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Ep. 71: The Fox and the Hedgehog

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Ep. 71: The Fox and the Hedgehog


This is HIDDEN BRAIN. I'm Shankar Vedantam. We like stories about leaders who have big ideas, who defy the odds and pursue their goals with messianic purpose. Think of Winston Churchill in World War II or Abraham Lincoln during the Civil War. But what happens when a leader's vision is the wrong one? How do we think about people who dream big only to invite disaster?

At such times, we might prefer a more cautious style, someone who plays the odds. Those leaders might not score historic triumphs, but they rarely cause catastrophes. Thousands of years ago, the Greek poet Archilochus summed up this idea. He said the fox knows many things, but the hedgehog knows one big thing.

PHIL TETLOCK: That parable has been the subject of much debate over the last 2,500 years - what exactly Archilochus meant.

VEDANTAM: This is psychologist Phil Tetlock.

TETLOCK: Various people have offered various interpretations - some people coming out on the side of the hedgehog, saying the hedgehog will trump the fox, and other people saying, no, it really means the fox is going to do better.

VEDANTAM: There are different ways to think about the metaphor, but here's how I see it. If a fox wants dinner, it has many options. It can chase down a hedgehog. It can find something else to eat. It can even go without food for a day. But if you're a hedgehog being chased by a fox, you don't have multiple goals. You have one overarching idea - don't get eaten.


VEDANTAM: Phil Tetlock thinks this metaphor also describes two different cognitive styles among people. Foxes have different strategies for different problems. They're comfortable with nuance. They can live with contradictions. Hedgehogs focus on the big picture. They see every problem through the lens of a single organizing principle.

TETLOCK: The hedgehogs are more the big-idea people, more decisive. In most MBA programs, they'd probably be viewed as better leadership material.

VEDANTAM: This week on HIDDEN BRAIN, we have the story of a hedgehog, a surgeon who changed the world in daring ways. His bold style made him a pioneer in what has today become the transgender movement. It also propelled him to create one of the world's first international medical missions. Like other hedgehogs, this surgeon experienced outsized success until one day, he didn't.

DON LAUB: It's just a goddamned disaster, an awful thing.

VEDANTAM: Greatness and tragedy, this week on HIDDEN BRAIN.


VEDANTAM: Sandy Stone was born in 1936 in the midst of the Great Depression. Her parents gave her a Hebrew name.

SANDY STONE: It was Zelig Ben-Natan (ph).

VEDANTAM: Zelig Ben-Natan - a boy's name. That's because her parents thought she was a boy. But from a very early age, she knew she was a girl. This was a long time ago, decades before the modern trans movement. When Sandy was a child, there were no words, no language to describe what she knew about herself.

STONE: It was lonely. It was disorienting. It was puzzling, confusing, scary. It was all of those things.

VEDANTAM: It stayed like that for Sandy all the way into adulthood. She went to school, became a recording engineer, moved to the Bay Area. All the while, everyone thought she was a man. She kept searching for help. In the San Francisco phone book, she found a promising lead. It was a group for gay men. When she called, they asked if she was gay. She said she wasn't. So they sent her away and told her to try another group. The outfit they recommended surprised Sandy. It was the San Francisco Police Department.

STONE: It turned out that the police department was running a counseling unit of sorts, which they did for the population of transgender people that lived in the San Francisco Tenderloin, which was sort of the down-and-out skid row section of town that tended to collect people who couldn't afford to live anywhere else or who had run out of options.

VEDANTAM: Trans people who ended up in the Tenderloin were at high risk for drug addiction and prostitution. They were social outcasts. When Sandy got in touch with the police to ask for help, the first thing they did was to dissuade her from acting on her feelings.

STONE: And they actually tried to discourage me by taking me on a tour that reminded me of Dante being led down into the lower circles of hell. They really showed me the worst of everything and then said, are you sure you still want to go ahead with what you're thinking of? And to be perfectly honest, I was not quite sure what I was thinking of. I was just trying to collect information. And I think it would be safe to say that that's what we were all doing at that time.

VEDANTAM: Still, the referral to the police turned out to be a stroke of luck. The cops told her that a center at Stanford University had recently started performing what were then called sex change operations.

STONE: They didn't refer me to Stanford as much as talk about it as the great, unattainable goal - the great, beautiful, shining star in the sky.

