Archive for March, 2010

Mission of GOD – 8

I will confess I have been somewhat distracted. Mainly by Steinbeck and Robinson and so it’s taken me  while to get back to Chris Wright.

But sitting here off work on the sick for a day to give me close proximity to a toilet, has given me the chance to catch up a bit.

In this penultimate chapter Wright covers GOD’s vision for the nations in the OT. From sunday school memories I remember a lot of violence, a lot of blood shed. In fact if you asked me to recall what happened in the historical narratives of the OT then that is what would immediately jump to mind.

The violence and the judgement happened, but it would be negligent to say that that was all that was going on. Although hardly unexpected the Bible gives a somewhat fuller and more nuanced account than what I seem to have immediately retained.

Here Wright articulates how the Mission of GOD involved and included the pagan nations of the OT accounts.

GOD’s mission is what fills the gap between the scattering of the nations in Gen 11 and the healing of the nations in Rev 22

He uses the example of the story of Jonah – which we see as the reluctant missionary who is eventualy persuaded. Perhaps because this is the closest thing we can find in the OT that looks like mission to us.

Wright argues that

the real missional challenge of the book is undoubtedly and intentionally lies in its portrayal of GOD. If Jonah is intended to represent Israel, as seems likely, then the book issues a strong challenge to Israel regarding their attitude to the nations and regarding their understanding of GOD’s attitude to the nations

It is here that we see GOD correcting Israel’s opinion of themselves. Yes – you are my chosen people, but chosen to fulfil my mission.

So why then all this focus on Israel- revelation. The fact that YHWH has revealed himself in word and deed and person to Israel. If they are special of favoured then this is why.

Israel stood visible to the nations, at the crossing point of the great civilisations, as conquerors, conquered and exiles they were visible as the people to whom the living GOD had revealed himself. Their ethical responsibilities were to reflect the revelation they had received.

GOD’s mission involves GOD’s people living in GOD’s way in the sight of the nations

Wright goes on to cover in some detail an array of texts that again and again state how GOD plans to reveal himself to the nations and how he will call them his people. A good example is Zech 9:7 when talking of the Phillistines

I will take the blood from their mouths, the forbidden food from between their teeth. And the remnant, even it will belong to our GOD. And it will be like a clan in Judah, and Ekron will be like the Jebusites.

The Philistines – the nasty Philistines that we’re forever hearing about in the OT – even they GOD wants a remnant of. Note that this same hope of a remnant is exactly the same hope offered to Israel.

And it is in verses like these that we now see where Paul was coming from in his mission to the gentiles. It was of course not his mission – it was the mission GOD had been pursuing since the beginning.

Battle of who could care less

In an excellent post on healthcare, post personal and international, Vinoth Ramachandra says this:

Economists limit their discussions of healthcare to the provision of medical services. But healthcare involves much more than good hospitals: concern for social justice in healthcare forces us to look at everything from sanitation, waste disposal, and climate change to the ethics of TV advertisements and food companies, the quality of secondary education and disparities in income and work opportunities. Prevention is far more effective than cures- and prevention mostly requires cash transfers to develop education and infrastructure, whereas curative medicine absorbs real resources.

Health is so much more than medicines and tests and doctors. We doctors may be the main determinants of healthcare costs (often unnecessarily) but we are certainly not the main determinants of health.

I’ve got your number

Found this on the EMA site, by Rick Bukata

NNT (number to needed to treat) is a great concept for getting some kind of message across to patients. That yes we have medicines to treat you but we cannot guarantee that you will personally benefit. Overall out of 200 or so people someone will benefit. I’m just not sure that’s you.

NNTs are generally lower for treating things that already exist. Eg most people with appendicitis will benefit from having their appendix removed.

NNTs are generally a lot higher when it comes to screening and preventing conditions developing.

He provides a few examples:

Mammographic Screening
How many women between the ages of 50-59 need to have a mammogram yearly for five years to prevent one death from breast cancer?  The number is about 2,500 such women.

