Sunday, July 29, 2007

Is there still hope?

Imagine a village destined to be drowned for a new reservoir. It will not take place for a few years; no-one has to move for a while. The kind, generous government has offered compensation for the houses at above the market rate, but it will take a few years before anyone has to decamp. There is a broken hinge on the garden gate at Rose Cottage, but it is hardly worth repairing as the owners will be gone soon. The road really needs resurfacing at Cooper's Corner, but fishes have no need of smooth tarmacadam, so why bother? Slowly the village becomes shabbier and more distressed; there is no hope for it.

Hope springs eternal in the human breast
Man never is, but always 'To be blest'.

wrote Alexander Pope. Is that still so? Have we given up waiting for something better? Or is Kipling more to our taste?
We are done with Hope and Honour, we are lost to Love and Truth
We are dropping down the ladder rung by rung;


Mark chapter 13 is one of the most controversial in the whole gospel. Jesus speaks of the destruction of Jerusalem and he talks of the Second Coming, but they are mixed up and confused. We have seen the fall of Jerusalem. Those great stones dislodged and degraded. The site built on by an alien religion. Jesus had already told his disciples that the time for Temple worship was over; that there was a new covenant. It is summarized in the letter to the Hebrews: 'It is impossible for the blood of bulls and goats to take away sins'. 'Day after day every priest stands and performs his religious duties; again and again he offers the same sacrifices, which can never take away sins.''He sets aside the first to establish the second.' 'But when this priest (Jesus) had offered for all time one sacrifice for sins, he sat down at the right hand of God.'

Naturally, the Temple would be destroyed. It was no longer fit for purpose.

But when oh when is he coming again?

Mark chapter 13 tells us not to be lulled into complacency. We are to watch as we wait. 'There will be many who come in my name, claiming I am He'. We are not to be gulled. There will be wars and rumors of wars. We are not to be impatient. There will be trials and tribulations. We are not to be discouraged.

There have been many cults with their charts and maps who claim to know the date of his return. Jesus said, "No-one knows about that day or that hour, not even the angels in heaven, nor the Son, but only the Father." We are not to be disappointed as milestones pass.

But be assured He will return. Unlike the inhabitants of the soon-to-be-drowned village, we should not neglect our post. The coming of the Lord is as close as a swallow swooping over the lake for Mayflies. And although we do not know the day when we 'will see the Son of Man coming in the clouds with great power and glory' for each of us there is a finite time of waiting with an indeterminate end. Our next breath might be our last.

'So do not throw away your confidence; it will be richly rewarded. You need to persevere so that when you have done the will of God, you will receive what he has promised. For in just a very little while He who is coming will come and will not delay... But we are not of those who shrink back and are destroyed, but of those who believe and are saved.

Saturday, July 28, 2007

Harry Potter

Google ‘Deathly Hallows review’ and you get over 6 million hits, so anyone who wants to know how it ends can soon find out without spending the £5 it cost me to buy the book in Asda, but if they do they will miss out on the fun of reading it. Over the past 10 years I have read all the books and seen all the films. Some American Christians have warned off potential readers with suggestions that this will lead children into the occult. For a community that invented the annual ritual of children dressing up as witches and going out tricking and treating on the evening of October 31st, this is a bit rich. The magic is just a literary device and is completely harmless.

The books have has many elements that make them readable for children. There are strong characters, a fantastic world, gross inventions of the Roald Dahl sort (vomit flavoured sweets), a new and exciting sport, teenage romance, monsters, a cracking pace, easy language, heroes and villains and silly jokes. They are not written as literature and there are plenty of clich├ęs for critics to get their teeth into. Then the critics hated Enid Blyton.

As Harry Potter has grown older, so the characters have become more complex and the narrative darker. In the final book we begin to see shades of grey in even the most saintly and most evil individuals. Dumbledore flirted with fascism. Voldemort had a deprived childhood.

For JK Rowling, the love of a mother for her child is perhaps the most powerful force in the universe. It was that which protected Harry from Voldemort’s murderous attack right at the beginning, and Mary Weasley is motivated by it to become a fearsome warrior in the final battle. Even for Narcissa Malfoy its power is greater than Voldemort’s hold over her.

‘Where your treasure is, there will your heart be also’. Rowling quotes from the Sermon on the Mount. She might also have quoted from John’s Gospel, ‘Greater love has no man than this that a man lay down his life for his friends’, for this is very much the theme of the novel.

Like all good fantasy books there is a quest at the heart of it. Ron, Hermione and Harry are searching for the Horcruxes, the artefacts where Voldemort has hidden pieces of his soul, but with Dumbledore dead and Hogwarts in the hands of Snape, all the world seems against them. Each of them has been left a clue by Dumbledore in his will: a strange silver cigarette lighter that absorbs all the light in a room to Ron, a book of children’s fairy tales to Hermione and a Quidditch Snitch to Harry, as well as the sword of Godric Gryffindor. All are to have important roles in the story, though the sword is withheld by the Ministry of Magic.

Rowling gives us a clue in that the book of fairy stories contains the moral of the tale, just as her books of fairy stories contain the moral she wishes us to absorb. In an oblique way it tells of the Deathly Hallows, objects of immense significance: a wand of enormous power, a stone with the power of resurrection and a cloak of invisibility. Which one would you desire?

The heroic trio fall out. Should they seek the Horcruxes or the Hallows? There are jealousies, arguments, sulks and angry words. We see old characters put in cameo appearances, including Rita Skeeter who has written an expose of the Hogwart’s headmaster, ‘The Life and lies of Albus Dumbledore’. Doubt overwhelms Harry as he reads extracts from it.

There are plenty of deaths, as promised. Rowling casts off familiar and well-loved characters right from the very beginning. In the previous books we were so used to her creations making miraculous escapes that when we first lose Hedwig, we are not sure that the owl is really dead, but as the body count rises and individuals that we have become attached to are summarily despatched we begin to realise that this is no game. No-one is invulnerable. It comes as no surprise that Harry eventually realises that Dumbledore had planned all along that he, Harry, would have to die in defeating Voldemort. Dumbledore was not the soft, cuddly uncle we had grown to love.

In the end all the threads come together. We understand. The best leaders are those who have it thrust upon them. Integrity will out. Those who seek power are not qualified to wield it. Blessed are the pure in heart.

Friday, July 27, 2007

Gene therapy death.

About to hit the news bulletins is another gene therapy death. This is the third. In September 1999 the death of an 18 year-old boy was attributed to gene therapy with an adenoviral vector delivered directly into his liver. He had Ornithine Transcarbamylase Deficiency, an inherited disorder that meant his liver was unable to break down ammonia. Over the following 4 days his condition deteriorated rapidly, and he died a severe immune reaction to the adenovirus.

The second death occurred in a small French trial for X-SCID (the boys-in-a-bubble disease). 12 children in France received gene therapy and four developed acute T cell leukaemia and one died in October 2005. 10 children have been treated in England with a similar protocol have not developed leukemia.

Earlier this week a patient died in an American trial of gene therapy for patients with severe rheumatoid arthritis. The trial involved the administration of an Adeno-associated virus expressing an inhibitor for TNF-alpha. 127 patients have so far been safely treated with this vector. this patient died of acute hepatitis. It is not yet clear what the role the gene therapy played in the death.

Gene therapy remains one of the safest forms of treatment, but as with all experimental therapy there are unforeseen hazards. Thousands of patients worldwide have received various forms of gene therapy, mostly for cancer.

Gene therapy involves introducing a foreign gene into the patient either to replace something that is missing or to invoke an immune response. There are many ways of doing this but commonly a partially inactivated virus is used. Currently many congenital diseases are being treated. Where the missing gene has been identified a virus is used to slip in a replacement copy. Hemophilia, congenital blindness, muscular dystrophy, various immune deficiencies and cystic fibrosis are all disease that show promising early results.

I have sat on the British Gene Therapy Advisory Committee for the past 5 and half years. I am constantly amazed at the quality of the science and equally at the quality of regulation. The people involved in this work are seriously bright and scrupulously honest.

Thursday, July 26, 2007

Secondary leukemia

While collecting a fax off the machine the other day I stumbled across a report on an old patient of mine. I had treated her about 10 years ago for follicular lymphoma but now she had developed acute myeloid leukemia. It is becoming apparent that the successful treatments for various cancers, themselves leave secondary cancers in their wake. Thinking back over my career of 35 years of treating cancer patients, the numbers are beginning to mount up.

