If you live in Texas, you probably already know about the growing controversy that surrounds Merck’s new Human Papillomavirus (HPV) vaccine, Gardasil. Some strains of HPV cause cervical cancer in adult women, and some public health organizations believe the best course of action is to require compulsory vaccination of schoolgirls as young as 11 years old. The controversy in Texas was apparently sufficient to induce Governor Perry to circumvent the legislature and require the vaccinations by executive order.
If you live in California, Colorado, Connecticut, D.C., Florida, Hawaii, Illinois, Indiana, Kansas, Kentucky, Maine, Michigan, Minnesota, Mississippi, New Jersey, New Mexico, Oklahoma, South Carolina, or Virgina, you may hear more about this issue soon. Published reports like this one in The Wall Street Journal say Merck is funding a nonprofit advocacy group, “Women in Government,” to get legislation introduced in all of these states to mandate HPV vaccinations for sixth-grade girls. Merck’s critics claim that Merck uses a two-track lobbying strategy, first getting all the states to require compulsory vaccinations, and then complaining to Congress that it must have some protection from products liability suits if so many states are going to require the administration of so many doses of the vaccine.
This bubbled up into quite a controversy on the e-mail list that our local PTA uses to keep parents informed of school-related news, because one parent posted two or three articles about it and other parents asked that mere discussion of the topic be banned. (One of the people who requested the ban happened to be the director of the health policy team in a PR company that represents something called the “Cancer Vaccine Consortium,” but she assured the group that had nothing to do with her opinion.)
Maryland sixth-graders, it turns out, are safe for now. The legislator who sponsored the bill had already lined up the support of nearly half the state senate, but then when controversy arose, she pulled the bill, saying the timing was bad. She says she’ll introduce it again in the next session.
So why the controversy?
1. HPV is transmitted sexually. Some religious groups oppose mandatory vaccination on the ground that it will promote sexual promiscuity among teens. This seems dubious to me; it seems to presuppose that some identifiable number of teenage girls currently abstain from sexual activity because of a concern that they might get cervical cancer twenty years later, and I don’t think teenagers spend too much time worrying about consequences that are twenty minutes off. But I suppose that fixing an age for a vaccination that is linked to the beginning of sexual activity could have a sort of “Start your engines” effect that it would be perfectly rational for parents to wish to avoid.
2. The benefits of Merck’s HPV vaccine are quite arguably being oversold. According to the CDC, the vaccine only protects against four strains of HPV, and those four strains only account for 70% of cervical cancers. That means that adult women should still have annual pap smears to screen for the development (and early, usually-successful treatment) of cervical cancer. Compulsory vaccination may breed a counterproductive complacency in that regard. Moreover, the number of cases of cervical cancer that occur in the U.S. each year — about 10,000 — seems fairly small in relation to the number of girls that would receive the $360 vaccinations under mandatory vaccination laws. Reasonable minds can and do differ as to the cost-benefit analysis, but the differences seem to me to turn on conflicting assumptions about matters of human behavior that are for the most part unknowable. In addition, Merck has not established the effectiveness of the vaccine for more than five years, which makes the idea of starting at age 11 even more offensive than it would otherwise be.
3 . The potential harms of mandatory vaccination are a matter of speculation. The vaccine has been tested and has received FDA approval, but only a very small number of the test subjects were pre-teen girls, so it cannot really be claimed that anyone knows what the potential side effects would be for the cohort directly affected by these laws. However, there is a fairly rich literature of the many adverse reactions that people have to particular vaccines, and many parents of autistic children are convinced to a moral certainty that the huge battery of vaccinations required at or about age 3 was at least a contributing cause of their child’s autism. Gardasil apparently does not contain thimerosol or mercury, which are the ingredients most widely suspected of causing this sort of reaction in the past, but who knows the long-term effects of what it does contain?
4. Principles of personal autonomy. It is no accident that compulsory vaccination cases were among the first to reach the U.S. Supreme Court under the Free Exercise clause of the first amendment. Forced medical treatment is a very serious interference with personal liberty, and it is usually thought to be justified only by very serious public health consequences for society as a whole. Vaccinations against diseases with epidemic potential, like smallpox, are much easier to justify than a vaccination against HPV. (If my kids are in danger of picking up HPV at school, then their school has problems that go way beyond the health consequences.)
In amplification of this last point, I find it particularly curious that the vaccination programs are proposed only for girls. Yes, I know that only women can get cervical cancer, and only girls can grow up to be women. But that’s just the point: Don’t girls and their mothers have every incentive to discuss this with a doctor and make individual decisions about the costs and benefits? Why must the state step in and make that choice for them? If there is a public-health-oriented case for compulsory vaccination here, I should think it would be for compulsory vaccination of the boys, who play their role spreading the virus but have no comparable incentive to innoculate themselves.
In sum, I don’t know what to think about innoculating my own daughter, but I’m pretty sure I’m going to get advice on the subject from our doctor rather than our state senator. Or Merck.