I haven’t written for a few days. Sorry about that, those of you who seem to hang on my every word. As the world is opening up and at least entering a breather, if not a true post-pandemic phase yet (I’m still expecting at least one more ugly surprise waiting for us), my schedule is starting to pile up and look more like it once did pre pandemic with my having to keep careful notes to make sure I am in the right place at the right time on the right day. I get more than 90% of it correct but I occasionally find myself heading for a meeting an hour early, or forgetting about that zoom call I should have been on twenty minutes ago. At least I’m not currently in rehearsal for anything. As that stands, that’s not going to happen until late April or early May with the first two projects lined up being Beethoven’s Ninth with the Alabama Symphony Orchestra (no I’m not singing the baritone solo – no one wants to hear that. I’ll be one of the cast of thousands in the choral balcony) and a role in a bucket list musical that I think I can announce but I haven’t fully cleared it yet with the production so I better keep mum in public forum for just a little while longer.

I had hoped to get away for awhile in late April and turn these missives back into a travel diary for a week or two but that is not to be. Outpatient geriatrics is becoming more and more short staffed with only two doctors and one nurse practitioner there more than once a week and, in late April, the other physician needs to visit her family on the other side of the planet and the nurse practitioner will be out on maternity leave. Yours truly will be pretty much last one standing so heading out of town just wasn’t in the cards for a functional clinic system. We’ve been through periods like this in the past but have always managed to claw our way back to adequate staffing so we can spell each other after a few months of hell. I’m not so certain about what’s going to happen this time. The number of qualified individuals looking for jobs in geriatric medicine is cratering just as the demand is starting to go into overdrive from the aging baby boom. I just don’t know where we’re going to get a new generation of providers from. This situation is not unique to UAB. It’s nationwide. It’s easily fixed by aligning some economic incentives such as loan forgiveness and salary structure in such a way for people to self select into the specialty but there’s been no motion from the powers that be to do anything of the sort. And they wonder why I’m contemplating retirement….

I can’t say I’m in despair regarding the future of clinical geriatrics. Concerned, yes. Despairing, no. Those of us who choose to practice in this way tend to be committed and resourceful individuals used to thinking on our feet and problem solving way outside of the box as the clinical issues dumped in our laps on a routine basis are not often amenable to textbook answers and yet we still have to come up with some sort of solutions. Someone once asked me to define geriatric medicine and my answer was ‘creative solutions to unsolvable problems’. I think I came up with that in the early 90s and have found it to remain true all of these years. What I am expecting is increased demand will start to spread to those in society with loud voices and the economic power to make those voices heard and that’s when things will begin to change for the better. I found out many years ago that the best way to get what you needed for geriatrics clinical programs was to take care of the chancellor’s mother in law.

There is, however, a great deal of despair abreast in the land and it’s about to get worse and it’s fueling a deadly pandemic that’s been traveling in tandem with Covid and which has largely fallen off the public radar screen and that is hospitalization and death due to the maladaptive coping mechanism of substance use. Most people don’t wake up one day and think ‘geez, I’d like to become an addict – it sounds like fun’. Instead, social situations and pressures create unhealthy stresses and toxic life events and there becomes a psychological need to escape – and, when there’s not a physical means of escape, there’s always drugs and alcohol. They buy at least a temporary and fleeting time away from the pressures and problems of the world. Unfortunately, they carry a lot of bad life choice baggage along with them.

In the two years since the start of the pandemic, deaths in the US related to alcohol have risen by about 25% over what they were at baseline. The lack of diversions of lockdown and the economic worries of lack of income and the stress of jobs that put people in harms way are probably all contributors. Some of this was mitigated by the various programs that paid extra federal dollars to individuals and prevented eviction for nonpayment of rent, but all of these programs are set to expire, along with the federal dollars that have paid for Covid care in the uninsured. Those on the lower rungs of society are about to be significantly squeezed by all of this and, if they do get sick, are going to be out of luck regarding medical care. This is going to set up social conditions ripe for new variants to percolate to the surface and spread and, if there’s one thing the history of infectious disease has taught us, it never remains contained in ‘those people’ while ‘we people’ are immune. It always spreads.

I expect the alcohol death rate to start going up again this summer as social stresses increase. How that’s most going to affect the general population is more drunk drivers on the road and we all know that they don’t only hurt themselves when there’s an accident. Traffic fatalities were up about 12% in 2021 over 2020. I haven’t seen any breakdown as to which percentage were alcohol or drug related but I have a sneaking suspicion it’s a cofactor. There’s always been something sort of bohemian romantic about drinking ones self to death. I don’t advise it. Anyone who’s in medicine can tell you that a death from liver failure is highly unpleasant and not something you wish to experience before you go.

The drug overdose epidemic continues unabated as well. Pre pandemic, the number was about 70,000 a year (which was extremely high when compared to a generation prior when it was about a third of that number) and it’s now topping 100,000 a year. And that number is rising astronomically despite the prevalence of naloxone, the opioid overdose anecdote being widely available. I cannot even write a prescription for an opioid in the VA system for anyone unless there’s a prescription for naloxone in the prior year. It’s a much lower number than Covid deaths but as these deaths are mainly young and healthy people, the number of potential years of life lost are similar, if not greater. There are any number of experiments that show that people (and other species) shy away from drugs as long as they have enriched, fulfilling lives without an over abundance of stressors. Unfortunately, we live in a society that tolerates the perfect conditions for creating addiction in certain subgroups.

It’s no accident that the current wave of drug use, triggered by Purdue pharmaceuticals outrageous peddling of OxyContin inappropriately in the late 90s and early 2000s, took shape in Appalachia. Appalachia, as a region, has an economy mainly based in extractive industries, such as coal, and some heavy manufacturing. With a globalized economy, and improved technology, the union jobs that supported the population and society collapsed leaving a hollowed out husk of mining towns that the young and energetic had to flee in order to have a future. The mining industry, in particular, with its company towns and health care, turned the population on to the power of the pill back in the 20s and 30s. The backbreaking labor of manual coal mining left the men with orthopedic issues and chronic pain which required meds for them to be able to continue their work underground. Their women were always anxious about their husbands, brothers, sons coming back up alive and were routinely prescribed sedatives so they could get through their days without being crippled by anxiety. Fast forward a few generations and a population with incredible economic stressors who have been socialized to believe in the power of the pill meets OxyContin and voila… When the medical system realized the extent of the opioid crisis and began to ratchet down the supply, the population turned to other sources and heroin use surged. And then some drug lord came up with the great idea of cutting the heroin with various fentanyl related compounds, many of which are deadly in very small quantities and the overdoses came thick and fast, spreading out from Appalachia through other small towns and inner cities and then creeping tentacles into suburbs and into the house down the block. And then came the pandemic…

People in these sorts of desperate straits long for an easy solution. They’re ripe for an autocrat who will tell them that they have the answers and a road to salvation. Most of DC, living inside the beltway and knowing no one and nothing of these people and towns and ways of life, have ignored them and their needs for decades but one populist presidential candidate a few years back got it and fashioned a message for them and they have responded with fealty that has completely changed the face of our political system in just a few short years. I have no ideas where it’s going but such political movements eventually gain their own momentum and no one can completely control where they end up. Just ask Maximilian Robespierre or Leon Trotsky.

