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Sandy
Germany May Have The Answer For Reducing Drug Prices
~3.9 mins read
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In Germany, drugmakers must prove that a new medication’s benefits merit a higher price than existing drugs. Ariel Dora Stern asks whether "value-based pricing" should become the standard elsewhere.
American lawmakers attempting to stem spiraling drug costs might find inspiration in Germany, where the government’s regulatory model has been curbing price growth without thwarting innovation or access, says research from Harvard Business School.
Since 2011, Germany has been requiring drugmakers to prove that a new medication’s benefits merit a higher price if cheaper, similar drugs are available. The process rewards companies whose drugs are more novel or help patients more, while forcing manufacturers of equally or less effective treatments to cut prices, says research by Ariel D. Stern, the Poronui Associate Professor of Business Administration.
Pharmaceutical companies have long opposed efforts to regulate drug prices, arguing that prices reflect the companies’ massive research investments. But Germany’s approach shows how the right incentives can push manufacturers to price based on performance, a step toward what health economists call “value-based pricing.”
“The implication for German health insurers—and indirectly, consumers—has been millions of euros in savings on drug spending, without any evidence so far of compromised access to the most valuable new drugs,” Stern says.
Her team detailed the findings in an article in the July edition of Health Affairs, The Impact of Price Regulation on the Availability of New Drugs in Germany.
If the panel deems a product equally or less beneficial than one or more drugs already available, the manufacturer can withdraw it from the market, price it no higher than comparable products, or negotiate a price with the association that represents Germany’s statutory health insurers, a potentially costly process.
Stern and her co-authors studied 171 new drugs that Germany’s IQWiG reviewed between 2012 and 2016. They found that manufacturers were 10 times more likely to withdraw products that lacked any evidence of added benefit than ones that performed better. Equally important, 98 percent of drugs with added benefits remained on the market, including all treatments for heart and respiratory diseases.
“The drugs that left the market were ‘me too’ drugs—only one of these drugs was shown to have added benefit over comparable therapies, but that decision was actually reversed in a later evaluation. That means that none of the drugs that left the market were, ultimately, ones that had additional patient benefit,” Stern says. “Innovative, high-value drugs that were found to lead to better patient outcomes all remained on the market.”
The Senate has been debating a bipartisan proposal to limit seniors’ out-of-pocket costs and curb price increases, while House leaders finalize a bill that would let Medicare negotiate drug prices.
After all, American voters want their government to reign in rising drug spending, according to recent polls. They spend twice as much a year per person on medications than the average Organisation for Economic Co-operation and Development member country. Americans also shoulder higher out-of-pocket costs for medical care, a financial burden that forces some consumers to skip doses or forgo treatment.
German consumers and physicians can also access the performance data that companies submit during the review process, so they can gauge a medication’s value. In the US, Medicare and Medicaid typically don’t consider a drug’s performance in coverage decisions.
“These are big pieces of the puzzle,” Stern says. The US “would need to figure those issues out, but it’s not impossible.”
Stern, who has been studying health care innovation for more than a decade, conducted her most recent research alongside Aaron S. Kesselheim and Ameet Sarpatwari from the Program on Regulation, Therapeutics, and Law at Harvard Medical School and Brigham & Women’s Hospital; Annika Herr, a professor at Leibniz University Hannover; and her former research fellow, Felicitas Pietrulla.
In future research, Stern is examining the pricing strategies for anti-cancer drugs during the years before and after Germany’s regulations took effect. She hopes to shed light on the underlying factors that help Germany’s policies link price to value for important new therapies.
“We’re looking at the extent to which these new German drug pricing laws were able to tie drugs’ negotiated prices to drug benefits,” Stern says. “If what we end up seeing is something that has moved closer to value-based drug pricing in Germany, that would be encouraging.”
About the Author
Danielle Kost is the senior editor of Harvard Business School Working Knowledge.
American lawmakers attempting to stem spiraling drug costs might find inspiration in Germany, where the government’s regulatory model has been curbing price growth without thwarting innovation or access, says research from Harvard Business School.
Since 2011, Germany has been requiring drugmakers to prove that a new medication’s benefits merit a higher price if cheaper, similar drugs are available. The process rewards companies whose drugs are more novel or help patients more, while forcing manufacturers of equally or less effective treatments to cut prices, says research by Ariel D. Stern, the Poronui Associate Professor of Business Administration.
Pharmaceutical companies have long opposed efforts to regulate drug prices, arguing that prices reflect the companies’ massive research investments. But Germany’s approach shows how the right incentives can push manufacturers to price based on performance, a step toward what health economists call “value-based pricing.”
“The implication for German health insurers—and indirectly, consumers—has been millions of euros in savings on drug spending, without any evidence so far of compromised access to the most valuable new drugs,” Stern says.
Her team detailed the findings in an article in the July edition of Health Affairs, The Impact of Price Regulation on the Availability of New Drugs in Germany.
Drug pricing, German-style
Before companies can set higher prices for new drugs in Germany—the world’s fourth-largest pharmaceutical market—they must demonstrate to an independent panel from the Institute for Quality and Efficiency in Health Care (IQWiG) that a new product works better than existing options for an identifiable group of patients. The rule doesn’t apply to rare diseases, for which there is often a dangerous dearth of treatment options.If the panel deems a product equally or less beneficial than one or more drugs already available, the manufacturer can withdraw it from the market, price it no higher than comparable products, or negotiate a price with the association that represents Germany’s statutory health insurers, a potentially costly process.
