or, how I spread monkeypox and got it myself.

This story contains nsfw (not safe for wife) stuff and shouldn't be read if you're under 18 or think I'm a newborn angel. After the opening, it's broken into three sections: a chronological explanation of my disease course, my ideas, and what I plan to do next.

Your journey awaits.

As early as mid-may, I was waltzing around the lab talking about monkeypox, a rare tropical disease with an inaccurate name. Monkeys are not its primary animal reservoir. It caused an outbreak among men who have sex with men across Europe, with unprecedented levels of person-to-person transmission. European health authorities speculated that the virus spread at raves and parties and was easily transferred through intimate, mainly sexual, contact. I had already read the nejm article about the first confirmed monkeypox patient in the u.s. and shared the photos on social media so people knew what to look for. The cdc information page only included 4 photographs of monkeypox lesions that looked like they were captured on a motorola razr.

I warned my ex-boyfriend about monkeypox. Monkeypox? responded.

Mom, I'm afraid about monkeypox. What's monkeypox?

My therapist is scared about monkeypox. What's monkeypox?

Was I alone? A few science gays on Twitter didn't make me feel overreacting.

This information got my gay head turning. The incubation period for the sickness is weeks. Many of my social media contacts are traveling to Europe this summer. What is pride? Travel, parties, and sex. Many people may become infected before attending these activities. Monkeypox will affect the lgbtq+ community.

Being right always stinks. My young scientist brain was right, though. Someone who saw this coming is one of the early victims. I'll talk about my feelings publicly, and trust me, I have many concerning what's occurring.

Part 1 is the specifics.

Wednesday nights are never smart but always entertaining. I didn't wake up until noon on june 23 and saw gay twitter blazing. Without warning, the nyc department of health announced a pop-up monkeypox immunization station in chelsea. Some days would be 11am-7pm. Walk-ins were welcome, however appointments were preferred. I tried to arrange an appointment after rubbing my eyes, but they were all taken. I got out of bed, washed my face, brushed my teeth, and put on short shorts because I wanted to get a walk-in dose and show off my legs. I got a 20-oz. cold brew on the way to the train and texted a chelsea-based acquaintance for help.

Clinic closed at 2pm. No more doses. Hundreds queued up. The government initially gave them only 1,000 dosages. For a city with 500,000 LGBT people, c'mon. What more could I do? I was upset by how things were handled. The evidence speaks for itself.

I decided to seek an appointment when additional doses were available and continued my weekend. I was celebrating nyc pride with pals. Fun! sex! * ‍

On tuesday after that, I felt a little burn. This wasn't surprising because I'd been sexually active throughout the weekend, so I got a sti panel the next day. I expected to get results in a few days, take antibiotics, and move on.

Emerging germs had other intentions. Wednesday night, I felt sore, and thursday morning, I had a blazing temperature and had sweat through my bedding. I had fever, chills, and body-wide aches and pains for three days. I reached 102 degrees. I believed I had covid over pride weekend, but I tested negative for three days straight.

STDs don't induce fevers or other systemic symptoms. If lymphogranuloma venereum advances, it can cause flu-like symptoms and swollen lymph nodes. I was suspicious and desperate for answers, so I researched monkeypox on the cdc website (for healthcare professionals). Much of what I saw on screen about monkeypox prodrome matched my symptoms. Multiple-day fever, headache, muscle aches, chills, tiredness, enlarged lymph nodes. Pox were lacking.

I told my doctor my concerns pre-medically. I'm occasionally annoying.

On saturday night, my fever broke and I felt better. Still burning, I was optimistic till sunday, when I woke up with five red splotches on my arms and fingertips.

As spots formed, burning became pain. I observed as spots developed on my body throughout the day. I had more than a dozen by the end of the day, and the early spots were pustular. I had monkeypox, as feared.

Fourth of July weekend limited my options. I'm well-connected in my school's infectious disease academic community, so I texted a coworker for advice. He agreed it was likely monkeypox and scheduled me for testing on tuesday.

nyc health could only perform 10 monkeypox tests every day. Before doctors could take swabs and send them in, each test had to be approved by the department. Some commercial labs can now perform monkeypox testing, but the backlog is huge. I still don't have a positive orthopoxvirus test five days after my test. *My 12-day-old case may not be included in the official monkeypox tally. This outbreak is far wider than we first thought, therefore I'm attempting to spread the information and help contain it.

*Update, 7/11: I have orthopoxvirus.

I spent all day in the bathtub because of the agony. Warm lavender epsom salts helped me feel better. I can't stand lavender anymore. I brought my laptop into the bathroom and viewed everything everywhere at once (2022). If my ex and I hadn't recently broken up, I wouldn't have monkeypox. All of these things made me cry, and I sat in the bathtub on the 4th of July sobbing. I thought, Is this it? I felt like Bridesmaids' Kristen Wiig (2011). I'm a flop. From here, things can only improve.

Later that night, I wore a mask and went to my roof to see the fireworks. Even though I don't like fireworks, there was something wonderful about them this year: the colors, how they illuminated the black surfaces around me, and their transient beauty. Joyful moments rarely linger long in our life. We must enjoy them now.

Several roofs away, my neighbors gathered. Happy 4th! I heard a woman yell. Why is this godforsaken country so happy? Instead of being rude, I replied. I didn't tell them I had monkeypox. I thought that would kill the mood.

By the time I went to the hospital the next day to get my lesions swabbed, wearing long sleeves, pants, and a mask, they looked like this:

I had 30 lesions on my arms, hands, stomach, back, legs, buttcheeks, face, scalp, and right eyebrow. I had some in my mouth, gums, and throat. Current medical thought is that lesions on mucous membranes cause discomfort in sensitive places. Internal lesions are a new feature of this outbreak of monkeypox. Despite being unattractive, the other sores weren't unpleasant or bothersome.

