July 1, 2021

The Aquarium – Branson Missouri

It’s another month and we’re half way through 2021. At times, the days fly by, and at other times each one seems to drip drip drip by at an interminable pace. I think pandemic thinking and experiences have screwed up my brain’s inner understanding of time. It no longer seems to be uniform with each hour identical, but more elastic stretching or compressing like Silly Putty depending on events or my inner moods. Society, at least around here, seems hell bent on restoring itself as if the pandemic were over and there’s a need to make up for lost time. The trouble is that it’s not. The number of cases and the death rate continue to inch up. We’re at something over 605,000 dead now, not that much further until it surpasses the Civil War and becomes the second largest mass casualty event in American history – the 1918-19 flu epidemic is likely to hold on to the number one spot, at least for a while.

The big problem area at the moment is Southwest Missouri, home of the Ozarks and Branson. I would venture to guess that the latter is why this region has become the first major cluster of the Delta variant. The type of person who vacations in Branson (and the usual tourist traps are booming as people come out of a year or so of restricted life and movement) is less likely to be vaccinated. They have come from all over, crowded into various theaters and attractions, and brought their viral hitchhikers with them passing them on to employees who then carry them into the surrounding communities. The local hospitals are inundated again and transferring patients to St Louis and Little Rock. I have a feeling that this is a canary in the coal mine moment and, as visitors to the area return to their homes, Delta will soon be popping up in a community near you where, given it’s increased transmissibility over the original strains and its predilection for young and unvaccinated people, numbers will start rising in hospital systems elsewhere. Given the usual timelines between seeding of virus, a significant population developing virus, and when that population starts getting seriously ill, I’m thinking we’ll start seeing a spike in casualties at the end of the month.

Of course, the vaccine will help, but the lack of enthusiasm for vaccination by a majority of the unvaccinated crowd means that even if it becomes clear that numbers are going up, the mass vaccination sites have been dismantled due to waning interest and there is roughly a month delay between first jab and full immunity so they would have to begin the process now to be protected by August when we’re likely to start seeing some more concerning numbers. I don’t have a lot of empathy for willful antivaxxers who are becoming ill at this point. Who I do have empathy for are the burnt out health care workers who are being called on to keep on keeping on in a preventable situation. This has very real consequences. People are quitting clinical health care positions in droves and there aren’t a lot of folk standing in line to take their place. Almost everyone I know of my generation and older is taking a fresh look at their retirement plans and the stories of docs having to not only do their work, but pitch in to change the sheets, administer the medications, and mop the floors due to a shortage of other clinical workers are legion. Most physicians I know will buckle down and do anything necessary in a crisis but it’s not a sustainable long term model for a functional health system.

I wish I had a better read at the moment on the business of health care. I knew I should have gotten that MBA when I seriously looked into it a couple of decades ago. From what I can tell, there’s a major acquisition spree going on in the C suites with small and medium size players being swallowed up for larger interstate players and this seems to be true in most sectors of the business. The AMA released a report this week that for the first time, a majority of physicians worked for a hospital or health system entity rather than for themselves in private practice. I don’t think that’s necessarily a bad thing. I have always worked for a large academic health system as faculty – it’s a model I grew up with, allows me a certain amount of freedom to feed my intellect and soul as well as make money, and I like knowing how much money is coming in each paycheck. I haven’t gotten rich doing it but I keep the bills paid and can afford to retire when I think the time is right. The problem is that most of the big players are not academic health systems, which are not for profit public goods but rather private companies whose only goal, ultimately is profit.

As the profit motive has invaded sector after sector of our economy and lives, there’s been a certain level of degradation of our way of living. The wheels of capitalism grind on, lifting a few up and right over the backs of most of the rest. That’s because of when we are asked to choose profit or people, we currently choose profit and turn a blind eye to the people that creation of profit may harm. In medicine, the profit motive at upper levels leads to additional layers of byzantine bureaucracy as each tiny kingdom attempts to minimize its cost centers and buff up its balance sheet. It leads to clinicians being asked to do more and more with less support. (Support salaries are expensive). It leads to an obsession with data and numbers over the actual patient. I keep having to teach medical residents that lab numbers are not interchangeable with the patient and to go talk to him or her and get a decent history about how they’re feeling and symptoms before relying on what spits out of a lab computer.

