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"100% Preventable by Behavioral Change":

Megan McArdle (Asymmetrical Information) posts about HPV immunization — she thinks it's good even if it's mandatory (which the Texas version apparently isn't) — and draws, among others, this comment:

HPV, like HIV and unlike Polio, Tetanus, Pertussis, etc is 100% preventable by behavioral change.

Let me stress it again: It is 100% preventable (setting aside rape and congenital transmission) by behavioral change — lifelong sexual abstinence. It is not preventable by only having sex within marriage, since your husband or husbands (even the most religious don't mind remarriage after a spouse's death) might have been infected with HPV when you married them, or might cheat on you after marriage, get infected, and reinfect you.

Having fewer sexual partners will decrease your chances of getting infected, but they won't decrease them by 100%, and the chances will remain pretty substantial, I'd wager, given that "At least 50% of sexually active people will get HPV at some time in their lives." Having one sexual partner and making sure that he was a virgin at the time decreases the chances further (if he doesn't cheat on you), but, you know, sometimes the person you fall in love with — even the person you think God may have meant for you, if you think about things that way — happens to have done some wrong things in the past. If "behavioral change" means "dumping the one person you've fallen in love with and want to spend the rest of your life with because they've had sex with some other people" (or even "because they fall within the 50% of the public that has been infected with HPV"), then it might be good to make that clear (though again even that won't give you 100% immunity unless you are 100% confident that your spouse won't cheat on you).

And of course on top of all this, we know that teenagers, even well-brought-up teenagers, aren't always the best at behavioral change. However moral you might be, and however moral you are bringing up your daughter, are you 100% sure that she's going to take that supposed 100% prevention approach? If your religion teaches that sin, and giving in to temptation, is part of human nature — and if you think our society has turned into a moral cesspool that constantly bombards young people with praise of sexual immorality — then why do you think that even well-intentioned, well-taught teenagers are going to be able to completely resist temptation and sin?

Look, if we're talking assumption of risk and "you could have prevented it yourself" in the context of skydiving or bungee-jumping, I can understand that. But if "100% preventable" means living an entirely asexual life, and "almost 100% preventable" means dumping the person you're in love with because he isn't a virgin (and maybe is even part of the 50% of the public that's HPV-infected), then we're way out of the range of normal assumption-of-risk talk. And when you add to that the fact that failure to immunize turns the unimmunized into unwitting but still dangerous vehicles of transmission of deadly disease — when a woman dies of HPV-related cervical cancer, the unimmunized people who helped spread the HPV to the woman helped cause her death — then the case for "never mind immunizing, people should prevent HPV themselves because it's 100% preventable by behavioral change" becomes very weak indeed.

Dr. T (mail) (www):
HPV vaccination is the latest in a string of overblown vaccine-related issues.
1. Although many persons acquire HPV infections, only a few strains of HPV are associated with cancers.
2. Of those infected with the cancer-related strains, only a small percentage will develop cancer (either cervical cancer in women or, much less often, penile cancer in men).
3. Of those women who get HPV-related cervical cancers, nearly all will are detected and eradicated in their pre-malignant phase by routine Pap smears.
4. The costs of widespread vaccination will greatly exceed the benefits. I estimate a few million dollars per year of life saved.
5. I disagree with the concern that HPV vaccination will make teens and adults more promiscuous. However, I suspect that women who get vaccinated against HPV will be less likely to get regular pelvic exams and Pap smears. This would increase the deaths from cervical cancer, because the vaccine is not 100% effective and because cervical cancer also occurs without HPV infection.

I favor voluntary HPV vaccinations, but I do not believe the vaccine will save many lives.
2.7.2007 8:28pm
Michelle Dulak Thomson (mail):
Eugene, it's "McArdle," not "McCardle."

And when you add to that the fact that failure to immunize turns the unimmunized into unwitting but still dangerous vehicles of transmission of deadly disease -- when a woman dies of HPV-related cervical cancer, the unimmunized people who helped spread the HPV to the woman helped cause her death -- then the case for "never mind immunizing, people should prevent HPV themselves because it's 100% preventable by behavioral change" becomes very weak indeed.

The fact that people not themselves at risk from the virus can transmit it is IMO the strongest argument for mandatory vaccination — of boys, not girls. The parents of girls have an obvious interest in protecting their daughters from a transmissible and potentially deadly infection; the parents of boys have no similar interest.
2.7.2007 8:35pm
AK (mail):
Here we have an early entry for the Fair-Weather Libertarianism Award for 2007. Government compulsion is bad, especially when the government tells you what you can and cannot put in your body. The exception is when the government forces you to do something that makes it safer for everyone to screw like rabbits with a coke habit. Then it's time for you to line up and take your shot. This will only hurt a little, and it's good for you, doncha know? Only a Christianist could disagree.
2.7.2007 8:38pm
Hei Lun Chan (mail) (www):
Why is it relevant that 50% of the public is HPV-infected? Isn't the important number the percentage of the population that is infected with the specific HPV strains that cause cervical cancer? According to one of the links above, "the American Cancer Society estimates that in 2006, over 9,700 women will be diagnosed with cervical cancer" while "[e]very year in the United States (U.S.), about 6.2 million people get HPV". Considering that 30% of cervical cancer is not caused by HPV and about half the population are women, doesn't this mean that only 1 out of every 457 women who get HPV will get cervical cancer?

So while Eugene is correct that a women would still have a 50% of contracting HPV if she only has sex with one non-virgin in her whole life, her risk of getting cervical cancer is far lower, at about 0.1%. Would Eugene agree with the statement that "cervical cancer is 99.9% preventable by behavioral change"?

(I'm still in favor of mandatory vaccination.)
2.7.2007 8:41pm
AK (mail):
Anyway, the 100% figure, as Volokh has pointed out, is wrong. But what's the real number? 20%? 50%? 90%? Does anyone have any idea?

Getting the number right matters for the cost-benefit analysis. If the risk of cervical cancer can be cut only 5% through reasonable behavior modification, then the case for mandatory vaccination is pretty good. But if the risk can be cut by 95% by making simple lifestyle modifications, the vaccination might not be worth the cost.
2.7.2007 8:44pm
Tom952 (mail):
What is the term for someone whose hidden agenda is anti-sex?
2.7.2007 8:46pm
AK (mail):
Not sure, Tom952. Personally I'm too busy trying to figure out the term for folks who imagine hidden anti-sex agendas in others.
2.7.2007 8:47pm
AK (mail):
So let me get this straight...

You're asking the government to:
(1) confiscate money from the public
(2) spend that money to force the unwilling to reduce risks that you could reduce just as well or better by paying for and getting the shot yourselves.

And you folks call yourselves libertarians?
2.7.2007 8:57pm
ReaderY:
The fact that the merits here are neither clear nor obvious is a good reason to ensure that decision-makers are democratically accountable and are permitted to make decisions based on pragmatic considerations and perceptions of common sense rather than adherence to rigid ideologies.
2.7.2007 9:00pm
Mike S.:
The case for mandatory vaccination seems weak to me. In the first place, with proper preventative care (i.e. Pap smears) the cancer is treatable, and, since the vaccine is only effective against some strains, the preventative care is still needed. This makes the cost/benefit ratio far less than it might otherwise be.

There is also always the possibility of some serious side effects that occur either too rarely or too slowly to show up in a clinical trial, but which may show up in large scale use. Since the risk of catching a cancer causing HPV infection clearly rises with the number of sexual partners (and the number of their sexual partners) there would seem to be a strong case for beginning the large scale use of the vaccine with the more promiscuous members of society; since they can expect a greater benefit, it makes more sense for them to assume the greater risk of early adoption. A voluntary system would encourage that sort of balance, as those who were at greatest risk would presumably be more eager to get the vaccine.
2.7.2007 9:23pm
Mark Field (mail):
All the diseases listed -- polio, tetanus, and pertussis -- can be prevented by behavioral change: don't drink any water except that which you yourself have tested for impurity; wear thick soled shoes and never handle sharp metal objects; wear a surgeon's mask at all times (or avoid human contact entirely).

Whatever the merits of the vaccination, this particular argument against it is silly.
2.7.2007 9:41pm
A Berman (mail):
Aaah, Eugene, here's where the whole individual vs. community thing shows itself in debate:
The monogamous *individual* is not protected from HPV or other STDs. However, the monogamous *community* is.

Keep in mind that most religious people are part of religious communities. That drives their thinking as much as anything else.

And yes, every community has it's secret strayers, etc..., so it's not going to be 100 percent. But you have to look at what traditional communities are willing to accept _as communities_.
2.7.2007 9:48pm
FantasiaWHT:
EV, why are you ignoring the argument that behavioral change by two people IS 100% preventitive? If both the woman and the man were monogamous before marriage then there is NO risk.

Just because the behavioral change involves both sides of the partnership doesn't mean it can be entirely discounted
2.7.2007 9:56pm
neutral:

Aaah, Eugene, here's where the whole individual vs. community thing shows itself in debate:
The monogamous *individual* is not protected from HPV or other STDs. However, the monogamous *community* is

Herd effect of monogamy, anyone?
2.7.2007 9:57pm
Erisian23 (mail):
>> But if "100% preventable" means living an entirely asexual life, [...] then we're way out of the range of normal assumption-of-risk talk.

I agree. It looks like another disingenuous and ultimately harmful argument from the "Abstinence Only Sex Education" ideology. Insofar as you are willing to forego all genital contact during your lifetime, you are as safe from HPV-related cervical cancer as anyone can be.

There's also no pressing need to do anything about those pesky drunk drivers if you people would just stay inside your houses in the first place. Oh, wait, I meant to say "If you forego leaving your home, you will dramatically reduce your risk of injury or death by drunk drivers."

I’ve also heard that if you assiduously avoid all forms of human contact, you virtually eliminate your chances of getting influenza, heartbreak, and cooties too! I may have just saved your life by informing you of that (influenza and pneumonia combined were the #8 cause of death in 2004, via NCHS). No need to thank me - that's just part of the public service I was put on this planet to perform.
2.7.2007 9:57pm
SeaLawyer:
People really need to get some facts on HPV. The vaccine does not work on males and males cannot be tested for it. The vaccine is only effective on 4 different strains of HPV. There is currently over 100 different strains or types of HPV, 30 of which are sexually transmitted. However 70% of cervical cancer is caused by the 4 strains covered by the vaccine. What percentage of women in the US that die from cervical cancer caused by HPV each year? A grand total of 0.00079%.
The CDC has a great deal of info on this here.
2.7.2007 10:00pm
SeaLawyer:

I agree. It looks like another disingenuous and ultimately harmful argument from the "Abstinence Only Sex Education" ideology. Insofar as you are willing to forego all genital contact during your lifetime, you are as safe from HPV-related cervical cancer as anyone can be.


No, it is about personal choice!
2.7.2007 10:08pm
Kovarsky (mail):
AK,

speaking of selectively libertarian awards - the system is not mandatory. it is a condition of enrollment in public schools. i.e. is a condition on a libertarian's consumption of a publicly provided good. it seems hypocrital in the utmost to, as a libertarian. scream bloody murder about having to accommodate one public benefit in order to secure the benefits of another.
2.7.2007 10:09pm
Kovarsky (mail):
[typing without my glasses sucks; let's try that again:]

AK,

speaking of selectively libertarian awards - the system is not mandatory; it is a condition of enrollment in public schools. i.e. is a condition on a libertarian's consumption of a publicly provided good. it seems hypocrital in the utmost to, as a libertarian, scream bloody murder about having to accommodate one public interest in order to secure the benefits of another.

and, it is not just about "choice." if we drop the ridiculous assumption that everyone remains 100% abstinent, then person A's decision not to get vaccinated has profound negative externalities.
2.7.2007 10:11pm
Kovarsky (mail):
Erisian,

I don't understand how this favors your point:

There's also no pressing need to do anything about those pesky drunk drivers if you people would just stay inside your houses in the first place. Oh, wait, I meant to say "If you forego leaving your home, you will dramatically reduce your risk of injury or death by drunk drivers."

One of the most pervasive ratioales for regulating drunk driving is that it is not just in the paternalistic interest of the drunk driver, but because drunk driving iposes social costs (accidents) on third parties that do not participate in the decision whether to drink or drive.

Also, I'd continue to point out that this is not "mandatory" - both in the sense that parents can opt their kids out on the basis of a conscientious objection, but more importantly because it's a condition of enrollment in school. you are not criminally punished for failure to get the vaccine.
2.7.2007 10:16pm
Kovarsky (mail):
Fantasia,

If both the woman and the man were monogamous before marriage then there is NO risk.

No, if both were virgins before marriage then there is NO risk.
2.7.2007 10:18pm
SeaLawyer:
I almost forgot the vaccine is only proven effective for 5 years at the present time, although with increased clinical trials that hopefully will prove longer.

My girlfriend has just received the vaccine (of her own free will) and I think it is a good thing. If I ever have a daughter I will encourage her to received it as well, but that will be a mutual decision between myself, my spouse and my daughter not the state.
2.7.2007 10:20pm
SeaLawyer:
Kovarsky,

it is a condition of enrollment in public schools. i.e. is a condition on a libertarian's consumption of a publicly provided good.


A publicly provided good that we pay for our entire lives.
2.7.2007 10:24pm
JoshL (mail):

No, if both were virgins before marriage then there is NO risk.


