Friday, February 26, 2010

Stafford and the NHS

It is an old story, but it has been given new prominence by the Francis Report into what went on at the Stafford Hospital.

In a report by the Healthcare Commission last March, Sir Ian Kennedy, the commission's chairman, said, "There is no doubt that patients will have suffered and some of them will have died as a result. The investigation found there were too few doctors and nurses, vital equipment was not available when needed, patients did not receive the care they deserved and the trust had no system in place to spot when things were going wrong."

Among the most serious failings were filthy wards, with blood and excrement encrusted on surfaces; nurses with inadequate training were unable to operate cardiac monitors or intravenous pumps, which meant patients were not receiving the correct medication or the right dose of fluids.

Furthermore patients were "dumped" for hours and even days at a time in smaller units without a dedicated nurse to care for them. There were too few consultants in A&E to provide adequate cover and often there was no experienced surgeon in the hospital after 9pm.

Appalling standards of care put many patients at risk, and between 400 and 1,200 more people died than would have been expected in a three-year period from 2005 to 2008, the commission found.

The Commission stated: "An analysis of the trust's board meetings from April 2005 to 2008 found discussions were dominated by finance, target and achieving foundation trust status.

"There is little evidence that poor standards of nursing care were identified and discussed. The investigation found that poor results of surveys of patients or staff were not discussed in public. It found that a doubling of C. difficile infection in the early months of 2006 was not released to the board nor the public."

Inquiry chairman, Robert Francis QC, made 18 recommendations for both the trust and the government in his final report after hearing evidence from more than 900 patients and families. Mr Francis also identified a chronic shortage of staff, particularly nurses, as being largely responsible for the sub-standard care give to patients. He also said that while many staff did their best in difficult circumstances, others showed a disturbing lack of compassion to patients.

Requests for assistance to use a bedpan or to get to and from the toilet were not responded to. "Patients were often left on commodes or in the toilet for far too long. They were also often left in sheets soiled with urine and feces for considerable periods of time, which was especially distressing for those whose incontinence was caused by Clostridium difficile. Considerable suffering, distress and embarrassment were caused to patients as a result. The inquiry also found that the attitude of some nurses "left much to be desired". It added: "Some families felt obliged or were left to take soiled sheets home to wash or to change beds when this should have been undertaken by the hospital and its staff. Some staff were dismissive of the needs of patients and their families."

It seems that the management of the hospital were more concerned with meeting government financial targets than caring for patients. Managers made nurses redundant to save money, but wasted over a million pounds in redundancy payments. At the same time they awarded themselves huge bonuses. The report can be viewed here.

How far should the disgraceful behavior at Stafford be seen as typical of the NHS? Is this what you get with 'socialized medicine'?

By definition this was not typical. Stafford was picked up because it was an outlier - by far the worst hospital in Britain. It is no more typical of the NHS than Harold Shipman was of GPs.

However, it does expose a risk when there is a monopoly provider in a particular area and the rigors of competition are removed. Where there is a state monopoly, institutions become too big to fail. Too big to fail is also a problem with other huge employers - take General Motors, Chryslers, and the Royal Bank of Scotland for example. To my mind it is a mistake to prop up failing enterprises. We must learn to manage failure. When a big company fails there will always be someone who can step in and buy what is valuable about the business - just as Barclays did with Lehman Bros. If there is a need for a service, a business will step in and fill it. When the British-owned car industry collapsed, the country didn't get out its bicycles; Nissan, Toyota and Honda stepped in and built factories. BMW, VW and Peugeot all stepped in and bought the profitable bits.

Although Stafford was the worst hospital in the NHS its problems were indicative of what can happen when government gets involved in healthcare. Because the taxpayer is footing the bill, there is a constant drive to cut down costs without concern for the individual circumstances of an area. Do you have more old people than normal? Your costs will be higher. Are house prices high in your area? You will have to pay more for adequate staff.

But we shouldn't lose sight of what is good about the NHS. Contrary to what people assume, there is a thriving insurance based system in the UK. But only 20% of the population chose to join it because the taxpayer-funded system is good enough for them. You might think it's because they don't want to pay twice, but in the US people pay twice: once in their taxes for Medicare, Medicaid, VA hospitals, the NIH, and County hospital ERs; and once for their insurance. And the proportion of the GDP spent on provided for government run services is much higher than the proportion of the (much smaller) British GDP spent on the NHS.

Monday, February 22, 2010

The anemia of chronic disorders

Although iron deficiency anemia can be easily recognized by a low hemoglobin and a low MCV, there are other causes of this picture and other tests for confirming iron deficiency. Looking at a stained blood film reveals red blood cells that are paler than usual. They are paler because they are thinner and thin cells let more light through. You can also measure the amount of iron in the blood: the serum iron level. Iron is carried in the blood on a carrier protein known as transferrin. Normally, the whole body plasma transferrin contains about 3mg of iron and it functions as a transit compartment. About 20mg of iron flows through it in a normal day. In iron deficiency there is spare carrying capacity and the serum transferrin is raised. Elsewhere in the body iron is bound to a storage protein called ferritin, so in iron deficiency the serum ferritin level is low. Finally, you can normally see bits of iron in macrophages in the bone marrow (they stain blue with a special stain called Perl’s stain). In iron deficiency the macrophages are empty.

However, in some apparent iron deficient anemias, although the serum iron is low the transferrin is also low and the ferritin high and there is plenty of stainable iron in the bone marrow macrophages. The red cells on the blood film are still pale and indeed the blood film is indistinguishable from any other case of iron deficiency. These cases often have chronic inflammatory conditions like rheumatoid arthritis, ulcerative colitis or Crohn’s disease, or chronic infections like TB or perhaps certain types of cancer. Sometimes the condition comes on very quickly, especially in severe acute infections. We call these anemias, the anemias of chronic disorders or sometimes the anemias of inflammation. We used to say that something was preventing the release of iron from the macrophages. We now know what that ‘something’ is, and as we might have expected it is more complicated than that.

The ‘something’ is now known to be Hepcidin (pronounced ‘hep – side – in’; ‘hep’ comes from the Greek for liver – ‘hepar’; ‘sidero’ is the Greek for iron). Hepcidin is a small peptide consisting of 25 amino-acids. As you might expect from its name, it is made mainly in the liver, though it can be made by both granulocytes and macrophages. A knockout mouse has been produced that lacks hepcidin and from studying this we know that hepcidin controls intestinal iron uptake and the retention of iron in macrophages. If you inject hepcidin it produces a 75% reduction of serum iron levels within an hour and the effect persists for two days. A diet laden with iron produces an increase in the production of hepcidin, and anemia or a shortage of oxygen reduces hepcidin production.

