Warm weather

Thank God for the Gulf Stream Drift. Here we are at 51 degrees North and the temperature is 61 today (16 for the European Union).

In the garden Camelias, Cyclamen and Azalias are flowering.

Death penalty for Saddam

Saddam is about to be hanged. This is the time to consider my views on the death penalty.

The arguments for:

It is the ultimate sanction. Deliberately taking a life should result in your own life being taken.

It is the penalty demanded by Scripture.

It deters others from committing murder.

It concentrates the mind of the murderer so that if he wishes to repent he knows he has but a short time in which to do it.

It brings 'closure'.

The arguments against:

It turns the state into a 'murderer'.

The wrong person might be executed.

It does not really deter.

Life imprisonment is a just puniushment which removes the murderer from repeating his offence and gives him time to contemplate what he has done.

In the case of Saddam there are other arguments against:

It would turn him into a martyr.

The execution itself would be an occasion to foment a riot.

And arguments in favor:

While he is alive the possibility of freeing him remains alive.

Some time in the future a Sunni regime may decide to do exactly that.

The only argument against that counts with me is the possibility of executing the wrong man. Undoubtedly there have been miscarriages of justice in the past. But there seems no doubt that Saddam is guilty.

He deserves death.

Over the past 50 years there has been a movement to lessen the significance of evil. People make excuses for it. It was his upbringing or his genes to blame. There is a willful misinterpretation of Scripture. "Thou shall not kill" is not a blanket ban on killing. Even a cursory reading of the Bible demonstrates that God sanctioned both killing of the enemy in war and judicial killing of criminals. I know that people tend to say that that was the Old Testament and we have different standards in the New Testament, but that is also incorrect.

Luke reports the thief on the cross saying, "We are punished justly, for we are getting what our deeds deserve." and later relates the story of Ananias and Sapphira who were struck dead for witholding from God what they had promised to give. Again King Herod was struck dead by an Angel of the Lord in Acts Ch 12 v 23, for setting himself up as a god. In I Corinthians Ch 11 v 30 Paul clearly indicates that some have died because they abused the Lord's Supper. Undoubtedly, both Old and New Testaments take a severe view of sin, and certainly don't rule out the death penalty where appropriate. Those who believe that Christians ought to be against the death penalty are making up their own religion.

The Archbishop's Christmas Message

From the Times today this comment on Iraq.

Christians in the Middle East are being put at unprecedented risk by the Government’s “shortsighted” and “ignorant” policy in Iraq, The Archbishop of Canterbury, Dr Rowan Williams, says today.

In an extraordinary attack, Dr Williams accuses Tony Blair and the US of endangering the lives and futures of many thousands of Christians in the Middle East, who are regarded by their countrymen as supporters of the “crusading West

How strange! I have seen no news items about US or British troops hunting out Christians and shooting them. Oh, I see! It's the fanatical Muslims who are terrorizing the Christian Iraqis. But aren't they also terrorizing thousands of moderate Muslims too? People are suffering in Iraq because armed gangs are rampaging in the streets without the control of law. Indeed these armed gangs have been recruited into the law-enforcing agencies and are murdering their political enemies by masquerading as policemen.

What does the Archbishop of Canterbury suggest? That British and American troops should leave and allow the opposing militias to slug it out until the land is bare of infesting humans? I suppose he can claim Biblical precedence. Jesus taught his disciples to 'shake the dust off their feet' and leave any village that did not receive them. But there is another precedent. Abraham negotiated with God, not to destroy Sodom if there were to be found ten righteous men in that city. As we know only Lot could be found as an example of righteousness and it was easier to remove Lot than preserve Sodom. Are there not ten righteous men in Baghdad?

What Rowan Williams is offering is appeasement of a particularly craven sort. If I keep my head below the parapet and don't make a fuss, perhaps they will leave me and mine alone.

Let us be clear: the evil doers in Iraq are not Tony Blair and George Bush. However unwise the invasion of Iraq has turned out to be, however, maladroit has been the handling of the occupation, their instincts in removing Saddam were correct.

Saddam was an evil dictator with no concern for his own people or his neighbors. In the film "Lords of War" the Ian Holm character was accused of selling arms to both sides in the Iran/Iraq war. "Has it ever occurred to you that I wanted both sides to lose?" he replies. That was the attitude of a lot of people at the time, but undoubtedly Saddam's regime was utterly vile.

The invasion of Kuwait gave the rest of the world sufficient cause for restraining him, but fear of unleashing chaos in Iraq held Bush 41 back from removing him. Instead he was hemmed in by sanctions.

Sanctions seldom work. Those imposing them are accused of harming the poor and needy. Pictures of starving children and hospitals without medicines were used to justify the oil for food program, money from which was diverted from food to palaces. France, Russia and China all connived with Saddam to beat the sanctions. The UN, which employs some of the biggest crooks on the planet, turned a blind eye to corruption within and without.

The choices in 2003 were to give in to Saddam and allow him to resume his nuclear ambitions or to take him out by actually enforcing Resolution 1441. Some nations for very good pecuniary reasons wanted a UN fudge; other saw more clearly that the charade could not continue.

I see Bush 41’s error as similar to King Saul’s in 1 Samuel chapter 15. Saul failed to utterly destroy the Amalekites and George H Bush failed to utterly destroy Saddam. Bush 43 had an option in 2003. He might have crushed completely the Baathists and installed a puppet king; instead he trusted the Iraqis to sort out their own mess with a little aid and training. By committing too few troops he ended up with a worse mess than he started with. Nearly every savage Muslim in the world has descended on Baghdad looking for trouble, and worse, their partial success has been an efficient recruiting sergeant.

Parallels with Viet Nam are easily drawn. A military success is allowed to become a propaganda defeat. The fourth estate has become a fifth column. Potentially Bush had five years to win this war but he squandered the goodwill and by losing the mid-terms he has emasculated himself.

There was a time when Christians would stand up and oppose evil. Robert Raikes saw poor children unable to read and write and started Sunday Schools, the forerunners of public education. William Wilberforce saw the slave trade and campaigned for his whole life to abolish it. Lord Shaftsbury saw children in factories and fought to abolish the practice. William Booth saw drunkenness destroying families and founded the Salvation Army. John Howard and Elizabeth Fry and the prisons, Florence Nightingale and hospitals, Dr Barnardo and orphans; all Christians who saw evil and stood up against it. Rowan Williams sees the evil of murderous Muslims in Iraq and lies down before it. If we keep very quiet and very small they might pass us by and go and kill somebody else instead.

Children's Christmas

Christmas is really
for the children.
Especially for children
who like animals, stable,
stars and babies wrapped
in swaddling clothes.
Then there are wise men,
kings in fine robes,
humble shepherds and a
hint of rich perfume.

Steve Turner's poem tell it all. We Christians would like to strip off the commercialism, the adverts telling us about Christmas food, special because they're M&S nauseatingly-rich, atheroma-inducing, mince pies; or Noddy Holder repeating incessantly, "But here it is, Merry Christmas, everybody's having fun"; or Business Report inviting us to shop harder because the retailers are missing out on their bonuses; or cheeky young kids who ring your doorbell and sing one chorus of Jingle Bells and expect to be tipped as carol singers, and when asked to sing a proper carol, can just manage, "Away in a manger la, la, la, la, la." before drying up. We could all do without the drunken parties and the parade of broken Nissans, Toyotas and young men left in their wake.

For most of us it takes us back to childhood. Christmas trees and fairy lights, dads dressed up like Santa, carols by candlelight, boys who want to be Joseph and girls who want to be Mary but both settling for third shepherd, Little Donkey and Little Drummer Boy. And babies.

I'm all for the sentiment, but it can mask what it's all about just as much as the commercialism.

The second stanza of Steve Turner's poem explains.

Easter is not really
for the children
unless accompanied by a
cream filled egg.
It has whips, blood, nails,
a spear and allegations
of body snatching.
It involves politics, God
and the sins of the world.
It is not good for people
of a nervous disposition.
They would do better to
think on rabbits, chicken
and the first snowdrop
of spring.
Or they'd do better to
wait for a re-run of
Christmas without asking
too many questions about
what Jesus did when he grew up
or whether there's any connection.

Everybody likes a baby, but let's not get mawkish. This baby came for a definite purpose; he came specifically to die. "But when the time had fully come, God sent His Son, born of a woman, born under the law, to redeem those under the law." (Galatians 4:4-5). Most of the Christmas hymns that we sing duck the issue except perhaps:

Who is he in yonder stall
At whose feet the shepherds fall?

Who is he to whom they bring
All their sick and sorrowing?

Who is he who stands and weeps
At the grave where Laz'rus sleeps?

Who is he on yonder tree
Dies in grief and agony?

Who is he who from the grave
Comes to rescue, help and save?

Who is he who from his throne
Comes to make the world his own?

'Tis the Lord! O wondrous story!
'Tis the Lord, the king of glory!
At his feet we humbly fall.
Crown him! Crown him Lord of all!

That's why this baby deserves such a welcome. That's why we give gifts at Christmas - to commemorate God's indescribable gift to us (2 Corinthians 10:15).

Christmas is coming.

The cold weather has certainly come to Britain. I remember one Christmas, it must have been 1957, when we had a houseful of visitors at Christmas, so much so that I was sleeping with brother on a matress on the living room floor. On that room the curtains didn't reach the floor at the French windows. I woke in the middle of the night to see snowflakes falling, snow on snow, as the carol says. That was about 40 miles from the sea; here on the coast we seldom have a white Christmas. This year it will be white, but white with frost and white with fog, but I doubt it will snow

There has been chaos at the airports, with most domestic flights cancelled. Eventually one 747 gathered up those waiting at Gatwick and took them to Edinburgh. The roads have not been much better, with crashes and delays on most of the motorways.

I have been out walking into the shops, rather than take the car. Well wrapped up, I have managed to keep warm and bought lots of silly things to go in my grandchildren's stockings. This is an annual tradition. The big presents are under the tree, to be opened after church, but the smallest ones in the house have stockings full of nonsense on their beds . Last year the youngest was 25, but this year we have some children.

