Chinese Hotel

Seen in hotel bathroom.

The Hell that Jesus knew about

As you drive into Bournemouth at 70 mph you see the 'Welcome to Bournemouth ' sign and immediately smell the sewage farm. You are then hit by a 50 mph sign and you slow down. Cars flash by you ignoring the sign - after all it's a clear road and a sunny day, and still a dual carriageway with a crash barrier, what harm could come? However, you know that at the crest of the hill there are speed cameras and you chuckle to yourself as the speeding BMW is flashed at 90 and will undoubtedly shortly receive a fine for £60 and three points on his license. You are feeling smug about it for knowing about the trap, when you pass the camera at 54 mph and you are flashed too. You will receive the same punishment. It's not fair. It's even more unfair when his smart lawyer gets him off on a technicality - he says it contradicts his human rights by admitting that he was driving the car - he has the right not to incriminate himself by anything he says. He even takes it to the European Court. It doesn't seem fair.

But if it is justice you want, then when you send in your £60 don't forget all the times you passed the camera at 51, 52, or 53 mph and it didn't flash and especially the time when you went by at 65 and it did flash, but luckily someone had forgtten to put film in the camera. So send in not £60 but £600 and send in you license for the extra points to be added and hire a chauffeur, since you are certainly going to be banned from driving for a long time, and you might as well sell the car because you won't be able to afford the insurance premium when you are allowed to drive again. You see what most of us want is not justice, but mercy.

At the end of chapter 9 of Mark's Gospel there are 9 verses where Jesus talks about Hell. That's the only place in the whole Gospel where he mentions it. Nevertheless, it is clear from what is written that Jesus believes in Hell. Modern day Christians tend not to talk about Hell. Some believe that when you die, unbelievers are simply snuffed out like a candle. Others talk of Hell as being separated from God. CS Lewis, in The Great Divorce pictured it as a dreary place like a wet and foggy street in a London suburb, waiting in a bus queue for a bus that never comes, with unpleasant people who never speak to you. In the middle ages it was pictured as a place of torture where the Devil thinks up ever more unpleasant persecutions.

Jesus's Hell is a terrible place. It is worse than death (v 42), even a terrible death of drowning in the sea because you are weighed down by a huge stone tied round your neck. It is worse than being maimed or crippled by having your hand or foot cut off (vv 43 & 45). It is worse than being blinded (v 47). It is everlasting: the fire never goes out (v 44) and the fire is not quenched (v 48). The phrase 'their worm does not die and the fire is not quenched' is a quotation of the last verse of the Book of Isaiah, referring to the fate of those who rebel against God. 'They will be loathsome to all mankind'.

If Jesus believed that such a terrible fate awaited unbelievers why aren't we out there with banners? Turn or Burn! Is it that we don't believe it? Or don't we care that so many are perishing? Come to think about it, why does mark wait until chapter 9 before telling us about it? Why doesn't he mention it again? Why does Paul never mention it in any of his sermons in the book of Acts? Why doesn't he mention it in any of his 13 letters?

Because it isn't the Gospel. The Good News is not that unbelievers go to hell. The Good News is that sinners go to heaven, saved by his precious blood.

Andrew Bonar was talking to his friend, Robert Murray McCheyne. McCheyne asked him what he had preached on that morning. Bonar replied, "Hell."

"Could you preach it with tenderness?" asked McCheyne.

No-one should talk about Hell, without tears in their eyes.

If we talk to our friends about Hell they may well think we are gloating over their misfortune, or bragging that in some way that we are better than they. Before we tell them about Hell we must show them that we love them.

They may say to us that they couldn't believe in a God who could send people to Hell. They will probably tell you that they couldn't believe in a God that would allow Auschwitz either. Or Tsunamis or AIDS.

Perhaps they might see Hell as the punishment for Auschwitz. If they come to understand Genesis they might understand how Tsunamis and AIDS are the consequence of sin. Then they might see Jesus as the remedy for sin.

Based on a sermon preached by Chris Kelly at Lansdowne Baptist Church, Bournemouth, 29th Ocrober 2006.

Barak Obama

This is a photograph of the new political phenomenon in the USA. His name is Barak Obama and he is a Democrat and a Christian. Some people think he will be the next Democratic candidate for the Presidency

Here is an extract from his book, The Audacity of Hope which was published in Time Magazine last week.

Two days after I won the Democratic nomination in my U.S. senate race, I received an email from a doctor at the University of Chicago Medical School.

"Congratulations on your overwhelming and inspiring primary win," the doctor wrote. "I was happy to vote for you, and I will tell you that I am seriously considering voting for you in the general election. I write to express my concerns that may, in the end, prevent me from supporting you."

The doctor described himself as a Christian who understood his commitments to be comprehensive and "totalizing." His faith led him to strongly oppose abortion and gay marriage, but he said his faith also led him to question the idolatry of the free market and the quick resort to militarism that seemed to characterize much of President Bush's foreign policy.

The reason the doctor was considering voting for my opponent was not my position on abortion as such. Rather, he had read an entry that my campaign had posted on my website, suggesting that I would fight "right-wing ideologues who want to take away a woman's right to choose." He went on to write: "Whatever your convictions, if you truly believe that those who oppose abortion are all ideologues driven by perverse desires to inflict suffering on women, then you, in my judgment, are not fair-minded. ... I do not ask at this point that you oppose abortion, only that you speak about this issue in fair-minded words."

I checked my website and found the offending words. They were not my own; my staff had posted them to summarize my pro-choice position during the Democratic primary, at a time when some of my opponents were questioning my commitment to protect Roe v. Wade. Within the bubble of Democratic Party politics, this was standard boilerplate, designed to fire up the base. The notion of engaging the other side on the issue was pointless, the argument went; any ambiguity on the issue implied weakness.

Rereading the doctor's letter, though, I felt a pang of shame. Yes, I thought, there were those in the antiabortion movement for whom I had no sympathy, those who jostled or blocked women who were entering clinics; those who bullied and intimidated and occasionally resorted to violence. But those antiabortion protesters weren't the ones who occasionally appeared at my campaign rallies. The ones I encountered usually showed up in the smaller communities that we visited, their expressions weary but determined as they stood in silent vigil outside whatever building in which the rally was taking place, their handmade signs or banners held before them like shields. They didn't yell or try to disrupt our events, although they still made my staff jumpy. The first time a group of protesters showed up, my advance team went on red alert; five minutes before my arrival at the meeting hall, they called the car I was in and suggested that I slip in through the rear entrance to avoid a confrontation.

"I don't want to go through the back," I told the staffer driving me. "Tell them we're coming through the front." We turned into the library parking lot and saw seven or eight protesters gathered along a fence: several older women and what looked to be a family—a man and woman with two young children. I got out of the car, walked up to the group, and introduced myself. The man shook my hand hesitantly and told me his name. He looked to be about my age, in jeans, a plaid shirt, and a St. Louis Cardinals cap. His wife shook my hand as well, but the older women kept their distance. The children, maybe 9 or 10 years old, stared at me with undisguised curiosity.

"You folks want to come inside?" I asked.

"No, thank you," the man said. He handed me a pamphlet. "Mr. Obama, I want you to know that I agree with a lot of what you have to say." "I appreciate that."

"And I know you're a Christian, with a family of your own."

"That's true."

"So how can you support murdering babies?"

I told him I understood his position but had to disagree with it. I explained my belief that few women made the decision to terminate a pregnancy casually; that any pregnant woman felt the full force of the moral issues involved and wrestled with her conscience when making that decision; that I feared a ban on abortion would force women to seek unsafe abortions, as they had once done in this country. I suggested that perhaps we could agree on ways to reduce the number of women who felt the need to have abortions in the first place.

The man listened politely and then pointed to statistics on the pamphlet listing the number of unborn children that, according to him, were sacrificed every year. After a few minutes, I said I had to go inside to greet my supporters and asked again if the group wanted to come in. Again the man declined. As I turned to go, his wife called out to me.

"I will pray for you," she said. "I pray that you have a change of heart."

Neither my mind nor my heart changed that day, nor did they in the days to come. But I did have that family in mind as I wrote back to the doctor and thanked him for his email. The next day, I had the language on my website changed to state in clear but simple terms my pro-choice position. And that night, before I went to bed, I said a prayer of my own—that I might extend the same presumption of good faith to others that the doctor had extended to me. p> It is a truism that we Americans are a religious people. According to the most recent surveys, 95% of Americans believe in God, more than two-thirds belong to a church, 37% call themselves committed Christians, and substantially more people believe in angels than believe in evolution. Nor is religion confined to places of worship. Books proclaiming the end of days sell millions of copies, Christian music fills the Billboard charts, and new megachurches seem to spring up daily, providing everything from day care to singles mixers to yoga and Pilates classes. Our President routinely remarks on how Christ changed his heart, and football players point to the heavens after every touchdown, as if God were calling plays from the celestial sidelines.

Today, white evangelical Christians (along with conservative Catholics) are the heart and soul of the Republican Party's grassroots base—a core following continually mobilized by a network of pulpits and media outlets that technology has only amplified. It is their issues—abortion, gay marriage, prayer in schools, intelligent design, Terri Schiavo, the posting of the Ten Commandments in the courthouse, home schooling, voucher plans, and the makeup of the Supreme Court—that often dominate the headlines and serve as one of the major fault lines in American politics. The single biggest gap in party affiliation among white Americans is not between men and women, or between those who reside in so-called red states and those who reside in blue states, but between those who attend church regularly and those who don't. Democrats, meanwhile, are scrambling to "get religion," even as a core segment of our constituency remains stubbornly secular in orientation, and fears—rightly, no doubt—that the agenda of an assertively Christian nation may not make room for them or their life choices.

There are various explanations for this trend, from the skill of evangelicals in marketing religion to the charisma of their leaders. But their success also points to a hunger for the product they are selling, a hunger that goes beyond any particular issue or cause. Each day, it seems, thousands of Americans are going about their daily rounds—dropping off the kids at school, driving to the office, flying to a business meeting, shopping at the mall, trying to stay on their diets—and coming to the realization that something is missing. They are deciding that their work, their possessions, their diversions, their sheer busyness are not enough. They want a sense of purpose, a narrative arc to their lives, something that will relieve a chronic loneliness or lift them above the exhausting, relentless toll of daily life. They need an assurance that somebody out there cares about them, is listening to them—that they are not just destined to travel down a long highway toward nothingness.