During inflammation, inflammatory cytokines are produced and one of the most important of these is interleukin-6 (IL-6) which is an important inducer of hepcidin production. Other cytokines including IL-1 and TGF-beta are also involved in hepcidin regulation.

There are several mechanisms for the absorption of iron from the diet. Dietary iron is either in the ferric form (Fe+++) or as heme (myoglobin, the respiratory pigment of muscle [otherwise known as meat] contains heme). Fe+++ must be reduced to the ferrous form (Fe++) for absorption and this is done with a ferric reductase enzyme. Fe++ is absorbed using DMT1 (a silly name that just stands for divalent metal transporter 1) and heme absorption uses the equally obviously named heme carrier protein 1 (HCP1). Both these mechanisms only take the iron as far as the lining cells (or enterocytes) of the duodenum. From here they have to pass into the plasma and thence to macrophages in the bone marrow and elsewhere for the manufacture of hemoglobin, myoglobin and other iron-dependent proteins. The protein responsible for getting iron out of cells into the plasma is called ferroportin (Latin this time meaning iron-door). Ferroportin is equally important for enterocytes and macrophages. Without it iron would be stuck in the enterocytes and lost when they migrate up the duodenal villi and are shed into the intestinal lumen, and iron that had entered the macrophages would be trapped there and never get to the developing red blood cells.

Hepcidin binds to ferroportin in the cell membrane and causes it to be internalized and degraded (to put it another way, hepcidin locks the iron door). So hepcidin acts as a regulator of iron absorption and usage. In anemia, when there is a shortage of iron, or when the patient is short of oxygen, hepcidin production is suppressed so that more iron is absorbed and more iron is released from macrophages. Of course, if the anemia is not caused by a shortage of iron there can be inappropriately increased absorption of iron and this occurs in some types of thalassaemia.

Hepcidin is produced when iron absorption is sufficient, when there is no anemia or hypoxia, so as to stop excessive iron absorption. Hepcidin is also produced in response to some inflammatory cytokines, particularly IL-6; hence in the anemia of chronic disorders iron gets trapped in macrophages and not released to the developing red cells. Thus in the anemia of chronic disorders, because the iron-door is bolted, the anemia has the appearance of iron deficiency.

Added later. I need to say that there is no point in trying to treat the anemia of chronic disorders with either oral or intravenous iron. It just won't work.

Wednesday, February 17, 2010


There has been a recent report of Progressive Multifocal Leukoencephalopathy (PML) in three patients with CLL treated with rituximab, and this has aroused some alarm in patients. The paper by D'Souza et al at the William Beaumont Hospital, Royal Oak Michigan has been published electronically in the journal Clinical Lymphoma, Myeloma & Leukemia Volume 10 pp E1 to E9.

PML is a disease of the nervous system caused by a virus named after John Cunningham (the JC virus) which most people contract in early life but which lays dormant controlled by the immune system for the rest of their lives. It is reactivated when the immune system fails and spreads to the brain where it infects oligodendrocytes and to a lesser extent astrocytes. There is a failure to make myelin, the insulating material around nerve cells, leading to confusion, disorientation, personality changes, loss of speech and balance, dementia and death. There is no effective treatment.

Although the three patients reported had all been treated with rituximab, they were all severely immunosuppressed from other treatments: the first with long term chlorambucil and then fludarabine, the second with fludarabine and cyclophosphamide and the third with chlorambucil, fludarabine, alemtuzumab, pentastatin and cyclophosphamide. They had had CLL for respectively 3 years, 8 years and 9 years.

Although PML is most commonly associated these days with AIDS, where it occurs in between 3-5% of patients, it was originally recognized in hematologic cancers including CLL. Immunity to the JC virus resides in the T cells rather than antibody, and the T-cell depletion seen in CLL patients treated with fludarabine or Campath is comparable with that seen in AIDS.

In Bournemouth, despite seeing close to 1000 patients with CLL we have not seen PML. This contrasts strongly with Royal Oak, Michigan where these three cases were among only 45 cases of CLL seen by them. I don't think we are missing the diagnosis.

Inpatients who have transplants it is much more common to reactivate other dormant viruses like Herpes Zoster, CMV and EBV, but PML does occur. In CLL it is often unrecognized how immunodeficient patients who have longstanding CLL plus multiple treatments can be. It is this group who are most likely to succumb to PML. Patients who receive rituximab alone or as part of FCR first line are most unlikely to reactivate JC.

Tuesday, February 16, 2010

New baby!

One of the reasons that I have been relatively silent over the past few weeks is that we have been waiting for our 6th grandchild. And here she is. Abygael Katherine Johnson. She was born on Sunday at 5 am to our daughter Karen. A sister to Alex, Hannah and Ben.

We were able to spend the day with them yesterday. It was also my first ever visit to a Burger King. We took Alex and Hannah for a meal to give Karen and Tim some time alone with the baby.
Here is Hannah holding the baby and finally a picture of Alex not holding the baby!

Saturday, February 13, 2010

The Law of Christ; walking the walk.

A pretty blogless week, it seems, though in truth, the last article, although started on Monday, took me most of the week to complete. It was based on one of Christ Kelly's sermons and I have also been thinking about the evening sermon on the same day. How it is possible to produce two such excellent sermons on one day is beyond me.

The question, which arises from the Sermon on the Mount, was what is Jesus' attitude to the law?

Whenever, a Christian brings up any practice that is clearly condemned in the Old Testament, he is likely to be criticised because he doesn't keep all the Old Testament laws. Have you made your wave offering for today? Do you avoid bacon sandwiches? Did you know that you shouldn't eat rabbit?

Some people wriggle round it by claiming that there are different kinds of law in the Old Testament: Ceremonial Law, Theocratic Law (laws pertaining to a state that is ruled by God - a Theocracy), and absolute Law (as manifested by the Ten Commandments). Only the latter is applicable today. But if that were true we should spend from sundown on Friday until sundown on Saturday as a Sabbath - with all the attendant rules that Jesus and his followers considered breakable.

We have to remember that Jesus didn't have the New Testament; the Old Testament was his Bible.

In the Sermon on the Mount, Jesus tells us, "Do not think that I have come to abolish the Law or the Prophets; I have not come to abolish them but to fulfill them. I tell you the truth, until heaven and earth disappear, not the smallest letter, nor the least stroke of a pen, will by any means disappear from the Law until everything is accomplished."