I have been watching Dekalog by Krzysztof Kieslowski. This is a series of Polish films, each one hour long, and each loosely based on one of the Ten Commandments. Made in 1987 they are all set around a dreary tower block in communist Poland. Being Catholic they omit the Commandment about graven images and split the coveting into two (your neighbors ass and his wife). I shall have something to say about them in a later blog.

I have also been building models for my grandson's model railway - so far a footbridge and a country church.

I am determined not to think about CLL this week. I have chalked it up as holiday.

Murder in Ipswich

They have arrested a man for killing, in the past 2 weeks, five prostitutes in Ipswich, the county town of Suffolk, and a miserable place - at least that's what it seemed like the only time I drove through it. Previously, its only claim to fame was its football team, which won the First Division some 40 years ago when managed by Sir Alf Ramsay, later to manage England in its only World Cup Victory. Another Ipswich manager, Sir Bobby Robson, also went on to manage England, though his best effort was to reach the semi-finals of Italia 90. A former Ipswich player, Paul Mariner, was once England's center forward.

All five prostitutes were heroin addicts, on the streets to feed their habits even though they new that someone was killing the working girls. The murders have led to calls for the legalization of both prostitution and of heroin. A similar libertarian demand might as well call for the legalization of murder.

Prostitution is not one business. At the lower end of the market, most of the girls working the streets are drug addicts, though a few are teenage runaways. Social security payments are enough to live on, but they are not available to the very young, who ought to be back with their parents, nor enough to support a drug habit.

Some street girls and some operating from brothels are controlled by a pimp, who may control them by supplying heroin or cocaine. Increasingly there are illegal immigrants who have been seduced by offers of a job, which turns out to be in prostitution, yet the girls dare not go to the police for fear of deportation.

At the top end of the market, the girls dress well, behave immaculately in public, and make a large amount of money. Their choice of prostitution as a livelihood is not out of necessity, but out of greed. For them it is a way of maximizing their income. Some even like the lifestyle.

In between are any number of variations on the theme.

The argument for legalizing prostitution is to remove the criminality. Just as prohibition brought the mafia into the sale of alcohol, so, the argument goes, the sale of sex is only infiltrated by criminals because it is illegal. The same argument is used in favor of legalizing hard drugs. It has been suggested that heroin be provided for free on the NHS.

The NHS is one of the reasons why neither prostitution nor hard drugs are likely to be legalized in the UK. The argument that I can do whatever I like to my body as long as it harms no-one else doesn't work if somebody else has to pick up the tab for the damage done. But even in America the cost of health care for the underclass on drugs and infected with sexually transmitted diseases is picked up by the taxpayer. The only arguments that wash with the taxpayer are economic ones, not moral ones. So if it could be shown that decriminalizing drugs would lead to fewer robberies and burglaries, less street violence and fewer infections from shared needles, then it might be a runner. Experience tells us, though, that the criminals will find something else to make their money from.

Prostitution is not illegal in the UK. The offences are soliciting, kerb-crawling, living off immoral earnings and running a brothel. Private arrangements between consenting adults are regarded as nobody's businee but their own.

A story, apochryphal I'm sure, is told of Henry Kissinger dancing, as was his wont, with a tall statuesque blonde, and whispering in her ear, "Will you sleep with me for $100,000?"

After receiving an answer in the affirmative and after a few more spin turns he asked again, "Will you sleep with me for $10?"

Affronted, she slapped his face, "What do you take me for, a common prostitute?"

"Madam," he replied, "we have already established that. Now we are negotiating as to price."

It is probably impossible to separate sex and money; however pure the majority someone will always find a way of connecting them.

Partition?

Here's an unwelcome fact. At the fall of the Ottoman Empire after the first world war, Britain had 410,000 troops in Iraq to control a much smaller population. America has 140,000 troops there now, and is considering withdrawing them. The Saudis are considering seriously funding the Sunni insurgents if the Iranians continue to fund the Shiites.

The Iraqi constitution was designed to allow the oil to be divided fairly between Sunni, Shiites and Kurds. If it comes to partition the Sunni will be the losers as there is little oil in the Sunni areas.

Although I doubt that the numbers of Iraqi dead are anything like the 600,000 estimated in the Lancet article, the numbers of Iraqis killing each other has grown and is growing.

Europe went through all this in the seventeenth century. Does no-one learn from other people's mistakes?

My text is John 3:18

John 3:18

"Whoever believes in him is not condemned, but whoever does not believe stands condemned already because he has not believed in the name of God's one and only son."

For those who don't read the 'Comments' section I draw your attention to this question from a reader:

Terry, do you really believe yourself that non-christians are all condemned automatically, that it is more important to have the right caling card than being a good person? That sounds rather arbitrary and un-just.

This is how I replied:

What is good?

When I was at school I remember being examined in woodwork. The project that session was to make a teapot stand. I don't think that mine was fantastic, and it was certainly not anything I would give houseroom to, but the angles were accurate and it fitted together without nails or glue.

The schoolmaster was marking the students' work but was getting bored with it. Eventually there were only a few teapot stands left in the box. He sneered at what was left. "All the rest can have 5%" he said.

5%! I only needed 50% to be top of the class. I protested. Taking my stand together with one of the others in the box I complained to the schoolmaster. "My teapot stand is much better than his," I insisted. "His has nails sticking out and it isn't square."

"You're right," answered the master, "you can have 6%."

There is another way to get to heaven. Can you get 100% in everything you do? If you are perfect you will be admitted to heaven. That's the standard. Unfortunately, the difference between the best of us and the worst of us is the difference between those teapot stands - the difference between 5% and 6%.

But trust in your own righteousness if you want to; I would rather trust in Jesus.

Getting to heaven isn't difficult. We don't have to climb Everest or swim the Atlantic. Just trusting Jesus is all; it involves a bit of pride swallowing which can be daunting.

It would be nice to think that everybody could go to heaven on their own merits. What a perfect world we would have if that were true! Were it so then the crucifixion would have been unnecessary.

As it is, Jesus said, "No man cometh to the Father but through me."

I want to expand on this.

It is not simply a matter of having the right label. A verbal assent to God and a life of dissolute behaviour will not do. "Faith without works is dead," wrote James. Nor should we think that we are repaying God for our salvation - as if we could! Paul wrote, "It is by grace (grace means an act of undeserved mercy) you have been saved, through faith - and this not from yourselves, it is the gift of God - not by works, so that no-one can boast. For we are God's workmanship, created in Christ Jesus to do good works which God prepared in advance for us to do. (Ephesians 2:8-10.)

Does this mean that only Christians can do good things? Of course not! Christians believe in something called common grace. In his mercy God restrains evil and uses the good deeds of men, believers and unbelievers, to fulfill his will. And it is not his will that any should perish. Peter wrote, "He is patient with you, not wanting anyone to perish, but everyone to come to repentance." (2 Peter 3:9).

Christians are sometimes accused of exclusivity. It is believed that they think of themselves as an exclusive club - extraordinary people with special merit - with special rights of entry to heaven. The truth is quite the opposite. Entry to heaven is a free gift available to anyone, rich or poor, Jew or Gentile, black or white, clever or stupid, male or female, laborer or intellectual, child or old person, Democrat or Republican. It was available to Hitler and Stalin.

Of course, Heaven is not what everyone wants. If you revel in hatred, desire dominance, delight in the unkind put-down, enjoy cheating your boss, your wife or your neighbor, love a lie or think yourself a God, then Heaven may not be what you're looking for. If you were in heaven like that you would spoil it for everybody else. If Godly characteristics are not up your street there is a place from which God has withdrawn even his common grace.

Look around yourself. Do you see evil in the world? I do.

Look into yourself. Do you see evil there? I do.

Paul writes quoting the Hebrew Bible, "There is no-one righteous, not even one; there is no-one who understands, no-one who seeks God. All have turned away, they have together become worthless; there is no-one who does good, not even one." (Romans 3:10-12) and he adds his own comment, "All have sinned and fall short of the glory of God." (v23)

If you say this doesn't include you, your standards are too low and what is more the Apostle John says you make God a liar.

Do you know anyone else who offers a remedy for your sin?

But Paul continues about all those who have sinned and fall short (the old English word 'sin' is an archery term that means your arrow falls short of the target), he continues, "they are justified freely by his grace through the redemption that came by Christ Jesus. God presented him as a sacrifice of atonement, through faith in his blood. He did this to demonstrate his justice, because in his forbearance he had left the sins committed beforehand unpunished - he did it to demonstrate his justice at the present time, so as to be just and the one who justifies those who have faith in Jesus." (v23-26)

Christmas is celebrated all over the world because it marks the day that God intervened in the mess we had made for ourselves.

Tests

I suppose they are called test matches because they test the patience of the most loyal English supporter. It looks as though by tomorrow it will be all over bar the shouting and the Ashes will be back in Australia's hands. It is difficult to work out exactly what went wrong, although it has to be said that England's for since winning the Ashes has not been good.

Several of the better players are missing including the captain, and it seems that giving the capataincy to Flintoff was as big a mistake as giving it to Botham in 1981. They are similar sorts of players. Their cricket is instinctive rather than thought out, and captaincy requires a thinker. No doubt having to run the match threatens one's own form for a while, but a good captain is worth his place even if he averages 25 with the bat as long as he induces the other batsmen to average over 40 and the bowlers to take wickets. Captains who are tyros with either bat or bowl tend not to bring out the best in the rest of the team.

This England team is young and inexperienced, with too many not used to Australian wickets. Nowadays the tours are so short and the games so few that there is little time to bed into the pace of the ball of the wicket and, especially in Perth, to the bounce.

My son flies to Melbourne on Christmas day. It looks as though it will be a dead rubber byefore he arrives.

Debunking Christmas

I brought my children up not believe what people told them without checking the facts themselves. I'm glad to see that my eldest son at least was listening. Over on his blog he does a pretty good job of debunking the impression that the secular world is out to destroy Christmas.

