Progress in understanding the nuclear equation of state at the quark level

At the present time there is a lively debate within the nuclear community concerning the relevance of quark degrees of freedom in understanding nuclear structure. We outline the key issues and review the impressive progress made recently within the framework of the quark-meson coupling model. In particular, we explain in quite general terms how the modification of the internal structure of hadrons in-medium leads naturally to three- and four-body forces, or equivalently, to density dependent effective interactions.