I went to a movie tonight. I think it’s been nearly 18 months since I last set foot in a movie theater (and I can’t even remember what film I last saw on the big screen). It was a friend’s birthday and his family rented out one of the theaters at The Summit multiplex for a group of vaccinated friends to enjoy. The movie was Disney’s new Cruella, an origin story for the villainess of 101 Dalmatians. How was it? Better than it had any right to be with a fabulous costume/production design, a killer soundtrack and a couple of great performances from the two Emmas, Stone and Thompson as dueling malevolent fashion divas. It’s also 20 minutes too long, drags badly in the middle, and is way too sophisticated for most children, unless your 8 year old son is asking for Auntie Mame Barbie for Christmas. MNM will write up her review later.

This is my second birthday party of the week. For the weekend, I made a mad dash to Columbia, South Carolina to attend the one year delayed 50th (now 51st) birthday of my dear friend Frank, attended by various Columbia theater luminaries, many of whom I have gotten to know through my forays into on line performance over this last year. It was nice to finally meet some cast members in person. Frank is an Anglophile (and is putting together a group trip to London for New Year’s if anyone is interested – PM me for details). So cucumber sandwiches were consumed (they were available at the market for ready money), libations were imbibed and it all ended up with a rather hilarious croquet match on the highly uneven and root snagged back lawn played through the dusk and into the dark necessitating portable lanterns to see whose ball was whose. I would not have been surprised to have seen a stray hedgehog or flamingo.

It’s safe to say that vaccinated social life is starting to return to normal. In reading over the statistics, transmission rates in the states where vaccines have been readily accepted are way down along with a significant decline in hospitalization and death rates. In states like mine, which has stalled out at about a 40% vaccination rate, numbers aren’t necessarily going up but they aren’t flatlining either as the virus continues to march through the willfully unvaccinated population. So, while I think we are approaching the end of the acute phase of the pandemic, I don’t think we’re at the end of Covid by a long shot. It will continue to fester in susceptible populations and some of those individuals, healthy teens through middle aged adults, are going to become deathly ill and some will die and there’s no need for it. It’s a sad situation but I just don’t know what I, or any one of us as individuals can do at this point. I’m just waiting for the Delta variant from India to firmly establish itself in the US (it’s going to get here) with its much higher levels of transmission. The vaccines seem to protect against it fine but it could start burning through the unvaccinated population at very rapid rates leading to a new surge just as we think we’ve got a handle on things. And it’s going to happen in the states least equipped to handle another surge due to the weaknesses in health structure wrought by decades of right wing austerity politics.

I’m feeling worn out by the events of the last year and a half. I don’t know if I’m crashing from a prolonged adrenaline high, I’m feeling deflated by actually finishing the book project, or I am disillusioned by the realities of modern politics and health care policy. My mind keeps wandering to retirement and doing something else. The pandemic has exposed the fault lines not just in how the medical system works, but also in my life and I haven’t figured out yet whether it will be better to paper over the cracks or to wedge them open and break things apart so I can construct things in a new way. My next big project, which I’ve been putting off for a year, is to go through all of my boxes of ephemera and family papers and genealogical research that have accumulated over the years. I’m the family archivist so it’s all come to rest with me and I want to put it all in order and digitize what needs to be saved so that it can be passed down in some semblance of a filing system to the next generation – assuming one of my nieces is going to be interested.

There’s nothing on the theatrical calendar for the rest of the year yet. Something will turn up. It usually does. There are rumblings of a new edition of Politically Incorrect Cabaret. There are a couple of things in the wind for which I might audition (but I’m going to have to go back to voice lessons before doing another musical – not singing much for a year and a half hasn’t helped my instrument in the least). There are a number of board and planning meetings coming up with various groups that I am involved with to try and shore up finances before venturing into production again. Will getting a juicy role to work on help my inner ennui? Maybe a weekend at the beach? I’ll solve it eventually. I always do.

We’re almost at 600,000 deaths in the US from Covid-19. We’re still having between 500 and 1,000 deaths daily in the US so we should pass that mark in another week. When we hit 610,000, and we will by the Fourth of July weekend, the pandemic will officially pass the Civil War to become the second largest mass casualty event in US history. The first is the 1918 flu pandemic at 675,000 and I can see Covid passing that over the course of this year if we don’t get better at reducing the unvaccinated population. My inpatient friends tell me that there’s still a significant number of people coming in with new Covid infections. They aren’t coming in the numbers they were earlier this year and the system is having no problems absorbing them. They all have one thing in common. They hadn’t gotten a vaccine. The inpatient docs are losing empathy for them as they are having to expend time and energy saving people from what is rapidly becoming a preventable disease.

The next big turning point is going to come when the FDA moves the vaccines from emergency use authorization to approved status. I don’t know when that’s going to happen yet but more than a hundred and twenty million successful vaccinations in the US with minimal complications and side effects is a pretty compelling data set. As long as they remain under EUA, they remain ‘experimental’ and it’s difficult to have regulations requiring them. Approved vaccines, however, have plenty of laws backing the rights of employers, schools, and other entities to demand vaccination. Once that happens, it will be interesting to see what happens to the anti-vaccine forces. I also remain suspicious that once the vaccines have official FDA approval, that there is going to be push by the insurance industry to add riders to health policy denying payment of claims for Covid-19 treatment in the voluntarily unvaccinated.