The CDC is still pretty gung ho on the current state of Covid infections and there are no local requirements or suggestions for masking. I’m still wearing mine at work due to the number of immunocompromised who enter my clinical workspaces. I pick and choose about where to wear it indoors currently but if I see the numbers start to tick up (and given trends in Asia and Europe, I think it will happen) I’ll be back to masking everywhere. Stay safe. Get your booster. And wash your hands.

Ukraine and related subjects continue to knock Covid off the front pages. Between this, the arrival of spring, and everyone exhausted from two years of at least pretending to comply with some basic public health members (I’m talking to you wearing your mask as some sort of chin strap), the media and society have sort of declared the pandemic over, not with a bang, but with a whimper. It would be nice if it were true but while we may be done with Covid (and around these parts, that happened a long time ago – at least the adherence to basic public health measures), I suspect it is not at all done with us.

Case rates in Europe are shooting back up and in some Asian countries such as South Korea and Hong Kong, case rates and mortality are higher than they are ever been. In our globalized world, this means that we have a chance to shoot back up again ourselves. What’s driving the numbers up overseas? If you look at it, it’s the BA 2 strain of omicron making inroads. The morbidity and mortality statistics are varying wildly from country to country depending on their various strategies over the course of the last two years. Hong Kong’s numbers are incredibly high as a relatively small number of their elder population was vaccinated and most were vaccinated with the Chinese product Sinovac (not available in the USA) which has proved relatively ineffective against omicron. This has led to high mortality rates. In Europe, on the other hand, where the vaccine rates are much higher and elderly are more likely to be vaccinated with one of the mRNA products, case rates are ticking up with the lifting of restrictions and mask mandates, but significant morbidity and mortality is not increasing concurrently. In other words, yes the disease prevalence is increasing but it’s not making people sick enough to need hospitalization or to die.

BA 2 is present in the US but not at very high levels. Will it cause another surge? I suspect there will be a case surge as it multiplies and starts to outcompete earlier strains but, with more than 90% of our elder population with at least one vaccine and more than 80% of them fully vaccinated, it may not make inroads. There are rumbles of a second booster for older and immunocompromised individuals coming down the pike shortly. I think it’s a good idea and even though I’m still a few years away from being officially ‘old’, I’ll get it if and when it’s released. At last count, somewhere between 45% and 55% of the US population was exposed to omicron between last Thanksgiving and now. That means there’s still a large number of omicron naive individuals out there in which BA 2 can catch hold and spread. Then there’s ‘deltacron’ which was generating some scare headlines. It’s a cross which basically has omicron spike proteins grafted on to a delta core. As the spike proteins are what make the virus infectious, it’s no worse than omicron in general. If you want a lot more analysis than this in easily understood terms, I highly recommend reading Katelyn Jetina who writes under the name ‘Your Local Epidemiologist’ She’s easy to find on social media and Substack.. She knows far more about all this than I do.

The mood is better after some sleep this weekend. It’s still not great and someone’s going to get an icepick through the eyeball in the near future if I don’t get some time off this spring. I’m still trying to calendar it in. With all of the various things that I seem to have become responsible for, it looks like late April will be the best time for me to absent myself for a few weeks. I’m taking nominations on things to do. I have several ideas but I’m open to thinking outside the box. Perhaps some beach time is in order. I haven’t had a dip in the ocean in a couple of years.

My long term house guest is kicking my rear and getting me to move ahead on some of my projects that I’ve been quietly tiptoeing around for the last year and a half. Art is being rehung and reframed as necessary. The filing cabinet is starting to fill back up with organized files. Some things that are purely in the way have been purged and demoted to storage. The ostensible reason is thinking about having a party, my first since moving. It’s a milestone birthday in two months. The question is whether to have it here or to have it in a larger venue to allow for more social distancing and air circulation. I wish I could predict what Covid is going to be up to the second week of May. My initial thought is to hire one or more of my pianist friends to play and tell everyone to bring their rep books, have a few drinks and let ‘er rip. It might not be the most dignified of 60th birthdays, but it could be fun. Sort of a Marie’s Crisis like thing. It’s already been dubbed ‘A Night at the Duxbury’ and various plans appear to be afoot that I am not privy to.

I hosted a meeting tonight to begin planning a celebration of life for the irreplaceable and irrepressible Diane McNaron who died so suddenly a few weeks ago. I’ve told the story before about how various threads of life came together nearly twenty years ago to allow her and I and Ellise Pruitt Mayor to create the Politically Incorrect Cabaret. (Don’t worry, it’s not dead yet… It’s been left in my hands. The Ansager, Waffle House Lady and others will return at some time in some form). PIC was very much the start of my performing life in Birmingham and will always hold a very special place in my heart, especially the out of state trips to venues involving a cast of fourteen changing in a hallway, no heat in January and no air conditioning in July, llamas outside the stage door, and pagans hoisting each other up by their piercings. However, it very much needs some new blood and a younger generation to join the merry band so if you’re a twenty or thirty something in the Birmingham theater scene and have an interest in Cabaret forms, political theater, street theater, or just general mayhem, come sit next to me. As the celebration comes together, details will be released.

Do you still have to wear a mask? While the CDC has said that transmission levels are low enough that you don’t have to, I still put mine on indoors in crowded situations and in health care buildings where there might be immunocompromised individuals or those who work or live with immunocompromised individuals. It’s become second nature to me now, like breathing out and breathing in. It doesn’t hurt me to slip it on, I barely notice it, and I’m not ready to write off older or ill persons as being unworthy of consideration. So keep it on you, put it on when appropriate, and keep those hands washed. I’d also still stay out of the mosh pit.

Another work week has come to an end, just in time for the beautiful and balmy days we’ve been having to replaced by a storm, a sudden temperature drop and a threat of snow. I won’t believe that last one until I actually see it on the ground. I’m feeling a bit less pressured this weekend than I was last. Work stuff is more under control so I can turn some energy and attention to some other projects like Volume 2 of The Accidental Plague Diaries. A lot of the text is done but there’s still much to do in order to make it a worthy sequel. I don’t want it to be like the usual Hollywood part 2 where the plot’s the same, only there are twice as many explosions and it’s only half as good.

