Monday, October 27, 2008

Isaiah chapter 12 - something to sing about

A young English woman is gunned down in Afghanistan by two young thugs on a motorcycle armed with an AK47. She has been 'spreading Christianity' by helping handicapped children.

Does that make you angry?

A 25-year old man killed his 16-month-old daughter by snapping her spine in a "chilling and brutal attack" following months of abuse.

Are you angry at that?

In Orissa, India, a nun was attacked and gang-raped by 40 men during anti-Christian attacks. Police are believed to be shielding her attackers.

How about that? Has that made your blood boil?

In Worcester, England, a gay Member of Parliament was attacked by a gang of youths as he delivered balloons to his parents for their 50th wedding anniversary. He was a bit battered and bruised with facial injuries and a black eye, but no broken bones.

How do you feel about that? Do you feel more sympathetic towards the attackers? They just roughed him up a bit. No real harm done. What do you expect, some middle aged gay guy camping it up with balloons? Don't you think he was asking for it? Sure, they went a bit far, but boys will be boys.

I have taken these examples from the newspapers over the past week to illustrate a couple of points. First, it is right to get angry about wickedness. We are not meant to pass by on the other side.

Isaiah Chapter 12 is a song that celebrates and summarizes the first section of the prophesy. Harking back to chapter 6 and Isaiah's appreciation of the holiness of God, we see that God is righteously angry with the wickedness of sin. We can sympathize with that - especially in the first three examples that I gave - but perhaps when it comes to gay-bashing some of us will tend to make allowances for the perpetrators. If not for them then certainly for others: perhaps members of a political party that we support who have been a little free with public money or been a bit underhand in how they have raised their funds; perhaps supporters of our favorite football club who have committed minor acts of vandalism; perhaps members of our armed services who under extreme provocation have caused what is euphemistically called 'collateral damage'.

This is my second point. God is angry with all sin. Because he is a merciful God we tend to think that He winks at some sin; that all sin does not really offend Him. Just as we might look for extenuating circumstances to forgive an offense, especially one committed by a person we like, so we imagine a God who is soft and easy on sin.

This is a very great mistake and it traduces the character of God. The Bible tells us that 'all have sinned'. There is no such thing as a big sin and a little sin. Sin is a technical term from archery - it means that your arrow falls short of the target. It doesn't matter how far short it falls - a miss is as good as a mile. Remember the movie "The Dam Busters"? Some bombers failed to release their bombs, some fell short, some overshot. It was only the bomb that hit the target in precisely the right place that destroyed the dam. For all that some of the bombers got mighty close, had not the one bomb hit exactly right, the other planes need not have bothered flying over Germany at all.

We don't get marks from God for a 'good try' at keeping his Laws. Attila the Hun and Mother Teresa are in the same basket - human beings who fell short of God's standards. Don't misunderstand me. I am sure that Mother Teresa was a much nicer person to know than Atilla. In general terms she left the world in a much better state than he did. But in this way only, in terms of who has satisfied God's standards, they both stand in the group labelled 'failed' along with Peter, Paul, John and all the Apostles, Moses, David, Abraham and Noah.

It is not until we see ourselves in that light that we have any use for a Savior at all.

In verse 1 of the song we have: In that day you will say: "I will praise you, O LORD. Although you were angry with me, your anger has turned away and you have comforted me."

What day is that? It refers back to verse 10 in the previous chapter: In that day the Root of Jesse will stand as a banner for the peoples; the nations will rally to him, and his place of rest will be glorious. Who or what is the root of Jesse?

In verse 1 we have: "A shoot will come up from the stump of Jesse; from his roots a Branch will bear fruit." This is the Messiah, the Christ. So, in the day of the Christ God's anger is turned away and He comforts us. How does the Christ turn away God's anger? By taking it upon himself.

God's anger is very real. Justly so. Those who sin deserve the strongest punishment. The book I am reading at the moment describes the court of Henry VIII. When a plot is discovered the conspirators are questioned. It is taken as a matter of fact that they will be tortured. The torturers are good at their jobs. Indeed they enjoy their work. They positively drool at the prospect of the rack. One character contemplates the prospect of boiling alive a cook who is suspected of poisoning his master. You can feel how he enjoys the prospect.

Richard Dawkins pictures the Christian god as a sadistic tyrant who tortures his own son. To think like that betrays a woeful ignorance of the nature of the Trinity. Punishment is just. There is but one God. Our recipe of Father, Son and Holy Spirit is the best we can do to represent the three persons of the Trinity. Whole volumes have been written on how there is only one God yet three persons and I could not begin to explain the Trinity to you. The Athenasian creed was formulated to guard us against the error of thinking that there are three gods while safeguarding the divinity of Christ. Let me just say that whenever we see God in human form - Jesus Christ or the theophanies of the Old Testament, that is the second person of the Trinity.

Thus when God the just must punish human sin, God the son receives the punishment in human form. God takes no pleasure in the death of the wicked; there is no sadism here. Nor does the Son hurry to the cross with relish as some sort of weird and perverse masochistic treat. "If it be thy will let this cup pass from me." said Jesus.

Picture it like this: a house in on fire. The flames have taken hold. The heat is tremendous. The neighbors hold back even though they know that trapped within the house is a small child. She might still be alive, for within the house is an airtight room and if the door has not yet burnt down she could yet have survived. Several have attempted to save her, but the intense heat has driven them back. One had even wrapped himself in soaking wet towels, but as he ventured inside the water in the towels had turned to steam and he had to wrench then from his face to save himself from scalding. Then comes the fireman. He really doesn't want to go inside the building. He knows that if he does there is little chance that he will come out alive. Yet there is a just a chance he can save the child. He walks into the house. The heat is unbearable. The plastic on his uniform is melting. His face is hurting. He can hardly breathe. His eyebrows singe. His hair catches fire, yet he reaches the sealed room. He opens the door and sees the little girl cowering there. She is crying and she's terrified. Without pausing he snatches her up and wraps her in his uniform coat, shielding her from the flames. He runs for the exit. The flames seem even hotter. The skin has burnt from his face now, exposing his bare skull. His vision has gone. He runs towards where he hears the crowd shouting and as he stumbles over the threshold, spilling the girl safe into the hands of her parents, he slumps to the ground, spent and dying.

Now imagine that within that sealed room was not an innocent child but the most black-hearted villain imaginable. Imagine it was a predatory paedophile; a wife-beating rapist; a recruiter of suicide bombers; an evil-hearted arms dealer. Jesus ventured all, even for them.

