October 15, 2022

Dateline – Columbus, Georgia

A number of obligations prevented me from getting out of town on my make it up as I go along week away as early as would have liked so I haven’t exactly made it terribly far. As these obligations included dinner with a friend, a fund raiser for the theater with which I have been most frequently affiliated over the last few decades, and a children’s opera in the park, I can’t say it wasn’t a pleasant delay before I was able to toss my bags into my Prius, the great red Hope, and finally start heading southward. The major last minute delay was getting the last of the notes and emails for work finished up. For reasons known only to the laws of firewalls, I can only get those to work properly on my old laptop which is not the one I use for browsing and writing and I didn’t feel like dragging two laptops down south with me. I hit send on the last note around 2:30 this afternoon and was able to leave the condo to the cats (Binx has finally come out of hiding and is doing the cat exploration thing which seems to consist mainly of knocking things over about 3 AM) and get on the road.

I thought about heading to the gulf beaches first, but after looking at hotel prices on Saturday night, I thought better of that and decided instead to head down highway 280 towards Georgia whence I could turn either towards western, central, or eastern Florida. As the miles hummed along, I realized that I would pass through Auburn, home of the university of that name and then it struck me. I’ve lived in Alabama for two dozen years and I’ve never been there so that would need to be the first stop. So a few hours later, I parked near campus, took a walk through some of the quads, saw Jordan-Hare stadium and Toomer’s corner and the other landmarks of which I have heard for years but never actually seen. Working at UAB, which is an urban campus without the rolling grounds and gardens and quadrangles typical of most American universities, you don’t get the usual rhythms of campus life, especially at my end, the medical and health professions end where everything goes hell for leather 365 days a year. This afternoon, in perfect weather, the Auburn campus was full of young people playing frisbee on the lawns, studying under trees, gathered around picnic tables with their lattes, the sort of things I did more than forty years ago when I was a college freshman just starting to discover adult life.

Fall is my favorite time of year. I think it has something to do with having always lived and worked in the educational environment. Fall is the time of new beginnings, the changing of the seasons away from excess heat (and humidity in the south), the colors of the leaves (orange is my favorite color – I have no idea why), and the expectations of the holidays to come. As I was watching those eighteen and nineteen year olds, young adults whose educational lives have been upended and scarred by the pandemic, I drifted back to other falls and other campuses: The Lakeside School in Seattle where I spent my high school years with its maple trees and New England style buildings of red brick, white paint, and the occasional cupola. Stanford University with its sandstone archways and red tile roofs. Washington State University with its views of the rolling wheat fields of the Palouse stretching off in every direction. The University of Washington with Mount Rainier always hovering in the background when the sun was out.

I figured I had to at least get across the state line and into the Eastern time zone prior to stopping so I kept on going and decided to spend the night in Columbus where I am ensconced in my usual Hampton Inn close to Fort Benning. It’s dark so I can’t tell too much about what’s going on out there other than there seem to be a great many pine trees and there seems to be some sort of marsh across the road. Maybe there will be some interesting bird life tomorrow. Today’s bird life consisted of a flock of lazy and somewhat bad tempered Canada Geese at Avondale Park. I had gone to the amphitheater there this morning to see Opera Birmingham’s children’s opera about Little Red Riding Hood. The geese were lounging besides the path leading up to the seating. Fortunately they stayed where they were rather than pestering the toddler patrons for their veggie straws.

Little Red Riding Hood’s Most Unusual Day was highly amusing. Like most good children’s theater, it operated on two levels, one for the children and the other for the adults. For the kids, the story was the familiar one (with some twists) and there was a certain amount of breaking of the fourth wall. For the adults, the music included spot on parodies of such familiar pieces as Largo al Factotum and Offenbach’s Barcarolle from The Tales of Hoffman. Children should be introduced to opera and serious music early. I know as a child I had kids records of a number of classical pieces such as Peter and the Wolf, The Carnival of the Animals, and selections from Gilbert and Sullivan. I attended my first adult opera in fourth grade under the aegis of the Seattle Public Schools. In that period, the early 1970s, Seattle Opera did school matinees in English and all those who wished to pay a small fee for the field trip, were bussed down to the Opera House at the Seattle Center for the performance. As an adult who now performs on stage, I wonder what those singers thought of a house of several thousand fourth and fifth graders (plus long suffering chaperones). As I remember it, we were reasonably well behaved for children and stayed in our seats but boy we were noisy before and after the performance.

The Opera House – as it was in the 60s and 70s

I recall performances of Faust, The Valkyrie, and The Barber of Seville. I think there was a fourth one in there but I’ve forgotten what it was. Did they make me an opera fanatic? No, but it raised my consciousness as to what opera was and kept me from being scared of it so I would catch the occasional broadcast of Live from the Met on PBS or see a performance and have a pretty good idea as to what I was in for and how it worked and what to listen for. It left me primed for being open to learning a great deal more when I met and eventually married a true classical musician in Tommy who had opera in his blood. (He made his debut at age 10 as the shepherd boy in Tosca). And now here I am as the president of Opera Birmingham’s board of directors. Something ten year old me, sitting in the audience of Faust in Seattle back in 1972 could never have conceived of.

I haven’t done much reading of my usual Covid materials and blogs recently as everything seems to be fairly quiet. I don’t know if that’s going to last. Apparently there’s a bunch of new strains beginning to spread. I’ll see what I can put together and try to write about that tomorrow, wherever I end up. Tampa? Orlando? Dexter’s boat?

October 9, 2022

I’m getting a lot of complaints from patients and their families about the lack of timely availability of specialty and other services these days. There isn’t a day in the office where I’m not having to try to end run scheduling software in order to get someone something before next March. It’s become yet another daily task for which I was left unprepared by medical school. We didn’t have classes in data entry either but that’s become a big piece of what clinicians have to do these days. Fortunately, my high school career as a keypunch operator gave me certain skills that I have retained. I suppose I have come full circle. The requests for additional data fields that have no clinical relevance in some parts of my job have required me to put my foot down occasionally. The data is there and the administrative office that wants it can hire an abstractor rather than make me fill out yet another form.

My patients keep asking me why the American health system, at least form their point of view, is falling apart. It’s a complicated question without an easy answer but I’ve been able to piece some things together and, of course, a good deal of it is pandemic related. I think we’re all going to continue to find that a lot of the changes that are coming in our society over the next decade will be traced back by historians to the pandemic and political upheavals of the last five years or so. Don’t expect any of this to end any time soon. The closest analog is likely the impact of World War I and the 1918-19 flu pandemic. Take a look at the society of Titanic (1912) and The Great Gatsby (1923) – only eleven years apart but everything has changed.

