Two musings in a row. That’s not something that happens too often these days. I guess I’m having to do some decompression or cleansing of the system or jetting out of the drains or whatever metaphor strikes your fancy and, as it’s my page and my writing, you all get to travel along with me if you so choose. Or you can scroll on by. Free will is still a thing. At least until the current administration shuts it down for being unpatriotic. I kid – they aren’t really going to come after anyone for their thoughts. But they seem to be dead serious about making sure we all understand that expressing our thoughts in certain ways is a good way to bring the full power of the US government down on individuals in sometimes a spectacularly cruel fashion – to demonstrate the consequences of not adhering to the party line in terms of history, science, culture, politics, economics, health, and dozens of other things where truth and fact are now regarded as so many political commodities and easily replaced.

Today I have been thinking about death. I last directed a musical in 2012 – 42nd Street for the Gardendale Arts Council – the budget was low but I was able to cajole a number of talented people into performing and on the artistic staff so the end result was actually pretty good. I had a number of high school and college age kids in the ensemble tapping up a storm. Two of them, Brandon and Angelicca, both died this week in their late 20s/early 30s. I can still see them as young people, grinning after a successful performance, not knowing or suspecting that their lives would be cut short not that many years later. This of course has got me thinking about other friends who died young – in traffic accidents, of suicide, murdered, of particulary nasty cancers. Because of theater, I tend to hang out with and have a lot of younger friends who should be outliving me and whenever one goes, I mourn the loss of the talent, and the light they brought to the world. Their creativity. Their humor.

I’m of an age now when my peer group are now all grandparents and starting to leave through the usual natural causes of aging organs or the cumulative effect of bad life choices. I’m well aware I’ll board the train myself one of these days. I’m not planning on it happening for a while but I am preparing for it. In my profession I’ve seen the thousand and one disasters that happen when there has been no preparation so I urge you, if you’re an aging adult, get that will updated, prepare an advance directive. Look around your living space and think about what needs to happen if you don’t have the ability to easily navigate stairs. Or if your memory isn’t quite what it once was. Or if you lose your ability to drive safely. I’ve thought through all of these possibilities for my life and have plans in place but most of us don’t because the inevitability of aging, debility and death remain the ultimate taboo in our society.

The first baby boomers turn 80 in just over four months. I refer to the 80s with my patients as the uncertain 80s. Most people – if they have had good fortune, good genes, good health care, and good choices, make it into their 80s relatively independent and unscathed. However, most people do not make it into their 90s in the same shape. The 80s is when most of our bodies and minds will fail. The policies being put into place by this administration are gutting health services for the aging. The current model of long term care/nursing home is going to become economically unsustainable very rapidly. As people on the lower 4/5 of the socioeconomic ladder age, given current trends, they’re likely to start plunging into poverty and ultimately homelessness which will lead to death. Their bodies won’t be able to hold up to those kinds of stresses.

But this seems to be ultimate goal of the current administration, a supplantation of our current reverence for life with a sort of necro-state designed to rapidly lower the population (other than those in the very top tier who don’t have to worry about a doubling of grocery or energy prices or a raising of rents out of reach of the younger generation). HHS is in the process of introducing rules to prevent the FDA from regulating the claims (and likely the ingredients) of patent medicines taking us back to the good old days of the 1890s when the American public poisoned itself at enormous rates. An inability to afford basic necessities will push more and more people onto the street where new laws against vagrancy will sweep them up into camps rife with disease (you didn’t really think all of these new camps would be reserved strictly for immigrants did you? They will be kept full with as many classes of undesirables as necessary to keep the contract money flowing). The federalization of law enforcement and the steps toward militarizing the national guard against the population of Democratic leaning cities does not bode well for anyone. We aren’t in a shooting civil war yet but the chess pieces are being moved into place. And then there’s Covid – with a recent pandemic that’s being erased from public consciousness for political reasons. It’s a virus that we still don’t completely understand and which likely will have significant long term effects on the population. But we’re highly unlikely to be allowed to study what they are as that would contradict the official narrative.

Put this all together and I see a couple of things coming. First, life expectancy in this country, already significantly lower than most other developed nations, is going to start moving down. The Boom and Generation X, who have aged seeing parent figures age successfully into their 80s and 90s are going to have difficulties matching this and are going to be livid that the quasi-immortality they have been promising themselves for decades will not be theirs for the taking. More and more young people, already being hammered by economic changes, student loans, and other such things that prevent them from maturing into such usual milestones as homeownership and parenthood, are going to be asked to help take care of aging family as there won’t be other options, adding further economic strains to family units.

While at times it’s lonely being responsible solely for myself in my aging state, I am thankful that I know enough about how all this works to prevent myself from being a significant burden as I complete my life cycle. But I’m not planning on closing that circle for a few years yet. I’ve got a few more things to do. Like finish all of Dickens’ novels – Read Little Dorrit last month. Four more to go.

It’s not quite a week post Shakespeare and I’m still trying to put my life rhythms back together. Sleep patterns are adjusting, stress level has gone down a bit, some things that have been sitting on the ‘to do’ list for a while have been stricken off. My big chore for the weekend is to get my final decision in regarding my fall trip. I have it down to two options and I’ve promised myself I will have a decision made by Sunday. I still haven’t come up with a decent travel companion with similar tastes, bucket list and finances. Some day… Or I strike it rich and start treating friends.

As I’ve come back to the surface and I’m starting to pay attention to the world outside of my condo, office and the theater, it looks like we’ve all stumbled into more of the Upside Down than I would have thought possible a few months ago. In the last few days I’ve seen mouthpieces for the administration opine that we should have taken Hitler’s side in World War II, that McCarthyism was a good thing and should be reestablished, and that the key to future success is the deportation of all non-native born Americans. Considering that pushback against these senitments has been muted at best and certainly there’s been none coming from the party in power, I can only assume that we’ve pretty much arrived at full blown fascism. There’s nothing I can do about it, just circle the wagons around me and the people whom I care about and hang on as things will get worse and there’s no white knight coming to the rescue.

Since I last paid major attention to politics, the president of the US has had private conversations with Putin (on American soil no less) where his aides were obviously distressed by the nature of the talks (pity there was not someone in a tree). The leaders on NATO dropped everything and raced to DC along with Zelenskyy to shore up support against Russian aggression. The secretary of defense keeps firing top military officers who insist on speaking truth rather than the lies he wants to hear. The Supreme Court continues to hand down decisions designed to speed up the conversion of government from tripartite to unitary executive. We’re busy opening concentration camps with cute names suitable for T-shirts and other merchandising opportunities. The Department of Health continues to suppress public health data.. All signs point to a sledgehammer about to be taken to the Smithsonian to rid it of degnerate history exhibits. And the FBI is being weaponized to attack Trump’s personal enemies. It’s enough to make anyone turn to drink and I have no idea how to parse it in such a way that I can even begin to wrap my brain around it.

On the Covid front, cases and hospitalizations continue to climb, especially in the West and Southwest. What few CDC numbers I can still find plus wastewater studies confirm this. Why this should be is unclear. It looks like we’re settling into a bimodal distribution with peaks in late summer and in midwinter. The peaks are likely related to human behavior and more extremes in temperature, whether cold or hot, pushing us indoors for either heat or AC and into closer proximity to our fellow beings. It’s still around locally. A local theater lost its star for the majority of the run of a cabaret show due to a covid infection last week. I haven’t been sick in some months following my winter from hell. It’s been nice to have felt normal for a while. This is probably a sign that I’ll come down with something next week. What likely saves me is the nature of my job which requires me to wash and sanitize my hands a dozen or so times a day which is going to reduce my environmental exposure.

I’m trying to figure out what I should write next. The posts about the state of all of our lives I’ve been writing for the last six months or so don’t lend themselves to much of anything other than Substack and I’m starting to think I need to embark on a project with a more definite goal in mind. Is there anything within my usual purview that people want to read about? Both of my vacation options come with some significant down time where I can possibly break the back on a new project of some sort. Perhaps a play in iambic pentameter. I tried that once. It was not a successful experiment. The juices just aren’t flowing at the moment.

Perhaps Richard II took more out of me than I quite understand given all of the various production disasters which I have detailed in previous missives. Anyone who wishes to judge my ides for themselves can do so at the following link: https://www.youtube.com/watch?v=00gvaegg120 – I have no idea if I managed to pull off even half of what I was going for. Maybe, maybe not. If you skim through it and like it, Yay. If you skim through it and hate it, tell me. I’m an adult, I can take it. You don’t improve without constructive criticism.

