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...]

Author Archive for David Healy

Go Figure: Murder or Accident?

Harold Shipman

Harold Shipman was a doctor in Britain, who was arrested for murder in 1998. He turned out to be a true Angel of Death, the most prolific known serial killer, who killed it is thought between two and three hundred of his patients by prescribing opioids in large doses.

After his trial and conviction and jailing, he committed suicide in jail with no-one any the wiser as to why he had behaved the way he did.

His killing spree led to a change in medicine’s regulatory apparatus, ostensibly to ensure this couldn’t happen again. Boxes were put in place, and mandatory courses on a range of issues from consent to continuing education. All of this takes time away from seeing people. But if Shipman’s case held any lesson it is that he was assiduous at ticking the boxes that registration bodies like the General Medical Council in Britain put in place. The system probably makes a future Shipman more rather than less likely.

Short of doctors who have been struck off for proven cases of negligent care or abuse of patients, we might all on average be safer with doctors the regulator is having problems with, who for the most part are more keen on seeing patients than spending time ticking boxes, rather than with the doctors who are in good standing with the regulator. But what can the system do? We, the public, won’t let it do nothing.


While Shipman’s killing spree with opiods was unfolding, North America was sinking into a prescribed opioid epidemic that now accounts for 100 deaths per day, over 30,000 per year, over half a million since the epidemic began, perhaps the single greatest cause of death in America today.

The way in to the epidemic was laid during the 1980s with the marketing of Oxycontin by Purdue Pharma, supported by Abbott, and later Janssen pushing Fentanyl. There was an astute marketing of an idea – that people with real pain do not become addicted to opioids – a myth equivalent to the myth of lowered serotonin in depression. This was allied to new standards of care for pain management which hinged on RCTs, all of which demonstrated that opioids were effective – again exactly the same dynamic exploited by companies marketing SSRIs. The result was mass prescription of opioids by doctors, many whom felt trapped between clinical wisdom and the risk of being sued. But clinical wisdom never makes it into guidelines or standards of care, and since standards of care emerged in the 1980s managers sack doctors who don’t stick to the guidelines – or refer them to their registration body.

Prescription-only status is another part of the regulatory apparatus. It was introduced in America in 1914 in response to escalating concerns about one of the first opioids – heroin.

Purdue’s marketing of Oxycontin exploited this deftly. Companies and doctors were in the clear provided all prescriptions were for physical conditions causing pain. Patients and doctors on cue, to a background tune being piped by Purdue and Janssen, engaged in a dance about the management of pain. There were no problems for doctors prescribing for pain but if they had been prescribing the same drugs for addiction they would have been struck off.

Faced with the horrific consequences of this dance, FDA intervened in extraordinary fashion two years ago. In 2014, a century after the introduction of prescription-only status, FDA made a potent opioid, naloxone, available over the counter in US States who were willing to endorse this option. Given intravenously or nasally, naloxone can save lives by reversing the effects of an overdose by other opioids.

To murder is human. To mass murder needs a regulatory apparatus. We have no problem viewing Shipman as a murderer. But what about Purdue or Janssen? And what about the role of regulators from FDA to the GMC?

Go Figure: Study 329


Editorial Note: This post merges the Go Figure sequence of posts from several weeks ago with the 329 series.

In the wake of the French Revolution of 1968, the government was still tottering when on February 4 1970, sixteen miners died with twelve others maimed in an explosion at a mine in Lens in France. The mine owners pitched the event as an accident. It didn’t help their case that Northern France had a history mine disasters, including the worst ever in Europe in 1906 at almost exactly the same spot, when over a thousand men lost their life. This is the reason we have insurance, the owners said. This is what the law of 1898 was all about.

The miners called on the Left-Wing philosopher Jean-Paul Sartre to prosecute their case. Sartre claimed there were no accidents, the owners knew there would be a certain number of deaths each year and factored this into their costs. There had been five the year before in a nearby mine. While injured workers thought of their job as risky and that when injured they had just been unlucky, they were wrong. It was murder, Sartre said.


Calling these deaths murder made the disaster an event. If it was murder, the owners should go on trial. Capitalists in general should go on trial. Perhaps even the government. This was a pivotal moment for the Left. Despite the lack of trust of many in France in their government, society didn’t follow Sartre down this route. Perhaps because the French State made a display of solidarity. The Left lost its grip to a New Left and others who were looking for a Third Way.


