Monsters Inside of Me

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Why do they lock gas station bathrooms? Are they afraid someone will clean them?” Anonymous

Growing up in the era of “Walk It Off” parenting, I was never allowed to get too in touch with my hypochondria. Occasionally, I might get my hands on a National Geographic magazine that would feature Amazon explorers, tribes that had never been touched by the outside world or an expedition into the heart of darkest Africa.  To properly frame the perilous nature of uncharted corners of the world, the articles would relate the hazards associated with indigenous people, nasty flora, unpredictable fauna and myriad microscopic predators that could all kill a man – often in bizarre and horrific ways.

I did not just want to know about the 1000 ways in which I could die – – I wanted to witness them.  The fact that most of these diseases, parasites and insidious bacteria were transmitted through unclean drinking water, monkey bites, and unnatural encounters in dark, forbidden places did not matter to me.  I was certain these germs were lingering everywhere.

These were the days before Purell and the bathroom at the local Shell gas station seemed the perfect breeding ground for microscopic predators waiting to hitch a ride home on an unwashed hand.  The public restroom was an essential pit stop for any kid on a long bike ride from home. I tried to hold it to avoid the dimly lit, gray tiled stall that seemed to radiate filth.  Truthfully, I’d rather risk getting caught in the bushes but sometimes nature left you no choice. I was fairly convinced that Lenny, the grease monkey who changed oil and pumped full service gas, had contracted some kind of brain parasite using his own bathroom.  Perhaps it was the fact that he always called me “Bubba” regardless of my repeatedly telling him my name was Mike. It might have been his perpetually filthy hands or his facial tic that would whip his head sideways as if a naked super model was riding by on a unicycle.

I did not appreciate just how microphobic I had become until I “stole” a free venereal disease pamphlet in the local pharmacy, went home and committed it to memory and then proceeded to contract the disease over the course of the next 24 hours.  I rationalized I must have picked up the STD from the Shell station toilet seat – even after using the wax paper seat cover that would always stay in place and then float away mischievously just before you sat down.  I distinctly remember my mother suffocating her laughter as I came clean about my condition.  She suggested that if I did not scrub so aggressively with the Dial soap, I might not have the “burning “ sensation.  I dialed down the Dial and things did improve.  However, I was wary. I understood this ancient scourge could incubate for years and lead to insanity.  Just ask King George III.

Things only got worse after seeing the movie “Hawaii” with Julie Andrews and Max Von Sydow where people stricken with the dreaded tropical disease leprosy were forcibly relocated to the island of Molokai.  The initial symptoms of leprosy might be as simple as a slow to heal lesion or cut.  My scraped knee that would ripped back open each week when sliding improperly in baseball might as well be a motel with a big neon sign saying “ vacancy “ to any tropical disease.  Before I knew it, my fingers would be breaking off on my pencil in geometry class.

Just a few months later, the film Papillion debuted with Steve McQueen starring as the convict determined to escape from French Guyana’s Devil’s Island.  In a particularly disturbing part of the prison escape adventure, Papillion attempts to enlist the help of a local leper colony to make his escape from captivity.  The head leper was grotesquely afflicted and eager to test Papillion’s willingness to accept the lepers as equals in exchange for their assistance.  “ Care to have a smoke?” The leper asks as he hands the Papillion the cigar he has just been smoking.  As Papillion takes the smoldering Cuban, he notices that the leper’s finger has come off and is clinging to the cigar.  As only Steve McQueen would do, he unflinchingly takes a deep satisfied puff.

It was about this time that my knee started to itch again.  The scab had healed but just one unclean cut and I could be easily transformed into one of those legless guys who pulled themselves around on skateboards begging for quarters. My mother once again intervened to explain that the incubation period for leprosy was three to five years.  If memory served, she was quite certain that I had not been in the tropics during my third grade school year.

Years later, I realized that my older brothers had much to do with my bacteriophobia. It was always the same scenario – – a summer campfire and a tall tale about the guy who became a zombie from tsetse fly sleeping sickness. Or he might describe the sad life of Jo-Jo, the Wolf Boy, afflicted with hypertrichosis also known as “the werewolf disease”.  Yet, the most indelible of all stories involved the dreaded intestinal tapeworm.

As the fire cast ominous shadows across my brother’s concerned face, he whispered. “You know how they would they would get rid of your tapeworm’s in the Middle Ages?” He would ask rhetorically with his face screwed into a grimace of false empathy.  “They would starve you, and then make you sit on a chair covered with honey.  The tapeworm would roar out starving for food and then five guys would pull and pull and pull.  If they got it all, you were cured.  If it broke off, forget it.”

Yes, it was very gross.  And yes, from that point forward I ordered well-done meat, compulsively washed my hands and refused to visit any country that had not been independent for at least 50 years.  My sib’s hyperbole included the description of a record-breaking 34-foot tape worm taken out of a man in the Philippines.

I suddenly began to suspect that our refrigerator was a youth hostel for killer microbes.  Raising boys had my mother permanently behind on household hygiene with our Frigidaire serving as the greatest living monument to this fact.  We were trained to check the expiration date on any perishable food item– lest we get a mouthful of lumpy milk, fuzzy gray piece of bread or cheese wedge with great blue mold spores blooming like spring forget-me-nots. She did her best, but it was a losing battle attempting to clean up behind four thoughtless primates.

