There’s quite a furor this week over the British General Medical Council’s censure of Dr. Andrew Wakefield for his research at the Royal Free Hospital, purportedly showing a link between MMR (measles-mumps-rubella) immunization and autism (Lancet 1998; 351(9103): 637–41).
As New Scientist points out, the GMC’s finding removes any impediment to charging Wakefield and two of his colleagues with misconduct. GMC may rule on that score in a few months, according to the BBC.
By and large, the talk about the verdict hasn’t been about the substance of the contentious vaccine-autism link. At Autism Science Foundation, Alison Singer (the group’s president) writes that
Anti vaccine autism advocates continue to see Wakefield as a hero who remains willing to take on the establishment and fight for their children. In the meantime, Wakefield’s actions have had a lasting negative effect on children’s health in that some people are still afraid of immunizations. In some cases, the younger siblings of children with autism are being denied life saving vaccines. This population of baby siblings, already at higher risk for developing autism, is now also being placed at risk for life threatening, vaccine preventable disease, despite mountains of scientific evidence indicating no link between vaccines and autism. This is the Wakefield legacy.
On the other side, Generation Rescue writes in support of Wakefield at Age of Autism. GR isn’t as cogent as Singer, but brings up the point that tends to complicate this and most discussions of autism: “Do you think pharmaceutical companies have too much influence in the laws, policies, and regulations of our government? We do.”
Liz Ditz provides a great service, compiling blog posts pro-Wakefield and, separately, those criticizing Wakefield and/or supporting the GMC’s decision. (As of today, the Wakefield critics seem to have been more prolific.)
Thursday’s BBC report concludes with a graphic showing a decline in MMR coverage in the UK between 1996-97, when it stood at around 90%, and 2004, when it bottomed at around 80%. Superimposed is the number of measles cases, which increased from a few dozen in 2005 to over 1200 in 2008. The implication is that Wakefield’s report was somehow responsible for the drop in coverage in the late ’90s and that that decline led to a sharp uptick in measles incidence. The graphic also implies that after Lancet retracted the original paper in 2004, public acceptance of MMR vaccine improved after Wakefield had been repudiated — but too late to prevent the measles upsurge.
Without supporting Wakefield’s methods, it’s still worth asking whether his 1998 paper should be held accountable for the decline in vaccine acceptability. As early as February 1998, England’s Communicable Disease Surveillance Centre was reporting on the drop in MMR coverage from 1996 and ‘97 data and BMJ reported in 2003 that the British trend was consonant with declines in MMR uptake in Europe generally:
[T]he experts say that coverage is substandard across Europe owing to a surprising lack of political will to implement an effective disease prevention programme, given the region’s stated goal to eliminate measles by 2007.
A decline in nationwide vaccine coverage to 80% is probably less important as an explanation for increasing measles incidence in the U.K. than two other factors: locally deficient MMR coverage and immigration from countries with lower vaccination rates. In fact, measles increases in the UK seem to have been attributable to outbreaks in the northern part of the country and to high incidences among very young children in London, according the UK’s Health Protection Agency.
What’s to be learned from the Wakefield mess?
1. The role of pharmaceutical companies (including vaccine makers) in setting scientific agendas and moving policy remains an issue for many people. Defenders of Big Public Health, like Mark Honigsbaum who writes an interesting piece in The Guardian today, tend to be dismissive of allegations that public health has become a game for technocrats in which corporations have too much sway. But the defenders misunderstand those critiques. The critics are not saying that government predictions are wrong where they should be right, nor that officials are on the take; the critique is this: the relationship between profit makers and public agencies is sometimes awfully cozy and the attentiveness to real suffering is remarkably slight.
2. The pre-eminence of ethics boards, like Britain’s GMC, doesn’t always sit well. With the Wakefield case, the MMR-autism controversy steps onto the slippery terrain of moral decision making in regard to research. Many people don’t feel perfectly reassured about the ethics of medical practice when the overseers are themselves physicians, and the moral reasoning often seems restricted to “did the physician follow the rules?”
3. The stance of official agencies on autism doesn’t inspire confidence. Vaccination is hard to exonerate as a cause of autism as long as the official approach is that autism is a disease, and by implication preventable — rather than a disability, which might or might not have a cause but whose sufferers, in either case, can be afforded decent lives. To make matters worse, official agencies’ stance doesn’t defuse the controversy. In the U.S. and U.K., they respond to anti-immunization claims with assertions about the safety of MMR in particular. But they don’t seem to want to support the research that would test whether some children might be susceptible to damage incurred cumulatively by undergoing the numerous vaccinations that are scheduled for children today. It’s unlikely that the scrutiny of immunization, or the controversy, is going to go away unless officials soften that stance.
We’ll probably hear more on this if the GMC rules to disbar Wakefield from practicing medicine.