Actually, that depends entirely on your definition of virginity. If it's penetration, then your statement isn't necessarily correct- several strains including the one most likely to cause cancer may be transmitted through oral sex, though that's rare.
2.7.2007 10:27pm
TJIT (mail):
The mandate is nothing but rent seeking by Merck. According to this article in the Houston Chronicle physicians are opposed to the mandate

From among others, the Texas Medical Association and the American Academy of Pediatrics, many doctors are saying it's too early to mandate the vaccine

Some Quotes from the article
Dr. Patricia Sulak, a professor of obstetrics-gynecology at the Texas A&M Health Science Center College of Medicine, said health-care providers she knows were shocked by the order. "It's such a new vaccine — they haven't had time to explain it to patients,"
and
Hinchey and others emphasized that although the vaccine is considered safe, there are questions of whether there is enough experience with it to warrant a mandate. They say that some girls eventually may experience rare adverse effects not yet identified.
If this were not an STD I think people most political philosphies would oppose the mandate. Libertarians would see rent seeking, liberals would see abuse of corporate power, and conservatives would see a reduction in parental rights. The fact that it is an STD has distracted from the real problems with the mandate.
2.7.2007 10:27pm
Duffy Pratt (mail):
Tell Arthur Ashe that HIV was 100% preventable by behavioral change. Oh yeah, he should have rejected the blood transfustion that gave it to him and died of blood loss.
2.7.2007 10:35pm
Chimaxx (mail):
SeaLawyer:
Sounds like you need some study as well.. You write: "The vaccine does not work on males and males cannot be tested for it." But the site you point to pretty directly contradicts the first:


What about vaccinating boys?
We do not yet know if the vaccine is effective in boys or men. It is possible that vaccinating males will have health benefits for them by preventing genital warts and rare cancers, such as penile and anal cancer. It is also possible that vaccinating boys/men will have indirect health benefits for girls/women. Studies are now being done to find out if the vaccine works to prevent HPV infection and disease in males. When more information is available, this vaccine may be licensed and recommended for boys/men as well.


And another CDC report contradicts the second:

The prevalence of genital HPV infection in men is more difficult to assess because it is not clear which are the optimal anatomic sites or specimens to test.... HPV DNA can be detected at various anogenital sites, including the penis, urethra, scrotum, or anus, as well as in urine and semen. In heterosexual men, infection is most commonly detected on the penis (54-57).


When the vaccine is approved and recommended for boys, the outcry will be even greater, because the primary direct male beneficiaries of the vaccines will be MSMs (men who have sex with men)--specifically those who engage in receptive anal intercourse, who get anal cancer at a similar rate as sexually active women get cervical cancer. The "you better not be implying my boy might be gay" crowd will stridently resist the attempts to extend the vaccination to boys. In fact, the fact that the vaccination for both didn't start at the same time will be part of the problem ("My daugher is already vaccinated; if some other jerk didn't vaccinate his daughter when he had the chance, that's not my fault.")
2.7.2007 10:39pm
Kovarsky (mail):
JoshL,

I think didn't read the commment to which I was responding, so my comment might seem out of context. I was responding to someone who said you were safe if you were monogamous before marriage. My point was that people can be at risk at a much lower quantum of promiscuity. Forms of sexual contact other than intercourse do, of course, put you at risk. I just dindn't feel like I needed to make the broadest possible claim to make my point concisely.
2.7.2007 10:41pm
SeaLawyer:
Chimaxx,
They do not know if the vaccine works on males. So currently no there is no vaccine for males.
2.7.2007 10:42pm
Lively:
Mike S.

There is also always the possibility of some serious side effects that occur either too rarely or too slowly to show up in a clinical trial, but which may show up in large scale use.

I tend to agree with this statement. Voluntary=okay; Mandatory...I do not like it. Remember the drug DES they gave pregnant women until 1971 to prevent miscarriages? Well, now they found out after a generation has grown up that the drug causes cancer. I say we need more research on this vaccine before forcing it on the female population.

Additionally, the drug company who issues the vaccine is not a 501(c)(3). Their mission statement is not to save lives, but to make a profit for shareholders. This is about money.
2.7.2007 10:43pm
SeaLawyer:
I did make an error on the percentage of women that die of cervical cancer each year it is ~0.0011888782972451982%, not 0.00079%. This is based on a ~1790 death rate per year on for ~150,562,089 women in the US.
2.7.2007 10:45pm
Kovarsky (mail):
TJIT,

From among others, the Texas Medical Association and the American Academy of Pediatrics, many doctors are saying it's too early to mandate the vaccine

Boy, that's dirty. The paragraph goes on to say that all think the vaccine is medically desirable, but they're concerned about the degree to which mandating it might displace preventative education. TJIT makes it sound like the basis of the opposition was uncertain science.
2.7.2007 10:45pm
Kovarsky (mail):
Sealawyer,

I'm guessing from his pseudonym that "Climaxx" might not hesitate to explain the anatomical nuance to you, but I'll jump the gun, so to speak:

MEN DON'T GET CERVICAL CANCER.
2.7.2007 10:47pm
Mary Katherine Day-Petrano (mail):
And the autism epidemic takes another rise ...

I have so had it with the destruction mercury-based vaccines has caused to my life, I would resist ever having another one. And all the victims of this just continue to be punished at every turn of their lives.

And this idea of making everyone take a flu shot with thimersol -- what is worse, the autism or the flu?

A no brainer.

Since I lost my driver's license because one or more judges believe I can't see very well, I have been with my husband in a monogamous 24/7 relationship. So I really would not want the HPV vaccination either.

I thought where disabled people are concerned (e.g., mercury poisoning victims), it violates Title II of the Americans With Disabilities Act for a state to remove all risks anyways ...
2.7.2007 10:51pm
Kovarsky (mail):
Dr. T has the quote of the post:

4. The costs of widespread vaccination will greatly exceed the benefits. I estimate a few million dollars per year of life saved.

There were 1169 new cases of cervical cancer last year, approximately 818 of which would be caused by HPV.

The vaccine is 100% effective in clinical trials (nobody disputes that), so the idea, i guess, is that the program would be somewhere in the neighborhood of 1 billion dollars according to the back-of-the-napkin "calculation."
2.7.2007 10:53pm
Terf1016 (mail):
The danger of legislating mandatory participation in this vaccine is succinctly this: THE VACCINE DOES NOT PREVENT CANCER - only the virus. Too many women who are immunized will assume they are now "protected" against uterine and cervical cancers, and they may well skip the screening processes for those cancers. Women are already jumping to that conclusion: I get this vaccine, I don't get cancer. It could kill more women than it saves. And I'm a little tired of the gov't telling us what we HAVE to do, anyway.
2.7.2007 11:02pm
stephen (mail):
Don't people get tested before having sex anymore or is that just sooo 90's of a person to ask? Besides, you don't need to be a unich to make it 100% preventable. You need only test your partner before entering a sexual relationship with her/him. Sure, people may not always do that but, (and this is the point of libertarianism, I think), I (big capital I here)will always do that. Good enough for me.
2.7.2007 11:05pm
SeaLawyer:

Sealawyer,

I'm guessing from his pseudonym that "Climaxx" might not hesitate to explain the anatomical nuance to you, but I'll jump the gun, so to speak:

MEN DON'T GET CERVICAL CANCER.


No kidding! What is your point?
2.7.2007 11:05pm
Reg (mail):
This isn't accurate:


"[HPV] is not preventable by only having sex within marriage, since your husband or husbands (even the most religious don't mind remarriage after a spouse's death) might have been infected with HPV when you married them, or might cheat on you after marriage, get infected, and reinfect you."


What you mean to say is "One cannot have 100% metaphysical certainty that one will not be exposed to HPV by having sex only within marriage." But so what? Millions of couples are completely monogomous throughout life. HPV is in fact 100% preventable if two people only have sex within marriage. One cannot guarantee that one is within that class, but one can very strongly believe that one is within that class. If an individual is certain enough to be comfortable with the decision not to be vaccinated, the state can butt out.

The state should not require a vaccination against a risk within that person's control, and when the person is in a situation where they are comfortable with their exposure to the risk.

There are all kinds of other risks that exist between married couples that one exposes themself to that the state doesn't attempt to prevent with regulation. The state doesn't require individuals to enter into prenuptual agreements in case one later decides to divorce, in the name of protecting the parties and their future children. The state doesn't married couples to be routinely tested for HIV or other STDs to protect the parties. HIV is pretty deadly, and many STDs have very serious health consequences. In these cases, the harms are serious, and can be prevented or mitigated by requiring relatively painless and low cost steps. Nevertheless, no libertarians are pushing for these measures.

If a risk can be eliminated by the combined behavior of oneself and one's spouse, and the parties are confident that they will behave to eliminate the risk, it is authoritarian for the state to step in require additional steps to prevent the risk.
2.7.2007 11:08pm
Erisian23 (mail):
Kovarsky:

>> One of the most pervasive ratioales for regulating drunk driving is that it is not just in the paternalistic interest of the drunk driver, but because drunk driving iposes social costs (accidents) on third parties that do not participate in the decision whether to drink or drive.

I see, my bad and my apologies. Let me take a shot at clarifying what I meant. Few people leave their homes with the goal of getting hit by a drunk driver. Equally few people have sex with the intention of obtaining HPV. When you go outside your home, you understand the risk of getting hit by a drunk driver. When you have (even protected) sex, you understand the risk of HPV infection. In neither case did you have sufficient information to know that *this* particular trip to the mall or *this* particular sexual encounter will result in your untimely subsequent death. We accept that people who are injured by a drunk driver are "victims", despite the 100% behavioral change they could have made to preclude the accident ("don't go outside"). I simply put HPV "victims" on the same level ("stop having sex"). Both are natural rights, both are voluntary, and both have well advertised risks. Why isn't the ideal solution to both total abstinence? Because it's better to deal with drunk driving and viral infection at the source.

The person who commented...

HPV, like HIV and unlike Polio, Tetanus, Pertussis, etc is 100% preventable by behavioral change.

...seems to believe having sex is somehow "dirty". I suggest this because what he/she said is true of many viral outbreaks, and yet I rarely hear folks of the "100% behavioral solution" camp suggest we stop going to work or school during the flu season. Comments like his/hers are easy to make if you have a prior assumption that people infected with STDs ("From sex? Naughty, naughty!") are less innocent - and thus, less victimized - than people infected with influenza ("From your friend's house while watching the Superbowl? Oh, you poor dear!") or the common cold.

When I read statements along the lines of "we don't need to address problem A because people can merely forego exercising right X, which I don't think they ought to exercise much anyways", I recall the 1980 movie "Airplane!" when the newscaster said, "Shanna, they bought their tickets, they knew what they were getting into. I say, let 'em crash." Sadly, some people are saying essentially just that today and they don't mean it as a joke.
2.7.2007 11:11pm
Owen Hutchins (mail):
The theory that mercury-containing preservatives in vaccines causes autism has been refuted by the CDC. Repeated studies found no link whatsoever.
2.7.2007 11:12pm
Kovarsky (mail):
Sealawyer,

MEN DON'T GET CERVICAL CANCER.



No kidding! What is your point?


The stated rationale of the executive order is the prevention of cervical cancer. The vaccine is not mandatory for men.
2.7.2007 11:15pm
Terf1016 (mail):
It should not be mandatory for anyone. I can see where the logical outcome of such legislation is "hey, you didn't get the vaccine, so you get no insurance coverage if you get cancer."

But that doesn't change the fact that the vaccine does NOT prevent cancer, only CERTAIN STRAINS of the virus.

This whole thing stinks, bigtime.
2.7.2007 11:20pm
SeaLawyer:

The vaccine is not mandatory for men.

Where have I stated that? Other people have stated that men should that men should get the vaccine to prevent the cervical cancer in women. So I am still trying to figure why you directed that comment at me?
2.7.2007 11:24pm
Kovarsky (mail):
Stephen,

Don't people get tested before having sex anymore or is that just sooo 90's of a person to ask?

No. They should. That doesn't mean we should invite the cancer whammy when they don't.

Besides, you don't need to be a unich to make it 100% preventable. You need only test your partner before entering a sexual relationship with her/him.

"Eunuch." Especially since eunuch's are castrated men, they're not really who we're concerned about with HPV. I assume you mean "abstinent," in which case you're wrong. You can contract HPV in a variety of ways, of which intercourse is only one. I suppose you could demand a full battery of sexual tests before sexual contact of any sort, but that seems an unrealistic assumption as a descriptive matter.

Sure, people may not always do that but, (and this is the point of libertarianism, I think), I (big capital I here)will always do that. Good enough for me.

That is not the point of libertariansim. See, e.g., Robert Nozick. Your personal autonomy does not include the right to spread a contagion, even if the persons to whom you might spread it do not maximise risk prevention.
2.7.2007 11:24pm
TJIT (mail):
Kovarksy,

I gave a link to the article, and the link text clearly said the concern was about the mandate. Don't think a person could be more honest and upfront then that.

Bluntly, If anyone is playing dirty it is you.

The physicians in the article gave several reasons for their opposition to the mandate. I included two of the reasons in the block quotes. Furthermore the physician opposition was not based on the displacement of preventative education as you imply. In fact the words preventative education do not appear anywhere in the linked article. As far as I can see the physicians in the article never even mention the concept of preventative education. It appears you have done what you accused me of doing.

For those have not gone to the linked article here are a few more of the physician objections to the mandate that Kovarsky did not see fit to mention.
Other reasons cited by doctors in Texas and across the country include the vaccine's newness; supply and distribution considerations; the possibility opposition could snowball and lead to a reduction in other immunizations; the possibility it could lull women into not going for still-necessary cervical cancer screenings; gender-equity issues; and the tradition of vaccines starting as voluntary and becoming mandatory after a need is demonstrated.
and
The statement also says the costs of such a program will further strain state vaccine programs already short on resources.

Contrary to what Kovarsky say in his post the physicians have numerous reasons for opposing the mandate and displacement of preventive education does not appear to be one of them.
2.7.2007 11:25pm
Kovarsky (mail):
But that doesn't change the fact that the vaccine does NOT prevent cancer, only CERTAIN STRAINS of the virus.

