PRESCRIPTION DRUGS THAT KILL: ANOTHER

KIND OF DRUG PROBLEM

By Peter Montague, Editor

RACHEL'S ENVIRONMENT & HEALTH WEEKLY

A medical report in 1998 estimated that adverse reactions to prescription drugs are killing
about 106,000 Americans each year -- roughly three times as many as are killed by
automobiles.[1] This makes prescription drugs the fourth leading killer in the U.S., after
heart disease, cancer, and stroke. The report included only drugs that were given properly
and under normal circumstances, excluding drugs that were administered in error or taken
in attempted suicides. (When errors of administration are included, the death toll may be
as high as 140,000 per year.[2] Such errors include prescribing the wrong drug or the
wrong dosage; giving medications to the wrong person; giving medications to the right
person but in the wrong quantities or the wrong frequencies, and so forth.)

According to the 1998 report, which analyzed the data from 39 separate studies
conducted over the last 32 years in U.S. hospitals, 3.2 out of every 1000 (or 3200 per
million) hospital patients die from adverse reactions to prescription drugs. Of the 106,000
people killed each year by prescription drugs in the U.S., 41% (43,000) were admitted to
the hospital because of an adverse drug reaction; the other 59% (63,000 people) were
hospitalized for some other cause but developed a fatal reaction to prescription drugs they
received while hospitalized. In the U.S. in 1994, there were 33,125,492 hospital
admissions.

The sale of prescription drugs has more than doubled in the U.S. during the past 8 years.
In 1990, Americans spent $37.7 billion on prescriptions; in 1997, national spending on
prescriptions reached 78.9 billion.[3] Prescription drugs are the fastest-growing portion of
health-care costs, having risen at the rate of 17% per year for the past few years.[3]

Urging physicians to prescribe particular drugs -- especially new drugs -- is a huge

business. According to the NEW YORK TIMES, the sales force of the largest 40 drug
companies has "exploded" in recent years.[3] In 1994, there were 35,000 full-time "detail
people" employed by drug companies to visit doctors and describe pharmaceutical
products; by 1998, the number had grown to 56,000 -- one sales person for every 11
physicians.[3] Drug companies spent $5.3 billion in the first 11 months of 1998 sending
their "detail people" into doctors' offices and hospitals, plus another $1 billion putting on
"marketing events" for doctors.

Not all adverse reactions to new drugs can be anticipated or avoided under the present
system, according to medical experts. "It is simply not possible to identify all the adverse
effects of drugs before they are marketed," say three physicians writing in the NEW
ENGLAND JOURNAL OF MEDICINE.[4] In fact, "Overall, 51% of approved drugs
have serious side effects not detected prior to approval."[5]
Side effects from new drugs cannot be anticipated for 2 main reasons: (1) Individuals
vary greatly in their reactions to chemical substances; and (2) drugs are tested rare side
effects may not appear in such a small group but may become painfully obvious when
millions of people start taking the drug. Even a few years ago, drugs reached a mass
audience slowly, providing time for unexpected side effects to show up in relatively small
numbers of people. But today drugs are marketed directly to consumers via TV, so a huge
market for a new product can be created quickly and side effects can appear in large
numbers of people. The sexual potency drug, Viagra, provides an example of this
phenomenon. Within a few months of its introduction, several million people began
taking Viagra, and many serious side effects, including fatalities, suddenly appeared.

Despite the widespread knowledge that half of all new drugs will cause serious side
effects in some people, neither the government nor the drug companies systematically
collect information on adverse reactions to new drugs. "Even when it is recognized that a
new drug will be given to many patients for many years, rarely are systematic post-
marketing studies carried out."[4]

In the U.S., there is no formal procedure for monitoring drug safety. If physicians became
aware that a new drug has killed or maimed one of their patients, or caused an allergic
reaction, they may report it but they also may not. As reports filter into the U.S. Food and
Drug Administration (FDA) in hit-or-miss fashion, FDA can revoke the approval of a
drug, and sometimes does, but almost never quickly. In December, 1997, the popular
nonsedating antihistamine terfenadine was withdrawn from the market because a safer
alternative existed without terfenadine's danger of a potentially fatal heart arrhythmia
(irregular heart beat). However, by that time terfenadine had been on the market 12 years.
Last September the FDA took the diet drugs fenfluramine and dexfenluramine off the
market because of heart valve damage to 31% of those who took the drugs in
combination with another diet pill, phentermine (a combination known as fen/- phen)
Fenfluramine could also damage heart valves when taken alone. By the time fenfluramine
was banned, it had been on the market for 24 years.