A century earlier faced with a predictable number of deaths from anesthesia each year, American surgeons in the first place, because anesthesia was developed there, faced questions about the ethics of doing evil in order to do good. If the patient died from the anesthetic, were they murderers?

We somehow collectively decided that no they weren’t. No-one sees us as duped for doing so, even though roughly one per thousand anesthetic events today lead to death. There are likely more deaths from anesthesia than from mining disasters each year. There are certainly more deaths per person year exposure.


The death of the comedian, Joan Rivers, some years ago under light anesthesia for an endoscopy, rather than plastic surgery, threw a light on this issue. Deaths under anesthesia have been happening for one hundred and seventy years but every so often a death or other happening becomes an Event. In this case, nothing happened.

“With plastic surgery, the general anesthetic is like a black-velvety sleep, and that’s what death is – without waking up to someone clapping and going, ‘Joan, wake up, it’s all over and you’re looking pretty’.

What is less forgivable perhaps is that anesthetists have a blind spot for the difficulties that may emerge days or weeks later linked to their procedures and agents.

String of Pills

Where do the adolescents or young adults or any of us who commit suicide or homicide triggered by an SSRI taken, or given, on the back of studies like 329 fit? What do we call this?

British papers over the weekend were full of a trial involving a footballer and an inebriated woman where he was convicted of rape in the first instance, with the sentence later quashed in controversial fashion. American and world media were filled with stories of Donald Trump and the question of consent. In the light of Study 329, is the consent people or their families have given to take a medication like paroxetine any more valid than a consent that after the event an inebriated woman is claimed to have given?

Like the mining accident in Lens, the Evans rape trials, the Trump candidacy, the republication of Study 329 is an event, possibly a pivotal moment. Details outlining trends in the rate at which articles are ghostwritten, or patients enter hospital because of treatment induced injuries are features of the contemporary landscape but every so often these features come together to make an Event and Events make history. They create a before and after – even if not necessarily right there and then.

Study 329 Taper Phase


Editorial Note: It was tempting not to run a post today for fear it might get lost in the wash of the Clinton-Trump debate. But today is the fourteenth anniversary of the day FDA issued an approvable letter for Paxil for children, as well as the fifty-fourth anniversary of the 1962 FDA Act that created the playing field on which Study 329 happened. It’s also World Mental Health Day. Freud might have been amused.

Study 329 recruited its last patient in 1997. The data was analyzed in 1998. Faced with the results, the plan was to pick out the good bits and publish them. This meant never publishing the Continuation Phase – the 24 week extension to the Acute Phase of Study 329. The good bits of the Acute Phase became the Keller et al 2001 paper – possibly now the most famous clinical trial publication of all time.

The Continuation Phase was published for the first time by Le Noury and colleagues in September 2016 – eighteen years later. It is available HERE along with reviews from JAACAP – not the journal in which it was published.

Among the most interesting findings are those from the Taper Phase. Publishing the Acute Phase only meant that the Taper Phase vanished. Whatever way the data are cut, whether in terms of all severe adverse events, or behavioral adverse events or suicidal adverse events the picture remains the same – the taper phase of this trial was the riskiest period for those on active treatment. This will come as no surprise to many who have learnt the hard way after the event. Others like Bruce Springsteen do not yet seem to have put two and two together – see Born to Withdraw.




The years 1997 and 1998 may be as important as the data. The Moneybags image above, an internal SmithKline Beecham image from 1997, brings out how the issue was viewed within the company. SmithKline were at the time under intense pressure from Lilly and Prozac, with Lilly running adverts for Prozac like the one below.

Prozac withdrawal

The material accompanying adverts like this specifically targeted Paxil – Seroxat, the drug that was Prozac’s most direct competition. This is an unusual thing for a pharmaceutical company to do. They have to be on solid ground. It was also deeply cynical in that Prozac also causes dependence and withdrawal but with the right study its long half life can appear to make this problem disappear.

SmithKline’s response was maybe even more cynical. For women worried about getting pregnant and possible risks to their unborn baby, the short half life of paroxetine and being able to get off it quickly was a blessing. If you were on Prozac, the implicit message was you were “fucked”.

