It’s Sunday night, the first day of Daylight Savings Time so my body is having a hard time deciding how late it is. I’m boycotting the Grammys – I still haven’t forgiven them for giving song of the year to Killing Me Softly With His Song over American Pie in 1972 and it’s time for my biweekly update of the Accidental Plague Diaries. I have no idea what I’m going to write about this evening, but that hasn’t stopped me in the past. Something usually starts to take place as I let my fingers run over the keyboard.

The weather has been lovely and spring like here in Birmingham the last few days. Sunshine. The pastels on the trees are bursting forth in their usual sequence. Tulip magnolias two weeks ago, Bradford pears this last week. Flowering plums and cherrys, dogwoods, redbuds and gobs of wisteria still to come. It’s my favorite time of year hear. The flowers are lovely, it turns warm without being hot and the humidity has not yet crept into town. I tell people that if they want to visit, late March through early May is the time to do it. We’re not out of the winter woods yet though. There’s usually a cold snap that breaks our weather into first and second spring and it’s threatening to arrive this next week. I’m just hoping for good weather the second week of April when we perform Pirates of Penzance outdoors. The only other outdoor show I’ve done in town was Twelfth Night for Shakespeare in the Park in August and that was miserably hot and sweaty.

There has been very good news on the Covid front. The numbers of vaccines available nationally is greatly accelerating. Per the CDC, nearly 4.6 million people received a vaccine yesterday. That’s up from the record 1.6 million people last weekend. At this rate the administration’s goal of getting every adult American a vaccine who wants one by the first of May is likely to be met. If you haven’t gotten yours yet, it’s coming. Just stay on those lists. The percentage of people refusing vaccine, mainly for political reasons remains too high for the epidemiologist in me to be comfortable. I keep hoping a cerain ex-president, who was vaccinated himself in January, will publicly call for the vaccine as a step of atonement but I’m probably reaching too high.

The most concerning issue remains the mutation of the virus and the rise of variants. The majority are still covered by the extant vaccine although there are variants in South Africa and Brazil where this isn’t as clear and the last thing we need is a resistant variant winging its way around the world just as we’re starting to get our vaccination game together. The Astra Zeneca vaccine (not yet approved in the US) was considered one of the major hopes for poorer nations as it was inexpensive to manufacture and easy to store. There are reports out of Scandinavia of a number of serious post vaccine clotting disorders and it has been pulled in Norway. If this turns out to be a real issue, there’s going to be a problem. We tend to forget in the US that the pandemic is a global, not a local issue, and that solutions need to be global in order for transmission to cease.

We’re heading into the easter season. In my house growing up, easter was big for the egg hunts. The first one I remember was shortly after we moved into the house in which I did most of my growing up. I was three, nearly four, and still an only child when I came down on easter morning and was upset because I could only find two eggs. I complained vociferously to my mother who told me that the easter bunny had determined that I was getting smarter and that eggs wouldn’t be in plain sight anymore and I needed to be more diligent in my searching. I went back and figured out that the easter bunny had put eggs inside of things or behind books. Later easters often found us traveling, either out to the Washington coast or down to San Francisco to see my grandparents and back. Our family easter bunny was quite resourceful at creating egg hunts in cheap motels and vacant fields across the road from cheap motels.

I kept up egg hunts well into adult hood. I used to do them for Steve when we lived in Sacramento and, at one point in the mid 80s when I was still in med school, I invented a game for an easter brunch at a friend’s house called ‘Dr. Jekyll and Easter Bunny’ in which there was an egg hunt with good and bad eggs. The object was to gather good eggs into your basket and slip the bad eggs into other people’s baskets when they weren’t looking. I can still remember a bunch of adults tearing around a backyard to the strains of Mendelssohn’s Italian Symphony as the game got under way. (Daniel James Cole I seem to remember you being there…) I haven’t done a good egg hunt in a while. I have a plan to remedy that this year.

In the meantime, onward with other projects, but always mask on hands washed and distanced (unless vaccinated and around small numbers of other vaccinated people according to the CDC).

One year. 525,600 minutes as Jonathan Larson taught us in his anthem from ‘Rent’. One year ago today, the World Health Organization officially classified Covid-19 as a pandemic and the coronavirus crystallized into the national consciousness in a way that it had not in the past. I had seen it coming. I know enough about virology and epidemiology from a physician’s training to know it was out of control and coming our way several weeks earlier. I, naive as I was, assumed that the combination of the resources of the US government and our national character of pulling together in adversity were going to help us brace for the impact and deflect the damage. I hadn’t understood just how hollowed out and damaged our institutions had become or how fractured we were as a society until those first few weeks when a combination of willfulness, ignorance, and spite took over what should have been a time of courage and sacrifice laying the groundwork for the next year of our lives that would profoundly affect us all.

I had written the first piece of what was to become these Accidental Plague Diaries the evening before. I was well aware of the issues and what was happening but I was afraid to write about it, to actually give it form and shape with my words and make it more real. Eventually, the shadow on the horizon loomed too large and there was no way I could not write about it and still make sense of the world and so I wrote… and wrote… and wrote. Producing over a hundred essays over the course of the year exploring the virus, the disease, the impact on the health system, the impact on society, historical parallels, and how I found myself changed by what was happening around me. I am in the process of editing a significant portion of them into book form and hope to have it published this summer. As I reread and edit those early pieces, the emotional state of last spring – the not knowing, the understanding that my professional world could collapse, the steeling myself for the losses that would happen – comes creeping back. I’m more optimisitic now in general but still feel like I am carrying a huge weight from everything that has occurred since pandemic day a year ago.

On that day, there were a total of 29 known Covid deaths. As of today, there are nearly 531,000 – roughly the same number as in Jonathan Larson’s famous lyric. An average of one person a minute every minute for a year suddenly gone leaving a hole in our social fabric and a bereft group of family and friends wondering why? Pandemics are not new. They crop up routinely like other natural disasters such as earthquakes or hurricanes and have been since the human race decided that hanging out in groups is beneficial. The difference this time around was an ignoring of the pandemic for political reasons leading to a death toll many times higher than it needed to be. Numbers are down, vaccine is out, but the mortality rate remains about 1,500 a day nationwide. That’s enough to cut a full year off American life expectancy – two and a half years for most American populations of color and less for white populations. Covid was the third highest cause of death for 2020 – bested only by heart disease and cancer.

The new administration is half way to the hundred day mark. It seems to have solved the problems of vaccine manufacture so there should be plenty of doses in the pipeline over the next month but has not yet completely solved the issues of vaccine distribution. The previous administrations plan of just distributing to state health departments, chronically underfunded institutions without much clinical infrastructure, turned out not to be the wisest of decisions and, as new rules have been put in place and vaccine is now sent to health systems used to creating clinical programs, things are improving in the get the shots in the arm deparment. We’ve still got quite a ways to go. UAB is opening up a 5th mass vaccination site this next week and I am pretty certain that the backlog of older and at risk people waiting for vaccinations will be cleared in our area by tax day. The VA, for all its faults, as a clinical system with access to supply from federal channels has done a heroic job with getting its patients vaccinated. The local VA has now given at least one shot to more than 50% of its active patients.

