Anti-vaccination nation?

Shortly before Christmas 2002, our practice nurse asked me to have a look at a 14-year old boy with a rash: ‘I think he might have measles.’

Sure enough, he had the typical red blotchy patches, the fever, the harsh cough, the sore red eyes. He even had the tiny mouth ulcers known as Koplik’s spots that, as medical students, we were always told to look out for, but never seemed to find. Most strikingly, he was quite ill: his red face and streaming eyes were a vivid reminder of the sheer misery of measles. Saliva tests confirmed the diagnosis.

We asked if he minded if some of our colleagues had a glimpse of his rash. Most doctors and nurses under the age of 50 have never seen a case of measles, so this was an opportunity not to be missed. This boy was a Polish gypsy, recently arrived in London, who had never been vaccinated as an infant. (This is unusual in this community whose members, perhaps having a greater respect for the dangers of infectious disease than is now common in Britain, are notably conscientious in getting their children immunised.) Fortunately, this outbreak did not extend beyond a handful of family members and our patient made a fairly rapid recovery.

It is a testament to the success of vaccination that the vast majority no longer have to worry about diseases such as measles. Being over the threshold of middle age, I have a better memory of measles than is now widespread either among doctors or in the general public. As a medical student in the mid-1970s, I spent a couple of months in a mission hospital in Tanzania where I saw children dying at an alarming rate from measles. The racking cough, the sunken, inflamed eyes, the peeling skin were unforgettable features of this devastating infection.

As a junior hospital doctor in Britain in the early 1980s, I recall admitting a child with a high fever one night for observation – only for the telltale rash to appear the next day. It was not so unusual to see children being nursed in darkened rooms – to ease the sore eyes of measles – and under a red blanket, a traditional measure for ‘bringing out the rash’. When I started as a trainee GP in East London, cases of measles were fairly common.

In more recent years, parents have sometimes brought children into the surgery, declaring ‘I think she’s got measles’. One glance at their healthy-looking and cheerful toddler playing in the corner – despite a bit of a cough, a few snuffles and some pale spots on the trunk – is enough to make this diagnosis highly improbable. It also prompts the reflection that these parents have obviously never seen a child with measles, and this is increasingly true of grandparents too.

Once reassured that their child probably has one of hundreds of viruses that cause minor coughs and colds and vague rashes, working parents’ main concern is ‘how long is this likely to last?’ The answer is, ‘perhaps a few days’. If the diagnosis was measles, the answer would be: ‘Two weeks – if you’re lucky.’ It would also mean two weeks of unremitting toil, caring for an often inconsolable toddler who is likely to demand attention day and night for the duration of the illness. It is not widely recognised that the sort of childcare arrangements that allow for both parents of young children to go out to work have been made possible by the virtual eradication of once common childhood diseases like measles. Today’s parents do not expect to have to spend weeks caring for sick children in a way that was commonplace only a generation ago. Nor are grandparents or other extended family members so readily available for nursing duties.

Mumps is another almost-forgotten illness, thanks to vaccination. Yet I remember looking after a child with mumps meningitis in hospital – until around 15 years ago mumps was one of the commonest causes of admission with meningitis. Now we rarely see the hamster-shaped jaw-line, with bulging parotid glands pushing out the ears, that was once the familiar sign of mumps.

Though it was never easy to be sure about the rash of rubella, its impact on the unborn babies of pregnant women could be devastating. In the 1960s there was an outbreak of rubella in London among newly arrived immigrants from the Caribbean: I have two patients who were born with the multiple severe mental and physical handicaps of the congenital rubella syndrome as a result.

Doctors remember the infectious diseases of childhood differently from other people. Some of my friends and patients nostalgically recall spending happy days off school with mothers and grandmothers. No doubt for most people, these illnesses were not so severe; for others, a benign amnesia seems to have blanked out the distressing aspects of the experience, as it often does the pangs of childbirth. In the nature of their work, doctors’ attention is drawn to the more severe cases and to patients who experience complications, most of all to the occasional fatalities, and these linger long in the memory.

Talking over today’s vaccination controversies with a now-elderly, long-retired paediatrician, he recalled seeing children with polio in the 1950s being kept alive with primitive ‘iron lung’ ventilators. He was horrified that the achievements of mass childhood immunisation were now questioned and at the prospect that diseases he had seen vanquished might return.