The sucking of money out of systems for profit is leading to other problems as well. Compare our decayed public infrastructure with that in other wealthy countries and a political system that is having extreme difficulties coming up with solutions as it might require additional public spending. It’s seeping over into private spending as well. Would the Surfside condominium tower have collapsed if the squabbling residents in the HOA had been willing to fund the urgently needed repairs when they were identified several years ago? Now I know a few readers are busy calling me communist in their heads. I’m not. I’m just not a vulture capitalist that believes that everything should always be about profit all the time. The profit motive is a good one and keeps us industrious but I do think it has to be shaped and managed by good government and policy so that a handful of families control more wealth than half the country. My work on rural house calls routinely takes me into the homes and lives of those that capitalism has completely crushed through no fault of their own and I get a lot more of the downsides than most in the professional classes, who have minimal contact with others not like them, do.

I’ve been booked as a ‘celebrity’ story teller at a fund raising event in a few weeks. I’m trying to decide just which of the stories of my life I need to tell. I’m leaning towards the saga of Steve’s cremains as it’s a classic but I’m afraid it may be just a bit morbid so I should think of something a bit more uplifting. While perusing the internet this week, I found that a previous blog (written from 2005-12) is still on line and accessible. Maybe I should poke around that. I have had two other blog lives – one from 2001 started just after Steve died and kept off an on up through meeting Tommy in 2003 (which I cannot find a trace of on the internet although it may be archived somewhere I haven’t thought of looking yet) and a group blog called Eternity LTD from the late 1990s that covered the period where everything fell apart in California and Steve and I had to relocate to Alabama. (I think I know where that one may have an archive.) Do I dare read any of them? Will I even be able to read these posts in another decade without cringing? And what about the book? Am I going to look at it in a few years as a significant accomplishment or a slight embarrassment? I would like to think that practice is making my writing better with time but one never knows, does one…

June 27, 2021

I’ve been exhausted most of the weekend. There’s no reason for me to be particularly tired but I still slept ten hours Friday night, required a two hour nap Saturday afternoon, slept another eight hours last night and napped again today. It reminds me of coming home from college for vacation. I’d do little but sleep as my body unwound from the stress of the previous quarter and prepared for the stress of the upcoming quarter. I’m not sure if this is about the receding of Covid and political stressors or if my body knows on some level that there’s more to come and making me slow down and store energy for the next round. All I know is I’m not proceeding terribly quickly on my next few projects. Fortunately, they aren’t things with specific deadlines attached so if I keep losing time to naps, I’ll still be OK. If nothing else, the cats seem very taken with my predeliction for falling asleep and snuggle up to do the same.

Covidland is relatively quiet. The number of US deaths has dropped below 300 a day, despite the spread of the delta variant. Whether this is now the new normal or the calm before the storm of an exponential rise in cases in states with low rates of vaccination remains to be seen. The problem with exponential numbers is that everything seem placid and calm and then all of a sudden things are everywhere seemingly out of the blue so it’s entirely possible that there will be a relatively rapid rise in cases to be followed by increased mortality later this summer. We shall see what we shall see. In the meantime, I’m taking advantage of a more open social life as the theater folk are starting to get back together as we have all been vaccinated. There was a very nice backyard gathering last night where I saw many folk I have not seen for the last year and a half.

The book is essentially finished. After much consultation with my editor/publisher we’ll be running a couple of preliminary copies next week to go over with a fine tooth comb to make sure all the errors have been caught and that all of the art/titles are correct. Advance copies should come out the second week of July to send to people to try and garner some positive buzz and reviews and then it should go on general sale at the end of July. I’ll be working on setting up some readings/signings locally. It still seems very dreamlike, as if I’m discussing someone else’s work and I don’t know if it will seem real until I have actual physical copies in my hands. Even then, it might not seem real. I don’t know if it’s my impostor syndrome or my underlying Eyore personality that makes me feel like it’s always someone else’s story anytime I have a significant accomplishment.