VEDANTAM: After years of suffering and loneliness and confusion, the Stanford program felt like a beacon. Sandy felt she might finally have a chance to live a more honest, satisfying life. But first, she had to convince the gatekeeper who stood between her and the person she wanted to become. He ran what was then called the gender dysphoria program at Stanford. His name was Don Laub.

The gatekeeper of Stanford's gender dysphoria program was a hedgehog. From a very early age, he had a big-picture idea. He wanted to help people. He wanted to help a lot of people. As a small child, when kids in his school were asked to donate money to a charity, his classmates contributed a dime. Don worked in a vegetable garden an entire summer to raise a whopping $10.

LAUB: Now, I got a letter, a preserved letter from - that my mother wrote to some of her friends saying, Don, he's done something that nobody has ever done.

VEDANTAM: Don's father feared his little boy was consumed with being a do-gooder, that he would turn out to be a failure at business. His father was right. Don Laub became a doctor. When he came to Stanford in the 1960s, he was a young, ambitious plastic surgeon very much in awe of his prize-winning colleagues.

LAUB: Coming to Stanford, I was overshadowed by the hugeness of what people were doing - the importance of it. So I knew that I had to do something, like, maybe - you know, I got to do this somewhere along the line because everybody else here is doing it.

VEDANTAM: Don was looking for a place to make his mark. One day, a colleague walked out of an examination room and came up to him.

LAUB: And said, Don, I want you to see a patient. It's a good case. You might not like it. It's a sex change.

VEDANTAM: Remember, this was 1968.

LAUB: I said, Dave, send that patient away. I'm a Catholic boy from the Midwest, and I'm at Stanford. We don't do those things.

VEDANTAM: But Don's colleague insisted he meet the patient. To be clear, this patient was not Sandy Stone.

LAUB: He said, do me a favor, and go in that room. So I went in the room and talked to the patient. And I said, now, why do you want this sex change? She said, well, I was born, and this is what I should be. I said, well, when did you decide that? She said, I didn't decide it. This is what I was born with from day one.

VEDANTAM: This patient was a pioneer. No one on the West Coast had received what's come to be known today as gender reassignment surgery or gender confirmation surgery. In fact, the surgery had been rarely performed across the whole world. Don was an unlikely choice of doctor. He was, by his own account, a prim man from the Midwest.

But although Don initially blanched at the idea of gender reassignment surgery, he felt a shiver of excitement. He didn't send the patient away. Instead, he went looking for information. He consulted with psychiatrists and the few surgeons around the world who'd already performed this kind of surgery.

What prompted you, this sort of, you know, Catholic doctor from the Midwest, to basically take this on? It seems like an unlikely fit.

LAUB: It was a wonderful opportunity to do a big thing and to help a lot of people.

VEDANTAM: Altruism and ambition were always tightly woven in Don's identity. He wasn't interested in superficial cosmetic work. He wanted to change the world. He decided to take the leap.


VEDANTAM: In November, 1968, Don Laub performed California's first gender reassignment surgery.

LAUB: Yeah, we were more than prepared for all the things that might happen. And the surgery went fine. It took about three and a half hours, and we did it with the skin graft method and no problem.

VEDANTAM: Don soon became one of the world's leading experts on gender reassignment surgery. He started a program. His reputation grew, a reputation for being a good surgeon and a tough gatekeeper. He turned away many people because he felt they weren't good candidates for surgery. Sandy Stone vividly remembers her first appointment with him in the mid-'70s.

STONE: I go in and sit down, and Don is behind his desk. And he's wearing his white coat. And he's very distinguished-looking and calm and very friendly and open. And he says, well, what can I do for you? And I say the first thing that comes into my head, which is I think I'm a woman. Now, the scene we have is Don behind his desk and me - I'm - I have a long black beard and wild black hair. I'm wearing a blue shirt, jeans and engineer's boots. I do not exactly look like I'm thinking of myself as a stereotypical woman.

And Don looks at me and says, really? And I say, what should I do? I mean, I'm totally - I'm completely open to anything. And I really don't know what I should do, what direction I should move in, what's right, what's wrong. And I'm looking to Donald to tell me. And in my memory of the thing, Donald then says, well, the first thing you should do is lose the beard.