Ukraine continues to push Covid off the front pages. The big news on the pandemic front this week was a study in the journal Nature which used various scientific methodologies to try and gauge the real impact of Covid deaths. The authors estimates are that the mortality rate was roughly three times the official counts meaning we’re at about 18 million deaths world wide rather than the 6 million showing up on the various Covid counters. The vagaries of reporting, especially in non-Western industrialized societies, has kept the real scope of the disaster from being appreciated. 18 million, roughly the population of Guatemala or The Netherlands, is a huge number. It’s 34 years worth of minutes. It’s the number of people in the US of Asian and Pacific Island Ancestry. It’s about half the distance between the Earth and Mars in miles. When you divide it over the total human population of the earth, it comes out to about 0.25%. Seems small until you consider that the total world death rate in 2019 was about 0.75% for all cause mortality. In other words, Covid, in it’s two years of existence, has killed about 1/3 the number of people that die for any reason in any given year. We haven’t had something like that come along in a long time.

I’m going to accept the current lull in cases with good grace and enjoy the fact that some of the pressures are off the health system. UAB is down to about 25-30 inpatients rather than 200 or more allowing us all to heave a sigh of relief and regroup for whatever comes next. There will be more. Hopefully the awful reports coming out of Eastern Europe will start to convince some of the vaccine holdouts what a real fight for freedom looks like and their courageous stands against public health measures, in the true scale of human catastrophe, just make them look foolish. It’s actually been rather amusing watching a right wing noise machine, that’s been awash in Russian money of dubious provenance for some years, trying desperately to back pedal. Then there’s the internecine skirmishes breaking out between main stream right wing and far right wing. I guess they’re learning that simply being against things and trying to move the Overton window as far right as possible isn’t really a viable policy position for a complicated global economy and political system.

My mood’s better. I have made the decision to take some time off late spring and that has definitely helped. Now I just have to figure out how to shoehorn it in to the work calendar, the theater calendar, the opera calendar, the church calendar and all the other things that vary my days. The last two weeks of April are looking the most promising. I don’t know what I’ll do with it yet but if I can get it blocked off, I can figure that part out later. I think the stresses of earlier this week were due to good old fashioned burn out and with some renewal time to look forward to, it shouldn’t be as much of an issue going forward.

I can feel a subtle, but definite shift happening at work in terms of the needs and wants of patients. My new patients and families who are establishing these days have a different set of goals. The questions are much more about prevention of the problems of aging, how to adjust diet for optimum health, what sort of exercise is necessary to maintain vitality and physical function. What supplements and vitamins work best. I wish I had good answers for all of these questions but I don’t. Generations living into their 80s and 90s in good health is a new phenomenon that has only really come into being during the time I’ve been in medical practice. We’re learning a lot about things (and when I think back on some of the commonplace interventions we made back in the 80s, I shudder) but there’s so much that’s unknown. With that, here are Dr. Duxbury’s rules for healthy aging.

1. Choose your parents carefully

2. Don’t fall down

3. Recognize that medications (including over the counter) are really controlled doses of poison and treat them with proper respect

4. Eat a balanced diet but realize life is too short to not eat dessert

5. Don’t force yourself into someone else’s sleep patterns

6. Walk when you can and don’t be afraid to use a stick

7. Don’t fill your head full of problems you can’t solve

8. Create something new

9. Make time for sunshine, children, pets, music, and green growing things

10. Try to find something interesting about tomorrow to look forward to

I should probably add to this, wash your hands and wear your mask indoors in times of respiratory illness pandemic.

I’m in a bad mood. It’s just as well that the only thing home besides me is the cat. I have no idea why I’m in such a bad mood. It was a pretty ordinary Monday at work without anything too crazy happening and I got all my meals and even caught up on a couple of work projects on which I had fallen behind, but by the time I got home, I felt like being a praying mantis and biting someone’s head off. Usually when I get like this, the mood doesn’t last too long and a decent meal and a good night’s sleep take care of the issue. As it was Monday night dinner at Tommy’s parents house, I am full of pork ribs, fried okra, potato salad, and chocolate pie so the first has been taken care of. I’m hoping some knitting up the raveled sleeve of care in an hour or so will supply the second.

At least in part, some of it is likely due to the demands of the world on me. I am a nurturer by nature and a fixer. I’ve been playing Dear Abby since I was in high school with my peer group and I have a certain amount of wisdom regarding how to approach life. The problem with that role, now that the world is opening up more and everyone is emerging from their cocoons with all of their personal mental health issues exacerbated by months and months of isolation and a constant barrage of bad news, is that a lot of people are turning to me for help. I give it freely. It’s my reason for being. But occasionally the well starts to run dry and my engine is barely running on fumes. The things that allow me to replenish, theater, travel – are coming back but I’m in the middle of a stretch without much going on besides work and that’s an issue. I’ll look into taking a long weekend or two off over the next month or so and maybe just the act of getting those on the calendar will be helpful.

The news of the outside world doesn’t help, of course. I’m trying to avoid following the ins and outs of Russian and Ukrainian politics and warfare too closely as I’m afraid I’ll identify too much and feel too deeply. It’s all connected. Russian imperial ambitions. Dark money flowing in to Western political groups whose intention is destabilization of democracy. Interference in the US, Brexit and Scottish independence elections. The firing up of cultural wars that are merely distractions from the real political and socioeconomic realities that we’re facing. I’m going to have to let others unpick that Gordian knot. I left my investigative journalist credentials in my other pants.

There is good news. Covid cases in the US continue to fall to much lower levels than they’ve been at for some time. Even the death rate is starting to come down now that we’re through the omicron hump but it’s still an unacceptably high 1200-1400 a day. We’re at roughly 960,000 US deaths (and the world death toll hit six million today, although that is most assuredly an undercount – the real count could be two to three times that). We’re still on track to hit the magic million in the US around Easter. Locally, the CDC has dropped our metro area to medium risk (masking not required indoors unless immunocompromised). As most people stopped wearing masks around here months ago, I can’t really tell the difference when I go out. I still slip mine on when going into stores or other places with quantities of people I don’t know. It’s easy to do. It’s polite. And, I have to wear one at work in clinical areas to protect patients anyway so half the time I don’t even notice whether I have one on or not. We may be done with Covid, but I don’t believe for a minute that it’s done with us and I’m not going to be in the least surprised if there’s a new strain or some other wrinkle popping up in the next few months.