As I don’t really have much to say this evening, I suppose it’s story time. This one is from many decades ago, back when Steve and I were first together. As I related in my last post, I have a bit of an odd GI tract that does weird things. One of the things that it does is react strangely to local water systems. I figured this out years and years ago when every time I would visit LA, I would have an upset stomach that would go away as soon as I returned to Seattle or Northern California. I don’t know what it is about LA but I assume it has something to do with the mineral content of the water or how it’s treated. Anyway, Steve was an LA boy who had only moved up to the Sacramento area about a year before we got together so most of his friends remained in LA. We therefore drove down a couple times a year to see some of his old friends and visit his old haunts. The run from Sacramento to LA down I-5 was about seven hours so we could even bop down for a long weekend, especially with two drivers.

A more famous banana stand then the one in question…

One visit, early in our relationship, we decided to go to Universal Studios – neither of us had been for at least a decade and we thought it might be fun. We got up early to get to the gates before things opened so we wouldn’t have to wait in line. My upper GI tract was bothering me, as it usually did in LA, so I hadn’t had any breakfast and really wasn’t interested in eating anything. Steve was having none of it so he went over to the snack kiosk and bought me a banana and stood over me forcing me to eat it. Ten minutes later, my stomach rebelled and the banana was going to reappear. We were in the middle of the plaza in front of the gates with no convenient rest room so I did the only thing I could do and leaned over the rail at the edge of the plaza. There was a drop of some forty feet down to a flower bed which the regurgitated banana sailed down, to the consternation of the tourists marching up the drive. Steve was mortified. I felt much better and we ended up having a great time on the tour. Steve learned his lesson. Ever after, if I told him I wasn’t hungry or didn’t want to eat something, he took me at my word. And to this day, I do not eat bananas other than the occasional slice in a fruit salad. And don’t get me started on banana pudding which is constantly offered but always politely refused.

June 23, 2021

Today is apparently International Widow(er)s Day. The things you learn from social media. It hasn’t quite become a Hallmark holiday. Even Hallmark would likely have difficulty selling greeting cards emblazoned with some variation of Happy Widowhood! on them. It’s not something one really feels like celebrating. It’s just an uncomfortable fact of life that when you have a partnership, if it ends through natural rather than accidental causes, as most do, one is going to survive the other. It’s a state I can’t really recommend. The hardest part about it is no longer having the one other person who knows all your secrets and stories and shared memories no longer there. You can build a new life and new patterns but the keeper of the flame of the old one is gone and the light is out in the temple and later you start to wonder what was real and what was nostalgia as that partnership recedes in the mists of time with no one to help you with a reality check. Steve will have been gone twenty years six weeks from now. So much of our time together is now almost dreamlike as we spent nearly all of it in another state from where we now live and I don’t have a lot of contact with people who knew him on a regular basis. Tommy, having been gone only three years, is much more real and there is a lot of life and people around who knew and loved us as a unit but I know even that will eventually change.

I’m thinking about the hundreds of thousands of new widows and widowers created over the last fifteen months by the pandemic. At least mine happened during relatively normal times when I could be surrounded by people, have proper wake/memorials, take the time I needed to travel and do the things I know that help heal myself. Too many people this year lost a partner to a plague they knew was allowed to spread through governmental inaction, could not be present for the death, could not hold a proper memorial, and then had to retire immediately to the place of their memories as there was no where else for them to go. Just one more piece in the giant pile of mental health issues that COVID-19 is leaving in its wake. As the pandemic wanes and patterns return, those of us in health care are seeing sharp upticks in behavioral issues, depression, anxiety, maladaptive coping mechanisms and all the other frustrating and agonizing parts of the human condition. It’s going to be a long few years and it’s going to take a lot more than prescriptions for Zoloft and Ativan.

We’re at about 603,000 dead as of today. The bodies are no longer piling up by the thousands, only by the tens and twenties, but its still too many as at this point, because with successful vaccines, COVID-19 is essentially a preventable disease. Almost nobody has to die going forward but with about 35% of the population unvaccinated nationwide (closer to 60% in Alabama), the casualties will continue to mount. There are now reports of the Delta variant in numerous places and hot spots are developing in various communities with low vaccination rates. Rural Missouri appears to be spiking currently. With its increased transmissibility, increased virulence, and rapid spread among young and healthy people, there are going to be a lot more young widows and widowers in the coming weeks. Someone is going to have to explain to me why ‘freedom’ is more important than ‘life’ in the minds of those who are of a more conservative bent than I am. I just don’t understand.

