Andrew Wakefield: misguided maverick
The doctor behind the MMR-autism scare has never proved his case. That hasn't prevented him from getting a platform everywhere from the Lancet to Private Eye.
A 32-page Private Eye special report, ‘MMR: the story so far’ by Heather Mills, offers ‘a comprehensive review of the MMR vaccination/autism controversy’ – from the perspective of Dr Andrew Wakefield, the gastroenterologist at the centre of the controversy (1).
Dr Wakefield’s choice of a popular satirical magazine and a journalist with no background in science to present his case in a major scientific controversy may seem curious. It confirms his maverick status, but it also undermines his claim to be taken seriously – even as a maverick. It also raises questions about the roles of the medical establishment and the media in the continuing MMR-autism panic.
The history of science and medicine provides many examples of dissidents and heretics, individuals who challenged conventional wisdom, suffered condemnation and rejection – or worse – only to be ultimately vindicated.
The gastroenterologist Barry Marshall is a recent example. When he first suggested in 1983 that the underlying cause of the excessive acid secretion that causes peptic ulcers was a chronic infection with the bacterium Helicobacter pylori, he was met with derision. He was, after all, an Australian junior hospital doctor and his hypothesis flew in the face of conventional wisdom.
Yet, within two years he had confirmed it, in part by staging a dramatic demonstration of drinking a solution of the bacterium, producing inflammation of his own stomach – confirmed by gastroscopy – and subsequently treating this (2). Marshall showed that Helicobacter was at the root of a range of diseases, including gastric and duodenal ulcers and stomach cancer, and he showed that its eradication (by a simple drug regime) produced dramatic results.
Mavericks who prevail against orthodoxy have to pass two tests. They have to substantiate their own hypotheses; and they have to convince their peers that they are right. Whereas Marshall spectacularly passed both tests between 1983 and 1985, since 1998, when Dr Wakefield first published his hypothesis that MMR may cause inflammatory bowel disease, which in turn may cause autism, Dr Wakefield has singularly failed to pass either test.
- Where’s the evidence?
The core of Dr Wakefield’s case is that, in some children, the MMR immunisation provokes inflammation of the small and large bowel – enterocolitis – and that this causes toxins to leak into the blood stream. These toxins then pass into the brain, producing damage that is manifested as the clinical picture of autism (3).
Though Dr Wakefield has published several papers since 1998, none provides significant evidence for his central hypothesis. For example, a widely publicised paper produced jointly with the Dublin-based virologist John O’Leary claims that measles virus particles have been discovered in the bowels of children with autism (4).
This paper does not indicate whether the children studied had received the MMR vaccine or whether the virus particles were the same as those in the MMR. Even the authors admitted that it shed no light on the question of a link between MMR, bowel disease and autism.
Far from working exhaustively on his core thesis, Dr Wakefield seems to have concentrated his energies on secondary issues, such as the surveillance for adverse effects following the introduction of MMR in Britain, and the controversy over the increased prevalence of autism (5). Studies in these areas have taken Dr Wakefield beyond his own sphere of professional competence – gastroenterology – into epidemiology, public health and autism in which he has no particular experience or expertise. These studies have failed to provide support for the MMR-bowel disease-autism link.
Dr Wakefield has conspicuously failed to persuade his medical colleagues of his case against MMR. A number of expert review groups have analysed the published work and some have received oral presentations from Dr Wakefield and his colleagues. The UK Medical Research Council (MRC) has produced three separate reports, in March 1998, April 2000 and December 2001. Other studies have been conducted by the American Medical Association, the Institute of Medicine (USA), the World Health Organisation, the American Academy of Paediatrics, the Canadian Public Health Body and the Irish Department of Child Health.
According to the survey published by the MRC in December 2001, these reviews were ‘unanimous in their conclusions that a causal link between the MMR vaccine and “autistic colitis” and autistic spectrum disorders was not proven and that current epidemiological evidence did not support this proposed link’ (6).
- Ducking the debate
The recent MRC autism review assembled many of the leading authorities in the field in Britain, as well as involving people with autism and advocacy groups, and produced a comprehensive report on the current state of medical science on the subject. For any scientist confident in an alternative theory of autism, this inquiry offered an ideal forum in which to present his research and make his reputation. Yet Dr Wakefield turned down an invitation to submit his case to the MRC.
According to the Private Eye report, this was because some members of the review had agreed to advise the vaccine manufacturers in litigation brought by groups of parents who believe that the MMR vaccine caused their children’s autism. These include Professor Michael Rutter, arguably Britain’s leading child psychiatrist over the past 20 years, and Dr Eric Fombonne, an internationally respected clinician and epidemiologist in autism.
