The HPV vaccine, my bread and butter, and why Rick Perry should have known better

From the moment Rick Perry announced his 2012 Presidential candidacy, I knew there would be trouble. Michelle Bachmann's critique that Perry was in the pocket of big pharma (Merck), back in 2007, may or may not have legitimacy, but Perry's attempt to require the HPV vaccine in Texas played perfectly into Merck's marketing strategy for its new (and potentially controversial) vaccine.

In February 2007, Rick Perry, then governor of Texas, overrode the state legislature to require the human papillomavirus (HPV) vaccine for school entry. At the time, the HPV vaccine, Gardasil, was only available for girls, making it a touchy subject for parents who didn't like to think about their adolescent girls' risks for STIs. Concurrent with Perry's gubenatorial power grab, Merck was quietly lobbying state legislatures around the country, mostly through a questionable organization Women in Government, trying to get states to include the HPV vaccine as part of school entry vaccines.

On one hand, school entry vaccines have a long history in the U.S. Though there are increasing numbers of parents who opt out of the school requirements, this topic is more or less a non-issue for most parents when they enroll their kids in kindergarten. What makes the HPV vaccine different is its requirements were for sixth or seventh graders, and at the time only for girls, heightening the emphasis on its possible tacit acceptance of adolescent sexual activity. Interestingly, the parents who resisted the HPV vaccine requirements tended to emphasize not its association with sexual behavior, but rather these parents focused on a libertarian/Tea Party (though this was not yet a widespread movement in the States at the time) position: we don't want government deciding what's "right" for our children. No one seemed upset about other government public health measures, such as water fluoridation or even other school entry vaccines. Yet few of the opponents to an HPV vaccine requirement voiced explicit resistance to its association with the most common sexually transmitted infection (STI).

Rick Perry, at the time of his infamous mandate, framed his decision especially oddly. He argued that this measure was a pro-life one, stating:

Never before have we had an opportunity to prevent cancer with a simple vaccine. While I understand the concerns expressed by some, I stand firmly on the side of protecting life. The HPV vaccine does not promote sex, it protects women's health. In the past, young women who have abstained from sex until marriage have contracted HPV from their husbands and faced the difficult task of defeating cervical cancer. This vaccine prevents that from happening (emphasis mine, La Prensa, February 14, 2007).

The succession of events were fast and furious, with multiple parents suing Perry for overstepping his executive office and the state legislature promptly overturning his inititative. He had also been accused of accepting Merck campaign funds and that his former aide was now a lobbyist for Merck. Simultaneously with Perry's undone executive order, the New York Times published a couple of articles identifying Merck as the lobbying force around many of the state legislature initiatives. Almost all of the state laws failed.

Now that Perry is trying to win the Republican nomination, it's no surprise that he's being resoundedly attacked by his competitors. Though Bachmann's unrelenting insistence that the vaccine could have "very dangerous" side effects is unfounded (especially her endorsement that one girl suffered mental retardation as a result), I'm fascinated by the unfolding of this more than 4-year old discussion.

Bachmann's decision to attack Perry on the HPV vaccine does not seem to address his willingness to override the legislature's role nor his explicit indifference to the preferences of his constituents. Instead Bachmann wants to drag him down for his exposing girls to a purportedly harmful vaccine, which she herself admits she is not knowledgeable enough to determine whether its safety should in fact be called into question.

What's most interesting to me about the rehashing of the HPV vaccine debates (and I have to say, having written my dissertation on the topic, it's a little boring to me), is how perfectly it fits into the Tea Party agenda and how well it reveals the logical inconsistencies of this movement. Further, I have long argued that in order to avoid the conservative backlash against the HPV vaccine, Merck marketed the vaccine as a vaccine against cancer, not as an STI preventive. Even during the FDA hearing to approve the vaccine, the conservative organizations emphasized that they would never be against a vaccine that protected against cancer. All of Merck's ads for the vaccine have promoted it as a cervical cancer preventive, avoiding the controversy associated with sex in the U.S. It's ironic, then that the conservative movement, especially the Tea Party, has still been distrustful and critical of the vaccine and any of its proponents. Ultimately, this suggests that the debates are tacitly about sex, even as other cultural zeitgeist topics such as government regulation are invoked as the reasons for the groups' objections.