In my view just the opposite is occurring. Christmas has become a very secular holiday. The retail industry does a huge proportion of its business during the Christmas shopping period, and, whatever they say, it shows little sign of diminishing. Of course they won't get rid of Christmas. "Season's Greetings" and "Happy Holidays" represent a PC attempt to avoid giving offence by mentally challenged individuals who know next to nothing about any religion, but the number of people who really want to take religion out of Christmas is vanishingly small. They hit the headlines on slow news days.

Christmas in the West is full of recent accretions to a schmalzy version of the Nativity. The following played no part in the original Christmas story: Santa Claus, the Grinch, Jack Frost, Father Christmas, Rudolf, Jingling bells, 3 kings, camels, Kris Kringle, children, Bing Crosby, snow, sleighs, reindeer, Scrooge, pipers piping, Tiny Tim, 34th Street, Snowmen, fir trees, turkeys, mince pies, plum puddings, tinsel, pumpkins, Chestnut Stuffing, mulled wine or alcohol of any sort, colored glass balls, carols, holly, ivy, merry gentlemen, stable, December 25th, mistletoe, Slade, innkeepers, stockings, cards, nuts, chocolates, dates, cakes, three ships, figs, colored lights, oxen, donkeys, little drummer boys, scarlet ribbons, berries, Morcombe & Wise, robins, Frosty, Elves, The North Pole, Polar Express, Partridges, The Nutcracker, Mother Goose, Babes in the Wood, Jack and the Beanstalk, Cinderella, Alladin, Egg Nog, Hershey's Kisses, Yukon Cornelius, Home Alone, The Queen, Crackers, paper hats and Robin Goodfellow.

Angels were there and so were shepherds. Magi eventually turned up following a star. Nothing is said regarding the mode of transport of either the Magi or Mary. There were three gifts which makes people think there werte three Magi, but all we know is that they were plural. The inn is a mistranslation. Elsewhere the Greek is translated as 'the upper room'. In the house downstairs the animals lived, but we don't know what sort of animals they were. The manger (feeding trough) was probably made of stone not wood. Herod had all the babies younger than two slaughtered, so the magi finally arrived any time up to two years after the birth. Biblical scholars have calculated the birth date as 23rd September 4BC, but I doubt anybody could be that precise. Martin Luther was overegging it to say of the baby Jesus, "No crying he made." There were a lot of dreams.

The Puritans baned Christmas in England, though it didn't last for long. Later they banned it in America.

I like Christmas, despite the extras clinging to it like barnacles. They represent the artistic impressions of Christmas added by countless generations. Of course they are often fairly trivial, and individually we could do without this or that, but about this time of year when the tree is decorated and a CD of carols is playing on the Hi-Fi, and presents are being wrapped, and neigbors drop in, and children are excited, and the streets are festooned with lights, suddenly there is a moment of silence and we remember that God became Man at Bethlehem specifically to die in our place. Facing certain destruction we are suddenly rescued. No wonder we rejoice.

ASH

ASH is over for another year. I arrived back on Tuesday morning and spent most of the day falling asleep at inappropriate times. Today I spent in London at the Gene Therapy Advisory Committee. One of the applicants sent his apologies as he had just returned from ASH. I saw him on the same plane as me, so if I could make the effort why couldn't he? I had the longer journey.

This year I decided to remain on European time to try an avoid the jet lag. Tuesday was still a write off. I really can't remember much about it. Apart from the 158 e-mails that I answered.

I will blog later about the impressions that ASH made upon me, but here are a few thoughts.

Over 150 CLL abstracts, but was there really a need to put on oral presentations on CLL at the same time so that it was impossible to go to everything?

Orlando has new entertainment attractions since the last time I went, but there was no time to visit any of them.

I'm sure that paying £3000+ for business class is not worth it. It would be more sensible to fly via New York, sleep in an airport hotel and get the daytime flight across the Atlantic - total cost around £500. The seats that lie flat in business class are too narrow and very hard.

American food is vast and tasteless, but they do good sandwiches.

I suppose it must be time to prepare for Christmas.

More Sword of Truth

I have just finished the ninth book in the Terry Goodkind "Sword of Truth" series. If you read the reviews on Amazon it seems that readers have got tired of the plot not moving on very much while being subjected to Goodkind's right-wing propaganda. I disagree. I think that in this book Goodkind tackles an important issue, that of pacifism.

I long ago decided that I was not a pacifist. As a teenager I flirted with the idea, declaring that although prepared to die for my country I was not prepared to kill for it. I grew to like my life too much for that. I am happy to live to benefit my country, and prepared to risk death if the cause is right, but rather than let an oppressor kill me in the hope that he would have it on his conscience, I would kill him first if I got the chance.

Goodkind propounds the view that the greatest danger to a community is the failure to recognize evil. To call evil misguidedness or lack of parental discipline or a deprived childhood or the consequence of poverty suggests that it is an illness that can be cured. Alas it is not so.

The Christian gospel offers redemption for sinners. Some liberal Christians believe that all will be saved and that Hell will be unpopulated (except perhaps for Hitler, Stalin and Menachem Begin). They believe that, even after death, unbelievers will be given a second chance. Some believe that good Jews or Moslems or Humanists are a sort of honorary Christians, and that the blood of Jesus was sufficient to redeem them even though they didn't know it and indeed had rejected the claims of Christ in their lifetimes. Some believe that there is always hope of a deathbed conversion and that no matter how wicked has a man been during his lifetime, we cannot know what interchange with God took place during the final moments of life.

From this premise they oppose the death penalty, they oppose war, and they oppose violence.

This view has elements of truth within it, but the end result is destructively wrong.

Jesus' blood is certainly sufficient to cover every sin, but it is not applied unless it is accepted. "God so loved the world that he gave his one and only son, that whoever believes in him shall not perish but have eternal life." Presumably those who do not believe in him will perish. Of course, because a couple of verses later we read, "Whoever believes in him is not condemned, but whoever does not believe stands condemned already because he has not believed in the name of God's one and only son."

We have so few of the actual words of Jesus that people are apt to make up their own Christianity, but here we have the actual words of Christ, and not some obscurantist words with alternative interpretations; these are words quoted now, always and everywhere as being Christianity in a nutshell. They are from John's Gospel Ch 3 verses 16 and 18.

The chapter continues, "Light has come into the world, but men liked darkness instead of light because their deeds were evil. Everyone who does evil hates the light for fear that his deeds will be exposed."

Jesus certainly recognized evil.

Would Jesus have opposed the death penalty?

He was himself subjected to the death penalty, and he confronted it when others were punished in the same way. It is interesting to view his response to the death penalty inflicted on two thieves who were crucified alongside him. Had he wished, he could have come down from the cross; he had that power. He could certainly have saved the two thieves. One of the thieves recognized this, "Aren't you the Christ? save yourself and us!" But when the second thief spoke to him like this, "Don't you fear God? (rebuking the first thief) We are punished justly, for we are getting what our deeds deserve, But this man has done nothing wrong. Jesus, remember me when you come into yours kingdom."

How did Jesus respond? "I forgive you, come down from the cross"? "This is the sort of injustice that you get with the death penalty"? "You have had a deathbed conversion, you don't need to be executed"? No. He says, "This day you will be with me in paradise."

Trying to make allowances for evil leads to appeasement rather than war. Appeasement is very popular at the time. Chamberlain was a popular man when he came home from Munich waving a piece of paper. True leadership requires toughing it out when life gets difficult. Churchill knew this. The foreign secretary, Lord Halifax, (he was the one who argued against bombing German munitions factories because they were private property) wanted an easy peace with Hitler. Churchill stood alone resisting the evil Hitler while everyone else had capitulated.

Margaret Thatcher knew this. After losing destroyers and her helicopters to the Exocet missiles sold to the Argentineans by the French and seeing soldiers burn to death on Sir Galahad, there were many advisors, not least the American Secretary of State, Al Haig, urging her to make peace with the evil oligarchy. She resisted the temptation and some rather tough soldiers marched, where they could not fly, across the frozen hills of the Falklands to take Port Stanley.

There is a lot of evil still out there.

In Goodkind's story the pacifists survived for many hundreds of years because of their remote location, but when finally invaded by brutal conquerors, they send for a hero to free them. But they view the hero as a savage; necessary to defeat the invader, but beneath their level of civilization, just someone to do the dirty work.

The hero refuses the task, recognizing that you can't defeat evil without the whole community steeling itself to resistance. It's like a viral infection in a CLL patient, get rid of this one and another will be along in a moment. Without stiffening the resistance there is no point to it.

An allegory for our time? You might think so, I could not possibly comment.

Food for thought

I had my first Christmas dinner yesterday. This morning I topped the 200 pounds mark. This year has been a poor year for the Hamblin shape. Last year I was down below 190 having reached 210 in 2004. I even had 2 inches taken in from the waist of every pair of trousers.

I know the remedy. Eat less and exercise more. The problem is, I like eating and dislike exercise.

That's not entirely true. Exercise can be exhilarating. When I am fit, a brisk walk on the beach, a cycle through the forest or even a jog to the hospital sends the adrenaline zinging round the body and leaves me with a warm glow, but getting fit: there's the rub. I gave up my gym membership in 2005; my daily cycle trip was sufficient to keep me losing about half a pound a week while cutting out bread and limiting potatoes to one a day. Then came Christmas. I like nuts. Nobody else does. Someone had to eat them.

If you were brought up under post-war austerity you were taught to leave nothing behind on your plate. It is hard to drill yourself into tasting a bit of this and a bit of that and leaving the plate fairly full, especially at Christmas. But that's what must be done.

Today I am fasting. Tomorrow as I sit in the British Airways executive lounge waiting for my flight to Orlando I must avoid the smoked salmon sandwiches and the claret. I must eschew the free glass of champagne as I get on the plane. I must get up and walk around the cabin.

I must keep repeating this mantra: Let it go to waste or else it will go to waist.

CLL mistakes

How much do general haematologists know about CLL? I have just been consulted about a patient who died of complications of treatment and I identified three mistakes that seem to be quite commonplace.

