Mandatory Opposition

We need to separate the good and bad arguments against mandating an HPV vaccine.

Sam Berger argues that despite concerns over the HPV vaccine, understanding the issue means separating the good arguments from the bad.

States across the country have been waging a heated debate about whether a new vaccine for human papillomavirus, one of the primary causes of cervical cancer, should be made mandatory for school children. There are certainly legitimate concerns about doing so, including the rapid pace at which legislation is moving forward, the lack of education for parents on the issue, the undue influence of pharmaceutical giant Merck on state legislators, and the tremendous cost of the vaccine. Yet, there has been little effort to distinguish these concerns from ill-supported arguments put forward by ideologues who oppose the vaccine for political reasons that have nothing to do with ensuring the most successful health intervention.

Cervical cancer affects over 11,000 women annually in the U.S., resulting in 3,700 deaths. The new HPV vaccines could significantly reduce the prevalence of cervical cancer. Merck and GlaxoSmithKline’s vaccines have so far proven 100 percent effective in preventing strains of HPV that are responsible for 70 percent of cervical cancer cases.

Yet, despite these tremendous benefits, Merck’s announcement of an HPV vaccine immediately created controversy. Social conservatives have used HPV—primarily transmitted through sexual contact—as a major argument against condom safety since the infection can be passed along even with proper condom use, although at a drastically lower rate. Many conservative advocates therefore decried the vaccine, although public criticism caused them to backpedal and eventually only argue against making the vaccination mandatory.

These conservative opponents have largely argued that mandating the vaccine will encourage sexual promiscuity and subvert parental authority. They have been joined in their opposition by anti-vaccine activists, who have raised their usual concerns about unknown risk factors and government conspiracies. None of these arguments carry much weight.

There is no evidence to support the claim that vaccinating young people against HPV will increase sexual promiscuity. A tetanus shot does not make children more likely to play near rusty metal, nor does it suggest that society condones such behavior. Many states already require infants to be vaccinated against Hepatitis B, a disease primarily transmitted through sexual contact and drug use, and there has been no evidence that this has increased promiscuity. And since public knowledge of HPV is notoriously low, particularly among young people, it is unlikely that vaccination would impact their decisions in a meaningful way.

Concerns about the negative health effects of the vaccine have also been overblown. The HPV vaccines have shown no dangerous side effects. Yet, anti-vaccine activists, who have been making erroneous claims about the connection between vaccines and autism for years, are more than happy to argue against any mandatory vaccination to decrease public confidence in vaccines in general.

The argument that mandating this vaccine will undermine parental authority is also shaky. Similar arguments could be made for making any vaccine mandatory, but social conservatives are not opposing mandatory chickenpox vaccinations. Also, almost all of the proposed state laws allow parents to opt their child out of mandatory HPV vaccination at their discretion.

Vaccines are made mandatory in order to protect public health, ensuring that enough people will get the vaccination to provide community immunity. Mandating vaccination is also the most effective means to provide public subsidies so low-income children and their parents can afford the vaccine, helping to reduce economic, ethnic, and racial health disparities.

But there are real questions about the benefits of mandating this vaccine so quickly. Few parents know much about HPV or its connection to cervical cancer. Yet, once they understand the potential benefits of the vaccine, they are very likely to support it. A recent study found that targeted educational interventions increased parental support for the vaccine from 55 percent to 75 percent. Focusing on public education rather than quickly mandating the vaccine—a model used with previous vaccines—could greatly improve public acceptance.

Public trust has been weakened, however, by revelations that Merck, the maker of the only FDA approved HPV vaccine, put heavy pressure on state legislators to quickly pass mandatory vaccination laws before a competitor vaccine was approved as well. The pharmaceutical company has since said it will cease its lobbying campaign, but many parents are concerned that Merck’s bottom line, not children’s health, is dictating decisions about the HPV vaccine.

Public concern roused by Merck’s behavior has also forced lawmakers to include strong opt-out clauses for parents who do not want their child vaccinated. Excessive use of these clauses could undermine parental acceptance and confidence in other vaccines as well.

But the cost of the vaccine is perhaps its most controversial feature. The three shot series costs $360, which makes it the most expensive on the market, and there is no proof that booster shots will not be needed in the future. Cervical cancer disproportionately affects low-income and minority women, so in order to effectively reduce the disease burden, the vaccine would have to be heavily subsidized so those most at risk could afford it.

Cervical cancer is a terrible disease, yet the U.S. has largely been able to control it through regular screening and pap smears. The disproportionate effects of the cancer are largely due to inequalities in healthcare access; half of all women with cervical cancer have never had a pap smear. Improving access to inexpensive screening measures could greatly reduce the disease burden for far less cost than the vaccine.

There are also valid concerns about the effects of subsidizing the cost of the vaccine on strained public health resources, particularly the worry that this could drain funding for more needed vaccinations. States should not be so quick to mandate the vaccine without first trying to negotiate lower prices with Merck or waiting for a competitor vaccine from GlaxoSmithKline, expected to be approved soon, to enter the market and drive down prices.

Certain questions about how to fund the HPV vaccine and how to best introduce it to the public require serious discussion. Yet, that debate should not provide an avenue for extremists to push forward their own poorly supported arguments about increased promiscuity, dangerous side effects, and usurped parental authority. We need to be engaging in a thoughtful debate about the most equitable, safe, and cost-effective means of advancing this particular public health intervention, rather than using it as a means of advancing extremist agendas.

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Sam Berger

Former Vice President, Democracy and Government Reform