MMR vaccine debate: Ben Goldacre vs. Melanie Phillip
Article by Ben Goldacre 2nd November, 2005 attacking Melanie Phillips' stance on MMR
(Letters to the Guardian)
Dangerous assumptions over MMR vaccine
Monday November 7, 2005
The latest victim of Ben Goldacre's diatribes is Melanie Phillips of the Daily Mail (The MMR sceptic who just doesn't understand science, November 2). Though many recipients of Goldacre's vitriol are deserving of his scorn, Melanie Phillips is not one of them. She, rightly, criticises the majority of her fellow journalists for writing a story based on a spun press release rather than a critical reading of the review paper itself.
The Cochrane collaboration report in question sets out its stall by asserting "measles, mumps and rubella are three very dangerous diseases". They are not. Measles has the potential to be serious, but to even suggest that mumps falls into the "very dangerous" category is laughable. As for safety, the closest the paper got to declaring the MMR vaccine safe was to state "exposure to MMR was unlikely to be associated with Crohn's disease, ulcerative colitis, autism ... " The report was highly critical of the safety trials on the MMR and commented on the "limited observation periods" of the studies which followed up children for no more than three weeks, apart from a single piece of research which extended to six weeks; this is totally inadequate to detect possible uncommon side-effects, such as autism.
Most of the studies claimed by the government to demonstrate the safety of the MMR were criticised as being of poor methodology. Conclusions of the full report included: "We found only limited evidence of safety of the MMR compared to [single vaccines]" and "we could not find studies assessing the effectiveness of the MMR that fulfilled our inclusion criteria".
Goldacre extols the ability of epidemiological studies to "detect a small increase in a given condition". Maybe, but only if they test the correct hypothesis, namely that the MMR vaccine triggers autism and bowel disease in a small subgroup of susceptible children. That requires a study with sufficient power to detect this possibility, something none of studies reviewed in the report has. Remarkably, the paper concluded that the safety studies into MMR were so poor that "the safety record of MMR is probably best attested by almost universal use". In other words, because the vaccine is so widely used it must be safe - a dangerous and decidedly unscientific assumption. The safety of the MMR vaccine remains on trial.
Dr Richard Halvorsen
The Holborn Medical Centre
Ben Goldacre has been prominent in attacking those who have raised questions over the MMR vaccine, implying that such questions are scare stories. However, there are legitimate questions about the MMR vaccine that are not being raised.
First of all, there were three brands of the vaccine introduced in the UK in 1988. Two of those were withdrawn from use in September 1992. At the time the government announced that this was merely a "change in supply", although subsequently the government has admitted that these vaccines were causing, in some instances, encephalitis - a serious brain condition. There were many children affected by this and this problem should be accepted and recognised.
Second, I note that it has been reported that the government says the vaccine is "perfectly safe". Many people might assume "perfectly safe" to mean that the vaccine is not capable of causing serious injury. However, in the leaflet I was given which came with the MMR vaccine given to my son, the manufacturers state that it is capable of causing meningitis/encephalitis; profound deafness; chronic arthritis; gradual mental deterioration; Guillam Barre Syndrome; idiopathic thrombocytopenic purpura; sub-acute sclerosing panencephalitis; fits/epilepsy. How can a product capable of causing such conditions be stated to be "perfectly safe"?
Lastly, it is commonly thought that the MMR vaccine litigation had legal aid funding withdrawn. However, although funding was withdrawn for autism/bowel inflammation cases, funding was restored for some claimants with some of the conditions mentioned above. Three of the clients that my legal firm continue to represent suffer from severe intractable epilepsy and brain damage which began within seven days of vaccination with MMR. One suffers from profound bilateral deafness. I would hope the great vaccine debate will eventually lead to an enlightened understanding that vaccination can, in rare cases, cause serious injury. To describe it therefore as "perfectly safe" is being somewhat economic with the truth. On a risk/benefit analysis, the evidence points strongly towards vaccination. However, those unfortunate enough to suffer serious injury at a very young age deserve support and decent compensation.