I'd love to see this logic applied to HIV and AIDS.
2.7.2007 11:27pm
Kovarsky (mail):
TJIT,

Yes, I'm sure that the "conservative" opponents would suspend the vaccination program on the grounds the doctors endorse - that we should instead focus on teaching kids everything they need to know about sex.
2.7.2007 11:30pm
TJIT (mail):
Kovarsky,

Men may not get cervical cancer but they can display some of the same cellular anomalies that occur in cervical tissue when infected with HPV. These changes can be seen by pathologists and provide a diagnostic aid for HPV infection in men.
2.7.2007 11:31pm
John Thacker (mail):
The 50% of the public that's HPV-infected

But surely lots of people, especially those who do intend to have lots of sex, will get the vaccination. So with this vaccine, less than 50% of the public will end up being infected. The 50% is simply not relevant in this case. The relevant statistic is the percentage of the population that will have HPV once the vaccine becomes common and commonly recommended (if not mandatory or if only "mandatory" but with easy exemptions). (And that's not even considering the part about what percentage is infected with the strains that this protects against.)

I'm not saying that that's enough to make the "can be avoided by behavior" a decisive argument. It does, however, alter the probabilities somewhat. It does mean that the risks of some people not getting vaccinated are significantly lower than the risks of some people not getting vaccinated against more easily communicable diseases.

It does argue that the standard for how much we should enforce people getting it is slightly lower than for something like polio or measles, and allowing op-outs is much less of an issue.

All that said, I'm not particularly exercised by a mandatory plan. It doesn't bother me much, mandating it.
2.7.2007 11:32pm
Kovarsky (mail):
Erisian,

But this just isn't true:

We accept that people who are injured by a drunk driver are "victims", despite the 100% behavioral change they could have made to preclude the accident ("don't go outside").

We make "not driving drunk" way more mandatory, by punishing it criminally, than we make getting a vaccine mandatory, by conditioning enrollment in public schools on it. In both instances the government imposes a social penalty (criminal punishment or barred educational benefits) to coerce "elective" behavior (driving drunk and getting vaccines) on behalf of parties not part of the transaction (future accident victims and future virus recipients).

Drunk driving laws strike me a quintessential example of where we coerce behavior as opposed to assume that everyone avoids risk at all cost.
2.7.2007 11:35pm
anym_avey (mail):
A pity Mr. Volokh has descended so far below his usual level of logic in approaching the replies to Ms. McArdle's post. Why do people have so much emotion bound up in such a flimsy premise as this?

There were many responses Mr. Volokh could have selected from in Ms. McArdle's reply thread -- for example, the ones that pointed out that we have NO test data on how this affects pre-pubescent girls (the age group who are supposed to receive the mandatory vaccination); or the ones pointing out that the Phase III trials on this were small of themselves and somewhat oddly structured; or the ones pointing out that Merck has a huge vested interest in this; or those (which, happily, have been reintroduced here) pointing out that measurable benefits of this proposal even if it DOES have a 100% prevention rate with no side effects, neither of which have been strictly proven, are in the range of the smaller fractions.

Then there's the fact, also pointed out repeatedly in that thread and trampled on several times in this one, that sexual relations among humans ARE optional activities. They may be very natural and pleasurable to undertake, but this is not in the same ballpark as catching a flu virus from off a doorknob. Those who are asserting that analogy are, however ignorantly, making a pathetic effort to deny that willfully-chosen actions primarily affecting only the individual have forseeable consequences, which must be weighed as a risk of undertaking said activity; and, if preventive care is to be taken, it should be taken generally at the recipient's discretion, not the mandate of the state.

"Oh, but even your good-girl daughter might have sex and get HPV" -- yeah, well, in that case she's also at risk for every other STD known to man, and pregnancy. Most of these have about the same overall risk of getting past a condom. I'd say we have worse problems at that point -- and the HPV issue is a non-issue if she undergoes regular feminine preventive care. If she doesn't, one of those others is far more likely to bite her first anyway, so...
2.7.2007 11:36pm
TJIT (mail):
Kovarsky,

Could you please explain this paragraph to me.
Yes, I'm sure that the "conservative" opponents would suspend the vaccination program on the grounds the doctors endorse - that we should instead focus on teaching kids everything they need to know about sex.
It does not make a lick of sense particularly since the physicians said nothing about teaching the kids about sex.
2.7.2007 11:37pm
Kovarsky (mail):
Erisian,

It may be more precise to say that while we consider these people "victims," that does not mean the harmful event could not have been avoided at all costs.

Then proceed to my next paragraph.
2.7.2007 11:39pm
Kovarsky (mail):
TJIT,

I'm not doing this with you. I'm not cutting and pasting the entire article. You're obviously not interested in representing it accurately.

So this is a one-time response from me. Don't expect me to go back and forth with you about it.

The article talks extensively about the doctors being concerned that vaccine programs will detract from a focus on educating people about STDs.

I don't mean to be rude, but I live in Houston, I get the Chronicle every morning, I've read these articles about 10 times, and I know exactly what they say. You are not interested in accurately representing the thrust of the article; you're cherry picking language.
2.7.2007 11:42pm
Kovarsky (mail):
Here, then I want to stop this exchange. From today's article to which you link:

Opposition from doctors was less expected. Virtually all hail the vaccine as a great breakthrough and call for the highest possible proportion of girls and women — and boys and men, eventually — to get immunized in hope of one day eliminating the virus.

"But education needs to come first," said Dr. Joseph Bocchini, chairman of the AAP's committee on infectious disease. "Much of the public doesn't know about HPV and its link to cervical cancer and other diseases. You can't put a mandate ahead of that."
2.7.2007 11:44pm
Stating the Obvious:
I'm a physician, and while this is not my specialty area, I'm pretty sure that there are no currently recognized laboratory tests to DETECT HPV in a screening MALE population. That is, if a man doesn't have a genital wart or penile/anal lesion to culture, there are no tests that can determine whether or not he is carrying HPV. If this is true, testing potential lovers before engaging in intimacy won't solve the problem.
2.7.2007 11:51pm
Ammonium (mail):
Wow, you've all convinced me that this vaccine should be legal.

Now tell me why it should be mandatory? Why should someone like my wife have $500 stolen from her to put in the pockets of Merck while exposing her to unknown risk?

Wouldn't it be a lot more productive to spend our time banning cigarettes? There are a lot more people who die from them. Some people claim that any amount of smoke can kill... the chances of somebody going "Oops, I breathed in smoke" are much higher than somebody saying "Oops, I just hand sex with somebody with HPV." What about the children of smokers? It's much harder to avoid the risks of cigarettes than it is to avoid getting HPV.

Why do we mandate HPV vaccines while cigarettes remain legal? Because the vaccine sends a bunch of money to Merck, which gets redirected to politicians. If cigarettes are banned, the tobacco companies get less money, and they stop giving to politicians.

It's all about the $$$.
2.7.2007 11:52pm
Kovarsky (mail):
Stating the Obvious,

You are correct. If you're a dude, you have to watch for genital warts; that's the only way.

It's also worth stating at this point that the American Cancer Society theorizes that some for of HPV is a prerequisite for cervical cancer. The argument that vaccinations prevent HPV, but not cervical cancer, is therefore incoherent.
2.7.2007 11:57pm
Erisian23 (mail):
SeaLawyer:

>> >> I agree. It looks like another disingenuous and ultimately harmful argument from the "Abstinence Only Sex Education" ideology. Insofar as you are willing to forego all genital contact during your lifetime, you are as safe from HPV-related cervical cancer as anyone can be.

>> No, it is about personal choice!

If Aunt Sally, age 63, has sex with a gentleman suitor unknowingly infected with HPV, contracts it, and subsequently dies of HPV-caused cervical cancer, it’s her fault because it’s about personal choice. No HPV vaccines are needed. Adults shouldn’t have sex with each other (presumably excluding marital). Got it.

Let’s run with that:

If Aunt Sally gives you a kiss on the cheek when you visit her unknowingly infected with influenza, contracts it, and dies from complications, it’s her fault because it’s about personal choice. Adults shouldn’t kiss each other. No flu vaccines are needed.

If Aunt Sally goes to a restaurant, enjoys an otherwise healthy meal unknowingly contaminated with botulin, and dies as a result, it’s her fault because it’s about person choice. Adults should not eat food they did not prepare for themselves. No treatments for botulism or improved food storage procedures are needed.

I see the pattern now! It goes like this:

If Aunt Sally engages in a Perfectly Normal But Optional Behavior and is injured as a result, we don’t need to find ways to make the Perfectly Normal But Optional Behavior safer in general because it’s about personal choice!

Got it. I specifically disagree with the pattern because I believe the Perfectly Normal But Optional Behavior ought to be made safer for everybody. If it’s perfectly normal, presumably enjoyable, and potentially even loving, I believe we ought to decrease the risks associated with it to better enable everyone to enjoy the freedom, even if some individuals will choose not to exercise that freedom.

I also generally disagree with the pattern because I believe it will be applied unfairly, not universally. For example, I have a sneaking suspicion that people who frown on non-marital sex will apply the “it is about personal choice!” clause to the risks of non-marital sex, but not to infectious and other risks associated with holding a loved one’s hand, kissing a friend or family member, driving a vehicle on public roads, congregating in church, or visiting a friend in a hospital. Those are also normal, natural, optional, and... exempt?
2.7.2007 11:59pm
Kovarsky (mail):
Erisian,

I think sometimes because your writing style alternates between sarcasm and sincerity I misunderstand what you're advocating. If I've done that, I'm sorry.
2.8.2007 12:06am
Kovarsky (mail):
Some of you people just don't care about the fact that this isn't mandatory. It's amazing.
2.8.2007 12:07am
SeaLawyer:
Erisian23,

SeaLawyer:

>> >> I agree. It looks like another disingenuous and ultimately harmful argument from the "Abstinence Only Sex Education" ideology. Insofar as you are willing to forego all genital contact during your lifetime, you are as safe from HPV-related cervical cancer as anyone can be.

>> No, it is about personal choice!

If Aunt Sally, age 63, has sex with a gentleman suitor unknowingly infected with HPV, contracts it, and subsequently dies of HPV-caused cervical cancer, it’s her fault because it’s about personal choice. No HPV vaccines are needed. Adults shouldn’t have sex with each other (presumably excluding marital). Got it.


Not one time have I said adults should not have sex.
Everyone has free will and that free will includes what type of vaccines that they want to get.

Are you willing to go out and get the anthrax vaccine? Do you think it should be mandatory?
2.8.2007 12:10am
Lev:
Kovarsky

Earlier in this thread you said the vaccine was 100% effective against the HPV.

According to an article you yourself linked to in one of the other threads on this subject, the vaccine is effective only against four HPV varieties, and is 100% effective against only two of those four.
2.8.2007 12:19am
Pendulum (mail):
>Now tell me why it should be mandatory?

It's not mandatory. As I understand it, there's an opt-out provision.
2.8.2007 12:22am
SeaLawyer:

Some of you people just don't care about the fact that this isn't mandatory. It's amazing


There are quite a few commenter's that are trying to make the case for it to be mandatory.
2.8.2007 12:24am
Kovarsky (mail):
Lev,

It has been cited as 100% effective against cervical cancer; the strains that you name are those that cause cervical cancer.

SeaLawyer,

While I disagree with you, I did not have you in mind when I wrote that.
2.8.2007 12:29am
SeaLawyer:
Erisian23

If Aunt Sally engages in a Perfectly Normal But Optional Behavior and is injured as a result, we don’t need to find ways to make the Perfectly Normal But Optional Behavior safer in general because it’s about personal choice!


I have never said that we don't need to find ways to make things safer. I even said that I would encourage my own daughter to get the vaccine. The point you are missing is that there are risks involved with everything we do, and how we project ourselves is a matter of personal choice.
2.8.2007 12:30am
Pendulum (mail):
Eugene's post above gave an excellent explanation for why to tip the scales from opt-in to opt-out. If you can at least grant that, the Texas law shouldn't be a problem, right?

Mandatory is problematic because it negates parents' rights. However, the problem with opt-out is that minor children are placed at the mercy of their parents, and cannot then get the vaccine when it's most effective. Thus, children's rights are sacrificed for parents' rights.

The Texas law, modified to allow the opportunity for a minor to cast a "secret veto" of the parents' opt-out would ensure the protection of everyone's rights best - no?

If you're going to argue against this, it seems you are stuck arguing against all mandatory vaccination. Right?
2.8.2007 12:33am
Pendulum (mail):
Question for the knowledgable: Do unvaccinated minors, under the Texas law, have the right to obtain the vaccine without parental approval?
2.8.2007 12:35am
Kovarsky (mail):
By the way,

Y'all know who Rick Perry is right? I mean the governor that passed this? This is not a man averse to playing conservative social politics. Today he made perhaps the only move I've ever been proud of. The opposition in Texas is not this principled libertarian objection; it's an objection rooted in "lets pretend our kids don't have sex" or, more precisely, "HPV vaccinations condone sex."

His official statement was, more or less, excellent. Perhaps some of you should read it before you use the term "mandatory" one more time:

Never before have we had an opportunity to prevent cancer with a simple vaccine. While I understand the concerns expressed by some, I stand firmly on the side of protecting life. The HPV vaccine does not promote sex, it protects women’s health. In the past, young women who have abstained from sex until marriage have contracted HPV from their husbands and faced the difficult task of defeating cervical cancer. This vaccine prevents that from happening.

“Providing the HPV vaccine doesn’t promote sexual promiscuity anymore than providing the Hepatitis B vaccine promotes drug use. If the medical community developed a vaccine for lung cancer, would the same critics oppose it claiming it would encourage smoking?

“Finally, parents need to know that they have the final decision about whether or not their daughter is vaccinated. I am a strong believer in protecting parental rights, which is why this executive order allows them to opt out.”