I can remember another woman of a similar age who developed her secondary leukemia five years after the lymphoma treatment. There was a woman with splenic marginal zone lymphoma who developed her leukemia after chlorambucil. This is the only time I have seen chlorambucil responsible. There was a man with an autoimmune condition, Wegener's granulomatosis, who developed first myelodysplastic syndrome (MDS) then acute myeloid leukemia (AML) after cyclophosphamide, and another woman with systemic lupus erythematosus who had a cyclophosphamide induced acute leukemia.

It is well established that cytotoxic drugs can cause both MDS and AML. The alkylating agents - mustine, cyclophosphamide, melphalan, thiotepa, chlorambucil and busulphan are well known to do so. Often they cause a loss of all or part of chromosomes 5 and 7, and the type of leukemia is usually difficult to treat and frequently fatal. Less well known is the fact that another type of cytotoxic drug, those that act as topoisomerase inhibitors (such as adriamycin and etoposide)can also cause leukemia, though these drugs induce chromosomal translocations like t(8;21), t(15;17) and inv 16.

In my experience cyclophophamide is more likely to induce leukemia than other cytotoxic drugs. This is paradoxical because it is less likely to induce permanent bone marrow damage than the others. Perhaps the others do not allow partially damaged cells to survive.

There is also some suggestion that the type of tumor being treated might influence whether or not secondary leukemias occur. We know that MDS and AML can occur with other lymphomas and leukemia even if no treatment is given. Myeloma is associated with MDS. In the 1980s I reported 20 patients with various B cell malignancies who developed MDS or AML without any treatment. I have seen AML develop in CLL patients twice; on both occasions the patient had received no treatment for the CLL. I have seen three patients who developed chronic myeloid leukemia (CML) to complicate their CLL even though they had had no treatment for their CLL.

The patient who had Wegener's Granulomatosis had a brother with kidney cancer. The woman with systemic lupus erythematosus was treated at the same time as another with the same diagnosis, only this woman was treated with plasma exchange rather than cytotoxic drugs. She developed kidney cancer.

To me this all suggests a genetic tendency to develop multiple disorders of the blood and immune systems. Treatment toxicity may synergize with this.

Why some patients develop secondary cancers and others do not, despite having teh same disease and the same treatment is a mystery. It is agood subject for research.

Tuesday, July 24, 2007

More and more houses

In 2001 there were 76,485 dwellings in Bournemouth. By 2003 this had risen to 76,798. An extra 313 houses or apartments in a town bounded in the south by the sea, in the north by the River Stour, in the east by the town of Christchurch and in the west by the town of Poole. The conurbation has been increasing for many years, but that has been mainly by building in Poole which has heathland to the west, or in the northern towns of Ferndown and West Moors which are new towns built of heathland. Exactly where in Bournemouth have they found space to build?

Worse was to come. In 2006 there were 86,138 dwellings in Bournemouth. Another 10,000! How could this town with its confined borders accommodate another 20,000 people?

The answer has to build on what the government calls 'brownfield sites'. What they mean is that they have pulled down old buildings and built on the same site.

This policy has some merit, especially in the north of England. The industrial revolution came early to England. The old industries of textiles, steel and coal-mining have migrated to areas of the world where labor is cheap and unregulated. There are some fine Victorian buildings that can be converted to interesting and well-built dwellings and there are deserted slums that can be pulled down and replaced by houses that people will want to live in. Bournemouth was never an industrial town. I know of one disused bakery that has been pulled down after being derelict for ten years or more, but what are being interpreted as 'brownfield sites' are people's gardens. Fine family homes are being demolished and turned into apartment blocks of up to 14 dwellings. The larger footprint is being accommodated on what used to be the garden. The green lung is being covered in concrete. The water absorbing soil is being covered with impervious run offs that overload the drains and cause flooding.

A house that cost £25,000 30 years ago sells today for £400,000. It is pulled down and replaced by 14 apartments each selling for £200,000. Someone makes a fine profit. Except that these apartments are a glut on the market.

One of Gordon Brown's first acts as prime minister has been to abolish England's regional assemblies - the final local planning authorities. These were put in place to address an electoral deficit. The European Union has attempted to solve the problem of large and small nations having different amounts of influence by breaking large nations into small regions. In the UK, Scotland, Wales and Northern Ireland, all small nations, have been given a degree of autonomy. However, England, a large nation, has all its political decisions made by the UK parliament not an english one. There has been a call for an English parliament to sort out the unfairness of having Scottish MPs decide English matters. The Labor Government are unwilling to concede this since it would mean that England would almost always be governed by the Conservative Party. Hence the Regional Assemblies, an attempt to create a number of small English 'nations'. Unfortunately for New Labor when a referendum was held to give these assemblies electoral validity - to make them elected rather than appointed bodies - the notion was heavily defeated in the North East, the one region where they were certain of support. Elected Assemblies were abandoned, but even appointed Assemblies opposed the idea of more houses. So they have gone too.

There is an electoral deficit in the UK. Will nothing stop the unregulated immigration that is the real cause of the need to build? Perhaps the rain will.

Monday, July 23, 2007

Knightwood Oak

Forty years of marriage! We took a trip to see our daughter on Hayling Island, driving via the New Forest. On the way we stopped off to view the Knightwood Oak, the oldest oak tree in the forest. At over 600 years old, it was 100 years of age when King Henry VIII rode by hunting deer. The tree is more than 25 feet in diameter and plays home to dozens of different species. It was pollarded when young. This is a process by which the main stem is cut to force the growth of side branches. The value of this is that the side branches can be harvested for wood without killing the tree. Pollarding in the New Forest was outlawed in 1698 because of concern that too few really tall trees were available to provide the wood for sailing ships. With the demise of wooden ships, pollarding has returned.

Alongside the massive oak, a sapling was planted in 1979. It is barely 5 feet tall. As we looked at the huge tree, our 40 years paled into insignificance.

In cricket, after a batsman has scored 100 runs, he is supposed to take a new guard, reset his concentration for the next 100. We have settled in for the next 40 years.

Friday, July 20, 2007

Sharpe

For Christmas last year one of my presents was a full set of the DVD's of the Sharpe series that has been on television. I have so far seen four of them. I have read all the books, but only caught snatches of the television series before. Interestingly, many of the people who made Morse were also involved in Sharpe. Of course the stories are very much 'Boy's Own' and complete fantasies, but they are competently made, with good Russian stuntmen and locations in the Ukraine and Turkey. The movies are shot in 30 days, with 36 scenes shot every day. Sean Bean, whom we met at my daughter's wedding last year, makes an engaging Sharpe, though his Sheffield accent is at odds with Bernard Cornwell's description of a Londoner. For today's youngster's who know virtually nothing of British history it is a painless way of learning about the Peninsular war.

I was brought up in Aldershot where the street names and pubs were all named after battles or generals. Talavera and Salamanca were the names of the old barracks where I did my boy-scouting

Phillip Marlowe's second cousin - twice removed

I have been reading thrillers about the LAPD. Elvis Cole is the Robert Crais. These are thrillers written in the first person and feature a wise-cracking private eye. He seems to live in the same house as Harry Bosch, Michael Connelly's detective. These characters all seem to be based on Phillip Marlowe. They are easy to read with entertaining plots, but without Chandeler's sense of style and verbal dexterity.

When I was at school my best friend was a member of the National Youth Orchestra, and he has had a career as a professional violinist. In the music exam he was marked down for composition with the comment, "Don't try and write like Mozart. You won't be able to do it as well as Wolfgang."

Seeing the state of modern music I think too may have taken this advice. the striving for something different hurts the ear. Still I would rather read sub-Chandler than have my brain ache from some modern writing.

97, 98, 99, 100

A long gap between blogs for me. Someone once gave me the advice that if I wanted to be a writer, I should try and write something every day. Well I haven't been slacking. I have been doing some data manipulation to try and prepare a couple of abstracts for the IWCLL meeting in September in London.