In a brief and paranoid span of a week, I began to hint at the lack of sanitation in our house.  As she wiped the counters with the sponge that smelled an old Gym sock, my mind’s eye saw our eating space as a massive Woodstock of breeding bacterium.  She would have been better off just wiping everything with a raw pork chop.  “ I heard you can catch a tape worm from eating off a dirty counter top.” I said with my most official sounding voice.  “ Hmmm” was all she said, absentmindedly continuing to load the dishwasher.  “I heard a kid from Pasadena got one that was 25 feet!” “ Really.” Again, no reaction.  “Yeah, and they had to tie him to a tree and starve him.  They put a jar of honey ten feet away and during the night the tapeworm crawled out to get the honey.  They caught it and it’s going to be in Ripley’s Believe It or Not.”  That got her.  “Michael, who have you been talking to?”

I survived my Andromeda Strain childhood somehow despite the imminent pandemics of flu – swine, bird and Spanish influenza as well as legionnaire’s disease, AIDS, Hantavirus and Ebola. Years later, in his book, Guns, Germs and Steel, award winning author Jared Diamond confirmed just how close to death I was sharing that most of the world’s pandemics initiated as a result of people living in proximity with animals. Apparently, dogs came with ringworm, tick bites and rabies.  The cat was memorialized by singer Ted Nugent for his ability to afflict a person with Bartonellosis also known as Cat Scratch Fever.  I shuddered at the millions of microbes we must have ingested as we handled rats, turtles, lizards, gerbils, hamsters, snakes, birds, rabbits and guinea pigs. As more evolved warm-blooded hosts, I was amazed that we did not become a hotel for hidden organisms.  Perhaps, all the nitrates and red dye #2 we consumed in hot dogs neutralized the sexual reproductive capabilities of the germs.

In my late forties, I had more or less subdued the demons of my mysophobia – fear of germs. However, society has changed.  The world has become flat and the numerous filters that once spared our adolescent minds from the media blitz of fear and loathing have been stripped away.  The media cannot wait to rub your nose in these terrible afflictions.  If it bleeds, it leads. Even educational channels have sold out to our fascination with stories of the bizarre.

Recently, my brother alerted me to a new Animal Planet television show called, “Monsters Inside of Me.” Ever the helpful sibling, he had pointed me back in the direction of my childhood fears.  I tuned in one evening just in time to watch a young American afflicted with botfly larvae (literally crawling out of his back) and a woman whose brain had been infested with maggots from eating raw pork. The show went on to describe how fast these flesh eating, blood sucking, brain damaging, and lung leeching parasites can kill their hosts.  Worst of all, it was all happening in America.  (My theory was they all used the same restroom at a New Jersey roadside rest stop. Those bathrooms, I’m telling you are killers.)

I now try to stay away from Animal Planet but it calls to me at night. The organisms are once again on the creep and coming to a theatre, hospital and public restroom near me. I must be ready.

And the weirdest part of all is my knee – – it’s started itching again.

Dreams of the Bosphorus

image“In reality, the great question remains: Who will control Constantinople?”  Napoleon Bonaparte

It was a cool May evening, as our passenger ferry coursed northeast along the Bosphorus. A warm breeze tumbled down from the Black Sea rising up only to be split by the prow of the pleasure ship. The black hole of a far eastern night was periodically interrupted by the glowing safety lights of dark, hulking freighters working their way past us to burst free into the Marmara Sea.  As the cargo ships passed,  our view was obscured to the east – a vision of ancient forts, modern apartment buildings and mosques bathed in ethereal green and blue lights.

My host, Nazim, appeared at a window, peering out to find me.  He was now sliding open the Captain’s door to the foredeck, allowing a burst of raucous laughter and music to escape. He moved silently across the wooden planks and gently clasped my shoulder.  “Our city is magnificent and mysterious, hey? – – Just like her.”He pointed through the bridge window down into a main cabin where a group of clapping men and women had formed a crescent surrounding a sultry, caramel skinned belly dancer.  Her silk hip scarf quivered and flashed with golden sequins as her body moved rhythmically to the Rom Sulukule music.

Earlier we had crossed under The Boğaziçi Köprüsü (Bosphorus Bridge), a grand arcing achievement of zigzagging suspension cables and pylons that stretched almost a half-mile across the horizon line connecting Europe and Asia.  The bridge, built in 1957, was the fulfillment of a vision to join two continents dating back to 500 BC and Darius I whose ambitions to invade into Greece and Europe would eventually clash with a 25 year old Macedonian commander named Alexander at the battles of Thermopylae and Gaugamela.  In the soft silk of this Istanbul night,  we moved through continents, time and space.  The sprawling city was a vast, milky way of motion – streaking automotive comets, black holes of collapsed history, and a thousand years of lights.

I had been dispatched against my will to work with our local Eastern European and Middle Eastern offices to better understand what investments were required to grow our indigenous business.  Much of our revenues had been historically derived from foreign multinationals doing business in countries like Turkey.  We relied on our offices in Istanbul and Ankara to coordinate our activities on the ground but never invested much to grow our local presence and brand. I preferred to work in our larger countries – – those with more revenues, mature infrastructure and developed markets.  I did not think I was being provincial in wanting to avoid these rough, and hardened pockets of raw commerce.  They were turbulent, risky and forever lashed to a fragile economic mast that would be tested over and over by winds of a political unrest.

Yet, my boss felt the opportunity was compelling. Turkey was the world’s 15th largest economy with a GDP of $880B.  It was hardly the chaotic, backward kingdom that I perceived to be constantly teetering uneasily on the edge of the 20th Century. This was a nation rising to meet the newly consummated European Union and the Western world.  It remained the only secular government in the Muslim world – a country with 73M practicing Muslims that trusted their army infinitely more than their government officials or financial institutions.  The army ensured appropriate stability and gave legitimacy to a government that sought to achieve greater regulatory, fiscal and legal certainty – – critical prerequisites to any country’s acceptance into the $12T Euro-zone.