If I have any insight into this movement toward a deepening religious commitment, perhaps it's because it's a road I have traveled.

I was not raised in a religious household. My maternal grandparents, who hailed from Kansas, had been steeped in Baptist and Methodist teachings as children, but religious faith never really took root in their hearts. My mother's own experiences as a bookish, sensitive child growing up in small towns in Kansas, Oklahoma and Texas only reinforced this inherited skepticism. Her memories of the Christians who populated her youth were not fond ones. Occasionally, for my benefit, she would recall the sanctimonious preachers who would dismiss three-quarters of the world's people as ignorant heathens doomed to spend the afterlife in eternal damnation—and who in the same breath would insist that the earth and the heavens had been created in seven days, all geologic and astrophysical evidence to the contrary. She remembered the respectable church ladies who were always so quick to shun those unable to meet their standards of propriety, even as they desperately concealed their own dirty little secrets; the church fathers who uttered racial epithets and chiseled their workers out of any nickel that they could.

For my mother, organized religion too often dressed up closed-mindedness in the garb of piety, cruelty and oppression in the cloak of righteousness.

This isn't to say that she provided me with no religious instruction. In her mind, a working knowledge of the world's great religions was a necessary part of any well-rounded education. In our household the Bible, the Koran, and the Bhagavad Gita sat on the shelf alongside books of Greek and Norse and African mythology. On Easter or Christmas Day my mother might drag me to church, just as she dragged me to the Buddhist temple, the Chinese New Year celebration, the Shinto shrine, and ancient Hawaiian burial sites. But I was made to understand that such religious samplings required no sustained commitment on my part—no introspective exertion or self-flagellation. Religion was an expression of human culture, she would explain, not its wellspring, just one of the many ways—and not necessarily the best way—that man attempted to control the unknowable and understand the deeper truths about our lives. In sum, my mother viewed religion through the eyes of the anthropologist that she would become; it was a phenomenon to be treated with a suitable respect, but with a suitable detachment as well. Moreover, as a child I rarely came in contact with those who might offer a substantially different view of faith. My father was almost entirely absent from my childhood, having been divorced from my mother when I was 2 years old; in any event, although my father had been raised a Muslim, by the time he met my mother he was a confirmed atheist, thinking religion to be so much superstition.

And yet for all her professed secularism, my mother was in many ways the most spiritually awakened person that I've ever known. She had an unswerving instinct for kindness, charity, and love, and spent much of her life acting on that instinct, sometimes to her detriment. Without the help of religious texts or outside authorities, she worked mightily to instill in me the values that many Americans learn in Sunday school: honesty, empathy, discipline, delayed gratification, and hard work. She raged at poverty and injustice.

Most of all, she possessed an abiding sense of wonder, a reverence for life and its precious, transitory nature that could properly be described as devotional. Sometimes, as I was growing up, she would wake me up in the middle of the night to have me gaze at a particularly spectacular moon, or she would have me close my eyes as we walked together at twilight to listen to the rustle of leaves. She loved to take? children—any child—and sit them in her lap and tickle them or play games with them or examine their hands, tracing out the miracle of bone and tendon and skin and delighting at the truths to be found there. She saw mysteries everywhere and took joy in the sheer strangeness of life.

It is only in retrospect, of course, that I fully understand how deeply this spirit of hers guided me on the path I would ultimately take. It was in search of confirmation of her values that I studied political philosophy, looking for both a language and systems of action that could help build community and make justice real. And it was in search of some practical application of those values that I accepted work after college as a community organizer for a group of churches in Chicago that were trying to cope with joblessness, drugs, and hopelessness in their midst.

My work with the pastors and laypeople there deepened my resolve to lead a public life, but it also forced me to confront a dilemma that my mother never fully resolved in her own life: the fact that I had no community or shared traditions in which to ground my most deeply held beliefs. The Christians with whom I worked recognized themselves in me; they saw that I knew their Book and shared their values and sang their songs. But they sensed that a part of me remained removed, detached, an observer among them. I came to realize that without an unequivocal commitment to a particular community of faith, I would be consigned at some level to always remain apart, free in the way that my mother was free, but also alone in the same ways she was ultimately alone.

In such a life I, too, might have contented myself had it not been for the particular attributes of the historically black church, attributes that helped me shed some of my skepticism and embrace the Christian faith.

For one thing, I was drawn to the power of the African American religious tradition to spur social change. Out of necessity, the black church had to minister to the whole person. Out of necessity, the black church rarely had the luxury of separating individual salvation from collective salvation. It had to serve as the center of the community's political, economic, and social as well as spiritual life; it understood in an intimate way the biblical call to feed the hungry and clothe the naked and challenge powers and principalities. In the history of these struggles, I was able to see faith as more than just a comfort to the weary or a hedge against death; rather, it was an active, palpable agent in the world.

And perhaps it was out of this intimate knowledge of hardship, the grounding of faith in struggle, that the historically black church offered me a second insight: that faith doesn't mean that you don't have doubts, or that you relinquish your hold on this world. Long before it became fashionable among television evangelists, the typical black sermon freely acknowledged that all Christians (including the pastors) could expect to still experience the same greed, resentment, lust, and anger that everyone else experienced. The gospel songs, the happy feet, and the tears and shouts all spoke of a release, an acknowledgment, and finally a channeling of those emotions. In the black community, the lines between sinner and saved were more fluid; the sins of those who came to church were not so different from the sins of those who didn't, and so were as likely to be talked about with humor as with condemnation. You needed to come to church precisely because you were of this world, not apart from it; rich, poor, sinner, saved, you needed to embrace Christ precisely because you had sins to wash away—because you were human and needed an ally in your difficult journey, to make the peaks and valleys smooth and render all those crooked paths straight.

It was because of these newfound understandings—that religious commitment did not require me to suspend critical thinking, disengage from the battle for economic and social justice, or otherwise retreat from the world that I knew and loved—that I was finally able to walk down the aisle of Trinity United Church of Christ one day and be baptized. It came about as a choice and not an epiphany; the questions I had did not magically disappear. But kneeling beneath that cross on the South Side of Chicago, I felt God's spirit beckoning me. I submitted myself to His will, and dedicated myself to discovering His truth.

Discussions of faith are rarely heavy-handed within the confines of the Senate. No one is quizzed on his or her religious affiliation; I have rarely heard God's name invoked during debate on the floor. Beyond the Senate's genteel confines, though, any discussion of religion and its role in politics can turn a bit less civil. Take my Republican opponent in 2004, Alan Keyes, who deployed a novel argument for attracting voters in the waning days of the campaign. "Christ would not vote for Barack Obama," Mr. Keyes proclaimed, "because Barack Obama has voted to behave in a way that it is inconceivable for Christ to have behaved."

Already disadvantaged by a late start and a lack of funds, Mr. Keyes had, during the course of a mere three months, managed to offend just about everybody. In that sense, he was an ideal opponent; all I had to do was keep my mouth shut and start planning my swearing-in ceremony. And yet, as the campaign progressed, I found him getting under my skin. For he claimed to speak for my religion—and although I might not like what came out of his mouth, I had to admit that some of his views had many adherents within the Christian church. His argument went something like this: America was founded on the twin principles of God-given liberty and Christian faith. Successive liberal administrations had hijacked the federal government to serve a godless materialism and had thereby steadily chipped away at individual liberty and traditional values. The answer to American renewal was simple: Restore religion generally—and Christianity in particular—to its rightful place at the center of our public and private lives and align the law with religious precepts. In other words, Alan Keyes presented the essential vision of the religious right in this country, shorn of all compromise. Within its own terms, it was entirely coherent, and provided Mr. Keyes with the certainty and fluency of an Old Testament prophet. And while I found it simple enough to dispose of his constitutional and policy arguments, his readings of Scripture put me on the defensive.

Mr. Obama says he's a Christian, Mr. Keyes would say, and yet he supports a lifestyle that the Bible calls an abomination. Mr. Obama says he's a Christian, but he supports the destruction of innocent and sacred life.

What could I say? That a literal reading of the Bible was folly? Unwilling to go there, I answered with the usual liberal response in such debates—that we live in a pluralistic society, that I can't impose my religious views on another, that I was running to be a U.S. senator from Illinois and not the minister of Illinois. But even as I answered, I was mindful of Mr. Keyes's implicit accusation—that I remained steeped in doubt, that my faith was adulterated, that I was not a true Christian.

In a sense, my dilemma with Mr. Keyes mirrors the broader dilemma that liberalism has faced in answering the religious right. Liberalism teaches us to be tolerant of other people's religious beliefs, so long as those beliefs don't cause anyone harm or impinge on another's right to believe differently. To the extent that religious communities are content to keep to themselves and faith is neatly confined as a matter of individual conscience, such tolerance is not tested.

But religion is rarely practiced in isolation; organized religion, at least, is a very public affair. The faithful may feel compelled by their religion to actively evangelize wherever they can. They may feel that a secular state promotes values that directly offend their beliefs. They may want the larger society to validate and reinforce their views.

And when the religiously motivated assert themselves politically to achieve these aims, liberals get nervous. Those of us in public office may try to avoid the conversation about religious values altogether, fearful of offending anyone and claiming that—regardless of our personal beliefs—constitutional principles tie our hands on issues like abortion or school prayer. Such strategies of avoidance may work for progressives when the opponent is Alan Keyes. But over the long haul, I think we make a mistake when we fail to acknowledge the power of faith in the lives of the American people, and so avoid joining a serious debate about how to reconcile faith with our modern, pluralistic democracy.

To begin with, it's bad politics. There are a whole lot of religious people in America, including the majority of Democrats. When we abandon the field of religious discourse—when we ignore the debate about what it means to be a good Christian or Muslim or Jew; when we discuss religion only in the negative sense of where or how it should not be practiced, rather than in the positive sense of what it tells us about our obligations toward one another; when we shy away from religious venues and religious broadcasts because we assume that we will be unwelcome—others will fill the vacuum. And those who do are likely to be those with the most insular views of faith, or who cynically use religion to justify partisan ends.

