17 Months.

 

Gentle Neighbors, 

My kids last went to full time school 17 months ago this Tuesday. We've piecemealed care from friends, neighbors, babysitters, older siblings, grandparents and other relatives over Zoom, harried daycare workers risking death and disability to stay open, TV watched on school-issued computers, letting them climb on us and destroy the house while we work, bringing them to work, etc. At one point I briefly left the cat in charge while I visited a very depressed friend. He's an impressive cat. 

I (like many parents) have responded by feeling angry, exhausted, proud, guilty, ill, hopeless, grateful, depressed, manic, faint, endlessly stressed, and just about every other feeling. 17 months of pandemic parenting seems a lifetime, and my rapidly graying beard shows it. Many parents and caregivers around here have had it far worse. I have a loving reliable co-parent, have the funds to pay for care when I need it, work in a place where I and my kids can be outdoors, have reliable vehicles, have supportive neighbors and friends, speak English, have fast internet, didn't catch COVID, and have healthy kids. I have trouble imagining how the many parents lacking any of these blessings have made it through these last 17 months. 

So what I want with all of this is to thank, and congratulate, and commiserate with, and hopefully to comfort the parents and caregivers who have made it this far. If you've made it through this in one piece, or even two or three, and have not attempted to murder anyone, you are an impressive and resilient human being. You deserve plaudits, and a raise, and less expensive housing, and a place where you can send your kids for several hours five days a week for free where dedicated professionals with advanced training and accreditation will teach them and feed them and provide them with a social life. 

Schools will be open in six days, twenty hours and (for my kids' school anyway) two minutes. You have overcome an extraordinary trial, challenge, stress. Whatever comes after this, you are stronger than it. Nice work. 

Gratefully, 

Dr. Dan Levitis

Violence is not entertaining.

 

Squirrels non-violently entertaining children at a campground

I am not entertained by violence. Not violence in TV shows or movies, not violence in games. Not in books or songs. I reject superhero violence, cartoon violence, dinosaur violence, monster violence, and spaceship violence. I will not look at vehicular, gun, sword, magic, or fist violence. Not sports that formalize or simulate violence. Not historical, sexual, or emotional violence. The threat of violence, the tools of violence, aptitude for violence, and the glorification of violence are unwelcome. My kids found superhero comic books at the library and I will not support the reading of them. Chess is the most violent thing I will entertain, and even there I would enjoy it more if there was less association with war. My feelings about this have only strengthened with age and events.

Feeling this way about violence is one reason I do not watch TV or movies, do not watch sports, and avidly avoid American Popular Culture, which makes allowance for those who are offended by sexuality but offers few refuges to those who are offended by violence. Facebook for example insists on showing me ads for horror movies, action movies, police movies, etc. That anyone can fail to be entertained by violence is not allowed for in any algorithm.  

I understand this focus on violence in popular entertainment in commercial terms, in anthropological terms, in sociological terms, in evolutionary psychology terms, but it feels alien and harmful.

Harmful in that it crowds out other ways for characters to interact with the world. Harmful in that it perpetuates toxically-masculine depictions of what a leader is, what an athlete is, what a conversation is. Just as much pornography teaches unhealthy lessons to young people about sexuality, violent entertainment teaches them unhealthy lessons about communication, empathy, politics, and conflict. I would not ban either, but see the same avenues of harm in both.

And it feels alien, not in the not-from-around-here way, but in the "I am unlike all these people" way. What most members of our culture will pay to see, I find depressing and enervating. The vast majority of fiction in our culture is about people being bad to each other, and I fundamentally do not identify with finding that interesting, relaxing, or desirable. Rejecting people-being-bad-to-each-other entertainment is a position so far outside the norm that even those who know me best tend to chuckle when I state my position. It cuts me off (by choice) from vast domains of human endeavor, foundational cultural touchstones, central shibboleths.