I need to get cracking on Volume II of the Accidental Plague Diaries. Now that I’ve committed to do it, I have to actually do the work necessary to get it into shape. It won’t be as hard as Volume I as I know what I’m doing this time around but there’s still bunches of stuff to write and reshape and make interesting for the casual reader. I found out this morning that Volume I won another award. A bronze medal from the Readers View Awards in the category of Non-fiction/societal. I’m not sure that means anything other than I can order some very nice bronze colored stickers to put on the cover if I so choose. It’s a finalist for a few other awards as well and, if it wins anything interesting, I’ll let everyone know. I don’t often win things. I’m not a very good self promoter and a huge piece of winning in competition, especially in arts awards, is creating the brand and playing to the crowd of potential judges. Ain’t nobody got time for dat. And that’s why the name of Duxbury isn’t as well known as that of Kardashian. I did win a stuffed tiger once in a raffle at Nordstrom’s (when it was still Nordstrom-Best). I was five. I still have him.

I’d like to see a tiger in the wild sometime. Not up close and personal, but at a safe distance from a guided tour in a well protected jeep. If Covid had not derailed all travel plans, I was supposed to be in India this spring and I might have been able to see one there. That is a trip that has been postponed to a later date. I have seen a few interesting species in the wild. When I was nineteen, I paid a visit to an elephant seal rookery in the Pribilof Islands. Bull seals smell horribly of fish, have a nasty temper, and move much more quickly on dry land then one would expect. I’ve seen one of the Puget Sound pods of orcas from a small boat. I once sailed up the strait between Maui and Lanai during calving season when the waters were full of blue whales. I walked into a very surprised black bear on a trail in Mount Rainier National Park. I’m not sure who was more startled, me or the bear. I was once kicked in the chest by a white tailed deer who took offense at the fact that I would not feed him my grapes. Just the usual run of the mill stuff.

Per usual, writing one of these missives has done the trick. My mood’s better. Time to watch some bad TV, get some sleep and face the world again tomorrow. Together with my hand sanitizer and a mask in my pocket.

If it’s not one thing, it’s another. Covid continues to recede both locally and nationally so let’s have a land war in central Europe and start shelling a nuclear reactor. I really have to stop reading my news feeds. They’re enough to drive anyone slightly batty. Fortunately, spring is in the air, the day has been lovely with the daffodils all coming up, the Japanese magnolias in full bloom, and the forsythia starting to come out. We’ll be in full pastel season in about another three or four weeks. It’s happening earlier than it used to. When I moved to Birmingham nearly a quarter century ago, the spring bloom tended to peak around the second week of April. Now it’s often the third or fourth week of March – global warming I presume. I may spend my dotage in a beachfront condo with a subtropical clime without having to actually move should the more dire predictions hold true.

The lovely spring weather and the reduction in Covid cases and reporting on Covid have led to a wholesale shedding of masks and activity restrictions in a lot of places. Is the pandemic over? I don’t think so. The coronavirus likely has a couple of nasty surprises left that are going to clobber us just when we think all is over and done. I’m expecting at least one more significant variant with either heightened transmissibility or heightened virulence sometime in the next few months. There’s too large a reservoir of unvaccinated individuals out there, and not just in the US, for something else not to rear its ugly head. There’s also the potential for some mixing and matching with other viruses in animal hosts and something entirely new arising somewhere. In the meantime, I’m planning on taking advantage of some of the weather over the weekend with some outdoor activity. It’s time for a visit to the botanical gardens and maybe even the zoo.

As war in Ukraine pushes Covid off of everyone’s news feed, I worry a bit about some new wrinkle not getting the public attention it will need when it arises and additional people getting sick and dying that need not because of a combination of ignorance and indifference. On the positive side, war has also pushed a lot of the antivaccination nonsense off of the public radar as well. Attempts to gather truck conveys to replicate the siege in Ottowa that dominated the news cycle last month have been an abysmal failure. Lack of attention plus a sudden spike in gas prices have put paid to those shenanigans. I saw photos somewhere of a rally in support where fewer than two dozen people turned up. It was rather sad, sort of like the birthday party that none of the invitees bothered to attend.

I received notification this week that the book is a finalist for a couple of other awards. I’ll know in a few weeks if it actually won any of them. It’s nice to know that one’s efforts are appreciated but the whole thing still feels a little surreal. When it comes to my writing, the impostor syndrome continues to loom large and I have a hard time believing that anyone is truly interested. Interested or not, I have begun work on a second volume of The Accidental Plague Diaries covering 2021. I have a goal of having some supplemental material written by the end of the month. As I don’t have anything theatrical in the hopper, that should be possible. I need to write some passaged that my editor and I refer to as ‘explainer’ topics – the rants where I set forth the history and workings of various aspects of the health care system. If anyone has a favorite thing that I haven’t tackled and it’s in my wheelhouse, drop me a line and I’ll add it to my list of things to prep.

I haven’t told any good stories lately. Probably because in the nearly four years I’ve been writing these entries, I’ve used up all my best stories at some point. Sorry about that. I’ve had some interesting things happen in my life, but it hasn’t been an unending well of incident. The news out of Eastern Europe has me thinking back over my experience of war. I, like most Americans, have been relatively untouched by the cataclysms of combat. The last major conflict on American soil was 160 years ago and I don’t think we realize how lucky we are that our infrastructure and cities has remained intact for well over a century. As I’ve been seeing stories of bombing in Ukraine, it seems incomprehensible and I imagine that’s how it felt to my grandparents when they saw newsreels of Germany invading Poland or the Japanese invading China in the late 1930s, before the US was drawn into the conflict. Some of my first memories of national politics are of war. I was born shortly before the Cuban missile crisis and Vietnam was in full swing during my young childhood. I think my first memory of Vietnam and what it meant was seeing the famous photo of the ‘napalm girl’ on the front page of the Seattle Times. Kim Phuc and I are roughly the same age and seeing a child of my age naked and screaming in pain as she ran down the road to escape the flames still haunts me. I remember my mother trying to explain how this could happen to children and being pretty much at a loss for words. For those of you who knew my mother, you know that was a rare occurrence indeed.

My childhood understanding of Vietnam, which included seing the huge antiwar demonstrations, were enough to turn me off of the military. I was the first year that had to register for selective service on turning 18. I did it using my college PO Box as my address figuring that would take the powers that be some time to find me and I studiously avoided anything that smacked of the military through my young adult life. Of course, some of that also had to do with my closeted gay self in a time even before ‘Don’t Ask Don’t Tell’ when gay people were routinely drummed out of the military simply for being themselves.

