Making medicines safer for all of us

Adverse drug events are now the fourth leading cause of death in hospitals.

It’s a reasonable bet they are an even greater cause of death in non-hospital settings where there is no one to monitor things going wrong and no one to intervene to save a life. In mental health, for instance, drug-induced problems are the leading cause of death — and these deaths happen in community rather than hospital settings.

There is also another drug crisis — we are failing to discover new drugs. [Read more...]

Archive for January 2013

The Antidepressant Era: The Movie

The Antidepressant Era was written in 1995, and first published in 1997. A paperback came out in 1999. It was close to universally welcomed – see reviews 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. It was favorably received by reviewers from the pharmaceutical industry, perhaps because it made clear that this branch of medical history had not been shaped by great men or great institutions but that other players, company people, had been at least as important.

Nobody objected to it, perhaps because at this point I had not agreed to be an expert witness in a pharmaceutical induced injury case. There were likely no PR companies who had a brief to manage Healy. I knew before The Creation of Psychopharmacology came out in 2002 that the response to it would be very different.

Disease mongering & the myth of lowered serotonin

Many of the ideas in The Antidepressant Era had appeared earlier. The idea that a lowering of serotonin (chapter 5) was a marketing myth and had nothing to do with science, first appeared in my doctoral thesis in 1985, and later in Psychopharmacological Revolutions in 1987. The idea that companies market diseases as a way of marketing medicines (chapter 6) first appeared in 1990 in Notes toward a History and The Marketing of 5HT.

The Antidepressant Era in turn contained many of the elements of Pharmageddon – the key role of the 1962 amendments to the Food and Drugs Act which, through product patents, prescription-only status for new drugs and the role of clinical trials, have created modern healthcare.

Is Valium a better drug than Prozac?

In 2000 I was approached by Duncan Dallas, an independent television producer from Leeds who wanted to do something critical on the antidepressants. Prozac was still at this point widely seen as a miracle of modern medicine, rather than an inferior drug to older antidepressants. Bioethicists and social scientists were still lining up to herald the creation of the New Man through modern genetics and modern psychotropic drugs.

Saying that what we were witnessing was a triumph of modern marketing rather than modern science caused a frisson in most circles. There were no natural allies – not in psychopharmacology or biological psychiatry but not in social science circles either.

But this is what Duncan wanted. The Antidepressant Era, the movie, opens with some of the hype around SSRIs, has astonishing footage of Roland Kuhn and Alan Broadhurst, two of the key people behind the discovery of imipramine, and outlines the overthrow of the benzodiazepines and their replacement by antidepressants.

It shows how rating scales and screening are used in psychiatry to create problems for which a drug becomes the answer. It was the first program to wheel on stage the marketing men who created the social anxiety campaigns that sold Paxil, and it outlined the role of DSM III in the creation of depression.

Duncan’s version has a wonderful artistry. The book opens with a quote from George Oppen’s The Skyscraper. The “movie” closes with the same quote.

The building of the skyscraper

The steelworker on the girder
Learned not to look down, and does his work
And there are words we have learned
Not to look at,
Not to look for substance
Below them. But we are on the verge
Of Vertigo.

There are words that mean nothing
But there is something to mean.
Not a declaration which is truth
But a thing
Which is…

Oh, the tree, growing from the sidewalk –
It has a little life, sprouting
Little green buds
Into the culture of the streets.
We look back
Three hundred years and see bare land.
And suffer vertigo.

Downfall – Adolf who?

Its central moment is an astonishing sequence featuring the then President of Hoffman-la-Roche, Adolf Jann, embarking on a rant that looks now like an uncanny forerunner of the famous Adolf Hitler rant in the movie Downfall. The rant that launched a thousand You-Tubes. Adolf Jahn thumps his fist on the table, voice rising, as he angrily tells an interviewer in effect “You – none of you – can do without us – just try”. See section at 20 minutes 50 seconds to 22 minutes.