The question I was addressing, was how mutated you have to be to be mutated. Another question is for which patients is it justified to conduct a randomized clinical trial of early treatment, because they have bad prognsostic markers. We now have about 400 patients for whom we have sequenced the IgVH genes plus another 600 for the CLL4 trial. 353 of our patients have also had CD38, ZAP-70 and FISH for del 11q and del 17p done. Our conslusion on the clinical trial is that almost all of the patients who have two of the following criteria: unmutated VH genes or if mutated, use of the V3-21 heavy chain, CD38 >20% expression, ZAP-70 >10% expression and del 11q or del 17p, will require treatment within three years of being diagnosed. But should unmutated mean >97% or >98% homology?

I looked first at whether there was a difference between different degrees of mutations and the acquisition of other adverse prognostic factors. There was. At 100% it was 96%, at 98 and 99% it was 82%, at 97% it was 59% and at less than 97% it was 31%. Then I looked at treatment-free survival curves for those without extra adverse factors. I was surprised to find that they all did equally well, no matter how many mutations they had, with a plateau of not needing treatment at about 60%. However, treatment-free survival curves of those who did acquire extra prognostic factors were different. For those with 97% or greater homology the average time to needing treatment was between 2 and 3 years, while for those with less than 97% homology, the average time to needing treatment was more than 10 years.

What this means is that IgVH genes have a double effect on CLL survival. First they represent a prognostic factor in their own right. If the homology is more than 97% they have a bad effect. But you need at least two things wrong to have a poor prognosis, and the VH gene mutation is only one of them. The second effect is to facilitated the acquisition of this second factor. With 100% it almost universal, whilc for those who are really mutated, only 3/10 will acquire another adverse factor (only for them it will be the first adverse factor). The 97% patients are about twice as likely as this to acquire a second factor, and those with 98 or 99% about 3 times as likely.

No wonder different labs have chosen different levels of mutation as the cut off.

Thursday, July 12, 2007

Duties of State: Rights of Individuals

Is universal health care a human right? If it is for people of the UK, why is it not for the people of Darfur? It is more properly regarded as a universal aspiration. I guess it is up to each nation to make a judgment on priorities, but it seems to me that there are at least some minimal standards that are in the interests of everyone in the community.

There are some basic public health matters that few will argue about. The separation of sewage from drinking water is a first priority. Immunization against the common infectious diseases protects not only the immunized, but by 'herd immunity', also those unable to be immunized successfully. Speed restrictions and traffic laws protect the whole community against death on the road. Laws against smoking in public protect non-smokers against passive smoking. Screening for tuberculosis protects the vulnerable in the community. But to what extent should the state intrude on the rights and responsibilities of the individual?

When visiting a friend in America I was surprised to find that he had to arrange to have his garbage taken away, that there were a few contractors who competed for the business in the area, and that some households employed no-one and disposed of it themselves. I presume there was some sort of failsafe mechanism that prevented people from allowing garbage to accumulate in the street attracting rats and other vermin. I was surprised because in the UK garbage disposal is the responsibility of the local authority. Before Margaret Thatcher the local authority used to employ its own labor force to do this, and one of the Thatcherite privatizations was to make the in-house workforce compete with private companies for the garbage clearing contract. But there was still a single purchaser (the local authority) and households could not opt out of buying this service through local taxation.

Exactly how much government involves itself in this way is a matter for each nation, and different communities have different traditions. How much is the basic minimum? Security is probably an essential. A standing army (though Costa Rica manages without one), a police force, prisons and a judiciary, some provision of public health facilities, roads and a transport infrastructure, control on land use; after that different traditions provide more or less. The danger of the government providing more is the reduction of personal freedom and the assumption by government that every whim of elected officials is something that the electors would want to pay for. Take twinning. Bournemouth is twinned with a town in Israel I have never heard of. Christchurch is twinned with Christchurch, New Zealand. All this does is provide an opportunity for councilors to have a junket at taxpayers' expense.

Should Christians provide more? Schools and hospitals were originally provided by religious organizations; universities were religious organizations. But it is a long step from charitable donations to local authorities or even central government providing optimum education and health care for all. There is an elision from all are equal in God's sight to all should be treated equally by the mayor. We don't expect everybody to drive the same car and live in the same type of house or even wear the same type of clothes (though GAP and Levi would like us to). Remember those Chinese leaders of the 1960s? Even they have started wearing business suits of immaculate cut.

On the other hand we become uncomfortable when we see some living in fine houses and their neighbors living in shacks made of cardboard and corrugated iron; when we see some in Christian Dior and others in rags. The Jewish doctrine of the Jubilee gave everyone a fresh start every 50 years (though it must have been hard to get credit in year 49). Perhaps the state should provide a baseline level of health care and education and leave people to buy better if they can afford it? The argument then becomes, 'how basic is basic?'

Those who live upright lives, eat healthily, exercise, save their money, invest wisely and avoid risky activities like smoking and riding motor cycles, have a legitimate gripe against those who do the opposite and turn up demanding state payouts for their heart disease, lung cancer, diabetes and fractured hips. Do those who were born with the genetic make-up that makes them fat, dim, disease-prone and even indolent have a legitimate gripe against those with genes that make them blond, blue eyed and have a foot that sends over immaculate free kicks even if it does leave them with a penchant for tattoos and a silly, high-pitched voice? Does the clever lad from the Gorbals have a legitimate gripe against the toff from Eton? Who is responsible for the man born blind?

Jesus had an answer to that. Who sinned, this man or his parents that he was born blind? neither this man nor his parents, but this happened that the works of God might be displayed in his life. The Christian has the duty to perform the works of God in the lives of the wastrel as well as the wealthy, the rotter and the Rothschild, the risk taker and risk averse. I seek to help the patient in front of me be he vile or virtuous.

Tuesday, July 10, 2007

Mark 12 concluded

In Mark chapter 12 we have come to the story of the widow’s mite. The story is so familiar. How can I make it come alive? The story is straightforward. Rich men were pouring gold coins into the offering trumpet but then a widow came along and emptied her purse of two small copper coins. Jesus’ comment: “They gave of their excess but she gave of her poverty.”

We all know the story from Sunday School. Because it is set in such a bygone age, when economic circumstances were different we find it hard to relate to. We need some modern day allusions.

First we should notice that Jesus was watching people giving. Have you ever thought that Jesus was watching what you give? I don’t know how the offering is taken up in your church; in a bag so that it is in secret? In a plate so your neighbors can see? In South Korea it is the custom for the names of donors and the amount they have given to be read out during the service. Are you happy for your giving to be made public? Would you be ready with the excuses? We have a rather large mortgage. We have children at private school or an Ivy League College. The payments on the SUV are due. If you saw my tax bill…

We should remember that in Israel the money given to the Temple treasury was in part for welfare, just as our taxes are today. People, who would not dream of failing to tithe, nevertheless use every dodge to avoid paying income tax. There is nothing illegal about it. The law allows it, but the end result is that very rich people fail to pay their fair share of the costs of community.

Jesus sat down opposite the place where the offerings were put and watched the crowd putting their money in the Temple treasury.

Many rich people threw in large amounts. There is nothing wrong with that. So they should, but by giving of their abundance they were nothing special. Have you noticed the special attention given to rich people in churches? They might be good for a new roof or a sports hall or a sound system. We need to keep them sweet; their monthly offering pays the salary of our youth worker. I know he has odd views on the second coming (baptism, the gifts of the Spirit, the Trinity, substitutionary atonement – take your pick), but he’s worth 20,000 a year to us. Jeremy Bentham is not someone I usually quote with approval but his dictum that ‘Everyone is worth one; no-one is worth more than one and no-one is worth less than one,’ is one that I endorse. Before God all men (and women) are equal.

But a poor widow put in two very small copper coins worth only a fraction of a penny. See that she is a widow. Jesus had just complained that the teachers of the Law ‘devour widow’s houses’. Here is a proper reverence for widows – symbolic of those that have not. Often the Bible lumps widows and orphans and the alien in your midst.

Especially today when we watch the conviction of the London attempted bombers of 7/21 who were all illegal immigrants, we are especially wary of the alien in our midst. I saw a man two weeks ago who was obviously a health tourist. From Nigeria, he pretended that he had only just discovered that he had AIDS. Plainly he knew the diagnosis and had come hunting for unaffordable anti-retroviral drugs. Although we must give emergency care, we have had instruction from the government to charge patients from abroad who try to use the NHS for free. If we charged him, how would he pay? It’s all very well to say that Nigeria is an oil-rich country, but he has none of it. Could we handle the whole world’s poor? No, but we can manage the ones and twos that pass our door.

