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Chapter Three. HPV Vaccination Campaigns: Masking Uncertainty, Erasing Complexity
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chapter three HPV Vaccination Campaigns Masking Uncertainty, Erasing Complexity Lundy Braun and Ling Phoun On June 8, 2006, the U.S. Food and Drug Administration (FDA) approved Gardasil, a quadrivalent vaccine marketed by Merck & Company to prevent anogenital infection with human papillomavirus types 6, 11, 16, and 18. A bivalent vaccine produced by GlaxoSmithKline, which contains only HPV 16 and HPV 18 virus-like particles (VLPs), was recently approved by the FDA. As a vaccine against virus-induced cancers that are ubiquitous throughout the world, the HPV vaccine has been hailed by physicians, public health practitioners , and the popular press as one of the most important public health advances in recent years. Such claims are, in many ways, well deserved. HPVs play a central role in the development of a variety of human cancers, such as cervical cancer. Cervical cancer is the second leading cause of cancer-related death in women worldwide and the leading cause of cancer deaths in many developing countries. Eighty-three percent of cases of cervical cancers occur in the developing world (Parkin and Bray 2006). Moreover, concerns about HPV infection extend beyond just cervical cancer. Some head and neck cancers, for example, contain HPV (Gillison et al. 2000), and HPV-induced anal cancers cause substantial 40 The Known and the Unknown morbidity among women and among men who have sex with men. Precancerous cervical lesions (variably referred to as cervical dysplasia, cervical intraepithelial neoplasia, or squamous intraepithelial lesions),1 though easily treated, trigger considerable anxiety among women and increase health care costs. In the United States, the lifetime probability of infection with heterosexually transmitted anogenital HPV is 75–80 percent. Infection is, in other words, common ; however, only a small proportion of women who acquire infection develop detectable lesions, and an even smaller proportion of precancerous lesions become cancerous. As Steven Epstein argues in chapter 4, much less is known about the course of disease (pathogenesis) of anal papillomavirus infection in men. Based on synthetic VLPs rather than killed or weakened virus, the vaccine represents a stunning accomplishment after years of labor-intensive and technically difficult research. Given claims for 100 percent efficacy, it certainly cannot be dismissed. Yet, as chapters 1, 9, 12, and 13 in this volume describe, approval of the vaccine triggered an almost immediate controversy centered on whether vaccination should be mandatory and whether it would encourage promiscuity . Some raised larger issues, such as the ethics of vaccinating only girls for an infection that was sexually transmitted; the high cost of the vaccine and its availability in industrialized as compared to developing countries; Merck’s marketing strategies; and the safety of vaccines in general. With minimal debate and without the input of the Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices (ACIP), the Department of Homeland Security added Gardasil to the required vaccine protocol for female immigrants to the United States of ages 11–26 (Magor 2008). Yet, many other technical and social issues remain unresolved. For example, there is little data on the duration of immunity or the potential effects of the vaccine on the utilization of Pap smear screening. Despite the intensity of the controversy, acceptance, albeit tentative, for what many journalists and scientists term a “medical breakthrough” appears to be widespread in the United States, and some states have moved to make the vaccine mandatory for girls. An MSNBC poll indicated that 80 percent of parents of children under 15 would give their daughter the vaccine (Gibbs 2006). The results of this poll pose the question, Why does the vaccine appear to have been accepted so widely and so quickly in the midst of controversy? Reasons for acceptance of this cancer vaccine defy simple explanation, but, as shown in this volume, interdisciplinary perspectives can provide valuable insights into the issue. What is emerging from the discussion of the HPV vaccine and associated [54.89.70.161] Project MUSE (2024-03-28 23:57 GMT) HPV Vaccination Campaigns 41 campaigns is that for the vaccine to be accepted, cervical cancer had to be constructed as a visible, tangible, and yet solvable problem for women—one that was easily preventable with a simple and culturally acceptable technical intervention. Making cervical cancer a problem solvable through a technical solution is simultaneously a political, sociocultural, and scientific process, which is situated in a long history of erasing the social context and the biological complexity of this cancer, although the particular forms of erasure have shifted over...