We are products of cultures built around violent entertainment. We print great mythical violence-makers onto diapers and metaphors. We parade children in costumes of characters named after the paramilitaries that brought the Nazis to power. We make aircraft carriers available to film-makers because it helps with recruiting actual sailors. I do not blame anyone for participating in our culture, but this aspect of it I hope will eventually change.


 

Jenner Highlands Bobcat

I took the day fully off today. No work, not even emails. No childcare, not even taxiing them around. Instead, I went for a long hike at Jenner Headlands Preserve, out on the Sonoma Coast, north and west of most places. 

I saw lots of good birds, an embarrassing amount of beautiful scenery, too many flowers and butterflies and such. Badger burrows, deer tracks, etc. But the clear highlight for me was a several minute look at a hunting bobcat.

When I first spotted it, near the top of the Raptor Ridge Trail, above Hawk Hill, beyond the Falcon's Fairway and within sight of Peregrine Point, it was standing still, a few hundred feet from me, silhouetted against the sky. I couldn't tell what it was until I had it in focus and zoomed in.

I braced myself against a fence post and stayed as still and quiet as I could in the whistling wind. It stood quite still for a minute or two, then pounced, paws together on landing, like a Lynx (which is in the same genus) crushing a vole's snow tunnel. 

 

The ground clearly caved in slightly under its paws, but whatever dug the tunnel had escaped. Immediately afterward it turned and gave me such a look, as though I was to blame.

It then spent several minutes slowly sauntering off along the ridge-line toward the trees, pausing occasionally to glower at me.

Bow Hunter's Syndrome Part 3: Wresting diagnosis and treatment from the jaws of modern medicine

The author, probably a horse

Doctors are trained, when faced with an unusual set of symptoms, to diagnose the patient as having an unusual presentation of a common problem, rather than a rare disease presenting in its normal way. As my pediatrician-mother likes to put it, "When you hear hoof beats, don't think of a zebra, it's probably a horse." This advice likely serves many doctors well. That odd looking rash on the baby's bum really is more likely to be an atypical diaper rash than amoebic tushitis.

The problem with this policy is those patient who truly are zebras. We are inevitably mistaken for, and treated as, horses. Before I knew of Bow Hunter's Syndrome, I saw two primary care physicians at the same office about my vertigo-dizziness- tinnitus-faintness-etc. symptoms. The first was sure I was depressed, asked if I had "heard of psychosomatic," and walked out when I insisted I was a zebra. The second, two weeks later, told me I was terribly allergic to my new home and would have to move out of town, closer to the sea, immediately. Shortly thereafter I had my first, and worst, "Bow Hunter's Stroke."

Luckily, none of the doctors at the clinic were free to see me that day, and I was shunted to their nurse practitioner. Nurse-practitioners, unlike M.D.s, have listening skills. I described the whole thing to her, and she immediately saw my stripes. I was no horse. She sent me for an ultrasound of my carotid arteries (to check if the main blood supply to my head was obstructed) which gave me a vital clue. While checking the carotid arteries, the technologist always did the vertebral arteries too. While both looked normal on the ultrasound (which was taken with my head in neutral position) this was my first inkling that a blockage of vertebral arteries was even possible.

I'm not going to describe in detail the extraordinarily stressful process of literature searching, doctor-switching, insurance switching, specialist bouncing, bureaucracy fighting, scans, rescans, etc. In short, I found Rotational Vertebral Artery Compression Syndrome in the literature, was struck by how exactly the case studies approximated me, and spent a year actively working toward official diagnosis and treatment, culminating in a near-fatal but successful surgery. There are several key lessons I learned along the way that I want to share with other putative sufferers of Bow-Hunter's Syndrome:

1. No doctor is going to bother to manage your care, but you have to let them pretend they are going to manage your care. Managing your own care is a full time job you have to do. Keep lists. Call every day to find out if a slot has opened up, remind people of things they already know, catch their errors, force them to communicate with you and each other, advocate for yourself. This difficult process was somewhat ameliorated by the fact that I am a white male with a greying beard. Bring an old white man with you, there are plenty of us around.