My first adult experience of war was the Gulf War of 1991 when Iraq invaded Kuwait and the US went in to restore the status quo. It didn’t affect me much as a third year medical resident other than, once again, not really having the psychic tools with which to process my feelings. Steve and I had been together a couple of years at that time and he helped me with that as he had been an adult in the Vietnam era. As an out gay man from the age of fourteen, he was not wanted by the military in the sixties and had never had to serve. His older brother had gone and returned with significant psychological damage. Some of my fellow residents, who had used military scholarships to pay for their medical education, were shocked to find themselves plucked out of their residency programs and bundled off to the Middle East. I had little sympathy. You take their money, you play by their rules.

Decades later, having seen Vietnam, the Cold War, the Gulf War, Afghanistan, Iraq, and lots of other conflicts, major and minor, I no longer get personally upset by images of death and destruction. It’s old hat and part of the human condition and has been going on since time immemorial. We’ve just traded in broadswords and javelins for howitzers and hyperbaric bombs. I can’t do anything about it. I can just support the younger generation who are processing what I had to process at that age, make appropriate donations for war and refugee relief, and put my energy on the side of moral right.

Хай Живе Вільна Україна

Some men are born great, some achieve greatness, and some have greatness thrust upon them. It’s a line from my favorite Shakespeare, Twelfth Night, and we’re seeing it play out in real time in Ukraine. Volodymyr Zelenskyy, the president, was considered a political lightweight and out of touch with real issues. An actor and comedian, he came to national attention in that country on a television show, Servant of the People, which was a satirical look at their politics. His character was a history teacher who became Ukrainian president after his rants against public corruption went viral. Life imitated art when the actor became interested in politics for real and ran for and won the presidency after the TV show ended.

Now, with the eyes of the world fixated on Ukraine with the Russian invasion moving forward, Zelenskyy has shown that it wasn’t an act. That he has what it takes to be a true leader in a crisis and that he is quite capable of rallying his population behind him. His refusal to slink off to exile and asylum and to remain at his post as significantly bolstered the resolve of Ukrainian defenses and his quote ‘I need ammunition, not a ride’ when offered an escape is likely to go down with ‘I have not yet begun to fight’ and ‘Damn the torpedoes, full speed ahead’ as a wartime catch phrase for posterity. Putin must be having a fit. I’m sure his plans were calculated on minimal resistance, a weak president that would turn tail and run, and superior fire power. The Russians seem woefully unprepared for active military and guerrilla engagements. It may be because they’re relying on a conscript army and the majority of the fighting men, being under the age of 35, have no memory of the USSR and Ukraine being part of Russian territory and can’t understand Putin’s wish to be lauded as Tsar of all the Russias. Ukraine is also proving very adept at the propaganda side of things. with a very good IT department hacking into Russian TV networks to play Ukrainian music and videos. I have no idea where the Russian tanks rolling across the steppes of Central Europe is going to end up and we’re only a few days into this, but it’s not likely to be Budapest 1956 or Prague 1968.

I wonder what role Covid is going to end up playing in all of this. Pandemic disease among military forces has altered the tides of history many times in the past. Crowding of men together in battle conditions is a surefire way to spread viral illness quickly. There is some evidence that World War I was ended when it was due to the spread of the flu pandemic causing significant issues in keeping healthy men at the front lines and that quick ending was one of the things that led into the treaty of Versailles which set the stage for World War II a generation later. The Plague of Justinian in the 6th century kept the advancing Byzantine armies from retaking Italy and Western Europe from the Gothic kingdoms. Wouldn’t the world be different today if the Eastern Empire had dominated Europe throughout the Middle Ages rather than the Roman Catholic Church. Russian Covid numbers are not necessarily the most accurate, but what can be found on line suggests that Omega has spread rapidly and their vaccination programs have not been the best. Russia is not what it was. It’s current economy is roughly the same as Italy’s or Texas’s and the economic sanctions being put in place in response to unprovoked attack are likely to hurt it badly.

One of my main beefs with the federal response to Covid from the beginning is the lack of coherent messaging and clear instructions to the population in terms of public health measures. I am well aware that early in the pandemic, there were significant unknowns that required forceful reaction and that the previous administration was spending most of its energy pretending the pandemic didn’t actually exist. However, the current administration has had over a year now to fix some of these issues and is only just now beginning to get its messaging together. The CDC has put together a new website allowing the public to check the current level of Covid circulation in their community (https://www.cdc.gov/…/your-health/covid-by-county.html), If your county’s level is low, there is no need for indoor masking by the general public. If your county’s level is medium, you should mask if you are at risk due to age/vaccination/immune status (or if you are polite and care about people at risk). If your county’s level is high, everyone should continue to mask indoors in public. It’s pretty clear, based on science, and there’s been almost no PR about it at all. Jefferson County, Alabama, where I live remains high but you’d never know based on public behavior and knowledge.

We all remain a little gun shy worrying about the next variant. Where is it going to come from? What’s it going to do? I wouldn’t be in the least surprised if it arose from war conditions in the Ukraine. The BA.2 variant of Omicron that’s been making the news recently is still Omicron. It appears to be somewhat more transmissible that the original Omicron (in communities where both are circulating, it spreads faster and more efficiently) but it does not appear to have significant effects on hospitalization rates or mortality rates so it remains Omicron. If you’ve had your two shots and a booster, Omicron remains relatively risk free in healthy people. At times it’s a bit tough to tease out, but data from countries that have lifted all restrictions due to Covid and who are careful in collecting data, like Denmark, are showing that we are starting to see fewer and fewer deaths in vaccinated populations from Covid. Instead, we’re seeing deaths with Covid. The death is really due to other underlying comorbidities of chronic disease and age and Covid may be incidental, or it may be the straw that breaks the camel’s back. We need a lot more data to be able to really figure this out.

The thing to keep in mind in all of this is that the vaccines remain our best weapon in our war against the pandemic. Get yours today. They’re free. There’s no recommendation yet on second boosters unless you have a significant immune compromise but we should have some further data on that shortly. The antivaccination crowd has, in recent days, gone all in for Putin and the Russians in the current war situation. There seems to be a psychological need to be on the wrong side of history all the way down the line. If the Russian economy falters and the oligarchs decide they don’t like losing money and push for regime change in Moscow, things may get very interesting indeed both there and on the American far right, which seems to have met the American far left recently going around the circle…

Plant sunflowers. And wash your hands.