Surely God is my salvation; I will trust and not be afraid. The LORD, the LORD, is my strength and my song; he has become my salvation.

Do you agree? When you are going through it, when everything seems against you, when your health is failing, your investments are sinking, your friends are all sickening and dying; when your marriage has hit the rocks, your house is being repossessed, your job has been downsized, you can't pay your debts; when the doctor tells you you have cancer; when your children reject you; when all men speak ill of you; where can you turn? Who can you trust?

Come and trust me - I will sort out your finances; I will heal your marriage; I will cut out your cancer; I will build you a house; I will rewire it; I will repair your car; trust me.

You'd be a fool if you did. If you want advice on CLL, perhaps, but I have no track record in marriage guidance or financial advice or housebuilding. Although I have a paper qualification in surgery, the only operation I completed by myself had the patient punching me on the nose when he recovered.

Who can you trust in times of distress? Trust someone with a proven track record. Who made you? Who knows every atom of your body? Who rescued Israel from the Egyptians? Who parted the Red Sea? Who brought water from a rock in a dry and parched land? Who fed 5000 with a few loaves and fishes? Who turned water into wine? Who made cripples walk, the blind to see, the dead to live? Who so loved the world that he gave his one and only son that whoever believes in him should not perish but have everlasting life? Who is the way, the truth and the life?

He will not only save you, he will strengthen you. This Trinity business is very confusing. God in His person of creator, first cause, initiator and general bloke in charge of the Universe we can just about understand. God the Son - divinity in human form who suffered for our sins and rose from the dead - at least we have some vision of. What about the third part of the Trinity. Unless I return to the Father I cannot send the comforter, said Jesus. 'Comfort' has lost its strength since the seventeenth century. We think of someone patting us on the back and saying, "There, there." You know what a fort is. A stronghold, safe against the enemy. 'Con' just means 'with'. The comforter is the strengthener. The Holy Spirit is called the 'paraclete', a Greek word that means 'the one who stands alongside'. Like in the cop shows where the attorney stands alongside the accused and says, "My clients declines to answer that question." Only this advocate presents and impassioned plea for the defence that convinces the jury, and Perry Mason-like exposes the real criminal. Wouldn't you like Perry Mason on your side? The Holy Spirit is better than that.

Now that's something to sing about.

Global cooling


Roger Helmer is Conservative MEP for the East Midlands. This increase in CO2 worries me. It seems to be making the world get colder!

Friday, October 24, 2008

Dark Fire

If you haven't discovered them yet do read the Matthew Shardlake novels by CJ Sansom. I have just finished the second which was better than the first. Shardlake is an honest lawyer (there are such things) at the time of the English Reformation. He mixes with power brokers. Thomas Cromwell, Archbishop Cranmer, The Duke of Norfolk and Henry VIII himself are among those he contends with. The plots are woven into actual historical events and full of exciting happenings. I promise you won't be disappointed.

Health update

I saw the surgeon today and we discussed what to do about the lymph node that could be seen on the CT. Thus far we have no explanation for it. Carcinoma and carcinoid seem to be ruled out. My favored explanation is that the NSAID I was taking was causing inflammation of the colon and this was a node reacting to the inflamation. Alternatively it could be an old TB node - I had a positive Mantoux when I was a teenager. Other possibilities could be lymphoma, though a single node just there would be very unusual and as a long shot, carcinoid producing something other than serotonin. I have hypercalcemia and parathormone producing carcinoids have been described. The options are laparoscopic biopsy now or repeat the CT scan in 3 months. I have opted for the latter, because even laparoscopy has a definite morbidity and I'm not sure that it is going to alter management

Increasingly abnormalities are being discovered on screening tests that don't amount to a hill of beans.

Thursday, October 23, 2008

FCR: No country for old men

Outcome of treatment for chronic lymphocytic leukemia (CLL) depends more upon the nature of the disease than the type of treatment given. Despite newer treatments producing higher response rates and longer remissions than older ones, no study has ever shown an overall survival benefit from their first-line use compared to treatments that have been available for fifty years.

Some patients survive for decades untreated. Such patients usually have mutated immunoglobulin heavy chain variable region genes (IGHV), low expression of CD38 and ZAP-70 and deletions at chromosome 13q14. Other patients require treatment within a year or two of diagnosis and survive for fewer than eight years. Such patients tend to have unmutated IGHV genes, raised expression of CD38 and ZAP-70 and different chromosomal aberrations including trisomy 12 and deletions at 11q23 or 17p13 [1].

Until now the treatment regimen that has performed best in randomized controlled trials has been the combination of fludarabine and cyclophosphamide (FC) which has been shown to produce a higher response rate and longer remissions than either fludarabine or an alkylating agent used alone [2].

For several years it has been very common for physicians in the United States and some European countries to add the monoclonal antibody rituximab to FC (the combination being designated FCR), even though rituximab has not been licensed for the treatment of CLL. The results of CLL8, a randomized controlled trial comparing FC and FCR, conducted by the German CLL study group will be reported shortly. Media reports suggest that the trial met its primary endpoint which was to demonstrate a 35% increase in progression-free survival for patients in the FCR arm [3].

Despite increased response rates and longer remissions from more intensive treatment, no form of treatment restores the intrinsic immune deficiency caused by CLL and concern has been raised that the lack of overall survival benefit from newer treatments might derive not merely from the availability of effective salvage treatments but also from long term toxicity. A higher rate of transformation to aggressive lymphoma (Richter’s syndrome), more severe and intractable infections and a greater risk of the development of autoimmune complications or myelodysplastic syndrome have been suggested implications of the use of very immunosuppressive combinations of drugs that include fludarabine [4, 5].

In the meantime a very large non-randomized phase II study of treatment with FCR has been taking place at the MD Anderson Cancer Center in Houston and results of this study have now been published [6]. Among 300 patients treated with FCR and followed up for a median of six years, the complete response rate was 72% - far higher than for previous treatments. In CLL a complete response according to the 1996 NCI criteria [7] allows for considerable residual disease and because of this, methods for the detection of minimal residual disease (MRD) have been developed using either flow cytometry or the polymerase chain reaction. Using the most sensitive of their techniques the Houston group found 28% to be negative for MRD. However, the techniques used for the detection of MRD were sub-optimal; others have described and used techniques that are five to ten times more sensitive [1].