How did he mean to fulfill them?

The problem in the world is not, at its heart, failing to keep the law, but what the Bible calls sin. It is the corruption in the center of the soul that rebels against the Creator. It is illustrated in the Bible by the story of Adam in the Garden of Eden. Despite being given all he could require, he insisted on choosing the one thing that was forbidden him. It was Adam's rebellion that undid the world and brought a curse upon it. As the Apostle Paul writes in Roman 5:12 as a result of Adam's sin, "Death came to all men" . This was before the Law had been given to Moses. In verse 13 Paul writes, "Before the Law was given, sin was in the world." And in verse 20, "The Law was added so that the trespass might increase."

That sounds strange. Why should God want trespass to increase? It sounds like the current government's policy of introducing more laws so that it can fund the budget deficit by collecting more fines. No, the Law is there to reveal the sin. If it's just the Ten Commandments, you could probably make a fair stab at keeping them as written. Don't steal, don't murder, don't commit adultery, don't commit perjury, don't covet, look after your parents - any decent person could feel that he could go along with that. Don't swear, get rid of your graven images, keep Sunday special, and only have one God -
(Thou shalt have one god only, who
Would be at the expense of two?
wrote Arthur Hugh Clough).

Later on in the Sermon on the Mount, Jesus goes on to expand on what it means not to murder and not to commit adultery, but the Pharisees had already made the same point about Sabbath keeping. Jesus seems to endorse the attitude of the Pharisees (who were a sect of ultra-religious Jews who were assiduous about every detail of the Law - they even took a tenth of the weeds growing in their gardens to give to the Temple). "I tell you that unless your righteousness surpasses that of the Pharisees and the teachers of the law, you will certainly not enter the kingdom of heaven."

What Jesus is saying is that it is impossible to be right with God simply by keeping the Law. The Pharisees had a jolly good shot at it, but even they fell short. I remember speaking at an old people's home and trying to make this point. To be good enough for heaven you have to make 100% in everything you do. Perfection is required. An old guy from the back of the room shouted out, "According to you, there will be nobody in heaven."

Exactly! He had it quite right. If we rely on ourselves there will be no-one in heaven.

The Law establishes that we cannot be good enough for God; we must throw ourselves upon his mercy.

The Ten Commandments were known to the Jews as the Decalogue or ten words. John's gospel tells us that the word became flesh.

In 1 Corinthians chapter 6 Paul tells us not to be deceived. "Neither the sexually immoral, not idolaters, nor adulterers, not male prostitutes, nor homosexual offenders, nor swindlers will inherit the kingdom of God." He goes on, "And that is what some of you were." He is writing to the Church of God at Corinth, people he says who have been called to be holy. How can they be holy if they were sinners? Is it just a matter of turning over a new leaf? What about all past sins?

The Bible tells us that Jesus dealt with all sins, past, present and future, on the cross. He who knew no sin became sin for us. The punishment that was due to us was inflicted upon him. Paul goes on, "You were washed, you were sanctified, you were justified in the name of the Lord Jesus Christ and by the Spirit of our God." When we can accept this, his Holy Spirit comes on board and guides us into all righteousness. We are no longer under Law but under Grace.

Does that mean we can do as we please? If future sins are forgiven dies it matter that we sin again and again? Paul deals with this question in Romans chapter 6. "Shall we go on sinning so that grace may increase?" He answers his own question. "By no means! We died to sin." and again, "Sin shall not be your master, because you are not under law but under grace."

Imagine yourself as a footballer contracted to Cloggers United. Your manager is one of the old school, so you are taught how to tug shirts, to tread on the striker's toes in the penalty area so he can't jump, to handle the ball behind the referee's back, to surreptitiously lean on your opponent and to dive flamboyantly at the slightest touch. Cloggers United score few goals themselves, but they are very good at stopping even the most talented teams from playing well. You find the whole set-up dismal, but there seems no hope for getting out of it. Then one day a bright new manager comes and buys you. You are transferred to Flair City. The watchword here is run, pass, move into space, pass again and score. You find the new manager's attitudes invigorating. This is football as it is meant to be played. Why would you want to go back to clogging? With this new flair you are top of the table. How could you ever choose mediocre again?

It is certainly true that we are not under the Law. In fact if we were not converted from Judaism, there was never a time when we were under the Law. At least not that law which was given to Moses so that the chosen people might recognize what sin was. But Paul in seeing that the Mosaic Law no longer applied cried out in 1 Corinthians 6:12, "Everything is permissible for me", but then he qualifies it, "but not everything is beneficial."

Although no longer bound by the Law, when dealing with Jews he voluntarily submits to it. Similarly, because he is intent on winning as many as possible for the Lord, when dealing with those not having the Law, he puts himself in the same position. He then makes this subtle distinction in 1 Corinthians 10:21, "Though I am not free from God's law but am under Christ's law."

What is Christ's law? Jesus gave us many commandments including new ones that we love one another and that we go into all the world and preach the gospel making disciples of all nations, but evil is still evil.

People today have a warped view of Jesus. Because he is a forgiving God he is taken as a soft touch. Paul is seen as a sort of corrupter of the faith, a bitter old bigot who brought in repressive doctrines that Jesus would never have assented to. They assume that to forgive is to condone. Such nonsense proceeds from ignorance, of course, but listen to Jesus on what evil is, "What comes out of a man is what makes him 'unclean'. For from within, out of men's hearts, come evil thoughts, sexual immorality, theft, murder, adultery, greed, malice, deceit, lewdness, envy, slander, arrogance and folly. All these evils come from inside and make a man 'unclean'."Mark 7:20-23.

The law of Christ is not a 'softer' law than the law of God; it is not more permissive. The grace of Jesus Christ brings forgiveness for the sin that law exposes, but when freed from the law and its punishment keeping close to Christ means living the life he modeled for us. We must walk the walk as well as talking the talk.

Monday, February 08, 2010

Christ at the center: 1 Peter 3:14-15

Who is going to harm you if you are eager to do good? But even if you should suffer for what is right, you are blessed. "Do not fear what they fear; do not be frightened." But in your hearts set apart Christ as Lord.

Kevin Davies, center forward for Bolton Wanderers, scored a perfectly good goal on Saturday, but the referee, Mark Clattenberg, disallowed it for pushing. TV replays showed no push. Davies is quoted in this morning's newspapers as saying that this referee has had it in for him for a long time. He knew when he saw who the referee was that he wouldn't be treated fairly. Davies is a tall player. In another newspaper this morning there is a report of a study which demonstrates that whenever players clash on a soccer field, the taller of the two is more likely to be given the blame. It's not fair!