I have the long weekend off and I thought perhaps a trip to the beach might be nice. Then I checked the lodging prices. When Motel 6 is over $400 a night, I stay home. I’m assuming that the owners of lodging establishments are attempting to cash in on everyone’s need for busting out of their cocoons of the last year and a half but I’m not sure predatory capitalism is the solution for society’s current ailments. I foresee a lot of people running up some significant debt as they splurge and then having to try and service that debt in an uncertain time. The 1918-19 pandemic helped fire off the Roaring 20s a century ago and we all know how that ultimately turned out for everyone in 1929.

I am not practicing predatory capitalism myself. The book, when it becomes available next month, will be priced at $14.95. I’m not trying to make money off it. I’m just trying to get it out there. If you want to be on my list of people to send teasers and other information to and you don’t think I have your email address, send it to me by DM. I will have a signing event or two in Birmingham for those who really want my terrible handwriting scrawled across the title page.

I haven’t told a story for a bit. Here’s one from a few years ago. Those of you who know me well know I have a bit of a weird GI system (thanks for those genes, Dad) which can act up from time to time. Generally it’s under reasonable control with medication but if it decides to go crazy, not much I can do about it. One of the things it can do is go into acutely painful intestinal spasm. I’ve gotten used to it – given that it’s been happening since I was a teenager – but my autonomic nervous system never has. When it really gets going, is sends my parasympathetic nerves into overdrive which do various things, especially drop my blood pressure causing me to roll up my eyes and faint. During medical school, I once did this in a room with forty medical students and eight attendings. There was a great deal of clamor and I got a free tour of the emergency department on a stretcher. The last time I had a severe attack, I was out shopping for supplies for one of Tommy and my famous cast parties. I had made the rounds – Winn Dixie, Sam’s Club, and, as a last stop, the liquor store. As I headed up to the cashier with my bottles of Cointreau and Amaretto, it hit and, while waiting to pay my bill, down I went in an ashen heap much to the consternation of the cashier and the other patrons. I came too enough to finish my transaction and stumble out the door. I just needed to get to the safety of my car. And down I went again in the rain in the middle of the parking lot. (Fortunately the bottles did not break). This time, I did not come to quickly and the ABC store clerk called the police about a drunk and disorderly. I was woken up by a nice policeman, came to enough to explain that I was a doctor, I was not drunk, I was not stoned, and I knew exactly what was happening. He took me at my word but flatly stated that he wasn’t going to let me drive anywhere. I returned home in the back of the squad car. I got home, took a nap, and then had to explain to Tommy, once he got home, just why we had to go back to the liquor store to pick up my car. He was highly amused. Every time we went to the liquor store together after that, he would inquire innocently if he should catch me as we approached the register. It’s missing the little jokes like that which can make widowhood difficult.

June 19, 2021

Happy Juneteenth. (A holiday long deserved and which better not be taken over by white culture with mattress sales or beer busts). Mine is starting at 4:30 AM as it’s my call weekend and a resident at the nursing home that I cover as part of my call duties decided this was the right time to act up in such a way that the nurses needed to wake me up. Call is a necessary part of the job and my duties aren’t especially onerous (about three weeknights a month and a weekend every other) but I learned long ago that my brain/sleep physiology is such that if I’m woken up in the middle of the night, I rarely am able to get myself back to sleep again and I’ll be faced with a number of hours of wakeful tiredness before I have to get up and face whatever the next day has to bring.

This is my first call night without a beeper. UAB has finally fully joined the digital/cell phone age and replaced beepers with an app on our smartphones that serves a similar function. Having had a beeper on my belt for professional purposes for something over thirty years, it feels a bit odd to be without one. I was a bit worried that the phone wouldn’t wake me up (I’m well conditioned to that obnoxious beep but can sleep through nearly anything else – internship in the pre-limitations on residency work hours will do that to you) but the ring tone they’ve chosen is piercing enough to work just fine. So here I am, in the pre-dawn hours, listening to the birds outside my bedroom window greeting the imminent arrival of the miracle of another day and batting away Anastasia who is trying to help me type.