Among patients with a partial response or better (all but 15 of the original cohort) the median time to progression was 80 months with a projected 60% progression-free at six years. Again, this is an impressive result but it must be seen in the context of the kinds of patients treated. First, the patients in this study were relatively young; the median age was only 57 and only 14% were aged 70 or older, whereas in the general CLL population, 70 is the median age of presentation. As a group, patients over the age of 70 were significantly less likely to complete the optimum six cycles of therapy (46% vs 79%) and significantly less likely to achieve a complete remission.

Second, most modern prognostic markers were not available for this study. Specifically, ZAP-70 expression, IGHV mutational status and FISH were not available. CD38 expression was tested for, but in only 21% of patients were more than 30% of cells CD38 positive. The comparable figure for my own treated patients is 64%. It is becoming possible to do some of the modern prognostic tests on archived material and we wait with interest the outcome of any future investigation.

Lacking a contemporary comparator, the chief interest in this trial is in the long term safety profile of this regimen. Here there is certainly some encouragement. The actuarial risk of Richter’s syndrome was 2.5% at six years – no more than for historical series. Likewise the actuarial risk of myelodysplastic syndrome was only 2.8% at six years. The well established effect of fludarabine in depleting circulating T cells [5] is certainly responsible for the 10% risk of serious or opportunistic infection during the first year of remission and 4% risk in the second year, but four of the five late deaths from infection were caused by bacteria rather than fungi or viruses.

The most unexpected toxicity was persistent cytopenia after completion of therapy, continuing for at least three months. This occurred in 19% of patients. However, following recovery of blood counts, recurrent late cytopenic episodes occurred in 28% of patients, predominantly in the first year of remission. Salvage of relapsing patients with persistent cytopenias is particularly taxing.

1. Dighiero G, Hamblin TJ (2008) Chronic Lymphocytic Leukemia. Lancet 371:1017-1029.
2. Catovsky D, Richards S, Matutes E, et al (2007). Assessment of fludarabine plus cyclophosphamide for patients with chronic lymphocytic leukemia (the LRF CLL4 trial): a randomised controlled trial. Lancet 370:230-239
3. Roche Media Release 25th January 2008. accessed 20th October 2008.
4. Milligan DW, Fernandes S, Dasgupta R et al (2005). Results of the MRC pilot study show autografting for younger patients with chronic lymphocytic leukemia is safe and achieves a high percentage of molecular responses. Blood 105:397-404.
5. Hamblin AD, Hamblin TJ. (2008) The immunodeficiency of chronic lymphocytic leukaemia. British Medical Bulletin 87:49-62.
6. Lam CS, O’Brien S, Wierda W et al. (2008) Long term results of the fludarabine, cyclophosphamide, and rituximab regimen as initial therapy of chronic lymphocytic leukemia. Blood 112:975-980
7. Cheson BD, Bennett JM, Grever M et al. (1996) National Cancer Institute-sponsored Working Group guidelines for chronic lymphocytic leukemia: revised guidelines for diagnosis and treatment. Blood 87:4990-4997.

Sunday, October 19, 2008

Screening tests

I have three times been tempted into having myself screened for serious disease. It seems like a sensible and prudent thing to do as one gets older, since, for the most part, early diagnosis means early treatment and early treatment carries with it a greater chance of cure.

Screening as an important plank in Public Health policy. Ideally a screening test should be for a serious and important disease. It should be a disease that is cured by early treatment, but dangerous if diagnosis is delayed. The test should pick up all the cases of the disease but not show up positive if the disease is absent. Finally the test should be affordable.

The first time I tested myself it was for prostrate cancer. The PSA test is cheap enough and misses very few cases, but unfortunately it shows up positive when the prostate is enlarged from whatever cause. I was one of those ensnared by a false positive. When this occurs the only thing to do is a prostatic biopsy.

A prostatic biopsy is done without anesthetic. I plastic probe is inserted into the rectum and a spring-loaded knife shoots out through the rectal wall into the prostate to take the biopsy. Only it isn't one biopsy; it's ten. It doesn't hurt, unless it happens to hit a nerve. Imagine that it hits a nerve on biopsy number two; you have eight more to imagine as you wince and sweat with the pain. That's what happened to me. Luckily the biopsy was benign, but as you wait several days for the result you envision bony secondaries and early death before your misery is relieved.

Serum cholesterol is high in populations with a high rate of heart disease. If you have high blood pressure and a high cholesterol, it seems a reasonable thing to take things further, since the risk of a heart attack might be averted by judicious diet, or even angioplasty. This was especially so because we had introduced CT angiograms that did not require catherization. An intravenous injection of radio-dye followed by a CT of the heart will demonstrate that the coronary arteries are patent. Unless there is calcification. Because one of my coronaries had a plaque of calcium in it, it was not possible to say whether it was patent or not. After all I had to have a standard angiogram. I tried not to think about the risk of heart attack or stroke as the cardiologist threaded his wire up my arm and into my heart. In truth, this is a painless procedure and for me the result was encouraging. I was put on statins just like nearly everybody else of my age and my choldesterol is now low-normal.

For ten years I administered chemotherapy to patients with colon cancer. Often I felt that there ought to be a screening test for this disease. About half the people diagnosed with colon cancer die from it, but early surgery is curative. Unfortunately the only screening test that picks up all the cases is colonoscopy, which is a skilled procedure in which a flexible telescope is inserted into the rectum and passed all the way round the colon until it reaches the appendix. This is a very long way, and the procedure takes at least half an hour.

Because an aunt recently had surgery for colon cancer, and two of my grandparents died from it, and because of my experience in treating the disease I thought I should have a colonoscopy, which took place a month ago. The procedure itself may or not be painful; I can't remember because they inject you with midazolam which doesn't send you to sleep, but you forget everything that happened. If the procedure is not unpleasant, the preparation is. The day before they give you a liquid that flushes everything out of your bowel; not a pleasant procedure and quite painful.

Unfortunately, my colonoscopy was not normal. The cecal wall was rather rigid and there were superficial ulcers. These were biopsied. I was sent for a CT scan the next day, and the radiologist found a small lymph node. The biopsies came back normal, but they thought that the lymph node looked like carcinoid. Carcinoid is a slow growing tumor that often starts in the appendix. It produces a hormone, serotonin, that causes flushing, diarrhea and asthma. It is only slow growing; it sounds nasty, but it is better than having carcinoma. I had a 24 hour urine collection for 5-HIAA, which was normal, and a radioactive octreotide scan. Octreotide is an antidote to serotonin that binds to it. After an injection of the octreotide, I had to lie under a gamma camera for two hours on three separate days. The scan was negative, but on hearing this the surgeon seemed to be resigned to the fact that I had cancer, and cancer that had spread to the lymph nodes at that. He booked me in for surgery for next Tuesday, likely to be followed by chemotherapy. As I remember my statistics, the five year survival for Dukes stage C bowel cancer following chemotherapy is about 60%.

