11/28/17

David and the Uncircumcised Philistine

Between 2007 and 2013 Yosef Garfinkel of the Hebrew University of Jerusalem and two others led excavations at a site in the Elah Valley known as Khirbet Qeiyfa. Among the artifacts found there is perhaps the oldest inscription written in Hebrew. There also was a cultic stone shrine decorated with architectural elements that echo biblical descriptions of Solomon’s Temple and his palace in Jerusalem. Carbon dating places the city’s existence around the 11^th and 10^th century BC, at the beginning of the Kingdom of Israel. Perhaps most intriguingly, the site is located on the Philistine and Judean border “in the area that has been identified as the location of the battle between David and Goliath.”

In September of 2016 the Bible Lands Museum in Jerusalem opened an exhibition focused on the archeological discoveries at Khirbet Qeiyfa called “In the Valley of David and Goliath.” The archaeologists only realized during their second season of excavations that their fortified town “perfectly fit the descriptions of the Biblical town of Shaarayim.” The Hebrew name of the town means “two gates,” which is what was uncovered during the excavations; two gates. You can watch a short video about the exhibition here. There is an article about the Khirbet Qeiyfa archeological site here.

The geographical location of the town also fits right in line with the Biblical depiction of Shaarayim, mentioned in the context of the aftermath of the battle between David and Goliath when the Philistines “fell on the way to Shaarayim.” The town is also mentioned in the book of Joshua as being situated near Socho and Azeka, two archaeological sites surrounding Khirbet Qeiyafa.

The story of David and Goliath is the classic biblical tale of the big bully getting his comeuppance from the little guy. In his commentary on 1 Samuel, Robert Bergen said in Western culture it has become the primary historical metaphor for “describing any individual or group who overcomes seemingly insurmountable odds to defeat an oppressor.” In 1960, the story became a feature length Italian film, where Orson Welles, no less, played King Saul. The feature length movie is available on Amazon Prime and YouTube. There is even a TED Talk by Malcom Gladwell that reviews the biblical account, “The Unheard Story of David and Goliath.”

Gladwell’s account of David and Goliath tends to minimize Goliath’s threat as an opponent to David, while drawing out the danger David and his sling posed to Goliath. According to Gladwell, Goliath was only 6’ 9’’ tall. He referred to Goliath’s shield bearer as a young boy or attendant who led him by the hand. And he cited medical speculation that Goliath’s 6’ 9” height was the result of acromegaly, a condition caused by a benign tumor on the pituitary gland that causes an overproduction of growth hormone. The distinct side effects from acromegaly were then used to explain other aspects of the David and Goliath encounter. Later we’ll look at biblical and extra biblical evidence that challenges this portrayal of Goliath, but first let’s look at his assessment of David and his choice of weapons.

David rejects the offered use of Saul’s armor, instead choosing to take his shepherd’s staff, his sling and five smooth stones. Gladwell noted where soldiers of that time would fight with slings. He speculated that when David released his rock, it was traveling 35 meters per second; faster than a baseball thrown by the best pitchers. “If you do the calculations on the ballistics, on the stopping power of the rock fired from David’s sling, it’s roughly equal to the stopping power of a [.45 caliber] handgun.”

This made the sling a very powerful weapon, one that some have called “the gun” of the ancient world. Sling stones excavated at the main gate of the city of Lachish (pictured below in The British Museum) were as big as tennis balls. Slingers are known to be accurate enough to hit birds in flight; and to hit, maim or kill a target up to 200 yards away. “If you go back over the history of ancient warfare, you will find time and time again that slingers were the decisive factor against infantry in one kind of battle or another.”

photo by: Osama Shukir Muhammed Amin; licensed under Creative Commons: Attribution-NonCommercial-ShareAlike

Goliath’s weapons and armor could have weighed more than 150 pounds (His armor alone weighed 126 pounds). His combat gear was designed for close combat. The weight of his spearhead was around fifteen pounds; too heavy and awkward for throwing. He was covered from head to toe in metal. He wore a bronze helmet; armor; bronze greaves (knee and shin protection). He had a bronze javelin (more likely a scimitar) slung between his shoulders. And he had a full body shield or ṣinnâ carried by a shield bearer, who went ahead of him. The assumption by Gladwell of Goliath being led by a youth is inaccurate.

Without Saul’s armor, David would have had greater mobility. This and the fact that Goliath was outfitted for close combat explain his invitation for David to “come to him” in 1 Samuel 17:44. David ran quickly towards Goliath after they exchanged insults because he wasn’t afraid, for two reasons. First and foremost, he knew that the Lord would deliver him (1 Samuel 17:37). Second, he knew from past experience that he had killed both lions and bears. Based on David’s future tactical skills in warfare, I would speculate that he realized Goliath’s vulnerability to attack by a skilled slinger, which he knew himself to be.

Goliath really was huge. He was 9’ 9’’ tall; not 6’ 9” tall. The different reported heights are due to the six cubit height recorded in 1 Samuel 17:4 versus the recorded height of four cubits in the Codex Vaticanus (an important Greek manuscript of the Old and New Testaments) and Josephus, as well as a copy of the Septuagint. Bergen suggested the shorter figure is an emendation to the text by a pious copyist to increase the text’s credibility. However, a smaller Goliath then creates problems for the bulk of his combat gear, like a 15-pound spearhead.

There are several other biblical references to giants. The twelve spies reported to the Israelites there were Anakim in the land, a people “greater and taller” than they were (Numbers 13:28; Deuteronomy 1:28). After wandering forty years in the wilderness, Moses told the Israelites they would confront the Anakim when they crossed the Jordan into Canaan (Deuteronomy 9:2). Joshua defeated the Anakim from the hill country of Judah, destroying them and their cities. But some remained in the Philistine cities of Gaza, Gath and Ashdod (Joshua 11:21-23). They were driven from Hebron by Caleb (Joshua 14:12-15).

The Anakim were believed to be the descendants of Anak and dwelt in the region around Hebron. Their name means “people of the necklace.” R. K. Harrison noted where the 18^th century BC Egyptian Execration Texts seemed to point to a tribe named Anak. Referring to the Egyptian Execration Texts in Space and Time in the Religious Life of the Near East, Nicholas Wyatt described how the Egyptians performed a curse ritual on their enemies in Canaan, including the rulers of Iy-Anaq. The IVP Bible Background Commentary: Old Testament reported that Papyrus Anastasi I, a 13^th century BC document, referred to fierce warriors that were seven to nine feet tall. Josephus described how Caleb conquered Hebron, killing all its inhabitants, who were a race of giants:

For which reason they removed their camp to Hebron; and when they had taken it, they slew all the inhabitants. There were till then left the race of giants, who had bodies so large, and countenances so entirely different from other men, that they were surprising to the sight, and terrible to the hearing. The bones of these men are still shown to this very day, unlike to any creditable relations of other men.

The IVP Bible Background Commentary: Old Testament also reported that two female skeletons about seven feet tall from the 12^th century BC were found at Tell es-Sa’ideyeh in Transjordan. However, Jonathan Tubb, who was in charge of the excavation of Tell es-Sa’ideyeh, said “no such skeletons were found there.”

Moderns are distant enough from Josephus and the biblical reports of the Anakim and Goliath to be skeptical that humans as tall as nine feet once lived on the earth. The confirmed proof of seven or nine foot skeletons has so far been lacking support. But there is a tantalizing suggestion that there was such evidence at one time. In On the Resurrection of the Flesh, as Tertullian speculated on the meaning of New Testament texts on the resurrection from the dead, he made an aside comment about giants: “There are the carcasses of the giants of old time; it will be obvious enough that they are not absolutely decayed, for their bony frames are still extant.”