Mistake 1] Late diagnosis. Nowadays people are having more frequent blood tests. The usual reason is to look for anemia in someone who is 'tired all the time'. Almost always the hemaglobin comes back normal, but modern blood counters give a lot of extra information. What should a hematologist do if the lymphocyte count count comes back greater than 3.5? In our lab we look at a blood film, and unless the extra lymphocytes are large granular cells, we do some simple immunophenotyping. We pick up an extra one or two cases of early CLL every week like this.

Does it matter? Most cases of CLL are fairly indolent and immunophenotyping is relatively expensive. So what if the CLL is not diagnosed until the lymphocyte count reaches 10? In 99% of cases it doesn't matter, but in the remaining one in a hundred there is a p53 deletion and late diagnosis can seriously harm the patient's health. A lot of money to pay for one in a hundred? Sure, but it's a lot of money if you get sued.

Mistake 2] Missing hemolytic anemia. Hemolytic anemia occurs in about 15% of patients with CLL. It can be severe and even fatal. The features are a rapidly falling hemoglobin and a positive direct antiglobulin test (Coombs test). This demonstrates that an autoimmune process is going on and that pretty big doses of steroids are needed. Autoimmune hemolytic anemia in CLL differs from other types in one particular, normally one would expect to find a rush of young red cells coming into the blood to replace those that have been destroyed. These young cells are called reticulocytes. In CLL this may not happen because the bone marrow is so stuffed with leukemia cells that there is no room to make new red cells. This can be a problem because you can get a positive Coombs test in CLL without hemolysis, so if there are no reticulocytes teh diagnosis is difficult to confirm.

If the anemia is very severe, it would be unwise to assume this is not hemolytic anemia. There are other tests that will help confirm the diagnosis. Looking at the blood smear you can see red cells that are spherical instead of flat discs. A protein called haptoglobin disappears from the blood because it is used up clearing released hemoglobin from the circulation, but the test that everybody forgets - probably because it is a urine test, normally done by nurses is a dipstick test for urinary urobilinogen. This is quick and easy, and an increase tells you that red cells are being broken down more rapidly than normal.

Mistake 3] Failure to recognise when CLL is drug resistant. The commonest cause of drug resistance is an abnormality of the p53 pathway. This is most easily detected by a FISH test for chromosome 17p.

p53 is required by most drugs to kill CLL cells, including chlorambucil, fludarabine, pentostatin, cladribine, cyclophosphamide, adriamysin, vincristine, rituximab and low dose steroids. The only drigs that we know work in p53 deficient CLL cells are high dose steroids, Campath and flavaperidol.

But you don't need sophisticated tests to discover the CLL is drug resistant; just give a couple of courses ofchlorambucil or fludarabine. If the patient is not by then in a partial remission the CLL is probably drug resistant.

These are not very difficult concepts to grasp: common sense really. Even if a hematologist is more interested in acute leukemia there is no excuse for not getting this right.

Christmas giving.

I doubt that it made many headlines in Europe or the USA but a couple of months ago a devastating typhoon that hit the Philippines south of Manilla.

For a while now we have been supporting a couple of Filippinos in this area in their work of reaching the lost for Christ.

Lourdes Manabat runs a Christian school on the mainland south of Manilla, the photograph shows some of her pupils. Her husband, Venancio, known as 'Boy', pastors a church on the island of Mindoro, which is a boat journey away. He also runs a free school for the Wawa people on the island. The church on Mindoro recently celebrated its first anniversary on the Island. the picture here shows the entrance. In addition he has undertaken the pastoring of another church on the island.


Recently, we received this e-mail from the Manabats.

"Two months ago, there’s a typhoon named “ Milenio “ a super typhoon strike Mindoro. Sad to say, that the church where our Brethren gathers, totally swept away. Now, they only gather in a four post with shade.

Here is an illustration.

The members in the church want to build it again, but they don’t have means to do it, for most of the members are farmers and selling charcoal that they get in the mountain. Now, as the steward of God in that place, we are burdened. We are praying and praying and think of means on how the church will be built again.

In San. Vicente, there is no Christian Church. Now, through the Grace of God, there will be a Christ Centered Christian Church in that place. Include us always in your prayers, that God will speed up the time in answering our prayers, to build a church building for the Glory of God. The estimated cost to build a simple church building is 3000,00 US dollars. It is not a concrete one, it will be made up of logs, woods and Galvanized Iron sheets. This Christmas, its our hope and faith that the church will be rebuilt again, so that they can worship God in a new sanctuary on Christmas eve.. And it will be a testimony to the community that our God is alive and can make a way, even there’s seems to be no way.

Since Ptr. Boy is pastoring two churches, 25km. Away from Wawa, we are praying for a motorcycle for him to use in taking care of the flock, transportation in going there is limited and there’s only a designated time for the tricycle to go there. We are praying for 1000,00 U$ to buy a motorcycle."

Today, we received another e-mail from Lourdes.

"Greetings in the Most Precious Name of our Lord Jesus Christ.

How are you? Its always our prayer that you are fine and always in good health and the whole family.

This week, the typhoon " Reming " strikes again the Philippines, specially the Province of Bicol Region, where hundrends of people died and buried alive by mud flows.

In Mindoro, our mission field was also strike by the typhoon. The mission House, where Pastor Boy leave was hit by a electric post and a tree. Praise God, for my husband transfer in the church before the post and tree fall down. In the church, he was not able to save the instruments used in Praise and Worship from water. The Church was being used now as an evacuation center,for the houses of the members were badly damage and needs repair.They are just made by nipa hut.

The church in Sn. Vicente... again...totally swept away for the second time. The members are so depressed. I dont know if where they held their worship service yesterday.

There are things that sometimes we dont understand. Christmas is coming, but before Christmas... disaster hit the Philippines, and most of our members were affected, not just their house, but even the Church. They really need prayers and to understand that all things work together for good....

Two days now, i dont have communication to my husband, i dont know now what is happening there, for theres a problem in electricity and communication.He mentioned to me last Friday that the tower of Globe telecoms fell down. But i trust God, that he is fine...

Remember us in your prayers, remember our brethren there in Mindoro. Their livelihood is fishing, but now...they cannot go out in the sea to catch fish to supply their needs.Help us in praying for a miracle blessings for them to survive and overcome all these things and become victorious in their christian life and with all these trials.

As their flock keeper, all we can do is to pray and ask for prayers, that miracles will happen. Some expect from us, but we expect God to move in a miraculous way.

Im so sorry for telling you every detailed of our ministry, you are also our prayer partner and this is also your ministry in the Philippines. You can share our situation and ask for prayers to our brethren, for we really need it... Through prayer, Gods hand move mightily.

God willing, the school permit will be released on the 6th of December. I already got the Mayors Permit.

Please,as Aaron's sponsor, dont be disappointed if Aaron stop in his schooling, we tried our best, but financially, we cant (Aaron is her son). We are disappointed also, specially Aaron, but we can do nothing but to accept it.the everyday expenses becomes our problem, not the entrance fees, because you provide it for them. Sir, i hope you understand. As parent, we want our children to finish their schooling..., but our present situation is our problem.... but i know...this is only TEMPORARY, for the Lord says..." for i know the plans i have for you, plan to prosper you and not to harm you, plan to give us hope..." As Christian, we need to pass this trials...and we will pass it, in Jesus Name.Amen."

We are obviously responding to her plea, but I have posted this message in the hope that others might like to share in this ministry. St Paul wrote this to the Church at Philippi, “ Not that I am looking for a gift, but I am looking for what may be credited to your account…” (Phil ch 4 v 17)

If anybody reading this has the opportunity to visit the Philippines you would be very welcome to help in this ministry of church building.

Vladimir Polon

A few days ago I posted on the folly of buying the new Eurofighter to defend ourselves against attack by the Russians. Has all this changed with the apparent murder of Alexander Litvinenko in London?

After faffing around with stories about Thallium, it has become clear that he was killed by ingesting the radioactive substance Putinium 210. Media speculation has it that his assasination was ordered by Russian President Vladimir Polon. Is this likely to be true?

The Russians have a history of murdering dissidents in London. Georgi Markov, the Bulgarian, was killed during the Cold War by a ricin injection from an umbrella tip.

Funny how these conspiracy theories have a hematological flavor. Ricin, the poison derived from the Caster oil plant, is employed as an anti-cancer agent. Ricin is one of the ribosome inactivating proteins which inhibit protein synthesis by enymatically interfering with the binding of the 60s microsomal subunit to elongation factor 2 (which I wrote about in Lancet 1983 i:512). Despite the many attempts to use ricin as a warhead for immune guided missiles, killing Russian dissidents seems to be the only practical use. Now we have the Russain dissident apparently killed by radioactivity which among other things wipes out the bone marrow.

Like most commentators in the MSM I have obtained most of the following information from Wikpedia.

Polonium was discovered by Marie Curie in 1897 while investigating the cause of pitchblende radioactivity. She named it after her homeland of Poland (Latin: Polonia,) then under foreign domination (by the Russians among others) in the hope of making a political point.

In 1934 an experiment showed that when natural 209Bi is bombarded with neutrons, 210Bi, the parent of polonium, is created. Polonium may now be made in milligram amounts in this procedure which uses high neutron fluxes found in nuclear reactors. Only about 100 grams (three and half ounces) is believed to be produced each year, making polonium exceedingly rare. Since it is also very heavy, three an half ounces is very small beer indeed.

210Po is the most available isotope. It is an alpha emitter with a half-life of just over 138 days. A milligram of 210Po emits as many alpha particles as 5 grams of radium. A great deal of energy is released by its decay with half a gram quickly reaching a temperature above 900 °F. Because it emits many alpha particles, which are stopped within a very short distance in dense media and release their energy, 210Po has been used as a lightweight heat source to power thermoelectric cells in artificial satellites.

Polonium dissolves readily in dilute acids, and it is easily vaporized. 50% of a sample is vaporized in air in 45 hours at 131°F. Hence the worry in London that others might have been exposed by inhaling the vapor.
Polonium is a highly radioactive and toxic element and is very difficult to handle. Even in microgram amounts, handling 210Po is extremely dangerous, requiring specialized equipment and strict handling procedures. Alpha particles emitted by polonium will damage organic tissue easily if polonium is ingested, inhaled, or absorbed (though they do not penetrate the skin and hence are not hazardous if the polonium is outside the body).