It’s been a quiet work week chez Andy. All the usual chores have been completed and the clinical programs for which I have responsibility are humming along without too much difficulty or need for excess oversight. It’s actually rather a nice change. I do chafe, however, at the amount of data entry that’s now required 0 and it seems to have doubled over the course of the pandemic. One would think that the US healthcare system would prefer its physicians to act as doctors rather than as typists but I could be wrong. It reminds me of my days back in the 70s as a keypunch operator. (To my younger readers, google Hollerith cards).

Nothing new has turned up yet as far as the performance career goes. The local theaters are all starting to get people together to figure out how to move forward in our changed environment so there should be projects I can audition for soon. A couple of people have suggested that I take selections from these posts and turn then into a one man Spalding Gray type monologue for performance. I’m not absolutely against that idea but I’d need an external director/dramaturg to help shape it properly. That’s not something I think I could do as I don’t have the correct objective eye for the material. If someone thinks this is a brilliant idea and wants to work on it, I’m open to conversation. In the meantime, something will come along soon. It usually does. I have board meetings for the Opera, a theater company, and a focus group for another theater company in the next two weeks so I should start to hear things. I have been asked to participate as a storyteller in a local festival fundraiser next month. I have no idea why they asked me, but I foolishly said yes and have to come up with a five to seven minute piece. The theme of the evening is apparently animals and I can’t think of any of my personal stories that involves animals that would keep an audience interested for that length of time. Perhaps my story that ends up with a glass Murano fish. (If you’ve heard me tell the story, you’ll know what I’m referring to).

I had a very odd dream last night. I was tasked with rescuing Queen Elizabeth from the top of some cliffs so I picked her up, tucked her under my arm and scaled down a rocky escarpment that turned into an urban hellscape. Eventually, I had to grab a rope and swing with her across a chasm in true Luke and Leia fashion to get her back to Buckingham Palace. Then, because I was wearing my pajamas, I had to go to the costume shop to find something appropriate to wear to the royal reception and there was nothing in my size other than mismatched plaids in neon colors. Someone will have to explain that one to me. My major take away was that the 95 year old queen wasn’t very heavy so I had no difficulty picking her up and having her cling to my side.

Perhaps it’s my inner David Lynch coming out. I’ve been binge watching Twin Peaks. I hadn’t ever seen it. It came out in 1990 when I was in residency and working 80 hours a week and watched essentially no TV. I’d always heard about it, new most of the references but really hadn’t a clue what it was really about. It’s interesting to see the exteriors of the Pacific Northwest as it was in my youth but I’m not sure I completely get the highly stylized performances and storytelling. If anything, it seems to be some sort of send up of the overblown evening soaps of the 80s like Dynasty and Falcon Crest and I can see why it didn’t last very long. Still, at least I’ll now be able to say I’ve seen it. One of the Broadway pages, in response to the Spielberg version of West Side Story that’s due out shortly, was discussing pairing up other famous film directors with musical remakes. I suggested a David Lynch version of Hello, Dolly! It would be weirdly fascinating and likely more watchable than the film we have.

It’s been a long weekend. And it has felt like the first normal holiday weekend in a year and a half, bookended as it was by backyard barbeques with old theater friends on Friday evening and earlier this evening. Good friends, good conversation, and the reliving of past triumphs and tragedies on the boards -the kind of reminiscing that theater people always do when they get together. I’ve noticed that theater folk are pretty much the same, at least in the English speaking world. Referential quips to famous lines and lyrics, spontaneous sing alongs, stories of random mishaps both backstage and onstage. I haven’t been to too many Broadway salons but I imagine it’s not all that different there.

I completed the two major projects I set for myself this weekend. The first was to get plants into all the pots on my deck so I could have some flowers and visual interest outside my windows. One trip to Home Depot for potting soil, several flats of annuals, a couple of hibiscus, a rose bush and a few other assorted odds and ends and I have living growing things around my seating areas. It remains to be seen if I can keep them alive for the season. I have two spots left and I have decided I’ll get a couple of potted ornamental cypress trees for those areas. I’ve seen some nice ones for sale at the Botanical Gardens so I’ll probably make a trip over there this next week.

The second was to get all of the proof edits done on the book. I finished that job this afternoon. Almost everything is essentially done now other than one more pass at the prologue and epilogue to see if I can get them right. They’re almost there but I think they need just a little bit more tweaking. Everything remains on schedule for the book to be available as of the last week of June or first week of July. As soon as I hear more details, I will let everyone know. Now that the world is opening up thanks to vaccines, people are starting to ask if I’m going to have a release party or signings at any of the local book stores or something else of the type. My ego is pulled two ways by this. First, I’m flattered that people care and are looking forward to seeing the finished product. And then that part of me that suffers from Impostor Syndrome kicks in and starts to believe that no one will actually ever want to read it and that the quicker I bury the project and move on to something else, the better.