The persistence of the beeper is only part of the health care system’s continued reliance on 80s/90s technology in a world where other industries have fully embraced the digital era. For instance, we are the only industry that still runs on the fax machine as an essential mode of communication. (I still have a landline not because I use it or because anyone ever actually calls me on it but because it’s necessary at times for me to fax documents larger than the fax app on my smartphone can handle). Some of this is due to the medico-legal system. Most of the laws that govern the handling of medical information were written forty or fifty years ago and haven’t been updated to take modern technology into account. Things change piecemeal bit by bit. The electronic transfer of prescriptions for controlled substances, which used to only be valid via hardcopy with an original signature, became a reality a couple of years ago making everyone’s lives easier. The home care and hospice industries, however, still run on fax and I get about 150 pages a week, each of which needs to be signed and dated and sorted into the appropriate piles to fax back. Everything in the medical system requires the signature of a licensed physician somewhere on some piece of paper in order for things to move forward. (Electronic signatures now work within certain parts of electronic health records). If we were all to break our wrists on the same weekend, the entire US healthcare system would grind to a halt.

Some of the lack of progress comes from the inherent conservatism of the profession and its practitioners. You don’t really learn to be a physician in medical school. You learn a lot of random facts and you learn how to train your mind to sort through those facts and parse them properly to understand what’s going on. All the things you really need to know are actually learned on the job by observing your colleagues and peers and modeling what they do. This makes the profession very dependent on ‘we do it that way because we’ve always done it that way’ thinking and highly resistant to change that does not naturally enter the work flow through physician practice. If you ever want to see physicians, especially clinicians, get their collective backs up, try imposing mandates on what they do from outside – especially when they come from areas where they are designed by individuals who are not themselves practicing clinicians.

Then there’s the silos and fractures in the system regarding information. Every other country with an advanced health system has a single way of collecting data and recording patient information no matter where in the system you may go. This allows charts to be shared electronically between any physician or nurse, any hospital, or any ancillary service and everyone is working off a single data stream. (We have that in this country in just one place – the VA system. It’s possible to pull up the same records in any VA hospital or clinic from Fairbanks to Miami). Everywhere else in the US works off jealously guarded proprietary information systems which do not interface with each other. I can see everything that happens in the UAB system in a patient’s electronic chart but if they see a provider or obtain a service outside of UAB, even if it’s across the street, forget it. (Unless somebody sends a fax.) Patients and their families really don’t understand this issue and think that records miraculously move from place to place. A huge amount of my time is spent trying to reconstruct what happened in another emergency room or repeating a test I really didn’t have to repeat because I had no way of accessing the results. Even in the same institution, the data systems often don’t interface properly so that the billing system and the clinical system, for instance, don’t talk to each other which requires everything to be entered twice. This is why you’re constantly filling out forms at the doctor asking for the same information over and over and over again.

We could have a single data system for health care in this country. It’s been proposed countless times. It tends to be shot down for the same reasons that the rest of our infrastructure is falling apart. The only entity that’s big enough to marshal the resources to make it work and bring it to every health care provider would be the federal government meaning a large outlay of tax dollars and some sort of federal agency to run it. For forty years now, the more conservative of our political parties has run on a platform that government is the problem, not the solution and wanted all such issues handled through private enterprise. The result is many small private solutions, developed piecemeal to the detriment of the system and the health of the great American public. It’s not a problem I have a solution to as long as that philosophy remains entrenched.

Back to the beeper. They have changed some over the years. When I started in medicine, they were analog short wave radio receivers. In the hospital, you called a number and spoke into the phone and your voice would emerge from the belt line of one of your colleagues. Given the age of medical residents and the punchiness of constant sleep deprivation, this usually led to a lot of practical jokes which we would find hilarious. One female resident of my acquaintance announced that her beeper must be like a penis. It hung at the front of her pants and would call attention to itself at inopportune moments in an obnoxious manner. No one disagreed. By the early 90s, beepers went fully digital and voices were replaced with short bursts of text. The arrival of the world wide web meant that you could access them from any digital device on your own. Before that, outside of the hospital, you had to call the hospital operator and ask them to access the system for you. The hospital operators knew everything about everyone and you never wanted to get on their bad side for fear they might spill the tea. The ones at UC Davis during my residency years were all very sweet and were good at keeping our private lives private – most of the time…

Digital communication has been a wild ride over my career – from landlines and pay phones to car phones to cell phones to smart phones. You have to wonder what’s next. Implantable devices allowing us to communicate with anyone anywhere without having to actually have an object external to our bodies? Wave your arm over the grocery check out to pay for your items? Download any piece of information directly into your brain? Who knows.

