MMR, autism and politics

spiked readers will be familiar with the writings of Dr Michael Fitzpatrick, east London GP and trenchant critic of official health policy. His new book, MMR and Autism: What parents need to know, develops the arguments put forward in his spiked columns around the MMR debacle, where highly dubious scientific claims about the potential damage caused by a triple vaccine have managed to throw the political and medical establishment into turmoil, and knock a major UK immunisation programme off course.

Dr Fitzpatrick persuasively and eloquently demolishes the key plank of the MMR panic: claims of a link between the measles, mumps and rubella (MMR) vaccine and autism. Indeed, any risks associated with the MMR vaccine are virtually non-existent: ‘when 500million doses of a vaccine have been given in 80 countries over more than 30 years, and serious adverse reactions are found to be extremely rare, then it is fair to describe it as “safe”’, he says. Meanwhile the case for immunisation is indisputable: ‘Diseases that had caused devastating epidemics in living memory, and had produced a significant toll of death and disability into the post-war period, have virtually disappeared.’

But while MMR and Autism is a thorough dissection of the scientific and medical issues arising from the MMR panic, the book’s scope is much broader than that. ‘It is not a self-help manual intended to reassure parents worried about the safety of the combined measles, mumps and rubella vaccine, though it might very well do this’, states an apt summary by Dr Anthony Daniels in the Sunday Telegraph (1). ‘[R]ather, it is a probing analysis of a continuing health scare, one that very soon suggests deep questions of political philosophy in general, and the nature of our society in particular.’ Which begs the question – why focus on MMR in the first place?

Not so long ago, Fitzpatrick was better known for his involvement with left-wing politics than his interest in child immunisation. But as he explains, politics has changed a great deal since then – as has the social significance of such basic medical issues as vaccines. ‘The MMR controversy is a good indicator of the changing character of politics over the past decade or so’, he says. ‘For a generation of young parents, the question of whether to give their child MMR – or single vaccines, or no vaccines at all – has become a bigger issue than which party to vote for in the election – or indeed, whether to vote at all.’

The MMR issue, he says, has divided partners, families and friends in the same way they were once divided ‘over Labour and Tory, or Thatcher and the miners. More dinner parties, barbecues and picnics have been spoiled by rows over MMR than even over the war in Iraq – never mind the European constitution’.

Why should this be the case? Fitzpatrick places the MMR controversy in the context of the collapse of traditional left and right politics, and the rise of a more individuated, risk-averse society. As Politics with a big ‘P’ has ceased to matter so much to people, issues relating to health – and those relating to lifestyle, education and other personal issues – have assumed an increasing importance in people’s lives.

And as people have become more preoccupied with their own health and that of their children, the government has adopted a much higher profile on health issues. ‘Health policy is no longer concerned primarily with providing services, but is more directed towards provoking individual anxieties and fears about smoking, obesity, and other “unhealthy” lifestyles, and relating to people’s daily health concerns through initiatives like NHS Direct’, he says.

In this situation, a health panic such as that surrounding the MMR vaccine is not a diversion from politics. It is politics. Like major political battles of the past, this scare has some very real and dangerous consequences – both for the state of debate, and for individuals’ own lives.

It is well known that Fitzpatrick also has a personal interest in the MMR debate: his younger son, James, is severely autistic. But he is highly critical of the way that parents’ groups have been hailed as the authority on MMR and autism, purely because they have autistic children, and stresses that James’ condition ‘does not give me any scientific insights. All it does is give me an insight into the experience of being a parent of an autistic child’.

However, he says, ‘I am in the fortunate position of also being medically trained – so although I have no specialist expertise in any of these areas, I am in a better position than most parents to survey the literature’. The difficulties in doing this, he argues, should not be underestimated. There is no shortage of information about MMR and autism – and with the growth of the internet this information is very readily accessible. Unfortunately junk science is much more readily accessible than quality science. But ‘what is difficult for parents is to assess the validity of this information. I do believe that many parents of autistic children have been seriously misguided’.

As an example of how parents of autistic children have been ‘cruelly misled’ on the MMR question, Fitzpatrick cites the recent litigation suit against manufacturers of the vaccine, into which more than 1000 parents were drawn. Back in 1994 the Legal Aid Board agreed to fund a number of claims for compensation for injury allegedly caused by MMR: the first case in which such funding had been used to finance scientific research.