Once upon a very long time ago in the spring of 2019, I had an idea for a book. It was to be called Boom! and, as I leisurely wrote it over the next five years or so, it would come out in the mid 2020s explaining how the health care system would be changed by the pressures of the aging Baby Boom which would start needing geriatric care en masse starting in the late 2020s and early 2030s. I wrote a couple of chapters over that spring and summer and then, as fall arrived, got caught up in various theatrical endeavors so I put it aside to work on again in the spring of 2020 when the theater season would be slowing down for summer. Nature, of course, had other ideas and upended all of our lives in March of 2020 and I, as part of my coping with wrenching change, began these writings, completely unaware that they would morph into what is now two and almost certainly to become three volumes of The Accidental Plague Diaries. The rough chapters of Boom! were transformed into some of the material that has gone into these essays – perhaps I’ll pull it out again and rework it and Boom! will live again. Perhaps not. I’ll just have to put aside those daydreams of being hailed as a clairvoyant as my predictions regarding the health system came true.

The pandemic put various trends that were already present on steroids and so here we are in 2022 starting to have problems that I thought we wouldn’t see for another five to ten years. The inability to provide services in a timely fashion is a key one. I won’t say that the US health care system is irreparably broken at this point, but it’s definitely on the critical list and it’s going to take some major changes in policy to right the ship. If that doesn’t happen, we’re going to see continued and worsening delays in the system and people will die as they won’t be able to get what they need when they need it.

So why is this? The first pandemic related reason is departure of skilled clinical staff. This doesn’t just apply to providers but to all of the other professions that make up modern health care – nurses, therapists, social workers, pharmacists, dietitians… the list goes on. Being on the front lines in the early pandemic prior to the availability of vaccines meant that some died or developed long covid related health issues that kept them from working. The older generation used the pandemic as a reason to retire. Loss of other family members forced some to leave the work force to take over as caregivers for suddenly parentless children or family elders who no longer had a consistent adult to help them at home. Most of these positions require a highly skilled individual with many years of training and licensure requirements. They can’t be created from scratch in a year or two. Personally, I had thirteen years of higher education. When everyone has a job, there’s no one left to hire. (Our current anti-immigration sentiment, even against highly skilled immigrants isn’t helping).

Tangential to this is that a lot of the departures to retirement are of senior individuals with decades of experience who are adept at caring for large panels of patients. It’s not something you can do right out of training. You have to have a great deal of real world experience to learn how to juggle all of the balls at once. I didn’t really become good at my job until between five and ten years after completing my training. That was now twenty years ago so I feel like I’m really good at it at this point but there are very few around who could step up and do just what I do. Every one that retires throws hundreds to thousands of patients back into the system looking for new medical care and snatching up new patient appointments.

The pandemic also prevented the system from operating normally for several years. It’s only really gotten back to working in its usual way this past summer. Two years of seat of the pants ad hoc medicine and postponement of routine procedures and screening tests means two years of disease that might have been detected early getting away and presenting at a more advanced and complicated state requiring more intensive treatment and more appointments. There’s a huge backlog of mammograms and colonoscopies and other such things that have to be worked through. I would like to think that we’ll be able to operate normally going forward but I’m not so sanguine in thinking that everything is over. New variants keep circulating and human nature, politics, and inertia are keeping people of getting their boosters.

After the pandemic, the next most important issue is demographics. Here comes the Baby Boom. The lead edge will turn 77 next year and the years form 75-85 are generally when individuals start to transition from the robust health of late middle age to the collections of chronic diseases and dysfunctions that characterize old age. The Greatest Generation and the Silent Generation (to which most of my current patients belong) tend to be a stoic and accepting lot who understand that as their bodies age, things will change and they aren’t happy about it, but they do get the basic biological issues that aging presents. The Baby Boom is not of this mindset. They consider themselves forever young and the problems of aging, being diseases, must therefore have cures and they must have them dealt with and removed now, thank you very much, for they are interfering with their life plans. As they continue to age, more and more of their problems will not be amenable to any sort of curative treatment and they are not going to like that one bit and make demands of the health care system that cannot be met. There is also the impact of their huge numbers. The Baby Boom in the US has had 10,000 people a day celebrating their 65th birthday since the first ones did on January 1, 2011 and that won’t end until December 31, 2029. We haven’t substantially increased training programs for health care providers since the turn of the century despite this demographic imperative. It’s too expensive.

Politics comes into play. The passage of the Patient Protection and Affordable Care Act (Obamacare if you will) substantially altered the US health insurance market and, in the decade or so since its implementation, the number of uninsured has fallen from about 15% to about 5% nationwide. This is a laudatory goal (and has anyone else noted that the Republican Party is no longer introducing bills to repeal Obamacare ever other week?) but it has had the effect of granting an additional thirty million people or so easier access to the system and all of them are wanting and should be entitled to services.

Then there are the rather peculiar capitalistic beliefs under riding American medicine. In most countries, the health system is studied and planned and the pieces are designed to maximize the health of the population and to provide the widest possible service for the lowest possible cost. This means the types of specialties are controlled to the needs of the population, not the needs of the stockholders of hospital corporations or other such motivators. Our system is more of a free for all. There are limitations on the number of specialty training positions but less popular specialties, which tend to include those that provide the majority of ambulatory care are often going begging. We need about 35,000 geriatricians in the 2030s and 2040s due to the needs of the Boom which will be in their 80s and 90s during that period. We have about 6,000 currently and we’re only producing about 200 new ones a year, just enough to offset retirements.

Put all of these things together and, yes, you’re going to have to wait for that appointment. I’ll do my best for you. I’ll pull strings when I can. But it’s just where we are.

October 5, 2022

The Hallelujah Girls – Bobby Dwayne sees Sugar Lee for the first time in thirty years

It’s been a week of endings. The Hallelujah Girls closed on Sunday after a glorious four performance run. As a character guy, it’s been quite some time since I’ve been asked to be charming on stage and I’ve gotten the girl at the end of the show. People seemed to like what I did with a redneck contractor trapped in rather absurd circumstances with a long ago flame so maybe more of those type of parts will come my way in the future. One good thing about the aging of the Boom (and their refusal to admit it) is more plays calling for older characters and scripts that allow older adults to have more fully realized lives and even a spot of romance or two. I don’t have anything specifically lined up for my next gig yet but something usually lands in my lap when the theatrical juices get flowing. At the moment, they’re at a low ebb and will be until I get back from my week off toward the end of the month.