There is nothing specific to Jann or Roche here. This was and is the common credo of the pharmaceutical industry. This is what the CEOs of GSK, Pfizer, Merck and Lilly are saying to governments today. Healthcare is not sustainable unless we develop drugs that get people well so they aren’t a burden on the State, and if healthcare is not sustainable democracy may not be either. Facilitate us or society as you know it goes down the drain.

It would be a mistake to see this as a horrible modern manifestation of rapacious capitalism. Socialists from George Bernard Shaw in the early twentieth century onwards have turned to biology as an answer to social problems. If we cannot get mankind to agree to change for the better, perhaps we can improve on mankind. This belief powered the efforts of governments to eliminate the unfit from the late nineteenth century through to the eugenics movement and underpins some of our hopes for the New Genetics.

Eugenics looks terrible in retrospect while modern genetics looks like our only hope – but the same impulse underpins both. There is no better example of what good history is about than this. Anyone writing the history of eugenics should really portray its prime movers in the same light as we now portray the heroes of the the Human Genome Project.

We should always remember that the nominees for the 1937 Nobel Peace Prize included both Gandhi and Hitler. There was a time when one looked at least as likely as the other to contribute to modern civilization.

Revolution’s little helper

The same dynamic made Valium look like a very dark drug in 2000 – so that even its name was withdrawn. Prozac in contrast looked like the gateway to the hoped for shiny uplands of the future, when by the mid-1990s Prozac should have been seen as a far darker drug than Valium.

Valium entered a world in which psychiatry in many ways led medicine as it had done for almost a hundred years. Psychiatry was the first branch of medicine to have specialist hospitals and specialist journals. And Valium really did work remarkably well. Far from being simply a superficial treatment it likely led to the disappearance of catatonia and saved a lot of lives.

Valium probably did a lot to stimulate the Revolution of 1968. The conventional wisdom now is that Valium was Mother’s Little Helper and in this role that it played a part in the imprisonment of women in suburbia. In fact, Valium and other benzodiazepines undo conditioned avoidance. They were advertised initially as being among other things useful for salesmen – to overcome their inhibitions. They almost certainly disinhibited many women to speak out against patriarchy. They helped students breach the double-binds that Ronnie Laing and others in the 1960s were preaching were holding back society.

Prozac and the SSRIs in contrast far more often produce an apathy that is destructive to engagement in society as Who Cares in Sweden shows. Prozac, Paxil, Zoloft, Efexor, Pristiq, and Cymbalta are far more likely to lead to suicide and murderous violence including school shootings than Valium ever did. And the SSRIs lead to just as many cases of dependence as the benzos ever did.

Tamiflu – PharMessiah?

Are we incapable of learning? Will we always be seduced by the latest PharMessiah?

The Antidepressant Era, the movie, contains an extraordinary comment on just this that no one could have foreseen when it was finished in 2001. It almost looks like the Scriptwriter in the Sky must have inserted the clip of Adolf Jahn telling us that if we don’t facilitate him and Roche society will collapse. We can only afford to keep our economy and society going if he and his company are let develop new drugs.

Well Roche got to develop Tamiflu. Where Valium was the headline drug in the 1980s for the problems a rampant pharmaceutical industry might pose, Tamiflu is now. Governments throughout the Western world stockpiled billions of dollars worth of Tamiflu on the promise that it would prevent the transmission of influenza and other viruses, and would either keep people in work or get them back to work faster, thus saving our economies huge amounts of money.

Except the drug now appears to be close to worthless and to have always been so. It seems that the impression that Tamiflu might help could only have been created because companies can hide the existence of many and in some cases most of their clinical trials and hide the data from all of them, ghostwriting the ones that are published in a manner that keeps all data out of the public domain.

Facilitate us too much and we will lead to your Downfall.

