False teeth and Constipation

Today was another Kings College Hospital day. This involves a total of five hours on the train, and today because of signal failure, a goods train stuck in the station and the failure of a door to open I was 30 minutes late arriving. I amused myself by working my way through Carol Vorderman's Massive Sudoku book. I don't know whether this Japanese craze has reached the rest of the world, but it passes the time.

For those who do not know, Carol, who is a nice looking lass in her forties presents an afternoon television program called Countdown. It has a simple format: competitors are given 30 seconds to find the longest word they can from 9 random letters (though they may specify the number of vowels there are within the 9). A mathematical variation has a selection of 6 numbers which must be added, subtracted, multiplied or divided to make a three figure total that is randomly generated.

This program runs for 45 minutes every afternoon and it is what retirement holds for millions of Britons. The giveaway is in the advertisements that interrupt the program. Glue to stop your false teeth shifting, constipation cures, stair lifts (you probably call them elevators), electric arm chairs that enable the weak to stand up, insurance companies offering ways of freeing up the equity in your house, walk in baths, devices for getting you out of the bath, anti-aging face cream; these are some of the products targeted at this audience.

Carol is an Oxford graduate who was paired with Richard Whitely, an oversized ex-local TV reporter noted for ostentatious jackets. Both got a third at Oxford, which is a sort of degree given to people who go to University determined to have a good time and not do any work. Sadly, Richard died last year. he has been replaced by Des Lynham, a pensioned off sports reporter who is the epitome of 'laid-back'.

After the ward round I had to rush off to be interviewed by BBC radio about the TeGenero affair. The week beginning September 24th is when it all breaks. There will be a Sunday Times article and radio and TV programs about it. Somebody will want a lot of compensation for the experiment that went wrong and somehow they will want to sue the one with the biggest purse (the taxpayer).

The up to date information on the experiment goes like this: the idea was to develop an antibody that would stimulate T cells. There are several disease where T cells are sleeping - AIDS is one and CLL is another. Normally anti-CD28 will only stimulate T cells if CD3 is also stimulated, but TeGenero discovered an antibody that would stimulate T cells all by itself. As they tested it they discovered that it seemed to stimulate regulatory T cells more than ordinary T cells. Regulatory T cells suppress the immune response and would be useful in autoimmune diseases like rheumatoid arthritis and diabetes.

Tegenero was in a quandary. Would their antibody stimulate ordinary T cells, and therefore be useful in CLL and AIDS or would it primarily stimulate regulatory T cells and switch of the immune response, making CLL worse? They tested it in monkeys where it didn't have much effect and from those studies chose a dose that ought to be safe. Because it had the potential to make either CLL or rheumatoid arthritis worse, they decided to test it in normal individuals at what they thought from the animal studies was a very low dose, expecting no effect in man, except minor changes in blood cell populations which would give an indication of which way it would act.

It turned out to be much more active than they had anticipated. Their strategy turned out to be flawed. They compounded the problem by treating 6 individuals with only minutes between them.

There will be several new recommendations from the MHRA which should stop such a disaster happening again. I think the core of the problem is the time that the MHRA is expected to turn around very complex applications. There is not enough time to consult appropriate experts.

Fatigue in CLL

Many patients with CLL complain about fatigue.

It is also true that many patients without CLL complain about fatigue.

The commonest reason for a general practitioner requesting a CBC is "tired all the time". I suspect that they suspect anemia, which is certainly a cause of fatigue. Hardly any of those patients have anemia.

There are many possible causes of fatigue. People feel fatigued when they have been working hard - either physically or mentally. If you play a hard game of rugby or soccer you certainly feel fatigued at the end of it. If you drive 200 miles, if you go for a job interview, if you watch you children perform in the school play, the emotional tension makes you feel tired afterwards.

Tiredness is the natural consequence of being awake for a while, an indication that we need to sleep. Clearly this is not what patients are complaining about.

There are medical conditions which manifest as tiredness. I'm not sure that tiredness is a good word to describe it, though it is certainly part of it. Fatigue is a word often used, though this is a technical word in medicine, which has a specific meaning. It refers to what happens when a muscles is stimulated repeatedly by electricity. After each stimulation there is a period when it cannot be stimulated again - the muscle is said to be fatigued and requires the regeneration of certain chemicals before it can be restimulated.

Asthenia was a word that was formerly used. It describes that feeling of exhaustion, lack of energy or indeed the will to do anything; being washed out and weak and watery. It was often associated with anemia or chronic infection, especially with TB.

Anemia induces this feeling because insufficient oxygen is reaching the muscles. In France and Germany doctors are prone to diagnose asthenic patients as having low blood pressure, and the German Health Service has quite a large budget to spend on drugs to raise the blood pressure, something that is unknown in the UK.

Some years ago I began to be referred patients who claimed that they had myalgic encephalitis or ME. There is an ME society. What these patients had in common was severe fatigue. Commonly they would sleep for 12-16 hours at night. Often they had muscle pains (hence the myalgia) and they would often complain of a muzzy head, being unable to concentrate or focus on anything (hence the encephalitis). They were unable to hold down a job. Many of them dated their symptoms from a viral infection, often glandular fever, that never seemed to have got better, although often the glandular fever had not been diagnosed virologically, but simply labelled as that from a GP without investigation. One woman dated her illness to when she was biten by a squirrel.

At the time I was interested in infectious mononucleosis. However, I could find no really convincing evidence of EBV having anything to do with it. A clinical trial of levamisole as an immune booster had no effect.

Nowadays this condition is called chronic fatigue syndrome and it is treated by cognitive behavioural therapy, though sometimes older doctors and rheumatologists label it as fibromyalgia (which being translated means, "I know you have aches and pains but I can't find anything wrong").

The problem about making the diagnosis of pathological fatigue is that it is a diagnosis of exclusion. That means that as it has no spcific symptoms and no clinical signs or characteristic blood tests, the doctor must first exclude all the conditions that can be tested for

Simply getting older is the commonest cause of fatigue. It affects some more than others.

Fatigue often has a psychological cause. It doesn't mean that you are psychologically ill, but things like children leaving home, retiring or nearing retirement, downsizing your house, divorce, bereavement, disappointments, fears, even the war in Iraq can leave us feeling fatigued.

Then there is actual depression. Subclinical depression is much commoner that is recognized. And so is anxiety neurosis.

Medications cause fatigue. Any sort of sleeping tablet, any type of blood pressure tablet, any type of anxiolytic, many antihistamines.

Sleep apnoea is a possibility, especially in anyone who is overweight, then there is any degree of heart failure, certain types of neurological disease, any type of cancer, diabetes, hypothyroidism, Addison's disease and I expect there are other conditions that I haven't thought of.