The archaeological evidence of an ancient race or tribe of giants, of Anakim, is still missing. Perhaps it will never be found and speculation on the veracity of the story of David and Goliath will continue. Biblical scholars have voiced a variety of concerns with it, including the differences between the Masoretic text (Goliath 9’ 9’’ tall) and the Septuigint (Goliath 6’ 9’’) noted above. Another concern is with 2 Samuel 21:19, where it says Elhanan struck down Goliath. Complicating the issue further, is 1 Chronicles 20:5, which says Elhanan struck down Lahmi, the brother of Goliath. The best explanation seems to be that 2 Samuel 21:19 is a copyist error from pre-Christian times. 1 Chronicles 20:5 preserves the correct and accurate reading.

Undoubtedly, the writer of 1 Samuel wanted to impress the story of David and Goliath onto the minds of his readers. Robert Bergen noted several narrative techniques that support this conjecture. First is the length of the account, 912 words in Hebrew. That is longer than any other single Davidic battle narrative. Second, there are more quotations (22) than there are in other stories. The longest quote in 1, 2 Samuel is by Goliath in 1 Samuel 17:8-9.

There are also details normally missing from similar narratives. We know the pieces and weight of Goliath’s armor, the number of cheeses and loaves of bread David brings from his father, how David selected his sling stones, and even that he drew Goliath’s sword from its sheath to kill him and cut off his head. “These details force the reader to ponder the narrative after its reading and thus make the story more memorable and more likely to be studied further.”

Bergen also noted the passage in 1 Samuel 17 was the longest description of military attire in the Old Testament. “Goliath’s physical stature, armor, weaponry, and shield bearer must have made him appear invincible.” All these external advantages suggest that chapter 17 was at least partly intended as an object lesson for the previous chapter in verse 16:7, when the Lord told Samuel to not look on the outward appearance of Eliab, David’s brother. Outwardly Goliath was the premier warrior. And yet, he was overcome and killed by the young shepherd David.

Another contrast exists between the physical stature of Saul and David. Saul was described as being taller than any of the people. He was literally head and shoulders above them. When Samuel presented Saul to the people he said: “Do you see him whom the Lord has chosen? There is none like him among all the people” (1 Samuel 10:23-24). David was just a youth (1 Samuel 17:33). He could not wear Saul’s armor when he went to challenge Goliath, because he had not tested it; he wasn’t used to it (1 Samuel 17:39). Yet David brought about the victory in the Valley of Elah that Saul, a proven warrior and leader, could not. The message of the passage is to simply not trust in outward appearances; trust God instead.

11/24/17

“Cash Cows” for the Drug Industry

The AARP, the American Association for Retired Persons, completed a report looking at the trends in the retail prices of prescription drugs used by older Americans between 2006 and 2015. And the report’s findings were disturbing. Between 2014 and 2015, the retail prices of 268 widely used brand name prescription drugs increased by 15.5%, the fourth year in a row of double-digit increases. The increase was almost 130 times faster than that of inflation—15.5% to .1% for inflation. The average annual retail cost for one brand name drug was over $5,800 in 2015, almost $1,000 more than the annual cost in 2014. “For the average older American taking 4.5 prescription drugs per month, the annual cost of [drug] therapy would have been more than $26,000 for 2015—more than three times the cost seen 10 years earlier.

This was an industry-wide trend, as the prices of the identified drugs, from all 35 drug manufacturers with at least two brand name drugs assessed within the study, increased faster than the rate of general inflation in 2015. “All but one of the therapeutic categories of brand name drugs had average annual price increases over 5% in 2015. . . . The higher costs are typically passed on to the consumer in the form of higher cost sharing, deductibles, and premiums.” These increases were far beyond the price increases for other consumer goods and services between 2006 and 2015. The following graph compares the annual price of brand name prescription drugs to rate of general inflation for the corresponding year.

The next figure illustrates how the average annual cost for widely used brand name drugs by older adults grew more than 300% from 2006 to 2015. The Medicare Part D program was first implemented in 2006. Older Americans fill an average of 4.5 prescriptions for medications per month. If they used brand name prescription drugs, their average annual retail cost for medications would be $26,132. “This annual retail cost of brand name prescription drugs exceeds the median annual income for a Medicare beneficiary ($24,150).”

It is no coincidence that these price increases for medications commonly used by older adults occurred after The “Medicare Prescription Drug, Improvement, and Modernization Act” was approved in 2003. “It expressly prohibited Medicare from negotiating bulk prescription drug prices.” But the Veterans Health Administration and the Defense Department were allowed to negotiate lower prescription drug prices. Prohibiting Medicare from negotiating bulk drug discounts seems directly related to increases in medications noted above.

The AARP Public Policy Institute found there were six specific brand name drugs with the highest percentage changes in retail price from 2006 to 2015. FIVE of them were from the same pharmaceutical company—Valeant. One mg and two mg tablets of Ativan (for anxiety) increased 2,873% and 2,080% respectively in their retail price. Cara .5% cream (certain skin disorders) increased 2,395%. Wellbutrin (for depression) increased 1,185%. Zovirax 5% cream (certain skin disorders) increased 783%. Eli Lilly’s Humulin R (U-500) 500 units/ml, an insulin drug used to treat diabetes, ONLY increased 530%.

If recent trends in brand name drug prices and related price increases continue unabated, the cost of drugs will prompt increasing numbers of older Americans to stop taking necessary medications due to affordability concerns. Continued excessive brand name drug price increases will also lead to increased cost sharing and premiums, which could ultimately make health care coverage unaffordable and lead to poorer health outcomes and to higher health care costs in the future.Given that health care reform expanded the number of people using prescription drugs, it would have been reasonable to expect smaller brand name drug price increases. Instead, brand name drug prices have accelerated substantially. Clearly, the economics of the pharmaceutical market are not working as expected.

Andy Slavitt, when he was the acting administrator for the Centers for Medicare & Medicaid Services, told the pharmaceutical industry in November of 2016 at a conference that increased medication costs were pervasive. Total prescription drug spending in 2015 was $457 billion, 16.7% of health care spending. Mylan’s Epipen was not even in their top twenty list for high price increases for 2015. Specialty drugs (like hepatitis C drugs) were a big part of the cost increase. They accounted for 31.8% of spending, while representing only 1% of prescriptions. Out of the 20 drugs with the highest per-unity cost increases in Medicaid, seven were generic drugs. Those increases were not to recoup drug development expenditures. See “Pharma’s not Getting the Message” for more on this topic.

The NYT reported there has been a sharp rise in polypharmacy, the use of three or more psychotropic drugs, with older adults. Almost half of these patients DID NOT have a diagnosis for mental health or pain disorder on record. Dr. Maust, a geriatric psychiatrist and lead author of the study, told Psychiatric News: “This begs the question of why physicians are exposing patients to all the risks of these medications, but not for the diagnoses they are intended to treat.” He thought the pattern suggested some inappropriate prescribing. Dr. Dilip Jeste, a geriatric neuropsychiatrist and past president of the American Psychiatric Association, said he was stunned to hear “that despite all the talk about how polypharmacy is bad for older people, this rate has doubled.” Over 90 percent of the office visits examined in the study occurred outside the psychiatric setting.

The AARP Public Policy Institute reported that 65% of adults over the age of 65 reported using 3 or more prescription drugs in the past 30 days. Ninety percent reported using one prescription drug in the past 30 days, while 39% said they used five or more. See the following figure from “Prescription Drug Abuse Among Older Adults.”