Stern and her co-authors studied 171 new drugs that Germany’s IQWiG reviewed between 2012 and 2016. They found that manufacturers were 10 times more likely to withdraw products that lacked any evidence of added benefit than ones that performed better. Equally important, 98 percent of drugs with added benefits remained on the market, including all treatments for heart and respiratory diseases.
“The drugs that left the market were ‘me too’ drugs—only one of these drugs was shown to have added benefit over comparable therapies, but that decision was actually reversed in a later evaluation. That means that none of the drugs that left the market were, ultimately, ones that had additional patient benefit,” Stern says. “Innovative, high-value drugs that were found to lead to better patient outcomes all remained on the market.”
Taking on drug prices in the US (again)
American political leaders have repeatedly tried and failed to stem spiraling drug costs. US President Donald Trump said in May that he expected drugmakers to voluntarily cut their costs, providing few details. However, a Wells Fargo Securities report said that pharmaceutical companies raised the prices of more than 100 medications by 32 percent, on average, in June and early July.The Senate has been debating a bipartisan proposal to limit seniors’ out-of-pocket costs and curb price increases, while House leaders finalize a bill that would let Medicare negotiate drug prices.
After all, American voters want their government to reign in rising drug spending, according to recent polls. They spend twice as much a year per person on medications than the average Organisation for Economic Co-operation and Development member country. Americans also shoulder higher out-of-pocket costs for medical care, a financial burden that forces some consumers to skip doses or forgo treatment.
The US isn’t Germany
While Germany's approach offers a relevant policy example, the country's health system differs from America's in several key ways. For example, Germany's statutory health insurers, who cover 90 percent of patients, jointly negotiate drug prices with manufacturers. In America's more fragmented and secretive system, pharmacy benefit managers act as mediators during many price negotiations.German consumers and physicians can also access the performance data that companies submit during the review process, so they can gauge a medication’s value. In the US, Medicare and Medicaid typically don’t consider a drug’s performance in coverage decisions.
“These are big pieces of the puzzle,” Stern says. The US “would need to figure those issues out, but it’s not impossible.”
Stern, who has been studying health care innovation for more than a decade, conducted her most recent research alongside Aaron S. Kesselheim and Ameet Sarpatwari from the Program on Regulation, Therapeutics, and Law at Harvard Medical School and Brigham & Women’s Hospital; Annika Herr, a professor at Leibniz University Hannover; and her former research fellow, Felicitas Pietrulla.
In future research, Stern is examining the pricing strategies for anti-cancer drugs during the years before and after Germany’s regulations took effect. She hopes to shed light on the underlying factors that help Germany’s policies link price to value for important new therapies.
“We’re looking at the extent to which these new German drug pricing laws were able to tie drugs’ negotiated prices to drug benefits,” Stern says. “If what we end up seeing is something that has moved closer to value-based drug pricing in Germany, that would be encouraging.”
About the Author
Danielle Kost is the senior editor of Harvard Business School Working Knowledge.
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Sandy
Dark And Violent
~16.2 mins read
They say the earliest years of a child’s life are the most important, that the core of the personality is forged and unchangeable by the time the child is five. Some experts argue that damage done in those critical first years can still be healed, the child re-forged from what his earliest experience made him to be.
Some people are born into darkness and that darkness shapes them into monsters. I always loved the debate of nature versus nurture. I knew it held the answers to my own life. For years I believed most in those who argued in favor of bad blood. In many ways it was easier to think that I had been born a monster, that nothing could change what I really was.
Yet somehow, perhaps those early years are what saved me from truly being a monster. I had to grow up very fast after my mother died, but she was the one who dominated my early years, not my father.
Maybe all the love I knew in those few years was enough to preserve a core of humanity, just a spark buried deep within what I was forced to become after she died.
Rain pounded the shingles as the thick, angry clouds lashed the world below. Lightning flashed; thunder rattled the windows. The raging storm sent residents of the cushy neighborhood scuttling for shelter, burrowing deep into their artificial worlds where they could drown out Nature’s fury with TV or board games, music or game consoles or anything that would make them forget that being well-off means nothing to Mother Nature. The luxurious houses around the cul-de-sac were much the same, not quite in the pre-fab style of Suburbia but more along the lines of the conformity found when upper-middle-class people clump together for a sense of security. It was the sort of neighborhood where everyone remembered to set their burglar alarms but nobody ever expected anything to destroy their high-priced serenity.
The storm was loud enough to drown out the screams and--other sounds. Inside the red brick house near the center of the cul-de-sac, in the shattered wreck of a living room, a dark-haired boy cowered between the end of the sofa and the wall with the end table an inadequate shelter, partially obstructing his view. He wanted to look away, but he could only stare.
His young mind couldn’t understand how this had happened, but somehow he knew it was his fault. Hadn’t his father started by yelling at him, not Mom? Wasn’t he the one Dad had been hitting first? He wasn’t sure what he had done wrong, but it had been his fault, and now…
He hadn’t been able to look away. He watched, at first astonished to see his sweet mother raging like that. He had never heard her raise her voice or use those words before. He couldn’t understand most of what she said, but in later years, he would come to realize that his tiny mother had attacked a man twice her size to save the life of her only child.
She wasn’t raging now. Dad had been just as surprised by her actions, but the surprise was quickly replaced by fury. The crack of a flat hand striking flesh hadn’t been so bad, even blended in with the thunder, but when Dad’s hands became fists…there was such a powerful, frightening difference between the snap of wood when she fell across the coffee table and the sickening crunch of bone breaking. She cried at first, screamed even, begging Dad to stop, but now she barely groaned.