2. Bow Hunter's Syndrome can only be definitively diagnosed by comparing blood flow through your vertebral arteries when you head is in a neutral position to when it is in a position that brings on your symptoms. Make sure your doctor is explicit about this need in ordering imaging. Medical technologists are often not willing to take imaging with your head turned. They are trained to do everything in a neutral position, and if you explain why it has to be done with your head turned, they will worry you are going to pass out in their expensive machine or onto their legally-liable floor. Call ahead several days before your x-ray, CT, MRI, whatever, and insist on talking with the technologist to be sure it will be done as ordered. They will tell you they need to consult with the radiologist, who will want to talk to your doctor, who won't be available, etc.

On the day of your scan, if the technologist won't unequivocally confirm that your scan will be done both straight and with your head turned far enough to induce symptoms, you must refuse to get in their machine. Stand there shivering in the buttless gown and calmly insist that they do the scan the way your doctor ordered it. If they tell you their MRI machine doesn't have space for you to turn your head, tell them they have to put on the coil after your head is already turned. If they insist the condition you are describing doesn't exist, whip out a published description. Walk out if you have to. Failing to do this once delayed my care by four months and cost me several thousand dollars because once the scan was done wrong, my insurance wouldn't approve the same scan again. I had to change to more expensive insurance and doctors, start the process from scratch, and learn to insist.

3. The ultimate confirmation of Bow-Hunter's Syndrome comes from fluoroscopic angiography with arterial catheterization. This means they take video of x-ray dye moving through your vertebral arteries, with your head in various positions. The dye is delivered through a small tube that is inserted through an incision into your thigh and wormed up as far as the back of your brain. I found the moments when they were squirting dye into my brain to be the most painful of the entire experience, despite the sedation and pain killers. However after this procedure no one questioned my self-diagnosis.

4. The most common surgery for Bow Hunter's Syndrome is called decompression. This means they made more space around one of my vertebral arteries (one unobstructed vertebral artery is generally enough to keep your brain stem ticking) by removing a piece of the bone that wraps around it on the side of my first cervical vertebra. Such decompressions are done for a variety of syndromes that are more common than Bow Hunter's Syndrome, and it is this fact that very nearly killed me.

Surgeons are very busy people, and generally make physicians look like excellent listeners. My surgeon performs a fair number of decompressions, but mine was his first for Bow Hunter's Syndrome. His protocol for this surgery starts with having another surgeon carve a path to the bone. Then he takes over and turns the patient's head for a clearer view of his work grinding away bone without damaging other important bits. You know, and I know, and he knew, that turning my head cut off the blood supply to my brainstem. He did it anyway. That was the next step in his protocol, he had not had time to think this through, and I had failed to manage my own care on this point. Several minutes later, when they checked, no blood was flowing through my vertebral arteries. He guessed it was measurement error, and had another machine sent. Still no blood flow. They righted my head, glued me up in a hurry, and went to scare the life out of my poor wife. Luckily, they frappéd jargon with indirectness and she didn't understand what had happened until after it was clear that I hadn't been killed. My brain stem responded well to the return of blood and I was out of the hospital the next morning. Recovery to the point of feeling better than before surgery took me about three months.

5. Finally, as this is now long, they insisted I would need opioids after my spine surgery. I did not. Accept them if you need to, don't assume that you will need to.

I'm happy to be your support group of one if you're wondering if this diagnosis is yours. I'm a Ph.D. though, not an M.D., so be aware that I can only offer one zebra's perspective.

Bow Hunter's Syndrome Part 2: What, with a dab of why

Bow Hunter's Syndrome is named for people who shoot arrows at wildlife. In order to do so, they have to turn their heads hard to one side and hold that position until they are ready to shoot. Attempting this with Bow Hunter's Syndrome lands them in the emergency room, and sometimes gets the actual attention of a doctor, who will occasionally figure out what is going on, possibly provide treatment, and if they've gone to that much bother, almost certainly publish a report mentioning said venery.

