September 11, 2021

Interior St Francis Church – Porto

Dateline – Porto, Portugal

Today was lovely. Sunny, no humidity, not too warm. A perfect day for walking tours and boat cruising on the Douro. After my sleep of the dead, the night before, I slept a more normal amount of hours and actually managed to make my way down to breakfast. Portugal definitely works on a different schedule than America. I was finished with breakfast by 7:30, had some time to kill and went out for a bit of a walk. I’ve always loved walking in European cities. One would think that at 8 AM the streets would be bustling. Deserted… even the local Starbucks didn’t open until 9:30 AM. Some of this might have to do with it being Saturday but as Iberian culture breakfasts between 9 and 10, lunches around 2 and doesn’t eat supper until after 9 PM, my guess is they don’t generally get up much before 8:30 for any reason.

The first part of the morning was a walk with the group through the old town. The highlight was a stop at the Church of St Francis. The exterior isn’t much – undistinguished early gothic with a bunch of clashing baroque additions, but the interior is a rococo fantasy of carved wood with every available service covered with gold leaf carried back from Brazil in the 16th and 17th centuries. The estimates are about half a ton of gold in total. It’s no longer used as a house of worship, just as a structure to be admired. I liked it very much but the choice of piped in music was a tad odd. (I got why Schubert’s Ave Maria but it was followed up by the William Tell overture and the Waltz of the Flowers.) Then further down the hill to the Douro riverbank and on to a boat to see all of the bridges from the river’s mouth to the highway bridge somewhat upstream of town. After that, on to one of the ancient port wineries on the other bank of the river. The one we toured was Taylor’s I’ve been to lots of wineries in my time but this was the first time I’d been in one in continuous operation since the 17th century. The process of creating port is somewhat different than table wine involving the adding of brandy very quickly in the aging process to stop the oxidation, and a major reason why port is about 20% alcohol compared to the usual 12% for table wine. Lunch at the winery accompanied by a Fado concert. (Think Edith Piaf songs of longing but sung in Portuguese and accompanied by guitar). Then back to the hotel, some shopping and sitting in sidewalk cafes people watching before turning in. Up relatively early tomorrow again as we make our way to Sintra and then to Lisbon.

Port aging in oak barrels

I would be remiss if I did not note that this was the twentieth anniversary of 9/11. I have very confused emotions about that day and its images due to its interconnectedness with my own private grief. Steve had died on August the first of 2001. It was not unexpected. He had been quite ill with his interstitial lung disease for some time and I had been taking care of him at home along with his paid caregiver Tameka (who was there when I was at work) and hospice services. When his battle was finally over, I decided to take two months off of work with a planned return on the first of October. I wrapped up the affairs that I had to right away, and then I loaded the car and headed out of town. I had no specific itinerary. I’d just been cooped up in the house for a couple of years in my 30s, unable to go much of anywhere other than work. I made a long meandering drive cross country, using the opportunity to connect or reconnect with various friends, eventually ending up in Southern California where I scattered Steve’s ashes in the Anza-Borrego desert (his favorite place on the planet). Well, there’s a very long convoluted story about that which I’ve written up before and which I won’t repeat now. I then headed north to Seattle to spend some time with the family, arriving in early September. I was staying at my brother’s house, sleeping in. He was at work, my sister-in-law was downstairs with my then two year old niece dealing with toddler breakfast things and she flipped on the news. Shriek and then yells up the stairs that I had to get up and see what was happening. She and I stayed glued to the television all morning, watching the drama unfold as the towers burned and collapsed.

Over the course of the next week or so, I flew to Alaska to see my old college roommate (I had been slated to fly out on the 12th but of course that didn’t happen), drove back across the country and ended up in Manhattan about two weeks later. The haze was still in the air. The flyers were still affixed to walls. The smell, a mixture of burning electrical systems and pulverized stone was endemic. I mourned for Steve. I mourned for the ugly scar in my beloved Manhattan. I mourned for the thousands dead and tens of thousands whose lives were uprooted by the tragedy. Even to this day, I cannot separate my grieving for Steve from my grieving for the country. I had hopes that such a national tragedy might unite us and make us stronger. Instead, as we all know, those sentiments were hijacked by the military industrial complex into fruitless conflicts across the globe which made elites wealthy and drained national wealth away from poorer classes helping exacerbate the economic conditions which leave us so riven.

I was wondering today what Steve might have made of this trip. He would have complained about the food (fortunately, McDonalds is close by and I could have sent him there). He would have complained about too much walking on cobblestones. He would have loved the weather and the boat ride. He could have done without the winery. He was seventeen years sober when I met him, and thirty years sober when he died and was prouder of that accomplishment more than anything else. Tommy, on the other hand, would have loved the winery. He never passed up a winery or a wine tasting if he could help it. As a super taster, he could identify all of the notes in a good wine. I can’t do it and he would always make fun of me for that genetic imperfection. The only time I remember him having an issue with wine was on one of our trips to Northern California. We drove up to Napa. He was having a snit about something (at this point I have no idea what) and, even though we stopped at several wineries, I could barely get him out of the car and he was sullen in the tasting rooms. Even a little alcohol in the system didn’t help. He made up for it on other trips where we went out of our way for Washington and Oregon wineries and Biltmore Vineyards in Asheville was a habitual stop.

Enough for tonight. On to the morrow. I have my hand sanitizer, my masks, and my CDC card all ready to go in my day bag.

September 10, 2021

Porto Cathedral

Dateline – Porto, Portugal

Having access to my CPAP last night plus two nights of poor sleep kicked off a chain reaction and I ended up sleeping for nearly fourteen hours. Fortunately, I had nowhere I needed to be or things I needed to do today so sleeping in and then some wasn’t a particular problem. I finally did bestir myself, was somewhat shocked by the time, and made myself move and get out out doors. The weather was pleasant. Yesterday’s rains have gone and we have blue skies, but the weather is still relatively cool in the 70s so it’s not too hot to amble about. The first order of business was brunch, a traditional Portuguese combination of espresso, port wine, custard tarts and something that I decided was a combination of deep fried seafood and potatoes. The server’s limited English precluded my being able to discover more. It was perfectly palatable whatever it was.

I headed in a different direction, up the hill to the cathedral, the oldest extant building in town, dating back to the 12th century and Romanesque in style as Gothic arches and flying buttresses had not yet been invented. they came along a century or so later. Impressive but not as fancy as some others I have been to. I have always been impressed by European medieval cathedrals. They were generally built over the course of centuries, mainly by individuals who knew that they would never see the completion of their work but who kept at it through war, famine and plague, for their love of God, culture, and their fellow humans. We could take a lesson or two from them. There’s more to life than that which gives us immediate gratification. Then, across the top of the Ponte de Dom Luis I which I had seen from below yesterday. Lovely views, a major plunge to the river far below, and a chance to marvel at the combination of beauty and ingenuity that those of the late 19th century brought to wrought iron. Some exploring of back streets, accompanied by generous helpings of gelato and an occasional glass of port and then it was time for dinner and a gathering of the tour group.