In lieu of my usual musings, I present the following. One of my Richard II cast used his experiences working on the show as part of a school project and, as part of that, asked me some questions. Here they are with my answers.

Can you give me a brief explanation of who you are and what your theater experience is like?

I’m a well-educated, highly imaginative man who has always tried to balance my right and left-brain lives in some way. I excelled in the hard sciences in high school and college and there was a family tradition of medical education that pushed me toward becoming a physician. I also always had a healthy interest in the humanities, reading voraciously and taking classes in history, sociology, literature, philosophy, and religion. At the age of sixteen, my high school built a new arts building with a theatre (we had never had one before). I had never done theater as a child but had been taken to live performance since I was old enough to sit still and had always enjoyed it. Something clicked, however, when I walked into that space and looked at things like the fly system. I wanted to learn how to use it to create. So, I signed up for technical theater and learned the basic elements of design, stage craft, and production. I found my niche as a stage manager and was later encouraged to try directing. I directed my first show, a one act, at the end of my senior year of high school.

When I went to college, I found there was a tradition of dorm theater. My freshman year, we decided to do a dorm production of You Can’t Take It With You. As I was the only one with directing experience, I got the job. The end result was reasonable It was seen by some upperclassmen prominent in campus theater who decided I had talent and was taken under their wing and I moved up the ranks in campus theater as both stage manager and director. Later, in medical school, I continued to stage manage and direct in community theater circles. It all came to an end when I hit residency and every fourth night on call.

I was away from theater for the next fifteen years building my medical career. In my early forties, after some life reverses, I felt a need to rebalance and decided to return to my old passion. I was encouraged this time to try performing. I had never considered myself a performer but figured what the heck and made the leap. Amazingly, I kept getting cast. Over the last two decades I’ve performed in over eighty productions in Birmingham and am occasionally given the chance to direct.

What inspired your production of Richard II?

Bell Tower Players, with whom I have worked off and on for a decade, is the only community theater locally that routinely does the classics. They have done a few Shakespeare plays in the past and a few years ago, decided to do Shakespeare in the summer and asked me to direct. My first production with them was A Midsummer Night’s Dream and last year we did The Merry Wives of Windsor. I wanted to challenge the group and move out of the comedies and didn’t think we were ready for any of the great tragedies so I decided that one of the history plays might be appropriate. I chose Richard II as I thought it would be castable out of our usual group and because it’s a particular favorite of mine in terms of its themes.

The play was chosen nearly a year ago and, as politics in the US progressed through that time, I began to think more and more about the themes of the play and how the major one that I wanted to highlight was that of power – how it is used, abused, and misused and how it can destroy an individual and ultimately a system of government. As I kept thinking about this, I decided that it would be interesting to highlight the parallels between Richard’s world and our own. Various ideas occurred to me and one of them was that the play was a memory play taking place in Richard’s mind as he awaits his inevitable death in his cell at the end. The technical limitations of our space and budget made me throw that out but I was intrigued of the idea of the jail setting and my original idea morphed into that of a political prison and more and more pieces fell into place as I continued to study the play.

I took ideas from varying sources such as Man of La Mancha, The Kiss of the Spiderwoman, Bent, the TV series Oz and scrambled them all together in my mind. I developed the idea of making the prison a temporary holding cell that has been thrown together, that it was a church basement to tie it closer to the audience’s actual experience, and came up with the idea of the color palette for the costumes to get the audience to subtly reflect on the meanings of the colors in various cultures. Then it was a matter of translating the action of the play into the milieu of the setting. What takes the place of throwing down gages? What does a tournament look like? How would a gardener show up to talk about plants?

Why do you believe community theater is important?

There are two words there. Community and Theater. I think the former is the most important. Community theaters are for the forming of a community, whether it be the show family created for each project or the group of people who find a theatrical home and return for production after production in some capacity. The theater is the team project. The thing that cannot be created by any one individual, but which requires everyone to do their part. Sometimes the smallest pieces become staggeringly important like with scissors. The pin is the most vital component. They are the training grounds where young people can get their first experience before moving on to more professional settings. They are the place of refuge for those who enjoy performing or creating but whose lives and life patterns preclude them from aspiring higher up the ladder. They can showcase incredible talents that will never be seen on Broadway and who deserve to share their gifts with the world. I see a lot of attitude among some in our area that they believe themselves too good to work on a small, low budget community theater show. I believe you’re never too good and that if the project is right for you, you can do smaller projects and mentor and inspire and raise the general quality of the art being produced.

How has being a part of community theater personally impacted you?

My adventures in community theater have taught me an enormous amount about human beings and human nature that has come in handy with my day job in medicine. It has helped me become a better and more creative problem solver. It has taught me communication skills that no class would be able to. I am definitely a more fulfilled, richer, and possibly more interesting person for all the things I’ve done.

What has been some challenges you’ve faced with Richard II?

I believe very strongly that good theater requires a cast to be an ensemble. That they learn to be comfortable with each other. To support each other. To work together as a unit. That way, when things go sideways, and they always do, they can handle it as a group and keep the show moving forward with minimal disruptions. With Richard II, I had a cast of sixteen, ranging in age from 19 to 86. Some had had decades of experience on stage. Some were complete novices. I had to figure out how to get them working together, to help them craft performances that balanced each other, and to keep them from being so scared of the language. As I say repeatedly, Shakespeare wasn’t writing Shakespeare. He was writing popular entertainments, and we need to approach it in that way to make sure it’s of interest to a modern audience. If everyone were to stand centerstage and declaim each speech in measured cadence, the audience would be asleep in twenty minutes. It has to be interesting. It has to be understood by the audience (which is more about intention and the actor understanding exactly what he or she is doing with what motivation) than it is about every word being perfect. We do these plays four hundred years later as Shakespeare was not only a brilliant poet, but also a keen observer of the human condition. It’s that latter which makes the plays still relatable and why we continue to enjoy them.

This particular production also had some major production issues. The lighting system died so I made the decision that we would simply use the work lights. As a concept, I didn’t hate it as that’s the kind of lighting this prison space would have had, but it meant we lost all control over using lights to help tell the story or to isolate particular areas of the stage that could have made it easier for the audience to follow some of the changes in setting in the Richard story. The costumer ending up in the ER twice in two weeks put costumes behind and I wasn’t able to refine some of the choices the way I might have otherwise. There were also significant difficulties with certain actors abilities to learn and retain their lines. One of them I planned for, the others I did not.

What about challenges with other productions?

I wrote, starred in, and helped produce a show called Politically Incorrect Cabaret that went through a dozen editions over fifteen years. We took it to venues in five states throughout the Southeast. The stories of that show are legion including unheated venues in below freezing weather, unairconditioned venues when it was over a hundred. Drunk tech crews (and one time a drunk cast member). Collapsing floors. Performing without a tech rehearsal. A power outage with the show done by candlelight and flashlights. I’m amazed that some of those actually made it on stage. But it’s semi-improv nature allowed us to get away with a lot.

I’ve had costumes disintegrate on stage, set pieces lowered on my head, falls off of platforms, a skid across the stage on my backside when a fellow cast member got a little over exuberant with a planned shove, been stuck on stage with a twelve year old when someone missed an entrance leading to five minutes of improv, missed cues, reordered lines, broken and missing props. It’s all part of what makes live theater so special.

I learned long ago to make Geoffrey Rush in Shakespeare in Love my spirit animal when it comes to theater.

What do you hope the audience takes away from Richard II?

I want them to leave the production thinking about something differently. Whether it is a different thought about our political moment, a new way of thinking about the possibilities of Shakespeare, or an increased respect for what Bell Tower Players and the performers are capable of achieving.

Can you share a story where you’ve witnessed the power of community theater positively impact another person?

I’ve seen a number of the young people with whom I have done community theater in the Birmingham area go on to professional careers. Perhaps the most famous is Jordan Fisher who will always be twelve-year-old Chulalongkorn in The King and I to me. Others I’ve worked with have gone on to national tours, Broadway, television, and national ad campaigns. I celebrate each and every one of them for their successes. Some get jealous. I don’t. I’m where I need to be.

Nearly twenty years ago, I played Mayor Shinn. The girl who played my younger daughter, eleven at the time, was just beginning in community theater. She went off, got her training and came back to town as a young adult and sixteen years later, I again played her father in Into the Woods in which she was a magical Cinderella.

What do you think about the health benefits (mental health or otherwise) of community theater, especially as a doctor?

Working in theater requires keeping ones mental faculties in shape and a certain level of self-discipline. It stimulates creativity, helps with memory, and often comes with a certain amount of aerobic exercise, especially when performing in a musical. A lot of stage performers continue to perform into their eighties as their training, and their performance regimens keep them in tip top shape.

