Omicron waves took over all of our lives. There are fewer than two dozen total Covid patients at UAB, and fewer than ten in the ICU (almost all unvaccinated). Deaths, however, remain around 1,000 a day nationwide and, while trending down in general, lead to an inexorable increase in the toll. We’re at 975,000 now in the two years of the pandemic and will almost certainly pass the magic million in the next few months sometime.

Here in Birmingham, where the spring brings all four seasons every forty eight hours or so, society has more or less decided the pandemic is over and pretty much everything is back to normal, or as normal as it gets after two years of pandemic havoc on all segments of society. The CDC lists Jefferson county as being in the green zone with low transmission. There’s one thing to be wary of in the new CDC red/yellow/green maps and levels. Where previous data was based on absolute case and transmission rates (the number of persons testing positive), the current data is based on whether or not the local health system is capable of handling the number of people expected to become seriously ill given vaccination rates and transmission in the area. In an urban county with large medical centers like ours, transmission can actually be quite high and not be reflected by higher risk levels as we have the capacity to provide care. I think it’s a bit of a cheat and most people don’t really understand these nuances when evaluating their personal risks. As it has been for some time, the best thing to do is get vaccinated and boosted. We’re all still waiting for updates on recommendations for second boosters. There’s data from Israel and Europe suggesting that it will be a very good idea for older people and those with immune compromise but the CDC hasn’t quite gotten its act together yet.

The theme of the week at work has been lack of services for lack of staffing. The enormous numbers of retirements in health care mixed with better opportunities for elder health workers has led to an exodus of staff from nursing homes, home healthcare agencies, and other senior services. Finding a hospice or a nursing home with adequate staffing and the ability to provide requested services to which elders are entitled has become quite the challenge over the last few months. The needs are becoming greater as the huge boom population continues to age and the leading age, now in their early 70s, has a few members with bad genetics or life choices which are pushing them into positions where they need support to live their lives and those supports are becoming scarcer and scarcer. It’s going to be an absolute nightmare in another five years or so when the early boomers have aged into their eighties. And upper level senior care positions aren’t exactly finding takers either. We’re continuing to shed geriatricians around here to retirement or other opportunities with no one coming in to replace them. There’s no one coming up through the ranks currently who could replace me. I’m not sure how I feel about that. On the one hand, it’s kind of nice to know you’re valuable, on the other hand, I know I can’t do this forever and I don’t want to see everything I’ve helped build over the last few decades crumble and fade as there’s no one left to do the work.

My burnout fatigue continues and likely will until I can arrange some time off. I might be able to do it in May but there are so few of us, we’ll have a very difficult time keeping clinical services open five days a week if I take any time off and I don’t see a lot of good solutions presenting themselves. It’s not like we can create a new geriatrician in a year or two. It takes a minimum of twelve years of higher education under the current system. We can create a geriatric nurse practitioner quicker than that with five or six years of higher education but they really need some clinical practice seasoning for a few years in addition to that to be up to the rigors of the job. I don’t have a solution. Those of you heading into your golden years or my younger friends with parents heading that way better start planning now for the potential complications of aging as there’s going to be a lot more ‘you’re on your own’.

That seems to be the current political ethos anyway. Our society seems intent on dismantling the commons for private profit and tossing anyone out of the boat that can’t pull their own weight. Some blame rapacious capitalism, some religious fundamentalism, some human nature. It doesn’t really matter. What really matters is if we can’t hang together, we will all hang separately as Benjamin Franklin wisely once said. I didn’t have the heart to watch the hearings for Justice Jackson but the little I did catch, full of rich white men who had got theirs trying desperately to demonize a capable black woman as ‘the other’ for political points was enough to make me nauseous. This week we also were treated to sitting US senators opining that Obergefell, Loving and Griswold were all wrongly decided so if you think that the right wing forces at play in this country will stop at an undoing of Roe v Wade, you’re delusional. They’re coming for anything that interferes with their nostalgic world view of a 1950s never never land gleaned mainly from reruns of old black and white sitcoms.

OK, I’m grumpy now so I’m going to put on some bad television. I’m trying to decide what to write about over the next few weeks while I begin editing volume 2 of The Accidental Plague Diaries and Covid seems to be in relative abeyance. (This is unlikely to last. Omicron BA2 is now 50% of new cases and there are new peaks happening overseas from this – it’s just a matter of time). If there are any requests, let me know. In the meantime, hand sanitizer, booster, and keep that mask handy. You’re likely to still need it.