Like  Rome, Istanbul grew to stretch across seven distinct hills – offering a skyline marked with the spires and minarets of mosques whose muezzins fervently called out for prayer five times a day to 11M residents.  Upon deplaning, I experienced that immediate sense of imbalance as I was engulfed by a miasma of scents – sewage, cumin, diesel, perfume, smoke, salt water, and concentrated humanity.  I unconsciously caressed the oddly shaped coins and bank notes that jingled in my pocket having exchanged my British pounds for Turkish Lira.  In developing countries, your Western brain cannot process quickly enough a culture with so few filters.  People do not speak, they shout.  Cars do not cruise, they cough, sputter, screech and honk.  Animals dart in and out of traffic dodging mopeds, motorcycles and bicycles swirling like twilight gnats.  Women move like phantoms swirling in hot wind and flowing bhurkas while a thousand eyes seemed to follow my every step.

Yet, I was unprepared for how Constantinople had transformed from a dusty, underdeveloped Ottoman relic to Istanbul, a wonderfully complicated city dominated by banking, telecom, infrastructure and textile companies. It was as intricate and unique as its precious Iznik tiles and patterned ceramics that accentuated its palaces and public markets.

This was the last stop on the fabled Orient Express releasing passengers into a seething anthill of antiquity, religious fervor, tradition and raw capitalism.  It seemed that with each minute, Turkey was building momentum toward inevitable and irreversible change.  Above the rail station on a peninsula that commanded a view of the fabled Golden Horn, the Bosphorus and the Sea of Marmar rested magnificent Tokapi Palace.  This golden age palace of Sultans dated back to the fifteenth century when Mehmed the Conqueror subjugated the final remnants of the Eastern Roman Empire.

In my travels to Istanbul, our country head, Nazim Mahmud became my guide, historian and lens to a world that Western culture had conspired to depict as backward and broken. Nazim was a passionate ambassador for his country.  He educated me on every detail of Turkish history ranging from Medmed’s capture of Istanbul to the successful Ottoman repulse of an invading Anzac invasion force at Gallipoli in 1917. As we walked, he led me into the Grand Bazaar, a cavernous domed labyrinth of over 4500 shops and stalls.  On this trip, he had stopped and purchased a book, The Long White Cloud- Gallipoli, by Buket Uzuner.  “I can see your fascination with WWI” he shared as he handed me the Turkish best seller.  “We perhaps picked the wrong side to support in WWI but we showed Churchill that we could defeat the world’s greatest navy.

The Grand Bazaar has been continuously the epicenter of commerce in Istanbul since the 16th century.  Gold, silver, ceramics, clothing and magnificent rugs are all distributed here through designated stalls and shops.  The art of purchasing any item is many ways a metaphor for all business.  It is hardly a sterile transaction. Commerce is a social, economic and cultural dance.  Negotiation is vital economic foreplay to Turkish business.  Any potential transaction is preceded by a courtship of mint tea, conversation leavened with grand, sycophantic compliments and finally, the merchandise.

A young shop owner, Mehet, offered me tea.  He discussed his desire for Turkey to join the EU and his cynicism over whether the West will ever truly accept an Islamic country as a member.  He shared fears that if Turkey’s ambition to join the European Union is rejected that it will make the country vulnerable for fundamentalism and more orthodox foreign and domestic policies.  “ We are on the edge of a falling into our future or plunging back into the past.”  For a young man in such a tiny business, Mehet seemed to contradict the region’s reputation of provincialism.  He certainly understood the complicated choices that lay ahead.

Later that night at dinner, I discussed the shifting plates of a new world order with young Turkish executives from our office.  These highly educated twenty-somethings exuded a sober optimism believing that the battle for the soul of Turkey would continue to rage well into the next decade.  “In many ways,“ a young woman commented, “ the first World War is still being fought.  While, the physical war ended in 1918, the ideological war of the West versus the Ottoman Empire has never ended.  Until Turkey joins the EU, there will always be a battle between authoritarian regimes and democracies for the hearts and minds of our people.“  Another young man jumped in. “ We feel terrible for what happened on 9/11 in America but you now know what it feels like to have consequences of your foreign policy occur within your borders.  (The day before a bomb had gone off in Ankara killing eight and injuring 23).  We are all in this together and we believe building consumer economies is the way to undermine fundamentalists.” I recall calling my wife that evening and relating to her how progressive Turkey had become.

Two months later, Chechen rebels seized my hotel and held all the guests hostage before peacefully negotiating a settlement with the government.  I was fortunate to be back in London at the time but I was rattled by the brush with reality. I thought about my dinner with those young, dynamic Turks who convinced me that their future depended on the West’s partnership. Without engagement, Turkey might more easily buy into the demonization of the West and drift backward toward authoritarianism.

That had been weeks ago.  I was now back in Istanbul standing with Nazim, looking across the dark evening waters.  I had to ask him about the Chechens.  He now knew me well enough to know it was on my mind.

He laughed and sighed. “You know, Michael, we have an expression: ‘abuk parlayan çabuk söner. ‘It means ‘What flares up fast, extinguishes soon.’  Whether it is inflation, Chechens or our naughty neighbors (Iran, Syria and Iraq), we will fulfill our destiny as a respected nation despite our obstacles.  It is our destiny. “

As I looked over to the shoreline, the modern buildings, old forts and minareted mosques did not seem so diametrically opposed.  Perhaps with Turkey finally coming of age, it was time for the West to accept them into the European Union.  While there are many who bitterly oppose yet another member nation whose debt is 40% of its GDP, there is a recognition that Turkey’s fate will exacerbate or diffuse the growing pressure within the region. With Turkey’s acceptance, perhaps the ideological warfare still waged from WWI might subside, breathing new life into the notion that Muslim and Christian cultures can forge a foundation for the future together.

