10

Grub Street Medicine

Monday October 8th to Friday October 19th

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.

• Blood-screening tests should always be done before planning colonoscopies.
• The Royal Free team definitely appeared to be involved in research rather then clinical work.
• Dr Wakefield frequently appeared to overstep the boundaries of his research employment.
• Dr Wakefield frequently overstepped his job description.
• Dr Wakefield should have had no part in admitting or helping get patients referred from GPs to the Royal Free.
• Many of the children were not suffering from disintegrative disorder as suggested by the protocol for project 172/96
• Many of the children reported in the Lancet study did not fulfil inclusion criteria for project 172/96.
• On occasions it appears that Dr Wakefield actually ordered an investigation.
• The team went further than initial/past diagnoses of diarrhoea or constipation to carry out more invasive tests which were rarely indicated.
• It is unusual to send a child patient to a tertiary clinical centre hundreds of miles away from their home.
• Should Dr Wakefield have been ‘working with children’ when he had no paediatric qualifications.
• In a number of cases Professor Booth saw no reason for follow up investigations.
• Professor Booth did not consider it ‘normal’ for a consultant to personally contact a GP, neither he nor any of his colleagues ever did this
• Dr Wakefield should have sought extra Research Ethical Committee approval for the prescription of a novel treatment. (This referred to some of the invasive procedures and prescriptions, but most particularly to ‘transfer factor’.)
• Dr Wakefield’s taking of blood samples for controls at his son’s birthday party Professor Booth considers ‘deeply disturbing’ and ‘utterly repellant’.

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.