I had a bacterial sti with the pox. Who knows if that would've created symptoms (often it doesn't), but different infections can happen at once. My care team remembered that having a sti doesn't exclude out monkeypox. doxycycline rocks!

The coworker who introduced me to testing also offered me his home. We share a restroom, and monkeypox can be spread through surfaces. (Being a dna virus gives it environmental hardiness that rna viruses like sars-cov-2 lack.) I disinfected our bathroom after every usage, but I was apprehensive. My friend's place has a guest room and second bathroom, so no cross-contamination. It was the ideal monkeypox isolation environment, so I accepted his offer and am writing this piece there. I don't know what I would have done without his hospitality and attention.

The next day, I started tecovirimat, or tpoxx, for 14 days. Smallpox has been eradicated worldwide since the 1980s but remains a bioterrorism concern. Tecovirimat has a unique, orthopoxvirus-specific method of action, which reduces side effects to headache and nausea. It hasn't been used in many people, therefore the cdc is encouraging patients who take it for monkeypox to track their disease and symptoms.

Tpoxx's oral absorption requires a fatty meal. The hospital ordered me to take the medication after a 600-calorie, 25-gram-fat meal every 12 hours. The coordinator joked, "Don't diet for the next two weeks." I wanted to get peanut butter delivered, but jif is recalling their supply due to salmonella. Please give pathogens a break. I got almond butter.

Tpoxx study enrollment was documented. After signing consent documents, my lesions were photographed and measured during a complete physical exam. I got bloodwork to assess my health. My medication delivery was precise; every step must be accounted for. I got a two-week supply and started taking it that night. I rewarded myself with McDonald's. I'd been hungry for a week. I was also prescribed ketorolac (aka toradol), a stronger ibuprofen, for my discomfort.

I thought tpoxx was a wonder medicine by day two of treatment. Early lesions looked like this.

however, They vanished. The three largest lesions on my back flattened and practically disappeared into my skin. Some pustular lesions were diminishing. Tpoxx+toradol has helped me sleep, focus, and feel human again. I'm down to twice-daily baths and feeling hungrier than ever in this illness. On day five of tpoxx, some of the lesions look like this:

I have a ways to go. We must believe I'll be contagious until the last of my patches scabs over, falls off, and sprouts new skin. There's no way to tell. After a week and a half of tremendous pain and psychological stress, any news is good news. I'm grateful for my slow but steady development.

Part 2 of the rant.

Being close to yet not in the medical world is interesting. It lets me know a lot about it without being persuaded by my involvement. Doctors identify and treat patients using a tool called differential diagnosis.

A doctor interviews a patient to learn about them and their symptoms. More is better. Doctors may ask, "Have you traveled recently?" sex life? Have pets? preferred streaming service? (No, really. (Hbomax is right.) After the inquisition, the doctor will complete a body exam ranging from looking in your eyes, ears, and throat to a thorough physical.

After collecting data, the doctor makes a mental (or physical) inventory of all the conceivable illnesses that could cause or explain the patient's symptoms. Differential diagnosis list. After establishing the differential, the clinician can eliminate options. The doctor will usually conduct nucleic acid tests on swab samples or bloodwork to learn more. This helps eliminate conditions from the differential or boosts a condition's likelihood. In an ideal circumstance, the doctor can eliminate all but one reason of your symptoms, leaving your formal diagnosis. Once diagnosed, treatment can begin. yay! Love medicine.

My symptoms two weeks ago did not suggest monkeypox. Fever, pains, weariness, and swollen lymph nodes are caused by several things. My scandalous symptoms weren't linked to common ones. My instance shows the importance of diversity and representation in healthcare. My doctor isn't gay, but he provides culturally sensitive care. I'd heard about monkeypox as a gay man in New York. I was hyper-aware of it and had heard of friends of friends who had contracted it the week before, even though the official case count in the US was 40. My physicians weren't concerned, but I was. How would it appear on his mental differential if it wasn't on his radar? Mental differential rhymes! I'll trademark it to prevent theft. differential!

I was in a rare position to recognize my condition and advocate for myself. I study infections. I'd spent months researching monkeypox. I work at a university where I rub shoulders with some of the country's greatest doctors. I'm a gay dude who follows nyc queer social networks online. All of these variables positioned me to think, "Maybe this is monkeypox," and to explain why.

This outbreak is another example of privilege at work. The brokenness of our healthcare system is once again exposed by the inequities produced by the vaccination rollout and the existence of people like myself who can pull strings owing to their line of work. I can't cure this situation on my own, but I can be a strong voice demanding the government do a better job addressing the outbreak and giving resources and advice to everyone I can.

lgbtqia+ community members' support has always impressed me in new york. The queer community has watched out for me and supported me in ways I never dreamed were possible.

Queer individuals are there for each other when societal structures fail. People went to the internet on the first day of the vaccine rollout to share appointment information and the vaccine clinic's message. Twitter timelines were more effective than marketing campaigns. Contrary to widespread anti-vaccine sentiment, the LGBT community was eager to protect themselves. Smallpox vaccination? sure. gimme. whether I'm safe. I credit the community's sex positivity. Many people are used to talking about STDs, so there's a reduced barrier to saying, "I think I have something, you should be on the watch too," and taking steps to protect our health.

Once I got monkeypox, I posted on Twitter and Instagram. Besides fueling my main character syndrome, I felt like I wasn't alone. My dc-based friend had monkeypox within hours. He told me about his experience and gave me ideas for managing the discomfort. I can't imagine life without him.