We’re rapidly evolving into a two tiered society of vaxxed and unvaxxed. People end up in one camp or the other for various reasons but, if you wish to get the vaccine, it’s now available essentially anywhere to anyone over the age of twelve. The relatively quick distribution of the last few months has contributed to a sharp drop in cases and deaths back to what they were in the earliest stages of the pandemic more than a year ago. But they do continue to mount, fed by the significant percentage of the population that remains unvaccinated. We’re now at about 595,000 deaths in the US since the beginning of the pandemic, only 15,000 to go to surpass the Civil War to become the second greatest mass casualty event in US history. (The 1918 flu has the number one slot at 675.000 deaths). The rate of spread in the unvaccinated population remains roughly the same as it was at the height of the pandemic in January. Death rates are lower, as the unvaccinated population tends to be younger and healthier, but there are still going to be a lot of people who die who don’t need to. Because of lingering propaganda from a previous administration which has poisoned certain communities’ trust in sound science.

When the variants from India get here, and they will get here, with their much higher levels of transmissibility and they find their way into the unvaccinated population, we may find ourselves back to overburdened Covid wards and strained health systems. It won’t be as bad as this past year as we’ve figured out what we’re doing in terms of treatment and we’re better at keeping people alive, but I remains gravely concerned about the health effects we don’t know about. We’ve become familiar with the small percentage of long haulers who months later have significant viral symptoms but I suspect there’s end organ damage that’s going to manifest in a decade or so as early onset chronic kidney disease or chronic obstructive pulmonary disease or early onset dementia or congestive heart failure and that’s going to take a lot of people, and the health system as a whole, by surprise.

I shall be happily retired at that point. I don’t know when exactly I’ll retire but Covid has certainly pushed me towards earlier rather than later. The fact that it is sneaking up on me was brought home by my receipt of my retirement packet from the University of California system that arrived in the mail this past week. My pension under that system stops accruing on my 60th birthday next year so it makes no sense to not start taking it at that time. It won’t amount to a lot of money but, considering what that system did to me and Steve in the end, I plan on collecting every penny out of them I can. The best revenge is living well.

You may not have to wear a mask any more if you’re vaccinated, but it’s still a good idea to wash your hands.

It’s raining this evening.  That ended up cutting church choir rehearsal, held outside, rather short; it’s obvious that my fellow Unitarians did not grow up in Seattle.  Those of us who did learn at an early age to trudge forward with whatever outdoor activity is at hand whether water is falling from the skies or not.  I will admit that Southern rains can be, at times, real gully washers that make this attitude impractical, but tonight’s has been a gentle rain, more like the drifting mists of home.  I suppose handling of soggy sheet music would have been unpleasant and we did get the pieces we needed to record for future services down so all was not lost.

It did not rain last night.  I took a couple of friends out for our first fine dining meal in fifteen months.  Vino in Mountain Brook has a large outdoor patio, the weather was warm, and we enjoyed the whole gamut from cocktails to appetizers to mains to dessert.  Good food, good friends, good conversation.  I had almost forgotten that sort of activity existed.  I had scallops in curried cream sauce.  It’s probably not on my diet plan and I know the tiramisu wasn’t.  I’ll work on losing my pandemic twenty another day.

As the world starts to open back up, I, along with the rest of us, am trying to figure out what the rules should be regarding social distancing and mask use.  All of our local mask ordinances expired as of Monday and are not being renewed so we are all left with CDC guidelines (and misinterpretation thereof) and various corporate policies.  I am continuing with mine in some situations and not in others based on what I think is a combination of common sense and good public health.  I don’t mind wearing it.  I’ve gotten so used to it over the last year or so that I don’t even notice when I have it on half the time.  If it’s not on, it rides around in my back pocket along with a spare just in case.

I work in health care which means I go in and out of buildings dedicated to healing and into which people with various illnesses, immune deficiencies, and other conditions that prevent them from being vaccinated at this time congregate.  Therefore, both UAB and VA are continuing mask mandates in buildings used for clinical care for the foreseeable future.  We wear them with patients, when in patient care areas, and when in the public areas of the building such as lobbies, hallways, and elevators.  If we’re in office suites or other places where patients do not go, we’ll take them off as staff are all vaccinated.  I am still wearing mine indoors in buildings where I don’t know others health and vaccination status such as stores.  I think it’s polite and telegraphs that I give a damn about the health of my fellow citizens and the health of the employees in such establishments.  I don’t wear it outside unless there’s a crowd of people (like the Saturday morning farmers market).  I don’t wear it at home or when in the company of a few people who are all vaccinated.  I do wear it on house calls as that’s a health care situation. If and when I start going back to the movies or getting on airplanes, I’ll gladly wear it.  Covid is not the only respiratory disease out there and I’ve noted that I haven’t had a single cold or bronchitic infection since this whole thing started and I usually get a couple a year.

While things are definitely improving, this whole thing isn’t over.  There’s still about thirty people in UAB hospital with active Covid infections and other thirty who are not actively infectious, but who are still too sick to go home.  This is way down from the average of three hundred a day we hit in January but it’s still a burden.  And, because the older population has been better about getting vaccinations, its mainly younger and middle aged people who are deathly ill.  The hospitalization rates for the vaccinated have fallen to negligible levels.  Those few who get Covid infection post vaccination generally don’t develop complications that can’t be handled at home.  The hospitalization rates for the unvaccinated population really haven’t changed.  It looks like nationally we’re going to end up with about 60% vaccinated and 40% not by the Fourth of July.  That 40%, as it’s a younger and healthier cohort than the total population, won’t have the roughly 2% chance of death we’ve seen; it will be lower.  But, that population is so large that there is still the chance of thousands and thousands of excess deaths still to come from what is starting to become a preventable disease. That’s not to mention the unknown long term complications of the illness.  There’s lots of end organ damage noted in lots of studies.  It might not matter much when you’re thirty-five, but it might play havoc a couple of decades later at sixty and shave years off of life expectancy.