His points:

(1) the medical cost-benefit is a no-brainer.
(2) the order implements a non-binding condition on enrollment in public schools.
2.8.2007 12:37am
TJIT (mail):
I have accurately represented the article.

If you follow the link and read the article you will find the extensive discussion on STD education Kovarksy cites simply does not exist. Out of an eighteen paragraph article the only discussion that even approaches STD education is contained in the final paragraph of his 11:44 post.

However, while reading the article again I did find another illustration of what an extreme rent seeking exercise Merck has going on here.
(The quickest a vaccine has gone from approval to mandatory in Texas was the chickenpox vaccine, which took 5 1/2 years.)
For those following along at home the HPV vaccine was approved in June of last year, a little more then seven months ago.
2.8.2007 12:38am
Pendulum (mail):
Actually, now that I think about it, I don't think my analysis above recognizes the problem of externalities.
2.8.2007 12:41am
Kovarsky (mail):
By the way, I should admit that I'm firmly in the camp of people that would allow the child to override a parental veto. Parental rights do not extend so far as to enable to gratuitous exposure to cancer.
2.8.2007 12:42am
Kovarsky (mail):
Are you people astronauts?
2.8.2007 12:49am
BobNSF (mail):
In the context of uh.. reality, this discussion which assumes widespread virginity borders on the surreal.

Trends in Premarital Sex in the United States, 1954­–2003


Results. Data from the 2002 survey indicate that by age 20, 77% of respondents had had sex, 75% had had premarital sex, and 12% had married; by age 44, 95% of respondents (94% of women, 96% of men, and 97% of those who had ever had sex) had had premarital sex. Even among those who abstained until at least age 20, 81% had had premarital sex by age 44. Among cohorts of women turning 15 between 1964 and 1993, at least 91% had had premarital sex by age 30. Among those turning 15 between 1954 and 1963, 82% had had premarital sex by age 30, and 88% had done so by age 44.


Conclusions. Almost all Americans have sex before marrying. These findings argue for education and interventions that provide the skills and information people need to protect themselves from unintended pregnancy and sexually transmitted diseases once they become sexually active, regardless of marital status.
2.8.2007 12:50am
John Thacker (mail):
If you're going to argue against this, it seems you are stuck arguing against all mandatory vaccination. Right?

I'm in favor of the Texas law as presented (with options for children to get it as well) and all, but I don't think that your point follows. As mentioned before, the 50% is a red herring... what matters is the percentage of the population that would have it after implementation of a non-mandatory law. Presumably some people would still get it.

The fact that behavior can prevent infection, and that once implemented a low fewer than 50% of the population would be infected even with an opt-in plan or a plan with easy opting out means that, while I still support a mandatory plan, I'm a lot less concerned with forcing people to get it than I am about the MMR vaccine.

With MMR, people not taking it is a huge problem, even a small clump of holdouts can be very bad. I'm just a little less concerned about it with this; just enough to not push quite so hard about forcing people to get it, though I think making it a standard mandatory shot is a good idea.
2.8.2007 12:50am
John Thacker (mail):
To put it another way... if 1% of people don't get the MMR shot, there's an enormous problem. If 1% of people don't get the HPV vaccine, the problem is considerably smaller. And that's enough to be much easier about letting people opt-out than with MMR.

And I see that this law does allow a lot of latitude for opting out, so it's all fine and reasonable.
2.8.2007 12:53am
Kovarsky (mail):
BobNSF,

and "my" kid doesn't drink beer or smoke pot, either.
2.8.2007 12:55am
Pendulum (mail):
John Thacker,

You're making a pragmatic, empirically based point. (The horror!)

The commenters above were making points based on moral theory and libertarian principle. I believe my argument holds for them.
2.8.2007 12:56am
SeaLawyer:

The opposition in Texas is not this principled libertarian objection; it's an objection rooted in "lets pretend our kids don't have sex" or, more precisely, "HPV vaccinations condone sex."


I don't live in Texas, but I am not in the pretend our kids don't have sex camp. I do get a little frustrated when people talk about basic personal freedoms that have little chance of affecting other people as being anti-sex.
Crack use has had a much more negative effect on society then cervical cancer yet on this blog all I hear is people wanting to end the war on drugs.

The fact remains that you can prevent cervical cancer by behavoir or with a vaccine. So why can't women chose which one?
2.8.2007 12:58am
Kovarsky (mail):
This is also a little stat-heavy, perhaps, but people shouldn't read too much into the lack of data for men.

HPV is not detectable through testing, you have to see lesions. In other words, the incidence of the dependent-variable event (a lesion) in men is much lower than the incidence of the dependent variable event (a positive pap smear test) in women. that means the data set to test the effectiveness of the vaccine has to be MUCH larger. you wouldnt expect a statistically significant outcome until the sample population of men gets much larger. that does NOT mean that the vaccine is less effective in men.
2.8.2007 12:59am
SeaLawyer:

Are you people astronauts?



Not if I have to drive to Florida in a diaper.
2.8.2007 1:00am
Kovarsky (mail):
For those people on this thread actually interested in facts and context, it should be noted that this is not a stand-alone order.

There is already a long schedule of vaccines upon which public schools condition enrollment. All the order did was add HPV to that list.
2.8.2007 1:03am
Erisian23 (mail):
Kovarsky:

>> I think sometimes because your writing style alternates between sarcasm and sincerity I misunderstand what you're advocating. If I've done that, I'm sorry.

Your first sentence is truth. I think if I want to be understood, I'd best adopt a particular tone and run with it. My response to SeaLawyer makes the same mistake.

I'm advocating two things.

Libertarian: If an action can rationally be accepted (“my health matters most”) or rejected (“it’s against God’s Will”), the gov’t of a free society must not act universally in loco parentis.

This is in direct response to the previous thread (and carried over to this one) where some people were arguing, in essence, that “because we believe every good parent will inject their daughter with this, the gov’t ought to make all parents do so.”

But I’m a poor hardcore libertarian in that I personally find Gov. Perry’s “libertarian paternalist” solution to be acceptable (“opt-out allowed if the gov’t approves of your good faith exemption claim, otherwise it’s three needles for your daughter”) and I’m even willing to have a measure of my (and your) personal income taxed to subsidize other people’s daughter’s injections.

Liberal: If a “behavior is perfectly normal, presumably enjoyable, and potentially even loving, I believe we (and our gov't) ought to decrease the risks associated with it to better enable everyone to enjoy the freedom, even if some individuals will choose not to exercise that freedom.”

This is in direct response to the comment Prof. Volokh quoted, “HPV, like HIV and unlike Polio, Tetanus, Pertussis, etc is 100% preventable by behavioral change.”

I’m inherently conservative enough to not want to encourage self-destructive behaviors (smoking, excessive alcohol consumption, unprotected sex, poor diet, and lack of exercise). But if we can eliminate some aspects of the destructive nature of these relatively common (if poorly chosen) behaviors, I’m for it. Living the life you personally find worth living may never be entirely risk free, but to the extent that we can reduce those risks, I’m willing to give it the old college try. HPV in particular gets my personal sympathies because it’s not clear that prophylactics alone are sufficient to entirely mitigate the risk, much like a wife’s fidelity to her husband is also no guarantee.
2.8.2007 1:05am
Kovarsky (mail):
I think one of the things I found most endearing about Newt Gingrich was his response to a question about him smoking pot. As compared to Clinton, who opted for a ham-handed non-answer, when asked if he tried pot and whether that proved something about his character, Gingrish shot back, "all that proves is that i was alive and in college during the sixties."

i think that many of gingrich's followers would benefit from a similar attitude towards sexual activity.
2.8.2007 1:10am
Elliot Reed:
Mandatory is problematic because it negates parents' rights. However, the problem with opt-out is that minor children are placed at the mercy of their parents, and cannot then get the vaccine when it's most effective. Thus, children's rights are sacrificed for parents' rights.
I agree, except for the bit about "parents' rights." Frankly I find it difficult to see why we should conceive of parents having a right to control their children at all. Parents aren't like property owners who have an entitlement to do what they want with their property: they're like trustees who have an obligation to act in the best interests of the beneficiaries. Saying a trustee can't do X because it's not in the interest of the beneficiary might be bad for a lot of reasons, but it's not interfering with the right of the trustee to do as they will with the trust property. There is no such right.

Of course, there are lots of reasons to give wide discretion to parents, but they're prudential reasons and have nothing to do with the supposed "rights" of the parents.
2.8.2007 1:16am
Kovarsky (mail):
I'm paraphrasing here, but libertariansim says, colloquially "do what you want to do, just don't harm other people."

the question is what constitutes "harm." presumably we can outlaw assault. do what you want to do, but you cant attack someone.

but consider drunk driving. i don't think libertarians mount a serious challenge to rules against it. "do you what you want to do, but you place other people at risk when you drive drunk; so we're going to coerce you not to."

here's the problem. of course other drivers, by choosing to get in their cars, assume some risk. but our solution is not to say that libertarianism includes the right to drive drunk, even though people could avoid the problem by not driving.

i don't see the difference here. we don't say you have the right to unknowingly transmit diseases, even though the people to whom they are transmitted could avoid the problem by remaining abstinent their whole lives.

the only possible distinction is that "sex is inherently wrong." that's just an objection i don't care about.
2.8.2007 1:23am
Kovarsky (mail):
thats just not an objection i care about, i mean.
2.8.2007 1:23am
Kovarsky (mail):
i just don't believe parents have a natural "right" to control the choices of their children's decisions. i think society is usually comfortable vesting them with this authority, and that is why sometimes it is treated as a "right." but that decision - to vest the parents with decisionmaking authority - is rooted in a belief that parents have an incentive to make the right decisions for their kids which, in the absence of exeternalities, are socially optimal.

but in instances where there is reason to believe that parents are not making socially optimal decisions on behalf of the child, i see no reason to respect the presumption in favor of parental authority.
2.8.2007 1:27am
Kovarsky (mail):
I just realized I said the same thing as Elliot Reed.
2.8.2007 1:28am
Erisian23 (mail):
>> Not one time have I said adults should not have sex.
>> Everyone has free will and that free will includes what type of vaccines that they want to get.

Reading that was a refreshing SeaBreeze. I clearly misunderstood your earlier comment to me since you've just said nothing I disagree with.

What I wrote regarding the "disingenuous and ultimately harmful argument from the 'Abstinence Only Sex Education' ideology" was not in support of eliminating choice one way or the other.

I have no issue with people promoting abstinence as a wise decision. I take serious issue with people promoting abstinence only, particularly in a situation where abstinence alone is not a sufficient solution to mitigate the risks. (I have to assume they don't truly mean "absolute lifelong abstinence" since not breeding a new generation to replace us brings reals harms above and beyond anything HPV can do - and it would also go against the marital mandate of some currently very popular dieties.)

>> Are you willing to go out and get the anthrax vaccine? Do you think it should be mandatory?

No. No.
2.8.2007 1:35am
Splunge (mail):
Holy cow, reading the fatuosity on display here about delicate shadings of legal rights and whatnot makes me think Shakespeare was on to something about lawyers (I'm sure y'all know the quote I mean, from Henry VI).

Should we go back and debate whether people's "rights" are violated because it's mandatory that you dispose of your shit in some approved receptacle, and you can't make the "personal choice" of throwing it out in the street? After all, those interested in not contracting typhus can just boil their water, and wash themselves very carefully with an antiseptic after taking a walk down the street.

Maybe we should stop requiring polio vaccine, and folks who don't want their children to spend their life in an iron lung can just lock them up inside until they're old enough to be taught to never use public water fountains, swimming pools, libraries, or telephones, or the bathrooms or kitchens of strangers.

Feh. The notion that any kind of individual "right" trumps any serious public health interest is ultimately so idiotically anti-social I'd gladly see those who hold it deported to Cuba. Indeed, we can afford to indulge such goofball notions only because our more realistic ancestors got serious enough about public health problems that we have, willy nilly, remarkably few of them left.

And, FYI, let me just note that HPV has only been linked to cervical cancer so far. Who would be so naive as to think that a virus (or rather large family of viruses) known to cause cancer causes only one type? Good grief.
2.8.2007 1:45am
Erisian23 (mail):
Splunge:

>> The notion that any kind of individual "right" trumps any serious public health interest is ultimately so idiotically anti-social I'd gladly see those who hold it deported to Cuba.

That sounds remarkably like an argument for a truly mandatory vaccination schedule. After all, "opt-out" is offered and exercised precisely to protect those individual "rights" you disdain in favor of the "public health". Are the ones who exercise the "opt-out" the same ones you'd gladly deport to Cuba?
2.8.2007 1:55am
Kovarsky (mail):
Splunge,

HPV causes several types of cancer. It's just that most believe it's the exclusive cause of cervical cancer - that's why it gets the most attention.
2.8.2007 2:04am
Daryl Herbert (www):
Prosecutions for "defamation of religion" are 100% avoidable by behavioral change.
2.8.2007 2:09am
Clayton E. Cramer (mail) (www):
I just watching libertarians defending state coercion to prevent the spread of a disease that isn't easily communicable! Let's see, what if the state decided to discourage (not criminalize, you understand, just propagandize against) sexual promiscuity in the interests of reducing the risks of STDs? Somehow, I think you would be amazed at how rapidly this wasn't properly the government's business.