There’s been some good news on the vaccine front. New numbers out this week show that the Johnson and Johnson vaccine, where earlier studies showed less efficacy post vaccination than Moderna and Pfizer, is pretty much equally effective after six weeks. So it doesn’t really matter which of the three you get. Six weeks after the initial inocculation, you’re pretty protected. There’s also new data out of Israel (the country which has done of the best jobs in getting its entire population vaccinated) suggesting that all of the vaccines significantly lower transmission rates in the community as well as protecting the individual. Pretty much all of the adult US population seeking vaccine should be well protected by late spring. Then comes the problem of trying to handle the significant portion of the population which will refuse for political or other reasons. As long as that sector of the population remains the size it is, the virus is going to continue to be an issue. I don’t have a solution for this one.

A number of people have approached me about getting vaccinations for frail elders bed bound at home who cannot easily be gotten into cars for drive through vaccination settings. It’s a population near and dear to my heart, the people that made me realize that geriatric medicine was my calling and around whom I have designed my career. I know what the problem is. The legislation regarding vaccine has the cost of the medication itself borne by the federal government. However, providers are allowed to charge an administration fee (waived by most programs currently) to cover their costs for supplies/labor etc. Delivering vaccine to homes is a labor intense proposition. Even using the Johnson and Johnson that does not require the cold chain still means a skilled vaccinator having to go out and administer. As all of the vaccines are under emergency use protocols, there are things that must be done in terms of paperwork and patient monitoring that are not necessary with approved vaccines like flu shots. It will take 30-40 minutes per household to deliver shots and, with travel time, you might be able to get in ten visits a day per vaccinator. No one has decided that they want to be the organization that is going to absorb these costs (with the exception of the VA locally) which is why it’s just not available. The state doesn’t have the money. Almost all health institutions are for profit in some way and aren’t going to want to take on a considerable unreimbursed cost. It will get solved eventually but things are a bit at an impasse.

Until all of these kinks can be worked out, even if you’re vaccinated, you know what you still need to do. Wear your mask. Wash your hands. Keep your distance. Like we’re doing on our imaginary beach in Penzance.

It’s Sunday evening. I’m not in a foul mood. I really don’t care what the Duke and Duchess of Sussex have to say about the British Royal Family. The weather has been nice. Vaccination news has been incredibly positive with several million more people receiving their jabs in this country over the weekend. So what to write about this evening? These essays are usually powered by a strong emotional through line of some sort but there really isn’t one percolating this evening.

Yesterday was about chores. Biweekly grocery run, once every few month Costco run, pet store for big bag of Science Diet Hairball Control Formula run, followed by laundry, and reorganizing a number of things around the condo that had fallen into disarray plus stowing away my makeshift film studio out of the dining room as Tartuffe is over and nothing else is on the horizon other than the filming of a lecture on basic geriatrics for a national board review course next week. The next theatrical project is rehearsing and performing in person over the next five weeks – masks, social distancing, and all such other safety protocols in place. Today was about connection. On line church service in the morning, picnicing in the park with old theater friends (properly socially distanced) in the afternoon, and the monthly extended family zoom meet up in the evening where the cousins all catch up with each other.

So I suppose the big question that I’m grappling with as things are improving is how much how fast and what will be restored to pre Covid norms and what will remain altered? Firstly, we are certainly improved in terms of hospitalization and death numbers from where we were early in the year and the fall has been relatively rapid, likely due to the use of vaccine among the most vulnerable populations. However, vaccine is still coming on line in fits and starts due to the previous administration’s not putting the full force of the federal government’s powers behind it and the current administration’s need to play catch up. We need to keep up all of our good habits for a while longer. If the amount of vaccine promised materializes, we’ll be in a situation around Easter where the majority of people who have been chasing vaccine will have received it and we will start to see vaccine chasing people as the public health system tries to find harder to reach and educate populations. A significant number of these people will need to be vaccinated in order for us to forego masks and social distancing, otherwise, there will be large populations trading virus around and higher chances for mutations and reintroduction into more protected areas of society.

When can we have blow out indoor parties and rehearsals and theater and sporting events and dances and all the other things we have been missing for the past year? I don’t know. I’m hopeful for the fall but a lot is going to depend on how accepting people who have been fighting against basic public health measures for political reasons come back into the fold. I would keep an eye on Texas. Their decision to completely open up everything as of this weekend will cause changes in behavior. Those changes in behavior show up as changes in case rate in 2-3 weeks, changes in hospitalization in 4-6 weeks and death rates in 6-10 weeks. It will be interesting to see what happens in Texas in April in comparison to other states playing it safely. It will also be interesting to see if new mutations spread within Texas, and then beyond its borders as traveling Texans carry it around. With luck, none of these will cause serious issues but one never knows, does one…

My professional life will have significant changes no matter what. Telemedicine is here to stay. I don’t particularly care for it on my end as I feel like I miss far too much not being in the physical presence of my patient and able to pick up on subtle cues. It will be OK for what I call my ‘Well Baby Checks’ on long term patients with stable issues, as long as they come in person occasionally, but it’s not good for new or unstable patients at all. I also have a feeling that masks are likely to remain de rigeur in health care facilities long after the pandemic has faded. They’ve made such a huge difference in the transmission of viral illness in general, as evidenced by our essentially non-existent flu season, that the Joint Commission is likely to require them on staff (and possibly on patients). I wonder if we will adopt in Western society, the habit of Asian societies of putting on a mask to go out when you have any sort of viral symptoms now that we’ve normalized them over the last year.

Both my friend and family gatherings today were interesting as the focus was not so much on the past and loss, but on the future and what possibilities are to come. The theater friends were full of discussion about what would be needed to jump start and rebuild live theater after the great pause. The family about what was coming up with professional lives and future plans for pushing ahead with life. I find that very hopeful. Americans are incredibly resilient when we need to be and move forward relatively well when given a few guideposts (and for the first time in years, I feel like we’ve been getting some from the very top). I only fear that as things improve and we all work on moving forward that we will forget the lessons the last year has taught us regading work/life balance, how to care for each other as communities, how to listen to those of differing experience, and how to slow down and savor smaller things.

I, for one, want to figure out a new balance between work, theater, writing, and just plain living. I don’t know what it’s going to be yet but going back to what was just doesn’t feel right. Forward, always forward, but with a mask on and social distancing for a few more months at least.