When a blood test for 'tired all the time' is done, some people will be found to have undiagnosed CLL. But perfectly well people having a blood test prior to, say, hernia repair, will also be found to have CLL. We can't just say, "Aha! We have found the cause of the fatigue." Lots of people, perhaps the majority, who have CLL do not have fatigue.

It must be galling for a patient to keep telling the doctor that the CLL is the cause of the fatigue and yet not have the doctor believe him or her. What more evidence do they want? I used to be well, then I got CLL, now I am fatigued. Why won't you believe me?

So what is the evidence that CLL is the cause of a particular patient's fatigue?

If you search for 'Fatigue' and 'CLL' on PubMed you find a couple of pages of papers most of which refer to fatigue as a complication of treatment or anemia. There is a paper which reviews studies of qualitiy of life in CLL.

This paper by Stephens et al Am J Ther 2005; 12:460-466. has the following quote: "We identified only 8 articles, and none of them analyzed the QOL in untreated CLL patients".

There has been no systematic study of the symptoms suffered by asymptomatic patients.

Some doctors are convinced that CLL causes fatigue. They believe this because a lot of CLL patients have told them that they suffer from fatigue. On the other hand doctors in some countries get paid a lot more if they give patients chemotherapy than if they simply offer watch and weight. Far be it for me to suggest that any doctor would be swayed by this, but some might opine that such a doctor might not be entirely objective.

There is a rationale for fatigue in CLL. We know that CLL cells in the test tube can be shown to secrete a number of cytokines including IL-1, IL-6, IL-8. IL-10, TNF-alpha, TGF-beta. It is also known that when certain cytokines are used therapeutically (IL-2 and interferon) the side effects include prostrating fatigue. In addition several conditions in which fatigue is prominent such as terminal cancer are associated with high levels of certain cytokine such as TNF alpha and IL-6.

If this is the mechanism then one would expect fatigue to be greatest in patients with the greatest bulk of disease. This is sometimes true, and it is behind the NCI guidelines that say that severe fatigue is an indication for treatment. On the other hand some patients who complain about fatigue have only small amounts of indolent disease. One then has to postulate that the tumor is an industrious cytokine secretor. Un fortunately there have been no studies done to measure cytokine levels in patients with fatigue, comparing them with levels in patients without fatigue.

Another possible cause for fatigue in patients with CLL is a chronic infection caused by the immunodefficiency. This might be a low grade bacterial infection; perhaps of the sinuses, or perhaps even TB. It could be the reactivation of a virus infection like EBV or CMV.

I am sure readers will see the theraputic conundrum here. If the fatigue is caused by cytokine secretion from the tumor, then chemotherapy will make it better. If, on the other hand, it is caused by chronic infection, chemotherapy will make the immunodeficiency worse and the infection will progress.

I am sbsolutely convinced that CLL patients get fatigue as a symptom. Trying to find out why is very difficult. Jumping into treatment may not be the correct path to follow. More research into this difficult problem is clearly needed.

If a trial of therapy is to be undertaken in a patient with low bulk disease, then I favor a trial of green tea extract. This will likely cause no harm, and it seems that some patients respond. Next in line would be rituximab alone.

Individuals

I have spent the week finalizing the protocol for our vaccination study, hence very little blogging, but in the evenings I have been watching DVDs.

When time is short I watch an episode of Sherlock Holmes. This week, “The Crouching Man”. I was pleased to have spotted that it was all about monkey glands well before the end, but perhaps my subconscious mind remembers reading the story. My son, who leaves for Seattle today, has left several of his books with me and among them is a collection of non-canonical Sherlock Holmes stories (ie not by Conan Doyle). I will read them next.

It looks as though our first visit to Seattle will be during the first two weeks in October.

I have also watched two movies this week. The first, recommended as a result of this blog, was “Something the Lord Made”, a biopic of Arthur Blalock, inventor of the Blalock shunt as a treatment for Fallot’s Tetralogy or ‘blue babies’. This was an HBO made for TV film that starred Alan Rickman.

Although an excellent movie, it was astonishing to see the way that doctors were treated like gods. Many years ago our laboratory was visited by a young American physician who had come to learn something about immunology. I was a young fellow at the time and was showing him round the hospital. We bumped into Roy Poulding, one of the leading cytogeneticists in the UK at the time. Roy had started as a laboratory technician, but had made himself into a leader of his field. As we were talking, the young American Fellow stomped off. When I caught up with him I asked him what the matter was. “Don’t you realize that I am a physician?” he said.

As I watched the humiliation of Vivien Thomas (ably played by Mos Def) I was reminded of that incident. Where do doctors get off for be so arrogant?

The other movie was “Shooting Dogs”. This was Hotel Rwanda revisited. John Hurt stars as a Catholic priest who runs a missionary school that is used as a refuge for Tutsis. The Belgian soldiers, who are part of a UNIFIL contingent there to ‘monitor the peace’, are unable to fire unless fired upon. Their anguish is ably demonstrated. How many times have we seen this? In Bosnia, in Rwanda and in Lebanon. If it is simply to observe, send in the media. Far better for any intervening force to behave as the British Army did in Sierra Leone.

I found the remarks of the BBC reporter particularly telling. “In Bosnia I saw these old women killed and I thought, ‘that could be my grandmother’ but here it’s just another dead African.” And the truth is that there are too many dead Africans, in Darfur, in Congo, in Somalia, in Northern Uganda, and previously in Angola, in Mozambique, in Biafra. Not to mention those dying of AIDS, TB, measles, malnutrition and the rest. They talk about compassion fatigue, and it is hard to see all these dead black bodies as individuals.

I have been reading the blogs recently. Much has been made of the fraudulent photography coming out of Lebanon. They make a convincing case that what we see on our TV screens is so much propaganda. But the blogs are fond of quoting the Jerusalem media. How unbiased is that?

When I used to be interviewed a lot by the newspapers and television, I was often shocked by what came out the other end. It seldom truly represented what I said. I usually found that the media got medical stories wrong. Even then I decided that if they could be so wrong about things I knew about, how could I trust them about things of which I was ignorant? I guess the answer is to read widely, looking at all sources and make a judgment.

The same blogs that call out Hezbollah as movie directors are usually passionately anti-Muslim. It is not a bunch of hotheads, they say, it is the religion itself. They quote from the Koran (I am not attempting any other way of transliterating it) demonstrating that Mohamed was a vicious pedophile who gloried in his blood lust. No wonder the young men turn out like this, they are just following their holy book.

The Muslims I know are not like that. In fact I would go further. I don’t think there is such a thing as a Muslim as a ‘category type’. I know Professor ***** who is a friendly, gentle, clever guy, I know Dr ******* who is hard working, polite and studious, I know Mrs ******** who dresses like everybody else here and is diligent single mother. I also remember Dr ******* who was arrogant and self important – he emigrated to America. Then there was Dr ******** who kept himself to himself. I could go on. Some of the individuals I have seen on my TV screen make my flesh creep. Some are so beset by prejudice and hate that they have made me hate them. When I saw a BBC film of a man in Gaza who said he had 4 women and 54 children and he was training them to be martyrs in the fight against Israel it made me weep for those little boys and girls.