The Boy With The Ponytail Who Kicked The Hornets’ Nest

In The boy with the ponytail who played with fire, we saw Jan Akerblom struggle up the side of a mountain in his attempt to drop the Ring of Power into Mount Doom. Where others, especially doctors, are seduced by the Precious he isn’t.

Why do it – because he saw lives destroyed and wonders if we are at risk of destroying society itself. Are any contracts anyone enters into while on an SSRI valid. Far-fetched?

Who cares in Sweden

My wife has left me

Imagine you are approached by someone who says his wife has been on an SSRI for several years and during this time she has changed personality. Where once she was very sensitive and caring she has become more callous and unfeeling. Where once she would be in floods of tears at a weepy movie, at the funeral of a beloved twin-brother who died in tragic circumstances she didn’t cry at all.

He contacts you because now she has left him. He concedes that maybe the marriage was heading for the rocks anyway but he is still concerned that this is not her. That if she ever stops the medication and starts feeling more like herself again she will regret what she has done – if not to him at least to her children.

What do you do?

There is abundant evidence SSRIs can cause exactly this kind of emotional blunting or disinhibition. The comments by Neil Gorman and Allostrata on The boy with the ponytail give detailed accounts and references. One of the first articles on the topic had a Baltimore society hostess while on fluvoxamine serving her guests wine while naked from the waist up.

Its worth thinking for a moment before reading on – if you were the doctor, what do you do?

It’s almost impossible to know. Little details can change the picture dramatically. Perhaps he is much older than her and now that she has grown up she has found herself and resents his control and the SSRI disinhibits her just enough to make it possible to do what she might in many respects be better off doing – leaving him. Would it really be better to live a safer life or a life of quiet desperation?

If you’re her doctor and he approaches you, what do you do? If you suggest reducing the dose and she insists that no this is the real her and perhaps brings friends along who vouch for the fact she is now doing what they’ve implored her to do for years, what do you do? Perhaps she tells you she will get the drug through the internet if you don’t prescribe.

Who are you to decide these important issues for someone else? You’ve had no training in matters like this. Better surely to play Pontius Pilate, continue prescribing, and let events take whatever course they will.

Who cares – about side effects?

Except as Who Cares in Sweden makes clear you cannot wash your hands of this responsibility.

This is not Side-Effects, the movie. You’re not in the position of Jonathon Banks (Jude Law) treating Emily Hawkins (Rooney Mara), whom you’re having an affair with and whom you’ve put on a new prescription drug, who has then perhaps gone on to kill her husband – we have to wait till February to see what actually does happen.

Unbelievable though it doubtless sounds, it’s worse. You are as much a police or probation officer as the doctor with whom every patient you prescribe for might want to have an affair with. This is whether it be an infant or a 96 year old. Prescription-only was a system introduced to control opiate and cocaine addicts. Anyone who gets their drugs through you is trapped in a set of Stockholm syndrome dynamics neither you nor they asked for.

But whether you asked for it or not you make your living out of it and the buck stops with you. Every inappropriate divorce, birth defect, school shooting, suicide, or case where a woman schoolteacher molests a juvenile male pupil that comes from your practice is your responsibility. Every heart attack on Chantix, cognitive dysfunction or muscle weakening on statins or premature death on the next Avandia or Vioxx is down to you. Every love affair that might happen on a clinical trial you are running is down to you. But you can’t find out what dramatists think the implications are because The Effect is booked out.

If it were your son?

If you have a son who is a fireman and his life depends on others in the fire crew “caring” normally, what do you do if a fireman’s wife comes in to you and says that her husband has been showing no emotions lately? Or her husband is a pilot with the airline that your family are due to fly with in a week’s time?

A cutthroat

If you appeal to the fact that you can’t be blamed for companies withholding data, you end up in a cutthroat. Either you say that whatever the data now reveals you would have used the drug anyway in which case the company walks away with no legal liability.

