Grub Street Medicine

Monday October 8th to Friday October 19th

by Martin J Walker 2007

I pointed out in the last section of this account, how Professor Rutter had found himself ‘de-experted’ by virtue of the fact that he was only able to discuss the psychiatric or psychological aspects of the cases reported in the Lancet. With Professor Westerby Booth, the second expert witness appearing for the prosecution, this problem was just as obviously manifest. Not only was Professor Booth not capable of commenting upon the psychological or autistic dimension of the cases but his gastrointestinal appraisal of the cases, although expert, could not have been more conservative. By leaving out a whole series of aspects that concerned the doctors working at the Royal Free, his expertise in gastroenterology failed completely to match the more complex cross disciplinary approach that imbued the work of the Royal Free team.

Although manifestly a consummate professional, with his patients at heart, Professor Booth showed himself to be the very kind of highly qualified clinical practitioner, whose safe conservatism probably led to parents seeking out more positive and investigative clinical attention from other practitioners. His diagnostic vision never seemed to stretch further than the most prominent and primary gastrointestinal symptom presented by the children in the Lancet study. He frequently commented on the fact that this or that child had constipation, or a typical type of diarrhoea, and one got the feeling that this could have been the beginning and end of the diagnostic work undertaken by him in such cases.

Professor Booth’s mental frame of reference appeared to be almost exactly opposite to that of Dr Wakefield and the gastrointestinal team at the Royal Free. Whereas the latter was expansive, interdisciplinary and creative, Professor Booth’s approach appeared to be single-symptom orientated, mono-disciplinary and conservative in its references.

For this reason alone, Professor Booth was a witness who contributed next to nothing to the overall picture. Nor did he further our understanding of the medical practice, or, from the prosecution’s point of view, the supposed criminality, of the doctor’s at the Royal Free. His answer to almost everything was the most conventional answer. What one does not do, he emphasised constantly, is anything unconventional. His evidence steered well clear of any mention of MMR, or vaccine strain measles virus, and he said almost nothing about autism.

Despite the fact that autism did not come within the scope of either his evidence-in chief or his cross examination, at the end of his evidence, he gave a stunningly forceful answer to a panel member who asked him whether disintegrative disorder  - so far accepted by everyone during the hearing as being a type of autism – was a product of inflammatory bowel disorder or was it a neuro-psychiatric disorder. The question was awkwardly put, but even so, the answer to it lies at the very heart of the hearing. The asking of the question, by this panel member, seemed to suggest that they had not yet grasped that the struggle between these two paradigms was essential to the evidence of both expert witnesses. Ensuring that the panel member stayed in the dark, Booth answered her with an utterly dogmatic response, saying: ‘It is a neuro-psychiatric disorder.  I have never seen a case’. Gladly straying beyond the remit for his expert evidence, Booth answered without faltering as if he had been eagerly awaiting the question.

So while even Professor Michael Rutter, the internationally renowned, but conservative expert on the psychological and genetic causes of autism was willing to allow a growing percentage of medically caused cases of autism due to environmental factors. Professor Booth, a relatively well known expert on paediatric gastroenterology, was dogmatically of the opinion that disintegrative disorder as a form of autism has no ‘medical’ causation, certainly in relation to the gastroenterological system. Had we known that this was Booth’s view at the beginning of his evidence, it might have explained a great deal.

As he entered the hearing, Professor Ian Westerby Booth looked like a traditional hospital consultant or surgeon, his face flushed with  nervousness and a dash of arrogance. A large, tall, broad shouldered man, with dark hair and silver highlights, wearing a charcoal black suit and black socks, with a blue and white checked shirt, he rarely smiled throughout his evidence.

Booth was ‘Rutter with attitude’ and listening to him, I began to reappraise my view of Professor Rutter. I suddenly began to miss the discursive and often pleasantly humorous style employed by Rutter throughout his evidence. In contrast to Booth, and consistent with what one requires from a scientist, Rutter, rarely appeared entirely secure in his views. He was even willing, on occasions, to laugh at himself. Rutter often put a humorous gloss on his evidence, so it was that he suggested, in answer to one question contrasting research to clinical work, ‘Well it smells like research’.

Looking back on Rutter’s evidence, it seems almost as if he was willing to live and let live, all the time conscious of the fact that he was an expert in a particular and very specific field and nothing could change that. Booth on the other hand, appeared insecure, his answers heavily laden with entrenched moral positions.

Professor Booth was the perfect fall-guy for Miss Smith and because of this, his journey through his evidence-in-chief, turned out to be even more boring than the evidence that had preceded it. Booth not only agreed with anything that Miss Smith put to him, but did so in a heavy and ponderous manner, adding a varnish of wrongdoing to simple and often quite uncertain matters.

