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by Jerry Avorn
Vintage, 2004
Review by Leo Uzych, J.D., M.P.H. on Oct 7th 2005

Powerful Medicines

   Prescription drugs, and attendant benefits, risks and costs, are the cynosure of the vastly-illumining and immensely-enthralling, if somewhat disheartening, tome entitled Powerful Medicines.   Highly-gifted writer, and sole author, Jerry Avorn is an Associate  Professor of Medicine, at Harvard Medical School.  The primal message imparted by Avorn, in unequivocally blunt, albeit non-abrasive, fashion, is that every drug has three "faces":  a possibly-therapeutically-healing  (or benefits) face; a potentially-deadly, side-effects (or risks) face; and, also importantly, an economically-rooted (or costs) face; and it is imperative for the three faces to be brought into much-better balance, in vigorous pursuit of optimizing the public's health.

   Throughout the expansive corpus of the brilliantly-written text, Avorn remonstrates relentlessly, and soberingly, regarding the cruel paradox of pharmaceuticals:  the potential healing powers of medicines, on the one hand; but, alas, their potential for highly-deleterious, even deadly, side effects, on the other.  Also, and quite significantly, interlaced into this paradoxically-woven tapestry is the problematically-exorbitant economic costs, of medicines.

   It is facile, but wrong, for critics to cast aside the contemplative musings, of Avorn, as simply constituting an unfair caricature of the pharmaceutical industry as being obsessively commercial-centric, and insufficiently attentive to ethics and the public's health.  Avorn, in fact, is often quite critical of pharmaceutical-industry practices; and the Food and Drug Administration, as well, is often pilloried.  But, it is also true that the enthrallingly-expert commentary, of Avorn, is perspicaciously filtered through the quite-discerning prism of Avorn's long-standing, and broad-ranging, professional experiences, as a:  clinician, epidemiologist, and health-policy and drug researcher.

   In an infectiously-visceral way, Avorn is enormously respectful of ethics, and extremely mindful of the primacy of the public's health.  Avorn unabashedly decries perceived flaws of America's marketplace model of healthcare, which work at cross purposes with optimal public health; and believes that, with respect to drugs, and healthcare in general, the extant, defect-ridden U.S. healthcare system must be substantially reorganized so as to be tethered securely to the transcendent goal of greatly improving the public's health.

   It cannot sensibly be gainsaid that the wellsprings of profound insight and knowledge, embedded in the text, should help slake the intellectual thirst of those coveting the imbibing of deep waters of erudition, germane to drugs, and accompanying benefits, risks, and costs.  Writing with gritty determination, measured hopefulness, and with a not-unreasonable sense of urgency, Avorn has beautifully crafted a refreshingly-candid and delectably-edifying book, which, truthfully, is very properly of pertinent interest to all Americans.

   Structurally, five "parts", which ramify into twenty-three chapters, comprise the mainstay pillars, supporting the book's structural foundation.  A riveting prologue functions as an exordium to the trunk of the textual body.  The crux of the adroitly-prepared first part of the book is the quite-vexing question of whether or not a particular medicine "works", in terms of therapeutic efficacy.  In the highly instructive, if somewhat-dispiriting, second part of the book, Avorn sharply focuses rapt attention on drugs, and allied risks.  Very skillfully employing a case-study format, to conduct engrossingly revealing "autopsies", with respect to problematic drugs, Avorn retraces, in detail-laden, critical fashion, the dreary regulatory and marketing trails of several drugs.  Particularly, case studies of the drugs Redux, Rezulin, and phenylpropanolamine distressingly show egregious failures with respect to drug risk assessment; and are striking, and disquieting, evidence of how the benefit-risk balance between drug-associated healing and harm can get badly out-of-control.  The increasingly-onerous economic costs of medicines, and increasingly-desperate efforts to contain such costs, are at the core of the book's third part.  The over-arching concern of the book's fourth part is attached firmly to real-life, information-related factors impinging on the writing of prescriptions by clinicians ensconced in the labyrinthine U.S. healthcare system, and provides bluntly-critical commentary appertaining to the real-life tug of war between the deluge of promotional materials poured on clinicians by the pharmaceutical industry in competition with scientific-evidence-based information, regarding drugs.  Finally, in the last part of the book, Avorn, exuding trenchant determination, discourses on the salient need for effectual harmonizing, of drug-related benefits, risks, and costs, by means of judicious policy and regulatory interventions and innovations.  A fairly limited number of well-annotated research "Notes" adjoin the textual body, and may efficaciously serve as a conduit, leading to further study of particular areas of research interest to individual readers.

   Wielding an immensely-intellectually-powerful ax, forged in the fire of his very considerable, real-life experiences as a clinical practitioner-researcher physician, Avorn toilsomely chops away at multifarious perceived deficiencies plaguing the pharmaceutical industry, and America's marketplace approach to healthcare generally.  Avorn's vast array of shrewd observations and insights are enshrouded by his manifest, very scrupulous honesty and integrity.

   This book, it should be noted, is not for the intellectually timid.  Avorn's multitudinous questions are often deeply-probing; and his observations and answers may be quite unsettling.  Truth, as Avorn lucidly sees it, is revealed, with no attempt made to shield warts and blemishes, however ugly.  Healthcare clinicians and researchers, public-health professionals, economists, policy makers and lawyers intertwined professionally with the healthcare field, epidemiologists, pharmacists, ethicists, and persons enmeshed in the pharmaceutical and health-insurance industries, are among those who should benefit greatly from this superb book.

 

© 2005 Leo Uzych

 

Leo Uzych (based in Wallingford,PA) earned a law degree, from Temple University; and a master of public health degree, from Columbia University.  His area of special professional interest is healthcare.