Facts and ideas from anywhere

SYRIAN MEDICINE

Syria's 7-year war is fueling a parallel disaster: a crippling public health catastrophe.¹ Some 400,000 Syrians have died from bullets, bombs, or torture, including alleged recent gas attacks. More may have died from the breakdown of its health care system. Chronic conditions such as diabetes and heart disease have become far deadlier, according to reports from the World Bank and the World Health Organization. The regime of Bashar al-Assad has targeted hospitals, clinics, and medical personnel in a strategy to destroy the country's medical infrastructure. Between the fighting and the destruction done to the health care system, today more Syrian people live <65 years. Many perish because they cannot get medicine or reach a hospital. Hundreds of medical facilities have been bombed out of operation, and thousands of medics have either been killed or forced to flee. About three-quarters of health care workers have fled the country, and more than half of the public hospitals and health centers have closed or are only partially functioning, according to the United Nations. The collapse of the medical sector has accelerated the spread of some infectious diseases and allowed others that had been all but stamped out to resurface. Physicians for Human Rights has corroborated 492 attacks on health care facilities and 847 deaths of medical personnel, including physicians, nurses, dentists, and medical students, since the beginning of the war. More than 90% were carried out by the Assad regime or Russia, the group says.

VENEZUELAN MEDICINE

When Hugo Chavez became Venezuela's new president in 1998, he promised to provide free health care to all and enshrined this right within Venezuela's new constitution, rewritten in 1999.² Progress was rapid and initial results were promising: life expectancy at birth rose from 71.8 to 74.1 years and infant mortality fell from 26.7 to 14.6 deaths per 100,000 live births between 1998 and 2013, the period of Chavez's rule. This initial success came on a backdrop of high oil prices, which provided the necessary government funding for health care spending and food imports. At the same time, a strong relation with Cuba saw an agreement in 2003 that in exchange for low-cost oil, Cuba would provide physicians, medical training, and medical supplies free of charge to Venezuela. When the oil price began to fall in 2008 and Chavez's revolutionary politics alienated foreign investors, the tide turned. The largest oil reserves in the world could not stave off economic collapse. The lower demand for oil, excessive government spending, US sanctions, and price controls led to rocketing inflation and falling gross domestic product. The impact on the health care system was further exaggerated by exchange rate controls, which led to a shortage of the foreign currency needed to import equipment, food, and medicines.

The last official report from the Venezuelan Ministry of Health was published in 2017. The report revealed a 65% increase in maternal mortality and a 30% increase in infant mortality during 2016. Malaria and diphtheria, which previously had been controlled, had returned in several outbreaks. Health care outcomes have continued to deteriorate rapidly. The Venezuelan government has steadily reduced the share of its annual expenditures dedicated to public health, from a high of 9.1% in 2010 to 5.8% in 2014. Medical supplies have been reported as going missing or being embargoed and sitting in ports, with some media alleging corruption hindering distribution. Some supplies for treating patients with heart disease and diabetes—the leading causes of death in Venezuela—are inadequate. As a result, patients have resorted to bringing their own surgical instruments, drugs, and food to hospitals. In private practice, medical professionals charge in US dollars, which makes health care unaffordable for most. Most laboratory services and hospital nutrition services are only available intermittently or are completely inoperative. There are shortages of medicines, catheters, surgical supplies, and infant supplies. Many intensive care units have been shut down. Many facilities have no water at all.

Venezuela's government has allowed the country's infrastructure to crumble, with fatal consequences for ordinary Venezuelans. Aware of the humanitarian crisis, worldwide aid has been offered by multiple countries and the United Nations. Yet, Venezuela's government has refused this humanitarian aid, denying the existence of a crisis—a very unfortunate situation.

CHINESE MEDICINE

Expanding universal health coverage has been made a clear policy goal in China.³ China's basic medical insurance and social old-age pension programs now cover 1.35 billion people, constituting the largest social safety net in the world. In 2018, basic medical insurance and serious disease insurance benefits will continue to be raised. The Chinese government's pledge to strengthen the general practice workforce, improve the primary care system, and increase per capital government subsidies for basic public health services is, of course, welcomed. Additionally, maternal and child health care will be improved, mainly by eradicating gender discrimination and enhancing the educational system.

Pollution is another pressing challenge for public health in China. Addressing pollution, tackling economic and financial risks, and alleviating poverty are recognized as three critical battles that China is determined to fight.

Acknowledging the importance of innovation in facilitating China's economic and social transformation, the Chinese government has increased investment in research and development at a growth rate of 11% annually. Thus, China is clearly making health a priority in 2018. Several important health issues make improvement a bit difficult. The burden of disease in China is dominated by noncommunicable diseases and consequences of tobacco use. Without widespread cessation of smoking, the annual number of deaths caused by tobacco will rise to about 2 million by 2030.

THE GENERIC DRUG INDUSTRY

The generic drug industry, which supplies almost 9 of 10 drugs prescribed in the USA, is in crisis.⁴ These manufacturers produce most of our bread-and-butter pills, including those for infections (antibiotics), arthritis, diabetes mellitus, and hypertension. With the profitability of these pills fading fast, generic companies are exiting or downsizing. The reason—plummeting prices. The problem is an arcane supply chain ruled by a tight-knit band of players forcing prices for most generic drugs lower and lower. Although the top three manufacturers—Teva, Mylan, and the Sandoz Generic Drug Division of Novartis AG—control only about one-third of the market by sales, numerous smaller players compete for business. The new entrants, which hire contract manufacturers around the globe, enter the market often by offering lower prices. Generic drug prices are falling about 11% a year, whereas brand-named drug prices are rising about 8% a year. Israel-based Teva Pharmaceutical Industries, Ltd., the number one supplier of generics to the USA, is laying off 14,000 employees and shuttering about half of its 80 manufacturing plants.

About 5 years ago, middlemen in the drug delivery supply chain started to form buying consortia to gain more leverage over drug makers. The consolidation has since become so extreme that just four groups now control 90% of drug buying in the USA, and two of the four are joining forces to purchase generics, a move likely to lower prices further. The squeeze is leading some manufacturers to stop making some critical low-margin drugs.

Not all prices in medicine are rising.

“AUTHORIZED GENERIC” DRUG

When a brand-name drug loses its patent, the original manufacturer sometimes strikes a deal with a generic drug maker.⁵ That allows the generic company to sell the exact same formulation, made from the same “recipe.” Sometimes the authorized generic is made on the same production line as the brand-name drug. Many physicians are unaware of this category. That may be in part because the generic drug industry, pharmacies, and the Food and Drug Administration (FDA) have promoted the idea that generic drugs in general are just as good as their brand-name equivalents. Authorized generics can be found in Joe and Teresa Graedon's Guide to Saving Money on Medicines. This online resource is available on www.Peoples Pharmacy.com. The National Drug Code is a unique number to identify every drug sold in the USA. The FDA maintains an online directory of all National Drug Code identifiers.