This was the first time in my life that I wished I was ignorant of medicine. Happy are those whose physicians look them in the eye and say, "My dear, I am going to look after you. Trust me."

I knew too much. Well do they say a coward dies a thousand deaths. I had a day of pure funk. For the first time I felt like a patient. After a day I settled down. I realized that taking 'anxious thought for the morrow' would not change anything. Many of my friends began to pray for me.

The surgeon decided that first he must take a look for himself (the original colonoscopy had been done by an assistant). Another day of bowel preparation. Ugh! It's not only the effect; the stuff tastes foul. As I was coming out of the influence of the midazolam he told me that all was fine. There was nothing abnormal to be found. The proposed operation was cancelled. I was in the clear! He wondered if I had been taking ibuprofen since they can cause ulcers in the bowel. It's true, I certainly had been following a wrench to my shoulder after falling from a ladder.

But I wonder if there's another explanation. Was it an answer to prayer? It certainly felt like one. Perhaps it was both an answer to prayer and had some physical explanation. Answers to prayer are by their nature incomprehensible.

I have only one word to add. Hallelujah!

Bad Science

For those who are still being taken in by the the Great Climate Change Fraud I recommend reading this essay by Lord Monkton. I am grateful to Seablogger for drawing my attention to it.

From it I have reprinted a small section that is nothing about climate change, but everything about the United Nations, Politicians who know no science and environmentalists. I don't know much about the climate but I know a lot about Public Health.

"DDT is the only effective agent against the mosquitoes that carry malaria. Its inventor won the Nobel Prize for Medicine because the use of DDT had reduced malaria deaths to 50,000 per year worldwide. DDT is entirely harmless to humans, who can eat it by the tablespoonful and not come to any harm. If sprayed in the interior of dwellings, it will not cause any harm to wildlife, except to mosquitoes.

Yet DDT was banned. The effect of the ban was murderous. Annual malaria deaths swiftly rose from 50,000 to 1 million. In a third of a century, the excess deaths caused by the ban on DDT amount - according to the scientific literature - to between 30 and 50 million. The "precautionary principle" is not a principle: nor do its advocates pray it in aid for any other reason than to provide a specious credibility for policies that would otherwise be self-evidently purposeless and cruel.

During the final stages of the case that led to the ban on DDT, the Board of the Environmental Defense Fund met with its lawyer. He said to the Chairman: "Sir, I beg you not to press for a total ban on DDT. If you succeed in getting it banned altogether, tens of millions of children will die of malaria. My advice is that, for pressing scientific reasons, you should allow it to be used indoors, so that children will not be bitten at home."

The lawyer carefully put before the Board the scientific evidence he had accumulated, and just as carefully - for he was scientifically literate and competent - he spelled out exactly why and how a total ban on DDT would kill tens of millions, and undo a malaria eradication program that had almost succeeded in wiping this curse from the Earth.

And what was the reaction of the Board of the Environmental Defense Fund? They dismissed their Counsel on the spot. As he left the room, he heard the Chairman say to the Board, "That's the last time we ever again employ a lawyer who knows anything about science."

Thursday, October 16, 2008


Readers may have seen the outrages taking place against Christians in the Indian State of Orissa. I wrote to my local MP, Tobias Ellwood about it. Via him, I had this response from Mark Malloch-Brown, the British Minister of State for Foreign Affairs:

"We condemn the recent attacks on innocent individuals that have led to the deaths, injuries and widespread displacements in Orissa. On 25 September the Indian Central Government ordered the Chief Secretary of Orissa State to take firm and effective steps to deal with these continued outbreaks of communal violence and bring the perpetrators to justice.

We welcome the Indian prime Minister’s unequivocal statements condemning these attacks, most recently on 29 September following the India EU summit. We also welcome the deployment of additional police in Orissa to restore law and order and the offer of compensation to victims. We were relieved to note the recent comments of local archbishops, state officials and police suggesting that the situation is slowly returning to normal, even though attacks are still being reported in Orissa, Karnataka and Tamil Nadu. I officially conveyed our concern at the current situation to the Indian High Commissioner on 1 October.

Our High Commissioner in Delhi, with European and other partners, has been monitoring the current situation in Orissa and in neighbouring states. They also monitor issues of religious freedom in India more generally. Our staff have regular meetings with the Indian authorities to express our concern about all incidents of religious intolerance. We use such occasions to urge the Indian government to uphold the right of freedom of religion enshrined in the Constitution and to bring to justice those responsible for attacks.”

Dealing with distractions

Do you find that when you decide to spend time in prayer you are bedevilled with distractions? The phone rings, a pneumatic drill starts up across the street, there's someone at the door, the kids burst in, you think of a task unfinished, you become sidetracked into thinking about a particularly nasty crime or you can't stop worrying about your children.

You are not alone. listen to what the sevententh century poet and divine, Joah Donne says:

I throwe my selfe downe in my Chamber, and I call in, and invite God, and his Angels thither, and when they are there, I neglect God and his Angels, for the noise of a Flie, for the rattling of a Coach, for the whining of a doore...A memory of yesterdays pleasures, a feare of tomorrows dangers, a straw under my knee, a noise in mine eare, a light in mine eye, an any thing, a nothing, a fancy, a Chimera in my braine, troubles me in prayer.

Despite the odd spelling and punctuation, he was just like us. And he was Dean of St Pauls.

Are there remedies? Certainly. Separate yourself from all electronic devices. Allow the answering machine to deal with the telephone. Keep a notepad and pencil by your side and note down any stray thought. Capturing it on paper lays it aside until later. Finally, turn distractions into prayer. If they, rather than prayer, are what demands your attention, then those are the things you really want to pray about. If you think that you ought to be praying about orphans in Darfur, but you can't stop thinking about your children's exam results, then pray about your children's exams. Don't be so high minded. Your heavenly Father wants to speak to the real you, not some bogus act you are putting on.

Wednesday, October 15, 2008

The death of Richard Cooey

The prisoner who claimed that he was too fat to be humanely executed by lethal injection was nonetheless put to death by this method in Ohio yesterday. Richard Cooey, aged 41, killed two students from an Ohio university twenty-two years ago. His final appeal was rejected by the US Supreme Court on Tuesday. Cooey and Clinton Dickens, his 17-year-old accomplice, were found guilty of the murders of Wendy Offredo and Dawn McCreery. The two men had been throwing concrete slabs from a bridge onto a main road. One of them struck Ms Offredo's car.