It Slices, It Dices, It Fleeces

Infomercials annoy me.  They are social polyps that have grown to outlandish proportions on the intestines of a bloated and sick American media.  The portmanteau term “ infomercial” is clearly an oxymoron describing the contradiction of programs that are both hosted and devoured by morons.  The fact that infomercials are even allowed by the FCC is a sign of the advanced dry rot in our American entertainment, economic and regulatory systems.

The FCC, according to one gadfly, now stands for “Forget Catching Criminals.”  It appears that after decades of exporting our innovation, manufacturing and customer service, the dregs of commerce have reached new lows where 30 minute advertisements fill vacant morning programming time –  feeding bread crumb promises to an inactive and unemployed America gulping down like boat marina carp visions of cleaner colons, miraculous weight loss without exercise and abs as chiseled as parking lot speed bumps.

I can recall the first time I was ripped off by a false advertisement via a DC Marvel comic book. The “Live Sea Horses” actually turned out to be ionized pieces of tire rubber.  As they floated and swirled in my “seahorse garden”, I felt my first sensations of buyer’s remorse. I had been had.  Weeks later, I was tempted to send away for X-Ray glasses.  The idea of being able to watch the older eighth grade girls PE class run laps with my three dimensional goggles was intoxicating.  Yet, the cynical memory of pathetic black floating bits of rubber had already eroded the tint from my rose colored glasses.  My father, the advertising man, later explained to me the simple Latin maxim that would echo in my brain for decades:  “Caveat Emptor – Buyer Beware.”

I was not the only mark in our household. Despite her ability to adroitly parent four boys, my mother’s Achilles heel was aggressive advertisements and new gadgets.  To my father’s chagrin, she purchased countless fad merchandise that measured biorhythms, cured headaches, preserved food and pureed any organic matter in the world.  Her first purchase was the Popeil Veg-o-matic.  “It slices, it dices and…it even juliennes!  We had no idea what julienning was but it sounded French and very fun.  I told my mother we must possess this critical appliance that promised to transform homemaking into a raucous affair. We might even eat more vegetables.

Ron Popeil, CEO of Ronco, was just beginning.  He later invented something called the Pocket Fisherman and showed America how a young boy could land a bass the size of a small car with a simple one-foot, hand held plastic rod.  I immediately saved my money and sent away for this compact angling gadget the size of a handgun.  The fact that I never caught a single fish or used it beyond a local pond was Ron’s gain and my loss.  I became a small brick in the $2B Ronco Empire which remains, to this day, hawking food dehydrators, rotisserie ovens, spray on hair, six star knives and the incredible “inside the egg shell” scrambler.

Ron Popeil actually attended college and received countless creative awards for his quirky inventions.  However, Ronco was but a muddy watering hole on the edge of an arid landscape of leafless shams and burnt out merchandise with names like Ding Kings, Jupiter Jacks and iTies- – items that sadly, only a hoarder could love.

Consider the warped world of Kevin Trudeau.  This handsome pitchman first solicited America with his Mega-Memory system promising to unleash the hidden Mensa member within each one of us.  Apparently, Kevin forgot to tell the FCC that he had spent two years in prison for fraud.  After being released from jail, Mr. Infomercial and a close friend (his fellow cellmate) joined Nutrition for Life, a multi-level marketing company that ended up bilking investors with natural cures.

No one seemed to notice our memory guru pivot into the natural remedies and self help cesspool. Trudeau’s Natural Cures “They” Don’t Want You to Know About sold an astounding five million copies and was on the NY Times best seller list for nine weeks.  Here’s a sample book review from a satisfied reader, “Kevin Trudeau is a scam artist. I am so disgusted with the book Natural Cures. Repetitive, redundant, riding on the coattails of others research and THEN to top it off referring the reader to his website where he wants to yank our chain for more money! He should be horsewhipped, tarred, feathered, and ran out of town. I am so mad. I have never before returned a book, but this one is going back.”

Oops! That can’t be right!  He’s on a talk show set that looks right out of Larry King and he is being interviewed by a very attractive woman. Kevin explains that the cures that “they” were hiding from us include panaceas for obesity, AIDS, Alzheimer’s and muscular dystrophy. Trudeau goes on to set the record straight that sunscreen causes cancer and that “they” – the drug and food companies along with a complicit FDA – have conspired to use drugs and additives to get us addicted to food.

After thousands of consumer complaints, a federal judge whose memory regarding fraud seemed quite sound, ordered Trudeau to pay $ 37M to plaintiffs for misleading and false statements. Yet the Trudeau marketing machine could not be stopped.  His next product was a clear threat to all plastic surgeons ( the proverbial “they”) offering a non-surgical facelift.  He followed on with debt cures that “they” did not want us to know about, baldness remedies and a primer on addiction relief.  It’s my theory that if you actually used or consumed all of these products you would end up looking like Don King and as broke as Mike Tyson.

On some nights, I surf across Klee Irwin, a contrepenuer and missing twin brother of bizarre cult director John Waters.  This creepy, Pee Wee Herman, pencil necked geek pitchman is always discussing his miracle product “Dual Action Colon Cleanser”.  If there is such a thing as too much information in an infomercial, this 15-minute advert crosses multiple lines. In fact, if the suggestions of the promoter are to be believed, we each have twenty pounds of sludge (my term) in our pipes (my term).  Talk about an opportunity for weight loss and detoxification.  Just use the Dual Action colon cleanse, grab your toilet seat and lose all the weight you want.  One critic put it a tad more harshly, “We now see that America is not obese, it is just completely full of $#@#.”