I’m tired again. So tired that I fell asleep at my VA desk in the middle of writing a progress note and it was the weird little sounds from my computer as my hand had depressed the front slash key, leading to a page of little diagonal lines that woke me up and got me going again. I’m not sure if it’s physiological or psychological. I’m thinking the latter as it’s been nothing but bad news coming in for the last few weeks – the clouds of war in Europe, continued turmoil and bad behavior on the domestic front, the slow motion collapse of both health care and education. I think my brain just wants out. This usually means its time to schedule a vacation. I’m hoping to lay out travel plans for the year over the next few weeks and that might bring things back into a focus.

On the good news front, my editor/publisher and I have decided to move forward with Volume II of the Accidental Plague Diaries. We think it should come together a bit quicker than the first book did as we both have more or less figured out how to do this thing. If we can keep on schedule, it should be out around Labor Day. i’m rather pleased that the original book has sold enough to make a continuation worth while and has won one award and is up for several others, but then there’s the piece of me that’s going oh lord, more work on the table. One thing that I’ve learned about myself over decades is that I do relatively well under deadline and pressure. It forces me to focus and organize and get things done. When left to my own timelines and devices, I’m apt to devolve into lazy afternoons of reading or bad television or long meandering walks that may clear the brain, but do little to accomplish anything constructive.

Covid numbers continue to fall so we’re more or less through Omicron at this point. I think people are taking the masks off a little too fast. I’m still wearing mine indoors with folk I don’t know and it remains policy at UAB and the VA (and in most health care institutions) to wear it at work, especially in clinical settings. It doesn’t bother me. I’ve been wearing them to work for two years now and I haven’t suffered much other than continuous glasses fog. Looking at the national numbers, even the mortality figures are starting finally to descend and we’re below 2,000 deaths a day finally. We’re coming up on 940,000 total and I imagine we’ll pass the magic million before the first of May. The new omicron variant is still out there and spreading, but it doesn’t appear to be catching hold the way the original strain did. This is likely due to a combination of vaccine and natural immunity given the number of people who caught the original Omicron strain over the last few months. Omicron did at least prod more people into getting the vaccine. Nationally, about 70% of the population over age 5 is fully vaccinated and it’s closer to 90% in my senior adult population.

It’s been a long and difficult road getting people vaccinated over the last fourteen months due to the amount of vaccine misinformation out there. The rabid antivaccination population, the sort that are driving truck convoys cross country and battling with the authorities over mandates is actually a relatively small minority of the population. They just make good copy in our multimedia news environment and generate clickbait headlines. One must always remember that the media does not exist to inform the population. It exists to make profit for the owners of said media and that has definitely colored reporting as more and more reportage moves away from print to online sources. Stories that guarantee clickbait headlines and photos or videos of visual interest will always move to the front of the pack, even if they’re not really the most pressing issues of the day.

I’m not sure what to make of the Russian moves on The Ukraine. It could be Putin’s megalomania coming to fruition as he attempts to become Tsar Vladimir the Great. It might be Russia’s way of testing how well their seeds of social unrest in the Western world are actually working. I really don’t understand the conservative wing of the Republican party going all in for the autocracy against the democracy. That does not bode well for the next few election cycles. We’ll be in real trouble if Russia succeeds in making NATO back down in Ukraine and then starts moving on the Baltics which are NATO members. I wasn’t expecting the next big conflagration in Europe. I’ve long predicted that it would erupt between China and India over declining water resources from the Himalayas as both countries have armies of excess young men due to the social pressures in those societies for sons over daughters. I can’t do anything about it and I’m too old fight. I’m not too old to be drafted though. The US can call up physicians of any age in a national emergency. I don’t imagine that geriatricians will be very high on that list, unless they need someone to take care of the Lieutenant Colonels’ mothers.

I was given a ticket to the National Tour of Cats this past weekend. I’ve seen Cats several times before, but not for some years. This is a newly staged/choreographed production (that’s not all that different from the original to my eye) and, while entertaining, just wasn’t all that good. I believe it was Sondheim, on seeing the original in the early 80s, who said something like it would have been more interesting if they’d spread the two million dollars it cost across the stage in small denomination bills and let the audience look at them. Cats was the big show of my college years. It opened in London early in my college career and came to New York my senior year. I didn’t see it in either place (tickets being expensive and hard to come by). I saw it for the first time in the summer of 1984 in the Theater an der Wien in Vienna, the theater in which Mozart’s later operas premiered, translated into German. I knew the score and lyrics so had no trouble with Jellicle Katzen. A month later, in London, I saw the original cast and production of Andrew Lloyd Webber’s follow up, Starlight Express, at the Apollo Victoria, the production where they built ramps all through the house for roller skating. It was technically marvelous, the skating was thrilling, but it was still The Little Engine That Could. And people wonder why I prefer Sondheim to Lloyd Webber. I’m hoping to get to UAB Theater Department’s production of Noises Off this weekend. I saw the original production in London on that same trip and I have never laughed so hard in a theater in my life. I’ve seen countless productions since (and it’s a bucket list show) but I’ve never seen a production come close to getting the laughs the original did. I think it was the British cast who so thoroughly understood every nuance of every joke, coming as they do out of British theater tradition.

I’ve nattered on long enough. House calls tomorrow. Complete with hand sanitizer, masks, and vaccines.

I had just about finished a number of paragraphs of deathless prose about life, the universe, and everything when the neighborhood was hit with some sort of power surge and kablooie, everything dissolved into electrons and transported itself into the ether. Now my immortal phrasing and the one paragraph that would have won me a Nobel in literature are gone and I have no idea exactly what I wrote so I shall never be able to recreate it. I know I should write these things in Word and save as I go and then paste them into Facebook to prevent this from happening, but I’m too lazy. I just open up my social media on my laptop, do some scrolling and, if I’m inspired, I just start writing. I should have written something last night to keep to my once every four days schedule, but after finishing up collecting everything my accountant is going to need for taxes last night, a rather heroic task that I am grateful comes but once a year, I just wasn’t feeling it and went to bed early.

The deep dive into my finances that I do annually told me that I can afford to retire as early as age 62 if I so choose. I doubt I’ll do that as that date is uncomfortably close and I don’t feel like I’ve gotten old or run out of steam quite yet. When will I retire? It’s likely to be in stages, dropping down from full time to part time for a while, jettisoning the more draining parts of my job. The last piece to go is likely to be my UAB outpatient clinic. I’ve invested a quarter century in making sure it can continue and I have such a deep relationship with so many of my patients and their families that I just can’t see putting up a ‘Gone Fishing’ sign on the door there until the very end. When that will be is going to depend on a lot of things – working conditions at UAB and the Birmingham VA, the continued effect of the pandemic on healthcare, new stresses as the aging Baby Boom begins to knock on my professional door, and my personal physical and mental health (which has taken something of a beating these last few years for various reasons all too familiar to my readers).

