We may all be preoccupied with dodging coronavirus but, against that background, life continues on with its minor domestic triumphs and tragedies. There’s part of me that wants to hide from the little curveballs life throws as I’m just tired of things happening and there’s another part that revels in them as it’s proof that I am alive and that the story goes on. It reminds me of the period when Steve was so sick and much of my energy went to taking care of him. The little ups and downs of life felt greatly magnified as the battle against his disease process took so much of usual living away from us. Now it’s Covid-19 stripping things away and leaving that which remains to occupy time and energy. It may not be much but when all your general connectedness is gone, it can feel like too much.

On the up side, I’m going to have to put my virtual film studio back together in the dining room. Someone dropped out of the Importance of Being Earnest so I’m picking up the slack and playing the other servant in Acts 2-4. I have to come up with a different look, voice, and physicality to try and disguise one person two butlers but I figure if Peter Sellers could do it, so can I. Holly, Tommy’s wig and makeup assistant is coming over later today and we’re going to experiment and see what looks good on camera. On the down side, something has gone wrong with the drain pipe from my kitchen sink. It’s not the trap. It’s deep inside a wall or maybe in some central piece of plumbing – I’m trying to find out if this is is something I need to take care of or if it’s the responsibility of the building. I’m hoping for the latter.

I had my annual review on Friday and I am happy to report that I have a job for at least another year. My 22nd anniversary at UAB comes up in a couple of weeks and it looks like I’ll be with them a total of 25-30 years by the time I get around to retiring. It seems funny to be contemplating that milestone as it doesn’t feel like it was that long ago that I was in college – med school – residency – fellowship but it was all a lifetime ago at this point. I have two things to do before I can contemplate stepping down – making sure health insurance issues are covered (Medicare or otherwise) and paying off this condo. I want the mortgage gone.

Back to some accidental plague diary thoughts. Numbers are spiking again in Europe leading to further shut downs. Numbers remain way out of control here. On the other hand, most of Asia has the disease under control and things are pretty much back to normal. It’s never really gained much of a foothold in Africa. If you look at rates in first world countries after mid-May (the time when there was enough understanding of the disease, its spread, and modes of transmission for governments to get their act together) some interesting things appear when you look at case rates normalized to population. While most of Europe and the rest of the first world was wildly out of control in March and April but came into control as more strict lockdowns were imposed and case rates were pretty low throughout the summer, just beginning to increase in the last few weeks. The two major outliers with much higher case rates are Sweden, which made a societal decision to let the disease spread and herd immunity take effect, and the United States where there are two populations divided by politics, one of which is vigilant in undertaking basic societal containment measures, and one which takes great joy in flouting those rules. Rates in the US are higher than in third world slum districts.

Why has Asia fared well and the first world not? I think there are a couple of cultural factors at play here. First, Asia is well versed in the spread of pandemic respiratory illness having been through SARS and various avian flu strains. Their populations, as soon as it became apparent that Covid-19 was going to be a problem, did the things they have been trained to do . They masked up and started practicing social distancing and obeyed their public health authorities as they have done many times in the past and the virus had difficulty getting a foothold and, where it did, was easily detected and abatement measures were targeted and put in place without public outcry.

Asian cultures are not cultures of individuality. They are cultures which put the well being of the group or the society ahead of the well being of the individual. People are willing to endure personal inconvenience as they innately understand a greater good is being served. We don’t do that very well in the USA. Modern Eurocentric culture comes into being in the post-Renaissance world with one of the lynchpins being that of Cartesian dualism with its corollary that every mind and individual is unique and that the needs of the individual and the ego should be paramount. Four centuries later, and we have constructed a technological society (with a heavy dose of Ayn Rand’s objectivism thrown in for good measure) in which people are not only unwilling to endure for the sake of the collective good, but are downright hostile to the idea. This ‘I have the right not to do anything I don’t want to do’ mentality is so ingrained in American thinking that it’s going to be very, very difficult to even begin to bring Covid-19 spread under control. The populations of those who understand what needs to be done and those that bristle at what they view as governmental intrusiveness are so intermixed that things will be dragged down to the lowest common denominator as the virus doesn’t care about these issues. It will spread where human behavior allows it to spread.

If there’s a change in administration in a few months, will we be able to start emulating societies with better track records? Not without good leadership and I am afraid that governmental leadership has been badly damaged. It’s going to take some sort of institution that a majority of Americans still trust to deliver messages and model behavior to start and turn things around. I have some hope that faith communities might start filling the gap. From what I can see, some of the leadership there has started to figure out that they have been rendering more to Caesar than to God in recent years and that this has seriously damaged their reputation and standing. This might be an area of the ‘love thy neighbor’ variety that they could enter and start turning the tide. Beyond that, I’m not sure if there’s a societal institution that both red and blue America trust in the same way. The military, perhaps, but public health really isn’t it’s role. Both sides tend to trust doctors but we aren’t given much of a public platform these days. The concerns of practicing physicians, especially in primary care are overwhelmed by the concerns of the administrators and money side of the system and that’s the narrative that makes it into the media and public discourse.

As the Emcee sang in the last show I did before theater vanished along ‘Money makes the world go round’CommentShare

I finished shooting my bits for the Fine Arts Center of Kershaw County’s online Zoom theater production of Oscar Wilde’s ‘The Importance of Being Earnest’ this evening.  It was the second project this week for which I was able to get my tailcoat out of its garment bag and give it a little fresh air.  The other was some filming for an online video from the Politically Incorrect Cabaret.  I took a moment afterwards to take down my jury-rigged green screen until it will next be needed, put my props away and turn my dining room back into some semblance of order.  Next up is another online classic, Moliere’s Tartuffe in which I am essaying Orgon. 