My buddy and colleague organized my medical care and let me remain in his home. His and his husband's friendliness and attention made a world of difference in my recovery. All of my friends and family who helped me, whether by venmo, doordash, or moral support, made me feel cared about. I don't deserve the amazing people in my life.

Finally, I think of everyone who commented on my social media posts regarding my trip. Friends from all sectors of my life and all sexualities have written me well wishes and complimented me for my vulnerability, but I feel the most gravitas from fellow lgbtq+ persons. They're learning to spot. They're learning where to go ill. They're learning self-advocacy. I'm another link in our network of caretaking. I've been cared for, therefore I want to do the same. Community and knowledge are powerful.

You're probably wondering where the diatribe is. You may believe he's gushing about his loved ones, and you'd be right. I say that just because the queer community can take care of itself doesn't mean we should.

Even when caused by the same pathogen, comparing health crises is risky. Aids is unlike covid-19 or monkeypox, yet all were caused by poorly understood viruses. The lgbtq+ community has a history of self-medicating. Queer people (and their supporters) have led the charge to protect themselves throughout history when the government refused. Surreal to experience this in real time.

First, vaccination access is a government failure. The strategic national stockpile contains tens of thousands of doses of jynneos, the newest fda-approved smallpox vaccine, and millions of doses of acam2000, an older vaccine for immunocompetent populations. Despite being a monkeypox hotspot and international crossroads, new york has only received 7,000 doses of the jynneos vaccine. Vaccine appointments are booked within minutes. It's showing Hunger Games, which bothers me.

Second, I think the government failed to recognize the severity of the european monkeypox outbreak. We saw abroad reports in may, but the first vaccines weren't available until june. Why was I a 26-year-old pharmacology grad student, able to see a monkeypox problem in europe but not the u.s. public health agency? Or was there too much bureaucracy and politicking, delaying action?

Lack of testing infrastructure for a known virus with vaccinations and therapies is appalling. More testing would have helped understand the problem's breadth. Many homosexual guys, including myself, didn't behave like monkeypox was a significant threat because there were only a dozen instances across the country. Our underestimating of the issue, spurred by a story of few infections, was huge.

Public health officials' response to infectious diseases frustrates me. A wait-and-see approach to infectious diseases is unsatisfactory. Before a sick person is recognized, they've exposed and maybe contaminated numerous others. Vaccinating susceptible populations before a disease becomes entrenched prevents disease. CDC might operate this way. When it was easier, they didn't control or prevent monkeypox. We'll learn when. Sometimes I fear never. Emerging viral infections are a menace in the era of climate change and globalization, and I fear our government will repeat the same mistakes. I don't work at the cdc, thus I have no idea what they do. As a scientist, a homosexual guy, and a citizen of this country, I feel confident declaring that the cdc has not done enough about monkeypox. Will they do enough about monkeypox? The strategic national stockpile can respond to a bioterrorism disaster in 12 hours. I'm skeptical following this outbreak.

It's simple to criticize the cdc, but they're not to blame. Underfunding public health services, especially the cdc, is another way our government fails to safeguard its citizens. I may gripe about the vaccination rollout all I want, but local health departments are doing their best with limited resources. They may not have enough workers to keep up with demand and run a contact-tracing program. Since my orthopoxvirus test is still negative, the doh hasn't asked about my close contacts. By then, my illness will be two weeks old, too long to do anything productive. Not their fault. They're functioning in a broken system that's underfunded for the work it does.

*Update, 7/11: I have orthopoxvirus.

Monkeypox is slow, so i've had time to contemplate. Now that I'm better, I'm angry. furious and sad I want to help. I wish to spare others my pain. This was preventable and solvable, I hope. HOW?

Third, the duty.

Family, especially selected family, helps each other. So many people have helped me throughout this difficult time. How can I give back? I have ideas.

1. Education. I've already started doing this by writing incredibly detailed posts on Instagram about my physical sickness and my thoughts on the entire scandal. via tweets. by producing this essay. I'll keep doing it even if people start to resent me! It's crucial! On my Instagram profile (@kyleplanckton), you may discover a story highlight with links to all of my bizarre yet educational posts.

2. Resources. I've forwarded the contact information for my institution's infectious diseases clinic to several folks who will hopefully be able to get tpoxx under the expanded use policy. Through my social networks, I've learned of similar institutions. I've also shared crowdsourced resources about symptom relief and vaccine appointment availability on social media. DM me or see my Instagram highlight for more.

3. Community action. During my illness, my friends' willingness to aid me has meant the most. It was nice to know I had folks on my side. One of my pals (thanks, kenny) snagged me a mcgriddle this morning when seamless canceled my order. This scenario has me thinking about methods to help people with monkeypox isolation. A two-week isolation period is financially damaging for many hourly workers. Certain governments required paid sick leave for covid-19 to allow employees to recover and prevent spread. No comparable program exists for monkeypox, and none seems to be planned shortly.

I want to aid monkeypox patients in severe financial conditions. I'm willing to pick up and bring groceries or fund meals/expenses for sick neighbors. I've seen several GoFundMe accounts, but I wish there was a centralized mechanism to link those in need with those who can help. Please contact me if you have expertise with mutual aid organizations. I hope we can start this shortly.

4. lobbying. Personal narratives are powerful. My narrative is only one, but I think it's compelling. Over the next day or so, i'll write to local, state, and federal officials about monkeypox. I wanted a vaccine but couldn't acquire one, and I feel tpoxx helped my disease. As a pharmacologist-in-training, I believe collecting data on a novel medicine is important, and there are ethical problems when making a drug with limited patient data broadly available. Many folks I know can't receive tpoxx due of red tape and a lack of contacts. People shouldn't have to go to an ivy league hospital to obtain the greatest care. Based on my experience and other people's tales, I believe tpoxx can drastically lessen monkeypox patients' pain and potentially curb transmission chains if administered early enough. This outbreak is manageable. It's not too late if we use all the instruments we have (diagnostic, vaccine, treatment).