That case study might refer to this condition as Rotational Vertebral Artery Compression Syndrome. The vertebral arteries are the main blood supply to the brain stem, one of those body parts humans can't do without, not even for a few seconds. There is one vertebral artery on each side of your spine, running up through tunnels in your cervical vertebrae, the spine bones in your neck. When a healthy person moves their head, each artery has enough space to wiggle in these tunnel, so that it doesn't get compressed, kinked, stretched, or otherwise lose flow. Rotational Vertebral Artery Compression Syndrome means that rotating your head pinches your vertebral arteries, usually at the joint between the two uppermost vertebrae, reducing or eliminating flow of blood to your brain stem. The various other names this condition goes by mostly include the word "insufficiency" referring to the shortage of oxygen in your brain stem, which is what causes the actual symptoms.

About those symptoms: tinnitus (a buzzing sometimes in both ears, sometimes just in my left), vertigo, dizziness, mental fatigue, and faintness, increased gradually over several years during which I did not notice that head position had anything to do with it. I would consistently feel dizzy while shopping in the grocery store, not noticing any connection to turning my head from side to side trying to find unsweetened pickles. Long after others had recovered from some cold, I would have lingering vertigo and a sense of mental fog. I gave up my habit of sleeping on my belly, which allowed me to fall asleep very quickly, but from which I eventually decided I was waking feeling tired and unwell. My first autumn in Wisconsin I wondered if I was wrapping my scarf too tight because I would start to feel like I was going to faint every time I tried to back my car out of the driveway. Attempts to discuss all of this with doctors were frequent but unproductive.

The symptoms became debilitating only after an accidental blow to the top of my spine that winter. I was diagnosed with a concussion, and because most of the symptoms of Bow Hunter's Syndrome are consistent with a concussion, I looked no further. Most of a year later, having recovered only slightly, I was a passenger in my moving van (on the way to California) when it turned over on the highway, flexing my neck too far forward. After that, the observation that the position of my neck had both immediate and lingering effects on my symptoms became unavoidable.

The blaring clue to my addled brain came from my new neighbors' fig tree. Having permission to pick, I was straining to reach a fig well above my head. I looked up, turned my head to the side, stretched my arm, and collapsed. My eyeballs were shaking, my vision went black, and the tinnitus became unimaginably loud, louder than the human ear could withstand if real sound was involved. I was breathing, but felt the urgent need to come up for air. I brought my head back to neutral and the screeching tsunami gradually receded, light started to return, the spinning slowed. I had survived my first "Bow Hunter's Stroke." I put that phrase in quotes because unlike a real stroke, no tissue damage showed on scans afterwards. My brain stem hadn't lost living tissue, just power. The medical jargon for such an event is a transient ischemic attack. My doctors were no more than puzzled.

In the fifteen months since then, I went through thousands of abstracts, scores of full scientific papers, two insurance companies, four primary care providers,  three neurologists and a wide variety of other specialists, countless imaging studies, three interventions including a poorly planned major surgery that nearly killed me right there on the table, and months of recovery before I could considered myself past Bow Hunter's Syndrome. All worth it. I'll dig around in the key pieces of that in Bow Hunter's Syndrome Part 3: Wresting diagnosis and treatment from the jaws of modern medicine.

Bow Hunter's Syndrome Part 1: A Survivors' Support Group of One

My doctor looked like I had just puked in his shoes, but eventually took the papers I was holding out to him. This was a better response than I had expected, but still I could tell he would not look at them. I switched doctors, and with the next one emailed him the papers after our appointment. He wrote the referral I needed but declined to see me for months thereafter, going so far as to change an in-person appointment for a possible broken wrist to a phone appointment, after I was already in his parking lot.