The other major project ending is the very last gasp of edits on the second volume of these Accidental Plague Diaries. I now await a proof copy to double check for a major missed typographical disaster and as soon as that happens, the publication date will be set. I guess that puts me in week 39 with my second child. It will soon be here and launched upon an unsuspecting world to sink or swim. If you want me to come do a reading or a signing, slide into my DMs, as the kids say, and we’ll set something up. It’s very odd putting the book forms of these writings together at the same time as I continue to spew out these missives. Volume II covers most of 2021, which wasn’t all that long ago, less than a year, and as I have written and edited and retouched some of the entries, they feel so foreign and far away. It also makes me wonder about the putative Volume III. The story isn’t over yet so I feel compelled to keep telling it but when does it become too much? Is there an ending? Does it just trail off in the way that society would like the pandemic just to vanish into the mists of time.

Looking at various data points, the pandemic isn’t going to blithely depart at any time in the immediate future. If you look at trends in Europe, numbers are going back up again in terms of cases (but not necessarily in terms of morbidity and mortality). We tend to lag behind Europe by six to ten weeks in general. As a good deal of Europe is further north than most of the US, the fall weather is already well established there and, with that seasonal change, human behavior regarding indoor versus outdoor activity changes. There’s some thought that this is why they’re going up and, as fall continues to come to our more southern latitudes and we do the same thing, our numbers will echo what is being seen there and the slow decreasing trends we have seen over the last few months will start heading back up.

All of the variants spreading worldwide still seem to be subvariants of omicron. There hasn’t been a huge antigenic shift since that became dominant last December. But we’re only doing about 10% of the testing and gene sequencing worldwide that was being done in 2020 and 2021 so we’re not getting anywhere near the same type of accurate picture as to what’s going on as we used to. It’s possible that there are new strains with highly unpleasant tendencies brewing out there but that we just haven’t yet detected them as no one’s looking. We do have one decent weapon, the new bivalent vaccine booster which has been formulated specifically around the omicron BA.5 variant which had come to dominate over the summer. Unfortunately, few people are taking advantage of it’s availability. Last I checked, only about 15% of the people who could benefit had actually gotten a shot. I’m hoping those numbers start going up a bit more later in the fall as people start thinking about flu shots and spreading respiratory viruses of all stripes.

The social scientists are starting to study and measure the changes in American society wrought by the pandemic. I’m not well trained in these methodologies but, from what I can tell, there are a number of scales on which American personality traits can be measured from various large data sets. In 2020, the first year of the pandemic, there was an improvement in general well being and a lessening of neurosis. The feeling of everyone being in this together and having to lay aside differences to help overcome a common adversity made a positive mark. This has apparently become completely undone over 2021 and the first half of 2022. The politicization of vaccines and public health measures, disagreements over best practices in education, and economic worries as the various pandemic linked shocks have hit different financial sectors have caused us to become more tribal, more suspicious, more distrusting, more willing to circle our wagons and not care about those outside of our camp.

I think the clearest place to see all of this is in the education system. The havoc wreaked by societal shutdowns and the failures of on line learning have left American parents somewhat frantic. At all socioeconomic strata, there is an understanding that a good education is the ticket to forward motion in society and anything that can impede that is anathema. The late high schoolers of the last few years are entering college without good study habits in place. The elementary and middle schoolers are behind where they should be. Energetic parents are helping their kids catch up and supplementing. Less energetic or more distrusting ones are looking for scapegoats. Masks! Critical Race Theory! Drag Queen Story Hours! I don’t know how the great pause is going to shake out in the arc of Generation Z’s life but there’s likely to be impacts felt for years to come. In another few years, the first of those who had truncated high school experiences will start turning up in medical school. It’ll be interesting to see what that will bring about. We can’t dumb down standards or coddle students when creating doctors. If we do, people will die.

I have seven more work days before I get a week off to recharge. I’m trying to decide if I’m going to completely unplug for the week or if I’ll keep up my usual social media presence. I’m heading to Miami to see an old friend for a few days. Leisurely drive down the Florida peninsula, more hell for leather return. I was going to go down the West coast as I have never been to the beaches or cities on that side but Hurricane Ian has put a stop to that plan. I’ll probably just go down the turnpike but I’ll keep an eye on the weather and flooding and adjust my route accordingly. I’m thinking about stopping in Orlando and spending a day at Disney or Universal. But I’m not sure I want to do that alone. It’s much more fun with a companion.

September 30, 2022

Time marches on and summer turns to fall. Around here, that means that the humidity has finally left the air and we’re having lovely days of 70s and low 80s that don’t feel like a malfunctioning steam bath and I, at least, don’t mind being out of doors. There’s also a bit of a nip in the air when I walk out the door in the morning and I’ll have to get out my official UAB jacket soon so I don’t develop too many goosebumps in my daily race from one office to another, trying to keep all the professional balls in the air.

The pandemic has done a number on health care. The effect on my specialty is not one of direct effect. Most of my patients were smart enough to isolate through the worst of it in 2020 and then get vaccinated as soon as they could in 2021. It’s the indirect effects. Disease processes having worsened because of delayed care. Impossibility of getting timely specialty services due to retirements and short staffing. The inability of senior living facilities and other services to meet demand and the endless array of complaints this brings to us from fed up patients and families – as if we had any control. The significant increase in mental health issues, especially anxiety which has led to more and more communications with our offices over relatively minor issues. Phone calls, emails, faxes, notes, complaints all up. Staffing down. One very tired and somewhat exasperated geriatrician caught in the middle. One of these days I will be able to convince the powers that be that for every person who comes through the door providing a billable visit, we hear from another eight or nine people that require some assistance that day (unbillable work and therefore not part of the computations regarding the need to increase staffing). Perhaps I should take an unscheduled vacation and forward all my phone lines and messages to the Dean’s office for a week.

A review of the numbers shows that we’re holding relatively steady at about 400 deaths daily but cases have continued to decline somewhat. I don’t know how much to trust the data in general as so there’s now so much variation in reportage but it looks like the current hot spots are Appalachia, especially Eastern Kentucky and Western Virginia and the Mountain West. I wonder if that’s related to lower vaccination rates in those areas due to political leanings. There’s still a lot of fear in the epidemiologic community that we’re going to go back up again significantly later in the fall as various omicron subvariants continue to spread and because people continue to not take advantage of our best weapon, vaccination.