Anti-vaccination campaigns, past and present

The achievements of mass childhood immunisation are routinely questioned these days. Britain has been in the grip of a panic over the measles, mumps and rubella vaccine (MMR), following gastroenterologist Dr Andrew Wakefield’s claim, first made in the Lancet in 1998, that it caused inflammatory bowel disease and autism. When it was revealed in August 2004 that the UK would introduce a ‘five-in-one’ vaccine – to protect children against diphtheria, tetanus, whooping cough, Hib and polio in a single shot – questions were instantly raised about whether the new jab would be safe.

Some commentators have drawn parallels between today’s anti-MMR campaign and the influence of anti-vaccination campaigns of the past, notably that against smallpox in the nineteenth century and against whooping cough in the 1970s. Supporters of the immunisation programme often illustrate their talks and articles with anti-vaccination cartoons from the nineteenth century, suggesting that these campaigns and their associated prejudices are always with us, but merely fluctuate in intensity over the years.

In a widely quoted article, Robert Wolfe and Lisa Sharpe argue that ‘the activities of today’s propagandists against immunisation are directly descended from, indeed little changed from, those of the anti-vaccinationists of the late nineteenth century’ (1). The authors provide a table of quotations from each era, under the heading ‘anti-vaccination arguments, past and present’. The parallels are indeed striking: vaccines are blamed for a wide range of disorders (whose cause is otherwise unknown); doctors and vaccine manufacturers are in an ‘unholy alliance for profit’; vaccines are ‘poisonous chemical cocktails’; there has been a ‘cover-up’ of the adverse effects of vaccines; vaccine programmes mark a step ‘towards totalitarianism’; vaccines are either ineffective or provide only temporary immunity; a healthy lifestyle provides a better protection against infectious diseases. The ‘uncanny similarities’ in these arguments suggests, according to the authors, ‘an unbroken transmission of core beliefs and attitudes over time’.

Yet historical accounts of anti-vaccination campaigns – including this one – reveal more discontinuity than continuity. Vaccination against smallpox, a cause of devastating epidemics in nineteenth-century Britain, was made compulsory by the Vaccination Act of 1853. Attempts to enforce this legislation in response to the 1870-71 epidemic provoked widespread protests and continuing agitation led to the establishment of a Royal Commission, which reported in 1896, upholding vaccination but recommending the abolition of cumulative penalties against defaulters.

A new Vaccination Act in 1898 duly abolished such penalties and introduced a clause allowing parents who did not believe that vaccination was efficacious or safe to obtain a certificate of exemption on grounds of conscience. Though this effectively marked the end of coercion, and of anti-vaccination campaigning, it was not until 1948 that compulsory vaccination was finally abandoned.

What is striking in the postwar years, during which new immunisations were introduced and uptake steadily increased, is that anti-vaccination campaigns, if they existed at all, had negligible influence. Even in the 1980s, when immunisation uptake increased rapidly – and when alternative health practices such as homeopathy began to gain in popularity – anti-vaccination ideas remained marginal. It was not until the late 1980s and early 1990s that anti-immunisation sentiment re-emerged and spread rapidly from a small number of people influenced by alternative health beliefs to find a much wider resonance in British society. The explanation for this phenomenon must be sought, not in the timeless appeal of superficially similar anti-immunisation arguments, but in the specific circumstances of modern Britain.

An apparent exception to this argument is the campaign against the whooping cough (pertussis) vaccine in the mid-1970s. Yet this scare had no direct connection with the earlier anti-vaccination campaigns: it arose in response to a report by a senior medical figure of specific adverse effects of the vaccine and this remained the sole concern of parents who refused to have their children immunised. It did not provoke a wider questioning of the principles of immunisation or the conduct of the immunisation programme.

Though the whooping cough vaccine scare had little in common with the anti-smallpox vaccine campaigns of the nineteenth century, it is often cited as the forerunner of the current anti-MMR campaign (indeed, as a link in the seamless progress of anti-vaccinationism through the ages) (2). The title of an editorial in the British Medical Journal summed up this view: ‘MMR vaccination and autism 1998; Déjà vu – pertussis and brain damage 1974?’ (3).

Yet a closer look at the whooping cough vaccine scare reveals striking similarities with the MMR controversy, but also crucial differences that illuminate the specific character of the current crisis.

