In a three-part series of articles published in the UK Daily Mail this week, Melanie Phillips provides a comprehensive endorsement of the campaign against the MMR vaccine that has been sponsored by the former Royal Free hospital gastroenterologist, Dr Andrew Wakefield.
| Relying on Dr Wakefield himself and the same handful of his campaign supporters who figure in earlier - remarkably similar - articles, Phillips' account falls short of her own standards (see my article, Andrew Wakefield: misguided maverick).
| Phillips' encouragement for the increasingly irrational and irresponsible anti-MMR campaign is likely to compound the unwarranted anxieties of parents whose infants are due to be immunised and result in a further decline in vaccine uptake. It will also intensify the distress of parents of autistic children, whose burden is now increased by feelings of guilt for having them immunised.
| While ill-advised parents of autistic children pursue litigation against vaccine manufacturers - with negligible chances of success - doctors apprehensively await the return of serious infectious diseases that we only recently believed were on the verge of disappearance.
| Here are some questions for Melanie Phillips.
| If Dr Wakefield has 'evidence that he thinks will prove that he was right all along', then why does he choose to disclose this in the Daily Mail rather than in a medical journal in which it can be properly evaluated by his peers?
| Wakefield has repeatedly promoted claims in public - at congressional hearings in the USA, on a BBC Panorama programme in 2002 - which have not held up to subsequent scrutiny. It would appear that Wakefield, having consistently failed to convince his peers of his case, has decided to present it directly to the public, via compliant journalists who lack the scientific expertise to assess the validity of his claims. The result is that, while Wakefield is no longer taken seriously in the world of medical science, he is still effective in provoking public anxiety.
| A further question arises: if Wakefield already has the evidence to clinch his case against MMR, why has the legal team pursuing litigation against the manufacturers, recently requested a further postponement of the High Court hearing, from October 2003 into 2004?
| If Professor John O'Leary has 'a cast-iron defence' for claims by 'his medical supporters' (viz Dr Wakefield) that he has discovered traces of measles virus from MMR in the guts of children said to have 'autistic enterocolitis', then why does he not publish this in a reputable scientific journal?
| On two occasions over the past year, Wakefield has made claims based on O'Leary's research which have subsequently been shown to have been unjustified - and on both occasions were explicitly repudiated by O'Leary himself.
| In the BBC Panorama special on MMR in February 2002, Wakefield claimed that O'Leary's team in Dublin had identified fragments of the measles virus in intestinal tissues of 75 out of 91 children with inflammatory bowel disease and developmental disorder. However, this study did not indicate whether the children had had measles or the MMR. When the study was hurriedly published, commentators observed that, even if these findings were confirmed and replicated (which they thought unlikely), the presence of measles virus fragments in the gut would not prove that they caused either inflammatory bowel disease or autism.
| In response to the controversy generated by his paper, O'Leary issued a statement insisting that he had 'not set out to investigate the role of MMR in the development of either bowel disease or developmental disorder, and no conclusions about such a role could, or should be, drawn from out findings'.
| In a presentation in June 2002 to a US congressional committee, Wakefield claimed that a study due to be presented by O'Leary at a conference in Dublin in July that year, would confirm that the measles virus present 'in the diseased intestinal tissues of children with regressive autism' was indeed derived from the MMR vaccine. For Wakefield, these studies constituted 'a key piece of evidence in the examination of the relationship between MMR vaccine and regressive autism'.
| O'Leary, however, promptly rejected Wakefield's interpretation of his work, insisting that it 'in no way establishes any link between the MMR vaccine and autism'. In further testimony in the USA, Dr Wakefield was obliged to accept the judgement of a World Health Organisation authority at the Public Health Laboratory Service in London that the technique used by O'Leary could not reliably distinguish between wild and vaccine strains of measles virus.
| A supplementary question: if, as Melanie Phillips reports, O'Leary refuses to speak to the media, why does he allow Wakefield to speak on his behalf - and then immediately contradict his claims?
| Given his failure to substantiate it, is it not time that Wakefield withdrew his 1998 hypothesis that MMR may cause autism?