We may be all in some form of quarantine/separation these days and gathering together in a playhouse is going to be one of the last things to come back from coronavirus restrictions, but theater people are going to theater one way or another.  One bright spot for me as been being asked to be part of projects originating with my dear friend Frank Thompson and his merry crew in Columbia South Carolina and getting to work with them on a piece after having known them casually through social media and the occasional theater party for many years now. Online theater does allow you to pull together a cast from all over and the technical requirements are minimal – a laptop with a camera, a Zoom hookup and a green screen for a virtual background and there you are.  I am considering driving back and forth to Seattle for my November vacation and, if I do, I will likely be hanging green Party City plastic and emoting Moliere in a selection of the country’s finest Hampton Inns.  I’ll just need to remember to pack some electric work lights as the lighting in most hotel rooms is suboptimal for filming.

One of the reasons I’m thinking about driving, other than giving myself some very long stretches to let my brain decompress and think about plenty of nothing while making my way across Kansas or Wyoming, is to get a sense of how the country is really reacting to Covid-19.  Most of the reporting on community issues is tainted by a certain amount of political agenda. Given a crisis where we should all be pulling together, politicians and the media have banded together to do their darndest to push us into one of two camps – the red and the blue for want of a better shorthand.  One group for political advantage and the other group for ratings and the money those translate into over time. One wonders what would have happened if, after Pearl Harbor and FDR’s call for entry into World War II, half of the population had enlisted and gone to work manufacturing armaments while the other half had paraded in the streets waving Nazi and Rising Sun flags and calling those that were preparing for war all sorts of unpleasant epithets and the press had covered it all with both sidesism and egged domestic disturbance on.  The ultimate outcome of the conflict might have been just a little bit different.

Now that we have more or less managed to create two very different approaches and attitudes towards a single universal problem, what do we do?  The red side’s denial of the seriousness of the problem angers me personally as I watch more and more of my patient population fall ill and hear of more and more young healthy people who have succumbed.  To me, those are lives wasted, not acceptable collateral damage.  Rates per unit population are surging in less populated conservative states but, as their populations are low, absolute numbers are low so there is a feeling in these communities that Covid-19 isn’t a problem other than for certain at-risk classes of individuals.  The trouble is that somewhere between 25 and 40% of the population falls into those at-risk classes and it is not possible to isolate those individuals.  Take the elderly.  Only about 10% of older Americans live in some sort of congregate facility.  The vast majority are in the community trying to live their lives day to day just as the rest of us are.  Even those in congregate living cannot be completely isolates.  Staff, caregivers, delivery people, and all the rest that keep a housing facility running cannot be isolated with them.  They are going to come and go in the community and many of them will return home to school age children who seem to be among the primary vectors.

Urban blue populations have adapted relatively well to new ways of living.  Most city dwellers mask up, gauge six or so feet appropriately, don’t crowd into small spaces, and have figured out how to protect themselves and their families through a thousand and one little changes and risk stratifications. They look down on red populations and their unwillingness to adapt with scorn.  The trouble is scorn and shame aren’t going to make anyone do things any differently.  People respond very negatively to it and a huge piece of our current divide comes from forty years or so of urban populations in service and tech economies looking down on rural populations in resource utilization economies.  Something I learned very early on when working with the mine workers programs in Appalachia that I medical directed for many years was that if I, a doctor at a medical school in an urban center, were to call a doctor in a rural community to suggest a different treatment plan for a patient, I would be frozen out and unheeded.  No one likes an outsider butting in and telling them how to do their job.  The strategy we hit on was to make sure we hired nurses of and from these small rural Appalachian communities and I would teach them modern approaches to geriatric medicine and how to think through problems.  These nurses could then go to the local doctors, their friends and neighbors for decades and present things and would be listened to as they were of that world. 

We need something similar at the moment to bring red and blue American together in better public health planning.  I don’t think it can happen under the current administration which has basically withdrawn the federal public health system including the CDC and the FDA from the battlefield but, if there is a change in administration, there can be strategies adopted that then flow to the states and then counties.  If untrusting populations see trustworthy information coming from local sources, they may begin to change their behaviors and we may start to make some inroads on bringing things under better control.  If we don’t, I feel we’re going to be in for a very long time of it with deaths approaching, if not over 7 figures.

In the meantime, do what you can do:  Wash your hands, wear your mask, stay out of crowds as much as possible.  It’s not that difficult.

Hurricane Delta is busy churning somewhere to the west of us as it takes leisurely course inland. It’s expected to stay well west and north of the Birmingham area so we shouldn’t have any major issues around here. The outer bands have been passing over all day causing intermittent rain showers with rainbows in between but we haven’t had much in the way of wind. It’s a good weekend to stay sequestered in the condo and work on various projects that are coming due. A couple of distanced theatrical things, a taped story for UAB’s Arts in Medicine program, several legal cases that need reviewing, and the slow methodical clean out of various bins and files as I keep working on life simplification.

Of course, a weekend alone and cooped up does nothing for my existential angst about the rising tide of insanity in the world outside. I speculated some on the president’s medical condition with my last entry in these accidental plague diaries. Nothing I have seen these last few days has suggested to me that his health has improved markedly. There was some sort of rally at the White House today. I did not tune in but someone in the campaign decided to give all the attendees periwinkle blue T-shirts to go with their red MAGA hats. With that color scheme, the few pictures I saw made the south lawn of the White House look like it had been suddenly taken over by a group of fractious garden gnomes. One wonders who is in charge of such things and whether they think before they order or if they’re just trying to enrich a certain vendor. The president’s appearance and remarks were about fifteen minutes in length. As he usually spends several hours extemporizing at his rallies, I assume his stamina is way below what it normally is as the adulation he receives at such affairs appears to be his oxygen. I doubt he’s out of the woods yet and I don’t see him being able to stand up to the rigors of campaigning during the home stretch.