A recent commentary by three doctors, published in the NEW ENGLAND JOURNAL

OF MEDICINE, contrasted prescription drug safety with airline safety.

Airplanes are built, licensed and flown according to standards set by the Federal Aviation
Administration (FAA). But whenever a plane crash occurs, a different agency (the
National Transportation Safety Board, or NTSB) steps in to establish the facts and make
recommendations for avoiding future crashes. The assumption is that a second,
independent agency is needed because the FAA would have a conflict of interest
investigating crashes of planes it had approved and licensed.

In drug safety, on the other hand, there is only one agency. The Food and Drug
Administration (FDA) approves pharmaceuticals and it also has responsibility for
investigating injuries and deaths caused by those pharmaceuticals. As we have seen, FDA
has a very limited capacity to conduct surveillance studies so, in fact, they rely on the
drug companies to provide data on deaths and illnesses caused by their own products.
As mentioned above, the diet drug dexfenfluramine was taken off the market in 1997
because, combined with phentermine (the fen/- phen diet-pill combination), it damaged
heart valves.[4] When the FDA learned that dexfenfluramine was dangerous, the agency
had no good data on the total number of people harmed. At the time, the director of
FDA's Office of Epidemiology and Biostatistics said, defensively, "We've done what is
necessary to determine there is a problem. Other information is up to American Home
Products [which marketed dexfenfluramine] to find out." Of course American Home
Products had little incentive to investigate the number of problems caused by its product.

The three doctors comment, "Given the litigious climate surrounding issues of drug
safety, information from investigations conducted by parties with vested interests is
unlikely to be impartial and is seldom publicly available to improve future decision
making."

The three doctors say an independent drug safety board -- analogous to the National
Transportation Safety Board -- is needed to study deaths and illnesses from drugs. They
point out that FDA officials spend up to a year of their lives evaluating a drug before
approving it for marketing "and it is unlikely that those who recommended a drug for
approval could later conduct a dispassionate evaluation of possible harm due to that
drug."

According to a recent commentary in the JOURNAL OF THE AMERICAN MEDICAL

ASSOCIATION, a competent drug safety program would have four parts:

(1) A program to monitor all adverse effects from prescription drugs and annually report
the number of injuries and deaths and their likely causes. Currently no one keeps such
statistics.

(2) A program to monitor side effects from new drugs. Presently, the FDA's Division of
Pharmacovigilance and Epidemiology (DPE) has a staff of 52 people, but only 8 of those
have MD degrees and only one has a Ph.D. in epidemiology. This small group collects
anecdotal information about side effects of new drugs, but hasn't the resources to be
systematic or thorough.

The problem with anecdotal information is that only about 1% of adverse drug reactions
get reported in this way. For example, the FDA received an average of 82 reports each
year about adverse reactions caused by the drug digoxin. This relatively small number of
reports seemed to indicate that digoxin was not a big problem. However a systematic
survey of Medicare records revealed 202,211 hospitalizations for adverse reactions to
digoxin during a seven-year period.

When FDA's DPE identifies a drug problem, they can only pass the information along to
the division of FDA that approved the drug. That division can require the manufacturer to
develop additional information. However, "The most common corrective action is a
change in the product disclosure label or package insert."[5] The question then becomes,
are such warnings effective?
(3) The third part of a competent drug safety program would make sure that safety
information is being disseminated and heeded by physicians. FDA currently has no such
program. "The limited information available, however, suggests that some important
safety information--such as boxed warnings on drug disclosure labels--either was not
received or had little effect. For example, one outcome of the protracted debate over the
safety of the sedative triazolam was a new drug label warning that it should be prescribed
for only 7 to 10 days. Several years later an FDA task force reported that 85% of the
prescriptions were being written for longer periods.... Neither the FDA nor any other
agency has an organized program to find out whether the important warning messages are
achieving their intended purpose of protecting the public and, if not, discovering the
cause."[5]

(4) The fourth part of a competent drug safety program would aggressively seek out
information about unsuspected adverse reactions to drugs. Instead of waiting passively
for anecdotal information to filter in, the government needs to aggressively look for drug
involvement in reported birth defects, heart problems and other common disorders that
are frequently caused by prescription drugs. In the same way that the world's public
health specialists aggressively seek out new strains of influenza, FDA needs to be
aggressively seeking out new side effects of drugs.

