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November 25, 2001
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·
Brit. Medical Breakthrough Editorial: MMR and the Age
Of Unreason*
·
GPs Call On Government To Drop MMR
·
MMR Expertopathy: Commentary
British Medical Breakthrough Editorial: MMR and the Age Of
Unreason
From the editor of the British Journal of General Practice
http://www.rcgp.org.uk/rcgp/journal/issues/nov01/editor1.asp
In the catalogue of modern medicine, it is hard to come up
with anything in which the benefits are so enormous and the risks so small, as immunisation
programmes. Whether immunisation, improving social standards or changes in
virulence can claim most of the credit for the reduction in mortality from
tuberculosis and measles is uncertain, but few would dispute the role of
immunisation in the worldwide eradication of smallpox, the ending of paralytic
poliomyelitis, the effective disappearance of diphtheria and tetanus and, more
recently, the fall in morbidity and mortality owing to haemophilus meningitis.
However, the extensive and effective programmes carry risks. First, the folk
memory of diseases and their severity fades quickly. All of us share in this:
there are now generations of doctors and nurses, as well as parents, who have
never seen children with measles. Second,
it is easy to become complacent about the balance of risks and benefits.
The continuing saga of the measles, mumps and rubella
(MMR) vaccine
will be familiar to most BJGP readers. Papers published in
the Lancet
suggested a causal link between MMR immunisation and both
inflammatory bowel
disease and autism.1,2 A number of studies have since
examined this claim
and failed to find any evidence to support the original
findings.3-6 A
review of the evidence set out chronologically, which was
recently published
in the Archives of Disease in Childhood, concluded that
‘There is no good
scientific evidence to support a link between MMR vaccine
and autism or
inflammatory bowel disease.’7 The United Kingdom’s
Department of Health
(DoH) examined the evidence, reached the same conclusion on
risks, and
stated that offering three separate vaccines would increase
the risk of
children catching the diseases.8
Meanwhile, vaccination rates nationally have fallen. The
latest data for England shows 87% coverage for 2000/2001.9 This is below the
target rate of 95% felt necessary to provide the level of herd immunity to
eliminate infection, but it also conceals regional variations, with London
having the lowest rate of 79%.9 Concerned parents continue to ask about the
risks that the medical profession and the government might be hiding from them,
and one doctor who has been supplying the vaccines separately in a non-National
Health Service (NHS) clinic has been reported to the General Medical Council.
In its public utterances, the DoH’s spokespersons betray a degree of
exasperation with the public’s refusal to accept both the evidence and the
vaccination being offered.
An article published in this month’s BJGP provides some
insight into one side of this story.10 A focus group study of parents — some of
whom had accepted and some of whom had decided against immunisation for their children
— reveals a mixture of careful decision making in the face of conflicting
information, some influence of modern folk knowledge, and scepticism of the
Government’s position. Some of these parents recognised that payments to
general practitioners based on achieving immunisation targets represent a major
conflict of interest that could compromise their ability to provide impartial
information and advice to their patients.
Behind the results reported by the authors, the data
reveal the culture so familiar to anyone working in primary care in the UK: a
healthy scepticism for any expert opinion, stronger after the BSE debacle and fuelled
by alarmist reporting on medical risks, such as the third-generation combined
contraceptives. However, when this is combined with a desire to be treated as
an equal when making decisions, and a view that, when there is uncertainty,
many members of the public would sooner not interfere by taking unnecessary
medicines, it can become a flight from reason.
The story raises numerous issues of fundamental importance
to any country’s medical system. Starting at the most basic level, it is an
example on a grand scale of the ethical conflicts all doctors face every day.
In its laudable desire to do good, the Government maintains its original line
that the MMR programme represents the best method of preventing diseases that carry
appreciable morbidity and mortality. It implicitly concludes that the only harm
will come from not taking its advice. Unfortunately, what is required in order
not to harm is not always the same as that for doing good. The report confirms anecdotal evidence that
there is a substantial minority of people who would like to make the decision
separately for the three diseases and who, if faced with the choice between
none and three vaccines, will opt for none. If the immunisation rates were to
fall dangerously low then the Department would have to bear some of the blame
for the resulting harm.