There’s an interesting set of moral questions regarding his treatment with the monoclonal antibodies manufactured by Regeneron, a company in which he appears to hold financial interest if various media outlets can be believed. First, the treatment is not FDA approved so there is no good science that it works. Second, the antibodies are developed from lines of fetal stem cells. (The pro-life movement would say they come from aborted babies and has successfully campaigned republican administrations, including the current one, to halt any science using such tissues – actually, they are usually obtained from embryos made during an in vitro fertilization process and which would be discarded as no longer needed after a successful pregnancy). Third, the cost for such a drug would be likely to run to six figures and, as it is not approved, would not be covered by even the most generous insurance plans. The claims that anyone can and will get the drug for Covid-19 are, excuse my French, horse shit.

So what happens next with monoclonal antibodies? Does the FDA fast track them for approval, possibly undercutting long established safeguards for a political win for the party in power? Does a Republican administration embrace a drug that owes its existence to a line of scientific research that is anathema to its evangelical base? Do they open up additional public coffers to pay for the treatment when much of that money will go into private hands tied to the president? I can’t answer these. All I can do is stay home alone with my cats and my projects as I am not stupid enough to attend mass gatherings at the White House which seem to turn themselves into super spreader events.

Covid-19 is going to have some very peculiar effects on this election cycle. It remains to be seen who will choose to vote early, who will choose to vote in person, or who will be forced into voting through a means not of their choice due to various voter suppression tactics such as limiting all counties to a single drop off box, be they population of 1500 or 1.5 million. Anyone who says they know what the outcome of November 3rd is going to be is deluding themselves. The dozen weeks between the election and the inauguration will also be anybody’s guess. There are so many unknowns regarding the behavior of the population under these stresses and so many knowns such as unstable personalities and large quantities of money wanting certain outcomes that it’s likely to be a very wild ride. One thing I’m fairly certain of is that the president has lost the loyalty of the Secret Service to his person rather than his office. I think the ride in the hermetically sealed limo which endangered them did that. Various Caesars found out that alienating the Praetorian Guard during times of political instability was an unwise choice.

There is an old curse that goes ‘May you live in interesting times’. I’ve had enough of interesting, thank you. I’d rather have some boring ones instead. At least boring enough for me to plan an interesting trip and an interesting show or two. In the meantime. Work – home – work – home – lather rinse repeat.

May you all stay well and remember:
Wash your hands
Wear your mask
Stay out of crowds

Like everyone else I know with formal medical training, I have been watching the events unfolding in Washington DC over the last few days with increasing puzzlement. Absolutely nothing that’s happening makes any sense from either a personal or a public health perspective. There are those that claim that the president’s recent diagnosis with Covid-19 was some sort of elaborate ruse but that seems exceedingly unlikely with the thick and fast news of multiple collateral diagnoses within the executive orbit. Then there was the very real evidence from yesterday. I have more than thirty years experience at sizing up aging adults and determining whether they are sick or not in the first thirty seconds of walking into the room and beginning to converse with them. It’s dozens of little cues from behavior to body posture to the look in their eyes that allow you to either tense up and prepare to send them immediately to the emergency department or relax and let them tell their story while you leisurely ponder differential diagnoses in your head. The man I saw walk up the stairs to the South Portico of the White House yesterday evening was sick.

His walking into the White House, a crowded workplace, with full blown Covid-19 while blithely removing his mask told me everything I need to know about the situation. I don’t think this there’s any sort of sinister cabal going on. I think we’re in full blown the inmates are running the asylum mode as anyone with either the knowledge or ability to deal appropriately with highly communicable infectious disease has either been purged or silenced. The virus will therefore continue to keep leaping around the executive branch and I expect the vast majority of those with easy access to the White House will likely be positive by the end of the week. Will any of them die? That remains to be seen. Likely not many but some are likely to become incredibly ill and others are likely to have permanent health complications.

There’s been a lot of posting about karma and schadenfreude (a word most American’s had to look up) over the last couple of days. As much as I detest the politics and policies coming out of this administration, it is made up of human beings and one thing that my religious tradition of Unitarian Universalism teaching me is that every human life has dignity and worth so I cannot wish ill on any of them. I can only say that when you go swimming in a lagoon posted ‘Danger: No swimming. Alligators’ don’t be surprised if you come back to shore missing a limb. Actions have consequences and people who take certain imbecilic actions better be prepared to live with the consequences of those actions.

Will the president recover uneventfully? Will he get worse? Will he be well enough for his next scheduled debate appearance? I can’t answer these questions. All I can say is that by all objective evidence available to me he’s sick, possibly seriously ill, and the puffery coming out of his medical team makes no sense from either a diagnostic or a treatment perspective so there’s really no way for me to have any sort of informed opinion. Things will happen as they will; hang on – the wild rollercoaster of the last few days isn’t likely to slow down for a while. In the meantime, there will be more and more blather of the uninformed, opining on the unintended consequences of the actions of the uncaring. It’s all making me a bit tired so I have gone to bed relatively early.

All I can say is that at this juncture in history, I’m glad I live in a smaller city with a relatively informed population with a high percentage of folk employed in health services. In Birmingham proper, most people are pretty good at social distancing, wearing their masks and not doing anything too crazy. This has kept our caseload relatively constant and allowed the local hospitals not to get too overloaded. I do my part and have given up much that I love for the greater good. Watching those to whom much has been given in terms of money and power blithely wander through life as if those were any sort of protections against the way the world actually works makes me a bit sick. As I have said, actions have consequences. I just hope that my positive actions in favor of protecting people I don’t know lead ultimately to positive consequences in my life. I’m a past master at delayed gratification. I can wait a while longer to find out.

I’m trying to process the events of the last 24 hours or so. In my ongoing saga of chronicling my peculiar take on the effect of Covid-19 on my life and American society, we may have reached an inflection point. I can’t say that I am the least bit surprised that the President has caught the virus. His very public behaviors over the last six months more or less made that inevitable but I’m a bit surprised at the rapidity of change from he’s fine, to he has significant symptoms, to he’s being airlifted to Walter Reed. None of us has reliable data on his health and speculation, while intriguing, is not especially useful. I’ve compared the White House’s response to the novel corona virus to Poe’s The Masque of the Red Death a number of times over the period that I’ve been writing these accidental plague diaries. I have a feeling that midnight has struck and that Prince Prospero and his guests are going to pay the price of believing that wealth and privilege somehow insulate one from science and fact. You can believe in virology and epidemiology or, you can pooh-pooh them for political reasons, but that doesn’t make the science any less true. Viruses have no political allegiance. They simply exist to propagate themselves from one host to the next.