Cocktails and dinner with the ten others (five couples roughly five to ten years older than I) with whom I will be spending the next two weeks. They all seem pleasant enough. Three of the couples had met on a previous small group tour with the same company in Italy a few years ago and had old home week. It looks like we will all be compatible as we spend the next few weeks together in various hotels, busses, airplanes, museums and the like. I am odd man out, being companionless, but I learned long ago how to be the extra man in polite society so I don’t think it’s going to be an issue. Dinner, at the hotel restaurant, was quite good. I had salmon, well cooked but I suspect farm raised rather than wild caught. Being from Seattle, one just knows these things.

I have been watching the reaction to Biden’s pronouncements on Covid control and vaccination with some interest. I turned on the local Portuguese news to see what they might have to say, but found that my understanding of spoken Portuguese was wholly inadequate to the task and had to resort to various internet news sites instead. The reactions from the Republican party and conservative governors, including Governor Meemaw in Alabama were wholly predictable, mainly of the third grade ‘No one is going to tell me what to do’ variety. I understand that argument, believe me I do. Bodily autonomy is fairly sacrosanct in terms of cultural mores, the legal system, and medical ethics. Having a governmental entity step up and say ‘Thou must’ is a significant issue. The question is, of course, where do you draw the lines when your choices in bodily autonomy are causing other people to get sick and die. Does the protection of those individuals and their bodily autonomy and right to life start to outweigh your personal beliefs and choices? In terms of vaccination, I thought we had settled that a century ago in the Supreme Court’s Jacobson decision of 1905. In that 7-2 decision, the court ruled that the state’s role in protecting others trumped the individual’s right to refuse and that vaccine mandates were permissible. We’ve been living with them for years and no one has been too fussy at the wiping out of smallpox, polio and a host of other feared diseases over the course of the 20th century.

The decision by various forces to politicize the Covid vaccine as a weapon for partisan purposes is something that’s a bit new in American politics and I can’t say I’m in favor of it on any level. If there were any proven extreme dangers, I could understand the trepidation but there really aren’t. Various people state that the VAERS database is full of underreported complications but if you look at it, it’s a database to which anyone can report anything without any vetting and I would suspect that a significant portion of the negative reports are there for political, rather than for medical purposes. There have been roughly 200 million doses of vaccine administered in the US over the last eight months and the number of serious complications that can be directly related to the vaccine is very, very small. On the same order of magnitude as being struck by lightning (1/500,000). That’s 400 serious complications for 200 million doses for those of you who aren’t so good at math.

My publisher continues to be happy with the book’s performance. Apparently it has been picked up by Target. I don’t know if that means it will be available at one near you or if it’s just going to be available through their website, but it does mean more exposure. There’s been a bit of a hoorah in the press about Amazon. The majority of their best seller titles for vaccination (one of my categories) are books full of misinformation and downright lies. This means, of course, that a lot of people are looking at the category and perhaps they shall see a new book with a sage green cover and some interesting pen and ink art of a medieval plague doctor and decide to add it to their carts while they are there. It’s all good. I’m not in this to get rich or hit a best seller list, but I do think there’s some good and rational perspectives about our trying times included that might help others sort out what we have to deal with.

I have to get up tomorrow for a walking tour (likely covering things I have already visited) and a boat tour up the Douro to a port winery complete with tastings. I shall wash my hands, wear my mask, and keep my distance while boarding.

September 9, 2021

Porto, the Douro and the Luis I bridge

Dateline – Porto, Portugal

Today was a very Seattle in the summer day. Low overcast with temperatures in the high 60s/low 70s – perfect for urban walking in the morning and early afternoon with drizzle and winds beginning mid-afternoon with the rain getting stronger and stronger around dinner time. I have no objection to rain, even on vacation. No native Seattleite does. If we fussed every time it turned gray and drizzly, we’d never get anything done in that corner of the world. Just pack your rain gear and go do it anyway. The rain showers were likely pushed this direction by hurricane Larry and my reading of the weather map shows sunshine coming the next few days.I got up relatively early this morning, at least for me on vacation, and was out on the street by 8 AM. My body hasn’t quite figured out what time zone it’s in. That will take another day or two. The fact that my CPAP was in the lost luggage didn’t help. I kept waking up last night unable to breathe properly. I don’t know which of my ancestors gave me the genes for a soft palate that won’t stay elevated when I’m asleep but I have a few choice words for him or her when we meet in the afterlife.

Igreja dos Clergios

My first stop on my self guided walking tour was Igreja dos Clergios, an 18th century church on top of the hill just beyond my hotel with a three hundred and some foot belfry that you can ascend for views of the entire city. I had hoped that in some 20th century renovation they might have installed an elevator, but that was not the case and I marched up and down all 216 steps (yes, I counted… I do things like that). My lungs did not like me on the way up and my knees did not like me on the way down. The church was lovely. The view was great. The family of selfie taking teenagers from somewhere in the South of France (judging my accent) were not good company.

From there, a ramble through the old down to the riverfront. Porto is built on the Ria Douro (which means River of Gold if I’m learning my Portuguese correctly). We’re very close to the Atlantic coast, a mile or so away. I’m assuming the Romans, who founded the city about 2300 years ago, decided that having it upstream a bit on the estuary protected it from Atlantic storms. The Douro snakes across the Portuguese countryside and into Northern Spain. There are week long boat tours up and down its length, but not for me this trip. The waterfront is dominated by an enormous wrought iron bridge, Ponte Dom Luis I which was designed by Eiffel and various other compatriots in the late 19th century. The old city is a UNESCO world heritage site and most of the buildings are 18th and 19th century with baroque detailing and painted tiles. A number are abandoned as the population moved away to the suburbs but, as in Birmingham, a new generation is discovering the positive things about living in reclaimed urban space and there is renovation happening everywhere. Out of curiosity, I stopped at a real estate office. I could afford a loft here but I don’t think retiring to a country where I know no one and don’t speak the language is the best of ideas.

Livaria Lello

Back up the hill from the river and more wandering through commercial and shopping areas. There was quite a line up outside of one establishment, something one rarely sees at bookstores. Then I realized that this shop Livaria Lello was a hangout of J.K. Rowling’s when she lived in Porto and was the model for Flourish and Blott’s in Diagon Alley (and used as the location for the film). It’s dominated by a gorgeous Art Nouveau staircase and central skylight. Of course I had to go in and I bought a copy of the first Harry Potter book in Portuguese and Camus’ The Plague in the original French. I’ve been meaning to read it all year and I’ll be interested to see if my rusty French is good enough for me to get through it without Larousse at my side. More window shopping and then, as the rain was strengthening, dinner al fresco in a sidewalk cafe accompanied by several classes of the local port (named after the city and where the grapes are grown and the wine manufactured). I returned to the hotel to find that my errant luggage had returned from its romantic tryst in Paris so all is well with the world on this Thursday evening.