The new bivalent vaccinations have been out for about a month now with their increased specificity against omicron. Not a lot of folk are taking advantage of them despite widespread availability. It may be due to the collapse of media coverage of Covid in the wake of other stories of national interest and the lead up to the midterm elections. It may be because the populations most likely to take advantage are waiting a bit more to take them a bit later in the fall along with their usual flu shot. It may be that there are a lot of folk like me, who had a mild infection within the last few months and are waiting out their three month post infection window before getting another booster. As more and more data comes in on the bivalent vaccine in populations, it is becoming clear that it provides longer protection, stronger protection, and broader protection allowing the immune system to react positively against new subvariants as they come into being. There’s a lot of reasons to get boosted if you’re over fifty or have an immune system issue or a chronic illness and not a lot of good reasons not to.

The Hallelujah Girls is up on its feet and half way through its glorious four performance run. It’s been a good time. It’s very rare for me to get cast as a romantic comedy lead as I’m a character type so I’m making the best of it as it’s likely to be a while before I get the girl on stage again. It’s not Shakespeare, Sheridan, Shaw or Shaffer, but it’s good fun and audiences are enjoying it and laughing appropriately at the antics of the Southern Belles and Rednecks inhabiting the Spa-Dee-Da day spa in the old church building in Eden Falls, Georgia. Most of the cast are people whom I have not worked with before and it’s been fun getting to know some new and talented folk. After closing on Sunday, I am turning off my theater brain for a few weeks, forgetting my pages of bad grammar dialog, ditching my redneck accent, and taking a few naps. I’m still not recovered from my recent Covid bout and just get tired far too easily. I can tell I’m improving but I keep falling asleep in the passenger seat on house calls or sitting in front of my computer writing notes and haven’t been able to do much outside of work/dress rehearsal/performance all week and the laundry and grocery store are calling.

I don’t have a publication date on Volume II of The Accidental Plague Diaries yet. Stop asking. As soon as it’s set, I’ll make sure everybody knows. There’s still a few more tweaks to make sure it’s all finished and good as it can be. In the meantime, go get your booster if eligible, stay home if you’re sick, and keep your hands washed.

September 24, 2022

And Volume II of the book form of these Accidental Plague Diaries is complete. Proof copies should arrive in a week or so and if they pass muster, I will announce a publication date so y’all can run to your local bookstore and tell them to order it for you. (And have them order a couple of copies of Volume I to put in the window while you’re at it.) This is about the extent of my PR campaign this time around. Neither the publishing house nor I have a budget so it’s going to be social media and word of mouth, unless someone can figure out a way to get a copy to Oprah or an article in the New York Times literary section. When I started these essays, I had no idea they would become a book, much less two. And all signs are pointing towards a third volume in another year. I think I’ll call it quits at that point. I’ve pretty much said everything I can say, unless Covid makes some sort of strange epidemiologic turn this fall – which could indeed happen.

I have no idea where to end a projected and final Volume. Does it end with various public figures declaring the pandemic is over, even though it obviously isn’t? Does it end with the American public returning the control of congress to a political party riddled with science and public health denying charlatans? Is there some grand announcement yet to come from WHO or the CDC? Or does Covid simply peter out, slinking off into the background of our lives. One more social problem we blithely ignore the same as we have made our peace with excess gun violence, underfunding of education and social services, and a mental health system in tatters. I suppose it will eventually become clear and an inflection point that makes sense to me, even if it doesn’t to anyone else, will present itself.

Covid continues to run rampant through my circles of acquaintance. Not a day goes by when I don’t hear of someone down with it from some area of my life. My acquaintances are, for the most part, vaccinated and have had at least one booster so no one is getting sick for more than a few days and it’s been months since someone I know has had to be hospitalized. We can live with this. But there are a couple of big unanswered questions. It is not known how long both natural and vaccine mediated immunity will last in the face of a virus that mutates as rapidly and in as many different ways as a coronavirus. We may be able to keep ahead of it with annual boosters but that is no sure thing. And even if the vaccine and boosters prevent severe disease, they don’t seem to be all that effective at preventing long Covid.

Long Covid is here to stay. We don’t know what it is. We don’t know the mechanisms behind it. We can only palliate symptoms. When I had my first bout of omicron nine months ago, I was significantly ill for about 36 hours. Felt unwell for another three days and then felt pretty normal. My most recent bout last month had me feeling far less acutely ill but the post viral fatigue has continued to this day. The first two weeks after my acute symptoms went away, I could barely drag myself to where I needed to be. Things improved some this past week. I am feeling more energetic but I can still tell I’m not at 100%, maybe 75% on a good day. Is this the way I’m going to feel going forward? Will I be able to keep up my usual life pace? Are there unpleasant Covid related surprises busy percolating in my heart or my brain tissue? I don’t know. At least I’m not feeling so rotten that I don’t want to get out of bed and my breathing is fine. I may have a little brain fog, but that’s been hanging around since I turned fifty.

I did something highly unusual for me today. I took the day off from all responsibilities and vegged. It was probably good for me but it does mean that I’ve got a ton of neglected work to do tomorrow to catch up. This next week is going to be busy with dress rehearsals and performances of The Hallelujah Girls (Eastlake Methodist Church fellowship hall – Thursday Friday and Saturday at 7:30 PM and Sunday at 2:30 PM). Then I’ll be over the hump with both the literary and theater careers quiescent for a month or so. And I’m finally going to get a vacation week in October. Granted, it’s only to Florida but I haven’t been much of anywhere since last holiday season.

Tomorrow is a reading of the new opera Touch that Opera Birmingham has commissioned. We’re doing the premiere production in January of 2024. It’s about Helen Keller’s life after her schooling and her complex relationships with Annie Sullivan and others as an adult. As president of the board, I’m helping steer this project forward. I’ve seen pieces on Zoom and video and I’m looking forward to hearing the music sung live. No, I will not be in it. I do not have a voice capable of singing opera roles. I can sing chorus, but I’d be laughed off the stage as anything other than Lillias Pastis in grand opera. I’ll stick with my musical comedy character parts when it comes to singing solo.

The bivalent vaccine is now available pretty much everywhere. Go get it. I would, but I have to wait for a while. You should allow twelve weeks between an acute infection and a booster. And keep your hands washed.