Extraordinarily in the face of this – twenty years ago – most doctors and regulators affected not to notice anything. Were they being adults trying to ignore children squabbling in the back of the car, or were they like terrified kids in Jurassic Park trying not to draw the attention of the Tyrannosaurs sniffing the air around them?

Most doctors still affect surprise at the idea SSRIs might come with withdrawal problems. Regulators since 2002 know very clearly about the problems but have decided to leave any communication of these issues in company hands.

It needs an anthem from someone like Bruce Springsteen to find the millions of people whom “Progress” has left washed up on a shore they never wanted to be on. An anthem to put the island on which they have been Shipwrecked on the map.

Study 329 Continuation Phase


Editorial: We interrupt the Go Figure series of posts to return for two posts to Study 329. We will then return to Go Figure.

All the fuss about Study 329 centers on its 8 week acute phase. But this study had a 24 week Continuation Phase that has never been published. Until Now.

We might have Marty Keller to thank for this Continuation Phase. His big deal was the long term treatment of depression. He made his name on the back of claims that depression was more chronic than people thought, and that treatment might have to carry on much longer than had been thought. Or perhaps industry made his name for him as this was such an appealing idea for them. He rapidly became one of the go-to key opinion leaders for antidepressants, along with Charlie Nemeroff in the US and Stuart Montgomery in Europe.

Rhode Island, and Brown University, must have looked Providential to Pharma in the early 1990s. Peter Kramer of Listening to Prozac fame was there too, also advocating pretty well permanent treatment for people who might be somewhat less than entirely chipper 100% of the time. Well would you take off a pair of spectacles if your sight was crisper wearing them? Why treat a drug any differently? We need to get over these Calvinist hang-ups about feeling better on medication, maybe even feeling better than well.

The continuation phase

The Acute Phase of Study 329 ran for 8 weeks – slightly longer than usual because the worry even before it began was that it was going to be difficult to show that treatment worked. But then after that the children could enter a further 24 week continuation phase. The idea was to see how ongoing treatment shaped up. The continuation phase was never published. Never even talked about.

To coincide with the Autumn Equinox, the International Journal of Risk and Safety in Medicine has published Study 329: The Continuation Phase.

The full text is available on Study, along with the reviews from the Journal of the American Association for Child and Adolescent Psychiatry (JAACAP). Click HERE.

JAACAP is not IJRSM – what’s up?

The original Keller paper was published in JAACAP. The former editor Mina Dulcan and the current editor Andres Martin and the American Association for Child and Adolescent Psychiatry were lobbied heavily over the years by Leemon McHenry and Jon Jureidini, trying to get them to do the decent thing and retract the paper. In vain.

So it seemed like a good idea to send Study 329 The Continuation Phase to JAACAP first. We were pretty certain they would refuse it. But they needed to be given the opportunity to dig a deeper hole. And they did. The reviews are published on Study


The primary theme of the reviews is there is too much data here, tell us what it means. Interpret it for us, and then we can tell you whether we agree with you or not. The paper may in fact have too many tables and figures but the key message behind Study 329 is that there is no authoritative interpretation. A lot hinges on almost arbitrary categorizations of the data. You the reader need to be able to play around with the data; you may well spot things others have missed. When it comes to adverse event data in particular there is no expertise. Things need to be picked over.

Off a cliff

There are some things about the Continuation Phase that are almost too shady to pick over too much, and we did not spend time on them. At the end of the Acute phase, for instance, there was an option for patients to continue into the next phase. It’s easy to understand why people doing poorly in the trial might have opted to drop out at that point. Some people doing well can also have been expected to drop out. What is harder to explain is why most of those doing well who dropped out were on placebo. A mixture of reasons were offered such as non-availability of trial medication but two thirds of those dropping out while doing well were taking placebo. This does not seem random. From GSK’s point of view having a large number of people doing well on placebo enter the continuation phase would not have been ideal.

The findings

Despite the placebo dropouts, there are more data to pick over in this study that for any other study. The data are not flattering for paroxetine – Paxil / Seroxat.


The relapse rate on paroxetine was higher than for imipramine or placebo. This relapse rate makes paroxetine a Gateway drug. People taking it end up worse off and their difficulties are interpreted as further evidence of illness, and in the real world this is likely to lead to additional diagnoses and additional treatments.