Worse, they pretended to "rescue" the women and took the victims to a remote field where they subjected them to three-and-a-half-hours of rape, torture, stabbing, and fatal bludgeoning. Cooey carved an "X" into the stomachs of both women.

Each man blamed the other for delivering the fatal blows, but both were convicted of murder. Dickens received a life sentence because of his age.

Six of Dawn McCreery's family members watched quietly as the execution took place. Mary Ann Hackenberg, mother of the 20-year old student, looked to the ceiling and let out a sigh when Cooey's death was announced at 10:28am local time.

Summit County Prosecutor Sherri Bevan Walsh said the family was disappointed that Cooey was vulgar and hateful to the end. "He still would not apologize and still would not accept responsibility for what he did," she said.

It is a terrible thing to take the life of another human being. For the state to do it in the name of its citizens is an awesome thing. The frightening possiblity that an innocent man might be executed would hold us back from rushing precipitously to the death penalty.

But then again, there are some crimes so horrible and some criminals so unrepentent
that they deserve death. The victim's blood cries out to us from the ground.

The American system of state executions, where numerous rounds of appeals and stays of execution at least give the murderer time to regret and repent, certainly has its critics. It is said that in the UK you get a life sentence for murder; in China you get the death penalty, but in the USA, first you get a life sentence and then you get the death penalty.

I find it strange that people who encourage the putting to death of babies in the womb lest they become an encumbrance to their irresponsible mothers, and who wish to put away old people who have outlived their 'usefulness', should wish to preserve the lives of monsters like Cooey.

I know hard cases make bad law and that there may well be grey areas concerning abortion, euthanasia and capital punishment that could be argued about, but would anybody like to stand up and say to Mrs Hackenberg that her daughter's killer should not have been executed?

Monday, October 13, 2008

No time for prayer?

I know how busy you are. Sometimes I wished for 8-day weeks or 25 hour days. Everything seems to be crammed into shorter and shorter times. I remember sitting in traffic lines while the stupid woman at the front stalls her engine or fails to see the right filter sign showing. I remember rushing from meeting to meeting, missing meals or snatching a sandwich at my desk. I remember squeezing in three extra patients into my morning clinic. I remember being booked to speak at three venues each 100 miles apart for the same lunch hour. I remember taking a plane from Southampton to Amsterdam, then a car through three countries to give a talk in Heidelburg before being driven to Bremen to catch a flight to Heathrow and then being driven back to Bournemouth, all to speak at a lunchtime meting for which I arrived 40 minutes late. I remember missing picking up my kids from school because a meeting overran and then hunting through classmates telephone numbers in a panic to find who had taken them to whose homes. I remember writing until four in the morning to get a paper finished in time. I remember driving 100 miles to deliver a letter because I had missed the post. I remember falling asleep at my desk.

Sounds familiar? No wonder there is no time to pray! Don't these clergymen realise how busy life is? They have plenty of time to pray - they only work Sundays!

I flinch as I remember myself saying it.

The truth is everybody has a 24 hour day and everyone has a 7 day week. No-one has more time than anyone else. It is a matter of how we prioritize our time.

Everyone has wasted moments. Lying in a bathtub, standing in line at a checkout, waiting in a traffic queue, exercising, riding a bus or a train, lying awake at night; all present opportunities for prayer. Rather than get irritated with impatience take time to thank God that you have a car, that you will be able to afford your supermarket bill, that someone has seen fit to invite you to speak, that your bed is warm and unlike some in the jungles of Congo you have a shelter to keep you dry. As you exercise pray for those who have lost limbs from land mines and can't run. As you soak give thanks for water and remember those who crave clean water.

We fill our minds with all sorts of trash from the television. Rather fill your mind with the goodness of God. If you must watch television, think what the advertisers are paying for 15 seconds of your time. Deny it them! Instead pray foe your pastor, your physician, the patient next to you in the clinic, your parliamentary representative, your neighbour, you husband or wife, your children or even your country's leader. Here is an exercise. On your next journey look out for five things you could turn into prayer. It could be a school, a bar, a church, a small child, or older person; there is no-one and nothing not in need of prayer. If you can't think of anyone else, pray for me.

We make a mistake in thinking we must pray like our pastor or like Liturgy of the Hours or like the Book of Common Prayer; speak to God as you would talk to your sister or brother. He wants to be on intimate terms with you. Give Him your confidence. Nothing is secret from Him anyway.

One thing you can pray for is discipline with your time. Pray for the grace to say no graciously, for protection from the tyranny of the urgent. There is nothing against special aids to help your memory. Muslims hear the call to prayer 5 times a day. Why not set your watch to vibrate every hour and bless it with a ten second prayer?


Wikipedia tells us The protein encoded by this gene is a type-1 membrane glycoprotein, which contains two immunoglobulin domains, and thus belongs to the immunoglobulin superfamily. Studies of the related genes in mouse and rat suggest that this gene may regulate myeloid cell activity and delivers an inhibitory signal for the macrophage lineage in diverse tissues.

So why should this be of any interest to a CLL doctor? A paper just published on line in Leukemia Research gives the answer. CD200 turns out to be overexpressed on CLL cells. Why is it there? It is thought that prolonged B cell receptor stimulation activates the MEK/ERK pathway and that up-regulation of ERK causes the upregulation of surface CD200. What is it doing there? It has three apparent functions. First it inhibits T cell proliferation. Second it suppresses T cells specific for a tumor associated angigen. Third it enhances regulatory T cells.

Why does this matter? There is some evidence that a patient's own T cells can be induced to kill his or her own CLL cells, but that this effect is inhibited by CD200. It is conceivable therefore that blockade of CD200 with an antibody would enhance the body's ability to rid itself of the tumor.


Prohibition does not work. My son Richard studied prohibition for his history degree at University College, London. He remains convinced that prohibition is an ineffective way of reducing alcohol consumption.

Do we need to reduce alcohol consumption? Of course, it is quite legal to drink and many people enjoy alcohol in a moderate and responsible way. Even Jesus had no problem in turning water into wine at a wedding feast. But at the risk of being labelled a health Nazi, I am very worried about an increase in alcohol consumption, especially here in Britain, but I have no doubt that this applies across the whole of the Western world. Indeed, it is not confined to the West; Russia has a real drink problem too. Estimates of the contribution of alcohol to mortality in Europe are striking: 45,000 deaths from cirrhosis, 50,000 deaths from cancer, 27,000 from accidents and 10,000 suicides. There may be as many as 200,000 episodes of alcohol-induced depression annually, and it has been estimated that 50% of violent crimes are alcohol fuelled along with 40% of murders. One in six cases of child abuse is alcohol-related. In young people, socialization and sexual problems are frequently alcohol-related.