| It is now more than five years since Wakefield suggested, in an 'early report' paper in The Lancet, featuring 12 cases, that MMR may be the cause of enterocolitis and autism in some children. His original paper indicated that 'virological studies are underway that may help to resolve this issue': as we have seen, those published so far by Professor O'Leary have failed to confirm this hypothesis.
| The paper further suggested that if there were a causal link between MMR and this syndrome, 'a rising incidence might be anticipated after the introduction of this vaccine in 1988' and concluded that 'further investigations' were needed. This proposition has been examined exhaustively in a number of different epidemiological studies in different countries, all reaching the conclusion that no such pattern suggesting a causative link could be discerned.
| Surely, time to move on? Not for Wakefield. His response to the failure of either virological or epidemiological studies to confirm his initial hypothesis has been to reformulate it to make it ever wider and more diffuse.
| Wakefield's 1998 paper emphasised the close temporal association between MMR immunisation and the onset of behavioural symptoms ('regression'); in the eight cases in which parents identified a link with MMR the average interval was 6.3 days (range 1-14). Wakefield has subsequently suggested that this period may be much longer and indeed that autistic features may appear at any time after immunisation (in other words, there is no temporal association).
| He has also retreated from the proposition that MMR may cause autism in general, to the claim that it may only do so in a small number of susceptible individuals. These may have been rendered vulnerable to MMR as a result of genetic factors (well known to play an important role in autism), or diverse environmental factors that are believed to compromise the infant immune system (a proposition for which there is no scientific basis). Antibiotics and other immunisations (especially DTP and other vaccinations containing mercury-based preservatives) are widely blamed by anti-vaccination campaigners.
| Wakefield's latest thesis, reported by Melanie Phillips, is that the problems arise from the 'double hit' impact of the second MMR jab, which is given at around the age of four, as a 'pre-school booster'. The increasing lack of precision of Wakefield's hypotheses makes them increasingly difficult to test and hence of declining scientific value.
| This continual shifting of the goalposts suggests that Wakefield is driven by a prejudice against MMR that has acquired the character of an article of faith, to which he clings despite the absence of evidence to support it. Thus, instead of pursuing the scientific approach of saying, 'well, if MMR doesn't cause these problems, what else might be the cause?', he says, 'I'm sure that MMR must be at least partly to blame for some aspect of these problems, so let's keep chasing that'. This is not only bad science, but given his high public profile, it has adverse consequences for the public health.
| If there is, as Melanie Phillips, following Dr Wakefield, maintains, an 'epidemic of autism' resulting at least in part from MMR, then why is this effect not discernible by epidemiological methods (as Wakefield and his supporters now maintain)?
| Wakefield and his supporters advance two irreconcilable propositions. On the one hand, they are convinced that there was an explosion in cases of autism and that, contrary to medical authorities attempts to 'dismiss' this as a result of improved recognition and wider diagnostic categories, this is at least partly a result of MMR (possibly in association with other environmental factors).
| On the other hand, they have reacted to the increasing weight of epidemiological studies failing to reveal an association by claiming that such techniques are too crude to detect the small number of cases resulting from MMR. Furthermore, if MMR is responsible for the more than 1000 cases of autism now pursuing compensation in the courts, this can scarcely be regarded as a rare event.
| Clearly, if MMR is responsible for an epidemic, epidemiological studies should readily confirm this. In fact, epidemiological studies are capable of identifying rare events - such as, for example, the occurrence of the blood disorder ITP following MMR at a rate of 1:32,000. The fact that diagnoses of autism have increased steadily over a period of time in which the uptake of MMR has remained fairly constant suggests that the former cannot explain the latter.
| Does the fact that Melanie Phillips receives money from the Daily Mail mean that she thereby relinquishes all professional integrity and independence?
| No doubt Phillips would regard such an allegation as preposterous and offensive - and she would be right. Yet this is exactly the charge she makes against a number of medical and scientific authorities involved in the MMR controversy. In this she echoes Wakefield, who has repeatedly sought to disparage his critics by alleging conflicts of interest arising from the fact that they receive fees or grants from pharmaceutical companies (generally of sums much smaller than the earnings of top tabloid journalists). When he was invited to present his case to the leading authorities in the world of autism in the Medical Research Council inquiry in 2001, he offered this pretext for his refusal to attend.