September 19, 2022

The pandemic is over. How do I know? Joe Biden said so yesterday on 60 Minutes. I wish I had his confidence but I’m not quite so sure. Today’s statistics show that we’re still losing more than 400 people a day and that number, while trending down, has remained relatively static for some months and is nowhere near as low as the troughs after the Alpha variant wave and the original Omicron wave. We still have over 30,000 people hospitalized nationwide with a coronavirus infection, roughly 10% of whom are in the ICU, and the test positivity rate (percent of tests done which are positive for illness) is something over 10%. The WHO sets a ceiling of 5% on this to declare an epidemic or a pandemic controlled. So, by any measure, Biden’s statement is one of wishful thinking.

There are also new Omicron variants in the wind. The one that is currently most widespread and causing most clinical illness is variant BA.5. However, variant BA.4.6 is on the move in New England from wastewater surveillance studies (fortunately, it doesn’t appear to be more infectious or virulent than other omicron varietals). It could lead to a surge if there happens to be a mutation. There’s also a new variant BA.2.75.2, not yet widespread but with multiple new mutations on the spike protein which could greatly increase its affinity for human cells and its chance of causing clinical disease. While there are very few cases, the number have been doubling every week the last few weeks and we should not forget the power in exponential numbers. Think back a year. At Thanksgiving last year, the original Omicron variant was just a whisper in South Africa. By Christmas, it was everywhere and cases were skyrocketing.

The end of the pandemic will come when the disease and its effects fade into the background of our daily lives as yet another endemic disease, something that isn’t going to seriously affect our lives and plans, but rather those of some comfortably distant other. We’re well on our way to doing that. The classes in this country who run our politics, economy, and society are predominantly healthy and vaccinated and as the virus interacts with them these days, it’s mainly as a nuisance. My recent infection wasn’t that bad as far as disease goes. The quarantine and time off work was more of a hassle. My long Covid symptom of fatigue feels like it’s beginning to lift. I definitely have more energy this week than I did last.

So what does the end look like? Ticker tape parades and church bells pealing out? More likely, just a willful indifference to something that can be relegated to the background as we all return to our usual daily distractions. We seem to be content with letting Covid settle in as the third leading cause of death after heart disease and cancer just as long as it’s not wreaking havoc in our particular social group. The health system can handle the current burden of 3-4% of hospital beds nationwide taken up with Covid patients. It’s only when the number gets up to 10% and above that the system completely breaks down. Like flu, the serious cases will be pushed more and more into populations of the old, the ill, and the marginalized.

There are still a lot of unanswered questions. What is long Covid and what causes it? Is it autoimmune in nature, the body’s natural defenses being over activated by the virus into attacking normal body tissues? Is it continued viral infection with the virus hiding deep within some organ system and continually causing minor flare ups? Is it a complication of micro clotting and hemorrhages in the capillaries leading to malfunctioning body systems? We don’t know. But more information comes out daily suggesting that the virus is bad news long term. A study from today has shown that older people with a Covid infection are 75% more likely to be diagnosed with dementia within a year than those without. Is the virus neurotoxic? Are there tiny strokes involved? Will this lead to much higher levels or earlier onset of dementia among the rapidly aging Baby Boom?

There’s still a lot of vaccine and Covid denialism out there. It’s not as prominent in the mass media as it was a year ago but those attitudes have not disappeared overnight. Most of the older generation got their vaccines but they haven’t been nearly as popular with the middle aged for political and other reasons. Unfortunately, today’s middle aged adults are tomorrow’s elderly and as the unvaccinated age and have the normal decline in immune function that accompanies getting older, they may find themselves in the cross hairs of the more serious complications of the virus. The vaccines remain our best weapons against this. I’m getting my bivalent booster shortly and, if you’re over fifty, I strongly recommend you do as well. I’ll get my flu shot in October. Living in a Southern climate, our flu season comes a bit later so getting the shot mid to late fall is usually OK. The Southern hemisphere flu season, especially in Australia, was rather hot and heavy this year. That’s usually a good predictor of what’s likely to happen to us. And I really can’t recommend getting Covid and flu together at the same time.

I’m going to get every booster that comes down the pike. There’s no reason not to and I kind of like living with most of my organ systems functioning to original manufacturer’s specifications. I’m a bit eccentric like that.

September 15, 2022

I am almost finished with the final edits for Volume II of the Accidental Plague Diaries (book form). It will be available for purchase next month sometime. I’m not sure how I feel about it. I never intended to write the first volume and now there’s about to be a second and there’s the strong promise of a third. What does it mean? Should I feel proud of the accomplishment? Maudlin at the ending of this phase of the project? Excited about holding a physical product sprung entirely from my intellect and imagination in my hands? Dejected that the total royalties will likely be not quite enough to buy dinner for one at Automatic Seafood? All of those at once? If I had more energy or time and wasn’t spending far more of my limited psychic resources trying to hold everything together at work, I might start putting together plans for readings and signing events but I just don’t know that I’ve got it in me at the moment. I’ll just throw the book out there and see what happens. In my wilder daydreams, somebody gets a copy to Oprah and she loves it and puts in her book club list and my career is made. Fat chance.

I think I’m still suffering from post Covid lethargy. Most of my friends who have had it this most recent go round have told me they were just tired for about a month after recovering from acute symptoms. I don’t feel sick. I just don’t have my usual energy. I’m making myself do all of my usual activities but at the end of the day when the circuit is done, I sit down and feel completely drained. Mid morning and mid afternoon I go through low periods where if I’m sitting still in a car or at a computer work station, I just black out and sleep for a few minutes. Coffee doesn’t seem to help. It doesn’t happen if I’m in constant motion, such as in clinic where I’m dashing from room to room with patients or back and forth from my office. It happened twice today. Once this afternoon while writing notes after today’s house calls and once this morning while doing house calls when I blanked out for a minute sitting on a patient’s too soft living room couch waiting for him to return from the bathroom.

If this is the extent of my long Covid, I can live with it. I’m keeping my fingers crossed that it’s going to lift in another week or two as it seems to have with peers. I’m not going to invite trouble and assume this is a new normal but I know from decades of doctoring how life can turn on a dime. You can be hale and hearty one minute and next saddled with a disease process that will keep you from leaving your house without grave difficulties. Good health and long life is promised to no one. You can increase your chances by making wise choices but sometimes the wheel just comes up green double zero and that’s that. One of my high school classmates passed on this past week. We’re now all sixty or so so we’ll start dropping more and more frequently from natural causes. There were only a hundred of us. A couple died young but most of us made it into healthy middle age but as the years go on, ‘natural causes’ will catch up with more and more of us.