June 15, 2021

I’m returning to the field with my VA house call program. Today was spent in Huntsville, last Thursday in Guntersville, and shortly off to Jasper. If all goes according to plan, I will be adding Childersburg to the list. At that point, if we can get functional teams in Muscle Shoals and Anniston, we’ll be able to offer house calls to every veteran in the Birmingham VA catchment area. If I retire with that having been accomplished, then I’ll think I’ve really managed to do something lasting with my job. Hopefully the stars will align. Who am I kidding? It’s not up to the stars, it’s up to the bean counters in a back office making decisions based on allocated funding and cost benefit analyses. Medicine, like everything else in US society, revolves entirely around money. The first thing I teach medical students when they ask why things are a certain way is for them to figure out who is being paid and how much. That usually answers their question for them.

I don’t have much to report from Covid land. We are over the 600,000 death mark. Only 10,000 more to go to top the Civil War in terms of casualties. We’ll likely hit that by fall as we’re still recording dozens, if not hundreds of daily deaths. The rates around here, which had been falling precipitously through the spring thanks to vaccination, have stalled and are now inching back up due to the number of unvaccinated people in our local communities. While a lot of states are celebrating the 70% level, Alabama remains stalled around 40%. The number of vaccines given the last couple of weeks has been going up, possibly due to the end of school and more free time for people to go get one, but we still need a lot more. We’re now about two weeks out from the long Memorial Day weekend so the hospitalization rate, if its been affected by behavior changes then, should reflect that this next week or so and the death rate will reflect it the first couple of weeks of July.

I’ve run into a number of people recently who have developed Covid these last few weeks despite being fully vaccinated. I’m wondering if that’s the spread of the more contagious and virulent Delta variant. The good news is that studies and anecdotal evidence have shown that if you catch the disease after full vaccination, you may be miserable for a while but you won’t be sick enough to require hospitalization and the chance of death is negligible. The bad news is that as people jettison their masks and learned behaviors for ‘normal’ and more than half remain unvaccinated, your chance of running into the disease remains rather high and, as the Delta variant takes hold and aggressively crowds out other strains, you may get sick this summer. I don’t take foolish chances, but I’m fully cognizant that I am not immune to the vagaries of fate so I’m expecting to feel rotten sometime between now and Labor Day.

The big thing at work, as far as my patients go, has been the approval of aducanamab (trade name Aduhelm), the first new medication for Alzheimer’s disease in decades. There has been some breathless coverage in the lay press aimed at seniors which has got a lot of people worked up about a potential miracle drug for themselves or loved ones. Alzheimer’s disease is one of the scariest diseases out there for most elders. Everyone recognizes it as the disease that destroys the self and, as the self is the most basic concept we have in Western thought, it is absolutely devastating for all involved. I’m rehearsing my gentle speeches for my patients in my head so when they ask, I can let them down gently and explain that the drug is not what they think it is. Most drugs rarely are.

When I entered geriatrics, back in the very early 1990s (30 years ago next month), there were no real medical treatments for Alzheimer’s or other dementias. We tried to control symptoms with various psychoactive drugs, often not very well, but we experimented and learned and stopped doing some of the more destructive things we were doing at the time because we didn’t know any better. Actually, there was one drug on the market for dementia – hydergine. I don’t think they even make it any more as it didn’t work. Everyone knew that the major mechanism in memory involved neurons using acetylcholine as a neurotransmitter and that if you could increase the amount of that chemical in the brain, things should get better. The problem is taking oral acetylcholine is useless – gastric acid breaks it down into acetate and choline which get nowhere near the brain.