Excess of care and the ongoing need for improvements in women's health

One of my main critiques of the HPV vaccine has been that the new technology may pre-empt efforts to improve existing practices. Women's healthcare remains full of unnecessary interventions, insufficient information, and an over-emphasis on reproductive health rather than holistic health. In the case of the HPV vaccine, I have argued that gynecological care remains static and frozen (in some respects) with the availability of new method for preventing HPV, rather than critically refining the way we do things now. And the way we do things now could use some refinements.

Almost two years ago, the guidelines for mammograms, the screening of women's breasts for potential tumors, were changed from recommending screening at age 40 to starting screening at 50. Part of the change was due to concerns of unnecessary tests that may produce false positives. The cost and the stress of the ambiguous results did not seem worthwhile. Further, the earlier testing failed to demonstrate a "significant" reduction of mortality due to breast cancer.

A lot of women were publicly outraged. They felt their health was being sacrificed for solely cost-saving reasons. My favorite post was George Lakoff's, a philosopher who teaches at Berkeley, who claimed that there would be thousands of women's lives affected by the changes. His argument was highly suspect, as he uses arithmetic to argue that nearly 42,000 women would die due to the new regulations. This is a far too simplistic argument for understanding health risks. Further, I expected more from a philosopher; his statement that women would die due to the regulations is completely fallacious. Not every woman with breast cancer dies. The reaction across the States to the change in regulations is a common one when it comes to shifts in existing medical interventions. None of us wants to be the one "sacrificed" for population-level purported benefits. And yet, this sense of entitlement is so very American and so very much part of why we have one of the most bloated and expensive healthcare systems in the world.

In a related article, shortly after the 2009 changes in mammogram recommendations, Barbara Ehrenreich wrote very convincingly about how the breast cancer advocacy industry has, in some ways, co-opted the feminist movement. The pink ribbon consumerism is the new rallying cry for women, rather than more substantive women's health concerns. Women's outrage about the mammogram guidelines' shift lacked a real understanding of the reasoning for the shifts. She also takes Lakoff to task for overly individualizing the experience of breast cancer (by a man, whose wife received a false positive, no less, though she does not make this point). And this undermines women's movements and the quest for improvements in women's healthcare, for which Ehrenreich calls.

Similarly, cervical cancer screening guidelines have also changed in the recent past. Instead of annual screenings with a pap smear (the scraping of cervical cells to identify abnormalities in the cervix), women over 30, who have normal results with a combined HPV test (a DNA-based test that can determine whether a woman has the higher-risk type of HPV that can lead to cervical cancer or the lower-risk type that does not lead to cervical cancer) and pap smear can then shift to the every three years' pap smear. Similarly, younger women should receive the pap every two years. (I should add that the guidelines are very convoluted and full of logic twists and turns that it's no wonder no one knows what is considered "appropriate" anymore.)

There's a recent government study that shows that MDs are actually over-testing women using both the pap smear and the HPV test. The issue of over-testing is similar to the reasons that the mammogram guidelines shifted. Or rather, similar, but also different. Young women are likely to have HPV if they're sexually active. But they're also likely to clear the infection on their own. If all women who are identified as having HPV receive the progressively more invasive interventions due to their positive HPV results, many women will be over-treated than necessary. And here, even more so, I think, than with mammograms, over-treatment is about more than just the economic burden. The biopsies and colposcopies that make up cervical cancer prevention are incredibly traumatic as is the even more invasive technique of loop electrosurgical excision procedure (LEEP).

Both the skepticism about mammograms and excessive gynecological interventions support my argument that we're not actually thinking very carefully about medical technologies. Another recent article on the excessive use of mammograms proposes that mammograms may not be the real reason for the decline in mortality due to breast cancer. The emphasis has been on more is more!! Let's do more! But this thinking obscures the existing problems with well-tread practices, and it fails to improve practices that might require tweaking without full-on replacement of new methods that have their own limitations.