11.5 Public engagement
Horton, R. (2004) ‘The lessons of MMR’, The Lancet, 363, 6 March 2004, pp 747–749 Elsevier. Copyright © 2004 Elsevier.
Many doctors and public-health officials have been frustrated by the debate over MMR. I have shared this frustration. One newspaper fancifully called our recent statement about the 1998 Lancet paper part of an “orchestrated campaign” to bolster MMR programmes.12 In fact, the events leading to today's partial retraction were sudden, sparked by an investigation by a newspaper, The Sunday Times. Our response was to determine answers to very specific allegations. We have had no contact with anybody at the Department of Health or elsewhere in Government, vaccine manufacturers, or lawyers involved in ongoing litigation. There was no orchestrated campaign.
But there are fair questions to be asked about the style of government and expert response to claims about the safety of MMR. Three reactions have been discernable. First, there has been an appeal to evidence. The Department of Health'swebsite contains a superb collection of materials designed to help parents make the “decision in your own time and on your own terms”. The difficulty is that in a post-BSE era, where government advice is no longer immediately taken on trust, the weight of accumulated evidence carries less force if it comes from government than it once did.
Second, public-health officials have disparaged as “poor science” evidence that appears to contradict their official message. This approach has a cost. The reason that today's retraction is partial and not total is that the discovery of a possible link between bowel disease and autism is a serious scientific idea, as recognised by the MRC,8 and one that deserves further investigation. Although dismissing the entire 1998 Lancet paper as poor science gives a clear and correct message to the public about the status of any claim regarding the safety of MMR, in scientific and clinical terms it is both wrong and damaging. The autism-bowel disease link was considered part of a series of physiological observations judged by the MRC to be “interesting and in principle worth investigating”. Subsequent research has yielded conflicting findings.13, 14 This work should be supported.
Third, there has been an effort to starve critics of legitimacy by refusing to engage them face-to-face. For example, when the drama Hear the Silence was broadcast on British television in December last year, there was a boycott of a subsequent discussion by many of those who could have best articulated the case for MMR. The reason advanced was that rational debate would not change the minds of an extreme few who believed MMR to be unsafe no matter what the evidence presented to them. Also, the composition of the panel discussion did not reflect the large measure of consensus that MMR is safe. Instead, it portrayed the issue as a finely balanced scientific exchange, when in truth there is very little scientific uncertainty.
How should we debate and discuss matters of public health concern? Certainly, with all the evidence before us. But perhaps this evidence is best provided by neutral and trusted third parties – not the Government. In the UK, one might turn to the Consumers’ Association, which publishes the respected Drug and Therapeutics Bulletin. Certainly, with strong public-health messages. But care must be taken not to dismiss important work that deserves continued support. And certainly robustly. But also directly, recognising that wider public trust is best fostered neither by referring to abstract evidence alone nor by official pronouncements of reassurance, but by explaining face-to-face15 in transparent, human, even anecdotal terms with personal stories, why a particular course of action is being advocated.
Persuading the public to support vaccination is not only a matter of winning an argument. It is also about understanding the reasons why parents are and are not inclined to take their children for immunisation.16 The complexity of this decision demands a more nuanced response from the public-health community than it has so far received.