reBOOKS • CD ROMSviews • ART • WEBSITES • MEDIA • PERSONAL VIEWS • SOUNDINGS

ful role of the media in the course of the of guilt over having had their children MMR controversy. immunised. It is true that the MMR-autism scare did Phillips is one of many journalists (by not start in the press. Both a reputable Lon- no means confined to the tabloids) who don teaching hospital and a prestigious have endorsed the anti-MMR campaign. medical journal allowed the scare to start. They have provided a voice for middle class Yet, once Wakefield decided to go public anxieties about environmental threats and Why can’t the Daily with his anti-MMR campaign, the media for the distrust of established sources of played a major part in promoting the scare. authority in science, medicine, and politics Mail eat humble pie Phillips’s response to the Cochrane study that have led some parents to reject MMR. follows the familiar themes of numerous Some journalists, writing as celebrity par- over MMR? anti-MMR articles over the years, including ents, have followed the principles of the several by Phillips herself. “journalism of attachment” popularised in recent military conflicts. This requires a he recent publication of a Cochrane Phillips’s article is scientifically flawed. high level of emotional engagement but no systematic review concluding that She seems to misunderstand the nature of a specialist knowledge of the subject (special- there is “no credible evidence” of a systematic review and to misinterpret any T criticism of studies of MMR safety, or any ist medical and scientific correspondents link between the measles, mumps, and have generally rejected the MMR-autism rubella (MMR) vaccine and either inflamma- expression of uncertainty about their link). Although autism has become fashion- tory bowel disease or autism provoked conclusions, as a vindication of Wakefield’s able in the media, a condition characterised demands that the British tabloid newspaper case. She echoes the mantra of anti-MMR by difficulties of communication remains the Daily Mail apologise for its role in campaigners that epidemiological methods uniquely terrifying to those who live by the promoting the MMR-autism scare (http:// are not suitable to discover an association word. For a profession renowned for its www.mrw.interscience.wiley.com/cochrane/ between MMR and autism, when this is pre- sociability, children for whom language and clsysrev/articles/CD004407/frame.html). cisely the point of such methods. Indeed, friendship are problematic are a source of Instead, on 31 October, the paper published this is why Wakefield explicitly invited potent fears. a feature by leading columnist Melanie Phil- epidemiological studies in his Lancet lips insisting that claims that MMR was safe paper—only to repudiate this approach were “a load of old baloney” (www.melanie- when one study after another failed to sup- British journalists have a phillips.com). Phillips proclaimed that, far port his hypothesis. from having received the “all-clear,” the In endorsing Wakefield’s claims, Phillips poor record on MMR and, “MMR scandal” was “getting worse.” ignores the overwhelming weight of scien- indeed, on autism The otherwise unanimous verdict of the tific evidence to the contrary. She insists that media was that the Cochrane review— his discovery of “autistic enterocolitis” has With a few notable exceptions—such as following a series of studies coming to the been replicated around the world and that Brian Deer, whose work for the Sunday same conclusion—confirmed that the scare “vaccine-strain” measles virus has been Times and Channel Four helped to discredit launched following the now notorious found in cerebrospinal fluid samples from Wakefield’s Lancet paper—British journalists Andrew Wakefield Lancet paper in 1998 was autistic children, though she fails to have a poor record on MMR and, indeed, finally over (Lancet 1998;351: 637). Phillips’s mention that these few studies have been on autism. While certain journalists have defiant article stands as a symbol of the woe- carried out by Wakefield or his collabora- lionised Wakefield, real scandals—such as tors and are universally dismissed by the recent death of an autistic boy from reputable authorities. Britain undergoing mercury chelation Two days after publication of her Daily therapy in the United States, or the Mail article, Phillips was criticised by doctor inadequacy of respite services revealed by and columnist Ben Goldacre, in a piece in the conviction of a 67 year old mother the Guardian newspaper. This week (8 for killing her adult autistic son when she November) the Guardian gave Phillips a could no longer cope with his violent right of reply, in which she defended the behaviour—have largely been ignored stance of her Mail article. (www.spiked-online.com). If children die Phillips appears to be captivated by from measles, the MMR scandal may indeed Wakefield’s self professed status as a maver- get worse. ick and crusader against the establishment. His posture of martyrdom and victimhood Michael Fitzpatrick general practitioner, London seems to have a particular appeal for [email protected] Phillips, whose polemical style provokes much animosity. The price of this self Competing interest: MF is the author of MMR indulgence (Phillips is one of Britain’s best and Autism: What Parents Need to Know paid journalists) is borne by the real victims (Routledge, 2004). of the MMR-autism fiasco. These are parents anxiously facing decisions about Items reviewed are rated on a 4 star scale immunisation and parents of children with (4=excellent) autism who carry an unwarranted burden