Beyond this is patients’ autonomy. Some parents have
clearly signalled their willingness to have their children immunised with one,
two, or even all three vaccines, provided they can be given separately. The
DoH’s position of simply repeating the evidence and its previous advice fails
to respect patients’ autonomy, or acknowledge that we all, as both patients and
professionals, make important decisions that are only partly based on the best
evidence. The DoH, as one arm of government, should try to be consistent about
this. It cannot encourage choice in some areas of public policy and discourage
it in others. At the same time, we should sympathise that the Department is in
a difficult position: any retreat from its current stance would prompt knowing
remarks along the lines of: ‘There — we always knew they weren’t telling us the
truth.’
For doctors giving advice the position is slightly different.
As things stand, and again based on the best evidence, our patients can only accept
or refuse the triple MMR. Since the evidence is unequivocal about the considerable
benefits and negligible risks, then we have to advise them to accept the MMR
vaccine. The DoH’s uncompromising stance may risk alienating the public, but in
the circumstances any other advice risks doing harm. Azeem Majeed has argued persuasively that if a parent refuses the
MMR vaccine then any advice we give to take the vaccines separately is minimising
the harm.11 However, there is a fine line between giving reluctant advice to
minimise harm, and colluding with decisions taken in good faith but unsupported
by the evidence. We too have to be consistent in communicating evidence. We
cannot appeal to patients’ reason when, for instance, we try to persuade them
to give up smoking, and ignore it when it comes to MMR. We may respect, or even
admire, them for rejecting the advice but we can do so without compromising our
own position.
The mass media also have a responsibility in the way
that they filter
and report medical research to the public. Bandolier
commented that ‘There
are lessons to be learned, certainly by news reporters,
certainly by editors
of learned journals and their peer reviewers, and probably
by providers of
healthcare.’12 There has been a suspicion among doctors that
mass
circulation newspapers are much more eager to report
alarming scare stories
than dull, reassuring ones. Support for this view comes from
a study
examining the frequency with which papers from the Lancet
and the BMJ were
reported in The Sun and The Times newspapers, showing that
randomised trials
and systematic reviews were less likely to be reported than
observational
studies, and that both newspapers over-reported on women’s
health and sexual
and reproductive health.13
While Evans and colleagues are only reporting a small
qualitative study, the findings on parents’ response to target payments is
worrying. It is generally agreed that target payments for the primary
immunisation programme have been effective in helping to improve the coverage
in the overall population. Such a system can work when there is a clear
consensus both about the objective and how it is to be achieved. However, once
the consensus breaks down target payments may also turn out to have negative effects,
and these could extend beyond the limited area of MMR immunisation.
The DoH may wish to consider whether preserving patients’
trust in their
doctors has a value that far outweighs the benefit of high
MMR immunisation
rates.14
Finally, does the DoH need to revise both its conclusions
and the process by which it reaches them? The website where its advice can be
found is admirably clear, well set out, and easy to navigate.8 However, it is striking
how many times it uses the word ‘expert’, as if the use of this mantra will
quash any disagreement. The DoH appears not to have noticed that experts are no
longer instantly deferred to by the medical profession, let alone the public.
The medical profession is struggling to involve patients much more in the
decisions concerning their own health and exploring the best ways of achieving
this. Lay representation is now familiar on many medical bodies, following the
pioneering example of the RCGP many years ago.
The DoH may need to recognise that people make decisions for legitimate reasons
other than pure science, and that it should include the lay voice, particularly
the dissenting voice, when it produces advice in controversial areas.
DAVID JEWELL
Editor
1. Thompson NP,
Montgomery SM, Pounder RE, Wakefield AJ. Is measles vaccination a risk factor
for inflammatory bowel disease? Lancet 1995; 345:
1071-1074.
2. Wakefield AJ, Murch
SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis,
and pervasive developmental disorder in children. Lancet 1998; 351: 637-641.
3. Peltola H, Patja A,
Leinikki P, et al. No evidence for measles, mumps, and rubella
vaccine-associated inflammatory bowel disease or autism in a 14-year
prospective study. Lancet 1998; 351: 1327-1328.