On Monday 8th October, the day that Booth began giving his evidence, Miss Smith, sporting a black cardigan and two strings of pearls appeared at her softest and most beguiling. After an hour of introducing Booth’s evidence-in-chief, I wrote in my notes that her presentation seemed slightly more upbeat than it had been previously. Not just that, but evidently the accumulation of information and experience over the last three months seemed finally to be sharpening up her presentation of the prosecution case.

However, Miss Smith was unable to sustain this cool style, which appeared and disappeared like poor radio reception, over the next few days. On Monday it lasted up until the incident of the exploding water bottle, in which Professor - now in charge of a medical school – Booth manages to flood the witness table while opening a bottle of fizzy water. Around that time, Miss Smith’s voice began to take on the same doleful timbre as had been evident in her previous presentations.

Perhaps more alarmingly, she took to speaking away from the microphone, and for the last hour of the morning I could hear little of what she said. This ‘loss’ was not so serious for participants as it was for observers., The participants had texts to follow, while Deer Brian and I had, in the main, to guess, or lip-read, what she was saying. Inevitably I began to nod off.

Late in the morning, Booth introduced a radical new note into the evidence, which although it had always slept uncomfortably beneath the surface of the prosecution, had found no one brave, or ill-informed enough, to adopt it. It had frequently been suggested that parents were the motivating force in the referral of patients from GPs to the Royal Free. In Booth’s evidence, this idea was embroidered and built upon. What he termed ‘parent objectivity’ – as if the very matter of being a parent was now one of scientific learning – might, he suggested, be skewed, with parents forcefully pushing the need for invasive investigations against the beleaguered clinician’s better medical judgement. In Booth’s rather bizarre world-view, the desperate parents of children with (psychologically induced) autism, had been willing to offer up their children for all kinds of damaging procedures.

Booth labelled the parents as just short of hysterical for searching unstintingly for a diagnosis and treatment of their children’s condition. Unlike the other witnesses, who had vaguely floated this notion, Booth made it an ideological tenet and he was to repeat it on a number of occasions. Although these remarks were introduced with the caveat ‘this is not to blame anyone’, according to him, parents were ‘vulnerable’ individuals willing to go to any lengths to find out what was causing their children’s (non-medical) pain and (non-medical) ill health. Although this concept might appear quite healthy to the lay population Professor Booth made it sound only a hairs breath away from the psychiatric condition Munchausen’s Syndrome by Proxy (A psychiatric term for a mental illness in which a person seeks attention by inducing or feigning illness in another person, typically a child)

This concept introduced a new and considerably different perception of the three doctors on trial. Parallel with the idea of vulnerable patients, or parents, runs the idea of exploitative doctors. This, then, is the prosecution getting the ‘parents complaints’, non-existent in reality, into the hearing via the back door. It could be deduced from Booth that the GMC was bringing the case on behalf of parents and children who had been led up the garden path by – and the motivation was never entirely clear – ‘non evidence based’ practitioners at the Royal Free. The very practitioners, who, in a somewhat circular argument, had themselves been led up the garden path by the parents. How much one would have preferred to hear the sane and humane parents of the Lancet paper children, telling the court how they felt, and what really happened.

It didn’t surprise me to find, when I dug a little, that Professor Booth was the co-author of a paper published in the Journal of Psychosomatic Research, entitled ‘Psychological Characteristics of People with Perceived Food Intolerance in a Community Sample’. In the paper, the first quoted reference is from a ‘study’ by Dr David Pearson, a stalwart of the HealthWatch anti-quackery movement who always professed the view common to this lobby, now re-organised by Sense About Science, that food allergy and intolerance, were, along with ME, multiple chemical sensitivity and suspicion of adverse drug reaction, mainly in the mind of sufferers. Booth’s paper makes bold and authoritative statements on the basis of Pearson’s ‘conclusions’ such as; ‘It has been suggested that the misperception of food intolerance largely arises from psychiatric illness or personality disorder’. While this is true, Booth et al  fail to make clear that almost the only advocate of this view, apart from a scattering of lobbyists on the fringes of the sane world, is Pearson.

Pearson suggested that people create pseudo-allergic reactions, ‘after reading books on the subject’ or ‘consulting people such as clinical ecologists’ (See this author's books: Dirty Medicine and SKEWED).  Of course, such paper weight subjective deductions, carried out from an ideologically skewed perspective, has no place in the annals of serious medical research. This paper, to which Booth has put his name, appeared in 1999, only four years before the Royal College of Physicians produced their first major report on food allergy, which disclosed that despite Dr Pearson’s pseudo-academic onanism Britain had one of the world’s highest levels of food allergy and the greatest number of deaths from anaphylactic shock amongst children (Allergy, the Unmet Need: A blue print for better patient care. Royal College of Physicians, 2003).