Or else you say you wouldn’t have used the drug but how can you be blamed if companies withhold data. Sounds good, except we’re not talking breaking news here. The information about SSRI induced disinhibition, violence and suicide has been in the public domain for nearly 25 years. The information about significant hazards on prescription drugs in general is out there for up to 20 years on average before you and your colleagues pay heed to it.

These drugs are available on prescription only because it was once thought you were the kind of person that might be able to quarry information out of companies or would steer people away from drugs if you were worried that we weren’t being told the full truth – it’s called professionalism.

They’ve started prosecuting doctors

Just recently a French psychiatrist Daniele Canarelli, 58, was found guilty after a patient of hers hacked a man to death. The court decided she should have recognized the risks he posed. This was the first case of its kind and it led to extensive media coverage worldwide because of the implications for doctors in general. It followed hard on the heels of a conviction of Italian seismologists for failures to warn sufficiently of earthquake risks.

Somewhere around 90% of the school or other mass shootings that have happened in recent years in America or Europe have involved shooters on psychotropic drugs usually antidepressants. The public sympathy for the victims typically also extends to the doctor who is seen as one more victim. But the so called perpetrator is much more likely to be a victim than the doctor. He may have been turned into a guided missile by his doctor. These are people in treatment whose doctors clearly failed to recognize the risks they posed.

Does anyone care in Sweden?

The Boy With The Ponytail Who Played With Fire

Who cares in Sweden

He is 6’4” at least – 192 cm. He has blonde hair tied back in a ponytail. When he first suggested making a program about SSRIs I was not very helpful – very little of the media coverage by 60 Minutes or anything else has ever seemed to make much of a difference. They may have just increased the sales of antidepressants by keeping the names of the various drugs in the limelight. And he was suggesting more talking heads which the cutting edge of journalism tells me is past tense.

But he was persistent and turned up on my doorstep, putting himself up in a very cheap hotel, because as I found out later he had almost no money. Many of the people I put him in touch with as he and his son Elias wound their way literally around the world making their program were far more generous than I in accommodating them in their own houses.

Who is he?

Who was he? He is Swedish and his wife Mexican – a striking genetic and cultural mix. She makes wrought-iron jewellery. He had been a classical musician but had decided orchestral living was not for him. This had led him to film-making. But finding work was difficult.

He was gifted. Seeing him edit the huge volumes of material he amassed, produce graphics to illustrate points and carve out a distinctive story line all in the apartment in Stockholm in which they lived – you couldn’t but be impressed. This was a far cry from BBC or CBS or CBC or NBC studios. When I went to visit him in Stockholm, the American version of The Girl with the Dragon Tattoo had just come out and it was difficult not to think of Lisbeth Salander.

Swedes would listen he said. He knew his countrymen and women. They still believed what they heard on the news and read in newspapers and they just needed to be told the truth up front. This didn’t seem completely naïve to me, Swedes are a bit like this. I was certain the rest of the world wouldn’t listen but if one country really did take the message on board who knows…

Who cares in Sweden?

The central idea was all his. He and Elias both had friends who were put on an SSRI who had lost their personalities. The drug produced a lack of caring that had spreading consequences for everything. Both had lost friends and families. But no-one said anything. Jan talked to eight doctors about it and they all told him he was wrong, “the medicine did not have these effects”. Finally he talked his friend off the medication and his personality was reborn.

If the doctors instead had answered: “That was interesting, I will keep that in mind.” … then he probably wouldn’t have started the project.

He ended up coming to me because he began by asking Swedish doctors to participate in the film and noticed that almost all said no. It would be too dangerous for their careers to be involved. He was regularly asked by doctors and politicians and others if he belonged to the Scientology Church. This puzzled him as he knew nothing about Scientology. He was also not anti-medication – several family members had been greatly helped by medicines.

Slowly he came to the view that Swedish journalists didn’t talk about the obvious corruption in Sweden because they didn’t care about the issue. For Jan the idea that a great deal of money from the pharmaceutical companies is being used to corrupt society is a non-starter as an explanation.