As the Efficacy data above shows, there is no evidence that patients given paroxetine show any benefits compared to placebo over the longer run – even when the deck is stacked against placebo by eliminating many of those who are taking it and doing well.

The suicide data also continued to be a problem into the Continuation phase as the graph below shows.


The word AG1TA here stands for agitation.

But there was another even more interesting finding in this paper which will feature in next weeks post. If you download the paper you will likely spot it. Surprisingly in the light of the finding, or unsurprisingly given the finding, the reviewers paid no heed it.

To be continued…

Go Figure: A Geek Tragedy


In 1939, in the laboratories of Geigy pharmaceuticals, Paul Mueller discovered that DichloroDiphenylTrichlorethane DDT killed insects more effectively that anything else then available.

Robert Domenjoz, the later creator of imipramine, had the job of evaluating it. He did the testing on lice that was to make DDT one of the best-selling pharmaceuticals in the world. He asked the Salvation Army to bring him two of the paupers who slept there and he bought their shirts – for their lice. He put the lice in small boxes which could be sealed with a sieve so that the lice could breathe. He attached the boxes to his arms so that they could live off his blood. Over weeks, they multiplied. When he had enough, they started testing DDT on them. It worked a treat.

Lice carried typhus, which killed more people in wars since Napoleon than the actual wars had killed. Domenjoz headed straight to the Swiss army who started using it and then presented the results at the American embassy in Bern. When the Americans invaded Italy soon after, the troops were all sprayed with DDT and pretty soon everyone who was liberated from the Germans was liberated from lice also.

After the war was over


After the War it became common to spray the public in cinema queues and at football games across Europe and America for instance as the photo shows. Mueller won the Nobel Prize in 1948. Domenjoz might have thought at the time he should have shared it.

As almost every ghostwritten article about all of the drugs in current use now says, DDT was very clearly safe and effective.

The use of DDT spread. The images most of us have now is of planes dusting crops with plumes trailing behind them.

Then in the early 1960s the wheels came off the bandwagon. By the time Rachel Carson’s Silent Spring was published, DDT was on the road to oblivion, with most of us thankful we had been saved from oblivion. DDT it became clear accumulated in the food chain, with small doses in some insects and crops, ending up as larger doses in the predators living on them,and larger and lethal doses in the birds, fish and other mammals living on them, or in their eggs or milk. And larger doses in us.

We had learnt that the acute effects of a drug given in a particular way might be dramatically different to the effect that came with chronic exposures or from unexpected routes of administration.

Wasn’t this what we learnt?

Geek tragedy

Controlled trials (RCTs) are all about establishing the acute effects of a drug given in a standardized way by drug companies who hope the verdict will be their chemical is safe and effective so that they can head out and put it in the drinking water (metaphorically). People will end up on these chemicals chronically and they will be mixed with lots of other chemicals in ways never imagined when the drug was first tested.

The result is biphosphonate drugs marketed to reduce the risk of fractures which increase the risk of serious fractures. Antidepressants marketed to reduce suicide risk, alcoholism, substance misuse, marriage breakdown etc which increase the risk of all these things, as well as causing Autistic Spectrum Disorder and birth defects. Statins marketed to reduce risks linked to diabetes which increase rates of diabetes, and to reduce the cognitive problems stemming from strokes but causing cognitive problems in their own right. RCTs miss all of these things – and when they don’t miss them as in the case of the antidepressants and suicide the data is fudged, sometimes fraudulently.

Far from recognizing the role of RCTs in producing a new Silent Sprint, RCT enthusiasts are spreading the word that we need more of them. No-one should be on a treatment who isn’t in an RCT. This is the script for a Geek Tragedy.

RCTs do more than miss the long term injuries a drug might do us. They get used to build standards of care to which doctors are obliged to adhere. Anyone who figures it might not be wise to add a sixth drug into the mix a person is on, or that thinks that maybe adolescent crises are not something that need medicating, will find themselves up against these standards of care facing managers who ask Who are you to go against the Standard of Care? Sorry we have to let you go.