To produce a potentially lethal radiation dose of 10 sieverts, if ingested, requires just 0.12 micrograms (millionths of a gram) of 210Po (about 525 microcuries of radioactivity). A cube of pure 210Po about the size of a written period (full stop, if you are English) would still be 3400 times the lethal dose. The maximum allowable body burden for ingested polonium is only 1,100 becquerels (0.03 microcurie), which is equivalent to a particle weighing only 6.8 × 10 to the power of -12 gram. Weight for weight, polonium is approximately 2.5 × 10 to the power of 11 (250 billion) times as toxic as hydrogen cyanide. The maximum permissible concentration for airborne soluble polonium compounds is about 7,500 Bq/cu m (2 × 10 to the power of -11 µCi/ cc). The biological halflife of polonium in humans is 30 to 50 days.

What is it used for?

1. When it is mixed or alloyed with beryllium, polonium can be a neutron source: beryllium releases a neutron upon absorption of an alpha particle that is supplied by 210Po. It has been used in this capacity as a neutron trigger for nuclear weapons. Other uses include:
2. Devices that eliminate static charges in textile mills and other places. However, beta sources are more commonly used and are less dangerous.
3. Brushes that remove accumulated dust from photographic films. The polonium used in these brushes is sealed and controlled thus minimizing radiation hazards.
4. As 210Po, a lightweight heat source to power thermoelectric cells.
   

Alexander Litvinenko became a KGB agent in 1986 and in 1988 was drafted into military intelligence. From 1989 to 1991 he served in counter-intelligence. In 1991, he was promoted to the Central Staff of the MB-FSK-FSB, specialising in counter-terrorist activities and infiltration of organized crime. In 1997, he was again promoted to the Department for the Analysis of Criminal Organizations of the Russian FSB with the title of senior operational officer and deputy head of the Seventh Section.
In 1998, Litvinenko claimed his superiors had ordered the killing of Boris Berezovsky, a Russian businessman who then held the high government post of Secretary of the Security Council and was close to President Boris Yeltsin; Berezovsky later fled to the UK. Litvinenko claims that he was dismissed from the FSB, and then arrested twice on charges which were dropped after he had spent time in Moscow prisons.

In 1999 he was arrested on counts of abusing duties during the anti-terrorist campaign in Kostroma. He was released a month later upon signing a written undertaking not to leave the country. Using his acquired freedom, Litvinenko fled before he could face the trial. He made his way without a passport to Turkey, where he joined his wife Marina and their son Anatoly, who had entered Turkey on tourist visas. On 1 November 2000, they immigrated to the United Kingdom, claiming political asylum, and in October 2006 he became a British citizen. In London he was employed by Berezovsky, and judging from his movements (which can be traced by a trail of radioactivity) he lived high on the hog. He has extensively criticized President Vladimir Putin, particularly his position on Chechnya.

He alleged that agents from the FSB co-ordinated the 1999 apartment block bombings in Russia that killed more than 300 people. Russian officials blamed the explosions on Chechen separatists. In December 2003 Litvinenko alleged that Vladimir Putin during his time at FSB was personally involved in organized crime.

Earlier that year he alleged that two of the Chechen terrorists involved in the 2002 Moscow theater siege were working for the FSB, and that the agency manipulated rebels into staging the attack. He claimed that the FSB got its agents out before the final attack.

In April 2006, a British MEP for London, Gerard Batten (UKIP), cited allegations by Litvinenko that Romano Prodi, the Italian Centre-Left leader (now Prime Minister) and former President of the European Commission, had been the KGB's "man in Italy". He told the European Parliament that Litvinenko had been informed by FSB deputy chief, General Anatoly Trofimov (who was shot dead in Moscow in 2005) that "Romano Prodi is our man (in Italy)". Among Litvinenko's most serious claims is that Prodi assisted in the protection of KGB operatives allegedly involved in the assassination attempt on Pope John Paul II in 1981.

In July 2006, an article written by Litvinenko alleged that Putin was a paedophile.

The papers are hinting that Putin is to blame, but as a reader of detective stories I am sensitized to the most obvious suspect being the killer. There have certainly been a series of suspicious deaths among Russian dissidents, of whom Anna Politkovskaya was the most recent until Litvinenko. We are hearing today on the News that a former Russian prime minister is ill in Moscow and that poisoning is suspected.

We have to ask the question, "What would Putin gain by having a critic killed in such a public way?" If he just wanted him disposed of, why not make it look like an accident or suicide? Was he just flexing his muscles knowing that with Europe dependent on Russian oil, he is untouchable?

Granted, Polonium210 is very difficult to get hold of and to handle, suggesting that a Government was involved. But perhaps Litvinenko was just a rather sophisticated suicide bomber (even perhaps an involuntary one); the point is not the death but the propaganda. Comrade Berezovsky might well be resourceful enough, brazen enough and callous enough to try something like that.

News from Pakistan

A report from Pakistan in today's Sunday Times caught my eye

One woman is raped every two hours and one gang-raped every eight hours, according to the country’s independent Human Rights Commission. But under the ordinance introduced in 1979 by the dictator General Zia ul-Haq as part of an Islamization campaign, rape cases have to be dealt with in sharia courts. Victims need four male witnesses to the crime — or face prosecution for adultery.

More than 2,000 women are in jail for intercourse — either victims of rape or those who have eloped to marry for love and have then been reported, usually by one of their parents.

But after 27 years of protests by activists such as Bokhari, Pakistan’s Senate finally voted last week to pass an amendment to the ordinance drawn up by President Pervez Musharraf, despite resignation threats from MPs from religious parties.

Described by Musharraf as “a victory of justice, truth and the progressive forces”, the Women’s Protection Bill will allow civil courts to try rape cases and admit DNA evidence. It also drops the penalty of stoning to death for sex outside marriage, although activists acknowledge that such sentences are not carried out.

Throughout Europe and now in America there is a war-weariness that wants to bring the troops home from Iraq and Afghanistan. All would be well if we were to leave the Middle East to the Islamists. They would not trouble us. we could live our lives and they could live theirs. This is totally to misunderstand the nature of the war we are fighting. 9/11 was not an isolated incident. There had been Islamist attacks on the West before and there have been since.

Also in the Sunday Times from Pakistan comes this.

THE British will never win in Afghanistan by military means and should open negotiations with the Taliban, according to the former leader of Pakistan’s forces in the border areas.

On the eve of a NATO summit in Riga at which member nations will be urged to send more troops, Lieutenant-General Ali Mohammad Jan Aurakzai, who led Pakistan’s hunt for Al-Qaeda until 2004 and is now governor of North West Frontier province, said: “Bring 50,000 more troops and fight for 10 to 15 years more and you won’t resolve it. The British with their history in Afghanistan should have known that better than anyone else.”


Aurakzai said that NATO had failed to achieve any of its objectives. “Why did the coalition come to Afghanistan? To find Al-Qaeda, Osama Bin Laden, Mullah Omar and the Taliban; for democracy, reconstruction and development, and [to] leave a stable Afghanistan which wouldn’t be vulnerable to terrorists.

“All very noble, but tell me which one of those objectives have been achieved? I went to Kabul in September and they are all living in a big bunker with no control over Afghanistan. There’s no law and order. The insurgency has become far worse . . . is that a success?”

Remember the Taliban? Remember how they dealt with women?

Many years ago it was common in India for widows to throw themselves on their late husband's funeral pyre. The British, as colonial power, outlawed the practice. Many years ago it was common for black men to be transported from Africa to the New World to work as slave labor for white men on cotton or sugar plantations. The British as colonial power outlawed this and fought battles to enforce their view. Eventually Americans fought an engagement in which more Americans were killed than any other to outlaw slavery.

What has happened to Principles? Millions of people worldwide are enslaved by evil men whose philosophy has not moved on from a 7th Century religious text written by an uneducated nomad. I'm not condemning Islam as a whole; no doubt many wise men have derived from that text principles suitable for living in the 21st Century, but the Islam of the Taliban is like the Christianity of mountain men who pick up snakes and drink poison because of the spurious ending Mark chapter 16. To abandon millions of people to Taliban rule would be cowardice and selfishness, and in the long term a spectacular own-goal.

This is not to say that you can gain victory with tanks and guns, but you can certainly achieve defeat without them. There are other weapons in this war that we are engaged in. Education, construction, fresh water and proper sewage systems, electricity, good roads, and above all religious instruction are all potent armaments, but without the defense forces to protect them from mortar attacks and machine guns, they cannot be deployed.

Christians, in particular, should listen to their own Bible. "Nothing can hinder the LORD from saving, whether by many or by few." The words were spoken by Jonathan, the son of King Saul, at a time when the Hebrews were oppressed by the Philistines. Blacksmiths had been banished from the land and the Hebrews had to take their ploughshares and pruning hooks to the Philistines for sharpening at exorbitant cost. Only Jonathan and his father owned a sword. Yet armed with sticks and stones alone the Hebrews were led by God to drive the Philistines from the land.

Time has come for Christians to put away the image of God as a wimp in a white nightdress. In the Old Testament God is established as an awesome figure. To have dealings with Him is a fearsome business. In the New Testament, Jesus shows us that God has that power under control; that He can act with gentleness and kindness; that His grace is as great as His power. But is folly to disregard His power or to think that He winks at sin. The book of Revelation is explicit about the judgment to come. Jesus explicitly tells us to fear Him.

Cross and crosser

The worm is turning. Christians are tired of being doormats. For years it has been forbidden (and downright dangerous) to mock a Moslem, bruise a Buddhist, jostle a Jew, harass a Hindu or slander a Sikh, but Christians have been fair game for any fundamentalist secularist to be rude about. Thus we have had the absurd Winterval as a replacement for Christmas, the Red Cross barring Christmas trees from its charity shops, the ridiculous "Happy Holidays" replacing "Merry Christmas", the dreadful "Jerry Springer - the opera", and religious symbols made from frozen urine and elephant dung.