What was the value of the lepton, the coin that the widow threw in the offering trumpet? Together they were worth a quarter of an assarius, which itself was one sixteenth of a denarius, which was what was paid to a common labourer for one day’s work. One sixty-fourth of a day’s pay. If he worked a 12 hour day, then two lepta were what he could earn in eleven and a quarter minutes. But it was all she had. It was the charitable handout from the Temple treasury. Enough to buy a little to eat, enough to keep body and soul together; by putting in her two lepta, she would go hungry that day.

She put in everything. The commitment that Christ demands is not our money but our all. I heard of a man who, when the offering plate came round, put it on the floor and stood on it. That is the point. We commit our whole lives to Christ. Ready to go wherever he calls, ready to spend whatever he asks for.

Some of you know that we have been supporting Lourdes Manabat in the Philippines. Earlier in the week I received this letter from her asking for support worldwide. I hope that some of my readers will feel moved to join us in this worthwhile endeavour.

GOD’S LAMP OF WISDOM LEARNING SCHOOL INC.
GOVERNMENT PERMIT No. E.126 s.2006
GOVERNMENT RECOGNITION P.E. No.061 s.2007


VISION:
“ To produce Christian Workers, Missionary, Leaders, Pastors, Teachers and Evangelist”


MISSION:
“ To train, teach and inculcate the Word of God in the minds of little children as early as 3 years old. ”


History

Nine years ago, God put the vision in my heart. As I see young people, there is difficulty in inviting them to go church to hear the Word of God. Sometimes, it will lead them to mock you and even the good news that we are trying to tell them. Why? Because there are teachings and beliefs that’s already in their minds, that is so quite so difficult to erase. It needs years of inviting, prayers and fasting just to win them for Christ.
Then, the Vision come, we need dedicated, committed Christian Workers. In reaching the world for the Lord. How can we do that, if the ratio is 100 is to 10. Let us accept that there are more unbelievers than believers. And a Christian will only feel the burden when she/he in his teen age, and sometimes, they are being carried by the world or influence by their friends, instead of winning the unbelievers.
The Bible says… “ Train up a child in the way he should go, and when he is old, He will not depart from it…” Prov.22:6 This is an assurance that if a child is being rooted by the Word of God, he will believe it and will not depart from it. This is the Mission God put in my heart. To teach little children, as early as 3years old. Little by little, learning the Word, through stories and Bible truths which is integrated by academic subjects. If they will be enrolled in the school from Nursery 3years old, Kinder 4 years old and Preparatory 5 years old, hearing the Word of God and Bible truths, in His own time, in Gods time, it will bear fruits.

This is how GOD’S LAMP OF WISDOM conceived in my heart and in our prayers. A school that provides quality education and Christian values. We don’t have place of our own, we are just renting a small classroom where we accommodate children. But miracles happen, when I applied for a Government Permit, the first one to secure… God allowed it to happen. Second to secure is the Government Recognition, through God’s power, the favor was given to us. We are recognized by the Government.

Little by little, God arranged and favored the school. We keep on praying that God will give us lot and school building as the training ground of the children that will become Church workers and leaders.

My heart desires is to give free education to these children, but I as of now, I cannot do that. The children pay a minimal amount of 13.00U$ per month to cover the school rental, bills and teacher’s Love gift. But if God will send people/person who wants to be a part of this ministry, we can give free education. And the result of this is we can minister the whole family. Before we will accept their child as recipient of free education, they will agree to attend an hour of Bible Study every week. We believe and it’s my faith, one year of Bible Study and prayer, they will accept Jesus as their Lord and Savior. Both, the child and the family will benefit, intellectually and spiritually.

Its been nine years that we are waiting and praying for this vision/mission be materialized. Our place is so little, and cannot attract people / parents. But there are few who still enroll in the school and we know, they are the fruits of our prayers. As of this year, we only have 22 children. We are praying and looking that one or two or all these children will become Pastor, missionary or Christian Workers someday. Because every day, we pray and lay hands on them.

As a Missionary and teacher, Im praying for people who will be with me in carrying this Vision/Mission. I have the heart and prayers, but as of now…I’m lack of provision.

Wisdom flow on me ,to share this burden to you, and let the Holy Spirit move and touch you. Unless the Holy Spirit moved, nothing will happen. But if He touches your heart, you can be a part in producing Christian Workers and Leader of this earth. Your seed will surely bear fruits for the Glory of God.

If God touches you, you can contact me or email. Lets us be partners in expanding the Kingdom of God, by producing Christian Workers.

My name is Lourdes V. Manabat
46 years old
A graduate of Philippine Missionary Institute year 1985 and 2006
With the Degree of Bachelor in Theology, Major in Christian Education
Married to Ptr. Venancio C. Manabat
We have 3 children. Aaron Paul 20, Lorah Love 16 and Myrtle Love 13.

Email lourdez_manabat@yahoo.com
glowlsi@yahoo.com


Thank you for giving time in reading this letter. And its my prayer that God will touch you and be part of the Vision/Mission.

God bless you…..


In His Service,

Lourdes V. Manabat

Saturday, July 07, 2007

Elizabethtown

There being absolutely nothing worth watching on television, I am working through my collection of DVDs. I finally got to see Elizabethtown (2005). Now I am considering what I thought of it. The MSM critics panned it, but it has a lot of supporters.

Here are a few of the comments about it available on the web:

"This is, without hyperbole, the worst film I have ever seen. It's impossible to summarize why it's so bad, and painful to relive the horrors of this abomination"

"It's not a movie for everyone, of course. But those who don't care for it are likely those who just don't find it to be their cuppa, because strictly speaking, this is a very good movie, with all its elements tying together gorgeously"

"could have been the basis for a real movie. Not the map part, just the wandering around and finding himself part. Maybe not an original movie, but a real one. Instead it was just one more disconnected sequence tacked onto a whole slew of them, and it made me angry that the movie was made in the first place."


"By the end of the movie, I found myself so in-love with the story, so in-love with living, and so in-love with America. Its exactly as a Cameron Crowe movie should be."

"How hard can it be to make another romcom? Well, very, apparently. For starters, it is extremely slow-paced. It just doesn't set off, drags on forever and simply won't end...Steer clear of this movie!"

"This film was excellent. ...the movie accomplishes what it means to. It tells a very moving story that almost forces the viewer to take an active part in it, a quality not found in most movies these days."

Very few come town in the middle; its a film you either hate or love. So what do I think?

First the plot is preposterous. There are so many flaws in its development that the director obviously doesn't intend us to take it seriously. I saw Cameron Crowe's previous movie Vanilla Sky, and in the end decided that it wasn't about plot; you had to let go of that and think about the characters. It's the same here. So who are the characters? Drew, played by Orlando Bloom is the protagonist, but he has no character. Bloom has presumably been chosen for the lead role because of his total inability to express emotion. Mark Kermode, the Radio 5 Live movie critic calls him Orloomo Bland. He's a pretty boy and can do sword fights, but he can't act. Luckily this part doesn't require acting. The director telegraphs this to us, he tells us that he is great at taking last impressions. Kirsten Dunst keeps taking these imaginary pictures. That is what it's about. Bloom is the camera. He is the voyeur watching a picture of America unfold.

The other lead, Dunst, is not real, either. Pollyanna-like she always sees the silver lining, but her purpose is to explain to Bloom, and therefore to us, the audience, that there are other things in life than money and success. I like Dunst. I enjoyed Wimbledon. Here she can't make up her mind how 'Southern' her accent was supposed to be. I think the movie would have been better were she less real. Had she appeared and disappeared without explanation, if Bloom alone could see her, the film would have been more interesting. Instead, we have to figure all this out from the ever present, ear-splitting grin and her Teflon personality.

The third character is Elizabethtown, representing small town America (especially of the South). It's a weird town and oppressively white. For non-Americans it is very alien. Had the plot developed to reveal that these were all pod-people I would not have been surprised. They are grotesques.

The final section of the film is a road trip from Kentucky back to Oregon to the accompaniment of modern pop music and a voice over from our guide (Dunst). It is added on to the film rather clunkily and makes the whole movie too long. It provides for the expected happy ending between the camera and the voice over.