Dad was breathing harshly, staring down at what he had done, at the broken remnants of room and woman. After a few moments, he unclenched his bloodied fists and wiped one big hand across his face. Johnny waited, but Dad seemed to have forgotten he was there. He watched, but all Dad did was stomp up the stairs. Johnny winced when he heard a door slam, then he scrambled out of hiding.
Mom didn’t look like she was breathing. Johnny crept closer. The smell of blood was strong. She lay sprawled across the carpet, one arm draped over her head. Her blond hair was stained red by the growing pool of blood.
Johnny touched her shoulder with a hesitant hand. She was warm, but she still wasn’t moving. Was she dead?
Then she gave a small, soft gasp. It was a wet, unhealthy sound, like even taking so small a breath hurt her.
“Mom?” he asked in a tiny whisper.
“Johnny.” It was barely more than an exhalation.
“Are you okay?” He snuggled close to her, needing comfort and reassurance.
She moved slowly, raising her broken arm from her battered face. Her blackened eyes were badly swollen, but they opened a crack, revealing the dark-blue eyes identical to his own. Her hand curved, cupped the side of his face as she always did. He pressed his hand against hers, needing that touch, despite the fact that it wasn’t remotely reassuring. Her hand was cold and her arm trembled with effort.
“Mommy? What can I do?” Tears filled his eyes. He wanted to be brave for her but he couldn’t keep the quaver out of his voice.
“Don’t…” Her eyes fluttered shut, then she drew another painful breath and they opened again. “Don’t let him…hurt you. Remember…what I taught you.”
“I will, Mommy.” His lips trembled but he fought back the tears.
“I love you.” Her breath was coming in labored gasps.
“I love you too.” The tears spilled over, hot against his cheeks, imparting transient warmth to her hand.
“Sorry I…couldn’t…protect you.”
“You did protect me.” He clutched her hand against his cheek when it started to fall away. Her arm had gone limp. “Mommy? Wake up.”
Blood bubbled form between her lips. He waited for the next breath, but it didn’t come.
“Wake up, Mommy.” Heedless of the blood, he snuggled closer, pressing his face into her neck, anxious to feel her arms around him. She didn’t move, and he began to sob in earnest.
After a few moments, he heard his father’s voice. “Get the hell up and stop that bawling, boy.”
For the first time he could remember, Johnny didn’t immediately obey. Instead, he clung more tightly to his mother’s body. He could feel a pulpy give where her ribs had been broken and his tears dried up as anger filled him. His father had done this.
“I said move it!” Dad gave him a boot in the ribs, hard enough to drive the breath from his body.
Johnny pried himself away from the cooling body. He was angry, but if he didn’t listen he’d be feeling Dad’s fists too and Mom didn’t want that. SHe wanted him to be safe and she had been teaching him how to handle Dad’s rages. The first step was control, so although he wanted to pound his own fists into Dad’s body for what he had done, Johnny mastered his rage and stood up, keeping his head down. Dad would see his anger as a sign of defiance and hit him, so Johnny walked quietly where he was told. He waited by the door while Dad rolled Mom’s body into a tarp.
“Get the door.” Dad grunted as he heaved the neatly wrapped bundle into his arms.
Johnny obeyed. As Dad walked past, Johnny could see the car waiting in the driveway, trunk open. He wrapped his arms around himself and followed in his father’s wake, wincing as the trunk slammed. Though he knew that MOm was past caring, he hated the thought of her lying alone in the cold, dark trunk.
THere was nothing he could do for her except survive. He didn’t want to be anywhere near his father, but he knew what was expected of him. He climbed into the back seat and stared daggers into the back of his father’s head.
THe rain let up gradually as they came out from under the storm cloud. Dad still hadn’t spoken, and Johnny wasn’t sure if Dad meant to kill him, too. Don’t let him hurt you, Mom had said. He needed to survive, he didn’t want to disappoint her. Surely Dad would stop somewhere and then he could run away. Far away, so far that Dad would never find him.
After the back of Dad’s head won the staring contest and contemplating the car’s interior lost its appeal, Johnny turned toward the window to study the stars. They blurred as the tears started again. His mother was gone. His father had done this.
But he only allowed himself to cry silently. If Dad heard him crying…
Eventually, the motion of the car and his crushing sense of loss lulled Johnny to sleep.
He woke when the car stopped. Blinking at his surroundings, he struggled to make sense of the world around him.
“You’ll keep your mouth shut, boy.” Dad’s voice came from the front seat and Dad twisted around to stare at him. “You hear me? If you ruin this for me, I swear I’ll kill you.”
Johnny shrank back into his seat and nodded. Looking out the windshield, he could see they were by the side of the road, with another car not far in front of them. A woman stood beside the car.
Dad climbed out of the car and walked over to her.
Johnny wrapped his arms around his middle, fighting the urge to scream a warning. Something about the way Dad moved made Johnny think that the woman was in terrible danger. So despite the cool weather, Johnny rolled the window down so he could hear what was being said.
“Thank you for stopping.” The woman’s voice was uncertain and her face was filled with fear. Dad was a very large man, an intimidating physical presence.
“No problem. I’m just on my way to Peoria with my son.” Dad gestured toward the car.
The woman looked at Johnny and smiled. She was young and pretty, a blonde with a passing resemblance to Mom. “Oh, you have a little boy. He’s adorable.”
“My pride and joy,” Dad said in a tone Johnny had only heard when strangers were around. “Is there something wrong with your car?”
Her smile turned sheepish. “Yeah, I was on the way home when I felt a pop and it started to smoke. I had to pull over. Do you know anything about cars?”
“Not really, but I can drive you somewhere where you can call for help. Your car ought to be okay as long as you lock it.” Dad took a half-step back toward the car.
