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Power, Politics and Pharmaceuticals
Power, Politics and Pharmaceuticals


 
Our Price:49.00
Authors: Orla O'Donovan and Kathy Glavanis-Grantham
Affiliation: University College Cork
Publication Year: Hardback 2007
Pages: 262
Size: 234 x 156mm

ISBN: 9781859184196
Qty:

Description
 

Public concerns about the regulation of the pharmaceutical industry have intensified in recent years, not least because of a series of controversies about drugs such as those used in the treatment of depression, arthritis, and AIDS. Paradoxically, these concerns centre on the over-consumption of medicines of dubious benefit in Western societies, and lack of access to essential medicines in the Global South.
Central questions that are explored include: what are the implications for health of existing systems of pharmaceutical drug regulation?; and what do existing systems of drug regulation reveal about the power of transnational pharmaceutical corporations to shape regulatory and other policies?

The importance attached to considering the Irish regulatory system in its international context is reflected in the inclusion of chapters that address the implications of World Trade Organisation and EU regulatory policies and regulatory trends in Canada, Britain and Australia.

By demonstrating how the analysis of pharmaceutical drug regulation can provide rich insights into the operation of power in contemporary society, this book challenges the prevailing construction of drug regulation as a sphere of 'policy without politics' and aims to contribute to the imagination of better ways of regulating medicines.

Orla O'Donovan is a Lecturer in the Department of Applied Social Studies at University College Cork. Kathy Glavanis-Grantham is Lecturer in Sociology at University College Cork.

Contents

Introduction by Orla O'Donovan

Globalisation, Power and the Politics of Science

Globalisation and Pharmaceuticals: Where Is the Power? Where to Resist? by Denis O'Hearn and Stephen McCloskey

The Pharmaceutical Industry and the World Trade Organisation's TRIPs Agreement: Intellectual Property, Global Governance and Health by Gerard Downes

Bias and Science in Knowledge Production: Implications for the Politics of Drug Regulation by John Abraham

Medicines Regulation in Ireland: Health and Democracy at Risk?

The Emergence of Pharmaceutical Industry Regulation for Competition (aka Profit) in Ireland by Orla O'Donovan

Alliance for Progress or Unholy Alliance? The Transnational Pharmaceutical Industry, the State and the University in Ireland by Kathy Glavanis-Grantham

Drug Expenditure in Ireland: Explaining Recent Trends by Michael Barry, Lesley Tilson and Máirín Ryan

The Medical Profession and the Pharmaceutical Industry: Entwined, Entangled or Ensnared? by Colin Bradley

The Dominance of Drug-Based Mental Health Care in Ireland: A Personal Account of a General Practitioner Turned Psychotherapist by Terry Lynch

Controversy and Change: Medicines Regulation in Canada, Britain and Australia
Chapter

New Directions in Canadian Drug Regulation: Whose Interests are Being Served? by Joel Lexchin

Turbulence in UK Medicines Regulation: A Stink about SSRI Antidepressants that Isn't Going Away by Andrew Herxheimer

Is Australia's National Medicines Policy Failing? The Case of COX-2 Inhibitors by Agnes Vitry, Joel Lexchin and Peter R. Mansfield