Perhaps it is the injunction to 'turn the other cheek' and 'go the extra mile' that has restrained Christians, and given the impression that Christians find some sort of perverse pleasure in being insulted. Church authorities have urged restraint and tolerance. Goodness knows we don't want to go back to the Spanish Inquisition.

Now two issues have roused the troops. The first is the small cross that a member of the check-in staff at British Airways wishes to wear, that technically breaks the Uniform code. Nadia Eweida could very well wear her cross beneath her uniform, but she chooses not to; she wants to display a visible evidence of her faith. Christians differ on such emblems, much as Moslems do with the wearing of the Hijab. It is not compulsory, but a matter of personal choice. Many years ago I wore a small fish as a lapel badge, not because of any superstition but because it identified me as a Christian to other Christians, and it could also be a conversation starter. After they became very common in the 1970s I stopped, largely because they were no longer started conversations.

People who don't live in Britain will not appreciate that the part of London around Heathrow has a large population from the Indian subcontinent. Large numbers of airport workers come from what are still termed the 'ethnic minorities' Many of these are allowed to wear symbols of their faith - turbans, bangles, red spots on their foreheads and headscarves - because they can't be worn invisibly beneath their uniforms. So it appears to be discriminatory against Christians.

The suspension of Miss Eweida has caused a furore. Bishops and archbishops have written a letter to the Times, 100 MPs have vowed to boycott BA, and a website has been started called BA Boycott. From this I have selected on comment which puts the thing in a nutshell:

To BA: So, tell us. When are you morons going to paint over the British flags on all of your aircraft? I’m an American, but even I know that your flag consists of three ***gasp*** crosses. The Cross of St. George, the Cross of St. Andrew, and the Cross of St. Patrick. Just imagine how “offensive” THAT is. Remove those, as surely you must to remain consistent in your foolishness, and all you’ll have left is a WHITE FLAG. How appropriate.

The second issue is the banning of Christian Unions by several British Universities. Their offence? They refuse to allow non-Christians on their Executive Boards. Now can you imagine the Moslem Society being run by Hindus? Or the Labor party being run by Conservatives? Or the Jewish Society being run by Moslems? Again the Bishops and Archbishops of the Church of England have been moved to protest. Indeed the Christian Law Society is going to the Courts about it.

What about turning the other cheek? Sometimes we long for the days when God used to unleash thunderbolts on the slightest offender. But these are days of restraint. God is not willing that any should perish but that all would turn from their wicked ways and live. However, St Paul in prison stood up for his rights as a Roman citizen and Christians should remember that the Jesus they follow is not a long-haired wimp in a white nightdress, but the coming King. Show Him some respect, for God's sake.

Chemotherapy combinations

Whenever an oncologist finds two drugs that are both effective in a particular cancer, his natural inclination is to combine them. It makes little sense to combine similar drugs, which work in the same way and have similar side effects. There would be little point in combining chlorambucil with cyclophosphamide or cisplatin with carboplatin or vinblastine with vincristine, but where you can mix drugs that have very different modes of action and different side effects then it often makes sense. One of the most successful combinations has been cyclophosphamide, vincristine, adriamycin and prednisolone (CHOP). Recently it has been shown that adding rituximab to this combination - R-CHOP - is even better in diffuse large cell lymphoma. However, it cannot be assumed that combination chemotherapy will necessarily be better than single agents with every tumor types. A good example of this is the comparison of CHOP and chlorambucil in CLL. Trials have shown that neither is superior, though chlorambucil is less toxic.

The CALGB trial that compared fludarabine with a fairly low dose of chlorambucil also originally had a third arm, fludarabine plus chlorambucil. The dose of fludarabine was reduced in this arm from 125 to 100 mg/sq m/month and the dose of chlorambucil was reduced from 40 to 20 mg/sq m/month. However, recruitment to this third arm was abandoned mid-trial because the toxicity was too great. Infections were more than three times as common as in the chlorambucil arm.

Cyclophosphamide is reputed to be less marrow toxic than chlorambucil, though perhaps more immunosuppressive. It didn't take a rocket scientist to think that the benefits of combination might be allied to less toxicity by combining fludarabine and cyclophosphamide (FC). The MDACC group performed a phase II trial with this combination (published in J Clin Oncol in 2001) with encouraging results. Consequently, both the Germans and the British have performed randomized phase III trials comparing fludarabine with FC. The trials differed slightly. The German trial was restricted to patients under 65, while the British trial also included an arm in which chlorambucil was given at a higher dose. The Germans used a slightly higher dose of fludarabine 150 versus 125 mg/sq m/month in the single agent arm and 90 versus 75 mg/sq m/month in the FC arm. For the latter two thirds of their trial the British used the drugs orally in equivalent doses. The CALGB trial had use 100 mg/sq m/month of fludarabine in the fludarabine plus chlorambucil combination.

Both the British and the German trials showed a higher response rate, higher complete response rate, and longer progression-free survival for the FC arm, but no difference in overall survival. In both trials FC gave significantly more bone marrow toxicity and in the British trial but not the German one, this translated into significantly more hospital admissions. In both trials the incidence of hemolytic anemia was much less in the FC arm.

In the follow up of the CALGB trial a paper published in J Clin Oncol in 2002 reported an excess of patients with myelodysplastic syndrome or acute myeloid leukemia occurring in patients who were entered into the abortive fludarabine plus chlorambucil arm There were 3.5% in this arm compared with 0.5% in the fludarabine arm and 0% in the chlorambucil arm. Indeed Guillaume Dighero, who ran the French CLL trials for many years, told me that he had never seen or heard of a case of MDS or AML occurring after chlorambucil treatment in any of the French trials. The possibility of late side effects after the combination of fludarabine plus an alkylating agent is something that needs to be worried about, and in that respect it is interesting that so far there has been only one patient developing MDS so far in the CLL4 trial. As might be expected this patient received FC, but it is far too early to draw any conclusions.

To sum up: FC might be better than chlorambucil for CLL, but it performs better only in respect of surrogate markers. It does not make you live longer than good old chlorambucil.

Interestingly, NICE looked at the the FC combination and were on the verge of recommending it on health economic grounds - a QALY would cost less than £3000. However, there is no marketing authority for the use of fludarabine in combination in the UK, and because of this NICE declined to make a recommendation. This seems to me to be crazy. There used to be a TV program in Britain called That's Life. Every week they would make a Jobsworth award for the silliest use of petty rules to avoid doing something sensible (Jobsworth comes from the expression "It's more than my jobs worth to allow you to do that"). It was suggested that a Jobsworth award should go to the British Airways official who prevented a check-in worker from wearing a small cross around her neck. With 100 British MPs vowing to boycott Brotish Airways flights, this is a supreme case of shooting yourself in the foot.

I suggest the Jobsworth award to NICE for their refusal to pronounce on the FC combination.

Faith Schools

Dr Patrick Sookhdeo is a priest in the Church of England. He is of Pakistani origin and is a convert from Islam. He is an academic with several links to various research institutions. This article appeared in the London Evening Standard last September.

Once there were tens. Then there were hundreds. Now Peter Clarke, head of Scotland Yard’s Anti-Terrorist Branch, speaks of thousands of militant British Muslims, indoctrinated and radicalised in British mosques and madrassas.

This is not, primarily, because of the influence of a handful of “preachers of hate”. Islamic extremism has spread in Britain thanks to a particular brand of multiculturalism encouraged by this Government. And until ministers tackle it - especially the influence of Muslim faith schools - all their new efforts to build cohesion will come to very little.

The context goes far beyond Britain. Contemporary Islam has burst out of its colonial restraints. Once colonialism removed power, jihad and territorial control from Islam, it was left a benign force focusing on prayer and good deeds. But contemporary Islam has reverted back to early Islam, with all its theological rage against the non-Muslim world. Issues like Iraq and Afghanistan have become valves for expressing this anger and hatred against Britain and the West.

Increasingly, it is the values and culture of Islam which define the identity of British Muslims. A senior British Muslim leader has defined Muslim identity as: creed, sharia and umma.

The Islamic creed is non-negotiable. Those who do not share this creed are despised as kafir (infidels). Hatred of non-Muslims is preached in many British mosques.

Meanwhile Islamic law, sharia, is deemed by the majority of Muslims unalterable. Its medieval formulations cannot be updated. Yet it is this discriminatory law which many British Muslims wish to see enforced.

Finally the umma, the worldwide community of Muslims, is the primary focus of loyalty. It represents the political as well as the religious. Muslims have a duty to defend each other. This defensive jihad is what leads Muslims to go and fight in places such as Iraq.

It might seem paradoxical that the UK, which has granted Muslims greater freedoms than any other Western country, should be the greatest Western incubator of Islamist violence. The explanation lies not only in the radicalisation of Islam but also in the Government’s policy on multiculturalism.

There is a positive aspect to a multiculturalism where people share and enjoy each other’s cultures. But the UK’s well-meaning policy of validating every faith and ethnic community culturally, in a depoliticised way, is naïve when it comes to Islam. For Islam does not separate the sacred from the secular: it seeks earthly power over earthly territory. The result is that already the UK has reached the stage of parallel societies, where purely Muslim areas function in isolation.

Worse, this is about to be made semi-official. In West Ham a gigantic mosque is planned by the radical Tablighi Jamaat group. The London Thames Gateway Development Corporation says that the new mosque will make West Ham a “cultural and religious destination”. This will be nothing less than an Islamic quarter of our capital city. But has anyone asked the people of West Ham? The non-Muslims? The moderate Muslims such as Barelwis and Sufis? The Muslim women? And shouldn’t the Government be looking into why a movement claimed as inspiration by a number of convicted terrorists should be allowed to control a whole community?

One must feel grateful for the police’s interception of terrorist plots. Yet we must tackle the root causes, rather than dealing with this threat simply by vigilance and appeasement. Giving in to the demands of Muslim extremists will not turn them into liberals loyal to the UK. They will simply want further concessions.

