Raggedy Ann, Human Papilloma Virus (HPV) and the ethics of vaccine policy. What’s the connection?
I’ve written about my perspective on vaccines previously, but the Texas HPV vaccine story and a new book on the history of vaccines prompted me to revisit the subject.
On Friday, February 2, Governor Rick Perry of Texas signed an executive order mandating vaccination against HPV for 11-12 year old girls in his state. This order, also being considered by other states, would require 365,000 girls in Texas to be vaccinated with an HPV vaccine starting in September 2008; the only currently licensed vaccine is Gardasil, made by Merck. Bypassing the Texas legislature (although they are now fighting back), Perry has accomplished the unlikely feat of drawing criticism from both the conservative, religious right (“vaccine against HPV promotes sexual activity”) and the liberal, civil liberties left (“this should be our choice”), according to a report in the Los Angeles Times. What’s the big deal? Well, as the Fort Bend Now notes, “Probably it would be easier to take the governor’s motives at face value if Merck & Co. were not the only manufacturer of the vaccine, if Merck were not charging physicians about $120 per dose of the three-dose vaccine, if Merck had not contributed $6,000 to Gov. Perry’s campaign and if Merck’s lobbyist in Texas were not Mike Toomey, the governor’s former chief of staff.” Whether or not Perry’s decision is motivated by good intentions or greed, these glaring conflict-of-interests only serve to further erode public trust in U.S. vaccine policy. Another battle looms in New Jersey, as the State Department of Health considers mandating influenza vaccine (and, for most receiving it, the thimerosal that comes with it) for infants and children entering preschool or daycare.
The debate about mandatory vaccination dates back to the 1800’s, as Arthur Allen points out in his new book, “VACCINE: The Controversial Story of Medicine’s Greatest Lifesaver.” Many objected to Edward Jenner’s smallpox vaccine at that time, citing the same principles as anti-vaccine folks do today; in essence, it’s a freedom-of-choice thing, which clashes with public health policy of herd immunity and protecting the greater good. There’s also a tendency towards conspiracy theory, which tends to further polarize and confuse the issue. Immunization is not, however, a simply scientific issue. Whether or not a vaccine is safe and effective (how safe? how effective?) is only one piece of the puzzle. Immunization delivery is a political and ethical policy in this country. We weigh the right of each family to decide for their child what treatment is appropriate versus the right of society as a whole to have protection against disease and illness. As James Colgrove points out in his editorial “The Ethics and Politics of Compulsory HPV Vaccination,” published in December’s New England Journal of Medicine, “A critical question is whether achieving a higher level of coverage justifies the infringement on parental autonomy that compulsory vaccination inevitably entails.” Note that HPV is not transmitted casually, unlike other vaccine-targetted viruses likes measles or polio. Is it therefore a good candidate for state-mandated vaccination, especially at a time when so many other vaccines are being introduced that may have greater public health consequences (e.g. adolescent pertussis and meningitis vaccines)?
Of interest, I learned something about American history in David Ochinsky’s excellent NYT book review of Allen’s work. “Indeed, one of the potent symbols of the early antivaccine movement was the limp “Raggedy Ann” doll, created in 1915 by a man whose daughter had died shortly after being vaccinated at school without parental consent. Authorities blamed a heart defect; her parents blamed the shot.” Turns out, the Raggedy Ann creation myth is in itself a bit controversial. If you’re really interested (I mean, REALLY) in the story, I recommend Patricia Hall’s dissertation, “Raggedy Ann and Andy: History and Legend.”
I agree that mandatory vaccine policies are on shaky ground in the purest sense of patient “rights”. What we really need is mandatory insurance coverage laws. The motivation of many government officials seems to be that insurance will only pay for “mandatory” vaccines. It seems we are once again designing a law to accommidate faulty insurance policies and sacrificing patient rights in the process. HPV is a great vaccine but definately not communicable in a “public” settings like school. I feel similarly about Hep B, which is mandatory for school entry in Ohio, who catches Hep B at school?