The MMR court cases are largely the result of the efforts of lawyers advised by Dr Wakefield (and parents encouraged by his claims). Once these actions were underway, it was inevitable that the vaccine manufacturers would seek advice from leading authorities in the field – such as Rutter, Fombonne and the others. These have only become advisors to the drug companies because of the allegations against MMR. Dr Wakefield’s explanation for his refusal to make a submission to the MRC seems more like a pretext to avoid an open debate with his peers.
The Private Eye report repeatedly refers to leading autism specialists as ‘advisors to the drug companies’, as though this impugns their professional integrity. However, it neglects to inform readers that the epidemiologist Professor Walter Spitzer, who provides pro bono advice to the litigants, is also a shareholder in Glaxo and Merck – as he informed the MRC review. Indeed, given the fact – included in the Private Eye report – that some 90 percent of authors in leading medical journals receive some funding from drug companies, refusing to discuss with anybody receiving such funding would drastically curtail medical debate.
No doubt there are problems arising from the role of the drug companies in medical research, but these are not peculiar to vaccines. Indeed, they have little impact on the world of autism, where drug treatment is very limited.
- Playing to the gallery
Though he has yet to substantiate his own hypothesis or convince his peers that the link between MMR and autism is anything more than speculation, Dr Wakefield has, in a series of newspaper and TV interviews, taken his case to the general public.
Dr Wakefield has a history of courting the press. As early as 1995 his photograph appears in a lengthy anti-MMR feature in the Sunday Times (London) magazine, in which his earlier (and subsequently discredited) thesis of a link between MMR and Crohn’s disease is quoted. It seems that parents of autistic children first began to make the link with MMR in response to this and similar articles in the mid-1990s, and brought their children to Dr Wakefield’s clinic at the Royal Free Hospital in North London.
Following the press conference to launch the February 1998 paper, all the headlines went to Dr Wakefield’s call for giving the MMR as separate vaccines – an issue not raised in the paper itself and not supported by any of his co-authors. In April 2000 he attracted attention by presenting unpublished data to a congressional inquiry in Washington, DC. The launch of Dr Wakefield’s paper criticising the introduction of MMR in Britain in January 2001 (in a journal with a circulation of 350) was staged by the medical research charity Visceral, of which Dr Wakefield was then a trustee and is now an employee. It became a media circus (7).
Dr Wakefield has received sympathetic coverage in most of the broadsheet newspapers and on several TV programmes. A special edition of the BBC’s flagship current affairs programme Panorama in February 2002 provided a major boost to the controversy, by reporting details of Dr Wakefield’s then unpublished Molecular Pathology paper, which claimed the presence of measles virus in the bowels of autistic children.
And now we have the Private Eye special, in which Dr Wakefield’s case is presented through the medium of a journalist who, we are told, has been ‘specialising in home and social affairs’ for more than 20 years. Heather Mills provides a hagiography of Dr Wakefield as a pioneering researcher who, having discovered the cause of Crohn’s disease (this will be big news in the world of gastroenterology), is now making major strides towards revealing the cause of autism (strides unrecognised in the world of autism). Mills offers a detailed account of Dr Wakefield’s case against MMR, even doughtily settling a few scores on his behalf against his detractors.
The problem here is that, whatever her journalistic skills, Ms Mills is incapable of evaluating Dr Wakefield’s scientific work. Take, for example, his most recent paper, entitled ‘Small intestinal enteropathy with epithelial IgG and complement deposition in children with regressive autism’ (8). No, I don’t know what this means either, and I have studied immunology.
This article is published in the journal Molecular Psychiatry, whose readers are ‘researchers and clinicians involved in neuroscience, psychiatry and areas allied to psychiatry including neurology, neurosurgery imaging and psychology’. This certainly excludes me and Ms Mills: in fact, there are probably only a few hundred people in the country capable of making an informed judgement on the significance of Dr Wakefield’s findings.
(Though I could make little headway with Dr Wakefield’s article, I was struck by the accompanying editorial comment that ‘there have been suggestions of autoimmune involvement in essentially all psychiatric disorders, including schizophrenia, depression and obsessive compulsive disorder, but the data do not yet support final conclusions. The field of psychiatry is plagued with the issue of non-replication’.) (9)
The selective presentation of findings from research of this sort, according to the requirements of an established line of argument, reduces science to propaganda.
Lacking scientific knowledge in any of the spheres involved in the MMR/autism controversy, Ms Mills has evidently put her trust in Dr Wakefield and her own prejudices on the subject. Of all prejudices, the most ancient is commonsense, which inevitably makes its appearance: ‘Commonsense suggests introducing one live vaccine with the potential to suppress the immune system must be safer than injecting three.’ (10)
To Pope Urban VIII in the seventeenth century, it was both commonsense and a matter of faith that the sun revolved around the earth. Galileo’s scientific discovery challenged both popular prejudice and divine authority. Similarly, medical science defies the intuition that a triple vaccine suppresses the immune system and confirms that it is indeed safer than single vaccines (see Myths of immunity, by Dr Michael Fitzpatrick).
