Opinion Articles

MMR, autism and the history of medical controversies

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Andrew Wakefield has been struck off by the General Medical Council for his research into a possible link between the Measles, Mumps and Rubella (MMR) vaccine and autism. Although he will appeal the verdict, it is another strike against him and his controversial theory.

This may be a good thing. Wakefield failed to provide evidence supporting his theory and, when he did conduct research, there were serious ethical problems with how he conducted it. Indeed, it was these ethical issues, rather than his specific claims, which led to his punishment. Even if Wakefield's theory was correct, and autism was caused by MMR, increases in cases of mumps, rubella, and particularly measles, would have had more serious repercussions than an increase in the prevalence of autism. Nevertheless, the fear of MMR and autism instilled in parents by Wakefield was enough to reduce significantly the uptake of the vaccine, causing mini-epidemics and deaths in many regions.

But when the MMR story is examined in more detail and in the light of historical analysis, a more complex controversy emerges. At its heart are a multitude of interests; those of media outlets, clinicians, scientists, parents, people with autism, pharmaceutical companies and health policy makers. Such interests were reflected neatly in BBC's Today programme which ran interviews with Wakefield and Michael Fitzgerald, who has written a book on the topic.

The Wakefield interview, far from focussing on the ethical issues that were the primary concern of the General Medical Council investigation, focussed on the broader implications of his theory. The tone of the interviewer was antagonistic, and Wakefield was correspondingly defensive, arguing that he was in fact the victim of the government's unwillingness to provide single-dose vaccines, which he believed were less dangerous that the all-in-one MMR. In contrast, the interview of Michael Fitzgerald, who lambasted Wakefield, was broadly sympathetic, focussing little on the fact that he himself has a child with autism and, therefore, did not bring a particularly objective perspective to the debate. Notably, Today failed to describe how the media itself was largely responsible for taking some relatively speculative comments made by Wakefield and his colleagues in an 'Early Report' or preliminary study in the Lancet and transforming them into arguably the most inflammatory medical controversy of the last decade. Understanding the MMR debate, therefore, involves much more than simply turning one physician into a pariah.

The emotive, vindictive, and dichotomised nature of the MMR controversy presents an opportunity for historians to get more involved in informing such debates and providing some context for why they become so divisive. Vaccination and its precursor, inoculation, has long been controversial. Almost as soon as inoculation was introduced to Colonial North America in the eighteenth century as a way to combat smallpox, people argued about the effectiveness, safety, and morality of the practice. While the Puritan minister Cotton Mather spoke out in favour of the procedure, others, such as the physician John Williams, disagreed, stating that inoculation violated the natural laws of medicine. The debates that ensued were imbued with religious argumentation, and ideologies of various kinds were never far from any of the resulting debates. Although vaccination has been seen by public health advocates as being an essential feature of limiting infectious disease, attempts to vaccinate large sectors of the population have often led to resistance and rioting in the United States, South America, and Europe. Public resistance to MMR during the twelve years since Wakefield's infamous article should be seen in this context.

And such controversy is understandable. Vaccination involves exposing healthy people, often children, to attenuated or inactivated (dead) viruses. Before technological improvements helped to standardise vaccines, and developments in immunology helped to explain why vaccines worked, it's not surprising that people were sceptical. Such practices were not always safe or effective; while some might succumb to the virus itself, others might fall ill due to serum sickness, an immunological reaction to the foreign protein. Even today, while some people experience no symptoms after being vaccinated, in other cases people will feel ill following the vaccination. Moreover, not all vaccines, nor vaccination programmes, are created equal. While some campaigns have contributed to some of the most profound medical achievements of the twentieth century, most notably, the eradication of smallpox and the near-eradication of polio, others, such as the debacle surrounding the recent swine flu scare, have exposed just how limited our understanding and approach to infectious disease remains.

The MMR controversy has been too often portrayed as a battle between a renegade clinician and his deluded followers on the one hand, and the public health establishment and the pharmaceutical industry on the other. Historical analysis indicates instead that MMR fits into a long history of vaccination controversies, controversies that say as much about the societies in which they take place as the science on either side of the debate. Parents did not believe Wakefield solely because of his persuasiveness; his research tapped into existing concerns about vaccination, growing mistrust in the medical establishment, increased fear of mental, as opposed to infectious, disease, and ecological arguments about the ongoing sanitisation of our environment. There are many sides to this story, not simply the two commonly presented, and we need to understand this if we are to deal with such controversies more effectively in future.

Please note: Views expressed are those of the author.


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