The science lobby has always argued vociferously that there is no environmental component to any illnesses. Of course, this argument aids not only the pharmaceutical and chemical companies but manufacturing corporations which do damage to workers. That people like Professor Simon Wessley can retain their exulted academic positions after having argued that Gulf War Syndrome, ME and more recently, mobile phone and mast sensitivities, exist only in the mind, says a great deal about the power of commerce and industry in Britain. Arguments about environmental factors in autism – with respect to the measles virus, mercury and other toxins - are presently at their height.

While individuals like Professor Rutter, might slowly be coming round to giving environmental factors a place in illness description and diagnosis, the die-in-the-wool, tree-swinging ideologues like Dr Michael Fitzpatrick can’t allow the slightest environmental faction into the equation in case this admission opens the flood gates. Professor Richard Lathe found this out when he published Autism, Brain, and Environment in 2006 (Jessica Kingsley, Hardback, ISBN: 9781843104384, 288pp, 2006). Lathe is a well known and previously conservative molecular biologist, a former professor at Strasbourg and Edinburgh Universities and the author of over a hundred peer reviewed journal articles.

His book, which suggested that various environmental toxins might play a part, together with genetic susceptibilities, in the causation of autism was unforgivingly reviewed in the BMJ by Fitzpatrick (BMJ  2006;333:205 (22 July), doi:10.1136/bmj.333.7560.205-a) the last paragraph bayed: 

Though Lathe's account has an aura of scientificity (and 1400 references) his central thesis is speculative and his approved treatments are unsupported by scientific evidence. This plausible book risks leading parents—and their children—into the hands of quacks and charlatans.

Could this be the same book of which ‘Nature’, no less, said:

His book is a clearly and accessibly written account of his proposal that environmental poisons, including heavy metals, interact with genetic vulnerability to cause damage to the limbic brain system...resulting in autism...This is, overall, a scholarly book providing a possible explanation of autism. It will be of interest to parents as well as professionals (Nature 442, 632 - 633 (09 Aug 2006) Books and Arts). 

How much of Booth’s evidence was tainted by the ideology of anti-environmentalism we do not know, but just off the top of my head, I think we can assume that the view that environmental factors are not responsible in any way for states of mind or patterns of behaviour, probably rates quite highly in his reasoning.  

Miss Smith spent almost three days again going through the case of each Lancet child with Professor Booth. This was the fourth time that she had performed this act and she was rightly confident in her presentation. We can bullet point the other areas in which Booth agreed with Miss Smith in her criticisms of Dr Wakefield and sometimes of Professor Walker-Smith and Professor Murch, which arose mainly during the prosecution review of the children’s cases.

Even on the last day of Booth’s evidence-in-chief, there were still periods of added strength in Miss Smith’s presentation as if she has finally got the measure of her case. Her most boring tone has been sloughed off and replaced by a louder and more determined voice.

However, it was evident now, at the end of her case, that the prosecution case was weaker than the one she set out with.  It has been whittled down, shorn of the filigree; its most baroque arguments pruned. The case which she now puts with some sureness was quite insubstantial and missing all the detail necessary to carry the traffic of heavy argument. If the prosecution case was a raincoat, one would have ended up soaked after the slightest shower.

Miss Smith is living proof of the old legal adage, ‘never ask a question to which you don’t know the answer’. So certain is she after asking a question that she often doesn’t bother to listen to the answer before she says an affirming ‘absolutely’ and moves on. During this final presentation Miss Smith displays some of her more charming traits of character. On a couple of occasions, she said determinedly to the whole hearing, ‘I’m sorry, I’ve interrupted myself again’. This is a really novel and charming idea, one that surely only Miss Smith could admit to.

The Cross Examination of Mr Booth

The cross examination of Professor Booth, like so many Manchester United games I have watched over the last thirty years, began full of hope on a clear cloudless day and ended with two players up to their waist in mud, struggling with the ball on the goal line. This isn’t of course to suggest that Mr Miller or Mr Hopkins for that matter, lacked skill, just that they were utterly unable to get the ball in the net because Professor Booth defended like a threshing machine, spouting endless off-the-point soliloquies.

I don’t know how good a gastro-enterologist Professor Booth is but one could say with absolute confidence that he would have made a better politician. In fact it filled me with melancholia seeing such massive and loquacious abilities wasted on someone whose main interest lies in the intestines.

