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 author of
The Tyranny of
Health: doctors and the regulation of lifestyle,
Routledge, 2000. 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
spiked-issue: MMR vaccineclass="NetscapeDummy" /> (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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