As a geriatrician, when I find out that my patients have some sort of background in performance or music, I encourage them to pursue it on some level. It helps them tie in to pleasant experiences, encourages social connection and there is research that shows that both physical and cognitive abilities improve

What is your hope for the future of community theater?

That it will be seen to be as much a part of a healthy civic community as a sports team or an educational system, or recreational opportunities. The arts are as deserving of public funding as other aspects of civic life and should not be relegated to the whims of private funding or thought of as being less than other things we willingly fund like sports stadiums. Theater, more than any other art form, is the mirror of society as it exists as a collaboration between the performers and the audience. No two performances are ever exactly the same as no two audiences are ever exactly the same so the energy in the room is never duplicated. A film is always exactly the same. A play or musical is constantly reinterpreted for new audiences with new experiences and new historical context. It can always reflect both our better selves and those parts of ourselves we would rather not see.

I’ve been meaning to write a long post for some days but something keeps getting in the way. Work progress notes, social obligations, exhaustion and recovery at the painful process of getting Richard II on stage and in front of those not involved in the creative process. And now it’s 11 PM and I should be thinking about sleep but, instead, I’m letting my fingers do the walking across my laptop keyboard and we shall see what ends up spilling out. It could be anything as I’m just punchy enough to not censor myself in quite the way I usually do when composing these glimpses into my interior life.

We’ll start with Richard II – four more chances to catch it tomorrow (Thursday) and Friday at 7:30 and Saturday and Sunday at 2:30 at Bell Tower Players in the East Lake UMC Cafetorium at Oporto-Madrid Road and Second Avenue South. The cast, ranging in age from 19 to 86 and in experience from second show as an adult to decades on stage are embodying what I think is important about community theater: Coming together as a community to tell a story that cannot be told by a single individual. Personally, I’m relatively happy with how it all turned out although I am busy, as I watch it multiple times in performance, nitpicking at all my directorial choices and beating myself up on what I now perceive I should have done differently. Live and learn. This is the third Shakespeare I have directed over the last three summers and each has presented very different challenges. Will there be a fourth next year? Let me recover completely before making a final decision (although I have been noodling around with some ideas for The Tempest).

Speaking of the performing arts, the Kennedy Center honorees, the first under the new regime, were announced this morning. Given the seizure of that cultural institution’s levers of power by the executive branch and the battles that have ensued (and I am fully expecting a renaming to The Trump or The Trump-Kennedy Center before too much more time elapses), the choices actually aren’t that bad. The rules have always been important contributions to America’s cultural landscape, be living, and be willing to attend the ceremony. Given that most artists are of political beliefs incompatible with the current executive party line, there were plenty of jokes about Kid Rock and Scott Baio being amongst the honorees. Seeing Gloria Gaynor on the list makes this burgeoning gay adolescent of the late 1970s heart happy. And my sister is probably reserving her tickets to see Kiss. (She’s been a huge fan for nearly fifty years to the point of having a working Kiss pinball machine in her basement).

This of course brings us to the continued rise of authoratarianism which has moved from creeping to Maserati driving I-80 across the Bonneville Salt Flats over the last few weeks. Some 19 year old DOGE operative best known as ‘Big Balls’ got punched in the nose by a 15 year old girl on the streets of DC and the rhetoric of DC being a crime ridden slum (it’s not) is everywhere and we’re federalizing law enforcement and moving in the National Guard. Their much touted sweep of the streets netted 23 arrests, mainly of low level offenders. If the streets were full of thugs and murderers, you think they might have found a bit more. The truth is, of course, that violent crime rates are significantly lower in DC and nationally and have been decreasing for years, other than a brief spike during the pandemic shutdown. Birmingham, which has long been touted as a ‘dangerous’ city as it’s majority Black, has a murder rate this year 50% lower than last year and most of the city, even in Black neighborhoods is quite safe. I’ve almost never felt endangered in my nearly thirty years here.

The issue, of course, is that this is another testing by the administration of just what they can get away with before there’s pushback by the courts or the public. The vast majority of the population strongly disapproves of the administration’s policies and its heavy handed ramming of Project 2025 down our throats. But there has yet to be any unified opposition that the majority can get behind. The Republican party under Trump has spent the last decade concocting a mostly fictitious narrative of urban America as a hellscape of out of control ‘woke’ minority governance, invading hordes of undcoumented immigrants, and public schools performing sex change surgeries on elementary school students. It’s all ridiculous if you spend any time looking around at objective truth but it’s an easily understood story and it’s reinforced in easily digesitble sound bites by a well financed media machine. The Democrats have not spent much, if any time, creating a strong and easily understood counter narrative. Human nature relies on stories to understand the complexities of the world. The side which can best tell the story usually wins. The other side gets its exhibits scrubbed from the Smithsonian.

Trump remains a chief symptom of out of control vulture capitalism determined to transfer all things of value from the commons to private ownership of a new aristocracy. The prestigious institutions – universities, media companies, professional associations – that could best offer a counter narrative are all busy rolling over and offering up their bellies to the administration to scratch as their leaders choose private privilege and membership amongst the elite over public good. Where does it end? I don’t know but the tensions between the various groups behind the transformation of society – religious zealots, insanely wealthy capitalists, tech bros – all of whom are using the current administration to further their own goals seem to be getting worse and when Trump is gone, as will happen – he’s not immortal – the jockeying for position and dictating of the direction we next head is going to get awfully interesting. Do we end up in Gilead? In Brave New World? In a new industial serfdom? One thing history teaches is that anything is possible. This is all not the sort of thing I should be thinking about right before bed.

Someone told me this past week that I was Birmingham’s answer to Kevin Bacon. Everyone in town either knows me or knows someone who knows me. I suppose that’s what comes of having a number of very different circles of acquaintance – UAB, VA, aging adults, elder care and policy, classical music, theater, writing/spoken word, liberal religion, liberal politics, patients, patient families etc. With all this going on, there’s no way I’m going to leave town when I retire. I’m much too embedded in everything that goes on around here. A couple of people have asked me if I would consider running for local office once I retire. My answer to that is not just no but hell no. I am no fan of how modern politics is conducted, I have a few skeletons I would like to keep firmly in the closet and not trumpeted across the blogosphere, and I much prefer working behind the scenes as an eminence grise. With Richard II out of the way, I’m going to keep my head down and stay home for a few months and play catch up and maybe take a vacation for a couple weeks. Who am I kidding. Someone will ask me to take something on in the next few weeks and I’ll be off to the races again. Somebody stop me.

I’ve been through some troubled tech periods in my time but the last few days with Richard II may take the gold star. And that’s saying a lot, given my adventures with Politically Incorrect Cabaret over the years. (Butler buildings without air conditioning in 100 degree summer weather, abandoned boot factories without heat in freezing winter weather, windstorms on sea piers, more than a dozen dressing in a small emergency exit corridor, llamas just outside the stage door, Katrina damaged houses in NOLA without intact floors or walls, Wiccans out back hauling each other up and down with pullies attached to various body piercings etc. etc.)

Bell Tower Players has somewhat limited technical facilities and capacities. We perform in the cafetorium of an aging church building. There have been issues with the lighting in particular for years, likely due to an aging electrical system. We scraped together the money to replace all the heavy duty Fresnels and can lights with new LED instruments which consume far less power and can have color adjustments made without gels. For some reason, during first tech, the entire house right bank of lights would die every ten minutes or so. Eventually I made the executive decision to perform under the fluorescent work lights. Not ideal by any stretch but they at least stay on and allow both actors and audience to see. We disconnected the board and unpowered the lighting system so, of course, first dress the lights proceeded to turn themselves off and on at random moments and in random color shades. The poltergeist in the lighting system was effectively banished final dress by throwing various circuit breakers.

Costumes were behind due to the costumer having had to spend a day in the ER last week and another day recuperating. We had the majority ready for first dress and planned out the fixes and the need for distressing so he loaded them all up to take them home and work on them the next day. On his way in for final dress, he had a car accident and was back in the ER and there was no way to get the costumes back to the theater for the run so final dress done without costumes. They did make it in time for opening last night – I would have asked for a few additional fixes but time’s up. To add insult to injury, on the night of final dress, after the run, I went to the ED to check on my costumer and hit a pothole and blew out one of my tires. By the time I got home at 2 am I was fried and did something I have never had to do before in my last 23 years of dual careers and took a mental health day to recuperate.