Rather than strengthening the U.S. government's drug safety programs, the present
Congress has recently diminished the powers of the FDA to monitor drug safety.
Congress now allows drug companies to pay fees which FDA uses to speed up the
approval process for new drugs. As a result, during 1996-1997, FDA approved 92 new
drugs for market -- twice the previous rate. However, Congress specifically prohibited
FDA from using any of the new money for monitoring drug safety.[4]

[1] Jason Lazarou and others, "Incidence of Adverse Drug Reactions in Hospitalized
Patients," JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Vol. 279, No.
15 (April 15, 1998), pgs. 1200-1205. And see: David W. Bates, "Drugs and Adverse Drug
Reactions; How Worried Should We Be? [editorial]" JOURNAL OF THE AMERICAN
MEDICAL ASSOCIATION Vol. 279, No. 15 (April 15, 1998), pgs. 1216-1217.

[2] David C. Classen and others, "Adverse Drug Events in Hospitalized Patients,"
JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Vol. 277, No. 4 (January
22/29, 1997), pgs. 301-306.

[3] Abigail Zuger, "Fever Pitch: Getting Doctors To Prescribe Is Big Business," NEW
YORK TIMES January 11, 1999, pgs. A1, A13.

[4] Alastair J.J. Wood and others, "Making Medicines Safer -- The Need for an
Independent Drug Safety Board," NEW ENGLAND JOURNAL OF MEDICINE Vol.
339, No. 25 (December 17, 1998), pgs. 1851-1854.
[5] Thomas J. Moore and others, "Time to Act on Drug Safety," JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION Vol. 279, No. 19 (May 20, 1998), pgs. 1571-
1573.

Descriptor terms: pharmaceutical drugs; hospitals; drug industry; fenfluramine;

dexfenfluramine; airline safety; phentermine; fda; faa; ntsb; fen/phen; fen-phen; drug
safety;

################################################################

NOTICE

Environmental Research Foundation provides this electronic version of RACHEL'S

ENVIRONMENT & HEALTH WEEKLY free of charge even though it costs our
organization considerable time and money to produce it. We would like to continue to
provide this service free. You could help by making a tax-deductible contribution
(anything you can afford, whether $5.00 or $500.00). Please send your tax-deductible
contribution to: Environmental Research Foundation, P.O. Box 5036, Annapolis, MD
21403-7036. Please do not send credit card information via E-mail. For further
information about making tax-deductible contributions to E.R.F. by credit card please
phone us toll free at 1-888-2RACHEL, or at (410) 263-1584, or fax us at (410) 263-8944.

--Peter Montague, Editor

################################################################

=======================Electronic Edition========================

. .

. RACHEL'S ENVIRONMENT & HEALTH WEEKLY #632 .

. ---January 7, 1999--- .

. HEADLINES: .

. ANOTHER KIND OF DRUG PROBLEM .

. ========== .

. Environmental Research Foundation .

. P.O. Box 5036, Annapolis, MD 21403 .

. Fax (410) 263-8944; E-mail: erf@rachel.org .

. ========== .

. Back issues available by E-mail; to get instructions, send .

. E-mail to INFO@rachel.clark.net with the single word HELP .

 . in the message; back issues also available from .

. http://www.rachel.org . To start your free subscriprion, .

. send E-mail to listserv@rachel.org with the words .

. SUBSCRIBE RACHEL-WEEKLY YOUR NAME in the message. .

=================================================================

Richard Alexander is a specialist in personal injury litigation with 30 years in-depth

experience. Emphasizing working relationships with clients has led to an exceptional
record of success. He has served as a member of the Board of Governors of The State Bar
of California, President of the Santa Clara County Bar Association and the Board of
Governors of Consumer Attorneys of California. He is a founding member of the
National Association of Consumer Advocates, and heads Alexander Hawes, LLP.

Alexander Hawes, LLP is a California law firm that specializes in personal injury,
wrongful death, and financial losses caused by negligence, defective products, toxic
chemicals, corporate misconduct or insurance fraud on behalf of consumers, small
investors, injured workers and small businesses. In addition to individual cases the firm
prosecutes class actions for large groups of individuals who have suffered financial loss
as a result of corporate fraud, defective consumer products, and environmental pollution.
The firm holds Martindale-Hubbell's highest rating and is recognized in the List of
Preeminent Law Firms in the U. S.

Press here for a free consultation.