Booth argued every question or statement that was put to him by Mr Miller and later Mr Hopkins. Although he managed to argue the defence to a stale-mate it is difficult to know whether his strategy actually won him friends. Getting into such personal arguments with counsel is like dancing naked at a psychiatric convention to prove your sanity. It is unlikely that you will gain much advantage from it, except by virtue of respect for your audacity.

It is hard to tell whether Booth embarked upon this strategy of  argument because he opposed the medical practices at the Royal Free, or because he is naturally an argumentative person. As time went by it became evident that Booth had come to the GMC to argue, to the point of irrationality, against the work of the Royal Free gastrointestinal team. He made this view clear, not just with reasoned quiet disputation but with free ranging argument that, to paraphrase Professor Rutter, ‘smelt like’ pure bloody mindedness. On the lighter side, his evidence resembled nothing so much as a medical version of The Office.

Both Mr Miller and Mr Hopkins cross examination focused on a small and contained number of specific points.

These seminal questions of the prosecution were restricted to the proper parameters of Professor Booth’s evidence, however, the tides of his evidence lapped on shores miles away from these more focused matters. Before going in detail through his approach to the cross examination, I would make reference to just one matter. Seemingly of a new generation of orthodox physicians, Professor Booth repeated whenever he could the expression ‘evidence-based medicine’; not once did anyone ask him what he meant by this.

I would make two points in relation to this absurd assumption that either Professor Booth or the GMC prosecution has been supporting ‘evidence based medicine’. First, it is palpably obvious that neither of the expert witnesses know anything at all about the real condition of any of the twelve children upon whose diagnosis and treatment they are commenting. At a distance of over ten years, with restricted notes and the absence of any record of conversations between doctors at the Royal Free and parents, Professor Booth, gave guestimates, over three days, as to what he would have done in ‘this situation’. It is difficult to imagine anything further away from the reality of ‘evidence-based medicine’.

Although Booth’s strategy of arguing about everything carried him through his evidence, and clearly disrupted the defence, he came unstuck on two occasions and was led into ridiculous overcompensation. Both these seminal arguments had to do with the place of colonoscopy in the diagnosis of IBD, a clearly essential component to a formulation of treatment. Nearing the end of a long day on Wednesday 17th. Mr Miller cross examined Professor Booth on a position paper, The Porto Criteria, which had been formulated by the IBD Working Group of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition and was termed a ‘Medical Position Paper’  and described as representing ‘recommendations for diagnosis’.

(Medical Position Paper Inflammatory Bowel Disease in Children and Adolescents:
Recommendations for Diagnosis—The Porto Criteria. IBD Working Group of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Journal of Pediatric Gastroenterology and Nutrition 41:1–7 Ó July 2005 Lippincott Williams & Wilkins, Philadelphia.)

Many academic societies, especially those concerned with medicine, publish position papers. These can vary from slavish adherence to the policy recommendations of drug company funders, to general common-sense consensual views of the society. Such medical ‘position papers’ should not be confused with either literature reviews or meta analysis of medical practice surveys. At best they are simply a rough guide for physicians practicing in the specific field.

When Mr Miller put ‘…the criteria for inclusion of colonoscopy in investigations of children suspected of having IBD…’, to Professor Booth the professor was unable to think quickly enough and deny their validity. The paper was very strong is suggesting that colonoscopy was ‘essential’ as a diagnostic aid in cases of children who might have IBD. In agreeing to sentences of the criteria as they were read to him by Mr Miller, Booth almost scuttled the prosecution boat.

In the night, someone must have whispered in his ear, for the next morning, when again confronted with the Porto Criteria, Booth denied them all plausibility. It was clear that someone had helped him find an argument. Now, while still agreeing with the separate criteria and their importance in diagnosis, he claimed that the document in which they were embedded had no validity at all. According to Booth such amateur papers, in this case written-up by 25 or so specialists, were clearly biased in favour of the authors opinions and had no authority. They had, said Professor Booth been overtaken by objective systematic reviews that scrutinized many papers and articles, coming to a completely independent view of what  was considered best practice.

This view was clearly claptrap. However, unfortunately for the defence lawyers, a GMC fitness to practice hearing, is not the place to argue sociology, methodology or science. I will briefly make a couple of points which could have been used by the defence in other circumstances. Firstly, the position paper was simply that. The consensual position of 25 practicing clinicians. It existed as a guide for anyone in the society who thought that it made sense. Secondly, it is not possible to arrive at an objective consensual view by systematic review in circumstances where there is major conflict. What does emerge from such work is the dominant and orthodox view that is usually the most conservative reduction; not necessarily the right conclusion or the most creative view. Finally, you only have to consider the conflict between the views of Professor Booth and Dr Wakefield on this matter to see that a consensus cannot be arrived at without manipulation, and the best that can be done when views are this divergent is to allow practices to continue until it can be shown, with the help of patients and proper recording, which of the two views is the better.