We opened last night. Small, but appreciative audience. I’m hoping houses improve. (Hint hint to all my local friends whom I come to see in their shows…) In general, I’m pleased with my cast who are giving it their all in a not so easy piece to perform and are holding to my directorial strictures and overall vision. Is everyone ready for the RSC? Of course not but they are working together as a company and an ensemble and supporting each other so that each gets their moments to shine but at the same time unify with each other to tell the story. I think people are getting what I’m doing with the piece politically with its modern settingand dual layer of story between the prison environment and the collapse of the Plantagenet kings into civil war. It may take me getting the pulse of several audiences to know for sure.

Now that my job is over as far as Richard II is concerned (other than showing up for performances and glad handing the audience), I can start concentrating on other things. Important stuff like what am I going to do this fall in terms of performance career (I’m not contracted for anything until January) and if I take a trip in October, where am I going to go? I’d also like to get some writing done that has specific end goals and isn’t just these random musings. I’ve also got to fix the floor where the great washing maching flood of 2025 buckled the parquet and I’m feeling an urge to do some decluttering, especially as I may be losing my office relatively soon. Most things in my academic office can be thrown out. A lot of the files date back to California but there are books, and diplomas and artwork that will need to be rehomed.

It also, of course, means that I’m paying attention to this modern world for the first time since last weekend. I’m not exactly sure that I wouldn’t enjoy putting my head back under my pillow for a few more weeks but forewarned is forearmed. What have I learned? The Republicans are attempting to force through a mid-decade census which only counts citizens and to base reapportionment on this. Fortunately, the constitution is pretty clear on both the timing of the census and whom is to be enumerated so I don’t see this going very far. Of course, it will depend on the courts actually doing their job regarding interpreting and defending the contstitution and the Roberts court has shown itself to be somewhat questionable in this regard, not to mention having minimal respect for stare decisis. The president still does not appear to understand what a tariff is or does and his followers are bewildered as they stare at higher prices and import fees. I have the feeling that all of the bored high schoolers in Ferris Bueller’s Day Off who were drifting off as Ben Stein was droning on about the Smoot-Hawley tariff grew up to be MAGA economic advisers.

The biggest threat regarding the census proposition is that it would be an easy step to move from certain classes of persons from being non-enumerated to being non-persons. And once people become non-people it is very easy for the state apparatus to eliminate them one way or another. It fits in with the way in which programs are being erased which support the disabled, the chronically ill, or others unable to exist physically or economically without some sort of assistance. Without support, these populations are naturally reduced as disease and despair lead to higher death rates. If you read through the philosophical ideals of Stephen Miller and some of the other idealogues in the administration, they envision a future where 340 million Americans are winnowed down to 100 million young, white, healthy rich folk and what happened to the others is not really of any concern. We’re not all that far away from American families having to choose between groceries and support for grandma.

Political theater is playing out in a grand manner in Texas. Gerrymandering is a tool as old as election districts and both sides are guilty at various times. Currently the Republicans are more blatant in their attempts to enshrine minority rule. Quorum busting is also an old technique which has been used by both sides at various times. It’s not illegal and the various threats are likely only so much saber rattling, but given the current adminstrations complete disregard for laws, rules, norms, and ethics who knows where this one is going to end up. All it does however is draw attention to a need to bend if not break rules in order for the Republicans to retain power in the midterms and middle America is starting to see that.

The Epstein files remain the gift that keeps on giving… something. No doubt Trump is in them. The two were close. No doubt Trump is guilty of bad behavior. He’s been well known for it for fifty years. Were laws broken and cans/should Trump be prosecuted? That’s the sixty-four dollar question. Highly likely given the circumstances of his life but I’m not going to rush to judgement without evidence. The Republicans, having used them to beat the Democrats over the head for years, are going to have to come clean at least about some things or, given the more salacious components of the whole affair, it’s not going to disappear from the headlines and the Democrats are going to keep fanning the flames going into next year’s midterms.

I’m thinking a cocktail or two before tonight’s performance may be in order.

T-3 and counting. Three tech/dress rehearsals before Richard II in unleashed on an unsuspecting world. Things are coming together so I am going to put on my best Geoffrey Rush from ‘Shakespeare in Love’ and assume it will all work itself out because it almost always does and that’s the magic of theatrical live performance. I do have to give kudos for my cast and staff for holding on to my fever dream of an idea about having this play about the abuse of power leading to the collapse of a societal order being used to mirror how those same dynamics are playing out in today’s world. It will be up and running and I’ll have had some audience feedback the next time I write one of these epistles and I guess I’ll know whether the show is a success or a craptastic flop. It takes really bright, talented people to create a theatrical disaster. The unimaginative and untalented just create mediocrity and not the disastrous flame outs that become theatrical legend.

I had my annual review this past week. I am gainfully employed for another year. Neither UAB nor the VA seems dissatisfied with how I get my job done. As I’ve been doing it for them for nearly three decades, I more or less have it figured out. I guess this is my penultimate review. I’ll have another one next summer but I plan to be retired before the summer of 2027 comes along. Of course there’s a lot that could change between now and then. Things remain unstable in federal agencies, academia, and health care due to the caprices of the current administration and I haven’t a clue where we’ll all be heading next month, much less a year and a half from now. I’m being encouraged to continue thinking outside of the box and coming up with new ways of positioning senior care in a constantly changing environment. I don’t mind a challenge but I think this one is beyond my capabilities.

As Richard II exits my life, I have to figure out what’s next to keep the creative juices flowing. My publisher remains out of pocket so the writing projects for him are on hold. My last few auditions haven’t led to any results. I am in talks for a few projects for the fall that won’t require a cattle call audition. (Good – I hate them and I’m not especially good at them). I do want to take a trip abroad in October of some sort but haven’t gotten anything narrowed down yet. I’m thinking something relaxing with some beach time but we shall see. I also have to get out to Seattle to see the family this fall. It will all puzzle together somehow and around about Halloween I’ll be looking at my schedule and lashing myself for my usual over commitments.

There hasn’t been much happening in covidland recently. Antivaccine voices are being magnified for political reasons and I’ve read things blaming covid vaccines, specifically spike proteins for everything from new onset schizophrenia to liver failure to increased asthma this summer. (First and second, not a shred of scientific evidence and third more likely due to heat domes and air quality). From what I can tell, vaccine will be available for fall boosters for those who want them (and only about 15-20% of the adult population is taking advantage) but given the actions and rhetoric out of DHS and CDC I wouldn’t count on much for next year. It looks like Kennedy is going to remove the regulations and laws which have shielded vaccine manufacturers from liability (a necessity to keep them in business in our litigious society). If that happens, manufacturers of all vaccines are likely to start withdrawing from the US market. Catch up now.

And that’s how this administration is operating to exert control across society. It’s actually rather clever. They’re not directly telling an institution what they can or cannot do, they are placing levers of power over the flow of dollars so that institutions will police themselves and fall into compliance with the political will of the current executive branch. Media companies are being blessed with ‘bias monitors’ as a condition of federal approval of mergers and acquisitions who, if they do not like a news story can trigger federal sanctions. Universities are accepting federal monitors who will check on admissions and hiring to prevent forbidden DEI practices or their federal funding for research grants and the like will be withheld. Critical voices are rapidly becoming complacent. And inconvenient truths are being erased. Take H5N1 bird flu. CDC is no longer tracking cases or spread. If it starts human to human transmission, there will be no early warnings and we won’t be aware of an emerging pandemic until it’s far too late to do anything to try and stop it.

Trump continues to turn the White House into Mar A Lago North. The pictures of the unsightly patio over the former rose garden lawn have done nothing to alleviate my fears over just what all else he has planned for the residence. And we found out this week that he is going to raze the east wing (no huge loss) for a huge gilt ballroom which appears to be modeled on Versailles (showing that he has no understanding of the neoclassical design of the building and its decor). I’m sure we will soon be treated to pictures of him on a dais smiling over a ballroom full of over dressed sycophants. It brings to my mind the old trope of the glittering ball just before the revolution that’s a mainstay of old Hollywood and potboiler novels. We’re reaching a revolutionary inflection point – inequality, hoarding of resources, an armed populace. It may get interesting in a year or two.

I’m having a grumpy night. It’s a night off from Richard II rehearsal so I used it to try and get a jump on my clinical work so it wouldn’t all be hovering over my head this weekend. However, no sooner did I sit down to try and work through various inboxes full of issues that really don’t require physician input when I fell into a doze and woke up about two hours later out of sorts. I did get the stuff I needed to fet finished done but getting ahead will have to wait for another day. My feelings of fatigue continue and it probably didn’t help that we were hit by a major thunderstorm just about then which passed directly overhead. There’s something about the sound of pouring rain that always wants to make me sleep.

