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

Chapter One. The Coercive Hand,the Beneficent Hand: What the History of Compulsory Vaccination Can Tell Usabout HPV Vaccine Mandates

chapter one The Coercive Hand, the Beneficent Hand What the History of Compulsory Vaccination Can Tell Us about HPV Vaccine Mandates James Colgrove The licensure of Gardasil in June 2006 set off a flurry of legislative activity as states around the country took steps to maximize the benefits of the product among their populations. States select from a variety of policy approaches to increase uptake of a vaccine. They can sponsor educational and promotional efforts through mass media or in clinical settings; allocate public funds to pay for the vaccine; require that private insurers doing business in the state reimburse it; or require or allow schools to provide education about it as part of health curricula or other science units.1 One of the most effective and efficient approaches, but also the most controversial, is to mandate a vaccine as a condition of attending school. Vaccination requirements, like all compulsory health measures, may be ethically troubling and politically sensitive because they represent an intrusion on individual autonomy. Weighed against these concerns is the success of mandates in achieving high levels of coverage.2 Mandates may be especially appropriate for adolescent vaccination because teens are in the age group least likely to have contact with a primary care provider . A recent study found that of numerous legal, financial, and promotional strategies for increasing rates of adolescent immunization, school entry mandates 4 The Known and the Unknown were the only consistently effective intervention.3 An ancillary benefit is that a clinical visit to comply with a school vaccine requirement can present an opportunity for health care providers to offer other needed screening, prevention , and care for teens.4 Proposals for compulsory human papillomavirus vaccination in middle school were among the first out of the legislative chute in late 2006 as states began their deliberations. Bills to require HPV vaccination for girls attending middle school were introduced in at least twenty-four states.5 Over the next three years, however, almost all of these bills stalled or were abandoned. This chapter situates the deliberations about HPV vaccine mandates within the context of two centuries of legally enforced vaccination. I begin by briefly tracing the initial efforts on the part of some legislators and policymakers to enact middle school mandates after the licensure of Gardasil. I then examine attempts since the nineteenth century to increase uptake of vaccines via the law and the popular responses these efforts have produced. Many aspects of compulsory vaccination have been subject to debate: their rationales, their purposes , their ethical and legal bases, and their consequences, both intended and unintended. I conclude by considering whether there are historical precedents or analogies that might be informative for current policy development. The Rise and Fall of Compulsory HPV Vaccination Much of the initial concern about mandating protection against HPV centered around the sexual behavior of teens. Before the vaccine was licensed, it was dubbed a “promiscuity vaccine,” and some religious conservatives expressed concern that the availability of a preventive against a sexually transmitted disease would increase the likelihood that teens receiving it would engage in sex. An early salvo was fired by the South Dakota–based group Abstinence Clearinghouse , whose president, Leslee Unruh, said, “I personally object to vaccinating children . . . against a disease that is one hundred percent preventable with proper sexual behavior. Premarital sex is dangerous, even deadly. Let’s not encourage it by vaccinating ten-year-olds so they think they’re safe.”6 Although high-profile conservative groups including Focus on the Family and the Family Research Council were wary of the vaccine initially, their stated positions following licensure were generally in support of making the vaccine available to parents who wanted it. When school mandates began to be placed on the table The Coercive Hand, the Beneficent Hand 5 in the fall of 2006, however, conservative groups were united in their opposition . In their view, such a requirement constituted an attempt by the state to force a child to undergo an intervention that was irreconcilable with her family ’s religious values and beliefs.7 Concerns about sexuality were soon joined—and often overshadowed—by criticisms related to potential adverse health effects. The high-profile debates in recent years about the alleged connection between autism and the measlesmumps -rubella (MMR) vaccine and the preservative thimerosal have created an environment of suspicion toward all vaccines. Even though the data on Gardasil ’s safety were very favorable, the...