HOSPITAL FINANCES

A piece in The Wall Street Journal was entitled “US Hospital Profits Fall as Labor Costs Grow and Patient Mix Shifts.”⁶ The median hospital cash-flow margin—monitored by Moody's Investors Service as a signal of financial strength—fell to 8.1% in 2017 from 9.5% in 2016. Those figures were based on a preliminary analysis of 160 nonprofit and public hospital systems with credit ratings from Moody's. The prior low point came in 2008, when the median margin reached 9.1%. That year, a deep recession sharply slowed growth and insurers' spending on hospital care; job losses stripped households of private insurance coverage; and states' physical distress curbed Medicaid budgets. Now, the decline points to new challenges for US hospitals as more patients seek medical care in nonhospital settings and as enrollment surges in Medicare, which typically pays hospitals less than commercial insurers do. These trends are squeezing hospital revenues while a tight labor market is driving expenses higher.

Hospital costs are the single largest expense in US health care, and most US hospitals are nonprofit or government-owned. Gains to hospitals from the Affordable Care Act's 2014 health insurance expansion have essentially been realized. Hospitals will likely see more unpaid bills and uninsured patients since Congress included a repeal of the act's individual insurance mandate in the December 2017 tax overhaul. Hospital finances could face still more pressure if a wave of possible health care deals, such as early stage talks between Walmart and Humana, create new competition for hospitals. Additionally, a nursing shortage has compounded an uptick in hospitals' operating expenses, whose growth outpaced revenues in both 2016 and in 2017. Some hospitals in tight labor markets for nurses are offering bonuses to hire and retain nurses and are relying on costly temporary nurse staffing agencies. Demand for nurses will particularly intensify where the population is aging and/or booming, such as in Texas, California, and Florida.

Not good news.

BODY WEIGHT AND MORTALITY

Kahn and colleagues⁷ studied a large group of individuals between 1964 and 2015, and all were free of cardiovascular disease at baseline. The authors calculated the body mass index (BMI) and found that total cardiovascular death (fatal and nonfatal coronary heart disease, stroke, heart failure, and other cardiovascular diseases) increased as BMI increased. Obesity (BMI ≥ 30 kg/m²) was associated with shorter longevity and significantly increased risk of both cardiovascular morbidity and mortality compared with normal BMI (≤25 kg/m²). Overweight was associated with a significantly increased risk of developing cardiovascular disease at an earlier age, resulting in a greater proportion of life lived with cardiovascular disease. The less we weigh, the longer we live.

THE BLACK MAN'S BARBERSHOP AND HIS BLOOD PRESSURE

When Dr. Ronald Victor was on the staff at Southwestern Medical School in Dallas, he led a study in 17 Dallas barbershops to screen patrons' blood pressures; if the blood pressure was elevated, the men were referred to physicians. Improvements were modest. Dr. Victor subsequently moved to Cedars-Sinai Medical Center in Los Angeles and did another study adding a pharmacist to the mix so that medicines could be prescribed on the spot if elevated blood pressure was detected.⁸ The study involved 303 men and 52 barbershops in the Los Angeles area. One group of customers just got pamphlets and blood pressure tips while getting haircuts. Another group met with pharmacists in the barbershops and could get treatment if their blood pressures were high. At the start of the study, the peak systolic blood pressure averaged 154 mm Hg; after 6 months, it fell 9 points for customers just given advice and by 27 points for those who saw pharmacists. Nearly two-thirds who saw pharmacists lowered their blood pressure to <130/80 mm Hg. In contrast, only 12% of the men who just got advice dropped to that level.

Elevated blood pressure, for unclear reasons, is a greater problem for black men than for white men. Barbershops are popular meeting places for black men.

Good job, Dr. Ronald Victor.

CHANGING CLIMATE—WHAT IT WILL MEAN FOR TEXANS

Professor Katherine Hayhoe runs the Climate Science Center at Texas Tech University and she, although not a household name, is a star.⁹ She has authored eight books. She cohosts a Sirius XM show, hosts the PBS digital series Global Weirding, and was an expert reviewer for the Intergovernmental Panel on Climate Change.

The year 2017 was a record one for weather and climate disasters, and most, including Professor Hayhoe, believe that the future will only get worse. Last year, hurricanes Harvey, Irma, and Maria; the wildfires and floods in California; and tornado outbreaks in the Midwest and South caused just over $306 billion in damage, more than any other year in history when adjusted for inflation.

Texas is particularly vulnerable to a changing climate. It has had costlier weather-related disasters than any other state, and those events will happen more often as air and ocean temperatures change, states Professor Hayhoe. Dallas–Fort Worth may see August temperatures rise from a mean of 86°F in 2000 to 94°F, with extremes rising above 120°F by 2041 to 2050. Longer droughts and more extreme rainstorms will pose a challenge for those who manage drinking water supplies, raise cattle, and oversee our roads and railways. The changes may also have unexpected effects on people's daily lives, including jobs. Intense heat can imperil cars and airplanes, evaporate drinking water supplies, and halt outdoor labor such as farmwork and construction. Adam Smith, a scientist with the federal government's main climate agency, the National Oceanic and Atmospheric Administration, calls Texas “the disaster capital of the United States.” Texas is susceptible to almost every kind of weather and climate hazard, from extreme cold to extreme heat, from severe drought and wildfires to torrential floods. Texas is also home to a booming population and critical infrastructure, including the petrochemical plants that were damaged in Hurricane Harvey.

Global average temperatures increased about 1.8°F in the last 115 years. In Dallas, they climbed from about 65°F during the early part of the 20th century to 68°F during the most recent decade. If nothing is done to reduce emissions of carbon dioxide and other greenhouse gases, average temperatures in this city may reach the low 70s by 2050 and surpass 75° by 2100. The Dallas area warmed twice as fast as the North Texas region as a whole because of urbanization combined with long-term warming. Rapid development in Dallas accelerates the so-called urban heat island effect. Manmade building materials absorb and lock in more heat than soil and natural landscapes, so urban areas are generally warmer than rural areas, especially after sunset.

Once temperatures reach the high 90s, equal to or above body temperature, fatality rates rise. One scientist predicts 24 extra deaths per 100,000 people each year in Dallas County by the end of the century if global emissions increase at the same rate they have been. That would be 600 extra deaths per year in the country's 2015 population level.

Heat also affects roads. A 2015 study on the effect of climate change on transportation predicted “an increase in wildfires along paved highways, heat-induced stress on bridges and railroads, air-conditioning problems in public transport vehicles, and heat-related accidents by failure of individual vehicles and heat-related stress.”¹⁰ Some of these changes are already happening. The same study predicts a reduction in soil moisture of 10% to 15% in all seasons by 2050, something that can lead to cracked pavement and the premature loss of roads, railways, and other infrastructure.