I’m grumpy tonight. I know why. It’s due to the unending public health idiocies being foisted upon us by conservative Southern governors who, despite all scientific evidence to the contrary, are busy abolishing mask mandates and social distancing requirments. Alabama hasn’t joined the parade yet but our governor has a press conference set for tomorrow morning and I’m pretty sure I can predict the substance of it. It all pisses me off for couple reasons. One, while numbers are down and vaccine is rolling out, we are not out of the woods yet and the rapid spread of more infectious variants means that relaxing of public health members is likely to send us towards another surge. Everytime we surge and numbers go up unnecessarily, for every thousand postitive tests, three people receive a death sentance. It’s also a huge slap in the face for an exhausted health care work force. And the people they are going to have to take care of are going to be middle aged folk who have either been unable to obtain vaccine or who have been taught by their information sources that they don’t need it. The elderly, being in the early group to get vaccine, will be relatively protected – the rapid decline in cases and deaths recently has been due to that low hanging fruit having been plucked. Then there’s my purely selfish reasons. If we start surging again and it prevents me from being able to do my planned travel and get back on stage again, Imma gonna be mad!

I wrote this essay a couple of weeks ago for an elder care website. Rather than go stream of consciousness this evening, I’m going to publish it here so I can spend the evening with my can of hard pear cider and old episodes of Community. Enjoy.

Why Can’t I Find a Geriatrician For Mom?

Most human beings, as they age, realize that their bodies and physiology changes from what it was in their younger adulthood. Things that never bothered them in the past start to hurt. Their reaction times slow. They have less strength and muscle mass. Eyesight and hearing aren’t as keen. American medicine began to understand that the precepts of medical treatment that were being developed post World War II, full of a newfound scientific rigor, might not be one size fits all and such specialties as pediatrics for children and obstetrics and gynecology for women were given new status. Geriatrics, a specialty dealing with aging and the older adult, was first formalized in this country with the founding of the American Geriatrics Society in 1942 but there wasn’t a lot of interest from either the medical community or from society at large as the numbers of individuals living healthy lives into their 80s and 90s was very, very small, most people being carried off by acute illness somewhere in what we would now consider late middle age.

Things began to change in the mid 1960s. First, the financing of health care for older individuals was radically transformed with the introduction of Medicare in 1965. This federal program, which was available to a majority of seniors, was instantly popular as aging adults suddenly had a resource for paying physician and hospital bills that did not rely on their own pocketbook. The older population signed up in droves and by the early 1970s it was fully enshrined in our culture as an entitlement, becoming one of those third rails of American politics. Second, demographers recognized and began to publicize what had been going on in America in the years following the end of the war. The relative privation of the Depression and World War II years, fifteen long years of never enough, had given way to prosperity and a resulting dramatic rise in the birth rate from the mid 40s through the mid 60s, forever known to history as the Baby Boom.

The scale of the Boom was enormous and society, rebuilding itself after years of trauma, was determined that this generation should never know want or unhappiness. A new media culture was created to reflect an idealized society from Sally, Dick and Jane to Leave It To Beaver. Schools were built and enlarged. Public Universities were lavishly funded to allow for their education at low prices. Their sheer numbers forced society to bend to their needs as they entered each stage of life. The demographers, forever thinking of the future, projected forward and began to wonder about what this might mean when they started to enter their elder years early in the 20th century, especially when other world populations were exploding meaning more and more competition for resources. The baby boom itself, as it matured, tended to ignore these calls as they, to this day, consider themselves a young and vital generation. The first year of the boom, turning 75 this year, contains such luminaries as Dolly Parton, Sylvester Stallone, Susan Sarandon, Bill Clinton, Sally Field, Donald Trump, and Cher – not exactly what we would consider a decrepit and over the hill cohort.

The medical system did start to take notice of what was coming and, in the early 1980s, began to formalize geriatric medicine as a specialty, creating (with the assistance of Medicare) specialized training programs for those who had completed initial training in either Internal Medicine or Family Practice. These fellowship programs began to pop up in University training programs by the late 1980s, usually as subunits of other programs rather than as fully funded entities in and of themselves. Formal educational criteria were set and board exams were created to determine who had the necessary skills to be called a geriatrician. For the first ten years of the board exams (mid 80s through 90s), there were two paths to becoming certified. You could either complete fellowship training or, if you had clinical experience in the field, you could apply to take the test based on that experience. Most individuals working in the field did so and the number of board certified geriatricians in the country rapidly rose peaking at about 9,000 in the late 1990s. Board certification is not life long, you must retest every ten years. Many of these early people who grandfathered in retired or found that maintaining certification was not worth the time and expense and the number of geriatricians began to fall. It’s between 5,000 and 6,000 today.

Those who study medical systems and the impact of aging populations on medical systems understand the role of the geriatrician in healthcare. Not everyone needs a geriatrician starting on their 65th birthday. Geriatricians are most valuable taking care of that subset of older people who have developed chronic disease burden to the point where their physical and/or cognitive function is impaired and they can no longer live independently in the life they have designed for themselves. Most of these people do not live in nursing homes or other congregate facilities. They mainly live in the community, cared for by an army of family members and friends doing the best they can. A geriatrician’s special skills in understanding the interplay between social and physical determinants of disease, medication management, fall prevention, maintenance of continence, management of dementia behaviors, and other such issues can make all the difference between a happy home life and misery for all concerned. Medical demographers have concluded that by 2030, when this country will enter peak age (the entire baby boom over the age of 65 but not yet having begun to die off in significant numbers) it will take about 30,000 geriatricians to provide optimal care, about five times as many as are available.

We are still training new geriatricians. There are roughly four hundred training slots available nationally on an annual basis. Only about two hundred of them fill with applicants after the matching process is complete. Here at UAB, we have been unable to attract a single applicant for the last three years. Geriatric medicine is the second least popular specialty among US medical school graduates, bested only by geriatric psychiatry. The reasons for this are complex. Some are buried deep within the culture of the US medical education system that devalues person to person work for complex procedural work. Some are tied up in the financing of health care and the pivot by health systems away from unprofitable service lines. Some are due to the economics of physician compensation. Geriatrics remains one of the lower paid specialties due to its reliance on Medicare reimbursement which is notoriously low for cognitive services.
This all leads to a fundamental problem. We have a rising demand due to the pressures from an aging baby boom on the health system. We have a society that has moved away from investment in public health infrastructure which would allow a less profitable specialty to sustain itself and provide compensation packages that would attract more medical graduates into the specialty. We have a stagnant number of qualified geriatricians. The two hundred new graduates a year just offsets the number who leave the specialty through retirement or change of job focus. Those few of us who remain in the field and committed to clinical geriatrics are well aware of all of these trends and saddle up for work every day determined to do the best we can but we are only human. The end result of all of this is finding a geriatrician for mom is exceedingly difficult. They just don’t exist.