Rather than banning alcohol we should look at incentives prevalent in society and seek to counter them. One of the most important handles we have on alcohol consumption is price. Since 1960 the price of alcohol has halved relative to income. In Finland where the government reduced alcohol excise duty by 33%, there was within a year a 17% increase in sudden deaths involving alcohol. It is estimated that a 10% rise in duty would produce a 28% decrease in alcohol-related deaths.

Alcohol advertising is another pinch-point. Alcohol intake by 11-15 year old children closely parallels the increase in expenditure on alcohol advertising from 1992-2000. 76% of EU citizens agree that alcohol advertising to young people should be banned.

The number of licensed and off-licensed premises have increased by 30% and 65% respectively in the past 50 years. Since the 24 hour availability of alcohol was introduced into Britain three years ago there has been an increase in alcohol-related admissions to accident and emergency departments in hospitals. Some supermarkets have alcohol sales as a major proportion of their business. More availability means more consumption.

In Europe the alcohol industry is worth 45 billions Euros to the economy. However, this is dwarfed by the 125 billion Euro cost of alcohol-related harm.

Sunday, October 12, 2008


Dr Philip Nitschke, a controversial Australian euthanasia advocate dubbed "Dr Death", has been banned a second time from hosting a DIY suicide workshop in Bournemouth. He was due to host the event in Bournemouth but a council-owned adult education centre refused to allow him to use their premises and now his second venue, the Hermitage Hotel, has also cancelled.

He chose the Bournemouth because of its large number of elderly residents. It seems a natural presumption. People generally die when they are old. Therefore old people must be waiting to die. If they are waiting to die, the doctors are probably denying them permission to die. Therefore they need his help.

This line of reasoning simply demonstrates how little he knows about old people. In my experience, old people are just like young people; they want to go on living. Of course there are some for whom life has become very difficult, but it is amazing how simply they can be helped. Old people sometimes fear becoming a burden on their family, but most children love their parents and delight in helping them. Simple walking aids, shopping bags on wheels, devices for opening bottles make a lot of difference and the example of Stephen Hawking demonstrates that the more complicated electronic devices can overcome almost any disability.

Dementia presents special problems, but most of us go about handling it in the wrong way. Help is now available from organizations like SPECAL which teach an easy and useful way of dealing with the problems. An example that they quote came home to me very directly. A relative had to go into a nursing home. Whenever, her husband visited her she asked the same question, "When am I coming home?" To reply truthfully, "Never," would have distressed her unnecessarily, instead, "You going to stay overnight, tonight, I'll be here tomorrow," comforted her. By the next day she had no recollection of any assumption she would be going home that day.

Similarly when a widow asks where her husband is, there is no point in reminding her of his death (which would cause her to grieve every time she was told), simply suggesting that he's gone out for a break will satisfy her. The same insight is found in Oliver Sacks' book The Man Who Mistook His Wife for a Hat.

Unfortunately, a utilitarian approach has captured the public psyche. People are valued not for their humanity, but for what they can contribute. Organizations like NICE that put a cash value on a single life year (QALYs) have no humanity. If we allow our health services to be dominated by this world view, we will go to the devil.

Friday, October 10, 2008

Discipline in prayer

Mother Teresa had her nuns rising at 4-30 am for a cold-water bath before morning prayers. Some Bible Colleges have a strict rule of rising at 6am for a 'quiet-time'. Philip Yancey writes that for years he resisted a regular routine of prayer, believing that communication with God should be spontaneous and free.

We live in days of indiscipline. If you watch the TV program 'Supernanny' in which a professional nanny goes into the homes of naughty children you will invariably see homes where the parents exert no discipline over their children. It isn't a matter of smacking or not smacking; it is a question of having limits and routines. Students at university learn how to live lives of no boundaries. Party all night, slumber all day; not exactly good preparation for life in the office, classroom or hospital ward.

Yet we resist discipline. It seems somehow authoritarian. It reminds us of the Russian army or goose-stepping Germans. We want to be free.

This is particularly true of the post 1970s generation. Before then society valued self-denial; now it values self fulfilment. We were used to delayed gratification. If you wanted something, you saved up to buy it. Now you use a credit card. If we are expecting prayer to flourish in this atmosphere we will be disappointed. Prayer involves persevering through periods of darkness and dryness. It's results are difficult to measure. There's not much fun in putting a dollar away in a savings bank every day, but that's what we do when we learn to pray. Remember that Peter, James and John and the rest found Jesus' prayer methods perplexing. "Lord, teach us to pray," they asked.

Kingsley Amis, whose lifestyle I hardly think you should emulate, was at least disciplined about his writing. Every morning he would sit down with pencil and paper and write. If he had no ideas, he would still write. The very act of writing would generate ideas of what to write.

People who write prayer manuals either come from convents or monasteries where they live in communities organized for the purpose of praying, or they have servants (or wives) to relieve them of the daily chores. If you work 70 hours a week at the office, and then have to come home to shopping and housework it is a little more difficult to find time for prayer. If you try at the end of the day, a pound to a penny-whistle you fall asleep in the middle of it.

Yet we do learn to be disciplined about some things. How many people manage to catch all the episodes of their favorite TV program? Most people manage to clean their teeth every day. We mostly manage to get to work on time every day. Not many house(wives/husbands) forget to cook the dinner. We forget to pray because we don't think of it as important as going to work, watching television, cooking dinner or cleaning our teeth.

Jesus said, "A man ought always to pray." And that is the key. Do you find prayer difficult? Start to pray. Does it seem futile? Keep on praying. Do your struggle to be fluent in prayer? Pray some more. If you have ever learnt a new language you will know that you only become proficient by using it. Stumbling and hesitant you may be; you can only get better by practising. Whenever I don't no what to write on my blog, I start writing. I write anything, I might need to wipe it out ans start again, but the very act of writing carries me forward. So it is with prayer; the very act of praying will make you better at it.

Thursday, October 09, 2008

Struck off!