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Dr Patrick Rowan looks at a new book which examine April 19, 2010
Reviewer: Irish Medical Times from Republic of Ireland  
Dr Patrick Rowan looks at a new book which examines the business of prescription drugs.  This series of essays is primarily concerned with the pharmaceutical industry in Ireland  but it also has reference to the industry in Canada  Australia and in the United Kingdom. They cover the regulation of the licensing of new prescription drugs  their follow up for significant side effects and the global consequences of companies maintaining high prices for these drugs   irrespective of particular countries  economies. In general  a critical approach is taken on how the trans national pharmaceutical companies operate.  Ireland has benefited enormously  financially  since foreign pharmaceutical companies began to establish bases here in the 1990s. The 12.5  corporation tax and an educated English speaking workforce was reputedly a big factor in their choosing Ireland over other EU countries.   By 2004  24 000 people were employed in these companies and annual exports of pharmaceutical products were worth over US 30 billlion. American pharmaceutical companies constitute 44 per cent of the total  German firms have 14 per cent  with lesser percentages from other countries.   It is only natural that the Irish Government should regard the locating of these companies in Ireland as a great achievement  especially as the employees are  on average  paid better than their peers in other companies.  Patent rights  Pharmaceutical companies always claim that the high price of new drugs is due to the cost of producing them  which is understandable as the cost of bringing a new drug to market is very high.   In 1995  under the Intellectual Property Rights Agreement  patent rights for 20 years were given to these companies where the drug was found to be innovative and useful.   This embargo curbs the flow of cheaper generic offspring  but it also means that companies tend to concentrate on the lucrative markets and find it less profitable to produce drugs for the more unusual tropical diseases.   Prescription drug regulation began in Ireland in the 1960s  following the thalidomide disaster. The Irish Government washed its hands of the thalidomide victims until it was shamed into acknowledgement in 1973.   John Abraham  Professor of Sociology in the University of Sussex  tells in his essay how very concerned he is that certain drugs were allowed on to the market. He cites the case of Opren  a drug that had treated only 39 patients and was then publicised in the media as a drug capable of modifying the course of rheumatoid arthritis.   Halcion is banned in England  Norway and Denmark  but its use in Ireland and the USA is permitted. Abraham is critical of the American Food and Drugs Administration  FDA  for its interpretation of the safety of this drug. He feels that the FDA  like our Irish Medicines Board  is not an ideal organisation to vet these drugs since both are financed largely by the fees paid to them by the drug companies.   Better informed  There appears to be general agreement that patients should be better informed about the risks of newly released medicines. Post marketing surveillance of new drugs should be more thorough  but it is way down the scale in comparison with getting of approval for the sale of new drugs.   It might be worth mentioning in this context that it is found that few health professionals report the drug reactions that they encounter. In the UK  the Medicines and Healthcare Products Regulatory Agency  MHRA  is regarded as one of the best such organisations in the world  but it took a BBC  Panorama  television programme to alert the public to the withdrawal side effects of Seroxat.  Yet  the original licence application recorded that when patients stopped taking this drug  30 per cent suffered withdrawal reactions. Dr Andrew Herscheimer  who founded the Drug and Therapeutic Bulletin  states in his essay that the discovery of the problems with the selective serotonin reuptake inhibitors showed serious deficiencies in the UK regulatory system.   Drug companies make great efforts to publicise products. This is to be expected  but how they go about it can cause problems for the medical profession. In the US  direct to consumer advertising is allowed.   Following America?  In Canada  disease awareness advertisements are permitted and the name and price may be shown  but the two may not be shown together. Now disease awareness advertisements are appearing on our own TV screens. Are we likely to follow the American model?   The purpose of this book is to show the haphazard nature of the regulation of prescription drugs  how drugs like Celebrex and Vioxx were allowed to be introduced with claims that they were safer than the older NSAIDs  and also how further safeguards might be put in place in the future to ensure adequate pre  and post marketing surveillance.It is in every doctor s interest in read this book.