The great advance of Christianity was to see people as individuals rather than as ‘category types’. We are saved as individuals. Jesus died for individuals. Or we are damned as individuals.

There is a very moving scene near the end of Shooting Dogs where the priest is confronted by a band of marauding Hutus. He recognizes one of them, presumably an old boy from the school. He talks to him by name. The Hutu has fear in his eyes. He cannot bear the shame of being an individual killing Tutsis. As part of a mob killing the ‘cockroaches’ he was fine. But being an individual frightens and shames him.

Labyrinth

Women all over England are raving about Labyrinth. It was chosen by Richard and Judy's book club as one of their books of the year. It is written by Kate Mosse (no not that one). You might describe it as Da Vinci Code meets Chick Lit. It is set in both the 13th century and the here and now and is about the Holy Grail and teh Albigenses or Cathars.

It is reasonably well written, without the pace of Dan Brown's book, but the plot is forever being interupted by unnecessary details about the color of the heroine's eye shadow, and what skirt she chooses to put on. I finished the 700 pages but had guessed the plot twists about 200 pages out - pretty well telegraphed by the use of "we" rather than "they".

My wife liked it but I won't be reading any more by Miss Mosse.

A Hair raising scandal.

On the first weekend of the new football season, with Manchester United 5-1 winners over Fulham whose near-neighbors Chelsea beat United's neighbors Manchester City 3-0, things slipped quickly back into last season's groove; but elsewhere in the sportosphere dramatic events were happening. We have had another cricket furore.

Cricket scandals are always headline news in England. The first was when England lost to the colonials. The Australian victory lead to a set of bails being burnt as their Ashes put in an urn and became the trophy that future teams would compete for. Then there was the 1932-3 bodyline tour when Douglas Jardine set his fast bowlers to bowl at Donald Bradman's body as the only way to cutail the run-making machine. There was further scandal when Kerry Packer recruited some of the best players in the world to play in his alternative competition.

There has always been some niggle between England and Pakistan. In 1987 the England captain, Mike Gatting had a stand up row with the the part time Pakistani umpire Shakoor Rana (Gatting made a half-hearted apology and the game continued, but the cricket Board sacked him the following year using the excuse of his affair with a bas-maid), and more recently there was a court case between former pakistan captain Imram Khan and former England captain Ian Botham over accuasations of cheating.

The fourth test between England and Pakistan looked to be heading for a consolation victory for Pakistan, who had already lost the series two down with one to play. What happened next was remarkable. The umpires judged that the ball had been tampered with by the Pakistan fielders, and awarded 5 runs to England and changed the ball. This angered the Pakistan team since it amounted to an accusation of cheating, and after the tea interval, the Pakistani team refused to come out and play.

This is the first time that the 5 run penalty for "tampering with the ball" has been awarded and the first time a Test Match had been forfeited for a side failing to take to the field of play.

There is, of course, a back story here. First, we need to explain the idea of swing bowling. The cricket ball is very hard with a polished red leather skin, and a prominent circumferential seam made of rather coarse thread and three-quartes of an inch wide. There is also a very fine quarter seam running perpendicular to the main seam. This seam is supposed to be next to invisible.

When the ball is new and shiny it tends to move around in the air ("swings") because of the different resistances to air flow presented by the shiny leather and the rough seam, but as it gets older (and you play with a single ball for 480 bowls) the seam gets flatter and the shine is lost so that it swings less and batting gets easier. At the start of an innings batting is very difficult. The ball whizzes by at 90+ mph with unpredictable movement in the air, and unlike baseball, off the pich as well, because on most occasions the ball bounces once befor reaching the batter. Specialist batsmen who have a strong defense begin the innings. Those with a weaker defense and a stronger attack tend to bat later to take advantage of the easier conditions.

Unlike baseball, some ball tampering is allowed. You are allowed, for example, to polish one side of the ball on your trousers, and a certain amount of spit or sweat is winked at to favor this process. What you are not allowed to do is to rough up the other side by rubbing the ball in the dirt, or by lifting the quarter seam with an implement or your fingernail.

Several years ago, Pakistani bowlers invented reverse swing. This means that an old ball (after about 250 bowls) starts moving in the air in the opposite direction to the expected one. An element required for achieving this is to keep one side of the ball wet (with spit or sweat) and the other dry (with resin or dust). Is this legitimate? There were lots of accusations of cheating and Pakistani players have been suspended and fined for it. But Michael Atherton, the England captain, was also fined several years ago for keeping a supply of dust in his pocket. However, although the Pakistanis have long been expert at this, most countries have learned the skill. Darren Gough, Simon Jones and Andrew Flintoff for England are all expert reverse swingers (though all are injured at present). What goes beyond the pale is lifting the quarter seam, and this is what the Pakistanis were accused of.

The England batters were making a good job of chasing the Pakistani score, when Alistair Cook, the young batting discovery for this year, was dismissed by Umar Gull with a ball that reversed severely. I think this was the unexpected event that led to Umpire Darrell Hair inspecting the ball. The Laws of the game say that the ball must be inspected frequently and irregularly. It was Hair's judgement that the seam had been picked. Sky had 30 TV cameras at the match recording everything, but they could find no footage of the alleged seam picking. Nevertheless, it is a tradition in cricket that the Umpire's word is final. Even the slightest show of dissent is treated very severely. A batsman who looks long and hard at where a ball pitched when out leg before wicket, and turns to the TV camera and purses his lips is likely to be fined half his match fee. So even if play had been allowed to continue after the Pakistani protest,it is likely that the whole team would have fined its pay for the game.

But there is more to this yet. The umpires for this game were from neutral countries. Of course they were, you may say, but not many years ago the home side always provided the umpires, and it was mainly because of suspected favoring of the home side, particularly on the Indian sub-continent, that neutral umpires were introduced. Darrell Hair is Australian and Billy Doctrove, West Indian.

Hair has stood in 76 tests and is the fourth most experienced umpire in the history of the game. He has clashed with Pakistani cricketers before. In last year's test series in Pakistan against England he was accused of favoring the English batsmen in close decisions - but then that is always the case. Some umpiring decisions like leg before wicket and caught at the wicket are extemely difficult and there is always a measure of inaccuracy - new electronic devices show that the umpire, who has only his eyes and ears, and is operating in real time not slow motion, gets most of the decisions right. He was also accused of unfairly giving the Pakistan captain run out when the English bowler threw down his stumps. The excuse was that the Pakistani would otherwise have been hit by the ball - he was protecting his life rather than his innings. All this shows is that Hair plays strictly to the rules without sentiment.