We now have a truly ridiculous law in Alabama banning ‘vaccine passports’ and not allowing public or private entities to discriminate in access to the public based on vaccine status.  It’s so inartfully written that it basically forbids state institutions, including UAB, from handing out vaccine documentation cards, will not let schools ever add another vaccine requirement for students, no matter what diseases may circulate, and tramples on the private property rights of individuals and businesses.  It’s likely to be ignored for the most part, but could certainly pop up as a poison pill in the future when the next pandemic disease comes to town.  And there will be a next one. If our grandparents had, in the forties and fifties, acted as we are today, we’d still be battling polio and smallpox. So do your civic duty and get your vaccine if you haven’t yet done so.  Operators are standing by to take your appointment.  The folks at the CDC and WHO with their years of training in virology and epidemiology and their billion dollar budgets are savvier than you and your Google search and friend on Facebook.

I’m back in my usual groove. I can tell because I fell asleep three times this afternoon while attempting to finish up my progress notes from this past week. I still have quite a number to go but have finished the batch that will be delinquent if they aren’t done this weekend. I write about 1500 of them a year – that’s about 50,000 over the course of my career to date and they have morphed from hand written documents to dictated notes transcribed by a specialist to computer assisted notes where the computer kept track of things like the med list but where you still dictated the meat of the note to now full electronic health record full of little point and click boxes and various free text fields in which I have to type various things, most dictated by payment systems, and not by clinical care. I’m not sure if that’s progress or not. My first job in high school was as a key punch operator working with Hollerith cards. I seem to have come full circle.

Covid continues to come under control nationally with fewer and fewer cases and deaths being reported. This is likely from a combination of the relatively speedy vaccine roll out over the last few months with some contribution of natural immunity due to the roughly 10-15% of the population that caught and recovered from the disease. The health system is breathing easier and there are reports of Covid units with no patients for the first time in well over a year. Does this mean we’re done? I don’t think so. It’s not a US disease, it’s a world disease so we are still at the mercy of trends and problems of other regions and what happens in them regarding vaccine and in the spread of variants with possible higher levels of contagion and higher mortality. India continues to be a problem spot. The official numbers there are echoing those here at the height of the winter surge this past January but the excess mortality in that country is much much higher given the number of bodies appearing everywhere. Their official statistics only count those who die in a hospital with a positive covid test. Those who die at home or those who die waiting for care who have not yet been tested are not counted.

Here in Alabama, we seem to have more or less reached the limit of the easily vaccinated at a measly 35% of the population with at least one vaccine and 28% fully vaccinated. The demand has fallen off and the large vaccination centers are closing one by one despite the huge number of residents that could still benefit. We’re a few percentage points higher locally in Jefferson county but we remain at risk with about a 4.5% positivity rate on tests and between 6 and 7 cases per 100,000 population daily. On my wanderings through life this past week, people are still masking up when going indoors in public places but generally wearing them under their nose which defeats the whole purpose. Can we get those numbers up? Only with some massive public health campaigns to counter some of the more ridiculous propaganda that has spread and I doubt any of our state or local agencies have the funds or the energy for that. Our mask ordinance expires in another week and probably won’t be continued.

I’m not worried about myself at this point and I’m not overly worried about most of my patients as they fought tooth and nail to find vaccine when it first came out. As elders, they understood they were at much higher risk. The CDC guidance is likely to keep evolving so that the vaccinated will be given free run of society while the unvaccinated will be told to continue to use caution and restraint. This is going to put in a sort of society wide honor system regarding masks which isn’t likely to be terribly helpful. After all, the great American public was hoarding gasoline in plastic garbage bags only two weeks ago. There’s going to be no way to know if the maskless are vaccinated or simply deranged. My rules are no need to mask outdoors, no need to mask with a small group of friends who are vaccinated, but I still mask in a store or other place with a lot of people that I don’t know. Health facilities are likely to continue the masking rule for quite some time as it’s cut down quite a bit on disease transmission of all stripes so I’ll continue to wear one at work for the indefinite future, at least while I am working in clinical care.

I went out last night (masked) to one of the first performances at the new Red Mountain Theater Arts Campus that’s taken shape near the ballpark. A table read of a new script about the history of lynchings in Jefferson County in the past that acts as both exploration of the real lives of the people and a memorial to them and condemnation of the heinous acts perpetrated on them. Powerhouse cast including Marc Raby, Brandon A. McCall, Shronda Major, Nick Crawford, and Rebecca Yeager ably directed by Aija Penix. Quinton Cockrell (whom I have known slightly for years but don’t seem to be Facebook Friends with) took the historical research and his imagination to intertwine the stories, the social trends that created the conditions that allowed for this to happen, and, as with all good theater, a mirror for the audience to see themselves and a litany of present day names and incidents showing how the stains of the past continue to color the present. It has a great future as a theater piece but it was so powerful in the simple way it was presented, that I worry that a wish to create a fully realized staging might lead to temptations to overproduce and lessen its impact.