We then shift to a smooth infomercial operator who attempts to dazzle us into purchasing his “Sham Wow “and his “Slap Chop”.  Unfortunately, his career has been cut a bit short. It seems this dashing young promoter was recently arrested after a prostitute that he had beaten up, saw his infomercial and mumbled out of her split lip to the police officer, “That’s the dude”.  My guess is he may need my new product the InstaShank – a new multi-purpose plastic construction tool that allows someone to quickly fashion a makeshift weapon such as a knife or spear out of any object.  I already have the tag line: “The InstaShank – retailing for $ 9.99 – ‘Cause you never know when someone’s going to stick it to you.”

Some may have heard the tragic story of Billy Mays, America’s pitchman who recently passed away from cardiac arrest at the young age of 52.  It appears that Billy’s heart literally burst from enthusiasm and perhaps, his recreational use of cocaine. It seems this hyperactive adolescent who put “Oxi-Clean” on the map was also taking copious amounts of Oxycontin.  Mays was a major league “pitchman” in high demand hawking the wares of uber marketers who pushed everything from gardening tools like The Awesome Augur, to kitchen appliances including the Big City Slider Station, a must have for hoarders and very large people who want to eat five small hamburgers at one sitting.  Mays sold it all – fly traps, ceramic plates with grater teeth and my favorite, “The EZ Crunch Bowl” which offered us all a “a new way to eat breakfast cereal”.

Some of you out there may already have scars inflicted from consumer fraud.  It may have been a burn from sending off for your indoor pet’s  “Potty Patch” or a cut from wiping out $ 19.99 of your hard earned cabbage when you bought the miraculous “Microfiber Wonder Cloth”.  You found out that the purported 30-day money back guarantee started at time of your order and after a four-week shipping period, your return time was up – and you owned it. You called a consumer support line that connected you to a Cuban restaurant in Miami.  You may have actually taken someone up on a “free” offer after just having to pay the $110 shipping fees.

I have to admit that after a bad day at work, it’s tempting to descend into the cesspool of infomercial marketing for a brisk and profitable swim.  Given all my business travel, I am working on something called the “ScumBuster”.   ” Ladies and gentleman, this handy cleaning gun uses a black light to identify every inch of invisible germs and pollution in your hotel or motel room.  It comes with a battery operated sterilization spray, steam gun, arsenic pellets for rodents and six penicillin jabs.  For an additional $ 1.99, we provide extender vials of holy water for to mitigate paranormal activity or out of control teenagers. If you act now, we will send the Lycrashield, a full body, antibacterial protection suit perfect for foreign travel, spring break motel sofas or your teenaged nephew’s bed when staying with your sister’s family at Thanksgiving.”

Showman PT Barnum summed it up best: “ There’s a sucker born every minute.” As our emotional IQs decline and our desire for rapid resolution increases, we seem all too willing to believe in the false promises and pickled pitches of snake oil salesmen.

Since the dawn of time, grifters have plagued us and exploited our fragile gullibility.  Mortality, low self esteem and popular culture perpetuates a massive marketplace for false hope and instant gratification. While shyster Kevin Trudeau has been recently banned for life from ever appearing on another infomercial, I hear he is running for Congress on the back of his new book, Deficit Reduction Cures That “They” Do Not Want You To Know About.

Who knows? This time, Kevin may finally be on to something.

All Creatures Great and Small

If evolution really works, how come mothers only have two hands? ~Milton Berle

I noticed the red hooded house finch as it darted past me gaining and losing altitude from a beak filled with long pine needles.  He was clearly in the process of building a nest. Off just to the side of the house came a cheerful warble and series of chirps.  A female finch was obviously supervising her mate’s construction of her spring nursery.

“I think a bird is building a condominium on our front door.” I shouted as I came inside. I turned around to examine the wreath with its arrangement of dried flowers and bird nests filled with artificial gray speckled eggs.  I could see how a finch could be fooled into thinking this was perhaps a perfect spot for public housing.

“Oh, my,” my spouse smiled approaching with curious approval.  She frowned. “Not exactly the most convenient location.” She pointed to the base of a fresh cone of tightly constructed twigs, green needles and mud.” A solitary speckled turquoise egg had tumbled out and now rested precariously on a ledge of uneven stained rattan.

I moved closer.” Oh, don’t touch it!” She whispered. Within minutes there was a sign on the door reading ” Birds Nest – knock lightly or use side door.” Mother Nature was now in charge.

Upon arriving home from work later in the week, family court was in session. “I didn’t do it.” was the plea from my youngest son who was being arraigned on one count of egg manslaughter and two counts of contravening a direct order to use the back door.

I had to give him credit. He had obviously been watching the Discovery Channel. “Listen, mom.  Birds lay more eggs than they need because some will die. It’s part of nature.” Yet, my spouse was already deeply attached to her feathered sister and her four unborn children. She knew Moms drew the short end of the stick. Occasionally, we would catch glimpses of the male finch, only to see him fly off to watch highlights of ESPN through someone’s den window or hang around a bird feeder talking to cardinals.  Like all males, he was always off somewhere when things happened.

As I watched the mother of my children open her heart to yet another dependent, I could not help but smile at the timeless ties between all mothers and the extended families of pets and animals that they are forced to adopt over the course of a child’s life.

Not a day that went by in the house of my youth that a boy would not come home, cupping some mysterious maimed, captured or presumably lost life form and beg the eternal question, “can I keep him?”

My mother dreaded these encounters – – the filthy child replete with earnest, Wild Kingdom expression. She had endured this “Groundhog Day “movie time and again. It always concluded with her feeding, caring, emotionally attaching and then eventually flushing, dumping or burying the pet of the month.  A pet’s lifespan might be reduced by one-half when it was introduced to our house of four boys, sadistic cat and determined dog.  By week two, the animal had usually been attacked, dropped so many times it had brain damage (that’s amazing, your lizard is so docile) or starved from neglect.  Invariably, it fell to our mother to make the last few months of the animal’s life as comfortable as possible. Caring for pets was just another thankless footnote in the fine print that she had failed to read when she met and married her dashing second lieutenant in 1955.