This is the case even though doctors are being corrupted. As he puts it “there is money that is being distributed as cash in small envelops, hand-to-hand or as repayment for consultant missions. The money can also be found hidden as funds for research or equipment or as invitations for doctors and journalists to international meetings. These offers are mostly sponsored by the pharmaceutical industry – all kinds of “services” seduce the recipients.

“Doctors end up getting trapped. On return home their colleagues never find out what really happened. They show their respect or feel envy for their colleagues who receive higher salaries, reputation and influence. Only a few people in Sweden acknowledge today how bad the situation is. Ignorance is massive”.

“That’s why we had to travel to foreign countries in order to find people willing to speak to us. As individuals we can’t make big changes or tell politicians, journalists or the justice system what to do. But as a production company, we are definitely able to produce films that may be helpful for society. There are many people searching the Internet for information about side effects that doctors have been taught to deny”.

Swedish catatonia

I knew nothing about his views when we met first. I was struck by another idea of his. If the treatment could produce something like this in his friend, there seemed to him to be no end to the implications. Would any of the contracts his friend might have entered into during this period, from business contracts to relationship contracts, to legal contracts, to property deals be valid? Were the contracts anyone entered into while on these medicines – stockbrokers, bankers, lawyers – valid?

The more he explored the more he found firemen who were aware of the effects on them or on those who had set fires by accident or on purpose, judges who were aware of the effects within the legal system, doctors treating children who knew of the effects – all of whom facing the problem turned mute and were paralyzed.

There is a condition called Catatonia that can be induced in animals by facing them with tasks such as having to distinguish between an oval and a circle in order to get a reward. As you gradually start making the oval more circular and the circle more ovoid, the dog or other animal gets distressed and finally freezes.

We can cope with judgement calls about responsibility when people who are normal do things and when people who are on an LSD-trip do something – especially if the person has been slipped the drug without knowing it. When someone in the midst of an LSD trip steps out of a twenty-fifth floor window, we do not regard this as suicide. LSD works on the serotonin system. Start making it harder to distinguish between normal and treated serotonin systems and both people and Society freezes up.

A Norse myth

I felt I was being educated about the drugs by someone who had no background in the issues. It was a story that definitely needed to be made if only because it has the dimensions of a Greek tragedy or myth.

The SSRIs are after all a Swedish invention. Arvid Carlsson who later won a Nobel Prize produced the first SSRI, zimelidine, 3 years before Prozac was made. Carlsson deliberately made an SSRI whereas Lilly only produced one as an accidental by-product of a search for a quite different drug. Zelmid was also brought to the market in 1981, 7 years before Prozac. See Let Them Eat Prozac for a history of what happened next.

Can antidepressants and even Zelmid cause suicide? According to Carlsson in 2000 yes – “we have known this for a long time”.

But it doesn’t stop there, Stockholm is of course the place where Stockholm syndrome was born.

In August 1973, a bank robbery at the Kreditbanken in Stockholm triggered a 5-day siege with bank employees held hostage. The media camped outside. After the siege ended, to the surprise of everyone many of the hostages, as if hypnotized, spoke well of their captors. “Stockholm syndrome” was born. Now recognized as common, the conditions that trigger this change in behavior seem to be isolation, a fear that your life is at risk and kindness on the part of the hostage takers.

Disease isolates us as profoundly as incarceration or anything else might. Our lives are at risk, and our doctors who control the exit to freedom are almost certain to be kind. But not a single doctor is trained to manage Stockholm syndrome, to suspect that apparent insouciance or congenial conversation might conceal deep unhappiness with a proposed course of treatment or worse again alarm at new problems that have emerged on treatment.

