RICHARD HORTON has, one suspects, rather more enemies than friends. The editor of The Lancet dismisses the Government’s efforts to manage public health scares as “ham-fisted” and accuses it of playing Russian roulette with children’s health. The Prime Minister, Horton rules, made a “grave misjudgment” in not disclosing whether his son Leo had the MMR jab. He condemns the pharmaceutical industry for turning science into “McScience ”, with companies buying up research departments and churning out improperly tested drugs that, on the whole, contribute little to public health. The stench of the profit motive can be smelt everywhere, with industry executives breathing down editors’ necks to get their dubious research published and, when that fails, operating sinister campaigns to destabilise opponents.
But Horton has become best known, notorious even, for his role in the MMR affair, which began six years ago when he published research by Dr Andrew Wakefield, of the Royal Free Hospital in London. Dr Wakefield’s paper described a new type of inflammatory bowel disease in a group of children with developmental disorders and speculated, without causal proof, that bowel disorders and autism could be linked to the measles, mumps and rubella (MMR) vaccine administered routinely to pre-school children.
It furnished Horton, 42, with yet more foes, not least public health officials, who saw parental confidence in vaccination crash. When it emerged that Dr Wakefield had received legal funding to establish grounds for a possible lawsuit against vaccine manufacturers — a conflict of interest — the paper was partially retracted.
With so much ire around, you would expect Horton, who has dissected the MMR affair in a new book, MMR: Science and Fiction, to be thoroughly unpleasant. One of those abrasive, cocksure doctors who scares the bedjackets off cowering patients, with an uncrushable backbone of self-belief hardened by his appointment as the Lancet’s custodian at just 33. Instead, when I arrive at his home in North London, I find a tall, quiet, rather academic-looking family man, who later seems touchingly baffled at how to deal with his 3-year-old daughter Isobel when she presses her face against the glass doors that have been closed for our meeting.
The book, Horton is keen to emphasise, is more than just a postmortem examination of the MMR saga. It deals with why the scare happened and how future ones can be prevented. He does not berate parents for shying away from vaccination. Instead, the medical profession, journal editors, the Government and the media must shoulder the blame. “You can’t hold a gun to parents’ heads and say ‘You must get your children vaccinated’,” says Horton. They need to be persuaded by rational argument but instead, he says, public debates descend into “vilification, censorship and punishing people who say things against the grain”.
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That the lessons from MMR have not been learnt is obvious to him, given the recent anxiety created by news of a five-in-one inoculation for babies. The information leaked out before a public announcement, again stoking parental suspicions. Horton rolls his eyes: “The Government made a serious error of judgment thinking that it could release the information to doctors ahead of the public. If you try to tell people privately, secretly, it will always leak out. It was clearly ham-fisted. We had two or three days of extreme headlines; the (Government) message that came back was that you will put your child at mortal risk if you don’t get the existing vaccine. So you counter one scare with another scare. If there was one thing that came out of MMR, it was that you don’t play Russian roulette with your children.”
Since public trust in Government has evaporated, Horton wants to see the creation of a new body, a National Agency for Science and Health (Nash), that can evaluate scientific studies and provide impartial guidance. He denies that Nash would represent a politicisation of science; such accusations have dogged the Food Standards Agency, whose independence is tainted by a perceived subservience to Government.
Instead, Horton argues, it would take the politics out of science and health policymaking: “Every health reform we’ve had since the inception of the NHS has been driven by ideology, whereas if we’d tested them properly, we would have learnt a huge amount about how to run a health service. That’s the politicisation of science. We have systems for evaluating drugs but no system for evaluating policies. How mad is that?”
Another reason to establish Nash is the ever-powerful pharmaceutical industry, with its massive marketing might. “If you look at the way that research has been influenced by industry — and how some scientists have been bought — you have to regard it is a serious threat,” he says.
He recalls one Lancet colleague being telephoned by a drug company and harangued over queries that had arisen during the peer-review process: “My colleague was told ‘Why are you raising all these difficult questions? Don’t you know we’re going to buy an enormous number of reprints?’ That is an unjustified, clearly damaging, intervention in the peer-review process. The implication was that the paper would be withdrawn and there would be loss of revenue (to The Lancet). This is not uncommon.
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“When we published criticism of one drug the company went ballistic. One of its board members rang me in a rage that we had published this and asked what the hell I was doing as it had come out in the week of their third-quarter results.” Horton says the company was offered the right of reply prior to publication but, for some reason, had not taken up the offer.
The matter did not end there: “Then there’s this behind-the-scenes threat that somehow you’ve behaved inappropriately. So, for example, one senior member of the company wrote to a senior member of our publishing group to complain about us — complain about me, I suspect, although I never saw the letter — and you see how this insidious process goes on to try to undermine you.”
More importantly for the public, the malign influence of Big Pharma means that drugs are not as well tested as they should be: “Drugs are licensed on the basis of small clinical trials, and while we are fairly sure of their efficacy, we are very uncertain about their safety.”