More fundamentally, the discomfort of some progressives with any hint of religiosity has often inhibited us from effectively addressing issues in moral terms. Some of the problem is rhetorical: Scrub language of all religious content and we forfeit the imagery and terminology through which millions of Americans understand both their personal morality and social justice. Imagine Lincoln's Second Inaugural Address without reference to "the judgments of the Lord," or King's "I Have a Dream" speech without reference to "all of God's children." Their summoning of a higher truth helped inspire what had seemed impossible and move the nation to embrace a common destiny. Of course organized religion doesn't have a monopoly on virtue, and one not need be religious to make moral claims or appeal to a common good. But we should not avoid making such claims or appeals—or abandon any reference to our rich religious traditions—in order to avoid giving offense.

Our failure as progressives to tap into the moral underpinnings of the nation is not just rhetorical, though. Our fear of getting "preachy" may also lead us to discount the role that values and culture play in addressing some of our most urgent social problems. After all, the problems of poverty and racism, the uninsured and the unemployed, are not simply technical problems in search of the perfect 10-point plan. They are also rooted in societal indifference and individual callousness—the desire among those at the top of the social ladder to maintain their wealth and status whatever the cost, as well as the despair and self-destructiveness among those at the bottom.

I am not suggesting that every progressive suddenly latch on to religious terminology. I am suggesting that perhaps if we progressives shed some of our own biases, we might recognize the values that both religious and secular people share when it comes to the moral and material direction of our country. We need to take faith seriously not simply to block the religious right but to engage all persons of faith in the larger project of American renewal. Some of this is already beginning to happen. Megachurch pastors like Rick Warren and T. D. Jakes are wielding their enormous influence to confront AIDS, Third World debt relief, and the genocide in Darfur. Self-described "progressive evangelicals" like Jim Wallis and Tony Campolo are lifting up the biblical injunction to help the poor as a means of mobilizing Christians against budget cuts to social programs and growing inequality. And across the country, individual churches like my own are sponsoring day-care programs, building senior centers, and helping ex-offenders reclaim their lives.

But to build on these still tentative partnerships between the religious and secular worlds, more work will need to be done. The first and most difficult step for some evangelical Christians is to acknowledge the critical role that the establishment clause has played not only in the development of our democracy but also in the robustness of our religious practice. Not only has America avoided the sorts of religious strife that plague the globe, but religious institutions have continued to thrive—a phenomenon that some observers attribute directly to the absence of a state-sponsored church.

Moreover, given the increasing diversity of America's population, the dangers of sectarianism have never been greater. Whatever we once were, we are no longer just a Christian nation; we are also a Jewish nation, a Muslim nation, a Buddhist nation, a Hindu nation, and a nation of nonbelievers.

What our deliberative, pluralistic democracy demands is that the religiously motivated translate their concerns into universal, rather than religion-specific, values. It requires that their proposals must be subject to argument and amenable to reason. If I am opposed to abortion for religious reasons and seek to pass a law banning the practice, I cannot simply point to the teachings of my church or invoke God's will and expect that argument to carry the day. If I want others to listen to me, then I have to explain why abortion violates some principle that is accessible to people of all faiths, including those with no faith at all.

For those who believe in the inerrancy of the Bible, as many evangelicals do, such rules of engagement may seem just one more example of the tyranny of the secular and material worlds over the sacred and eternal. But in a pluralistic democracy, we have no choice. Almost by definition, faith and reason operate in different domains and involve different paths to discerning truth.

The story of Abraham and Isaac offers a simple but powerful example. According to the Bible, Abraham is ordered by God to offer up his "only son, Isaac, whom you love," as a burnt offering. Without argument, Abraham takes Isaac to the mountaintop, binds him to an altar, and raises his knife, prepared to act as God has commanded. Of course, we know the happy ending—God sends down an angel to intercede at the very last minute. Abraham has passed God's test of devotion. He becomes a model of fidelity to God, and his great faith is rewarded through future generations. And yet it is fair to say that if any of us saw a 21st century Abraham raising the knife on the roof of his apartment building, we would call the police; we would wrestle him down; even if we saw him lower the knife at the last minute, we would expect the Department of Children and Family Services to take Isaac away and charge Abraham with child abuse. We would do so because God doesn't reveal Himself or His angels to all of us in a single moment. We do not hear what Abraham hears, do not see what Abraham sees, true as those experiences may be. So the best we can do is act in accordance with those things that are possible for all of us to know, understanding that a part of what we know to be true—as individuals or communities of faith—will be true for us alone.

This is not to say that I'm unanchored in my faith. There are some things that I'm absolutely sure about—the Golden Rule, the need to battle cruelty in all its forms, the value of love and charity, humility and grace.

Those beliefs were driven home two years ago when I flew down to Birmingham, Alabama, to deliver a speech at the city's Civil Rights Institute. The institute is right across the street from the Sixteenth Street Baptist Church, the site where, in 1963, four young children—Addie Mae Collins, Carole Robertson, Cynthia Wesley, and Denise McNair—lost their lives when a bomb planted by white supremacists exploded during Sunday school, and before my talk I took the opportunity to visit the church. The young pastor and several deacons greeted me at the door and showed me the still-visible scar along the wall where the bomb went off. I saw the clock at the back of the church, still frozen at 10:22 a.m. I studied the portraits of the four little girls.

After the tour, the pastor, deacons, and I held hands and said a prayer in the sanctuary. Then they left me to sit in one of the pews and gather my thoughts. What must it have been like for those parents 40 years ago, I wondered, knowing that their precious daughters had been snatched away by violence at once so casual and so vicious? How could they endure the anguish unless they were certain that some purpose lay behind their children's murders, that some meaning could be found in immeasurable loss? Those parents would have seen the mourners pour in from all across the nation, would have read the condolences from across the globe, would have watched as Lyndon Johnson announced on national television that the time had come to overcome, would have seen Congress finally pass the Civil Rights Act of 1964. Friends and strangers alike would have assured them that their daughters had not died in vain—that they had awakened the conscience of a nation and helped liberate a people; that the bomb had burst a dam to let justice roll down like water and righteousness like a mighty stream. And yet would even that knowledge be enough to console your grief, to keep you from madness and eternal rage—unless you also knew that your child had gone on to a better place?

My thoughts turned to my mother and her final days, after cancer had spread through her body and it was clear that there was no coming back. She had admitted to me during the course of her illness that she was not ready to die; the suddenness of it all had taken her by surprise, as if the physical world she loved so much had betrayed her. And although she fought valiantly, endured the pain and chemotherapy with grace and good humor to the very end, more than once I saw fear flash across her eyes. More than fear of pain or fear of the unknown, it was the sheer loneliness of death that frightened her, I think—the notion that on this final journey, on this last adventure, she would have no one to fully share her experiences with. I carried such thoughts with me as I left the church and made my speech. Later that night, back home in Chicago, I sat at the dinner table, watching Malia and Sasha as they laughed and bickered and resisted their string beans before their mother chased them up the stairs and to their baths. Alone in the kitchen washing the dishes, I imagined my two girls growing up, and I felt the ache that every parent must feel at one time or another, that desire to snatch up each moment of your child's presence and never let go—to preserve every gesture, to lock in for all eternity the sight of their curls or the feel of their fingers clasped around yours. I thought of Sasha asking me once what happened when we die—"I don't want to die, Daddy," she had added matter-of-factly—and I had hugged her and said, "You've got a long, long way before you have to worry about that," which had seemed to satisfy her. I wondered whether I should have told her the truth, that I wasn't sure what happens when we die, any more than I was sure of where the soul resides or what existed before the Big Bang. Walking up the stairs, though, I knew what I hoped for—that my mother was together in some way with those four little girls, capable in some fashion of embracing them, of finding joy in their spirits.

I know that tucking in my daughters that night, I grasped a little bit of heaven.

I suppose that some might regard this as a cynical attempt to get the Christian vote to switch sides. He clearly doesn't dot all the 'I's and cross all the 'T's for those who believe in the inerrancy of Scripture, but he presents a reasonable and attractive alternative to President Bush.

I can't help thinking about his name. You can read about Barak in the Bible, in Judges Chapter 4. You will see that Barak was a man who could have been the leader of his nation, but he deferred to a woman, only her name was Deborah, not Hillary.

BBC bias

Many people in Britin do not think that the BBC is biased. I came across this piece from the Guardian of all places.

BBC man criticises 'war bias'

Jason Deans
Wednesday March 26, 2003
MediaGuardian.co.uk


The BBC's coverage of the war has come under fire from one of its own correspondents in the Gulf who has fired off a furious memo claiming the corporation is misleading viewers about the conflict in Iraq.
Paul Adams, the BBC's defence correspondent who is based at the coalition command centre in Qatar, complained that the corporation was conveying a untruthful picture of how the war was progressing.

Adams accused the BBC's coverage of exaggerating the military impact of casualties suffered by UK forces and downplaying their achievements on the battlefield during the first few days of the conflict.

"I was gobsmacked to hear, in a set of headlines today, that the coalition was suffering 'significant casualties'. This is simply not true," Adams said in the memo.

"Nor is it true to say - as the same intro stated - that coalition forces are fighting 'guerrillas'. It may be guerrilla warfare, but they are not guerrillas," he stormed.

"Who dreamed up the line that the coalition are achieving 'small victories at a very high price?' The truth is exactly the opposite. The gains are huge and costs still relatively low. This is real warfare, however one-sided, and losses are to be expected," Adams continued.

The memo, which has been leaked to the Sun newspaper, was sent to BBC executives including the head of TV news programmes, Roger Mosey, and his radio counterpart, Stephen Mitchell.

The BBC has come under attack for describing the loss of two soldiers as the "worst possible news for the armed forces".

Labour MP Alice Mahon has also complained that the BBC is too pro-war and is not showing enough of the casualties inflicted on the Iraqis or the problems with humanitarian aid.

Earlier this week the BBC was forced to promise that it would no longer show footage of seriously injured British troops, after the mother of a Royal Marine watched her son set on fire during a gun battle on a BBC early evening bulletin.

A BBC spokeswoman said the corporation could not confirm the contents of what was an internal memo.