Disturbingly, this study looked at polypharmacy with medications noted within the Beers Criteria, named after its originator with the American Geriatrics Society twenty years ago. The Beer Criteria lists dozens of medications and their mutual interactions that are potentially harmful when prescribed to older adults. “Geriatric medical organizations have long warned against overprescribing to older people, who are more susceptible to common side effects of psychotropic drugs, such as dizziness and confusion.” The Psychiatric News article linked above has a chart of the Beer’s list of CNS medications, their potential risks and alternative clinical recommendations. The classes of medications examined in the study include: antipsychotics, benzodiazepines, sedative hypnotics for sleep (like Ambien), antidepressants (tricyclics and SSRIs) and opioids. An article in the Journal of the American Geriatrics Society on the 2015 updated Beers Criteria is available here.

Data reported by the AARP Public Policy Institute in “Prescription Drug Abuse Among Older Adults” also noted that older adults has several unique risk factors making them particularly susceptible to misuse of prescription drugs. Misuse is defined here as “the use of prescription drugs in a way a doctor did not direct.” First, older adults use more prescription drugs than any other age group. They also have higher rates of pain, anxiety, and sleep disorders. There could be memory problems that interfere with taking medications at the right time and in the right doses. The high rates of polypharmacy can also lead to potentially dangerous drug interactions.

Age-related physiological changes can also increase the potential for prescription drug abuse. Changes in metabolism, weight, and body fat can affect how a medication works in the body, increasing the potential for misuse and abuse and potentially dangerous side effects. The combination of alcohol and medications can bring about particularly adverse reactions among older adults, as their bodies detoxify and eliminate medications and alcohol more slowly.

Recommendations to prevent drug misuse with older adults include: regular reevaluation of drug dosages to help compensate for physiological changes and declining drug metabolism. Monitor for any inappropriate prescribing of prescription medications. Use of the Beer Criteria discussed above would be helpful. here Because patients often see multiple healthcare providers and obtain multiple prescriptions, keep an eye on a patient’s entire regimen of prescription and nonprescription drug use.

It seems hard to deny that pharmaceutical companies corralled older adults over the past twenty years and branded them as “cash cows” for the drug industry.

11/21/17

Cunning, Baffling, Powerful

Vincent Dole was one of the three physicians who originated methadone as a maintenance drug treatment for heroin addiction in the 1960s. Rather unexpectedly, he was asked to serve as a Class A, non-alcoholic, trustee for the General Service Board of Alcoholics Anonymous. He thought they had made a mistake so before accepting the position, he discussed his research into “chemotherapy for narcotic addiction” with executives of the A.A. Fellowship. They didn’t see any problem or conflict of interest with his appointment and Dr. Dole served as a trustee for A.A. for eleven years, from April of 1965 until April of 1975.

At one point in his tenure as a trustee, he served as a co-chair for the General Service Board. In his farewell letter to the A.A. GSO, printed in the August-September issue of Box 4-5-9, the newsletter from the General Service Office of A.A., he said he would always remain identified with A.A. “My heart is with the Fellowship.”

Like most in A.A., I have gained more in the association than I have been able to give. Especially, it has been a privilege to witness the power of love when focused and unsentimental. I have seen that: Salvation is found in helping others; help stems from knowledge, humility, compassion, and toughness; success is possible.My greatest concern for the future of A.A. is that the principle of personal service might be eroded by money and professionalism. Fortunately, most of the membership of A.A., especially the oldtimers, know that A.A. cannot be commercialized. It is not a trade union of professional counselors or an agency hustling for a budget. The mysterious wisdom of A.A. will discover how to cooperate in reaching out to sick alcoholics while maintaining its Traditions.

In a 1991 article he wrote for the journal Alcoholism, “Addiction as a Public Health Problem,” Dr. Dole said that throughout his time as a trustee he was puzzled by why he specifically was asked to serve. He ended by assuming he had been “brought in as a smoke alarm, a canary in the mine” to guard against “the Fellowship being distorted by aggressive person with dogmatic opinions.” Then, in the late 1960s, he believed a more specific reason emerged, not long before Bill W.’s death. An excerpt from that article is available here: “The Methadone/AA Link.”

A more specific answer, however, emerged in the late 1960s, not long before Bill’s death. At the last trustee meeting that we both attended, he spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. Always the good shepherd, he was thinking about the many sheep who are lost in the dark world of alcoholism. He suggested that in my future research I should look for an analogue of methadone, a medicine that would relieve the alcoholic’s sometimes irresistible craving and enable him to continue his progress in AA toward social and emotional recovery, following the Twelve Steps. I was moved by his concern, and in fact subsequently undertook such a study.

Dr. Dole went on to say he unsuccessfully sought to find that analogue in his laboratory until it closed in 1991. But he thought the work had just begun. Other laboratories and investigators would continue to work on the analogue problem. “With the rapid advance in neurosciences, I believe that Bill’s vision of adjunctive chemotherapy for alcoholics will be realized in the coming decade.”

Since Dr. Dole made that optimistic prediction, several different medications have been used as a harm reduction strategy for individuals with alcohol dependence or alcohol use disorders. Two opioid antagonists, nalmefene and naltrexone and three drugs acting on the gamma-aminobutyric acid (GABA)ergic system (baclofen, acamprosate and toprimate) has been used formally or informally to reduce alcohol consumption or maintain abstinence. Recently in the journal Addiction, Palpacuer et al. did a meta-analysis of 32 double-blind randomized controlled trials of these five medications. The studies were published between 1994 and 2015, and had a combination of 6,036 patients between them. They concluded:

There is currently no high-grade evidence for pharmacological treatment to control drinking using nalmefene, naltrexone, acamprosate, baclofen or topiramate in patients with alcohol dependence or alcohol use disorder. Some treatments show low to medium efficacy in reducing drinking across a range of studies with a high risk of bias. None demonstrates any benefit on health outcomes.

There was no evidence of any significant reduction in serious adverse events or mortality. Studies that sought to assess the efficacy of these medications as maintenance drugs, similar to how methadone is used, “were inadequate to investigate” whether they reduced serious adverse events. “In addition, any pharmacological approach that might benefit patients by reducing their alcohol consumption might also harm them because of safety issues.” As a result, the researchers advocated for long-term mega-trials exploring health outcomes.

To conclude, our results suggest that no treatment currently has high-grade evidence for pharmacologically controlled drinking in the treatment of patients suffering from alcohol dependence or alcohol use disorders. At best, some showed low to medium efficacy in reducing drinking, but across a range of studies with a high risk of bias. Although based on all available data in the public domain, this meta-analysis found no evidence of any benefit of the use of drugs aiming for a controlled drinking strategy on health outcomes. We invite researchers and stakeholders to set up a coherent agenda to demonstrate that pharmacologically controlled drinking can be translated into genuine harm reduction for patients. From the clinical perspective, while this new approach is often presented as a ‘paradigm shift’ in terms of therapeutics, doctors and patients should be informed that the critical examination of the pros and cons of the evidence clearly questions the current guidelines that promote drugs in this indication.

Reporting for The Guardian, Sarah Boseley further noted that one of the reasons for the inconclusive findings in Palpacuer et al. was because of the high drop out rates in the studies. “So many people dropped out of the trials that 26 of the 32 studies – 81% of them – had unclear or incomplete outcome data.” The lead author for the study, Clément Palpacuer, said the report did not mean the drugs weren’t effective. “It means we don’t yet know if they are effective. To know that, we need more studies.” There have also been concerns raised about the drugs by some studies already.

Bosley cited Fitzgerald et al., a review of the trial evidence used to approve nalmefene for use in the NHS. The researchers said at best, there was only modest evidence of efficacy in reducing alcohol consumption. This was despite stacking the deck in how the data was analyzed for approval of the drug.

Important weaknesses in nalmefene trial registration, design, analysis and reporting hamper efforts to understand if and how it can contribute to treating alcohol problems in general practice or elsewhere. The efficacy of nalmefene appears uncertain; a judgement of possible limited efficacy in an unusually defined and highly specific post‐hoc subgroup should not provide the basis for licensing or recommending a drug.

