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Medical Science: What’s in a name?

The Green Cow

Originally this month your cow would be talking about survival and what it means to have ’a four times better survival.’ A few months ago there was an issue in Belgium about survival in patients with oesophagus (gullet) carcinoma. It was said that patients had a four times better survival in certain hospitals. This is a not very accurate description, so an ideal subject for your cow. However, they seem to have rephrased the article, so the origin of my complaints seems to be removed. Therefore, this month the topic will be a controversial article by A.J. Wakefield et al. published in 1998 in The Lancet 1 A lot has been written about this article. The article got famous because some people interpreted it as a proof for a link between autistic disorders and measle, mumps and rubella (MMR) vaccination. It even was retracted by The Lancet. However, I am not going to comment on the person of Wakefield, his research in general or his conviction for unethical scientific behavior. What I would like to do, is to learn you to mistrust this kind of medical “science” by looking at the article itself.

The article
After the article2 was published, a lot of other scientists studied the relation between MMR-vaccination and autistic disorders. That is off course the proper thing to do if there are doubts about the safety of a vaccine (or any other medication). However, if you read the article carefully, you shouldn’t be too scared, because it is not really convincing at all. Let’s start from the beginning and point out the problems of this article. First thing to notice is that the title is not saying anything about MMR vaccination. That is off course not a problem, but it indicates that the authors were not studying the effects of the MMR vaccination. If they really wanted to say something about adverse effects of the vaccine, they would have hinted at that in the title. The findings concerning the vaccine were most likely only a coincidence. In (medical) science there is always
A. J. Wakefield, S. H. Murch, A. Anthony, J. Linnell, D. M. Casson, M. Malik, M. Berelowitz, A. P. Dhillon, M. A. Thomson, P. Harvey, A. Valentine, S. E. Davies, J. A. Walker-Smith Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children The Lancet 1998: Vol 351 p.637-641 2 which you can find here
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a risk of finding effects that are not real but arise merely by coincidence. This is more often the case when something is found without a theoretical explanation, as is the case here. A second thing that should make you suspicious is that there were only 12 (sic!) children included in this study, as you can already read in the abstract (summary) of the article. This is far too few to say something about the whole population of children in the United Kingdom where over 600,000 children are born in a typical year (source). In the early 1990’s over 90 percent of children got the MMR-vaccine in the UK. So 12 children form only about 0.02% of the children that were born and vaccinated in the UK in one year. This is not enough to say something about the whole population of children. The next thing that “alarms” me, is the lack of a clear study aim. Normally this is briefly described in the introduction of an article. Here the introduction only states that they saw a few children with some common characteristics and that they describe them. Studies without a clear research question tend to describe coincidences rather than real effects. (This has a lot to do with statistics and the common knowledge that with statistics you can proof anything.) So I’m only half a page into the article and I already have three warning flags. Interesting. In the “Patients and methods” section there are a further two flags. First, there is no description of the selection criteria for the patients. That is an indication - an indication, not a proof - that only children were included who fitted into a frame of what the researchers wanted to demonstrate. Second, there is a description of what kind of investigations were done, but nowhere is described why these investigations were done, or what the researchers where looking for. (A clear research question would have helped to understand this.) The “Results” section describes some findings regarding intestinal problems. The exact meaning of these findings is not really clear and is not related to the MMR-vaccination by the authors. I will therefore not comment on this aspect. The ‘results’ regarding the relation between MMR-vaccine and autistic disorders are presented in a table (table 2 of the article). (I place the word results in quotes, because what is written in the article is not really a scientific result. I realize some people find this a bad use for quotes.) Note that only in 7 of the 12 children MMR-vaccination is listed as an “exposure identified by parents or doctor.” For a few other children the ages of MMR-vaccination are listed, although this was not mentioned by the parents as a relevant exposure. Also note the intervals between the exposure and the the first behavioral symptoms. The fact that these intervals are very different (from 1 day to 2 weeks or even more) is another flag, warning me to be suspicious about this so-called study. (The written text about the MMR-behavior link, only describes what is in the table, so I will 2

not go into detail.) Finally, I want to quote from the discussion of the article: “We did not prove an association between measles, mumps, and rubella vaccine and the syndrome described.” And: “Published evidence is inadequate to show whether there is a change in incidence or a link with measles, mumps, and rubella vaccine.”

So what’s all the fuzz about?
3 Honestly,

I don’t know. The article is actually completely worthless. It does not propose a research question and it doesn’t answer one either. It is not a good article, but it is not worse than a lot of articles that where not retracted. 4 It is just an article that got hyped due to the lack of knowledge on scientific methods by journalists and the general public. Hopefully this will help you when you encounter such an article next time.

Not “a frizzy mass of hair or fibre” as Oxford online dictionary suggests. I don’t know the details of the accusation about non-ethical conduct of the studies by Wakefield, so I do not comment on that.
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