I just finished Isabel Wilkerson’s new book ‘Caste’ which posits that the way in which we need to view American society is as a caste system, every bit as complex and rigid as the one in India and that many of the difficulties of our times and much modern politics – everything from the white working class consistently voting against their own economic interests to the poor response to the pandemic can be explained by the thousand and one little social rules we unconsciously abide by to keep certain people in the ruling caste and other people locked into subordinate castes. I highly recommend it. I am not a product of the deep south, having not come here until my mid 30s, and I have always been able to see certain things that I have considered wrong and called out which others have considered normal but the more reading I have done, the more I have come to understand my own socialization and unconscious biases and I have spent years trying to unlearn them and replace them with more equitable ways of viewing the world. It’s a constant battle but it’s a good fight and I hope my African American friends see me continually working to improve. Tommy, coming from a Walker County white working class background always accused me of having been born with a silver spoon. I suppose I was in some ways, but I’ve been trying to use it to dig my way to a better understanding of all of us.

Returning back to work after being away for a few weeks is always painful. I have piles of papers requiring signature, multiple mailboxes, both regular and e variety, to empty and sort, and there’s always a subtle sense of something vital that got missed along the way. You know it’s going to reappear later and with innumerable complications, usually at a particularly inopportune time. I’ve had a full day at the UAB half of the job and a full day at the VA half of the job. Things aren’t yet fully caught up but there’s a plan in place to get everything back to where it belongs by the end of the week. A lot of my patients and their families seem to think that only I can help with the latest issue. I trust my teams and colleagues implicitly and have them well trained and they do just fine in my absence, even if they are met by grumbling at time that it’s not me. I wonder what they’re all going to do in a few years when I announce my retirement? I’m not exactly sure when that will be. Sometime between 2024 and 2029 I expect. I’m keeping my options open.

I will be bowing out in time to not have to deal with the enormous problems that ‘peak age’ are going to bring to the health system. This happens between 2030 and 2035. It’s the time when the entire baby boom will be over the age of 65 and eligible for Medicare but will not yet have entered their major die off. That will start in full force around 2032 and accelerate through the early 2040s and then end around 2050 or so. The baby boom generation will lose its grip on social power in the late 30s due to these inevitable demographic changes and will basically be irrelevant around 2050 (at that time, the oldest boomers will be 104 – Cher will be doing another farewell tour and the youngest will be 86). In 2060, the boomers will be what World War II veterans are today. A few still around to be celebrated, but the vast majority gone. They will continue to linger on until the very last one dies in roughly 2080 when one of the youngest boomers, almost certainly female, born in 1963 of 1964 will die at the age of 116 or so.

The book I was writing was about this phenomenon and my predictions regarding the impact of the boom on the health care system over the next decade or so as the irresistible force of the aging boom generation with their expectation of eternal youth meets the immovable object of biological aging and the structure of the health care system. Maybe I’ll return to it. Covid sidetracked it into the Accidental Plague Diaries which is in the process of undergoing its last few minor edits prior to publication. It should be available for purchase as of the end of June. Yes, I’ll give everyone plenty of notice and, as things are opening up, I’ll even have a signing party somewhere. It still feels somewhat unreal that I actually managed to finish a whole book which, according to my beta readers, is well worth reading. I don’t know that I’ll actually believe it until I hold a physical copy in my hand. I still believe in physical media and have shelf after shelf of books, DVDs and CDs in my home. I just don’t completely trust ‘the cloud’. I want to know that what I have purchased is mine to do with as I please without some sort of digital overlord able to make changes on whatever whim.

I’m still not sure what to make of the most recent CDC guidance regarding vaccination and masking. I understand that they’re trying to use ‘vaccination’ = ‘ditch the mask’ as a selling point to get those on the fence in for their jabs but it does seem as if it creates a sort of nationwide honor system regarding vaccination status. There’s no way to tell if the nice person smiling at you is fully vaccinated or a rabid anti-masker who believes in vaccine microchips and other such nonsense and is a potential sort of contagion. if the last few years has taught me anything, it’s that I need to be wary of the American population as a whole. They have shown themselves not to be the most trustworthy and it strikes me that a significant part of the population has dumped the Golden Rule and the other teachings of religion in favor of the collected philosophies of Ayn Rand and Roy Cohn.

We’ll all find out if the current optimism regarding Covid is correct over the next month or so. The numbers are way down, the fourth wave that it looked like it was developing in mid-Spring, having sputtered out. Whether this is due to increasing vaccination rates or other phenomena is unclear. The change in behavior over the last week or so with less restrictions will be reflected in infection rates around Memorial day and, if we’ve got it wrong, the death rates will start going up again in mid-June. I certainly hope we have it right but I’m still being cautious. I put my mask on when I go indoors with people whose vaccination status I don’t know. The issues of the unvaccinated and inequality in vaccine distribution pretty much all come down to ‘No one is alone’. We live in a complex interdependent world where the health of all of us depends on the health of all of us. Any group left behind or left out, when it comes to pandemic illness, can serve as the breeding ground for the next contagion. We are lucky that this one was not more fatal than it was. If the next thing that comes around as the mortality rate of Ebola, we’d be looking at wholesale societal collapse. And I’m not sure that Western societies, with their tilt away from public good to private gain will be able to do better in the future with the next inevitable viral illness that comes along.