Can this problem be fixed in the short amount of time remaining before peak age? Of course it can. We know this from looking at recent medical history. Prior to the 1990s, there was really no such thing as a hospitalist. There are now more than 40,000 of them nationwide. Financial incentives, working conditions, and system structures were changed in that decade to make it a viable choice for new physicians and they came flocking to the job opportunities. Something similar could be done for geriatric medicine. All it requires is a health system willing to make those changes, either intrinsically which would require economic inducements, or extrinsically through legislative fiat. These are things I cannot accomplish on my own. It will require societal will. In the meantime, I’ll keep saving the world one patient at a time.

And then there were three. We have a third vaccine available for Covid-19 approved for emergency use as of this weekend meaning it can be shipped and available for willing arms as early as tomorrow. This one, from Johnson & Johnson has several distinct advantages over the previous vaccines from Moderna and Pfizer. It is a single dose vaccine. Once you have your first shot you’re done – no need planning to come back within the necessary window of time for a second shot. It’s also much more stable and does not require the cold temperatures of the mRNA vaccines and can be kept in an ordinary refrigerator. This combination of factors will make it much easier to distribute, especially to more isolated populations. The homebound elders I take care of, outside of the VA who has a separate system, have for the most part been out of luck at obtaining vaccine as no good system for getting vaccine out into the community without compromising the cold chain had yet been devised locally. That will no longer be an issue.

The reason for this ease of use is that the Johnson & Johnson shot is a very different technology than that of the earlier vaccines. While the two in circulation are based on a method of getting mRNA that encodes for spike proteins into our cells and letting our own immune systems then take over to produce antibodies against those proteins and, therefore, against the corona virus, this vaccine works more akin to an inactivated virus vaccine such as for flu. This vaccine uses a modified adenovirus (a type of virus that causes a range of respiratory and GI viral illnesses) that cannot cause human illness. These viruses are DNA based viruses (unlike the coronavirus which is RNA based). DNA that encodes for spike protein is added to the adenovirus and, with the immunization, the introduced adenovirus is taken up by human cells. The virus itself is destroyed but the DNA in question is taken up by the nucleus and the cell makes mRNA for the spike protein which is then recognized by the immune system as foreign, priming the body to react against coronavirus should it be exposed later.

The numbers in regards to protection for the Johnson & Johnson vaccine aren’t quite as spectacular as for the two prior vaccines but still plenty high enough to prevent significant illness in someone who is later exposed. Cold symptoms we can tolerate. Shutting down of the respiratory system we can’t. WIth all three vaccines now approved and in circulation, we really have a chance of getting ahead of the virus and its spread and we may be able to have a semblance of normal life again this summer. I’m dreaming of sitting on a patio with a cocktail and a bunch of friends having adult conversation.

The deccline in cases nationally no longer continues to decline, but appears to have plateaued. The numbers are far below that they were at their January peak but they remain worse than they were in the early fall before cases really started to skyrocket. I am not an epidemiologist but my guess is the rapid fall was a result of picking the easy fruit. The rapidity of vaccination of seniors in congregate living is the likely driver as their chances of acquiring and becoming seriously ill was so high. With that particular population stabilizing, we’re probably looking now at numbers for the general population and those will be much tougher to get under control, especially as roughly 1/3 of the adults in the country are living in a political fantasy land where such things as facts and how biology works just doesn’t matter. The new variants which are more contagious continue to spread, but the vaccines appear to be as effective against them as they had been against original strains. Just to be on the safe side, the vaccine companies are working on boosters and tweaks should they be needed.

The biggest issue is one that has not yet reared its head but very well could. The coronavirus is a very simple organism genetically. It’s RNA code is not that many base pairs and it has very few parts. As RNA and DNA are constantly mutating as nature tries things out (evolution exists whether you choose to believe in it or not), and those mutation rates are relatively constant, there will, over time, be more and more variants and eventually one of those variants may develop a resistance to vaccine, or a quality that makes it much more lethal to humans. And if that starts to spread in the midst of our current political climate, there may be hell to pay.

I haven’t been feeling great the last couple of days. (I’m pretty sure it’s not Covid but UAB, from an abundance of caution, is going to test me in the morning and have me work from home tomorrow). This is one of the few times since the pandemic broke that I haven’t felt up to snuff. Covid avoidance as kept me away from all of the other mild ailments that I usually get. There is a code in medicine that you don’t take sick time when you’re under the weather as it means your workload will simply be added to someone else’s when you’re out. It’s instilled during med school and residency which is full of stories about residents putting in their own IVs and making their rounds dragging an IV pole when they’ve been so sick and dehydrated that they can barely stand up. These stories are told in such a way as to make trainees feel that they should have a constitution of iron and they are unworthy if they don’t. I’m not sure that’s a healthy attitude and I’m pretty sure I’ve gotten or given viral illness to and from colleagues and/or patients in the past. Maybe a gift of the current pandemic is a change in the culture to make it a positive move to stay home when we are sick and thus lessen the chances of iatrogenic infection.

Checklist for tomorrow: Drive through Covid testing. Telemedicine from my dining room table. Keep hands washed. Wear mask outside condo. Keep my distance. Drive through dinner. Early to bed.

I’m not keen on emotions. I don’t understand them very well. When I feel something swell up inside me, I have a difficult time determining if it’s something positive or negative (I can usually figure it out eventually from context) and what my reactions should be to it. I tend to draw back from it, get quiet and try to analyze it and figure out just what it should be rather than let go and feel it. Perhaps that underlies my affinity for Sondheim as so much of his writing is for characters trying to move from the outside of intellect and analysis to the inside of emotional connection. Time to put on ‘Anyone Can Whistle’ for the umpteenth time. At least I have a new recording of that score to enjoy courtesy of Jay records. It’s also likely why my only successful romantic relationships have both been with men who were creatures of instinct and emotions strong enough to batter down all of my carefully constructed walls. Keep that in mind before you try and fix me up with someone.

I just know that at the moment I am feeling and it’s a combination of positive and negative things. Today was the first live in person rehearsal I have had in nearly a year. I was bouncing up and down in my chair at work all day with excitement. It’s been a rare week I’ve gone without a rehearsal or a performance of some sort since launching myself into my late life performing career back in 2003 and it’s now just two weeks short of year since I last sat in a seat with other people and we joined our voices together to make music. I’m playing one of the policemen in a truncated, outdoor version of The Pirates of Penzance produced by Opera Birmingham going up at Avondale Ampitheater in April. We’re rehearsing masked and outdoors. We’re maintaining social distancing in both rehearsal and staging but when we began to sing the counterpoint of ‘When The Foeman Bares His Steel’ and ‘Go Ye Heroes’ I wanted to cry. It’s my favorite piece of music from the show and to be enveloped in those 150 year old melodies with a group of people just as grateful to be there as I was as special a moment as I have had in a while. We’re rehearsing in a covered parking garage so the acoustics aren’t bad, the cast is talented and full of old friends, and I can’t wait until we have the next one. So, it you’re around 6th Avenue South in Avondale the next month or so and you hear operetta drifting by on the wind, you’ll know what’s going on.

