Critical Health Information Can Be Misleading or Simply Ignored

by Guy McKhann, M.D.

March 17, 2010

There is a lot of information out there about the brain. Some is right and some is wrong. Complicating the issue is the media and public reaction to the information. There are two examples in this issue that demonstrate the ends of the spectrum

We have many conditions in neurology and psychiatry for which we do not have a mechanism: multiple sclerosis, amyotrophic lateral sclerosis (also known as ALS or Lou Gehrig’s disease), Parkinson’s disease, and autism are prime examples. Desperate parents or patients with these conditions are set-ups for desperate solutions.

As described in The Wall Street Journal article “Lancet Retracts Study Tying Vaccine to Autism,” the furor over the association of a measles vaccine and autism was started by a paper in the British journal Lancet in 1998. This paper reported that 12 children who were said to have been studied sequentially (that is, 12 children seen in a row) were found to have a link between autism and both the triple vaccine (measles-mumps-rubella, or MMR) and gastrointestinal disease. The original paper emphasized the association with colitis and, after varying intervals, decline in behavioral cognitive performance. Over time, the emphasis changed to an association of MMR vaccine with autism.

The media went nuts, blaming vaccines. The effects of the paper and its subsequent coverage were devastating. Many parents abandoned vaccination, with vaccination rates for measles dropping from more than 90 percent to about 70 percent, allowing the virus to become more prevalent. For example, in England and Wales in 1998, before the paper’s publication, there were 56 cases of measles. In 2008, there were 1,348 cases. Measles is not a benign disease; about 15 percent of people have complications, including acute encephalitis and death.

Numerous studies have failed to demonstrate any association between MMR vaccination and autism. In 1994, the Lancet “partially” withdrew the paper, and in 2010 the journal finally retracted it. In 2007, the lead author, Andrew Wakefield, became the subject of  disciplinary hearings over allegations that his research had received funding related to litigation against MMR-vaccine manufacturers, and he had concealed this fact from the Lancet. It was later revealed that Wakefield received $780,000 for consulting work related to possible lawsuits.

There were substantive issues as well. The research subjects were selected and not obtained in serial order. Some may have had cognitive problems before they were given the MMR vaccine; in addition, invasive procedures, like colonoscopy and lumbar puncture, were performed without proper consent.

All this fuss and confusion from a flawed paper that involved only 12 subjects!

What are the messages from this story? A possible breakthrough in understanding a disease must be carefully vetted, replicated, and treated cautiously, until proven correct. Emotional responses by high-profile advocates may get media attention, but do not advance the correctness of an observation. Finally, the medical establishment, as represented by the journal Lancet, is not blameless. It should not have published the original paper without more careful review, and was agonizingly slow to admit the errors.

In contrast to the situation with MMR and autism—where public and media outcry inflamed the situation—the issue of head injuries and subsequent cognitive problems in football players was all but suppressed. It is only recently that the NFL admitted that repeated concussions could be associated with long-term cognitive problems (“Will Science Take the Field?”). Football is not the only culprit; boxing, soccer, and lacrosse are also head-contact sports. This may surprise you, but the people in boxing have actually been the most responsible, setting up guidelines that limit a boxer from fighting too soon after being knocked out.

Football can be a violent game. Enormously big, enormously fast, enormously competitive human beings are colliding with one another. There is the misinterpretation that a concussion has occurred only when someone is “knocked out.” That is not true. Symptoms of confusion and general disorientation indicate that the brain is not functioning correctly. On occasions I have been a doctor at a football game (though not on the professional level). The first thing you ask a player who has had his “bell rung” are: “Where are you?” “Whom are you playing?” “What’s the score?” or “What quarter is it?”

Keeping a player who can’t answer those questions from returning to the game used to be nigh impossible. Fortunately this is no longer the case, as coaches, parents, and even the players themselves have recognized that further injury should be avoided. Die-hards will complain that such precautions and long-term concerns will ruin the game. I suspect that similar concerns were raised when helmets were first introduced, as occurred with face masks for hockey goalies. My advice to younger people getting involved in these contact sports is that it is your brain, the only one you will ever have—protect it!