I have been reading a book on scientific fraud. The author was drawn to the subject by the case of Margot O'Toole. She had been working in the laboratory of Thereza Imanishi-Kara and uncovered evidence of fabrication of data. Quite properly she blew the whistle. Unfortunately for Margot, one of Imanishi-Kara's collaborators was the eminent scientist and Nobel Prize winner, David Baltimore, who would not review the evidence but insisted that Imanishi-Kara's work was genuine. Despite what, to my mind, is convincing evidence of fraud, it was the whistleblower who came off worst. She was unable to get another job in science and had to find work in a call center. It's not fair!

When Elvis Presley was getting past his prime, with corpulence setting in, he entered a provincial Elvis Presley look-alike competition. He did quite well. He came third. It's not fair!

Life is like that. It is only in fairy tales that everything is fair and everybody lives happily ever after. That's why they are called fair-y tales.

For Christians things are worse. Not only do we face the sea of troubles that flesh is heir to, but we face opposition. Jesus predicted as much. We are in a spiritual battle; Satan is our enemy. People have the wrong idea about this, looking for all sorts of weird happenings. Satan is more subtle than that. In Luke 22:3 we read that Satan entered Judas. What was the result? Did his eyes turn red and his face turn green? Did smoke come out if his ears? Was there ominous music or flashing lights? No, he just went to the Chief Priests and offered to betray Jesus. When we face Satanic opposition it comes from ordinary looking people, who may not even know that they are doing the Devil's work.

I sometimes post extracts from the newsletter of the Barnabas Fund, the latest of which reminds us of the plight of Christian villagers in Burma. The Burmese army attacked on 17 and 18 January 2010. Eleven villages in Nyaunglebin District were attacked and villagers ran for their lives. When some people later returned to one village to retrieve some of their belongings, two men were shot and killed, including Saw Mya Kaw Htoo who leaves a wife and six children. If you search the archives on this site you will find countless instances of physical persecution of Christians. And the way things are moving in the West, the time cannot be far away when Christian pastors are arrested for preaching from certain passages in the Bible.

But despite this opposition, this passage reminds us that we are blessed. Even if you should suffer for what is right, you are blessed.

In Europe and much of America we suffer from light pollution. There are children in many of our cities who have never seen very many stars - the glare from our streetlights has hidden them. Go to Africa and there are millions of stars in the sky - each one representing a fiery ball of unimaginable heat and light. Our local 'blessing' of light at night has hidden the pomp and power of real light from our eyes. In a similar way we suffer from spiritual light pollution. We have many blessings in our lives. I live in a warm house. During that spell of snowy weather, I was tucked up warm inside. I never go hungry. We don't even get power cuts now; always I have electricity at the flip of a switch. I can travel anywhere I please - I have my own personal automobile; my wife has one too. I can communicate with whomever I please, by telephone, by e-mail or by reliable postal service. The shops stock anything I could desire. I have fresh and pure water on tap. I have hundreds of television channels I can watch. I have the Internet. Truly I am greatly blessed.

Some friends have just returned from a village in Malawi. The people there have no electricity. They have no fresh water or sewerage system. They have a truck, but no diesel to power it. No mobile phone, no computer, no air-conditioning, not even an electric fan; their entertainment is what they can sing to each other. For them, in their darkness, the news that one day they will go to heaven because God loves them and has given his only son for them stands out like the myriad stars against the black African sky. For us such good news is dimmed against the prospect of getting a Wii for Christmas.

Black clouds sometimes envelope us. In the past couple of years we have suffered attack after attack. Bereavements, family illness, accidents, all culminating with the news that I had cancer. Then I had to withstand months of chemotherapy. My circumstances are not unusual. I know what it is like to suffer, but so do most of my readers. But despite the black clouds we are still blessed.

Have you ever been in an airplane taking off through black clouds? By the time we reach our cruising altitude the clouds are gone and the sun is shining. In truth, the sun had never stopped shining; black clouds had hid it from view. In just the same way God never stops loving us. He doesn't go through phases when first he loves us then he punishes us. Even though he allows us to be tested by the harshest circumstances, he never stops loving us. "He comforts us in all our troubles," writes Paul. "Just as the sufferings of Christ flow over into our lives, so also in Christ our comfort overflows."

In one of Helen Roseveare's books she describes a vision she had of Jesus. Helen was a missionary who was brutally beaten and raped in the Congo during the Simba uprising in 1964. She tells us how in her vision Jesus told her that he had need of her body to suffer in. Now this must not be taken too specifically; the sufferings on the cross were complete and sufficient to atone for all our sins; but this is a reference to Philippians 3:10 I want to know Christ and the power of his resurrection and the fellowship of sharing in his sufferings, becoming like him in his death.

This is how she put it: "When I called you to myself, I called you to the fellowship of my sufferings. They are not attacking you, they are attacking me. I'm just using your body to show myself to the people around you."

It was not only Christian missionaries who were raped and beaten in the Simba uprising. Thousands suffered, but Christians were especially blessed. Why? Because with suffering for Christ comes the comfort of Christ. 2 Corinthians 1:5 puts it this way: For just as the sufferings of Christ flow over into our lives, so also through Christ our comfort overflows. Many of those who were rescued in Haiti came out from the rubble singing and praising God. What despair there was for those with no hope!

When bad things happen it is easy to become overwhelmed by fear. When I learned of my diagnosis I was very afraid. In the immediate post-operative period I was in a lot of pain. It was worst in the middle of the night. In my panic the Lord sent me a text. "Thou wilt keep him in perfect peace, whose mind is stayed on thee: because he trusteth in thee". Strange how the memory still retains the KJV after more than 20 years of using the NIV. As I repeated the verse to myself I relaxed and drifted off to sleep again.

Fear paralyses us. It's like being a rabbit caught in the headlights; we freeze. But rather than letting fear reign in our heart we must set Christ at the center; In your hearts set apart Christ as Lord.

When Peter denied Jesus fear of being detected took hold of him. He followed at a distance. He crept into the courtyard to hear the proceedings but denied he was a follower of Jesus for fear of being caught. When he was challenged, he denied Jesus with curses and swearing. Then Jesus looked at him and he went outside and wept bitter tears. Fear had consumed Peter, but Jesus had restored him. By the sea of Galilee he had the opportunity to replace fear in his heart with Jesus Christ. Perfect love casts out fear.