VEDANTAM: That was the beginning of Sandy's long transformative journey. It was a tough journey. Don wanted Sandy to be sure she was making the right decision. So before he would even consider surgery, Sandy says he told her she would have to live openly and fully as a woman for one full year. It was a requirement based on the reality of the time. No one, not Sandy nor Don, knew what might come from these surgeries in the long term. These were early days. It was all a bit of an experiment, a shot in the dark.

STONE: It was fraught. It was fraught for everyone. And it was fraught because, at that time, it was not clear. What would happen later? We didn't have very many examples of transgender people who had had surgery who went on to have fulfilling lives and live to tell about it, which is to say came back later and reported back to the program.

VEDANTAM: They were experimenting on the fringe of what both medicine and society thought was acceptable. Don was taking risks with his professional reputation. Sandy was taking risks with her life. There was one moment, Sandy says, when she and Don clashed. The conflict boiled down to their cognitive styles.

STONE: At some point, he asked me if I were 100 percent committed to wanting surgery. And I said, no, I'm not. I'm probably 99.9 percent. I think anyone who is 100 percent committed to anything is probably crazy. You have to have some reservations in life. You have to have an overview of everything that you're doing and have alternative plans if what you're looking for doesn't work out. And Don said, well, in that case, you're not eligible for surgery. You have to be 100 percent committed.

VEDANTAM: It took a mediated session with Don's assistant for the two of them to resolve the conflict. But the incident revealed something about the way a hedgehog moves through the world. Hedgehogs are decisive. Don could not understand anything less than 100 percent commitment, even if the .1 percent of doubt was simply a way to say I'm human, how can I be absolutely sure?

Sandy tells another story of a time she came in for an appointment wearing jeans and a T-shirt. Don asked her why she wasn't dressed like a woman. He'd missed the bell-bottom-jeans-and-tie-dye revolution happening right outside his window. It was the kind of thing that could have led to a fight except for one thing. Sandy understood where Don was coming from. She knew that underneath the tough exterior, he really wanted to help and not just in a medical sense. More than anything Don wanted Sandy to live a life where she didn't feel like an outcast.

STONE: He wanted his people to be totally unremarkable, to just fit in, to be able to live their lives, to be able to be inconspicuous and just get along. And that's a good thing to watch for 99 percent of your waking - day is just to be able to live your life, to be able to live with other people and not rub people the wrong way.

VEDANTAM: Sandy Stone successfully underwent surgery in 1977. When I interviewed Sandy, I told her that her story reminded me of another case that Don told me about.

It's interesting because I - Don first came to my attention because of another case involving cleft lip surgery, and it's so striking that as you're saying this I'm sort of hearing echoes of that other work as well, this drive that he had to just help people to essentially live what he would think of as being a normal life, a life that they're not ostracized and a life that they're not feeling like they're outcasts, that they're functioning, they are - they can get an education if they're a child or they can get a job if they're an adult, that they can be happy. And I feel there's something actually very Midwestern about that idea.

STONE: That's the word. That word you said is correct. Don wanted people to be happy. Don did it professionally. His job was to help people to be happy. And for that, I owe him a lifetime debt. I would not have done anything I think that I did after the 1980s if it weren't for Don Laub - or the '70s rather - if it weren't for Don Laub.

VEDANTAM: Sandy went on to become a prominent writer and theorist and eventually helped found the Academic Discipline of Transgender Studies. When she considers Don's influence on her life, she says it all comes down to the pursuit of a big idea.

STONE: Do you go for the big one or do you accept something less? And many of us accept something less because we don't want to take the risk, and then we may go through life maybe - maybe we'll be happy with our measure or maybe we'll say what if I had gone for what I really wanted? What would that have been like? Maybe I would have died. Yeah, maybe, I would have. But I didn't. I beat the odds, and I went on to be gloriously happy. That's something in life, and Don brought that to many people. I don't see how one could do better than that.

VEDANTAM: Don's leap into the unknown, his willingness to bet his professional reputation on a big idea, his confidence in his own judgment - it had all paid off. The hedgehog had won, but pursuing a big idea with determination doesn't always pay off, and when a hedgehog fails, the fall can be painful. Don Laub knows about that part of the story, too. Stay with us.