Heat and drought also pose a problem for drinking water supplies, which North Texas receives from surface reservoirs that will be increasingly prone to evaporation. Professor Hayhoe says that some water managers are considering pumping reservoirs underground during exceptionally hot and dry conditions or covering them with polymer “blankets.” The blankets are an invisible layer of organic molecules that can help reduce evaporation.

Though it is not likely that annual precipitation totals will change in North Texas, it is likely rainfall patterns will. Professor Hayhoe says we are likely to see enhanced “feast or famine” cycles with torrential rainstorms in the spring followed by longer than usual dry periods. The severe rainstorms will have the capacity to flood highway exits and service roads. Though the state highway system was built above flooding levels, the connector roads may be easily flooded.

Two events climate scientists cannot likely predict are hail storms and tornados. The historical record apparently is not large enough for longer-term forecasts. There is some evidence that tornados, like rainstorms, are becoming more concentrated on fewer days and that their season has become less predictable. The same is true with hail.

One scientist at the University of Chicago predicts that climate change will decrease Dallas County's annual income by 10% to 20% in the coming decade unless emissions are reduced. North Texas appears to be one of the worst-affected places in the country. Much of the loss comes from higher mortality rates, soaring air-conditioning costs, and reduced labor productivity.

All of this does not sound good.

CHANGING US POPULATION

In March 2018, the Census Bureau updated population projections for the next several decades.¹¹ People >65 years of age will outnumber children by 2035, a first in US history. Trends in births and immigration have slowed the rate at which the country is becoming more diverse. Whites who are not Hispanic will begin shrinking as a group by 2024. They will drop below half of the population by 2045. By 2020, less than half of those under 18 years old will be non-Hispanic white. The Census Bureau projects that the country will grow to 355 million by 2030. This is an annual average growth rate of 0.7%, in line with recent rates but well below historical levels. Unlike many European nations, the USA will continue to grow, reaching 440 million by 2060. It will rival fast-growing Nigeria as the third most populous after India and China, according to Census and United Nations projections. The share of Americans who are foreign born, now about 13%, is expected to reach 15% by 2028, topping a mark set in 1890. That share would rise to 17% by 2060.

EFFECT OF A SUDDEN LOSS OF WEALTH ON HEALTH

Pool and colleagues¹² from Northwestern University Feinberg School of Medicine in Chicago designed a study to determine whether a sudden loss of wealth—a negative wealth shock—was associated with an increase in all-cause mortality during a 20-year follow-up. There were 8714 participants over age 50 years at study entry: 2430 experienced a negative wealth shock during follow-up, 749 had asset poverty at baseline, and 5535 had continual wealth growth. A total of 2823 deaths occurred during the 80,683 person-years of follow-up. There were 31 vs 65 deaths per 1000 person-years for those with continuously positive wealth vs negative wealth shock and 73 deaths per 1000 person-years for those with poverty at baseline. Thus, loss of wealth over a 2-year period was associated with an increased frequency of all-cause mortality. Save your money.

PREMATURE US DEATHS

Substance abuse, suicides, and diabetes mellitus are producing a steep rise in deaths in the USA among people aged 20 to 55 years.¹³ Between 1990 and 2016, the percentage increase of the leading 25 causes of death among people in the USA aged 20 to 55 were as follows: opioid use disorders, 343%; endocrine/immune disorders, 89%; chronic kidney disease, 61%; suicide (not by a firearm), 17%; chronic obstructive pulmonary disease, 14%; Alzheimer's/dementia, 12%; cirrhosis/liver disease (alcohol use), 10%; cirrhosis/liver disease (hepatitis C), 8%; hypertensive heart disease, 3%; and pancreatic cancer, 0.4%. Rates went down for several cancers and motor vehicle crashes during this 16-year period. Hawaii had the highest life expectancy at birth in 2016 at 81.3 years, whereas Mississippi had the lowest, at 74.7 years. For Americans between 20 and 55, the risk or probability of death over the years studied rose more than 10% in five states: West Virginia, Oklahoma, New Mexico, Kentucky, and Wyoming. Mental and substance use disorders were the biggest drivers of an increase in probability of death in West Virginia, a state hard hit by the opioid epidemic. Suicide also played a large role. The increases in mortality were so large that they did not offset declines in deaths from cardiovascular disease, accidents, and HIV. Minnesota, the state with the lowest probability of death for this age group in 2016, had a decrease in deaths from cardiovascular disease, cancer, injuries, and HIV that far offset an increase in deaths from mental and substance use disorders.

THE JUUL

Juul is a type of e-cigarette that delivers a powerful dose of nicotine derived from tobacco and a salt solution that smokers say closely mimics the feeling of inhaling cigarettes.^14,15 It has become a coveted teen status symbol and a growing problem in middle and high schools in the USA. After 2 decades of declining teen cigarette use, “Juuling” is exploding. The Juul liquid's 5% nicotine concentration is significantly higher than that of most other commercially available e-cigarettes. Juul Labs Inc., maker of the device, says that one liquid pod delivers nicotine comparable to that delivered by a pack of cigarettes or 200 puffs. It is also part of what attracts teens to the product, which some experts say is potentially as addictive as cigarettes and has schools and parents scrambling to get a grip on the problem.

In March 2018, medical and advocacy groups, including the American Academy of Pediatrics and the Campaign for Tobacco-Free Kids, sued the FDA, challenging its 2016 decision to extend certain deadlines for e-cigarette makers seeking FDA approval for their products. One big concern, addiction researchers say, is that Juul lacks many characteristics that deter people from smoking in the first place, such as a harsh smell and burnt tobacco taste. Juul flavors include crème brûlée, fruit medley, and mango, in addition to classic tobacco. Juul is a highly addictive product for youth.

The Juul device fits easily in a pocket and looks nondescript when plugged into a laptop's USB drive to recharge. Teachers say that students gather in bathrooms, laboratory carrels, and locker rooms to pass Juuls. The minimal vapor and inapparent smell make it harder to detect than some other e-cigarettes.

DEPRESSION ON COLLEGE CAMPUSES

Record numbers of college students in the USA are seeking treatment for depression and anxiety, and schools cannot keep up.¹⁶ The Center for Collegiate Mental Health also found a consistent increase in the prevalence of suicide attempts and other self-harming behaviors among students seeking mental health treatment each year since 2010. The percentage of college students visiting counseling centers increased on average 30% from 2009 to 2015. College students in the last 12 months who said they had “felt so depressed that it was difficult for them to function” increased 39%; the number who “felt overwhelming anxiety” increased 61%, and those who “seriously considered suicide” increased 10%.

