November 4, 2005
When does the good of the one…
…outweigh the good of the many? This question--usually stated the other way around and not as a question but as axiomatic to the Vulcan culture--was a central theme of the great 20th century philosopher and science-fiction writer, Gene Roddenberry. Star Trek dealt with this question many times, and it was a central feature of Kirk-Spock tension.
In healthcare, stated another way, when does individual choice outweigh a public health mandate? And when do group and/or sect beliefs outweigh public health policy? And more importantly, who gets to decide? Individuals? Parents on behalf of legal minors? Government experts?
I must admit that my first response to the story “Vaccine for Cervical Cancer Sparks Debate” by Rob Stein on the MSNBC Web site October 31 was blood pressure elevation. The tag line is: “Conservative groups fear drug may lead to promiscuity among teens.” I thought, “Here we go.” But on further reflection, this issue is representative of a much larger debate occurring in healthcare these days. Who ever thought the Cartel would come under attack from Conservatives?
I'll give my conclusion about the article first: both sides of the debate as represented are wrong.
Here's the bait:
“A new vaccine that protects against cervical cancer has set up a clash between health advocates who want to use the shots aggressively to prevent thousands of malignancies and social conservatives who say immunizing teenagers could encourage sexual activity.”
By the way, I took the bait. My blood pressure was rising about right here.
“Groups working to reduce the toll of the cancer are eagerly awaiting the vaccine and want it to become part of the standard roster of shots that children, especially girls, receive just before puberty.” OK, this sounds right. Does anyone have bad motives or intensions here?
“Because the vaccine protects against a sexually transmitted virus, many conservatives oppose making it mandatory, citing fears that it could send a subtle message condoning sexual activity before marriage.”
Whoa, whoa!!! Did you say “mandatory”? Blood pressure went up again. The story just sort of slipped that word in there.
It seems that the advocates are not content just advocating, they would like this vaccine to become required in the same package needed to go to public school. Does Human Papilloma Virus (HPV) infection rise to the same level of needed protection as polio, diphtheria, pertussis and other epidemic disease?
This is quite a stretch in my opinion. These latter diseases are easily spread in populations by casual contact either with food or air. HPV requires sexual contact—as in, exercise of free will. To have sex or not have sex? Using protection or not? One can decide. Eating and inhaling tend to be less optional.
It is not a question of vaccine efficacy. The article recounts the statistics: “The vaccine protects women against strains of a ubiquitous germ called the human papilloma virus. Although many strains of the virus are innocuous, some can cause cancerous lesions on the cervix (the outer end of the uterus), making them the primary cause of this cancer in the United States. Cervical cancer strikes more than 10,000 U.S. women each year, killing more than 3,700. The vaccine appears to be virtually 100 percent effective against two of the most common cancer-causing HPV strains.”
\But it gets worse: “Exactly how the vaccine is used, however, will be largely determined by the Advisory Committee on Immunization Practices, a panel of experts assembled by the Centers for Disease Control and Prevention in Atlanta. The panel issues widely followed guidelines, including recommendations for childhood vaccines that become the basis for vaccination requirements set by public schools.”
Experts!!?? Experts!!?? The intellectual descendents of monarchical court jesters and courtesans??? Telling me how to live? Spare me, please. OK, I can deal with experts. Aw, hell, I used to be one. Sorry, blood pressure was going up again.
Now for the expert rationale: "If you really want to have cervical cancer rates fall as much as possible as quickly as possible, then you want as many people to get vaccinated as possible," said Mark Feinberg, Merck's vice president of medical affairs and policy, noting that "school mandates have been one of the most effective ways to increase immunization rates." This is true, especially if you happen to be selling the vaccine.
OK, 10,000 cases per year in the US out of a female population of what, about 160 million that is 45-65% infected during the sexually active years? That's a lot of vaccinating for a little benefit. Why can't individuals decide along with their health providers who should get the vaccine???
Everybody seems wrong in this debate. Is it just me??
Here is an expert overreaching: "I would like to see it that if you don't have your HPV vaccine, you can't start high school," said Juan Carlos Felix of the University of Southern California in Los Angeles , who leads the National Cervical Cancer Coalition's medical advisory panel.” Scary man. Guess he didn't even have to dress up for Halloween.
Let's see if we can sort this out. The public health people want to force mandatory HPV vaccination on all young women around age 14 and maybe all young men. This to prevent 10,000 of cervical cancer. HPV is not polio, diphtheria, pertussis or any other innocent bystander type infection. One has to have sex to get it. Get it? I think that public health people can advocate all they want. Educate. Plead. Get a condom and a shot. Whatever. Fine. Mandatory to go to high school. No.
The Conservatives are worried about a vaccine promoting sexual activity. Hello!!! Vaccines don't promote sexual activity, people do. Irrelevant for the vast, vast majority. Who makes this stuff up? A doctrinaire approach stretched to the limit and beyond. But, I do agree on principle that individuals, families and their health providers should be in charge of their own health. And not expert mandates.
Robert B. Teague is a pulmonologist and business consultant who is based in Houston, Texas. E-mail him.
Read other blogs in this series.