Richard II is coming together. Five more rehearsals until it is presented to the public. The cast are starting to get their lines down. Characters and performances are pretty much there. The set is done. The props are done. The costumes are in progress and should be done this weekend. Sound and light cues are at least understood and we’ll try to get them all programmed into the system on Saturday. I hope that my vision comes across clearly and that people understand the show as I understand it. I guess I’ll find out. I’m preparing myself mentally for people to hate it as it is very nontraditional and because it comments on modern politics. It’s somewhat dicey to do that in modern Alabama. Fortunately the sort of people who are likely to attend Shakespeare performed in a church basement are likely to be intelligent enough to get what we’re doing.

The drain line on my washing machine backed up this past weekend and caused a major flood in my main hallway. There was already some minor damage from a previous flood from the HVAC line six months ago but this one did a real number on the parquet with a lot of the tiles buckling. I’m waiting for it all to dry out thoroughly so I can take stock and figure out what it’s going to take to repair it. It’s always something. Fortunately I have an emergency home repair fund squirreled away, having learned a few things from bitter experience. Water/plumbing issues have been the bane of my existence since moving in here five years ago. I’ve had to have the kitchen sink drain line repaired, the shower hot water line fixed twice after it kept backing hot water up into the toilet, the HVAC drain dealt with, the two year saga of redoing the drainage on my deck, and now the washing machine drain. All I need is an exploding toilet to get a Bingo on my card.

I did a little noodling around covid data this week. Numbers are increasing, but not by a lot. It’s becoming harder and harder to find reliable sources of information as the federal government continues to try and rewrite the pandemic narrative for political reasons. Acute phase covid doesn’t appear to be the major risk at this point. Long covid, seems to be the major issue moving forward with significant cardiorespiratory and neurological problems becoming more and more prevalent but as money is being diverted away from these sorts of public health issues, it’s really tough to figure out what may be going on. Beware of just googling. More and more of the hits appear to be from pseudoscience organizations with political agenda who are trying to make the health issues all about vaccines and vaccine side effects rather than the actual disease. I’ve gotten to the point where I just don’t engage anymore. It just sucks up my time and energy to no avail.

There are all of the usual political outrages. Other people analyze them better than I do. I’m not a historian, a social scientist, or directly involved in politics myself. The trends I find most concerning, besides the undermining of the health system and the advancement of knowledge, are the steps being taken to muzzle news reportage and the flow of information. Both CBS and NBC are under major fire from the administration for reporting news in a way that the administration does not regard as favorable and with threats to broadcast licenses etc., they are backing off. The way things are going it won’t be long before all of the major media outlets news reportage will be parroting administration talking points and unfavorable stories will be buried. And does something actually exist if we don’t know about it? There will be independent sources and investigative reporters who take their jobs seriously but that information will be relegated to the fringes of the media landscape and difficult to find, especially with the loss of net neurtrality.

Emil Bove, Turmps personal lawyer, was confirmed to a seat on the third circuit federal court of appeals. Bove has made no bones about his adulation of an authoritarian executive and that he thinks it’s perfectly OK to act in an illegal manner and to ignore court rulings in order to achieve that end. The SCOTUS confirmation of absolute presidential immunity for official acts has given the cover necessary for him and his ilk to move forward. Now that he is on an appeals court, I expect either Clarence Thomas or Sam Alito to step down from the supreme court opening up a seat and dollars to donuts, Bove will be the nominee and in a position to move the judicial levers even closer to the executive for the taking.

And then there’s the ever rising cost of living which current policies are not going to address. I have a number of much younger friends who are being decimated financially by skyrocketing rents and food costs. As these are being driven by forces of vulture capitalism, and not by the presence of immigrant communities, the administration’s focus on shipping people out, no matter how valuable they may be to our society, isn’t likely to help. The administration has been crowing about the amount of tariff revenue they’ve brought in. The MAGA movement still doesn’t understand that that was money we paid in higher prices of imported goods. It wasn’t paid to us by entities outside of the country. Apparently basic economics hasn’t been taught in American high schools for the last forty years.

Twenty-one months….

People don’t believe me when I tell them that I don’t plan these pieces out in advance. I simply feel a need to write and then I open up the laptop, chase a cat or two out of the way and set my mind in brain dump mode and out it call comes. Sometimes there’s a theme or a throughline. Sometimes one develops as I sit there for an hour letting my fingers doing the talking. Sometimes it’s a bit of an incoherent muddle. But still I keep it up – nearly 700 long posts/rants/musings/travelogues/history lessons/meditations over the last seven plus years. If I were to collect and publish them all the way I did the Covid posts, we’d be running somewhere in the eight to ten volume range and ain’t no one got time fo’ dat. I’ll just leave them here quietly moldering in cyberspace, of interest to few but myself and perhaps some future historian looking for primary sources on how ordinary folk felt and coped with the extraordinary times in which we find ourselves.

Someone told me this week that I am Birmingham’s answer to Kevin Bacon. you can connect pretty much any two Birminghamians through me in only a couple of steps because my circles of acquaintance are so large and so disparate – aging services, liberal religion, classical music, musical theatre, LGBTQIA issues, patients and their families. I suppose that’s a compliment. I’ve never met Mr. Bacon but he seems to have had a great career, a nice stable marriage, and I’ve never heard anything particularly negative about him through my Broadway and Hollywood connections so I suppose I could do worse. He’s a few years older than I and seems to be keeping his looks better. But then he’s likely got a personal trainer, a photo shoot makeup artist, and doesn’t havve to deal with the absurdities of the American medical system on a daily basis. When I was younger, I looked very like Nicolas Cage (to the point that people who knew him mistook me for him). Now, I just look like me. I think I’m OK with that.

Time for an update on the health system as it pertains to someone like me. RFK Jr. is in the process of firing the entire United States Preventive Services Task Force. I predicted this some weeks ago so I don’t find it particularly surprising. It’s just more of the administration’s war on inconvenient scientific facts which don’t fit their political agenda. The practical result of this is that a packed new board is likely to discount many of the findings and recommendations that have been promulgated in the past. Legislation that was part of the PPACA required that health insurers cover screening tests and preventive services that USPSTF rated highly. If these are downgrated or discarded, health insurers will be under no legal obligation to continue covering them. My guess is the first to go will be vaccine recommendations. There appears to be a multipronged attack on vaccinations happening. They’re opening up vaccine manufactuers to all sorts of liability which will make it economically unfeasible for them to continue to sell to the US market and, by eliminatiing payment mandates, those vaccines that remain will quickly become unaffordable to a majority. So, if you’re behind in any of your shots and boosters, it’s probably best to get them quickly before you simply can’t unless you can afford some medical tourism to a country which still believes in the findings of medical science. Meanwhile, the rest of the Kennedy family are expressing their ire at renaming the opera house at Kennedy Center after Melania Trump. Well, she does seem to have modeled her life on Cunegonde’s Act I coloratura aria.

What’s going on with covid? Numbers are increasing. There’s been a surge each of the last few summers starting in late July and this year is no exception. What drives it? I would guess that the oppressive heat is driving more and more of us into airconditioned shared spaces and therefore we’re simply more likely to run into the virus. Mortality rates don’t seem to be particularly increasing, so that’s good news and there doesn’t appear to be a lot of new mutations out there yet. The right wing propaganda machine continues to try and rewrite history casting the covid vaccine as the cause of the increase in chronic illness over the course of the last few years rather than the virus itself. Most of us caught the virus at least once. The vaccines kept a whole lot more of us from dying of vascular and respiratory collapse. I’ve long predicted that the virus, by its nature, was going to have nasty surprises waiting for us as time went on. I think the increase in general unwellness happening at the moment may be part of that. It’s far more likely than some of the more far fetched ideas I’ve been reading on the site formerly known as Twitter (where millions of people seem to have conspiracy theories over such natural phenomena as clouds).

Of course the big story of the week continues to be the Schrodinger Epstein files and what’s in them which seem to both exist and not exist at the same time. Given everything that’s been known about Trump (and I’ve certainly known who he is and his reputation with women for about forty years now), I can’t for a minute believe that he’s not all through the 300,000 pages of evidence collected on Jeffrey Epstein and his bad behavior. However, by making Epstein a rallying point of an anti-Democrat conspiracy theory (Comet Ping Pong Pizza anyone?) he has painted himself into a corner. If he allows everything to become public and everyone sees the depth of his involvement, he’s toast. If he uses his powers to try and make it all go away, it becomes a massive coverup and he’s toast. The Republican legislators appear to be collapsing like a pile of wet noodles as they’re smart enough to understand the perdicament. And then there was the icing on the cake – this week’s episode of South Park. Parker and Stone know that the way you destroy a narcissist is not to hurl invective and not to try and show fact and reason to counter the narrative, the only true weapon is to laugh at him and refuse to take him seriously.