Our home was a living farm. Each boy’s room was adorned with some live animal – – an ant farm with red ants encased in a plastic window, a fish bowl or terrarium with a reptile that was always hidden under a dry branches or a rock.  There was a brief period of turtles that was cut short by a libelous article in Ladies Home Journal about diseases turtles carried including salmonella and e coli.  Since she knew we had not washed our hands since LBJ was President, turtles became amphibians non grata in our home.

There was a rodent period with rats, mice and hamsters.  A hamster is essentially what you get if you breed a rat and a mouse. They lived in expensive translucent plastic cages joined by tubes and habitation spaces called a Habitrail.  At one point, my brother had four hamsters moving through a complex grid of adjoining cages, tubes and running wheels – – until the cat discovered how to knock the tubes off and proceed to harvest the chubby hot dogs one by one across a long hot summer afternoon while we were at the beach.

When the inevitable last breath bubbled from the lips of a pet, our mother was there like a funeral home director to make arrangements. In a period where heads of state funerals were often shown live on TV, we held a public burial for our kangaroo rat who we had made the mistake of housing with our common gangster house rat.  No one knows what words were exchanged but the next morning, we found “Oz” without his head and Fritz covered in blood with a ” hey, he called me vermin and nobody calls me vermin” look.

We used kite string to lower Oz into a two-foot hole.  Given his condition, it was closed casket. We somberly returned to the house, ate some Oreos and reflected on the good times we had with the kangaroo rat for all of the two weeks that he had been in our family.  We were learning about life and death.

The 70s was a Wild West time for pets. In many houses, mothers actually allowed snakes as pets.  There was one problem: serpents always escaped. My mother drew the line at snakes.  She loathed them and refused to even entertain an earthworm after hearing of a Burmese Python that escaped into its owners house (the son apparently did not tell his parents that the six foot snake had flown the coop), ate the family cat, and was finally captured after it slithered under the dining room during a dinner party with a huge bulge in its mid section.

Our mother understood that caring for pets was essential to a child learning responsibility.  Perhaps the most dominant trait she hoped to teach was to subordinate oneself to a greater purpose, person or cause.  She knew pets could teach us how to unconditionally care.  I am certain my mother resented every poop scoop, litter box, meal worm, salt lick, fish feed, and squeaky hamster wheel moment of it. Yet, like all moms her feet went in one direction – – forward — for a kid, for a dog and even for a slimy, brown newt.

Fast forward to Finchville 2010. I hear a grand commotion and screaming. “Dad! Dad!” My son is yelling.  “The bird flew in the front door and the cat has it!” More emotional shouts as my wife, daughter, her boyfriend and our two sons are attempting to rescue the bird. The cat’s tail is twitching in triumph as the mother finch struggles in her mouth. My spouse asserts herself. ” Crystal, let her go!”

The cat is stunned with the scolding when she had expected praise.  The stunned mother finch falls to the ground and flies erratically into my daughter’s bathroom. For the next hour, the animal rescuers try vainly to coax the bird out of the tiny upstairs bath. Judging from all the arguing and yelling, it is not going well. I am annoyed, as it is looking inevitable that I am going to be asked to play Animal Control. My daughter’s boyfriend has been banished into the dark front yard and instructed by my wife to warble like a male finch.

As I walk upstairs I hear him tweeting outside (lucky your buddies cannot see you doing this) trying to coax the bird outside. I enter the bathroom and stoop down to grab the bird as it flaps to the other side of the room and hits the wall. My wife squeals, “Oh, don’t hurt her.” I finally cradle the bird and toss her into the night. As I turn in triumph, she proceeds to fly right back into the illuminated window.  As I reach to grab the bird, my wife turns off the light thinking the light was confusing the bird. I now cannot see a thing and proceed to crash into my daughter’s shelf.  Perfume and shampoo noisily cascade to the floor.  “What are you doing in there?” my daughter yells from outside. More crashing.  “Turn the light on! I cannot see a thing!”I finally catch the finch and drop her into the ebony chasm of the front garden. My wife runs downstairs to see if the brave girl has returned to her dimpled blue eggs.

Hours later, we finally see her tiny head poking out of the nest. She is back safely – for now.  My spouse is exhausted but content having helped her feathered friend to save her fledgling family. The crisis has passed. As we talk across the darkness at bedtime, I can hear her exhaustion and relief.  “What a scene that was. I hope she and the babies are alright. As she falls asleep, I recall the old Yiddish proverb, “God cannot be everywhere at once.  That is why he invented mothers.”

Managed Care 2.0 – The Chrysalis

The law of unintended consequences is what happens when a simple system tries to regulate a complex system. The political system is simple, it operates with limited information (rational ignorance), short time horizons, low feedback, and poor and misaligned incentives. Society in contrast is a complex, evolving, high-feedback, incentive-driven system. When a simple system tries to regulate a complex system you often get unintended consequences. Stephen Dubner and Steven Levitt, Freakonomics

When The Patient Protection and Affordable Care Act (PPAC) and its companion legislation was ratified by Congress and signed by the President into law, there was a great expectation for sweeping change. Yet, change is a scary proposition for 180M Americans who believe the devil they know (employer based private coverage) is preferred to a government run system.

Seniors are suddenly doing the math and wondering if their beloved Medicare will default on their watch. More than 50% of these same seniors, when polled, shared they do not want a government run healthcare system ——even though Medicare is a government run system.  People are confused, angry and wary. Yet PPAC is now law and despite its obvious flaws and potential for unintended consequences, it is unlikely to be repealed or deconstructed.  For better or worse, it is the foundation for Managed Care 2.0.