There is more. in 2004 Hair reported the Pakistani fast bowler Shabbir Ahnmed for throwing - the rules say that a bowler must keep his elbow straight when bowling; a bent elbow constitutes a throw which is not allowed. However, in 2003 when South Africa toured Pakistan, South Africa accused him of favoring the home team. The South African captain was fined the whole of his match fee for dissent. Back in 1994 another South African batsman was fined 65% of his fee for arguing with Hair.

Hair has been particularly harsh on suspect bowling actions. Both Grant Flower, the Zimbabwean left arm spinner, and famously Muttiah Muralitharan, the Sri Lankan off spinner, have been brabded as throwers by Hair.

Given his history I don't think he shows favoritism. In his second year as a Test umpire in a Test match Australia versus the West Indies in 1992, he gave a dodgy decision in favor of the West Indies that denied vistory to the Aussies. What he is is a very strict umpire who salls the shots as he sees them without fear or favor, and won't be moved by protest or demonstration or even a TV replay. It was entirely in character that he would not chane his opinion once he had removed the bails and declared the match forfeited no matter how much cajoling from officials. It means a loss of revenue by the Cricket Board since a day's play was lost, but that doesn't concern Hair.

The Pakistan Cricket Board have declared that will never again take part in a cricket match in which Hair is umpire. And that settles that.

Vertigo

I was born on a Thursday.

The children's rhyme says it all (as featured in the Quiller Memorandum) - Thursday's child has vertigo.

I have had my grandchildren with us today; the last Saturday before they leave for Seattle. Everything is settled at this end. The house is let for the year, the car is sold, the check has arrived, schools are fixed, a house is rented, they are ready to go.

Today we took the girls to an Alice in Wonderland theme park. First we took them on a swing boat ride. It gave me such an attack of vertigo that my head was spinning for the rest of the afternoon. That's me done for roller-coasters.

Channel 4

I have now completed 10 of the tasks I listed a couple of days ago.

Yesterday I spent the afternoon being interviewed for a Channel 4 television program on the Te Genero affair, to be broadcast in September. It was an interesting session that took place in the Royal Society of Medicine, which is like a Gentleman's Club for Doctors.

I have done a fair bit of television in the past, but this was a bit special as they had two cameras running - one for me and one for the interviewer. Normally they only have one and they take pictures of the interviewer doing his 'noddies' afterwards. Noddies are when they cut to someone nodding in response to answers.

Television is such a powerful medium and so easy to fake. One of the things they had to stress to me was to look at the interviewer, not at the producer. if I kept looking from one to another, as you do when you have more than one person in the room, it makes you look shifty. in the end the producer had to hide under the table so I wouldn't see her.

Remember the film Broadcast news some years ago. They had this guy interviewing a punter about some tragedy in her family, and then they cut to the interviewer who had tears running down his cheek. the broadcast got plaudits until someone remembered that he'd had only one camera with him. the tear shot must have been shot as a noddy afterwards and the tears were gelatin.

Of course, the whole thing is edited and you reshoot the questions several times. It's easy to be spontaneous when you do it for the first time, when you've never heard the question before, but when you know what you're going to say it sounds like you're acting.

I expect the program will be on the web eventually so people will be able to judge how I did.

Right or left

As my wife was leaving a store in town, she overheard a woman asking directions from the assistant. "As you leave the store take a left," she said.

The woman followed my wife from the store and approached her as they both reached the street. "Can you tell me which way is left," she said, "I'm not very good on left or right."

It puts me in mind of children's shoes marked with a big L or R so that they would know the difference.

Of course the Japanese have difficulties with their Ls and Rs; there is no such sound in Japanese so when they learn English they get them mixed up.

When I went to Japan for the first time I learned how to count to 99 in Japanese. It goes: Itchy, knee, sun, she, go, run, hitch, hutch, queue, Jew. Form there you just put the didgets together: Jew-itchy, Jew-Knee, Jew-run ... and so-on until you get to queue-Jew-queue. I've forgotten what 100 is. Of course, this is just what the words sound like, I'm not sure whether you can transcribe Japanese into English characters, or if you can, how to spell them.

The other remarkable thing was to hear a japanese lecturer talking about leukemia research, only on his slide he had spelled it Reukemia Lesearch.

Don't ever get operated on by a Japanese surgeon lest he mistake your L kidney from your R kidney.

It seems to me that politicians are getting their left and right mixed up. Of course American politics is divided between a right wing party and a very right wing party, but in England the conservatives are supposed to be right wing and the Labor party, left wing. But things are confused. We have Tony Blair, a Labor politician as George Bush's closest ally. In England he is often called Bush's poodle, but that is unfair. I tend to think of him as Bush's more articulate brother. Many of his policies are very similar to Margaret Thatcher, indeed, when he was elected Prime Minister, Mrs Thatcher was heard to refer to him as her spiritual heir.

On the other wing we have David Cameron, the new leader of the Conservative party. His new policy document stresses green issues and public services. He seems further to the left than new Labor.

Perhaps the left/right divide has had its day, and the dividion that is now important is between libertarian and authoritarian.

Walk the Line

Last evening Diane and I watched the Johnny Cash biopic "Walk the Line" on DVD. The music was the sound of my childhood. It was astonishing to see Elvis, Carl Perkins, Jerry Lee Lewis, Cash and June Carter traveling around the country from gig to gig in an old jalopy. What came across was the strong Baptist guilt that enveloped all that they did. You can take the child out of the church, but you can never get the church out of the child.

Yet, well is it said that God has no grandchildren. Strict, god-fearing parents to not instil belief in their children. They instil fear and guilt, but that never saved anyone. Each person has to come to his own crossroads. Johnny Cash followed the path trod by many a youngster - sex, drugs and rock'n'roll. In the process he made some great music. Did he find true faith or middle class respectability?

NK cell tumors

Natural killer (NK) cells are interesting little beasties. They represent part of the innate immune system that is able to kill without the normal MHC dependent recognition system. They have resposibilities as effector cells to make antibodies kill, but also are used by the body to kill virus infected cells while the T cells are reving up the specific response. They are activated by gamma interferon and other macrophage induced cytokines.

NK cell tumors are very rare, especially among Caucasians.

There exists an NK cell lymphoma of the nasal cavity which occurs mainly in Orientals, Asians and South Americans and is EBV related. When it occurs in the blood it is rapidly progressive and drug resistant.

There is also an NK cell leukaemia, again commoner in Asians than Caucasians that presents as a large granular lymphocytosis. Again this may be associated with EB virus, and again it is rapidly progressive and difficult to treat. It occurs in teenagers and young adults.

There is a chronic indolent large granular lymphocytic leukaemia, the majority of which are T-cell type. It tends to be associated with splenomegaly, neutropenia, anaemia and arthritis. Perhaps 10% of them are of NK cell type.