There are those who are descending down the black holes of various conspiracy theories regarding Covid-19, now that it has reached the highest offices in the land. It’s a little silly. The current group of politicians in power in DC haven’t been able to run the government with all of the tools at their disposal. Imagining them running some sort of shadowy network of interconnected outrageous plots out of a Ian Fleming or Robert Ludlam defies belief. Anyone who has ever been a corporate project manager can tell you that human beings in groups just aren’t capable of such Byzantine and opaque maneuverings without the whole thing crashing down because someone wanted to binge watch the latest season of Schitt’s Creek rather than do their portion of the assignment.

The Ancient Greeks would have loved the current situation in the capital. President Trump very much fits their mold of the leader who rises too high, too fast in mockery of the gods and it ultimately undone by his own nature and character flaws. The rapid fire revelations about his tax and financial status, the economic collapse of his campaign, and now the illness, likely linked to the stubborn refusal of him and his followers to obey even the simplest precepts of public health measures to prevent viral transmission. We don’t know what the next act of the drama is going to play like. I know what I would write if I were creating a drama of hubris, but it’s not up to me.

I’ve tried to leave politics out of these diaries for the most part. When it comes to Covid-19, politics is immaterial as the virus is completely apolitical and I feel very strongly that what I’ve been able to learn about the disease and how it affects our lives is a subject that should be of interest to the entire spectrum of opinions. It sneaks in occasionally because the US response to the virus has been allowed to become politicized at nearly every step of the process of pandemic response. We are the weaker for it, hundreds of thousands are dead and, within a month or so, it will move from the fourth worst mass casualty event in American history to the third, surpassing World War II. (If it kills more than 600,000 eventually, it will surpass the Civil War, leaving it only behind the Flu Pandemic of 1918.) Would the impact have been lessened with a less political response? It’s tough to say but we probably wouldn’t be having a mask war in society and adherence to things like masking and social distancing would probably be much greater and our casualty rates would likely be more in line with those in Western Europe.

I hope I live long enough to be able to read the definitive history of the Trump presidency that some Barbara Tuchman of the future will write sometime after 2030, when enough time will have passed for us all to be able to get some perspective on what we are living through. I also have the feeling that this particular moment in history is going to inspire some great artistic works. Trump, himself, is too big a character for traditional film or stage. He is an operatic figure and I think only a grand opera in the Verdi tradition can totally explore his psychology and motivations. (Ricky Ian Gordon – here’s your potential masterwork…) The Black Death gave us the Italian Renaissance. What is Covid-19 going to give us?I too will be checking my news feeds in the morning for the next chapter.

In the meantime, you all know the drill.

Wash your hands.

Wear your masks.

Keep six feet apart.

And it’s another evening of feeling a bit like Neville, my favorite Gashlycrumb Tiny with whom I have always identified. I should be celebrating as the sale of the old house closed yesterday but there’s not a lot of joy in life and society and I really don’t have anyone much to rejoice with once I leave work these days. I did get to meet the new owners of 4334 Clairmont Avenue South at the closing yesterday morning. (I knew who they were through some mutual friends but had not yet had the pleasure of meeting them). They seem sympatico with what Tommy and my ideas for the house were had life turned out differently and we had stayed there for a few decades as originally planned. Their plan for the much needed kitchen remodel was pretty much exactly what we had intended so I feel the house is in good hands and I wish them much joy in the years to come.

Not much exciting going on in my new abode other than a few lessons learned in regards to the production of Zoom theater. The Kelly Green plastic tablecloths from Party City ($1.49 apiece or a roll of 100 feet for $10) make an acceptable green screen for inserting virtual backgrounds, but if you cut them too long and they hand too low, your cats will love batting at them and trying to pull them down at inopportune moments. Those projects are taking up a little time and creative energy but I still have more hours to fill so I bought myself the unlimited access Rosetta Stone language plan and am going back over all the basic languages I have learned over the years for some additional ear training and grammar. I’ve started with French, which I learned as a child and is still fairly intact when I need it but I have to use it routinely to have it come with any fluency.

Where are we with the accidental plague diaries? One million dead world wide, 200,000 dead in the USA and a significant portion of the population still refusing the most basic public health precautions through some sort of misguided political allegiance that I just don’t understand. I did not watch the presidential debate last night. I prefer not to torture myself after hours. From the continuous comments on my Facebook feed, it seems it turned out pretty much as expected and the inability of the federal government to handle a crisis in any sort of measured or logical way was on full display.

I haven’t come up with a new or interesting angle on Covid-19 to write about this evening. That’s been the thing I’ve been most worried about since I started writing these missives more than six months ago. How can I make this one subject fresh and impart fresh insights without getting awfully repetitive. I think I generally do a good job but there are times, like this evening, when the pandemic has dropped to a dull roar out there in the world and I can’t think of much of anything to say about it without going down a path I’ve trod before. New things are published routinely and there are constantly shifting battles and skirmishes between the population and the microbe so that’s unlikely to last. The thing I’m looking for is what’s going to happen later this fall in response to the outbreaks traceable to college and university reopenings? For the most part, the students won’t be overly effected but what’s going to happen to the populations of college towns and institutions in close proximity to colleges such as hospitals and elder care centers? There’s a well recognized pattern. Population behavior changes. Case numbers reflect that change three or four weeks later. Mortality statistics reflect that change another month or so after that. We’re about a month in to fall quarter. Cases are rising in places like Utah driven by University exposures. What happens a month from now? What happens when flu starts circulating? I am keeping my fingers crossed on flu season. As a goodly percentage of the population are being careful about viral exposure, this will interrupt seasonal flu transmission as well as Covid-19 and hopefully keep the flu season on the lighter end.