Those of us in our sixties and seventies, who are generally in good health thanks to reasonable genetics, access to decent medical care, and good life choices are probably all sitting around and looking at the number of people in our parents generation still living vital functional lives in their late eighties and early nineties and assuming that we will be able to do the same. I’m not so sure. That generation, having come of age in a time of scarcity, may have gotten a longevity boost from the semi-starved rat hypothesis and we, their children, coming of age in a time of plenty, may not have that and our years may be less. Add to that the rather precipitous drop in life expectancy from the Covid pandemic and other social ills. And then there’s the unknown effects of climate change that may cause totally unpredictable health hazards going forward.

I read a number of sources of material on Covid and the pandemic and digest it before sitting down to write these musings. I look at charts and graphs. I read scientific papers. I look at opinion pieces from both sides of the divide. Perhaps the best general source I have found are postings by Katelyn Jetelina who writes as Your Local Epidemiologist. She has far greater training in public health and epidemiology than I and has a gift of translating complex data into an easily understood format. Her most recent posting was a succinct look at who is still dying from Covid in the US. We continue to lose 400+ people daily nationwide, making Covid still the third leading cause of death after heart disease and cancer. The biggest predictor for mortality remains unvaccinated status. The more vaccines and boosters you have on board, the less likely you are to die. The second big predictor is age greater than 65. The majority of elders in the country have gotten their vaccines but not all and many, while they got their original vaccine, have not gotten boosted. So, if you’re an older individual, just keep getting your shots as they come down the pike. The bivalent omicron booster is becoming more and more available. I’m going to go get mine this next week.

Struldbruggs as envisioned by Louis Rhead

I can’t think of anything much worse than immortality without eternal youth. If you end up with an extra decade, it’s going to come in your 80s and 90s, not in your 20s and 30s no matter who you may be. Jonathan Swift got it right with his Struldbruggs of Luggnagg. If I cannot maintain my own body or am descending into the dream state of dementing illness to the point where I require 24 hour babysitting, I’ll be happy to go. At that point, death will be an old friend and I’ll be asking what took you so long. I have enough difficulty keeping up with the young uns and the way they look at the world at sixty and it’s going to be even harder in another generation or two, when those who understand the world as I do are slipping away.

We’re about to enter an interesting time. The Baby Boom, the generation that has dominated American culture for so long is going to start it’s die off in a few years. It really hasn’t begun yet. The oldest Boomers are 76 this year and will start turning 77 in a few months. This is still a relatively healthy cohort. In 2030, when the oldest boomers are turning 84, it’s going to be a very different equation. Assuming there aren’t more pandemics or other major disasters and death patterns are similar to what they have been recently, about 80% of the Baby Boom dies between 2030 and 2050. And given what I know about them characterologically, there will be a lot of raging at the dying of the light. Will this change the way American culture thinks of death? Will our death rituals change? What will younger generations do with the transfer of social power? Interesting thoughts to ponder on. But I’m not going to do that tonight. I’m too dang tired.

September 11, 2022

She was there for more than 70 years. You assumed she was eternal and would forever be part of your life. And then, one day, pffft… gone. I am referring, of course to Bogue’s restaurant, my local greasy spoon American diner that’s been a fixture in Birmingham since the 1930s. It closed suddenly this past week. For years now, my routine was to have a big breakfast there on Saturday morning, any weekend I was in town to tank up for the chores of the weekend, be it shopping, laundry, yardwork, or wading through dozens of unfinished progress notes or other work projects. I guess I’ll have to find another Saturday morning bacon, egg and country gravy place to patronize.

Queen Elizabeth II also died this week. Having seen various news photos of her over the last year or so since the death of Prince Philip, her death did not come as a surprise to this geriatrician. I have no idea what her health conditions actually were but I could tell from posture, fit of clothes, skin tone, and other clues that she was not doing well. When I heard that her brief meetings with Boris Johnson and Liz Truss regarding the changing of the guard at 10 Downing Street had pretty much taken all of her strength, I figured the end was near. Her Majesty had been on the throne for a decade when I came along and I’m no spring chicken so there’s really no one under the age of about 76 with any sort of memories of George VI’s reign and to have even childhood memories of George V and the short reign of Edward VIII and the abdication would require you to be in your mid 90s or older.

There’s going to be a lot of reassessing of the monarchy and the direction of the UK in general with this particular passing of the torch. The Empire is no more. The Commonwealth is on somewhat shaky ground. Brexit has done a number of the economy and society. Will Charles III have the skills necessary to walk the tightrope between tradition and modern needs? It remains to be seen. He’s been preparing for the job for more than half a century. Let’s see if any of that training has paid off. As I read some of the social media kerfuffles regarding the Queen, it strikes me that there is a certain confusion between the Queen, the person, and the Queen, the symbol. By all accounts, the person was intelligent, perceptive, had a great sense of humor and dedicated her entire life to the well being of her country. The Queen the symbol is more difficult. With the various titles and roles and the concepts of being anointed by God and head of the Church of England, she got boxed into a corner numerous times between her duties as the monarch and her duties to her family as wife, mother, sister, aunt, and grandmother. This of course led to the rather disastrous marriage of her sister Margaret, the doomed story of Charles and Diana (I actually have a lot of sympathy for Camilla – she and Charles were perfect for each other even in youth but the Queen and court could not permit the marriage as she was not a virgin among other reasons), and some of the nastier exploits of Prince Andrew. She was not responsible for the depredations of the British Empire (it was pretty much dismantled by the time she took the throne). She had very little say in legislative affairs. And while the monarchy is an expensive institution, when you divide the amount of public funds appropriated to it over the population of the UK, it comes out to about $1.50 a person which isn’t a bad price for that much pomp, pageantry, tradition, and connection to the past.

My mother, although American, was basically raised in a British household. Her parents emigrated to the US just before she was born and never became US citizens. They always retained their British citizenship and passports. The books she grew up with, the cultural references around the dinner table, the way in which the household was run – very British upper middle class. A certain amount of that trickled down to me and my siblings a generation later. We read British children’s classics that aren’t as popular on this side of the pond and were steered towards Dickens and Austen and the Brontes by middle school. We watched the Britcoms on PBS and I soon realized that I got more of the jokes than most of my peers. I became fascinated by history relatively early on and my mother would read children’s histories of the world and of Britain to me and by the age of ten or so I was more certain about the names and historical importance of various British monarchs over the years than I was of American presidents.