Doctors are also increasingly likely to suffer their own Stockholm syndrome. If something goes wrong with a treatment a doctor gives, even though the label may concede that the drug can cause the problem, the makers of the drug and other doctors will deny that it is likely to have done so in any particular case. Speaking up about a problem, once the material of medical advance, is now a recipe for professional suicide. A doctor attempting to rescue a patient is likely to be accused of being a persecutor who takes patient hostage by withholding effective treatment.

Offers to describe problems at professional meetings are turned down. Journals are ever less likely to accept publications outlining a new problem. Invitations to apply for better jobs, to attend conferences, or simply to go with colleagues to local eateries funded by drug companies are ever less likely to happen for doctors linked to adverse events. Those holding doctors hostage have been very kind indeed – there are ever fewer medical departments or medical conferences not awash with company support, when it comes to paying for meals with colleagues most doctors have forgotten what a credit card looks like, and of course in supplying drugs they supply the objects that make doctors desirable.

What can a Hobbit do?

“We all must take advantage of freedom of speech and freedom of press. This is what the small individual can do in a democracy. Thereafter it’s up to the professional journalist and politician to act. The truth is that Sweden needs help from foreign politicians, scientists and journalists. It is very sad to have to admit that many homicides, school shootings and other horrible killings are linked to medication and that this fact is being suppressed as journalists exclusively talk about weapons”.

“Many people decide to stop their medication when they start getting the “numb feeling” or the “derealisation feeling”. However, in the majority of cases, doctors insist they continue until the side effects “disappear”.

So Jan Akerblom made Who Cares in Sweden. This is playing with fire. He has taken on the Swedish establishment for real. Lisbeth Salander is the myth, Jan Akerblom the reality. Watch the Who Cares in Sweden – official trailer.

“Our conclusion is that, the best advice, in order to clarify any problems is to talk to the person’s family, friends and colleagues. The person themselves may not be aware of the side effects, the change of personality, the problems he or she creates. People sometimes say that the “medicines work” precisely because they just don’t care anymore”.

This conclusion about what he had to do and also what needs to be done to clarify individual problems are exactly the conclusions that Rosie Meysenburg came to that led her to create SSRI Stories.

In the next post, we’ll see some of the consequences of Kicking the Hornet’s Nest.

The Girl Who Was Not Heard When She Cried Wolf

Crusoe was called to see Lisbeth. The girl – young woman was mute and catatonic by day but after she fell asleep she had nightmares when she wailed piteously, rent her nightdress, walked in her sleep muttering ‘the children, the children’ or other such phrases. It was a similar pattern each night, the parents said. The dreams seemed to repeat.

Crusoe came in the evening when the room was dark except for a scented candle flickering in the corner. Lisbeth lay on her bed, one arm stretched out over the side. Crusoe pulled up a chair beside her. The parents hovered anxiously in the background.

The doctor's nightmare (from Fildes)

To sleep perchance to dream

After she had been there for nearly an hour, the girl began to stir. She sat up and screamed, clutching her shoulders, looking at the place where her arms should be. Then her face grimaced and neck bent as though she had a severe pain in her chest. She jumped as if she had been cracked with a whip and felt for her Achilles’ tendons on either side.

She got up and walked to the bathroom. She bent down and stared at the rug for what seemed like an age. She came back and picking up a limp cloth doll from a bookshelf on the way placed it on her bed, knelt down beside the bed and began apparently sawing at where the doll’s breastbone might have been, after which she made to pull open the chest cavity as if to work on the heart inside.

Inception

When she finished this, Crusoe intervened, helped her back into bed, and moved closer. The girl was having waking dreams. Crusoe must some how have slipped into this one. Suddenly Lisbeth began talking: Dr. Crusoe, Dr. Crusoe it’s terrible, terrible. I see children born without arms or legs. I try to tell someone what is happening but no-one listens.

I went to a door marked FDA and someone looked out but couldn’t see me.