I haven’t told a story for a while so I’ll end up this evening with one. This one goes back to the summer I was 22. I had graduated from Stanford and was to start medical school in the fall. As a graduation present, my parents gave me a plane ticket to Europe, a second class Eurail pass, a knapsack and some traveler’s checks (remember those?) and told me to go have fun. I had never been off the continent before and was uncertain when I would be again so I was determined to see as much as I could squeeze into my eight weeks as I could. (Fourteen countries by the time I arrived back in the US, exhausted and fifteen pounds lighter from all the walking and cheap eats). About a third of the way through my jaunt, I had taken the train from Paris to the French Riviera and then, after a day or two, onwards into Italy. One Sunday in July, after touring Rome for most of the previous few days, I realized I had a relatively free day as I still had not made it to the Vatican museums and they were not open on Sundays so I decided to take the train down to Naples and visit Pompeii. I caught the first train of the morning. Five minutes after we were to depart, there was an unintelligible Italian address over the PA. Much groaning and everyone detrained and headed over to the second train of the morning and reseated themselves. (I hadn’t a clue what had been said but I could follow the crowd.) Forty minutes later, the same thing happened and the swelling number of irate Naples bound passengers detrained again to board the third train of the morning. This one actually departed and off we went around the bay.

I arrived in Naples later than I had anticipated, toured the museum and then boarded the local train that headed to Pompeii. I made a mistake with this train and ended up getting off one stop too early. (Apparently the stop labeled Pompeii was not the stop for the ruins) and I headed down the road thinking I was in one place when I was, in fact, in quite another. When I realized my mistake, I thought, oh well, and, having taken orienteering in Boy Scouts, that I should be able to get where I needed to go by wandering down the country lanes as long as I kept Vesuvius on my left. Off I went and after about half a mile, passed an Italian farm house where a huge extended Italian family were having Sunday dinner in the courtyard. They leapt up excitedly at the strange young tall blond and obviously lost young man wandering past their compound and soon, I was being dragged in and invited to share the meal. They spoke not a word of English and I not a word of Italian past Prego but we finally found some common ground in French and were able to roughly communicate for an hour while I was offered several sorts of pasta and what I think was veal. I thanked them for their hospitality and departed with one of the sons who looked to be about fifteen who escorted me to the right road towards the entrance to the ruins.

I had a lovely (if somewhat warm) afternoon wandering through Pompeii, and as the sun was going down, headed off to the correct train station to take the train back to Naples. When I arrived in Naples, I was hungry again so I found a little seafood restaurant right on the harbor where they were frying up the catch of the day so I ordered the special (which contained mussels, octopi, seahorses, a couple of kinds of fish and who knows what else) and a bottle of the house wine. It was lovely watching the sun set into the Mediterranean and I kept eating and drinking and then I suddenly realized I had finished off the entire bottle of wine by myself and it was starting to hit. I stumbled to the train station to get a seat on the overnight back to Rome, found myself with a few hours to kill before boarding, and promptly lay down on the floor of the train station and sort of passed out until I was roused by a not overly friendly carabinieri. I was able to get to my feet, produce my ticket to the train, and stumble in the right general direction so I managed to avoid a trip to the drunk tank, get on the train, and more or less pass out again until it pulled up to the station in Rome. By that time I had sobered up, taken a couple of aspirin, had a cup of coffee and headed off to see the Vatican thoroughly hung over. I quite enjoyed the Vatican other than the Sistine chapel. Every time I tilted my head back to look at the ceiling, it would make the headache worse. The moral of the story. Don’t visit buildings with famous painted ceilings when you’re hung over.

Today, I was either a slug or a sloth or perhaps some sort of hybrid. It took me something over three hours after waking up to actually get out of bed and I’ve had two additional cat naps so far and I may be heading for a third. I think my lizard brain has permanently switched from hypervigilance in the face of danger to a state of chronic play dead and conserve energy for further perils to come. I sometimes really do feel like I’m slowly being ground to fine powder between the Scylla of Covid-19 and the Charybdis of Social Isolation and have to remind myself that no matter how horrible things seem to be, I have a roof over my head, food in the pantry, a job that continues to pay me, and a large supportive circle of friends who remain part of my life even if we can’t be together in the usual ways.

I started these posts two and a half years ago in the face of personal tragedy as a way to help myself puzzle out thoughts and feelings and reinvent myself for a new phase of life. I assumed they wouldn’t be of much interest to anyone but I quickly got a response and a loyal readership, especially to my anecdotes about some of the odd things that have happened throughout the course of my life. I started to write those as it was dawning on me that I had aged into being an elder in the traditional sense. The elders are those with the life experience to understand the human condition and to translate it into forms palatable for consumption, originally around the campfire, and then later on in poetry, prose and song that could transfer collective wisdom generation to generation. They are the story tellers. My stories, without Tommy in my life, no longer had a home and were going to die with me if I didn’t start telling them in some form and this seemed as good a way as any to send them out into the world.

I assumed that these posts would revolve around the areas of my life in which new stories might arise… theatrical endeavors, travel, encounters with new and interesting people. But six months ago, all that changed as the whole world shifted and I started to write more and more about Covid-19 and its effects on the health care system, my personal life, and the world at large. And thus, the Accidental Plague Diaries were born. It just happened. I didn’t set out to do it. When I first started my Covid-19 posts, I assumed that the institutions that have saved us from serious trouble with infectious disease in the past would swing into action and that the whole thing would likely be over in six months or so, at least in terms of writing. Now, I can clearly see my own naivete. There is no clear end in sight at this point – and my posts on the subject are now at book length.