Lipid Treatment
71 patients with known cardiovascular risk factors have to be treated with a statin for 3-5 years to prevent one serious adverse cardiovascular event.  But no increase in total mortality or total serious events can be expected.  To put this into perspective, at $1,000 per year per patient for statins, for 71 patients taking them for an average of four years, the cost to prevent one serious adverse cardiovascular event is 71 patients x $1,000 x 4 years = $284,000


Prevention of Colon Cancer Death with Occult Blood Testing
The number needed to screen for five years to prevent one death from colon cancer is 1,374 patients.

Prevention of Hip Fracture by Treatment of Osteoporosis
In women without risk factors, approximately 2,000 women between the ages of 60-64 need to be screened and subsequently treated for osteoporosis for five years to prevent one hip fracture (1,000 women if there is at least one risk factor).

Detection of Diabetes in Men With and Without Hypertension
The number is 13 in 55-year-old men with hypertension, and 19 in those without hypertension.

Simple Antihypertensive Treatment for Mild Hypertension
700 patients would need to be treated for one year to prevent one stroke, MI or death in that year.

Prophylactic Antibiotics for Dog Bites
Only about one in 16 patients will benefit.

Compression Stockings to Prevent Post-Op DVT
One in nine patients may be expected to benefit.

Antibiotics to Improve Short-Term Outcomes in Otitis Media
Only one in seven patients can expect to benefit from antibiotics (i.e., decreased symptoms at 7-14 days post onset of treatment).

Aspirin in Healthy Physicians to Prevent an MI or CV Death
The number is 500 over one year.

All of these numbers are only as good as the data that you’ve calculated it from but still it puts some things in perspective.

Harder to Breathe

Even the non-medics will find this kind of cool.

Anyone fancy doing it on their local, friendly, useful med students?

[Via Life in the fast lane]

The magic numbers

This [Via wee Phil]

Experts in the math of probability and statistics are well aware of these problems and have for decades expressed concern about them in major journals. Over the years, hundreds of published papers have warned that science’s love affair with statistics has spawned countless illegitimate findings. In fact, if you believe what you read in the scientific literature, you shouldn’t believe what you read in the scientific literature.

I have a very dubious and incomplete knowledge of statistics. Unsurprisingly we had modules of it in medical school. Also unsurprisingly I didn’t go to any of the classes. They were were quite staggeringly dull and I had better things to do like read CS Lewis.

These days I spend a lot of time reading medical studies and trying to critique the numbers and methodologies found there in. There is a tremendous amount of Bad Science out there. And don’t be fooled into believing that it’s just the SCAMs (Supplements, Complementary and Alternative Medicine) – there’s plenty of badly done stuff in the professional and published medical literature.

People say statistics can be used to prove anything. People say that 62% of statistics are made up. These things may be true. I just can’t prove it.

Doctors bow before the throne of the randomised clinical trial. Where a bunch of people get one drug and a bunch of people get placebo and no one knows what anyone got till after the trial is over and the scientists go back and look at how people did on either the drug or the placebo.

If more people lived while on drug then they compare the numbers and calculate the probability that the observed positive results of the drug would be due to chance alone (this involves assuming a null hypothesis) and if this number is less than 5% (ie the chance of the observed results being to chance alone is less than 5%) then it is called a significant difference.

[Apparently this idea was birthed by a chap called Fisher in the 1920s who was looking at agricultural yields with fertiliser]

The problem being that statistical significance has little to do with clinical or actual significance.

If you do a big enough trial involving 1000s of people on a certain drug you can prove a stastistically significant benefit from your drug even if the actual difference between the two groups was 3 people out of 10000 dying in the placebo group and 2 people out of 10000 dying in the wonderdrug group (incidentally you could also quote a 50% relative reduction or a 0.01% absolute reduction in death in this trial).

So you see that the numbers appear very different depending on how you quote them.

The 5% number (p<0.05) is an arbitrary number. Let that sink in. Someone just decided that 5% defined statistical significance. In the name of objectivity and scientific rationalism surely that can’t be right!