There was an executive order this week calling for all homeless to be rounded up and removed from the streets, promising federal grants to states who stepped up with plants to execute this. Buried in the language of the order are some very vague terms which would pretty much allow the government to declare anyone they feel is mentally ill an undesirable who could be detained. This could easily be used against the trans or the wider LGBTQIA community. They seem to define ‘woke’ as a mental illness so it could easily drag in minorities and those of liberal political affiliation. Perhaps this is the true purpose of the rapid building out of detention centers. It’s not truly about immigrants. Once they are built, economics will demand that they be kept full with someone. All I can say is that when I’m shipped off to one, I’ll likely meet some interesting people with whom I can have some meaningful conversations.

And this is why I am directing Richard II the way I am. I’m setting it in the holding cell of a detention center that has rapidly been put together in a church basement. It’s not supposed to be America of today. I’m deliberately making it vague. The ideas regarding the abuse of power that led to England tearing itself apart in a four generation civil war whihch Shakespeare so eloquently puts forward in his play are the same issues we are confronting today. My cast are finally getting what it is I’m trying to do and are beginning to play both the Shakespeare history and the framing device of the prison together. Thiis crazy idea of mine, which I dreamed up very early in this second Trump administration, before even a fraction of what we are now dealing with surfaced, appears to have some prescience and traction and I hope audiences leave thinking about how human nature hasn’t changed over the centuries and that we must look to the past if we are going to take control of the future.

I’ve got rehearsal in the morning. Trying to clean up the interactions between prison guards and prisoners and how that highlights certain major themes and plot points. Wish me luck.

Pulpit Message given today, July 20th 2025 at the Unitarian Universalist Church of Birmingham. For those who would prefer to listen, I attach a link to the stream of the service. The sermon begins at 37:45. The service ends rather abruptly due to a medical emergency. I swear it wasn’t my fault…

Moral Injury and Evil: American Health Care

Good morning. I’m Andrew Duxbury. I’ve been a member of this congregation for twenty-five years and when I’m not making good trouble around here, I’m a professor of clinical geriatrics at UAB. Someone decided it was a good idea for me to speak from the pulpit today. I have decided to speak about a world in which I have been steeped for more than four decades, the American Health Care system. To paraphrase Mark Twain – everyone complains about it but no one does anything about it despite becoming, as the kids like to say, problematic. So, I thought I’d take a little time to examine what that’s all about.

I’ve entitled todays remarks Moral Injury and Evil – American Health Care. I did this because, in the four decades that I’ve been part of the system – and I can’t always tell if I’m part of the problem or part of the solution – I have noticed certain issues and themes which violate the first rule of medical ethics- Primum non nocere – first do no harm. These trends seem to be accelerating these days, driven by all sorts of forces far outside the control of any one individual and, in my case, they are driving me out the door. Earlier generations of physicians felt a calling to practice as long as they were physically and cognitively able. I can’t do that. I was created by medical education for a different era of healthcare, and I find that I no longer fit. Trying to change to fit more would violate some fundamental ethical codes – it’s going to have to be new generation that carries things forward, one trained for the times in which we find ourselves.

If we’re going to talk about what is moral and what is not, I suppose we’d better define what moral means. So I went to Google, the fount of all knowledge, and asked it to provide a definition. Here’s what I got – concerned with the principles of right and wrong behavior and the goodness or badness of human character and holding or manifesting high principles for proper conduct. This sounds reasonable to me. I was raised by parents who had expectations that we would live upright lives. I wasn’t beaten over the head with religion. I was raised Congregationalist and our services were very similar to what we do here in UU but we had a cross rather than a chalice and we talked about Jesus a little bit more. But I was guided to be truthful, to myself and others, to follow through on commitments, to share, to give others a hand up when I could, to do my best and learn from my failures rather than let them defeat me. By the time I was an adolescent, I had a strong moral code embedded throughout my personality. Sin was not what you did, it was the harm your choices caused to others. (Hey – it was the 70s).

There is a good deal of soul searching going on among the thinkers in the American Health Care System regarding moral injury among health care providers. It’s been one of the main drivers that is causing workers to leave clinical care fields – and they are in droves. 20% of the workforce that was in clinical care at the beginning of 2020 no longer works there. The reasons for this are not strictly due to moral injury, the changes wrought by the pandemic are a more proximate cause, but the transgressions of various types keep piling on. Again, we should probably take a minute to make sure we’re all using the same definition. Dr. Google says moral injury is a specific type of psychological harm that results from experiencing events that violate a person’s deeply held moral beliefs and values. It can occur when someone perpetrates, witnesses, or fails to prevent actions that go against their own moral compass. This can lead to feelings of guilt, shame, anger, and a sense of betrayal, impacting their self-image, worldview, and sense of well-being. The last five years have seen a rise in bad behavior, an undermining of the scientific principles upon which American healthcare is built, a significant shift in the power structure away from the needs of patients to the needs of big data, and an out of control profit motive warping everyone’s missions.

Most practitioners would deny that they are agents of moral evil or that the American healthcare system exists for purposes other than good. Again, to make sure we’re all using the same definition, Dr. Google says moral evil, in philosophical terms, refers to harm or suffering caused by the intentional actions or inactions of moral agents, such as human beings. I would beg to differ somewhat. My personal ethical code, for instance, refuses to let me consider the effect a patient’s treatment plan may have on my personal income. I have navigated this comfortably by making the decision early in my career to always work for salary. I’ve made a lot less money, but I can sleep at night. I give every patient the same care and attention no matter what their financial means are, and I don’t make decisions based on what it might mean financially for me or my employer. I know plenty of health care providers whose decisions are much more based around maximizing revenues and tricks of billing and deciding what is the minimum they can deliver and remain within terms of contract. There are also social moral evils – various isms such as racism and sexism which have dogged the healthcare system and which continue to cause inequities – the current presidential administration wishes to punish those who point them out.

American healthcare is an odd amalgamation of scientific knowledge, historical accident, capitalism run amok, and beleaguered allegiance to the past. No one sat down and planned it to be the way it is. Even as we all despair and curse over its current structure and function, it was not conceived and constructed by idiots. It was put together over many generations by very smart people confronted with specific problems which needed to be solved. For the most part, their decisions defeated the issues that plagued their time but they were unable to foresee and project what their solutions would do over the course of decades, especially when fossilized by commerce and custom.

What we have now in this country is unique. There’s no other system like it in the world in terms of structure, cost and results. We continue to have a cultural belief in American exceptionalism in medicine. That we are cutting edge, that we can do things that can’t be done elsewhere, that this is where the rich and powerful of the world flock for treatment. And for decades, there was fact and data to back up those beliefs. Unfortunately, we continue to carry them with us, inscribed on our cultural DNA despite the world having changed significantly in recent years.

We are the only developed country who ties health care to employment. It’s a historical accident but it reinforces the concept that those who are productive are deserving and that those who are not productive are undeserving of health services. This false dichotomy rears its head in political discourse more times than I care to count and has been particularly prevalent in current budget discussions and the obfuscation of very real cuts to public funding of healthcare.

We put more money into our healthcare system than any other developed nation. Fully 16 percent of our GDP enters the health care sector of our economy. The next highest, Switzerland, spends 11 percent of its GDP. Most developed nations spend somewhere between 9 and 10 percent. We are an extreme outlier. One would think, with that much money sloshing around the system, that we would be close to the top in terms of results. Wrong. Our life expectancy is amongst the lowest in the developed world, our maternal mortality and infant mortality rates are very high and in some of our poorer areas approach those of sub-Saharan Africa. When our health system is ranked against other world health systems on access, efficiency and results, we usually end up somewhere between number 15 and 45 on the list depending on the exact measurement criteria. We’re usually down around Slovenia and Costa Rica. Who’s on top? Taiwan.

As I said earlier, none of this was created with ill intent. To understand what happened and why, we have to dive back a bit into history, going back to the beginning of the 20th century and what was known as the progressive era. 19th century medicine, to our eyes, seems barbaric relying on primitive surgical technique, a poor understanding of hygiene, a lack of anesthesia, and a medical education system that varied widely in its ability to train physicians. Some schools granted diplomas with no clinical experience or exposure to anatomy at all. Most medical treatment was delivered in the home by Granny with the help of various patent medicines that were nostrums at best and poisons at worst; they often contained significant amounts of alcohol or opioids turning a large portion of the population into addicts. The political pressures that led to the creation of the Food and Drug Administration, public sanitation projects, and the clearing of tenement slums, spilled over into the medical profession.