My mother was the same generation as Queen Elizabeth II (the Queen was a few years older) and her mother, the Queen mother, was the same age as my beloved maternal grandmother. Watching those two royals function and age in the press over the course of my life has always reminded me of my mother and grandmother and of maternal love and maternal pride in my accomplishments so I have always viewed the Queen through a somewhat different and more personal lens than most. My grandfather, with his intense social climbing inherited from his people, also never let it be forgot that we were quasi-related. He and Anne Messel, Anthony Armstrong-Jones’ mother were second cousins and palled around together in the Bright Young Things society of between the wars London. Anthony, of course, married Princess Margaret becoming the Earl of Snowden and their children, the Queen’s nephew and niece, are therefore my fourth cousins. Never met them. Never will.

The Queen’s impending funeral is likely to keep Covid off the front pages for the next week ago so we should probably check the numbers to see how things are faring. Numbers are continuing to go down. The daily death toll has dropped under 400 a day for the first time in some weeks. That’s all well and good until you start to multiply it out and you start to realize that the weekly death toll all this past summer has been higher than the death toll of the 9/11 attacks. There hasn’t been much chatter about new variants. The new bivalent vaccine with additional omicron protection continues to come on line. If you’re more than about ten to twelve weeks out from a previous booster, it’s a good idea to go out and get one.

It is the 21st anniversary of the 9/11 attacks today. I haven’t forgotten. The news telecasts have been running news footage from that day all day. I don’t need to tune in. I lived through it and remember it all to well. I feel no need to relive that day visually or emotionally. I will quietly mourn for the victims, and more for the country that squandered the good will of the world in misguided military adventures in the years following.

September 7, 2022

The VA has allowed me to return to work so I guess I am no longer Typhoid Mary. I went in today and cleared out various boxes that were overflowing with important messages, on paper and electronic, and tried to get everything ready for resumption of my normal rural house call schedule tomorrow. It wasn’t too bad. As a number of other people in my unit went out with Covid at the exact same time as I (making the VA the likely source of my infection), it has been relatively quiet over the last ten days. I haven’t been allowed back at UAB yet. I should get the all clear tomorrow but anything is possible. I’ve been doing as much of my work on that side from home as possible so it shouldn’t be too bad getting everything up and running again.

I’m in the process of editing the galley proofs for the new book, Volume II of these Accidental Plague Diaries. The material is only just over a year old but so much has happened in that year that in some ways it feels like I’m editing some sort of historical text. Does anybody remember the delta variant? Last summer’s school mask wars? Does anybody care? I guess I’ll find out when the book is done and out there and if anyone actually buys a copy. Going through it line by line, I think there’s some good stuff in it and there’s some stuff that I’m cringing at a bit but it’s what was going on in the world and in my head at the time. When will it be done and available through a book retailer near you? I was hoping the end of this month. It’s likely to be mid-October though as I’m not progressing quite as quickly as I might like as other things grab my attention.

So where are the numbers now? Trends are all going the right way, but slowly. Daily deaths have dropped from the mid 400s to the low 400s. Test positivity rate is down from about 20% to about 15%. New diagnoses are down about 20% from a couple of weeks ago. Not as low as we have been during some of our previous lulls but not as bad as it certainly good be. Will we go shooting up again this fall and winter? It remains to be seen. Some will depend on the numbers and kind of people who go get their bivalent booster shot for additional omicron protection. Some will depend on our social behavior patterns over the next few months (which may in turn depend on all of the rather strange weather we’ve had this year due to climate change). Some will depend on whether a new viral mutation comes into play.

The chatter in the science community is that the government is gearing up for a future with an annual Covid booster, likely in the fall, to coincide with the annual flu booster we’ve all gotten used to in recent years. That would certainly help with messaging and with convenience, especially if they work out a way to combine the two vaccines into one (it’s being worked on). The only flaw with this tentative plan is that it assumes that Covid and influenza are similar viruses with similar annual patterns. Unfortunately, they aren’t. Influenza has significant seasonal variation. Flu season usually runs November to April with minimal cases outside of that window. This allows us to predict with some success, the timing of when a flu vaccine will be the most effective leading to the annual fall campaign. Covid hasn’t shown a seasonal predeliction. We’ve had surges in the winter and in the summer. The flu virus tends to mutate in a predictable pattern allowing us to guess how to adjust the strains in the vaccine in advance. Covid is more random in its mutation (or it has a pattern we just haven’t ferreted out yet). The bivalent omicron vaccine has been approved and is in the process of heading out through distribution networks and is already available at some locations. If you’re more than sixty days out from a prior booster, it’s probably a good idea to go get one, especially if you’re over fifty or have any issues with your immune system.

My own personal Covid case has essentially resolved. The only symptom that remains is fatigue. It’s not a bone weariness, it’s just a feeling of weakness and that I just don’t have the stamina I think I should. I’m capable of doing everything I need to do but I find I need to sit down more and I’m more likely to nod off once I find someplace comfortable. Most of my friends of my generation who’ve had a recent second omicron infection like mine have had similar feelings and have told me it takes about two to three weeks for it to go away so I’ll give it another ten days or so to resolve itself. I’m keeping my fingers crossed that this is not the beginning of some sort of long Covid nightmare that’s going to haunt me for a while. It also better not keep me from learning my lines. I have enough trouble with that already at my age.

Rehearsals for ‘The Hallelujah Girls’ are going smoothly. It’s not Shakespeare but it’s good fun and it’s not often that I’m asked to play a sex symbol so I’ll take it. I’m having difficulty finding just the right southern dialect for the character. It’s supposed to be rural Georgia but I keep slipping between Charleston and backwoods Tennessee, neither of which is quite right. I’ll figure it out. Dialect is not my strong suit. I suppose that’s what comes of going into acting without much in the way of formal training. I do take the occasional class but most of what I do these days is dramatic improvisation which is very helpful for character building.

‘Too Darn Hot’ from The Kiss Me Kate I directed – Virginia Samford Theater – June 2006

I’d like to direct again. It’s been a decade since I last did. I love directing big old fashioned musicals best but few companies are doing these at the moment due to the expense involved and the size of the casts. Everyone is in a period of financial retrenching after the last few years of disaster and so things have titled more towards chamber pieces. My favorite directing assignment was Kiss Me, Kate, Cole Porter’s musical send up of The Taming of the Shrew. It’s a great show, if a bit dated (and some of the gender politics are questionable but can be dealt with with proper staging and interpretation) with an absolutely fabulous score. When I directed it, now sixteen years ago, it became clear to me why it isn’t done more often. It depends heavily on men (often in short supply in community theater) and is basically two different period shows happening together at the same time. One of my less stellar moments came at the first orchestra rehearsal. I had this idea for the top of the second act, leading into ‘Too Darn Hot’ that we would hear the orchestra at a distance as if they were playing inside the theater, while the cast cooled off outside. This would necessitate a prerecorded track and a sound cue, and then the live orchestra would take over. So I sat there and explained what I wanted and told the music director and orchestra in all earnestness ‘So when we get to this orchestral entrance, I want you all to play with yourselves’. Silence. Then hysteria. And that idea was quickly jettisoned.