Everywhere I go, when I see people whom I haven’t seen for a while, they bring up my writing and how it has helped them make sense of a non-sensical world and how they are grateful for the combination of trying to stick to fact and trying to navigate a centrist position through the hysterical hyperbole that informs reporting on the subject on both sides of the political spectrum. I don’t know what to say. I’m immensely gratified that people like these essays but I hope they realize that I am as lost and confused in modern life as they are and that sitting down a couple of times a week to let my fingers dance over the keyboard is more about educating myself than other people. If I can find the words for difficult concepts that others can understand, then I know I’ve gotten things straight in my mind. And if I can get it together in my head, then I can pull it together to make it through the next day, the next week, the next month…

We’re now at seven million cases of Covid-19 in the US. We were at six million only three and a half weeks ago so we are in no way getting the pandemic under control. It’s now the third highest cause of death in the country (superseded only by cancer and heart disease). The long term effects on those who recover remain completely unknown. There are tantalizing glimpses of why it is so serious in some people and essentially asymptomatic in others. If those could be figured out, we might be able to figure out protections for the more susceptible and let the unsusceptible get on with life but we’re a long way from clear understanding. Life is beginning to return to pre-Covid norms in other parts of the world (but reporting in US media is spotty as it becomes more and more concerned with election politics) but those areas have robust public health programs not undermined by politics with authority to implement tried and true public health measures.

There’s a piece of me that wonders if part of the predicament we find ourselves in comes from the Boom generation’s refusal to accept elderhood. I’ve written before about how Boomers refuse to consider themselves as old, even though the leading edge is now in their 70s. I use the Cher scale at work. Cher was born in 1946, the first year of the Boom. I have my med students rate patient age based on Cher – Cher + 3 years, Cher – 2 years to help them understand just what a demographic watershed that year has proved to be. Part of the reason that the Boom has always felt young is that the generation above them, the Silent Generation, has smashed all actuarial tables in terms of living long healthy lives. Many of the cohort now in their 80s and early 90s remain with us and in quite good shape. The Boom, having always had stable elders to look up to, thinks of themselves as young in part because of that generation who have always been old to them. (Old is always fifteen years older than you are).

There is a lot of speculation as to why the Silent Generation have lived such a long, healthy life. The one that I think is the truth is known as the semi-starved rat hypothesis. This is a phenomenon first noted in rats, but replicated over time in many other species including primates. If you take the young of a species and calorie restrict them, it extends their life span. The Silent Generation was young during the Depression/World War II years. They didn’t starve but weren’t able to glut either. The long lived Silent Generation have helped keep the Boom from embracing their own aging and mortality and, as the Boom have been the political and economic power generation of the last thirty years, they haven’t developed a generational empathy for aging. What does this have to do with Covid-19? If the Boom can’t be old, then they can’t be in danger from things that happen to old people and therefore those things need not be worried about and policies that might help older people aren’t as important. This is being played out in very real threats to the ACA and Medicare which a shift in the makeup of the Supreme Court is not likely to help.

That’s enough for this evening. Going to go back to working on transforming my dining room into a movie studio for Zoom theater projects and have some left over Chicken Korma.

It’s one of those evenings when I’m in a French existentialist mood. Everything’s terrible and nothing I can do or say can make it any better. Time to break out a beret, a black T-shirt, and an unfiltered Gauloise and yammer on about the futility of modern living. But that sort of thing generally doesn’t last with me. I have a deep seated optimism by nature that no matter how bad things seem to get, human beings eventually get their act together and start responding to their better selves. The question just becomes how low can we go before that kicks in or whether it will kick in quickly enough to save us from our worst impulses. I don’t know the answer to these things. I may have to take a sabbatical from my usual diet of political news for sanity’s sake. I don’t watch any of it on television, I’m not that much of a masochist, but I do read relatively extensively on politics, especially as it intersects with health policy so that I have some clue as to how to begin positioning the little corners of health care for which I have some responsibility to weather the storms of administrative and financial craziness that have become all to frequent recently.

I’m not sure what’s put me in such a dreary mood. Nothing too horrible has happened at work. In fact most things are ticking along. There have been some hiccups with expanding the VA house call program into the Huntsville area but nothing that can’t be overcome with some training and attention to staff. UAB is functioning relatively normally in the outpatient arena. Perhaps it’s a side effect of my annual flu shot which I received earlier today. They generally don’t bother me but one never really knows how the central nervous system is affected by the state of one’s physical health. You are living inside of it and are usually the last one to notice anything different. One of the problems with being alone after so many years of coupledom is there’s no one who can look at me at home and tell me when I’m a bit off and my personal barometer may just not be the most accurate. I’m hoping a cocktail, some left over chicken masaman, and some reading of Sondheim studies before a decent night’s sleep will take care of the issue.

We officially passed 200,000 Covid-19 deaths in the USA today. That could easily double again in the next few months. If only those who led our country would approach matters of public health with the speed and gusto they are approaching the prospect of filling a vacant Supreme Court seat. SCOTUS will still be there after the first of the year. Another 100,000 Americans or so may not be. It’s become painfully clear that the powers that be consider all of us not of their class expendable. Couple this with economic imbalance of the type that led to the French Revolution and I fear sometimes we may really all be dancing on the edge of the abyss. And then I decide, no, it’s not that bad and start trying to figure out when I can next go to Seattle to see my family.

The Politically Incorrect Cabaret is talking about doing some on-line content, perhaps some things from the archives edited together with some new stuff. On line theater techniques would allow us to pull in some members who have since moved away. The Ansager would be happy to come out and play. I don’t mind monologuing it but one thing I have discovered is that I cannot sing or learn music well in isolation. Too much of my ability to learn music comes from being surrounded by sound of either accompanist or other singers and without all those subtle cues, I get lost in terms of either rhythm or pitch (often both) and the resulting product is terrible. I also am terribly self conscious when I sing solo. I can do it in character when it’s not me but I have a dreadful time when it’s Andy up there exposed. It’s why I hate recital singing and won’t sing for church outside of choral work. Give me a character and a situation in a theatrical piece where I can work it out in my head as to just why I’m singing and I can do it no problem (except when the part was written for lyric baritone and I have to cheat as a bass-baritone who has gotten lower with age for all those above the staff notes).