Comparing and contrasting the whooping cough and MMR scares

In March 1974, consultant paediatric neurologist Dr John Wilson published a study of 36 cases of children who had been admitted to Great Ormond Street Children’s Hospital in London, over a period of 11 years, with ‘neurological complications’ following immunisation against whooping cough (pertussis) (4).

They had usually received this in the combined form of the triple vaccination against diphtheria, tetanus and pertussis (DTP). Though Dr Wilson insisted that his conclusions were ‘tentative’ and his study merely ‘hypothesis-generating’, it was widely interpreted as showing that whooping cough immunisation caused brain damage. An Association of Parents of Vaccine-Damaged Children was formed and some 200 families were soon pursuing compensation claims against vaccine manufacturers, the government and family GPs. By 1976, vaccine uptake had dropped from 80 per cent to 30 per cent.

The campaign against the whooping cough vaccine appeared to be at least partially vindicated by the publication in 1981 of the preliminary results of the National Childhood Encephalopathy Study (5). This report concluded that the whooping cough vaccine had, in a small number of cases, caused permanent brain damage: it estimated a risk of 1 in 310,000, a figure that was accepted – and widely quoted – by vaccination authorities in Britain and around the world. Here matters stood until the claims for compensation came to court.

In a trial lasting four months, the court heard 19 expert witnesses as Lord Justice Stuart-Smith subjected the case against whooping cough vaccine to the most rigorous scrutiny: his judgment ran to 100,000 words and took two days to read (6). After insisting on reviewing the raw data of the National Childhood Encephalopathy Survey, Stuart-Smith exposed a range of biases and errors that resulted in the conclusion of the preliminary report that the vaccine (rarely) caused brain damage. He found ‘no evidence of permanent brain damage’ and concluded that the widely quoted risk of 1 in 310,000, ‘cannot be supported’ and that ‘any substituted figure would be so enormous as to be meaningless’ (7). He also found that there was no conclusive evidence supporting any of the proposed mechanisms through which the vaccine was supposed to cause brain damage.

The judgment was highly critical of Dr Wilson (he was ‘so completely committed to the view that the vaccine could cause brain damage that he was reluctant to re-examine evidence’) and of other expert witnesses supporting the plaintiff’s case against the vaccine. (A review of Wilson’s original 36 cases revealed that in only 12 was there a close temporal association between the vaccine and manifestations of brain damage – most commonly epileptic fits. In the notorious case of twin girls, who were included in the 36 but had subsequently died of a rare genetic disorder, it was discovered that they had never received the whooping cough vaccine.) Noting the persistent tendency of critics of the vaccine to present the temporal association of vaccination and neurological events as evidence of causation, he quoted Dr Johnson: ‘It is incident I am afraid, in physicians above all men, to mistake subsequences for consequences.’

This is how Stuart-Smith concluded his classic judgment: ‘When I embarked on consideration of the preliminary issue, I was impressed by the case reports and what was evidently a widely held belief that the vaccine could, albeit rarely, cause permanent brain damage. I was ready to accept that this belief was well founded. But over the weeks that I have listened to and examined the evidence and arguments I have become more and more doubtful that this is so. I have now come to the clear conclusion that the Plaintiff fails to satisfy me on the balance of probability that pertussis vaccine can cause permanent brain damage in young children. It is possible that it does; the contrary cannot be proved. But in the result the Plaintiff’s claim must fall.’ (8)

Subsequent follow-up reports on the cases included in the National Childhood Encephalopathy Study and authoritative reviews have provided further epidemiological support for this legal judgment (9).

While controversy raged over the vaccine, whooping cough returned: epidemics between 1977 and 1979 resulted in 27 deaths and 17 cases of permanent brain damage. There was disagreement over whether the vaccine caused brain damage rarely or not at all: there could be no dispute that whooping cough caused both damage and death on a substantial scale (10). By 1988, the total number of deaths resulting from more than 300,000 notified cases of whooping cough was estimated as ‘at least 70’ (11).

There are striking parallels between the whooping cough and MMR scares. Both emerged from studies presenting a small series of case reports. Both put great emphasis on the close temporal association between vaccination and the appearance of the adverse effect. Defenders of the vaccines pointed out that both fits and autism commonly appeared around the time of immunisation and that, if one followed the other, coincidence was the most likely explanation. Though readily criticised for being open to bias in their selection of cases, and for confusing association with causation, case report studies had a profound effect on public opinion, particularly when presented in the form of human interest stories in the popular media.