It may still be too darn hot out there, but not so hot you can’t keep your hands washed and sign up for your boosters.

September 3, 2022

The acute Covid infection is over. It’s been a week now and all that’s left is a bit of a stuffy nose and a feeling of significant fatigue that leads me to needing a nap and ten hours at night rather than my usual seven. There’s no fever, no myalgias, no feeling sick. I hope the fatigue clears itself up over the long weekend and isn’t going to settle into some sort of post viral chronic fatigue. Ain’t nobody got time for that. But what will be, will be and I’m pretty good at reading my body and what it needs. I still haven’t heard much from my dueling employee health departments on when I can actually return to work. I’m hoping Tuesday, but who knows. I may be stuck teleworking another week… or two… or three… It’s hardly ideal but I can at least stay caught up to a certain extent, at least on the UAB side. The VA decided somewhere in the last six months to revoke my telework privileges over whatever arbitrary unfiled form so there’s not much I can do there until they clear me for duty.

So how have I occupied my last few days of confinement? I’m working on the final edit of Volume II of these Accidental Plague Diaries and if all goes well it will be out by the end of the month. I’m working on my lines in a prayer of being off book when I get back to rehearsal this next week. I’ve done some clean up around the house. I broke out the Xbox and realized I’m just no good at Grand Theft Auto V. I’ve read most of The Once and Future Witches which I quite like, other than some rather ham fisted political allegory. Just the usual things a sixty year old man does when left to his own devices at home for a number of days.

I’ve been living with a ghost. Binx, my new cat, absolutely refuses to have anything to do with me or Oliver, my geriatric cat who seems to live mainly on my bed these days. I know he’s here in the condo. Food disappears. Poop appears in his litterbox. I occasionally hear him late at night or catch a glimpse of him out of the corner of my eye. I figure one of these days he’ll figure out I’m not that scary or dangerous and he will start coming out of his hidey holes more often. I’ve found a few more he’s utilizing – behind the washing machine, on one of the bookshelves behind the foreign language dictionaries – he’s going to run out new ones soon. There’s only so many possibilities.

This evening, I ventured out. It’s been more than five days so under current CDC guidelines it’s OK as I have been asymptomatic and afebrile more than 24 hours as long as I keep a mask on (which I did). The opera chorus got together to sing Libiamo from La Traviata at the wake for one of our own who died a suicide a few months ago. I had known my colleague for a very long time. He was a physician like myself, although a generation younger. He had sought me out early in his medical school career as I was one of the very few out gay male faculty at the time and I helped him as a gay man in a homophobic profession through his med school years. He eventually went away for residency for a while and then came back to Birmingham about two years ago when he joined UAB as junior clinical faculty. He attended my church, sang with me in the church choir and the opera chorus and we were always friendly.

When someone commits suicide, especially someone who seems to have a happy and functional life, there are always unanswered questions. The what ifs. The did I miss somethings. Having lost a number of friends to suicide over the years, all I can say is they’re fairly useless questions. We can never really know the interior lives of another, even those with whom we share intimacy. I lived for well over a decade with both Steve and Tommy and never completely understood what they were thinking or how they would react to a given situation. There were always surprises. That’s part of what held the relationships together. There were new discoveries and hidden facets there to be found.

The gathering tonight was a party in a local nightclub/bar, hosted by his fiance (it was the place where they had been planning to have their wedding reception) and it was very much a festive wake. Music, dancing, food, drink and celebration for the fact that he had lived and touched all of us. Despite the surrounding gaiety (much of it literal), I was melancholy. I was having flashbacks to Tommy’s memorial of four years ago. Tommy’s affair was more sedate and had far fewer hula hoops in evidence but had the same air of festivity combined with sorrow for a life cut short. I suppose, at least for the next few years, any memorial I go to for a younger person is likely to jerk me back in that way. The memorials for older people who have passed in their eighties or nineties that I’ve gone to haven’t affected me in the same way. They’re much more of a bravo for a full life well lived.

As I read through the Covid news digests that I receive regularly in one form or another, I wonder if we’re about to head into another surge with the fall and if that is going to lead to more lives cut short, especially younger ones with so much yet to accomplish. US life expectancy has plummeted nearly three years since the beginning of the pandemic, from 79 to 76. Got to remember what that number means. Life expectancy from birth is the calculated actuarial statistical average length of life of the cohort born in that year. Babies born in 2019 could look forward to an average life of 79 years. Babies born in 2021 could look forward to an average life of 76 years. The last time there was this precipitous a drop was in the early 1940s when World War II killed a lot of young people; for it is early preventable deaths that have the most effect on the number. A person that dies at 30 loses about 50 more years of life than someone who dies at 80. And Covid continues to kill young healthy people.

The government of South Africa has a very robust wastewater monitoring program. They take sewer samples (as we all shed virus into our toilets when taking care of business) and find the coronavirus and genetically sequence it and map out the various subtypes that are turning up week to week. They were the first to identify omicron through their diligence last fall. They’re starting to find some new variants in their recent samples. Whether they are more contagious or virulent remains to be seen but when I hear of reports from there, my antennae go up.

On the good news front, both Moderna and Pfizer have had their bivalent vaccines approved for use (Pfizer for 12 and older, Moderna for 18 and older). The bivalent means that there are two different targets, one for the original Covid and one tailored specifically for omicron. Both vaccines are now being manufactured and are working their way into the supply chain and may become available quite soon. Check with your pharmacist. You can get it if you have had a recent Covid infection as long as you’re fully recovered. You can get it if you have had either one or two boosters prior. It appears to work best if there’s roughly a two to three month window since your most recent booster. So, if you had a booster in July or August, I would wait a few weeks. If you had it earlier than that, go ahead and get it ahead of fall. The more I see of the disease and the unknowns, the more I believe that you can’t have too many boosters. There have been hundreds of millions of doses given in this country with minimal problems and it’s certainly best to have as much immunity in place as one can. I’ll be marching out to get my bivalent booster within the next few weeks as I had my second in April.