VEDANTAM: According to the ancient Greek poet Archilochus, The fox knows many things, but the hedgehog knows one big thing. Psychologist Phil Tetlock says the metaphor describes two kinds of people. Small picture tacticians are foxes. Big picture strategists are hedgehogs. Before Don Laub became a world renowned gender reassignment surgeon, he had another big idea. It started this way. One day, a colleague asked him if he could help with a surgery. The patient was a child from Mexico.

LAUB: This was a 14-year-old boy who had no other deformity than his cleft lip and palate.

VEDANTAM: But because of it, the boy was shunned. A group of priests had driven him north all the way to Stanford to get him help. Don immediately understood that the cleft lip wasn't just a medical problem.

LAUB: He had not gone to school. He had no educational advancement. He had no friends.

VEDANTAM: The surgery to repair the cleft lip and palate was simple and quick. It was so easy, and it gave this child a real chance in life. Don says performing the surgery made him feel really good. As someone with deep religious roots and a Catholic education that emphasized helping the poor, Don felt this was the kind of patient he wanted to serve. He turned to the priests who brought the boy from Mexico.

LAUB: I asked him are there other patients in Mexico like this? They said the place is full of them. So we bought an airplane ticket and went down to Mexicali and asked for a clinic.

VEDANTAM: Just like that where a fox may have considered the upside and the downside, the hedgehog simply picked up and went. In Mexicali, Don found a dusty border town in the desert where the people were very poor.

LAUB: Most of the houses were made of packing crates at that time, and there was no paving in Mexicali of 200,000 people.

VEDANTAM: Mexicali's main medical facility was an old, wood home.

LAUB: It had a dirt floor for part of it with the back part of that clinic was used to raise fighting cocks.

VEDANTAM: A rational fox may have calculated the risks and backed down, not Don. He recruited local health officials to get word out that they would be providing free surgeries for children with cleft lips and burn scars. The clinic was quickly packed.

LAUB: It was 10:30 in the morning. In that desert, there had not been rain there for three years. Hot in the morning - it was about a 106 degrees already. You couldn't touch anything metal because you'd burn your hand. The first patient I saw was sitting there with a bag on a his head with two little peepholes. I said what's with the - why the bag?

VEDANTAM: Behind those peepholes, the boy was hiding his face in shame. Don asked if he could take a look.

LAUB: So he got the bag off, and he had a burn scar that pulled his eyelid down - a simple thing to repair.

VEDANTAM: As with Sandy, Don wanted to make the little boy unremarkable. He wanted him to lead an ordinary life, unmarked by stigma and shame. That first trip was just a fact-finding mission, a way to see if there was a need. By the time Don went back to Stanford, a plan had formed in his mind. He wanted to recruit the best doctors from the United States and fly them to Mexico to perform free surgeries on children with birth defects. He recruited surgical residents to join skilled surgeons on the trips. He found pilots willing to transport medical equipment. Hedgehogs have charisma. They can see the shining city on the hill so clearly that everyone around them starts to see it, too.

LAUB: Everybody jumped on it. I had a high when I'd go in a hospital because people wanted to get in on this.

VEDANTAM: In 1966, the official medical missions began. Now, it's important to remember that at this time, the idea of plastic surgeons going abroad to provide free surgery was almost unheard off. There were fewer parameters of how international aid organizations should operate. Don was flying by the seat of his pants.

Every few months, the doctors would descend on Mexicali. They'd throw themselves into four marathon days of back-to-back surgeries and consultations. Over the years, they'd come back again and again performing more than 2,000 surgeries in all. One of Don's patients was a little boy named Eugenio (ph). He was the boy who had worn the bag over his head. Don repaired the scarred eyelid and still remembers the boy's first reaction.

LAUB: He had a very nice, huge smile.

VEDANTAM: On a follow-up trip, Don tracked Eugenio down.

LAUB: We shook hands and everything like that, even as a young kid. And he said I have friends in school now.

VEDANTAM: Don loved it.

LAUB: It's a real happiness. It's a source of happiness is the best description.

HOWARD HOLDERNESS: With - if anything, Don had a - I would describe it as a very - and I think he would accept this. I think it was a very sort of missionary zeal.

VEDANTAM: This is plastic surgeon Howard Holderness. He was part of the team of residents helping perform surgeries in Mexicali. Howard says that Don's vision drove the whole team.