There are issues noted with baclofen as well. A co-author of Fitzgerald et al. noted one French study raised concerns with the safety of baclofen, with more deaths in the treatment group (7 of 162) than the placebo group (3 of 158). A further study by France’s medicines safety agency drew attention to additional adverse effects: “In particular, the risk of intoxication, epilepsy and unexplained death [on the death certificate] increases with the dosage of baclofen.” See “Sure Cure for Drunkenness” and “A ‘Cure’ for Alcoholism” and “The End of Alcoholism?” Part 1, Part 2 and Part 3 for more concerns with baclofen and nalmefene.

Vincent Dole’s search for a methadone analogue or adjunctive chemotherapy for alcoholism is unlikely to be successful. As Carleton Erickson pointed out in The Science of Addiction, alcohol is different than other drugs. He said: “Unlike other drugs, alcohol has no specific receptor to activate in the brain.” Cocaine works on the dopamine transporter. Heroin and other opioids work on the opioid receptor; and marijuana works on the cannabinoid receptor. “Alcohol is known to affect the GABA receptor, the NMDA receptor, and probably others.”

There isn’t a hand-in-glove fit between a receptor and alcohol as there is with the opioid receptor and heroin or other opioids. So there isn’t a medication that can single handedly block alcohol as there is with heroin and other opioids. As Bill W. knew from personal experience, alcohol is cunning, baffling and powerful.

11/17/17

Evolutionary Wars

credit: Steve Cardino, from “The Lie: Evolution”

The cartoon image here portrays a war between Humanism and Christianity, where Humanism is founded on evolution and Satan, while Christianity is founded on creation and Christ. The castle of Christianity is starting to collapse as the castle of Humanism systematically attacks the rock of its foundation in the cartoon, creation. The Christian guns are ineffectively aimed either nowhere or at the balloons (issues) of humanism instead of it evolutionary foundation. The message it sends is clear: Christianity is in danger of losing the cultural war with Humanism because it isn’t attacking the Satanic foundation it’s based on, evolution.

The cartoon originally appeared in a 1987 book by Ken Ham titled: The Lie: Evolution. In “Creation, Culture Wars, and the Search for Certainty,” Ted Davis said it has been the “signature icon” for Answers in Genesis (AiG), an organization founded by Ken Ham. Over time the image has been modified, as it reflected the ‘evolution’ of Ham’s and AiG’s thought. “Over time, I began to emphasize that believing in the creation account in Genesis means accepting God’s Word as the ultimate authority, and believing in the secular idea of evolution is to accept man’s word as the ultimate authority.”

In a 2002 version of the cartoon, the castle of Christianity was represented as being founded on six literal creation days equaling God’s authority, versus the millions of years equally man’s authority for the foundation of the humanism castle. In 2010, the foundations were “no longer creation vs. evolution or six days vs. millions of years, but ‘autonomous human reasoning”’ vs. ‘revelation/God’s word.’” See “Creation and Culture Wars” for the images.

Although Ham’s signature icon is still very much alive, it has evolved into a more sophisticated new species that is better adapted to twenty-first century culture wars, in which biblical faith is increasingly seen as contrary to science and reason. Ironically, Ham’s ministry itself is a primary cause of that perception.

Ted Davis noted how Ken Ham echoes the belief of William Jennings Bryan in the early twentieth century, that evolution inevitably undermines Christian faith. Like Ham, Bryan represented his thought in a cartoon. He saw evolution as causing modernism and leading to “the progressive elimination of the vital truths of the bible.” Bryan’s cartoon has three modernists, a student, a minister and a scientist descending a staircase that represents a slippery slope stemming from “the progressive elimination of the vital truths of the bible.” The descent starts with evolution and ends with the scientist stepping from Agnosticism to Atheism.

credit: original cartoon by Ernest James Pace; photograph by Ted Davis

The “Descent of the Modernists” cartoon appeared originally in Bryan’s 1924 book, Seven Questions in Dispute, published the year before his death, which took place days after his participation in the infamous Scope Trial. See “’Conflict Between Science and Religion’” and “No Contest; No Victory” for more on Bryan.

Despite the parallels in their thinking about creationism and the culture, Davis noted that Henry Morris, not Bryan, had the greater influence on Ham’s thought. AiG refers to the late Henry Morris as ‘the father’ of the modern creationist movement. His book, The Genesis Flood (1961), was the beginning of the revival of creationist thought that faded from the church with the passing of Bryan and the retreat of fundamentalism from cultural engagement after the Scopes Trial. Davis noted that in another book by Morris, The Troubled Waters of Evolution (1974), he argued evolutionary thought could be traced back beyond the “evolutionary pantheists” of the ancient Greco-Roman world. True as far as that statement goes, Davis noted where “Darwin’s theory was immensely more sophisticated and far more plausible than any ancient theory—but Morris goes much further.”

Morris traced the origins of evolutionary thought back through all the religions of the world other than Christianity, Judaism and Islam. These are excluded because they are based on Genesis. All other religions are “evolutionary” religions, including: Buddhism, Hinduism, Taoism, Confucianism, Atheism and ‘liberal Christianity.’ He said that evolution itself is a religion. He does not mean Darwinian evolution, but belief in the idea that all things have arisen by innate processes in the universe: the belief that the universe had no beginning; that it is eternal. You can watch a YouTube video series of a talk Morris gave titled “The Troubled Waters of Evolution.” It is in five parts. If you watch Part 1, notice the parallels between the metaphor Morris uses of the “fruit tree” of evolution producing harmful philosophies and evil practices the humanistic “balloons” in Ken Ham’s cartoon.

But Morris goes back even further in his book, The Troubled Waters of Evolution, according to Davis. He attributes the origins of evolution with Nimrod and the Tower of Babel in Genesis 10:8-10. According to Morris, it was part of the pantheistic polytheism of Babel Connected with astrology, idolatry, and the worship of fallen angels. “It is therefore a reasonable deduction, even though hardly capable of proof, that the entire monstrous complex [of evolution] was revealed to Nimrod at Babel by demonic influences, perhaps by Satan himself.” Therefore, evolution is “the world-view with which the whole world has been deceived.”

That’s why the foundation of Ham’s humanism castle connects evolution with Satan—and why evolution gets blamed for social ills that plagued us long before Darwin was born and would still be prevalent today even if Darwin had never existed. Evolution becomes the scapegoat for many sinful behaviors, to such an extent that it is virtually equated with sin itself, or even seen as inherently Satanic. This is a profoundly unhelpful way of approaching historical and cultural aspects of evolution, and it fails entirely to explain why many people who utterly reject evolution commit the very sins that Ham connects with belief in evolution.

Despite the revisions over time to the AiG “signature icon,” its foundations have actually changed very little. For AiG, Christianity sits on the foundation of “Creation;” which means “6 (24 hour) Days” for creation is equivalent to God’s authority; and only this interpretation is true “Revelation in God’s Word.” On the other hand, Humanism sits on the foundation of “Evolution;” which wrongly believes in “millions of years” for creation according to human authority; making “human reason autonomous” from the revelation of God’s Word. In other words, respect for the authority of God’s Word requires an agreement with the AiG view of creation in six 24 hour days—and its companion doctrines of 6,000 years since the creation and a global Noachian Flood (See the AiG Statement of Faith). In contrast, Humanism and its issues rest on autonomous reason, manifested in allowing millions of years for creation and allowing evolution rather than creation to explain how the universe and humanity came into being.