The only thing a doctor likes less than a patient walking in with an obscure self-diagnosis they found on the internet is when the patient brings the medical literature about that diagnosis for the doctor to read. I knew this, but also that my doctors had not heard of Rotational Vertebral Artery Compression Syndrome, and that I needed treatment for it. Adding insult to injury, my obscure self-diagnosis would eventually be unquestionably confirmed and successfully treated.

This same condition goes by multiple names in the medical literature including Rotational Vertebral Artery Compression Syndrome, Positional VertebrobasilarIschemia, Positional Vertebrobasilar Insufficiency, and Bow Hunter's Syndrome. This last name is the least descriptive, but also the shortest and least jargony, so I tend to use it.

Bow Hunter's Syndrome is quite rarely diagnosed. There are perhaps a few hundred cases documented in the medical literature, total, globally. This could mean that it is a rarely occurring condition, but given the lengths I had to go to get it diagnosed, the severity of those cases that are documented, and the peculiar circumstances that allowed me to reach diagnosis, I suspect rather that it is an only slight uncommon condition which generally goes undiagnosed. As a neurological condition not caused by any neurological defect, Bow Hunter's Syndrome tends to fall through the cracks.

I was able to diagnose my own case because I have a Ph.D. in biology, loquacious physicians as parents, and extensive experience finding obscure scientific literature outside my field of expertise. I knew I had something, as most patients do, but I also knew how to search the scientific literature for conditions associated with terms like "cervical vertigo," "rotational stenosis," "positional tinnitus," and "nystagmus,"  then skim through the results, read those papers that seemed most relevant, follow citations back and forth, improve my search terms, and so on to a diagnosis. What I had to figure out was how to then navigate Earth's most wasteful medical system (USA! USA!) to arrive at an official diagnosis and ultimately treatment, and I had to do all of this while suffering the symptoms of Bow Hunter's Syndrome (including vertigo, ringing in my ears, dizziness, intermittently blurred vision, and faintness).

The good news is that I am largely recovered from it, and from the surgery that resolved it.

The bad news is that I will be posting here a series of short essays with the hope of making this process slightly easier for other sufferers of Bow Hunter's Syndrome, a purpose which I do hereby gleefully acknowledge will horrify all medical professionals that happen upon this. There are, so far as I can tell, no popular accounts, no support groups, no blog posts written for the uninitiated, describing what Bow Hunter's Syndrome is, what it feels like, how to approach being a patient with it. Perhaps soon more patients will be wobbling into their doctors' offices mumbling about the blood supply to their brain stem and a condition the doctor has never heard of. One can hope.

Next: Bow Hunter's Syndrome Part 2: What, with a dab of why

Then: Bow Hunter's Syndrome Part 3: Wresting diagnosis and treatment from the jaws of modern medicine

Condor games

In elementary school they made boys play my least-favorite-except-dodgeball game. It consisted of everyone chasing after whoever had the ball, trying to mug them so that everyone could then violate the new ball-carrier. I was mortified by the aggression of it more than afraid of the assaults, as I made only transparently symbolic attempts to even catch the riot.

Over a decade later (December 2011) on a California mountain, I stepped out of a US government SUV to watch the world's largest flock of North America's biggest land birds playing this same game. The US Fish and Wildlife Service releases captive bred California Condors at Hopper Mountain Wildlife Refuge. Huge, ugly, smelly, fascinating, beautiful, precious birds, they are highly endangered and carefully managed. I was an intern on the Condor Recovery Program, and first thing every morning my assignment was to make sure we knew where they were. This morning I found them up Hopper Mountain with a Coke can. Condors, carrion eaters, are drawn to red, and prone to swallowing (and dying from) garbage. The Refuge is closed to the public, but trucks heading to oil wells in the mountains have to pass though, and we often found litter along those roads.

I radioed Mike Stockton, the flamboyant hippy cowboy biologist in charge. "Morning Mike, I'm looking at the whole flock standing on the road. They found a Coke can, and they all want it."

"You'd better just take it," was his only reply. "Roger that," I said, girding up.