- Who’s to blame?
Though Dr Wakefield has made negligible headway in convincing the worlds of science and medicine of his theories, he has had a major impact on public opinion. In response to health panics such as that over MMR and autism, the media are often blamed for scare-mongering. But as the MMR/autism story illustrates, such scares often begin within the medical-scientific establishment.
The origins of this scare lie in Dr Wakefield’s decision to go public with his hypothesis of a link between MMR and autism before he had either produced evidence in support of it, or succeeded in persuading any significant section of scientific or medical opinion of the validity of his theory.
A lesser, but not insignificant, factor was the failure of the process of peer review to protect the public from the adverse consequences of junk science. Was it legitimate for the Lancet to publish Wakefield’s 1998 paper? Even though it appeared accompanied by a critical commentary, the prestige of the Lancet gave the paper a legitimacy it would have been denied if it had appeared in a specialist journal. Furthermore, the recent trend for controversial articles in leading medical journals to make headlines in the mainstream press, and to circulate on the internet, guaranteed a major public impact.
The paper’s methodological flaws were readily apparent: the selection bias resulting from the subjects’ attendance at the clinic of a well-known anti-MMR campaigner; the recall bias arising from the parents’ recollection of the relationship between immunisation and the onset of symptoms; the small number and heterogeneous character of the cases; the lack of precision in the diagnosis of autism. These errors, and the highly speculative character of the paper’s conclusions, made it unsuitable for publication in a journal such as the Lancet.
Dr Richard Horton, the Lancet‘s editor, justified his decision to publish the article on the grounds that, in the spirit of openness proclaimed in the Phillips Report on the BSE/CJD debacle, ‘full disclosure of new data – subject to external peer review – is preferable to well-meaning censorship’ (11). But this was not an issue of censorship, or of disclosure of data, though the fact that the peer review process missed the manifest deficiencies of the Wakefield paper is a cause for concern.
The key question is whether an authoritative medical journal should publish a paper that is likely to undermine public confidence in the national immunisation programme without substantiating a single link in the proposed chain of causality between MMR and autism. This paper caused great public anxiety and a fall in the uptake of MMR – without advancing the scientific understanding of autism one iota.
It is also regrettable that Dr Wakefield’s immediate colleagues were so reticent in making their own positions clear. Though, as it was widely pointed out, there were more signatories to the February 1998 paper (thirteen) than the number of children on whom it was based (twelve), Dr Wakefield’s co-authors remained aloof from the controversy. While three paediatricians involved in the study distanced themselves from the call for single vaccines, it was left to another Royal Free paediatrician – Professor Brent Taylor – to provide a comprehensive exposure of Dr Wakefield’s case.
Apart from muted endorsements of the national immunisation programme, it was nearly four years before any member of the team broke the collective silence (four years in which Dr Wakefield was highly vocal). Finally, in February 2002, the most senior member of the team, the eminent paediatric gastroenterologist Professor John Walker-Smith, wrote to the Lancet declaring his personal confidence in MMR (12).
In an attempt at even-handedness, Professor Walker-Smith condemned the ‘adversarial approach’ of the legal action against the vaccine manufacturers and of some Department of Health officials towards Dr Wakefield. (It would surely be considered reprehensible if such officials failed to take an adversarial approach to unsubstantiated claims that the national vaccination policy was responsible for causing a devastating condition like autism among thousands of children.) Professor Walker-Smith’s main point was the need for further research to identify whether ‘there are factors that may place a very small but important group of children at risk’ of autism.
The notion of a subgroup of children vulnerable to MMR is not advanced in the February 1998 paper – it represents a fallback position adopted by Wakefield in response to the weight of epidemiological evidence that MMR could not be a factor in the vast majority of cases of autism. But there is no better evidence for a vulnerable subgroup than there is for total population vulnerability to MMR (and if this subgroup corresponds to the number of cases now pursuing litigation, it cannot be regarded as ‘very small’).
One might have expected the senior clinician involved in the 1998 study to acknowledge that, after four years, the further investigations called for in the final paragraph of that paper had failed to confirm its speculations about a ‘chronic enterocolitis in children that may be related to neuropsychiatric dysfunction’, and the link between the onset of these symptoms and the MMR immunisation. While more research is always desirable, further explorations of this hypothesis seem like throwing good money after bad.
- How the press swallowed the maverick myth
The role of the media in health scares is generally secondary to that of medical authorities (13). However, at a time when there is a high level of popular anxiety about health issues, the media plays an important role in amplifying public concerns and reinforcing anxieties.