Another common feature of both anti-vaccine campaigns was their difficulty in explaining how the vaccine produced the adverse effect with which it was associated. It is interesting to note that though some two decades separated the campaigns, they put forward strikingly similar theories. Some critics proposed that the vaccine produced a neurotoxic effect (via effects on adenosine/glutamate neurotransmitters in the case of whooping cough vaccine, via opioid peptides in the case of MMR). Others argued for an autoimmune process (an adjuvant effect of immunisation in enhancing the immune response to viral antigens in the case of whooping cough vaccine; an anti-myelin antibody response with MMR). The speculative character of these explanations encouraged some to combine these and other theories into increasingly complex – and increasingly unsatisfactory – ‘multifactorial’ explanations.

As evidence mounted against the anti-vaccinationists in both campaigns, they tended to retreat from claiming that adverse reactions were a common cause of serious disorders, to arguing that they did so only in small numbers of children, in whom there was some inherent, probably genetic, susceptibility. Leading proponents of the case against vaccines had another common fall back position: what Dr John Wilson termed ‘double reaction’ cases from the whooping cough vaccine, and Dr Andrew Wakefield referred to as ‘re-challenge’ or ‘double hit’ cases from MMR.

In these cases, adverse reactions – or increasingly severe reactions – were noted after two or more exposures to the vaccine (whooping cough vaccine is routinely administered in a schedule of three immunisations in the first year; MMR is administered at around 15 months and again in the form of a ‘pre-school booster’). There was, however, no better explanation for double than single-dose vaccine effects.

Perhaps the most striking difference between the whooping cough vaccine and the MMR vaccine scares was their differential impact. Whereas uptake of whooping cough vaccine dropped precipitously to 30 per cent, MMR fell by only seven per cent from a much higher baseline level in the four years after the publication of the Wakefield paper in 1998 (from 92 to 85 per cent). This resilience of MMR is all the more surprising given the wider political impact of the Wakefield campaign. Though the whooping cough scare produced a dramatic fall in vaccine uptake, it did not become a major political issue. By contrast the MMR scare, though producing a much smaller drop in uptake, created a major stir in British politics.

The differing impact of these two scares reflects the changing character of British society over the past quarter of a century. In the mid-1970s parental (usually maternal) decisions about immunisation were largely private and personal, influenced more by immediate family members than by either health professionals or the wider debate. These decisions had an instinctive and pragmatic character; they were rarely based on any familiarity with the medical or scientific literature. Parents did not turn up at baby clinics in those days armed with anti-vaccination pamphlets and documents downloaded from the internet.

By contrast, in the late 1990s parental discussions were both intensely personal (tending to involve fathers as well as mothers) and subject to wider public and political influences. Decisions about MMR tended to reflect attitudes on the range of issues raised by the controversy: the authority of medical science and the medical profession, the trustworthiness of vaccine manufacturers, civil servants and politicians.

Whatever their decision on MMR, the issue of vaccination was a focus of considerable parental anxiety as discussion – and sometimes argument – raged among family and friends. The inclination of some parents to delay vaccination in the hope that matters would become clearer tended only to prolong the agony. The intensive media coverage of the issue – and the involvement of politicians – both reflected and encouraged this high level of popular concern about MMR. Thus, though uptake of MMR did not fall as dramatically as that of whooping cough vaccine, it is arguable that the scare had a more profound impact on society.

The controversy around the demand for separate vaccines illustrates these wider political consequences of the MMR scare.

The separate vaccines campaign

Dr Wakefield first suggested that parents should give the MMR in its three separate components at intervals of 12 months at the press conference launching his Lancet paper in February 1998.

However, demand for separate vaccines grew slowly – until December 2001, when Conservative MP Julie Kirkbride asked prime minister Tony Blair whether his infant son Leo had received his MMR. Mr Blair’s equivocal response was probably the most significant public relations setback for MMR since Dr Wakefield’s initial allegations. Though he refused to disclose whether Leo had been immunised (claiming that this was a private family matter), Blair indicated his support for the official line on MMR.