The second of Booth’s pratfalls also grew from his attempt to extricate himself from his previous days agreement with the Porto criteria. Now, under cross examination from Mr Hopkins, Booth developed a theme that he had been warming to throughout his evidence and which suited most completely his bizarre argumentative disposition. In order to deny the symptomatic criteria for the use of colonoscopy in the investigation of suspected cases of IBD, Booth denied that what he called ‘tick lists’ were of any use. If he had left this view as a general remark, in the way that Professor Rutter might, there can be no doubt that it might have held some meaning. Unfortunately for all those who had to listen, Booth became involved in a repetitive incantation that claimed not only were all these listed symptomatic criteria in the Porto document known to every practicing gastroenterologist, but checklists were useless without the experiential skill of the physician who could asses and balance the various items on the list. When Booth made deep incursions into this argument, he began to sound quite barmy because of course no one had ever suggested that these lists should be used by first time amateur practitioners, say the next door neighbour, who had decided to carry out a helpful colonoscopy. Everyone, of course, had taken it for granted that it was experienced doctors who diagnosed IBD and decided whether or not colonoscopies were a necessary investigation.

It was mainly as a consequence of the interminable argument around the Porto criteria that at one point during the day, I found myself noting this entirely personal contribution:

I desperately want to leave, because listening to Booth is doing my head in. It occurred to me that Mr Hopkins might ask Booth, ‘Is it Thursday today?’, to which Booth would have answered, ‘It depends what you mean by Thursday’, ‘I’m not sure what you’re asking me? Do you mean that with the pre-Christian calendar, Thursday would have fallen on a day other than today?’

If it wasn’t so serious this hearing could be classified as an elaborate joke. It was clear from the beginning of Professor Booth’s evidence that he and the doctors practising at the Royal Free had completely different approaches and were looking for quite different things in their patients.

While those at the Royal Free were of the opinion that an extensive and cross disciplinary ‘work-up’ was of the essence in attempting to diagnose and therefore treat the basic illnesses of the children concerned, Professor Booth, no less professionally, believed that a gastroenterologist should be mainly concerned with first symptomatic manifestations, best diagnosed and treated without invasive investigations; an approach, as Mr Miller put to Professor Booth in cross examination, that might be described as ‘wooden’. This was particularly the case, with those children whom Professor Booth understood from notes, were presenting primarily with constipation. According to Booth, when this condition was presented the diagnosing doctor need look no further.

There is of course an absurdity, especially in terms of ‘evidence -based medicine’ in a doctor reviewing decade old cases from partial notes provided by the prosecution. But when this review takes place while also ignoring fundamental questions implicit in the approach of the initial clinicians and the children’s parents, then the whole matter becomes a completely irrational exercise.

What came across as outstanding in Professor Booth’s evidence was the fact that orthodox medicine had very few diagnostic or treatment alternatives in relation to childhood gastrointestinal conditions. This in part explains the reliance of doctors like Booth on primary but not necessarily causal symptoms. This model of diagnosis and treatment raises a most important question which was never really tackled during Booth’s evidence. Are the diagnostic tools used in cases of undiagnosed illness by necessity different from those used in the diagnosis of simple primary and apparently well understood causal symptoms?

To this might be added another question which is vitally important in this circus of a hearing. In the case of undiagnosed illnesses, or illnesses of which the cause is unknown, can diagnostic testing be extended without it entering into the forbidden area of ‘research’. This is in essence what Booth was arguing about. In retreat from the big bad scary world where post industrial science is unravelling and possibly causing illness rather than curing it, some doctors go for the ‘easy option’ of primary symptoms while others try to ‘work-up’ their cases taking a large number of factors into account. In fact, in a passing remark, Booth actually alluded to this predicament when he said that the main function of the diagnostic process was to gather as much information as possible.

In this case, there is another massive consideration which makes inevitable the divergent approach of the two sides when it comes to evaluating whether or not the Royal Free team were involved in clinical diagnosis and treatment or research. For obvious reasons, the prosecution have censured the initials MMR from the Panel hearing, except, that is, to be scathing and cynical when discussing parental hysteria and irrationality. Of course if we chose not to believe the group of parents who found their way to the Royal Free Hospital about the connection between their child’s MMR, MR or other vaccination and their adverse reaction, or if we chose to believe that measles virus plays no part in Crohns disease or IBD, then we might consider some of the investigative procedures used at the Royal Free to be irrational and unrelated to the diagnostic process. Unfortunately, it is not until the defence case, that the panel and others are going to be able to understand the diagnostic procedures at the Royal Free within some kind of context.