As Fitzpatrick puts it, ‘the Legal Aid Board sponsored a fishing trip by solicitors who hoped they would find some evidence to link MMR and autism. Nine years later, after spending £15million of public money and failing to find such evidence, the then Legal Services Commission (LSC) [which replaced the Legal Aid Board] concluded that “in retrospect it was not effective or appropriate for the LSC to fund research”’. The court case that had been planned to start in April 2004 was abandoned, leaving the parents concerned twisting in the wind (see Medicine on trial, by Dr Michael Fitzpatrick).

This legal campaign, says Fitzpatrick, ‘has had a wholly negative effect, nurturing the energies of parents in a thoroughly destructive way’. He is now challenging the LSC to release the research into the alleged link between MMR and autism. Though the LSC indicated that the results of these investigations would be passed on to the Medical Research Council (MRC), eight months later this has yet to happen.

In the absence of this research, the key ‘evidence’ of a link between MMR and autism remains the work of Dr Andrew Wakefield – the high-profile gastroenterologist widely credited (and now officially discredited) as the protagonist in the MMR debate. His claims, that there was a link between the MMR vaccine and autism that was mediated by inflammatory bowel disease, were first publicised in 1998. Fitzpatrick’s initial response when reading the paper was sheer amazement. ‘I could not believe that such an insubstantial and speculative report could have such an impact’, he says. ‘It did not provide any evidence of a link between MMR and autism. All it reported was the conviction of the parents of eight of the 12 children in the study that such a link existed.’

It was the claims in Wakefield’s paper that provoked the initial wave of parental anxiety about whether to immunise their children or not. But while Fitzpatrick claims that Wakefield ‘has behaved in a thoroughly reprehensible way’, by choosing to launch a public campaign after failing to substantiate his hypothesis in the scientific world, he stresses that the problem cannot be reduced to Wakefield’s actions. ‘The broader question is why is it that one scientist who has gone over the wall can have such an influence’, he says. ‘The striking thing is that Wakefield is almost universally regarded by serious scientists as someone whose work cannot be taken seriously. Yet he seems to have been very persuasive to some journalists who have given him a remarkable degree of influence.’

‘There’s a great irony here’, continues Fitzpatrick. ‘The anti-MMR campaign has been very successful in the media and one of its great successes has been to depict itself as being victimised and intimidated. Whereas the opposite is true: the people who have been really victimised and intimidated are the supporters of the vaccine, who have been subjected to vilification and abuse of quite an unprecedented character. It is true that Wakefield lost his job: but in the world of scientific research you cannot expect people to finance your research if you cannot substantiate your hypotheses. It is not so much that Wakefield has been victimised as that he’s a casualty of his own dogmatic refusal to recognise reality.’

Fitzpatrick says that the anti-MMR campaign has also had a rather intimidating effect on the supporters of the vaccine. This is particularly the case in the world of autism: ‘because the parents of autistic children have a vociferous pressure group, autism specialists, who almost universally don’t believe in the MMR-autism link, are very reluctant to challenge it.’

However, it is not good enough to explain Wakefield’s influence merely on the basis of the fickleness of the media. Wakefield would never have got this kind of hearing, Fitzpatrick argues, if it wasn’t for the broader climate of public insecurity around health-related issues. ‘The 1990s was a decade in which anxieties about health were reflected in the impact of a wide range of health scares and environmental alarms’, he explains, in which a heightened sense of individual insecurity was expressed in a popular mood of risk-aversion and a culture of litigation. ‘The narrowing scope of the realm of politics encouraged the politicisation of issues of health and disease, family relationships and childrearing practices. All these factors had a significant and growing impact on the MMR controversy throughout the 1990s.’

The disproportionate impact of Wakefield’s allegations, Fitzpatrick says, illustrates the effect 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 government that has tried doggedly but increasingly unsuccessfully to hold the line against a set of values (notably those of consumer sovereignty and choice) that it has done much to promote. When the same government that, for its own reasons, pushes the importance of patient involvement and choice in every layer of medical care then attempts to stand firm against growing parental demands for separate vaccines for measles, mumps and rubella, no wonder people suspect that something is afoot.

Although Fitzpatrick believes that the government’s firm stand and robust challenge to the junk science around MMR provide a good model for what should be its approach in other areas, he believes that the government only has itself to blame for the MMR mess. Not only is ‘its robust stance at such variance with the rest of its policy’ – it is the government that has persistently made scares and panics central to health policy.