Part of the tragedy is that we would in fact save vast amounts of money by giving the pharmaceutical companies 10 times the inflated prices they currently receive for drugs as part of a bargain where their marketing ensures that only 10% of those currently taking lipid-lowering drugs, antidepressants, biphosphonate and other drugs end up on them – and perhaps slightly higher proportions for hypoglycemic drugs, antihypertensives and antibiotics. The savings would come from shutting down osteoporosis screening services. From the savings on not having to treat treatment induced disabilities. From Elective patients (patients on cancer chemotherapy) not having their bed blocked by an antidepressant induced suicide attempt or biphosphonate triggered fracture of the femur, or a hypoglycemic episode (the biggest cause of brain damage) triggered by the use of extra hypogylcemic drugs being used to lower blood sugars elevated by the use of Statins that current standards of care mandate in diabetes.

Most of us thankfully won’t get tangled up in these elements of the tragedy – the final scenes where as in King Lear the corpses are strewn around the stage. For most of us the ending will more like the ending of a play by Samuel Beckett – The Algorithm will See You Now.

Go Figure on Perversity


In 1936, three workers at the Halowax Corporation in New York State, who had been working with chlorinated naphthalenes, developed chloracne – a skin condition that Viktor Yushenko’s face brought dramatically to world attention in 2004, when he was standing as the pro-Western candidate for the presidency of Ukraine.

Chloracne can be caused by many chlorinated compounds from vinyl chloride, through polyvinyl chloride (PVC) and polychlorinated biphenyls (PCBs). Many medicines are chlorinated. I have no idea if this chlorination, as in Zyprexa, olanzapine, for instance can be a problem but Zyprexa and other compounds can certainly give rise to chloracne.

The three workers went on to develop jaundice and then liver failure and died. Halowax had shortly beforehand increased the strength of the chlorinated compounds that went into their halowaxes, which were used as insulators for electrical wires.

The company called in Cecil Drinker, then the dean of Harvard School of Public Health. Drinker and colleagues had helped create industrial hygiene. In this case, the approach involved taking air samples and then testing the chemicals found in the air on laboratory animals – chlorinated naphthalenes and biphenyls. The new more intensely chlorinated compounds were in fact more likely to cause liver damage than the older mixes. The trick then was to find the dose that could cause this problem in rats, half the dose, set this new dose as the maximal exposure permitted, and then recommend ventilation and related measures that would ensure the factory milieu never reached these levels.

There was a tacit understanding that industrial hygienists would not recommend safe levels too difficult for factories to reach. Having undertaken work to manage the issues, factories were well placed in the case of litigation to show they had acted responsibly.

Your point being?

The problem was these tests measured the acute effects of chlorinated compounds – six weeks. They assumed the problems arose from inhalation. And they measured the average effects. This leaves no room for an unusual sensitivity to a chemical, or chronic exposure or exposure that arises from chlorides or related compounds absorbed in unexpected ways.

Vinyl Chlorides can be very safe if used acutely and with discrimination. They are among the materials of choice for dominatrix outfits – as in the featured image.

The vinyl chlorides however also give rise to dioxins. Viktor Yanushenko’s chloracne likely came from dioxin levels that were at 4000 times the safe level in his body. He survived this apparently very acute exposure, which is widely thought to have been a poisoning.

But the cancers that lots of other people have developed since have come not from poisoning by political opponents, or from Sexual Games even those that until recently might have been seen as perverse (longer than usual exposure, variations on the norm and… ), but from chronic exposure to much lower doses than were in the Halowax air in the form of dioxins that have ended up in the food chain.


Without any conspiracy involved, the best science of the day, stamped with a Harvard imprimatur, completely missed the problem. But it did give industry great cover, and helped create the Harvard Department of Public Health and now Global Health.

To be continued.

Go Figure: Digging for the Truth of Injuries

Quarry men

Editorial Note: In her comment, reproduced below,Sally was the person who best got to grips with what I was struggling with in last week’s post and this week’s and for the next few weeks. Drug induced injury is one sphere in which we get injured. Turning to other spheres may give us some ideas about how to handle the dilemma of a treatment induced injury – how to avoid being singled out the system, how to build a community that can resist and seek redress.

The Silver Lining Clouds the View outlined how working with mercury can cause a distinct psychosis or tremor or confusion that clears when the person leaves work.

But what about when a worker gets an illness like tuberculosis? This is not a specific industrial injury.