Nothing major going on in the world of Covid around here. The only issue I’ve run across is that sit down restaurants are starting to demand vaccine passports on weekends (at least for indoor dining). The unwillingness of the US to do such things means I cannot easily get one. I do have my vaccine card and I can get an instatest if need be. It shouldn’t be an issue as I am in the hands of Tauck tours as of tomorrow at 1800 and they take care of all that. Looking at America from a lens of several thousand miles, I noticed that Jim Jordan tweeted that ‘Real America is done with Covid-19’. That’s nice Jim, because Covid isn’t done with America. The numbers keep escalating, the health system is buckling, the schools are a shambles, and all because a once great political party decided to kowtow to science denialism and anti-intellectualism just so they could be against what the other side was for. The Biden administration is tired of letting that minority destroy lives, public health, and the economy for no particular reason and, as I write this is coming down hard with some new mandatory vaccination policies. Cue the howls of outrage in 3…2…1

Bedtime for Bonzo. I haven’t figured out what I am doing tomorrow day yet. I’m going to play it by ear. But whatever I do, I have my mask, I have my hand sanitizer, I don’t crowd up on people I don’t know, and I have had my vaccines.

September 8, 2021

Dateline – Porto, Portugal

International Travel in the time of the Delta variant. I wouldn’t have booked this trip last spring if I had any idea of what was going to happen over the last couple of months but I did and when push came to shove, I decided Europe, where the population still believes in basic public health measures and community values was likely safer than the rural communities of North Alabama that I make my house calls in so here we are. My general takeaway from a twenty hour travel day involving four airports, three flights, two continents, and one set of lost luggage? Europeans are much better at universal masking than Americans, no one fusses about it, and everyone fills out a whole lot of paperwork so the authorities can find you and get you tested if you’re determined to have been in close contact with an infected person. Testing and contact tracing are believed in as general public health tools that have been used for centuries to mitigate epidemic disease rather than as some sort of impingement on ‘freedom’.

I arrived at Birmingham airport yesterday afternoon with plenty of time to spare just to give me some breathing room in case anything went wrong with my sheaf of travel and health documents. The lady at the Delta counter was very nice but thoroughly confused as to what I needed to have for the various legs of my flight as the rules keep changing and they no sooner get training in how to assist passengers then it all proves to be out of date. Bags checked through to Porto, a quick snack and then the hop to Atlanta for the trans Atlantic flight. We board in Atlanta and get settled in our seats. At takeoff time, we don’t – instead of phalanx of maintenance guys come down the aisle bearing mops. Not a good sign. The intercom comes on in English, and then French with a Chinese accent (my French is pretty good, but I could barely make out every fourth word. The flight attendant responsible for the French announcements was a native Chinese speaker and some of the pronunciations were quite new to me…) One of the aisles is dripping with water and we’re not going anywhere until the source is found and it’s cleaned up and repaired. The mop guys figured out the problems pretty quickly, a broken water line in one of the lavatories and not something that was going to bring the plane down, replaced a section of the aisle carpeting and we got underway an hour late.

The long flight was uneventful, save for a closed lavatory on the opposite side of the plane, and we arrived at Charles De Gaulle airport in Paris safely, just an hour later than planned. That took my two hour layover down to one hour and it was a quick sprint through a maze of tunnels and concourses to find the domestic terminal. The only real issue being that the airport is designed so that you exit the secure area on leaving the international terminal and therefore have to go through security screening again. Fortunately, the line was moving without too much difficulty. On to the next plane for a flight over the Pyrenees from Paris to Porto. Unfortunately, I did not have a window seat so I didn’t get to see very much. Porto airport looks like every other midsize city airport you’ve ever been in. Down to baggage claim to wait for suitcases that never arrived. All of us who had been on that trans Atlantic flight, about ten of us, were luggageopenic. Apparently the late arrival kept the Delta carts from interfacing with the Air France carts or some such. I have a feeling that anyone who had less than a two hour layover that was on my transatlantic flight arrived at their destination sans baggage. Large crowd at the baggage office to register our missing bags (all apparently happily spending a night in Paris) and I have been told they will be on tomorrow’s flight and delivered to the hotel – unless the flight is late in which case they’ll show up on Friday. As I’m here until Sunday, it’s all good.

I was met by a lovely young man with a luxurious Mercedes who drove me from the airport into town and to my hotel, the Intercontinental, right in the middle of the old city. I got to my room, threw open the curtains and discovered that my usual luck was holding. I have a lovely view of the construction site next door. As I had no clothes other than the ones I’d been wearing for thirty six hours and had slept in, I located the nearby pedestrian shopping street, wandered up there, and found an H & M and a Benneton which supplied the basics for the next few days. The only thing in the suitcases I’m going to miss is my CPAP machine, too bulky for my carry on. Ah well, I just won’t sleep as well tonight as I might otherwise. I haven’t seen a lot of Porto yet. I’ll take care of that over the next couple of days. It appears to be a pleasant enough small city, full of baroque building covered with decorative tiles and with red tile roofs being the order of the day. Lots of tourists so plenty of different languages on the street. I can understand the English, French, some of the German, and some of the Spanish I’m hearing. I haven’t figured out the Portugese yet. I can read it without too much trouble but I haven’t figured out the rules of pronunciation.

I’m going to bed early this evening and will try to sleep as well as I can and that should adjust me for the rest of my sojourn.Be like the Portugese – wear your masks, watch your distance, wash your hands, get your shots.

September 6, 2021

It’s a double holiday today. Happy Labor Day and thank the union members of earlier generations who fought and died for weekends and the forty hour work week. Union membership as a counterweight to capital built the middle class in this country and it’s no accident that the decline of unions following the Reagan administration’s union busting tactics and successful campaign of rebranding unions as parasites in the eyes of voters parallels the decline of the working class into impoverishment. In addition, La Shana Tova to all of the members of the tribe out there. As a proud Unitarian Universalist, I’m happy to celebrate any religious tradition’s holiday that comes along. As we enter the year 5782, I have lots of things to look back on and lots of things to look forward to as well.