*UPDATE 7/15: I submitted the following letter to Chuck Schumer and Kirsten Gillibrand. I've addressed identical letters to local, state, and federal officials, including the CDC and HHS.

I hope to join RESPND-MI, an LGBTQ+ community-led assessment of monkeypox symptoms and networks in NYC. Visit their website to learn more and give to this community-based charity.

How I got monkeypox is a mystery. I received it through a pride physical interaction, but i'm not sure which one. This outbreak will expand unless leaders act quickly. Until then, I'll keep educating and connecting people to care in my neighborhood.

Despite my misgivings, I see some optimism. Health department social media efforts are underway. During the outbreak, the CDC provided nonjudgmental suggestions for safer social and sexual activity. There's additional information regarding the disease course online, including how to request tpoxx for sufferers. These materials can help people advocate for themselves if they're sick. Importantly, homosexual guys are listening when they discuss about monkeypox online and irl. Learners They're serious.

The government has a terrible track record with lgtbq+ health issues, and they're not off to a good start this time. I hope this time will be better. If I can aid even one individual, I'll do so.

Thanks for reading, supporting me, and spreading awareness about the 2022 monkeypox outbreak. My dms are accessible if you want info, resources, queries, or to chat.

y'all well

kyle

I apologize if this sounds basic, but throughout my career, I've always been clear that a company's activities are shaped by its founder(s)' morality.

I consider Palantir, owned by PayPal founder Peter Thiel, evil. He got $5 billion tax-free by hacking a statute to help middle-class savings. That may appear clever, but I think it demonstrates a shocking lack of solidarity with society. As a result of this and other things he has said and done, I early on dismissed Peter Thiel as someone who could contribute anything positive to society, and events soon proved me right: we are talking about someone who clearly considers himself above everyone else and who does not hesitate to set up a company, Palantir, to exploit the data of the little people and sell it to the highest bidder, whoever that is and whatever the consequences.

The German courts have confirmed my warnings concerning Palantir. The problem is that politicians love its surveillance tools because they think knowing more about their constituents gives them power. These are ideal for dictatorships who want to snoop on their populace. Hence, Silicon Valley's triumphalist dialectic has seduced many governments at many levels and collected massive volumes of data to hold forever.

Dangerous company. There are many more. My analysis of the moral principles that disclose company management changed my opinion of Facebook, now Meta, and anyone with a modicum of interest might deduce when that happened, a discovery that leaves you dumbfounded. TikTok was easy because its lack of morality was revealed early when I saw the videos it encouraged minors to post and the repercussions of sharing them through its content recommendation algorithm. When you see something like this, nothing can convince you that the firm can change its morals and become good. Nothing. You know the company is awful and will fail. Speak it, announce it, and change it. It's like a fingerprint—unchangeable.

Some of you who read me frequently make its Facebook today jokes when I write about these firms, and that's fine: they're my moral standards, those of an elderly professor with thirty-five years of experience studying corporations and discussing their cases in class, but you don't have to share them. Since I'm writing this and don't have to submit to any editorial review, that's what it is: when you continuously read a person, you have to assume that they have moral standards and that sometimes you'll agree with them and sometimes you won't. Morality accepts hierarchies, nuances, and even obsessions. I know not everyone shares my opinions, but at least I can voice them. One day, one of those firms may sue me (as record companies did some years ago).

Palantir is incredibly harmful. Limit its operations. Like Meta and TikTok, its business strategy is shaped by its founders' immorality. Such a procedure can never be beneficial.

ZERO GRACE/ZERO MALICE

Amazon's purchase of One Medical could speed up American healthcare

The U.S. healthcare industry is a 7-ton seal bleeding at sea. Predators are circling. Unearned margin: price increases relative to inflation without quality improvements. Amazon is the 11-foot megalodon with 7-inch teeth. Amazon is no longer circling... but attacking.

In 2020 dollars, per capita U.S. healthcare spending increased from $2,968 in 1980 to $12,531. The result is a massive industry with 13% of the nation's workers and a fifth of GDP.

Doctor No

In 40 years, healthcare has made progress. From 73.7 in 1980 to 78.8 in 2019, life expectancy rose (before Covid knocked it back down a bit). Pharmacological therapies have revolutionized, and genetic research is paying off. The financial return, improvement split by cost increases, is terrible. No country has expense rises like the U.S., and no one spends as much per capita as we do. Developed countries have longer life expectancies, healthier populations, and less economic hardship.

Two-thirds of U.S. personal bankruptcies are due to medical expenses and/or missed work. Mom or Dad getting cancer could bankrupt many middle-class American families. 40% of American adults delayed or skipped needed care due to cost. Every healthcare improvement seems to have a downside. Same pharmacological revolution that helped millions caused opioid epidemic. Our results are poor in many areas: The U.S. has a high infant mortality rate.

Healthcare is the second-worst retail industry in the country. Gas stations are #1. Imagine walking into a Best Buy to buy a TV and a Blue Shirt associate requests you fill out the same 14 pages of paperwork you filled out yesterday. Then you wait in a crowded room until they call you, 20 minutes after the scheduled appointment you were asked to arrive early for, to see the one person in the store who can talk to you about TVs, who has 10 minutes for you. The average emergency room wait time in New York is 6 hours and 10 minutes.

If it's bad for the customer, it's worse for the business. Physicians spend 27% of their time helping patients; 49% on EHRs. Documentation, order entry, billing, and inbox management. Spend a decade getting an M.D., then become a bureaucrat.