Lastly, the warfare metaphor in the AiG “signature icon” was actually first used by John William Draper and Andrew Dickinson White in their books on the perceived conflict or “war” between science and religion at the end of the 19^th century. Draper wrote History of the Conflict Between Religion and Science (1874) and White wrote History of the Warfare of Science with Theology in Christendom (1896). In the Preface of his book, Draper seemed to set conflict between religion and science on a foundation that was eerily similar to the 2010 AiG cartoon. “The history of Science is … a narrative of the conflict of two contending powers, the expansive force of the human intellect on one side, and the compression arising from traditionary faith and human interests on the other.”

Warfare or conflict rhetoric tempts us to see dichotomy where there may not be one. And when Christians use it to compare their understanding of a Biblical passage like Genesis 1 to alternative interpretations by other Christians (who also affirm the authority of Scripture), they need to be aware of the danger of imputing the rightful authority of Scripture onto their interpretation of the Biblical passage in question. It seems to me that is what has happened with Henry Morris and AiG.

11/14/17

Pharma’s Not Getting the Message

In response to rapidly increasing prescription drug prices and congressional inability or unwillingness to intervene, individual states are attempting to address the issue. While Californians approved a ballot initiative for recreational marijuana in November of 2016, state voters also turned down one aimed at curbing the high cost of prescription drugs. The California Drug Price Relief Act, or Proposition 61, sought to limit the state’s health programs from paying more than the U.S. Department of Veterans Affairs (VA), which receives the steepest discounts in the country, according to Reuters. Pharma companies lobbying against Proposition 61 spent $100 million to defeat it.

Proposition 61’s opponents, led by global drugmakers such as Pfizer Inc and Amgen Inc, spent around $106 million. They argued that it would benefit only 12 percent of Californians, while putting the other 88 percent, and veterans across the country, at risk of higher drug costs.

The defeat of the measure: “reaffirms the power of the biomedical lobby,” according to Brian Abrahams, a Senior Biotechnology Analyst at CIBC World Markets. Stuart Schweitzer, a professor of health policy and management at the University of California, said the measure would have only had a modest impact on state drug costs. Nevertheless, “They wanted to draw a line in the sand.” A similar proposition will be on Ohio’s 2017 November ballot.

U.S. New and World Report said New York State approved rules in April of 2017 that will put pressure on pharmaceutical companies if they want to continue doing business in the state. If Pharma companies don’t agree to voluntarily rebate or return money to the state if prescription medication spending is projected to exceed the sum of medical inflation plus 5 percent, New York State could initiate a series of reviews using scientific studies and other information to evaluate whether specific medications are overpriced. “Drug makers generally object to such reviews and often dispute their results.” The NY State Medicaid Director said the law created an incentive for pharmaceutical companies to collaborate and give the state rebates.

New York is not the only state taking action. Vermont lawmakers passed legislation requiring justification for price increases that are driving up spending in state programs like Medicaid. In March of 2017 Maryland lawmakers passed legislation, still not signed by the governor, directing Medicaid to notify the state attorney general when off-patent or generic drugs have “an excessive price increase.” The new law also sets financial penalties if the pharmaceutical company can’t justify the price hike. Louisiana officials are looking into whether a rarely used federal law could be used to “sidestep patents and allow government programs to get lower-cost generic versions of pricey hepatitis C treatments.”

In August of 2017, JAMA gave greater details about the New York legislation in: “Value-Based Pricing and State Reform of Prescription Drug Costs.” Hwang et al. said if the rate of drug spending growth exceeded the 10-year average inflation plus 5% in 2017-2018 or 4% in 2018-2019, the state department of health would be authorized to identify and refer high-cost drugs to a drug utilization review board to determine a target rebate amount. The provisions are likely to trigger a review this year. The board may consider the effectiveness of the drug, its therapeutic alternatives, and the seriousness and prevalence of the disease in formulating its recommendation for a value-based price.

If the state and manufacturer fail to agree on a rebate that is at least 75% of the difference between the drug’s current price and value-based price, the state may waive provisions that currently require managed care plans to cover medically necessary drugs in certain protected classes, including antidepressants, antiretrovirals, and hermatologic drugs. Furthermore, if total drug expenditures continue to increase faster than inflation despite these new rebates, the state may implement more aggressive actions to promote use of clinical alternatives, including directing managed care plans to remove drugs from their formularies that lack new rebate agreements.

The pharmaceutical industry is taking steps to prepare to do battle against these and other steps taken to rein in drug prices. The pharmaceutical lobby, PhRMA (Pharmaceutical Research and Manufacturers of America), is increasing membership dues by 50 percent to raise an additional $100 million PER YEAR to fund its ongoing fight over drug prices. “PhRMA has consistently ranked among the biggest lobbying spenders in Washington over the past few years.” By August of 2016, it had already spent $11.8 million that year, making it the fourth-largest lobbying group in Washington DC. TV advertising in 2017 was to target how “new drugs could add years to patients’ lives, as well as the years of complex research needed to develop a drug.”

The Intercept reported that newspapers in the Washington D.C. area were getting swamped in April of 2017 with ads warning of the dire consequences of proposals to lower drug prices. The groups placing the ads had no obvious connections to pharmaceutical companies. The ads appeared in the Washington Post, Washington Times, Roll Call, The Hill and Politico just as legislators were taking up proposals to lower drug prices. As it turned out, the organizations had undisclosed financial ties to PhRMA.

A bill proposed by Senator Al Franken would reverse a 2003 law prohibiting Medicare from using its collective bargaining power to negotiate lower drug prices. Legislators who wrote the 2003 bill worked closely with PhRMA lobbyists while drafting the legislation. The bill’s sponsor later became the president of PhRMA. Franken and others introduced the “Improving Access to Affordable Prescription Drugs Act” on March 29, 2017. Here is a five-page summary of the bill. A companion bill to “Improving Access to Affordable Prescription Drugs Act” was introduced in the House on the same day.

Some of its provisions would include several current problems with prescription drug costs. It would close the coverage gap in Medicare Part D coverage (known as the donut hole) in 2018, two years earlier than under current law. Tax credits given to pharmaceutical companies for their direct-to-consumer (DTC) advertisements would be eliminated. (WE WERE GIVING PHARMA COMPANIES TAX CREDITS WHEN THEY TRY TO GET US TO BUY THEIR DRUGS?) It would allow individuals, wholesalers and licensed U.S. pharmacies to import prescription drugs manufactured at FDA-inspected facilities from licensed Canadian sellers.

Significantly, Section 201 would allow the Secretary of Health and Human Services to negotiate with drug companies to lower prescription drug prices. It directs the Secretary to “prioritize negotiations on specialty and other high-priced drugs.” Under existing law, unlike Medicaid and the VA, Medicare is not allowed to leverage its purchasing power to negotiate lower drug prices.

STAT News reported that the Thursday before the November 2017 election, Andy Slavitt, the acting administrator for Medicare and Medicaid Services, said the rising costs for prescription drugs “will put unsustainable pressure on the Medicare program, and action is going to be necessary to address them.” He was addressing the BioPharma Congress, an industry conference. He said: “Drug costs have become the health policy issue Americans are most anxious to see us act on, and we have a responsibility to them to explore all the options available us to make their medications more affordable.” He told those at the conference that we could have both innovation and affordability. “These two goals shouldn’t be in opposition.”

In every-forward looking industry outside of health care, we see that competition actually fuels innovation, and affordability improves alongside the development of new technologies. . . . There are plenty of policy options and certainly a number of ways innovators like you can choose to respond – from disputing the math and fighting it, to looking for win-wins.

So far, it seems Pharma is ignoring the message. They are still trying to convince the American public and U.S. lawmakers that innovation in drug development will dry up if price caps are enacted.