I hope that every girl in this country gets Gardisil. But the only good argument for making it mandatory is the same communitarian argument for prohibiting sexual promiscuity.
2.8.2007 2:12am
Clayton E. Cramer (mail) (www):
Splunge writes:


Feh. The notion that any kind of individual "right" trumps any serious public health interest is ultimately so idiotically anti-social I'd gladly see those who hold it deported to Cuba. Indeed, we can afford to indulge such goofball notions only because our more realistic ancestors got serious enough about public health problems that we have, willy nilly, remarkably few of them left.
Darn straight! So, when are we going to prohibit anonymous anal sex between strangers? Oh, you weren't serious about this, I guess.
2.8.2007 2:15am
Kovarsky (mail):
Clayton,

Start over. "Not easily communicable?" What?
2.8.2007 2:16am
Erisian23 (mail):
Kovarsky:

(Sorry to keep quoting you so much... You have a way of bringing up topics that pique my interests :-)

>> in instances where there is reason to believe that parents are not making socially optimal decisions on behalf of the child, i see no
reason to respect the presumption in favor of parental authority

“socially optimal”? Collective constructs in policy conversations make me nervous, particularly because phrases like “for the public health” have been used (in this thread, no less) to suggest imposing one person’s view of “what’s best” on everyone else. I can see a fair argument that forcing an injection on all girls age 9 without exception may very well be socially optimal in some meaningful sense of that phrase, but I’m not prepared to accept that it’s categorically in the best interest of every single one of those children.

Someone who supports “vaccination opt-out” probably doesn’t define “socially optimal” as “society’s best interests over the individual’s best interests”. So I’m curious, how do you define “socially optimal” in the context in which you’ve used it? It was my understanding that parental decisions ought to be made in the “best interests of the child”. The socially optimal decision may frequently correspond, but the focus ought to properly rest upon the child’s needs and wellbeing, not society’s.

(Society doesn’t need more starving artists. If your child wants to be an artist and expresses interest in after-school art classes, do you as the parent force them to attend the computer club instead? Society could use more engineers.)

I see no reason to respect the presumption in favor of parent authority when the parents are making patently irrational, illegal, or abusive decisions regarding their children. I don't suspect the list of terms is properly exhaustive either. And of course, those terms are subject to judicial interpretation on a case-by-case basis, but the focus at least remains on the child’s best interests.
2.8.2007 2:54am
Kovarsky (mail):
Erisian,

As I was typing that, I made a mental note to change that phrasing, but forgot to. I need to rephrase, and will. Basically I don't think parents asserting authority over children are asserting a "right" over anything. They're vested as fiduciaries.

In instances where the child's expressed preference contravenes that of the parent, and when there are significant third party benefits to the child's preference, in light of the fact that a parent is not asserning a right that he or she "owns," but a proxy-right, I think it can both yield and be easily distinguished from some of the more gruesome slippery slope arguments.

I think I left out the part about the child disagreeing with the parental veto.
2.8.2007 3:13am
logicnazi (mail) (www):
But almost ALL diseases are 100% preventable by behavior change.

If I go live in a bubble or even just isolate myself in a hepa-filtered sealed environment, eat and drink only sterilized food and so forth I can totally prevent many diseases. Or at least reduce the chances of getting them to the same risk that one runs of getting these diseases by blood transfusion, medical error etc..

For a more realistic example note that lice is pretty much completely preventable by shaving all of one's hair.

Ask yourself would you take the same attitude if we found a diseases that was completely preventable by refusing to shake hands, or by becoming vegetarian or even better that was prevented by having sex with multiple partners (say it stimulates parts of the immune system).

I suspect if we make the behaviors something that people approve of the whole attitude changes. So the truth is this has nothing to do with whether it is preventable by behavior change and everything to do with whether you think those behaviors are morally suspect and those who engage in them are more deserving of bad consequences than those who shake hands.
2.8.2007 4:16am
Brian K (mail):
SeaLawyer, you need to take you own advice.


People really need to get some facts on HPV. The vaccine does not work on males and males cannot be tested for it. The vaccine is only effective on 4 different strains of HPV. There is currently over 100 different strains or types of HPV, 30 of which are sexually transmitted. However 70% of cervical cancer is caused by the 4 strains covered by the vaccine.


The vaccine hasn't been tested on males, that doesn't mean it doesn't work on them. It most likely will given that the mode of infection is the same for both men and women. Also 2 of the 4 strains account for 70% of all cervical cancer cases. The other 2 strains account for an approximately equal percentage of genital warts (a symptom which has its own health problems independent of cervical cancer).
2.8.2007 4:53am
Brian K (mail):
I see someone beat me to the punch...my bad...I didn't read far enough down before posting my response.
2.8.2007 5:35am
Ruy Diaz (mail) (www):
From AK: "Here we have an early entry for the Fair-Weather Libertarianism Award for 2007."

You are: ABSOLUTELY CORRECT SIR. Some Libertarians are for liberty... unless they can abandon their "principles" and screw religious conservatives. (Pardon the pun.)
2.8.2007 6:32am
David M. Nieporent (www):
For those people on this thread actually interested in facts and context, it should be noted that this is not a stand-alone order.

There is already a long schedule of vaccines upon which public schools condition enrollment. All the order did was add HPV to that list.
Yes, but those other vaccines are for communicable diseases, which, if one is infected with, one can spread simply by going to school. There's a direct connection between the vaccine and the enrollment. That isn't the case here, so the analogy doesn't hold.
2.8.2007 7:07am
plunge (mail):
Eugene: did you know that it can actually be the case that MORE sex can actually SLOW the transmission of a disease through a population, provided that it's the right people increasing their sex? Very counter-intuitive, but mathematically sound.

Basically, the argument is like this: there are people who want a current level of highly promiscuous sex who will search for partners amongst, generally, others who are promiscuous, and thus who are most likely to be infected. However, if folks that have before been generally prude start having more promiscuous sex, this decreases the chance that any given sexual encounter will lead to transmission.

Thus, if messages to sleep around less reach mostly only those who are most inclined to be prude already, they will have the effect of INCREASING transmission rates!

Take the issue of Africa, where AIDS spreads so quickly in part through men having sex with highly-likely to be prostitutes, and then infecting their mostly monogamous wives. If those wives were to increase their partnering: i.e. engage in a lot more wife swapping, the transmission rates for everyone, men and wives, would go down.

It sounds crazy, but the models and math based on it work. It does, of course, require certain things to be true about the sexual habits of a population (i.e. it wont work in every case), but several studies have found various populations to exhibit the factors in which it is true (many places in Africa being one example)
2.8.2007 7:34am
David C. (www):
Very amusing.
As a christianist, I will be getting my daughters vacinated. However, I am amused, as are many of the posters, by the normally libertarian VC supporting a mandated goverment program that is a direct invasion of an individual and a familys life.

VC sounds very "liberal" today
2.8.2007 7:44am
neutral:
The whole drunk driving analogy spat (and other analogies being thrown around) is revolving around attitudes to sex, of course. Some people believe in casual sex and can not imagine a life can be fulfilling without. Some people recoil in horror. Accordingly, the former see opponents of vaccine as idiots standing in the way of progress (making casual sex safer for everyone will make society as a whole happier). Their opponents resist. So this discussion has degenerated into another round of culture wars. Arguments are cherry-picked on both sides to fits the agenda.
2.8.2007 8:47am
Bruce Hayden (mail) (www):
Interesting discussion. I am still of the opt-in persuasion, but would push a daughter to do so.

Not that I don't believe there is a problem, but the opt-out seems a bit too heavy handed for me.

Also, part of the problem with men is apparently detection. We don't get Pap smears and genital warts are often much, much, less noticable.

That reminds me of a female ob/gyn a couple of decades ago who was on a tear about genital warts. Male doctors treating men tended to ignore them because they didn't cause their patients any real problems, nor were they often even visible. But the men would transmit to their female partners, who would then turn up with negative Pap smears (not always of course, but enough to make this one physician irate at her male colleages).
2.8.2007 9:50am
lucia (mail) (www):
David C said:
...by the normally libertarian VC supporting a mandated goverment program that is a direct invasion of an individual and a familys life.


I'm not surprised by the posts by normally VC commenters. After all, many posters aren't mega-ultra libertarians; many are libertarian leaning. Besides that, this law just barely invades family life and some of the posted objections are attempts to make the law more libertarian.

Specifically, many in comments applaud the opt-out which means the "direct invasion" of parents role is that parents are required only to file paperwork. (I realize a true-blue, mega-ultra libertarians might object to anyone being required to file paperwork for anything. However, those objecting to paperwork in general, should, presumably object all sorts of other paperwork and not limit their objections to the HPV vaccine issue.)

And a number of people, including at Kovarsky, Pendulum and me (on another thread) would like to see a major change that would improve the libertarian credentials of this law. Specifically, we'd like the law modified to permit daughters to overide their parents' veto.

This change in law would permit the daughter the liberty to protect her own health using the means she prefers which includes having a vaccine injected into her own body. The alternative is to give exclusive veto power to the parents-- who aren't the ones getting injected. That's not a particularly 'libertarian' stance unless you think kids belong to parents the same way that pets belong to their owners.

How is this point of view surprising in VC comments?
2.8.2007 10:01am
John Thacker (mail):
Logicnazi: I suspect if we make the behaviors something that people approve of the whole attitude changes.

This is undoubtedly true. However, the analysis in either case is not, to me, about how easily it is for one to change one's own behavior. That, by itself, only plays into an indvidual's decision to get vaccinated onself.

The case for collective action is motivated by the externalities, by how likely it is that other people are negatively impacted by refusals to get vaccinated. If the externalities are small, and it is relatively difficult to get the disease from others unwillingly, then mandatory action is not quite as necessary.

A "disease that was completely preventable by becoming vegetarian," eh? Suppose that we're talking about something like E. coli that infects only meat, is only communicated by eating infected meat, and there's a vaccine to prevent it. Would there be a case for mandatory vaccination? Not so much of one. The presence of one additional unvaccinated person would not increase the chance of someone else getting the disease. In fact, the reverse may be true-- if nearly everyone is vaccinated, people are likely to be far more lax about storing and preparing food properly in order to prevent infection. The incentives would be lined up in an acceptable manner.

By contrast, diseases communicated by breathing the same air as someone else and extremely contagious are at the opposite end of the spectrum. These have extremely high externalities, and unvaccinated people place a tremendous burden on each other. It is very difficult to avoid breathing the same air as other people. For this reason, mandatory vaccinations are extremely important.

A sexually transmitted disease lies somewhere in the middle. I suspect indeed that one's particular views on the likelihood of multiple sex partners and promiscuity will dramatically affect one's estimates of the costs and burdens imposed. So, too, how much one believes in getting tested for STDs before having sex with someone. This would not necessarily mean dumping the person if they have a positive test, if the vaccine is one that would work when taken at an older age; apparently this one has issues, though, which is another important factor in the calculation. In any case, I think it's clear that we shake hands and breathe the air of more people than we have sex with.

Note that for each level of how easily communicable the disease is, the mathematics of epidemiology dramatically change, and a different level of unvaccinated population is allowable before an outbreak becomes likely. If you admit at all that there is a cost (however small) in mandatory vaccinations, then it's at least reasonable to have a somewhat different level of strictness in the mandatory nature of the vaccine. A default with opt-out is probably sufficient for an STD like HPV, a strictly mandatory vaccine is probably necessary for MMR, and an opt-in vaccine may be acceptable for diseases spread only by contaminated food.

This explains, of course, why the Hepatitis B vaccine is considered much more important to make sure that people get than Hepatitis A vaccine. B is an STD, A is from food.
2.8.2007 10:02am
Kent G. Budge (mail) (www):
And the autism epidemic takes another rise ...

I have so had it with the destruction mercury-based vaccines has caused to my life, I would resist ever having another one. And all the victims of this just continue to be punished at every turn of their lives.

And this idea of making everyone take a flu shot with thimersol — what is worse, the autism or the flu?


*Sigh.* The mercury-autism link has been more thoroughly debunked than almost any junk science I know of. The latest is here.

But I doubt this makes any difference to those for whom blaming mercury fills a deep emotional need.
2.8.2007 10:25am
IANAD:
My objections to widespread, mandatory use of the vaccine are essentially pragmatic, and may be answerable by some here with expertise:

1. Risks of the vaccine: There's a few things here that worry me. Has the vaccine been tested for side effects on a statistically significant population of prepubescent and adolescent girls and/or boys? I'm not a doctor, but I'm pretty sure those demographics sometimes have significantly different responses than do adult populations.

Someone mentioned that it's been only seven months since the vaccination was approved, and that the last vaccination in Texas to be mandated for use in public schools (is that a word?) had a period of 5 1/2 years between approval and mandate. Is that unusual? Has the vaccine been tested for an extended, multi-year period to screen for intermediate/long-term side effects?

The other concern I have has also been brought up, but not really discussed. What effect will it have on other preventive behavior (i.e., pap smears)? One big argument I'm seeing in support of mandate is more or less "People are gonna have sex, and many will not test their partners because of stupidity/inconvenience/etc., so we might as well make it less dangerous." If people behave that short-sightedly, doesn't it make sense that at least significant proportion of people will decide that pap smears are inconvenient and unnecessary if they have been vaccinated?

2. Efficacy of the vaccine:

Here:

The vaccine hasn't been tested on males, that doesn't mean it doesn't work on them. It most likely will given that the mode of infection is the same for both men and women. Also 2 of the 4 strains account for 70% of all cervical cancer cases. The other 2 strains account for an approximately equal percentage of genital warts (a symptom which has its own health problems independent of cervical cancer).


But then here:

It has been cited as 100% effective against cervical cancer; the strains that you name are those that cause cervical cancer.


I'm a little confused. Does this mean that 30% of all cervical cancer is not caused by HPV at all, or that 30% is not caused by those two particular strands? This may seem rather nit-picky, but the answer has an effect on the next question:

Is the vaccination cost-effective compared to the alternatives?


Of those women who get HPV-related cervical cancers, nearly all will are detected and eradicated in their pre-malignant phase by routine Pap smears.


What's the cost of mandatory (or at least subsidized) detection (and then treatment per actual incidence) compared to the cost of mandatory vaccination? Are pap smears good for detecting non-HPV-related cervical cancer?