To distinguish between the T cell type and the NK cell types we must do lymphocyte markers. The NK cell type is CD2+, CD7+, CD8+, CD56+, CD16+ but CD3-, CD5-, CD57-.

The NK cell type is less likely to have anemia, neutropenia, splenomegaly and arthritis, however some cases have been associated with a cutaneous vasculitis, usually present before the LGL leukemia appears.

Often treatment is unnecessary, but when it is ciclosporin should be first line, rather than chemotherapy.

I'm a retiree; get me out of here!

After the holiday I settle down and make a list of all the things I have to do.
1 Organize a clinic for tomorrow
2 Review a new textbook for NEJM
3 Write an article for Tom Kipps' new book
4 Review a grant proposal for CLL Global
5 Complete the registration of my new charity "Form of a Servant" with the Charity Commissioners
6 Review an article for Blood
7 Complete the Annual Report for two Charities for which I am Trustee
8 Arrange the UKCLL Forum meeting for November
9 Cancell my ultrsound on my arm as all my symptoms have now gone.
10 Complete review for Haematologica
11 Complete protocol for Vaccination study for CLL patients
12 Review ammendment to a protocol for GTAC
13 Organize flights to Vienna for meeting next month
14 Edit new batch of papers for Leukemia Research
15 Review book sent by lady from Georgia for Leukemia Research
16 Fill out tax return
17 Review Grant proposal for Action Medical Research
18 Read through Grant Proposals for LRF CTAP meeting next month
Then today new tasks appear. Arrange to be interviewed by Channel 4 TV for program on Northwick Park disaster. Receive e-mail from National Institute for Clinical Excellence about a report they expect from me on Fludarabine. Help! I didn't know they were expecting one.

Later: 4 of the above tasks completed (the easiest ones)

Offensive generosity

The first moral argument of children is, "That's not fair!"

Very few England football fans can forget the 'Hand of God' goal by Diego Maradona that saw England beaten by Argentina in the 1982 World Cup. The sense of unfairness resonates down the years and is not assuaged by the fact that Michael Owen clearly dived to win the penalty by which England defeated Argentina in 2002.

Jesus foresaw all this when he told the parable of the over-generous employer in Matthew chapter 20.

It follows on immediately after the story of the rich young ruler, which has the disciples smugly boasting that they had given up everything to follow Jesus.

The story is about the owner of a vineyard who goes out at 6am to hire grape pickers, agreeing with them a fair day's wage for the job. At 9 am he sees that he needs more laborers so he goes out and hires some more, and so on throughout the day. Finally at 5pm, an hour before knocking-off time, he finds some workers still unemployed. Now you might wonder why they were still unemployed at harvest time at 5pm. You can bet that these were the layabouts, the stupid, the handicapped, the unreliable - the sort of worker that nobody wants. Nonetheless, he employs them too.

At the end of the day the workers come for their pay. Those that had worked for just one hour in the evening were paid what they would have gotten had they worked the whole 12 hours. So it goes on, everyone gets the same. Those who have worked all day are expecting more, after all, had they not borne the heat of the day? They are offended that they only get the same as the 5 o'clock slackers. That's not fair!

The landowner replies, "Did we not agree on such and such a wage. Have I not paid what we agreed. It's my money. Can I not do with it whatever I want?"

That is the offensive generosity of the gospel. For those who cry out for justice beware. You would not really want justice. You would prefer mercy.

That early observation of children is true. Life is unfair.

But the promise of the Gospel is that everyone who has left houses or brothers or sisters or father or mother or children or fields for Jesus' sake will receive a hundred times as much and will inherit eternal life.

Camel stories

Camels are strange looking beasts. I know a lot of very funny stories about them. One of the funniest concernes a camel trying to squeeze himself so small that he will fit into a very tiny place. In fact, so small that he would go through the eye of a needle.

The story of the rich young ruler is not preached much from affluent pulpits, and if it is there are always two caveats. First, they say that this isn't meant to be applied to everybody, only to specific cases; and second, they indicate that the 'eye of the needle' that the camel is supposed to pass through isn't an actual needle, but refers to a very small gate in the walls of Jerusalem, which a camel could just about go through, as long as it went through on its knees and divested itself of all its accoutrements.

To deal with the second first: this is an absolute fiction. There never was such a gate. It was invented in the eleventh century to give rich people wriggle room.

The picture of the camel divesting itself of all its possessions and humbling itself by bowing low, tells us that we need to do something - just what the rich young ruler thought.

But if it's a real needle the camel doesn't need to change his clothes, he need to change himself, and that's what's impossible with men; but with God all things are possible.

And why do we think it doesn't apply to us?

I suppose because we believe in free grace. Salvation is a free gift.

The point of the story of the rich young ruler is that he didn't. What can I do to inherit eternal life?

To receive salvation you have to come to the point of realising that nothing you can do will achieve salvation. The rich young ruler claimed he had kept the commandments from his youth up. Jesus plays along with him. Which commandments? The list he gives is of the 'social commandments' - murder, theft, adultery, - generally loving your neighbor as yourself. In the non-cannonical Gospel of the Hebrews, we see Jesus turning to him and pointing out that many of his Jewish brothers are living in poverty, hungry and without shelter, while he lives in the lap of luxury. That's not in the Bible, but Jesus would have had every reason to say it, and his actual instruction to sell all that he had and give to the poor, implies that rebuke.

But the ten Commandments begin with "Thou shall have no other gods before me."

And here is the application that is relevant to our hearts. Everyone of us in the West is rich. You have access to clean water? You are rich. You have had an education? You are rich. You are a woman who can walk down the street without fear of rape or abuse? You are rich. For the true poor in this world (and there are millions of them)have none of these. I sometimes get angry at those who tell us about the poor among us and show us on our television screens those living on the minimum wage or a pension, who neverthelesss are smoking and watching color television. Why is it that millions of migrants are coming to our shores, prepared to work for slave wages and yet send money home to their relatives? Only becsuse conditions are far worse in their home countries.

If we are rich then we should see this story as a warning. It may be that money is not the idol that we hold more dearly than God, but it may be the means by which we obtain the idol. Is it pride of possesions? The way we demonstrate that we are somebody - the car we drive, the clothes we wear, the neighborhood we live in, the school we can send our children to?

Is it simply greed? Our need to own every new thing that we see advertised?

Is it security? Something we are saving for a rainy day? You may not be extravagant, but are you a miser? Is your security your money or your God?

Jesus didn't tell this to the rich young ruler to shame him. We read in Mark 10:21 That Jesus looked at him and loved him.

The application for us is to look honestly at ourselves and ask ourselves the question, "What is our money for?"

The rich young ruler was offered the chance to lay up treasure in heaven.