People were experimenting with direct injections of acetylcholine into brain ventricles and all sorts of other iffy things without much success until someone hit on the idea of just using the acetylcholine that was already in the brain. Rather than adding more, create a medicine that would prevent it from being broken down in the brain’s constant recycling of materials. Drugs were developed that blocked the enzyme responsible for this breakdown. The first one was tacrine (Cognex) which came out towards the end of my fellowship. It was imperfect. It had to be taken four times a day and it was very toxic to the liver in certain individuals requiring regular blood tests. (Both of these things can be problematic in the demented.) A few years later, better drugs came along with the same mechanism of action donepezil (Aricept), rivastigmine (Exelon) and galantamine (Razadyne). They were not toxic in the same way and could be dosed once or twice a day. None of these drugs is great. They may show down the disease process some for a time, generally not more than a year or two, but they cannot prevent the disease’s slow inexorable march across the brain. But they are something and we use them routinely.

About twenty years ago, one more drug appeared, memantine (Namenda) – it has a very different mechanism of action. It prevents neural cell death by blocking the process of apoptosis – programmed cell destruction. It is only proven to have positive clinical effects in moderate dementia (the point at which someone cannot go into the bathroom in the morning and get ready for the day without help) but again, it’s something. Aducanamab, unlike these other medications, is not an oral drug but rather a monoclonal antibody which enters the brain and prevents amyloid protein (which slimes over and prevents proper function of neurons) from attaching itself and accumulating with time the way it usually does in Alzheimer’s. The clinical trials showed no clinical benefit in terms of improving memory in test subjects, they instead showed a decline in protein accumulation over time. Whether this change manifests itself as any sort of benefit in a living person remains unclear. This is why a lot of experts in the area were against the approval of the drug and a number of people affiliated with the FDA resigned when it was approved as they were so against a drug of such unclear benefit being launched on the world. Monoclonal antibodies must be given as infusions, not as pills. They would be destroyed by the acid environment of the stomach. There are some significant brain bleeding complications in certain individuals requiring routine MRI scans of the brain to detect early problems. Trying to explain infusions and MRIs to the demented can be problematic and the procedures themselves are scary. Then there’s the cost. Biogen has decided $56,000 a year is appropriate. It is unclear which insurances are likely to cover it due to its weak evidence. The FDA has demanded post approval data showing clinical benefit or they will rescind their approval. We don’t know if it will be possible to ascertain this.

Needless to say, it’s not high on my list of things to prescribe to patients. I’ve been laying this all out to patients and families so they have information on which to base choices. We’ll see who opts for the drug and I’ll report back on my clinical experience when I have some.

June 12, 2021

Tomorrow, the US will hit 600,000 Covid deaths since the beginning of the pandemic. Actually, we probably hit it today, or maybe even yesterday. As the vaccines have rolled out and the educated moneyed classes have been protected, there’s less and less interest in following the disease in real time and state health departments are no longer uploading daily totals, but rather biweekly or even weekly totals. That may make the functionaries who gather and tabulate data have an easier life but it means we lose the ability to pinpoint what’s going on with any accuracy. These decisions are being made just as the Delta variant, which spreads much more quickly that the original strain, is starting to make significant inroads and, with more lax data reporting, its possible that weeks may go by before we start to notice a disturbing trend – and with exponential numbers, that may be a significant issue.

Today is either the 456th or the 458th day of the pandemic. It’s the former if we use the date the Trump administration called a national emergency on March 13, 2020 – two days after the WHO declared the SARS-2 coronavirus a global pandemic on March 11. Thanks to human ingenuity, and some political changes at the top, things are starting to return to normal, at least among the privileged classes with access to vaccines, health care, information, communication, transportation and all the rest of it. Those of us who live in this world usually consider it to be the norm as everyone they know and interact with on any sort of equal footing belongs to it. I spend a good part of my life, thanks to decades of house calls and case management programs in rural and impoverished areas, in and out of the homes of people who are not of this world. For various reasons, the pandemic isn’t over there and isn’t likely to be over there for quite some time. One of the great failings of our health system currently is that it’s designed by the upper classes for the upper classes and there are really no mechanisms by which less privileged communities can get it on the ground floor to tell their stories and needs so that systems can be designed to help them from the ground up rather than a shoddy attempt at retrofitting after the fact. A great case in point was the pivot to telemedicine last spring where more than one health administrator of my acquaintance assumed that all patients would have a smartphone or iPad, home WiFi and be adept at using said tools.

