Three Shots at Prevention: The HPV Vaccine and the Politics of Medicine's Simple Solutions

Chapter Fifteen. HPV Vaccination in Context: A View from France

chapter fifteen HPV Vaccination in Context A View from France Ilana Löwy Medical innovations need to make a place for themselves among prevailing concepts , practices, professional traditions, material constraints, institutional variables , beliefs, attitudes, and power relations. They are also, to a large extent, local developments. The globalization and homogenization of biomedical knowledge was not accompanied by a parallel homogenization of medical practices. Even countries with comparable levels of income and medical infrastructures frequently develop divergent approaches to disease prevention and treatment. Debates about human papillomavirus vaccination typically have failed to take note of the disparate patterns of dissemination of the HPV vaccine in industrialized countries—an omission that Andrea Stöckl successfully challenges in chapter 14. Stöckl reveals important differences in the reception of the HPV vaccine in the United Kingdom, Germany, Austria, and Italy. This current chapter identifies possible reasons for such differences, based on an in-depth analysis of a single case: the reactions to the vaccine in France. To understand the way professionals and the lay public in France reacted to the promise to control cervical cancer through vaccination, I temporarily put aside the global debates on broad themes such as sexuality and morality, individual versus collective responsibility, HPV Vaccination in Context 271 ethical aspects of mandatory health measures, adolescent sexuality and parental rights, and the risk-to-benefit ratio of medical innovations with unknown longterm consequences. Instead, I focus on specific topics such as local medical and public health traditions as well as on national variables and contingent developments . I propose that the introduction of HPV vaccines in France was significantly shaped by two earlier histories: the difficulties encountered in attempting to implement a national plan to screen for cervical cancer and the turbulent history of the introduction of hepatitis B vaccination in the 1990s. The failure to ensure that all French women undergo regular cervical smears stimulated a search for alternative ways to reduce the risk of cervical cancer—thus making the HPV a source of much interest within the medical community. However, the recent attempts to vaccinate all French school children against hepatitis B dampened enthusiasm for another nationwide campaign of vaccination of children against a sexually transmitted disease. Exfoliate Cytology in France: A Patchy Landscape One of the arguments of opponents of Gardasil is that vaccination against cervical cancer risk is not necessary, at least in Western countries.1 Critics argue that nowadays, cervical cancer is a rare disease, which can be nearly completely prevented by appropriate public health measures. The majority of women diagnosed with cervical malignancies were not screened properly for precancerous lesions of the cervix. Countries that successfully introduced screening for such lesions, such as the Scandinavian countries, drastically reduced the prevalence of cervical cancer and the mortality from this disease. Moreover, as all the experts emphasize, vaccination will not abolish the need for regular vaginal smears. Why should one introduce an expensive and potentially risky public health measure instead of investing in better means of disseminating an existing and proven approach and reinforcing other reproductive health programs that, in all probability, will provide better returns? The Pap smear’s cost-to-effectiveness ratio has already been widely acclaimed , thus making it an important investment in the prevention of cervical cancer. In the United States, exfoliate cytology was introduced in the late 1940s. In 1941, scientists found a correlation between the presence of abnormal cells in cervical smears and the diagnosis of cervical tumors; this finding was rapidly followed gynecologists’ adoption of the Pap smear.2 In 1947, the Boston City Hospital opened a clinic for early detection of cervical cancer, and all the 272 In Search of Good Government departments of the hospital were requested to refer as many women over age 35 as possible to the Gynecological Clinics for screening.3 This was probably the first use of the term screening in this context. Women with suspicious vaginal smears were subjected to a biopsy by curettage, a cervical biopsy, or both. In many cases these procedures led to a diagnosis of previously unsuspected malignancies. At first, the sole aim of exfoliate cytology was the detection of invasive carcinoma,4 but it rapidly became a test to detect preinvasive, in situ lesions.5 In the United States, the use of Pap smear technology was strongly supported by the American Cancer Society (ACS).6 The ACS sponsored the First National Cytology Conference (Boston, 1948) and funded...