ROGER GILBERT BANNISTER, MD (1929–2018)

My daughter Fran and Dr. Fred Koberg both sent me a piece on Sir Roger Bannister, MD,^17,18 a medical student in London who, on May 6, 1954, at age 25, worked his usual morning shift at St. Mary's Hospital, took a train to Oxford, had lunch with some old friends, met some of his track teammates, and went to the track. As a member of an amateur all-star team, they were preparing to run against Oxford University. Although the weather was blistery and damp, about 1200 people showed up at Oxford's unimpressive Iffley Road track to watch the event. Bannister ran the mile in 3:59.4 minutes, becoming the first man to break the mystical 4-minute barrier and creating a seminal moment in sports history. Bannister's feat was trumpeted on front pages around the world. He had reached “one of man's hitherto unattainable goals,” like those of Babe Ruth, Bobby Jones, and Jesse Owens.

His record-setting feat would be surpassed many times. Runners in the next decades would be faster, stronger, better equipped, better trained, and able to devote much of their time to the pursuit while benefiting from advances in sports science. But their later success did not dim the significance of Bannister's run. As Sebastian Coe, who set the world record in the mile three different times, once said,

He was running on 28 training miles a week; he did it on limited scientific knowledge, with leather shoes in which the spikes alone probably weighed more than the tissue-thin shoes today, on a track at which speedway riders would turn up their noses. So as far as I'm concerned, that was one of the great runs of all time.

Bannister was a gentleman athlete. He was a quiet, unassuming champion, a character of a type uncommon today. Sports Illustrated called him “among the most private of public men, inexhaustibly polite, cheerfully distant, open and complex.”

Roger Bannister was born on March 23, 1929, in the London suburb of Harrow. His father, a civil servant, had been a runner of sorts: he won his school mile. Young Roger ran both for the thrill of it and out of fear to steer clear of bullies and in response to air raid sirens he heard as a boy in World War II during the Battle of London. After his family had been evacuated to the city of Bath, he earned acceptance at school by winning cross-country races. When he returned to London, however, his school there prized sports like rowing and rugby above running, and his racing career stalled until he entered Oxford University, where at age 17 he was introduced to spiked shoes and ran his first mile in 4:53 minutes.

On June 21, 1954, just weeks after Bannister's breakthrough, John Landy lowered the world record to 3:58 and set the stage for an epic encounter between the two men at the Empire Games in Vancouver, British Columbia, Canada. On August 7, 1954, before 45,000 spectators, in a race that quickly came to be known as both the “Mile of the Century” and the “Miracle Mile,” Landry took an early lead but was chased down on the final lap by Bannister. Both men broke 4.0 minutes, with Bannister's winning time, 3:58.8, being his personal best. Bannister later said that Vancouver had been a more satisfying race than the celebrated one at Iffley Road because it was a victory achieved against a great competitor and not merely against a clock. Three weeks later, he won another important race, the 1500 meters, at the European Champions. He retired in December 1954.

Over the next decade, the record for the mile was reduced to 3:54.1. In 1975, the 3:50 barrier was breached for the first time by John Walter of New Zealand, and in 1999, Hicham el Guerouj, a Moroccan, set the current world record of 3:43.13. Had they been on the same race, el Guerouj would have beaten Bannister by 100 meters.

On the day before the seminal race, Bannister met Moyra Jacobsson, a painter and the daughter of Per Jacobsson, the Swedish economist who became managing director of the International Monetary Fund. They married the next year. Bannister liked to point out that she did not really understand what this running business was all about. “For a time my wife thought I had run 4 miles in one minute.” They had two sons and two daughters.

In addition to his medical career (neurologist), he became director of the National Hospital for Nervous Diseases in London. From 1971 to 1974, Bannister served as the unpaid chairman of the British Sports Council, a government-sponsored organization that helped build and maintain sports facilities, and from 1976 to 1983, he was president of the International Council of Sports Science and Physical Recreation, an umbrella group founded in 1958 to disseminate new findings in sport science and promote their applications. From 1985 to 1993, he was head of the Pembroke College. A most distinguished life.

JACK BAYLOR MCCONNELL, MD (1925–2018)

He was born in Crumpler, West Virginia, in 1925 and grew up in Tennessee.¹⁹ His father was a Methodist minister who was never able to afford a car but would often ask his children at dinner: “What have you done for someone today?” Jack McConnell was the youngest of eight children. After finishing high school in 1943, McConnell joined the Navy and was in a program that paid for him to attend the University of Virginia and then medical school at the University of Tennessee. He did a residency in pediatrics at Baylor University. Around the time he was completing his residency, he was diagnosed with tuberculosis and spent a year in bed recuperating. He decided to focus on medical research. At American Cyanamid Companies' Lederly Laboratories, he helped develop a test for tuberculosis, worked on the polio vaccine, and was recruited to Johnson & Johnson's McNeill Laboratories. He helped lead the development of Tylenol tablets. He then was promoted to corporate director for advanced technology at the company.

He and his wife, the parents of three offspring, retired to Hilton Head, South Carolina, in 1989. Then the former Johnson & Johnson executive found a different distraction. In his chats with landscapers, waiters, and others who worked in the retirement paradise, he learned that few of them could afford health care. In 1991, the McConnells had a holiday party and attempted to rally retired physicians and other medical personnel to provide free care for the poor. It was a tricky undertaking, but eventually he formed the National Volunteers in Medicine, an organization to help communities set up free clinics. There are now 89 affiliated clinics in 28 states. He developed Alzheimer's in his early 80s and died at age 93 in 2018. The original Volunteers in Medicine clinic in the Hilton Head community now involves 100 volunteer physicians and handles nearly 30,000 patient visits a year; the free service is available for those with a family income below 200% of the federal poverty guidelines, living or working on Hilton Head or nearby islands. Good for you, Dr. McConnell.

FERDIE PACHECO, MD (1927–2017)

Ferdie Pacheco was Muhammad Ali's private physician during the boxer's golden years.²⁰ Known as the “Fight Doctor,” he was ringside when Ali claimed his first world heavyweight championship in 1964. After Ali's 10-round win against Joe Frazier in 1975, Ali told Pacheco, “This is the closest I've come to dying.” As the bouts and the blows stacked up, Pacheco became increasingly worried about Ali's health. He urged Ali to retire after a brutal 15-round battle with Alfredo Evangelista in 1977, and he quit as his physician when the fighter refused to follow his advice. Seven years later, the boxer was diagnosed with Parkinson's disease.

Pacheco had met Ali in 1960 when the boxer started training at a Miami gym where Pacheco “provided free medical treatment for fighters and their families.” He described Ali as “the most magnificent physical specimen I've ever seen.” Pacheco served as Ali's “corner man” and personal physician for 15 years. In 1977, he sent Ali's medical exam results to the boxer's inner circle, warning that the champ had “no shot at a normal life if he stayed in the ring.” After quitting Ali's entourage, Pacheco became a television boxing commentator. He spent 19 years in broadcasting, winning two Emmys for his work, and he used his perch to call for safety reforms in the sport. He later became a prolific author and successful painter and increasingly found himself questioning his prior involvement in boxing. “Why was I, an ethical physician with a large charity practice, part of a sport that allowed death?” he once asked.