I do have to begin phase one of retirement in the next couple of months. I must officially retire from the University of California, an institution from which I have not drawn a paycheck in nearly a quarter century and from which I parted on not good terms due to internal political battles over funding of geriatrics programs (but not before vesting in the retirement system). The plan stops accruing on my sixtieth birthday, less than three months from now so it’s time to become an official retiree. I suppose I’ll need to go to McDonald’s for my morning coffee and start wearing shorts and sandals with black socks. At least I don’t have a front lawn from which to chase the neighborhood children. I love watching small children at play. The previous house was across the street from the neighborhood park and I could see them out the windows and hear them while doing housework or writing. Like all gay men of my generation, I have to watch from a distance unless invited as there are too many who would ascribe nefarious motives to my wanting to be close to children. It’s not fair, but it’s one of those things you recognize if you’re gay, especially in a culture as judgmental as the one of the deep south.

We’re more or less over the omicron wave. I’ve been looking at the numbers and the national and local numbers are back where they were earlier in the fall before omicron swept through. Our inpatient and ICU numbers have come back down to manageable levels. It’s not gone by any stretch of the imagination and there should still be a certain amount of caution exercised. The mortality figures still remain high with more than 2,000 people a day dying. It’s going to take another month for those numbers to go down as the small percentage of those (mainly unvaccinated) who became extremely ill with omicron lose their battles. What’s reasonable as to behavior at this point? I think it’s fine to go out and to go into indoor space with others, but I would still remain masked for both yourself and as a courtesy to others. It’s not that difficult to keep a mask in your pocket and slip it on at the door. As long as you’ve been vaccinated and had a booster, you should be fine.

People have been asking me about the need for a second booster. There are no official recommendations for this yet for the general public of any age. Studies are ongoing. For those with significant immunodeficiencies or who are undergoing medical treatment that cause immunodeficiency, it’s reasonable to do. You should check with your physician to see if he or she thinks you fall into one of those categories and would recommend a second booster at this time. I believe a general recommendation for second booster is coming eventually and we’re likely going to need additional boosters at some yet to be determined schedule going forward. We deal with annual flu shots. We can deal with Covid boosters.

I’ve been lying on the bed going bleah most of this week when not at work. I haven’t been feeling physically the best, something in my weird gut is out of sorts. Generally I find that if I don’t eat a lot and get plenty of sleep, it works itself out. Given the close intertwining of gut health and mental health, I think at least some of it is due to the fact that I don’t have any particular joy to look forward to for a while. Since Tommy’s death, I’ve found I do best as long as I have about one thing a month – a performance, a weekend trip, a vacation, a visitor from out of town – that sparks a feeling of happiness. There’s just not much on the calendar at the moment. I have a theatrical project coming up that I’m looking forward to but that’s not until June. The Alabama Symphony Orchestra Chorus is gearing up again with Beethoven’s Ninth but that’s not until May. I like singing the Ode to Joy. Tommy and I were both in the chorus the last time I did it. He did it a couple of times prior to that before I was a member and I have a very nice photo on the wall of the symphony and chorus from one of those performances. The only issue is that Izcaray Carlos tends to take that last part at tempo di bat out of hell and I have a hard time turning the pages fast enough to keep up. I have an out of town weekend on the books in April. I need to find something for March. I also got hold of my travel agent so I can start thinking about the big trip for 2022. Likely September. No specific destinations in mind yet as I’m still, like everyone else, trying to figure out what Covid’s next move is likely to be and how the world is going to respond.

In the meantime – vaccinate, hand wash, mask up.

It’s February 14th. The day before half price on chocolate and adorable stuffed animal day at your local Walgreens. I actually received a valentine’s surprise on my doorstep this morning, courtesy of a good friend. It was not roses or chocolates or a teddy bear, it was a jigsaw puzzle which is much more appropriate for me as a gesture of affection. It’s also what would have been mine and Steve’s 33rd anniversary. There’s a lot of water under the bridge since we first met on a dreary February day in Sacramento and had dinner together at Carrow’s restaurant just off Alhambra. (Carrow’s is like Denny’s only with wooden rather than plastic furniture). Steve’s been gone for more than twenty years now, which is just as well as I doubt he would have enjoyed being a septuagenarian and I’m staring down the shotgun barrel of a milestone birthday coming up in a couple of months myself.

Today also marks the 77th anniversary of the Dresden fire bombing. When I first came to Birmingham, where there is a sizeable German emigre community courtesy of the rocket industry in Huntsville, I took care of several survivors of that horrific event. They didn’t particularly care to talk about if but it was clear that although they lived full and productive lives after the war, that particular experience was a defining moment in creating who they were and what they became in later years. They were kind, charming people who spent their lives outside of their careers working for various antiwar causes, having seen the sort of destruction war can wreak on the innocent at first hand.

It makes me wonder what the pandemic will do to Generation Z, our current young people, and it will inform their lives and their choices going forward. Will it push them towards greater cooperation and harmony in society as they learn the lesson that great problems are only solvable by working together or will they pick up on the backlash of ‘freedom’ that’s permeating the air and become more separated from each other and less caring about those not of their own tribe. I guess we’ll find out over the next ten to twenty years. This will also coincide with the aging and the beginning of the passing of the boom generation and how those two societal forces will rub up against each other is anyone’s guess.

Omicron continues to recede. At UAB, we’re back under 100 in the hospital for the first time in several months. Case numbers in the community are also falling precipitously. I figure at least, in part. that omicron pretty much felled anyone at major risk of contracting it already and can’t find new populations in which to spread. The only number that hasn’t particularly declined nationally is the mortality rate which is still sitting around two and a half thousand deaths a day. (Think five or six fully loaded Boeing 747s crashing a day or just a few hundred less than 9/11). This number should start to come down in a few weeks as the seriously ill move through the system and don’t recover.

I’ve been reading a lot about the truck convoy nonsense in Ottawa and elsewhere over the last few weeks. As always, when something idiotic is going on (and a group that’s busy pissing all over the Canadian Tomb of the Unknown Soldier really deserves a much unkinder word than idiotic but I’ll let you choose the one you prefer) I ask myself cui bono – who benefits? It’s certainly not the Canadian trucking industry (90% of Canadian truckers are vaccinated and all official spokes organizations for truckers such as the Teamsters union on both sides of the border have denounced what’s going on). It certainly isn’t benefiting truckers or transportation. It’s not benefiting the American or the Canadian governments. It’s playing havoc with the supply chain. There seem to be two beneficiaries, the conservative Republican forces who gleefully gin up trouble to keep systems for working so they can blame the Democrats in power for problems and foreign actors (whose troll farms seem to be behind a lot of the ‘grass roots support’) who benefit from general disarray in the West. Then there seems to be a huge grift in terms of accepting ‘donations’ to assist the demonstrations. I doubt most of that money gets anywhere near Ottawa.