No industry better illustrates scale diseconomies. If we got the same return on healthcare spending as other countries, we'd all live to 100. We could spend less, live longer and healthier, and pay off the national debt in 15 years. U.S. healthcare is the worst ever.

What now? Competition is at the heart of capitalism, the worst system of its kind.

Priority Time

Amazon is buying One Medical for $3.9 billion. I think this deal will liberate society. Two years in, I think One Medical is great. When I got Covid, I pressed the One Medical symbol on my phone; a nurse practitioner prescribed Paxlovid and told me which pharmacies had it in stock.

Amazon enables the company's vision. One Medical's stock is down to $10 from $40 at the start of 2021. Last year, it lost $250 million and needs cash (Amazon has $60 billion). ONEM must grow. The service has 736,000 members. Half of U.S. households have Amazon Prime. Finally, delivery. One Medical is a digital health/physical office hybrid, but you must pick up medication at the pharmacy. Upgrade your Paxlovid delivery time after a remote consultation. Amazon's core competency means it'll happen. Healthcare speed and convenience will feel alien.

It's been a long, winding road to disruption. Amazon, JPMorgan, and Berkshire Hathaway formed Haven four years ago to provide better healthcare for their 1.5 million employees. It rocked healthcare stocks the morning of the press release, but folded in 2021.

Amazon Care is an employee-focused service. Home-delivered virtual health services and nurses. It's doing well, expanding nationwide, and providing healthcare for other companies. Hilton is Amazon Care's biggest customer. The acquisition of One Medical will bring 66 million Prime households capital, domain expertise, and billing infrastructure. Imagine:

"Alexa, I'm hot and my back hurts."

"Connecting you to a Prime doctor now."

Want to vs. Have to

I predicted Amazon entering healthcare years ago. Why? For the same reason Apple is getting into auto. Amazon's P/E is 56, double Walmart's. The corporation must add $250 billion in revenue over the next five years to retain its share price. White-label clothes or smart home products won't generate as much revenue. It must enter a huge market without scale, operational competence, and data skills.

Current Situation

Healthcare reform benefits both consumers and investors. In 2015, healthcare services had S&P 500-average multiples. The market is losing faith in public healthcare businesses' growth. Healthcare services have lower EV/EBITDA multiples than the S&P 500.

Amazon isn't the only prey-hunter. Walmart and Alibaba are starting pharmacies. Uber is developing medical transportation. Private markets invested $29 billion in telehealth last year, up 95% from 2020.

The pandemic accelerated telehealth, the immediate unlock. After the first positive Covid case in the U.S., services that had to be delivered in person shifted to Zoom... We lived. We grew. Video house calls continued after in-person visits were allowed. McKinsey estimates telehealth visits are 38 times pre-pandemic levels. Doctors adopted the technology, regulators loosened restrictions, and patients saved time. We're far from remote surgery, but many patient visits are unnecessary. A study of 40 million patients during lockdown found that for chronic disease patients, online visits didn't affect outcomes. This method of care will only improve.

Amazon's disruption will be significant and will inspire a flood of capital, startups, and consumer brands. Mark Cuban launched a pharmacy that eliminates middlemen in January. Outcome? A 90-day supply of acid-reflux medication costs $17. Medicare could have saved $3.6 billion by buying generic drugs from Cuban's pharmacy. Other apex predators will look at different limbs of the carcass for food. Nike could enter healthcare via orthopedics, acupuncture, and chiropractic. LVMH, L'Oréal, and Estée Lauder may launch global plastic surgery brands. Hilton and Four Seasons may open hospitals. Lennar and Pulte could build "Active Living" communities that Nana would leave feet first, avoiding the expense and tragedy of dying among strangers.

Risks

Privacy matters: HIV status is different from credit card and billing address. Most customers (60%) feel fine sharing personal health data via virtual technologies, though. Unavoidable. 85% of doctors believe data-sharing and interoperability will become the norm. Amazon is the most trusted tech company for handling personal data. Not Meta: Amazon.

What about antitrust, then?

Amazon should be required to spin off AWS and/or Amazon Fulfillment and banned from promoting its own products. It should be allowed to acquire hospitals. One Medical's $3.9 billion acquisition is a drop in the bucket compared to UnitedHealth's $498 billion market valuation.

Antitrust enforcement shouldn't assume some people/firms are good/bad. It should recognize that competition is good and focus on making markets more competitive in each deal. The FTC should force asset divestitures in e-commerce, digital marketing, and social media. These companies can also promote competition in a social ill.

U.S. healthcare makes us fat, depressed, and broke. Competition has produced massive value and prosperity across most of our economy.

Dear Amazon … bring it.

Only two of the following three options can be achieved: consistency, availability, and partition tolerance

Someone told me that growing from 30 to 60 is the biggest adjustment for a team or business.

I remember thinking, That's random. Each company is unique. I've seen teams of all types confront the same issues during development periods. With new enterprises starting every year, we should be better at navigating growing difficulties.

As a team grows, its processes and systems break down, requiring reorganization or declining results. Why always? Why isn't there a perfect scaling model? Why hasn't that been found?

The Three Things Productive Organizations Must Have

Any company should be efficient and productive. Three items are needed:

First, it must verify that no two team members have conflicting information about the roadmap, strategy, or any input that could affect execution. Teamwork is required.

Second, it must ensure that everyone can receive the information they need from everyone else quickly, especially as teams become more specialized (an inevitability in a developing organization). It requires everyone's accessibility.

Third, it must ensure that the organization can operate efficiently even if a piece is unavailable. It's partition-tolerant.

From my experience with the many teams I've been on, invested in, or advised, achieving all three is nearly impossible. Why a perfect organization model cannot exist is clear after analysis.

The CAP Theorem: What is it?