People often have it the wrong way round. They think it says to put your treasure where your heart is, but what it actually says is "where your treasure is there will your heart be also". And how true that is. When we invest in something we are so much more interested in its wellbeing. If we have shares in Manchester united we will follow the football results. If we put our money in bricks and mortar we will be concerned about the housing market. If we put our money into missionary work we will be concerned about the lost.

That's what I call a holiday

The grandchildren have gone back to their parents. Everything is quieter and more relaxed. We have had five days of intense activity. On Monday we took them to a country park for rambles and an adventure playground, countryside quizes and nature study. On Tuesday we went to the Heavy Horse Centre at Verwood where we saw the giant Clydesdales and the tiny Shetlands; they spent time on giant pedal cars and trampolines. On Wednesday we went on the water in Christchurch Harbor. On Thursday we visited the Model Town at Wimborne.

Wimborne is dominated by the Minster, a huge Norman Church built in the 12th century. It is a picturesque little town of about 6000 inhabitants, and in one corner is a site given over to a model of the town, frozen as it was in the 1950s. The largest building is about four feet tall. The best way to see it is to take one of the quiz sheets and answer the questions. You have to crawl on your hands and knees to find which window displays a notice of Mudeford plaice at 2/- a lb. (That's how we used to write two shillings a pound in the 1950s).

Wimborne Minster is dedicated to St Cuthburger who founded the original Nunnery on this site in 705 AD. It was from here that St Boniface (his original name was Winfrith) recruited missionaries to the pagan land of Germany. Boniface was martyred there in 755 AD. In 871 King Alfred the Great buried his brother Ethelred (not the Unready) at Wimborne after the Battle of Martin against the Danes, However, the Nunnery was destroyed by the Danes in 1013. In 1043 Edward the Confessor built a College on the site, but the present church building is Norman dating from 1120.
Among the Deans of Wimborne are numbered Hugh Oldham who became Bishop of Exeter and founded both Corpus Christi Collge, Oxford and Manchester Grammar School, and Reginald Pole, who became Archbishop of Canterbury after Cramner was burnt at the stake by Queen Mary. His great task in life was to restore the Church of England to Rome. He failed.

The church is huge with the second largest chained library in England. Anyone thinking of visiting England should come and see Wimborne for himself.

On Friday we visited Moors Valley Country Park. We were among about 5000 visitors that day. It is spread over a large area that includes a lake and a golf course. For the children there was a play area with slides and climbing frames of intricate design, a narrow guage steam railway, a trail through the woods that is interrupted by large timber constructions to play in, with tunnels and bridges and wire rides and mazes and climbing frames. It is an exciting day out and not normally so crowded.

Most evenings we had a game of cricket in the garden when we returned.

After a week of this I came to the conclusion that going back to work might be less exhausting

Intolerance

How should we in Britain regard the dicovery of a Jihadi plot to blow up several transatlantic airliners? The government are taking the line that this is a group of criminals who just happen to be Muslim; most Muslims are law abiding citizens who have fitted in to our community.

The BBC avoid mentioning the fact that they are Muslim. They are British citizens of Pakistan origin. As if we were unaware that Pakistan was specifically created in 1947 to provide a separate homeland for India's Muslims.

I spoke to an English lady yesterday. She was a typical middle class, well-educated, middle aged woman. A church going Christian who had brought up four children to be law-abiding, hard-working, honest citizens, all succesful in their chosen vocations. I have always found her to be gentle, soft spoken and tolerant. She is the last person you would expect to have strong opinions about politics.

This is what she said to me, "I hate those men with their aggressive black beards and those women dressed in blackout curtains. I hate what they stand for. How dare they come to our country and try to change us to their disgusting ways? They oppress women. They are so sexually incontinent that they have to cover every part of their women to stop themselves being inflamed. What sort of message does that send to our women? Cover yourself up or we will rape you. They mutilate the genitals of their own daughters. Why are they here? I don't care if they are born here, why did we let their parents in? If they don't like the way we live there are plenty of countries in the world where they stone women taken in adultery (though not men), where they hang homosexuals and cut the hands of thieves. Let them go there. But no, they like the money they get here, they like the properity. Don't they realise that we are propsperous because of the way we live? If we lived like them we would all be poor. The only rich muslims are thieves or plain lucky in living over an oil well that somebody else has found."

I tried telling her that I knew many Muslims who were fully Westernised; who were urbane, modern gentlemen; but she was having none of it. The latest story of airline suicide bombers had caused something to snap.

People in Britain have bent over backwards to be polite and welcoming to immigrants. The mainstream media have been particularly acomodating. Last night I watched part of a programme on channel 4 entitled Shariah TV. But many now think that that hospitality has been abused. Hindus and Sikhs are objecting to be lumped together with Muslims as British Asians.

At least one Christian theologian believes that intolerance is intrinsic to Islam.

Cranmer would like to point out that those who use this surah to insist that Islam means 'peace' are quoting out of context. This passage is from the sixth year of the Hijrah, when the Muslims were a strong and influential community, but not supreme. Mohammed ordered them to defend themselves against Meccan attacks, but not be aggressors because they had a treaty. Many of them were exiles from Mecca, where the Pagans had established an intolerant autocracy, persecuting Muslims. When they tried to assert their rights, the result was bloodshed. This surah was therefore concerned with a specific period of self-preservation; it is not a blanket command regarding all acts of violence

Mohammad used murder, aggression, and terrorism in order to propagate his beliefs and spread his ideology. (Quran 8.17; 33.26; 8.67). He raided towns without warning, killed unarmed men who had gone to the fields and markets on their daily business, captured their wives and children and distributed the younger women among his soldiers while always keeping the prettiest ones for himself and having sex with them in the same day he murdered their fathers, husbands and loved ones. These are not fables, but history as recorded in the Qur’an and the Hadith. This is the ‘prophet’ who sets the example for today’s Muslim youth.

As I have said before the first great virtue is politeness. Without it society cannot exist. It is not the greatest virtue, that is love, but it is foundational. This is the sort of fundementalism that I approve of.

Fauxtography

Clever new word to describe the fraudulent news coming out of Lebanon. The best summary of what has been going on is here.

One of the most interesting features of the whole story is the power of the web to spot misrepresentation from professionals. On AOL recently there was a debate about the Web: is it a danger or a boon? Certainly there are thousands of porn sites and many criminals out there, but the availability of information in an easily accessable form is a tremendous blessing.

All professions are a conspiracy against the laity. So said Bernard Shaw in The Doctor's Dilemma. Nobody can now get away with misinformation about CLL since we have Chaya and ACOR, but there are plenty of other diseases out there where patients need protecting and plenty of other professions that need investigating. Photojournalists are the latest to be hit by the hidden expertise amongst bloggers.

Let me think; lawyers, real-estate persons, architects, surveyors, automobile engineers, artists, accountants...