But she added that the BBC was not the only news organisation highlighting British casualties.

"This is an immensely complicated and difficult story and the big challenge for the BBC, as for other broadcasters, is getting the balance right. We are constantly monitoring the language and tone of reports to achieve this balance," the spokeswoman said.

"We think we get it right most of the time, but we know we don't always. This seems to have been an internal memo and we can't confirm its content, but this is the kind of debate about editorial tone that's going on in newsrooms all over the world about this particular story."

I know it's old news, but this even before things started to go wrong in Iraq.

What's in the local paper?

I don't often read the local paper and I don't know why I did tonight, especially as the front page headline was about some common land being fenced off for the grazing of cattle. It sounded like something from the beginning of the Nineteenth Century. But there were two articles that caught my eye. One was about the report of the Police and Crime Standards Directorate, which apparently ranks the local police force as third best in the country.

The second was about the Health Commission’s report in the local hospital. On use of resources it ranked excellent but on quality of services it ranked only fair. This was despite meeting all 24 core standards and gaining an 'excellent' for diagnostic services (my old department). Apparently it fell down in three areas. The first was in meeting targets for reducing smoking. What exactly a hospital can do about this, I'm not sure - surely it is a task for the community and general practitioners? However, the failing was that junior doctors were not sufficiently rigorous in writing in the patients' notes whether they were smokers or not.

The second area of concern was tardiness in transferring patients out of hospital. In Bournemouth this generally means transferring old people from hospital to rest home. Unfortunately, there is not much they can do about this. Compared to a few years ago, the number of beds for residential care has diminished. This is almost entirely because of government regulation. The economics of running a care home have changed. First, costs have increased. The national minimum wage has meant that staff costs have risen, and the European Working Time Directive has limited the amount of overtime staff can do. Health and safety regulations have added costs - fire doors wheelchair ramps, stair lifts etc have all become necessary. Second, reimbursement from the public sector has not kept up with inflation. This is because the government measure of inflation gives a falsely low rate, by weighting it with things that are reducing in price, like DVDs and electrical goods rather than things that increasing in price rapidly, like fuel, food and staff costs. Third, reorganization of local authorities has meant that rather than having dedicated social workers specializing in patient transfer, achieved by having larger local authorities, the smaller local authorities have to employ 'Jack-of-all-trades'. One physician for the elderly told me that whereas he had a specialized team of social workers to move patients into residential care, he was now dealing with 19 different social workers who were trying to transfer 29 different patients. Fourth, there are now perverse incentives for owners of property formerly used for residential care.

Recently, a house a few doors along the road from us sold for £417,000. It was not in very good condition, and I thought it a good price. It was demolished and a block of 8 apartments assembled on the site of the house and garden. Each will have 2 bedrooms and sell for £200,000. The whole build took 4 months and cost about £100,000. The developer makes a cool million pounds. The government is encouraging high density housing. Why? Because they admitted between half and three-quarters of a million immigrants from Eastern Europe last year and they have to live somewhere. No wonder we have too few places for residential care. it is not a sensible place to put your money.

The third area where the hospital fell down was a failure to make a 50% reduction in the number of cases of MRSA. The difficulty was that there were so few cases to start with. If you are overrun by MRSA like some big London teaching hospitals with Victorian buildings, it is quite easy with simple measures to make a big reduction in cases. However, if you have a modern hospital with clean customers and very low incidence, making a 50% reduction is next to impossible. The pips are already squeaking.

This is the problem with targets. They are never sufficiently tailored to the individual organization. It's like setting the same target for a child in his first year at school as one in his sixth year. It comes from central direction of health care. There are only few hundred hospitals. Why doesn't somebody have the bright idea of setting them individual targets? Imagine if HR departments set every employee the same target. If anybody reading this knows anybody in the Health Commission, perhaps they will suggest it.

Monty Python

Like most people in Britain I am growing increasingly opposed to the European Union. A piece today at EU Referendum tells you why.

Looking around the blogosphere one finds some very interesting and, often, perplexing items of news and information. Bloggers being arrested in China and Iran - to be expected, really, though we do promise to post soon a round-up of the stories from those countries.

However, here is a story from Spain. It seems that a Cuban blogger who lives in Galicia, in Spain, has fallen foul of the the Major of Oleiros who is supposed to be a Galician nationalist, which he seems to display by attacking the United States and, especially, Israel whenever he can.

The blogger, Alejandro de Llano has criticized the Major's anti-zionist (for which read anti-semitic in this case) campaign as well as his tendency to attack Cuban dissidents.
On October 13th, 2006, he has received a summons from a Criminal Judge announcing him that he is held responsible of the crime of supporting Israel and also of acting against Palestinian people. They did not give him a copy of the summons and they did not let him make any copies.

Monty Python had it right. No-one expects the Spanish Inquisition

Tortoises

David Arenson's blog has an interesting take on the way of the tortoise. As a matter of fact my wife collects tortoises. She has 23 of them of all sizes and shapes, and made from diverse materials, including two made from clay by our grandchildren. I try and find a new model whenever I go on a trip.

We once had a pet tortoise called Montezuma. This was a compliment on his speed. He was much faster than you would expect. You'd put him somewhere in the garden and then watch Monty zoom away.

Shoots and leaves.

There is nothing so satisfying as watching someone being hoist with his own petard, and if you want to be so hoisted, write an article about punctuation. It isn't really fair to criticize the punctuation of bloggers, because blogs are often written in haste and seldom proof-read or subjected to the scrutiny of Microsoft grammarians. But it is fun.

As a writer, I was brought up on Fowler. To be correct, on the Second Edition, as revised by Sir Ernest Gowers, and I have on my shelf the following: The Complete Plain Words by Gowers, Mother Tongue by Bill Bryson, The Pedant's Revolt by Andrea Bareham, Eats, Shoots & Leaves by Lynne Truss, The King's English by Kingsley Amis, Lapsing Into a Comma by Bill Walsh, Paradigms Lost by John Simon, Troublesome Words by Bill Bryson, Usage and Abusage by Eric Partridge, and Full Marks by John Kirkman. In addition I have another 36 books on the English language in its various forms.

Despite this, I am prone to making mistakes. Good writing is not just about being grammatically correct; it is more about using grammar to make meaning clear and reading a pleasure. The more you know about the structure of language, the more you can use it well. So, grammar is not a game of spotting flaws in other people's prose, but an exercise in imagination, creativity and clarity. It means taking risks. It means laying yourself open to criticism.

Then again, it's a matter of style. Some people like long sentences full of subordinate clauses, which work very well if you are writing a technical description for a scientific journal like the Lancet, which, incidentally, has a completely different style from the British Medical Journal (parenthetically, can I interpose that I once wrote the same article for the BMJ and Lancet - they were published anonymously in the same week - the same article, but with different styles, so that no-one, not even the editors, knew that they had been written by the same author), but less well if you are aiming to be understood because you have to unravel all the subordinate clauses to see which one come first. Others prefer short sentences. Punctuation becomes a problem with longer sentences. Short sentences are clearer. They also get boring to read. Especially if they don't have a verb. As in Kathy Reichs. Grammar helps us to be both understood and entertained.

Even Fowler allows split infinitives. The lengths that some newsreaders go to carefully to avoid splitting an infinitive leads to English that sounds stilted and unnatural. 'To boldly go' doesn’t mean quite the same thing as 'to go boldly' or 'boldly to go'; in fact the very act of splitting that infinitive captured the flavor of Star Trek. The fact is that good writers break rules and it makes their writing more attractive.

And so to bed.

Sword of Truth

That was the phrase that Jonathan Aitken used when attacking the press when he was found out in a lie about his hotel bill. It is also the title of a series of Tolkienesque novels by Terry Goodkind. I confess to being an addict of the genre. The best series of this type that I have read was by Stephen Donaldson, The Chronicles of Thomas Covenant, Unbeliever. They can be read as straight adventure stories, but like science fiction stories, they often have an underlying philosphical or political theme.

Soul of Fire, the fifth book in the Terry Goodkind series, is on one level about that American ideal, Freedom, and on another about the battle between Good and Evil. So many American ideals are related to freedom and date back to the 1776 revolution. The French Revolution, which was almost contemporaneous with the American one cried "Liberté, Egalité, Fraternité!" the Americans concentrated on the first of these. Freedom from Empire, freeing the slaves in the Civil War, freeing Europe from Nazi domination in World War 2, freeing Europe from Communist domination in the Cold War, freeing Iraqis from the evil Saddam (perhaps a pseudonym for Satan?); Americans tend to see politics in terms of a war of liberation. The very federal arrangement for government in America is all about freedom from government, or at least freedom from Washington. (Of course freedom is something of a watchword for we Brits; freeing the slaves was a British idea. We tend to be a little less precipitate in our reaction to the word, though.) I am sometimes amused to hear the war cry "Freedom!" in American movies where it is clearly anachronistic.

Anyway, freedom in the story means a nation gives up its own culture and voluntarily enters into another more correct type of culture run on Utopian lines (everybody equal, the rule of law, free trade, you know the sort of thing). The leader of this Federation is an aristocrat by birth, but really one of the people because he was brought up away from the palace by a simple woodsman. The rulers of the nation have already (sort of) committed the nation into the hands of the opposing forces on promises of greater wealth for themselves (oil concessions etc, you know the sort of thing). This opposing Empire (there's that word again) is led by an Evil Emperor who has access to unnatural powers; he is not a nice chap. Why should both factions want this nation? Obviously because it is a tremendous source of agricultural produce (cynics can read 'oil' here if you like). Both sides have huge armies and are backing up their offers with threats of force.

The solution that the autocratic rulers of this agricultural nation hit upon is to have a referendum. Although originally a delaying tactic, a ruthless politician (interestingly a man of high moral standards on sexual matters, but none at all when it comes to politics, resorting to thuggery and murder to get his way) sees a way of getting the 'right' result. There are two races living alongside each other in this country, the red-haired race are downtrodden by the dark-haired race, who won't even allow them to learn to read. However, all are to be given a vote in the referendum. This politician is a brilliant spin doctor and by playing on the cultural identity of the poor he spins the election in favor of the Evil Empire.