I thought it might be better in England and went to one marked MHRA. This had names on the door – Sir this and Sir that.  I thought Knights of the Round Table, ah good! But, they said, you think this drug has caused children to be born with shortened arms or legs, how do you know that the drug didn’t just prevent spontaneous miscarriages so that these children who would never have been born are now born?

I told them I thought the pain in my chest must be linked to the Plavix I was taking– it came every time I tried to stop it.  They said, they couldn’t be certain that I wasn’t aspirin resistant. When my tendons snapped, the pain was excruciating – I was certain it was the Cipro I was on but they stared at me blankly – don’t be silly an antibiotic couldn’t do that.

I told them I had seen Matt Miller, in his bright orange football gear, 13 years old. I can see him now – over there. I saw him put on Zoloft by his doctor when he was anxious in a new school. I followed him a week later when he went into the bathroom between his bedroom and his parents’ room and hung himself there. Are you sure they smirked that this wasn’t auto-erotic asphyxiation? You know what little boys are like! Perhaps he accidentally went too far. I watched a person from Pfizer check the carpet for seminal stains, she said, looking at Crusoe. I went and looked, but there were none there.

There are too many babies needing heart repairs, I can’t keep up, she said, and who is going to help all those children queuing up outside who have autism and learning disabilities.

When I was in America I picked up the phone and tried calling GSK, using the phone numbers on their adverts. Many of the numbers didn’t work. On others I got put through to a call centre, not a doctor. They told me not to tell them anything but to send my report to the FDA instead. This sounded good but when it got there, I saw FDA filed some reports and binned others.

There used to be a picture of the Pied Piper in my Grimm’s book of fairy tales years ago taking the children away. I can’t see him now but I can hear the tune that is leading women to take antidepressants just before they get pregnant. It goes round and round in my head. Can’t anyone stop it?

Can anyone hear me?

Can’t they see that when things go wrong, the AMA, and RCP, and ICP will line up to tell you it was your illness that caused the problem?

I see an endless line of mothers knock on doors. I see them in England where they get sent from the DoH to the GMC to the RCP, to MHRA to NICE. The Department of Health say it’s the General Medical Council’s job, who say it’s the Royal Colleges job, who say it’s the regulator who say it’s the people who make the guidelines, who say it’s the Department of Health. You’d have thought the Royals might have done something.

I see them in America where they get sent from the HHS, to the FDA to the IOM, to the AMA but the same message everywhere – “not us, lady”.

FBI, CIA, IRA, EMA, MI6, KGB – can anyone hear me?

Who dares wins

Lisbeth dreamt Crusoe held her and whispered: “When you wake, you and I will go to England to see the SAS. They don’t have them in America, but if they did I suppose they’d be called SEALs”.

SAS – Short –Arm-Squad
SEALs – thalidomide caused phocomelia – seal-like limbs

FDA – Food and Drugs Administration
MHRA – Medical and Healthcare Products Regulatory Agency
NICE – National Institute for Healthcare and Clinical Excellence
AMA – American Medical Association
RCP – Royal College of Physicians
ICP – Irish College of Psychiatrists
HHS – Health and Human Services
IOM – Institute of Medicine
EMA – European Medicines’ Agency
IRA – Irish Republican Army

SAS to Lisbeth

From [email protected]

I dreamt I saw Joe Hill last night,
Alive as you or me
Says I, “But Joe, you’re ten years dead,”
“I never died”, says he
“I never died”, says he

“In Salt Lake City”, Joe, says I
Him standing by my bed,
“They claimed you died from your disease
Says Joe, “I didn’t die”
Says Joe, “I didn’t die”

“The pharma bosses killed you, Joe
They pumped you full of drugs”,
“Takes more than drugs to kill a man”
Says Joe, “And I ain’t dead
Says Joe, “And I ain’t dead

And standing there as big as life
And smiling with his eyes
Joe says, “What they forgot to kill
Went on to organize
Went on to organize”

Illustration: The Doctor’s Nightmare (from Fildes), © 2012 Billiam James