I happened to be doing the baby clinic on the day in April 1998 when the story broke here in the UK about a link between the measles, mumps and rubella (MMR) vaccine and autism.
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In the lull before the clinic got underway I rang the 'immunisation hotline', a service that was advertised in a yellowing poster on the noticeboard, to find out the official response to what seemed likely to become a major scare. Visualising a red phone ringing and flashing on some distant government desk, I was surprised to find the call answered promptly by our friendly local community paediatrician.
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She tried to reassure me that a detailed refutation of the paper published in The Lancet by gastroenterologist Andrew Wakefield and others claiming to have established a link between the MMR vaccine and autism, mediated by inflammatory bowel disease, would be circulated shortly. This, she said, should suffice to assuage parental fears. She was taken aback when I suggested that this scare might finish off the MMR vaccine. Nearly three years later, as the rate of uptake of the vaccine has fallen below 85 percent - 10 percent lower than the target required to prevent outbreaks of measles - it looks as though my forebodings were right.
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I should declare an interest in this subject beyond my work as a general practitioner (GP) and occasional visitor to the baby clinic. I have two sons, one autistic and one not, both of whom had the MMR vaccination. I do not believe that there is any causal relation between MMR and autism in the case of my son or any other person with autism.
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The case against Dr Wakefield has been widely documented, most recently and most comprehensively in the Medical Research Council's (MRC's) Review of Autism Research: Epidemiology and Causes, published in December 2001 (1). Quite apart from the methodological and epidemiological weaknesses of this study, in the three years since his paper was published Wakefield has failed to substantiate either the specific character of gastrointestinal pathology in children with autism or the mechanism through which this is supposed to cause the distinctive psychological features of autism.
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It was regrettable that Wakefield declined to make a submission to the MRC study, despite being invited to do so. In short, though Wakefield - and others - have usefully focused on the prevalence of bowel problems in children with autism, his allegation of a link with MMR cannot be taken seriously.
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 | | If Leo Blair had had his MMR, surely it would have been publicised? |
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Yet, despite the overwhelming weight of scientific evidence against Wakefield, this one paper - based on a series of a dozen cases - appears to have brought down a nationwide immunisation programme that had become firmly established, at considerable cost, over the past decade. Wakefield's paper appears to be a dramatic example of the butterfly effect celebrated in chaos theory, in which the flutter of tiny wings on one continent is amplified around the planet to produce a tidal wave on some distant shore.
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Perhaps more prosaically, the Wakefield effect may be understood as an illustration of the impact of a particularly potent health scare in a society pervaded by an enhanced consciousness of risk. In this febrile climate, the MMR scare has provoked a revolt of the anxious middle classes against a New Labour government that has tried doggedly, but increasingly unsuccessfully, to hold the line against a set of values it has done much to promote.
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'Dissenting parents, with their mixture of cynicism about bio-medicine and anger about their rights as citizen-consumers, exude their own version of outrage and indignation.' The interesting thing about this (sympathetic) account of parental rejection of official vaccination policy is that it was published three years before the MMR scare (2). The MMR scare found a ready response, particularly among the increasingly anxious middle classes, in the aftermath of BSE/CJD and other scandals. Popular fears about diverse environmental dangers were compounded by suspicion of scientific and professional expertise and resentment at government secrecy and links with vested interests.
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Commentators sympathetic to the anti-vaccination cause approve the growing scepticism towards scientific authority and the apparent decline in deference to the medical profession. They seem oblivious to the parallel increase in credulity towards alternative beliefs, such as the conceptions of the 'immune system' commonly adduced against vaccination, which are both excessively literal (mistaking a metaphor for a coherent anatomical/physiological entity) and quasi-mystical (endowing various defence mechanisms against infection with a life of their own).
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While lauding the end of deference towards established scientific and medical authorities, they appear to approve deference to a new group of experts who are distinguished by their refusal to submit their work to peer review or other ways of establishing the authenticity of claims to the advancement of knowledge.
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The anti-MMR cause has readily acquired prominent political and journalistic backing, and the endorsement of a few high-profile medical dissidents. As the controversy spread from the broadsheets to the tabloids, to the daytime talkshows and the radio phone-ins, parental anxieties intensified. The result was a fall in demand for the triple vaccine - and an increase in demand for single vaccines, which the government has categorically refused to meet.