This is now the Government’s dilemma. With the launch of the Commission on Integration and Cohesion last month, it recognised that it must address the development of separate societies. Privately, ministers are deeply worried.

Yet at the same time the Government seems fixated on empowering an ultra-conservative Muslim leadership embodied by the Muslim Council of Britain and Muslim Association of Britain. It says sharia will never be permitted in Britain, yet it has allowed sharia-compliant mortgages, and admits that many British cities have sharia councils.

Just as important, communities minister Ruth Kelly has already excluded faith schools from the remit of her examination of integration and cohesion. Yet many Islamic schools are known to nurture values that are radically different from those of the prevailing society.

Faith schools have a long and noble tradition within the British Isles. Christian denominational schools as well as Jewish schools continue to play an important role in community cohesion. Whether Islamic schools can fill such a role is highly questionable.

Has the time come to say no to Islamic schools, whilst allowing the others to exist, even though this may seem unjust? Or should we consider a new kind of school where all children can study core subjects together in the same environment, with religious teachers - be they mullahs, rabbis or priests - instructing the children in their own faiths?

I believe Islam needs different treatment from other faiths because Islam is different from other faiths. It is the only one which teaches its followers to gain political power and then impose a law which governs every aspect of life, discriminating against women and non-believers alike. And this is ultimately why a naive multiculturalism leads not to a mosaic of cultures living in harmony, but to one threatened by Islamic extremism.

Most British Muslims are not supporters of terrorism. Some have embraced Western liberal values and society. Others are peaceful but simply prefer to live in their own separate community. Mainstream figures such as Shahid Malik MP have courageously called for British Muslims to fight against extremism.

But unless all of us, Muslim and non-Muslim alike, join forces against the kind of multiculturalism which has nurtured extremism, we may eventually find that whole swathes of London and other cities have become “cultural and religious destinations” dominated by Islamic extremists - men who would remove the very freedoms so many moderate British Muslims now appreciate.

Uzbekistan

Dr Patrick Sookhdeo, International Director of Barnabas Fund, sends this message from Uzbekistan

During August 2006 there was evidnece of increasing persecution of Protestant church leaders and their families, many of whom have now gone into hiding. This follows a surge of anti-Christian activity in Uzbekistan over several months. It is believed that this is linked with the 15th anniversary of Uzbekistan’s independence, today, 1st September.

A well-known church leader and evangelist, Sergey Hripunov, was given a week to leave the country with his wife and children. This is the second incident of deportation of a church leader from Uzbekistan in a month. The leader of a church started by Sergey Hripunov was given only 24 hours to leave the country with his wife and two children, the youngest of whom was only two weeks old. They were given no reason for the order, nor was there a court order accompanying it.

Around 24th August a group of Christians were arrested in the town of Termez by the Security Services. Some of the Christians, including women and children, were beaten. The following day some of the group were released, but six men were kept under arrest. Officials have as yet given no information as to why the Christians were arrested. One of the men detained was a Ukraine national, called Yuri Stefanko, visiting some friends in Uzbekistan.

In another incident in August a group of Uzbek Christians, mostly young men but also including a pregnant woman, were arrested in Surhandarya. The men were beaten and detained in jail.

Earlier in August the government introduced an increase to fines for unregistered religious activity. Anyone caught sharing their faith will now face fines between 200 and 600 times the minimum monthly salary. This is an increase on the current fines which stand at 50 to 70 times the minimum monthly salary. According to some reports their church minister will also face a fine. If a person continues to share their faith and is caught a second time they, and their church minister also, will face a prison sentence of three to eight years.

Surrogate markers

A recent Cochrane review of trials comparing fludarabine and alkylating agents (such as chlorambucil) as first line treatment for CLL found no difference in overall survival. In a meta-analysis of five trials randomizing 1838 patients there was no significant difference. What is more, it is highly likely that however many trials are done and however long we wait, we will never find a difference.

In my opinion there will be no more trials comparing fludarabine with alkylating agents. For one thing these trials take so long to do. The successor to CLL4 was projected to last 11 years. Even the MRC, which is committed to staying the course, jibbed at that. Pharmaceutical companies, who must see a return on their investment before the patent runs out, are not going to consider such trials. Another reason is the fact that you don’t just get treated once for CLL. When you relapse there is something else to try, and with the number of new agents in the pipeline there will be things to try even if you were to relapse 10 years down the line.

I want to draw your attention to an abstract at the forthcoming ASH meeting in Orlando.

This is abstract # 304 from Daniel Catovsky, Monica Else, Sue Richards, Peter Hillmen: The Lack of Survival Differences in Randomized Trials in CLL May Be Related to the Effect of Second Line Therapies. A Report from the LRF CLL4 Trial.

“We conclude from this analysis that the likely reason for the lack of (overall) survival differences in CLL4 and in other CLL trials relates directly to the better responses and improved survival rates after second line treatment in those receiving the less effective therapy first, i.e. chlorambucil (or fludarabine) in CLL4.”

What they are saying is that CLL differs from acute leukemia where the response to the first course of treatment determines the outcome. It has even been suggested that you can tell from a bone marrow biopsy 6 days after chemotherapy for acute leukemia whether the patient is going to be a long term survivor. If there is any leukemia left the patients will do badly. However, it seems to be the case that it doesn’t matter whether you give fludarabine or chlorambucil first, because you will able to get a good response second time around.

They go on to say:

“Our findings support the view that PFS (progression-free survival) and quality of life should be used when assessing new treatment modalities in CLL, while continuing to evaluate survival differences to ensure that there is no adverse effect.”

Those who design clinical trials in CLL have accepted that overall survival cannot be used as an end-point except in patients who have had several rounds of treatment and have a short life expectancy. These other end-points, PFS and QOL (quality of life), are known as surrogate end points.

I won’t say much about quality of life in this essay. For one thing it is very difficult to measure – one man’s meat is another man’s poison, but also CLL4 has so far shown no difference in QOL. It seems to be the case that patients in remission have a better QOL than patients in relapse, but whether that still holds good when you push chemotherapy to get a deeper remission has yet to be evaluated.

As far as PFS is concerned a salutary lesson was learned from a study in myeloma published earlier this year in the New England Journal of Medicine. The study from Little Rock examined the effect of thalidomide on patients having so called ‘total therapy’ ‘Total therapy’ means two autologous stem cell transplants. It had already been established that giving thalidomide after the second transplant prolonged life, so the obvious question was whether giving thalidomide from the beginning of treatment was even better. Sure enough, there was a higher response rate and a longer progression-free survival in those who had the long-term thalidomide. But overall survival was the same.

Now taking thalidomide is no picnic. It causes constipation, sleepiness and peripheral neuropathy. So the conclusion of the trial was that more thalidomide meant more side-effects but no more life.

Surrogate markers are useful if they really do translate into extra life or at least a better quality of life, but otherwise they give a false sense of security.

All we know from all these trials is that fludarabine is an active agent in CLL, with about as much activity as alkylating agents. When oncologists find two agents that are both active in a disease, which neither cures, the next thing we do is combine them. Next time I will write about combinations.

Orissa, India

It isn't only Muslims that object to conversion to Christianity as this message form India demonstrates:

Orissa: Six women converts to Christianity were beaten and then tonsured when they refused to return to Hinduism.

On 6 February a large gang of Hindu extremists forcibly entered the homes of six women, in Kilipala village, Jagatsinghpur district, and dragged them into the street. The women were singled out as they were converts to Christianity and refused to return to Hinduism. They were then subjected to beatings and the humiliation of having their heads tonsured. Those who resisted were further degraded by being stripped.

Sanjukta Kandi, one of the six victims, declared “The villagers tortured and humiliated me before forcibly tonsuring my head. They didn’t even spare my daughter.” Two of those attacked were only 15 years old. All of them have since fled the village, along with around 15 other Christians, for fear of future attacks.

Thirty-five people have been accused of the attack, including Hindu relatives of the six women. The district administration has promised to bring the perpetrators to justice, but the state of Orissa has a bad record for turning a blind eye to the persecution of Christians.

More on chlorambucil

Although in the latest British CLL4 trials fludarabine and the higher dose of chlorambucil were indistinguishable in efficacy, fludarabine was slightly more toxic. Neutrophil counts of less than 1000/cu mm occurred in 41% compared to 28%, hospitalization for more than a day occurred in 36% compared to 22% and diarrhea in 24% compared to 13%. Interestingly, haemolytic anemia was equally common in these two groups at 11% and 12%, but it tended to be more severe after fludarabine and there were some deaths among this group. Small wonder then, that NICE found that chlorambucil was actually superior to fludarabine as a single agent as first line treatment of CLL.

Why, you may ask, has the rest of the world preferred fludarabine? It was clearly on the basis of chlorambucil being given at a reduced dose in the CALGB trial. Remember that trial used chlorambucil at 57% of the dose used in the CLL4 trial, and even at the larger dose, chlorambucil was less toxic than fludarabine.

What is the proper dose of chlorambucil? For many years I have used the dose of 10mg daily for 14 days followed by 14 days rest. Few patients have not tolerated this dose. Expressed as mg/sq m/month and assuming an average surface are of 1.72 sq m, that works out as 81 mg/sq m. Clearly the LRF trial was not overdosing the chlorambucil at 70 mg/sq m.

Far be it for me to suggest that there was any irregularity in the choice of dose of chlorambucil in the CALGB trial, but the effect of this choice has been to maximize sales of fludarabine.

Another area of comparison between the two drugs has been in suppression of T cells. The results for CD4+ T cells after fludarabine are given in a paper by Keating et al in Blood 1998; 92:1165-71. They studied 127 patients whose median pre-treatment CD4+ count was 1562 per microliter. After 3 courses of fludarabine the median level was 172 and after 6 courses 163. It is difficult to discover what happens on follow up as no numbers are given, but there is a figure with a logarithmic scale. My reading of this figure is that the median CD4+ T cell count does not return to above 200 by 24 months follow-up. I should remind you that a CD4+ count of less than 200 in patients with HIV is what defines AIDS.