Eric Brewer of Berkeley discovered the CAP Theorem, which argues that a distributed data storage should have three benefits. One can only have two at once.

The three benefits are consistency, availability, and partition tolerance, which implies that even if part of the system is offline, the remainder continues to work.

This notion is usually applied to computer science, but I've realized it's also true for human organizations. In a post-COVID world, many organizations are hiring non-co-located staff as they grow. CAP Theorem is more important than ever. Growing teams sometimes think they can develop ways to bypass this law, dooming themselves to a less-than-optimal team dynamic. They should adopt CAP to maximize productivity.

Path 1: Consistency and availability equal no tolerance for partitions

Let's imagine you want your team to always be in sync (i.e., for someone to be the source of truth for the latest information) and to be able to share information with each other. Only division into domains will do.

Numerous developing organizations do this, especially after the early stage (say, 30 people) when everyone may wear many hats and be aware of all the moving elements. After a certain point, it's tougher to keep generalists aligned than to divide them into specialized tasks.

In a specialized, segmented team, leaders optimize consistency and availability (i.e. every function is up-to-speed on the latest strategy, no one is out of sync, and everyone is able to unblock and inform everyone else).

Partition tolerance suffers. If any component of the organization breaks down (someone goes on vacation, quits, underperforms, or Gmail or Slack goes down), productivity stops. There's no way to give the team stability, availability, and smooth operation during a hiccup.

Path 2: Partition Tolerance and Availability = No Consistency

Some businesses avoid relying too heavily on any one person or sub-team by maximizing availability and partition tolerance (the organization continues to function as a whole even if particular components fail). Only redundancy can do that. Instead of specializing each member, the team spreads expertise so people can work in parallel. I switched from Path 1 to Path 2 because I realized too much reliance on one person is risky.

What happens after redundancy? Unreliable. The more people may run independently and in parallel, the less anyone can be the truth. Lack of alignment or updated information can lead to people executing slightly different strategies. So, resources are squandered on the wrong work.

Path 3: Partition and Consistency "Tolerance" equates to "absence"

The third, least-used path stresses partition tolerance and consistency (meaning answers are always correct and up-to-date). In this organizational style, it's most critical to maintain the system operating and keep everyone aligned. No one is allowed to read anything without an assurance that it's up-to-date (i.e. there’s no availability).

Always short-lived. In my experience, a business that prioritizes quality and scalability over speedy information transmission can get bogged down in heavy processes that hinder production. Large-scale, this is unsustainable.

Accepting CAP

When two puzzle pieces fit, the third won't. I've watched developing teams try to tackle these difficulties, only to find, as their ancestors did, that they can never be entirely solved. Idealized solutions fail in reality, causing lost effort, confusion, and lower production.

As teams develop and change, they should embrace CAP, acknowledge there is a limit to productivity in a scaling business, and choose the best two-out-of-three path.

Effective: August 31, 2022

These Terms of Service ("Terms") govern your access to and use of INTΞGRITY’s (or "we") websites, mobile applications, and other online products and services (collectively, the "Services"). By clicking your assent (e.g. "Continue," "Sign-in," or "Sign-up") or by utilizing our Services, you consent to these Terms, including the mandatory arbitration provision and class action waiver in the Resolving Disputes; Binding Arbitration Section.

Our Privacy Policy describes how we gather and utilize your information, while our Rules detail your duties when utilizing our Services. You agree to be bound by these Terms and our Rules by utilizing our Services. Please refer to our Privacy Statement for details on how we collect, utilize, disclose, and otherwise manage your information.

Please contact us at hello@int3grity.com if you have any queries regarding these Terms or our Services.

Account Details and Responsibilities

You are responsible for your use of the Services and any content you contribute, including compliance with all relevant laws. The Services may host content that is protected by the intellectual property rights of third parties. Please do not copy, post, download, or distribute content without permission.

You must adhere to our Rules when using the Services.

To use any or all of our services, you may need to register for an account. Contribute to the protection of your account. Protect your account's password, and maintain accurate account details. We advise you not to share your password with anyone else.

If you are accepting these Terms and using the Services on behalf of someone else (such as another person or entity), you confirm that you are allowed to do so, and the words "you" or "your" in these Terms refer to that other person or entity.

You must be at least 13 years old to access our services.

If you use the Services to access, collect, or otherwise utilize the personal information of other INTΞGRITY users ("Personal Information"), you agree to comply with all applicable laws. You also undertake not to sell any Personal Information, where "sell" has the meaning ascribed to it by relevant legislation.

For Personal Information you provide to us (as a Newsletter Editor, for example), you represent and warrant that you have lawfully collected the Personal Information and that you or a third party have provided all required notices and obtained all required consents prior to collecting the Personal Information. You further represent and warrant that INTΞGRITY’s use of such Personal Information in accordance with the purposes for which you provided the Personal Information will not violate, misappropriate, or infringe any rights of a third party (including intellectual property rights or privacy rights) or cause us to violate any applicable laws.

The Services' User Content

INTΞGRITY may monitor your conduct and material for compliance with these Terms and our Rules, and reserves the right to remove any content that violates these guidelines.

INTΞGRITY maintains the right to remove or disable content that is accused to violate the intellectual property rights of others, as well as to cancel the accounts of repeat infringers. We respond to notifications of alleged copyright violations if they comply with the law; please report such notices using our Copyright Policy.

Ownership and Rights

You maintain ownership of all content that you submit, upload, or display on or through the Services.

By submitting, posting, or displaying content on or through the Services, unless otherwise agreed in writing, you grant INTΞGRITY a nonexclusive, royalty-free, worldwide, fully paid, and sublicensable license to use, reproduce, modify, adapt, publish, translate, create derivative works from, distribute, publicly perform and display your content and any name, username or likeness provided in connection with your content in all media formats and distribution methods now known or later developed.