This particular crumbling road, like many of those on the Refuge, had steep slopes up and down on either side. The condors, each four feet tall and armed with a beak that could disembowel a mastodon, were gathered at a bend in the road, a peninsula that ended in a cliff. Condors are too heavy to fly with anything in their beaks or feet, so R7, the dominant male, was cornered. Normally the whole flock was scared of him, but now his armament was full of Coke can. Several other condors charged him. He dropped it, jumped off, spread his ten foot wings and lifted skyward. He flew so close over my head I could almost taste his foulness, and could feel the heavy flapping of his wings. While I concentrated for a moment on not wetting myself, another condor grabbed the can and ran straight toward me. Fifteen birds, each incredibly important for this species' survival, each reeking of carrion and looking every bit like carnivorous dinosaur zombies prone to projectile vomiting, came running after the can and thereby towards me.

I took a step towards them and they stopped. I took a few more steps, and the lead bird, the one with the can, turned, ran right through the thicket of snapping beaks, and was back at the cliff's end, surrounded. I continued slowly forward.  A few more steps forward and most of the condors had jumped. Two more steps, the air filled with giant birds and their aroma, and it was just me and the condor with the can, still on the cliff's edge.

He hissed and flushed his face purple, trying to scare me off. "Boo!," I replied in kind, and he fled. Lunging after the can, I lay on my belly and examined my prize, a beat-up Coke can with one beak-tip-shaped bite snipped from its middle. I got to my feet, realizing I was now the one surrounded at cliff's end. I stuffed the can inside my jacket and tried to look fierce. We all stood there for a while. One condor after another stepped off the edge and floated into the morning sky. I finally won that god-awful game.

Mountain Lion

Sugarloaf Ridge State Park, Sonoma County, CA

Sept 28, 2018 

Hiking a bit over six miles this morning I saw no other human on the trails save an AT&T worker in his truck. It was foggy and cool (in the 50s when I set out about 8:40, but clear on the hilltops and ridges I was walking on by 10:00). There was no notable wind, and the forest was largely quiet except for jays disputing territories and a weed-wacker buzzing in the valley below.

At 11:21 AM, walking east along the Grey Pine Trail roughly .3 miles from Bald Mountain, I came around a bend in the trail and simultaneously heard two loud noises from a low pile of logs and brush on the left (north) side of the trail about 40-50 feet from me. These were crashing and a scream, both from the same animal. The scream was a deep loud snarl or growl that instantly struck me as feline and made my heart jump in my chest. The crashing was that of a large animal emerging from the pile and plunging downhill into brush. I saw only the rear end of the animal (and for only an instant). It struck me as quite large (roughly the size and height of a large German Shepard's) with a long thickly furred tail. In the full mid-day sun, during the single bound that took it from the wood pile and into the thick vegetation, the fur on its rear looked rufous, almost brick red, while what I saw of the tail was black. After it disappeared into the brush (which just there looked like it had not been burned last year) I heard crashing moving down the northward slope for only a few seconds. It moved quite fast. I looked in the loosely organized wood pile but could not see any kill, den, fur, scat, etc. Listening, I could hear nothing else of it, but did hear a woman’s voice in the distance, back towards Bald Mt. On the road there were numerous deer tracks, tire tracks, and shoe tracks, but nothing else I could locate.

Without having ever seen a wild big cat before (I've seen plenty of bobcats, but they don't count as BIG) I can't be sure this was a mountain lion, but I can't think of anything else it could have been, and lions are relatively common on these mountains.