The debate over the cost of drug development has been going on since the late 1950s, believe it or not. An often-quoted 2003 study, “The Price of Innovation,” which was published in the Journal of Health Economics, estimated it cost $802 million in 2000 dollars to bring a new drug to market. PhRMA’s 2014 profile found that estimate low and said it actually costs $1.2 billion to develop a new drug. However, “Demythologizing the High Costs of Pharmaceutical Research,” in the journal BioSocieties, suggested the true research and development costs were a median of about $43.4 million per new drug. That is about 5.4% of “The Price of Innovation’s” cost projection and 3.6% of the PhRMA estimate. See “Pharma and Its Golden Hoard” for a further discussion of what a new drug costs.

11/10/17

Here’s Some Gray Death

The fact-checking website Snopes looked into a report from Indiana claiming there is a new and dangerous drug called “Gray Death.” The report claimed Gray Death could cause the overdose or death of a drug user if it was accidentally inhaled after it became airborne or if it was absorbed through the skin after contact. Their investigation found the report was true. A local Indiana TV station, WDRB, was the source for the Snopes investigation, saying the Indiana Department of Homeland Security announced Gray Death was found in the Hoosier state beginning in May of 2017. But it seems Indiana was late to the Gray Death party.

Gray Death is a drug cocktail of heroin, fentanyl, carfentanl, and often U-47700 known on the street as “Pink” or “U4.” Heroin is two to three times as powerful as morphine. Fentanyl is about 50 to 100 times more powerful than heroin. Carfentil is about 100 times more powerful than fentanyl. U4 is the weakest drug in the mix after heroin, at only 7. 5 times the strength of morphine. The drug cocktail looks like concrete mix, thus the nickname of gray death.

Russ Baer of the DEA told NBC News on May 5, 2017 that Gray Death was initially limited to the Gulf Coast and states like Georgia and the mid-West state of Ohio. But it’s also been spotted in places like Chicago, San Diego, and Lexington. A “Pink”-free precursor to Gray Death was spotted in the Atlanta area back in 2012. “We are more routinely seeing deadly cocktails of heroin, fentanyl, various fentanyl-class substances, along with combinations of other controlled substances of varying potencies including cocaine, methamphetamine, and THC. . . . No one should underestimate the deadly nature associated with these cocktails.”

CNN noted that not only do the ingredients of Gray Death vary from sample to sample, some are present in such low concentrations (because of their strength) they may not show up on tests. Donna Ula, director of forensic chemistry at a biochemical company working with state and federal officials to identify unknown street drugs, said “It’s going to constantly vary, and it’s going to keep the chemists and the medical examiners on their toes.” She said Gray Death is “a fast-track route to the morgue.” A forensic chemist with the Georgia Bureau of investigation said even its gray color is a mysterious. “Nothing in and of itself should be that color.”

There have been several overdoses and overdose-related deaths in Georgia and Alabama linked to Gray Death. The Georgia Bureau of Investigation issued a public safety alert on May 4, 2017 about illegal synthetic opioids (Gray Death). The GBI Crime Lab has received about 50 cases of suspected Gray Death this year. Many contain three or four different opioids. One Metro-Atlanta law enforcement agency seized around 8 kilograms of a substance that when field-tested, didn’t identify what the mixture was. Further analysis at the GBI Lab found furanyl fentanyl and U-47700, two of the opioids regularly found in the Georgia Gray Death cocktail.

On May 10, 2017 The Morning Call reported there is Gray Death in the Lehigh Valley of Pennsylvania. After making two undercover drug buys at a woman’s home in Bethlehem PA, investigators had the drug packets tested because of their off-white color. They suspected they might contain fentanyl. But the preliminary results showed the packets contained a mixture of heroin, fentanyl and U4—Gray Death. After the preliminary identification, a search warrant was quickly issued: “We wanted to get it off the street as fast as possible.”

The woman’s three children, between the ages of 3 and 9, were living in the home with their mother. Police found some of the drug in a cup sitting on the shelf of a kitchen cabinet” within east reach of the children. The woman was arrested and charged with endangering the welfare of children, drug possession and possession of drug paraphernalia. She was freed after posting $5,000 bail. No word was reported on the children, but they were likely not in their mother’s custody given her charges.

According to Healthline News, the combination of synthetic opioids and/or heroin making up Gray Death varies widely. Given that the drugs or their precursors are created in unregulated labs, domestic drug dealers don’t always know how strong a batch is. “The potency can change from one batch to the next.” Dr. Seonaid Nolan, a clinical scientist in addiction medication at the University of British Columbia said: “Because it’s so potent, a small misstep in the preparation of the drug can lead to lethal consequences.”

This high potency also means it’s more difficult for customs and law enforcement to make searches and seizures, as it allows the drug syndicates to ship less physical product across the border. Sometimes the drugs are even shipped directly through the postal system. “Drug traffickers can move a high quantity or high volume of the product in a fairly small package.”

Traditional opiates like heroin are derived from the poppy plant, meaning the poppy plants have to be grown, harvested and then processed before heroin can be manufactured. “However, synthetic opioids can be produced entirely from chemical precursors.” This makes their production much simpler than heroin, since the entire manufacturing process can be done in a lab.

Fentanyl and its analogues have a high lipid solubility, meaning they readily pass through fatty tissues in the body. So fentanyl is used in transdermal patches and even lollipops, allowing it to enter the blood stream without having to be digested in the stomach. Since it doesn’t get metabolized, you need smaller amounts of fentanyl because it can go directly to the brain through the blood system. This also explains its danger if it becomes airborne or comes in contact with exposed skin. Edward Bilsky, a professor of Biomedical Sciences at Pacific Northwest University said:

[These drugs] are very fast acting and produce profound depression of respiration and other central nervous system functions leading to many deaths. . . . First responders and others around the victim need to be careful due to secondary exposure.

According to the DEA, fentanyl analogs, like acetyl fentanyl and furanyl fentanyl are manufactured in China by clandestine labs, and then smuggled into the U.S. through established drug smuggling routes in Mexico. Mexican drug traffickers also manufacture their own analogs of fentanyl. In the past, the Chinese government denied they were the source of illicit fentanyl being smuggled into the U.S. But DEA officials and others met with Chinese officials in 2016, which prompted China to regulate four fentanyl-related substances in an effort to help stem the flow of these opioids into the U.S. in action that went into effect in March of 2017.

Carfentanil was one of these substances. Because of its off-the-charts strength, it was receiving a lot of press coverage in 2016. See “Fentanyl: Fraud and Fatality” and “The Devil in Ohio.” But unless you followed news on the death of Prince, you may not have heard of “Pink” (U-47700 or U4) before. In addition to fentanyl and Percocet (oxycodone-acetaminophen), Pink was found in his system. In November of 2016, the DEA temporarily classified U-47700 as a Schedule I controlled substance, due to its “immanent threat to public health and safety.” The DEA received at least 46 confirmed reports of deaths associated with U-47700—31 in the state of New York and 10 in North Carolina. “This scheduling action will last for 24 months, with a possible 12-month extension if DEA needs more data to determine whether it should be permanently scheduled.”

In addition to Georgia, Pennsylvania and Ohio, drug busts in multiple states are reporting they have seized quantities of Grey Death. Traffic stops in Greenville County South Carolina found 17 pounds of heroin and one pound of Grey Death. There have been two reported seizures of Grey Death in Virginia. Grey Death has been reported in Florida since November of 2016. It’s been found in Alabama. In a video from WCPO in Cincinnati, Ohio, Detective Jim Larkin of the Lorain County Sheriff’s Department wondered why anyone would try something called Grey Death. “Here’s some Grey Death. Now what do think is going to happen to you? Why do you think it’s called Grey Death?”