Have we learned lessons as a society that will stick with us? It’s hard to say. The American attention span isn’t all that long and there are political and economic forces at work trying to downplay a lot of the bad that’s been going on in the society. This isn’t just limited to health issues. I read comments today from a sitting member of congress, one photographed blockading the doors of the house chambers with furniture on the day of the insurrection, describing the events as nothing more than a bunch of tourists. It makes me wonder what his family vacations are like. Did they storm Old Faithful waving flags and armed with assault rifles last summer? Perhaps they broke through the emergency doors to ‘It’s A Small World’ to make sure they got into the front of the boat. There’s an agenda at work here that I don’t completely understand but I’m trying to get a better sense of how it crosses with health policy. I’ll let someone with more experience than I analyze the political trends.

Dateline: Evansville, Indiana

Tonight is the last night on the road. Tomorrow will be the last drive and the day after I am due back in my usual life and patterns and will have to plug back in to my usual life and patterns. This two weeks of unplugging has been good for me but it is time to get back to those who depend on me in one way or another at work and with life in general. I’ll be in normal patterns through the summer and, in September, I’ll get to break away again assuming that Covid doesn’t mutate in such a way as to shut travel back down. Anything is possible with that disease and we’re fooling ourselves if we think the last chapters of the saga have been written yet. I’m sure there is more to come; I just don’t yet know what form it is likely to take.

Today started with Drag Brunch in Council Bluffs, Iowa. Now there’s a sentence I never thought I would write. Lynn Jensen Kvigne, whom I have known and corresponded with since the early days of Epinions and Mrs. Norman Maine lo these twenty plus years ago, but whom I had never actually met lives in the area and I suggested we get together for brunch before I got on the road. Her researches turned up a decent brunch place in downtown Council Bluffs and, as luck would have it, today was there once a month Saturday brunch with drag queen entertainment. How could we not? She had a breakfast sandwich, I had French toast. We caught up and were entertained by beefy country boys in body suits, wigs that Tommy would want to restyle, and excessive pancake, busy lip synching to disco hits popular before they were born. It was lovely. Unfortunately, I could not order the drinks served in small fish bowls as I had a 600 mile drive in front of me.

After departing Council Bluffs, I headed south along the Missouri river, eventually ending up on the opposite end of Kansas City from the end I hit on my outbound trip, there I turned east, crossed Missouri to St. Louis, became very confused by the interchanges leading from I-70to I-64 and had to get off the highway downtown near the Gateway Arch in order to figure it back out and eventually headed on the right road out of town. (Tommy and I went to St. Louis together a dozen or so years ago to see Roderick George as Tamino in Zauberflote and went up the Arch that trip so felt no need to stop this time). Then, across Southern Illinois, and into the Southern tip of Indiana, stopping tonight in Evansville. None of the scenery was terribly exciting – typical rolling hills, some woodlands, and a lot of pastureland. Also an inordinate number of dead deer on the roadside. Fortunately, I did not hit any.

I picked Evansville deliberately. In this town, 73 years ago, Jon Steven Spivey made his entrance into the world. His father was from Crawfordsville and his mother from Russellville, both in Northern Indiana. Steve was a little hazy about how the family had ended up in the Southern part of the state but there was some story about his father needing to make a geographic relocation to stay a step ahead of some sort of unspecified trouble. He never said for certain, but I believe it was alcohol related. Alcohol issues tended to follow the Spivey men and Steve was thirty years sober when he died. When Steve was four, the family made another major geographic relocation to suburban LA (Sun Valley in the San Fernando Valley, just a bit north of Studio City) and that was where he grew up. To my knowledge, Steve never returned to Evansville and the two of us never passed through on any of our Midwest/Appalachian trips when he was doing his genealogical research so I thought I would take this chance to at least see what it looks like.

My audiobook the last few days has been Isabelle Wilkerson’s Caste which has got me thinking about a whole lot of issues but I’m going to need to think about them for a few days before writing about them. Until then, bad television, a good night’s sleep and home tomorrow before dinner time.

Dateline: Council Bluffs, Iowa

Another unexciting drive across the Great Plains today. At least yesterday’s storms had petered out and the weather was fair with only a smattering of raindrops in a couple of places. From Rapid City, the road descends out of the Black Hills onto the plain and then runs more or less in a straight line for hundreds of miles. It’s flat, farm country, and pretty much featureless. An hour or so to the east of the hill country is the nothing town of Wall, South Dakota, home to Wall Drug, a small business of infinite self promotion with essentially no competition in a several hundred mile radius. I passed the billboards. I did not stop as I visited the establishment on my last trip across I-90 and generally don’t feel a need to return to tourist traps of no consequence.