PRESCRIPTION DRUGS THAT KILL: ANOTHER

KIND OF DRUG PROBLEM
By Peter Montague, Editor

RACHEL'S ENVIRONMENT & HEALTH WEEKLY

A medical report in 1998 estimated that adverse reactions to prescription drugs are killing
about 106,000 Americans each year -- roughly three times as many as are killed by
automobiles.[1] This makes prescription drugs the fourth leading killer in the U.S., after
heart disease, cancer, and stroke. The report included only drugs that were given properly
and under normal circumstances, excluding drugs that were administered in error or taken
in attempted suicides. (When errors of administration are included, the death toll may be
as high as 140,000 per year.[2] Such errors include prescribing the wrong drug or the
wrong dosage; giving medications to the wrong person; giving medications to the right
person but in the wrong quantities or the wrong frequencies, and so forth.)
According to the 1998 report, which analyzed the data from 39 separate studies
conducted over the last 32 years in U.S. hospitals, 3.2 out of every 1000 (or 3200 per
million) hospital patients die from adverse reactions to prescription drugs. Of the 106,000
people killed each year by prescription drugs in the U.S., 41% (43,000) were admitted to
the hospital because of an adverse drug reaction; the other 59% (63,000 people) were
hospitalized for some other cause but developed a fatal reaction to prescription drugs they
received while hospitalized. In the U.S. in 1994, there were 33,125,492 hospital
admissions.

The sale of prescription drugs has more than doubled in the U.S. during the past 8 years.
In 1990, Americans spent $37.7 billion on prescriptions; in 1997, national spending on
prescriptions reached 78.9 billion.[3] Prescription drugs are the fastest-growing portion of
health-care costs, having risen at the rate of 17% per year for the past few years.[3]

Urging physicians to prescribe particular drugs -- especially new drugs -- is a huge

business. According to the NEW YORK TIMES, the sales force of the largest 40 drug
companies has "exploded" in recent years.[3] In 1994, there were 35,000 full-time "detail
people" employed by drug companies to visit doctors and describe pharmaceutical
products; by 1998, the number had grown to 56,000 -- one sales person for every 11
physicians.[3] Drug companies spent $5.3 billion in the first 11 months of 1998 sending
their "detail people" into doctors' offices and hospitals, plus another $1 billion putting on
"marketing events" for doctors.

Not all adverse reactions to new drugs can be anticipated or avoided under the present
system, according to medical experts. "It is simply not possible to identify all the adverse
effects of drugs before they are marketed," say three physicians writing in the NEW
ENGLAND JOURNAL OF MEDICINE.[4] In fact, "Overall, 51% of approved drugs
have serious side effects not detected prior to approval."[5]

Side effects from new drugs cannot be anticipated for 2 main reasons: (1) Individuals
vary greatly in their reactions to chemical substances; and (2) drugs are tested rare side
effects may not appear in such a small group but may become painfully obvious when
millions of people start taking the drug. Even a few years ago, drugs reached a mass
audience slowly, providing time for unexpected side effects to show up in relatively small
numbers of people. But today drugs are marketed directly to consumers via TV, so a huge
market for a new product can be created quickly and side effects can appear in large
numbers of people. The sexual potency drug, Viagra, provides an example of this
phenomenon. Within a few months of its introduction, several million people began
taking Viagra, and many serious side effects, including fatalities, suddenly appeared.

Despite the widespread knowledge that half of all new drugs will cause serious side
effects in some people, neither the government nor the drug companies systematically
collect information on adverse reactions to new drugs. "Even when it is recognized that a
new drug will be given to many patients for many years, rarely are systematic post-
marketing studies carried out."[4]
In the U.S., there is no formal procedure for monitoring drug safety. If physicians became
aware that a new drug has killed or maimed one of their patients, or caused an allergic
reaction, they may report it but they also may not. As reports filter into the U.S. Food and
Drug Administration (FDA) in hit-or-miss fashion, FDA can revoke the approval of a
drug, and sometimes does, but almost never quickly. In December, 1997, the popular
nonsedating antihistamine terfenadine was withdrawn from the market because a safer
alternative existed without terfenadine's danger of a potentially fatal heart arrhythmia
(irregular heart beat). However, by that time terfenadine had been on the market 12 years.
Last September the FDA took the diet drugs fenfluramine and dexfenluramine off the
market because of heart valve damage to 31% of those who took the drugs in
combination with another diet pill, phentermine (a combination known as fen/- phen)
Fenfluramine could also damage heart valves when taken alone. By the time fenfluramine
was banned, it had been on the market for 24 years.