Johnny frowned. Dad worked on their car all the time, he said it was cheaper than those price-gouging mechanics.
The woman closed the distance between herself and Dad, and walked toward the car with him. Johnny quickly rolled up the window so Dad wouldn’t know he’d been eavesdropping. When the woman got into the passenger seat, she turned so she could smile at Johnny.
“Hi,” she said to Johnny in a bright voice. “Your dad is giving me a ride. I’m so glad the two of you showed up. I’d been afraid some creep would pull over.”
“Hi,” Johnny mumbled, looking away. He thought of Mom’s body in the trunk and the disconcerting gleam in Dad’s eyes when he threatened Johnny’s life. Something was very wrong here.
“Oh, is he shy?” The woman turned her attention to Dad, settling into the driver’s seat.
“Yeah, he’s a quiet kid.” Dad reached back and tousled Johnny’s hair with a rough hand. The warning was clear.
“I’m Laurie Anderson.”
“John Winslow. That’s my son John Jr., my wife and I call him Johnny.”
How dare he mention Mom?
“How sweet. He looks just like you.”
Johnny turned his head to look out the window, hating how right she was. Except for the midnight-blue eyes, he was a perfect miniature of his father.
They pulled back onto the road. Johnny looked out the window; there were no signs to say how far to the nearest exit. They were in the middle of nowhere.
“How old is Johnny?” Laurie asked.
“Nine.”
“He’s so small, I would’ve thought he was younger than that.”
Dad shrugged. “My wife’s a little woman. He may take after her more. It’s hard to tell, he’s still young. He could hit a growth spurt when he reaches puberty.”
“Kids are like that,” Laurie said with a laugh. “I know my own little one grows so fast.”
She’s a mother? Run run run… Johnny squeezed his eyes shut, fighting tears.
“You look too young to have a kid.” There was a hint of disapproval in Dad’s tone.
Laurie’s laugh was light and easy. “Yeah, I’m young. But so’s my baby, you know? She’s only four months old, but she gained weight soooo fast. I’m sure your boy will grow into a big strapping man like you.”
Dad said nothing for a moment. “Where’s your baby now?”
“With my mom. I just ran to the store for more formula.” Laurie’s sweet voice reminded Johnny of Mom.
It’s not too late. Jump out of the car, now, Johnny begged her silently. But of course, Laurie couldn’t hear him and Johnny didn’t dare say anything to warn her.
Dad and Laurie chatted about her baby and about Johnny’s baby days for many minutes while Johnny cowered in his seat, certain that something bad was going to happen but unable to put a name to his fears.
“Damn,” Dad said eventually. “We’re miles from anywhere and I have to pee. I’ll have to pull over. You don’t mind keeping an eye on Johnny, do you?”
Laurie smiled. “Not at all.”
Dad pulled the car off the road and cut the engine. “There’s a cooler in the trunk. Would you like anything to drink while we’re stopped? I’m sorry, I should have offered it to you before…”
“Sure, I’d love a water or a soda, whatever you have is fine.”
Johnny squeezed his eyes shut. There was nothing in the trunk except Dad’s tools and what was left of Mom. What was Dad up to? Johnny was alternately hot and cold as he struggled with himself. He should tell Laurie to be on her guard, but what could she do against such a physically powerful man if Dad decided to hurt her? Besides, what could he say except that he had a bad feeling?
Dad popped the trunk and got out of the car. He rummaged in the trunk for a moment before he came around to the passenger side and opened Laurie’s door. She looked up at him in confusion, then squealed when he jerked her out of the car.
“What are you doing?” she cried.
“Taking what I want.” Dad said in that cold, terrible voice.
Johnny cowered and covered his ears with his hands, his eyes screwed shut. Having witnessed what his father was willing to do to a helpless woman, he was absolutely certain he did not want to see whatever was coming.
Laurie screamed, loud and piercing. Then came the crack of a hand striking flesh and the sound of tearing fabric. The unmistakable sounds of a struggle, followed by the sound of her crying. Dad was grunting rhythmically, a rough counterpoint to her tears. Johnny kept his eyes shut.
It seemed to go on forever, until finally Dad let out a low groan. Had she managed to hurt him? Johnny opened his eyes.
He couldn’t see Laurie or his father in the darkness. Then, through the still-open passenger-side door, Johnny caught sight of feet. Laurie and Dad were lying together in the ditch and Dad was on top of her. As Johnny watched, Dad reared up. There was a terrible look on his face, a mixture of rage and dark glee, and there was a knife in his hands.
Laurie screamed again, a raw noise of terror unlike anything Johnny had ever heard. “No, please!”
Then Dad’s arm came down with an awful meaty sound--
--she screamed--
--and screamed--
--and screamed--
The arm came down again and again, light from the car’s interior reflecting off the bloody blade in Dad’s hand.
The screams faded to a wet gurgle and for a few terrible moments, there was silence.
Johnny realized he was shaking. He stared at Laurie’s motionless feet, paralyzed, as Dad’s feet rolled out of view. When Dad stood, his face was dreamy and speckled with red. He closed the car door and went around to the trunk, which he also closed. Dad climbed back into the car, minus both knife and shirt.
“That was a unique experience,” Dad said in a soft, wondering voice.
Johnny pressed himself against the car door and hid his face from the man he knew to be a monster.
“It’ll be a while before anyone finds her. Who would even know where to look?”
Johnny knew Dad was not talking to him. Not with that tone. Dad always addressed him as if he was an unwelcome obstacle, a problem to be dealt with. Since Dad couldn’t see him while driving, Johnny dared to put his fingers in his ears.