If a significant number of cancers are unrelated to the virus, and the vaccine decreases the likelihood that those cancers will be diagnosed, wouldn't it make more sense to invest in the detection/diagnosis of the cancer rather than one of the causes?

It looks like this particular issue seems to have a lot of specific information that needs to be understood before taking a position. The principled objections ("The state should let us choose the vaccine on our own") and supports ("The state should do what's necessary to safeguard the public health") both come across as fairly well-founded to me, and it's kind of a pick your poison. The libertarian position doesn't seem to significantly threaten the well-being of the community (unlike MMR, for example), and the public-health one doesn't seem to encroach drastically on freedoms (adding another line to the list of required vaccinations, and this one even comes with an opt-out).

The people espousing one principle or the other are overstating their cases, and missing what (to me) are serious pragmatic questions about efficacy, side-effects, and opportunity-loss.
2.8.2007 10:38am
Kovarsky (mail):
Neutral

The whole drunk driving analogy spat (and other analogies being thrown around) is revolving around attitudes to sex, of course. Some people believe in casual sex and can not imagine a life can be fulfilling without. Some people recoil in horror. Accordingly, the former see opponents of vaccine as idiots standing in the way of progress (making casual sex safer for everyone will make society as a whole happier). Their opponents resist. So this discussion has degenerated into another round of culture wars. Arguments are cherry-picked on both sides to fits the agenda.

O you're so above the fray I can hardly stand it. Actually the analogy is about how government coerces individual behavior on behalf of third party beneficiaries whose interests are not taken into account in the private transactional decision. But you just stay above the fray.
2.8.2007 10:38am
BladeDoc (mail):
The 100% behavioral prevention does NOT come down to never having sex. The options are multiple and include (risks taken from the nci website):
1) Don't get vaccinated, have average # partners, don't get screened (PAP) -- est. lifetime risk of cervical cancer 1.7%
2) No vaccine + screening + average # sex partners = risk of 0.7%
3) No vaccine +/- screening + monogamous sex = lower risk (but no-one knows the number)
4) Celibacy = 0 risk (and 0 fun)
5) VOLUNTARILY get vaccinated in conjuntion with any of the above to reduce your risk by an estimated 70%
6) Only have sex with people of known negative HPV status by PCR as recommended for other STDs and why in some states STD testing is mandatory prior to marriage(? cost/practicality). For men this is as easy of only having relations with women who have been vaccinated.

I look at those numbers and would recommend vaccination (and will have my daughter vaccinated at the appropriate age) but frankly do not believe that the risks support forcing people to get vaccinated for this particular illness.

Finally not only is Merck looking to make a lot of money by rapidly expanding the market without having to go through the annoying "convince the consumer the product is worth it" phase of capitalism they are also seeking to avoid liability by getting the vaccine declared mandatory. I believe that this would put it into the Fed. vaccine liability program. Classic rent seeking AND use of gov. power to enforce a monopoly, AND an attempt to avoid liability for harm. I need to buy stock in Merck.
2.8.2007 10:42am
Brian K (mail):
IANAD,

To answer your question:

Does this mean that 30% of all cervical cancer is not caused by HPV at all, or that 30% is not caused by those two particular strands? This may seem rather nit-picky, but the answer has an effect on the next question:


The vaccine protects nearly completely against the strains that cause 70% of cervical cancer from HPV. This accounts for the both of your questioned statements. The vaccine is nearly 100% effective at what it does, which is protect the patient from those 4 specific strains. HPV also accounts for the vast majority of cervical cancer cases. While there are other risk factors, studies have shown that infection at some point with HPV is a prerequisite for cervical cancer. (It has to do with the effect that the virus has on human DNA.)

I hope this helps.
2.8.2007 10:54am
Brian K (mail):
As for this statement:


Of those women who get HPV-related cervical cancers, nearly all will are detected and eradicated in their pre-malignant phase by routine Pap smears.


It's not true by a long shot. Somewhere around 10,000 people/year get cervical cancer. About 4,000 people/year will die from it.

If they were all detected, then why are people still dying from it?

Also, even if it is detected early enough to prevent death, it doesn't mean there won't long lasting health consequences.
2.8.2007 10:57am
Captain Holly (mail):
I've noted on other fora that I normally don't see an Eeevil Corporate Conspiracy behind every rock, but the HPV vaccine is so over-hyped I can't help but think many of the more vocal supporters have benefited or will benefit financially from it (such as Governor Perry, who has already received about $6,000 in campaign contributions from Merck).

Everyone is all a-flutter at how Gardasil prevents cervical cancer. Which, of course, is false: It prevents infection by four strains of HPV that cause about 70% of the cases of genital warts, which are strongly associated with cervical cancer.

Yet some would argue that is a good idea in light of the hysterical statistic that some "50% of people get HPV!" during their lifetimes. There are two significant caveats to that statistic; one, it is describing non-monogamous, sexually-active persons; and two, it includes all sexually-transmitted forms of HPV, not just the ones that cause genital warts. Your prudish spinster aunt is unlikely to have been infected by any of them.

Of the some 100 strains of HPV, only about 30 are sexually-transmitted, and of those only 6 cause genital warts which are strongly associated with the later development of cervical cancer. Most sexually-transmitted infections with HPV are mild and usually self-resolve within a few days; the person has little idea that he or she is infected. Gardasil only prevents infection by four of the wart-causing strains. So even successful vaccination with Gardasil won't completely prevent genital warts or cervical cancer.

Indeed, as some have already pointed out, cervical cancer is a relatively rare cancer already, and both the death and incidence rates from the disease have been steadily declining for the past 30 years, largely due to Pap smears. A woman who gets yearly Pap smears and cervical exams has a much reduced chance of getting cervical cancer, and even less chance of dying from it.

Which is why even if a woman does get immunized against HPV she is still advised to get yearly Pap smears, simply because the vaccine doesn't prevent infection by all types of HPV.

And there is a dirty, very un-PC secret about cervical cancer: Most cases occur in poor minority women, probably because they can't afford regular medical exams. White, middle- and upper-class women are the ones least likely to develop cervical cancer.

So, in summary, you have:

an expensive, difficult-to-administer vaccine that doesn't even protect the recipient from all forms of the disease,

that requires the recipient to continue to receive the treatment that largely prevents the disease in the first place,

that requires the recipient to continue to act as if they hadn't been vaccinated,

and that prevents infection by a disease that is not transmitted by casual contact.

In my book, I don't see the massive public health advantage to it. I think much of the hype is due to people trying to be cool: No one wants to be seen as an anti-sex square, so otherwise rational people don't bother to look at the facts and instead follow the herd.
2.8.2007 11:31am
Brian K (mail):
Captian Holly,

I don't know where you getting your information from, but its not right.

from wikipedia (emphasis added):
"The American Cancer Society provides the following list of risk factors for cervical cancer: human papillomavirus infection, smoking, HIV infection, chlamydia infection, dietary factors, oral contraceptives, multiple pregnancies, use of the hormonal drug diethylstilbestrol (DES) and a family history of cervical cancer.

The presence of strains 16, 18 and 31 of human papillomavirus (HPV) is the prime risk factor for cervical cancer, and Walboomers et al. (1999) reported that the presence of HPV is a necessary condition for the development of cervical cancer . A virus cancer link with HPV has been found to trigger alterations in the cells of the cervix, leading to the development of cervical intraepithelial neoplasia and cancer.

HPV subtypes 16 and 18 introduce two genes called E6 and E7 which code for proteins that inhibit p53 and Rb, which are two important tumor suppressor genes in humans. The p53 gene product is involved in regulation of apoptosis (cell suicide), and Rb is responsible for halting the cell cycle at the G1-phase. When Rb function is impaired, the cell is allowed to progress to S-phase and complete mitosis, resulting in proliferation and hence neoplastic transformation.

Genital warts are caused by different HPV types, and are not related to cervical cancer.

The medically accepted paradigm, officially endorsed by the American Cancer Society and other organizations, is that a patient must have been infected with HPV to develop cervical cancer, and is hence viewed as a sexually transmitted disease. Not all women infected with HPV also develop cervical cancer (Snijders et al, 2006). Use of condoms will not always prevent transmission. Likewise, HPV can be transmitted by skin-to-skin-contact with infected areas."

(I only quote from wikipedia because its the most concise, but any medical website you go to will give you the same information. For full references go to: http://en.wikipedia.org/wiki/Cervical_cancer)

The vaccine protects against four strains of HPV (6,11,16,18).

Pap smears are a screening procedure, NOT a treatment. If you get a negative pap smear, then you still have to undergo appropriate treatment.
2.8.2007 12:01pm
Kovarsky (mail):
Yeah the 50% number is completely is misleading:

There are two significant caveats to that statistic; one, it is describing non-monogamous, sexually-active persons;

I mean, that only describes 97% of the human population.
2.8.2007 12:24pm
Kovarsky (mail):
I can assure you that $6,000 in past campaign contributions doesn't buy you favors with Rick Perry.
2.8.2007 12:26pm
DeezRightWingNutz:
People that have pre-marital sex and people that are monogamous aren't mutually exlusive. There are some people that have pre-marital sex with one person, their future spouse.
2.8.2007 1:01pm
TJIT (mail):
The Texas medical association opposes the mandate, the American Association of Pediatrics opposes the mandate. Doctors say Perry's vaccine mandate for girls is premature According to the linked article the fastest a vaccine has previously gone from approval to mandatory usage in Texas is 5 and 1/2 years. This vaccine has been approved for seven months Who supports the mandate? Merck, its lobbyists and the politicians they support.

Merck decided direct to patient advertising was too slow they opted for direct to patient mandates.

I am stunned at the number of people who are cheering on the complete gutting of the normal medical, and scientific review process for mandating a vaccine. You are cheering on the replacement of clinical study and medical investigation with the use of raw political power and astute lobbying.

Removing the physicians and scientists from the vaccine mandating process and replacing them with lobbyists and politicians is foolish and sets a very bad precedent.
2.8.2007 1:15pm
Brian K (mail):
I've noticed some glaring inconsistencies in arguments.

1) opponents of the HPV vaccine, either in general or overall, are more than happy to tout statistics to say the number of cervical cancer cases it will prevent is small compared to the population, but the mere possibility of abstaining or having a completely monogamous relationship or of having only a single lifetime sex partner or what have you is plenty of reason to not use/mandate the vaccine regardless of what the actual chances of that happening are.

2) conservatives and/or libertarians, who usually see absolutely no problems with unfettered corporations and who will many times bitterly oppose any attempts at corporate regulations, are all of a sudden calling foul that merck is lobbying for something that stands to make them some money. Isn't that just a little hypocritical?
2.8.2007 1:40pm
Thorley Winston (mail) (www):
From AK: "Here we have an early entry for the Fair-Weather Libertarianism Award for 2007."

You are: ABSOLUTELY CORRECT SIR. Some Libertarians are for liberty... unless they can abandon their "principles" and screw religious conservatives. (Pardon the pun.)


Haven’t you heard, “liberaltarianism” is the new “fusionism.”

Seriously this discussion has been enlightening in that it demonstrates that “social liberalism” is in ultimately incompatible with limited government because social liberals almost invariably end up demanding that the Nanny State intrude on the rights of the rest of us to protect themselves from their own choices.
2.8.2007 2:01pm
Thorley Winston (mail) (www):
conservatives and/or libertarians, who usually see absolutely no problems with unfettered corporations and who will many times bitterly oppose any attempts at corporate regulations, are all of a sudden calling foul that merck is lobbying for something that stands to make them some money. Isn't that just a little hypocritical?


Not really because (a) the “conservatives and/or libertarians, who usually see absolutely no problems with unfettered corporations” is a strawman you pulled out of your arse and (b) the objection here is to the action of the government which would be opposed regardless of who asked them to do it.
2.8.2007 2:04pm
whit:
i have no doubt that the "feminists" who support the "right" of a 15 year old girl to seek an abortion without parental notification, will not see any reason why a 15 yr old girl would have a right to refuse an HPV vaccination
2.8.2007 2:11pm
IANAD:
Brian and others, thanks for the response. It's a lot clearer now.


As for this statement:

Of those women who get HPV-related cervical cancers, nearly all will are detected and eradicated in their pre-malignant phase by routine Pap smears.

It's not true by a long shot. Somewhere around 10,000 people/year get cervical cancer. About 4,000 people/year will die from it.

If they were all detected, then why are people still dying from it?


http://adam.about.com/reports/000046_3.htm :

In women who receive treatment when cervical cancer is still local, the cure rate is about 90%.


That means that, if detected early, we should have an annual death rate of ~1,000, not 4,000. Ergo, at least 3,000 (or about 75%) of the current death rate is likely preventable through regular screening - and that doesn't account for the untreated intermediate and late stage lucky cases where radiation/chemo/surgery save their lives.

I can't find how much a pap smear costs - but it does cover all cervical cancers, not just those caused by two strains. Some sources are citing very high accuracy (I've seen 85-90%, 90%, and 99%), and others are citing "suspected" error rates from 15% to 25%. However, they all emphasize that if you get one every 1-2 years (assuming no abnormalities on the test), you would be able to catch any cervical cancer early with extremely low cumulative error rates.

Then there's the cost of treatment of those 70% that might otherwise not have been diagnosed with the cancer. It sounds like a lot, percentage-wise, but

This brings us back to the beginning, where we ask if the state should mandate this vaccination. There's plenty of reason to individually consider getting the vaccination - if I had a daughter of that age, I'd probably have her get it. However, the requirement of the procedure introduces some ugly factors: that it hasn't been tested extensively on prepubescent/adolescent females; that it's being rushed from approval to imperative in an unusually short period; that the HPV/cancer issue is not epidemic (while HPV is very prevalent, the resulting cancer is rare, slow, and relatively treatable even among those with HPV); the prevention is economically costly to everyone but the monopoly that produces it; the prevention is inherently incomplete, preventing it from eliminating the source completely (like we have with the bubonic plague and others); that the costs could be better spent on the other end of the pathology (diagnosis); and that historically, the incidence of cervical cancer is on its way down, not up.