A recent commentary by three doctors, published in the NEW ENGLAND JOURNAL

OF MEDICINE, contrasted prescription drug safety with airline safety.

Airplanes are built, licensed and flown according to standards set by the Federal Aviation
Administration (FAA). But whenever a plane crash occurs, a different agency (the
National Transportation Safety Board, or NTSB) steps in to establish the facts and make
recommendations for avoiding future crashes. The assumption is that a second,
independent agency is needed because the FAA would have a conflict of interest
investigating crashes of planes it had approved and licensed.

In drug safety, on the other hand, there is only one agency. The Food and Drug
Administration (FDA) approves pharmaceuticals and it also has responsibility for
investigating injuries and deaths caused by those pharmaceuticals. As we have seen, FDA
has a very limited capacity to conduct surveillance studies so, in fact, they rely on the
drug companies to provide data on deaths and illnesses caused by their own products.

As mentioned above, the diet drug dexfenfluramine was taken off the market in 1997
because, combined with phentermine (the fen/- phen diet-pill combination), it damaged
heart valves.[4] When the FDA learned that dexfenfluramine was dangerous, the agency
had no good data on the total number of people harmed. At the time, the director of
FDA's Office of Epidemiology and Biostatistics said, defensively, "We've done what is
necessary to determine there is a problem. Other information is up to American Home
Products [which marketed dexfenfluramine] to find out." Of course American Home
Products had little incentive to investigate the number of problems caused by its product.

The three doctors comment, "Given the litigious climate surrounding issues of drug
safety, information from investigations conducted by parties with vested interests is
unlikely to be impartial and is seldom publicly available to improve future decision
making."

The three doctors say an independent drug safety board -- analogous to the National
Transportation Safety Board -- is needed to study deaths and illnesses from drugs. They
point out that FDA officials spend up to a year of their lives evaluating a drug before
approving it for marketing "and it is unlikely that those who recommended a drug for
approval could later conduct a dispassionate evaluation of possible harm due to that
drug."

According to a recent commentary in the JOURNAL OF THE AMERICAN MEDICAL

ASSOCIATION, a competent drug safety program would have four parts:

(1) A program to monitor all adverse effects from prescription drugs and annually report
the number of injuries and deaths and their likely causes. Currently no one keeps such
statistics.

(2) A program to monitor side effects from new drugs. Presently, the FDA's Division of
Pharmacovigilance and Epidemiology (DPE) has a staff of 52 people, but only 8 of those
have MD degrees and only one has a Ph.D. in epidemiology. This small group collects
anecdotal information about side effects of new drugs, but hasn't the resources to be
systematic or thorough.

The problem with anecdotal information is that only about 1% of adverse drug reactions
get reported in this way. For example, the FDA received an average of 82 reports each
year about adverse reactions caused by the drug digoxin. This relatively small number of
reports seemed to indicate that digoxin was not a big problem. However a systematic
survey of Medicare records revealed 202,211 hospitalizations for adverse reactions to
digoxin during a seven-year period.

When FDA's DPE identifies a drug problem, they can only pass the information along to
the division of FDA that approved the drug. That division can require the manufacturer to
develop additional information. However, "The most common corrective action is a
change in the product disclosure label or package insert."[5] The question then becomes,
are such warnings effective?

(3) The third part of a competent drug safety program would make sure that safety
information is being disseminated and heeded by physicians. FDA currently has no such
program. "The limited information available, however, suggests that some important
safety information--such as boxed warnings on drug disclosure labels--either was not
received or had little effect. For example, one outcome of the protracted debate over the
safety of the sedative triazolam was a new drug label warning that it should be prescribed
for only 7 to 10 days. Several years later an FDA task force reported that 85% of the
prescriptions were being written for longer periods.... Neither the FDA nor any other
agency has an organized program to find out whether the important warning messages are
achieving their intended purpose of protecting the public and, if not, discovering the
cause."[5]

(4) The fourth part of a competent drug safety program would aggressively seek out
information about unsuspected adverse reactions to drugs. Instead of waiting passively
for anecdotal information to filter in, the government needs to aggressively look for drug
involvement in reported birth defects, heart problems and other common disorders that
are frequently caused by prescription drugs. In the same way that the world's public
health specialists aggressively seek out new strains of influenza, FDA needs to be
aggressively seeking out new side effects of drugs.