People have asked why we haven’t done more Politically Incorrect Cabarets during the Trump era. It’s because out current political moment is nigh on impossible to satirize. No matter what I could possibly dream up, reality will top it next week. Think of all the things that would have been unthinkable five years ago that have become normalized in terms of political ideology and discourse. Politically Incorrect was born, in part, out of a theatrical moment in March of 2003. At that time, as the drums of war were leading up to the invasion of Iraq, performing artists around the world decided to make an antiwar statement and on 3/3/03, theater companies around the world did performances of Aristophanes’ Lysistrata as a message. Some were readings, some semi-staged, some fully staged. I was part of the Birmingham production put on by the Birmingham Peace Project and it was my first appearance as an actor on a Birmingham stage outside of a church show. There is some thought that maybe Birmingham needs a Zoom version of Lysistrata as a reminder. I was the narrator that held that original production together. Tommy was one of the soldiers and I still remember him coming up the aisle with his balloon phallus fully inflated. Fortunately or unfortunately, I don’t think any pictures recorded that particular moment.

I think the thing I’m the most scared of at the moment is the opacity of information regarding Covid-19. The combination of lack of interest from the federal government with the strict control of information that flows from federal sources such as the CDC and the FDA (which is the prerogative of the executive branch – they are all executive agencies) makes it difficult to know where to turn for well sourced science regarding spread, responses, impact of morbidity over time and the like. When the CDC recommendations flop back and forth in a rather ham fisted way, one can only surmise that non-scientists are calling the shots for political expediency. If the political system tries to hide the true extent of the virus and what it’s doing to the population, we’re going to have a world of hurt. I am not a conspiracy theorist. Anyone who has ever been a project manager knows that you can’t keep a dozen people on task and not talking about what they’re working on. You can’t have nefarious complicated cabals of tens of thousands without somebody somewhere accidentally spilling the beans. For this reason alone, truth will always eventually out and if the public ever decides that their loved ones died because the government decided they were expendable or acceptable collateral damage, there’s going to be hell to pay.

Usually, by the time I finish one of these and I’ve been in a funky mood, I’ve straightened my head out a bit. Not so much this evening. Anastasia kitty has decided to snuggle so I’ll finish this up and go back to my reading for a bit followed by my Schitt’s Creek binge watch marathon.

You know the litany:

Stay in when you can.

Wear your mask.

Wash your hands.

It’s that simple.

The Notorious RBG is gone. It’s not often that elderly women become pop culture icons, but once in a while, one breaks through and is embraced by all ages as a symbol of the strength and wisdom of the elder. Or maybe it’s a testament to the very human need to believe in endurance, no matter what life throws at each of us and those few work and live their full best lives into their eighties and beyond, come to embody that hope for continued relevance as time continues to march on and on and on. It’s been marching across my face recently. I looked in the mirror this morning when I got up and was not happy with the cross of Christopher Walken’s Headless Horseman and Christopher Lloyd’s Doc Brown that looked back at me.

One of the curses of being a well trained geriatrician is hearing news about the health of aging public figures and being able to draw far more conclusions about life span than most. I’ve got a good deal more data to work with than the average American. I wasn’t in the least surprised by RBG’s death. I had hoped she would hang on a while longer but frankly, I was surprised she made it as long as she did given what I was able to glean from news reports about her overall health. As much as I admired her and her jurisprudence over many years, I was never able to cast her in my mind as this tiny, but towering figure holding dark forces at bay and I doubt she ever conceived of herself that way either. She used her keen mind and her wit and her knowledge to make the law serve as many people as possible, rather than serve the few and bludgeon the many, and she was well aware that some of her opinions were going to be in the minority. She never fussed, she never went to the media trying to rally the court of public opinion. She simply dissented with vigor and well honed argument knowing full well that her dissents and their legal reasoning might help form the basis of a win sometime in the future.

The biggest problem with the American political system at the moment is the American preoccupation with instant gratification. We want results and we want them now. The system wasn’t built that way and by, trying to force it into that mold, it’s been made into a constant two party slugfest with one side constantly trying to score a TKO and proclaim victory. There’s lots of things that have gone into this devolution. The rise of 24 hour news and news cycles, consolidation of media outlets, politicians playing to the camera rather than to the public, the expense of campaigning requiring constant fundraising etc. etc. RBG knew this all to well and avoided it. Her best friend on and off the court for years was Justice Scalia. Despite their diametrically opposed judicial philosophies, they bonded over their love of the arts, especially opera. The two of them may have lived in different idealogical worlds but they inhabited the same cultural sphere as Americans and it strikes me that we need to start doing more of that as a people, get out of our confirmatory bias echo chambers and spend more time together in common space. Of course that’s been made a tad more difficult due to our old friend Covid-19.

And here’s where I cleverly segue to tonight’s accidental plague diary. which is about an event scheduled for November 10th. On that day, the Trump administration will argue California v Texas in front of the Supreme Court. For those of you who have forgotten, this is a case brought by a number of conservative states claiming that the Affordable Care Act is fundamentally flawed from a constitutional point of view and that the entire law must be declared unconstitutional and therefore, null and void. It is highly unlikely that RBG’s seat will be filled in seven weeks no matter what happens, so only eight justices will hear the arguments with a decision likely rendered in the late spring before the court retires for the summer.

What happens if the ACA is found unconstitutional? The most important thing in regards to Covid-19 is the provision about pre-existing conditions. Since the ACA was passed in 2010, it has been illegal for health insurance to discriminate against you based on your past health history. If this goes away again, then pretty much anyone who was infected with Covid-19 will become uninsureable. No insurance underwriter in their right mind is going to allow someone to purchase their product who has been infected by a disease that causes significant changes to nearly every organ system and for which the possible long term sequelae are essentially unknown. That’s roughly 7 million people so far and growing rapidly. And given that the attempts to limit its spread on any sort of a national level are sorely lacking, we may get to that mythical herd immunity at some point, but only after the numbers of those infected are in the tens of millions.