JOHN EDWARD SULSTON (1942–2018)

The nematode worm known as Caenorhabditis elegans is only a millimeter long, eats bacteria, wriggles around, and reaches adulthood in 3 days. It consists of basically two tubes, one inside the other. For years, Dr. Sulston spent up to 8 hours a day peering through microscopes at these worms, although some colleagues thought he was wasting time.²¹ His findings, however, on the genetics of worms won him the Nobel Prize in physiology in 2002. His work also helped prepare the scientific world for the more glamorous project of mapping the human genome, in which Dr. Sulston played a large role. He fought successfully to keep data from the Human Genome Project in the public domain rather than letting any single company own it. Detailed mapping of the genome, the genetic coding needed to make a human being, of course was one of the most celebrated scientific triumphs of the 20th century. Dr. Sulston described the feat in more modest terms: “What we've done is to read the language of evolution. We have the hieroglyph … and now we are working on its interpretation.”

CHANG AND ENG (1811–1874)

Chang and Eng, the famed Siamese twins of the 19th century, have inspired numerous biographies, plays, and historical novels.²² The new book Inseparable by Unte Huang recently appeared and tells the story of these twins joined at the breastbone by a thick, flexible, 5-inch-wide band of flesh. They were born in Thailand (then Siam) to a Chinese fisherman and his Chinese-Siamese wife. When news of the birth of this “double-boy” reached the king, he considered it an evil omen and ordered a death warrant but soon had a change of heart. In 1829, the twins were “discovered” by a Scottish merchant, Robert Hunter, who marveled at the sight of the boys gracefully swimming in tandem. He and an American sea captain, Able Coffin, successfully petitioned the king to allow them to take the twins to Europe and the USA where they would be exhibited as one of the wonders of Siam. Chang and Eng's mother consented to the deal, accepting $500 in cash and a promise that in 5 years her sons would return. They never did. Coffin soon bought out Hunter's share of the joint contract and exploited the twins as “freaks of nature.”

With no say-so as to any part of their lives, they lived where Coffin put them, ate what he gave them, and performed where and when he told them to. The twins toured the northern US states, Canada, and England. They quickly learned to speak and write English. They were natural showmen and accomplished athletes. Their movements were fluidly synchronized and they could do somersaults and backflips. They soon developed a stage routine with good-humored lines of patter and, especially during the question-and-answer series of their act, a warm and witty rapport with their audience.

After 5 years of indentured servitude, Change and Eng negotiated their freedom from Coffin. Now accomplished showmen with extensive business contacts, they hired a manager who booked their appearances in cities small and large. In 1839, after saving an impressive sum of money, they retired to Mount Airy, North Carolina, where as naturalized citizens of the USA, they married white sisters and sired 22 children between them. They lived there from the late 1830s until their deaths in 1874.

Change and Eng enjoyed the privileges of most Southern gentlemen of that era. They owned a business—a general store—improved their property (a working farm), and bought and sold slaves. At the peak of their wealth, Chang and Eng possessed 32 slaves, worth about $26,000 according to county tax records. When the Civil War broke out, Chang and Eng, as slave-holding southern gentry, stood staunchly with the Confederacy. Although they themselves could not join the military, the twins sent their first two sons to the battlegrounds, where both were wounded and captured by Union troops. The twins were fortunate to see their sons come home alive. The war meant the freeing of their slaves and wiped out their financial investments made in Confederate money. Defeated and broke, they resorted to the one asset they still possessed: their conjoined body. They hit the road again as itinerant showmen. This time, they took along some of their children, occasionally even their wives, to show the world that, however abnormal they might look, their double union with two white women was able to produce normal offspring.

On January 17, 1874, Chang and Eng died at home in Mount Airy—Chang first and Eng a few hours later. Their legacy, not surprisingly, survived far beyond their deaths. Their brand name now applies to every pair of conjoined twins. Their descendants number >1500 today. Their shared liver is on permanent display as an anatomical curiosity at the Mütter Museum in Philadelphia. Today, almost certainly they could be successfully separated surgically.

The twins' adopted hometown of Mount Airy, where they lived for almost 3 decades, became the birthplace of the actor Andy Griffith and the inspiration for Mayberry R.F.D., the fictional setting for the popular 1960s American sitcom, The Andy Griffith Show.

ANIMAL POPULATIONS

The numbers of cattle, sheep, and goats roaming the earth have increased in the past 10 years such that now 1.5 billion cows, nearly 1.2 billion sheep, and 1.0 billion goats live here.²³ The cows, particularly, account for a good percentage of our greenhouse gases, and the cows' bovine muscle, milk, butter, and cheese play a large role in our cholesterol and body weight numbers.

COWS

Since 1966, Congress has established 22 agricultural industry-backed research and promotion boards, which have funded iconic campaigns such as “Got Milk?,” “The Incredible, Edible Egg,” and “Beef. It's What's for Dinner.”²⁴ So-called checkoff fees to pay for such marketing became mandatory in the 1990s, and today these fees total about $700 million a year. Some ranchers recently sued the Department of Agriculture to end the fee mandate. Each time a head of cattle is sold in the USA, part of the proceeds goes toward the checkoff fund. The average auction cost of a 1200-pound steer is about $1400, and $1.00 goes to the fund. The US beef market projections for 2018 include 28 billion pounds of domestic bovine muscle and 3 billion pounds of imported bovine muscle. All of this is enemy #1 for our health.

HAPPINESS AT WORK

Morten T. Hansen has written Great at Work: How Top Performers Do Less, Work Better, and Achieve More.²⁵ He studied 5000 employees and managers. He writes that there are two ingredients to happiness at work: (1) pursuing one's passion in navigating a career and (2) connecting that passion with a clear sense of purpose on the job. Whereas passion is doing what you love, purpose is doing what contributes. He found that people who matched passion with purpose in this way performed much better than their peers who did not. He advises, “Try to cultivate more passion and purpose in the place where you already are. Chances are that you will find more ways to feel passionate and a strong sense of purpose. It will make your job more interesting, and you will also likely perform far better.”