INTΞGRITY requires this license because you are the owner of your material, and INTΞGRITY cannot show it across its multiple platforms (mobile, online) without your consent.

This type of license is also required for content distribution throughout our Services. For example, you may publish a piece on INTΞGRITY. It is duplicated as versions on both our website and app, and distributed to many locations on INTΞGRITY, including the homepage and reading lists. A tweak could be that we display a fragment of your work as a preview (rather than the entire post), with attribution. An example of a derivative work might be a list of top authors or quotations on INTΞGRITY that includes chunks of your article, again with full attribution. This license solely applies to our Services and does not grant us permissions outside of our Services.

So long as you comply with these Terms, INTΞGRITY grants you a limited, non-exclusive, personal, and non-transferable license to access and utilize our Services.

Copyright, trademark, and other United States and international laws protect the Services. These Terms do not grant you any right, title, or interest in the Services, the material posted by other users on the Services, or INTΞGRITY’s trademarks, logos, or other brand characteristics.

In addition to the content you submit, post, or display on our Services, we appreciate your feedback, which may include your thoughts, ideas, and suggestions regarding our Services. This input may be used for any reason at our sole discretion and without obligation to you. We may treat your comments as non-confidential.

We reserve the right, at our sole discretion, to discontinue the Services or any of its features. In addition, we reserve the right to impose limits on use and storage, and to remove or restrict the distribution of content on the Services.

Termination

You are allowed to terminate your use of our services at any time. We have the right to stop or cancel your use of the Services with or without notice.

Moving and Processing Information

To enable us to deliver our Services, you accept that we may handle, transfer, and retain information about you in the United States and other countries, where you may not enjoy the same rights and protections as you do under local law.

Indemnification

To the maximum extent permitted by applicable law, you will indemnify, defend, and hold harmless INTΞGRITY, and our officers, directors, agents, partners, and employees (collectively, the "INTΞGRITY Parties"), from and against any losses, liabilities, claims, demands, damages, expenses or costs ("Claims") arising out of or relating to your violation, misappropriation, or infringement of any rights of another (including intellectual property rights or privacy rights). You undertake to promptly notify INTΞGRITY Parties of any third-party Claims, to assist INTΞGRITY Parties in fighting such Claims, and to pay any fees, charges, and expenses connected with defending such Claims (including attorneys' fees). You further agree that, at INTΞGRITY’s sole discretion, the INTΞGRITY Parties will govern the defense or settlement of any third-party Claims.

Disclaimers — Services Provided "As Is"

INTΞGRITY strives to provide you with excellent Services, but there are certain things we cannot guarantee. Utilization of our services is at your own risk. You acknowledge that our Services and any content uploaded or shared by users on the Services are given "as is" and "as available" without explicit or implied warranties of any kind, including warranties of merchantability, fitness for a particular purpose, title, and non-infringement. In addition, INTΞGRITY does not represent or promise that our Services are accurate, comprehensive, dependable, up-to-date, or error-free. No advice or information gained from INTΞGRITY or via the Services shall create any warranty or representation unless expressly set forth in this section. INTΞGRITY may provide information on third-party products, services, activities, or events, or we may permit third parties to make their material and information accessible via our Services (collectively, "Third-Party Content"). We neither control nor endorse any Third-Party Content, nor do we make any claims or warranties about it. Accessing and utilizing Third-Party Content is at your own risk. The disclaimers in this section may not apply to you if they are prohibited in your location.

Limitation of Liability

We do not exclude or limit our obligation to you where it would be unlawful to do so; this includes any liability for the gross negligence, fraud, or willful misconduct of INTΞGRITY or the other INTΞGRITY Parties in providing the Services. In jurisdictions where the foregoing exclusions are not permitted, our liability to you is limited to losses and damages that are reasonably foreseeable as a result of our failure to exercise reasonable care and skill or breach of contract with you. This paragraph does not impact consumer rights that cannot be waived or limited by contract.

In jurisdictions that permit liability exclusions or limits, INTΞGRITY and INTΞGRITY Parties will not be liable for:

(a) Any indirect, consequential, exemplary, incidental, punitive, or extraordinary damages, or any loss of use, data, or profits, based on any legal theory, even if INTΞGRITY or the other INTΞGRITY Parties were advised of the potential of such damages.

(b) Except for the types of liability we cannot limit by law (as described in this section), we limit the total liability of INTΞGRITY and the other INTΞGRITY Parties for any claim arising out of or related to these Terms or our Services, regardless of the form of action, to $100.00 USD.

Arbitration; Resolution of Disputes

We intend to address your concerns without filing a formal lawsuit. Before making a claim against INTΞGRITY, you agree to contact us and attempt to resolve the dispute informally by emailing hello@int3grity.com or by sending certified mail to INTΞGRITY, P.O. JOY, 479 Jessie St, San Francisco, CA 94103. The notice must (a) contain your name, address, email address, and telephone number; (b) identify the nature and grounds of the claim; and (c) detail the relief requested. Our notice to you will be sent to the email address linked with your online account and will contain the information specified in the preceding section. Any party may commence a formal procedure if we are unable to reach a resolution within thirty (30) days of the date of any notice.

Please read the following section carefully because it compels you to arbitrate certain claims and disputes with INTΞGRITY and limits the method in which you can seek redress from us, unless you opt out of arbitration by following the steps provided below. This arbitration provision does not permit class or representative lawsuits or arbitrations. In addition, arbitration prohibits you from filing a lawsuit or having a jury trial.

(a) Absence of Representative Actions You and INTΞGRITY agree that any dispute arising out of or relating to these Terms or our Services is personal to you and INTΞGRITY and will be resolved entirely via individual action, and not by class arbitration, class action, or other representative procedure.