I just don't see any compelling reason, given the facts, to have all public school students by default given this vaccination. Alternative: One of the biggest problems with cervical cancer is getting people to get a checkup. There's a lot of good that could come of requiring middle-schoolers/high-schoolers to get a pap smear a couple of times in school instead of the vaccination.

I imagine that would accustom many more people to the test (which, frankly, doesn't look like something I'd want to do voluntarily unless I were already feeling ill). Getting women more comfortable with gynecological examinations would probably go a long way not just in this case, but in many other issues that come up as a result of a reluctance to see a doctor who peers and pokes around your crotch. Am I off base with this assumption?

Conversely, being vaccinated may cause a change in behavior due to perception (which is what the doctors in the article sound like they're afraid of). To be clear, I do not buy the argument that the vaccination will make more people screw. It may have a small marginal effect, but I think the prevalence of HPV and the public ignorance of the issue show an indifference to the risks involved with sex. However, I think it will have a significant effect on how many women are willing to get regular checkups. When there's already little enough motivation, a combination of ignorance, reluctance, and rationalization will make for both fewer women and less frequent visits.

That result would be a Very Bad Thing (tm). The one convergence point of the differing strains of HPV is the slow onset of the cancer itself. The one place (so far) that we can effectively "head it off at the pass" is the early stage, and the only way to do that is with regular screening. In the future, things may change; we might have a vaccine or combination of vaccine that eliminates all carcinogenic strains of HPV, for low/negligible risk and reasonable cost. However, this is not that vaccine. Pretending like it is and prematurely pushing it out will probably have some minor repercussions, and may have some serious ones as well.
2.8.2007 2:28pm
IANAD:
Gah, I'm retarded - I went to pee, and broke off a paragraph :P

Here's the fixed chunk:

Then there's the cost of treatment of those 70% that might otherwise not have been diagnosed with the cancer. It sounds like a lot, percentage-wise, but when compared to the costs of millions of vaccinations, and the high success rate of early diagnoses, it seems much more palatable. Start with the numbers from here:

11,150 diagnosed
3760 dead

If we take 70% straight off the top, we have 3345 new cases and 1128 dead. Big cuts, right? What if we redirect that money to mandatory screening instead, catching them at early (90% survival) stages? Assuming the same number of cases, we'll end up with 1150 dead - slightly more than 1128. But what are the secondary benefits? Widespread screening is almost certain to increase the frequency of diagnosis, simply because we're looking more. That would increase the diagnosis AND therefore the death rate, right? Well, let's look at before and after. Before: Jane didn't get screened, didn't know she had cancer, didn't get treated. She doesn't show up in the numbers until years later, where she ends up in both columns. After: Jane got added to the list, but she has a chance now (probably a relatively good one too, considering it's cancer we're talking about here).


OK, that paragraph kinda ran away with itself. I have to get to work.
2.8.2007 2:56pm
lucia (mail) (www):
Whit said:
i have no doubt that the "feminists" who support the "right" of a 15 year old girl to seek an abortion without parental notification, will not see any reason why a 15 yr old girl would have a right to refuse an HPV vaccination

Well, whit, you will find some feminists who not only think a 15 year old girl has a right to refuse an HPV vaccine but that she should also have a right to refuse an abortion should her parents insist she have one. Heck, some feminists even hold the radical notion that a woman can refuse to have an abortion even if the embryo's father insists she have an abortion!

Currently, the way the Texas law stands, the girl has no direct say in this vaccine. Her parents can give her the vaccine or they can decline. Maybe, if she's lucky, her parents will consider her preferences, but that's not required as a matter of Texas law.

If I lived in Texas, I'd be writing my legislator requesting they permit 14 year old girls to overide their parents opt-out.
2.8.2007 3:14pm
David M. Nieporent (www):
Well, whit, you will find some feminists who not only think a 15 year old girl has a right to refuse an HPV vaccine but that she should also have a right to refuse an abortion should her parents insist she have one. Heck, some feminists even hold the radical notion that a woman can refuse to have an abortion even if the embryo's father insists she have an abortion!
Well, I wonder how many of these feminists think that this girl should have the right to buy cigarettes and take up smoking, even if her parents or the government doesn't want her to.
2.8.2007 3:29pm
whit:
also note that many feminists that supposedly think whatever a woman wants to do with her body is between her and her doctor are vehemently against silicone implants, etc.

i just find these inconsistencies telling
2.8.2007 3:54pm
lucia (mail) (www):
Whit: I know feminist who have implants!

David: I bet you can't find a feminist who thinks parents should be able to force their daughters to smoke even if the daughter doesn't want to and the government is silent on this! :)

Ok. I'll admit, I haven't discussed the freedom to smoke with feminists. Still, I have not met a feminist who has said she's for letting girls smoke, and I'd guess there were very few. I suspect the true purely feminist position is smoking laws should be the same for boys and girls.

Other than that, smoking isn't a feminist issue per se, and you might have a range of ideas.

Feminism is not, after all, libertarianism. They aren't necessarily being inconsistent by not sounding like libertarians.


In any case, until Whit actually finds a feminist who thinks a 15 year old girl has the right to override a parental veto of an abortion, but does not have the right to refuse the HPV vaccine, it might be best if Whit avoided arguing by just making stuff up!
2.8.2007 4:12pm
whit:
i wasn't arguing

i was conjecturing

hth

:l
2.8.2007 4:18pm
Clayton E. Cramer (mail) (www):

Clayton,

Start over. "Not easily communicable?" What?
No one ever got HPV from sitting in a classroom next to someone who was infected. No one ever got HPV from a dirty doorknob. You have to do a bit more than shake hands to get infected--unlike measles, mumps, whooping cough, and many of the other infectious diseases that have traditionally caused schools to require vaccination.

Perhaps you are confused about how one gets HPV. Or perhaps you don't realize that most people don't have sex with everyone they meet.
2.8.2007 4:30pm
Clayton E. Cramer (mail) (www):
From the statements that Kovarsky keeps making, I conclude he's getting a lot of action!


Yeah the 50% number is completely is misleading:


There are two significant caveats to that statistic; one, it is describing non-monogamous, sexually-active persons;



I mean, that only describes 97% of the human population.
There are a surprising number of people who manage to get through life with half a dozen sexual partners--and a surprising number who get through with only one or two.

You should spend more time talking to straight people. You might be surprised at how many people don't need a database and a JumpDrive to keep track of their sexual partner history.
2.8.2007 4:36pm
An Unpractical Man (www):
This whole debate seems off the rails. Does anyone here actually think that if a vaccine is (a) the most effective measure against a (b) widespread, (c) easily transmissable, and (d) dangerous disease, then requiring it for public schooling is unreasonable (esp. if it includes an opt-out clause)?

Isn't the debate actually about the pragmatic questions? Let me presume that everyone agrees that HPV is widespread, and that HPV is dangerous primarily in so far as it leads to cervical cancer. It seems then that there are two main pragmatic questions: Is this the most cost effective way to prevent cervical cancer, deaths from cervical cancer, and other serious effects of HPV? Is the risk of spreading HPV via sexual contact high enough, or HPV dangerous enough that state coercion is justified (and what level of coercion)?

So in the spirit of refocusing the debate and addressing the first question, I ask those who have studied this issue more than I the following questions (for clarity each in terms of per 1000 vaccinations issued): How much does the full course of the vaccine cost? How many deaths or serious injuries will result from this vaccine? How much additional cost will the hospitalization for those injuries incur? What do we know about long-term side effects? How expensive are those side-effects? How many deaths due to cervical cancer will this prevent? How many cases of cervical cancer will this prevent? Is this a good use of the money spent? Are there other large benefits from eradicating HPV?

This seems the primary question, which must be addressed before we move to the "juicier question" of whether we can justify coercion. After all, if the vaccine isn't a good buy for the money, the second issue is moot.
2.8.2007 4:45pm
Captain Holly (mail):
I don't know where you getting your information from, but its not right.

Try http://www.cdc.gov/nip/vaccine/hpv/hpv-faqs.htm#1

After reviewing the FAQ, I must admit that I misread parts of it. It is rather poorly written; for example it seems to imply that all 100 strains of HPV are sexually-transmitted. Nevertheless, the only statement in my original post that is contradicted by your information is the strong association between genital warts and cervical cancer; everything else is still factual.

However, all nitpicking aside, none of what you posted contradicts any of my main points, to wit: The vaccine is expensive, not completely effective, does not protect against an easily-transmitted disease, and does not provide any real protection to vaccinated individuals over non-vaccinated ones.

The best one can say about the vaccine is that it is an insurance policy that gives an irresponsible recipient some protection against certain types of HPV. Considering the limits of the vaccine's protection, that's not very reassuring.
2.8.2007 4:46pm
Brian K (mail):
IANAD,


As for this statement:


Of those women who get HPV-related cervical cancers, nearly all will are detected and eradicated in their pre-malignant phase by routine Pap smears.


It's not true by a long shot. Somewhere around 10,000 people/year get cervical cancer. About 4,000 people/year will die from it.

If they were all detected, then why are people still dying from it?



http://adam.about.com/reports/000046_3.htm :


In women who receive treatment when cervical cancer is still local, the cure rate is about 90%.



That means that, if detected early, we should have an annual death rate of ~1,000, not 4,000. Ergo, at least 3,000 (or about 75%) of the current death rate is likely preventable through regular screening - and that doesn't account for the untreated intermediate and late stage lucky cases where radiation/chemo/surgery save their lives.


IANAD, your absolutely right. I was taking issue with the fact that the statement assumes that every women gets a routine pap smear. Which is not true. Depending on ethnic groups only 78-88% of women will get a pap smear in a 3-5 year period. Not enough women get one often enough such that "nearly all will are detected and eradicated in their pre-malignant phase by routine Pap smears" Also, many women who have an abnormal pap smear do not return for follow up.

The pap smear itself is only 40-85% specific. This means that of the abnormal pap smears "only an estimated 25–35% of them actually have cervical disease. The remaining 65–75% of these women go through needless physical and emotional stress." You have to factor in the cost of unnecessary treatment into your analysis also. New and better detection methods are being researched, but given that they are molecular assays, they will undoubtedly be more expensive than a pap smear.

I think this is the key paragraph in the report:

If HPV is detected early enough, virtually all cervical cancer is preventable. Only when the disease progresses to the invasive stage will it require treatment. The most common form of treatment is removal of the diseased tissue by conventional surgery, laser excision, or cryosurgery, often followed by chemotherapy or radiation. In some extreme cases, a hysterectomy might have to be performed. But these measures address the effects of the disease, not its cause. It is clear that the only way cervical cancer is going to be cured is through effective therapeutics against HPV.

Eliminating the two primary strains of cervical causing HPV would go a long way towards this goal.

Source: http://pubs.acs.org/hotartcl/mdd/00/jul/thomas.html
2.8.2007 4:54pm
Captain Holly (mail):
I can assure you that $6,000 in past campaign contributions doesn't buy you favors with Rick Perry.

No, but it sure makes him eager to take your order....

Campaign contributions aside, perhaps this was a big factor in his decision:


Merck is bankrolling efforts to pass state laws across the country mandating Gardasil for girls as young as 11 or 12. It doubled its lobbying budget in Texas and has funneled money through Women in Government, an advocacy group made up of female state legislators around the country.

Perry has ties to Merck and Women in Government. One of the drug company's three lobbyists in Texas is Mike Toomey, Perry's former chief of staff. His current chief of staff's mother-in-law, Texas Republican state Rep. Dianne White Delisi, is a state director for Women in Government.


This stinks to high heaven.
2.8.2007 4:57pm
Captain Holly (mail):
Eliminating the two primary strains of cervical causing HPV would go a long way towards this goal.

Any more than regular screening and reductions in smoking have already done? Especially since such things are already recommended?

Cervical cancer death and incidence rates have declined by almost 50% for all races in the past 20 years, and all data suggest that the trend will continue for the forseeable future. Given the limitations of the vaccine, I don't see how you can justify forcing everyone to accept it.
2.8.2007 5:09pm
lucia (mail) (www):
Clayton wrote:
From the statements that Kovarsky keeps making, I conclude he's getting a lot of action!

Well, maybe he's cuter than you are?

Are we seriously arguing by conjecturing that people with different views are promiscuous homosexuals?
2.8.2007 5:15pm
Brian K (mail):
Captain Holly,

Actually a lot more than just that one statement is contradicted:

It prevents infection by four strains of HPV that cause about 70% of the cases of genital warts

It prevents infection by 2 strains that cause 70% of genital warts and 2 strains that cause 70% of all cervical cancers. The immunity from the latter 2 strains is why this vaccine is seen as being so important and why the merits of mandatory vaccination are even being debated. This is by far the most egregious error you've made as it shows you know very little about what you're talking about.

I've discussed problems with pap smears in a previous post that explains why they aren't viewed as an optimal solution.


And there is a dirty, very un-PC secret about cervical cancer: Most cases occur in poor minority women, probably because they can't afford regular medical exams. White, middle- and upper-class women are the ones least likely to develop cervical cancer.

While it is true that minorities suffer from higher rates of cervical cancer, I trouble with the implications of your statement. Do you mean to imply that there is no point in trying to minimize incidents of cervical cancer because it primarily affect people who aren't white?

"an expensive, difficult-to-administer vaccine that doesn't even protect the recipient from all forms of the disease"
- its an approx $300 series of 3 shots. roughly equivalent to the hepatitis series. it can easily be administered by a nurse and is relatively cheap.