Fitzpatrick has for a long time warned against the danger of using the tactic of scaremongering to promote public health. In his previous book, Tyranny of Health, Fitzpatrick emphatically lays out his objection to public health campaigns ‘that have an emphasis on moralising about people’s lifestyles when the evidence for their efficacy is very dubious’. Those public health campaigns to which he objects are distinct, he stresses, from ‘public health measures which have been shown to be dramatically effective – like sanitation reform and immunisation campaigns. These have been demonstrated over a very long period of time to have very palpable benefits’.

The irony is that the anti- MMR campaign has succeeded in raising fears over public health intervention, he explains, ‘because the government has taken a leading role in promoting these sorts of scare campaigns: around issues such as HIV/AIDS, sun-related skin cancer, “mad cow disease”, deep-vein thrombosis [DVT] and more’. In other words, the government has put itself in a very weak position to combat those scares that it does not want to promote. Worse still, the government has tried to use counter-scares to combat the anti-MMR campaign – for example, issuing dire threats about the impending threat of measles, ‘in a way that, of course, is entirely ineffective’.

In addition to the government, Fitzpatrick is also critical of the medical and scientific establishments, for their ineffectiveness in combating the anti-MMR campaign. ‘This is because of their reluctance, over a period of time, to combat irrational trends in science generally. One illustration is the reluctance of those in the medical world to challenge anti-immunisation campaigns, which have grown from the margins of society to mainstream influence without being seriously challenged.’

This has led to the MMR controversy becoming the focus for a wider set of anxieties. ‘That is what makes the issue of choice so central: people feel they can make a choice by opting for single vaccines in a way they feel unable to with very many other things in their lives’, explains Fitzpatrick. ‘At least they can say: “right, I am not going to do this.” But unfortunately the victim of that false sense of choice is their own child and other people’s children. This is the sad thing – that people feel they can only exercise choice in such limited areas, where the consequences of exercising the choice has an entirely negative effect both on their children, who are left vulnerable, and other people’s children, who are also left vulnerable.’

‘The government has made choice a central theme of health policy and this is a good example of the sort of problem it creates’, he says. ‘The object of immunisation policy is not to provide a “pick-and-mix” selection to the public, but to provide a coherent programme for the prevention of infectious diseases.’

But does it matter if parents don’t give their children the triple vaccine if instead they go for the single vaccines? At least their children are still immunised. Fitzpatrick does not agree. ‘Even if they go for the single vaccine there’s inevitably going to be a delay in their coverage and it is already clear that most people do not complete the single vaccines, for all sorts of obvious reasons.’

As well as providing a thorough critique of the MMR panic, MMR and Autism also gives an extensive review of the literature on autism. It is striking how little is still known about the condition, and Fitzpatrick is adamant that there is not going to be any cure for it anytime soon. ‘It is inconceivable. Anybody that has any understanding of the profundity of the problem of autism will know that there is not going to be any fundamental cure for it in the lifetime of our children. That does not mean to say that there’s nothing you can do about it. It does mean to say that if someone comes to you offering a miracle cure it’s not going to work and is more likely to do harm.’ Fitzpatrick strongly agrees with the point made by Charlotte Moore, in her book George and Sam: Autism in the family,that ‘acceptance is all’. ‘You have got to accept that your child is not going to be cured, but the question is how can you do the best you can for them.’

‘One of the great problems with the MMR controversy’, argues Fitzpatrick, ‘is that it has become a complete red herring in terms of the sorts of interventions that are likely to be helpful’. One stark example is the contrast between the £15million of public money spent on the Legal Services Commission’s ‘fishing trip’ for evidence of a link between MMR and autism, and the government announcing in 2002, in a blaze of publicity, that it was granting a mere £3.5million to autism research.

‘There are very inadequate levels of teacher training to do with autism and very inadequate levels of social services support for families with autistic children’, says Fitzpatrick. ‘These are the really important areas, and the great problem with the MMR controversy is that it has distracted attention from this area – areas where research ought to be going.’

MMR and Autism: What parents need to know is published by Routledge, June 2004. Buy this book from Amazon (UK) or Amazon (USA).

(1) ‘You can’t innoculate against panic’, Sunday Telegraph, 20 June 2004