Then there was the Susan Sarandon tap-dance at her husband's funeral. Gross!

Was it a success? Not for me. Then I hated June Bug.

Friday, July 06, 2007

NICE AND NASTY

The NHS is not perfect. It needs reforming. (It needs more money, reply the doctors). Tony Blair puts in more money. Lots of it. But like Mrs Thatcher before hime he wants to be sure that the money is spent wisely. There must be closer oversight of how the money is spent.

So, one of the 'reforms' of the NHS brought in by the Labor government was the introduction of a greater regulation of the service. Two of the most prominent regulatory bodies were dubbed NICE and NASTY. NICE was an acronym - The National Institute for Clinical Excellence; NASTY was an insult for CHI, the Commission for Health Improvement, now renamed the Healthcare Commission. NICE's remit was to ensure the practise of evidence based medicine, though it quickly became apparent that its real purpose was to ensure that what doctors did was cost effective. Even then its real target was the new expensive medicines that pharmaceutical companies want to introduce.

There are plenty of practises paid for by the NHS that have no evidence base. This includes most of surgery, most of general practice, most of dermatology, almost all of psychiatry and virtually all of alternative medicine. A huge amount of money is spent on homeopathy for which there is not a slither of evidence and indeed not even a sensible rationale, but because it is the favored method of treatment for the Royal Family it is regarded as untouchable. When NICE began the UK spent £167 million per year on cancer chemotherapy compared to £2.2 billion on indigestion remedies. Yet the major attack of NICE has been on anticancer drugs. In fact, rather than change the way doctors have uselessly prescribed in the past they have concentrated on the really expensive drugs which may be needed for relatively few people.

CHI was instituted to improve standards. How do you improve standards without inspecting what the standards were to start with? Nobody likes being inspected, so CHI got a bad reputation from the outset. In fact, in pathology we had been doing this for years. Clinical Pathology Accreditation was the brainchild of pathologists and inspections were performed by pathologists. Reports were confidential to the laboratories concerned and were used as weapons against management to improve facilities.

The government developed the star system for hospitals which was policed by CHI. In principle hospitals had to meet certain targets, and getting more stars was rewarded with extra money. The problem was that the targets were surrogates and the hospitals (and other Trusts) gamed them, They achieved the target without making the improvement that the target was a surrogate for. So more money went into anti-gaming activities.

You can see how bureaucracy increases. Then there is choice. With the bureaucracy burgeoning someone calls for the discipline of the market. We must have choice. But it's a strange sort of choice. Most hospitals are 95% full, so there is no enthusiasm for increasing market share and nobody believes that the government would let a major hospital go to the wall. So the "choice" is a mirage.

There may be room for some rationalization, but very few patients want choice. For example Salisbury is a pretty market town in Wiltshire. Its (very new) hospital serves around 125,000 people in several rural communities. It has difficulty in making economies of scale because of its size. Compared with its nearest neighbors, Southampton, Bournemouth and Bath, each serving populations of half a million it is pretty inefficient. A hard nosed businessman would close Salisbury and transfer the patients to the surrounding hospitals, each about 30 miles away, but 30 miles takes at least 45 minutes to drive. There are already small towns out in the sticks that are 30 minutes from Salisbury. Imagine the outcry if someone announced that Salisbury Hospital was closing.

Given the choice, the people of Wiltshire would rather have a good enough hospital in Salisbury than a superb facility in Southampton. They don't want a league table of hospitals. What they want is a hospital within easy traveling distance that meets the standard benchmark of qualities. It's not me saying this, recent research has shown exactly this.

What conclusions do I draw from these impressions? It really doesn't matter how you organize your health care system, there are always going to be intractable problems and someone is going to complain. However, most people are satisfied with the system that they've got and wouldn't change it for what somebody else has got. We can learn from each other, though, and we should not be put off by slogans like 'socialized medicine' and '41 million uninsured'.

Beta-2 microglobulin

I am beginning to have a different view of beta-2 microglobulin as a prognostic factor in CLL. Hitherto, I have been suspicious of its value. It has been championed by the people at MD Anderson Cancer Center and it is practically the only factor they use. I have always contended that it is not so much a prognostic factor as a declaration of how much disease the patient has. I spoke to John Gribben yesterday and he agreed with me.

However, I saw some new data yesterday from the CLL4 trial. They have just done an analysis of the prognostic factors in that trial and for the first time included beta-2M. Sure enough in a multivariate analysis is does help to separate good risk from intermediate risk patients. However, it is interesting to note that when beta-2M is included the prognostic value of stage is eliminated.

Here's what I think is happening. Beta-2M is a measurement of disease bulk. It refines clinical staging. Earlier this year the German group demonstrated that stage A patients included patients with enlarged nodes in their abdomens that were not picked up by routine clinical examination. If these were moved into stage B, then the remaining stage A patients had a better prognosis. We have also known for some time that bone marrow biopsy histology is an important prognostic factor - a diffuse pattern of histology has a worse prognosis than any other. Rai or Binet stages do not show this. To reach stage C or stage III or IV requires a high degree of marrow infiltration. However, as CLL4 demonstrates, patients with 'progressive stage A' have the same prognosis as those with stage B. Progressive stage A comprised patients with s degree of anemia or thrombocytopenia that was insufficient to make them stage C, but was evidence that the marrow was filling up with CLL. If you have more disease you are further along the natural history of the disease.

Look at it this way: Supposing you are stage A (or Rai stage 0,I or II) but your beta-2M is 4.5 then you have either some hidden nodes or relatively large amounts of bone marrow disease. This means that you have had the disease longer than other stage A patients. Supposing the average survival of stage A patients is 12 years, you may well have had the disease for 4 or 5 years already rather than the one or two years of the rest of the cohort. In terms of natural history you have s shorter time left.

Beta-2M, therefore, is a prognostic factor of a different quality to VH genes, ZAP-70 or CD38, which tell you something about the rate of growth of the CLL, or from del 17p and perhaps del 11q, which say something about rate of turnover, something about loss of molecular control and something about drug resistance. Beta-2M is more like stage or marrow histology.

This is not to say it is not valuable. It may well be more useful than CT scanning and bone marrow biopsy, which are both more experimental and invasive.

Having changed my mind I will now interpret beta-2M levels in the light of this new concept.

Wednesday, July 04, 2007

That was then; this is now.

When I trained as a medical student I was very disappointed in the course. I was excited by the discovery of the structure of DNA, by the interaction of actin and myosin in muscle and by the articles appearing in Scientific American every month about the new science of molecular biology. But the course at my University seemed not to have changed from the 1930s when the professors were students. We spent hours cutting up dead bodies. We killed frogs and experimented on their leg muscles using smoked drums to record the responses. We watched demonstrators kill rabbits and snatch their still beating hearts from them so that we could perfuse various chemicals through them. We were given bits of rat uterus to suspend in beakers of salt water while we dropped hormones on them. When we eventually visited the wards we were shown endless cases of rheumatic heart disease, or men who had a heart attack weeks ago, lying still and sedated while their hearts ‘rested’. There were lots of women with fractured hips lying in bed wearing Thompson’s splints until they healed, or more likely died form urinary infections or pulmonary embolus.

The wards were long ‘Nightingale’ rooms with solid fuel stoves at one end. The beds were rigidly marshaled with every sheet straight patrolled by nurses in ridiculous hats who were supervised by sisters who with menacing eye ensured that every stocking seem was also straight. As medical students we were forbidden to talk to the nurses; it seemed our only role was to take blood samples from patients using heavy glass syringes that had to be sterilized between patients and steel needles that must be sharpened and boiled between venepunctures. Fortunately, blood tests were seldom requested.

In the operating theatre the consultant surgeons were treated like gods as they performed operation named after famous practitioners – Halstead, Bilroth and Patey, I remember. In fact almost everything was named after some doctor, diseases, operations, surgical instruments, even the wards themselves. Despite their eminence, we seldom saw the ‘gods’. Presumably they were doing their private practice somewhere. The hospitals were run by the Senior Registrars, very competent men in their early forties who were waiting for dead men’s shoes.