(b) Dispute Arbitration. Except for small claims disputes in which you or INTΞGRITY seeks to bring an individual action in small claims court located in the county where you reside and disputes in which you or INTΞGRITY seeks injunctive or other equitable relief for the alleged infringement or misappropriation of intellectual property, you and INTΞGRITY waive your rights to a jury trial and to have any other dispute arising out of or relating to these Terms or our Services, including claims related to privity of contract, decided by a jury. All Disputes submitted to JAMS shall be decided by confidential, binding arbitration before a single arbitrator. If you are a consumer, you may choose to have the arbitration in your county of residence. A "consumer" is a person who uses the Services for personal, family, or household purposes for the purposes of this provision. You and INTΞGRITY agree that Disputes shall be resolved using the JAMS Streamlined Arbitration Rules and Procedures ("JAMS Rules"). The latest version of the JAMS Rules is accessible on the JAMS website and is incorporated herein by reference. Either you accept and agree that you have read and comprehended the JAMS Rules or you forfeit your right to read the JAMS Rules and any claim that the JAMS Rules are unreasonable or should not apply for any reason.

(c) You and INTΞGRITY agree that these Terms affect interstate commerce and that the enforceability of this provision is subject to the Federal Arbitration Act, 9 U.S.C. 1 et seq. (the "FAA"), to the maximum extent permissible by applicable law. As limited by the FAA, these Terms, and the JAMS Rules, the arbitrator will have sole authority to make all procedural and substantive judgments regarding any Dispute, and to grant any remedy that would otherwise be available in court, including the authority to determine arbitrability. The arbitrator may only conduct an individual arbitration and may not consolidate the claims of more than one party, preside over any sort of class or representative procedure, or preside over any proceeding involving more than one party.

d) The arbitration will permit the discovery or exchange of nonconfidential information pertinent to the Dispute. The arbitrator, INTΞGRITY, and you will maintain the confidentiality of all arbitration proceedings, judgments, and awards, as well as any information gathered, prepared, or presented for the purposes of the arbitration or relating to the Dispute(s) therein. Unless the law specifies otherwise, the arbitrator will have the right to make decisions that protect confidentiality. The duty of confidentiality does not apply where disclosure is required to prepare for or conduct the arbitration hearing on the merits, in connection with a court application for a preliminary remedy, in connection with a judicial challenge to an arbitration award or its enforcement, or where disclosure is otherwise required by law or judicial decision.

e) You and INTΞGRITY agree that for any arbitration you begin, you will pay the filing fee (up to $250 if you are a consumer) and INTΞGRITY will pay the remaining JAMS fees and costs. INTΞGRITY will pay all JAMS fees and costs for any and all arbitrations it initiates. You and INTΞGRITY agree that the state and federal courts of California and the United States located in San Francisco have exclusive jurisdiction over any appeals and the implementation of an arbitration award.

(f) Any Dispute must be filed within one year after the relevant claim arose; otherwise, the Dispute is permanently barred, meaning that neither you nor INTΞGRITY will be able to assert the claim.

(g) You have the right to opt-out of binding arbitration within 30 days of the date you initially accepted the terms of this section by sending an email to hello@int3grity.com. For the opt-out notification to be effective, it must include your full name and address and clearly explain your intent to opt out of binding arbitration. By declining binding arbitration, you consent to the resolution of Disputes in accordance with "Governing Law and Venue" below.

(h) If any portion of this section is found to be unenforceable or unlawful for any reason: (1) the unenforceable or unlawful provision shall be severed from these Terms; (2) the severance of the unenforceable or unlawful provision shall have no effect whatsoever on the remainder of this section or the parties' ability to compel arbitration of any remaining claims on an individual basis pursuant to this section; and (3) to the extent that any claims must therefore proceed on an individual basis, the parties agree to arbitrate those claims on an individual basis. In addition, if it is determined that any portion of this section prohibits an individual claim seeking public injunctive relief, that provision will be null and void to the extent that such relief may be sought outside of arbitration, and the balance of this section will be enforceable.

Statute and Location

These Terms and any dispute that may arise between you and INTΞGRITY are governed by California law, excluding its conflict of law provisions. Any issue between the parties that is not arbitrable or cannot be heard in small claims court will be determined by the state or federal courts of California and the United States, sitting in San Francisco, California.

Some nations have regulations that require agreements to be controlled by the consumer's country's laws. These statutes are not overridden by this paragraph.

Amendments

Periodically, we may make modifications to these Terms. If we make modifications, we will notify you by sending an email to the address connected with your account, providing an in-product message, or amending the date at the top of these Terms. Unless we specify otherwise in our notification, the modified Terms will take effect immediately, and your continued use of our Services after we issue such notice indicates your acceptance of the changes. If you do not accept the updated Terms, you must cease using our services.

Severability

If any section or portion of a provision of these Terms is determined to be unlawful, void, or unenforceable, that provision or part of the provision shall be deemed severable from these Terms and shall not affect the validity and enforceability of the other terms.

Miscellaneous INTΞGRITY’s omission to assert or enforce any right or term of these Terms is not a waiver of such right or provision. These Terms and the terms and policies specified in the Other Terms and Policies that May Apply to You Section constitute the complete agreement between the parties pertaining to the subject matter hereof and supersede all prior agreements, statements, and understandings between the parties. The section headings in these Terms are for convenience only and have no legal or contractual significance. The use of the word "including" shall be taken to mean "including without limitation." Unless otherwise specified, these Terms are intended solely for the benefit of the parties and are not intended to confer third-party beneficiary rights on any other person or entity. You consent to the use of electronic means for our communications and transactions.