1148 BMJ VOLUME 331 12 NOVEMBER 2005 bmj.com reviews

people working at the community level to take on poverty and global health. Less publi- cised, a group of international health leaders met at Yale University as part of the Oxford Health Alliance to increase global attention to the epidemics of chronic diseases such as diabetes, cardiovascular disease, and cancer. The US Public These events put sharp focus on the need for strong collective action, and they pointed out Broadcasting System in clear terms that we have the historical and Time Magazine knowledge and the economic means to make an immediate difference in these global take on global health problems. The PBS series, narrated by Hollywood A week of events including the television actor Brad Pitt, began with in-depth coverage series RX for Survival: A Global Health of the current polio campaign, focusing on Challenge, broadcast on PBS from 1 to 3 the last remaining pockets of resistance and November and available on VHS and DVD the last residual cases of acute flaccid www.pbs.org/wgbh/rxforsurvival/index.html paralysis. David Heymann, WHO polio campaign director, remarked that as a result Rating: ★★★ of the most sweeping public health campaign in history, we might soon see the last cases of ith the discovery of penicillin in polio. In 1977, after thousands of years of the 1940s, scientists were confi- human suffering, we saw the last case of small- dent that “humanity had finally W pox in Somalia, eliminated using ring vacci- provides cheap transportation for medical won” in the war with microbes. Infectious care and medicines, delivers health care to the diseases that had devastated the globe for nation and creative surveillance to isolate cases and prevent spread. But these two most remote places in Africa. In west Africa, centuries were in abeyance by the 1970s, ivermectin is distributed as a cooperative and most people in developed countries did eradication campaigns are different, and the story behind them, told by smallpox warriors effort between Merck, the World Bank, the not fear the old scourges of smallpox, Carter Center in Atlanta, and others to halt cholera, plague, malaria, and tuberculosis. D A Henderson and William Foege, revealed what has to be done to eradicate polio. One river blindness in its tracks. In Botswana and Since then, however, the world has been Uganda, the pan-African disaster of HIV/ shocked by the rise of new plagues such as must overcome not only huge logistic problems, but also political and religious AIDS has been slowed through good medical HIV/AIDS and SARS (severe acute respira- practice and increased financing. tory syndrome), haemorrhagic fevers arising resistance and misguided complacency. In Nigeria, rumours that Western coun- Without such interventions, life expect- from Ebola and Marburg viruses, and the ancy can be expected to go down, and the threat of avian influenza. But many old tries included sterilising chemicals in the polio vaccine caused resistance to the costs of inaction will overwhelm economies plagues still devastate developing countries, and health systems. Already, 80% of all hos- destabilising the global community and campaign, and polio then spread to other sub-Saharan African countries; in India, pital admissions in sub-Saharan Africa are unnecessarily killing millions. In response, for AIDS related illness. The money is avail- rock stars, developmental economists, bil- devout Muslims preferred to trust in god rather than Western-sponsored campaigns to able, prevention and treatment options are lionaire entrepreneurs, and even occasional well established, and now commitment, governments now recognise the need for protect their children; in affluent US commu- nities, well off mothers refuse vaccines funding, science, and human resources can commitment to global health. make a difference. Last week the US Public Broadcasting because of potential harm to their individual Although the series referred to the System (PBS) put out a six-part series entitled children. All of these resistant cases are epidemic of obesity as an emerging global Rx for Survival, dedicated to explaining the targeted as part of a collective enterprise health threat in both affluent and emerging historical successes and new challenges in requiring cooperation and commitment to economies, it made no mention of the infectious disease control. Time Magazine universal immunisation, just as many other enormous burden caused by tobacco, the simultaneously staged a global health summit diseases require cooperation and commit- high burden of disease resulting from mental in New York that attracted former US ment for the greater public good. ill health, and the growing impact of physical president Bill Clinton, Microsoft founder Bill An episode entitled “The Rise of the inactivity and poor diet on health equity. The Gates, Jeffrey Sachs, director of Columbia Superbugs” pointed out the clear, imminent Oxford Health Alliance represents the most University’s Earth Institute, Peter Piot of danger we face with resistant organisms, visible recent effort to focus on these UNAIDS, the World Health Organization’s especially tuberculosis, and the lack of new problems. Jim Kim, and (by video) U2’s Bono. antibiotics in the drug development pipe- The PBS series showed that cooperation In addition, a special Time issue on global line. A perfect microbial storm may be is vital, and that the private sector, govern- health highlighted the “heroism” of 18 ahead, with poverty, health systems failures, and lack of investment in therapeutics all ments, and media are all needed to make a coalescing to threaten not only the poor of difference in global health. The Time Global the world, but all persons affected by these Health Summit was heavy with celebrity, organisms. Paul Farmer and Jim Kim of the bringing, as Bono put it, the bright lights to non-governmental organisation Partners in the problem. People like Bill and Melinda Health have shown how, despite abject pov- Gates bring resources, but governments erty, multiple-drug resistant tuberculosis is must bring leadership. Global health is nec- confronted and controlled through creativ- essary as a moral and economic imperative, ity and dogged determination. These bugs and now, more than ever, it has been placed will never go away by themselves. on the international agenda for all. In an episode on “Delivering the Goods,” 21st century technologies were shown to Thomas E Novotny professor in residence, epidemiology and biostatistics, and education TABITHA JACKSON, COURTESY OF WGBH extend the reach of good medicine through coordinator, University of California at San The series’ message was that cooperation is proper management and individual commit- Francisco Global Health Sciences, USA vital for health in the developing world ment. Riders for Health, an NGO that [email protected]

