I was flicking through a copy of the Daily Mail on Tuesday that someone had left in the coffee room. A Colleague asked me if it was really a good idea to read that just before operating as it’s quite hard to perform surgery when shaking with anger.
It wasn’t actually a problem because the article that I want to talk about didn’t actually make me angry, simply because I can’t take the Mail seriously.
However, I think that might be a mistake. Sadly lots of people do take the Mail seriously – as is evident from the comments section of each article.
The story I want to bring to the Mob’s attention from Tuesday’s Wail is this one: ‘Agony of doctor’s receptionist paralysed by swine flu jab‘ about the Swine flu vaccine. Along with this one from a few months back: ‘MMR and the lessons doctors must learn‘ which I looked up on the website deliberately as I was very curious as to how they would report the Andrew Wakefield story.
The Daily Mail hates vaccines. I can’t quite work out why, but any anti-vaccine nonsense they can pick up anywhere gets an instant story. Which is intriguing as the Irish Daily Mail is campaigning for the Irish government to fund the HPV vaccine.
Swine Flu Vaccine (2/2/10)
A GP receptionist contracted Myasthenia Gravis six weeks after having the H1N1 vaccine and now is quite debilitated by it. So it must be the vaccine that’s the cause and isn’t it awful how she was advised to get it and is now really disabled. (I’m paraphrasing only very slightly).
Increasingly, I am discovering that the media cannot do nuance. Everything has to be black and white. Almost nothing in life is that straight forward and certainly nothing in medicine. The issue of a potential flu pandemic poses a problem for the media. The question the media has been wrestling with since H1N1 became pandemic is this: Is swine flu like any other flu or potentially the end of the world as we know it? The problem for the media is that the only honest answer to that is “both.”
There is nothing special about the H1N1 strain that’s going around the world at the moment. H1N1 isn’t particularly deadly but it is a strain of flu that hasn’t been seen much for around 40 years and that’s the key. Every 40 years or so there is an influenza pandemic across the world. There’s a very good reason for this. The ‘H’ and the ‘N’ names of influenza are the type or strain. There are multiple sub-types but in general, being immune to one subtype of H1N1 would make you immune to any of the other subtypes in that group. Whenever a strain spreads through the population, some people die, some get ill and then get better and some contract it without ever having any symptoms.
All of the people who survive then carry immunity to that strain. Eventually enough people in a population are immune that the epidemic dies out. Each individual who carries a virus will expose other people to it but only some of them will contract it and as the number in a population who are immune to that strain increases, the chances of making that jump from person to person falls and the epidemic slows and then ends. So why do we see these periodic pandemics of influenza? 40 years ago, lots of people were immune to H1N1 – having been exposed to it. As many of that generation die off, the number of immune individuals in the population drops and when it falls below a critical level a pandemic becomes possible.
So how bad can a flu pandemic be? We don’t really know the answer to that question. The Pandemic of 1918-21 was devastating, killing many more people than the First World War. The problem is that you cannot just transpose that onto 2009-2010 and use that as a basis to predict what a pandemic would look like. There are too many unknowns. In 1918 there was a massive refugee population, people were undernourished and unhealthy and there were no antibiotics. (Most influenza deaths are due to secondary bacterial infections). Conversely, the world is much more inter-dependent now with international air travel making it possible for diseases to spread very rapidly across continents.
So, when we saw a pandemic beginning in 2009 in Mexico. The government, very sensibly put orders in with 2 companies to produce vaccines as soon as possible. That vaccine is certainly one of the reasons why there have been so few deaths thus far – although it’s far too early to be complacent. The H1N1 vaccine was tested on over 50,000 volunteers across the world before being rolled out. Even if it hadn’t I would still have had it. There is nothing new in making influenza vaccines, we’ve being doing it for a while now – the technique is the same it just has to be tailored to each individual strain. Most people who get flu have a self-limiting illness. A small number become very ill.
This story is a classic example of the inaccuracy of headlines – even within the article it becomes clear that the headline may not be entirely true. A couple of points to draw your attention to: an unattributed specialist apparently told her the vaccine was responsible for her condition. Her Myasthenia Gravis started six weeks after she had the vaccine. There is no evidence at all in the medical literature linking MG to any influenza vaccine. This is a classic example of the Post hoc ergo propter hoc fallacy. We’ll come back to that.
Human Papilloma Virus
Most cancers are not caused by viruses. Some are. Wouldn’t it be wonderful if we could make a vaccine for the viruses that cause such cancers and hence totally prevent them – rather than just screening for them and then having to do invasive treatments.
Cervical cancer is a devastating disease affecting young women. The new HPV vaccines are a massive step forward and will literally save thousands of lives. The vaccines have been through rigorous safety checks and, as always are carefully monitored as the new vaccine program is rolled out.
A few months ago, the Daily Mail ran this story: ‘The worries over the cervical cancer jab and the questions that must be answered‘. The main argument being that the HPV vaccination is responsible for these devastating effects. Of course there’s no evidence beyond the fact that the symptoms began after the vaccination (post hoc ergo…) but that didn’t stop the Mail from making the link sound undeniable.