A warning for doctors who recommend alternative therapies appeared today in the records of the General Medical Council. A doctor had been a patient's GP until 1995, but when she transferred to another GP, she continued to advise her on alternative therapies. In 2004 the patient was admitted to hospital cardiomyopathy which was treated and the patient discharged on drugs. Two months later the doctor sent a message to the patient telling her to stop her digoxin and then a few days later e-mailed her telling her to stop all her heart medication and sent a further message advising homeopathic remedies and diet. Eight days later the patient was admitted to hospital and died. The cause of death was given as 'acute heart failure due to treatment discontinuation'.

In 2007 the GMC fitness to practice panel ordered that the doctor be suspended from the medical register for one year, and this year her situation was reconsidered. The doctor complained that she had done nothing wrong, and that given the chance she would do the same thing again. Accordingly the Panel erased her name from the Medical Register.

You are changing me

I have not abandoned my study of prayer, but for the past month events have consumed my time, and I had reached an impasse concerning the immutability of God.

“Prayer does not change God, but it changes him who prays,” said S├śren Kierkegaard. On the other hand, Karl Barth says, “He is not deaf, he listens; more than that, he acts. He does not act in the same way whether we pray of not.”

I will come back to the question, but today I want to explore the effect that prayer has on the prayer. Cicero says of pagan prayer, “We do not pray to Jupiter to make us good, but to give us material benefits.” For the Christian it is the other way round. By praying we allow God to change us. The more I pray, the more I see things God’s way.

Sometimes we are taken in by Biblical texts like “Ask and it shall be given unto you” and “You receive not because you ask not” as if God were a sugar-daddy who would spoil us with presents we didn’t really need. “A god who would grant every request of every man or every company of men would be an evil God – that is no God, but a demon,” said George MacDonald.

St Augustine said, “A person prays that he himself may be constructed, not that God may be instructed.” That is the key. Jacob the twister walked arrogantly on two good legs; Israel limped into history as the father of nations. Peter took a simple query about different types of food to the roof of the house, but climbed down after a lesson in legalism and racism. Paul prayed for healing and received humility. All prayer is answered; it’s just that the answer may not be the one we are expecting.

“We are God’s workmanship, created in Christ Jesus to do good works.” (Ephesians 2:10) ‘Workmanship’ is a poor translation of the Greek ‘poiema’ from which we get ‘poem’. Better to say we are God’s work of art. Prayer enables God to refine and remodel us so that we become (one hopes) God’s masterpiece.

Wednesday, October 08, 2008

Anne Boleyn

Anne Boleyn lost her head in the last episode of the second series of the Tudors. The series made her out to be a conniving, ambitious seductress who was vindictive and quite nasty. As a corrective I have been reading Women of the Reformation by Ellen O Clayton. The book is undated but feels Victorian. It gives a very different picture of Queen Anne. It agrees with the modern take that she was both beautiful and vivacious, but shows her as pious and loyal, and a leading figure in the introduction of reformed theology into England. Both versions find her innocent of the charges of adultery that Henry used to rid himself of her when his roving eye had strayed elsewhere.

What I had not realised was that her uncle was the Duke of Norfolk, still England's leading Roman Catholic. No wonder she invoked such anger from the Catholic party.

Monday, October 06, 2008

Aphorsims for this week

Communism, socialism, Keynesianism; so many ‘isms’ have become ‘wasms’.

Doctors become terrorists because death is too easy for them; it no longer hurts.

Blind to one’s own faults; vigilant for those of others.

If a man can’t find something it’s because he hasn’t looked hard enough; if a woman can’t find it, it’s because it isn’t there.

I like the tortoise; in order to get anywhere it has to stick its neck out.

Life is a sexually transmitted condition; universally fatal.

As I get older I learn never to pass by a bathroom – HRH the Duke of Edinburgh.

I have CDO; it’s like OCD but with the letters in alphabetical order. As they should be!

The ground is level at the foot of the cross.

Where can wisdom be found?”…“the deep says ‘it is not in me’; the sea says ‘it is not in me’. It cannot be bought with the finest gold, nor its price be weighed in silver. Job 28 v12 -15

If a penny becomes the apple of your eye it blots out the sun.

The devil has no difficulty in making sin look innocent.

There is no such thing as a little sin; for that to be true there would have to be a little God.

Payment God cannot twice demand
First at my Savior's bleeding hand
And then at mine.

Friday, October 03, 2008

There is a hope.

Everybody knows the story of Job. He was a wealthy man and everything had turned out right for him. He had a nice home, a nice wife, good kids and a successful business. He was devout. Then calamity upon calamity. He lost everything. His children were all killed. Finally he was attacked by a disgusting disease.

Everyone he knew reasoned that Job was responsible for his own woes. His friends reasoned that he must have done something terrible to be punished in this way. Of course, Job knew that this was not true, and when his wife suggested that he curse God and die, he refuses. But he is perplexed as to why God should treat him so.

Of course, he doesn't know what we know, that he is being allowed to be a test bed of Satan to demonstrate that his faith is true, but he demands that God tells him why this is all happening.

God answers him, but he doesn't give him an answer. He merely scoffs at Job's presumption. Who is Job to tell God how to run His universe? Finally Job is humbled. "My ears had heard of you but now my eyes have seen you. Therefore I despise myself and repent in dust and ashes."

In the end God blessed the latter part of Job's life more than he had the first.

I guess there must be plenty of people suffering at the present time. Bankruptcies and foreclosures are the order of the day. I am conscious that many of my readers have dread diseases. If not they themselves, then often a relative. Here a sister whose breast cancer has returned in her bones; here a wife with unresponsive lymphoma; here a father with bowel cancer; there will be friends who have been struck down with a brain hemorrhage, many who have lost their grip on the present as they wander down that dark tunnel called dementia. Others, who have not yet been diagnosed who are waiting for the results of tests, will be imagining the worst and be unable to sleep. The carers also suffer. How do you keep cheerful when all seems dismal and depressing?

For some it is not illness but unkindness. A lifetime partner who has left for a younger model. An angry silence pervading the home or workplace. The fat or skinny or lame or bald, who are the butts of everyone's jokes; I know it hurts.

Many will turn to the book of Job and complain that Job may have suffered but in the end he was given even more than he started with. They can see no way that their fortunes will be restored. "I have only death to look forward to; and that after a deal of torture."

But this is to mistake the meaning of Job. We must read the Old Testament through the spectacles of the New. Prosperity for us is not gold or dollars, new houses, smart furniture, jewelry and clothes from Armani. Today's financial shutdown must show us the hollowness of all that. Our riches and inheritance are in Christ and what he has purchased for us on the cross.

Stuart Townend says it in an unrivalled way.