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Shrouded in an elitist mystique the pharmaceutica April 19, 2010
Reviewer: Verbal Magazine from Republic of Ireland  
Shrouded in an elitist mystique  the pharmaceutical industry has enjoyed decades of unrivalled  in house  secrecy  protecting the integrity of their drug designs. However  recent public controversies have prised open the laboratory doors and exposed these companies as transnational corporate giants who are active ingredients in the expansion of globalisation.   Power  Politics and Pharmaceuticals is a collection of articles written by a multidisciplinary group of contributors; ranging from experts in drug regulation and pharmacoeconomics to social science. Putting the existing systems which regulate the pharmaceutical industry under the microscope  it examines how and why these companies have undergone such an economic mutation and  through this  offers a unique hypothesis on the structure of power in the world today.   These articles portray the pharmaceutical industry as virus like  invading all sectors of influence until becoming an opaque  yet significant  transnational presence in the world marketplace. Vying for global custom it trades with governments desperate for economic regeneration  prepared to soften policies such as low corporate tax rates and the availability of land sites that meet industrial locational requirements securing much needed foreign investment.    It details  shockingly  the extent of the role played by the pharmaceutical industry in Ireland s economic upsurge  arguing that the Celtic tiger s drug induced performance was enhanced when sixteen of the top pharmaceutical companies established facilities in the Republic. Between 1996 and 2003  Ireland s exports of pharmaceuticals increased by an incredible 1 514  accounting for almost a quarter of Irish exports.     These investigations also expose an ingratiating  partnership  between the industry  healthcare professionals and the academic world through funding research facilities and up to 80 90  of post graduate training. The recent controversy surrounding Glaxo Smith Kline and key clinical trial data on an anti depressant suggests that this ethical entanglement enables drug companies to subtly influence their own research agenda  suppressing unfavourable findings.   Most shocking  however  is the accusation that Pfizer  whose market value of  266 billion  larger than the combined GDP of the eighteen biggest economies in sub Saharan Africa  legally blocked attempts to produce cheaper versions of HIV/Aids drugs in the disease ravaged continent. Such behaviour could be described as a pharmaceutical regime  parasitically earning off the very people it claims to serve.   While the topics Power  Politics and Pharmaceuticals cover are vast and the terminology quite scientific  it is brilliantly edited to make for insightful yet uncomfortable reading. Despite its blistering attack on the industry it argues for independent  patient accountable regulation as the remedy to return it to a patient  not profit led organisation.   When medicine is traded on the global economic floor like oil or steel then the very ethos of healthcare has a price. What this book argues passionately is that beneath the white coats of the pharmaceutical world there are the designer suits of corporate commerce manipulating the costs of our health  our lives and even our deaths.