Dad continued to talk, reliving the experience out loud. But with his fingers in his ears, Johnny could only understand the distant mumble of his father’s voice, not the actual words. He had seen enough, he didn’t need to hear how thrilled Dad was by killing her.
Laurie Anderson. That had been her name. He wouldn’t forget. He was certain he would never forget her screaming, either.
Johnny fell asleep with his fingers in his ears. He dreamed of blood and screaming and woke with tears running down his face.
After a few moments of terror and confusion, he was able to orient himself. The car was parked in the driveway again, but there was something different about the house. Lights were on downstairs, but this light was orange. It seemed to flicker, and in its glow, he could see wisps of smoke.
Fire! How many times had he sat near the fireplace with Mom, staring into the flames while she read to him? Johnny leapt out of the car and bolted inside. He didn’t care one way or another about his father, but he had to save something of his mother’s from the flames. Anything he could grab to remember her by.
Dad was in the living room, heading for the front door when Johnny burst into the house. Dad yelled at him to get out, but Johnny dodged him and ran upstairs.
He knew smoke traveled upward and smoke could kill him before the flames even touched him. He kept low to the ground and ran into his room. Coughing, he dumped his backpack on the bed and stuffed a few things inside. A change of clothes, photo album, a few gifts from his mother…Mom’s things! A few treasured items, he couldn’t leave them behind. He rummaged through his parents’s bedroom and bolted down the stairs, crashing into the wall to keep from stepping on what was laying on the landing.
He must have missed her when he flew up the stairs. Dad had dumped Mom’s body at the foot of the stairs, sprawled as if she had fallen.
Johnny barely paused to think. Mom was wearing two rings, her wedding ring on one hand and a family heirloom on the other. Both were valuable, so Dad must have left them behind for a reason. Johnny tugged them off and put them in his pocket. Maybe he could use them for money.
The fire was spreading from the fireplace as if by accident, but it was moving fast. Johnny hesitated, then ran through the flames, snatching up Mom’s favorite books as he went past. There wasn’t much more he could carry, but if he was to get away from his father, he would need food. He grabbed a few things at random and ran out the back door.
Now only a six-foot fence stood between him and freedom. Johnny scaled the side like a monkey, tossed his backpack over the top, and jumped down the other side. He hit the ground hard and rolled, his feet stinging. From there, he was able to run far and fast, through unkempt grounds around the cul-de-sac and into the scrubland beyond. Only when he was safe under the cover of brush and darkness did he stop to rest.
His lungs were burning. He hadn’t grabbed anything to drink because liquid was heavy. He coughed and began to drip rainwater from grasses and leaves into his mouth. It was cold and soothed his seared throat. He took sips from the greenery as flames engulfed his home.
Firefighters arrived before the fire spread to the second floor. Johnny watched them for many minutes, then realized they might go looking for survivors. He didn’t want to be found. MOving low, he crept deeper into the undeveloped land, dragging his backpack behind himself, until he figured he was far enough away from the house that he would be lost in the darkness. Then he stood and slung the pack over his shoulders. Without a backward glance, he walked off into the night.
The dark, lonely world was a scary place for a nine-year-old boy, but nowhere near as frightening as the world he was trying to escape. Johnny was morose, exhausted and directionless, with only one destination in mind: away. He walked until he stumbled across an abandoned vehicle. It was rusty, but unlocked and dry on the inside.
Johnny wrinkled his nose at the musty smell inside the old truck, but the bench seat was long enough for him to stretch out. He shut the door firmly behind himself and pulled his blankie out of his backpack. Mom had made it for him when he was a baby.
Tears started again. He burrowed his face into the blankie. The familiar softness was comforting, though the smell was tainted by the acrid tang of smoke. Before long, he was asleep.
Dawn woke him a few hours later. He sat up, disoriented. Why was he inside an unfamiliar vehicle, smelling of smoke? Why did his chest ache, and where…?
Where was his mother?
He curled up on himself as memory returned. Mom’s face, broken and bleeding. Laurie Anderson screaming. Darkness and death. Then fire, consuming his home, devouring what was left of Mom.
His father had done this.
Johnny sat up and clutched his head, forcing himself to take deep, even breaths. Control was everything. Mom had taught him that. Stay in control. You may not be able to control what’s happening to you, you may not be able to control other people, but you could always control yourself. Sometimes it was the only power you had.
So he buried his grief and his fear.
Some people are born into darkness and that darkness shapes them into monsters. I always loved the debate of nature versus nurture. I knew it held the answers to my own life. For years I believed most in those who argued in favor of bad blood. In many ways it was easier to think that I had been born a monster, that nothing could change what I really was.
Yet somehow, perhaps those early years are what saved me from truly being a monster. I had to grow up very fast after my mother died, but she was the one who dominated my early years, not my father.
Maybe all the love I knew in those few years was enough to preserve a core of humanity, just a spark buried deep within what I was forced to become after she died.
Rain pounded the shingles as the thick, angry clouds lashed the world below. Lightning flashed; thunder rattled the windows. The raging storm sent residents of the cushy neighborhood scuttling for shelter, burrowing deep into their artificial worlds where they could drown out Nature’s fury with TV or board games, music or game consoles or anything that would make them forget that being well-off means nothing to Mother Nature. The luxurious houses around the cul-de-sac were much the same, not quite in the pre-fab style of Suburbia but more along the lines of the conformity found when upper-middle-class people clump together for a sense of security. It was the sort of neighborhood where everyone remembered to set their burglar alarms but nobody ever expected anything to destroy their high-priced serenity.