After

The hills will look lifeless when you return, the char infinitely deep, like death on a cracker but the cracker has burned and so has the plate. But before the ravens, getting soot on their jet, remove the last body of evidence of life that was, the hills' funerary garb will be sullied, pimpled, with brown. The refugees are returning from the underworld. Gophers, their digging fanatical, already are turning the ash down into the soil that insulated them, churning the living earth to the surface, and making withdrawals from the seed bank. All the dungeon dwellers of their domain, moles and voles, snakes and salamanders, beetles and bugs, are filing out of Hades' unguarded gates, hunting water, and each other. Plants whose ancestors have persisted through every fire for ages are doing it again, resurrecting themselves according to each family's tradition. Deer who fled to the valley are hoofing it back to the unburned patches, nibbling everything that isn't too crispy, and trying to catch the scent of mountain lion through the dissipating olfactory roar of fire. Seeds will ride up the hill on pelts, and wind, and in cheek-pouches and colons, joining the feast of uncontested soil and light. Ashen mountain mourning garb will give way to a new morning's green and the united kingdom of death to rebellious, fractious life. As surely as the gophers make the soil boil in slow motion, the forest will return, and forget, and repeat its mistakes.

Current sea surface temperatures

Seeing this, it seems somehow unsurprising that we got three simultaneous Atlantic Hurricanes, including two that repeatedly made landfall as Major hurricanes. That many millions of square miles of high-energy water are not natural, and not good news.

Meiosis kills! (Now in print, and video)

Scientists are rarely dispassionate about their research. Why spend years trying to figure out the fine details of something you have no interest in? Before my wife and I lost two pregnancies, I had thought abstractly about the question of why developmental failure is so common across plants and animals, but it wasn't personal. I was interested in the fact that dying before reproductive age means an individual does not get to pass on whatever traits caused it to die. In other words, natural selection should quickly remove any heritable trait that commonly causes developmental failure. At the same time, pretty much any organism loses some of its offspring, implying some broad based mechanism WAS commonly causing developmental failure. I even went so far as to publish a review article focusing on what this mechanism might be.

But once developmental failure became personal, I wasn't just interested, I needed to know.  

The result of that impulse was just published by Proceedings B, one of my favorite scientific journals. 

In addition, I worked with Sarah Friedrich, the extremely talented Graphics Specialist in my department, to make this video explaining the science in public-friendly ways:

I, lichen.

This fungal individual makes lots of complex structures, on which microbes live. So do you.

A lichen is an ecosystem. It consists of a multicellular fungus that provides the gross structure of the lichen, and a community of microbes that live in and on that structure, including photosynthesizers.

A human is an ecosystem. It consists of a multicellular animal that that provides the gross structure of the human, and a community of microbes that live in and on that structure. A human, unlike a lichen, generally cannot photosynthesize. 

We usually see humans as individuals, but lichens as ecosystems. In the last few years some scientists have advocating deep thought about humans as ecosystems. There has been very little deep thought about lichens as individuals.

Me as a peer reviwer

I find it painful to read a very critical peer review, even if it clearly intended to be constructive. This is somehow especially true when I am the reviewer. That I've just written a rejection-worthy critical review, and seem to do so fairly often (always accompanied by specific suggestions for improvements) is part of my job, but not one I relish.

My brother and the failure of TrumpCare

Why, please ask yourself, do the Republicans, after years of wishing to replace the Affordable Care Act, have no replacement even they can support? One clear answer is illustrated by my brother, Jason Levitis, an unsung American hero. I've mostly kept quiet about this, because he has, but the cat is out of the bag, Jason is out of government, and the time has come. In his recent article in Vox, his byline reads, "Jason A. Levitis is a senior fellow at the Solomon Center for Health Law and Policy at Yale Law School. He led ACA implementation at the Treasury Department during the Obama administration." That's all true, but Jason was on this long before the ACA was law. He was the single most frequent visitor to the White House throughout the entire Obama administration, and he wasn't there for the tour. I feel safe in saying that no one in the world knows the Affordable Care Act better than my brother, or has thought more deeply about why each part of it functions as it does. When President Trump said, "Nobody knew health care could be so complicated," my response was, "actually, my brother knows exactly how complicated."