THERE IS A HOPE that burns within my heart,
That gives me strength for every passing day;
A glimpse of glory now revealed in meagre part,
Yet drives all doubt away:
I stand in Christ, with sins forgiven;
And Christ in me, the hope of heaven!
My highest calling and my deepest joy,
To make His will my home.

There is a hope that lifts my weary head,
A consolation strong against despair,
That when the world has plunged me in its deepest pit,
I find the Saviour there!
Through present sufferings, future's fear,
He whispers 'courage' in my ear.
For I am safe in everlasting arms,
And they will lead me home.

There is a hope that stands the test of time,
That lifts my eyes beyond the beckoning grave,
To see the matchless beauty of a day divine
When I behold His face!
When sufferings cease and sorrows die,
And every longing satisfied.
Then joy unspeakable will flood my soul,
For I am truly home

Thursday, October 02, 2008

Merkel Cell Carcinoma

About one third of cases of Merkel cell carcinoma occur in patients with CLL. Although second cancers reputedly occur more commonly in patients with CLL, it is remarkably difficult to demonstrate the fact in epidemiological studies. It is only very obvious in tumors where the immune system plays a large part in the control of the tumor, like in melanoma or Kaposi's sarcoma. So the betting was always that Merkel cell carcinoma was one of those rare human tumors caused by a virus. Research published this year suggests that this guess was right.

Merkel Cell Carcinoma, also known as trabecular cancer, Apudoma of skin, or Small cell neuroepithelial tumor of the skin, is a rare and highly aggressive cancer where malignant cancer cells develop on or just beneath the skin and in hair follicles. This cancer is a type of neuroendocrine tumor, like small cell lung cancer. Once it has metastasized to the lymph nodes, the 5-year survival rate for a patient is about 50 percent. Small tumors (less than 2 cm) that have not metastasized to the lymph nodes have a 5-year survival rate of more than 90 percent, however.

It occurs most often on the face, head, and neck. It usually appears as firm, painless nodules. These flesh-colored, red, or blue tumors vary in size from 5 mm (less than a quarter of an inch) to more than 5cm (2 inches). The tumor grows rapidly. About half of all Merkel cell cancers occur on the sun-exposed areas of the head and neck, while one-third begin on the legs, and 15% occur on the arms. The cancer may also begin on other parts of the body, such as the trunk.

From initial onset, Merkel cell cancer metastasizes quickly and spreads to other parts of the body, tending towards the regional lymph nodes. The tumor tends to invade underlying subcutaneous fat, fascia, and muscle. It can also metastasize to the liver, lungs, brain or bones.

This type of cancer occurs mostly in white Caucasians between 60 and 80 years of age. It occurs about twice as often in males as in females. There are roughly 1200 new cases diagnosed a year in the United States, compared to 60,000 new cases of melanoma and over 1 million new cases of nonmelanoma skin cancer. Merkel cell cancer can be mistaken for another cancer like basal cell carcinoma, squamous cell carcinoma, malignant melanoma, lymphoma, or small cell carcinoma, or may appear to be a benign cyst. Researchers believe that exposure to sunlight or ultraviolet light may increase a person’s risk of this disease.

Immune suppression can profoundly increase one's risk of developing Merkel cell cancer. Merkel cell carcinoma occurs 13.4 times more often in people with advanced HIV as compared to the general population. Solid organ transplant recipients have similarly increased risk and so do those taking immunosuppressive drugs such as fludarabine and Campath.

A newly discovered virus called Merkel cell polyomavirus (MCV) is suspected to contribute to the development of the majority of MCC. Approximately 80% of MCC tumors have this virus integrated in a monoclonal pattern, indicating that the infection was present in a precursor cell before it became cancerous. Polyomaviruses have been known to be cancer viruses in animals since the 1950s, but this is the first polyomavirus strongly suspected to cause tumors in humans. Like other tumor viruses, most people who are infected with MCV probably do not develop MCC; it is unknown what other steps are required for the development of MCC. Ultraviolet light (sun) exposure probably contributes to MCC development in a large number of cases. MCC also occurs more frequently than expected among immunosuppressed patients, such as transplant patients, AIDS patients, those on immunosuppressive drugs and the very old.

Surgery is the usual treatment for Merkel cell cancer. The tumor is removed along with a border of healthy tissue surrounding it. Nearby, or regional, lymph nodes are often removed because they may contain cancer cells. Sometimes the doctor performs a sentinel lymph node biopsy. In this procedure, the doctor injects a dye or radioactive substance near the tumor. This material flows into the first lymph nodes where cancer is likely to spread (the sentinel nodes). These nodes are then removed and checked for cancer cells. This procedure has been demonstrated to be an important prognostic indicator. Results help dictate the use of appropriate adjuvant therapy, if necessary.

Adjuvant radiotherapy has been shown to be effective in reducing recurrence and increasing five year survival of patients with Merkel Cell Carcinoma. Patients who present with no metastases and a negative sentinel lymph node biopsy have a good prognosis when treated with surgery and radiotherapy - approximately 90% survival at five years.

Merkel cell cancer that has metastasized may respond to treatment with chemotherapy and/or radiation. This therapy usually does not cure the disease, but can be effective in shrinking the tumor if the tumor is too large to be removed, or is located in a place where removal would be difficult or dangerous.

For those who would be soft on Iran

This from the Barnabas Fund: On 9 September the Iranian Parliament gave provisional approval, by a majority of 196 to seven, to a bill that mandates the death penalty for any male Muslim who converts to another faith. Until now Iranian judges could impose the death penalty in such cases only on the basis of Islamic law and fatwas, not on the basis of Iranian law. The bill prescribes lifelong imprisonment for female converts from Islam.

The bill also gives the Iranian secular courts authority to convict Iranians living outside the country of crimes relating to Iranian national security. It seems likely that this could be used against the many Iranian Christians who live outside Iran but are involved in evangelism within it.

There is still opportunity for MPs to amend the bill before it becomes law. It must also be vetted by the Council of Guardians for conformity to Islamic law and the constitution.

The progress of the bill coincides with the formal charging of two Christian converts from Islam, Arash Basirat and Mahmood Matin-Azad, with apostasy. Some Iranian Christians fear that the authorities are seeking to make an example of the two Christians, so giving the prospective law a “test run”.

Arash and Mahmood, who had only recently converted from Islam, were arrested in a park in Shiraz on 15 May (see PFU June & July) and have been in detention since then. They were subjected to two months’ solitary confinement and to lengthy and inhumane interrogations. Attempts by their families to have the two men released on bail were refused by the authorities. Family members are especially concerned about Arash’s health as he is suffering from diabetes.