The storm was loud enough to drown out the screams and--other sounds. Inside the red brick house near the center of the cul-de-sac, in the shattered wreck of a living room, a dark-haired boy cowered between the end of the sofa and the wall with the end table an inadequate shelter, partially obstructing his view. He wanted to look away, but he could only stare.
His young mind couldn’t understand how this had happened, but somehow he knew it was his fault. Hadn’t his father started by yelling at him, not Mom? Wasn’t he the one Dad had been hitting first? He wasn’t sure what he had done wrong, but it had been his fault, and now…
He hadn’t been able to look away. He watched, at first astonished to see his sweet mother raging like that. He had never heard her raise her voice or use those words before. He couldn’t understand most of what she said, but in later years, he would come to realize that his tiny mother had attacked a man twice her size to save the life of her only child.
She wasn’t raging now. Dad had been just as surprised by her actions, but the surprise was quickly replaced by fury. The crack of a flat hand striking flesh hadn’t been so bad, even blended in with the thunder, but when Dad’s hands became fists…there was such a powerful, frightening difference between the snap of wood when she fell across the coffee table and the sickening crunch of bone breaking. She cried at first, screamed even, begging Dad to stop, but now she barely groaned.
Dad was breathing harshly, staring down at what he had done, at the broken remnants of room and woman. After a few moments, he unclenched his bloodied fists and wiped one big hand across his face. Johnny waited, but Dad seemed to have forgotten he was there. He watched, but all Dad did was stomp up the stairs. Johnny winced when he heard a door slam, then he scrambled out of hiding.
Mom didn’t look like she was breathing. Johnny crept closer. The smell of blood was strong. She lay sprawled across the carpet, one arm draped over her head. Her blond hair was stained red by the growing pool of blood.
Johnny touched her shoulder with a hesitant hand. She was warm, but she still wasn’t moving. Was she dead?
Then she gave a small, soft gasp. It was a wet, unhealthy sound, like even taking so small a breath hurt her.
“Mom?” he asked in a tiny whisper.
“Johnny.” It was barely more than an exhalation.
“Are you okay?” He snuggled close to her, needing comfort and reassurance.
She moved slowly, raising her broken arm from her battered face. Her blackened eyes were badly swollen, but they opened a crack, revealing the dark-blue eyes identical to his own. Her hand curved, cupped the side of his face as she always did. He pressed his hand against hers, needing that touch, despite the fact that it wasn’t remotely reassuring. Her hand was cold and her arm trembled with effort.
“Mommy? What can I do?” Tears filled his eyes. He wanted to be brave for her but he couldn’t keep the quaver out of his voice.
“Don’t…” Her eyes fluttered shut, then she drew another painful breath and they opened again. “Don’t let him…hurt you. Remember…what I taught you.”
“I will, Mommy.” His lips trembled but he fought back the tears.
“I love you.” Her breath was coming in labored gasps.
“I love you too.” The tears spilled over, hot against his cheeks, imparting transient warmth to her hand.
“Sorry I…couldn’t…protect you.”
“You did protect me.” He clutched her hand against his cheek when it started to fall away. Her arm had gone limp. “Mommy? Wake up.”
Blood bubbled form between her lips. He waited for the next breath, but it didn’t come.
“Wake up, Mommy.” Heedless of the blood, he snuggled closer, pressing his face into her neck, anxious to feel her arms around him. She didn’t move, and he began to sob in earnest.
After a few moments, he heard his father’s voice. “Get the hell up and stop that bawling, boy.”
For the first time he could remember, Johnny didn’t immediately obey. Instead, he clung more tightly to his mother’s body. He could feel a pulpy give where her ribs had been broken and his tears dried up as anger filled him. His father had done this.
“I said move it!” Dad gave him a boot in the ribs, hard enough to drive the breath from his body.
Johnny pried himself away from the cooling body. He was angry, but if he didn’t listen he’d be feeling Dad’s fists too and Mom didn’t want that. SHe wanted him to be safe and she had been teaching him how to handle Dad’s rages. The first step was control, so although he wanted to pound his own fists into Dad’s body for what he had done, Johnny mastered his rage and stood up, keeping his head down. Dad would see his anger as a sign of defiance and hit him, so Johnny walked quietly where he was told. He waited by the door while Dad rolled Mom’s body into a tarp.
“Get the door.” Dad grunted as he heaved the neatly wrapped bundle into his arms.
Johnny obeyed. As Dad walked past, Johnny could see the car waiting in the driveway, trunk open. He wrapped his arms around himself and followed in his father’s wake, wincing as the trunk slammed. Though he knew that MOm was past caring, he hated the thought of her lying alone in the cold, dark trunk.
THere was nothing he could do for her except survive. He didn’t want to be anywhere near his father, but he knew what was expected of him. He climbed into the back seat and stared daggers into the back of his father’s head.
THe rain let up gradually as they came out from under the storm cloud. Dad still hadn’t spoken, and Johnny wasn’t sure if Dad meant to kill him, too. Don’t let him hurt you, Mom had said. He needed to survive, he didn’t want to disappoint her. Surely Dad would stop somewhere and then he could run away. Far away, so far that Dad would never find him.
After the back of Dad’s head won the staring contest and contemplating the car’s interior lost its appeal, Johnny turned toward the window to study the stars. They blurred as the tears started again. His mother was gone. His father had done this.
But he only allowed himself to cry silently. If Dad heard him crying…
Eventually, the motion of the car and his crushing sense of loss lulled Johnny to sleep.
He woke when the car stopped. Blinking at his surroundings, he struggled to make sense of the world around him.
“You’ll keep your mouth shut, boy.” Dad’s voice came from the front seat and Dad twisted around to stare at him. “You hear me? If you ruin this for me, I swear I’ll kill you.”