More and more flatlands, with the Badlands on the horizon to the South, with the occasional sign pointing to DeSmet (the little town on the prairie where Laura Ingalls Wilder spent her girl hood) or the Corn Palace. (I stopped for lunch at that exit and drove past – it’s a Shriner’s auditorium covered with corn husks). At Sioux Falls, right turn from I-90 to I-29 and south for a few hundred miles and out of South Dakota and across the Missouri River (again) and into Iowa at Sioux City. More flat lands and then there’s the few towers of Omaha rising out of the flat lands looking like a less colorful Emerald City. My Hampton Inn of the evening turned out to be right across the river in Council Bluffs, part of a complex of hotels on the water centered around a Riverboat casino that, while technically on the water, has obviously never sailed anywhere. The CDC may be loosening restrictions, but jostling around middle America feeding one arm bandits did not appeal, so I took a walk around the outside before retiring for the evening.

I’m still trying to digest the change in CDC guidance regarding indoor masking that came down yesterday and how I should apply it in my life. There are a few salient points. The CDC did not say that it is safe for people to gather indoor unmasked. It said it was safe for fully vaccinated people to gather indoors unmasked and that most normal activities are safe for them. They are not safe for unvaccinated people. What does this mean in practical terms? I think if you are gathering privately with family or friends and everyone is vaccinated, there’s nothing to worry about. Larger public gatherings are still problematic as not everyone who wishes a vaccine as been able to obtain one. And there remains a significant subset of the population who are refusing vaccination, largely due to political reasons.

There’s no way to tell who has been vaccinated and who has not other than self report. There has been a lot of discussion of vaccine passports on smart phones (but this will leave out the significant population that is not capable of using or who cannot afford such devices) so I have reservations about such a system. And having uniformed people at the entrance of a place of public gathering demanding ‘Papieren bitte’ brings up images of totalitarianism that we just don’t need. I’ve opined before that the liability insurance industry is likely to begin writing the rules going forward as they will not want to indemnify businesses depending on people coming together if the business does not have a plan to prevent the spread of pandemic disease in place. Variants of various stripes are spreading and they will all eventually reach the US and will pass into the unvaccinated population and be spread. We live in such an interconnected world that pandemic disease is a global problem, not a national problem and we’ve been so preoccupied with our issues here and how the previous administration dropped the ball, that we’ve been paying very little attention to what’s been going on elsewhere in the world. From what we know so far, the vaccines are protecting against spread and serious disease from variants. The mRNA technology behind the Pfizer and Moderna vaccines is such that tweaks can be made quickly. We’re unlikely to be caught in a situation as we were last winter going forward but anything is possible. We may need to keep getting Covid boosters going forward. I’d rather have a booster than a ventilator any day.

There were a number of reports today about spread of Covid in the fully vaccinated NY Yankees organization. People have tested positive. One was mildly symptomatic leading to the testing but most were asymptomatic and it doesn’t look like anyone is getting seriously ill. I think that’s the thing to remember here. The vaccines aren’t perfect in regards to protection against infection. What’s important is that they offer a very high level of protection against serious disease requiring hospitalization. If we test widely, we’re going to find a lot of asymptomatic infections as the virus isn’t going away. As long as people aren’t getting seriously ill, I wouldn’t worry a lot about these reports. It’s going to be problematic, however, if the disease gets into organizations catering to those refusing vaccine for political reasons. We’re going to continue to see spread and serious illness and death in these situations and I don’t know what we can do about it. Private entities can mandate vaccine as a condition of employment or entry but we’ve so weakened the ability of government to do this at the behest of concerned parents of the antivaxxer movement over the last few decades that it will be difficult to get government involved on anything other than an advisory role.

Brunch with a friend tomorrow, and then further southwards…

Dateline: Rapid City, South Dakota

I realized as I studied the map last night I had two basic choices for today. I could cut things a little short and spend the night in Rapid City, South Dakota, on the western border of the state, or I could power through and drive nearly 700 miles and spend the night in Sioux Falls on the eastern border of the state. There is nothing between them other than Wall Drug and I had no interest in bunking there for the night. I decided, as the weather was not the best and I was dodging rain showers all day, that it would be wise to choose the former course and end early.

From Billings, the road veers Southeast and passes next to the Little Big Horn battlefield, site of Custer’s famed defeat. As I was in no hurry, I stopped for a while. I had been here once before several decades ago and it hasn’t changed much. Rolling hills above the Little Big Horn river dotted with white marble markers where the 7th Cavalry fell. Fortunately, we are starting to wake up to the fact that the ‘taming of the west’ is a complex story and it’s probably best not to celebrate genocidal wars without acknowledging the other side so there are now exhibits celebrating the Lakota and Oglala Sioux, Cheyenne, Arapahoe and other indigenous people involved in a battle to preserve their way of life and brown marble markers are being placed where their warriors died. I also noted that the Lewis and Clark trail historical markers have been redesigned to include Sacajawea and her baby which is only fitting.

The road then crosses into the high mountain plains of northeast Wyoming for a few hundred miles and then enters South Dakota in the Black Hills, just north of Deadwood. By this time, it was really raining so my thoughts of detouring to Deadwood and Mount Rushmore fell by the wayside as heading up into the mountains in a rainstorm seemed like a really bad idea. Besides, I’d already been there on a previous visit to the region. So, I had an early dinner in Rapid City and checked into the Hampton Inn where I found I had been upgraded to what I take is their honeymoon suite from the large jacuzzi tub in the living room. After three days of driving, a nice hot bath with jets seemed like a swell idea so I filled it up and soaked for a bit.