An interesting insight into his methods sees his recruitment of young people to sit on the ground between opposing armies shouting out, "Give peace a chance."

A further twist is that the agricultural nation is defended by a super-weapon of mass destruction. So powerful and comprehensive is this that they have allowed their conventional forces to decay to a ceremonial army of no consequence.

How it all works out is that the country-boy/aristocrat being defeated by the referendum by his own ingenuity and creativity renders the WMD useless, and sets in train a way of making the crops poisonous. He then leaves the country to the 'mercies' of the evil Empire. Meantime, the internal corruption of country's rulers rebounds on itself. The ruthless politician seeing his wife seduced by the Sovereign, exercising his 'droit de seigneur', deliberately infects himself with a fatal sexually transmitted disease (AIDS reference?), infects his wife and thus the sovereign and thus all the fine ladies of the court and thus their husbands and thus the ruling elite.

Thus individual brilliance triumphs over evil government. But that's the American way, isn't it?

Book 6 awaits.

Deaths in Iraq

What should we make of the Lancet paper showing 655,000 excess deaths in Iraq? My immediate reaction is that it is poppycock. To say why it is nonsense requires statistical expertise beyond my own. Readers can make their own minds up by going to websites here or here or here or here or here or here.

Statistical evidence is beyond the understanding of most people. Some people believe that statistics don't lie, other believe that there are lies, damned lies and statistics. I rather take the view that things that are obviously true don't need statistics to prove them, but statistical evidence is easlily abused by those with a strong point of view such as pharmaceutical companies who want to sell their wares, politicians who want to mislead the public and scientists who want to get published for the sake of career advancement. A short while ago a paper published in the BMJ claimed that only 30% of scientific papers used statistics correctly.

So I like to subject statistical claims to a reality check. Here is a quote from the first of the links:

If you finished a cohort study which concluded that the forest, by extrapolation was denuded yet aerial photography did not show any logged over areas then you would be exactly in the position of accepting Burnham's proposition that 655,000 people died without observing the masses of widows, orphans, mass graves and bomb craters that one would expect to accompany such an enormous loss. My parents were unfortunate enough to go through a major urban battle. It only killed 100K people but what it did was produce a flood of refugees and displaced persons whose existence was palpable. One quarter of Burnham's sample is from Baghdad. Where are the refugees? It is not widely appreciated but Iraq is host to millions of Shi'ite pilgrims every year. There is not a single historical instance I can think of where tourists continued to visit a country beset on the scale claimed.

Here's another:
Now let's consider Mr. Burnham's claim that "Overall, 13% of deaths were attributed to airstrikes" because this gives us a window into his data. A sample of his sample, so to speak. That's 85,000 deaths from airstrikes. The problem with this is that airstrikes virtually ceased since 2004. Now maybe "airstrikes" is really understood to be all kinds of fire. Could this be true?

Where would these airstrikes have happened? Where Burnham sampled, of course because he claims these deaths are backed by death certificates. Now recall that of his 47 clusters, 12 were in Baghdad, 2 were in Basra, and 3 were in Anbar. But wait! Basra is in the British sector and there have been no air missions in Basra to speak of. As for Baghdad, if which has 1/4 of the clusters, at least 20,000 people would have died in airstrikes within full view of the media since 2004. Anbar is the place where most airstrikes would probably have occured. But it's a sparsely populated area and contains 3/47 clusters. Could it be that most of the airstrikes were there?

So we come to the question of what his snapshots really look like. And as I said, I am disappointed.

Finally, it is worth looking at where the information is coming from. The Lancet under Rchard Horton has assumed a stance to the left of the Independent. It has always had a reputation for playing fast and loose with the peerr reviewing process, preferring to publish what is 'newsy' rather than what is scientifically correct, witness the MMR scandal. Richard Horton, himself, goes on 'Stop the War' marches. Under his editorship it has sunk from being the permier medical journal to perhaps the 3rd or 4th.

So, for many reasons, even without statistical expertise I think the Lancet article is poppycock.

The Fall

How the weather changes from day to day. Although this is definitely Autumn (or Fall in the US) most of the trees still have green leaves. There's a horse chestnut that I can see from my window that has golden leaves but I can also see silver birch, hawthorn, magnolia and mountain ash with leaves still unturned. The temperature is 65, the sun is shining and the wind is still. Yesterday, the day was grey and wet. Solidly overcast, cool (about 50) and dark; the motor cars had headlights on all day. I didn't venture out but watched a couple of videos.

The first was an old Morse, the one about the masons set to the background of The Magic Flute. Marvelous music! Morse finds himself accused of murder. One of the villains was Hugh McDairmid who Star Wars fans will recognize as the villain in Episode 3. This was Morse at his best. For once he was not the most intelligent person on view. Of course, being Morse, he falls for, not one but, two women of a certain age. The first is murdered and the second wants to murder Morse. What is satisfying is that it is Lewis who is the hero.

The second was Young Adam. This is another of those Scottish movies starring Peter Mullen. Ewan MacGregor is a young drifter, Joe, working on a coal barge who finds a young woman's nearly naked body (Emily Mortimer) in the River Clyde. The fourth principal is Tilda Swinton (straight from Narnia and Constantine), she plays Ella, wife of Peter Mullen and apparently a downtrodden 1950s woman who has given up on life.

This is a bleak, unhappy movie. None of the characters are admirable. The enigmatic title seems to suggest this. These are people in whom the fall is self evident. Joe clearly knows something about the body in the Clyde. He treats it with a reverence uncharacteristic for a working man, and then at the tea table he eulogizes her in words too subtle, too poetic, too complicated for a working man. We learn that he is a failed writer who was once the live-in lover of Mortimer, but not before he has begun a blatant affair with Swinton behind the back of her husband.

This aspect of the film will put a lot of people off. The nudity is full frontal and the sex is ugly. I would not recommend this film to young people. Yet it does not titillate. The sex is cold and selfish. Joe is promiscuous. He seems to be able to charm any woman, rather in the way that Michael Cain did in Alfie, but without the humor. Joe performs coldly and efficiently. He betrays Swinton just as he as betrayed Mullen.

The film is very well crafted and the acting is tremendous. It won 4 Scottish Baftas and you can see why. But I kept imagining what Joe would be like now. He was born in, say 1936. He would be an old man of 70 were he still alive. I would expect him to be unmarried. He might be dead; if he'd continued smoking at this rate he probably would be. Probably he wouldn't have a home, but would drift from hostel to hostel, sometimes sleeping rough. He would still be drinking but no longer reading. He would have known many women but have loved none of them. Many women would have loved him, though more recently they would have coupled with him fro pity's sake rather than for love. Some of them may have borne his children but he would not know about that.

He would have been wandering all this time trying to forget that he had been born beautiful with brains. He had received an education. But he had eaten the fruit of the tree of the knowledge of good and evil and chosen evil. He would still remember the face of the innocent man who had been hanged, whom he had declined to save when he might easily have done so.

Nova

I doubt a God with stars to see
Would ever deign to look at me;
Yet if he tried, yes if he tried,
I'd find some secret place to hide
The guilty murmurs of my mind;
My angry thoughts, my thoughts unkind;
As they are hid by everyone
Who fears his precious pride undone.

Nothing can hide me from His sight;
To Him the darkness is as light.
A beacon burns for my disgrace
Across infinities of space.
The brightest stars are dimmed beside
The luminosity of pride,
Hate, envy, greed; a fiery flood;
I hide them only in His blood.

Veil of Tears

I watched Question Time on the BBC last night. The panel consisted of Hillary Armstrong (the New Labor politician who best exemplifies the Peter Principle), Chris Huhn (a LibDem politician who failed in his bid for leadership of the party when the previous leader was found out to be a cheerful drunk; his chief characteristics seem to be his coiffure and his permatan. The LibDems have taken up a political position to the left of Tony Blair), Teresa May (a New Tory politician whose one claim to fame was wearing shoes made of Alligator skin at the Tory Party Conference), a left wing Sikh comedian with a Scottish accent, and a Moslem woman who was also vice-chair of the Respect party. It is strange that the BBC claims not to be biased when they happily give a platform to the far left Respect party (that's George Galloway's lot) but never do the same for the far right British National party. The audience was packed with Moslem women wearing the full regalia with only their eyes showing.

It was no surprise therefore that half the program was given over to discussing the affair of the primary school teaching assistant who was employed to teach English to small immigrant children whose first language was Urdu. These were mainly Pakistani children, and the school was a Church of England school. She insisted on wearing a full veil while teaching. Teaching assistants are there to assist teachers. They work in the same classroom as the teacher. The young woman would not have veiled up if only the children were present, but because the class teacher was a man, she insisted on wearing the veil. The school reckoned that it was impossible to teach a new language to children with your face covered, because the children needed to watch her lips to see how the sounds were formed. They therefore suspended her. She appealed against her suspension and yesterday a tribunal found in favor of the school.

It seems to me that the woman picked a fight over an unwinnable issue, assuming the well known ploy of crying victimization of an ethnic priority would trump common sense. It is good to know that common sense has triumphed.

However, there is a larger issue here. Should Moslem women be permitted to wear the veil in public. France, which is a much more secular society, would suppress the wearing of a Moslem uniform. In England we believe that people should be free to wear whatever they like unless it is dangerous or likely to cause a breach of the peace. Last year a man was permitted to walk naked from Lands End to John O'Groats, only getting arrested in towns where a breach of the peace was likely (from offended ladies). We frequently see young women with their navels showing in January, often with pieces of metal stapled to it. People dress up in all sorts of weird costumes. Very seldom is dress or lack of it commented upon.

We do not object to religious symbols. Sikhs where turbans, Moslem women wear the Hijab, Buddhists go about with bald heads and saffron robes and one Christian walks about dragging a huge cross behind him. There have been objections to hoodies. These are jackets with hoods that cover the face, a garb adopted by young people to cover their shyness and by criminals to hide from CCTV cameras. Shopkeepers refuse to serve young men wearing those large, face-covering, rash helmets. This is for the same reason, it conceals the identity, and some robbers wear them to hide from the ubiquitous CCTV. In our society anyone concealing their face is a figure of fear. English people do not wave their arms about while talking in the way that Italians or Spaniards do, but we do use body language. It is subtle. It is done with the face. Full communication is face to face. Phone calls limit communication. Letters are better because the English language is so full of nuance that by choosing the correct word you can communicate so much more than just the plain meaning. I sometimes take days to write a letter so as not to cause offence. E-mailers have developed emoticons to soften the effect of straight prose ;-)

Moslem women who insist on covering their faces are being as culturally insensitive as the English woman who drives a car in Riyadh with the top down and cleavage showing.