4. Taylor B, Miller E,
Farrington CP, et al. Autism and measles, mumps, and rubella vaccine: no
epidemiological evidence for a causal association. Lancet 1999; 353: 2026-2029.
5. DeWilde S, Carey I,
Richards N, et al. Do children who become autistic consult more often after MMR
vaccination? Br J Gen Pract 2001; 51:
226-227.
6. Arlett P, Bryan P,
Evans S. A response to ‘Measles, mumps, rubella vaccine: Through a glass,
darkly’ by AJ Wakefield and SM Montgomery and published reviewers’ comments.
Adverse Drug React Toxicol Rev 2001; 20:
37-45.
7. Elliman DAC,
Bedford HE. MMR vaccine — worries are not justified.
Arch Dis Child 2001; 85: 271-274.
8. Department of
Health. Measles, mumps and rubella vaccine (MMR). http://www.doh.gov.uk/mmr.htm
9. Department of
Health. NHS Immunisation Statistics, England:
2000-2001. http://www.doh.gov.uk/public/sb0121.htm
10. Evans M, Stoddart H,
Condon L, et al. Parents’perspectives on the
MMR immunisation. A focus group study. Br J Gen Pract
2001; 51: 904-910 [this issue].
11. Majeed A. Referral
of Dr Peter Mansfield to the GMC. BMJ 2001;
323: 163.
12. Bandolier. Even more
on MMR.
http://www.jr2.ox.ac.uk/bandolier/band88/b88-2.html
13. Bartlett C, Sterne
J, Egger M. What is newsworthy? A comparison of reporting of medical research
in British tabloid and broadsheet newspapers.
Fourth International Congress on Peer Review in Biomedical Publication.
Barcelona, Spain, 14 to 16 September 2001.
14. Fugelli P. Trust –
in general practice. Br J Gen Pract 2001; 51:
575-579.
15. Sackett DL. The sins
of expertness and a proposal for redemption.
Address for correspondence
Dr David Jewell British Journal of General Practice,
Royal College of
General Practitioners, 14 Princes Gate, Hyde Park, London
SW7 1PU
E-mail: journal@rcgp.org.uk
·
Perhaps an obtuse reference to Jean-Paul Sartre’s book “The
Age of Reason” which such reference would no doubt instill him with Nausea,
were he still alive. He is however, quite dead, and thankfully so is his stupid
existentialism “philosophy.” But I
digress. . . -LS
>>> PROFESSORS, TEACHERS, TRAINERS
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* * *
Public trust more important.
[Press reaction to the above editorial. By Sarah-Kate
Templeton Health
Editor, Sunday Herald. Thanks to Richard Miles for these
postings.]
http://www.sundayherald.co.uk/20428
The government has been urged to introduce single vaccines
for measles, mumps and rubella in an editorial in the journal of the Royal College
of General Practitioners, the professional body for family doctors.
The British Journal of General Practice argues that the
government is inconsistent in refusing to offer separate vaccines to parents
who fear a link between the MMR inoculation and autism. It also warns that the Department
of Health would be responsible for any outbreak of childhood disease due to
unvaccinated infants.
The journal also calls for payments to GPs who meet
immunisation targets to be scrapped after a survey found that the policy causes
patients to distrust their doctor.
Dr David Jewell, editor of the journal, said: ‘The report
confirms anecdotal evidence that there is a substantial minority of people who
would like to make the decision separately for the three diseases and who, if faced
with the choice between none and three vaccines, will opt for none. If the
immunisation rate were to fall dangerously low then the department would have
to bear some of the blame for the resulting harm.
‘Beyond this is patients’ autonomy. Some parents have
clearly signalled their willingness to have their children immunised with one,
two or even all three vaccines, provided they can be given separately. The Department
of Health’s position of simply repeating the evidence and its previous advice
fails to respect patients’ autonomy, or acknowledge that we all, as both
patients and professionals, make important decisions that are only partly based
on the best evidence. The DoH, as one arm of government, should try to be
consistent about this. It cannot encourage choice in some areas of public
policy and discourage it in others.’