Rather than strengthening the U.S. government's drug safety programs, the present
Congress has recently diminished the powers of the FDA to monitor drug safety.
Congress now allows drug companies to pay fees which FDA uses to speed up the
approval process for new drugs. As a result, during 1996-1997, FDA approved 92 new
drugs for market -- twice the previous rate. However, Congress specifically prohibited
FDA from using any of the new money for monitoring drug safety.[4]

[1] Jason Lazarou and others, "Incidence of Adverse Drug Reactions in Hospitalized
Patients," JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Vol. 279, No.
15 (April 15, 1998), pgs. 1200-1205. And see: David W. Bates, "Drugs and Adverse Drug
Reactions; How Worried Should We Be? [editorial]" JOURNAL OF THE AMERICAN
MEDICAL ASSOCIATION Vol. 279, No. 15 (April 15, 1998), pgs. 1216-1217.

[2] David C. Classen and others, "Adverse Drug Events in Hospitalized Patients,"
JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Vol. 277, No. 4 (January
22/29, 1997), pgs. 301-306.

[3] Abigail Zuger, "Fever Pitch: Getting Doctors To Prescribe Is Big Business," NEW
YORK TIMES January 11, 1999, pgs. A1, A13.

[4] Alastair J.J. Wood and others, "Making Medicines Safer -- The Need for an
Independent Drug Safety Board," NEW ENGLAND JOURNAL OF MEDICINE Vol.
339, No. 25 (December 17, 1998), pgs. 1851-1854.

[5] Thomas J. Moore and others, "Time to Act on Drug Safety," JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION Vol. 279, No. 19 (May 20, 1998), pgs. 1571-
1573.

Descriptor terms: pharmaceutical drugs; hospitals; drug industry; fenfluramine;

dexfenfluramine; airline safety; phentermine; fda; faa; ntsb; fen/phen; fen-phen; drug
safety;

################################################################

NOTICE

Environmental Research Foundation provides this electronic version of RACHEL'S

ENVIRONMENT & HEALTH WEEKLY free of charge even though it costs our
organization considerable time and money to produce it. We would like to continue to
provide this service free. You could help by making a tax-deductible contribution
(anything you can afford, whether $5.00 or $500.00). Please send your tax-deductible
contribution to: Environmental Research Foundation, P.O. Box 5036, Annapolis, MD
21403-7036. Please do not send credit card information via E-mail. For further
information about making tax-deductible contributions to E.R.F. by credit card please
phone us toll free at 1-888-2RACHEL, or at (410) 263-1584, or fax us at (410) 263-8944.

--Peter Montague, Editor

################################################################

=======================Electronic Edition========================

. .

. RACHEL'S ENVIRONMENT & HEALTH WEEKLY #632 .

. ---January 7, 1999--- .

. HEADLINES: .

. ANOTHER KIND OF DRUG PROBLEM .

. ========== .

. Environmental Research Foundation .

. P.O. Box 5036, Annapolis, MD 21403 .

. Fax (410) 263-8944; E-mail: erf@rachel.org .

. ========== .

. Back issues available by E-mail; to get instructions, send .

. E-mail to INFO@rachel.clark.net with the single word HELP .

. in the message; back issues also available from .

. http://www.rachel.org . To start your free subscriprion, .

. send E-mail to listserv@rachel.org with the words .

. SUBSCRIBE RACHEL-WEEKLY YOUR NAME in the message. .

=================================================================

Richard Alexander is a specialist in personal injury litigation with 30 years in-depth

experience. Emphasizing working relationships with clients has led to an exceptional
record of success. He has served as a member of the Board of Governors of The State Bar
of California, President of the Santa Clara County Bar Association and the Board of
Governors of Consumer Attorneys of California. He is a founding member of the
National Association of Consumer Advocates, and heads Alexander Hawes, LLP.
Alexander Hawes, LLP is a California law firm that specializes in personal injury,
wrongful death, and financial losses caused by negligence, defective products, toxic
chemicals, corporate misconduct or insurance fraud on behalf of consumers, small
investors, injured workers and small businesses. In addition to individual cases the firm
prosecutes class actions for large groups of individuals who have suffered financial loss
as a result of corporate fraud, defective consumer products, and environmental pollution.
The firm holds Martindale-Hubbell's highest rating and is recognized in the List of
Preeminent Law Firms in the U. S.

Press here for a free consultation.