Hodge Jones & Allen
Ben Goldacre is right to say there are no certainties in science. Yet authority after authority has been quick to conclude the MMR is safe and not linked to autism and bowel disease. Authors and reviewers of epidemiological papers have claimed repeatedly that their scientific findings are conclusive. The government declares the issue closed and refuses to finance replication studies to settle whether or not the measles virus is found in the bodies of autistic children but rarely in controls. Instead, it relies, as does Goldacre, on the spurious power of numbers to suggest that the population-wide studies are far more capable of detecting pathological abnormalities in a population than a clinical study of 12 children, such as Wakefield's 1998 "early report" in the Lancet - let alone his subsequent studies of larger groups of children in peer-reviewed journals Goldacre doesn't mention. Doubt about MMR safety will continue for as long as research funding supports epidemiological and not clinical research.
Dr Martin Hewitt
Melanie Phillips Response
The case against me boils down to smear and evasion
Scrutiny of evidence on the MMR vaccine is being stifled by the government and a reckless medical establishment
Tuesday November 8, 2005
At the heart of the MMR vaccine controversy is an attempt to blind people with science. Proponents of the vaccine say science has proved it is safe and that those who deny this are scientifically illiterate. This argument has been used to tell parents that the evidence of their own eyes is not true. While the vast majority of children have had no problem with the MMR vaccine, a small proportion of parents found that after vaccination their children developed bowel problems, an allergic reaction to various foods, and a halt to their behavioural development that produced the symptoms of autism.
Their concerns were dismissed by the medical profession. One doctor who did take them seriously was a gastroenterologist, Andrew Wakefield. In a Lancet paper he said the children were suffering from a new disease, autistic enterocolitis; at a press conference he suggested that to be safe children should have single jabs instead of the triple MMR.
Since then the government has pointed to a succession of epidemiological studies that, it says, prove that MMR is safe. A recent meta-study by the Cochrane Library was likewise reported to have said that fears about the vaccine were based on "unreliable evidence".
But the study itself did not say this. On the contrary, it found that nine of the most prominent epidemiology studies that are employed to attack Wakefield's research were unreliable. Since it did not look at Wakefield's research, it did not address the questions raised over the vaccine in the first place. The report therefore could not bear the conclusion attributed to it that MMR was safe.
When I pointed this out in the Daily Mail last week, I was attacked in these pages by Dr Ben Goldacre, who said I did not understand how science worked. On the contrary, it is Goldacre who is ignoring the evidence, and his errors go to the essence of the MMR controversy.
Like the government, Goldacre believes clinical findings are trumped by epidemiology, which he says is "evidence-based" medicine. But the attempt to refute Wakefield by epidemiology is a category confusion. Epidemiology looks at patterns of disease in a population. It cannot prove or disprove cause and effect in individual patients.
A paper published in the Journal of American Physicians and Surgeons says epidemiology "cannot establish a causal association unless other biological evidence backs it up", and does not meet a scientific standard of proof since it is prone to bias - the very criticism that the Cochrane report made of the epidemiological studies of MMR and autism.
Having accused me of misunderstanding "real" science, Goldacre then claims that I have fallen for pseudoscience by believing evidence that has never been peer-reviewed. Bizarrely, he asserts that I have relied upon research that has been published only in the "in-house magazine of a rightwing US pressure group well known for polemics on homosexuality, abortion and vaccines".
What on earth is he talking about? The devastating finding of measles virus in the cerebro-spinal fluid of some autistic children who had been given the MMR vaccine has been peer-reviewed in the Journal of American Physicians and Surgeons.
He claims that Wakefield's term "autistic enterocolitis" has appeared in no other studies that have endorsed it. But Wakefield's core finding of a unique gut-brain disease has been replicated in peer-reviewed papers in the Journal of Paediatric Neurology, Neuropsychobiology, the Journal of Paediatrics, the Journal of Clinical Immunology and the American Journal of Gastroenterology.
So what is this sinister "rightwing" organisation upon which I am supposed to have relied? Alas, Goldacre does not tell us. So let us guess. Might it be, perhaps, the Association of American Physicians and Surgeons, which published the evidence of measles virus in cerebro-spinal fluid? Or might it be the American Institute of Medicine, which said that any evidence that symptoms worsen after booster jabs (as has been claimed with MMR) was real evidence of a link between a vaccine and a disorder?