There is no instruction in the Qu'ran that women should wear veils. They should dress in a modest and seemly manner, but that is an instruction for Christian (I Corinthians Ch 11) and Jewish (Proverbs Ch 31) women too. The veil is not a feature of female dress in most Moslem countries. It is not seen in Turkey, Malaysia, Indonesia, Pakistan or India, the Sudan or in Arab countries except Saudi. It was a feature of Afghanistan under the Taliban, where it was a symbol of subjugation of women.

The veil is principally a political statement. Even the headscarf was not seen commonly in the UK until the 1970s when radical Arabs started hijacking airliners. It has become much commoner since 9/11.

There is nothing more nauseating than draping a political cause in religious dress. Whether it was the IRA appealing to the Catholic heart or the Loyalist paramilitaries in Northern Ireland masquerading as Protestants or the Republican Party becoming synonymous with followers of Jerry Falwell or Jihadists claiming to be the purest Moslems, it is sanctimonious garbage. It enlists the sympathies of co-religionists, blinding them to the political errors. It is no longer "My country, right or wrong!" but "My God, right or wrong!". The only place for such unquestioning loyalty is when supporting Manchester United.

Yes, of course, I must follow God rather than man. But follow what God says about himself, not what some leader says about God. The very central verse in the Bible says, "It is better to take refuge in the Lord than to trust in man."

We should not allow politicians to hide behind religious sensibilities. If Tony Blair makes an ass of himself it is perfectly legitimate for David Cameron to call him a silly Billy - or even to use stronger language. He can't turn around and say I'm a Christian , I'm one of a persecuted minority you can't abuse me like that. No more should a veiled woman be able to make her political statement and then claim to be a protected species by virtue of her race or religion. It would be like an IRA terrorist wearing a Balaclava to hide his face and then when told to tkae it off claiming he was being abused as part of the Catholic oppressed miority.

Setting questions

I have spent an interesting day learning to set multiple choice questions at the Royal College of Pathologists. The principle is to put more detail in the question stem. Make the question sound more like real life, rather than a contrived examination of trivia designed to make the examiner feel one-up on the student. Here are some of the questions I designed.

A 53 year old woman had suffered from systemic lupus erythematosus since the age of 30. It manifested mainly as malar rash, arthralgia, hair loss, and five years ago with acute nephritis. Initial treatment was with steroids and then plasma exchange was introduced. Arthralgia was well controlled with chloroquine, but with the onset of the renal disease she was treated and brought under control with six courses of cyclophosphamide, vincristine and prednisolone. Over the past two months she has developed mild pancytopenia. Her FBC showed Hb 10.2 g/dL, MCV 99fl, WBC 2.3 x 109/L, (neutrophils 53%, lymphocytes 44%), platelets 103 x 109/L

From the following options select the most likely cause of the pancytopenia?

Option A Acute lymphoblastic leukaemia
Option B Aplastic anaemia
Option C Megaloblastic anaemia
Option D Myelodysplastic syndrome
Option E Systemic lupus erythematosus

Correct answer Myelodysplastic syndrome

A 73 year old widower is brought into accident and emergency confused and disoriented which had been coming on over the past 2 weeks. He had been coping well at home until recently, cooking his own meals and doing his own washing. It is impossible to obtain a full history form him, but you learn from his daughter that he had recently won a pub quiz competition. On examination he does not have a fever. He has some raised red lumps 0.5 cm in diameter on both forearms. His chest is dull at the left base with limited air entry and his spleen is palpable. FBC shows Hb 12.2 g/dL, MCV 101 fl, WBC 73.3 x 109/L (neutrophils 37%, lymphocytes 4%, monocytes 58%, blasts 1%), platelets 74 x 109/L.

From the following options select most likely cause of the confusion?

Option A Alcoholism
Option B Cerebrovascular haemorrhage
Option C Cerebral leucostasis
Option D Cerebral secondaries
Option E Pneumonia

Correct answer Pneumonia

A 68 year old lifelong smoker is admitted with an unrelenting cough. He has recently brought up some green sputum with flecks of blood. Since he is seeing a chest physician he is sent immediately for a chest X-ray which shows a mass in the right hilum. Bronchoscopy reveals this to be a non-small cell carcinoma of the bronchus. A stickler for detail, the chest physician orders a blood count, and this is found to show Hb 11.9 g/dL. WBC 9.8 x 109/L (neutrophils 79%, lymphocytes 8%, monocytes 13%), platelets 97 x 109/L. Blood film shows a few Pelger cells and hypogranular neutrophils with some basophilic stippling. The chest physician insists on a bone marrow aspirate which shows no cancer cells, but erythroid hypoplasia with irregularly shaped normoblasts and dyskaryorrhexis, 10% ringed sideroblasts, myeloid hyperplasia, with myelocytes lacking secondary granulation, increased promyelocytes and 4% myeloblasts, and increased megakaryocytes, many with dispersed multiple nuclei.

From the following options selct the correct haematological diagnosis.

Option A Chronic myelomonocytic leukaemia
Option B Myelodysplastic syndrome (unclassified)
Option C Refractory anaemia with excess of blasts
Option D Refractory anaemia with multilineage dysplasia
Option E Refractory anaemia with ringed sideroblasts

Correct answer Chronic myelomonocytic leukaemia

A 37 year old Turkish immigrant presented with bruises on her forearms. She had come to the UK three years ago having previously worked on a farm in central Turkey. She was living in a squat in Camden Town. She denied having been subject to trauma. Clinical examination was unremarkable apart from the bruises. Her FBC showed Hb 12.7 g/dL, WBC 6.4 x 109/L, (neutrophils 69%, lymphocytes 26%, and monocytes 4%), platelets 37 x 109/L. A bone marrow aspirate is performed, but the only abnormality seen is a reduction in megakaryocytes.

Select from the following options your next investigation.

Option A
Antinuclear factor
Option B
Blood test for drugs and toxins
Option C
Cytogenetics
Option D
Electron microscopy of the bone marrow
Option E
Platelet associated IgG

Correct answer
Cytogenetics

A 47 year old writer of crime fiction had been complaining of pain in her left side. Her GP felt she could feel a mass there and referred her to the hospital for investigation. There was much argument amongst the junior doctor over whether the spleen could be felt. A bone marrow aspirate was a dry tap. A marrow trephine and a CT barium were ordered.The bone marrow showed general hyperplasia with trilineage dysplasia with no increased myelobalsts but with greatly increased reticulin staining. The CT barium showed a constricting carcinoma of the descending colon which was successfully removed under platelet cover. The writer named her next murderer after the haematologist who performed the bone marrow trephine.

Select from the following options the most likely bone marrow diagnosis.

Option A
Aplastic anaemia with a 'hot spot'
Option B
Myelodysplastic syndrome (unclassifiable)
Option C
Myelofibrosis
Option D
Refractory anaemia
Optiion E
Refractory anaemia with multilineage dysplasia

Correct answer
Myelodysplastic syndrome (unclassifiable)

ZAP-70

ZAP-70 is a molecule used to transmit a signal from the T-cell receptor to downstream pathways. Most B cells lack ZAP-70 and instead use a related tyrosine kinase, Syk, instead. In most cases of CLL with mutated IgVH genes, stimulation of the B cell receptor fails to cause a signal to get through, while most cases with unmutated IgVH genes signal satisfactorily. The reason for this is unknown, but may have something to do with abnormalities of the accessory signaling molecules in CLL. Somehow the presence of ZAP-70 overcomes this defect. B-cell mediated activation of ZAP-70 is negligible when compared to activation of Syk. It seems likely that the effect of ZAP-70 is to inhibit the decay of downstream factors which normally terminates the signaling response

ZAP-70 appears to be a client protein of the molecular chaperone, heat shock protein 90 (Hsp90). Whereas in normal tissue Hsp90 is in a latent, uncomplexed state, in advanced cancers it exists in an activated form complexed with other molecular chaperones and catalyzes the conformational maturation of a large range of signalling proteins. The geldanamycin derivatives, 17-AAG and 17-DAG, inhibit Hsp-90. It has been shown that ZAP-70 is an Hsp90 client protein in CLL cells with unmutated IgVH genes, but not in T cells. The inhibitors blocked BCR signalling in ZAP-70 positive cells, by causing the degradation of ZAP-70 and killing the CLL cells.

The group at NIH and their extra-mural collaborators, found that ZAP-70 expression correctly predicted the IgV mutation status in 93% of cases. Four patients with mutated IgV genes had high ZAP-70 expression and three with unmutated IgV genes had low ZAP-70 expression. Both ZAP-70 expression and IgV mutational status were equally able to predict time to requirement of treatment.. In the same paper they reported on two simplified assays, Western blotting and immunohistochemistry, that they thought might be suitable for introduction into routine laboratories. However, most laboratories regarded these techniques as too cumbersome, and require a flow cytometric assay. These have proved difficult, especially as ZAP-70 is an intracellular antigen so that the cells require permeabilization, but three different methods have been reported. The first two both used the Upstate antibody 2F3.2 in an indirect assay, differing mainly on where to set the zero, one using an isotype control and the other using the lower limit of the patient’s own T cells. Not surprisingly, the two assays give different normal ranges, the first up to 10% positive cells, the second up to 20%. Several laboratories had problems setting up these assays, probably because the antibody does not appear to be stable when stored at 4oC. The third assay used a directly labeled antibody. Directly labeled 2F3.2 seems to give too many false positives, and this group therefore used a new antibody, 1E7.2, labeled with a new fluorochrome ALEXA 488.

Whereas, the first two assays produce a concordance with IgVH gene mutations of over 90%, the concordance of the third, and easier to perform, assay was only 77%. This third paper also suggested that ZAP-70 expression added prognostic information that was independent of the effect of IgVH gene mutations. Far from being able to abandon costly and labour-intensive gene sequencing, the CLL community is faced with having to do both assays. There is clearly some discrepancy between IgVH gene mutations and ZAP-70 expression, but a lot of the discrepancy is down to technical problems.

