The MMR Vaccine
| Author | Ruth Webster |
| Published date | 01 October 2007 |
| DOI | 10.1177/0952076707081588 |
| Date | 01 October 2007 |
| Subject Matter | Articles |
© Public Policy and Administration
SAGE Publications Ltd
Los Angeles, London, New Delhi
and Singapore
0952-0767
200710 22(4) 423–441
The MMR Vaccine
A Case Study of Policy Stability
Ruth Webster
Glasgow Caledonian University, UK
Abstract
The policy on mass childhood immunization is an established element of the
UK’s approach to public health. During the late 1990s the triple measles,
mumps and rubella (MMR) vaccine was the subject of widespread concern
vis-a-vis its possible link with bowel disorders and autism. The government
resisted calls for policy change despite a decline in MMR uptake. Why did the
government continue to support MMR? The article explores this question and
advances a possible explanation of policy stability in the face of pressure for
policy change. It draws on the advocacy coalition framework to examine the
immunization policy process, analyse the role of expert advice and contrast the
relative strength of the government’s case with the relative weakness of those
actors advocating policy change. While the advocacy coalition framework
helps to frame the analysis, it is an imperfect fit for the case study. Instead of a
policy subsystem of competing advocacy coalitions, the case reveals a
dominant group of actors (likened to a policy fortress) presiding over
immunization policy. It is suggested that the presence of such a group would
make it difficult for all but the most highly organized, strategically minded
actors to advance their cause.
Keywords
advocacy coalitions, health policy, implementation, pressure groups
Introduction
Explaining change is a core line of inquiry in public policy research. Policy change
may occur slowly, allowing for absorption and adaptation. Alternatively, policies
can be transformed quickly by, inter alia, events, crises, ideas and actions. It is just
as important to investigate the reasons why some policies persist while others
reformulate. Models and frameworks capturing the myriad facets of policy change
and/or stability include policy streams (Kingdon, 1984), the advocacy coalition
DOI: 10.1177/0952076707081588
Ruth Webster, Globalisation and Public Policy, Glasgow Caledonian Business School,
Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, UK.
[email: Ruth.Webster@gcal.ac.uk]
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Public Policy and Administration 22(4)
framework (Sabatier, 1988; Sabatier and Jenkins-Smith, 1993, 1999) and the
punctuated equilibrium model (Baumgartner and Jones, 1993). Drawing on the
idea of change and stability, and aspects of the advocacy coalition framework in
particular, this article presents a case study of policy stability in the face of
pressure for policy change.1
The policy on mass childhood immunization is a long-established, successful
element of the UK’s approach to public health. Children receive a series of vacci-
nations including the triple vaccine, which guards against measles, mumps and
rubella (MMR). During the late 1990s the MMR vaccine became the focus of
widespread concern over its possible links with bowel disorders and autism (see
for example Fitzpatrick, 2004; Horton, 2004). This culminated in calls for a
change to this aspect of the existing policy that would make single vaccines avail-
able as an alternative to the combined MMR vaccine. However, the government
maintained its commitment to existing provision in spite of declining levels of
MMR uptake, a clear policy alternative and pressure for change from a range of
actors.
There have been similar challenges to immunization policy over the years. For
example, fear over the possible link between the pertussis (whooping cough)
vaccine and brain damage in the 1970s led to a dramatic decline in whooping
cough immunization uptake followed by the return of the disease and 27 deaths
between 1977 and 1979 (Fitzpatrick, 2004: 25). Fitzpatrick (2004: 27) compares
the impact of the whooping cough and MMR controversies both with regard to
vaccine uptake and political significance. He contends that:
Although the whooping cough scare produced a dramatic fall in vaccine uptake, it did
not become a major political issue. By contrast the MMR scare, though causing a much
smaller drop in uptake, created a major stir in British politics. (Fitzpatrick, 2004: 27)
The ‘stir’ created by MMR makes it an interesting case study of policy stability.
When faced with considerable pressure from scientists, politicians, anti-vaccine
groups and sections of the media, why did the government not capitulate? The
article seeks to explore this question and advance a possible explanation of policy
stability. It draws on the advocacy coalition framework to achieve this. A discus-
sion of the MMR case highlighting key events and actors is the subject of the next
section. It is followed by an outline of the advocacy coalition framework and its
applicability to the case study. The final section presents a possible explanation of
the government’s support for the existing policy on MMR with reference to the
advocacy coalition framework.