Johnny shrank back into his seat and nodded. Looking out the windshield, he could see they were by the side of the road, with another car not far in front of them. A woman stood beside the car.
Dad climbed out of the car and walked over to her.
Johnny wrapped his arms around his middle, fighting the urge to scream a warning. Something about the way Dad moved made Johnny think that the woman was in terrible danger. So despite the cool weather, Johnny rolled the window down so he could hear what was being said.
“Thank you for stopping.” The woman’s voice was uncertain and her face was filled with fear. Dad was a very large man, an intimidating physical presence.
“No problem. I’m just on my way to Peoria with my son.” Dad gestured toward the car.
The woman looked at Johnny and smiled. She was young and pretty, a blonde with a passing resemblance to Mom. “Oh, you have a little boy. He’s adorable.”
“My pride and joy,” Dad said in a tone Johnny had only heard when strangers were around. “Is there something wrong with your car?”
Her smile turned sheepish. “Yeah, I was on the way home when I felt a pop and it started to smoke. I had to pull over. Do you know anything about cars?”
“Not really, but I can drive you somewhere where you can call for help. Your car ought to be okay as long as you lock it.” Dad took a half-step back toward the car.
Johnny frowned. Dad worked on their car all the time, he said it was cheaper than those price-gouging mechanics.
The woman closed the distance between herself and Dad, and walked toward the car with him. Johnny quickly rolled up the window so Dad wouldn’t know he’d been eavesdropping. When the woman got into the passenger seat, she turned so she could smile at Johnny.
“Hi,” she said to Johnny in a bright voice. “Your dad is giving me a ride. I’m so glad the two of you showed up. I’d been afraid some creep would pull over.”
“Hi,” Johnny mumbled, looking away. He thought of Mom’s body in the trunk and the disconcerting gleam in Dad’s eyes when he threatened Johnny’s life. Something was very wrong here.
“Oh, is he shy?” The woman turned her attention to Dad, settling into the driver’s seat.
“Yeah, he’s a quiet kid.” Dad reached back and tousled Johnny’s hair with a rough hand. The warning was clear.
“I’m Laurie Anderson.”
“John Winslow. That’s my son John Jr., my wife and I call him Johnny.”
How dare he mention Mom?
“How sweet. He looks just like you.”
Johnny turned his head to look out the window, hating how right she was. Except for the midnight-blue eyes, he was a perfect miniature of his father.
They pulled back onto the road. Johnny looked out the window; there were no signs to say how far to the nearest exit. They were in the middle of nowhere.
“How old is Johnny?” Laurie asked.
“Nine.”
“He’s so small, I would’ve thought he was younger than that.”
Dad shrugged. “My wife’s a little woman. He may take after her more. It’s hard to tell, he’s still young. He could hit a growth spurt when he reaches puberty.”
“Kids are like that,” Laurie said with a laugh. “I know my own little one grows so fast.”
She’s a mother? Run run run… Johnny squeezed his eyes shut, fighting tears.
“You look too young to have a kid.” There was a hint of disapproval in Dad’s tone.
Laurie’s laugh was light and easy. “Yeah, I’m young. But so’s my baby, you know? She’s only four months old, but she gained weight soooo fast. I’m sure your boy will grow into a big strapping man like you.”
Dad said nothing for a moment. “Where’s your baby now?”
“With my mom. I just ran to the store for more formula.” Laurie’s sweet voice reminded Johnny of Mom.
It’s not too late. Jump out of the car, now, Johnny begged her silently. But of course, Laurie couldn’t hear him and Johnny didn’t dare say anything to warn her.
Dad and Laurie chatted about her baby and about Johnny’s baby days for many minutes while Johnny cowered in his seat, certain that something bad was going to happen but unable to put a name to his fears.
“Damn,” Dad said eventually. “We’re miles from anywhere and I have to pee. I’ll have to pull over. You don’t mind keeping an eye on Johnny, do you?”
Laurie smiled. “Not at all.”
Dad pulled the car off the road and cut the engine. “There’s a cooler in the trunk. Would you like anything to drink while we’re stopped? I’m sorry, I should have offered it to you before…”
“Sure, I’d love a water or a soda, whatever you have is fine.”
Johnny squeezed his eyes shut. There was nothing in the trunk except Dad’s tools and what was left of Mom. What was Dad up to? Johnny was alternately hot and cold as he struggled with himself. He should tell Laurie to be on her guard, but what could she do against such a physically powerful man if Dad decided to hurt her? Besides, what could he say except that he had a bad feeling?
Dad popped the trunk and got out of the car. He rummaged in the trunk for a moment before he came around to the passenger side and opened Laurie’s door. She looked up at him in confusion, then squealed when he jerked her out of the car.
“What are you doing?” she cried.
“Taking what I want.” Dad said in that cold, terrible voice.
Johnny cowered and covered his ears with his hands, his eyes screwed shut. Having witnessed what his father was willing to do to a helpless woman, he was absolutely certain he did not want to see whatever was coming.
Laurie screamed, loud and piercing. Then came the crack of a hand striking flesh and the sound of tearing fabric. The unmistakable sounds of a struggle, followed by the sound of her crying. Dad was grunting rhythmically, a rough counterpoint to her tears. Johnny kept his eyes shut.
It seemed to go on forever, until finally Dad let out a low groan. Had she managed to hurt him? Johnny opened his eyes.
He couldn’t see Laurie or his father in the darkness. Then, through the still-open passenger-side door, Johnny caught sight of feet. Laurie and Dad were lying together in the ditch and Dad was on top of her. As Johnny watched, Dad reared up. There was a terrible look on his face, a mixture of rage and dark glee, and there was a knife in his hands.