This feeling, which I suppose is joy, is getting thoroughly mixed up with another one which I suppose is sorrow as I continue to work through the impact of Covid on my world. We’re at 508,000 deaths, according to the Johns Hopkins Coronavirus Counter, out of 28.4 million US cases. We’re still a few days from the first anniversary of a death from an observed US infection (February 29, 2020 – the few deaths earlier were traced back months later using blood and tissue samples). We’ll end up somewhere around 510-515 thousand deaths at the one year mark (37th largest city in the USA between the population of Atlanta and Sacramento). That’s roughly ten times the number of flu deaths in the worst flu years and twenty five times the number of flu deaths in light years. Flu is practically non-existent this year. Our good health habits are keeping it from propogating. I know the devestating impact that death of important people has had on my life. Those of you who have not been widowed have no idea how much that process turns your life and your world upside down. This year has created hundreds of thousands of new widows. New single parent families. New orphans. A new crop of parents burying their children before them. And all having to be done while navigating a myriad of new social customs and rules, many of which keep us from being together. There are really only two things that heal grief – time, and the presence of others in our lives and that latter one has been hard. What does grief deferred due to an individual? To a society? I think back on the generations that survived World War II or the Civil War and wonder what lessons they have to teach us about coping in healthy ways.

Steve died twenty years ago this year. It’s a long time and I’ve had a whole other life in those years but I can still feel his presence, hear his voice and his laughter as if he had just left the room. His death, as it was a prolonged process of several years, caused me to make some life decisions that continue to have repercussions. When he became ill and I needed to spend more time and energy at home with him, I took myself off the fast track to academic success, leaving behind research interests and the very long hours that would have been necessary to position myself where I would be competitive for the department chair and deans level jobs. Could I have done both? Possibly, but likely at significant cost to my humanity so I didn’t want to try. Plus, I had the added burden of being openly gay at a time when few medical school faculty were and those in my generation learned early and often that if you were open, you had to be twice as good to get half the credit.

Steve’s death boomeranged me into a different career trajectory, maybe not as rewarding in terms of money or professional accolades, but certainly more fulfilling and it allowed me the time and the energy to become a fully realized human being with my rediscovery of theater under the tutelage of Tommy. I’m sure Tommy’s death has also pushed my life in a new direction that’s not yet fully clear. I’ve made certain decisions about what’s important in my professional and personal lives that made me decide that downsizing and simplifying were something I needed to do. They also have made me decide that pulling up stakes and trying to vault up the ladder somewhere else (something I was looking at together with Tommy prior to his death) is not likely to happen. Tommy’s been gone nearly three years now. That wound is far fresher and there are times I mourn. For some reason, last night, rather than doing something constructive (sorry people to whom I owe that Topics in Geriatrics lecture), I opened his Facebook and scrolled through the whole thing back to 2007. Was I feeling sorrow? Was I feeling joy at what was? Was I feeling nostalgic? I really can’t say. I just know that I was feeling. And I think it was brought about by a combination of the joy of impending rehearsal and the sorrow of being surrounded by so much death and despair. The feeling of being alive. (There goes Sondheim again and I didn’t even intend it…)

Be like the singers of Opera Birmingham. Wear your mask (singing through it is… interesting). Wash your hands. Sit six feet apart. Make the world a better place with music.

Everybody talks about the weather, but no one does anything about it. I wish I could take credit for that particular bon mot, but it’s been floating around for more than a century, attributed to various Edwardian era wits, most frequently Mark Twain. Sometimes I think I missed my century; that I was born to sit around a splendid drawing room in evening wear with a snifter of brandy and a cigar trading epigrams with celebrated names. And then I think of general standards of public health and hygiene at the time and feel thankful to have come of age in post war America. Besides which, I’m not nearly as witty on my feet as I like to think I am. I do my best when scripted or in character in some way. When I’m just being me, my general introversion and insecurities tend to take over.

The weather around here has been cold, but relatively pleasant following the snow and ice of last Tuesday (which was gone by Wednesday). Not so much in Texas where the deep freeze continues to bedevil the population with power outages and lack of potable water. If I understand things correctly, plans were drawn up ten years ago following the last bad winter storm to hit the state but nothing was done to implement any of the recommendations as that would be expensive and cut into profits. The wholesale transfer of the commons to private corporations for purposes of enriching stockholders of the last forty years has consequences. It’s been cast in political terms as a battle between capitalism and socialism but it’s really more about a battle between private greed and public good. To my mind, there are certain sectors of the economy that should be kept public and not for profit because when they become private for profit concerns, the law of unintended consequences hurts us all. These include health care, education, corrections, the military and utilities.

On the Covid front, I remain cautiously optimistic. The numbers continue to decline nationwide. No one is quite certain why. Is it the presence of vaccinated individuals interrupting transmission chains, the surge caused by holiday behaviors being finally behind us (and only to increase again with some new social trend), the numbers of infected individuals rising as a percentage of the population (28 million official cases in the US – about 9% of the population but this is almost certainly a significant undercount), some new and as yet unidentified factor? Inquiring minds want to know. We are at 498,500 deaths today, meaning we will pass the half million mark tomorrow or the day after, less than a year since the pandemic really established itself in North America. It’s hard to understand just what sort of number that is. It’s big enough that the US as a whole lost a whole year of life expectancy during the first six months of 2020 (and that’s before the winter surge – when the final numbers are in for 2020 we may have lost as many as three years in total – something that hasn’t happened in generations).

People don’t really understand what that life expectancy number is. It’s been hovering in the high 70s for the last couple of decades, inching up a bit here and there. It doesn’t mean, obviously, that everyone only lives to that age. It’s the statistical mean age to which the cohort of babies born in that year will live. So the babies born in the first half of 2020 can expect a year shorter life than those born in 2019 due to the impact of Covid on society. Life expectancy is driven down by disease processes that kill the young. It was only in the mid 40s a century ago, not because people died of old age at 50 but because so many babies and children died of what, with public health measures and antibiotics, became preventable diseases. Covid is a preventable disease with proper public health measures but politics got in the way. We can tell that mitigation measures are working, even the imperfect ones we have in place by looking at this year’s flu statistics. The number of flu cases this year is less than 1% of what is seen in a typical year. Socail distancing and masking prevents influenza from being transmitted as well as Covid.

Tartuffe concludes filming this next week and will be available in mid March for your amusement. I’ve auditioned for a few other projects and am waiting to hear. I’m also starting outdoor, socially distanced and masked rehearsals for a condensed production of The Pirates of Penzance later this next week. I have not yet been informed if I am a pirate, a policeman, or one of Major General Stanley’s daughters – or perhaps all three. And last night, I was the MC for the church’s annual fundraising evening – on zoom rather than live this year – 19 years after I first did it (my first Birmingham acting gig and the first appearance of what becaome the Politically Incorrect Cabaret Ansager). I paid an homage to previous years by continuously changing my coats. There’s only so much you can do in front of the webcam. Work has been somewhat busy the last few weeks with various minor projects coming due so between those and theater, I’ve been pretty nose to the grindstone and will be into early March. At that point, it will be time to take up the second edit on the book to try and trim it down to appropriate size so as to stay on schedule for a summer publication. I’ll be looking for early readers after the second edit is finished.