Goldacre's case boils down to evasiveness, ignorance, misrepresentation and smear. Are these really the attributes of a scientific vocabulary? Is this really "evidence-based medicine"? Of course, it is important to vaccinate children against dangerous diseases. But if even a small subsection of children is badly affected - which is all that is being claimed over MMR - the balance of risk dramatically changes.
The government and the medical establishment deny the evidence of any such effect. They claim that science has shown there is no case to answer. But it depends on which type of science, and whether it is being used appropriately. The fact is that scientists are making progress in deciphering the mysterious relationship, which Wakefield first identified, between a new type of bowel disease and brain disorder. The connection between this relationship and the MMR vaccine is far from proven. But legitimate scrutiny of the real questions that have been raised are being stifled by the government and a medical establishment that have behaved recklessly and spinelessly, and are busy suppressing all attempts to hold this up to the light.
Melanie Phillips is a Daily Mail columnist
http://www.melaniephillips.com/diary/archives/001477.html November 08, 2005
The MMR controversy, yet again.
Readers may have noted a novel development on my Articles page - a piece by me which was published today in the Guardian. This was a riposte to an article last week attacking me by Dr Ben Goldacre, which you can read here, following the column I wrote on the MMR controversy in last week's Daily Mail.
I have received a huge amount of support for both my articles - along with three like-minded letters printed in the Guardian yesterday. Following today's piece, however, I have received a number of notable emails - notable, that is, for their extreme condescension and vitriol on the basis that I, as a mere non-scientist, not only never knew what I was talking about in the first place but have had the damned cheek to show up a professed scientist for his ignorance and bias. Not that they say that, of course - I've apparently merely exposed my own ignorance even more thoroughly.
So what do these scientists say that shows their superior grasp of evidence and commitment to scientific inquiry? Here's a distinguished opinion from a biochemist:
You ARE a moron & an irresponsible hack. That is why you write for the Daily Jackboot. Do fuck off why doncha.
Slightly more temperately - if no less unscientifically - some correspondents claim that I have relied for most of my information on the Journal of Physicians and Surgeons, described by one as 'a bunch of screaming fascists' and which is not even listed by PubMed, the international directory of peer-reviewed medical publications. This, they say, underlines the fact that I cannot tell bad science from the real thing.
Not so fast. First, this totally ignores the various research papers* -- which have been published in a range of distinguished journals -- to which I referred in my article, along with the American Institute of Medicine, also all but totally ignored. In fact, I was entirely unaware of the existence of the Journal of Physicians and Surgeons until I wrote the Guardian article. Moreover, I have written extensively about MMR in the past, have read most of the literature and interviewed a large number of parents of affected children as well as government officials - which, I wager, is more than my Ph.D-laden correspondents, whose idea of 'research' appears to be a quick trawl through Google.
Because of such lazy web-surfing, they appear to be unaware that this Journal is a new publication dating from 2003, when it replaced the American Association of Physicians and Surgeons' 'Medical Sentinel'. At this point, it changed its whole approach to something that appears to be much more rigorous. As a result, it is indeed being listed in PubMed later this year. PubMed requires a year's articles before it will consider listing a publication, and only meets once in a blue moon to consider them. So it's a slow process. The Journal says its papers are peer reviewed in the normal way by acknowledged experts. PubMed's imprimatur would appear to confirm this.
Above all, surely what matters is the quality of the science in these papers. No-one has shown there is anything wrong with the paper by Bradstreet et al showing the presence of measles virus in cerebro-spinal fluid. Ignoring the science while mounting what appears to be a smear
campaign against the journal in which it is published seems to me to be a less than scientific approach -- compounded in several of these messages by virulent prejudice.
Next, I am accused of believing that epidemiology establishes proof when all it can do is estimate probability. Oh dear: another major point missed. It is not I who claim epidemiological proof but the government and others who claim that the epidemiology 'proves' MMR is safe. I'm the person saying there is no proof, remember?