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Medicines policy and drug company investments: th April 19, 2010
Reviewer: Australian Health Review from Republic of Ireland  
Medicines policy and drug company investments:  the Irish experience    THIS BOOK IS ABOUT MANIFESTATIONS of power in  medicines and pharmaceutical industry policy.  The main focus is on the Republic of Ireland but  there are chapters also on drug regulation in  Canada  Britain and Australia. The multinational  pharma companies loom larger in Ireland than in  most other countries; several chapters detail the  implications for this small country of the presence  of a major cluster of global drug companies.  Globalisation is the hallmark of the drug sector;  innovation and production occur within international  networks which are mirrored by interaction  between regulatory agencies which operate  similar systems of control and monitoring. Since  the 1990s  many aspects of product safety regulation  have been standardised across the developed  countries through the International Conference  on Harmonization  ICH  process  sponsored by  the regulatory agencies and industry associations  of the USA  the European Union and Japan.  While orchestrating vast scientific  economic and  technological resources  the big pharma companies  participate as insiders in national policy  processes  such as those described in this book.  Firms typically affirm a commitment to the health  and economic concerns of the local jurisdiction    however governments cannot help but be  sensitive to their global reach and power to  choose where to invest.  Globalisation is often said to have enhanced  this type of structural power. Yet significant scope  remains for nationally unique health policy  arrangements and in drug reimbursement and  pricing policy. Indeed  it may be that the very  process of globalisation is eroding the advantages  of big pharma vis   vis actors concerned with  health and social policy.  Governments and other  non corporate actors  have ready access to  information about drug  company act ivi t i es  everywhere  including  safety and ethical controversies   and there is  overlap and exchange in  policy debates across  the globe. An obvious case in point is Australia s  pioneering of cost effectiveness analyses in the  Pharmaceutical Benefits Scheme  PBS  listing  process  a model which has attracted much international  interest  and similar systems have been  introduced or are under consideration in many  countries. At times public health activists effectively  challenge the power of the industry  as  exemplified by the successful shaming of companies  for access to HIV/AIDS medications in Africa.  That there is a shift in drug policy dynamics is  reflected in the centrality today of the notion of   partnerships . This theme is particularly conspicuous  in Australia where it underpins the  National Medicines Policy  NMP . Since its inception  in the early 1990s  the very premise of the  NMP is that all stakeholders  including consumers   should be able to exercise some influence.  It seems there is no similar framework for  medicines policy in Ireland   several analyses in  this book highlight the absence of effective constraints  on industry power. This is explained as  the outcome of economic policy which has created  an unusual dependence on foreign multinationals   a development model described as  inimical to economic diversity  domestic innovation  and the quality of medicines regulation.   Indeed  presently Ireland is among the European  countries most severely affected by the global  economic crisis  which raises further doubts  about this model.  It is not to be expected then  that the Irish perspective lends itself to an appreciation  of the countervailing powers accrued by  other policy actors in the pharmaceutical sector   in some national and international contexts  or of  the problems and contradictions of the big  pharma model itself  much discussed in the  recent trade and academic literatures. Yet this  excellent collection of essays is in itself testimony  to the resourcefulness and intellectual depth of  the international community of public health  activists. The editors are members of Health  Action International  and among the contributors  are analysts based in Canada  Joel Lexchin   the  UK  John Abraham and Andrew Herxheimer  and  Australia  Agnes Vitry and Peter R Mansfield .  Several chapters explore tensions between  public health and commercial interests through  analyses of the incapacity or disinclination of  regulatory agencies to appropriately and fearlessly  assess medicinal products for safety and efficacy.  The dependence of these agencies  including  Australia s Therapeutic Goods Administration   TGA   on fees and charges paid by its  clients    that is  the pharmaceutical industry  and their  general concern to retain close relations with the  industry  is shown to give rise to bias in the  regulatory process. John Abraham argues that  institutional context and culture make scientists  and others involved in drug testing and regulation  unduly sensitive to commercial interests.  