That'll do for a start. Anyone who purports to have a special skill had better look out. The bloggers are about.

Grandchildren

Today we took out a small boat in Christchurch harbor. The Hampshire Avon and the Dorset Stour meet at Christchurch close to the beautiful Priory, an eleventh century church which is the largest parish church in England. A few years ago I preached there at the St Luke's Day service.

We have had our grandchildren with us this week and it has been a great joy. On Monday we took them to a country park, yesterday to a farm for heavy horses and today on the water. We took the little motor boat up river fpr about 20 minutes and then back down into the harbor, almost out to sea, and then back against the current and teh wind to our mooring. It was a lovely sunny day and quite calm. There is something about being on the water that thrills the blood of an Englishman - it's probably the Viking in our blood. We are a hybrid nation - I can trace German, Irish, Cornish and Jew in my ancestors. There are probably many other strains.

The cricket match was exciting. Pakistan more than matched England's forst innings total, but Andrew Strauss scored a century in England's second innings and Chris Read got a 50. England bowled well in the Pakistan second innings, particularly the two British Asians Mahmood and Parnesa; Muslim and Sikh respectively. They at least passed Lord Tebbit's cricket test.

Before we went on the water the childen sat down with me and watched the Tim Rice and Andrew Lloyd Webber Joseph as performed by the English National Theatre with Dickie Attenborough, Joan Collins and Maria Friedman. I can't get the songs out of my head. I know people say that LLoyd Webber is very derivative, but Joseph, his first musical remains a wonderful performance piece, originally written for schoolchildren.

Matters of Integrity

The blogosphere is alive with the sound of propaganda. Reuters have sacked the photographer Adnan Hajj for faking photographs with his Photoshop kit. This was not simply gilding the lily, but a clumsy attempt (literally) to paint Israel blacker than it really is. It was so clumsy that it was rapidly spotted by amateurs on the web. Which all begs the question, what were the photo-editors at Reuters doing? We now hear professional photographers commenting that it was a very amateur attempt at deception, and boasting that if they wanted to distort a photograph no-one would be able to spot it. Why wasn't it spotted before it was published? Over 900 of Hajj's photographs have now been withdrawn by Reuters.

Which raises the question of how unbiased are the Media. I try to read 4 newspapers every day: The Times, The Telegraph, The Guardian and The Independent. I recognise that none of them are unbiased, but I know where they are coming from. It used to be possible to rely on the BBC for unbiased news reports, but it has now become clear that it too has an agenda. It has been taken over by the Guardianistas.

There are issues on which it is right to be anti-American or anti-Israeli or anti-Christian or anti-Tory; but equally there are issues on which it is right to be anti-Russian, anti-Arab, anti-Moslem and Anti-LibDem. That doesn't make any of these parties or people completely right or completely wrong. We live in a fallen world peopled by sinners.

The war between Israel and Lebanon is being played out on the television screens of the world. It is perhaps a good thing that it is. The carnage and cruelty of World War One could not have continued had there been people watching at home, whatever the jingoism or lies by governments. However, that puts an especial responsibility on journalists and photographers. During the Iraq war we had reports from journalists who prefaced their reports with the information that they were embedded with American Forces. It is clear that reports from Lebanon (and indeed Israel) are from reporters who are effectively embedded with Hezbollah (or with the IDF). We should be told this.

What I have gained from watching this war is:
1] It began when Hezbollah invaded Israel, killed 8 soldiers and captured 2.
2] It then began to fire short range rockets into northern Israel.
3] Israel responded by bombing Hezbollah targets and Lebanese infrastructure, notably, Beirut airport, fuel tanks at one of the ports, roads and bridges all over Lebanon.
4] This bombing has been described as an over-reaction.
5] There are many claims of excessive collateral damage with mainly women and children killed.
6] Hezbollah have been firing more and more rockets with anti-personel warheads into Israel killing close to 100 Israelis (roughly 3000 - for comparison the Germans fired about 4000 V1 and V2 weapons at London in 1944-5).
7]The ratio of deaths is roughly 10 Lebanese to each Israeli.

However, my knowledge of the background tells me this:
1] Since the establishment of the state of Israel there have always been Arabs who resent it and some who will not be satisfied until Israel is wiped from the face of the map.
2] There is some justification for this resentment. Some Arabs were forcibly removed from their homes, and some fled in fear.
3] It isn't going to happen. Even if the Israelis were unable to defend themselves the world's only superpower would guarantee their presence.
4] If agreement cannot be reached with surrounding nations, Israel will simply hunker down behind a high wall and bomb anyone who attacks.
5] It would be infinitely preferable to reach agreement with surrounding countries and sign peace treaties.
6] It would be cheaper for America to pay every displaced Arab for his land than pay for increasingly expensive weaponry for Israel.
7] Eventually there will be a cease fire in this war and the sides will have to negotiate.
8] Neither side is ready to stop yet.

There are some things to learn from the way that the media has handled this war.
1] There is no such thing as right being completely on one side or the other. Even in wars fought with the purest of motives such as World War 2, atrocities occur on both the good and evil side. There may have been no other way to stop Hitler and his evil plans, but there is no doubt that the bombing of German cities killed thousands of non-combitants in an horrific way. There is no doubt that allied soldiers shot prisoners just as German soldiers did. Allied propagands was certainly successful. Churchill's famous speeches to the House of Commons were made at a time when there were no microphones there. They were later re-recorded by an actor in a studio and released to the broadcast media.
2] The manipulation of the media by Hezbollah has been impressive. The media should have been allerted to the possibility because they have been hoodwinked in the past by Hezbollah.
3] Why have most of the dead bodies in Lebanon been women, children and old people? Clearly because showing dead Hezbollah fighters would be bad for morale and showing the pictures of children recruits more sympathy. But think about it. Even if the Israelis were deliberately targeting women and children they would have killed some Hezbollah by collateral damage. One of the reasons that the Geneva Convention insists on soldiers wearing uniform is to protect civilians. Since Hezbollah do not wear uniforms, not only are they beyond the protection of Geneva, but they deliberately expose their own civilians to retaliation. How many of the Lebanese dead are Hezbollah (choose your own noun to go with the adjective - soldiers, fighters, militants, terrorists)?
4] The media must learn to be more sophisticated in the way it reports these wars so that it does not become a tool of one side or the other. The BBC has a special responsibility in this. It is funded from the public purse. Its charter says it must be impartial.

One hypothesis for the cause of this war that has been aired on the internet has been the suggestion that Iran has enginered this war to distract attention from its development of nuclear weapons. Because I can no longer trust the media, I don't know how likely this is to be true. Apparently something special is due on August 22nd. Watch this space.