How do we change things for the better? We do this by using the system the way it was designed to work. It’s a slow, laborious process which requires a lot of labor, patience, and willingness to accept defeat, learn from it and move on. We have to let go of the idea that a single election or a single figure is going to either save or condemn us. We have to be willing to understand and play the long game. As Tip O’Neill famously said, all politics is local. If you want to see change, join the local chapter of your preferred political party. Volunteer to be a precinct chair. Be willing to do a lot of thankless work in terms of door knocking, get out the vote campaigns, learning to compromise while crafting platform positions. When you lose an election, take a day off to mourn, then start working on the next one. That’s how it works. The national parties bubble up from the grassroots. The work that has come to fruition in conservative circles over the last decade is the result of this kind of work starting in the early 1970s. It took them nearly fifty years to get where they wanted. If you want something different in the future, go to work now. Of course, you can always tear the entire system down in some sort of revolutionary action but movements like that are often either hijacked or take on a life of their own and you end up somewhere very different from where you intended so I can’t say I recommend that course of action.

Quiet weekend here at the condo. Me and the kitties reading, writing, and watching bad television. I feel a need to burst out of here next weekend. Maybe I will. If I do, you’ll hear about it.

It’s hurricane season again. Sally (not to be confused with my sister-in-law) has been busy battering the Alabama coast line and is slowly making its way northeast into Georgia and points beyond. Here in Birmingham, about 200 miles from the coast, we only got a few of the outer bands which brought lovely cool temperatures, some wind and a smattering of rain. Nothing to cause any difficulties here. Friends on the gulf coast have been checking in and everyone seems OK but there’s been a lot of flooding and wind damage in the beach towns. My guest suite is currently unoccupied if someone needs respite for a few days. There are four more storms lined up out in the Atlantic so we may get something worse in the days to come. Fires in the west, flooding in the south, pestilence everywhere. Just another week in the life of 2020.

Jefferson County, home to Birmingham and the most populous in Alabama, has generally posted somewhere between 70-130 new cases of Covid-19 daily over the last month or so. Yesterday, they posted over 1,000 new cases. The number is so out of line with where things have been that I assume it’s a data anomaly due to a data dump or an adjustment in the statistics. Either that or we’re seeing the result of people getting a little too friendly with each other at their Labor Day picnics and barbeques a few weeks ago. Time will tell. The numbers at UAB hospital have remained relatively steady. Far more than we would like, but low enough for the system to handle without buckling.
The medical residents are back on their usual rotations and I have had a flock of new interns rotating through my UAB Geriatrics Clinic over the course of the last month or so. Residency is hard enough and I can’t begin to imagine what it must be like with the added stresses of duty on Covid-19 wards and the shut down of a lot of the ways that young people like and need to blow off steam after grueling weeks. Our rotation is pretty easy for them compared to others that they have to do and we try to give them a chance to explore some of the more interesting things that geriatrics has to offer in the hopes that it might rub off a little and one of them might be willing to make it a career choice. We occasionally succeed but we need a lot more of them to look our way. We are really down on clinical faculty and it’s very difficult to find new ones and entice them to Birmingham. One of my best tools has been taking them out on my rural house calls with the VA, but those remain in abeyance due to Covid-19 risks. Hopefully I’ll be out in the field again after the first of the year. Telemedicine is useful but it doesn’t give you the real picture of what’s going on.

I’m getting a little tired of video evidence of ‘anti-maskers’ or ‘mask deniers’ or whatever they’re calling themselves these days. It’s a piece of cloth on your face, you wear coverings on most of the rest of your body without incident. It’s not chain mail or barbed wire but the amount of carrying on that seems to go on with some people for political reasons strikes me as being completely out of proportion with what is being asked. Perhaps if people would stop posting video of ordinary people behaving badly in Target or Wal-Mart, there would be less self aggrandizement and less monkey see, monkey do. Do me a favor and don’t send me a copy of the latest ignoramus in high dudgeon over being asked by society to do something relatively simple to help other people and society as a whole.
I was reading Andy Slavitt’s notes the other day. (If you haven’t heard of him, he was the head of the Center for Medicare and Medicaid Services under Obama and he’s a fierce defender of science in public health). He’s become a significant critic of the Trump administration’s response to Covid-19 and does a routine deep dive into the science which he puts out on Twitter and on his podcast. He did some modelling based on what is known about the Ro (infectiousness of the virus in a naive population) and Re (infectiousness of the virus in a population taking steps to control the pandemic) and came up with a rather startling figure. Every 1% of the US population that refuses to mask will result in an extra 10,000 deaths from Covid-19 over the next year. So, if 30% are anti-maskers, there will be an additional 300,000 deaths in this country that doing something as simple as universal masking when out and about would have prevented. I highly recommend following him and reading his notes. They are literate, easily understood by the lay public, and point out the real issues. He also is incredibly experienced in how public health and governance work together.

There is an old saying that the one who saves one life, saves the world entire. Encouraging an additional percentage to mask up spares 10,000 lives. That’s got to be more than the world, perhaps the galaxy, or at least our quadrant. I just don’t understand the complete lack of empathy that our culture seems to have bred into a considerable percentage that leads people not to want to do something so simple to help others. It just doesn’t compute. The ultimate message of almost every religious tradition is one of caring for the stranger as you would care for your own so I don’t see how people who profess to follow any sort of spiritual life would have any qualms about not only masking up, but assisting their neighbor in doing the same. I guess it just shows how poisoned some religious traditions have become in a lust for secular power. Until we all take this seriously, I and my coreligionists in our church choir will continue to meet by Zoom and discuss how we can have a safe community sing/rehearsal in the church parking lot where we can be masked, socially distance, and out of doors.

Enough of that rant. Time to switch over to a different part of the brain. I have a couple of new movie columns to finish up. If you have films you want Mrs. Norman Maine to tackle in the coming months, she’s taking nominations.