While many doctors have held unrealistic expectations of antibiotics, we have all perhaps cherished unrealistic expectations of what hospitals can do. The idea of public health was born when hospitals were ‘little more than warehouses for the dying’, according to Garrett.6 During the third quarter of the twentieth century, they became rather more than that, but this period currently appears to us more like a brief interlude than the latest stage of an upward progress. In terms of infectious disease, hospitals may be reverting to type.
The reasons advanced for this reflect the range of political prejudices about how health services should be run. The transfer of power from the public health authorities to the medical profession in the United States and the reorganization of public hospitals as trusts in Britain are among the suggested factors. The introduction of privatized services, including cleaning, coincides unfortunately with the rise of resistant bacteria. Hospital mergers and centralization may also play a role, since larger hospitals tend to have disproportionate levels of MRSA, while closures facilitate the spread of superbugs as workers relocate.
A full hospital that turns beds over rapidly presumably restores more people to health than a half-empty one. But high occupancy rates are also thought to help the spread of MRSA. ‘Headlines about patients dying while waiting to go to a hospital have given way to reports of patients dying simply by staying in one,’ as one newspaper tartly put it. An occupancy rate of 82 per cent was cited as a maximum by the Department of Health: ‘If occupancy is at 95 per cent, then no amount of handwashing will stop infections.’
MRSA levels are high in the United States and Britain, comparable with France, but twice the level in Germany or Spain. The situation in all these countries has been compared unfavourably with that in the Netherlands and Denmark, where MRSA infection is extremely low. However, some countries have little MRSA but more of other hospital-associated infections, and it is not clear that anybody has a complete answer. Dutch hospitals operate a praised ‘search and destroy’ policy whereby patients are screened for MRSA on admittance and placed in isolation wards if necessary. But in Britain this has seemed to be ruled out. Avoiding any mention of isolation wards, the website of the Health Protection Agency at one time invited readers to assume that screening would simply lead to people being excluded from hospital altogether.7 The advice has changed following a policy U-turn in 2007.
The British government’s response to the MRSA crisis has instead been to promote hand-washing, reintroduce matrons to hospital wards and – inevitably – set targets. This last measure has been criticized as crude as it simply records the percentage rise or fall in MRSA. This can penalize hospitals that have cut their infection rates to low levels only to find that an ‘unlucky’ outbreak sends the figure soaring. In one hospital an admirably low two cases in one month was followed by a still low seven cases the next, due mainly to an influx of new patients. The 250 per cent increase meant that the hospital failed to meet its target.
It is tempting to seek parallels for the MRSA phenomenon in previous scares to do with bacteria, such as salmonella and listeria in food, as well as diseases such as BSE in beef cattle or the threat of avian flu, and a generalized fear of invisible germs. But this is to neglect the hospital connection that is so much a feature of the media coverage. Consider instead that the fear of hospital-associated infection may mask a deeper fear – that of having to go to hospital at all. The dread of surgery in particular, though seldom discussed, ranks among the highest public fears, according to Paul Slovic’s The Perception of Risk.8
Another distinctive factor in the MRSA story is that at least part of the solution to the crisis is widely thought to lie with improved hospital hygiene. Unlike the transmission and treatment of infectious diseases, this is a topic on which everybody has an opinion. We see with our own eyes that many hospitals are filthy. The issue of cleanliness which emerged as MRSA infections climbed in the late 1990s gave the media and the public a campaigning focus of both practical and metaphorical value. Hospitals needed to be cleaner, but the way they were run could use a ‘clean-up’ as well.
The Labour government responded by rolling out a ‘Clean your hands’ campaign across the nation’s hospitals in 2004 – with modest results. The Conservatives fought the election the following year using a number of ingenuous Joe Public remarks linked by the refrain: ‘Are you thinking what we’re thinking?’ One of these was: ‘I mean, how hard is it to keep a hospital clean?’ The only mildly counter-intuitive answer is, of course, that it is pretty hard and, in terms of microbial contamination, harder than many other places.