BMJ VOLUME 331 12 NOVEMBER 2005 bmj.com 1149 reviews

Nelson’s Surgeon: William none the less usually from more privileged backgrounds than most of the crew and they Beatty, Naval Medicine, and resented their lowly standing, often being the Battle of Trafalgar forbidden from dining with the officers and, Laurence Brockliss, John Cardwell, if present, the ship’s physician. The career Michael Moss structure of the naval surgeon appeared to have been a precarious one, depending as Oxford University Press, £45, much on the patronage of the captain of the pp 236 ISBN 0 19 928742 2 vessel they were assigned to as their technical skill and judgment. Rating: ★★★ One such example is that of Sir William Beatty, an Irishman whose career got off to an inauspicious start when he fell foul of Commander Lord Augustus Fitzroy, who accused him of bowing sarcastically. A court martial rejected the case as trivial, effectively ending Fitzroy’s career. Working for the industrious Captain Henry Digby, Beatty WELLCOME LIBRARY, LONDON enjoyed better fortune and his excellent Beatty: excellent health statistics he 200th anniversary this year of the health statistics brought them both to the attention of Admiral Nelson. Battle of Trafalgar has sparked new brutality and occasional tedium of life on In 1804 Nelson appointed Beatty to the life into the subject of Britain’s mari- board a vessel of Nelson’s fleet. They imply T HMS Victory, the flagship of the British fleet. time history. But the work of naval surgeons that a critical factor in the success of the At Trafalgar one year later, Beatty was to dis- has rarely been explored in any great detail. British fleet was that its sailors were healthier tinguish himself, as 96 of 102 casualties— Signing up for the navy was often seen as a than their French counterparts, largely including nine of the 11 amputees— route by which young men with an interest owing to advocates of preventive medicine survived. The average death rate from in surgery and a basic qualification provided such as Beatty. The class politics and struggle amputation at the time was about 33%. by the Company of Surgeons could gain for surgeons to have their skills recognised experience before furthering their career in Beatty was unable to save Nelson, however, permeate this work, hinting at the seething private, civilian practice. For others it was the who died in battle. resentment that lay at the interface between only opportunity to practise, their level of Based loosely on the life and career of physicians, surgeons, and the Royal Navy. proficiency being deemed inappropriately William Beatty, Nelson’s Surgeon is a study of poor to be let loose on the public. naval surgery during the Napoleonic wars. Graeme Glass senior house officer in plastic At a time when surgeons were not In a rigorously researched piece of work the surgery, St George’s Hospital, London required to have studied medicine, they were authors paint a vivid portrait of the hellish [email protected]