PARENTS READING TO THEIR OFFSPRING

Ann Casey, an intermediate school teacher, had a lovely piece on parents' reading to their offspring.²⁶ Her advice and opinions were this: Few human encounters are as gratifying as sharing a beloved book with a favorite person. People read to babies and toddlers and then to preschoolers. Yet, once kids are reading chapters in books independently, many parents unnecessarily abandon the ritual of reading aloud to their children. She warns that this is a lost opportunity. Delving into books with older children creates a space for intimacy, shared values, and discussions of big ideas. Much research proves that students who are read to throughout their school years fare better than their non–read-to peers. The readings build listening skills, improve vocabulary and background knowledge, and produce better comprehension of advanced sentence structure. The most compelling reason to read aloud, in her view, is for the pleasure of it. She writes that some of her richest memories of parenting are associated with reading. “I've rolled on the floor laughing with my kids over the antics of Junie B. Jones.” Her son was mesmerized by Greek myths, so she read The Odyssey to him. He was seven and never could have appreciated Homer's epic on his own, but in the reading, he was captivated by the action and the otherworldliness. Read to yourself and to others.

CORPORATE FINANCES

Dr. Fred Koberg of Graham, Texas, recently sent me several clippings regarding corporate finances. The CEO of Blackstone, the world's largest private-equity firm, took home at least $800 million in 2017, an amount greater than six times the combined pay in 2017 of the heads of Goldman Sachs, Citigroup, JP Morgan Chase, Bank of America, and Morgan Stanley. At the insurance company Humana, the median employee made $57,000 and the CEO made 344 times that amount, or nearly $20 million. Whirlpool's median worker in Brazil earned $20,000 in 2017, whereas the CEO made $7 million, or 356 times as much. Despite recording $5.6 billion in profits in 2017, Amazon paid zero taxes for that year.

THE PERSONAL LIBRARY

In March 2018, I moved from a two-story house to a one-floor condominium in a high-rise building. The move was a bit traumatic in that I suspected that the condo did not have enough space to accommodate my books, which number about 2500. In the process, I gave many medical books to Baylor University Medical Center and left in the house a number of books to my son, Charles, who in April 2018 moved to Dallas to join the Department of Cardiothoracic Surgery and moved into my previous house. Charles also has a large personal library and plans to place at least part of it on the first floor. When I was in the house, most of my books, in contrast, were on the second floor, so visitors had no idea what intrigued me.

Feeling at times a bit overwhelmed in trying to decide whether to keep a particular book or let it go, I came across the recently published book entitled Packing My Library by Alberto Manguel.²⁷ In 2015, the widely traveled Argentine writer was appointed director of Argentina's national library. Not long thereafter, Mr. Manguel found himself faced with a bookish dilemma that verged on a psychological crisis. He was moving to an apartment in New York City with his personal library of >35,000 volumes. He tells the story by alternating intimate chapters that make up an “elegy” for his library with 10 digressions on his life as a reader and lover of books. When reading that this man had over 35,000 volumes, I quickly eliminated my self-pity with having to deal with 2500 volumes. I agree with Mr. Manguel's statement: “My library explained who I was. The books both enclosed and mirrored me.” At any rate, the books are now in my condo and appear to be resting well on new shelves. Dr. William Mayo of Mayo Clinic fame apparently stated that bookshelves make better wall coverings than pictures. I tend to agree with him.

CHARLES DARWIN (1809–1882), THE EARLY LIFE

Paul Johnson was introduced to me by my son Charles and subsequently I have found him to be one of my favorite authors. He is now 87 years old and has written over 15 books, including several relatively short biographies and 3 books including chapter biographies of a number of creators, intellectuals, and heroes. His book on Charles Darwin appeared in 2012, and in his characteristic fashion he makes Charles Darwin as fascinating as he was in life.²⁸

All of his life, Charles Darwin believed that inheritance was much more important in shaping a man or woman than education or environment. (I believe the same.) Though he knew nothing of the science of genetics, more than a quarter century after his death he is a classic case of spectacular genetic inheritance. Indeed, two of his grandparents and his father can be classified as geniuses. His paternal grandfather, Erasmus Darwin (1731–1802), came from a family of modest landowners. After Cambridge, he trained as a physician at Edinburgh and then practiced in Lynchfield, Dr. Samuel Johnson's town. He was successful and had many patients, easily earning >1000 pounds a year, a handsome income then. He was offered the post of royal doctor to the king but declined. Erasmus Darwin was happy combining a busy provincial practice with poetry and science. His coach, which he designed himself, was fitted with a writing desk, a skylight, and a portion of his library so he could carry on his intellectual pursuits while going on his daily rounds. He was interested in every aspect of science, both theoretical and empirical. He read widely and attended regular discussion groups with early industrialists. His chief passions were botany and animal life. He wrote and published a two-part didactic poem, The Botanic Garden, which was highly successful. He expanded the poem in a prose work, The Phytologic; or The Philosophy of Agriculture and Gardening (1799), which contains much speculation about the degenerative life of plants. His treatise Zoonomia, or The Laws of Organic Life best illustrates his imaginative genius. Thus, Erasmus Darwin was an extraordinary polymath, an instinctive inventor of mechanical gadgets, and a man who had theories and ideas about everything. Twice married, he had three sons by his first wife and four sons and three daughters by his second wife.

The third son by his first marriage was Robert Darwin, who went to Edinburgh, qualified as a physician, and practiced in Shrewsbury, becoming one of the wealthiest general practitioners in England, a man famous in learned circles, and a Fellow of the Royal Society. He also was the father of Charles Darwin. Robert Darwin was a man of powerful intellect, an immensely hard worker, laboring long hours in surgery and on his rounds. Like his father, he was large—74 inches tall and big boned. He practiced medicine for 60 years. He disapproved of many injurious current practices such as bleeding. His treatment was usually sensible advice and reassurance. As Johnson said, “The best doctors in the early nineteenth century were those who, physically, did the least.” Robert Darwin was one of them. Instead, he provided wisdom and sensibility.

Erasmus Darwin, the father of Robert and the grandfather of Charles, was a member of the Lunar Society, whose members, the Lunatics, met on moonlit nights when their coachmen could see to drive. They included the Midland intelligentsia and successful businessmen and professionals, mainly those with a scientific bent. Nearly all were unorthodox and many were Unitarians. Some were closet skeptics. Among them was Joshua Wedgewood, the Staffordshire potter whose daughter Susannah married Robert Darwin. She provided him with six children, the youngest one being Charles. Susannah was 43 when he was born, and she died when Charles was 8. Thus, Charles inherited the Wedgewood genes of his maternal grandfather, another genius. Joshua Wedgewood (1730–1795) was the 13th and youngest child of an old and prolific Midland family. Many had been involved in the primitive pottery trade. His father had died when he was 8. He was immediately taken from school and put to work. He thus had virtually no education. His intelligence was enormous, versatile, highly flexible, and, above all, practical. He was an empirical scientist on a superhuman scale. Without any theoretical training or knowledge, he understood the physics of baking pots; the chemistry of glazes, dyes, and colors; the geology of clays; and the machinery of mass production. He had an extraordinary talent for design and a gift for introducing new materials, combinations, and colorings.