The obsessive focus on hygiene by the media, and subsequently by politicians with an eye for cheap measures that might make a visible difference, has disguised the fact that the other part of the solution to bacterial resistance must be the creation of more effective antibiotics. For all the use of words such as ‘doomsday’ and ‘apocalypse’, there is no destined biological end point where all bacteria become resistant to all antibiotics. Instead, we need to develop new antibiotics to keep pace with the emergence of new resistant strains and at the same time remain disciplined in prescribing them only in specific circumstances so as not to spur the emergence of resistance. Sadly, this means letting go of the notion that the antibiotics of the last century are everlasting miracle cures and adjusting to the fact that bacteria adapt and change.
It’s amazing what they can do. The bugs, that is.
Completing the Course
‘Jab damaged our children, say 2,000’ Daily Mail
The triple vaccine for measles, mumps and rubella (MMR) was the basis for one of the biggest recent scare stories in the United Kingdom. The story blew up not when the vaccine was introduced in 1988, but ten years later, when a doctor at the Royal Free Hospital in London published a paper that appeared to link the vaccine to autism and bowel disease.
The MMR vaccine was designed to protect against three viral diseases of which older readers may have direct memories. Measles is a highly contagious disease characterized by an itchy rash. In developed countries, the mortality rate is one in 3,000, but it can be as much as one in ten where malnutrition is rife. In 2001, according to figures from the World Health Organization, measles claimed 745,000 lives among unvaccinated populations worldwide. Mumps produces glandular swelling and is generally less serious, but both mumps and measles can produce life-threatening complications. The principal risk from rubella is to women in early pregnancy whose babies may be born with birth defects.
These diseases have been virtually eradicated in the West since the introduction of vaccines in the 1960s and 1970s. However, a large proportion of the population must be vaccinated in order for society as a whole to be protected. For measles vaccine, the coverage required for the population as a whole to be safe from an epidemic (to reach what is called herd immunity) is 90 per cent or more because the disease is so contagious. Measles remains a major killer in developing countries simply because the vaccine doesn’t reach enough people. Because it is hard to achieve the necessary coverage, and because not all vaccine doses are effective, immunization programmes frequently recommend a second dose, which greatly reduces the chances that a given person does not have at least some protection.
The measles-only vaccine introduced into the UK in 1970 reduced annual deaths from a hundred or so to an average of twenty. In 1988, just before the introduction of the MMR vaccine, there were 86,001 notified measles cases and sixteen deaths. From 1989 to 1997, MMR coverage then reached more than 90 per cent and measles deaths fell to two a year.1
What happened next was to derail the juggernaut of medical progress towards the eradication of measles in Britain and beyond. In February 1998, Dr Andrew Wakefield, a gastroenterologist at the Royal Free Hospital, published results of tests on twelve children with both intestinal inflammation and developmental disorders including autism. The paper mentioned work by others (and previous work by Wakefield on the measles-only vaccine) in which the viruses and/or t
heir vaccines were ‘associated’ with or ‘implicated as risk factors’ for autism; it left similar doubt hanging in the air over the MMR vaccine. ‘We did not prove an association between measles, mumps and rubella vaccine and the syndrome described,’ the authors wrote in the Lancet.2
Not only did Wakefield not prove an association, he did not produce any evidence to support one. Wakefield simply wrote: ‘Onset of behavioural symptoms was associated, by the parents, with measles, mumps and rubella vaccination’ (italics added). That was all. There the story surely would have died a death but for the fact that at a press conference Wakefield then pursued this idea of a link and suggested that parents might wish to have their children put through three courses of separate vaccinations rather than undergo the triple vaccine.
The story hit the headlines immediately, but grew only slowly in ferocity for reasons largely unrelated to the quality of the original science. ‘Measles vaccine’s link with autism studied’ was the anodyne way that The Times put it as the Lancet came out. Two months later new work appeared to refute Wakefield, and another paper countered: ‘MMR study dismisses fears as groundless.’ At this point, the Daily Mail got the scent of a David-and-Goliath battle between put-upon consumers and medical authority. ‘Vaccine experts clash again’, reported its sister paper, the Mail on Sunday, noting that the row ‘is set to intensify’.