This is illustrated by three cases studies: an  analysis of the role of the sponsoring company in  the production of scientific papers in support of  marketing approval of a particular drug  a study  of the way evidence is interpreted in the regulatory  process  and an analysis of the production of  international standards in the ICH process. Joel  Lexchin assesses the Canadian system of so called  smart drug regulation  administered by the Therapeutic  Products Directorate  TPD . This is an  agency which  according to Lexchin  is strongly  committed to a business friendly environment  even to the point of neglecting public health. In  this context Lexchin identifies a shift in the  regulatory philosophy of the TPD away from the  precautionary principle  in favour of the risk  management model. Risk management entails a  risk cost benefit approach said to be premised  on an assumption of safety  unless there is information  to the contrary and  therefore  in general   products should be allowed unfettered access to  the market and once there largely left unattended    p. 156 . Lexchin details the high priority  assigned in Canada to speeding up the drug  approval process while making only inadequate  resources available for post marketing surveillance.  This pattern applies across the major regulatory  agencies; thus  in 1999  the FDA had 1 408  employees to review new drug applications  and  72 handling the post marketing surveillance of  nearly 50 000 medicines   p. 168 .  Additional evidence suggesting an unhealthy  relationship between regulatory agencies and the  drug industry is provided in Andrew Herxheimer s  chapter on the story of shortcomings in  the regulation of SSRI antidepressants in the UK.  The sales of antidepressants in the UK expanded  by 300  between 1990 and 2000 as paroxetine   Seroxat   fluoxetine  Prozac  and similar products  entered the market. There were early warning  signs that the new SSRIs could increase risks  of suicidality and drug dependence. Herxheimer  details the reluctance of regulators in the UK  and  other countries  to take this possibility seriously.  It took many years  several inquires  and recurrent  media attention  for these risks to be  accepted as real and for consumer reports of  adverse events to be accepted as valid inputs to  the post marketing surveillance system. In the  UK  this experience  led to the discovery of  serious deficiencies in the regulatory system  both  in its legal basis and in the way in which the  regulations are applied   p. 181 .  A similar story is told in the chapter by Agnes  Vitry and co authors on the case of COX 2  inhibitors  titled  Is Australia s National Medicines  Policy Failing? . The TGA approved the  marketing of celecoxib  Celebrex  and rofecoxib   Vioxx  in 1999. These drugs were subsequently  listed on the PBS as restricted benefits for specific  conditions but heavily promoted  in ways that  implied superior safety and efficacy over other  [non steroidal anti inflammatory drugs]  despite  the fact that studies had not shown any overall  safety and efficacy advantages   p. 188 . A 2003  study showed that a large proportion of prescriptions  of both products were in breach of these  restrictions. Vioxx was voluntarily withdrawn  worldwide by Merck in 2004 after evidence of an  association with increased risks of heart attacks  and strokes had become incontrovertible. Celebrex  was not withdrawn  but the TGA advised in  2004 that  all drugs in the class of Cox 2  inhibitors should be regarded as having an  increased cardiovascular risk until more is  known   TGA Media statement 20 December  2004 . The authors argue that Australia s regulatory  system  the TGA and the PBS  and associated  programs for  quality use of medicines   failed in  recognising and acting on early evidence pointing  to serious safety concerns.  The second specific theme of the book is the  success of the Republic of Ireland in attracting  drug company investments. Ireland has figured  only peripherally in Australian medicines policy  debates. Yet the Irish experience is significant  from an Australian perspective   with respect to  drug company activity  this small country has  achieved what Australian governments have  talked about for the twenty years  with disappointing  results. As a market  the Republic of  Ireland  with a population of about 4 million  is  not significant. Australia carries greater weight in  this respect   not only because of its absolute  size  but because Australia  notwithstanding perennial  industry complaints about PBS pricing  has  come to be viewed as a prestige market. Commercial  success in Australia is seen as potentially  valuable in marketing efforts elsewhere. But this  has not translated into very significant investments   as distinct from supply through imports.  