But these are the tools we have and the tools we use to misunderstand and spin the medical literature.

This is how lots of people build their CVs and careers – you can’t get anywhere without publishing. And this is how lots of people make large amounts of money from new drugs that are basically stereo-isomers or other barely changed molecules from the previous ones.

Worth reading anyhow.

Bottle up and explode

This is the X-ray you’re never meant to take. So we’re told

This is the x-ray i took on Friday morning.

93 year old lady (background of chronic lung disease, but in pretty good nick considering, gets out and about once a week, no other co-morbidities) , short of breath for a week, worse on the day of admission.

She was breathless but alert, orientated and able to speak. Minimal air entry on either side of the chest, normal BP and heart rate, no distended neck veins.

Mild to moderate type II respiratory failure on her gas. Seemed like a good candidate for non-invasive ventilation.

Got a quick CXR and popped her on the ventilator while waiting for the film to print out. After 10 minutes on the vent she’s improving, less work of breathing, resp rate dropping.

X-ray comes back and yes of course there’s the tension pneumothorax.

Mea Culpa.

So what about the x-ray you’re never meant to take? Most medical dogma is just that. Based on cliche and things grey haired consultants say on post-take ward rounds. They have little relevance to real world medicine.

In the real world of frail, crumbly elderly patients (and this is a large part of our population, not the young professionals of ER and House) “classic” presentations are rare and examination findings in acutely sick people are frequently unreliable.

If you work in emergency medicine long enough you learn quickly not to make dogmatic statements or speak with too much certainty. If you have no room for doubt and uncertainty then find another job.

One of my last referrals last night was a 52 year old lady whose Dad died at the age of 50 with an MI and with chest pain that just might have been ischemic in nature (we see 20 of these patients a  day and maybe one of them rules in for ischemic heart disease).

I wanted her admitted for serial ECGs and enzymes. The response of the medical reg was the she was too young to have anything significant. I suggested that we should have told the patients father that when he died at the age of 50 with the same symptoms.

Medicine is a complex and often unpredictable beast and as much as we’d like it to be it’s not nearly as scientific as we’d like it to be.

Mission of GOD – 7

Chris Wright now turns to GOD’s image bearers – us, and looks at what the Bible says about us and how that impacts on how we do mission.

To be human is to be the image of GOD.

Kind of powerful. And several books in itself.

To briefly summarise Wright covers 4 points

  1. All human beings are addressable by GOD
  2. All human beings are accountable to GOD
  3. All human beings have dignity and equality
  4. The biblical gospel fits all

my favourite quote was this, regarding the ethics of mission:

Anything that denies other human beings their dignity or fails to show respect, interest and informed understanding for all that they hold precious is actually a failure of love.

He goes on to cover how our image bearing status has a lot of important aspects in how we live.

  • we were commanded (as image-bearers) to rule over the earth – the other creatures were given no such command (they had no need of commands or instruction it seems). And in the context we are to exert this as a King not a tyrant over creation
  • we were created in relationship – the first not good of the Bible follows on from a long list of …and GOD saw that it was good… – and that not good was applied to the man’s state as being alone. This was not that he was emotionally and needed a companion – a merely emotional, psychological not good (though it includes that) – it is much more. The fact is that as bearers of GOD’s image we need to be in relationship as GOD is in the trinity, and with us. We are created relational because GOD is relational.

Wright goes on to cover the impact that sin has on us as GOD’s image bearers and uses HIV/AIDS as a paradigm of how we are broken and how the church should respond.

He closes he chapter with a review of the wisdom literature and the common place finding of doubt, questions and suffering. It is here, in the context of a people steeped in YHWH montheism and the law that we find people holding up what appear to be contradictory.

They contrast Deuteronomy 30:15-20 with with what seems quite clearly to not be the case. Often it appears that the wicked prosper and the innocent suffer. The wisdom literature is the Bible’s own candid and honest struggle with questions it cannot wholly answer – either within the limits of our own experience or even the limits of GOD’s revelation to us.


March 2010
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