In 1904, in a bid to prevent the federal regulation of the practice of medicine, the American Medical Association created a council on medical education determined to improve the standing of the profession and hired the Carnegie Foundation to aid it in its quest. In 1910, Abraham Flexner, under the aegis of the Carnegie Foundation, produced a report on the state of medical education in the US. His report called for standardization of medical education based in medical science, the closure of schools that could not meet basic standards, and the selection of students based on demonstrated skill and aptitudes. Within the next decade or so, there was a major reduction and consolidation of US medical schools and a domination of the field by allopathic schools, those granting an MD degree and based on the disease model of acute care medicine. The Flexner report also emphasized that a physician was responsible for his patient and not for the community at large, leading to the split between medicine and public health which continues to this day.

Flexner’s report, while protecting the public and laying the groundwork for licensure, board certification, and the specialization system that still prevails, had some inherent flaws. Like many things of its time, it was steeped in systemic racism, advocating that African American doctors should only treat African American patients and that the needs of that community were lesser. Most of the predominantly African American medical schools of the time did not have access to the resources necessary to bring themselves up to new standards and subsequently closed severely limiting the ability of minorities to enter the profession. The Flexner report also discounted the role of women in medicine and actively discouraged the admission of women to training, something that was not to change for more than sixty years. Medicine in this country very much came under the control of and was limited to WASP men and the moral evils of racism and sexism were very much part of how the modern system was put together. Even the Jewish community was shut out but they pooled their own resources and built their own parallel institutions such as Mount Siani and Beth Israel.

As the first generation of newly trained physicians entered society in the years after World War I, America was still dubious regarding the medical profession. In the 1920s, the average household spent more on cosmetics than on health care and most treatment was still happening within the family. The new medical schools needed patients to train their future doctors and nurses and the economy of the roaring 20s was leading them to expand their physical plants and to construct new hospital facilities. Advances in asepsis and anesthesia were creating significant improvements in surgery. In 1929, Baylor University, in Dallas Texas, built a new hospital to benefit its medical education programs but were having difficulty finding patients to admit. Justin Ford Kimball, then Baylor’s vice president for health sciences, had a bright idea. He went to the Dallas Teachers Union and struck a deal. If the union would pay a flat fee monthly to Baylor for each of its members, than any member who became sick would be entitled to a stay at the hospital and use Baylor’s medical services free of additional charge. It was the first modern health insurance program and eventually changed its name to Blue Cross.

A few years later, everything changed. The US became involved in World War II. This cataclysmic event radically transformed the American health care system in a number of ways. First, an enormous number of American citizens were shipped out and put in harms way some were killed, but even more were wounded or became ill from exposure to unfamiliar disease vectors and the rigors of warfare. More and more healthy young bodies with significant pathology returned to the US allowing our medical system to study illness and injury in great depth and our understanding of pathology and how to better care for ill and wounded humans skyrocketed forward. This coincided with one of the great medical discoveries. Alexander Fleming had discovered the penicillium mold on oranges in the 1920s and its antibiotic properties were known by 1930 when it was first used to treat an infection (conjunctivitis in newborns). There was a problem, however, the means to isolate the chemical which we now call penicillin from the mold and then produce it in quantity had not yet been figured out. This puzzle was cracked in the early 1940s, shortly before the US entered the war. This new miracle drug gave the US a new weapon in the war which every army has faced since the beginning of time, that against wound infections. As it was of national security importance, research on antibiotics amped up and by the mid-1940s, they were available not just to the military, but to civilians causing a revolution in the perception of health care.

Antibiotics, which initially needed to be administered intravenously and therefore required hospital care, led to more and more people, whom loved ones would have witnessed dying at home just a few years earlier, going to the hospital and walking out. Our infrastructure, including our health system, was intact following the war while that of most other developed countries was in ruins. We were able to get the jump on everyone else and the idea of American exceptionalism in medical care was born and, within a few short years, we had developed our current acute care hospital centered system of providing care.

In addition to this, the industrial economy was heating up. American factories needed to produce goods not just for the US but for the world suffering form fifteen years of pent-up demand caused by the Depression and World War II. Jobs were plentiful and everyone was hiring. However, there were wage and price control laws on the books left over from the economic management of the Depression. These prevented employers from boosting salaries to attract talent, so they turned to other inducements which became the benefits package. By 1947, the titans of industry turned to congress and had the tax code rewritten to make it financially advantageous for employers to provide health insurance and an employment-based system was born. It took root nowhere else.

It was quickly realized that an employment-based system left out the post-employed and the unemployable so steps were taken to create legislation which would provide a federal safety net for these individuals. Unfortunately, these attempts were branded as ‘socialized medicine’ and ran into the red scare of the late 40s and early 50s and went nowhere. It wasn’t until 1964 that the political moment became right and under the Johnson administration, the major federal health and welfare programs such as Medicare and Medicaid became law. There was abundant opposition to these programs, led by the AMA who believed firmly that inserting a federal dollar into the patient/physician dyad would add a third decision maker, causing problems for both sides. They hired an out of work movie actor to be their celebrity spokesperson for their campaign against Medicare, Ronald Reagan. He found he had a knack for politics.

Fifteen years later, Reagan came to the presidency on a tide of government isn’t the solution, it’s the problem. His economic policies began a transfer of wealth upward and encouraged economic consolidation. Reaganomics hit medicine as much as any other sector. Before the creation of federal payment systems, medicine was primarily a small business operation. Physician practices were privately owned. Hospitals usually were owned and run by not-for-profit institutions of charitable mission, whether religious or secular. Medicine was by law and custom a not-for profit-enterprise which existed for social good. In 1974, when Richard Nixon, at the behest of his old friend Charles Kaiser, signed the HMO act, he opened the door for private enterprise to purchase and make profit from entities providing medical service. Reaganomics put this move on steroids and by the mid-1980s, for profit hospital chains and insurance companies began to dominate the market. Wall Street took notice of the amount of money that could be gleaned from the system. It came calling and an earlier generation of clinicians sold out for personal profit.

Since the 1990s, the trend has been consolidation, corporate ownership, additional layers of management such as pharmacy benefit managers which add complication but do little to actually improve healthcare. The rise of computers and AI has added a whole new set of complications as medicine as an entity increasingly reacts to aggregate big data and less to the needs of the individual. This has placed the physician in the midst of a moral dilemma. To whom does he owe allegiance? The patient or the paycheck? Our time is spent in data gathering and data entry (my day is becoming reminiscent of my very first job at age 15 when I was a data entry clerk and keypunch operator). The computers track our every move. If we don’t meet our metrics, we will be dismissed and replaced allowing us to help no one. I didn’t know I was spending thirteen years in higher education to learn to type.

Starting in 2020, it’s all started to unravel. I call this ‘The Great Undoing’. It began, of course, with the Covid-19 pandemic. The lack of preparation, the neglect from the highest levels of government, the trauma of provision of care in impossible circumstances, the indifference of administrative layers safely cocooned in their working from home environments led to a wholesale rush for the exits from the older generation. Everyone is short staffed. It takes more than a decade to train a doctor and almost as long to train a nurse practitioner. You can’t replace the workforce with a couple of weekend seminars and some YouTube videos. Everyone has noted the inability to get appointments and the delays in care that have become commonplace. We want to help but there’s only so many of us left to go around.

In addition to this, this past year has led to a presidential administration determined to bring down American medicine for political gain. The great institutions created from the ideals of American exceptionalism are being decimated. The research universities which create our knowledge and train our future providers are under attack and having their funds sharply curtailed. Those put in charge of our major health programs proudly advertise their ignorance of science casting aspersions on centuries of learning. I’m all for making America healthy again but throwing out the last century and a half of medical advancement is not the best way to accomplish that goal.

This leads the average practitioner open to the death of a thousand cuts of moral injury. On a daily basis we must pay more attention to a machine than to our patient, constantly try to do more with less as the money in the system dries up, argue with clerks at insurance companies and pharmacy benefit management firms to try and get what we, with our many years of training and experience, know our patients need but which keeps getting shut down by someone with a high school diploma and a company manual, endure arguments from patients and families, based not in science or logic, but on the latest misinformation advocated by media conglomerates or fueled by direct to consumer advertising, try to bolster the morale of our colleagues who may be in a worse position than we are in, have to fill out the same form for the third time because an insurance company doesn’t like our choice of wording (what part of both legs amputated don’t they understand?) and on it goes.