HOLDERNESS: I think he felt very close to trying to do things that - not only practice medicine in its - in all of its forms of science and everything, but the art of medicine and some of the spiritual aspects of being a good doctor.

VEDANTAM: He was doing more than surgeries. Don was developing a program that could set an example for others to follow around the world. One day about two years into the Mexico program, a woman arrived at the clinic with her young son. His name was Salvador (ph). Compared with the other patients, Salvador had a more severe birth defect. He had bilateral clefs - two clefs rather than one.

LAUB: When you have this bilateral, the muscles are cut twice. So when you smile, they pull out. If they're repaired, they pull in. See? So every time he would have a visual expression, it would be awful. You'd see these teeth on both sides.

VEDANTAM: Salvador was a perfect candidate for surgery. That is until a doctor on the team gave the boy a thorough physical and listened to his heart with a stethoscope.

LAUB: His mother brought him in and the pediatrician listened and it was whoosh, whoosh, whoosh - the heart sounds.

VEDANTAM: These were not normal sounds. The boy's heart had a hole in it. The risk of proceeding with surgery was small, but potentially fatal. They gave the mother the bad news.

LAUB: We can't operate because we don't have the equipment in Mexicali to do the heart catheterization or anything like that or any - even get the EKG today so...

VEDANTAM: So Don and his team turned away the mother and the little boy. I should say here that we're going only on Don's account of what happened. The medical records from that era are incomplete, and we weren't able to find the mother. A few months after sending the child away, Don and his team were back in Mexicali. The mother and her son were waiting. Salvador, she told them, was shunned. He had no friends. Other children called him the monster.

LAUB: The mother said this child has no chance in life. You've got to fix it.

VEDANTAM: Don's heart went out to the little boy. He explained the danger again. The risk was small, but it did mean that things could go seriously wrong. Don held the stethoscope up to the mother's ears.

LAUB: Listen. She can hear it whoosh, whoosh, whoosh.

VEDANTAM: So the answer again was no. More months passed. Don return to the clinic, so did the mother.

LAUB: Por favor, please doctor. Can you see that this child has no life?

VEDANTAM: This was a critical moment. Don could again have said no. Medical protocol said that was the right call. But Don also knew that without surgery, Salvador would always be an outcast. Could he have tried to take the boy back to Stanford where heart surgeons could have assisted with his care? Maybe but that would have been complicated, expensive and a drain on critical resources from the project in Mexico, resources that were helping hundreds of other children. So Don did what Don always did. He took a look at the child, took a deep breath and said, OK, we'll do it.

LAUB: I feel like that's why I existed is for this judgment. I mean, I'm not there to take care of little pimples. I'm there to do the tough cases. So this was putting it right on the line. You got to do it or put your tail between your legs and get out of there.

VEDANTAM: It's been nearly 50 years since Don Laub performed that surgery on a 6-year-old boy in Mexicali, Mexico. He's had thousands of patients since then, but the details of that day are still vivid in his mind. The morning of the surgery, the boy went through the standard pre-surgery lab tests and check-up, an IV was started and he received extra glucose in case his blood sugar was low from stomach worms. And then the boy walked by himself into the operating room.

LAUB: And he gets on the operating table himself because he trusts the whole world.

VEDANTAM: The surgery began. First, the child was anesthetized.

LAUB: So that went fine. It went perfect, no problem at all.

VEDANTAM: Then Don and his team began the surgery.

LAUB: When we were operating, everything was going perfect.

VEDANTAM: And then just like that it wasn't.

LAUB: The anesthesiologist said, boys, we have no pulse.

VEDANTAM: They tried everything - CPR, medicine to jumpstart the heart. Nothing worked. Dan suspected a blood clot. The boy was dead. They put away their surgical tools. They wheeled the body to the morgue, all the while Don's heart was starting to race. He was working in a foreign country, and he had made a risky judgment call in violation of medical protocol.

LAUB: My mind is going a thousand miles and then it - why am I here in Mexico? Why did I get into this? What the hell is the matter with you? Here you are in a foreign country. You're going to end up in jail. It's just a goddamn disaster, an awful thing.

VEDANTAM: And, of course, there was the boy's mother waiting anxiously outside for news of her son. Don remembers stepping out of the operating room and walking up to her. He told her they'd been complications that they had tried hard, but the boy had died. The mother began to sob. But then, Don says, she did something surprising. She asked him why he was upset.