While loyal supporters defended the Blairs’ claim to privacy, other ministers (such as Yvette Cooper) disclosed their decision to give their children MMR. Critics insisted that immunisation was a matter of public health, not personal treatment – and recalled the willingness of members of the Royal Family to disclose that they had given their children the whooping cough vaccine following the 1970s scare. To the public, Blair’s stand seemed disingenuous: few doubted that if Leo had been immunised his parents would have been happy to publicise the fact. Given Cherie Blair’s well-known proclivity for New Age charms and alternative healthcare, many believed that she had opted against MMR. The consequences for the public reputation of MMR were grim: if the prime minister’s family doubted its safety, why should the public trust it?

Blair’s continuing evasiveness on MMR ensured that the controversy rumbled on into the New Year. The MMR-autism link was no longer a debate among medical experts, or even among specialist journalists and campaigning parents; now it became an issue for politicians, for political columnists and for leader-writers.

In February 2002, Liam Fox, shadow health minister and himself a GP, came out in support of the demand for separate vaccines, and the whole issue increasingly assumed a party-political form. The MMR controversy has produced an unprecedented breakdown in the long-established cross-party consensus on vaccination policy. Party political divisions were reflected in the press: the Daily Mail, the Sun and the Telegraph supported the anti-MMR campaign; the Mirror and the Express were more sympathetic to the government line.

The key problem was that New Labour’s stand against separate vaccines ran counter to one of its central policy themes – the empowerment of the individual consumer, particularly in public services. This point was well made by the National Autistic Society in its March 2002 ‘position statement’: ‘The government promotes choice in many areas of public policy. In rejecting it here it may fail to recognise assertions of patients’ autonomy and a perception of paternalism may well have caused some of the reluctance to vaccinate.’ (12).

In the same week in January 2001 that Dr Wakefield held a press conference questioning the safety of MMR, Sir Donald Irvine, outgoing president of the General Medical Council gave a lecture at the Royal Society of Medicine. He used the occasion to reiterate the central theme of his drive to reform and modernise the medical profession: ‘The cultural flaws in the medical profession show up as excessive paternalism, lack of respect for patients and their right to make decisions about their care, secrecy and complacency about poor practice.’ (13)

Criticisms of doctors for being aloof and arrogant, authoritarian and paternalistic, were recurrent themes of inquiries into scandals such as that over retained organs at Alder Hey Hospital and the children’s heart surgery unit at Bristol (both of which reported in 2001, making a major public impact). Reformers, such as Dr Irvine, and Professor Ian Kennedy who presided over the Bristol inquiry, received enthusiastic backing from the New Labour government. Promoting patient empowerment in defiance of medical paternalism was central to Blair’s modernising agenda in the health service.

As chief medical officer, Professor Donaldson was an active promoter of this agenda. Indeed, on the publication of the Alder Hey report in February 2001, Donaldson appeared at a joint press conference with representatives of parents’ organisations to indicate the medical establishment’s commitment to challenging paternalism. In September 2001, he approved a report (produced by a task force of which he was chair) promoting the notion of ‘expert patients’, sufferers from chronic conditions whose long experience meant that they understood their diseases better than their doctors. Though this report insisted that the expert patients programme was ‘not an anti-professional initiative’. it took its place in a series of explicitly anti-professional initiatives (14).

In December 2001, Donaldson endorsed a report on ME/chronic fatigue syndrome produced by a committee dominated by representatives of patients’ groups after most of the clinicians on the committee had resigned (15). He emphasised that the particular approach to the problems of chronic fatigue favoured by patients would be foisted on the medical profession. This elevation of subjective experience and consumer choice over medical science and expertise in these instances suited the government’s purpose of introducing new mechanisms of professional regulation. But it came to grief over MMR.

The problem that emerged with MMR is that individual choice cannot be reconciled with a mass childhood immunisation programme. Mass immunisation is a policy for preventing diseases at a population level. It requires that individual children be immunised, but decisions about what diseases to immunise against, when and how, can only be taken from the perspective of society as a whole, taking into account the nature of the diseases, the efficacy and availability of vaccines, and other factors.

For every individual, the question of whether or not to get immunised depends on a judgement of the balance of benefits and risks. In the past, this was fairly straightforward: the risk of infectious disease was significant and the consequences of infection serious; the small risk of vaccine complications was widely regarded as one worth taking. The problem with MMR is that as the diseases have become uncommon, the risk of adverse effects, however rare, looms ever larger. However, once a significant proportion of the population opts out of the immunisation, then the risk of the old diseases returning inevitably increases. The further, peculiar, problem of the recent MMR crisis is the emergence of a section of society prepared to opt out of the immunisation (and accept the risk of disease for their children) in response to a risk which is entirely speculative.