When Helen Roseveare was preparing to become a missionary, the missionary society sent her Foxe's Book of Martyrs to read. She sent it back, thinking that such excesses had nothing to do with modern missionary work. She was a doctor who was going to bring modern medicine to the poor blacks of Africa.

Later as a captive of those 'poor blacks' she says, "As I anticipated the suffering in my imagination and thought of what those cruel soldiers would do next, I quivered with fear... But when the moment came for action He filled me with a peace and an assurance about what to say or do that amazed me and often defeated the immediate attack of the enemy."

It is not only fear that claim our hearts. Riches, pleasure, family, success, peace and quiet, and even our Christian duties can take pride of place; can usurp the place of Christ. But Jesus is not only our creator, he is our savior. He has bought us with a price. Everything must be subservient to him.

Sunday, February 07, 2010

Anemia with small red cells.

I prefer to classify anemias according to the size of the red blood cells and for this reason I regard the mean cell volume (MCV) as the most important of the red cell indices. An MCV of less than 80 fl indicates a microcytic anemia.

Since red cell consists of mainly hemoglobin, a microcytic anemia occurs when the body can't make enough hemoglobin. Either it can't make globin or it can't make heme. Inability to make globin is almost always a congenital condition, and collectively these are known as the thalassemias. I shall write about these on another day.

The rate-limiting step in heme production is the availability of iron.

We need to obtain iron from our diet because we are constantly losing it. Everybody loses about 0.5 mg a day, mainly from bowel cells shed in the motions, though shed skin cells are also involved. Women lose on average 0.5 mg a day from menstruation (equivalent to 80ml of blood loss a month). Therefore women need about twice as much iron every day in their diet as men. During pregnancy the average extra requirement is about another 1mg spread out over the whole 9 months, though at certain times they need as much as 6mg a day. The extra iron is required to provide for the baby's blood and muscle, the extra blood in the mother's circulation and the increased muscle in the uterus.

In the diet, iron is available in a usable form in sufficient quantities, only in meat. There is iron in vegetables but in such small quantities and so poorly absorbed that it can be discounted. This is particularly true of spinach. I will write that in capitals. SPINACH IS A VERY POOR SOURCE OF IRON. A German chemist put the decimal point in the wrong place when making the calculation.

Although dietary iron deficiency is common in developing countries, it is almost unknown in the West, except in vegetarian women. Iron deficiency is almost always caused by bleeding. I used to call it iron loss anemia rather than iron deficiency anemia.

The commonest cause of excessive iron loss is menorrhagia, but it is difficult to assess. It is not something women compare notes on. Most women think they have normal periods, but a Swedish gynecologist who investigated exactly how much women who thought their periods were normal actually lost per month, found it varied tenfold, from 50 ml to 500 ml, and the person who thought 500 ml was normal was the Swedish gynecologist herself.

The most important source of bleeding is the gastro-intestinal tract. Often overlooked is aspirin. It always causes some bleeding from the stomach. It may be as little as 0.2 ml per tablet or as much as 2 ml per tablet. Occasionally it is responsible for a torrential hemorrhage. Acetaminophen (paracetamol) does not do this, but ibuprofen does.

Peptic ulcer in stomach or duodenum is less common than it used to be because it is now recognized to be a treatable infection. From the large bowel, we are most concerned about colorectal cancer. In people over 60, iron deficiency is caused by occult bleeding from colorectal cancer in 18% of cases. Therefore if no obvious cause of bleeding is apparent, a person with iron deficiency should be investigated by both upper GI endoscopy and colonoscopy. Colonic diverticulae may cause acute bleeds but they are not the cause of chronic blood loss. Angiodysplasia, abnormal blood vessels, in the large bowel can be the source of bleeding, but in my experience this is only the case when there is an associated clotting disorder.

If no obvious source of bleeding is found there are some techniques to employ to look harder. The urine should be examined for blood and iron. Hematruria from bladder or kidney cancer is important to identify, but in some hemolytic anemias iron, rather than blood, is lost from the kidneys. Blood coagulation should be tested. Bleeding disorders such as mild hemophilia or Von Willebrand's disease may be the cause. Sometimes the bleeding is from the small bowel, which cannot be reached by either gastroscope or colonoscope. Special techniques are required for these.

Does malabsorption of iron occur? People with celiac disease malabsorb fats and other vital dietary elements. What about iron? Some people think that they also malabsorb iron, but for me the evidence favors increased loss of iron-laded bowel cells. In celiac disease they are shed 7 times more rapidly. In past-gastrectomy syndromes they may be shed five times as fast as normal and 50% of those who have had a gastrectomy become iron deficient.

There are still a large number of people who have apparent iron deficiency in whom no cause will be found. Some of them have plenty of iron in their body; it's just that they cannot use it. Collectively these are known as the anemias of chronic disorders, and I shall write about these next.

Saturday, February 06, 2010

Scientific Fraud

It is nearly thirty years ago that I wrote a piece for the Christmas edition of the British Medical Journal, entitled Fake! In it I detailed some well known fakes, frauds and mistakes made by scientists and doctors. Among them were the misconception that spinach was a good source of iron (a German chemist put the decimal point in the wrong place), the Piltdown fraud (and there are many others concerning ape-men) and Gregor Mendel's statistics (they were too perfect - he must have fiddled them).

At that time there had been a rash of scientific frauds, particularly from the North Eastern states of the USA, that had hit the headlines. The whole paper is available on line so I won't list them. The most remarkable concerned a Jordanian (or perhaps Iraqi) research fellow, called Elias A K Alsabti, who had plagiarized 63 papers. He made use of the fact that many scientific articles are hardly ever read. (I have to confess that of more than 700 articles that I have written, more than 100 have never been cited - though many of them like book reviews and polemical pieces were not written to be cited.) Alsabti used to raid his boss's filing cabinet at night and photocopy articles that had been sent for review. A new title and new authors, and it was apparently a new article, ready to be sent to an obscure journal. The amazing thing was that he went on for so long without being caught.

But the fraud that I want to draw attention to was that committed by Sir Cyril Burt. Burt was the doyen of educational psychologists. He was editor of a major psychology journal and an advisor to the British government. He believed that intelligence was inherited and set about to prove it. He reported on pairs of identical twins separated at birth by being adopted by families of different social class. He tested their IQs and demonstrated that they were virtually identical despite one being brought up by, say, a factory worker and the other by, say, an academic.