In order to resolve the conflicting findings of the various flow cytometry assays for ZAP-70 there has been much interaction between academic laboratories, commercial companies and quality assurance laboratories. Following a satellite ZAP-70 Workshop at the 20th annual meeting of the Clinical Cytometry Society in 2005 a special issue of Cytometry Part B (Clinical Cytometry) was commissioned to deal with these issues and this has just been published.

Although the best method is still disputed there is a measure of agreement. The use of commercial fixation and permeabilization kits is satisfactory although these might yet be improved upon, but despite this ZAP-70 expression changes on storage. The type of anticoagulant affects this. Over the course of 48 hours ZAP-70 levels of cells held in preservative-free heparin fell by 13%, while that of those held in EDTA rose by 3%. However, for samples to be analysed in the first 24 hours after drawing the blood, heparin gave the less variation.

Given that brightness of fluorescence is greater using indirect methods, there is still general agreement that the reagent should be directly conjugated. All directly conjugated antibodies show a degree of non-specific binding but this is greatest when antibodies conjugated with phycoerythrin. Most agree that 1E7.2, conjugated to ALEXA 488 performs well. Setting the zero remains a problem. Many laboratories continue to prefer the left hand edge of the T and NK cells or the right hand edge of residual CD5 negative B cells, others are convinced as I am that an isotope control remains the answer. Rather than report the percentage of positive cells there is strong agreement that some measurement of the degree of positivity such as mean fluorescent intensity. However, because of intralaboratory variation this needs to be calibrated either by the ratio of geometric means of test and control populations, or as molecules equivalent fluorescence against calibrating beads.

It is not completely clear that ZAP-70 is stable over time. Levels are higher in cells from bone marrow rather than peripheral blood and it is known that it can be upregulated in response to T cell stimulation. Although most workers believe it to be stable, and we have one patient in whom the CD38 expression increased from 3% to 76% over time while showing consistent ZAP-70 levels, but one study showed changes (usually from positive to negative) in 9 out of 111 patients with at least two estimates separated by a median of 29 months.

The bottom line is that ZAP-70 is still not a reliable assay on which to base treatment decisions. IgVH gene mutations remain the gold standard.

Wintersmith

I have just finished Wintersmith the new Terry Pratchett. For those who are unfamiliar with Pratchett's work, he is a moral philosopher who conceals his insights in whimsical tales set in a fantastic world where physical laws are suspended and replaced by heavy doses of narrativium, the base element of stories. The earth is flat (of course)and carried on the back of four elephants, themselves standing on the back of a giant turtle. The rainbow has eight colors, the eighth being the color of magic. It is world where horses provide the power for transport (apart from the broomsticks), where there are still Princesses and Barons in castles, where witches and wizards practise their very different kinds of magic, and where people are just like us.

Within this environment Pratchett pokes gentle fun at Australia, Hollywood, Islam, China, newspapers, universities, I.T., Christmas, policemen, aristocracy and anything else he can imagine. He has certain sets of characters. There are the academic wizards of the Unseen University, the local police force - a mixture of low cunning and sheer bravery and an outstanding example of racial tolerance (they let in werewolves and dwarfs; although the chief dwarf only thinks he's a dwarf, having been brought up by dwarfs; actually he is six foot four, muscle bound, clean shaven and in actual fact King), DEATH (who always speaks in CAPITAL LETTERS), and of course the witches.

Wintersmith is a tale of the witches and features old friends Granny Weatherwax and Nanny Ogg, but it is a rather different witches story. Pratchett also writes children's stories (you might be surprised that the Discworld series is meant for grown-ups). The last 2 children's stories have been The Wee Free Men and A Hat Full of Sky. Both have featured the Nac Mac Feegles, two-inch high blue men with red hair kilts, and a Glasgow accent and a trainee child-witch, Tiffany Aching. Wintersmith is the sequel to these two, but written for rather older children (including adults). It is about teenage love. I suppose you could call it Chick-lit meets Discworld. It also lets you into the secret of Morris dancing.

Writing a chapter

For the past couple of days I have been beavering away on an article for a book that Tom Kipps is editing. I was hindered today when the internet went down for 4 hours, which denied me access to PubMed. Anyway here is a flavor. The spelling is in English English.

Lymphocyte doubling time

Montserrat et al analysed the lymphocyte doubling time (LDT), defined as the time needed to double the peripheral lymphocyte count, in 100 untreated patients with CLL. Although there was some correlation with clinical stage and the pattern of bone marrow infiltration, LTD was shown to have independent prognostic significance [11]. The prognostic significance of lymphocyte trends in peripheral blood was first suggested by Galton [12]. Although, both he [13] and Dameshek [14] independently concluded that CLL was a disease of accumulation rather than proliferation of lymphocytes, tests that measure proliferation rate in vitro, such as tritiated thymidine incorporation [15] or the percentage of lymphocytes in S-phase [16] or the percentage of cells staining with Ki-67 [17] or antibodies against proliferating cell nuclear antigen (PCNA) [18] all provide prognostic information. Cell division increases telomerase activity and shortens telomere length. Not surprisingly shorter telomeres and greater amounts of telomerase correlate with more aggressive CLL [19].

The idea that CLL cells have inconsequential levels of cell division was finally put to rest by experiments by Messmer et al [20] using an in vivo stable isotope labeling technique. They administered heavy water (2H2O) orally for 84 days in order to incorporate deuterium into the deoxyribose moiety of DNA in newly divided CLL cells, which could be measured by gas chromatography/mass spectroscopy. They established that CLL cells had a birth rate of between 0.1% and >1% of the total leukemic clone every day. Those patients with birth rates of >0.35% per day had more active and progressive disease than those with lower birth rates.

LDT is a simple method of measuring proliferation rate and has been confirmed many times to be a useful prognostic marker [21-23] and it has been incorporated into the NCI guidelines [4] in a more stringent form, requiring an LDT of < 6 months before treatment is started. Its drawbacks are that it is not available at diagnosis, that the lymphocyte count may have a misleading transient rise during an infection, therapy with corticosteroids or following vaccination and that, as described by Galton [12], the lymphocyte count may reach a plateau after an initial rise. LDT, therefore, needs to be evaluated in the context of the patient as a whole and not reacted to in a ‘paint-by-numbers’ response.

It was not clear whether proliferation was an intrinsic property of the CLL clone or caused by a subsequent transition to a more aggressive phase. Nor was it clear whether every patient with CLL was susceptible to transition to an aggressive phase or whether this was a danger in only a portion. Without this knowledge every untreated patient must be subjected to a regimen of ‘watch and wait and worry’. Some insight was gained into this problem by the recognition of ‘smouldering’ CLL. The Spanish group [24] defined smouldering cases as stage A patients having Hb >13 g/dL, lymphocyte count <30 x 109/L, non-diffuse bone marrow histology and an LDT >12 months. The French Co-operative group [25] recognized a type of smouldering Binet stage A’ CLL with Hb >12 g/dL and lymphocyte count <30 x 109/L. However, smouldering CLL still progresses. Of patients fulfilling the French criteria 25% had progressed by 5 years. In the Spanish study the actuarial ten year progression-free survival for these was 78%.

The realisation that there were effectively two types of CLL, one inclined to progress and one inclined not to, and that these tendencies were inbuilt and not acquired, came from a study of immunoglobulin heavy chain variable region (IgVH) genes.

Intelligent Design

Here is an extract from a Sunday Times article published today.

Why is the universe, like the porridge in the tale of Goldilocks and the three bears, “just right” for life? Even cosmologists have said it looks like a fix or a put-up job. Is it a fluke or providence that it appears set up expressly for the purpose of spawning sentient beings?

Until recently the Goldilocks question was almost completely ignored by scientists. But dramatic developments in our understanding are propelling the issue to the forefront of the agenda, according to the acclaimed British physicist and bestselling author Paul Davies. To stoke the fire, he is to chair a debate between advocates of alternative theories at Oxford on Friday

What concerns him in his new book The Goldilocks Enigma is science and the universe’s stringent conditions for existence, so finely tuned that even the slightest twiddle of the dials would wreck any hope of life emerging in the universe. “No scientific explanation of the universe can be deemed complete unless it accounts for this appearance of judicious design,” he says.

Beyond the obvious prerequisites such as water, the sun’s energy and the various chemical elements (oxygen, hydrogen, nitrogen, etc) needed to make biomass, there’s the tricky stuff. If protons were a tiny bit heavier they would decay into neutrons, and atoms would disintegrate. No carbon would have been formed by nuclear reactions inside stars if the nuclear force varied by more than a scintilla.

He is fascinated by an alternative answer to the Goldilocks question. “Somehow,” he writes, “the universe has engineered, not just its own awareness, but its own comprehension. Mindless, blundering atoms have conspired to make, not just life, not just mind, but understanding. The evolving cosmos has spawned beings who are able not merely to watch the show, but to unravel the plot.”

The Goldilocks Enigma: Why is the Universe Just Right for Life? by Paul Davies is published by Allen Lane, £22.

This is the conundrum that has one obvious answer: The universe appears to have been designed because it has a designer. This answer is unpopular with scientists because it takes the question out of the realm of science into theology where it cannot be tested by the scientific method.

Cosmologists seek to explain the bio-friendliness of the universe by postulating a multitude of universes or a multiverse, believing that the laws of physics would be different in neighboring universes. Particle physicists, particularly adherents of string theory, regard this as a cop-out. Since experiments can't be done to show what even one other universe would be like, it is just a God-free escape from scientific examination. Then there is Richard Dawkins, who believes that life is an essentially pointless by-product that came about by chance. Note the "believes". We are still in the realm of theological debate.

I fear that it will remain there, but it is good to see a scientist recognize the problem.