owners, local corruption, and the belief that In the third story a Canadian porn actor having sex with a virgin can cure HIV tries to forge an HIV test by using his grand- infection, which in turn leads the disease to be father’s blood. When he is found out, his spread further among young women and mother (played by Stockard Channing), in a children. desperate bid to pull her family out of China is the setting for the second story, poverty, tries to exploit insurance compa- where poor farmers in a remote village are nies. In their recklessness both mother and 3 Needles paid money to donate blood, which is then son spread HIV, without any feelings of guilt transported to the West to be made into or remorse. Directed by Thom Fitzgerald blood products. Poverty and need force resi- The triad of ignorance, poverty, and Shown at the London Film Festival on dents to sell even their young children’s poor health that 3 Needles portrays perpetu- 31 October and 1 November blood. ates itself in a vicious cycle, resulting in death Rating: ★★★ and destruction of whole civilisations. The messages of the film are clear: religion is not he Canadian film 3 Needles is a chal- the answer; salvation cannot come through lenging attempt to analyse the role prayers alone; educating people about how of the West in causing disease and HIV is spread and to practise safe sex is the T only effective way of combating AIDS. poverty in the developing world. Set in South Africa, China, and Canada, it weaves This film is a timely reminder that the together three stories with the common AIDS pandemic is still with us, especially in theme of blood, religion, and sacrifice. Africa. For example, a recent census showed It begins in South Africa, portraying the that 38% of adults in Botswana are infected rituals of male circumcision and young with HIV. However, 3 Needles does suffer adolescents’ entry into a new world of from a lack of real character development; manhood and adult responsibilities. Into this most of its characters have a symbolic role, climate of deep-rooted cultural beliefs comes representing whole nations. Despite this, an idealistic young nun-nurse (played by and the lack of a clear narrative link and the Chloë Savigny), who believes that prayer can film’s occasionally confusing structure, it is make the world a better place. She seeks to worth watching for its powerful global convert Africans dying from AIDS to health message. Catholicism and puts her own life at risk in the process. The story is told against a The film is timely reminder that AIDS is still Khalid Ali senior lecturer, University of Sussex background of exploitation by rich farm with us [email protected]

