A case study: the HPV vaccine disaster (Science of Science Communication Course, Session 1) - Cultural Cognition of Health

This semester I’m teaching a course entitled the Science of Science Communication. I’ve posted general information on the course and will be posting the reading list at regular intervals. I will also post syntheses of the readings and the (provisional, as always) impressions I have formed based on them and on class discussion. This is this first such synthesis. I eagerly invite others to offer their own views, particularly if they are at variance with my own, and to call attention to additional sources that can inform understanding of the particular topic in question and of the scientific study of science communication in general.

HPV stands for human papilomavirus. It is a sexually transmitted disease.

The infection rate is extremely high: 45% for women in their twenties, and almost certainly just as high for men, in whom the disease cannot reliably be identified by test.

The vast majority of people who get HPV experience no symptoms.

Some of them–over 3500 women per yr in U.S. — die.

In 2006, the FDA approved an HPV vaccine, Gardasil, manufactured by the New Jersey pharmaceutical firm Merck. Gardasil is believed to confer immunity to 70% of the HPV strains that cause cervical cancer. The vaccine was approved only for women, because only in women had HPV been linked to a “serious disease” (cervical cancer), a condition of eligibility for the fast-track approval procedures that Merck applied for. Shortly after FDA approval, the Center for Disease Control recommended universal vaccination for adolescent girls and young women.

The initial public response featured intense division. The conflict centered on proposals to add the vaccine—for girls only—to the schedule of mandatory immunizations required for middle school enrollment. Conservative religious groups and other mandate opponents challenged evidence of the effectiveness of Gardasil and raised concerns about unanticipated (or undisclosed) side-effects. They also argued that vaccination would increase teen pregnancy and other STDs by investing teenage girls with a false sense of security that would lull them into engaging in unprotected, promiscuous sex. Led by women’s advocacy groups, mandate proponents dismissed these arguments as pretexts, motivated by animosity toward violation of traditional gender norms.

In 2007, Texas briefly became the first state with a mandatory vaccination requirement when Governor Perry—a conservative Republican aligned with the religious right—enacted one by executive order. When news surfaced that Perry had accepted campaign contributions from Merck (which also had hired one of Perry’s top aids to lobby him), the state legislature angrily overturned the order.

Soon thereafter, additional stories appeared disclosing the major, largely behind-the-scene operation of the pharmaceutical company in the national campaign to enact mandatory vaccination programs.  Many opinion leaders who previously had advocated the vaccine now became critics of the company, which announced that it was “suspending” its “lobbying” activity. Dozens of states rejected mandatory vaccination, which was implemented in only one, Virginia, where Merck had agreed to build a vaccine-manufacturing facility, plus the District of Columbia.

Current public opinion is characterized less by division than by deep ambivalence. Some states have enacted programs subsidizing voluntary vaccination, which in other states is covered by insurance and furnished free of cost to uninsured families by various governmental and private groups. Nevertheless, “uptake” (public health speak for vaccination rate) among adolescent girls and young women is substantially lower here (32%) than it is in nations with inferior public health systems, including ones that likewise have failed to make vaccination compulsory (e.g., Mexico, 67%, and Portugal, 81%). The vaccination rate for boys, for whom the FDA approved Gardasil in 2009, is a dismal 7%.

2. What’s the issue? (What “disaster”?)

The American pubic tends to have tremendous confidence in the medical profession, and is not hostile to vaccinations, mandatory or otherwise (I’ll say more about the “anti-vaccine movement” another time but for now let’s just say it is quite small). When the CDC recommended vaccination for H1N1 in December 2009, for example, polls showed that a majority of the U.S. population intended to get the vaccine, which ran out before the highest-risk members of the population—children and the elderly—were fully inoculated. In a typical flu season, uptake rates for children usually exceed 50%.

The flu, of course, is not an STD. But Hepatitis B is. The vast majority of states implemented mandatory HBV vaccination programs—without fuss, via administrative directives issued by public health professionals—after the CDC recommended universal immunization of infants in 1995. Like the HPV vaccine, the HBV vaccine involves a course of two to three injections.  National coverage for children is over 90%.

There are (it seems to me!) arguments that a sensible sexually active young adult could understandably, defensibly credit for forgoing the HPV vaccination, and that reasonable parents and reasonable citizens could for not having the vaccine administered to their children and mandated for others’. But the arguments are no stronger than—not not at all different from—the ones that could be made against HBV vaccination. They don’t explain, then, why in the case of the HPV vaccine the public didn’t react with its business-as-usual acceptance when public health officials recommended that children and young adults be vaccinated.

What does? That question needs an answer regardless of how one feels about the HPV vaccine or the public reaction to it—indeed, in order even to know how one should feel about those matters.

3. A polluted science communication environment

The answer—or at least one that is both plausible and supported by empirical evidence—is the contamination of the “science communication environment.”  People are generally remarkably proficient at figuring out who knows what; they are experts in identifying who the experts are and reliably discerning what those with expertise counsel them to do. But that capacity—that faculty of reasoning and perception—becomes disabled (confused, unreliable) when an empirical fact that admits of scientific investigation provokes controversy among groups united by shared values and perspectives.

Most of us have witnessed this situation via casual observation; scholars who carefully looked at parents trying to figure out what to think about the HPV vaccine saw that they were in that situation. They saw, for example, the mixture of shame and confusion experienced by an individual mother who acknowledged (admitted; confessed?) in the midst of a luncheon conversation with scandalized friends (also mothers) that she had allowed her middle-school daughter to be vaccinated (“what–why? . . .”; “Well, because that’s what the doctor advised . . . .” “Then, you had better find a new doctor, dear . . . . ”).

Scholars using more stylized but more controlled methods to investigate how people form perceptions of the HPV vaccine report the same thing.  In one, researchers tested how exposure to two versions of a fictional news articles affected public support for mandatory HPV vaccination.  Both versions described (real) support for mandatory vaccination by public health experts. But one, in addition, adverted without elaboration to “medical and political conflict” surrounding a mandatory-vaccine proposal. The group exposed to the “controversy” version of the report were less likely to support the proposal—indeed, on the whole were inclined to oppose it—than those in the “no controversy” group. This effect, moreover, was as strong among subjects inclined to support mandatory vaccination policies generally as among those who weren’t/

The study result admits (I admit!) of more than one plausible explanation. But one is that being advised the matter was “politically controversial” operated as a cue that generated hesitation to credit evidence of expert opinion among people otherwise disposed to use it as their guide on public health issues.