The criticism of current vaccination policy will be a
major blow to the government which had boasted the support of GPs in refusing
to introduce single vaccines.
Fears were raised over the safety of the triple vaccine
after a paper published in the Lancet suggested a link between the jab and
autism and bowel disease in children. This link has been widely disputed.
The editorial was prompted by the findings of a survey of
parents’ views published in this month’s edition of the journal.
It states: ‘Some of these parents recognised that payments
to GPs based on achieving immunisation targets represent a major conflict of interest
that could compromise their ability to provide impartial information and advice
to their patients.
‘The DoH may wish to consider whether preserving patients’
trust in their doctors has a value that far outweighs the benefit of high MMR immunisation
rates.’
The survey, led by Bristol University researchers, states:
‘Parents reported unwelcome pressure from professionals to accept immunisation
and many had accepted MMR because of this pressure rather than making an informed
choice, feeling that it was easier to comply than to refuse.
‘All groups emphasised that parents should be able to
choose which immunisations, if any, their children received, and they all
wanted the single vaccines for measles, mumps, and rubella to be available as
an alternative to MMR. Parents felt that the promotion of MMR was partly on considerations
of cost and convenience, such as the potential difficulty in tracking individuals
for separate immunisations.’
Last week a ruling by the General Medical Council opened
the way for Dr Peter Mansfield to continue giving inoculations against measles,
mumps, and rubella instead of the MMR triple vaccine.
The GP was reported to the GMC by Worcestershire Health
Authority which claimed he was acting contrary to normal medical practice and
against the best interests of patients.
Dr Peter Copp, whose private Edinburgh clinic GP Plus has
been offering single vaccines, said: ‘This editorial is of great significance because
it is going to be read by almost every GP. This journal is the defining journal
of the Royal College of General Practitioners. It is the academic bible of
British GPs. Along with what happened with Dr Mansfield this marks the
beginning of a change in attitude to acknowledge that offering an alternative
to the MMR is a reasonable and even laudable thing to do.’
Bill Welsh, the grandfather of an autistic child and chair
of Action on Autism, added: ‘The GMC decision last week confirmed that it is acceptable
for parents to have single vaccines. That senior doctors are now calling for ‘choice’
indicates how out of step the civil servants are on this issue.’
The Scottish Executive last night reiterated that the MMR
vaccine has been proven to be safe and there would be no change in vaccination
policy.
A spokeswoman added that new information packs on MMR to
family health professionals across the country.
* * *
MMR Expertopathy
Commentary
Those who doubt the MMR vaccine, either in combination or
even separately, just may not have concluded, as the good Doctor Jewell does in
the British Journal of General Practice editorial, that the evidence gathered
to date demonstrates clear cut safety of the potion. Here, as elsewhere,
dissenters are characterized as “unreasonable” followers of ideas not borne of “pure
science”, but of something less. While
the Doctor correctly cites the counterproductive patronizing spin found on the
DoH website with their “expert” assurances, curiously he nonetheless remains blind
to his own.
The editorial calls for the medical legalization of time
separated measles, mumps and rubella vaccines.
This is a significant breaking from the British medical establishment
ranks and worth noting.
The issue of combination vaccines is a proxy controversy
for the larger issue of vaccine safety in whatever form. Worry over single vaccinations
is silly. After all, separated doses have been available in the United States
for some time and vaccine compliance rates here remain at all time highs,
outbreaks at all time lows. It is the
camel’s nose of doubt under the tent of British medical expertise imagery that
worries all the king’s men. Their overstated pronouncements of categorical
scientific vaccine safety belie a public health system short on
self-confidence. Expert blustering will
not do well to win over the growing troublesome hysterical rabble who in the
experts’ eyes, seem to prefer the health advice of faeries and leprechauns, on
or off the internet.
The begged question underlying all the vaccine controversy
still remains largely unasked, let alone answered by the medical guardians on either
side of the big pond: if it isn’t the vaccines rendering our children autistic
in purported epidemic numbers, then what is?
·
Lenny Schafer
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