The most immediate one is I think I’ve made it through all the hoops and should be able to leave on vacation tomorrow. Fully vaccinated? Check. Negative Covid test yesterday? Check. Passport still in date? Check. Compression socks to keep the legs from swelling? Check. Forms filed with the Portugese Government so that they can track me down if the wrong person coughs on me on the trip? Check. I still fully expect something to go wrong and be turned back at one of the four airports I need to pass through in the next thirty six hours. But no one can say I won’t have tried. There’s a piece of me feeling very guilty about not having voluntarily cancelled this trip, booked in the heady optimism of last May when everything was improving on all fronts. Am I flaunting my privilege? Is it irresponsible of me to be traveling, especially by air, while Delta is running rampant? I’m not especially worried about being exposed during the trip. The tour company is mandating full vaccination for all guests and staff and, given the way things have been going around here, I’m likely less likely to be exposed in the museums and cathedrals of Iberia than I am in the local Wal-Mart. Travel journaling plus a look at American society and politics with an outside perspective should commence soon. If I don’t make it successfully, I’ll take some pictures off my back deck with the cats and we can all pretend they’re exotic.

I had dinner with Tommy’s parents tonight. We stay in touch and see each other every few months. They’re good people and we’ve worked out an appropriate friendly relationship now that Tommy is gone. Actually, I’ve always gotten along better with his parents than he did in our time together. I think deep down he wished that they had been a different kind of people, maybe more like my parents where I have always been perfectly happy to accept them and meet them where they are. I gave them a copy of the book. I wonder what they’ll think of it? They aren’t on line so they haven’t read any of the material before. I warned them that they might know far more about me than they want to know by the time they finish it.

The Original MTV VJs

On the way to and from their house, I had the XM radio on the 80s station and they were rebroadcasting a special they did last month celebrating the fortieth anniversary of MTV which began broadcasting August 1, 1981 with, as every trivia afficianado knows, the video to the Buggles’ Video Killed the Radio Star. All of the surviving original VJs were participating along with artists whose videos were played that first day. I didn’t see MTV at its debut. On August 1, 1981 I was floating somewhere in the Bering Sea on the University of Washington’s research vessel running water sampling equipment. I arrived back in Seattle a week or two later and did some odd jobs before heading to California and my sophomore year at Stanford. My parents didn’t have cable, so the early cable channels were something I enjoyed when visiting the family home of my college roommate Craig Mollerstuen, whose father was an executive in the Silicon Valley tech industry and who had all the latest gadgets. I do remember catching MTV with him, his younger brother David Mollerstuen, and a few others in their family room lat that summer and early fall. The songs they featured: Rick Springfield, Huey Lewis and the News, Men at Work, and all the rest immediately take me back to my undergraduate days, a period of time I enjoyed immensely. I also remember having quite the crush on the young, cute blond VJ Alan Hunter, never dreaming that our paths would actually cross about a quarter century later.

We all lay down the soundtrack of our lives from about the age of 11 to 25. I read somewhere that the pivotal year is the year we are 14. Whatever we are listening to at that time is what we carry in our brain as good music for the rest of our days. When working with my dementia families, one of the things I encourage them to do is figure out what the patient’s musical life was like at that stage and then get recordings of that music and keep them handy. When they’re getting restless or agitated, put that on and encourage them to sing along. It usually works and it’s a lot safer than antipsychotics. For my patients that grew up country without a lot of recorded music exposure, it’s the old hymns in traditional arrangements that work best. For those who had radios, Big Band, Frank Sinatra, Jo Stafford, Patti Page, Dinah Shore and others of that ilk. When I become demented, which I sometimes feel could happen as early as next week, people better start putting together a mixtape of 70s-80s pop, classic Broadway, the great American songbook, and symphonic music of the Romantic era, especially Tschaikovsky.

I’m going to try and get some decent sleep tonight as tomorrow night is a redeye flight and I doubt I’ll get a lot. Got my masks, got my hand sanitizer, got my shots, and I’ll try not to get too close to anyone.

September 2, 2021

We’re inching up on forty million confirmed cases of Covid-19 in the US since the pandemic began about 18 months ago. Over the last four weeks, there have about 4 million new infections and about 27,000 deaths. We’re not quite where we were last winter when no one was protected by vaccines but we’re rapidly approaching it, and have certainly surpassed it in the Republican states that have decided basic public health measures are somehow un-American. Florida, of course, continues to lead the way with numbers blowing last winter out of the water and Texas isn’t far behind. Alabama is not doing well, but at least our governor is taking a laissez-faire attitude towards tried and true means of spreading infectious disease rather than actively campaigning against them. The 7 day average for cases in Alabama is now about 15% higher than it was at the peak of the winter surge. How that’s going to translate into hospitalizations and mortality in a month or so remains to be seen as it’s unclear to me how many of those cases are in at risk for serious complication populations and how many are breakthrough cases in the fully vaccinated.

The resident I took on my rural house calls rotation today just came off the medical intensive care service and had a couple of interesting things to say about it. Last year, the residents did not work with Covid cases. Before the vaccine, we were not about to risk the health and lives of young people just beginning their careers. Now that health care workers are vaccinated, the risks are much lower and the house staff are working with those patients on those floors. This young woman mentioned that all she took care of during her month of ICU was Covid. She felt good about handling those individuals but feels that maybe she was cheated out of learning about other medical conditions that require intensive care, everything else having been crowded out. She also was very interested in the family dynamics of the people she treated. The majority were in their forties and fifties, previously healthy, and, therefore, had not given thought to their mortality and prepared no advance directives and had no discussions with their families about such things as code status, CPR, or final wishes. Time and again she found herself in the waiting room with their children, mainly high school age to mid-20s asking them what should be done and these young people not really being able to comprehend what was being asked of them. They almost always said ‘Do Everything’ because it’s their understanding that they should have their parents until they themselves are comfortably middle aged and they can’t imagine being young without them. They don’t really comprehend that ‘Do Everything’ in an ICU situation with a disease that destroys the lungs rarely turns out well for anyone concerned.

I was wondering what I should write about this evening when I ran across yet another news story about ivermectin, the antiparasitic drug that has caught on as a treatment for Covid-19. In this particular column, the author was talking about people getting the veterinary version as a topical paste, diluting it with water, and then injecting it. The trained physician in me just shivered as there’s so many things wrong with that approach that I don’t know where to begin. Perhaps they’ll start rubbing it into their eyeballs next. As I believe I wrote earlier, there is good scientific evidence that ivermectin blocked replication of the virus in the laboratory. Experiments to show what dose might be appropriate in a living human and whether it has that same effect in living tissue rather than in cell culture have begun but have not yet produced any data that would allow the FDA or any other regulatory body to approve the drug for use in the treatment of Covid. These experiments are in process and, if they show promise, I’ll certainly write about it at that time. In the meantime, ingesting topical horse paste or injecting dewormer mixed with tap water is a really bad idea. There are a number of people in ICUs nationwide with liver failure from ivermectin toxicity, taking up those few beds not occupied by Covid patients. And take it from a physician, dying from liver failure is not a pleasant way to go.