I would be more willing to listen to political opinions different from my own if they contained anything constructive in terms of policy that was designed to move the country or society forward in some way. Most of the rhetoric, however, is about being destructive and tearing things down. I’ve never found that a way to success. The only constructive idea seems to be reducing taxes again on the wealthy and corporations to free up capital for private ownership. We now have forty years of data on ‘trickle down economics’ – it doesn’t work. The tearing down of things keeps spilling over into new areas. The recent local one is the education system of the wealthiest of the local suburbs. Conservative parents are now going after state mandated standards on social emotional learning which teaches students to be empathetic and listen to each other as some secret way to teach their precious children critical race theory. This in the same district where a Jewish child was reprimanded for reporting that a lesson in which a teacher was getting the class to do a Nazi salute made him feel uncomfortable.

‘What About The Children?’ is going to play into suburban angst and is going to help the Republican party pick up Suburban votes they may not otherwise get and help them regain control of congress. The other side of the aisle is ignoring this issue and not reframing it as the coded racism and classism that it is and that’s a problem. Playing ostrich never made a political problem go away. These sorts of divide and conquer tactics may be a win in the short term but they’re going to be a huge problem in the long term as every win is going to energize the Dominionists and other ultra conservative forces into pushing just a little further and a little further, moving the Overton window until any outsider community is firmly put in their place as those individuals see it. I can’t fix it. I can just identify the trends. And wash my hands. And stay vaccinated. And still wear my mask at Costco.

This is the first evening for weeks when I haven’t had a pile of things to finish before bed. It feels a bit odd. There’s still a lot on the to do list but it’s all optional and non deadline stuff that can wait for the weekend, or next week, or next month so I took a little time for myself and did some reading, watched the video of the recent 9 to 5 so I could finally tell what some of the scenes were actually about, and ate a few more jelly beans than I probably should of. (I’m going to put those fifteen pounds back on if I don’t watch it…) It’s very hard for me to do nothing and relax. I think it’s the medical training. One of my colleagues wrote an essay on this recently which I posted as I found it quite profound. Physicians have enormous expectations placed on them by their patients, their peers, their systems, and themselves and there is sense of pride instilled early on in the training at the being able to power through, no matter the challenges, the sleep deprivation, the physical health, or the emotional state.

We all went into the pandemic with an adrenaline charge and with that sort of thinking imbued in us for our entire professional careers and it certainly sustained us in those initial uncertain months of lockdowns, unknowns about the disease itself, and need to change pretty much everything about how our jobs operate within weeks. The vision of the vaccine on the horizon sustained us that first year and, when it became available, a mere ten months or so after the first US cases (a medical miracle), we all breathed easier thinking things would improve and wind down. I don’t think any of us had counted on the ugly politicization of health care that rose up in the spring, ensuring the continuation of the pandemic and unsustainable working conditions. Now, two years in, with the politics firmly entrenched, even the waning of the fast and furious omicron crisis evokes no joy in Mudville.

There’s a lot of speculation about how much more the American health care system can weather before it breaks down. I think that’s the wrong question. The American health care system is already broken at this point. We’re just driving the car on a couple of flat tires and hoping that the pistons don’t give way. How is it broken? The selfishness of a certain portion of the American population, putting their need to belong to a certain political ideology ahead of their health, their neighbors’ health, or societal needs, put a system, that was designed to run close to maximum capacity with just in time ordering in order to maximize profits and minimize expenses, into overload and I’m wondering if it can recover. Currently, American health care can’t do its most basic job, which is treat curable disease. Elective surgeries are postponed. Screening tests don’t happen. Getting a new primary care provider is nigh on impossible. Rehab facilities can’t get staff. Nurses are leaving floor and clinic jobs for the astronomical salaries being offered in understaffed Covid units. A friend of mine, who works per diem nursing at a local hospital, worked a weekend shift recently. She walked on to her ward and found one of the patients working as the unit secretary. There was no one else to do the job.

The biggest driver of the breakdown is, like with so many other social movements, the Baby Boom generation. Aging in good health, many of them had been working well into their sixties and early seventies. Covid and its stresses have caused many of them to reevaluate their life priorities and to retire and leave the work force all at once. Retirement of people over age 60 is the biggest driver of the Great Resignation, not government payments. Women leaving due to childcare issues is a distant second contributor. In health care, that means those with the enormous repositories of clinical experience are departing. There is a phenomenon in human learning and intuition. When you work in a field for decades, you become so attuned to the nuances that you just know things. You can’t really explain why you know, but somehow your memory banks are comparing the current situation against decades of prior experiences and the answer is just there. I’ve been finding this happening more and more frequently to me personally over the last decade or so. This is my 38th year in medicine so the data bank is vast but it took me decades to build it.

Losing those senior people as providers and nurses and therapists and pharmacists and all of the other myriad professions that make the American health system go round is going to cause issues for years because it’s going to take years for younger people to amass that sort of knowledge base. Seasoned people don’t just pop out of medical or nursing school. They require years and years of nurturing and exploring and occasional failure. And, this loss of these individuals is just about to collide with the aging Baby Boom turning to the health system for the problems of aging. Their first impulses, given their generational behavior to date, is going to demand that the system fix them so they can keep what they view as their eternal youth. It won’t be possible and the tensions that are going to develop between them and health care are going to rise significantly. No health system is ready for this. They’ve been kicking that particular can down the road for decades and now Covid issues have become all consuming. The lead edge of the boom starts turning 80 in less than four years.

I’ve poured nearly a quarter century, most of my adult career, into making geriatric medicine viable within the UAB system. It will continue to work as long as I carry it, but the teetering system is taking its toll on me as much as it is on the pulmonologists who man the Covid wards. Will I be able to do this for another two years? Another five? If I step down, who steps up? US medical graduates continue to avoid training in geriatrics like the plague. These questions haunt me sometimes at night. And then I remember what I figured out years ago, the world is not saved all at once, but rather one patient at a time. Focus on the work in front of you, not the potential work that is not yet yours. And do the health system a favor. Wash your hands. Get your vaccines. Stay home if you’re sick. Carry a mask with you and put it on when appropriate. It’s not that hard to be part of the solution.