His conclusion encouraged the government to design an examination at the age of 11 which would segregate children into those who would benefit from an academic education and those who would not. Since intelligence was genetically determined there would be no need for multiple tests at different ages. In America his work was cited by those who believed that intelligence was racially determined.

Years later, a psychologist called Leo Kamin, a man of the Left who had different prejudices, investigated Burt's work. What he found was astonishing. At different stages Burt had reported on 21, more than 30, and 53 pairs of identical twins raised apart, but in each report the correlation factor was precisely 0.771, while the correlation for the twins raised together, no matter how many, was always 0.944. This is clearly an impossibility. A little later, in 1976, Oliver Gillie, a British journalist, sought out Burt's co-workers, Jane Conway and Margaret Howard. They could not be found. They were just as much inventions of Burt's fertile mind as his separated twins.

Why do I drag up these old cases? Because we may be witnessing a fraud of even greater proportions. The Climategate e-mails have shaken people's confidence in anthropogenic global warming. In the UK more people disbelieve it than believe it. I am not a climate scientist and I would not be any good at disentangling the data that has been presented, but have some experience of scientific fraud.

The e-mails seem to be saying that there was a conspiracy to deny doubters access to the raw data on climate measurements. Freedom of information requests can be troublesome for researchers. They may involve a good deal of time which would be better spent on getting on with the job. But the e-mails seem to be saying that data were destroyed rather than allowing them to be seen by sceptics. It wasn't only the University of East Anglia involved; other climate change researchers seem to have been collaborating in what must be called a cover-up. There seems to have been a conspiracy to 'peer-review' particularly harshly any papers suggesting an alternative explanation for the data so as to prevent their publication.

I find it hard to come to any other conclusion about what was going on.

On these two points alone I am extremely worried for the reputation of this field of science. The purpose of publication is to invite criticism. How ever much evidence you accumulate to support your hypothesis, it cannot be proved to be true. It may be contingently true; contingent on someone not coming up with contrary evidence. But if you refuse to look for that contrary evidence then your hypothesis is very weak indeed.

Consider the hypothesis that ALL SWANS ARE WHITE. You might travel up an down the land from Cornwall to the Shetland islands and demonstrate that every swan you see is white, but unless you travel to Australia, you really haven't tested your hypothesis. The climate conspiracy is worse. It is like they have seen early stamps form South Australia that were adorned with a black swan, but they refuse to go and look there, declaring that the picture was a figment of the artist's imagination.

Worse still is the hiding of data. Several frauds have involved fictitious or manipulated data. Publication of raw data in electronic form has become the norm in many scientific fields, and it should always be available to journals if a question is raised about the article. Malcolm Pearce, a British obstetrician reported that he had rescued an ectopic pregnancy by reimplanting the fetus in the womb. He was exposed as a fraud because he could not produce the patient's record. Imagine if he had said, "The records are confidential. I am not going to reveal them to those silly individuals who don't believe me."

Science involves two things: 1] imagining an explanation for an observation; 2] designing an experiment to prove the explanation wrong. I am worried that climate scientists are very good at 1] but instead of doing 2] they have become polemicists whose role is to convince others that their view is right. The Himalayan glaciers were an instance of polemicism rather than science.

Friday, February 05, 2010

Suffering in Haiti

How could an all powerful, all loving God allow 150,000 people in Haiti to die in an earthquake? Pat Robinson thinks that it’s because of their sinful involvement with voodoo. That, of course, is nonsense. Even if they were the most terrible sinners around, God doesn’t act like that and in any case, despite the influence of voodoo, Haiti is one of the most Christian countries in the world. And, Pat Robinson, it is estimated by the publication ‘Operation World’ that 30% of the population are evangelical Christians, just like you are supposed to be.

Remember how Jesus was confronted by questioners who asked about some Galileans whose blood Pilate had mixed with their sacrifices?

Jesus answered, "Do you think that these Galileans were worse sinners than all the other Galileans because they suffered this way? I tell you, no! But unless you repent, you too will all perish. Or those eighteen who died when the tower in Siloam fell on them—do you think they were more guilty than all the others living in Jerusalem? I tell you, no! But unless you repent, you too will all perish." (Luke 13:1-5)

Bad things happen to good people, and it is nothing to do with how sinful they have been. It’s not that they have secret undeclared sins. Of course, there are natural consequences of sin. If you sleep around you are more likely to contract a sexually transmitted disease, but the child with congenital syphilis is not to blame for his sickness. Many very sinful people prosper in this world – their criminal behaviour allows them to escape just punishment.

But consider this. An earthquake of similar magnitude happened in California. Fewer than 70 people died. Why the difference? California has buildings that don’t fall down when the earth quivers. California has sophisticated medical services. California has helicopters and trained rescue teams. Haiti has none of these. California is rich; Haiti is poor. If you read my previous article on Haiti you will see some of the reasons why this is so.

Nobody likes talking about death; it’s called the last enemy. Some deaths we accept as natural and necessary. When an old lady of 109 passes, we are likely to murmur some platitude like, “She had a good innings,” or, “It was a happy release.” A few weeks ago, in one of those violent Muslim countries, a security guard was killed stopping a suicide bomber gaining access to a crowded area. His death was heroic and although tragic, we thought that his death had a purpose. But all those pointless deaths: the child dying of leukemia, the boy crushed by a truck, the freak accident at work, the teenager with meningitis, the golfer struck by lightning, the helicopter crash, encephalitis following vaccination, the operation that went wrong, the guy whose motor cycle struck a pothole, the young woman trapped in the snow, the policemen who drowned when the bridge collapsed, the baby in the house that caught fire, the mother with breast cancer…

150,000 deaths in Haiti is more newsworthy but not more painful for the person bereaved. I have gripped the arm of the father whose son succumbed to leukemia 20 years ago. I have locked eyes with the woman whose brother died of lymphoma. I have prayed with the man whose wife of 30 years Cheyne-Stoked towards her end. “Any man’s death diminishes me,” wrote John Donne, Dean of St Paul’s and poet.

We thrash around looking for someone to blame. “I’ll have that doctor struck off.” “I’ll sue the Council.” “They’ll pay for this.” Whoever ‘They’ are. And when we find no-one to hold responsible, we blame God.

If only You had done something this would never have happened.