Physicians, with our ceremonial robes of the white coat, descend from the priesthood. We are the intercessors with the gods and with fate who miraculously restore the balance of the world through the healing of the individual. As George R. R. Martin put it, ‘What do we say to the god of death? Not today…’ As these age old archetypes have come down to modern America, a little of the idea of healing magic has continued to cling around the edges. We’re a very literal people so we like our magic to take physical form so we embody it in the prescription. Most healthy people, when they have need of medicine, have developed an acute illness or complaint that has some sort of reliable cure or amelioration. If we’re going to take a day off work, drive downtown, spend twenty minutes trying to find a parking space in the over full deck, wait while the doctor is running an hour or more late thumbing through an old Golf Digest, and then sit in a too cold exam room in our underwear, we figure we better get something for all that inconvenience or we’ve wasted our time. The prescription in part of the deal and its implicitly understood on both sides of healer and patient. We therefore tend to imbue the prescription with supernatural powers for good and we carry that idea of medicine is a good thing with us throughout our lives. When this gets mixed in with our cultural ideal of the quick fix, we lose track of what medications actually are. Medications are controlled doses of poisons.

What is a poison? A poison is a substance, which when taken into the body, alters that body’s balance and physiology to a negative end result. A medication is a carefully measured and tested substance, which when taken into the body, alters that body’s balance and physiology. It’s more or less the same thing, only with medicine you trust you aren’t going to get that bad thing happening. Some medications are literally poisons. The most famous example is the drug warfarin (brand name Coumadin) which is used as a blood thinner. It’s called warfarin because it was developed at the Wisconsin Army Research Facility (WARF) – it’s intended use when first invented? Rat poison. In the 19th century when medications were not regulated, people were poisoned and died from them all the time. The public outcry during the progressive era is what led to the creation of the FDA to begin with. It coincided with the Flexner report that helped to standardize medical education and society accepted that only trained individuals should handle and dispense medications as they could be dangerous in untrained hands which is why physicians, nurses, pharmacists and the like all have to go to school for a very long time and pass innumerable exams to get licensed. Every state in the union has a vested interest in making sure that even controlled doses of poisons are used judiciously with appropriate understanding – something one does not find in social media groups of people hawking outlandish cures.

The biggest issue I have with medications as a geriatrician is in convincing older people that sometimes deprescribing is better than prescribing. Older people, as they sail through life, collect up various ailments and disease processes. It’s inevitable. With access to Medicare and an almost unlimited number of specialists, they also collect up any number of medicines to treat these, or the side effects of the original medications (controlled doses of poison, remember…) Sometimes you need to put the ship in drydock and scrape a few of the barnacles off. Geriatricians are comfortable with this. Patients, their families, and most other doctors are not. There was a great experiment done a few decades ago using family practice residents. The residents sent their older patients to a geriatrician who would then make recommendations for care and send them back to the resident for implementation. Residents are young, impressionable, want to be the best they can be, and take their elders ideas and ideals as gospel as they prepare to move up in the world. You could see this in this experiment. If the geriatrician suggested that the resident start a new medication, they did this more than 95% of the time. However, if the expert recommendation was to stop a medication, the resident would only do this about 30% of the time. They would not deprescribe. Deprescribing is antithetical to how we are trained to think as doctors and it’s a concept that’s difficult for a brain, trained to hone down through a differential diagnosis to find just what the problem is an just the right medication to fix it, to wrap itself around.

As the baby boom, with its generational love of substances of all types, continues to age, becoming more and more geriatric by the year, it’s going to become even harder for I and my colleagues to keep people out of trouble. Not only do we have to worry about medications, we have to worry about substance use, over the counter medicines, herbal and other natural remedies, things hawked on late night infomercials, and stuff they borrowed from the neighbor which may or may not be appropriate for who they are. The average older person takes seven medications daily (four prescribed, three over the counter). There has never been a controlled study published in any language on a human body with more than three drugs circulating in their system at the same time. It’s too hard. We have no clue from a scientific point of view what’s going on in someone with 7…9…16…22…37 medications entering the blood stream daily. That’s the art of medicine and it’s more medicine Jackson Pollock than medical Rembrandt.

It’s late. I have an early morning meeting. You know what comes next. Wash your hands. Wear your mask. Keep your distance. Get your vaccine.

August 30, 2021

The book has been launched on an unsuspecting world. The publisher sent everything to Amazon and to Ingram book distributors on Thursday night last week and we figured that it would take at least a week for all the computers and algorithms to do their thing but lo and behold, it popped up as ready to go on Sunday afternoon. Thanks to the rapid spread of the news via social media, early orders have pushed it up the Amazon charts and it is in the top 10 in two of its categories (epidemiology and vaccinations) and top 50 in its other (industries). I’m not sure those are the most accurate descriptors of what it is but I’ll take what I can get. There was no Amazon category for plague diary. I hope everyone who is purchasing a copy enjoys it and, if you do, leave a good word on Amazon or Good Reads or some such so that all of the little algorithmic twists and turns bring it to the notice of other people who might enjoy it. There’s one little Easter Egg in the newly published edition. I rewrote the afterword last Wednesday so those who get their copies this week are going to have material less than a week old. The miracles of modern publishing and print on demand technology…

This is my last work week before some extended time off (three weeks with bookending long weekends). I haven’t taken this much time at once since well before the pandemic began. The EU has suggested to its member states that American tourists again become personae non gratae so the planned trip may not come off and I may not even know if things are on until I’m on my way to the airport in a week. No matter what happens, I am determined to enjoy myself, recoup some of my energies, and think about what the next projects are going to be. Finish up a second volume of The Accidental Plague Diaries? Get an e-book and audio book of the current volume done? Finally get around to some of my home projects that have been languishing? Watch a bunch of movies and write a number of my movie columns on which I am woefully behind? Audition for and book a decent role? If there’s one thing the last eighteen months have taught me, it’s that I’m pretty terrible at predicting the future so it’s probably not wise to plan too far ahead. Just keep moving, keep breathing, and go with the flow.

The rains of Hurricane Ida are pattering down outside. No major wind to speak of as we’re only getting some of the outer bands herein Birmingham. From what I can tell, all of my New Orleans friends have come through all right, but there’s a lot of damage – dormers blown off roofs, trees down, that sort of thing. I am quite concerned about the state of the hospitals, overcrowded with Covid and no power to speak of anywhere in the metro area and the latest estimates I have seen are up to three weeks to get everything back up and functional. The inpatient healthcare workers are exhausted already and additional privations related to power failure may send some of them over the proverbial edge.

The local Covid mask wars appear to be calming down as more and more prominent antimask/antivaccine personalities fall ill with the Delta variant. The number of news articles I’ve seen regarding someone of this type being hospitalized with critical illness or dying are heading towards the triple digits so maybe the message is finally beginning to seep through that defiance of public health precepts in the presence of a highly contagious viral illness may not be the best strategy for a long and happy life. We shall see. Rumor has it that the hold out local school district over masking is capitulating and I have certainly seen more and more adherence to masking and social distancing in my journeys around town over the last few weeks. My pharmacist friends also say that they are booking more and more appointments for first vaccine.