For fifty years around 1900, North Wales had the biggest slate quarries in the world. At a time when deaths from tuberculosis were falling in Britain, these quarries had increasing rates of tuberculosis and deaths. Repeated enquiries reviewed all options. Quarrying gave the workers silicosis. Did silicosis make tuberculosis more likely?

Local doctors said no. The problem was down to poor diet. The modern housewife spent too much time at school and her only domestic skill was the ability to use a tin opener. These medical views passed muster as the considered judgments of scientifically trained men.

Silicosis does predispose to TB. But, just as the mirror workers in Furth fifty years earlier took their chances with mercury, so too the quarrymen kept quiet about their chest problems. They steered clear of doctors. There was no other employment in the area if they were signed off. Both workers and employers knew that jobs in the mines were dying out.

You don’t have to silver a mirror or go down a mine to appreciate the psychology and politics at play here. You just have to take a medicine. Drugs come with risks. Even when things go wrong on treatment, short of being invalided, most people opt to cope with it, often silently, rather than own up. Owning up, especially if there is no treatment, makes you a loser, and the herd leaves losers behind. The injured worker or patient is like a dog barking at the passing caravan.

Your point being?

Sometimes truth is not something you dig for.

The link between treatment and injury may be a social one. The entire community may know what is going on. But the doctor will see a picture where it is not proven what causes what, and one of his options is to take your moral failings into account. This is often the most convenient option – for him, especially if you’re a woman.

This is a delicate world, a world in which there are no accidents if by accident we mean random events. An unexpected or unintended event is not an accident – although we use the word that way when we are knocked down by a car, and lawyers advertise their expertise in accidents. But Road Traffic Accidents, no less than Drug Traffic Accidents are rarely Acts of God.

An Act of God is when a cow jumps over a ditch and onto your car. In Road Traffic Accidents or Drug Traffic Accidents, someone has always been careless. It may be like the carelessness that started with the American Civil War when rifles that could hit a target at long range replaced muskets that couldn’t and all of a sudden troops could be picked off by a sniper. Being picked off by a sniper sounds almost random, but after the first time it happens, the military top brass are responsible for your death if, having seen what can happen, they do nothing to prevent it happening again.

If the event is not random, the question of responsibility comes into play. Before 1800 roughly we used to be able to attribute misfortune to God or Fate. It is now down to us. If I didn’t intend to hurt you, I am unlikely to concede that something I did in fact did hurt you. The bystanders, those with a superficial knowledge, will side with the likely winner rather than the likely loser, unless forced to delve deeper. Everybody takes steps to avoid being the person responsible, or on the side of the person responsible.

In nurseries for 4 year olds now if a mother brings in a cake on her son’s birthday, the staff will not let other children have a piece because they cannot validate her cake-making. A piece of cake will be put in a take home bag for the children, whose parents can let them have it, if the parents take responsibility.

For the loser in games like this, beyond the injury an identity is destroyed, as surely as if acid has been thrown in a face. I am now marked as a loser and the only people who can understand that are those marked in the same way. But no-one, not even a loser, likes the company of losers. The loser in the lottery of life will also likely lose any contest about what has happened her.

In the world of treatment induced injuries, God fails as an explanation. The modern replacement for God, Science, also fails. We are Shipwrecked and on our own.

Go Figure: The Silver Lining Clouds the View

The Mad Hatter

Editorial Note: Sally’s first Go Figure post with its 100 comments outlines the basic dilemma facing RxISK – how can anyone who has been injured by treatment get people who have not yet been injured to wake up. The next 5 – 10 posts will pick up various ways this dilemma has been answered over the last century. All comments welcome along with any posts – something more than a comment – anyone figures they have.

In 1861, the Furth Provincial Medical Association reported on mercury poisoning among mirror workers in the Furth-Nuremberg area. Along with Venice, Nuremberg was a center of the European mirror industry. The first Guild for Mirror Makers opened here in 1373. The craftsmen were using a technique developed in Venice of silvering the backs of mirrors with a mercury tin amalgam to improve the reflection.

The workers were suffering. Few complained. Their problems were only detected when they came to the doctor with other issues or if some new treatment, such as electrotherapy appeared, that some workers figured might be worth getting the doctor to try to manage the problems they were having.

The workers could see in the mirror exactly what mercury was causing when doctors hadn’t – a flush, tremors, irritability, and madness. It caused their feet to burn or go numb.

