by revere, cross-posted from Effect Measure

My sciblings at Scienceblogs have done a pretty thorough fisking of the Andrew Wakefield affair.To recap breifly, a paper by Wakefield and others in The Lancet in 1998 raised an alarm that the widely used measles-mumps-rubella (MMR) vaccine was the cause of some cases of childhood autism and a chronic inflammatory bowel disease. The incriminated agent was alleged to be measles virus contained in the vaccine (MMR has never contained mercury preservative). The impact was dramatic and this issue became a powerful engine propelling the anti-vaccine movement. The result has been a real public health crisis as falling vaccination rates in the UK and elsewhere have allowed measles and mumps to make a comeback after being almost eradicated. While all three of these diseases are usually relatively mild childhood maladies, some case are serious or even fatal. They are also totally preventable.

So over the weekend when an investigative report by The Times in London was published that seemed to show fairly conclusively Wakefield had doctored the data to have in come out the way he wanted, it was a big deal. This explains why no one has been able to replicate his findings: in fact there was no demonstrable relationship between the autism seen in his 12 child case series and the vaccination itself. Since others here at Scienceblogs have covered this extensively I want to discuss another aspect of it, the role (or lack of it) of the respected medical journal, The Lancet, in publishing what is apparently bogus if not fraudulent research. Before I do so, you need to know the nature of the doctored evidence.

The Times has published a fairly extensive catalog of each case but I will only present two here, so you can get the idea of what was involved:

The first, in the Lancet tables, concerned the first child in the paper: Child One, from Cottesmore, Leicestershire. He was 3½ years old and the son of an air force pilot. In November 1995, his parents had been devastated after receiving a diagnosis of autism.“Mr and Mrs [One]’s most recent concern is that the MMR vaccination given to their son may be responsible,” their GP told the hospital in a letter.

In the paper this claim would be adopted, with Wakefield and his team reporting that Child One’s parents said “behavioural symptoms” started “one week” after he received the MMR.

The boy’s medical records reveal a subtly different story, one familiar to mothers and fathers of autistic children. At the age of 9½ months, 10 weeks before his jab, his mother had become worried that he did not hear properly: the classic first symptom presented by sufferers of autism.

Child One was among the eight reported with the apparent sudden onset of the condition. So was the next child to be admitted.

This was Child Two, an eight-year-old boy from Peter-borough, Cambridgeshire, diagnosed with regressive autism, which, according to the Lancet paper, started “two weeks” after his jab.

However, this child’s medical records, backed by numerous specialist assessments, said his problems began three to five months later.

The difference between 14 days and a few months is significant, according to experts. Autism usually reveals itself in the second year of life, when the vaccine is routinely given. If there was no sudden onset after the MMR injection, as claimed for the “syndrome”, the condition could be ascribed to a conventional pattern. (TimesOnline)

 

The dreary record goes on, through all twelve cases, none of which supported Wakefield’s conclusions. So why didn’t the “peer reviewed” scientific journal, The Lancet, catch it before it was published? First, a disclosure. I quite like The Lancet and admire its tendency to take courageous stands on controversial issues. I have also been a peer reviewer for them, on multiple occasions. Second, I am also co-Editor in Chief of a peer reviewed scientific journal, so I have both sympathy and understanding of the position they are in, but perhaps more of a tendency to defend them because of that. You’ll have to decide if what I say makes sense.

A word about peer review. This is the process whereby journal editors send manuscripts to experts in the field for their evaluation of scientific soundness. Based on the comments, editors then make a decision as to whether to publish or not. That decision may or may not be the same as the reviewers’. There are many considerations whether to publish something or not (is it of sufficient interest to the readership or does it make enough of a contribution to the field, for example). In general, however, depend on reviewers for the science. Most journals do closed, anonymous reviews. This means that the authors don’t know who the reviewers are and the reviews are not provided to the readers. Often the names of the authors are also kept from the reviewers so as not to prejudice their judgment. Some journals (like the one I edit) practice open review, meaning that reviewers’ names are known to the authors (and vice versa) and that the reviews themselves are available to readers when the paper is published. In the case of the Wakefield paper we don’t know the names of the reviewers or what they said.

Reviewing papers is a chore and if done conscientiously, hard work. You get paid nothing for it and you do it on a deadline. All you have is the submitted manuscript and any other supplementary materials that may be submitted along with it. In 1998 supplementary data files were uncommon because journals were mostly read in hard copy via the journal. Today it is common for readers to have access to supplementary files via the journal’s website, and in my experience as an editor many reviewers consult these files. But even if they had been available in 1998 it wouldn’t have made any difference. Wakefield provided the case summaries (which we now know were doctored) and a reviewer would not have had access to or had the time to look at the original medical records. The same is true for the journal. Accurate representation of raw data is taken on trust. I don’t think The Lancet can be taken to task for not catching this. This kind of scientific misconduct is only found after the fact.

Still, one might wonder at The Lancet’s penchant for controversial topics. Science journals are not just about science. They compete with each other for readership, public recognition and prestige.It used to be that in the UK publishing world The British Medical Journal (BMJ) was the dull, conservative journal and The Lancet was more “out there.” As one of the leading medical journals in the world, it perhaps could afford to be. Now they seemed to have switched places. BMJ is tending to push the envelope with more aggressive contrarian articles and The Lancet has gotten duller. In general I like a bit of daring, but there is a risk, too, and in this case the result was bad for public health.

It is still an uphill battle to repair the zombie undead idea that MMR causes autism. I have quite a lot of sympathy for the parents of these children, sympathy that is personal in nature. They want to know “why their child.” I want to know why their child, too. The answer to “why?” isn’t MMR vaccine, however, and while having an answer might satisfy a need, when the answer is wrong but keeps getting spread, it can cause great harm. On the other hand, I can easily imagine a circumstance where the answer to the question,”why did my child get a life threatening pneumonia?” could easily be: “Andrew Wakefield.”