It is a question as old as the hills. Epicurus, the Greek philosopher, put it this way:
God perhaps wishes to take away evil and is unable; or he is able and unwilling; or he is neither willing nor able; or he is both willing and able. If he is willing but unable, he is feeble, which is not in accordance with the character of God. If he is able and unwilling, he is envious, which is equally at variance with God. If he is neither willing nor able, he is both envious and feeble, and therefore not God. If he is both willing and able, which alone is suitable for God, from what source then is evil? Or why does he not remove it? (According to Lactantius in A Treatise on the Anger of God, cited by W Wiersbe in Why Us? Fleming H Revell; 1984)

This is only a problem for those who believe in a personal and loving God. The Hindu says Karma, the Muslim inshallah; the Buddhist would regard you as unenlightened for asking the question, while the atheist would say with Richard Dawkins:

In a universe of blind physical forces and genetic replications some people are going to get lucky and some people are going to get hurt and we won’t find any rhyme or reason to it, nor any justice. The universe we observe has precisely the properties we should expect if there is at the bottom no design, no purpose, no evil and no good. Nothing but blind pitiless indifference. DNA neither knows nor cares. DNA just is and we dance to its music. (River out of Eden: A Darwinian View of Life. London:Phoenix 1995; p133)

Cold comfort indeed! Dr Dawkins, I suggest you try that out on the next bereaved mother you see. Roger Carswell tells us that he sometimes asks atheists what God they don’t believe in, and when they tell him he replies, “If God were like that, I’d be an atheist too.” (Where is God in a messed up world? IVP 2006; p 30)

If you want a philosophical answer to the question, one has been available for thousands of years. It is in the Book of Job (Chapter 38 and following). When Job asks the reason for his suffering God replies, “Where were you when I laid the earth’s foundation?” Then he follows up with a series of answerable questions – unanswerable by anyone who wasn’t there from the beginning. “Would you discredit my justice?” asks God. “Would you condemn me to justify yourself?”

Tim Keller points out that there is a major flaw in the reasoning of philosophers from Epicurus to David Hume, such that no serious philosopher now employs this argument against the Christian God.

Tucked away with the assertion that the world is filled with pointless evil is the hidden premise that if evil is pointless to me then it must be pointless. (The Reason for God. Hodder and Stoughton. 2008; p23)

As Job found out, just because we can’t see or imagine why God may allow something to happen doesn’t mean that there can’t be one. We have numerous examples where something bad happens to someone yet it was necessary that good might follow. The story of Joseph in Genesis is a good example. Joseph’s brothers sold him into slavery in Egypt. It was a wicked and cruel act. While a slave he was unjustly accused by Potiphar’s wife and was thrown into prison. In prison he gained a reputation as an interpreter of dreams and despite spending many years in confinement he was eventually sent for to interpret Pharaoh’s dreams. Such was his success that he was appointed Prime Minister in Egypt from which position he was able to save thousands of lives from starvation, including his own family.

As a more recent example consider Corrie Ten Boom who with her sister, Betsie, was thrown into the Ravensbrük Nazi concentration camp for sheltering Jews. In Ravensbrük, she and Betsie were confined in a hut beset with fleas and bed bugs. They began holding Bible studies but were surprised that the guards never disturbed them. Eventually they worked out that the reason that the guards stayed away was the presence of the very fleas and bed bugs that disgusted them.

Nevertheless, it has to be admitted that most clouds don’t have obvious silver linings. The puzzle remains, but if I understood the mind of God, I would have to be his equal. I watched The Longest Day last week. I doubt that any other film has had so many stars acting in it. The future James Bond played a common soldier. Even though he would one day be the central character in movie blockbusters, Sean Connery’s character in this had very little idea of what was going on around him. He just had to get up that beach. All around him private soldiers were being mown down by machine gun bullets. General Eisenhower had planned it. No doubt Patton and Montgomery knew the strategy. But for most it was simply a matter of following orders. God has a plan for us. We know the general outline. We have been given a manual. But as for the details – well it’s not our concern.

There is a logical answer to the puzzle too. Nobody would deny that human beings have a great sense of justice. If you have ever been to a soccer match you will have experienced the great sense of indignation that goes up when a handball goes unpunished. Even worse is the baying for blood when a murdering pedophile is caught. Why should this be? The evolutionary mechanism depends on death, destruction and violence of the strong against the weak. Recently, on one of those nature programs that TV does so well, I witnessed a water buffalo attacked by Kimono Dragons. After poisoning it with a bite to its heel, the lizards stalked it for several days until it collapsed. They then proceeded to eat it while it was still living. Even the cameraman broke down before the spectacle. Why was it so horrific? It was just nature ‘red in tooth and claw’. Without it, according to evolutionary theory, none of us would be here.

If there is no God, what right do we have to be outraged by injustice and cruelty?

“If you were God and you wanted to rid the world of suffering and pain, where would you start?” asks Michael Ots (What kind of God? IVP; 2008 p44).

Most people begin with terrorists, rapists, pedophiles, and serial killers. If these were all taken out of the world would it then be a perfect place? Who would be next to be thrown out? Bank robbers, burglars, confidence tricksters, common or garden murderers and wife beaters? Would that make things perfect? Bankers and their bonuses? Politicians and their fraudulent expenses claims? Real Estate agents? Traffic cops? Used-car salesmen? The realization dawns that sooner or later down the line, we fit in too.

Who will be left? Is there anyone without sin? I disqualify myself and I can’t believe that everyone would not do the same. There is a corruption there at the very heart. The Apostle Paul, writing to Christians in Rome, said, “All have sinned and fall short of the glory of God,” and “The wages of sin is death.”

I suppose another Flood might be the answer, but He did promise not to do that again.

Why would a god make a world like this, where so many things go wrong? Actually He didn’t. The Bible tells us that the world he made was perfect. It has been corrupted since. Many people dismiss the early chapters of Genesis as myth and fairy tale, but they are crucial to the Bible’s message. Without the Fall, without Adam’s rebellion, without this explanation of what has gone wrong, the whole Christian story is meaningless. The apostle Paul wrote to the Christians at Rome, “For if by the trespass of the one man (ie Adam) death reigned through that one man, how much more will those that receive God’s abundant provision of grace and the gift of righteousness reign in life through the one man, Jesus Christ.” (Romans 5:17). To the church in Corinth he wrote, “For as in Adam all die, so in Christ all will be made alive.” (1 Corinthians 15:22).

And it wasn’t just humankind that has been suffering. To the church at Rome, Paul wrote, “We know that the whole creation has been groaning as in the pains of childbirth right up to the present time. Not only so, but we ourselves, who have the first fruits of the Spirit, groan inwardly as we wait eagerly for our adoption as sons, the redemption of our bodies.” (Romans 8:22-23).