There was a last witness. The prosecution brought a world-ranking  immunologist, Professor Sir Peter Lachmann. Lachmann was there to comment on ‘transfer factor’, the use of which Dr Wakefield had supported and advocated. The prosecution case in respect of transfer factor was that it was a quack therapy, used by Dr Wakefield without Research Ethical Committee approval.

Sir Peter, got in under the wire, so to speak on the last day of the prosecution case. It is perhaps a shame that he didn’t appear earlier and the defence had taken the opportunity to ask him a few questions about his interests.

(For further information on Sir Peter Lachmann, see Martin Walker’s Brave New World of Zero Risk and go to the GM Watch web site for a full appraisal of his previous involvement with industrial interests on the question of genetically modified food; especially his role in the Arpad Pusztai affair.
http://www.gmwatch.org/profile1.asp?PrId=74&page=L )

Sir Peter Lachmann is professor of immunology at the University of Cambridge, and a former vice president and biological secretary of the Royal Society, as well as a former president of the UK's Academy of Medical Sciences. Lachmann chaired the Royal Society expert group which produced the Royal Society's first report on GM crops in 1998. Entitled ‘Genetically Modified Plants for Food Use’, that drew entirely beneficial conclusion about the use of GM plants for food.

Lachmann is also a member of the Sense About Science working party on peer review, and is also on the Advisory Council of Sense About Science. Sense about Science is partially funded by drug companies. He is also an advisor to the Genetic Interest Group, to which SmithKline Beecham have been controversially linked.  He has also been a scientific advisor to SmithKline Beecham and a former non-executive director and current chair of the  Scientific Advisory Board  of Adprotech plc, a biotech company  which he helped spin out from SmithKline Beecham.

Sir Peter, was an excellent witness for the vaccine companies. Whoops! sorry, the GMC. His part in any future film of the hearing has to be played by Woody Allen. I had noticed Sir Peter, earlier in the morning, sitting around in the GMC. He was a little disorganised man, whose papers were always appearing to get the better of him. He gave evidence much like the archetypal absent minded professor.

The essence of the evidence which Miss Smith drew from him, was that Dr Wakefield’s variety of transfer factor was decidedly shaky and of little if any clinical value. Perhaps because everyone wanted the hearing to finish on its allotted day, no one had any questions on cross examination for Sir Peter and his evidence, seemed to pass into a prosecution black hole that awaited exploration by the defence in four months time.

The End of a Tawdry Affair

On Friday October 19th  the prosecution finished presenting its tawdry case. It was a case strung together with only the weakest of threads. How much it has cost to stage this show-trial we will probably never know, although when it ends, it might be worth asking your MP to write to the GMC enquiring about just this.

The panel are paid Ł350 a day plus expenses (for those who travel from other parts of Britain and stay in hotels), when they are sitting. Although this seems reasonable, a comparison is bound to be raised when comparing the payment of this panel for an intermittent hearing of a year, and the financial difficulties with which some parents of some vaccine damaged children have to cope with or alternatively, the willingness of the State to provide funding research for the research work begun at the Royal Free.

However strenuously the prosecution have fought their corner, the case, even in the most befuddled mind, could not be said to have been cohesive, unified or even clear. The majority of allegations made by the prosecution have, in the main, been simply one side of an academic discourse from which no real blame or responsibility might be deduced. Take the matter of Dr Wakefield’s phone calls to GPs ensuring that they went ahead with referrals to the Royal Free. Unusual perhaps, but hardly a criminal matter or one for which a doctor could be struck off. Or the matter of giving advice as a researcher to clinicians; hardly problematic when those at the Royal Free were working as a close interdisciplinary team. Take, in fact, the rock-bed of the prosecution case that the 11 children whose cases were reviewed in the Lancet article were research subjects and not diagnosed or treated on the basis of clinical need. The prosecution have failed convincingly to link any of the cases to project 172/96 or proven to even a minor degree that the Lancet paper was in fact the result of work carried out under 172/96.

And so we might go on through an endless litany of mealy- mouthed complaints and minor irritations, brought before the hearing, to ensure that Dr Wakefield in particular is never able to give expert evidence or write again, in Britain with any authority about the MMR vaccination. Nothing, however, could possibly draw attention to the chicanery of this GMC prosecution as clearly as two matters which lie at the heart of the case.

 First, there were no complaints from the hundreds of parents who went to the Royal Free Hospital for diagnosis and treatment of their children. However hypocritically the prosecution mouths-off about vulnerable and therefore exploited parents and children, or however many times witnesses suggest that the parents were neurotic in searching for a fitting diagnosis and treatment for their children, anyone could see that the three doctors on trial have never offended against public morality or ethics.