But against these risks, the only cure was to stop working which brought the certainty of pauperism and maybe death. So the workers lied to their doctors out of fear of losing their jobs. Besides pay was tied to risk – make the job safer and the rates of pay were likely to drop. Did they want a safer job or more pay? The factory owners denied the link.

Mercury had been causing problems for centuries. It was used in felt hats and caused confusion and disorientation to hatters, leading to the phrase Mad as a Hatter and to the Mad Hatter in Alice in Wonderland in 1865.

Administered as a paste for syphilitic sores from 1600 onwards it seemed to help them heal. This led to its use internally and after 1780 to the use of the stronger form – mercuric chloride or Calomel. Soon after this began to be used widely, dementia paralytica appeared, a psychotic disorder commonly put down to syphilis but which only happened where mercuric chloride was used in its treatment. The combination of syphilis and mercury likely did for Mozart (kidney disease), Beethoven and Schubert. See The Day the Music Died.

But in 1861 the link between mercury and health problems, always known at one level but persistently denied, didn’t go away. Adolf Kussmaul, a university physician, agreed with the link the Furth “general practitioners” were proposing.

There was another factor. Chemistry was flourishing and Justus Liebig and others came up with alternate ways to silver mirrors. Mercury was no longer needed and in 1886 its use for silvering was banned.

Your point being?

Faced with a plague, many of us emigrate, a smaller number stay and resist, but most of us get on the train. It is only if there are options that anything else happens. In Furth there were options in terms of new ways to make a living and perhaps some unusual doctors.

In 1848, revolutions across Europe led to changes of government. Doctors played a big part in these uprisings as they had in Paris in 1790. Two of the revolutionaries in Germany, Rudolf Virchow and Karl Marx, had an enduring impact on politics and healthcare politics. Virchow saw doctors as a revolutionary class, where Marx saw workers.

Industrial health issues, exactly like those the Furth mirror workers demonstrated, triggered the formation of a German Workers Association in 1863. A German Socialist party appeared in 1869. There was a growing number of strikes. In 1869, the response from Bismarck, the German Chancellor, was a Factory Act that left owners free of obligations other than those they voluntarily took on. Factories were regarded as private property – not part of the public realm, and not subject to inspections.

In 1875, the Worker’s Association and Socialist party merged to form the Socialist Workers Party, later the Social Democrats. The socialists accepted the validity of the state and the need to work with its institutions to bring about change – workers health and safety were a critical testing ground for whether this was possible.

Industry argued that technology was so diverse and growing so rapidly that it was not possible to legislate in a way that would work. Bismarck again accepted the employers’ argument that money put into health and safety was a tax on jobs and at a time of growing international competition this was not in the national interest.

In 1878, he enacted a set of punitive Anti-Socialist laws.

But he also took another step. Just as the Republican President Dwight Eisenhower put in place a program of interstate highway construction in the United States in the 1950s as a form of state socialism, so in the 1880s Bismarck put State sponsored health insurance schemes on the table as a means to stave off revolution:

“A duty of a state preserving policy should be to cultivate the conception among the non-propertied classes which form at once the most numerous and the least instructed part of the population that the state is not merely a necessary but a beneficent institution”.

The certification or not of workers as sick was a new role that opened up for doctors, a source of income. But it also made them part of the apparatus of the State. They “matured”. As Adolph Beyer in a lecture to the German Association for Public Health in 1877 put it:

“Precisely in this field, prudence and caution are necessary and one should not try to support a safety which risks or neglects the main priority, the securing of the daily bread. That is why it is necessary to openly oppose those immoderate demands which hide behind their pleasant mask of safety and humanitarian ends quite different aims. One should not let emotions reign, but considerations and experience”.

Go Figure: Sally’s Problem with Whinging about Medicines

99 percent

Two weeks ago in response to the last post in the Study 329 series, Sally MacGregor added the comment – that features as a post below. It’s spot on. The problem is how to avoid being marginalized, becoming part of a 1%. How to capture the attention of the 99% for whom the meds work just fine thanks. There will be more on this theme over the next few posts.