As far as hematology was concerned we learned that there were 4 blood groups, A, B, O and AB, and that iron and B12 deficiency were important causes of anemia. I never saw a patient with leukemia and the only cancers we saw were treated surgically. It was commonplace when disseminated cancer was found at operation that the patient was kept unconscious until he died. Patients were never told they had cancer; euphemisms like ‘neoplasm’ or ‘mitotic lesion’ were used. Indeed patients weren’t even treated like people. They were teaching material. They were discussed from the end of the bed in the third person singular and if they interrupted they were told, “This doesn’t concern you.”

As students we were instructed as much on how to present ourselves as about medicine. Make sure you wear a clean shirt that your trousers have a sharp crease, that your shoes are polished, your hair short and your fingernails clean. After qualification you suddenly found responsibility and realized that you knew nothing. It was then that I began to meet people who were interested in the science of medicine. They were unpopular with the ‘gods’ because they questioned authority. They wanted evidence for doing things this way, and ‘we have always done things this way’ was not evidence. They were unpopular with the hospital administrators because the old ways were cheap and the new ways more expensive.

I began an intensive course of finding things out for myself. I found the textbooks to be largely useless. When I finally settled on hematology I had to describe things from my own observations down the microscope. It was necessary to get rid of the old men’s names. Who cared about Di Guglielmo or Helen Wills? There were diseases out there that were very common that nobody knew about. A textbook of Immunology stated boldly that nobody knew what lymphocytes did, but one thing could be certain: they were nothing to do with the immune response. My professor taught, from his experience with rats, that they were the precursors of red cells.

When I was appointed to Bournemouth there were three consultant physicians; now there are over thirty. I was the first haematologist and I doubled up as the first medical oncologist. There are now seven individuals doing these jobs. We used to deal with 80 blood counts a day; now they have more than 800.

We were advised to retire at 60, because if we waited until 65 we could expect less than 2 years of retirement – and we were lucky, average life expectancy for men was 64 and for women 68.

I write these things to give a flavour of how far we have come. If you look at the graphs of yesterday’s post you may be surprised at the rapid increase in expenditure. Don’t be. We can do much more than we used to be able to and we have the results to prove it.

Chicago

I finally got to see Chicago on video last night. What rubbish! What tosh! I am afraid I just don't get it. Perhaps it was better on stage, but as I remember the film won a couple of Oscars. I watched to the end just to tick it off as seen, but it's going to the charity shop on friday.

Tuesday, July 03, 2007

The NHS now

(Click on pictrure to enlarge)

"12 months to save the NHS" was the election slogan used by Tony Blair. When Labor took over the running of the NHS in 1997 there was undoubtedly a problem. Doctors had been complaining for years about underfunding, but all their complaints had done was to trigger yet another reorganization. Make the pips squeak, said Tory Chancellor, Kenneth Clarke. It was felt that by increasing efficiency more could be obtained from the same amount of investment.

In fact, the NHS was very efficient indeed. The graphs demonstrate that health spending in the UK lagged far beyond similar spending in Europe and North America, yet the quality of care was not that different. At its best the NHS was the equal of any health care provider, and if you were acutely ill it pulled out all the stops. The major problem was waiting. You could get everything for free, but you had to wait for it. At one time a hip replacement meant a 5 year wait. A prostate operation might mean an indefinite wait unless the whole thing seized up, in which case you would be in as an emergency and operated on the next day. In 1997 there were over a million people waiting for operations. Of course as my son has pointed out, it's not how many who are waiting that matters but how long they wait. Ten million waiting for two weeks is not a problem; 100,000 waiting for ten years is. Nevertheless, a million waiting for operations is a powerful political slogan and the government targeted this. A lot more money went into health care, but if you pay a lot more you will need to make sure that the money is well spent. Hence a massive increase in bureaucracy.

What started out as an attempt to remedy a political slogan ended up a bureaucratic nightmare and more and more targets accrued. It's not just the total wait that matters, but how long you wait in the ER to get seen, how long for an outpatient appointment, how long an ambulance takes to get to the scene of an accident. And cancer patients are a special case; they need to be sen quicker than someone with a hernia. So the targets multiply.

With more targets there is a diversion of resources from providing good health care to meeting targets. As in Education they teach to the exam rather than educate the child, so in medicine they respond to the target rather than the patient. Thus we see cancer specialists who must see a new patient with cancer within two weeks of a referral complaining that their clinics are full of patients with benign breast lumps (which might remotely be cancer) and patients with more serious non-cancer diagnoses being delayed.

Those who run services spend time gaming the system rather than improving the service. If patients in the ER must be admitted within 4 hours of being seen, it's quite simple, you rename a trolley a 'bed', and call a corridor a 'ward'. If an ambulance must be on the scene within eight minutes of receiving a call then you re-designate the time that the call was received to eight minutes before the ambulance arrives. The polite term is 'gaming'; the less polite is 'lying'.

In the days of the USSR nail factories had targets to produce a certain number of nails; they responded by producing millions of very small nails. When the target was changed to a certain weight of nails they responded by producing one very large nail. This analysis sees the problem as central direction. One solution sees the answer as introducing more competition. Let the market take care of the problem. The difficulty with this solution is that a free market depends on certain providers going out of business. Imagine no hospitals in Philadelphia; all the business has gone to Wilmington because the taxation scheme there is more favorable.

Then there is 'post-code prescribing'. Yesterday I emphasized the importance to our Lords and Masters of Equality. Despite all claims to the contrary, people are not equal. Some are more beautiful, some are more intelligent, some are richer, some are more athletic, some are fatter, some are predisposed to sickle cell disease, some to diabetes, some to certain types of cancer. Whatever health system is established, some will do better out of it than others. If you live in Bournemouth you will live longer than if you live in Middlesborough. Why? 1] You are likely to be richer. 2] You are likely to have had a less strenuous job. 3] You are less likely to have come into contact with toxic chemicals. 4]You are less likely to be a smoker 5] You are likely to drink less 6]You are likely to be in a higher social class. 7] You are likely to have a better doctor. (Doctors like to live in nice parts of the country too, so there is competition for jobs here. You have to be a saint or an immigrant or to have been born there to want to practise in Middlesborough.)

Allocation of funds for health care might be thought simple. Just divide the available money according to the number of people living there. But old people are much more likely to get ill, so there needs to be an age weighting. One in three living in Bournemouth is over 60 while it is one in six in the rest of the country. But then other factors are relevant. Some ethnic communities have a greater need - sickle cell disease and thalassemia. Poor people use the health service more. Do you compensate for that by putting in more health care money or deal with the social factors separately?

I have mentioned all these drawbacks, not because I think that the NHS is a bad thing, quite the reverse. But Sicko makes it sound like paradise, which it is not. Don't think that the ills of the American health care system can be remedied just by changing to a single purchaser or (heaven forefend) asking for advice from Fidel Castro. Every country is going to have difficulties providing health care for its citizens and there are problems and solutions that are common to all.

Tony Blair has put billions more into the NHS yet funding still lagsfar behaind that of other countries. Tomorrow I will discuss why health care keeps costing more.

Monday, July 02, 2007

The beginnings of the NHS

I have been prompted by a couple of e-mails to say something about the NHS and NICE. Michael Moore’s film Sicko has raised the profile of the NHS in America and recently the election of a Democrat congress and the possibility of a Democrat President have made it more likely than not that something will be done to change the organization of health care for America.

The National Health Service (NHS) was introduced in Britain in 1948 at a time when the country was on its knees following World War Two. Britain (and its empire) was the only country that had fought against Germany for the whole of two world wars and despite having entered the twentieth century as the richest nation on earth, it had become not just impoverished, but also indebted. In 1945 a Socialist government was elected. Perhaps as a necessity almost everything was nationalized: coal, steel, the railways, the docks, much food production, and medicine. The Thatcherite revolution has undone all of that but medicine remains a nationalized industry. Why is that?

Establishing an NHS was not primarily an idea of the socialists. It had started under Lloyd George, the Liberal Party Prime Minister early in the century and multi-party committees operating during WWII produced the Beveridge (a liberal Peer) Report that advocated major changes in how health care was provided. There were already many quasi-insurance schemes that enabled the poor to get access to doctors. Before the NHS most doctors operated a sort of ‘club’ scheme whereby relatively poor people, by paying a small amount a week, could have access to a family doctor when they needed one. There were even schemes where employers operated such systems for the benefit of their employees. The great teaching hospitals were charitable trusts where free treatment was available to the poor, the consultants making no charge for their time, but making up for that by charging a great deal to their rich private patients. Harley Street and Wimpole Street were the sites of many consulting rooms and patients came from all over the country to see the great men. There were private hospitals and private wings in the teaching hospitals.

