MMR: ‘A reparation, of sorts’
Lancet editor Richard Horton's new book on the MMR debacle doesn't explain why he published Andrew Wakefield's flawed research in the first place.
MMR: Science and Fiction: Exploring the Vaccine Crisis, Richard Horton, Granta, 2004.
‘The Wakefield affair reveals a society undone and unable to come to terms with dissent, uncertainty, the meaning of evidence, the inescapable human need for trust, and our wider global responsibilities.’
In his decision to publish in the Lancet in February 1998 the paper in which Andrew Wakefield suggested a link between the MMR vaccine and autism, the editor Richard Horton played an important role in launching one of the great health scares of recent years (1). No doubt, as Dr Horton argues in his apologia for his role, the subsequent furore reflects many of the problems of contemporary society. But it raises a much more specific question: how did Dr Wakefield persuade a leading journal of medical science to publish a paper that was both bad science and damaging to public health?
The Lancet’s difficulties are not resolved by the ‘partial retraction’ of the Wakefield paper in February 2004 by ten of its signatories (but not including Dr Wakefield himself). This followed the revelation, by Brian Deer in The Sunday Times, that Dr Wakefield had failed to disclose a conflict of interests arising from his receipt of £55,000 from the legal aid board in pursuit of litigation against the manufacturers of MMR. Dr Wakefield should certainly have disclosed his interest, but the key defect of his study was not the fact that its lead author failed such a clear duty, but that the cases included in it were not randomly selected. Many parents brought their children to the Royal Free clinic because of their prior exposure to Dr Wakefield’s theories and to the wider anti-MMR campaign (both had received national publicity in the preceding months).
Dr Horton argues that, though Dr Wakefield’s conflict of interest invalidated his central claim of a link between MMR and autism, his additional claim to have identified a new syndrome (later dubbed ‘autistic enterocolitis’) remained ‘intact’. But the bias in the selection of cases meant that it was impossible to maintain that the results of investigating these dozen children were in any way characteristic of autistic children in general. It was therefore also impossible to have any confidence in the existence of the new syndrome. Dr Horton’s argument appears to be that, even though Wakefield’s methods were flawed, his conclusions were valid. In fact, as Professor Trisha Greenhalgh, one of Britain’s leading authorities on evidence-based medicine, points out, ‘the Wakefield study was scientifically flawed on numerous counts’ (2). She is ‘surprised that neither the editor nor the reviewers spotted these flaws when the paper was submitted’.
So why did the Lancet publish the Wakefield paper? I believe that Dr Horton, like many medical colleagues as well as parents and journalists, was captivated by Dr Wakefield’s charm. Though Dr Wakefield’s scientific credentials may be suspect, there can be no disputing his promotional skills. In the early 1990s he was already presenting his work at press conferences and he later successfully presented himself (with the help of an elite PR company and compliant journalists) as humble listener to parents, as courageous champion of autistic children, as maverick scientist battling orthodoxy and commercial vested interests, and later still as martyr to a conspiracy of the medical establishment, the government and the drug companies. He appears in all these guises in the TV docudrama Hear the Silence broadcast by Channel 5 in December 2003 (3).
It may also have been that Dr Horton had a desire for wider recognition in the world beyond the normal readership of medical journals. Indeed, in a critical aside on contemporary journalism, he sees how other editors succumb to temptations of this sort. Dr Horton argues that ‘the shift away from forums for serious public discussion has led some news media to exaggerate or emphasise the sensationalist elements of a story, in the hope of successfully introducing entertainment into old-fashioned news reporting’.
Ironically, something similar appears to have happened at the Lancet. Publishing works like that of Dr Wakefield – or that of Arpad Pusztai on GM food – might have achieved higher media profile for the Lancet, but at the expense of the journal’s reputation for scientific rigour (4).
When Dr Wakefield used the press conference to launch the February 1998 paper to issue his notorious call to suspend MMR in favour of separate vaccines, his Royal Free colleagues discovered the risks involved in sharing the limelight with him. Dr Horton recalls wistfully that, for everybody apart from Wakefield, the idea of this press conference was that it would afford ‘an opportunity to stress the benefits of the MMR vaccine and the inconclusive nature of their results with respect to the link between the syndrome and the vaccine’. That was certainly not how the story appeared in the newspapers the following day. Like the Royal Free team, Dr Horton soon discovered that grandstanding with Dr Wakefield was a high-risk activity.
Being on the receiving end of angry condemnations by prominent public health and vaccine specialists, and of hostile interrogations by journalists and politicians, has understandably been an uncomfortable experience for Dr Horton. It appears to have given him an enduring sympathy for Dr Wakefield, with whom he shares a sense of victimhood. Dr Horton is horrified by the often intemperate terms in which the MMR controversy has been conducted. Yet he remains oblivious to the extent to which the Wakefield campaign has fostered this climate, by allegations of corruption and conspiracy against supporters of MMR and by personal abuse, aptly symbolised by the grotesque caricatures of Dr Wakefield’s former Royal Free colleagues presented in Hear the Silence.