There are no precisely similar results for treatment with chlorambucil, but a paper appeared in Annals of Hematology last month (Lazlo et al, Ann Hematol 2006; 85:813-4). They studied the effect of chlorambucil 42 mg/sq m/week for 6 weeks and rituximab 350mg/sq m for 4 weeks followed by 4 additional cycles of chlorambucil 84mg/sq m/month on 27 patients with low grade lymphomas (some of which had CLL). Median counts at baseline were just over 500 and after the first 6 weeks they had fallen to a median of 246. After the 4 further months of chlorambucil they had fallen further to a median of 216. At nine months follow up the median count was back in the normal range.

While these studies are not completely comparable, they tend to confirm what has long been believed that fludarabine is particularly immunosuppressive compared with chlorambucil. Fludarabine is regularly used as an immunosuppressive in mini-stem cell transplants – nobody would use chlorambucil for that purpose.

Does this matter? The risks of T-cell depletion are mainly those of infection. The MDACC paper reported a risk of shingles in 13.8% of patients at risk and reactivation of herpes simplex in 3.8%. More important 8.8% developed Richter’s syndrome, which as we now know is frequently cause by failure of control of existing EBV infection. This is reminiscent of the experience of the Royal Marsden Hospital in London where they observed a 12% incidence of Richter’s transformation among CLL patients treated with fludarabine. (Thornton et al Leuk Res. 2005 ;29:389-95).

In the unpublished MRC CLL3NR trial patients failing to respond to chlorambucil or relapsing after chlorambucil were offered treatment with fludarabine second-line. The response rate was 80%. In LRF CLL4 the response rate to fludarabine given first line was 80%. In the UK fludarabine is licensed and recommended for use second-line in CLL.

As far as it goes the NICE decision not to recommend fludarabine as a single agent for first line use in CLL seems to me to be perfectly correct.

Martyrs still

Somali Christian sources report that Ali Mustaf Maka‘il, who converted from Islam to Christianity eleven months ago, was shot and killed in the Manabolyo quarter of Mogadishu on 7 September 2006. Ali (22) was a cloth merchant and college student.

According to the source, the gunman was loyal to the Union of Islamic Courts (ICU), the Islamist organisation that took power in Mogadishu in early June 2006 and now controls much of southern Somalia. The gunman shot Ali in the back after he refused to join a crowd chanting verses from the Koran in honor of the lunar eclipse. (Solar and lunar eclipses are significant in Islam and are accompanied by special congregational prayers.) The ICU confiscated his body for 24 hours before delivering it to the grieving family.

It seems that under the new Islamist rulers, who include hard-line jihadi elements, the tragic history of persecution and martyrdom for Somalia’s tiny Christian community is set to continue and most likely to worsen.

In July 2006 there were unconfirmed reports that three Christians had been shot and killed by Islamists as they returned home from a prayer meeting. In October 2005 an evangelist and house church leader, Osman Sheik Ahmed, was shot dead by Islamist radicals. Children of Christian Somali refugees in Kenya have been kidnapped by Muslim relatives and taken to Islamic institutions in Somalia for “rehabilitation”.

The leader of the ICU, Hassan Dahir Aweys, promised to implement sharia in all areas he controls. According to his interpretation of sharia, apostates (those who leave Islam for another religion), must be killed. ICU leaders have even threatened to kill as apostates Muslims who are lax in their prayers, claiming this is commanded by sharia. Several Muslims have been publicly flogged for drug related offences since the ICU took control.

Over 99.5% of Somalis are Muslims and regard Christianity as a foreign religion of their historic enemies in Ethiopia and of their former colonial masters the Italians and the British. There is a long history of conflict between Muslim Somalis and Christian Ethiopians, so anti-Christian sentiment runs deep. Most Somalis take it for granted that a true Somali is a Muslim and converts to Christianity must be traitors. These prejudices, widely held by Muslim Somalis, seem to used to justify violence against Christians, both indigenous and expatriate. The US-led invasions of Afghanistan and Iraq and the recent Israeli campaign against Hizbullah in Lebanon have fuelled and inflamed the inherent hostility to the West and to Christians.

NICE work

It is a full ten years since the Lancet paper from Steve Johnson and many others (you will find my name in the small print at the end of the article) demonstrated that fludarabine produced a higher response rate and a longer progression-free survival than CAP, a combination of alkylating agent, anthracycline and prednisolone, when used as first-line treatment for CLL. This CAP combination had been shown previously to be equivalent to chlorambucil in effect. It is 6 years since Kanti Rai's CALGB trial reported that fludarabine was superior to chlorambucil in the New England Journal. In America hardly anyone still uses chlorambucil. John Gribben joshes me when I mention it. He thinks he came across a History of Medicine paper that mentioned it once. Why is it then that chlorambucil is still the only drug that is licensed for the first-line treatment of CLL in the UK?

I was privileged to be asked to take part in the NICE review of fludarabine which took place this autumn. The National Institute for Clinical Excellence goes by the acronym NICE and there have been continual cracks about it being more nasty than nice. The job it has is to look at new and existing treatments for various diseases and make a recommendation as to whether they should be available on the National Health Service.

There are three 'E's when it comes to providing health care.

Equality is what the Government is most concerned about. This is supposed to be a National Health Service. They can't abide what is known as post-code prescribing: the idea that you can get a drug in Dover but not in Darlington or that you have to wait 3 months for your hip replacement in Bournemouth but 24 months in Birmingham. They won't listen to the argument that if there was a true market everyone could get it next week; markets in health care are an anathema to the British public. Markets would, of course, mean that you could buy different standards of care for different prices, and even New Labor shrinks at the idea that rich people should get better care than poor people. So regulation is necessary to hold back the convoy to the speed of the slowest ship.

Effectiveness is what the patient is concerned about and also the concern of most doctors. We want the best result for the patient in front of us. If treatment A cures 70% of patients at a cost of £100,000 a cure while treatment B cures 50% of patients at a cost of £1000 a cure, we would still want treatment A for all our patients.

Efficiency is what the health economists want. In a way you can see what's behind their thinking. Supposing there is a limited health care budget, you would want to see it spent in the most effective way. You would want everybody to get the most effective treatment. You wouldn't want money wasted on treatments that didn't work. You wouldn't want speculative spending at the expense of proven treatments. If there was a doubt about whether a treatment worked, you would want the treatment tested so that you knew for sure whether it worked. When new, expensive drugs were introduced, you would want to know whether they produce value for money, especially in days when the market is being flooded with new products, all very expensive.

In order to compare different treatments, they have hit upon QALYs. This stands for Quality Added Life Years. It boils down to, "How much does it cost to add one extra year of high quality life?"

This approach has inherent dangers. The most cost effective treatments turn out to be ones that reduce infant mortality. Allowing a baby to live who would otherwise die adds 80 or so QALYs. Helping an 80 year old live an extra 6 months doesn't score very highly. The policy is therefore Ageist. It is also misleading to suggest that there is a limited health care budget. America is now spending approaching 20% of GDP on health. In France and Germany it is 12+%. In the UK it is 7% - still comparatively very low despite the government massively increasing what it was pre-1997. Taxpayers will only stand so much taxation. Gordon Brown has proved a master in introducing stealth taxes that people have not noticed, but if that button is pressed to often the electorate will vote for the other lot.

The rest of government spending is not subject to the same stringency. Take Transport. Installing crash barriers between opposing lanes on motorways saves lives. It may well have saved my daughter's life last week. But the cost of each life saved is £1 million. For the automatic train warning system, a system that stops railway trains passing red signals, the cost is £3 million for every life saved. On the other hand if a new drug costs more than £25,000 per QALY it will not be recommended.

The Royal Air Force has just taken delivery of the new Eurofighter. These are superb airplanes. Probably they outperform anything the Russians or Americans have produced. If either America or Russia invades us we will be able to defend ourselves. Meantime, we are still using 'snatch' Land Rovers in Iraq and Afghanistan where they are susceptible to roadside bombs and RPGs because we can't afford better.

I could give examples across government spending. Educational policies are introduced at the whim of an advisor without objective evidence of improved effectiveness. An Identity Card is about to be introduced without evidence that it will help anything. Huge amounts (equivalent to 1% of the world GDP) have been committed to fight global warming when a fraction of the amount would wipe out malaria from the planet and as a consequence raise world GDP by 3%. Prisons policy, road building, housing policy; whatever are you look at government spending is in a spiral of out of control increase. Yet because it can be measured the cost of new effective drugs is 'controlled'.

However, this is the system we've got and we have to live with it.

The NICE examination was mainly informed by the recent LRF CLL4 trial that compared chlorambucil with fludarabine with fludarabine plus cyclophosphamide as first line treatment for CLL. The important difference from other trials was that chlorambucil was given in a bigger dose than previously. The dose in the CALGB trial was 40 mg per sq meter per month; in CLL4 the dose was 70 mg sq meter per month. Even at this dose it was less toxic than was the fludarabine arm. CLL4 showed that although there was a slightly higher response rate with fludarabine, this was not statistically significant. This was a large trial with nearly 800 participants. It was powered to detect quite small differences between the treatments. There was no difference between these two drugs in terms of progression-free survival or overall survival. The combination of fludarabine and cyclophosphamide (FC), however, proved superior to both chlorambucil and fludarabine as single agents in terms of the response rate, the complete response rate and the length of remission. The differences were statistically significant. However, there was no difference in overall survival between any of the treatment groups. In fact at 5 years follow-up the chlorambucil group was doing slightly better, though the differences were not statistically significant. Patients who failed to respond to the FC had a very poor survival indeed with most failing to live 2 years. On the other hand non-responders to either chlorambucil or fludarabine could be rescued by salvage therapy.

It is likely that this is the last word in chlorambucil trials. A recent Cochrane review, which performed a meta-analysis of all the trials comparing fludarabine and chlorambucil has failed to find a difference in overall survival. The most likely reason for this is that patients who fail treatment can be salvaged by other treatments so that it does not matter much which treatment is given first.

Is that the end of the story? Are all those people in the world who have avoided chlorambucil and gone straight to fludarabine combinations wrong? Don’t miss the next exciting episode of this story.