I turned on the news in time to catch the CDCs announcement that masks would no longer be required indoors for the fully vaccinated in uncrowded situations. The number of vaccinated adults has continued to increase, especially in urban areas and a dozen states are above 2/3 of their population vaccinated. In Seattle, the neighborhoods where my family live are over 80% vaccinated. This is leading to a precipitous fall in deaths, if not total cases (the disease having been pushed into a younger cohort less likely to be vaccinated but also less likely to die. I hadn’t checked the statistics for a while so Iooked them up. About 33 million US cases (roughly 10% of the population) and about 584,000 deaths to date. I’m starting to wonder if this means the end of the Accidental Plague Diaries? They’ve occupied a lot of the last fourteen months of my life (and the first ten months comprise ‘the book’). Part of me would hope so, but I don’t think this story is over yet by a long shot. Our current political climate is going to ensure that. Despite the incredible biomedical effort that the development and administration of a vaccine in just over a year represents, we still have a major political party dancing around full of delusions regarding the operation of science, medicine, and public health. And the more time goes by, the more delusional it appears to become. At the moment it’s trying the gaslight the entire world into believing that what occurred on January 6th was not what was recorded and played out in real time in front of all of our horrified eyes.

I have to get back into my usual groove and off the road and start thinking about all this a bit more and then I’ll be able to give a better assessment about what I think of the Covid-19 endgame and what is likely to come next.

Dateline: Billings, Montana

Today was a straight 540 mile shot on I-90. Not so straight as it’s primarily through mountain country so lots of ups, downs, S-curves, slow trucks, views of lakes, mountain peaks, and rushing rivers that only needed a young Brad Pitt in hip waders to be complete. The weather is holding. There is no gas shortage in this part of the country. Hampton Inns are pretty much the same everywhere you go. (They offer major Hilton points at the moment…)

From Spokane, the road curves along Lake Coeur D’Alene in Idaho while crossing the panhandle, and then climbs up into the mountain country of Western Montana. The passes were all clear of snow, even at the 6500 foot level of the Continental Divide outside of Butte. All of the clusters of mountains have range names but they are part of the same cordillera that contains the Rockies so I have always thought of them as the northern Rockies. Once up in the high plateau, it’s mainly the broad river valleys of the Missouri headwaters and the Yellowstone, bypassing the park on it’s northern border and after passing through Missoula and Bozeman, eventually arrives at Billings which was far enough to go in one drive.

Many long years ago, I spent a month or so in Western Montana, north of Kalispell, in the little town of Whitefish. (Long before it became a trendy Western mecca for the well heeled). I was there to do my rotation in Family Practice and attached to a group of FPs that were the major providers in town and were first call to the ED. As a fourth year student, I was responsible for the after hours ED calls to do a preliminary evaluation and warrant whether a ‘real’ doctor needed to be woken up. Drunk tourist with a bellyache? I could handle that. Gored by bull. As the wound was in the belly, that had to be loaded up in an ambulance and taken to Kalispell for surgical evaluation. Fell off a horse on a trail ride? Colle’s risk fracture. Apply splint and help them arrange for orthopedic follow up when they got back home to Minnesota. It was one of the experiences that taught me how to think well on my feet and one which kept me from being afraid of rural medicine or of delivering care without a tertiary care university hospital hovering behind me. Whitefish is just outside of Glacier National Park, so I was in the park on day hikes every day off. I got one long weekend during my time there and used that to head up to Banff/Jasper where I had not been since I was a tot of four. (A trip long remembered in family lore as the engine fell out of the car in the middle of the Banff Jasper highway leading to a number of complications…)

I want to go back to Glacier/Banff/Jasper/Waterton Lakes as a mature adult and see them all again. Perhaps after I retire, I’ll take a leisurely trip out to Seattle and spend some time going all the way up the Rockies from Denver taking in the Tetons, Yellowstone, and the others mentioned above. Then again, I might skip Waterton Lakes. The last time I was there, around age 12, a deer came up to me in the campground. When I had nothing to feed it, it reared up on its hind legs and planted both its forehooves in the middle of my chest, knocking me over, before stalking off in search of another campsite where they might be freer with the treats. My encounters with deer and elk this trip have been less dramatic, just having seen them in passing from the car. No bear this trip. I can do without seeing a grizzly in the wild but I don’t mind the occasional black bear encounter though. I’ve had a number of those over the years. The bear is usually not at all interested and ambles off another direction. The only one that was at all unusual was when I was four on the same Banff trip when the car fell apart. My mother was reading to me in the tent when our dog, Duffy, a West Highland White terrier who was tied up outside, began to bark. This was unusual so she stuck her head out of the tent to find a large black bear pawing at the things in the next campsite. My mother scooped me up and took off down the road (and I remember her running with me in her arms quite clearly) and took refuge at the ranger station. My father, when he came back from dealing with car trouble, was glad we were OK (the bear having been chased off by the rangers) but was upset at my mother for having not grabbed up the dog at the same time she grabbed me. The dog was fine. The bear wasn’t the least bit interested in yapping terriers.

Down from the mountains and onto the plains tomorrow.