The whole point about the revisited Study 329 for me was that it was so meticulously and scrupulously carried out by a team of researchers, in a way that left no wriggle-room for it to be dismissed as ‘bad science’. (Even though some have tried). So it stands as a solid, irrefutable, excellent piece of science, which will be cited in the literature, and, crucially, is likely to pop up on Google. It’s kind of embedded now, which seems to me to be its lasting legacy. That it concerned GSK and paroxetine is secondary – Eli Lilly were just as murderously and indifferently mendacious – and in the UK get much, much less publicity for their callously commercial behavior.

The difficulties in getting through the hoops to the BMJ must have been incredibly frustrating, but – is anyone outside the ‘Study 329’ inner circle, or people who suffered from paroxetine, truly interested in the fact that someone’s husband was related to someone else who might have hindered the path to publication. It GOT published – which is the really important thing.

No one I know, service users included, had even heard of Study 329 – although several friends were very interested in the RIAT paper – mainly as a concrete example of meretricious Big Pharma mendacity. Hell – I’d never heard of Study 329 until 2013.

I’m playing devil’s advocate to a degree but sometimes I think we have to get real about life outside, where the chemical imbalance theory still reigns supreme, and if the public perceive any problem at all with antidepressants it is far more likely to be along the lines of ‘well he/she wasn’t taking their medication, that’s why they went berserk’.

No one will like me saying this – but I am sometimes reluctant to point people in the direction of David’s blog and Rxisk because, coming at it from a newcomer’s perspective, people don’t understand why AllTrials is suspect, (no one ever slows down and explains, for one reason) what on earth the BMJ did wrong, why Fiona Godlee is Nurse Ratchett, or what on earth is the point of laboriously transcribing an exchange between Goldacre just to show he’s an unreliable twat… And those new visitors will probably never repeat the experience.

Drawing new people in, from places other than those (like me) who’ve been dreadfully harmed is really important: doctors, researchers, scientists, our children, relatives, neighbours, philosophers, writers, journalists. We honestly HAVE to broaden the debate otherwise it simply becomes an incestuous gathering of victims and activists, who already know all there is to know about the damage. If visitors from outside don’t feel welcome, or just don’t understand what everyone’s going on about, then what on earth is the point?

Believe me, I’ve tried getting people to engage with Rxisk and David’s blog but it hasn’t worked – for all the reasons I’ve just stated. But they are surely the truly important people to get on board? Otherwise both forums just end up with ‘I am a victim’ hand-wringing on a big scale which does nothing to spread the message…no one apart from Johanna offered me any help with my ‘Take a Rxisk report to your GP’ request – and that was a challenge thrown out by David, which I didn’t especially want to do, but was willing to give it a go.

Similarly, with the Complex Withdrawal site (which I’m deeply interested in, as it might just offer some hope in the future for people like me) – I asked around, as requested, got some small bits of information from my hairdresser and a friend who’s a beautician– but there is no where sensible to put it, and the comments section has (yet again) been mainly co-opted by people offering well meaning but probably useless dietary advice or repeating, yet again, their stories. Surely the challenge was to GET MORE AND DIFFERENT people involved in collecting information?

It seems to me that every single attempt to move forward just dies – because no one slows down long enough to consolidate the practical ideas which might just make a difference to future victims. It’s too late for me, but I’d like to do my best to see that help is there for all those still to come. We can carry on preaching to the converted till the cows come home, but seems to me far more important to educate, persuade, chip away at societal views about antidepressants (non addictive, no such thing as withdrawal etc etc) without making people who take them feel alienated and ashamed.

I’m fed up with bashing away and for anyone who wants to reply ‘I did not like this comment’ – go figure.

Why Do People Sing?

Under African Skies

In 1989, BBC ran a program Under African Skies covering the music of the continent. The program and music from it captured on Cassette and later Record became widely known.

On Side 2 of 4 sides of cassette, there is a brief snippet of 4 children at St Joseph’s Music School in Harare answering their teacher’s question – Why do People Sing?

Peter: People sing to pass a message to others through music

Tom: People sing because they want to forget their problem

Terra: People sing because they want to get even

Art: People sing because they want to entertain others.

The soundtrack is Here.

Its worth listening to just to get the music of the childrens’ voices but it would also be great if someone can decipher what Terra says – the current suggestion is “because they want to get even” and the name of the last boy – seems like Art.

This is an introduction to a new series of posts. More once the reasons why people sing are filled in. Readers are welcome to offer more reasons for singing.