Immunization Policy and the MMR Vaccine
The combined measles, mumps and rubella vaccine was introduced in the UK in
1988. It replaced single component vaccines and is one of the vaccines adminis-
tered as part of the policy on mass childhood immunization. The policy is
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Webster: The MMR Vaccine
developed and coordinated centrally from Whitehall and implemented throughout
the country with only minor differences (when deemed necessary) in the devolved
administrations (Salisbury, 2005). Immunization is not compulsory, marking out
the UK from countries such as the USA.
On the recommendation of its expert advisory group (the Joint Committee on
Vaccination and Immunisation [JCVI]), the Conservative government approved
the use of the MMR vaccine. Reflecting the general achievements of the policy on
childhood immunization, uptake rates of the MMR vaccine rose steadily from its
introduction to 92 per cent in England by 1992 (Fitzpatrick, 2004: 13).
Subsequently, rates of measles, rubella and mumps infection declined (Horton,
2004: 18). In addition to these measures of success, there are additional factors
favouring the MMR vaccine over single component vaccines, namely an easily
administered process and lower costs (Horton, 2004: 19). Thus:
Given that all the early evidence showed that MMR had an efficacy and safety profile
comparable with single vaccines, the triple vaccine was seen as a massive step forward
for child health protection. (Horton, 2004: 19)
However, anti-vaccine sentiment in general, and towards MMR in particular,
developed in the 1990s. The main concern was vaccine safety and the possibility
that some children experience adverse reactions. Fitzpatrick (2004: 101) suggests
that a government campaign in 1994 to immunize schoolchildren against measles
and rubella galvanized anti-immunization feeling. The measles and rubella (MR)
campaign was launched in response to concerns about a potential measles
epidemic and the rising number of rubella cases. The campaign was successful,
having ‘reached 92 per cent of its target population’ (Fitzpatrick, 2004: 102) but
not everyone was certain that such a campaign was warranted. For example, the
Secretary of State for Health was asked about the rationale for the MR campaign,
the evidence on which a potential measles epidemic was predicted and the
possible side-effects of the vaccine on some of the children who received it (HC
Deb, 2 November 1995). Fitzpatrick (2004: 102) regards the public information
strategy for the MR campaign as one of the factors contributing to anti-vaccine
feeling because of its emphasis on the dangers associated with the diseases. He
also argues that growing anti-immunization sentiment, particularly in the after-
math of the MR campaign, together with the creation of parental action groups
such as JABS (Justice, Awareness, Basic Support) and the preparation of a legal
case against vaccine manufacturers, contributed to the anti-MMR campaign
(Fitzpatrick, 2004: 103–6). The work of Dr Andrew Wakefield had a similar
effect.
Dr Wakefield’s work in the early 1990s identified a potential link between the
measles virus/vaccine and Crohn’s disease:
He eventually suggested that one source of measles might be the measles vaccine. The
risk of developing Crohn’s disease in those who received live measles vaccine was three
times greater than those who did not. (Horton, 2004: 22–3)
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However, no claims of proof were made (Horton, 2004: 23). Wakefield’s work
received public attention when it featured in a Sunday Times article in December
1995 (Fitzpatrick, 2004: 106–7). Yet it was the publication of an early research
article in The Lancet by Dr Wakefield and a team of scientists from the Royal Free
Hospital in February 1998 that brought concerns over the safety of the MMR
vaccine to a wider audience and marked the beginning of a potentially serious
challenge to immunization policy. The article, entitled ‘Ileal lymphoid-nodular
hyperplasia, non-specific colitis, and pervasive development disorder in children’
(Wakefield et al., 1998), presented the team’s findings from a study of 12 children
who had been referred to the Royal Free Hospital. The authors identified a
potential link between the MMR vaccine and the development of bowel disease
and autism in children. While discussing their children’s symptoms some of the
parents had mentioned the MMR vaccine (Horton, 2004: 23). The article was care-
ful not to suggest that the research proved any such link (Fitzpatrick, 2004: 119;
Horton,...
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