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| | In the spiral of panic, attempts at reassurance only exacerbate the problem |
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The UK government's peculiar difficulty with the MMR scare arises from the fact that the notions of risk awareness and consumer choice expressed by parents refusing the vaccine are the very values that New Labour has generally tried to promote in other policy areas. Anthony Giddens, director of the London School of Economics and a prominent adviser to UK prime minister Tony Blair, has advocated the virtues of the risk society as a new moral framework for the 'third way' society towards which New Labour aspires. The government has sought to promote these values to undermine traditional sources of authority - notably in the professions and civil service - in the process of forging a new elite in British society.
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The problem with this approach in relation to MMR - a scare that emerged outside the control of the government - is that once take-up falls below a critical level, there is a risk of serious diseases making a comeback. Hence the government's first response to the scare was to try to combat it with another scare: if you don't get your child immunised they may get measles, mumps or rubella and possibly a wide range of grisly complications. Not surprisingly, given the receding folk memories of these diseases, this was more effective in intensifying parental anxiety and resentment of government than it was in preventing the decline in take-up of the vaccine.
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The other line of government policy was to refuse to make the triple vaccine available in its separate components. The scientific and practical arguments against this are strong: there is no advantage in separate vaccinations and many disadvantages - it means more injections, increased risk of missing some and of acquiring infections between injections.
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But, having fanned the flames of consumer activism and citizens' rights as part of its campaign to undermine professional authority in health, education, law and other areas, the government is in a weak position to deny anti-vaccination parents their inalienable, if irrational, demand for separate vaccines. When the General Medical Council was invited to discipline Dr Peter Mansfield for providing single vaccines in defiance of the official line, it wisely ducked the challenge, denying the campaign its first martyr.
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It was, however, Blair's infant son Leo who innocently and inadvertently dealt the official campaign its biggest blow. Though Leo should have had his MMR sometime in 2001, his parents have pointedly refused to confirm whether or not he has had it. Blair's claim of privacy is disingenous: who can doubt that, if Leo had had his MMR, this would have been publicised?
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As numerous commentators have pointed out, vaccination is inescapably a public as well as a private matter: to provide effective 'herd immunity' - protection for the community as a whole - it is necessary to ensure a high level of individual vaccination. The Blair family's refusal to acknowledge Leo's MMR suggests that at least one of his parents does not accept government policy on this question. This surely confirms the bleak future of the MMR programme as a whole.
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| | There is an understandable quest for somebody to blame for family misfortunes |
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The MMR story, one with many victims and few beneficiaries, reveals the demoralising character of the risk society. The government and the public are now trapped in a spiral of panic in which all attempts at reassurance are destined to exacerbate the problem. As take-up continues to fall, new outbreaks of old diseases, whose casualties are as predictable as those of MMR are speculative, now seem inevitable.
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For parents now facing the decision on whether to vaccinate their children, there is no escape from competing anxieties. Doctors and nurses are faced with protracted discussions and negotiations over the whole range of vaccination policy, in a climate rendered rancorous and distrustful by specious anti-vaccination propaganda. (The provision of financial incentives to GPs to reach immunisation targets has undoubtedly helped to sour relations between doctors and patients in baby clinics.)
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Perhaps the only beneficiaries of the MMR scare are the lawyers still pursuing a class action on behalf of 1000 families claiming damages from the government and the vaccine manufacturers, on the grounds that the MMR rendered their child autistic. This action - and the expenditure of more than £1million of legal aid funds - has not been deterred by the absence of scientific evidence for the alleged link between MMR and autism.
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I am sceptical of claims that such actions are a legitimate claim for some compensation for the sufferings of autism and some contribution towards the cost of care. They pander to the understandable quest for somebody to blame for family misfortunes by offering illusory explanations, reinforcing the effect of the wider scare in intensifying the distress of families affected by autism.
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Instead of enriching plausible lawyers and their hired experts, scarce public funds would be better spent on serious research into the causes of autism and the provision of care for sufferers and their families.
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Dr Michael Fitzpatrick is the author of MMR and Autism, 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). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).
Read on:
MMR: immune system as metaphor, by Dr Michael Fitzpatrick
Immune to the evidence, by Dr Michael Fitzpatrick
MMR: why government reassurances won't work, by Dr Michael Fitzpatrick
Communication breakdown, by Jenny Cunningham
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(1) The Medical Research Council's Review of Autism Research: Epidemiology and Causes, is available from the Medical Research Council website
(2) 'The risk of resistance: perspectives on the mass childhood immunisation programme', Anne Rogers and David Pilgrim, in Jonathan Gabe (ed) Medicine, Health and Risk: Sociological Approaches, Blackwell, 1995
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