“I have a higher and grander standard of principle than George Washington. He could not lie; I can, but I won’t.” (Mark Twain – 1835-1910)
It is with some dismay that I have watched the news reports concerning the re-emergence of measles, a viral illness within the paramyxovirus family that is highly contagious via casual contact or the air. Measles remains one of the leading causes of death among young children (145,700 people died from measles in 2013.)1 despite that an effective vaccine for the disease has been available since the 1970’s. Prior to the availability of routine vaccinations for measles, about 2.6 million deaths were attributed to the virus. Because of routine mass vaccination in the United States (the MMR — measles, mumps, rubella shot on your immunization record) for the past 50 years, many physicians, myself included, have never seen an actual case of measles.
Dr. John Franklin Enders is likely most responsible for the development of a working measles vaccine during the 1960s. The effectiveness of the measles vaccination is an empirical fact with decades of few measles outbreaks and countless families spared the emotional devastation of the loss of a child in the United States. This all comes at the bargain basement price of approximately $1 per dose of the vaccine. This is truly a public health win of epic proportion for the American public.
Like many vaccination programs, the effectiveness of the vaccine depends on “community immunity” (sometimes referred to as herd immunity). Put simply, the more individuals who are healthy and immunized within a population, the less chance for the disease to take hold and spread within that population. Those who, for various reasons, cannot be vaccinated — such as immunocompromised people, pregnant women and infants — receive protection from the large number of vaccinated people in the community. Obviously, for vaccination programs to be successful, a certain amount of collective public responsibility is needed to ensure that a large majority of community members are vaccinated in order to obtain the community immunity benefit that protects from outbreaks of this deadly disease and to avoid the community disruption that ensues from outbreaks.
Anything we do in medicine carries some amount of risk, and vaccination is no exception. Few patients have any problems with the vaccination itself, but for those who do have problems, the issues are usually mild, and the rare, serious problems (pneumonia, bowel inflammation, blood in the urine or stool, as examples) often are difficult to link directly to the vaccination. Compared to many other things we do to patients as providers in the name of “better health,” the risk/benefit ratio of vaccines is truly laudable. So why is this, for all intents and purposes, eradicated disease back on the public stage? Enter the villain of this editorial, Dr. (I am using the broadest definition here) Andrew Jeremy Wakefield, a former British surgeon and medical researcher.
In 1998, Dr. Wakefield wrote a paper for The Lancet, along with a number of co-authors, that reported on 12 children with sudden onset inflammatory bowel disease or autism or both, which many of the parents associated with the recent MMR vaccination the children had received. Although the paper in question never actually made this link, Dr. Wakefield suggested the issue deserved further scrutiny. In short, Dr. Wakefield had a hypothesis concerning a correlation between vaccinations and autism. At this point, it was fine to raise the question if the paper had been factual (which it was not), since many medical breakthroughs occur as unexpected findings during routine exploratory research with small sample sizes. In fact, good research usually results in far more new questions than answers. As a medical scientist, Dr. Wakefield was honor bound to follow the scientific method and test this hypothesis through experimentation and empirical observation before releasing his findings to the general public as medical fact. Instead, armed with no real scientific evidence, he launched a public campaign besmirching the MMR vaccine that has since terrified many parents and allowed measles to regain a foothold in the United States, along with the human suffering and death that is a product of this disease.
Subsequent research into this issue by many different research teams has failed to find any link between the MMR vaccine and autism.2 It is OK to be wrong as a scientist. The dustbin of history is replete with examples of scientific theories and hypotheses that have been destroyed by application of the scientific method. It is not OK to use one’s position as a physician and scientist to sow fear in the public, desperate to avoid the emotional isolation of autism in a family member, to further one’s opinion and despite all the available evidence to the contrary. What could possibly motivate a physician to continue to make this claim, when the science does not support his position?
Sadly, this is where the story really gets nasty. An investigative journalist, Brian Deer, looked into the Wakefield controversy in 2004 and discovered a financial relationship between Wakefield and lawyer Richard Barr, who was interested in developing class action lawsuits against manufacturers of the MMR vaccine. It was later discovered that Dr. Wakefield had received about $750,000 from Barr and was involved in developing a measles vaccine alternative to MMR. An investigation by the UK Legal Services Commission found that Dr. Wakefield had an obvious but undeclared financial interest in his research claims.3 The Lancet, after re-reviewing Dr. Wakefield’s original paper, found numerous flaws and fabrications in the data and retracted the paper.
Unfortunately, the damage had been done and large communities of misinformed parents have since failed to vaccinate their children, to the detriment of all.
As federal medicine providers, we have a “higher and grander standard” and responsibility to keep abreast of and provide the best medical evidence available. We are expected to, and we must, place our patient’s self-interest before our own. It is hard to overemphasize the damage Dr. Wakefield has done to the public’s faith in the practice of immunization and the incalculable harm he has caused the public through his baseless crusade against MMR vaccinations. To quote a friend and mentor, LTG (ret) Eric Schoomaker, “Our insistence upon evidence in our work obtained ethically, without even the appearance of a conflict of interest, must be unimpeachable.”
1http://www.who.int/mediacentre/factsheets/fs286/en/ accessed 25 February 2015.
2http://www.immunize.org/catg.d/p4026.pdf accessed 26 February 2015.
3http://www.briandeer.com/mmr/lancet-summary.htm accessed 26 February 2015.