By failing to bring any parents forward and by claiming sotto voce, that the parents don’t understand such high medical matters, the GMC has done the most terrible damage to paediatric medicine in Britain while showing itself to be a pawn in the hands of both the government and the Association of British Pharmaceutical Industries.

The second matter is the chilling fact that the complaint that was prosecuted was made by a single hack, Brian Deer, who has a history of writing in sympathy with vaccine manufacturers and unsympathetically of doctors who research vaccine adverse reactions and vaccine damage claimants. Despite all the moral and ethical kafuffle about conflict of interests gravely indulged in by Miss Smith and prosecution witnesses, they did not see fit to bring Deer forward as a witness so that he could be cross examined about his investigation, his motives or any vested interests he might have. This hiding of the major prosecution witness exhibits a kind of legal primitivism, the worst aspects of McCarthyism and the Stalinist Show trials.

It was clearly not in the interests of the prosecution to give us the full story of the children, their illnesses and how their parents have struggled to cope. Instead of bringing the parents as witnesses, we have struggled through every Lancet child’s case history, piecing together the case from fragments of notes. Exempting the parents from giving evidence and in fact discreetly putting them on trial along with the doctors who helped them is nothing short of an abuse of professional power by the GMC. 

Anyone even vaguely interested in the morality of this case should ask how it could be that parents who have suffered one of the most painful experiences likely to be encountered in life, of having to watch their children, in the words of one mother ‘disappear’ while recognising that they will have to be cared for throughout a lifetime, should be labelled as money grubbing neurotic conspirators. Running like a thread through the evidence is the feeling that these parents either exaggerated or made-up the severity of the illnesses of their children.

This is what the pharmaceutical industry and in this case, the state, now does to people who suffer adverse reactions to drugs or vaccines. 

The findings of Professor Munir Pirmohamed’s study in Liverpool suggested that the equivalent of up to seven 800-bed hospitals may be occupied at any one time by patients with adverse drug reactions (ADR), and that ADRs upon admission may be responsible for up to 5,700 hospital deaths a year.
See also Lazarou J, Pomeranz BH, Corey PN. ‘Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies’. JAMA. 1998 Apr 15; 279(15):1200-5.

Earlier on in the proceedings, the prosecution mentioned thalidomide. The context was something like, ‘Of course, this was not a situation like thalidomide where the adverse reactions were recognised and everyone knew about it’. The lies that they tell! It took years before the terrible damage that Thalidomide had done reached the surface of public society and the pharmaceutical companies tried every trick in the book to make the problem invisible. In the end, not one pharmaceutical executive or corporation was found liable. In the German court cases the manufacturers employed private detectives to seek out information about claimants that might be used by the defence to damage their characters. In fact there has never been a case of adverse drug reaction where the pharmaceutical industry has acted in good faith towards those damaged or destroyed by their products; pharmaceutical-company responsibility is an oxymoron.
If the prosecution’s characterisation of the parents is of a disparate group of vulnerable but neurotic individuals, who, encouraged by a mercenary solicitor and venal doctors sought someone to blame for their children’s condition, what is the defence view of them? As is usually the case with those suffering from adverse reactions to medical drugs or procedures, it is in fact, completely opposite. The parents of vaccine damaged children have to be understood in the context of the adverse reactions that their children have suffered. In British society, those who suffer adverse reactions to drugs become part of the ‘unbelieved’ a diaspora of the undiagnosed ill, who, if they persist with their complaint can easily be labelled with a psychiatric condition.

Parents contacted Dr Andrew Wakefield and the Royal Free Hospital between 1992 and 1997. Only a small minority of them came via the firm of solicitors which was making the claim for vaccine damage. The children had a number of common problems which the parents identified following their MMR or MR vaccinations. These parents were not involved in any conspiracy or collective delusion in identifying the onset of their children’s illnesses with their vaccination, in many cases, the association was clear and obvious, at least to the child’s parents who had no vested interests, except the love of their child.

In the main the children had serious bowel problems, linked in varying degrees to regressive autistic and behavioural disorders. The children were often in considerable pain and many of those that had, as babies and infants, made clear progress and met all their early behavioural markers, lost their language, mobility and the beginning of previously learnt social skills. Hundreds of parents contacted the Royal Free in particular because in the great majority of cases, their GPs and even local consultants had not the slightest idea of a possible diagnosis.

The doctors at the Royal Free gastrointestinal department acted as any good doctor would. Realising the advent of a medical and public health crisis they used every possible technique, strategy and even novel practice, to arrive at a new diagnosis and possible remedial treatments for the condition that they were witnessing. Of course, they paid intimate attention to the stories the parents had to tell and of course they believed the parents when they pin-pointed the onset of their child’s illnesses with their vaccination. These were good doctors. What the prosecution seems unable to grasp, is that in acting as conscientious doctors, all three men on trial at the GMC, spent long periods talking to parents and discussing their children. This patient care, this support, these conversations, this interest in the patient was not always reported in full or extensive notes by the doctors. It does not always become part of the public narrative which describes the medical journey of the child.

