Tuesday, July 18, 2006

HPV Vaccine vs. Pap Smears? What's wrong here?

Thanks to Evelyn for inviting me to contribute. I was working on a more theoretical post about feminist philosophers of science and what, if anything, they should want to say about the issue of scientific realism/antirealism and I hope to post something on that later, but I had a negative reaction to an essay, “A New Vaccine for Girls, but Should It Be Compulsory?”, by Roni Rabin on the opinion page in the NYT today and so I wanted to say something in response to it.

First, the parts I think are right. Yes, we should be careful when advocating compulsory health care. Yes, we should make it possible for all women to get routine Pap smears. Both of these points seem right, but this argument is constructed in such a way that one might walk away thinking that Pap smears will prevent cervical cancer and so there is really no need for this vaccine, end of story. But this is disingenuous and misleading. It isn’t Pap smears that prevent cervical cancer. Pap smears alert us to the need to proceed to other procedures that can prevent cervical cancer. So they are necessary but not sufficient. Since the current vaccine prevents only the four of the most common forms of HPV (which account for 70% of cervical cancers), it is not sufficient to prevent cervical cancer either and so does not eliminate the need for Pap smears. The lesson here should be that this is not an either/or situation; the ideal is both vaccine and Paps.

There’s another concern that I have though. Rabin focuses on the number of deaths from cervical cancer (relatively low) and notes that these have been and can continue to be reduced though Pap smears as part of routine health care for women. True, but the medical cost of HPV should not be weighed only in terms of deaths. Women whose immune systems do not automatically clear the virus will need more frequent Pap smears (every three or 6 months rather than once a year) and may also need more invasive treatment to remove dysplasic cells. These treatments, such as the LEEP procedure, while done on an outpatient basis, can be uncomfortable and expensive. Repeated incidents of “bad” Pap results can mean multiple procedures. The jury is out on whether and if so to what extent repeated procedures compromise cervical competence and so put future pregnancies at risk. (Samson SL, Bentley JR, Fahey TJ, et al: The effect of loop electrosurgical excision procedure on future pregnancy outcome. Obstet Gynecol 2005 Feb; 105(2): 325-32.) So while certainly the most frightening cost of HPV is cervical cancer it is not the only cost.

Given a political climate in which it has already been suggested that this vaccine should not be offered because it will encourage sexual promiscuousness, I think we need to be very clear about just what and are not the consequences of advocating particular public health policies. While I fully agree that it should be a public health priority to ensure that all women are informed and able to get Pap smears as part of their routine health care, I do not think we should be seeing this as an alternative to making use of a vaccine that can cut out the possibility of contracting the forms of HPV which result in 70% of cervical cancers. This strikes me as another case of false economic reasoning about health care that occurs in a society that does not have health care as a priority for all of its citizens.

General information about the vaccine from the CDC here.

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