Books

I finished Brideshead Revisited during the week. The second half concerned Charles Ryder's lapse into Catholicism. I say lapse, because it seemed just to make him more miserable. "Religion never was designed to make our pleasures less" wrote Isaac Watts. Quite right! The hill of Zion yields a thousand sacred sweets before we reach the hevenly fields or walk the golden streets. If it is just pie in the sky when you die, it is a pretty miserable religion. The old hymns emphasized the joy of religion. O happy day that fixed my choice on Thee, my Savior and my God. Blessed assurance, Jesus is mine! O what a foretaste of glory divine! Happy the man that finds the grace, the blessings of God's chosen race. Ten thousand thousand precious gifts my daily thanks employ; nor is the least a thankful heart, that takes those gifts with joy. I will sing the wondrous story of the Christ who died for me. Great things he has taught us, great things he has done, and great our rejoicing through Jesus the son. How good is the God we adore, our faithful, unchangeable friend! His love is as great as His power and knows neither measure nor end!

So why was Charles Ryder so miserable?

After this I read Tuesdays with Morrie. Several people had recommended this to me, and I picked up a copy at a second-hand bookstore. It is a series of conversations between a well-known sports reporter and his old college professor who is dying of motor neurone disease. What we in the UK recognise as the Stephen Hawking Syndrome, but is better known in the States as the Lou Gehrig Disease. I have to say I was disappointed in it. Sure the old guy knew how to die, but the discussions were a bit superficial. It was full of apple pie aphorisms.

I have now started the new Terry Pratchett.

Jack Straw

I see that Jack Straw, ex-British Foreign Secretary and now Leader of the House of Commons, has got into trouble by asking veiled Moslem women, who consult him as their MP at his constituency surgeries, to remove their veils when talking to him.

I remember when 'nice' English ladies used to wear a veil, usually to church, certainly to funerals, and always to their own wedding. But by this time the veil had degenerated from a sign of modesty to a fashion item.

It is by no means universal for Moslem women to wear the veil. We have imported into Britain a form of Islam that has brought with it all the cultural traditions of village life in rural south-east Asia. It used to be said that English missionaries to Africa took with them, not only the Gospel, but also the traditions of Victorian England, so that now you have African churchmen dressing up in dog collars and white and purple nightdresses that have nothing to do with the African way of life and not much to do with the current English way of life either.

I think that the same thing is happening in Islam in reverse. We are importing Imams who do not speak the language and are trying to inflict on their congregations the social habits of villages in the Pakistani mountains.

Only thieves cover their faces in English Society. And scrub nurses.

Anyone who has worked in an operating theater cannot have failed to notice the allure of those eyes. The face hidden behind a surgical mask, the hair covered by a green cap, all we can see are the eyes. My goodness! The effect that they have!

Perhaps that is why, the converts especially, have taken to the veil.

It reminds me of a piece of doggerel.

We cannot hope for souls to wed
While writhing idly on a bed,
But how can they stay long away
When I have watched your eyes all day?

Imiquimod Trial 3

Over the past couple of days I have posted details of the Imiquimod trial that we intend conducting in Bournemouth this autumn.

The idea for this trial was Chaya Venkat's and it seemed to me a very good one. Rather than try another combination of chemotherapeutic agents that would make patient's immunity worse, we decided to attack one of the problems that patients have difficulties with, namely respiratory infections. Why patients with CLL are immunodeficient is not clear, but one possiblity is that their dendritic cells don't work properly. Imiquimod is drug that is already licensed that works by stimulating dendritic cells.

There have been problems in getting the study going, and teh main one is in securing a quantity of flu vaccine. Apparently there is a national shortage in the UK. then there are the regulatory authorities. Wow! There are so many perverse incentives to not bothering with trials and just going ahead without evidence.

Anyway we hope to start work soon. We have had generous funding from CLL Topics Inc. and we hope also from the UK CLL Support Association.

Imiquimod Trial (Part 2)

Objectives

1. To determine the antibody response rates to subcutaneous vaccination with influenza vaccine in patients with untreated stage A chronic lymphocytic leukaemia.
2. To determine whether subsequent application of Imiquimod cream to the vaccination site will enhance the antibody response.
3. To vaccinate patients’ spouses to control for the subcutaneous route and the older age group to which patients are likely to belong
4. To save samples of blood for subsequent investigation of T cell responses.

Trial Design

This is a randomized phase II study comparing antibody responses to two influenza vaccination protocols in patients with untreated stage A CLL.

Eligibility

All patients with CLL stage A (see BCSH guidelines3) who have not been treated with corticosteroids, chemotherapy or monoclonal antibodies.

Exclusion Criteria

1. Patients with other malignancies
2. Patients receiving corticosteroids or other immunosuppressive drugs
3. Patients who have received vaccination against influenza in the past 6 months
4. Patients who have had an allergic reaction to a flu shot in the past, or have an allergy to eggs or who previously developed Guillain-Barré syndrome within 6 weeks of getting a flu shot
5. Patients failing to give informed consent.

List of Recommended Investigations

1. Prior to vaccination: FBC, urea and electrolytes, liver functions studies, serum immunoglobulins.
2. Prior to vaccination: in patients who have not previously be tested for prognostic factors: IgVH mutations, CD38, ZAP-70, FISH for del11q and del 17p.
3. Prior to vaccination: serum sample for antibodies to influenza haemagglutinins.
4. Prior to vaccination: 50mls whole blood for future T cells studies.
5. 28 days post vaccination: serum sample for antibodies to influenza haemagglutinins
6. 14 days post vaccination: 50 ml whole blood for future T cells studies.


How Investigations will be carried out

Routine blood counts and biochemistry will be carried out at the laboratories of the Royal Bournemouth Hospital. Samples for T cells testing will be separated and frozen down for future study. We expect to receive future funding to carry out these investigations in house. These will comprise Elispot tests to investigate specific release of cytokines from T cells.

Samples for haemagglutination inhibition titres against influenza H1N1, H2N3, and B antigens will be batched and frozen, and tested under contract by the Central Public Health Laboratory Specialist & Reference Microbiology Division, 61, Colindale Avenue, London NW9 5HT.

Vaccination procedure


Vaccination will use the 2006--07 trivalent influenza vaccine virus strains: A/New Caledonia/20/1999 (H1N1)-like, A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like antigens. For the A/Wisconsin/67/2005 (H3N2)-like antigen, the vaccine may contain instead the antigenically equivalent A/Hiroshima/52/2005 virus; for the B/Malaysia/2506/2004-like antigen, the vaccine may contain the antigenically equivalent B/Ohio/1/2005 virus.

0.5 ml of the vaccine will be administered subcutaneously under the skin over the deltoid muscle. A two cm diameter circle will be drawn on the skin around the injection site in water insoluble ink

Those patients randomized to receive Imiquimod will be instructed to rub a small amount Imiquimod cream into the skin within the circle, starting on the day after the vaccination and continuing daily for five days. Imiquimod comes in a sachet that can be sealed by a paper clip, and should be kept refrigerated between applications. The cream should be left on the skin for 8 hours and then washed off with soap and water.

Patients’ spouses will be offered vaccination and if they consent they will receive subcutaneous vaccination in the same way as the patients, but they will not receive application of the Imiquimod cream.

Side effects

Imiquimod is licensed for application to genital skin. It can produce local erythema with itching and pain with prolonged use. A single application is likely to produce nothing more than mild local inflammation.

Influenza vaccines are produced in the allantoic cavity of chick embryos and are therefore contraindicated in those with allergy to eggs. Otherwise, mild local inflammation and mild ‘flu like symptoms are the most likely side effects.

Source of patients for study

There are currently just over 100 untreated stage A CLL patients attending out-patient clinics at the Royal Bournemouth Hospital who have had blood tested for prognostic markers. It is from this group of patients that subjects for the study will initially be recruited. If insufficient patients can be recruited from the study from this cohort, patients who have not had prognostic markers studied will be invited to participate. Prognostic markers will be determined for this group.


Randomization

Randomization will be achieved by opening a series of numbered sealed envelopes kept in the office of the Haematology secretariat. The envelopes will contain a card on which is written A or B; computer generated random numbers will determine which, A for even numbers, B for odd numbers.

Statistical Calculations

Assuming that the control group has a 15% response to vaccination, an improvement to a 50% response rate would be worthwhile. To have an 90% chance of detecting such an improvement at the p=5% level would require 34 patients in each arm.

Evaluation

Response to vaccination is defined as a fourfold increase in haemagglutination inhibition titre. A haemagglutination inhibition titre of 100 is regarded as protective. Results will be compared between the two arms of the study. Responses to vaccination will be compared with several other factors, including age, sex, presence or absence of palpable lymph nodes and spleen, serum immunoglobulin levels, prognostic factors and length of time the patient has been diagnosed for.

Ethical Considerations

Prior to starting the study, the protocol must be approved by Local Research and Ethical Committee (LREC). Amendments to the protocol may only be made with approval by the Principal Investigator, and will be subject to review by the LREC. Written documentation of the Ethics Committee approval must be received before the amendment can be incorporated into the protocol.

The patient will be given time to discuss his/her participation in the study with the Investigator concerned and family members as well as his or her GP. Before the patient is entered into the study, the patient’s written consent must be obtained. A copy will be retained by the patient and the original filed in the Investigator's Trial File unless otherwise agreed.

The patient may refuse treatment either before or at any time during the study. Refusal to participate will involve no penalty or loss of benefits to which the patient is otherwise entitled.

The study will be carried out in accordance with the Declaration of Helsinki.

Suspected Unexpected Serious Adverse Events (SUSARs)

An adverse reaction is ‘serious’ if it:
a. results in death;
b. is life-threatening;
c. requires hospitalization or prolongation of existing hospitalization;
d. results in persistent or significant disability or incapacity;
e. consists of a congenital anomaly or birth defect.
An adverse reaction is ‘unexpected’ if its nature and severity are not consistent with the information about the medicinal product in question set out:
a. in the case of a product with a marketing authorization, in the summary of product characteristics for that product;
b. in the case of any other investigational medicinal product, in the investigator’s brochure relating to the trial in question.

A SUSAR which is fatal or life-threatening must be reported to the LREC as soon as possible and in any event within seven days after the sponsor became aware of the event. Any additional information must be reported within eight days of sending the first report.
A SUSAR which is not fatal or life-threatening must be reported to the LREC as soon as possible and in any event within 15 days after the sponsor became aware of the event.

Publication policy

Results of this study will be submitted for publication.