There can be no doubt that the approach of the medical team at the Royal Free was innovative, that it was multidisciplinary, that it went way beyond either simply diagnostic review or an attempt to fit on-the-surface symptoms to previously recognised conditions. The authors of the Lancet case series paper pointed to ‘a new syndrome’ and in these three words we can identify all the major failings, both in the GMC prosecution and the wider conspiracy to criminalise the Royal Free team. Had any epidemiological studies previously identified this syndrome? No. It is therefore not surprising that none of these studies show evidence of it. Did any of the professors or consultants called by the prosecution find this syndrome? No. It is therefore unlikely that they could comment upon it with any authority.

When we reflect on Andrew Wakefield, we have to acknowledge that we are seeing a rare phenomenon. Not only is Wakefield a patient empathc physician and research worker but he is clearly an original thinker and necessarily, in today’s world, a brave and principled man. It is when one considers these virtues that the straight, conventional and inevitably restricted witnesses who have been chosen to give evidence against him, appear to be so lack-lustre.

Creativity and collectivity count for nothing in Britain today. Following the managerial revolution of the nineteen-eighties and nineties and the great tide of political correctness which has swept across Britain, rules, regulations and an obsequious dedication to jobsworthian job preservation, are all that matters. In fact one could go as far as to suggest that the new century ushered in a post-industrial style of ‘I’m all Right Jack’. Nowhere is this new and hypocritical conservatism more obvious than in the higher echelons of medical administration and research.

*    *    *

After Booth’s evidence, perhaps accosted by a sudden sense of relief, I drifted, not for the first time during the hearing, into a deep sleep. During this relapse, I had a peculiarly real dream. I was standing outside the hearing room, in the foyer, as Professor Booth came out and went to leave.

Booth appeared flustered and disorientated. At first he strode towards the exit’s glass doors, then turned and walked back to the front desk, turned again and walked back towards the glass doors.

The young Australian lad on the desk stood up, eager to help him:

‘Do you want a way out mate?’

Booth looked at him distractedly,

‘I did all right yesterday, coming and going, I just did it empirically. But then when I got home last night, I got a call from Miss Smith. She was very annoyed, apparently I had “let the side down” in telling the hearing that I agreed with simply walking in and walking out of the building. “Don’t you know” she said, “there has been a review of 326 peer reviewed papers which discuss the question of how to get in and out of the GMC building? Would you please” she asked, “get yourself up to scratch with the science and read the review before you decide which route you take into the building tomorrow morning?”’

 'I was up most of the night, learning everything there was to learn about the route into and out of the GMC. But after the last cross-examination I’ve got all confused again.'

‘Sorry I just thought you might want to go home’. The Australian said, going to sit back down at his computer terminal.

Professor Booth turned on the young man, frowned, and gathered his thoughts before speaking.

‘Definitely not. Professors used to do that, but not anymore. The most recent evidence-based literature review of going-home-time for professors, puts it at about 17.15 and it’s now only 15.00 hours. I should therefore go home in about 2 hours and 15 minutes. So no, I’m not going home, I wouldn’t go home and you can’t make me say that I’m going home now’.

 ‘Gee mate, I wish I’d never asked. Look do you want to go home or not?’

‘Well it depends what you mean by home? Just because the great and the good get together in a place like Portugal, even if between themselves they have maybe 250 years experience, and they say ‘home is where the heart is’, doesn’t mean to say that this is right. Even I’ve been in a place that I have called home and thought it was home, only to be told that there had just been a study review published in the New England Journal of Medicine, and I’m obviously wrong.’

‘Look at it this way, just because this building is where your wife and a couple of children with the same surname as you live, and there’s a big notice in the hall saying ‘Home Sweet Home’, it doesn’t mean this is your home. In fact doctors, especially those living in the Midlands have a much higher threshold for calling any building with a kitchen and a bathroom and a resident wife in it, a home. Personally I think screening tests should be carried out by the person’s neighbours to see if the place really is your home, certainly before you embark upon any risky procedures such as cooking or fire lighting. And it would probably be wise to return to the hospital at least twice and retrace your steps, just to make sure you didn’t take any wrong turnings.’

When I woke to see Professor Lachmann introduced to the hearing, I thought for a time that the dream had turned to a nightmare. In fact I was fully awake and the last dreamy image I had of Professor Booth saw him walking round in ever decreasing circles.