To justify its refusal to provide separate vaccines, the government was obliged to fall back on the arguments that its MMR policy was supported by expert medical advice and that there was no scientific evidence to justify the proposed alternative. This was true, but given its own tendency to disparage both the medical profession and scientific evidence it was not surprising that this approach made little impact on an increasingly cynical public.

The demand for the right to choose separate vaccines had a ready appeal to a public whose right to choose schools and hospitals, methods of childbirth and dates for surgery, had been elevated into a principle of public policy. It was readily promoted by a range of private doctors and entrepreneurs who eagerly met the demand for separate vaccines resulting from the MMR scare. Profiting handsomely from the anti-MMR campaign, the proprietors of these clinics emerged as some of the most ardent supporters of Dr Wakefield’s crusade.

The October 2003 withdrawal of legal aid funding for the anti-MMR litigation was readily justifiable on scientific grounds. Indeed, given the absence of scientific evidence for the MMR-autism link, this funding should never have been granted in the first place – as the Legal Services Commission belated recognised (16).

Though the collapse of the litigation spared the families involved prolonged further agonies in the courts, it was unfortunate in one respect: it prevented the sort of public exposure of the scientific, legal and moral bankruptcy of the anti-MMR campaign that so dramatically ended the campaign against the whooping cough vaccine some 16 years ago.

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).

Read on

After Bristol: the humbling of the medical profession, by Dr Michael Fitzpatrick

spiked-issue: MMR vaccine

(1) Anti­vaccinationists past and present (.pdf 211 KB), Lisa K Sharp and Robert M Wolfe, British Medical Journal, 24 August 2002, p430

(2) ‘The pertussis vaccine controversy in Great Britain, 1974-1986’, Jeffrey P Baker, Vaccine, 8 September 2003, p4003-4010

(3) MMR vaccination and autism 1998: déjà vu – pertussis and brain damage 1974? (.pdf 215 KB), David Elliman, Angus Nicoll and Euan Ross, British Medical Journal, 7 March 1998, p715-716

(4) ‘Neurological complications of pertussis inoculation’, M Kulenkampff, JS Schwartzman and J Wilson, Archives of Disease in Childhood, January 1974, p46-49

(5) ‘Pertussis immunisation and serious acute neurological illness in children’, R Alderslade, MH Bellman, DL Miller, NSB Rawson, EM Ross, British Medical Journal, 282:1595-1599

(6) Murray Stuart-Smith, Loveday v Renton and Another, 1988; ‘Lessons from the pertussis vaccine trial’, C Bowie, Lancet, 1990, 335:397-399

(7) Murray Stuart-Smith, Loveday v Renton and Another, 1988

(8) Murray Stuart-Smith, Loveday v Renton and Another, 1988

(9) ‘Pertussis immunisation and serious acute neurological illness in children’, J Diamond, N Madge, D Miller, E Ross, J Wadsworth, British Medical Journal, 1993, 307:1171-1176; ‘Pertussis vaccine and injury to the brain’, GS Golden, Journal of Paediatrics, 1990, 116:854-861

(10) ‘Whooping cough immunisation: fact and fiction’, Public Health London, 1980, 94:350-355; ‘Pertussis vaccine and injury to the brain’, GS Golden, Journal of Paediatrics, 1990, 116:854-861

(11) MMR vaccination and autism 1998: déjà vu – pertussis and brain damage 1974? (.pdf 215 KB), David Elliman, Angus Nicoll and Euan Ross, British Medical Journal, 7 March 1998, p715-716

(12) National Autistic Society, March 2002

(13) NHS ‘must speed up change’, Sarah Boseley, Guardian, 16 January 2001

(14) The Expert Patient: A New Approach to Chronic Disease Management for the Twenty-First Century (.pdf 217 KB), Department of Health, 2001

(15) A Report of the Chronic Fatigue Syndrome/Myalgic Encephalomyelitis Working Group (.pdf 311 KB), Department of Health, 2002; ‘Myalgic encephalomyelitis: the dangers of Cartesian dualism’, Michael Fitzpatrick, British Journal of General Practice, 2002, 52:432-433

(16) See MMR and Autism: What Parents Need to Know, Michael Fitzpatrick, Routledge, 2004, p113