Astonishingly  Ireland  the  Celtic Tiger   has  emerged as  the biggest net exporter of pharmaceuticals  in the world  ahead of Switzerland   p.  92 . Pharmaceutical plants  mostly producing  active pharmaceutical ingredients  APIs  rather  than final drugs  are concentrated to the Cork  region  the second largest city with a population  of about 200 000. By 2004 there were 72 pharmaceutical  plants in Ireland and thirteen of the  global top fifteen companies had established   substantial operations   pp. 87 8 . Strategic government  policy is central to this development   including a very low corporate tax rate of 12.5 .  This compares with Australia s rate of 30  and  European Union corporate tax rates typically  around 30 35 . A host of other industry support  measures and incentives are provided through the  Irish Government s Industrial Development  Authority  IDA   as detailed in a chapter by Kathy  Glavanis Grantham. Another significant factor is  Ireland s geographic location as bridgehead to  Europe for US companies  particularly in the  early stages of European economic integration.  While a  partnership  approach  as noted  does  not seem significant in Irish medicines policy   Ireland s overall economic and social development  has been framed by a model of  social  partnership .  By contrast  according to a 2005 report by the  Economist Intelligence Unit  in Australia  most of  the global pharmaceuticals firms restrict their  activities . . . to distribution . Only  a small  number  were engaged in  secondary manufacturing   and an even smaller number . . . in actives  manufacturing . There were only five instances of  API production  mostly of a niche character  the  alkaloid extraction from poppies in Tasmania is  an exception 1  pp. 18 19 . Governments have  introduced one program after another to promote  the pharmaceutical industry and make Australia a  competitive alternative to Singapore and Shanghai  as a location for regional head offices. Yet the  results are unimpressive   Australia has made no  gains  in relative or even absolute terms  as a  global drug industry hub. Indeed  in recent years  Johnson   Johnson  Schering Plough  Bayer   Merck  Sharp   Dohme  GlaxoSmithKline and  Wyeth have announced plant closures or redundancies.  What has Ireland then done right   and what  are the costs and benefits of major drug manufacturing  operations? This book presents  in several  chapters  a critical perspective on these issues.  For example  the benefits in terms of employment  are less significant than might be expected; relatively  few jobs have been created. In 2004 there  were about 17 000 employees in this sector with a  similar number of people working in related  engineering  maintenance  catering and transport  sectors. The explanation is of course that drug  manufacturing is highly capital intensive. Each  plant typically employs only around 350 people  and operations are not closely integrated with the  local economy. Companies are thus not necessarily  locked in for the long term   manufacturing  of this type is relatively footloose and can be  relocated if more favourable conditions are  offered elsewhere  for example in Eastern Europe  where costs may be lower and the infrastructure  of similar quality. It would have been interesting  to find out more about the environmental aspects  of the concentration of API production to a small  area around Cork; this issue is referred to only in  passing. The environmental impact of such production  is increasingly recognised as a problem in  developing countries such as India  from where a  large proportion of global API supplies is now  derived.  It is detailed in several chapters how the sheer  economic weight of the industry constrains and  influences health and medicines policy. For example   there does not seem to be a mechanism in  Ireland for cost effectiveness assessments before  the listing of new drugs under the Community  Drugs scheme. Generics have a weak presence; in  2003  only about 19   of prescription items were  dispensed generically  and generic substitution is  not allowed  p. 113 .  Yet Ireland provides consumers with more  comprehensive protection against drug costs than  does Australia. Low income earners entitled to a   medical card  have access to free  no copayments   medical and surgical services and free  prescription drugs  no copayments . Between  2001 and 2008 all residents over the age of  seventy were entitled to a medical card regardless  of means  but in 2009 income and assets tests  were introduced. In 2005 around 30  of the  population were eligible for free drugs under  different schemes while copayments applied for  about two thirds of the population.  This valuable volume is mostly accessible to  non experts including undergraduate students. It  is of interest to an international readership concerned  with a wide range of medicines policy  issues. Through its particular  though not exclusive   focus on Ireland  and its remarkable experience  of big pharma activities  it should serve as a  useful resource to Australian readers interested in  the implications of the NMP objective of sustaining  a  responsible and viable medicines industry .  There is unfortunately no comparable book about  Australian medicines and pharmaceutical industry  policy.