| Two points are worth making. The first is that, as a result of the litigation directly resulting from Wakefield's campaign, vaccine manufacturers have been obliged to seek expert witnesses from among the small pool of specialists in the relevant disciplines. This means that, just as Wakefield and his supporters have become the beneficiaries of the legal aid revenues amassed by their solicitors, so Wakefield's critics will receive appropriate fees from the defendants. If, as Phillips implies, everybody involved is now governed by pecuniary motives, then all discussion of the subject among its leading protagonists is invalidated and should cease forthwith.
| The second is that, in some areas of research - for example, in vaccines - it is, for practical purposes, impossible to proceed without some relationship with the vaccine manufacturers and public authorities. Indeed, such relationships have existed between doctors and scientists on the one hand, and pharmaceutical companies and governments on the other, since the dawn of scientific medicine. These relationships have not been without tensions and conflicts, but neither have they been without public benefit.
| Melanie Phillips and Dr Andrew Wakefield may yearn for the collective ownership of the means of production in pharmaceuticals as in other areas, but while capitalism exists, doctors are obliged to negotiate with the framework of corporate profitability. The allegation that doctors who have links with drug companies are incapable of making objective scientific judgements is simply populist posturing.
- Declaration of interests:
As a GP I receive a pittance from the NHS in return for hours of discussions about the safety of MMR with parents made anxious by the publicity given by credulous journalists to Dr Wakefield's anti-MMR campaign. This is likely to be substantially reduced this year, if as seems likely despite our best efforts to combat our patients' fears, we fail to meet the higher uptake target.
| I have an autistic son.
| 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:
spiked-issue: MMR
References:
Epidemiology: no association between MMR and autism
'A Population-Based Study of Measles, Mumps, and Rubella Vaccination and Autism', KM Madsen, A Hviid, M Vestergaard, D Schendel, J Wohlfahrt, P Thorsen, J Olsen and M Melbye, New England Journal of Medicine, 7 November 2002, 347:1477-1482
'Autism and measles, mumps, and rubella vaccine: no epidemiological evidence for a causal association'
Brent Taylor, Elizabeth Miller, C Paddy Farrington, Maria-Christina Petropoulos, Isabelle Favot-Mayaud, Jun Li and Pauline A Waight, Lancet, 12 June 1999, 353(9169):2026-2029
'MMR and autism', C Gillberg and H Heijbel, Autism, 1998, 2:423-424
'Time Trends in Autism and in MMR Immunisation Coverage in California', L Dales, S J Hammer and NJ Smith, Yearbook of Psychiatry and Applied Mental Health, 2002:47-48
'No evidence that MMR vaccine is associated with autism or bowel disease', A Donald and V Muthu, Clinical Evidence, 2002, 7:331-40
'MMR and autism: further evidence against a causal association', P Farrington et al, Vaccine, 2001. 19: 3632-5
O'Leary/Wakefield
Link found between measles virus and gut abnormalities in children with developmental disorder, JJ O'Leary, 11 February 2002
Neither this publication nor any public presentation by me or my research team has stated that MMR causes autism, JJ O'Leary, 16 June 2002
Infectious diseases in the news, Public Health Laboratory Service, 27 June 2002
Development of an 'allelic discrimination' type assay to differentiate between the strain origins of measles virus detected in intestinal tissue of children with ileocolonic lymphonodular hyperplasia and concomitant developmental disorder O Shiels and JJ O'Leary JJ, abstract, June 2002
'Small intestinal enteropathy with epithelial IgG and complement deposition in children with regressive autism', F Torrente et al, Molecular Psychiatry, 2002, 7 (4): 375-82
'Potential viral pathogenic mechanism for new variant IBD', V Uhlmann, O Shiels, AJ Wakefield, J O'Leary, J Clin Pathol Mol Pathol, 2002, 55 (2): 84-90
'Testimony of Dr Andrew J Wakefield', AJ Wakefield, AJ, Committee on Government Reform, US House of Representatives, June 2002
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