I can clearly remember Jason telling me that he was going to reform the U.S. healthcare system in the year 2000. He and I were both recovering from injuries, limping through the newly reopened Hayden Planetarium at the American Museum of Natural History. Both of us, as patients, had been screwed by the healthcare system. Our parents, both physicians, had recently retired early because they just couldn't stand being part of that system anymore. As we crept along, two very similar looking young men on canes, to an evening planetarium show, he explained matter-of-factly that he had decide that the most important thing he could do was fix American Healthcare. This, he explained, would require years of work to understand the system, probably a law degree, the building of connections in the policy world, and an activist White House brave enough to succeed where "HillaryCare" had failed. His younger brother, I had to admit he was talented enough to carry out each step, and still found it improbable.  As we watched billions of years of galactic evolution whiz around us, I wondered how long my always swirling brother could focus on this very long-term plan.

Seventeen years later, he is still following his plan. He built his detailed understanding of the system as a Senior Analyst in the health economics department at the Greater New York Hospital Association. Then he got his law degree at Yale. Then he built connections and expertise in health law at Connecticut Voices for Children. He moved from there to being a Senior Analyst and Counsel at the Center on Budget and Policy Priorities, a DC think tank that is just as wonkish and unflashy as its name implies. He testified before various state legislatures about earned income tax credits and other stuff that I only understand because he explains it well, and I thought his singular focus on health policy had melted. I was wrong. He had become a respected part of DC health policy wonkdom, and with his co-wonks was working up a national policy resembling Massachusetts’s health reforms, aka RomneyCare. By 2008, when Obama ran for president, their framework was far better developed than the final TrumpCare bill that failed today.

President Obama appointed Jason as Senior Advisor to the Assistant Secretary for Tax Policy, Department of the Treasury. In practice, Jason worked day and night, often over 100 hours a week, writing the text of the bill that would come to be known as the Affordable Care Act. He would come to an important family event and would pull out two Blackberries, communicating on both simultaneously with the half dozen other people writing the bill with him. He would go into the bathroom and be arguing with somebody about the wording and punctuation of some sentence that was likely to be challenged in court.  He fought for fine policy details that his training in both law and economics told him would actually help the American people, not just make good TV. He sat next to Obama's people as they testified before Congress, feeding them the details they needed to give full answers. He undertook endless last-minute rewrites to try to meet the demands of that one last wavering Democratic Senator. Once the bill became law, he spent years writing the regulations needed to implement it. He, with a few close colleagues, is the policy brain of the Affordable Care Act.

I tell you all of this not only to praise my brother, although he clearly deserves it. The Affordable Care Act has brought health coverage to millions of Americans, slowed the increase in healthcare costs, spurred needed innovation and raised standards across the American healthcare system, and in the process saved countless lives. My purpose here is not to litigate the merits of the law, but to point out the intellectual rigor at the heart of the Affordable Care Act, and contrast it with the mushy sloganeering and flailing demagoguery that is the Republican approach to health legislation. The entire Republican machine spent years scheming to replace the ACA, made that their mantra, and have utterly failed to find any solution that isn't demonstrably, disastrously worse. There is no Republican reflection of my brother, no Nosaj Sitivel, because one can't take the details and ramifications as seriously as Jason does without rejecting conservative "principles." There is no health policy wonk taken seriously by Republican leaders who saw these problems  two decades ago and resolved, without ideological baggage, to learn how to increase healthcare access and quality. There is no one in the Republican establishment willing to fight for effective policy that is hard to explain and harder to sell. So as many years as they spent railing against Obamacare's imagined failings, and promising to replace it with bottled heaven, they remain incapable of offering any substance. TrumpCare failed because nobody involved in writing it actually cares.

You want to know how to improve on the ACA? Ask my brother. He, of course, has detailed, well researched, carefully considered lists of fixes. Will our current all facade, no building, leaders implement any of that? Of course not, they want the ACA to fail so they can blame Democrats. But with the defeat of the American Health Care Act of 2017, it seems much more likely that government with an honest interest in good policy will be back. Facts matter, logic matters, policy matters, even in politics. And that is reason for hope.