Laurie screamed again, a raw noise of terror unlike anything Johnny had ever heard. “No, please!”
Then Dad’s arm came down with an awful meaty sound--
--she screamed--
--and screamed--
--and screamed--
The arm came down again and again, light from the car’s interior reflecting off the bloody blade in Dad’s hand.
The screams faded to a wet gurgle and for a few terrible moments, there was silence.
Johnny realized he was shaking. He stared at Laurie’s motionless feet, paralyzed, as Dad’s feet rolled out of view. When Dad stood, his face was dreamy and speckled with red. He closed the car door and went around to the trunk, which he also closed. Dad climbed back into the car, minus both knife and shirt.
“That was a unique experience,” Dad said in a soft, wondering voice.
Johnny pressed himself against the car door and hid his face from the man he knew to be a monster.
“It’ll be a while before anyone finds her. Who would even know where to look?”
Johnny knew Dad was not talking to him. Not with that tone. Dad always addressed him as if he was an unwelcome obstacle, a problem to be dealt with. Since Dad couldn’t see him while driving, Johnny dared to put his fingers in his ears.
Dad continued to talk, reliving the experience out loud. But with his fingers in his ears, Johnny could only understand the distant mumble of his father’s voice, not the actual words. He had seen enough, he didn’t need to hear how thrilled Dad was by killing her.
Laurie Anderson. That had been her name. He wouldn’t forget. He was certain he would never forget her screaming, either.
Johnny fell asleep with his fingers in his ears. He dreamed of blood and screaming and woke with tears running down his face.
After a few moments of terror and confusion, he was able to orient himself. The car was parked in the driveway again, but there was something different about the house. Lights were on downstairs, but this light was orange. It seemed to flicker, and in its glow, he could see wisps of smoke.
Fire! How many times had he sat near the fireplace with Mom, staring into the flames while she read to him? Johnny leapt out of the car and bolted inside. He didn’t care one way or another about his father, but he had to save something of his mother’s from the flames. Anything he could grab to remember her by.
Dad was in the living room, heading for the front door when Johnny burst into the house. Dad yelled at him to get out, but Johnny dodged him and ran upstairs.
He knew smoke traveled upward and smoke could kill him before the flames even touched him. He kept low to the ground and ran into his room. Coughing, he dumped his backpack on the bed and stuffed a few things inside. A change of clothes, photo album, a few gifts from his mother…Mom’s things! A few treasured items, he couldn’t leave them behind. He rummaged through his parents’s bedroom and bolted down the stairs, crashing into the wall to keep from stepping on what was laying on the landing.
He must have missed her when he flew up the stairs. Dad had dumped Mom’s body at the foot of the stairs, sprawled as if she had fallen.
Johnny barely paused to think. Mom was wearing two rings, her wedding ring on one hand and a family heirloom on the other. Both were valuable, so Dad must have left them behind for a reason. Johnny tugged them off and put them in his pocket. Maybe he could use them for money.
The fire was spreading from the fireplace as if by accident, but it was moving fast. Johnny hesitated, then ran through the flames, snatching up Mom’s favorite books as he went past. There wasn’t much more he could carry, but if he was to get away from his father, he would need food. He grabbed a few things at random and ran out the back door.
Now only a six-foot fence stood between him and freedom. Johnny scaled the side like a monkey, tossed his backpack over the top, and jumped down the other side. He hit the ground hard and rolled, his feet stinging. From there, he was able to run far and fast, through unkempt grounds around the cul-de-sac and into the scrubland beyond. Only when he was safe under the cover of brush and darkness did he stop to rest.
His lungs were burning. He hadn’t grabbed anything to drink because liquid was heavy. He coughed and began to drip rainwater from grasses and leaves into his mouth. It was cold and soothed his seared throat. He took sips from the greenery as flames engulfed his home.
Firefighters arrived before the fire spread to the second floor. Johnny watched them for many minutes, then realized they might go looking for survivors. He didn’t want to be found. MOving low, he crept deeper into the undeveloped land, dragging his backpack behind himself, until he figured he was far enough away from the house that he would be lost in the darkness. Then he stood and slung the pack over his shoulders. Without a backward glance, he walked off into the night.
The dark, lonely world was a scary place for a nine-year-old boy, but nowhere near as frightening as the world he was trying to escape. Johnny was morose, exhausted and directionless, with only one destination in mind: away. He walked until he stumbled across an abandoned vehicle. It was rusty, but unlocked and dry on the inside.
Johnny wrinkled his nose at the musty smell inside the old truck, but the bench seat was long enough for him to stretch out. He shut the door firmly behind himself and pulled his blankie out of his backpack. Mom had made it for him when he was a baby.
Tears started again. He burrowed his face into the blankie. The familiar softness was comforting, though the smell was tainted by the acrid tang of smoke. Before long, he was asleep.
Dawn woke him a few hours later. He sat up, disoriented. Why was he inside an unfamiliar vehicle, smelling of smoke? Why did his chest ache, and where…?
Where was his mother?
He curled up on himself as memory returned. Mom’s face, broken and bleeding. Laurie Anderson screaming. Darkness and death. Then fire, consuming his home, devouring what was left of Mom.
His father had done this.
Johnny sat up and clutched his head, forcing himself to take deep, even breaths. Control was everything. Mom had taught him that. Stay in control. You may not be able to control what’s happening to you, you may not be able to control other people, but you could always control yourself. Sometimes it was the only power you had.
So he buried his grief and his fear.
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