As the progeny of three such remarkable men, Erasmus Darwin, Robert Darwin, and Josiah Wedgewood—the imaginative genius, the intuitive genius, and the empirical genius—Charles Darwin had access to a gene pool of the highest possible quality. All three forebears were skillful in handling money. Hence, Charles Darwin became a gentleman scientist and remained one all his life. He never had to worry about money. He never had to compromise, limit, or adjust his scientific activities for financial reasons. Accordingly, he was virtually unique among famous scientists. Moreover, he inherited the talent for managing money. Charles Darwin, though he never earned a penny in salary and made scarcely 10,000 pounds from his books in his lifetime, grew steadily richer, and in his later years had an investment income alone of >8000 pounds a year, leaving at his death a fortune, at least 280,000 pounds.

The Darwin and Wedgewood families were thus favored by wealth makers and preservers. They were highly philoprogenitive and clustered in great family groups, living nearby and thus often intermarrying. Charles Darwin married his first cousin and begat 10 children, 7 of whom survived to maturity. Charles Darwin was born into a teeming and valuable acquaintance, which he assiduously maintained and polished all of his life, in many ways but especially by a vast correspondence. Its characteristics were a high intelligence, interest in technical and scientific matters, religious unorthodoxy or disbelief, industry, and persistence. Acquisitiveness, not just in money and property but in specimens of every kind, from butterflies to fossils, was almost universal, and the comfortable rectories and purpose-built villas in which the families lived were crammed with books and cases of stuffed birds, animals, rocks, and potshards, their spacious gardens often containing exotic trees and shrubs, servants of all kinds, and children of all ages. Darwin conformed to this pattern in every respect throughout his life.

Charles Darwin was born on February 12, 1809, the same day as Abraham Lincoln. According to Johnson, Charles Darwin, of all of the great scientists in history, was the most favored by fortune. His genetic inheritance, as described, was magnificent. He had a happy childhood despite his mother's early death. He loved and admired his father. The family was harmonious and the servants plentiful. Charles was born a gentleman in an age when the term had a specific meaning and legal status. He learned to ride a horse and shoot. The shooting sport nurtured his scientific curiosity. At no point did he find it unusual to hunt, catch, kill, and dissect an enormous number of insects, invertebrates, birds, and animals in the quest for knowledge despite detesting cruelty in any form and acquiring a positive affection for the species he investigated. Charles was a collector from a very early age: shells, seals, francs, coins, and minerals. Writing about himself after he became famous, he emphasized that his intellectual development sprang from innate qualities and not from formal education. He acquired a superb command of written English, together with habits of industry and intellectual tidiness. He also developed a strong taste for literature, especially poetry, and he had a great capacity for friendship his entire life.

Charles initially was sent to Edinburgh to qualify as a physician, but after two full sessions his father switched him to Cambridge to prepare for ordination. Charles never showed the slightest enthusiasm or aptitude for medical or clerical life. Quite the contrary—in both cases Charles became a consummate scientific polymath in many ways, except in anthropology. Darwin also failed to acquire, as he admitted, any skill in drawing, and this made it difficult for him later to produce effective diagrams in his works or visual illustrations to organize parts that were hard to describe in words.

The most important sojourns in high places of learning were vital to him because of the scholars he met and the relationships he formed. He was gregarious; people liked him and took to him. He could attract, interest, and, above all, charm when he needed to do so. Moreover, he enjoyed working among the learned at a professional level. He had a natural gift for what we now call networking and a taste for it too. Edinburgh and Cambridge gave him the opportunity to lay the foundation of an immense range of contacts in the scientific world, and he took full advantage of it.

Darwin's time at Edinburgh and Cambridge was of inestimable value to him. It was full of memorable incidents. He attended a meeting of the Royal Society presided over by Sir Walter Scott. In Cambridge he saw two body snatchers lynched by a mob. At Cambridge he was required to read thoroughly William Paley's View of the Evidences of Christianity. This work was and still is remarkable, not so much because it “proves” that nature is the work of a Supreme Being but because it is a model of the deductive logic, step-by-step argument, and, not least, clarity of exposition. Darwin learned a great deal from Paley about how exactly to make a lucid, cogent, and sustained case; if he had not read and absorbed that book, The Origin of Species would have been a much less effective work.

Finally, he met many scholars and formed relationships with them. He made an immense range of contacts in the academic world. One was the Reverend John Stevens Hinslow, formerly professor of mineralogy and later professor of botany and general scientific polymath. Darwin cultivated him assiduously, and he became in turn devoted to the young man. Darwin said that Hinslow's “strongest taste was to draw conclusions from long continued minute observations,” something Darwin learned to emulate. He learned the need to take systematic and copious notes. Hinslow had wide contacts and used them to favor students he esteemed. At the end of the summer of 1831, he wrote to Darwin, saying that he had been asked to recommend a young gentleman naturalist to accompany a global voyage by a naval 10-gun brig for scientific purposes. Hinslow told him, “You are the very man they are in search of, Darwin.” The voyage, of course, was the biggest stroke of luck in his entire life, yet it was not just luck. The First Reform Bill was then before Parliament, and the old order was changing, but in 1831, it was still largely intact and plum appointments went by privilege contacts.

Robert FitzRoy, captain of the HMS Beagle, was himself an aristocrat, pushed up to captain at the age of 27 and now given this excellent assignment largely because his uncle was a famous foreign secretary. The voyage was planned initially for 2 years but it took nearly 5. What the captain wanted as his naturalist was a gentleman companion, who could share his day cabin and his table. Darwin, as Hinslow noted, was “not a finished naturalist” but well on the way—almost certainly the best-educated student naturalist then at Cambridge. But, more important, he had the manners and means of a gentleman. His father supplied him with ample funds, which enabled him to hire a valet assistant at 60 pounds a year (then a huge salary for a servant) and to ensure that all of his specimens and notes were periodically sent back to England during the long voyage in a most expeditious route. The FitzRoy-Darwin combination was thus a double job. The arrangement worked perfectly. FitzRoy was a man with an incandescent temper who occasionally stormed at his companion (he eventually blew his own brains out), but he was an excellent navigator. He quickly saw the point of Darwin and fitted the ship's movement to his program of work. Darwin, for his part, was quiet, obsequious, and conciliatory.

Darwin was given only a month to prepare for his voyage. The Beagle left Devonport on December 27, 1831, and returned to England on October 2, 1836. It visited the Cape Verde Islands, various places in Brazil and Argentina, the Falkland Islands, Patagonia, Tierra del Fuego, the Straits of Magellan, central Chile, Chiloé, the Chonos Islands, the extreme earthquake region of Chile at Valdivia, northern Chile and Peru, the Galápagos Archipelago, Tahiti, New Zealand, Australia, the coral formation of Keeling Island, and Mauritius. At intervals in the 5-year voyage, Darwin would spend a total of 3 years and 1 month on land, traveling widely, collecting botanical, organic, animal, fossil, metallurgical, and mineral specimens of all kinds and recording his observations of flora, fauna, and human inhabitants. He shot a wide variety of birds and animals, went on an ostrich hunt, studied the effects of a large-scale earthquake, observed a major volcanic eruption, and visited tropical rainforests, high mountains, sierras, pampas, other grasslands, rivers, lakes, and a wide variety of shrub, brushwood areas, as well as scores of native villages, settler towns, mines, and cities.