I’m trying to think of a good story to tell as it’s been a while since I recounted one of the adventures of my misspent youth. I’ve told all my personal hurricane stories in previous installments of these diaries so I’ll have to think of something else that involves Stormy Weather but without Lena Horne. (I did see her one woman show on stage in London back in 1984 and she was fabulous). I am the eldest child. My sister and brother are five and six years younger than I am respectively. In adulthood, that doesn’t mean much, but in childhood, it was a bit of a problem as I tended to be in a very different developmental stage than they were. My parents solved some of that by sending me off to summer camp for a few weeks every July to a place that specialized in horseback riding. My mother had been quite a horsewoman as a teen and she wanted her kids to have that experience as well. The camp I went to was called the Flying Horseshoe Ranch and it was in the Teanaway Valley just outside of Cle Elum. (For those of you who are not Washingtonians, this, of course, means nothing). I took to camp life and, although I was physically quite small, I had inherited some of my mother’s horsey genes and was quite good on horseback and came home with a number of blue ribbons from the horse show over the years. We did all of the usual camp things although, as this was the early 1970s, our counselors were a bit more permissive than they might be today and looked the other way sometimes when we were up to no good.

One year, we had a boys campout/sleep under the stars overnight away from the camp. We were all bussed to a campground on a stream higher up in the Cascades where we were allowed to run around and be little hooligans and work off our excess energy. It was a beautiful day but, that night, there was an unexpected thunderstorm. Lightning, pouring rain, and we were all just stretched out under the pines in sleeping bags without a tent in sight. Most of us crawled under the picnic tables which didn’t help a hole lot in terms of keeping the rain off and the counselors (old and wise to 12 year old me but likely all of 18 or 19) tried to figure out what to do. They decided to get us back to the camp that night. Of course the bus wasn’t slated to return until the next day so they stuffed us all in the three cars they had available and drove us back. I still remember being crammed in the back of an early 70s El Camino with nine other 9-12 year old boys, whizzing down a mountain road in a roaring rainstorm and having a great time. My frontal cortex not yet having developed enough to understand that maybe this wasn’t the wisest of ideas. We got back about 2:30 AM, nobody was hurt, and we all had stories to tell each other for the next few days in the ways of twelve year olds.

I’m hungry. Going to raid the refrigerator. Remember the litany. Wash your hands. Keep your distance. Wear your mask in public. Get your vaccine. Maybe I can make a campfire song out of it.

August 27, 2021

And another work week comes to an end. One more until I get a much needed break. My last time off was in early May, a time of optimism with vaccine being jabbed into willing arms and rapidly falling case loads. I made the mistake of coming back from that break, the drive cross country to Seattle and back, and setting up what I thought would be a pretty sure bet vacation in which I could recuperate from all of the stresses and strains of the past year. I set it for September, early enough for good weather, but late enough to avoid the crowds. More fool I having no idea of what was to come over the summer. I knew that the Delta variant was going to be a risk. I had no idea that half the country would refuse the vaccine and spend the latter part of the summer eating horse deworming paste. I’m still planning to leave after Labor Day but I am clear eyed enough to know that anything is possible over the next ten days and who knows whether I will get to enjoy a little R and R or be stuck with yet another staycation with the cats.

Things aren’t looking a lot better since the last time I ran the numbers. Birmingham and UAB are still holding steady at around 175 inpatients with Covid. The number of new cases statewide are now up over 5,000 daily which is the highest they’ve ever been Those will translate into hospitalizations in mid September and deaths at the end of that month. The lackadaisical attitude toward masking in local school districts has led to up to 20% of the students being out with Covid in some places. The teachers and staff are also getting sick leading to interrupted instruction, lack of supervision, and a rapid movement of the educators of my generation towards retirement. The morgue trailers are rolling into the Southern part of the state while the governor refuses to exercise any of her powers and the state board of education spends its time trying to protect impressionable young minds from critical race theory, taught only in PhD programs and law schools.

I think the theme of the evening is parasites. According to my dictionary, a parasite is an organism that lives in or on another organism and gets its sustenance from or at the expense of its host. There’s a lot of that going on in society at the moment. One sees that throughout the economic and political system – various and sundry types of people who do little to actually improve the world but who gather their riches from it all the same. There are those who might say the whole capitalist enterprise is parasitical in nature, with its emphasis on creating wealth from public resources and the labor of others and certainly the Marxists among us would have a lot to say about the parasitical nature of the bourgeoisie vis a vis the proletariat. But I am not a trained economist so I’m not going to belabor those points.

To start with the most basic of parasites, the biological kind. Ivermectin has been all over the Covid headlines in recent weeks. It’s been touted in alternative medicine circles as a cheap and effective treatment for Covid for some time, since nearly the beginning of the pandemic. Ivermectin is an antiparasitical drug that’s been around for decades, mainly to treat enteric worms in both animals and humans. I learned about it in med school in association with strongyloidiasis, ascariasis, filariasis and various other worm related diseases you’ve never heard of. Early on in the pandemic, when research labs around the world were trying various drugs off the shelf to see if anything would work in vitro to inhibit coronavirus replication, ivermectin was noted to work. This finding was rushed to publication and soon picked up by the lay press. What was not made clear by the initial reporting was that in order to attain the concentrations of drug in a living human that were possible in the test tube, you would have to give doses about a hundred times the fatal dose and that the results had yet to be replicated in vivo. (In vitro means in the lab/cell culture/test tube and in vivo means in a living organism for those not wise in the ways of science). Lots of studies all over the world were done with ivermectin with results all over the map. Some show efficacy. Some don’t. There have been significant charges of data manipulation and plagiarism with some studies causing them to be withdrawn. Let us just say that the jury is very much out so the FDA is not about to approve it as a treatment.

America’s Frontline Doctors, an alternative medicine group pretty much frowned upon by most physicians and medical organizations. (One of their leaders, Dr. Stella Immanuel, is the one going around stating ovarian cysts are caused by incubi and demon semen), picked up on Ivermectin and began promoting it, bringing it to the attention of the portion of the population conditioned to react badly to expert consensus and what they view as the elites. The Frontline group then partnered with an online pharmacy to begin writing prescriptions to pretty much anyone who asked and with the help of social media, demand escalated quickly, overwhelming the ability of the group to meet it. This caused a less sophisticated population with rural roots to realize that ivermectin was the active ingredient in a number of agricultural products available at your local Tractor Supply and there you have it. The thing that interests me most about this whole story is the economics. It takes a certain amount of cash to get the word out, set up partnerships with pharmacies and all the rest of it. Who fronted the dollars and who is making a killing on the back end?