I wrote a compelling essay on why you can’t find a geritarician for your aging parent which I will post, but it’s embargoed until after it goes live on the website I wrote it for. You will all just have to wait. In the meantime, keep those hands washed, those masks on, and that space between you.

Snow day! Or at least some white stuff on the ground and some ice on the roads day. I woke up this morning to white flakes drifting dreamily down past my windows, told the VA that they could call me if they needed me, and rolled over and went back to sleep for another four hours. I haven’t been that busy or that active recently so I assume it was some sort of destressing mechanism on the part of my brain, especially as those last few hours were full of wild dreams including a visit to Disney in which I could not figure out how to get inside the park, some sort of cruise to an unpleasant destination and even worse people and a sequence where I kept breaking into my pastor’s house in order to find a nice quiet place to read and recuperate. She kept coming home and chasing me out again – politely, but firmly setting her boundaries for family time.

It would have been nice if I could have spent the snow day in some mindless activity, but alas a phone call from an attorney stating he needed a report in writing tomorrow on the case I have been revieiwing put paid to that idea, and I had to dive back into 2500 pages of mainly unreadable electronic health records trying to extract nuggets of fact that would support my opinions. Success as I found what I was looking for, wrote up five pages, and got it to him by close of business Eastern time and now have the evening to myself. I really should charge more for rush jobs. Reviewing medical records is nowhere near as fun as it was when I first started decades ago. Then I would get a bankers box shipped parcel post full of barely legible photocopies of physician handwriting to deciper. Now I get access to a drop box full of perfectly legible electronic records spat out by some computer, most of which are useless garbage when trying to reconstruct what happened around a particular incident or illness.

There has been some speculation that at least some of the issues of response to Covid and Covid vaccination are tied up in the electronic health record that has become so pervasive. The groundwork for such records was laid in the late 1990s after the invention of the World Wide Web as medicine, along with other industries embraced the ability for information exchange this allowed. Some bad actors early on who were buying and selling health information led congress to pass the Health Insurance Portability and Accountability Act (HIPAA) in 1996 under the Clinton presidency. This law explicity protected the privacy of health information so that it could not be used in inappropriate ways. Unfortunately, it also tied a lot of information exchange to 1990s technology which is why health care, as an industry, still depends on the fax machine. It’s considered HIPAA compliant while newer methods of information exchange are not addressed in the legislation and it has yet to be updated. In the early 2000s, various private companies becan to get into the electronic health record business, knowing it would be the wave of the future. (Cerner and Epic are the biggest but there are lots of smaller ones out there). The VA actually offered it’s in house EMR, known as CPRS, free of charge to the country so that there could be a national standard and all records could be easily traded between states and institutions without difficulty, but the Republican president and congress of the time preferred to let private enterprise take precedent over the public commons and this idea was abandoned in favor of dozens of incompatible systems incapable to talking to each other, leading to a dramatic increase in siloing of health systems along information lines.

Another complicating factor regarding electronic health records is what they are asked to do. When clinicians sold control of the health system to industry and administrators in the late 70s and early 80s, there was a shift in the power dynamic. Where before, the needs of the physician were paramount, after the needs of the industry as exemplified by revenue generation became the most important thing in terms of data management. As administrators were in charge of purchasing health information systems, they looked for systems that could assist with capturing charges, identifying utilization trends, and assisting with quality metrics. The actual needs of an individual provider/patient encounter became subservient to these big data analytic requirements. Administrative systems were modified to fulfill clinical requirements instead of vice versa. This was all put on steroids by the HITECH legislation signed by Obama in 2009 as part of the recovery from the great recession where the health care industry was offered financial incentives to adopt electronic health records and pretty much everyone went digital over the next decade, each in their own way.

The end result is millions of data points that can be spit out at the touch of a button but none of the logical thinking and cohesiveness that a physician mind uses to take all of that and turn it into an understandable narrative. A set of vital signs or a set of lab values taken in isolation don’t mean much. It needs to be combined with clinical reasoning skills, an understanding of the prior medical history of the patient, the unique circumstances of life surrounding the patient, and occasional serendipity to be made to mean anything. You learn to look at voluminous records and recognize that there are only a few sections, those where a clinician is entering data by free text or dication, that can really let you know what you need to know and, when meeting a new record system, learning where those few areas can be found makes all the difference.

In the 1980s, when I began in medicine, pretty much everything was handwritten. That’s why doctors’ penmanship is so notorious. Years and years of having to write so much so fast. In the 1990s, the handwritten notes tended to be interspersed with dictations, especially of summary notes such as admitting histories and discharge summaries. When I first came to UAB, there was no centralized medical record on the outpatient side. If I wanted to know what cardiology was doing with one of my patients, I had to go down to the cardiology clinic, pull their chart, and take a peek. That started to change in the early 2000s where more centralized records became the norm, with dictated notes being accessible throughout the health system and electronic medication lists coming into being which could be updated and modified by any provider. In the 2010s, the full electronic health record went into play. Notes pull information in from various places in the system but, as it is done automatically, there’s no real understanding of relevance and many notes become pages and pages of extraneous numbers and information with no clinical bearing on care. Who knows what the 2020s will bring. I’m hoping for systems programmed more to respond to clinical needs than administrative ones where physicians and other clinicians are part of the teams that develop the programming so that it becomes more intuitive.

Back to the Covid issues: As these systems are now everywhere, but are decentralized, when a national emergency such as the current pandemic hits, it’s difficult, if not impossible, to get health systems to pull together as one as their data systems are completely incompatible. As a UAB physician, I have no way to know what happens to my patients at St Vincents or in the Baptist system unless the providers there are kind enough to send me records of the visit. (It happens sometimes). Those records can be scanned in to the UAB system but they cannot be converted into a format where the data can be taken up and integrated with UAB data. It can make life very interesting when I have a patient who wants to get their primary care from me but still sees their cardiologist at St Vincents and their endocrinologsit at Brookwood and their neurologist at Grandview. With these fault lines, I don’t know how the administrative folk at the Alabama Department of Public Health or at the upper echelons at UAB are supposed to coordinate their efforts or know how well they are doing vaccinating 5 million Alabamians, half of whom fall into a risk group of some sort. That things are going as well as they are is a minor miracle.