These moral injuries, to me, have root in moral evils. What are they? The first comes out of the old adage: Radix Malorum est Cupiditas. Greed is the root of all evil. I’m not against capitalism and I’m not against making a profit. I am against the making of money to pay shareholders being the be all and the end all of such a vital part of our lives. There is a role for the federal government to manage important sectors of our economy so that they can exist and work for the entire population. A second moral evil is our construction of a system that exists to prevent care. The ubiquitous middlemen that are now part of every decision process need to be replaced with people who understand the nature of clinical medicine and the sacred bond that develops between patient and physician which allows true healing to occur. Our third major moral evil is the rejection of knowledge, science and fact for political expediency. This one is probably the easiest to deal with. Fact is fact no matter how hard you deny it and, as will eventually happen, when something arises to bite us all in the butt because we refuse to understand how nature works and our place within natural systems, we may quickly reverse course.

So how do we fix this mess? It’s fixable but it’s going to take a lot of political will and a certain amount of uniting of the country behind a movement to accomplish this – and our current politics don’t allow for uniting over much of anything. If we eventually come around to an understanding that we are stronger together rather than on opposite sides of the football stadium, we may be able to take on some of these tasks. These include resource redirection away from administrative functions to clinical functions, a better understanding of morbidity and mortality so that we no longer hold impossible ideals like ‘death is optional’ , creation of universal data systems so that information can be quickly shared throughout the system, development of single payor mechanisms, and subsidization of medical and nursing students so they don’t enter life with six figure debts that require them to concentrate in higher reimbursement specialties.

What comes next? I haven’t a clue. Stay tuned. I’ll probably write something about it eventually. There’s only one thing of which I’m fairly certain. Retirement in 22 months. But who’s counting? Thank you.

I’ve been meeting to write a long post for days but every evening when I have completed the tasks of the day, I’ve just been too tired and crawl under the covers instead. I’m still somewhat more fatigued than I think I should be. (Nothing seriously physiologically wrong as I had my usual medical check up a few weeks ago and everything was fine). Maybe it’s just the thing I discuss constantly with my patients – a brain that thinks it’s somewhere around thirty years old and a body that is definitely not. I continue to keep up with everything I need to do (although rehearsal on top of a full work day is a bit harder than it used to be) and I’ll just continue to carve out naptime.

What may be going on is a natural phenomenon deeply connected with primitive brain reflex arcs. Our brains are built from the inside out with the most primitive functions tied to keeping us alive in the deepest and most ancient structures (what I usually refer to as the lizard brain). Our lizard brain is what keeps our internal organs running, provides the circuitry that creates such things as hunger and thirst, and is acutely aware of danger and makes us do what is necessary to preserve life and limb. Our primitive reaction to danger is usually referred to as fight or flight. But there is a third setting – play dead. I don’t know about the rest of you but modern politics and pandemics have created a constant stream of danger stimuli for roughly a decade now which is pretty inescapable if you’re an informed person. My danger circuits may just have worn out and gotten stuck in the play dead setting making motion and activity just that much harder than it needs to be. I’ve certainly noticed this for some years in subtle ways like a need to sit in the car for a few minutes when first arriving home after work and allowing my brain a little off time before I get out and head into new patterns and activities. When I query friends, many of them have noticed themselves doing something similar. And it’s a new behavior for all of us.

I attended a performance of Big River at Virginia Samford Theatre this evening. For those of you not conversant with everything Broadway of the last century, it’s a musical adaptation of Mark Twain’s The Adventures of Huckleberry Finn written by Roger Miller in the mid 80s. I last saw it staged about forty years ago in Sacramento at Sacramento Music Circus. (Music Circus is one of the last surviving old fashioned summer stock companies staging eight or so musical revivals, one a week, in the round in a large tent). When I first moved to Sacramento for my residency, my apartment was three blocks away so I saw pretty much everything they did. I eventually moved about twelve blocks uptown but Steve and I continued to walk down on summer nights seeing sll sorts of terrific Broadway names in the classics. As far as I know, Music CIrcus continues strong even though I haven’t been back to Sacramento for any significant length of time since being forced out by UC Davis’ bad decision making in the late 90s. I hope the tent has better air conditioning than it used to.

As I was watching the show tonight, I began to think about Mark Twain’s ruminations on the American character as exemplified by Huck and Jim’s journey downstream on their raft and how there are observations that he made with Huck’s awakening to Jim’s humanity that very much apply to our political moment. The electorate, both red and blue are together on a metaphorical raft at the moment and, like Huck, prey to being forced to share their space with con men like the King and the Duke (who are cut from the same cloth as some of our current power figures). We too can open our eyes, join together, help each other, and come out the better. But we need to want that and I’m not sure that either side has decided they really want to bridge the divide quite yet. I don’t know what it’s going to take. And that’s one of the things that scares me most.

This week has been about the base of MAGA, the part that organized itself around a bunch of nonsensical social media posts by someone purporting to have the real truth of the so called deep state and how it has something to do with sex trafficking and cannibalism amongst other eddifying issues, erupting in fury as Trump has tried to downplay the various scandals involving his old buddy Jeffrey Epstein. For those who were hoping MAGA would implode, it won’t. It’s going to take a lot more than decades old gossip about bad behavior amongst the rich and powerful to undo that particular brain fever. It does, however, give some interesting insights into the mindset of those who follow the QANON cult thinking and how detatched from obersvable reality they seem to have become. None of the Epstein issues really bothers me one way or another. Let the court system sort it all out and if there has been illegal behavior and it has been proven, let it be appropriately punished, no matter who was involved or what their political affiliation. I read someone’s opinion piece that this is all coming to a head now because Trump has started to realize how badly played he has been by Putin and he has therefore tilted the US back toward the Ukraine. As Putin’s only real interest in Trump was for him to hand him Ukraine on a silver platter, with that moving out of reach, he’s now trying to push the Epstein narrative as a way to take Trump down. Given that many of the loudest social media voices on the right are amplified by Russian bot farms, there may be something to this.

There’s been lots of bad news in the last week but there’s only two things that truly scare me. The first is the speed with which the administration is busy building and consolidating an extrajudicial detention and punishment apparatus. The politicization of the military with the National Guard in California, the building of detention centers with zero information and oversight, the enormous increase in budgets for iCE which is being remade in the mode of a secret police force does not bode well. They’ve pretty much limited themselves to detaining immigrants at the moment but there are signs that they are spoiling to go after those whom they feel are getting in the way of their detention plans. I can easily see rounding up and detaining of citizen demonstrators and monitors of ICE action coming shortly and it will only be a short step from that to detaining those whom they feel fund or provide support to these people and then it will be open season on political opposition. And when citizens are disappeared into detention without warrants or judicial review, what will you do? It’s not that much of a step to make the disappearance of inconvenient persons permanent.

The other is the silencing of media opposition through the leveraging of corporate power. Anyone who thought that corporations would stand against the current administration is awfully naive. Corporations exist for the sole purpose of producing profit. They will bend whatever way they think is necessary to keep the money flowing. It took less than six months for most of corporate America to back away from DEI and support of the LGBTQIA community. The government has essentially killed PBS and NPR with the recision bill that it forced through congress. CBS, as its parent company Paramount Global is desperate to complete a merger with Skydance which requires federal approval, has essentially emasculated Sixty Minutes and offered up Stephen Colbert’s head on a silver platter to appease Trump. From what I can tell, both the Washington Post and the New York Times have both backed off any hard hitting reporting on the administration at the behest of corporate ownership. Pretty much all media in the US is owned by one of six large corporate entities which will do whatever is necessary to preserve their bottom lines. Given recent history, this means not leaning too hard on the administration or its policies. So how are we supposed to get the information we need as to what’s actually going on in DC?

Only about 10% of the population pays attention to politics and federal policy. The vast majority of Americans have no idea of the enormity of the change that’s currently going on or what it is likely to mean for their lives over the next year or two. A compliant media isn’t likely to inform them. It’s not in their interest. When things start going south for more and more of us, I have no idea how people are going to interpret that or where they are going to try and place blame. That’s one thing I really despise about American culture – the idea that everything bad must be somebody’s fault and that you need find the culprit and blame/shame them. The world doesn’t really work that way. But we’ve never been a country willing to accept how the world works – either the natural or the man made.

Sometimes I think I need to get on a raft and head off somewhere myself.