But I do not regret publishing the original
Wakefield paper. Progress in medicine depends
on the free expression of new ideas. In
science, it was only this commitment to free
expression that shook free the tight grip of
religion on the way human beings understood
their world. Sometimes the ideas proposed
will be unpalatable. Nobody wanted to believe
the existence of the first few cases of AIDS
in the early 1980s. Nobody wanted to believe
that bovine spongiform encephalopathy (BSE)
would somehow jump species to cause variant
Creutzfeldt-Jakob disease among humans. In
that instance, it was the suppression of
concerns about this possibility that led to
massive public fear and anger when the first
cases were confirmed. Whenever new ideas are
reported, they must be subsequently tested to
check their reproducibility and validity.
Verification is the right test of new
thinking, not censorship. Debate since
publication of the Wakefield paper has
established that his work opened up an
important new field of science - the relation
between the brain and the intestine in the
etiology of autism.
There was also an unpleasant
whiff or arrogance in this whole debate. Can
the public not be trusted with a
controversial hypothesis? Must people be
protected from information judged too
sensitive for their consumption by a
scientific elite? The view that the public
cannot interpret uncertainty indicates an
old-fashioned paternalism at work. But one
could argue that believing in unfettered open
debate, while intellectually credible (that
is, the public is entitled to know as much as
possible), ignores the brutal realities of
the disease. The fall in rates of MMR
vaccination after publication of the
Wakefield paper was striking, In the UK, MMR
vaccine coverage in children over two years
of age was above 90 percent in the
pre-Wakefield era. One year later, rates had
fallen to 87.6 percent, a small but
significant drop. The rate had dropped still
further, to 83.8 percent, by July 2002.
Measles outbreaks occurred in poorly
protected communities. Creating the
conditions for a resurgence of measles is bad
medicine. Or is it? Good medicine, by this
definition, means forcing families to
immunize their children with the MMR vaccine.
Fortunately, we do not yet live in a police
state where public health doctors dictate
what we can do (exercise and eat fruit) and
what we cannot (smoke and eat burgers), even
if their advice is wise and reasonable. If
one of the results of freedom of choice is an
adverse outcome for the public’s health,
that is a regrettable but necessary
consequence of our democracy. The
responsibility rests with public health
experts to educate and to persuade with
understanding and compassion - not to berate
with anger and frustration. And medical
journals are not instruments of the public
healthy service. Medical journals are simply
highly specialized newspapers. We publish
what is new and newsworthy in medicine and we
do our best to publish work that is true. But
only time, sometimes a long time, will tell
if we have chosen well...
I worked at the Royal Free from
1988 to 1990 and met him on many occasions.
He is a committed, engaging, and charismatic
clinician and scientist. He asks big
questions about diseases - what are their
ultimate causes? - and his ambition often
brings quick and impressive results. But his
findings sometimes have limited staying
power, and are overturned or substantially
modified by less iconoclastic colleagues. His
reputation unfairly in tatters, Wakefield
resigned from the Royal Free Hospital,
realizing that he had no future there and
that he would be virtually unemployable in
the work that he wanted to do anywhere else
in the UK. There were rumours, not denied,
that he was put under pressure by university
authorities to leave. His colleagues, once so
eager to pursue their careers on his
coattails, mostly abandoned him...
The MMR vaccine paper was
published not because peer review indicated
that the findings were true - peer review can
never prove truth, only indicate
acceptability to a few experts, as was indeed
the case with Wakefield’s findings - but
because the issue raised was so important for
public health and so in need of urgent
verification that not to publish with
appropriate caveats would, in my view, have
been an outrageous act of censorship.
Richard Horton, Second
Opinion, Granta Books, 2003