Reading this book is like sitting on the side of a hill watching a faulty train full of happy passengers hurtling towards inevitable catastrophe and being powerless to stop it happening. In fact it's like watching wreck after wreck take place. In these cases the trains are manufactured by the pharmaceutical industry, the passengers are the trusting patients and the drivers are the prescribers who appear blind to the possibility that there could be any danger ahead. The controllers and signallers are the regulatory authorities who may be in the pay of the train's manufacturers or dominated by politicians.

The book starts with examples of recent drug catastrophes. It lays out how, particularly in the USA, the reach of the pharmaceutical industry is everywhere. The authorities, who should be the guardians of drug safety, are subject to a Congress and Senators in the pay of the industry and they are guided by professional experts who should be objective, but instead are recipients of payments and other inducements to support products and launder data. Although we all suspect this to be the case, the true extent of it is almost beyond comprehension.

The book is a very balanced text as would be expected when the author is one of the world's foremost pharmacoepidemiologists. It is not all anti-drug or anti-industry, there are sections on benefits as well as risks and costs. There are sections on policy and on how information about drugs is collected and used. There is an excellent discussion about the choices society has to make about how to get the best value from health dollars.

The book has, of course, a heavy focus on the USA. While this may make it of less interest to readers outside that country, there are many similarities with events here that readers will recognise. For example, the infiltration of the research agenda by the pharmaceutical industry as public research funds become more scarce, and the hijacking of postgraduate education in the same way. We also have medical experts, 'key opinion leaders', who have been subtly bought by the industry.

My one criticism is the use of American trade names even though generic names are usually, but inconsistently, given. Although some generic names are cumbersome and not easily recognised, the international reader will not recognise many of the American names.

The book makes complex topics easily comprehensible. What makes the book so readable, beyond the voyeuristic fascination of watching tragedy after tragedy unfold, is Avorn's sharp humour. For example, '... anti-Parkinson drugs are a rough crowd to invite across your blood-brain barrier if you don't have to'.

Jerry Avorn is a world expert and also a brave crusader. Anyone who ever prescribes, dispenses or takes a medication should pause before they do so to read this book. They may make a different choice as a result.

John Marley

Pro Vice-Chancellor, Faculty of Health, University of Newcastle, Newcastle, NSW