Since I have had cancer, I have had a fellow-feeling with those undergoing chemotherapy. Before, I knew the side effects and could list them for you, but I had never experienced the absolute exhaustion, never known the numb fingers and toes and never been breathless at the slightest exertion. Now I have an empathy with anyone who has been through what I went through.

There are some things that I can’t imagine. Free-fall parachuting, bungee-jumping, base-jumping, marathon running and taking a trip on the Space Shuttle are all beyond my experience. Imagine me trying to quell the fears of someone about to jump out of an airplane for the first time. My whole being cries out, “Don’t do it!” But if you have to have chemotherapy I can empathize with you. I know what it’s like to feel sick, to feel exhausted, and to have mouth ulcers and all those things that the doctors consider trivial.

Can we really expect a God with supernatural powers, invulnerable to heat or cold or even machine gun bullets, unlimited by ignorance or fear, and impervious to temptation to understand the human condition?

Christmas is past. We have put away the tinsel and the tree lights for another year. Today the shops were empty and we dine on egg and fries rather than turkey and mince pies. For all its frippery, Christmas is about the incarnation. God became man and dwelt among us. When he fell over and grazed his knee, it hurt at the time and was sore afterwards. He could have been caught and slaughtered by King Herod. At the end of the day, he was tired and longed for his bed. He knew hunger and thirst. He knew poverty. He was tempted by Satan himself. He was let down by his pupils, abused by the authorities, betrayed by his friend, deserted by his followers, mocked by bystanders, abused and tortured by soldiers, cheated by the lawyers, and murdered by those in charge. He was no stranger to the human condition.

Far from standing idly by as we suffer, God came and joined us and shared in our suffering.

The crucifixion was a very nasty way of killing people, but Jesus was not the only one to suffer it. The Romans crucified tens of thousands. Since then men have invented even worse forms of torture and murder. A recent television program portrayed the procedure of ‘necklacing’ practised in South Africa. An old car tire is placed around the neck of the victim and filled with petrol. The whole think is then set on fire. On television, the victim was a 15-year old girl who had tried to escape from her forced prostitution.

Why do Christians make so much of the Crucifixion? If it were that alone, Jesus would qualify as a minor martyr. Others have died more terrible deaths – many of them among His followers. The answer is that his death had a spiritual dimension that we cannot appreciate. The clue is in his cry of dereliction, “My God, my God, why hast thou forsaken me?”

We don’t like to talk about Hell. Medieval images conjured up by Dante’s poem are embarrassing to us now. But if we see Hell for what it is – total and complete separation from God – it becomes both less embarrassing and more logical. Common grace, the benefits of God’s presence in the world and His residual image in Man, diminish the evil of our lives. This world is not as bad as it could be. Imagine Haiti happened and nobody went to help. Imagine only looters and no rescuers. These dytopias have been imagined in post-apocalyptic movies. Hell indeed! But life is not like this. People who don’t know God still show kindness and concern. There is a sense of justice. If, as philosophers like Nietzsche suggest, God is dead, where does this leavening of love come from? Nietzsche thought that seeking after power was the driving force for mankind and that the ‘Superman’ would prevail over the worthless hoards of weaklings. Instead we see true humanity in acts of sacrifice for the weaker brethren.

What would life be like without it? Brutish and short.

From eternity past Jesus had been in sweet communion with his Father. On the cross that constant union was wrenched apart, the godhead torn asunder. In a very real sense Jesus experienced Hell for us.

How could an all powerful God of love stand by and do nothing while watching the suffering of Haiti? He has not. He has come and has remedied the underlying fault. Not for him a cosmetic clearance of the symptoms of the problem. He shared in our suffering and endured Hell so that we need not.

Jesus’ resurrection is just about the most well attested event in Roman history. Caesar’s conquest of Gaul; Pliny the Younger’s view of the eruption of Vesuvius; Mark Anthony’s romance with Cleopatra; all have less documentary evidence than Jesus rising from the dead. Was it Julius Caesar who crossed the Channel or some underling who was told to give Caesar the credit? We know that Pompeii was smothered in lava, but was Pliny’s account of it imaginative fiction; a hagiography of his uncle (Pliny the Elder who supposedly died rescuing survivors from the Bay of Naples)? Were Anthony and Cleopatra anything more than a Mills and Boon style reconstruction of a political alliance?

Paul says about the resurrection “If Christ has not be raised, our preaching is useless and so is your faith.” It is the central event in history. The resurrection is what holds out promise that we shall all be raised. But Paul continues, “Christ has indeed been raised from the dead, the first fruits of those who have fallen asleep. For since death came through a man (ie Adam), the resurrection from the dead comes also through a man (ie Jesus) (1 Corinthians 15: 20-21).

One of Jesus’ disciples, John, escaped martyrdom. Instead he was exiled to the Aegean island of Patmos. Here he had a vision of the risen Lord Jesus. His apocalyptic view of the future is reported in the book of Revelation. “Then I saw a new heaven and a new earth, for the first heaven and the first earth had passed away,” writes John, reporting on his vision. He goes on, “I heard a loud voice from the throne (Jesus’) saying, ‘Now the dwelling of God is with men, and he will live with them and be their God. He will wipe away every tear from their eyes. There will be no more death or mourning or crying or pain, for the old order of things has passed away.’

He who was seated on the throne said, “I am making everything new!’” (Revelation 21:1-5)

When we see what the future is we can say with the Apostle that our present sufferings are not worth comparing with the glory to come. We can only ask why he delays. We have a saying that justice delayed is justice denied. But that saying assumes that our lives are finite. They are not. He delays because he doesn’t want anyone to perish. There are millions waiting to be told the good news. That’s why Haiti, tragedy that it is, presents us with an opportunity. There may yet be some who will see our good works and praise our Father in heaven. We have the opportunity to demonstrate that

The love of God is greater far
Than tongue or pen can ever tell;
It goes beyond the highest star,
And reaches deep where sinners dwell.
The guilty pair, bowed down with care,
God gave His Son to win;
His erring child He reconciled,
And pardoned from his sin.

When hoary time shall pass away,
And earthly thrones and kingdoms fall;
When men who hear refuse to pray,
On rocks and hills and mountains call;
God's love, so pure, shall still endure,
All measureless and strong;
Redeeming grace to Adam's race—
The saints' and angels' song.

Could we with ink the ocean fill,
And were the skies of parchment made;
Were every stalk on earth a quill,
And every man a scribe by trade;
To write the love of God, above
Would drain the ocean dry;
Nor could the scroll contain the whole,
Though stretched from sky to sky.