Piltdown medicine: the missing link between MMR and autism

Introducing Secrets of the MMR scare, a special BMJ series

BMJ online, 5 January 2011

Brian Deer

On 21 November 1953, what is now Britain’s Natural History Museum stunned both science and the public by calling the fraud in the case of “Piltdown Man.” Fragments of fossilized jaw, skull, and tooth, unearthed shortly before World War I from gravel beds, 45 miles south of London, were not, as had been believed, the remains of an aberrant part-human, part-ape “missing link”. They were an elaborate, highly motivated hoax.

Today, the BMJ calls the fraud over medicine’s missing link: the research linking MMR with autism. Published in a five-page Lancet paper in February 1998, it triggered media campaigns which sent vaccination rates plummeting and caused the most intractable health alarm in a generation.

The paper claimed that in two thirds of 12 consecutive child patients with “regressive developmental disorder” and enterocolitis attending one London hospital’s paediatric gastroentreology clinic, the “apparent precipitating event” was a measles, mumps, and rubella vaccine, with a temporal link between shot and symptoms of ≤14 days.

At first, the comparison may feel disconcerting. The Piltdown scandal lay in fossils, while the MMR scare rested on the status of young children. But the parallels are striking. The modus operandi was essentially the same: the dishonest representation of pre-assembled artifacts. The dramatis personae, meanwhile, were similar in their conduct: they contrived, or they were duped, or they failed to act.

READ HOW DEER’S WAKEFIELD
INVESTIGATION WAS CHECKED

This week, the BMJ begins a series which lays bare the MMR scandal in detail never published before. Drawing on interviews, documents, and properly obtained data, collected during seven years of inquiries, we show how one man, former gastroenterology researcher Andrew Wakefield, was able to manufacture the appearance of a purported medical syndrome, whilst not only in receipt of large sums of money, but also scheming businesses that promised him more. His was a fraud, moreover, of more than academic vanity. It unleashed fear, parental guilt, costly government intervention, and outbreaks of infectious disease.

The Piltdown contrivance involved the pre-arranged “discovery” of features brought together to be sensationally “found”. A piece of skullcap was human; a partial jaw was an orangutan’s; and a tooth was a chimpanzee’s, filed down. They were stained with chemicals and, to fabricate a temporal link, were buried with flint tools in a datable gravel bed near the tiny village of Piltdown, East Sussex.

Some would suggest their proximity was chance, but the odds of this would have taxed an astronomer. “That two different individuals were present,” one of the scientists who unmasked the fraud explained later, “a fossil man, represented by a cranium without a jaw, and a fossil ape, represented by a jaw without a cranium, within a few feet of each other and so similar in colour and preservation, would be a coincidence, amazing beyond belief.”

And so it was with Wakefield, eight decades later: amazing beyond belief. For skullcap read “developmental disorders”, for the jaw “enterocolitis”, and for the tooth “parental complaints about MMR”. Bring them together at one London hospital, with a 14-day maximum temporal link, and another assemblage was “found”.

“Onset of behavioural symptoms was associated by the parents with measles, mumps, and rubella vaccination in eight of the 12 children,” declared the Lancet paper’s “findings” section. “In these eight children the average interval from exposure to first behavioural symptoms was 6.3 days (range 1-14),” added a “results” narrative, adopting the “findings” as fact. “Interpretation. We identified associated gastrointestinal disease and developmental regression in a group of previously normal children, which was generally associated in time with possible environmental triggers.”

So how was it done? For a decade this remained hidden in the children’s hospital and general practice records. Only when public uproar over my first Sunday Times MMR reports led to the retraction of the paper’s “interpretation” section in March 2004, and the UK General Medical Council invoked its formidable powers under the 1983 Medical Act, were they brought to light at a fitness to practise hearing. That hearing was the longest ever, running 217 days between July 2007 and May 2010.

Some elements behind the scam were already known, as a result of my continuing investigation. Two years before the paper, Wakefield had been retained by a high street solicitor, hoping to raise a “class action” lawsuit over MMR. The doctor was contracted to be paid at the extraordinary rate of £150 an hour, grossing him £435,643, plus expenses. This was eight times his reported annual salary as a non-clinical researcher at the Royal Free medical school, Hampstead.

I also revealed – years after the paper’s publication – that the children’s parents were seeking compensation. They were mostly clients and contacts of the solicitor, based in Norfolk, and had come to the Royal Free precisely to blame MMR, wanting Wakefield to help their children and their claims. This was not, as the profession and the public had thought, merely a snapshot from a large hospital’s case load. The “finding” of complaints about the vaccine was pre-ordained.