However what really angered me was the placing of the photo of Natalie Morton in the article, whose post mortem showed there was no way the vaccine could be responsible for her very sad and very untimely death. Not only is that hugely irresponsible – associating the sad death with the vaccine in such a way that will undoubtedly scare people – but moreover I can think of nothing more insensitive and insulting than to use the death of a child to further a particular cause – especially when the evidence is clear that her case does not in any way support their argument.
MMR and Dr Wakefield
After a very long enquiry, the General Medical Council has finally produced its verdict on Dr Wakefield. Andrew Wakefield was responsible for the massive MMR scare in Britain. Well, actually, Andrew Wakefield was in part responsible for the massive MMR scare in Britain. The Daily Mail is in part responsible. Other news organisations have a measure of culpability too, but no newspaper more than the Mail sought to further the view that MMR is linked to autism. As can be seen from the following articles: ‘Six months after the MMR jab… a bubbly little girl now struggles to speak, walk and feed herself‘. Baby died ten days after being given MMR jab ‘because of failure to warn of possible complications‘. Another study raises questions over MMR‘ and there are many others. Honesty compels me to tell you that not all of the articles were anti-MMR but in many ways that’s beside the point.
Once again the post hoc fallacy (after the event, therefore because of it) – because the autism becomes apparent after the vaccination it must be caused by it.
Let us clear one thing up, there is no link between MMR and autism. I am as certain of that as it is possible to be certain of anything in medicine. If there was indeed, even a small risk, then the rates of autism would have increased when MMR was rolled out. They didn’t. At all.
Much of Dr Wakefield’s ‘success’ was born out of the huge need for parents who see their child ‘becoming’ autistic to find an explanation, a reason, someone or something to blame. This is an entirely normal and healthy part of grief. It is however extremely sick to prey on this need. And that is what Wakefield and The Daily Mail and many others have (whether consciously or not) ceaselessly done. So now that the GMC has finally concluded in an official way how unprofessional Wakefield was, I was very interested to see The Mail reporting of this.
This is what they managed: ‘MMR and the lessons doctors must learn‘. It’s so refreshing to see a newspaper admit its mistakes. To see in print the contrite tone, the sorry we scared you for no good reason. It’s wonderful to see the we got it wrong.
Or sadly not. It’s okay, it’s all the fault of doctors.
Vaccines and informing the public.
Why does this all matter, why have I taken over 1500 words to go through these three inter-related topics? The answer to that is simple; vaccines save lives. Lots of them. In modern medicine, heart transplants and intensive care units grab the headlines. The latest cancer therapy or cardiac medicine is hailed as a massive breakthrough. However none of these come close to vaccines. No single intervention has been more effective, has been responsible for more lives saved than vaccines.
We don’t fear most of these diseases anymore – we’ve forgotten how bad they can be. Talk to people who were parents before the polio vaccine became available – they were terrified when there was a big outbreak because their children could go to bed healthy and wake up paralysed or not even wake up at all. That simply does not happen in Britain anymore because we have eradicated polio in the western world.
Vaccine safety is not a simple issue. No vaccine is 100% safe. Nothing in medicine is. Nothing in life is for that matter. Intriguingly the oral polio vaccine has never been a cause of controversy whilst that was the least safe of mass vaccinations. Not widely known, because it’s not widely reported, all of the cases of polio in the UK in the past 30 years (that weren’t contracted abroad) were caused by the vaccine. This is the main reason for the switch to the injected polio vaccine.
There is this very dangerous perception that not vaccinating yourself or your child is a risk-neutral and a morally neutral choice. It’s not. “I wouldn’t take the risk of having my child vaccinated….” is the phrase you hear. The answer to that is two fold. First and foremost, not vaccinating is not a risk-free choice. In fact, not vaccinating carries more risk than vaccinating – this is the reason why we have vaccine programs.
Vaccination has been a true victim of its own success. Because these diseases are now rare (because of vaccinations) they are not feared anymore. The perception of risk is misguided. People think that these diseases don’t exist anymore. Secondly, the highest cause of death for children over the age of two is road traffic accidents. There hasn’t been a vaccine-related death for at least ten years and yet how many parents stop and think before putting their child in the back of the car. Nor should they, necessarily – you can’t live your life like that. The problem is the perception of risk is massively misplaced.
I am not arguing that parents shouldn’t be able to make informed choices about vaccination. In fact, I’m arguing the exact opposite; it should be informed choice. And I am not for one moment suggesting that the medical profession has not been guilty of not communicating effectively. We have not done enough to get the message across. The introduction of Meningococcal C vaccine has saved lives; from 100 deaths per year of meningitis from the group C bacteria to none. HiB (haemophilus influenza B) saves lives, as does tetanus and diphtheria vaccines.
Some people are not able to have vaccines – children with HIV for example cannot have live vaccines. They can still be protected by being in a population that is vaccinated. So choosing not to have a vaccine, also has an impact on other people.
Sadly, there is a very real consequence to the media coverage of these stories. Thanks to the drop in MMR uptake we have are seeing more and more measles cases. It is entirely true that measles is a mild disease. Most of the time. But children are sometimes left severely disabled by it. And two children have died.
One can never be entirely sure, but it is not remotely unreasonable to assert that those two deaths were due to fear of the vaccine. How about this for a headline: Andrew Wakefield and the Daily Mail linked to the death of two children.
Of course, you couldn’t run that, it‘s true.