Apart from his older contemporary, the great German naturalist Alexander von Humboldt, who spent the years 1799 to 1804 in Latin America, no other scientist had traveled anywhere as much as Darwin had, making studies on the spot, or had observed so wide a variety of phenomena on land and sea. Darwin called the voyage “the most important event of my life.” The extensive records he kept, both descriptive and speculative, and the specimens he shipped home and brought back with him provided him material for the rest of his life. He wrote a comprehensive account, Journal of Researches into the Natural Histories and Geology of the Countries Visited on the Voyage of HMS Beagle Around the World Under the Command of Captain FitzRoy RN. It formed the first volume of a three-volume report, was presented by FitzRoy to the Admiralty, and was later revised and republished as The Voyage of the Beagle. In addition, Darwin produced and printed a large number of learned articles arising from the voyage. He also circulated his observations, discoveries, and notes widely among the scientific community during the voyage so that by the time he returned to England, he was already becoming well known and highly respected among his peers, and this esteem was reinforced by his publications. By 1840, when he was in his early 30s, he was on the edge of fame.

A shock that Darwin experienced on the Beagle was the emotional frisson of grasping the immensity of time. He became aware of the colossal age of the universe and the earth within it, of the time-space available for almost unimaginable numbers of minute changes to take place and cumulatively to effect staggering transformations. The year before the Beagle set out, Charles Lyell (1797–1875), the great geologist, had published the first volume of his three-volume work, The Principles of Geology (subsequent volumes came out in 1832 and 1833). Captain FitzRoy, who kept up with the latest scientific publications, presented Darwin with the book before they set out. Darwin read it, was enthralled, and got the other two volumes later in the voyage. Lyell demonstrated, beyond any possible doubt, that by dividing the geological system into three groups, which he called Eocene, Miocene, and Pliocene, characterized by the proportion of recent extinct shells embedded in rocks, the age of the earth could be calculated in many millions of years instead of the 6000 or so reached by extrapolated figures given in Genesis and other biblical records. Lyell's work was more effective in presenting the scientific case against biblical fundamentalism than anything that followed, including Darwin's The Origin of Species. Its effect on Darwin was not so much to destroy his faith but to open possibilities. There was no need to look for catastrophic events and huge shocks in bringing about the world and the organic creatures and vegetation on it and beneath its oceans. There had been plenty of time for everything in creation to emerge gradually, and as Darwin had already observed, nature tended to operate so gradually that natural progress could be described as an endless succession of minute events rather than bold acts of creation.

Toward the end of the Beagle's voyage, in spring 1836, he observed such a process of infinite minutiae when the ship called at Cocos or Keeling Islands in the Indian Ocean. To compile a global record of navigable harbors, the admiralty had ordered FitzRoy to investigate how much ocean coral reef had formed to create anchorages. Darwin was put in charge of the project, and he conducted it with such thoroughness and success as to give complete satisfaction to FitzRoy, the Admiralty, and himself. This project, studying the way in which nature effects major changes by a series of countless minute changes over long periods, was exactly to Darwin's taste and appealed strongly to his particular kind of intellect. He much preferred the tiny to the gigantic and the slow to the sudden. The formation of oceanic reefs and atolls from coral polyps had been going on for eons, and the results were measurable. It was still going on and human memory was available to record recent results. The formation was not gradual only, for earthquakes and major storms hastened, reinforced, or diverted the process; by questioning sailors, missionaries, and natives, Darwin was able to include this kind of evidence. But his chief interest was in the actual coral formation, its accumulation, the subsistence it provided, and its relation to volcanos, active or dormant, and to areas where the earth's crust was pushing up or settling down. He divided coral reefs and atolls into distinct categories, explaining why differences occurred and showing why they occurred in specific parts of the sea. The account was eventually published in book form.

His work on the Galapagos Islands, a group of 10 islands with numerous rocky inlets of volcanic formation, may have been even more important. Darwin took intense delight in investigating the creatures he found there, including giant tortoises, marine and terrestrial lizards, and numerous birds, especially finches. It was easy for the Beagle to dump him and a colleague, plus servants, on an island for a week at a time while the ship went on to take aboard fresh water supplies. Darwin had a good chance to take detailed observations while living off turtle soup and roasted turtle's breastplate. He examined the birds in particular, especially the 26 kinds of land birds. He was intrigued by 13 species of finches. He noted that all of the species were peculiar to the Galápagos, with but one exception, and that there were small but significant variations in their beaks. He did drawings of them and then added a significant sentence: “Seeing this gradation and diversity of structure in one small, intimately related group of birds, one might really fancy that from an original paucity of birds in this archipelago, one species had been taken and modified for different ends.” Here was the germ of a seminal idea!

He investigated many other creatures on the islands. He was also struck by the distinctiveness of their flora and fauna. Although the islands were 500 to 600 miles from the mainland, driftwood, bamboo, and other objects from South America washed up on the islands. And the Galápagos were clearly part of the continent zoologically and in other ways. Most land animals and half of the flowering plants were aboriginal productions. Darwin was also struck that the different islands to a considerable extent were inhabited by a different set of beings. Locals, he found, could look at the creatures or plants and tell you which island they came from. In short, not only had organisms on the islands evolved differently from the mainland but within the group, distinct evolutions or transformation had taken place.

The Beagle voyage transformed Darwin from a promising naturalist to a widely experienced and dedicated one. He now knew what he loved: investigating nature in its greatest possible detail and on the widest possible scale. He said later that he had become a machine for accumulating countless facts and finding out from them universal laws. He delighted in being that machine.

Charles's father, Robert, was most impressed with what his son Charles had done on the near 5-year voyage. His father now plainly had the intention and the means to set up his son as a gentleman-scientist, free from financial worries and able to devote his entire time to research. Darwin never had to exhaust his energies on teaching, to scrabble about to get an academic appointment or to keep it by conforming to the fashions and prejudices of the academy and the rules about publication. This blessing had the overwhelming advantage of giving the 27-year-old complete freedom to pursue the lines of inquiry he thought most likely to produce worthwhile knowledge. He had no one to report to except his own conscience and no institution or body to fit in with except the confraternity of learned men. Was ever a scientist more fortunate or happier?

The information discussed above is found in the first 35 pages of Paul Johnson's book. The remaining 110 pages are just as fascinating, and the read is highly recommended.