Birdsong

The other day I came across a graph I had drawn of the number of live births in England and Wales during Twentieth Century. What was even more noticeable than the post-war baby boomers and the drop in live births after 1966, when the combined effect of the Pill and the Abortion Act cut births by a third, was the fall in the number of births during and after the First World War

Birdsong is a novel by Sebastian Faulks. If you saw the film, Charlotte Gray, it was based on another book by Faulks. Birdsong recounts the story of Stephen Wraysford during World War 1. As a doctor I am not squeamish about injuries, body parts or even mutilation; but as I read the description of the Battle of the Somme I found tears leaking from my eyes. The horror and stupidity was so great that Generals were shooting themselves in their guilt.

The book cleverly contrasts the modern day attitudes to life with the fear, then resignation, then indifference shown by the men in the trenches.

The other day I had an MRI. As I moved into the tunnel I had feelings of claustrophobia, but I really began to sweat when I read about the tunellers in the front line who dug tunnels 70 feet below the surface with the intent of blowing up the enemy above them. The enemy dug counter tunnels with the aim of collapsing their tunnels and burying them alive.

This is a book with the power to reveal the unimaginably horrid. Anyone whoever supported a war anywhere should read it. Yet 21 years later they started all over again.

There is nothing glorious in war. As our television screens show us yet again buildings that have collapsed under rockets or bombs, and reporters tell us of people crushed beneath them you have to wonder why it continues.

When was it ever decided that might was right? Suppose the whole thing was to be decided on a football match? Would the result make one side right and the other wrong?

Sure, every nation that is attacked has the right to defend itself. Sure, unfairness abounds. Sure, some countries are run by criminals.

I remember being told a fable when I was very young about the sun and the wind trying to get a man to remove his overcoat. The wind blew as hard as it could but although it almost flew from his shoulders, he pulled it all the tighter and it would not dislodge. The sun simply shone and shone, and the man took his own overcoat off.

The intractable war in Ulster that began with the Romans and continued off and on for 2000 years, ended not because of military success, but because Eire became more affluent.

The rights and wrongs of the war against Israel, which some say began in 1948 and has continued off and on for nearly 60 years, and some say began with Abraham and has continued on and off for 4000 years, are impossible to resolve. A compromise will, in the end, have to be reached and continued killing only delays the inevitable and makes the compromise more difficult to swallow.

In Europe there has been war between France and Germany since records began. The Rome Treaty in 1961(?) was, in part, designed to put a stop to war. By and large it has succeeded in this (though not in much else). The point I am trying to make is that the bitterest enemies can become friends. If they don’t blood feud heaps upon blood feud and vengeance is never done. To end it someone has to accept less than they deserve.

Difficulty arises when one side won’t listen to reason. Alas, I suspect that in this war at lest one of the sides will not listen, because it will not relent on its premise that the other side should not be allowed to exist. But no amount of bombing will make it see reason. However, if people in that country attained the affluence of some in that country, then support for the criminal terrorist would leak away.

Pakistan v England

I spent an enjoyable day watching the Test Match on TV. It does not look as though the Headingly wicket is capable of producing a result. The Pakistani attack is very poor with even the England tail-enders looking comfortable, and certainly it is unlikely to bowl England out twice, but England bowled too short, with only Monty Panesar looking penetrative. There are a lot of players on both sides out injured, so this may not be a fair comparison. Pakistan outplayed England on their home turf, but equally apart from their middle order,they do not have the skills for playing in England.

The umpiring has not really been first class either, with Pakistan suffering more.

Pietersen was outstanding again today and Bell grafted well for his ton.

Lebanon again

In the book of Genesis there is a story of how Jacob is tricked into marrying Leah rather than his true love, Rachal, and how later on he gets his own back on his father-in-law by some sort of jiggery-pokery with spotted sheep. Jacob (whose other name was Israel)had already tricked his brother Esau out of his birthright with a mess of pottage.

It appears that in the Middle East whatever side you are on a good trick is better regarded than the truth. I have spent some time over the past couple of days combing the internet trying to work my way through the propaganda coming from both sides in this nasty little war. As they say, in any war the first casualty is the truth.

In this post-modern age when absolutes are dead you just don't know who to believe. I take it for granted that The Independent and the Guardian have a left-wing bias ane The Mail and the Telegraph, a right wing bias. The BBC is consistently pro-Arab and Fox News pro-Israeli. Journalists are basically lazy, prefering to be fed slops rather than forage for the truth and most bloggers are doing it becuase they want to hear their point of view listened to.

So I was pleased to find this blog from a Lebanese Christian. Here is where he is coming from:

"The last civil war that ravaged my country taught me a very important lesson, and that is, no foreign country wishes any good for Lebanon. They all seek to complete their own agendas, at the expense of the Lebanese people, regardless of religion:

The Arabs (Gulf and Egypt): after two unsuccessful wars against Israel, in 1967 and 1973, found it easier to fight Israel using Lebanon as a proxy
The Palestinians: after seeking refuge in Lebanon, they used it to launch attacks against Israel
The Americans: they usually made sure Israel’s best interests were kept , and they also wanted to resist the spread of communism to the Middle East Region.
The Soviets mainly supported the Arab countries in their fight against Israel, as they saw it as an opportunity to export communism to the area.
The Israelis: even though they assisted the Christian militias in their fight against the Palestinians (PLO) from the mid seventies to the early eighties, they were doing so for their own benefits
The Syrians: many of them refuse to consider Lebanon as a free sovereign state and consider it a part of Syria. In 1976, they entered Lebanon as a peace keeping force and soon turned into an occupation force, an occupation that lasted to the year 2005.
The Iranians: after the Iranian revolution in the late seventies, they saw the Lebanese Shiites as a medium to expand their Islamic revolutionary ideologies and export them to the other countries"

With that degree of realism I feel that I can to some extent rely on what he says. His message is that although he hates what the Israelis are doing to his country, he lays the blame at Hizbollah. He gives witness to the fact that they really are sheltering behind the skirts of women as they fire their rockets from built up areas, but even worse hold the villagers there at gun point so that innocents bear the brunt of Israeli retalliation for propaganda purposes. Try reading his blog. I guess it will offend any Shiite Muslims who read this.

Gibson again

A lot of reaction to Mel Gibson's drunken rudeness. Where were all the critics when he made those two travesties of history, Braveheart and The Patriot?

Castro

Fidel Castro is ailing. Like all kings he has named a family member, his brother, as his successor. Isn't it strange how the need to sire a dynasty is common to all tyrants, especially communist ones. I keep reading that Castro is theworld's second longest ruler after Queen Elizabeth the 2nd in Britain. It isn't true. She inherited the British throne in 1952.

His Majesty Bhumibol Adulyadej, King Rama IX of Thailand (royal name Phra Chaoyuhua Bhumibol Adulyadej), the Great (born December 5, 1927), has been King of Thailand since 1946. He is the world's longest-serving head of state, and is the ninth king of the Chakri Dynasty.