11/7/17

Swallowing a Camel

The Babylon Bee reported that NYPD detectives are investigating an attack on a group of teen-aged youths who were mauled by two female grizzly bears in Central Park. According to witnesses, when pastor and author Tim Keller was on his morning run through Central Park he passed a group of young men. One of them shouted, “Hey baldy! Run, baldy, run!” Another youth echoed the sentiment before the two high-fived each other. Onlookers reported that Keller stopped jogging, closed his eyes and prayed. Immediately two massive grizzlies charged out of a nearby wood and mauled the group of boys.

The event, of course is not true. And if you are not familiar with the Babylon Bee, you would have missed the clue it gave that you were about to read a satirical piece of “news.” The back-story to the above is in 2 Kings 2:23-25, when the newly anointed prophet Elisha was traveling from Jericho to Bethel after his predecessor, Elijah, was taken up to heaven in a fiery chariot. A group of forty-two young boys (The Hebrew phrase can refer to youths between the ages of twelve and thirty) came out of Bethel and jeered at him, saying, “Go on up you bald head!” In his commentary on 2 Kings, Paul House suggested their jeering seems to be a contemptuous reference to Elijah’s being taken up to heaven, with the sense of “Go away like Elijah.” Elisha cursed them in the name of the Lord, as their behavior was an insult directed at him as a prophet, and therefore the Lord who he represented. “And two she-bears came out of the woods and tore forty-two of the boys.”

What happened in the 2 Kings passage was not an example of biblical satire, but Leland Ryken commented in How to Read the Bible as Literature, that there is more satire in the Bible than you might think. Much of the Bible’s truth and wisdom has been shaped as satire. “By framing truth as an attack on vice or folly, biblical satire drives its point home with an electric charge.” Despite the negative approach of the satirist, a positive norm emerges from biblical satire because it includes a foil to the evil it attacks. “That foil is usually the character or law of God.”

Satire, Ryken said, is “the exposure, ridicule or rebuke, of human vice or folly.” It can “appear in any literary genre (such as narrative, lyric or parable), and it may be either a minor part of a work or the main content of an entire work.” The reader’s task with satire is fourfold: to identify the object(s) of attack, the satirical vehicle that embodies the attack, the tone (either biting or laughing), and the norm or standard by which the criticism is made.

Satire usually has one main object of attack, but it could also have a number of jabs in various directions, called “satiric ripples.” When satire “is an attack on historical particulars it means that the reader of satire usually needs help in reconstructing the assumed social context—the economic, political, religious, or social conditions that the satirist attacks.”

The object of attack could be a single thing, as in the parable of the rich man and Lazarus (Luke 16:19-31), which attacks the love of money and the callous unconcern it encourages. Or it could be a series of objects as with Jesus’ discourse against the Pharisees in Matthew 23. There Jesus rapidly ridiculed the scribes and Pharisees, saying they tithe mint, dill and cumin, but neglect the weighty matters of justice, mercy and faithfulness. They are like whitewashed tombs that outwardly appear beautiful, but are full of dead bones and uncleanness. “So you also outwardly appear righteous to others, but within you are full of hypocrisy and lawlessness.”

The object could be a historical particular, like the attack on the self-righteousness of the Pharisees in parable of the Pharisee and the tax collector (Luke 18:9-14); or it could be about a universal vice like greed, as in the parable of the rich fool (Luke 12:13-21), planning to build larger barns to store all his grains and goods.

The most common satiric vehicle is story, as with Jonah or the satiric parables of Jesus. There may also be brief snatches of action, as when Isaiah 46:5-7 briefly narrates how idol worshipers first have to have a goldsmith make an image in order for them to fall down before it and worship! Or there could be a portrait or character sketch as in Isaiah 3:16: “The Lord said: Because the daughters of Zion are haughty and walk with outstretched necks, glancing wantonly with their eyes, mincing along as they go, tinkling with their feet.” Narratives and portraits are among the most artistic and sophisticated types of satiric vehicle. At the more informal end are cruder statements, as when Amos calls the wealthy women of Israel “cows of Bashan” (Amos 4:1); or the “woe formula” used by Jesus in Matthew 23 cited above.

Biblical satire always has one of two prevailing tones. One is gentle, smiling and subtle. “It aims to correct folly or vice by gentle laughter, on the premise that it can be laughed out of existence.” Examples of such a “soft sell” would include the story of Jonah as a whiny, pouting prophet. Or Isaiah 44:9-17, where those who fashion idols are described as taking part of a tree to build a fire in order to warm himself or bake bread, while with the rest he makes into a god, his idol, and falls down and worships it.

The second tone is biting, bitter and sharp. “It points with contempt and moral indignation at the corruptness and evil of people and institutions.” Most biblical satire is of this type, and includes a good bit of scorn, as opposed to humorous laughter.

The fourth and final aspect of satire to look for is the satiric norm; the standard by which the object of attack is being criticized. “The satiric norm is the positive model that is offered to the reader as an alternative to the negative picture that always dominates a satiric work.” In Jonah, the universal mercy of God is extended to the repentant city of Nineveh as a positive foil to Jonah’s misguided patriotism. “In the Sermon on the Mount, each of Jesus’ satiric charges against the Pharisees is accompanied by a positive command (Matt. 6:1-14).”

Satire is found throughout the Bible. The books of Jonah and Amos are entirely satirical. The orthodox comforters in Job are the ones who are rebuked. “The book of Ecclesiastes is a prolonged satiric attack against a society that is much like our own—acquisitive, materialistic, hedonistic, secular.” Many of Jesus’ parables, like the rich man and Lazarus (Luke 16:19-31) or the tax collector and the Pharisee (Luke 18:9-14) are satiric. Whenever a biblical narrative prominently displays a character’s flaws, as with Jacob’s greed or Haman’s pride, there is a thread of satire.

Given this discussion of satire, I’ll offer the following suggestion of why the Babylon Bee story about Tim Keller is satirical. Remember that satire is “the exposure, ridicule or rebuke, of human vice and folly.”

The object of attack is against the infighting that occurs among evangelicals when ministers are perceived to be “too liberal” because they don’t hold to certain doctrinal positions. You can Google “Tim Keller” and “critique” to see what I mean. There are articles on Tim Keller’s “false gospel,” his “disappointing” comments on homosexuality and more. He’s been roundly criticized for what he’s said with regard to evolutionary creation. There’s even a book giving “a gracious criticism of some aspects” of his theology.

The satiric vehicle is an alternate reality story that portrays Tim Keller as Elisha in a modern version of 2 Kings 2:23-25. The satiric tone is subtle and laughing. Praying for judgment against his critics is the last thing to expect from someone like Tim Keller. Note also how the Babylon Bee article said Keller “calmly closed his eyes and uttered a prayer” as opposed to Elisha calling down a curse against those who were ridiculing him.

The satiric norm for the Babylon Bee article would be to remind those critics of Keller that they are also, in a manner of speaking, being critical of the God he serves as a minister. I don’t mean that questioning the opinions of Tim Keller is tantamount to debating Paul or Moses on some of their doctrinal positions. But (to use another satirical image), I think they are straining out a gnat and swallowing a camel (Matthew 23:24). With all the cultural critiques they could be addressing today, they are going after Tim Keller. Really?

11/3/17

Downward Spiral of Antipsychotics

Antipsychotic or neuroleptic drugs became big business for pharmaceutical companies about nine years ago, reaching sales of $14.6 billion in 2008. This made them the best selling therapeutic class of medications in the U.S. that year. Not only are they used to treat psychosis and bipolar disorder, several have been approved as an add-on medication to treat depression. Additionally they are used off-label with children and the elderly for behavioral control. And they are the primary cause for a serious neurological disorder called tardive dyskinesia.

