All other knowledge is hurtful to him who has not honesty and good-nature ~ Michel Eyquem de Montaigne-Delecroix (1533–1592)
This article was prepared before the current measles outbreak was announced. It is even more relevant now.
The MMR (measles, mumps and rubella) vaccine has been routinely administered to most one-year-olds in the US since the early 1970s. It was widely introduced into the UK in 1988. Ten years later, in February 1998, thirteen doctors based at the Royal Free Hospital in Hampstead published a report in the Lancet, alleging that the vaccine was linked to the development of inflammatory bowel disease and autism. (The same research team had already suggested in 1995 that MMR was associated with Crohn's disease, although this claim had quietly been abandoned.) The new report was based on a finding that eight out of twelve children referred to the hospital had suffered from sudden onset of developmental disorders very soon after the administration of the vaccine.
The Guardian, at the time, stated that: "A medical study suggests today that there could be a link between the measles, mumps and rubella vaccine (MMR) given to children in their second year of life and inflammatory bowel disease and autism … They also found that the behavioural changes in the children which are typical of autism, such as forgetting the basic language they had just learned, began within days of their MMR vaccination".
The doctors' report was discredited by the investigative journalist, Brian Deer, who commented that: "even a superficial examination of the report revealed crude errors, inconsistencies and omissions which might properly have been challenged by the Lancet's editor". Instead of such careful scrutiny, The Royal Free Hospital was quick to promote the report through a press release, a video news release and a press conference.
Deer's investigation, published in a Sunday Times special report and a Channel 4 documentary programme, revealed that Dr Andrew Wakefield, who fronted the study, was receiving payments from Richard Barr, a solicitor who was trying to bring a case (financed by the British Legal Aid Fund) against the vaccine manufacturers. The children cited in the doctors' report, were in fact associated with Barr and his action.
The effects of the controversy were to undermine confidence and to drastically reduce the uptake of the MMR vaccination. Between 1995, when information began to appear suggesting that the MMR vaccine was implicated in bowel disorders, and 1998, when the paper was published alleging the link with autism, the uptake of the vaccine fell from 92% (close to the World Health Organisation's recommended level of 95% for the protection of a population) to 88%. It hovered at about this level until 2001 when the case was taken up by the media with a sustained attack on the vaccine.
By 2003, the level of uptake had fallen to around 80%. By then, 12% per year of young children had been put at risk by a scare which proved to be unsubstantiated. And it took until 2005 to bring the uptake rate back to 84%, which is better but still more than 10% below the World Health Organisation's recommended level.
Harm done to the nation's health
It is difficult to assess the harm which this has done to the nation's health.
The chart below, showing the incidence of the three diseases, looks dramatic; incautious journalists might jump to the conclusion that we are in the grip of a mumps epidemic caused by the MMR debacle. They would be wrong. The rise in mumps cases is mostly in the over-15 age group – a group who (as children) were too young to benefit from the introduction of MMR. This is the normal type of epidemic which occurs from time to time and which blanket vaccination is designed to prevent.
There has also been a smaller – but still significant – rise in cases in the under-15s, which probably did result from the MMR boycott. With an epidemic among teenagers and young adults (for whom MMR was not available), and with parents avoiding MMR, young children are being exposed to mumps with no protection against catching the disease.
The second chart shows the infection rates of the other diseases in a little more detail by cutting off the top of the graph and the mumps spike. It shows that there was very little effect on infection rates during the problem period. Epidemics come and go, and luckily there has been no significant outbreak of measles or rubella during the period, as there was with mumps. However, the low level of immunisation has put children and unimmunised adults at risk, in the same way that young adults are currently at risk of catching mumps.
All three diseases are dangerous and can cause serious long term consequences:
- mumps can cause sterility
- rubella can cause birth defects in babies whose mothers are infected during pregnancy
- measles can cause death; in 2006 an uninoculated thirteen-year-old (with an underlying lung condition) was the first child to die of measles in the UK for 14 years
Children who missed out on the MMR are growing up vulnerable to these diseases. More than 3000 of them have already fallen victim to mumps.
So how did we get here and what can we learn? The government, faced with the problem of falling confidence, did not handle the situation well.
Loss of trust
The first and most serious problem was that it had lost the trust of the public. This is not a problem peculiar to the MMR crisis. But it does show how important it is for a government to show itself to be honest and open. Without trust, it cannot carry out its job properly. Here are some factors which led to this disintegration of trust:
- The handling of the BSE crisis by the previous Conservative government which undermined faith in official scientific advice.
- The disastrous strategy used in the 2001 foot-and-mouth outbreak which led to the closure of the countryside and pyres of burning carcases – how could people trust a government that let things get so out of hand?
- The failure to address the growing menace of hospital acquired infections – most people knew someone who was affected.
- The failure to demonstrate that the huge additional resources which were being poured into the NHS were making a difference – this had a disastrous effect on NHS staff morale and undermined public trust further.
- The style adopted by ministers and officials when questioned about their policies and actions; this had become mealy-mouthed and defensive.
- The failure of Tony Blair to say whether his son Leo had been given the MMR. This undermined confidence in government advice and was a particularly crass version of the "do what I say not what I do" attitude. Blair should have known better. He was a father of a young baby and was dealing with a public fearful for the health of their children and had been given a unique opportunity to demonstrate confidence in the advice of government scientists – an opportunity which he flunked.
In addition, faced with a potential public health disaster, the government failed to try an alternative strategy. Instead of insisting that it was MMR or nothing, they could have offered separate inoculations, an option chosen by many richer parents (including the Blairs? – a later leak suggested that Leo had been given the MMR but by then it was too late). Offering an alternative to MMR, with a carefully-reasoned explanation of why the government felt it was right to choose the three-in-one, would have been so much more reassuring than the "we know best approach" which put thousands of children at risk.
Of course the government were not the only culprits. The more drama-driven elements of the press were all too keen to spread doom-laden predictions over their front pages, to ferment fear and insecurity in their readers. And we must remember who started the whole debacle. Scientists who do not follow proper procedure undermine respect for all scientific research.
And so children were put at risk by a three pronged failure:
- Shoddy science
- A hysterical press
- A mistrusted government
Luck may run out
There is a risk that the whole can of worms will be reopened now that Dr Wakefield and two of his colleagues (Professor John Walker-Smith and Dr Simon Murch) face a hearing before the General Medical Council. They will be questioned about the conduct of the research that underpinned their report. Let us hope that lessons have been learnt and – equally importantly – that no efforts are made to reignite the fears. So far we have been lucky, with only a limited impact from reduced immunisation. Luck may run out.