Elsewhere in the country the hospitals were sometimes also charitable trusts but sometimes owned and run by the municipal authorities. There is no doubt that most doctors were very well paid. They drove the sort of cars that had the stamp of quality. It was usual that a teaching hospital consultant drove a Rolls-Royce. Even a family doctor would drive a Rover. If you read AJ Cronin’s The Citadel you will get a good flavour of how it was.

There was a great deal of resistance from the doctors to the imposition of the NHS. Eventually Aneurin Bevan, the fiery Welsh Health Minister famously ‘stuffed their mouths with gold’. He allowed the consultants to keep their private practice and allowed the family doctors to run their own businesses. This remains to this day; family doctors (known in the UK as General practitioners – GPs) still act on a contractual basis, each partnership having a separate contract to provide health care as a business, and consultants, though salaried, have the right to have a private practice outside their contracted hours.

When the NHS began there was very little that medicine could do. The surgeons could do most, and these comprised most of the consultants. (When the Bournemouth Hospital was taken over by the NHS it was discovered that there was a substantial Trust Fund). The Medical Staff Committee decided what to do with it. It would be split into 8 shares. One share would go to each of the seven surgeons and the remaining share would be split between the anesthesiologists.) Most of the operations that were done then are no longer performed. Most physicians were little different from GPs, but they had the right to admit patients into hospital. They also often doubled up as anesthesiologists. There were no pathologists except in the Teaching Hospitals and doctors had to act as their own radiologists.

At that time TB was the great health problem. In Bournemouth there was a country branch of the Brompton Hospital, the famous London Chest hospital, but even this was about to be replaced by a sanatorium among the pines of the New Forest. Streptomycin meant that it never opened. Until recently you could visit the ruins of the half-constructed hospital.

Even though the health service could provide little beyond now-defunct operations it soon began to run out of money. Patients were able to obtain for free anything remotely health-related – even hot-water bottles to keep out the cold at night. The nation was on its knees. In 1947 Churchill famously criticized the Labor government “…on an island made mainly of coal and surrounded by fish, this government has contrived a shortage of both.” New medicines were coming on line at an alarming rate. The cost of the NHS doubled and then trebled. In order to contain the costs the government introduced a charge for prescriptions. Rationing had begun. This was a resigning issue for Anuerin Bevan.

In fact it quickly became clear that the demand for health care is unlimited but the money available for it has to be limited. Enoch Powell, Tory health minister in the 1960s and a very clear thinker – Professor of Classics in Sydney, Australia at the age of 28 – recognized this and said that rationing is inevitable. All health care is rationed, wherever you are in the world. In America it is rationed by price. Anything is available if you can pay for it. If you can’t then you can’t have it unless you can persuade someone else to pay for it. In Cuba there is no rationing by price, but for many treatments nobody can have them.

Over the past nearly 60 years there have been many reorganizations of the NHS. The biggest pressures have been for equality and efficiency. The drive for equality has meant more and more central control; the drive for efficiency have given us NICE. I have said before that what patients want is not either of these but another ‘E’ – effectiveness.

I shall write some more tomorrow.

Sunday, July 01, 2007

Heartlands

Heartlands is the second feature film made by Damien O'Donnell afer East is East. Set in the North of England nice-guy Colin is a dart's player and a newsagent. His life is monumentally boring. His wife, Sandy, seeking excitement starts an affair with the captain of the darts team who dismissed Colin from the team and runs away with her to Blackpool. Colin decides to follow on his 50cc Honda moped. Colin's 'adventures' on the road change him. He meets a biker who drags him out of the 1970s with a haircut and a new jumper, a randy publican with a fat barmaid and a moaning kid, a tree-hugger, and a girl guide leader with a troop of brownies. When he finally confronts the eloping couple she has tired of the oafush team captain and wants to come home, but Colin gives her the keys to the house and the shop and is off to see how the world works. This is a gentle film with gentle laughs and a warm feeling. Not hard to watch on a boring, wet afternoon.

Michael Ots' evening sermon

This evenings sermon by Michael Ots, evangelist at Lansdowne Baptist Church seems to me to be so important that I reproduce it here as much as I can from memory.

Richard Dawkins has suggested that a God who kills his own son to pay for the wrong things that others have done is a malicious, sadomasochistic and repellent pervert. Jeffrey John, the Anglican priest who was disappointed for his hopes of a bishopric because of his homosexuality has railed against the notion of substitutionary atonement. Even Steve Chalke, supposedly an evangelical, has disowned this precious gospel. How can this charge be answered?

In part the problem arises because of the illustration that have been used to explain the gospel. Illustrations like the story of a signalman who sees his own son playing on the railway lines as the express thunders towards him. He has the option of throwing the points so that the train misses his child but enters a siding that will cause the train to crash with the loss of many lives. Although this gives the idea of one dying for many, it portrays God as someone trapped into a corner, having to act in an unprepared way at the last minute. Or like the illustration in the Bridge on the River Kwai of the discovery of a missing spade. The camp commander says that unless the thief steps forward, all the prisoners will be shot. The chaplain steps forward, an innocent man dying for many. Later it transpires that there has been a miscount; no spade is missing. But that story portrays God as as cruel and malicious as a commander of a Japanese prisoner of war camp. Or the story of the judge who sentences a prisoner, but then comes down from the bench and stands in the dock himself to be taken away to serve the sentence. But that picture is false because no such provision exists in any judicial system.

It is a problem because people misunderstand the gospel.
1. They do not realise the willingness of Jesus. No-one takes my life from me. I lay it down. The cross was not imposed on him. He knew about it from the beginning of time. It was his eternal plan.
2. They do not understand the attitude of the Father. God hates sin. How could be leave sin unpunished? He does not hate his son. He loves his son. God punishes sin; his son interposes himself between the punnishment and the sinners.
3. They do not understand the Trinity. Who does understand it? There are not three gods. There is only one God. I and my father are one, said Jesus. The punishment of the cross was not just the blood and pain that Mel Gibson showed us; that was just a picture of it. The cry of dereliction, "My God, why hast thou forsaken me?" denotes the tearing apart of the godhead and it was suffered by father and son alike.
4. They do not understand the nature of forgiveness. Why doesn't God just forgive sinners? they ask. Suppose your little daughter was abducted and raped. You confront the perpetrator and they ask you to forgive him. Could you do it? And if you could what would it cost you? All forgiveness is costly. It costs God to forgive you.
5. They don't understand the results of the cross. "For the joy that was set before him (he) endured the cross, scorning its shame". What was that joy? It was the millions upon millions saved from perishing.

This bloody gospel is not a sadistic thing. It is not divine child abuse. Had there been any other way would not a just and loving God have taken it?

More Mark 12

Jesus certainly knew his Psalms. Having silenced his critics he asks them a question. "How is it that the scribes say that the Messiah is the son of David?"

The coming of the Messiah was a great event which the Jews looked forward to (and some still do). We are so used to seeing Jesus in say, Isaiah 53, that we find it hard to believe that the Jews deny this. Yet Jews believe that the suffering servant is the nation of Israel itself. Here Jesus is once again claiming to be the Messiah.

The Jews knew that Jesus had raised no objection to being called the son of David, eg Matthew Ch 21 v 15, "Hosanna to the son of David". They knew at once the implications of this, "Do you hear what these children are saying?" they challenged him. His reply was unequivocal, "From the lips of children and infants you have ordained praise." quoting from Psalm 8. This incident although not reported by Mark occurs immediately after the clearing of the Temple. So Jesus is continuing the same discussion.

He quotes again from the Psalms, this time 110: The LORD said to my Lord, "Sit at my right hand until I put your enemies under my feet." The Messiah is not only the son of David; he is also the son of God.

Notice also how he describes the Psalm: David himself, speaking by the Holy Spirit, declared... He is the special nature of Scripture that differentiates it from all other literature; it is written by human authors who are 'speaking by the Holy Spirit'.

He has already told one scribe that he is not far from the kingdom of heaven. Now he is offering to put right what is missing. We know from elsewhere in Scripture what is necessary to be saved. "Believe on the Lord Jesus Christ, and you will be saved." He is declaring himself to be the anointed one, the Savior of Israel.