LAUB: She said, you should be happy because the child is seeing God with a complete face.

VEDANTAM: Don had expected accusation and anger. Instead, he encountered a mother who leaned heavily on her faith. Don says she was comforted by the thought that her child was now repaired and beautiful and at home with God. Salvador was finally at peace. Don stared at the mother. He was speechless, not just because of what she'd said but because he was struck by another thought. The mother didn't know this, but Salvador's face was not repaired. He died before the surgery was complete. What would the mother say when she saw her son at the funeral?

Again, the medical protocol was clear. Don had to turn the body over to Salvatore's mother, but he felt he couldn't bring himself to do this. It would only compound the first tragedy. He conferred with his team about finishing the surgery on Salvador.

LAUB: I said it's against the law, but I think in this case we should.

VEDANTAM: The rest of the team unanimously agreed. The little boy was brought back from the morgue.

LAUB: The child came back in a body bag, and we did the whole thing as if the child was awake.

VEDANTAM: It took 25 minutes to complete the surgery. I interviewed Don several times for the story. I pushed hard to understand why he decided to operate on Salvador.

What were you telling yourself, again, emotionally that made you change your mind that made you say, yes, I recognize this is a risk, but I have to do this?

LAUB: I thought, this is what I am for. This is my purpose...

VEDANTAM: And you said it's worth...

LAUB: ...I mean, I was standing there, and I couldn't say no again. I didn't. I couldn't, and I made that - when I said that let's go ahead and do the case, I didn't have any second thoughts. I - emotionally, I figured out that this is what I should do.

VEDANTAM: Don still thinks about Salvador, has thought about him thousands of times over the years. He's turned the case over in his head in every possible way. I asked him over and over whether he felt regret.

LAUB: No. Well, I (laughter) - of course, I do. Of course, I do. Yes, I do. I mean, as you said just a minute ago, it was a mistake. But I don't have - I'm not whipping myself.

VEDANTAM: Not whipping himself, Don says, because he was trying to do the right thing. That's the reason he decided to operate. That's the reason he completed the surgery after the child was dead.

What was more important than being on the right side of the law?

LAUB: Doing the right thing.

VEDANTAM: By the mother and by the child?

LAUB: Yes. Yeah. No, you must always do the right thing. That is the highest priority over all different laws and commandments or any of that thing. You have to do the right thing.

VEDANTAM: The day after Salvatore died, Don Laub was back in the operating room. There were more children waiting for surgery. He remembers looking out the windows at the sky. It was, he says, a perfect azure blue. At 10:30, the time when Salvatore was to be buried, everyone on the team fell silent and paused. There was no sound except for the whoosh of the anesthesia machine.

When we think of foxes and hedgehogs, it's completely understandable that we want the best of both worlds. We love bold visionaries who take big risks, except when the risks don't work. At moments like that, we prefer the visionaries to be more cautious, filled with a little self-doubt. Now, people don't always fall neatly into one camp or the other. Some of us can be both fox and hedgehog. We can think and dream big, but also change course, adapt to circumstances. But it may be that we can't have our cake and eat it, too. If we want the visionary Steve Jobs who helped usher in the age of the iPhone, we might also get the tyrannical CEO who nearly ran Apple computers into the ground in the 1980s.

It's odd to think of Gandhi and Napoleon and Churchill and Mao in the same breath, but they are cut from the same cloth of messianic vision. It's easy not to like the kind of people who create history's greatest failures. But it turns out they're also the people who produce our greatest triumphs.


VEDANTAM: This week's show was produced by Jenny Schmidt and edited by Tara Boyle. Our team includes Maggie Penman, Renee Klahr and Rhaina Cohen. The music in today's show was composed by Ramteen Arab Louie (ph).

Our unsung hero this week is another hedgehog and another Don. Donald Drake was a colleague and friend of mine at the Philadelphia Inquirer many years ago. He taught me many things about writing and storytelling. We even wrote a play together. Don's in poor health right now in Philadelphia, and I wanted to give him a shout out for all that he's done for me. Thanks, Don.

For more HIDDEN BRAIN, you can follow us on Facebook and Twitter and listen to my stories on your local public radio station. I'm Shankar Vedantam, and this is NPR.

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