And this was only the start of the fix.

It took the GMC’s lawyers to drill deeper into the material. Who were these 12 families? What was wrong with these children? Why were they admitted to the Royal Free? The answers tumbled out over 197 days of open sessions, focused on Wakefield and his senior colleague, John Walker-Smith. In the end, they were struck off, but only after the laying down of bitter truths, in forensic detail, captured for the public record.

None of the families came from anywhere near London. One had flown in from California. They had been targeted, pre-selected for the children’s symptoms. And when Wakefield’s research failed to show the “new syndrome” he was contracted by the solicitor to find, the results were “reviewed”, changed and misreported in the Lancet – such that in not one of the 12 cases can the Royal Free’s paper be reconciled with National Health Service records.

Scholars still debate the identity of the Piltdown cheat, although most agree it was an amateur fossil hunter, Charles Dawson. In the MMR fraud, it was plainly Wakefield, with no evidence that even the lawyer knew much about what was happening. As reported in my feature this week, Wakefield took clinical records and reinterpreted them to suit himself, chiseling histories and changing clinicans’ diagnoses. He reported unremarkable bowel histology as “non-specific colitis”. And he concealed the source and status of the children.

“In reaching its decision,” the five-member GMC tribunal ruled in January 2010, among dozens of proven findings, “the panel notes that the project reported in the Lancet paper was established with the purpose to investigate a postulated new syndrome and yet the Lancet paper did not describe this fact at all. Because you [Wakefield] drafted and wrote the final version of the paper, and omitted correct information about the purpose of the study or the patient population, the panel is satisfied that your conduct was irresponsible and dishonest.”

This was one of four charges of dishonesty found proven – to an onerous criminal standard of sureness. Another was dishonest misuse of legal aid money obtained by Wakefield to pay for the study. Two more were counts of dishonesty when responding to doctors, including a Medical Research Council panel, who asked the critical questions: what were the sources of his funding and patients?

None of Wakefield’s colleagues knew what was really going on, although some knew enough to be concerned. But it would not be fair to say that he acted alone, or that the scandal was merely due to one man. During the life of the MMR crisis, he was aided or supported by many – who themselves were generally duped. These included clinicians, research scientists, journalists, Lancet editors, hospital and medical school managers, and even the academic institution which eventually fired him.

Again, the anthropological hoax involved a similar story. The findings had rested on the most credible reputations. At a breathless Geological Society meeting at Burlington House, Piccadilly, in December 1912, for instance, it was the distinguished keeper of geology at the British Museum, Arthur Smith Woodward, who vouched for Piltdown Man. In the company of Dawson, he would personally recover fragments of the purported hominid and reputedly coined the popular phrase “missing link”.

In the MMR fraud, the big name to be misled was Walker-Smith, professor of paediatric gastroenterology. Although he slipped off on holiday when Wakefield’s findings were unveiled at a now-notorious press conference at the Royal Free, it was in part his reputation that got them published. “He was an important mentor in my career,” David Candy, professor of paediatric gastroenterology in Chichester, who peer-reviewed the paper, told the GMC panel. “In a way I knew it was going to be a good paper, I knew it was going to be well written, and I knew it was going to be data that could be believed in.”

But Walker-Smith and 11 other co-authors did not even know which child was which in the patient-anonymised text and tables of the paper. In February 2004, as the Lancet moved to head off my investigation – rushing out still-unretracted statements denying what the GMC would later prove – Walker-Smith and fellow co-author Simon Murch had to wait on Wakefield to fax them the children’s names so they could pull the records in order to frame the Lancet’s rebuttals.

And yet the Wakefield fraud had sat in plain view for six years before serious challenge. Journals, the BMJ included, had fretted over epidemiology and viral studies without giving pause to the remarkable, now fully retracted, fundamentals. Did the scientific community ever really believe that 12 families had turned up consecutively at one hospital with no reputation for developmental disorders and make the same highly specific allegations – with a time-link of just days – and there was not something fishy going on?

Piltdown Man offers the salutary lesson. Polite society could not harbour such thoughts. Even as the skullcap, jaw, and tooth were first laid out for public inspection before the Great War’s outbreak, some among the audience were muttering fraud. But they were urged not to rock the establishment’s boat with the implication that a gentleman could not be trusted. “He was a delightful colleague in scientific research,” Woodward said later of the fossil-hunter Dawson.

“We all rely on trust,” Walker-Smith told the GMC panel, in words for which he will be remembered. “I trusted Dr Wakefield.”

Did we all?