But he knows that the teachers of the Law will not follow where he leads. He sees their hearts. he knows that their behavior betrays their beliefs.

"Watch out," he warns, "for the teachers of the law. They like to walk around in flowing robes and be greeted in the market place, and have the most important seats in the synagogues and the places of honor at banquets. They devour widow's houses and for a show make lengthy prayers. Such men will be punished most severely."

It is a good thing to desire to be a leader but leaders have special responsibilities. Asked what they want to be today, young people often reply that they want to be famous. They see actors and footballers given the red carpet treatment and want the same; they little realize that even actors and footballers have had to work for their fame. Young people want the fame but not the work. We see ministers of religion enjoying the exposure of the media, careful for their hair styles and tans, conscious of what looks good on camera. We see preachers milking the little old ladies. Little changes.

A minister is a servant. Whether he is a minister of religion or a government minister. By their fruits shall you know them. Heresy leads to hypocrisy.

Dr Who regenerates

The third season of the new Dr Who has ended. Those of us who watched Dr Who from behind the sofa in our childhood wondered what the reincarnation would be like. I am pleased to say that it has surpassed the old. Gone are the cardboard sets and the hammy acting. Now we have CGI.

In the last three episodes we have seen the reappearance of the Master, the Doctor's old nemesis. He is the only other Time Lord left in the Universe, and his powers are as great as the Doctor's but his are unrestrained by a wish to do good. The Master was played by first Derek Jacoby and then by John Simm (from Life on Mars).

The Master has used satellite broadcasts to hypnotise the British people to elect him Prime Minister. From that position of power he seeks to dominate the whole world. After the Master has captured the Doctor and aged him 900 years so he is powerless, he has opened a rift in time to allow mysterious aliens into Earth of the 21st century to kill and enslave the humans. The only hope is Martha, the Doctor's companion. We see her landing on a South Coast beach apparently seeking the fourth chemical that will power the gun that will be powerful enough to kill a Time Lord. She has travelled the world in the last year apparently seeking the other three components. Enlisting the help of an old professor she discovers that the mysterious aliens are in fact humans from the end of time when the Universe is dying. They have been brought to the present by the Master and enabled to kill their ancestors because the Master has converted the Doctor's TARDIS (his time traveling device) into a Paradox machine. But she is betrayed by the professor and captured by the Master's guards. The Master destroys her Time Lord killing gun, but she reveals that the gun was only a ruse to get herself captured, it would not work. Her real mission was to tell the enslaved peoples the truth about the Master and the Doctor and to reprogram the satellite system by reversing the polarity (nice touch of the Star Treks) so that a single thought of the whole people would arrive powerfully at the Master's lair.

The Master's response is classic, "Prayer? You thought to defeat me with prayer?"

Yet that is what happens. The whole world thinks, "Doctor!" and the Doctor's ageing is reversed and he is restore to his full power and defeats the Master who cringes before him, begging for death. The Doctor has something worse than that for him. He has known the Master since they were children together on Galifrey. I have something for you more powerful than all the weapons that you have sought to dominate with. He puts his arms around the Master, "I forgive you," he said.

A parable? Certainly. Love is stronger than hate. The Doctor is a Christ-like figure, apparently defeated by the evil one, yet restored to life with supernatural power. The powerful God invoked by prayer. Forgiveness conquers all.

Two more movies

I have watched two films from my video collection this week. The first was Mike Leigh's All or Nothing. Mike Leigh is a celebrated film director lauded in Europe but a minority taste in Britain and America. Secrets and lies is perhaps his best known movie. In this 2003 film Timothy Spall is the only well known actor and he plays the part of Phil, a fat and feckless driver of a mini-cab in South London (the famous London black cabs reputedly won't go south - pronounced 'sarf' - of the river). He is the common law husband of Penny who works on a supermarket checkout. They have two children, fat Rachel who mops up at an old people's care home, and fat Rory, who inhabits a sofa from where, he eats junk food, watches junk television and shouts abuse at his parents in junk language. They live in a council flat in a tower block. Their neighbors are Ron who also drives a mini-cab, but keeps on having accidents, always blaming a woman in a Volvo which at least sometimes is imaginary, (Volvos are legendary non-cool cars in England and women drivers - well, women drivers! - are the butt of every poor driver's ire), and Carol who is perpetually drunk. Their daughter is the local tart, practising her wiles on a strange young man who hangs around beneath the tower block. The other neighbor is Maureen, a single mother who takes in other people's washing. Her daughter is another hopeless case who gets pregnant by a foul-mouthed lout, Jason. His reaction is to thump her and then protest that he will do the decent thing; he will drive her to the abortionist rather than make her take the bus.

Phil's life is so terrible that he survives by living on another planet with his phone and radio switched off. Penny holds things together resentfully. Maureen is the only upbeat character. She sings (well) at a Karaoke pub about the one who made her brown eyes blue. She knows she can cope with hardship and keep smiling.

This is not a movie that many people will like. The foul language will deter many and the relentlessly depressing subject matter will put others off. It is undoubtedly a masterpiece of film making - the acting is wonderful, the characterisation Dickensian and the direction and editing superb. But is it true? I suspect that the picture of Britain portrayed is exaggerated. I could believe this of 1979 but surely life has got better. If the characters are really true to life then there is little hope for London. I could well see a future fascist party deciding that they would make good cannon fodder in some future war.

The White Countess, directed by James Ivory, is another movie by a well respected director. Set in the Shanghai of 1936/7 it stars Ralph Feinnes as Jackson, an American diplomat who was there at Versailles and whose career has taken him to China where he lost his wife, child and sight in two separate urban bombings. He has prostituted his good name by allowing it to be appended to some business firm's letterhead in return for a stipend. Natasha Richardson plays Sofia, a Russian countess driven out by the Communists and now living in penury with her in-laws (which includes her real life mother and aunt, the Redgrave sisters). While the family puts on airs, she is sent out to work as a night club hostess with a bit of prostitution on the side to earn enough to keep her daughter and in-laws fed. They despise her for what she does. Jackson drinks too much, but has one ambition which he shares with Matsuda, a mysterious Japanese. He wants to create the perfect night club as a work of art. After some luck at the racetrack this is what he does and invites Sofia to become his centerpiece - she will no longer have to sell her body.

The nightclub lack political frisson and to remedy that Jackson turns to Matsuda to provide Nationalists, Communists, Chinese soldiers and Japanese businessmen. The relationship between Feinnes and Richardson, which is the real centerpiece of the film, is kept simmering without ever boiling over by the sang froid of the English actors. It suggests passion under control. It takes the Japanese invasion (as we knew it would) to unleash their true feelings. Some have thought that Jackson was modelled on Rick in Casablanca, but I think he more closely resembles the English Colonel in Bridge on the River Kwai.

Some Merchant/Ivory aficionados were disappointed in this, the last of their movies, but I thought it better than that. The 1930s were such an important decade. The generation that lived through them is beginning to die off. Films like this that hark back to the style of that tumultuous era get my vote every time.

Is it prayer that keeps us safe?

Reflecting on the three attempts at car bombs in the past couple of days it is hard to know what to conclude. Since 7/7 we had the copycat attempt to blow up trains two weeks later that failed. We have had several attempts to cause mayhem that have been foiled by the security services (the conspiritors are now in gaol), the two car bombs in central London which failed to explode and the strange incident at Glasgow airport where two men drove a Jeep Cherokee into the glass door of the Terminal building, poured petrol over themselves and the car, which was loaded with propane gas, and set it and one of them on fire, but were forestalled from killing anybody by a member of the public who threw a right hook and downed the flaming terrorist before the police arrive to subdue him. Either the terrorists are amazingly incompetent or we are being specially protected.

My atheists friends will reply that we weren't kept safe on 7/7, were we? But on 7/7 no-one, or very few, were specifically praying for our protection from bombs. That is not the case now. The security services are doing all they can. It is said that they have over 2000 suspected Islamist terrorists under surveillance, and that one of those responsible for Picadilly is a colleague of those gaoled for the 'liquids on airplanes' plot, but it has always been said that the bomber will always get through.

I don't want to sound complacent, but if it is prayer, it is being answered, which is more than you can say for that of the Islamists in Britain. So if you are praying for our safety, thanks, and keep praying.