Managed Care 2.0 – Reform is setting the stage for a new era of American healthcare – Managed Care 2.0.  In launching this new period anchored by expanded access and insurance market reforms, we are expecting to say farewell to the three decade era of Managed Care 1.0 – a barren stretch of fiscal and social desert marked by spiraling costs, misaligned financial incentives, massive underfunding of Medicare and Medicaid obligations, fraud, over-treatment, public to private cost shifting, historic rates of chronic illness and the slow erosion of employer sponsored healthcare leading to an astounding 40M Americans without insurance.

Where Managed Care 1.0 was a time characterized by consolidation of stakeholders, cost shifting, risk shifting and scorched earth, Darwinian battles on the supply and delivery side, Managed Care 2.0 will begin, as one pundit called it, “ the battle for the soul of medicine”.

Supporters of change contend that Managed Care 2.0 will be measured in years and not decades.  It will be a chrysalis period where private and public healthcare begin to transform from less efficient analog systems of manual, fee for service medicine to a brave new 3.0 world characterized by integrated delivery, population risk improvement, shared risk, quality measurements and transparency.

The building blocks of the Patient Protection and Affordable Care Act are insurance market and access reforms — legislation that unfortunately has little to do with moderating rising medical costs.  It’s not that those that conceived the legislation did not understand or consider more draconian steps toward achieving affordability.  However, no politician wants to break the news that Managed Care 3.0, the rationing of care, is inevitable. That next chapter of Managed Care would be far too scary a bedtime story for adolescent, recession sick America to hear.

The story would involve a future where tough decisions will need to be made about who gets how much care. There will not be clear heroes and villains. It will be set in an ambiguous gray world of ethical and moral dilemmas — do we reduce reimbursement to our revered doctors and hospitals? How can we assure that our best and brightest continue to practice medicine?  Do we cut Medicare? Will venture capital, public and private equity flee out of healthcare profoundly effecting research and development?  How do we tackle the march towards chronic illness of Americans who are obese and unable to take personal responsibility for their health? Should we ask all Americans for a durable power of attorney so we have the ability to make the hard choices about end of life care?

The great question that remains in this debate over healthcare reform is what’s next?  Most experts agree that current reforms that will characterize this period will do little to change the trajectory of rising healthcare costs.  Managed Care 2.0 will most likely be a brief metamorphosis period for the last private healthcare system in the industrialized world.

The question is what emerges from this 2.0 cocoon?

Pro or Con? To supporters of reform, Managed Care 2.0 must be characterized by public policy changes that accelerate the US’s migration to a single payer system.  This butterfly could only take wing after the introduction of a government rate authority, and a public option that can slowly take market share from private insurers who have not demonstrated an ability to control healthcare costs yet seem to have profited disproportionately from our dysfunctional system.

For opponents of an expanded role of government in healthcare, there is great concern over escalating public debt, dubious CBO estimates of savings, legislation that fails to address the cost drivers that are making healthcare unaffordable and a deeply held, cynical view that our public systems of Medicare and Medicaid achieve affordability through serial underpayment of doctors and hospitals, not through effective clinical oversight or controls.  This contingent argues that this period of Managed 2.0 must be dedicated to attacking root causes of rising costs, making tough, politically unpopular decisions about restructuring into a sustainable system that preserves quality through for profit incentives while creating regulatory guardrails tight enough to prevent inequity and imbalance.

Key Political Milestones – The period of 2010 to 2014 will witness insurance market reforms and expanded coverage. It will also be characterized by a continuing rise in medical costs and the possibility of small employers electing to drop coverage and pay penalties in lieu of proving coverage that will most likely be double those costs to not offer insurance.  A new and broader market of individual consumers will emerge challenging the notion of employer sponsored healthcare and B2B insurance models.  Most view the next decade of Managed Care 2.0 as a period where stakeholders will reorganize as the debate over how to finance and fix healthcare continues.

Reform advocates, supply and delivery side stakeholders will be heavily invested in 2010 mid-term elections.  Generally, major domestic policy decisions made in mid-term election years have not boded well for the majority party.  Yet, many predict that 2010 mid-terms will be less about anti-Democrat sentiment and more about anti-incumbency.  However, should the GOP make larger gains, the next phases of Managed Care 2.0 could find the momentum slowing toward additional public policy interventions and in its place, a bigger effort emerges to engage private stakeholders to play a bigger role in the affordability challenges that lay ahead.

Most experts seem to agree that if unemployment is running lower than 8%, the current administration stands a decent shot at a second term.  If the economy continues to stumble and current GDP growth is attributed more to cotton candy stimulus than substantive economic recovery, we could see a change in the White House and a course correction on policies regulating the next phases of Managed Care 2.0.

Managed Care 2.0 will find insurers and states locked in mortal combat over prior approval of rates.  As this is written, the National Association of Insurance Commissioners (NAIC) is drafting its recommendations for Health and Human Services on how to regulate loss ratios of insurers under PPAC. These will not be simple algorithms but a more complex calculus that affords states the latitude to potentially dictate insurers profits in certain lines of business. The ability for states to approve or deny requested rate increases will continue to be heavily politicized as insurance commissioners and governors use the bully pulpit of their roles as local regulators to attempt to control profit taking and in doing so, win populist support.

Will Managed Care 2.0 Lead to More Competition? – Where are the competitors you ask?  When insurers are raising rates, why are there no new entrants to steal market share as is often the case in other industries primed by a free market pump.  Simply put, the barriers to entry in a 2.0 Managed Care world still remain too high for new entrants.  The economics of provider contracting (which drive 80% or more of a payer’s costs) are such that a payer has to have membership to get the best economics from a provider.

