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.