We hit 100,000 domestic deaths on 5/27/2020 (Day 77). 200,000 on 9/22/2020 (Day 195). 300,000 on 12/14/2020 (Day 278). 400,000 on 1/19/2021 (Day 314). 500,000 on 2/22/2021 (Day 348) and now 600,000 on 6/13/2021 (Day 458). Obviously the vaccine is working to reduce the death toll but the disease remains, although, at least anecdotally, it’s circulating mainly in unvaccinated populations where, as the substrate tends to be young and healthy, it’s not causing the same rates of illness but continues to send people who should have long and fruitful lives ahead of them to the ICU and to the morgue. As more than half of the state of Alabama remains unvaccinated, despite the pleading of all of us who work in health care, we’re going to be coping with Covid for a very long time.


D

Today was Central Alabama Pride. Given the pandemic conditions of the last year, planning and permitting for the usual parade in Birmingham was not possible so it was more of street fair with entertainment this year. It was very hot and sticky so I did not stay long but I did break out my festive new shirt bought for the occasion covered with rainbow dragons. I do so like to be tastefully understated in my sartorial choices. In my forty plus years as an adult gay man (most of them very out of the closet), I have been to lots of Pride celebrations. I’ve been to parades and gatherings in Seattle, Sacramento, San Francisco, Los Angeles, San Diego, Birmingham, Atlanta, New York, and Amsterdam – and those are just the ones I can recall quickly. I have rainbow Tshirts, necklaces, hats and other accoutrements stretching back to the mid 80s packed away in various boxes. Steve, who loved Pride because he came out seven years prior to Stonewall, and had way too many memories of police raids and a complete inability to be an authentic human in public, instilled the value of Pride celebrations in me during our years together. It was one day where we could walk down the street, hand in hand, without fearing reprisals. Where we could greet friends with a hug and a peck on the lips without drawing withering stares. Wherever we were in June, we made sure to attend the local celebration. My standard uniform for Pride for years was a Tshirt he bought me at San Francisco Pride, our first summer together, with a hand done silkscreen of a rainbow over the Golden Gate Bridge.

The Prides of the 80s and early 90s of my youth were very different than they are now. LGBTQIA issues were not part of the national conversation. There were no corporate sponsors. (The liquor companies and HIV pharmaceutical companies started to creep in in the 90s sometime). Everything was local community time and energy. The moneyed gay community, at best discreetly out, did not make free with their power and connections. Things were a bit ramshackle, but the HIV crisis had turbocharged the need to organize and to get things done quickly and efficiently and that spilled over into Pride and didn’t just reside in health care. The young people of today have no idea of how different it was – the presence of the sick among us, the inability of public officials to acknowledge the existence of the community (I remember Steve and I whooping when we watched the Clinton inaugural in 93 when Maya Angelou read her poem as it explicitly mentioned gay people – it was unheard of for something like that to happen on a national occasion of the type), the knowledge that if the wrong person spotted you, even as an observer on the sidewalk, that it could mean the loss of your job or your lease. Now Target hauls out the rainbow merchandise in June in the annual rotation between Easter and the Fourth of July. A whole new world indeed.

Tommy was deeply ambivalent about Pride. He was fine with the concept and would usually go with me to the event but he didn’t like the fact that the most visible parts would be the drag queens or the leather guys or the go go boys from the local strip bar. He hated that those images would dominated the media coverage and that the world would then apply those images to him. I kept trying to explain to him that we live in a visual media world and that whatever makes the best viusals is going to make the news. You don’t get ratings when you broadcast a bunch of gay and lesbian CPAs walking down the street in business suits. He would have none of it. I don’t mind any of it. It’s our party. We can act and dress how we want. It doesn’t make us less human or less worthy of respect. The straight world is perfectly welcome to join the party but it’s the one day a year it gets to be our day and our rules and if you don’t like it, you can lump it.

June 7, 2021

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

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

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

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

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

June 3, 2021

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


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


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


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


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


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

May 31, 2021

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


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


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


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


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


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


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

May 26, 2021

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

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

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

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

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

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