A lot of people remain angry that they or their loved one have not yet been able to get scheduled for a Covid shot. The limitation is the amount of vaccine coming into the state. It’s freeing up and supplies are better than they were. Given that it’s a commodity with far more demand then supply, people are turning their frustration on each other. Why is so and so able to get a shot when I have not. Why is this risk group deemed more important than that risk group. The anger is misplaced. It shouldn’t be leveled at vaccine recipients (it’s the sort of divide and conquer that keeps propblematic social structures in place). It should be leveled where it belongs, directly at the previous administration who did little to make the vaccine available in a timely fashion. If they had used the powers of the federal government back in Decemeber when the vaccines were first approved to accelerate manufacture and to coordinate distribution, it’s likely that everyone at risk would be vaccinated at this point. They didn’t, meaning that a true ramp up of vaccine delivery didn’t start until after the change in administration a month later. We’ll get there. I am very optimistic that those at significant risk will all be vaccinated by Easter. That’s forty days from now. (I know this as today is Mardi Gras or, given the temperatures outside, Mardi Froid might be more apropos). It’s going to take more than fractured information systems and the ineffectiveness of administrations past to keep the American people down.

In the meantime, you know what to do: Keep your hands washed, keep your distance, keep your mask on, keep out of indoor locations with lots of other people, keep on keeping on.LikeCommentShare

Another Saturday night and I ain’t got nobody. I think somebody else sang that first. And it’s not entirely true, Anastasia the cat is snuggled up to my feet on the bed as I write this, purring away while Oliver is yowling in the next room, hoping I’ll get up and give him more kitty treats as if I didn’t give him a few an hour ago. Tommy’s been gone nearly three years now and people are kindly sidling up to me asking me when I’m going to date seriously again. I don’t know. Next week? Next month? Next year? Next decade? I don’t feel any particular compulsion to pair up again, except when it’s Valentine’s Day Eve and your social media is full of pictures of the happy couples of your acquaintance.
Dating in the gay world is hard. There’s not a lot of social supports for gay male romance, especially in my age group.

The last time I went through all this, twenty years ago, the number of eligible men local to Birmingham was rather small. (Prior to meeting Tommy, I had been dating a man who lived in Michigan – we would meet for the weekend once a month or so somewhere in between). Tommy fell into my life in an odd way. We had been chatting online, he had called me up in my professional capacity to gather information on elder care for a grant proposal he was writing for his job at Birmingham Health Care, and he started turning up at church where he was good friends with some other congregants. When I figured out it was the same guy turning up in all these different areas of my life at the same time, I decided the universe was trying to tell me something so I asked him out and the rest, as they say, is history. It did lead to a very public courtship with the entire congregation of the Unitarian Universalist Church of Birmingham egging us on. If the right guy turns up again in a similar serendipitous manner, I’ll consider a third husband, but I’m not going to actively look.

Covid is, of course, making dating nigh on impossible. There’s no going out to dinner, or for drinks after work or to the movies. I suppose a day hike together through one of the local mountain parks is a possibility but its a bit chilly for that. Maybe later in the spring. In the meantime, I have all my various home projects plus a few extra work things that I’ve taken on to supplement my salary that has this mysterious way of going down rather than up these days due to the crazy impact of the current crisis on the fiscal underpinnings of medicine. I spent most of today wrestling with 2500 pages of medical records for a legal case in defense of a nursing home and next week I get to figure out how to collapse all I know about geriatric syndromes into a 75 minute lecture for a national board review course.

The news on Covid continues to improve. The numbers locally and nationally continue to fall from their peak five weeks ago but they’re hardly going away. We’re up to 27.5 million cases total and we will surpass 500,000 deaths by the end of the month. Our local system for vaccine distribution appears to be working well and I have heard nothing but rave reviews from my patients and their families for the efficiency with which the mass vaccination sites are operating at UAB and in Hoover at the Hoover Met stadium. The only limitation is flow of vaccine into the state but that appears to be happening in a much more predictable fashion than a month ago and most of my over 75 patients who want a vaccine have either had their first dose or are scheduled within the next couple of weeks. Every vaccine delivered is one more person that will not end up in the ICU in a month or two giving our frazzled health system and its providers a bit of breathing space.

As I read through the information on the Pfizer and Moderna vaccines and how they are performing, it’s safe to say that they are doing a very good job at preventing illness and complication. It’s less clear if they are preventing transmission. Some data is coming in suggesting that they do indeed do this as well but we’ll have to wait for the data scientists to capture and crunch the numbers before any definitive statements can be made. If this is indeed true, we should be able to reduce our need for masking and social distancing some this summer. I just want to get back in rehearsal. So much of my social life and my equipoise is tied up in creating art with others in the rehearsal room and on stage that I just feel incomplete without it. I even miss tech.

The political world today progressed exactly as predicted with a pretty much party line impeachment acquital of the former president. For good or ill, I don’t think that particular story is over in the least. The fault lines remain. The former president, if true to character, will not remain quietly off the political stage but will continue to try and exert his will through his usual methods. What that will lead to, I haven’t the vaguest. At the moment, my part of the medical world is just happy that the CDC is authoring recommendations that make scientific sense, the FDA is offering well sourced information about treatment alternatives, and the powers of the executive are working together to get vaccine out in a streamlined fashion. I’ll take it.

I haven’t told a story for a while as corona virus kind of keeps me looking for metaphors and connections between pandemic and other areas of life rather than just thinking back on my past. Here’s one from my early house call days. I went out to take a look at a demented gentleman who kept getting burns on his toes. He and his family didn’t have much money and lived in a rental home that might best be described as a tar paper shack. Like a lot of older homes, it was heated in winter by gas heaters that were attached to the gas line with a rubber hose so that you could place the heater in various parts of the house. The joists and the floor boards were rotted and it was somewhat tricky to pick your way through the living room without putting your foot through to the crawl space. It didn’t take long to figure out the reason he was burning his toes was because when he complained of cold feet, the family wheeled him up to the heater and his diabetic neuropathy prevented him from noticing when they got him a little too close. He was eating badly and we needed to get a weight on him. He couldn’t stand on his own and they only had a bathroom scale so I weighed myself and then, he being a small and somewhat emaciated man, I picked him up and stood on the scale so we could get his weight by subtracting out mine. He peed all down my front as I had him in a honeymoon carry. Meanwhile, his wife (schizophrenic and refusing to take her meds) was frying something up in the kitchen for breakfast. She reached up and opened a cupboard and an enormous winged roach flew out and settled itself on the cooking. WIthout missing a beat, she picked up a can of Raid, sprayed the roach (which flew off elsewhere), the food, and the open flame of the gas stove with it. Fortunately, there was no explosion but she did turn around and asked me if I would like to stay for the meal. I politely declined, finished my visit and hightailed it back to the car for a clean T-shirt and the bottle of Febreze. Geriatrics – the glamour specialty.

Stay well, stay warm, stay distant, wear your mask, wash your hands, use your sanitizer – but keep it off your breakfast sausage.