1150 BMJ VOLUME 331 12 NOVEMBER 2005 bmj.com reviews

PERSONAL VIEWS SOUNDINGS In Pakistan’s earthquake zone global relief Just listening has so far failed its test A few years ago I helped with a door to door survey on a grotty council estate. I t over 1.83 metres tall and a former to my feet and wave my arms violently, had been drafted on to some ménage à soldier, I do not cry easily, yet I am trying to attract the pilots’ attention. trois collaboration (academic, service, and A certainly crying now. The reason? “Panjgiran!” I yell, “Come on guys, give us voluntary sector), and we were heavy on Frustration following Pakistan’s earthquake, some of your load!” I cup my hands around hearing local voices. perhaps the biggest disaster to strike this my mouth and shout the village’s coordi- I had helped design the survey and planet in my lifetime and something that the nates, “North 34° 26' 47.3", East 73° 37' done my utmost to ensure that it was world’s largest aid effort seems powerless to 12.3"!” But the helicopters carry onwards, evidence based. We especially wanted to relieve. clearly unaware that I even exist. So I sit include refugees, chain smokers, single I am in the Neelam down hard, childishly hold- parents, people who didn’t speak valley, east of Muzaffarabad, There is no way of ing my head in my hands, as English, the unemployed, people who helping to establish two I realise that my efforts are sell sex, those addicted to illegal small field hospitals. At the reaching every wasted. Of course the pilots substances, etc, so that we could design beginning the situation was person other than cannot see me, a tiny accessible and culturally congruent hopeless, with large num- frustrated speck on the side services at the interface between health bers of disaster tourists and on foot of a massive 3000 metre and social care. their cameras, each seeking mountain. I parked my car two miles away and the one image that could establish their The problem is clear although the solu- made my way across a motorway bridge, careers. Then there were the tedious tion is not. No matter how many helicopters through an alley, past burnt out vans and meetings with aid agencies from around the may be donated, no matter how much abandoned junk, to the far corner of the world. The answer was clear. The people money is given, the end point of delivery is a estate, where my target block of needed action, not discussion. Today I am in small, destroyed household perched on a most-deprived flats lay. the little village of Panjgiran, in the company mountainside. Even if a helipad does exist it Times have moved on. You can now of Ahmad, a respected local in the throes of is likely only to be able to take the smallest of explore the perspective of society’s post-traumatic stress after losing his entire helicopters. In my time here I have seen sev- have-nots without setting foot outside family in the earthquake. It was at 8 52 am eral machines sink beyond their axles into your ivory tower. Just send them the URL on 8 October when, unexpectedly, the the clay-like mud. Physically, there is no way of the Department of Health’s latest ground shot vertically upwards. Within three of reaching every person other than on foot listening exercise, “Your health, your care, seconds it was all over with three million or, perhaps, encouraging the householder to your say” (www.nhs.uk/yoursay/). Your homeless and to date around 80 000 dead. come down. If they can, of course, with their sample can simply click a radio button to As I walk through the village, it is clear festering wounds, neglected fractures, and indicate whether they would prefer to that there is no building intact. Ahmad half-starved bodies. Only yesterday I saw a receive “Information, support and advice shows me the pile of rubble that was once 12 year old boy who had dislocated his right on tackling drug use,” “An NHS book on his house and the corner of the ruin from hip during the earthquake. It had taken him taking care of your own health,” or “Routine physical examinations for which he extracted his mother’s corpse. We more than a day to reach me, carried by his anyone who wants one.” walk on, tears streaming down our faces, father. His mother and his sister were long Their responses constitute, in the until we reach the school. This, too, has been since dead, one beheaded by their corru- government’s own words, “democracy in flattened. Exercise books, once carefully gated iron roof on 8 October, the other action.” They will—presumably—be written and cared for, now flap uselessly in smothered by sliding rubble. collated and used to prioritise the wind while opposite sits a group of four In the distance I see the helicopters community based service provision for children. They are motionless; eyes open in deliver their cargo to a military base and I the disempowered and socially excluded. incomprehension, orphaned that terrible know that that is the end of the line for the day and, even now, with no one to care for Because thousands of people have aid. There are few smaller helicopters to clicked their way through the survey, the them. deliver the items further up the mountain- data generated will be robust and On we walk, the stench of death still lin- side. I have also heard that there is a cash reliable—or so the government thinks. gering in the air, families grouped by the crisis and that relief flights may be Because people have been asked for roadside, their most senior male member suspended within the next few days. So I sit their views directly, rather than rising to greet me. I try to explain the prob- on my mountainside feeling helpless. Mad professionals or voluntary sector lems; the endless, futile meetings, the lack of ideas flit through my mind. Employ 10 000 advocates speaking on their behalf, helicopters, and the size of the relief mountain guides to walk every ridge in service users are expected to be more operation, but I can see my explanations Kashmir, or mobilise every soldier, sailor, empowered. landing on deaf ears. I see instantly what is and pilot in the globe. Yet even then only An elderly woman has just been needed. A tent for each family, a guaranteed the surface would be scratched. At 8 52 am given a suspended prison sentence for food supply, and health care for their fester- on 8 October global relief began its test; to suffocating her severely disturbed and ing wounds. date, it has failed. However deep we all dig, violent 36 year old autistic son. She had I shake Ahmad by the hand, mumbling the end point is the 12 year old boy, or been his devoted carer for 30 years, and something useless such as “I’ll do what I Ahmad, or the millions like them, stranded had written repeatedly to social services can,” and find myself a lonely spot on the on remote mountainsides in the wilds of pleading for help, with no meaningful mountainside overlooking the valley. Kashmir. Tears of frustration are no help. It response. Now there’s a listening exercise Beneath me I see a blue, winding, is just that crying is all I can think of right that the government might like to reflect picturesque river, but all around there is now. on. evidence of landslides, both old and new. Below also is the road, now impassable. Richard Villar consultant orthopaedic surgeon, Trisha Greenhalgh professor of primary health Another helicopter flies overhead, and Wellington Hospital, London care, University College London another, and another, and another. I jump [email protected]

BMJ VOLUME 331 12 NOVEMBER 2005 bmj.com 1151