In the current MMR-autism panic the way the media has helped to politicise the controversy has ensured that it has had a wider impact. This was most apparent in the furore over whether the UK prime minister’s infant son Leo had been immunised, in which newspapers and politicians tended to line up according to party loyalties. The media has also encouraged the campaign for single vaccines, which has been presented as an issue of choice and rights – and was taken up in these terms by opposition politicians.
It says much about the degradation of the concept of rights in contemporary society that some parents are now demanding that the state subsidises their choice to expose their children – and other people’s children irrespective of their parents’ choices – to an increased risk of infectious diseases. The major beneficiaries of this scare have been private doctors who have skilfully exploited public fears to boost their income.
For all its sanctimonious posturing about doctors who act as paid advisors to drug companies, Private Eye appears oblivious to the commercial interests of the private GPs who have emerged as some of Dr Wakefield’s staunchest supporters. It is similarly indulgent of the lawyers who are also great champions of Dr Wakefield’s cause, and have already earned more than £1million in legal aid funding.
Perhaps the most striking feature of the MMR-autism scare – well illustrated by the Private Eye special – is the media’s uncritical acceptance of the myth of Dr Wakefield as a maverick. Though this myth has been assiduously promoted by Dr Wakefield, who appears to relish his role as martyr to the medical establishment, his record in defying scientific and medical orthodoxy is unimpressive. Indeed his appeal to the public reflects his failure to win over his peers. Yet Dr Wakefield is generally taken at his own estimation, as a David ranged against the Goliath of the medical establishment, who has suffered personal and professional persecution as a result.
It is true that Dr Wakefield’s work has been criticised by a number of medical authorities, and his campaign against MMR has been vigorously repudiated by various professional bodies that are concerned with implementing the vaccination programme. But, given the seriousness of Dr Wakefield’s allegations, the absence of scientific evidence for them, and the potentially dangerous consequences for public health, the official response to him has been remarkable for its restraint.
In the past, health correspondents have been criticised for simply parroting Department of Health press releases and recycling articles from the medical journals. Yet they now seem to have extended this uncritical approach to a self-proclaimed maverick. A few awkward questions to Dr Wakefield might shed more light on his position than the sycophantic demeanour adopted by Heather Mills and several earlier interviewers.
If Dr Wakefield has made such dramatic breakthroughs in his research into Crohn’s disease, then why is it that these are not generally recognised? Indeed why has he now apparently abandoned that field entirely? If his work on the MMR-autism link is a genuine scientific advance, then why has this not been acknowledged by experts in this field? If he believes he has made a significant breakthrough, then why is he so reluctant to argue his case with the experts? Why is it that other researchers have failed to replicate his findings – in relation to both Crohn’s and autism?
There has been much discussion of the dangers of the anti-MMR campaign to public health. There is little doubt that the publicity Dr Wakefield’s work has received has contributed to a decline in the uptake of MMR over the past four years, with the consequence that outbreaks of measles, mumps and rubella are now more likely. Yet, perhaps because of Dr Wakefield’s presentation of himself as a champion of the families of children with autism, there has been less attention to the problems that this furore has caused to these families.
In my surgery the mother of a boy recently diagnosed as autistic told me how guilty she felt about having allowed him to have the MMR. While self-deluded scientists, lazy journalists, unscrupulous lawyers and private GPs are ready to exploit her grief and anger, she is not a step nearer understanding her son’s condition, and several steps further away from coping with it.
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)).
Myths of immunity, by Dr Michael Fitzpatrick
(1) ‘MMR: The story so far’, Private Eye Special Report, May 2002
(2) See James LeFanu, The Rise and Fall of Modern Medicine, 1999, p177-186
(3) Wakefield AJ et al (1998) ‘Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children’, The Lancet 351: 637-41
(4) Wakefield, AJ et al, ‘Potential viral pathogenic mechanism for new variant inflammatory bowel disease’, Molecular Pathology, 2002, 55: 0-6
(5) Wakefield AJ and Montgomery SM, ‘MMR vaccine: through a glass darkly’, Adverse Drug Reactions and Toxicological Reviews, 2000: 19: 265-83
(6) MRC, Review of Autism Research: Epidemiology and Causes, December 2001, p28
(7) See Kamran Abbasi, ‘Man, mission, rumpus’, British Medical Journal, 3 February 2001
(8) Molecular Psychiatry, 2002, 7: 375-382
(9) Licinio, J et al, ‘Autoimmunity in autism’, Molecular Psychiatry 2002, 7: 329
(10) ‘MMR: The story so far’, Private Eye Special Report, May 2002, p31
(11) ‘Nothing to Fear’, BMA News Review, 16 May 1998
(12) Lancet, 23 February 2002; 359: 637
(13) The Tyranny of Health, Dr Michael Fitzpatrick, Routledge, 2000, p30. Buy this book from Amazon (UK) or Amazon (USA)
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