I wasn’t going to write an entry tonight but when I opened up my laptop after work, some siren song seduced me into starting into the woods again. I’ve been doing this long enough now to know that when the muse calls, you better answer because those half formed ideas at the back of your brain won’t be there when you look for them later. I’ve always written best by just letting my brain go into a sort of detatched zone where I’m not really thinking, just letting the words come as they will. When I write these essays, I sometimes have an idea or two, sometimes a whole paragraph is in mind. Other times, I just start writing and off we go. It’s a bit of a dissociative state that lasts usually about 75 minutes or so and I find there’s 1200-1500 words on the screen. I don’t rewrite. I just hit post and hope for the best.

It’s been interesting going back as I edit these Accidental Plague Diaries into book form. They weren’t written with that in mind and the chore of analyzing the ideas in each one, making sure there’s a certain stylistic and thematic unity, getting rid of odd tangents, the occasional major grammatical error, misspelling, or wrong word choice is teaching me a lot about what my writing actually is. The first pass edit is nearly done. A second pass with shorten the manuscript to acceptable length and then there will be something to show people and see if I can drum up any interest outside of my immediate circle of friends. My editor asked me the ultimate question in our last conference. Why is such a book important? I want it to be a primary source document of a particular moment in history written as that history was unfolding from the perspective of someone with some understanding of both the health and sociological implications that are happening all around and the impact the corona virus had on both one person and the country as a whole. We’ll see if I managed to actually do that.

There’s not a lot to report from the battlefield from the last few days. The number of hospitalized cases continue to dwindle locally as the holiday fueled surge continues to recede. UAB hospital, which topped out at about 300 inpatients at the peak, is down to just over half that at the moment. I am breathing a major sigh of relief as that means it is unlikely that I will be called in to work jeopardy inpatient duty later this month. If I was called in, my plan was to go in, tell the residents that I hadn’t really done this sort of work since before they were born (not quite true) and to please lead me gently by the hand through anything for which they needed staff authorization. The vaccination centers are also apparently working relatively well and I see more and more friends outside of healthcare proudly holding up their vaccination cards on social media. We just need to get more vaccine into the state faster. We’ve also got to keep working against some of the more ridiculous disinformation that’s circulating out there. Tyler Perry did a very good PSA on the vaccine aimed at the African American community (it’s on YouTube) which does a nice job dispelling many of the worse myths. The most worrying thing at the moment is the rapid spread of the UK strain that is much more infectious. It’s currently doubling in prevalence roughly every ten days. At that rate, it will be 1,000 times as prevalent in three months and nearly 10,000 times as prevalent in four (ah the magic of exponents).

The creators of modern myths were on full display today as the curtain rose on Impeachment 2: Electric Boogaloo. It’s quite something when the second worst performance by an attorney on a given day involved a zoom court appearance and a cat filter. I try to be evenhanded in my approach to politics but I’m having grave difficulties listening to even sound bites from the pundits trying to gaslight me into believing the Capitol Insurrection was not what it was. The ceremonies will play out. There will be some sort of legalistic coda. But nothing will really change as nothing has been done about the media and political landscape that has let untruth and half truth flourish to the point of having two societies trying to coexist with alternative facts. I don’t know how to fix it. All I can do is try and understand it.

I was thinking about our divided society and how to really grasp what it means when I realized it’s something I deal with everyday, only in microcosm. Perhaps the most common serious health problem for which I am consulted is cognitive change. The memory loss that afflicts the aging which is usually, but not always a dementing illness. It’s relatively uncommon before the age of 75, and then starts to rise exponentially (meaning the Baby Boom is just starting to enter the dementia years this year). Prevalence of significant memory loss is less than 10% at age 75, 20% at age 80, 40% at age 85, 60% at age 90, 80% at age 95 and pretty universal at age 100. There is plenty of evidence that if all humans lived long enough, we would all develop Alzheimer’s type dementia (there’s even some evidence that it’s a life long process, wired into our central nervous system’s design – the price we pay for our intellects). In previous generations, the majority died of other causes long before it would have become apparent. Will the boom, still considering themselves young in their late 60s and early 70s, and living to age in reasonable health be able to cope with the combination of physical health and cognitive failure?

An interesting thing happens to long term married couples where one partner develops dementia with age and the other does not. The well partner is usually the last to come to grips with the changes and deficits in their spouse. Alzheimer’s type dementia is usually of such slow onset and progression that the well spouse unconciously adapts to that change, taking on more and more of the life and life tasks without necessarily understanding that they are doing so. It’s the child who lives out of state who hasn’t been home in several years who arrives for the holidays who can truly see the changes as the delta between what they expect to see and what they do see is large enough.
Once the spouse starts to understand that there partner is not reacting to them in the way they are used to, they try all of the techniques a lifetime of marriage has taught them in terms of cajoling, fighting, teaching, and just being. They don’t work. So they double down and try even harder and get the opposite resutls of what they expect. They show up in my office angry, frustrated, resentful, sad, and not understanding why the dynamics of their relationship aren’t working the way that they think they should. It’s my job to begin the process of teaching them that the demented spouse lives in a different reality with different rules. Time may not exist in the same way. They may both look at the same thing but see something different as the demented brain may interpret signals in unusual patterns. Reality is what our brains tell us it is. As most of our brains function in roughly the same way, we agree on it or, as Lily Tomlin once put it ‘Reality is a collective hunch’. When a brain no longer functions in the same way, reality becomes different and that person no longer lives in our world and we aren’t really capable of visiting their world either.

There are tantalizing clues as to what the world of dementia is like. When one looks at demented visual artists, they pick strong and vibrant colors and simplify line and detail. Other people strip away adult dissimulation and artifice and become plainspoken and absolute truth tellers. It’s no accident that in classical literature the fool is always the one who speaks truth to power. Shakespeare brings it all together in King Lear when the king and the fool confront the storm on the heath. Lear is a portrait of dementia robbing a powerful man of independence, but not self awareness and the fool is the one person who understands him. The relationship between Lear and his daughters is acted out in my waiting room about once a week as adult children try to figure out what to do with daddy as he’s losing his faculties.

Our current society is much like a long term couple where one partner has dementia. (I won’t say which one – people of different political persuasions will pick different sides but the analogy holds either way). Red America and Blue America are trying to exist in two different realities and the relationship is frustrated and foundering because they’re trying to use the same old same old communication methods to get through to each other and all it’s doing is raising the level of anger. Perhaps we all could take a lesson or two from a friendly geriatrician and take a step back and not try to force each other into old roles, but gently explore who we are as new and evolving people in a spirit of mutual respect. Some of my usual suggestions, like distracting each other with cookies to help change brain patterns aren’t going to work but an acknowledgement that we have to move forward towards new ways of rapproachment might be useful.

We’re going to have to do something to get us all on the same page regarding public health if we really want to bring COVID to task. In the meantime, wash your hands, wear your mask, keep your distance, get your shot, have a cookie.