Tardive dyskinesia (TD) is a group of involuntary movement disorders caused by drug-induced (iatrogenic) neurological damage, primarily from antipsychotic drugs and a few others that block the function of dopamine in the brain. “TD can vary from a disfiguring grimace to a totally disabling array of spasms and often bizarre movements of any part of the body.” If TD is not identified early on and the drugs stopped, “these disorders nearly always become permanent.” Both patients and their doctors often fail to recognize or diagnose its symptoms.

The above short introduction was gleaned from Dr. Peter Breggin’s “Antipsychotic Drugs and Tardive Dyskinesia (TD) Resources Center.” If you can spare a few minutes, watch a ten-minute TD video edited by Dr. Breggin from existing videos available on the Internet. The video contains a series of individuals with the three general types of tardive dyskinesia whose ages range from pre-adolescence to seniors. These types are: tardive dystonia, a series of involuntary movements that include painful muscle contractions or spasms; tardive akathisia, psychomotor agitation; and classic tardive dyskinesia, the rapid, jerky movements or uncontrollable head bobbing or movements of the arms, hands, feet fingers or toes. The following is a reproduction of a table from Psychiatric Drug Withdrawal by Peter Breggin more fully describing the symptoms of tardive dyskinesia.

Symptoms of Tardive Dyskinesia

Tardive Dyskinesia (Classic)

Rapid, irregular (choreiform), or slow and serpentine (athetoid) movements; often bizarre looking; involving any voluntary muscle, including:

Face, eyelids and eye muscles, jaw (chewing movements, tongue biting), mouth lips, or tongue (protruding, trembling curling, cupping)

Head (nodding), neck (twisting, turning), shoulders (shrugging), back, torso (rocking movements), or abdomen

Arms and legs (may move slowly or jerk out of control)

Ankles, feet and toes; wrists, hands, and fingers (sometimes producing flexion, extension or rotation)

Breathing (diaphragm and ribs; grunting), swallowing (choking), and speaking (dysphonis)

Balance, posture, and gait (sometimes worse when slow, often spastic)

Tardive Dystonia

Often painful sustained contractions (spasms) of any voluntary muscle group; potentially causing muscular hypertrophy, arthritis, and fixed joints; frequently involving the following:

Neck (torticolis, retrocollis) and shoulders

Face (sustained grimacing and tongue protrusion)

Mouth and jaw (sustained opening or clamping shut)

Arms and hands; legs and feet (spastic flexion or extension)

Torso (twisting and thrusting movements; flexion of spine)

Eye lids (blepharospasm)

Gait (spastic; mincing)

Tardive Akathisia

Potential agonizing inner agitation or tension, usually (but not always) compelling the patient to move, commonly manifested as the following:

Restless leg movements (when awake)

Foot stamping

Marching in place, pacing

Jitteriness

Clasping hands or arms

Inability to sit still

TD can impair any muscle functions that are partially or wholly under voluntary control such as the face, eye muscles, tongue, neck, back, abdomen, extremities, diaphragm and respiration, swallowing, and vocal cords. Coordination and posture can be afflicted. TD can cause tremors, tics, and paresthesias (e.g., burning sensations, numbness). TD can also afflict the autonomic nervous system, especially impairing gastrointestinal functioning.

TD sufferers are often exhausted by these unrelenting body movements; even when they are limited to one area of the body, such as the jaw, neck or feet. They become socially withdrawn and isolated—humiliated by the stigma of their uncontrollable movement disorder. One muscle group, such as the tongue or fingers, or various muscle groups can be afflicted. TD symptoms can also change over time from one muscle group to another. This can occur over a period of minutes, days, weeks or years. “Especially in the dystonic forms, the pain can be very severe, and the physical stress can cause serious orthopedic problems.” Antipsychotic drugs are the primary cause of this neurological disorder.

Antipsychotic drugs are also called neuroleptics. Prescribers often promote them in a misleading fashion as antidepressants, mood stabilizers, bipolar drugs, sleeping pills, and behavior control drugs in children. Recent ones include Risperdal (risperidone), Abilify (aripiprazole), Geodon (ziprasidone), Invega (paliperidone), Latuda (lurasidone), Rexulti (brexpiprazole), Risperdal (risperidone), Saphris (asenapine), Seroquel (quetiapine), and Zyprexa (olanzapine). Older antipsychotics include Haldol (haloperidol) and Thorazine (chlorpromazine). [See a more complete listing of antipsychotics here]

Drug companies have made claims that the newer, so-called atypical antipsychotic drugs are less likely to cause TD, but those claims are false or misleading. A 2008 study by Chouinard found a high prevalence of DIMD (drug-induced movement disorders). Nearly 50% of patients had a definite DIMD. The authors also said that DIMD persisted with atypical antipsychotics. “It is crucial to acknowledge that there is a persistence of DIMD with atypical antipsychotics, which are not recognized and confounded with psychiatric symptoms.” Caroff, Miller and Rosenheck reported in “Extrapyramidal Side Effects” that there were no significant differences in measuring the incident rates of TD and other DIMDs between atypical antipsychotics and an older antipsychotic, perphenazine (Trilafon).

According to Dr. Breggin, TD occurs around a rate of 5 to 8 percent per year in adults up to the age of 40, with an accumulating risk of 20% to 24% after four years. The rates increase rapidly over forty. “For a 40-year-old patient, the risk is 18% at 2 years [9% per year] and 30% at 4 years.” In patients over 45, “the cumulative incident of TD after neuroleptic exposure is 26%, 52%, and 60% after 1, 2, and 3 years, respectively.”

Recently the FDA approved two medications to treat TD. Let this sink in. A serious neurological disease, which is primarily caused by a class of psychiatric medications, is being treated with another medication. Neurology Advisor interviewed two experts medical experts on the current state of treatment for TD. One of the experts interviewed said:

The main issue in the “treatment” of TD is prevention. It is important to use offending agents only when the potential benefit is higher than this risk. Once it appears, the first step is to determine whether symptoms are bothersome or disabling to warrant treatment. If possible, either discontinue the offending agent, although this might not improve symptoms permanently, and they will probably worsen initially, or change to a similar agent less likely to cause TD. In terms of prescription medications for TD, I have observed significant variability in treatment approaches depending on physician choice. Over the last few years, I personally found tetrabenazine to be the most efficient agent.

Tetrabenazine (Xenazine) was approved to treat the movement disorder associated with Huntington’s chorea, but has been used off-label to treat TD. It is now off patent and available as a generic. On patent, it sold for $152,000 per year. The generic version is $96,000 per year. However, there have been two new drugs approved specifically to treat TD: Austedo (deutetrabenazine) and Ingrezza (vabenazine). Both are being priced at around $60,000 per year. All three medications carry “black box” warnings from the FDA because of their risk for depression and suicide. You can read more about these medications here, here, here and here.

In addition to TD, antipsychotics have been linked to adverse cardio vascular events, brain shrinkage, dopamine supersensitivity, weight gain, diabetes, a shortened life span and more. The risk-benefit ratio may see a need for short-term use of antipsychotics, but the long-term benefits of their use are questioned by many credible sources. There have been follow up studies that support that concern. See this blog post by Thomas Insel, the former director of the NIMH, the National Institute of Mental Health.

It seems to be stepping onto a downward spiral to use medications with serious side effects to treat TD, a serious side effect from antipsychotics. As the above quoted expert, suggested, the best treatment for tardive dyskinesia is prevention—avoid antipsychotics if at all possible. For more information on concerns and adverse effects with antipsychotics, see: “Blind Spots with Antipsychotics” Part 1 and Part 2, “Antipsychotic Big Bang”, “Wolves in Sheep’s Clothing” and “Hollow Man Syndrome.”

Faith Seeking Understanding

Charles Sigler, D.Phil.

Monthly Archives: November 2017