Now on to Afghanistan and the ignominious end of the twenty years of misadventure there. It’s hardly the longest war in history. Both the thirty years war and the hundred years war in Europe far exceeded it but some of our current boots on the ground there weren’t born when it began. Why did we stay so long past all common sense and a decade after the stated objective of removing Osama Bin Laden was achieved? Again, I believe the answer is parasites. These parasites are contractors within the military industrial complex who scooped up more than their share of the two and a half trillion dollars expended over the last few decades. Ending things would have endangered their cash flow so lots of lobbying in DC to protect the status quo which continued until the previous administration set up the withdrawal on the worst possible terms. I feel very sorry for the young people of urban Afghanistan. All those under thirty who lived in population centers grew up under a relatively permissive society where they could start to realize their potentials. The Taliban is likely to extinguish this rapidly, but it’s not likely to be as easy for them this time around and I expect we will see a good deal of civil war for a very long time.

My last thought on parasites brings us back to Covid and some very dangerous rhetoric that is becoming more and more common from powerful voices. The governors of Texas and Florida, in particular, but they are not alone, have been blaming the spread of Covid in their states on illegal immigration across the southern border. This is easily debunked. If immigration were the cause the highest rates would be in border towns such as El Paso and McAllen and it’s not. Nor would it explain how it leaps hundreds of miles to Florida which has no Southern land border and I think we’d hear about it if thousands of boatloads of immigrants were descending on the beaches nightly. The problem is that the language regarding immigrants is changing and becoming more metaphorical. That they are diseased. That they are vermin. That they are parasites endangering the American citizenry. This language of dehumanization, which equates society with the body and the other as the disease invading the body is one of the necessary steps towards mass murder and genocide. It’s been well studied. If you look up the ten steps of genocide, it’s step four. We may like to think it can’t happen here, but I don’t think the people of Sarajevo at the time of their Olympiad imagined Srebenica was just over a decade in their future either. My antennae are up, especially if there is any movement towards organized paramilitaries aimed at ‘defense’ against ‘invasion’. That’s step five…

Enough negative thoughts for tonight. I’m going to pour myself another glass of wine and find a mental comfort food film, something like a cheesy 70s disaster flick or an 80s team comedy. I’m sure there’s something new out there, but nothing I’ve heard of has really spoken to me for a few weeks. And I’m trying to isolate some outside of work so I don’t get a breakthrough infection just as I’m trying to leave on vacation.

August 24, 2021

Another day, another slops bucket full of bad news. The seven day average of new cases in Alabama is back up over 4,000 cases a day for the first time since the peak of the winter surge in January. US deaths are back up over 1,000 a day. Statewide, we have about 60 more ICU patients than staffing. The nursing shortage is becoming more and more acute with hospitals frantically looking for and paying top dollar to anyone with a nursing license who is willing to work. (I’ve heard of signing bonuses in excess of $30,000). Birmingham itself remains relatively resilient as medicine is its major service industry so we have a lot of capacity in terms of both physical plants and staffing but, if the models that have cases doubling again between now and Labor Day hold true, even we will be treating people in parking garages and tents.

The local scuttlebutt passed around physician to physician is multiple stories of young healthy people 20-50, who went from the sniffles to full fledged Covid pneumonitis within a few days and are now fighting for their lives in the various ICUs around town. Nearly all unvaccinated, either for reasons of politics or inertia, they are the ordinary and everyday people that make up the background of our lives. A kindergarten teacher, a school bus driver, a fast food worker, an apparel store clerk. A tired workforce of nurses, therapists, physicians, pharmacists, unit clerks, custodians, dietary workers, and all the other people that make up the modern hospital trudge in for their shifts, hope to win small battles, and lock down the anguish when they lose and another once vital young person is no longer here. One of the things I hear bandied about is the idea of why should we worry, it kills less than 1%. (Actually, the total death toll to date is closer to 2% but as the elderly with much higher death rates have gotten vaccinated, the number is starting to fall…) It may be only 1% but for the people that love each victim, it’s a 100% loss. It’s easy to write off other people’s lives in the abstract, but a much tougher proposition in the concrete when it’s someone in whom you have emotional investment.

I read somewhere once about the shopping cart test. The way to tell if someone has empathy or consideration outside of themselves is to watch what they do with the shopping cart in the grocery store parking lot once they’ve loaded their purchases into their car. The empathic person returns the cart to the cart corral. It’s an easy thing to do, requires little effort on the part of the shopper, but does mean that they have to go out of their way a little bit to make someone else’s life easier. The non-empathic person leaves the cart to fend for itself, uncaring that they’ve created more work for the person whose job it is to round the carts up and return them to the front of the store for the next go round. And there’s the issue. Currently we’ve developed a society that not only doesn’t return its shopping carts, but also runs over them a few times with their SUV on the way out of the parking lot.

This innate selfishness shows up in a lot of different ways. Perhaps the most obvious is the forty plus year march to privatize and monetize the public sector which has left our governmental buildings and general infrastructure something of a shambles. Compare the public/governmental buildings of the US built over the last forty years to those built in almost any other developed country in terms of architecture, artistry, use of open space, and pleasant environment. I see it most clearly in the VA part of my job. The buildings and offices we work in, as they have had to be constructed on limited budgets, are functional but not necessarily inviting or inspiring of confidence. Today was an election day locally for mayoral, city council and school board candidates. All I could think of was the pictures of people waiting in lines hours long to vote in some precincts during the last national election and just what care was taken to design a system to allow that as, in my neighborhood, there would be a riot and a rush on city hall by people ‘that matter’ if such a thing were to happen.

I got wind today of a bill making its way through congress. The pandemic has ripped the blinders off our national government exposing something that I have been shouting from rooftops for the last thirty years. The departure of nurses, nurses aids, and other direct care providers from the health care industry is leaving a huge gap in available care for vulnerable and aging adults, just as the baby boom is starting into its years of infirmity. Anyone who has looked at a demographic chart for the US created after 1960 has known this would happen, it’s just a couple of years ahead of schedule due to the stresses of the pandemic. The bill in question would mandate a minimum wage of $15 an hour for any person involved in direct care for an elderly or otherwise vulnerable adult. This would include nurses aids, home health aides, sitters, therapy assistants, housekeeping assistants. Any one of the lower level positions that has to lay on hands in some way. The theory is that if the wages are improved, more people will flock to these jobs. I don’t think it’s going to be quite so simple. The nursing home and home health industries have structured themselves over decades around low wages for these sorts of positions (usually in the $8-10 an hour range) and mandating huge increases are going to put enormous strains on the corporate structures behind these companies. We’ve allowed this sector to move from not for profit to for profit and, if they can’t make a profit, these companies will simply cease to offer these services. Driving eldercare into bankruptcy just as the baby boom is going to require it doesn’t strike me as sound social policy. How to balance this? Quite frankly, I don’t know. These are issues that have been predictable and discussed in geriatrics/gerontology quarters for well over half a century. Society, with its focus on youth, hasn’t wanted to pay attention. They may be forced into it sooner than even I had thought. I was expecting the 2030s to be the decade of eldercare quandaries – looks like I was off by a few years.

