Medawar C, Hardon A. Amsterdam: Aksant Academic Press; 2004.
Amsterdam: Aksant Academic Press; 2004. 258 pages. Price approx $64*

This book is not for the faint-hearted. It is in small type, heavily referenced (30 pages of references), and has extensive footnotes (on some pages the footnotes occupy more space than the text). However, as a chronicle of the complexity of the development and use of drugs in modern medicine it makes fascinating reading.

The authors use the example of the selective serotonin reuptake inhibitors (SSRIs) and the slow percolation of knowledge about their adverse effects to develop the overall thesis that we are all part of a 'conspiracy of goodwill' regarding new drugs. They contend that this conspiracy is fostered by the pharmaceutical industry for its own financial purposes. The book also contends that the industry is aided by academia and the medical profession, not only by their endless pursuit of panaceas and naive faith that new drugs must be better than old ones, but also by their reluctance to tackle the conflicts of interest that arise in acting as intermediaries between the industry and patients.

Despite its focus on the SSRIs, the book is wide ranging in its scope - and criticism. It puts the SSRIs into a historical perspective, arguing that it was naive to think that the SSRIs would prove fundamentally different from their antecedents - alcohol, opioids, bromides, barbiturates and benzodiazepines. Along the way, the book strays into discussion of other aspects of modern drug use. These include the disease creation and awareness industry, the dangers of direct-to-consumer advertising and the power of changing terminology (for example, withdrawal syndromes becoming discontinuation syndromes).

The book is particularly critical of the reliance of regulatory systems on voluntary reporting of adverse drug reactions. It contends that for years it was clear in the voluntary reports that there were extensive problems of withdrawal reactions to SSRIs. These reactions went unrecognised because of the rigid classification system used by the regulators and their reluctance to revisit their initial evaluation that the drugs had few adverse effects. They (and others, including academia) fell for the 'NERO' argument - no evidence of risk equals evidence of no risk.

There are some strong streaks of 'wisdom of hindsight', and even paranoia, in this book, but it is powerful and well argued. It should be read by everyone interested in the sociology of the use of pharmaceuticals in modern medicine.

* ISBN 9052601348. Available from DA Information Services
(03)9210 7177 or e-mail [email protected]

Robert Moulds

Professor of Medicine, Fiji School of Medicine, Suva, Fiji

Chairman, Australian Prescriber Editorial Executive Committee