He rejects the argument that tightening up safety procedures deprives patients of much-needed drugs: “That is 99.9 per cent nonsense. Occasionally a drug comes along that is a big innovation, but most drugs that get licensed are me-too drugs (copies of existing medicines). It’s outrageous that drugs get licensed by being compared with placebos rather than with similar drugs. The system is weighted heavily in the pharmaceutical industry’s favour. Lies are put out about the cost of designing and taking drugs to market.
“The myths that surround drug development are legion. And there is this strange conspiracy between the medical profession and the industry because so much of medicine needs industry to support its research. The medical profession believes that we can’t do research unless we have industry on our side. I’m sympathetic to that view, but the result is that we make a bargain with the devil.”
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If the public knew more about the way doctors interact with industry, Horton says, “they would be horrified to realise that what they would imagine to be independent medical practitioners are very often in the pockets of companies that are driven totally by the profit motive and not by public health”.
Horton has often been accused of making risky editorial decisions that undermine the standing of The Lancet, and he knows that many people would like to see him sacked. The Wakefield paper was his most public trial, and the subsequent partial retraction left Horton’s critics feeling vindicated and Horton defensive.
“Journals are there to be provocative,” insists Horton, standing by the partial retraction. “The other way we could go is to be deeply conservative, to not publish anything that’s controversial, and to censor things that are difficult and uncomfortable. Of course, everyone would think that we are doing a wonderful job supporting science and public health and then, five years down the line, something (difficult) could come out and people would say, why did you sit on this and censor it?”
Dr Michael Fitzpatrick, a former Lancet columnist, the father of an autistic son and stout defender of the triple jab, doesn’t buy the “censorship” defence. In his book, MMR and Autism: What Parents Need to Know, Dr Fitzpatrick points to the “basic errors in design, execution, analysis and interpretation in the Wakefield paper”.
Horton says that much of the criticism is “nonsense”. But he obviously still feels bad — he calls his book “a reparation, of sorts”. In the midst, he says, those with autism have been forgotten, which is why he is donating book royalties to an autism charity. Horton says he regrets not being more suspicious of Dr Wakefield’s motives, a lapse he puts down to naivety, not incompetence.
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In one sense, Horton can dissociate himself semi-honourably from the MMR episode. The real damage was done not by anything published in The Lancet, but by what Dr Wakefield said, unexpectedly, at a press conference called by the Royal Free. His co-authors sat open-mouthed as Dr Wakefield called for the MMR vaccine to be split into three single vaccines. Nobody saw it coming; Horton describes the resulting furore as a storm spinning out of control.
His family was quickly sucked in. When the retraction was published, somebody rang BT twice posing as Horton, attempting to get hold of his home phone records (he never reported the incident to police, as BT said the caller could not be traced). And when Horton revealed in a heated radio interview that Isobel, his only child, had received the MMR jab, a friend compared his action to that of John Selwyn Gummer, the Tory Minister who inexplicably decided that feeding his daughter a burger in front of TV cameras would quell the BSE scare. Did the comparison hurt?
“Yes, because it was a fundamental misreading of what I was trying to do. I wasn’t dragging Isobel to the Today studio to get her vaccinated live on air. My wife and I didn’t have agonising discussions about it (Isobel having the MMR jab) because our reading of the evidence was very clear. I didn’t see that there was any shame in saying that.” Horton and his wife, Ingrid Wolfe, a paediatrician and public health researcher, had already decided that disclosure was the correct thing to do.
He believes that the Prime Minister had, and still has, a duty to reveal whether Leo has had the MMR jab: “People do look and say ‘Well, you are making these claims, so what do you do? Does your behaviour match up with what you say?’ Not only should the PM have said (whether Leo received MMR) but I think it was a grave misjudgment not to have done . . . Many people I’ve spoken to believe that if Leo had had MMR, the Government would have been out there straight away saying he’d had it. That’s why I think the defence of privacy is a false defence. The PM is the first to parade his children at No 10 or on holiday for photoshoots — it’s privacy when he feels like privacy.”
Horton was at the Royal Free when Dr Wakefield joined the department, though they were never colleagues: “At the Free (Wakefield) was a charismatic individual who was working in a department that was not one of the best in the country. He came in with a lot of ideas and enthusiasm and became very successful. By charismatic, I mean that he was a strong personality. What happened to take him from a position of being absolutely rooted in mainstream science to now being an evangelist for the cause against MMR I just don’t understand. I don’t think anybody quite understands the psychology of it.”
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Horton left medicine for journalism early in his career; he had been at The Lancet for several years when he was made editor. The consequence is that he, too, is something of an enigma: to doctors, he is a journalist, burdened with all the pejorative connotations that carries.
Yet he still regards himself as a doctor, and an idealistic one, too, clinging to the fundamental principles of dignity, compassion, independence and rationality. If he sounds frustrated about his chosen profession, it is because he wants it to reclaim its integrity.
“I love medicine,” he reassures me. “What I’m sad about are the conditions in which medicine is practised, which have become open to the highest bidder.”
MMR: Science & Fiction, by Richard Horton, Granta Books, £7.99