The book is coming! Those of you who have signed up for more information at https://bit.ly/apd-sign-up should be getting an email from the publisher today. It should be live on Amazon in about a week and you can get your local bookseller to order it for you from Ingram as of this weekend. Early word of mouth from various reviewers etc. has been positive (and most of you saw my note from Stephen Sondheim regarding my theatrical Easter Egg in the chapter titles). Even though I have been delivering advance copies for a week, it still doesn’t quite feel real. I’ve decided the moment it becomes real is when I spot a copy someplace unexpected in the wild, one that I had no hand in getting there. For those of you who have read/are reading it – if you like it, tell people. Gotta sell a few…

In the meantime, you all know the drill. Wash your hands, stay distant in crowds, wear your mask indoors in public, get your vaccine.

August 20, 2021

The cast of Downton Abbey

Today is my early day so I came home early after my lunch meeting to do my zoom meetings I had scheduled. I finished them up around 3 PM and made my list of all the wondrous things I was going to get done with the rest of the afternoon. Next thing I know, it’s after 6 PM and I’ve been asleep on the couch for three hours. The lizard brain has me going into play dead mode again, making me save energy for further disasters to come – add that to the very long and somewhat toxic work week this week and nothing was going to get done whether I wanted it to or not.

I’m tired. No, I think a more correct way to put it is I’m tired of being tired. The health system is under severe strain again due to the never ending spread of the Delta variant and things are rolling downhill and I and what I do are squarely in the way. We’re pivoting back to more telemedicine appointments, on-line team meetings, virtual house calls, and losing our trainees to Covid surge teams. UAB and the Birmingham VA have got this. 2020 taught us all what to do but everyone in clinical medicine is getting tired and in need of a little R and R for rejuvenation. The other major difference between what’s happening now and what happened last year. Prior to the vaccine and a better understanding of Covid, everyone was at risk of serious complication and those of in health care understood that but for the grace of God, the person in front of them could be their spouse, their parent, their child. Now, the vast majority of those presenting with serious illness belong to a self selected group who have chosen not to take advantage of some fairly basic preventive measures. It’s getting harder and harder to generate empathy as the Delta surge rolls on.

Readying the cow pasture

The current local numbers are still running about 3,700 cases a day statewide. In the last two weeks, Birmingham metro has had about 10,000 new diagnoses. The number of children hospitalized has increased 500% in the last month and the state now has the highest rate of child hospitalization in the country. Statewide, we’re technically out of ICU beds (although here in Birmingham metro we’re still OK). The US death toll now stands at 628,000, surpassing the Civil War and moving Covid to the second highest mass casualty event in US history, ranking only below the Flu pandemic of 1918-20. The exact US casualties from that are not known. Estimates range from 500,000 – 850,000 with most coming in around 700,000. We’ll be there by the end of the year. In the meantime, the governor and state officials refuse to do much of anything regarding public health measures besides widely ignored suggestions. The mask wars rage on, especially in the schools where the virus is running rampant. And to top it off, the prior president is holding one of his rallies in a cow pasture roughly 50 miles north of town. I doubt there will be a mask in sight and I won’t be a bit surprised if we see an uptick in local cases in a couple of weeks that can be traced to the event. Our wet summer continues and I won’t be in the least bit downcast if it rains tomorrow and all the attendees find themselves up to their ankles in mud. It might be a reasonable metaphor.

The images of the last week, from babies being tossed over the wall of the Kabul airport to get them out of a Taliban controlled Afghanistan, to severely ill people lying on the floor of the main library in Jacksonville waiting to get monoclonal antibody treatments to hopefully keep them out of the hospital. (There are no hospital beds to be had), to right wing extremists frothing at the mouth as they confront school boards, city councils, and public health hearings full of high dudgeon and misinformation are enough to exhaust anyone. I gave up television news long ago. I realized it was bad for me. I’m currently giving Downton Abbey a rewatch. It’s a bit deceptive though. While it’s placid on the surface and full of lovely costumes and crisp dialogue, the subtext of a world undergoing wrenching changes from the Edwardian period to the Jazz age in some ways mirrors are current times where we are definitely evolving from something to something. Part of our problem as a society at the moment is that this process is happening so fast, that we can’t see very clearly where we were or where we’re going and all any of us can do is hold tight to the back of the dragon and try not to fall off.

Cliveden House, Berkshire

My mother’s parents grew up in the society of Downton Abbey. They were teens during World War I, and emerged into adulthood immediately thereafter as members of the Lost Generation. My grandmother, whose father was a physician in Edinburgh who died young, applied herself to her studies, went to medical school and qualified as a pediatrician going to work in the Lake District caring for the children of the villages there. She was well educated, somewhat fearless, making her rounds on a motorcycle, and as a woman in medicine, a bit of a novelty giving her a bit of an entree, but not a place in ‘society’. My grandfather, who came from a family of social climbers who had emigrated to South Africa, was sent to England for schooling at sixteen, also went into medicine (his father too, was a physician) and was a member of the Bright Young Things set in London. He was a popular extra man at country house weekend parties, being tall, good looking, athletic, an excellent golfer, and perfectly charming when he wanted to be. I don’t know if he ever spent a weekend at Highclere castle, but he was frequently a guest of Lord and Lady Astor at Cliveden. He eventually met my grandmother when he too finished his medical training at the University of Edinburgh. Various twists of fate brought them to this country in the early 1930s where they settled in San Francisco. My grandmother never practiced after she emigrated. She became the power behind my grandfather’s rise at the University of California, all the way to chancellor and became a friend and beloved mentor to the few women in medical school during the 30s, 40s and 50s. My grandfather used his charisma, his erudition, his athletic prowess, and his force of will to succeed. Unfortunately, he saved it all for his professional facade. He was nowhere near as nice a man in private life. But those are stories for another day.

I am supposed to go to Europe in two and a half weeks for my R and R. I keep expecting the trip to be cancelled by the tour company or flights to be grounded or some other disaster. It would fit in with this whole crappy year. There’s also a piece of me that feels incredibly guilty for wanting to go. That somehow it’s a flaunting of privilege in a world of suffering and discontent. I realize that I am very lucky. I am not in danger of losing my job. I have enough money to pay my bills. I can even afford a few little extravagances now and then. So many cannot say these things. But I do what I can. I get up in the morning, go to work, and try to save the world entire, one patient at a time. It’s all I can handle. And these days, there are times when I’m not sure I can even do that.

Enough… Time for the Dowager Countess of Grantham and her continuing battles with Mrs. Crawley. They knew a few things then. They washed their hands, kept appropriate distance from others, wore a mask when indicated, and believed in modern medicine.