Through the rest of 1998, worried parents sought single vaccinations against the three diseases, or vaccination solely against measles. Supplies of single vaccines ran out in less than a fortnight while the government insisted that people rely on the combined vaccine. The Daily Mail took up aggrieved parents’ cause, championing their attempt to win the right to choice in court: ‘Parents shun MMR jab over health fears’; ‘Jab damaged our children, say 2,000’; ‘Parents’ fear as the single measles jab is withdrawn. Drug company denies giving in to government pressure.’
The scare was unusually effective for a number of reasons: the public trusts what doctors say, but does not like being told what to do by governments; parents seek their children’s safety and well-being; people naturally fear immunization; and autism was apparently on the increase. The numbers of people identified with autism had begun to rise in the 1970s in the United States and in the 1980s in Britain, largely coincident with the respective dates of introduction of the MMR vaccine. Autism was doubling every five years, partly because of better diagnosis and more inclusive definitions of the condition, but partly, it seemed, because of unidentified, possibly environmental, factors. Identifying links with other conditions might help scientists understand the causes of autism, and it was understandable that people should light upon one potential link where it was easy to lay the blame.
The immediate consequence of the press campaign was a fall in immunization levels. Coverage fell from 91 per cent of two-year-olds in 1998 to 88 per cent the following year. It continued to decline steadily, reaching 80 per cent in England and Wales by 2004, and much less in some areas. No evidence has been presented to support Wakefield’s theory, while many large studies, including one in the Lancet as early as 1999, could find no link. These culminated in a review of thirty-one studies, each involving hundreds, and in one case half a million, subjects, by an international team for the Cochrane Library, an organization set up to evaluate medical research.3 This received a fraction of the coverage of Wakefield’s study of twelve children, although the Sun put it in plain English under the headline ‘MMR in clear’: ‘The Cochrane Review analysed 31 studies from around the world and said there was NO evidence to back up the fears.’4
As evidence grew refuting Wakefield’s claim, Wakefield himself was accused of having been paid £55,000 by lawyers for the families who had brought their children to him, an interest he had not declared to the Lancet. Most of his co-authors publicly dissociated themselves from him. But the Daily Mail still backed him. ‘MMR safe? Baloney. This is one scandal that’s getting worse,’ opined Melanie Phillips in a typically strident column.
Catching Phillips out on science is like drowning rats, but somebody has to do it. So, here goes (and you can repeat this check for yourself). Phillips writes that Wakefield’s discovery of autistic enterocolitis, the condition supposed to explain the link between MMR, autism and bowel disease, ‘as a completely new syndrome has now been replicated in studies around the world’. Let’s see. The simple expedient of a search on Google Scholar, the academic search engine, produces forty-one hits where enough access to the scientific papers is granted in order to be able to take a view. Six references take a pro-Wakefield line, Wakefield himself is an author of eleven more, but twenty-four papers dismiss his result. Hardly ringing confirmation.
Parents with children of immunizable age could be excused for being muddled about all this. In any case their stories seldom fit into neat clinical slots. So in order to imagine their predicament it may help to consider some examples. (The stories are true, although some details have been changed.)
It’s 1999. William, a bookie, has his first addition to the family. He remembers having measles as a child and figures it didn’t kill him. He is a little worried by what he has read about the MMR vaccine, but notes that MMR coverage is holding up and reckons his child will be safest of all unimmunized but reliant on herd immunity.
2001. Fiona, a florist, has a two-year-old son beginning to show signs of a developmental disorder. The boy had his first MMR shot a year ago, but now she must consider whether his young sister should have her first shot in a few months’ time. The boy’s disorder may be genetic, but there again, perhaps the MMR was responsible. She decides the girl should have the vaccines singly in a private clinic. As the doctor gives the jab, he vouchsafes that, by the way, his children had the combined vaccine, and he thinks it’s safe.
