Our Best Shot

State legislatures across the country have begun debating whether to make vaccination against the sexually transmitted human papillomavirus (HPV) mandatory for all sixth-grade girls. And most local coverage of the debate has included stories about parents considering whether to vaccinate their daughters. Such Oprah-style tales of educated mothers and their wide-eyed tweens having heart-to-heart chats behind closed bedroom doors never mention that these girls are at very low risk for dying from HPV-related cervical cancer.

It's the daughters of lower-income, minority families who are really at risk.

Cervical cancer has a high survival rate if treated early, but early treatment depends on regular screenings. Lower-income women are less likely to receive annual pap smears -- and so for them, the disease is more likely to be deadly. More than half of all U.S. women diagnosed with cervical cancer have not had a pap test in the last three years, and the incidence of cervical cancer is approximately 1.5 times higher among African American and Latina women than among white women.

That's why state-level debates over whether to make the vaccine mandatory for 11- and 12-year-old girls are so important. Women's health advocates are concerned that lower-income girls -- those who need the vaccine most -- won't get the shots unless they are required for school admission. "Drop-out rates begin at 13," said Cynthia Dailard*, senior public policy associate at the Guttmacher Institute. "How do we reach these individuals before they're disconnected from health care later in life? This is a key way to do that." Historically, requiring vaccines for school attendance has helped to close racial, ethnic, and socioeconomic gaps in immunization rates.

The fight over mandatory vaccination began soon after the FDA approved the vaccine, developed by Merck & Co. and sold under the name Gardasil, in June. The Centers for Disease Control and Prevention recommended that all 11- and 12-year-old girls receive the vaccine -- and that women up to age 26 get vaccinated, too, as a "catch-up."

Now individual states must decide whether to follow the recommendation by adding Gardasil to the list of immunizations necessary for public school enrollment. Last session, a mandatory vaccination bill narrowly failed in the Michigan house. And this year, at least 15 states and the District of Columbia have introduced legislation to require the vaccine for all sixth-grade girls.

The vaccine is most effective if girls receive it before they become sexually active, so women's health advocates are pushing hard for school-based mandatory vaccination. And so is Merck. Gardasil sales topped $80 million in its first three months, and the Baltimore Sun recently reported that state mandates would ensure the vaccine becomes a "mega-blockbuster" drug, raking in more than $4 billion within five years.

Conservative Christian groups have been the most vocal opponents of mandatory vaccination, pushing talking points on how it will lead to a spike in teen sex. "They may see it as a license to engage in premarital sex," the Family Research Council told the British publication NewScientist, and Leslee Unruh, president of the Abstinence Clearinghouse, said HPV is "100 percent preventable with proper sexual behavior. Premarital sex is dangerous, even deadly. Let's not encourage it by vaccinating 10-year-olds so they think they're safe." They also charge that mandatory immunization will take control away from parents, even though families with religious or moral objections would be allowed to opt out.

But the conservatives' real problem with universal vaccination is that it would eliminate some of their best “evidence” that premarital sex is dangerous. The Christian right has long hyped the HPV threat -- the American Family Association once called it a "bigger killer" than AIDS. Because it is transmitted by skin contact, HPV is one of the few STDs that condoms do not protect against. This makes it of great use to the abstinence-only movement. Even though CDC research has shown that "fear of an STD is not a major motivation for abstinence," abstinence-only curricula have long featured the information that condoms fail to protect you from dozens of STDs -- the "dozens" being all the different strains of HPV. (Four of those strains – the ones Gardasil protects against -- cause the majority of cases of genital warts and cervical cancer.) If the HPV vaccine is universally administered, one of abstinence promoters' most powerful, "science"-based anecdotes will be nullified.

But the Christian right isn't the only group vehemently opposing mandatory immunization. A growing anti-vaccine movement has also spoken out against it on the grounds that it will have adverse health effects. "This is not just about teenagers having sex, it is also about whether Gardasil has been proven safe and effective for little girls," says a press release from the National Vaccine Information Center, a group that opposes all mandatory vaccination. According to the CDC, however, the vaccine "has been tested in over 11,000 females (ages 9-26 years) around the world. These studies have shown no serious side effects."

Surprisingly, those groups are joined by many public health professionals, who may favor universal immunization in principle but are all too aware that their budget for vaccines is already stretched to the limit. "Some of the people who run state immunization programs are against making this mandatory because if you require children to be vaccinated there is an attendant obligation on the part of the state to pay for the vaccine," Dailard said. "Of course, it's an incredibly expensive vaccine. That is a problem."

The vaccine costs a whopping $360 for a three-shot regimen, and most states that have proposed universal vaccination have failed to introduce accompanying legislation that would address the issue of funding. Gardasil is covered under the federal Vaccines for Children program, meaning that Medicaid-eligible girls age 18 and under can receive it free of charge. But just because a vaccine is included in Vaccines for Children does not mean the entire cost is covered; most states will have to pick up the slack by dipping into their own funds or applying for federal grants. Immunization rates vary greatly by state, with some assuring access to all children and others -- particularly poorer states -- vaccinating a much smaller percentage.

Which is why it's so important for state legislatures to consider the funding issue when they decide whether to mandate HPV vaccination. A few of the states currently debating mandatory HPV immunization have introduced legislation that would address funding concerns. New Jersey, for example, is considering companion bills that would ensure the HPV vaccine is covered by private insurers and state health plans.

If state legislatures are truly interested in prioritizing women's health, they should follow New Jersey's lead and not only make HPV vaccination mandatory, but also allocate proper funding for it. Otherwise the vaccine will remain for only the white and wealthy, who are at considerably lower risk for dying of cervical cancer. And the lower-income women who really need the vaccine will be out of luck.

* Editor's Note: Dailard, who was interviewed for this article in November, died suddenly in December of a previously undetected heart defect.

Ann Friedman is associate web editor of the Prospect. Her biweekly column appears on Thursdays.

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