Managed Care 2.0 will not see new players and additional competition. In many US markets that are dominated by a handful of players, the cost of building market share to achieve similar economics to the market’s largest competitor is too high — particularly for a public company.  You essentially can only enter a new market by purchasing a competitor – – which is expensive and carries enormous execution risk for the capital being employed.

Trying to unseat a deeply entrenched Blues plan with 70% market share and most favored nation pricing deals with hospitals, is an almost impossible feat for any new payer.  No insurer has the financial will to enter a new market against a giant competitor that controls as much as 50% of the individual and small group market — a market where margins are largest.   A further complication arises if that entrenched competitor is a not for profit sitting on huge reserves and you are a for-profit company expected to show earnings improvement quarter over quarter. No shareholder or private equity owner has the patience to wait out the price war that you would inevitably engage to take market share.

So, who can compete with a large competitor controlling a disproportionate amount of market share? United Healthcare?  Aetna? Harvard Pilgrim?  Kaiser? Bzzzzzzz!  Sorry, wrong answer.  It is the government.

Ah yes, the dreaded public option defined by some as “Medicare Lite,” ” Obamacare” or ” Death Panels for Granny”.  Expect during this 2.0 period that debate will resurface over the public option. Many believe that a public option is really the only viable way to create competition within markets where competition does not exist.  Other see it as a Trojan Horse leading to unfair competition where taxpayer dollars are used to subsidize the cannibalization of private care by a public plan with the ultimate goal being a single payer, socialized medicine model.

Where Is 2.0 Already Happening ? – The next chapter of the Managed Care 2.0 story is being read aloud in Maine, California and most interestingly in Massachusetts.

Already having achieved universal coverage through reform, the Bay State is seeing costs in its merged individual and small group pool continue to surge. In an election year game of cat and mouse, Governor Deval Patrick is restricting non profit insurers to live with rate increases well below those required to cover the costs of ever increasing medical utilization.  When Massachusetts passed reform, it covered all individuals but simply did not confront the underlying factors contributing to rising costs.  Before you shout, “Those damn insurers,” remember that 95% of Mass’ insurers are not for profit.

To add insult to injury, the Massachusetts legislature has recently proposed a bill that would require any physician seeking to be licensed in the Bay State to accept Medicare and Medicaid reimbursement levels.  It may be time for Kaiser to move into Massachusetts as the alternative employer of choice to the state.

Most new Massachusetts insureds can’t find a primary care doctor as too few are left after years of under reimbursement. This leaves our newly covered — many of who are chronically ill and require coordinated care — to access the system through the least efficient point of entry, the emergency room.  The state’s not for profit insurers are in a profound pickle.  They have statutory reserves that will soon be depleted if they cannot raise rates.  However, it is an election year and the governor is using an age old lever, price controls, to buy time, point fingers and escalate the debate.

Hospitals Will Navigate Managed Care 2.0 But… In 2.0, hospitals will benefit by the reduced number of uncompensated care cases and bad debt write-offs.  30M new insureds will continue to consume healthcare and may end up, as a result of a near term primary care crisis, accessing the hospital through the emergency room as their primary care point of entry.  Rural hospitals may not fare as well as a disproportionate number of their patients are covered under government plans that will be reducing payments.

Specialists will begin to see fee cuts as Medicare cuts begin to impact fee for service reimbursement.  The greater emphasis on restoring the role of primary care providers will see specialists in particular, increasingly disaffected as they lose optimism that no scenario of reform will ensure their ability to arrest the income erosion that they have been working so hard to address. Greater chasms will emerge within the provider community as primary care providers and specialists tangle over the resurgence of the gatekeeper and medical home models.

What Next? – Insurers understand that Managed Care 2.0 is just that — a next stage in an irreversible process of transformation.  Their greatest fear did not immediately occur — the establishment of a federal rate authority administered by Health and Human Services.  However, if minimum loss ratio thresholds prove inadequate to contain costs (and they will prove inadequate), we are likely to see the two headed beast appear that will be a harbinger of Managed Care 3.0 — rate controls and a public option. Prior approval of rates are already embedded in 50% of US markets.  Rate debate is happening with little imagination around the reality that guaranteeing America access without tackling affordability is like a flashlight without batteries — it doesn’t work.

My guess is by the time health exchanges are established for individuals and small employers in 2014, costs will have risen another 30%-40%.  The government will realize that $500B of Medicare cuts to finance access for new insureds did nothing to reduce its $38T unfunded liabilities. Medicare will continue to hurtle towards insolvency until the real cost containment legislation is passed. Managed Care 2.0 will be seen merely a detour on the road toward the inevitable — a radical restructuring of our entire system.

In this 2.0 era, the average cost for private insurance will increase with mandated coverage minimums and guarantee issue, non cancelable coverage. An individual above 400% of the poverty line will find it just as hard to afford coverage and may spend a large percentage of their discretionary income on health insurance.  Larger employers are likely to pull up their drawbridges and begin to slowly cut coverage — starting first with retiree benefits.  Mid-sized and smaller business will do the simple calculus around whether they keep or drop insurance. No one will want to be the first guy to drop coverage but no one wants to be the last guy who pays for the $15,000 aspirin as cost shifting hits its high water mark.

The middle class will take it on the chin as they always do.  At this point, we will rally around the cry for affordability.  The pitchforks and torches will once again appear and we will look for a common enemy. It will usher in a new era and it may very well set in motion the next phase of Managed Care – – an era characterized by the death of private insurance.

One thing is certain: the US healthcare system will go through inevitable transformation in this 2.0 period.  The beauty of whatever emerges from this chrysalis will most certainly be in the eyes of the beholder.