2002. Juliet, a busy actor, has a daughter who had the MMR jab and now must decide whether to do the same with her eighteen-month-old son. She remembers reading an article a couple of years ago in Private Eye recounting the conviction of a parent of a child who had developed autism that it was the MMR vaccine that must have caused it. Her ‘blind faith’ in medicine is rocked. ‘I had learned how vigilant you have to be as a parent because you are responsible for this little life.’ She books her boy in to a private clinic to have the three vaccines separately: first measles, then rubella and finally mumps.
How did these children fare? Fiona’s daughter is protected against measles and turns out not to develop her sibling’s disorder. William realizes that protection against contagion is actually frighteningly low where he lives – against Department of Health advice, people are holding ‘measles parties’ so that their unprotected children might get the disease over with. He belatedly puts his child in for the MMR jab. Fortunately, the child has not caught measles in the interim. Juliet (who is in fact the actor Juliet Stevenson) duly takes her son to a crowded, disorganized clinic for the measles and rubella shots. By the time that she is free of work commitments and can think about the final shot for mumps, she calls the clinic only to find that it has closed some months ago. The doctor who ran it has been arrested and charged with forging the results of blood tests. An independent test shows that Juliet’s son actually has no protection against measles. ‘Now I don’t know what to do. Do I get him single measles again, or forget the whole thing?’ she wonders aloud to the Mail on Sunday while promoting her role in a cathartic drama about the dangers of MMR.
As the example of mothers like Juliet Stevenson shows, the relative safety of a vaccine shown by statistical evidence is not always persuasive. Vaccination allows a pollutant to enter the body and so breaks a deep taboo. Vaccines do not work in all cases and produce adverse reactions in some. For these reasons people have feared vaccination since its invention – an occasion commemorated in a lurid caricature published in 1802 by James Gillray showing people receiving Edward Jenner’s smallpox vaccine erupting in bovine buboes.
This timeless fear is overlaid by characteristically modern concerns that seem bound t
o surface afresh with each new vaccine introduction. ‘Vaccines come under greatest scrutiny when they are successful,’ as one doctor pointed out in the Guardian at the height of the single vaccine rush. When they are the only alternative to a nasty disease, they are uncritically accepted. But today we – including many of our doctors – have forgotten what it is like to suffer, or witness suffering, from many of the diseases that we now immunize against. Smallpox was the biggest killer disease in the West during the eighteenth century, tuberculosis in the nineteenth, both eradicated by vaccination.
Without unpleasant reminders of what vaccines are for, we have the luxury of speculating about side-effects and links to other disorders. Combined vaccines – which are likely to become more of a feature of immunization in the future – mean fewer jabs, but excite fears of chemical ‘cocktails’ and overloading of children’s immune systems. As Stevenson told her interviewer, ‘There are hundreds if not thousands of parents in this country who deeply believe that their children were damaged by this vaccine, yet they have still not been given credibility.’ But most parents are not immunologists, and while the depth of their belief is not in question, its basis in reliable observation most definitely is.
Autism is an obvious focus for parents’ fears because it is often first observed at an age shortly after children have had their first immunizations. (Before MMR there were fears that other vaccines might be linked to autism.) However, a closer look at the timing of autism diagnosis in relation to immunization reveals an interesting pattern, with parents tending to spot signs much sooner (around six weeks) than health professionals (six months or more).5 Yet if there was a link between MMR and autism, one would expect the professionals to notice the signs as soon as the parents. Alternatively, if there is no link, one would again expect everybody to notice signs at the same time – when they appear. The fact that the experts observe the signs later could conceivably point to professional conservatism, incompetence or denial. Perhaps the parents’ earlier observation can be attributed to entirely natural anxiety. Sadly, this does not mean that the autism is not real, but it does suggest that the link with the MMR vaccine is imagined.
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