Dr Horton’s sympathy for Dr Wakefield does not extend to the paediatricians and public health authorities whose response to the Royal Free press conference he describes as ‘apoplectic’. Dr Horton is right to uphold the responsibility of the editor of a journal of medical science to publish research, even though it may cause problems for public health. But what outraged these doctors was what one leading microbiologist recently described as his decision ‘to give an unsubstantiated speculation masquerading as science the accolade and validation that comes from publishing it in one of the world’s leading medical journals’ (5).
Doctors who have seen children suffering and dying from measles and other infectious diseases – and have seen too the dramatic decline in these diseases as a result of immunisation – tend to be somewhat emotional in their commitment to child immunisation. The MMR programme was, up to the mid-1990s, a great success – a success achieved through the combined and sustained efforts of numerous doctors, health visitors and nurses.
If the programme had been set back by the exposure of a real problem with the vaccine, this would have caused sadness and regret. But to see it damaged by nothing more than speculation and egotism was enough to drive some of those closely involved, well, apoplectic. This is why most doctors appreciated the robust rebuttal of Dr Wakefield’s baseless claims by leading vaccine and public health figures (who, as a result, have suffered much gratuitous abuse from the Wakefield campaign and its allies in the media). Though Dr Horton discusses, at some length, the prospects for the global eradication of measles, he neglects to mention that, largely because of the Wakefield campaign, this goal – considered attainable in Britain in the mid-1990s – is unlikely to be realised in the foreseeable future.
There are other blind spots in Dr Horton’s account. One concerns the agonies the MMR controversy has created for parents facing decisions about immunisation. For the well heeled, the choice to give their children separate vaccines causes no great difficulties. Matters were not so straightforward for one of my patients, an unemployed single parent in Hackney, who told me how she was considering using funds set aside for a holiday to pay for a course of separate vaccines at a private clinic. (One of my few happy moments in this controversy came when she decided to follow my advice to give her son the MMR vaccine: he thereby got the best protection against disease and a holiday – and the sleazy clinics lost another customer.)
Last summer’s court case arising from the conflict between estranged parents over whether their children should be immunised is an extreme illustration of the high level of anxiety and animosity surrounding MMR, which continues to cause tensions between parents, within families, among friends, between parents and health professionals.
Dr Horton also ignores the distress the MMR controversy has caused to families of children with autism. He claims, bizarrely, that parents who believe that MMR caused their child’s autism have been ‘excluded from any public conversation in the media about MMR’. In fact, this small group of parents has received enormous publicity: they feature in every newspaper account and television programme on the subject, their views have been promoted in a special edition of Private Eye and were dramatised (very effectively by the actress Juliet Stevenson) in Hear the Silence. They were prominently represented in the Medical Research Council’s 2001 inquiry into the causes of autism.
They may not have been ignored, but it may be that these are the parents who have suffered the most from being dragged into the Wakefield campaign and the ill-conceived and ill-fated litigation against the manufacturers of MMR (which Dr Horton acknowledges was ‘irresponsibly supported by the Legal Aid Board, costing British taxpayers millions of wasted pounds’). The costs to families whose hopes and expectations were unrealistically raised were even greater: when legal aid was finally withdrawn in October 2003, they were left stranded, with no compensation and in many cases without even basic legal advice.
The large majority of parents of children with autism – those who do not believe in the MMR-autism link – have also been ill-served by the Wakefield campaign. Dr Horton refers to the grim history of parents being blamed for causing their children to become autistic, but fails to recognise how the campaign against MMR (which is linked to attempts to attribute autism to other environmental agents, from vaccines containing mercury to dietary factors), has revived the parent-blaming tradition. Instead of feeling guilty over their defective child-rearing practices, parents now feel guilty that they gave their child MMR.
Dr Horton claims that ‘one of the positive consequences of the debate surrounding the safety of the MMR vaccine is that the spotlight has fallen on autism like never before’. As the parent of an autistic child, I find it difficult to see any positive consequences of this debate. It may have produced more funding for research, though I doubt whether this compensates for the resources that have been wasted pursuing the MMR theory. The whole affair has been, at best, a distraction from the real problems of autism (in the spheres of education and social provision as well as in science) and, at worst, an additional, utterly unwarranted, burden on already over-stretched families.
Dr Horton offers his book as ‘a reparation, of sorts’, but, though he provides a candid account of the MMR debacle, he fails to make amends for his part in boosting the Wakefield campaign.
Dr Michael Fitzpatrick is the author of MMR and Autism: What Parents Need to Know, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA).
(1) I should perhaps declare two things. Dr Horton refers in this book (very fairly) to some of my interventions in this matter, though he also misinterprets my criticism of the anti-MMR campaign as a ‘generalised adverse characterisation’ of the parents involved. Secondly, between January 2003 and April 2004, I wrote a regular column for the Lancet.
(2) ‘A critical appraisal of the Wakefield et al paper’, by Trisha Greenhalgh
(3) ‘MMR: fact and fiction’, by Michael Fitzpatrick
(4) See Richard Horton, Second Opinion: Doctors, Diseases and Decisions in Modern Medicine, Granta, 2003, pp304-313
(5) Hugh Pennington, ‘Why can’t doctors be more scientific?’, London Review of Books, 8 July 2004
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