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This is an original and very important book break January 12, 2010
Reviewer: Peadar Kirby Irish Journal of Sociology from Republic of Ireland  
This is an original and very important book  breaking new ground in interdisciplinary social studies of contemporary Irish society and drawing into sharp focus some very disturbing features of state market relations in Ireland today and their implications for society  communities and individuals. Furthermore  the book begins by placing its subject in a global context that makes it an illustration of much wider power shifts that characterise our globalised world. It thus provides a badly needed rejoinder to the euphoric reception of globalisation discourse among policy elites and opinion formers in Ireland.        In her introductory chapter  Orla O Donovan signals the book s ambitious reach. Beginning with a tragic case of a suicide that  it is believed  was prompted by the effects of the antidepressant drug Seroxat prescribed to the victim  she situates this case as one example of a growing concern internationally at the nature of state regulation of the pharmaceutical industry. The book is therefore essentially about the implications for people s health of the existing system of pharmaceutical drug regulation but the editors are to be greatly commended for the many different optics through which the subject is treated. This is what makes the book so original and challenging  and scary  as it includes not only political economy and sociological accounts but also those of doctors  of pharmacists  of a psychotherapist and of a pharmacologist. While Ireland is principal case studied  chapters on Canada  the UK and Australia show that the Irish case is not unique.       To this reviewer  the most revealing of all the chapters is the one on bias and science in knowledge production by John Abraham  a sociologist who is co director of the Centre for Research in Health and Medicine at the University of Sussex. This illustrates convincingly through three case studies that  bias towards the commercial interests of the pharmaceutical industry is a problem in the science of drug testing and regulation   p. 45  which is evident in  a great deal of technical manipulation  of the scientific evidence  an inconsistency of interpretation of types of data  technically contradictory treatments of scientific findings and a deference towards interpretations supplied by the drug companies  p. 52 .       A number of contributors examine how the dynamics of this bias towards commercial interests plays out in Ireland which is described by Denis O Hearn and Stephen McCloskey in their chapter as  the key producing and exporting region in Europe for most of the transnational drugs producers   14 . In Chapter 4  Orla O Donovan traces the evolution of state regulation of pharmaceutical drugs in Ireland  from a situation at the time of the thalidomide drug disaster in the 1960s when the state washed its hands of any responsibility  to a form of  hands off  regulation with the establishment of the National Drugs Advisory Board in 1966 which was underfunded and relied on reporting of adverse drug reactions by health professionals. Increasingly criticised for its slowness in processing licence applications  it was replaced in 1995 by the Irish Medicines Board which is largely funded by the pharmaceutical industry. Not surprisingly  O Donovan concludes that  medicines regulation in Ireland has followed a neo liberal pharma friendly course   p. 80  but perhaps most telling is her finding that  within parliamentary arenas the industry financing arrangement was generally perceived to be laudable   p. 73 .       Kathy Glavanis Grantham uncovers in her chapter what she identifies  in relation to the pharmaceutical industry  as  a web of intersecting and mutually supporting interests between transnational capital  the state and the educational sector in Ireland   102 . Her account of the extensive involvement of multinational pharmaceutical companies as significant funders of academic activities in UCC raises the need  as she herself writes  to examine  the ways in which the pharmaceutical industry has come to influence health priorities and scientific research  in Ireland  p. 100 . Her chapter is also noteworthy for describing forms of resistance to the growing influence of the industry  particularly the activities of a small Irish organisation  Medicines for All  formed in 2003 by a group of professionals.      It is  however  the chapters by health professionals that help underline the immense importance of the book s analysis for every user of the Irish health service. This is what gives this book its unique edge  bridging very effectively the gap that often exists between academic analyses and the experiences of citizens. The chapters by Colin Bradley  professor of general practice at UCC  and Terry Lynch  a GP turned psychotherapist  are particularly revealing. Bradley examines the differing interests of the pharmaceutical industry  of doctors  of patients and of the state  describing the various forms of  entanglement  between industry representatives and doctors through  for example  regular visits  the regular receipt of hospitality at a variety of educational and other meetings  the industry has  a very major involvement in the provision of postgraduate educational and continuing professional development in Ireland   p. 125    and the testing of drugs. Bradley writes that  medicine is a more explicitly commercial enterprise in Ireland than is the case in many other European countries   p. 129  and he wonders if the industry and doctors are entwined or entangled  or if doctors are ensnared. He goes for the middle option. Lynch s chapter complements this when he writes of his experience that most doctors do not question the industry representatives  rely on them for information and fail to question their practice when evidence emerges of the malign effects of certain drugs they widely prescribe  as in the example with which the book opens . The failure of the medical press to keep a critical distance from the industry and even to report on evidence about the ill effects of drugs is a particularly disturbing aspect of this chapter.      This book deserves very wide and careful reading in the hope that it might stimulate a more critical awareness of the power of an industry to affect the ways we look at our own health and seek to ensure our wellbeing  both mental and physical. It raises issues of the utmost concern about global and local politics and their relationship with some of the world s most powerful companies. If any criticism can be made it is simply that it would have benefited from a final concluding chapter drawing together the various rich strands of the argument. It challenges all of us as social scientists to produce work that gets to the heart of the implications for our social and personal well being of the extensive restructuring of Irish society over recent decades.

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