Next, I'm told epidemiology can and does prove causal associations. Maybe so. I didn't say it couldn't or didn't. What I said was that it could not disprove the clinical findings from a group of patients. Can't these guys even read?
Next, I'm told (again) that I don't understand that epidemiology is perfectly capable of disproving the Wakefield thesis. One correspondent wrote:
'I can think of no scientist or doctor in my wide circle of colleagues in Oxford, Cambridge, London and Boston who would disagree with the main points of his [Goldacre's] article.'
Oh dear oh dear. My observations are based on what I have been told by a wide variety of doctors and scientists, who tell me the limitations of epidemiology that I have highlighted are as accurate as they are elementary. Let me spell it out again for those who have difficulty understanding. In order even to begin to test Wakefield's thesis with a degree of credibility, any such study would have to specifically test whether MMR had affected a small sub-set of vaccinated children. No epidemiological study has done this. They have therefore tested something which Wakefield never alleged. One does not have to be a rocket scientist - or indeed any kind of scientist - to spot this most elementary of flaws.
All those who so kindly suggested that I did not know my epidemiology from my elbow might also care to reflect on this, from the American Institute of Medicine's report on the MMR controversy:
The evidence favours rejection of a causal relationship at the population level between MMR vaccine and ASDs [Autism Spectrum Disorder]. However, the committee notes that its conclusion does not exclude the possibility that MMR vaccine could contribute to ASD in a small number of children because the epidemiological evidence lacks the precision to assess rare occurrences of a response to MMR vaccine leading to ASD and the proposed biological models linking MMR vaccine to ASD, although far from established, are nevertheless not disproved.
The IoM recommended the issue should receive 'continued attention' -- which it never has, except from those who wish to bury it.
What price the future of science, when so many of today's alleged practitioners appear not to understand the difference between fact and
*Some papers endorsing or replicating the Wakefield research:
1) Evaluation of an association between gastrointestinal symptoms and cytokine production against common dietary proteins in children with autism spectrum disorders; Harumi Jyonouchi MD, Lee Geng PhD, Agnes Ruby BS, Chitra Reddy MD and Barbie Zimmerman-Bier, MD
Journal of Pediatrics, May 2005, p 610
2) Dysregulated Innate Immune Responses in Young Children with Autism Spectrum Disorders: Their Relationship to Gastrointestinal Symptoms and Dietary Intervention; Harumi Jyonouchi Lee Geng Agnes Ruby Barbie Zimmerman-Bier Department of
Pediatrics, New Jersey Medical School, UMDNJ, Newark, N.J. , USA
3) Some aspects about the clinical and pathogenetic characteristics of the presumed persistent measles infections: SSPE and MINE;
Paul Richard Dyken, Institute for Research in Childhood Neurodegenerative Diseases, Mobile, Alabama, U.S.A.
Journal of Pediatric Neurology 2004; 2(3): 121-124
4) Spontaneous Mucosal Lymphocyte Cytokine Profiles in Children
with Autism and Gastrointestinal Symptoms: Mucosal Immune
Activation and Reduced Counter Regulatory Interleukin-10
Paul Ashwood, Andrew Anthony, Franco Torrente and Andrew Wakefield
Journal of Clinical Immunology, Vol. 24, No. 6, November 2004 ( C_ 2004)
5) Panenteric IBD-Like Disease in a Patient with Regressive Autism Shown for the First Time by the Wireless Capsule Enteroscopy: Another Piece in the Jigsaw of this Gut-Brain Syndrome?
Federico Balzola , Valeria Barbon , Alessandro Repici , Mario Rizzetto , Daniela Clauser , Marina Gandione , Anna Sapino.
American Journal of Gastroenterology, April 2005
6) Gastrointestinal abnormalities in children with
autistic disorder Karoly Horvath, MD, PhD, John C. Papadimitriou, MD, PhD, Anna Rabsztyn, Cinthia Drachenberg, MD.
Journal of Pediatrics, Vol 125, no 5
7) Autistic disorder and gastrointestinal disease
Karoly Horvath, MD, PhD, and Jay A. Perman, MD
Pediatrics 2002, 14:583-587
Posted by Melanie at November 8, 2005
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