"that requires the recipient to continue to receive the treatment that largely prevents the disease in the first place"
- pap smear is not a treatment. it is a screening procedure. see my post above.

"Your prudish spinster aunt is unlikely to have been infected by any of them"
- actually given the demographics, HPV and cervical cancer are most prevalent in OLDER people. your prudish aunt is one of the most likely people to have it. I'll ignore your other inaccurate comment about the 50% statistic as that would be nitpicking.


The vaccine is expensive, not completely effective, does not protect against an easily-transmitted disease, and does not provide any real protection to vaccinated individuals over non-vaccinated ones


See above. A 70% reduction in your chance of getting cervical cancer is not a benefit or a protection? HPV is extremely easy to transmit. The hold up you seem to have about it is that it is transmitted through sex.

Given the trade-offs associated with the disease versus contracting genital warts or cervical cancer, a mandatory vaccine with an opt-out mechanism is a good way to go.
2.8.2007 5:24pm
Brian K (mail):
Holly,


Given the limitations of the vaccine, I don't see how you can justify forcing everyone to accept it.


Have you not read the law? Or any of the other comments on this board? You can OPT-OUT of getting the vaccine. And its not even difficult.
2.8.2007 5:28pm
Brian K (mail):
IANAD,

I've been trying to do a rough cost analysis and decided its futile. There's just too much we don't know and I can't easily find. I think though you have to factor in the costs associated with getting more women to get screenings and maintain regular office visits. Changing public attitudes about this has proven a very hard thing to do and the necessary marketing costs would very likely be huge. (bigger than the cost of vaccinating everyone? I have no idea).

I agree with you that the promiscuity argument isn't convincing, to say the least. But I also don't much stock in any argument that depends on changing attitudes and opinions. It is next to impossible to do in the short term, (certain lightning rod issues not withstanding), and the outcome of any attempt is unpredictable.

I personally like the opt-out plan that texas instituted, if for no other reason that it forces parents to seriously consider and weigh the effects of HPV and the vaccine on their child. It doesn't have much of an impact on individual choice.

As for the side effects of the vaccine, a look at the type of vaccine it is and the current research out there suggest that they will be minimal. Reactions of people who have currently taken it show that a very small percentage experience pain, swelling, itchiness, or redness at the site of injection, nothing systemic or long lasting.
2.8.2007 5:51pm
Captain Holly (mail):
It prevents infection by 2 strains that cause 70% of genital warts and 2 strains that cause 70% of all cervical cancers. The immunity from the latter 2 strains is why this vaccine is seen as being so important and why the merits of mandatory vaccination are even being debated. This is by far the most egregious error you've made as it shows you know very little about what you're talking about.

Speaking of egregious errors, you should have wrote that as "90% of genital warts" (I know, I know, nitpicking, but you seem to have an appetite for that). I admitted that I conflated the two; even then, it still doesn't change the basic fact that the vaccine does not offer total protection against cervical cancer, as I said in my original post.

While it is true that minorities suffer from higher rates of cervical cancer, I trouble with the implications of your statement. Do you mean to imply that there is no point in trying to minimize incidents of cervical cancer because it primarily affect people who aren't white?

Of course not, but nice try to paint me as a racist. The point is, if cases of cervical cancer are not evenly distributed throughout the population, why force the vaccine on everyone? If we know certain populations are at higher risk, why not direct prevention efforts there? Why pretend that every woman has the same risk, when she clearly does not?

its an approx $300 series of 3 shots. roughly equivalent to the hepatitis series. it can easily be administered by a nurse and is relatively cheap.

Actually, it's $360 (sorry, nitpicking again), and that's pretty damn expensive for a vaccine. In fact, that's more than I've ever paid for a vaccination. My insurance doesn't cover vaccinations, and considering all the other vaccines mandated for school, for someone with four kids it adds up fast.

pap smear is not a treatment. it is a screening procedure. see my post above.

Yes, yes, yes, and substitute "screening procedure" for "treatment" and you'll find the basic meaning of my statement is completely unchanged: Women will still be required to have their yearly Pap smears because the vaccine doesn't protect against all types of HPV.

actually given the demographics, HPV and cervical cancer are most prevalent in OLDER people. your prudish aunt is one of the most likely people to have it. I'll ignore your other inaccurate comment about the 50% statistic as that would be nitpicking.

And you're ignoring the biggest risk factor of all for HPV infection: Total number of sexual partners. A prudish aunt who's never been married and has no sexual relationships has zero chance of getting HPV. Your implication that she has a high risk for cervical cancer has no basis in fact.

As for the "nitpicking" about that statistic: What was wrong about it? Are you arguing that even monogamous married women have the same risk for HPV infection as free-wheeling singles? Are you saying that 50% of women have been infected with the cancer-causing strains of HPV? If so, where are all those extra cases of cancer?

See above. A 70% reduction in your chance of getting cervical cancer is not a benefit or a protection? HPV is extremely easy to transmit. The hold up you seem to have about it is that it is transmitted through sex.

And you seem to assume that everyone has sex with everyone else at the drop of a hat. I can eat, sleep, study, work, and live in the same room as someone who has HPV and my risk of contracting the virus is virtually ZERO. As long as I don't engage in sexual activity with that person, I have almost no chance of getting it.

OTOH, if I tried that with someone who has influenza, measles, smallpox, pertussis, or even hepatitis A I'd have a good chance of getting ill if I had not been vaccinated first.

On the other hand, assume I did get my daughters vaccinated against HPV: What advantage do they now have that they didn't before? Can they have unprotected sex now? NO. Can they stop getting yearly Pap smears? NO. Can they stop worrying about ever getting HPV, cervical cancer, or genital warts? NO.

So how is being vaccinated make any practical difference in how they live? Or are you saying that they can be free and easy now because they have a reduced risk of getting genital warts and cervical cancer? Or are they under the same obligation to be sexually responsible?
2.8.2007 6:07pm
Captain Holly (mail):
Have you not read the law? Or any of the other comments on this board? You can OPT-OUT of getting the vaccine. And its not even difficult.

First off, I don't live in Texas, so it's irrelevant. But I'm wondering: Do you have any kids? Have you ever tried to "opt-out" of a vaccine? I have, and it's not that easy because the system is heavily biased towards vaccinations.

We chose not to give my daughter her chickenpox vaccine because of questions about efficacy. My wife went to the school and got the form; she was treated like she was a nut. And even then, it didn't make any difference: The nurse just went ahead and gave her the vaccine anyway, because she assumed that -- like everyone else -- we wanted it.

But then again, why should parents in Texas have to "opt-out"? From what I've read -- and other than nitpicking, no one has contradicted me -- the vaccine only provides a marginal benefit to its recipients. It's hardly an essential public health breakthrough. Why should they be forced to do it for such a small benefit?
2.8.2007 6:17pm
Brian K (mail):
Holly,


Speaking of egregious errors, you should have wrote that as "90% of genital warts"...it still doesn't change the basic fact that the vaccine does not offer total protection against cervical cancer

you got me there. I was going off lecture notes, which frequently have minor errors. And I never claimed it offers complete protection...I'll I've said is that it significantly reduces your chances.


Of course not, but nice try to paint me as a racist. The point is, if cases of cervical cancer are not evenly distributed throughout the population, why force the vaccine on everyone? If we know certain populations are at higher risk, why not direct prevention efforts there? Why pretend that every woman has the same risk, when she clearly does not?

I never said you were a racist...I asked if that was what you meant by it. yes, certain populations are more at risk. the reason why they recommend it for everyone is that no one has a zero chance of getting infected with HPV. The policy assumes that everyone has some risk of catching HPV, which is true.


Actually, it's $360 (sorry, nitpicking again), and that's pretty damn expensive for a vaccine. In fact, that's more than I've ever paid for a vaccination. My insurance doesn't cover vaccinations, and considering all the other vaccines mandated for school, for someone with four kids it adds up fast.

When I said relatively cheap I was comparing it to the cost of treatment for cervical cancer and/or genital warts or of dealing with false-positive pap smear results. Most large insurance companies will cover the vaccine because it is recommended by the CDC. Yours appears to be an exception.


Yes, yes, yes, and substitute "screening procedure" for "treatment" and you'll find the basic meaning of my statement is completely unchanged: Women will still be required to have their yearly Pap smears because the vaccine doesn't protect against all types of HPV.

Low risk groups can very likely go less often and/or beginning at a later age. Screening for many types of cancer are done this way. People who have received the HPV vaccine would fall into a low risk group.


And you're ignoring the biggest risk factor of all for HPV infection: Total number of sexual partners. A prudish aunt who's never been married and has no sexual relationships has zero chance of getting HPV. Your implication that she has a high risk for cervical cancer has no basis in fact.

What percentage of the population goes their entire life without having sex? That's just not a realistic scenario. "77% of 19 year old females have engaged in sexual intercourse and 85% of 19 year old males have engaged in sexual intercourse [Sources: The Urban Institute, "National Survey of Adolescent Males," National Institute of Child Health and Human Development, 1995. CDC "National Survey of Family Growth," 1995.]" The percentage who have engaged in a broader definition of sexual activity is higher. I can guarantee you that 80% of the population is not married, or even in a monogamous relationship, by the age of 19.



As for the "nitpicking" about that statistic: What was wrong about it?

The cited statistic is for ALL women. You can't draw meaningful conclusions about subgroups from it. You can surmise that it would be less, but is 1% less or 30% less? who knows? its minor, which is why I said it was nitpicking.


And you seem to assume that everyone has sex with everyone else at the drop of a hat. I can eat, sleep, study, work, and live in the same room as someone who has HPV and my risk of contracting the virus is virtually ZERO. As long as I don't engage in sexual activity with that person, I have almost no chance of getting it.

I don't assume everyone has sex with everyone else...statistics (as the one I've cited above) show that younger people very frequently do have sex. Statistics also show that they are much less cautious about it when they have it. This occurs regardless of what the parents believe or how they raised their kids. Good public policy should be based on reality and not on ideals that unfortunately don't hold true. And for the record, the reason the vaccine targets girls when they are so young is because it is only effective BEFORE they've had sex. "Approximately 1 in every 5 adolescents have had sexual intercourse before his or her 15th birthday [Source: The National Campaign Publication "14 and Younger: The Sexual Behavior of Young Adolescents," National Campaign to Prevent Teen Pregnancy, May 2003.]"



On the other hand, assume I did get my daughters vaccinated against HPV: What advantage do they now have that they didn't before? Can they have unprotected sex now? NO. Can they stop getting yearly Pap smears? NO. Can they stop worrying about ever getting HPV, cervical cancer, or genital warts? NO.

The benefits are listed. If you can't see them, I sure hope your daughters do.



So how is being vaccinated make any practical difference in how they live? Or are you saying that they can be free and easy now because they have a reduced risk of getting genital warts and cervical cancer? Or are they under the same obligation to be sexually responsible?

I have already said the promiscuity argument is wholly unconvincing. It is unlikely that this vaccine will change anyones behavior, but it will decrease the risks associated with that behavior.
2.8.2007 7:03pm
Captain Holly (mail):
It is unlikely that this vaccine will change anyones behavior, but it will decrease the risks associated with that behavior.

The question is then, does it provide a large enough benefit to justify forcing everyone to accept the vaccine? You look at the information and say yes, I look at it and say no. Philosophical differences that would appear to be irreconcilable.

Furthermore, the fact that kids report having frequent sex does not necessarily translate into more cases of cervical cancer; in fact, it's just the opposite. Since the beginning of the Sexual Revolution in the 60's, both the number of cases of cervical cancer and deaths caused by it have steadily and significantly declined, and the trend shows no sign of stopping.

It would logically follow then that either infections by cancer-causing HPV must have declined as well, or that perhaps HPV infection is not the horrible death sentence that vaccine proponents are suggesting it is. This renders the "50% of women are infected" statistic meaningless, because it would appear to have no relationship to the actual frequency of cancer in the population.

I'm not arguing that HPV does not cause cervical cancer; what I'm saying is that lifestyle changes, coupled with improved screening and treatment have already drastically cut the number of cervical cancer cases and deaths. In my view, because of its limitations the vaccine will not have a significant impact on that trend, and therefore is an expensive and unecessary diversion.

In the world of vaccines, the best ones only require a single shot and are relatively inexpensive. Influenza vaccine, for example, costs about $15 and requires only one shot to be effective. True, it does not protect against all strains of the virus, but considering that the flu kills more than 10 times the number of persons each year than HPV it is a far more effective vaccine overall. And even then, it is only recommended for "high risk" groups -- the elderly, children, and immunocompromised.

This is my beef with the HPV vaccine. It is being touted as a necessary step to prevent cervical cancer, when it doesn't even protect against all strains of cancer-causing virus. It is claimed to be a important remedy to a significant health problem, when statistically speaking that relatively uncommon problem has been getting "better" every year. And it offers a false sense of protection to the recipient, when in reality responsible behavior has proven to be far more effective in preventing the disease.

Add to all that the shady and arbitrary way that it was forced on the people of Texas, and I simply see this as an over-hyped attempt to make easy money for a big pharmaceutical company. If parents wish to vaccinate their daughters against HPV, that's their choice. But it should be a choice, not a requirement.
2.8.2007 10:07pm
A.C.:
I would have no problem with making the vaccine available in schools at low or no cost, but nobody has convinced me that it is a good idea to make the vaccine a condition of school enrollment. Opt-out provisions don't impress me, for reasons noted by Captain Holly.

Regardless of whether a mandatory vaccine might have some public benefits that would outweigh its costs, and regardless of any lobbying by Merck or opinions of feminists or fundamentalists, there is no logical link between school enrollment and an HPV vaccine. There is such a link in the case of vaccines for diseases you can catch in the classroom, as several people have noted here. In such cases, the vaccine protects not only the vaccinated individual but also everyone else forced to be in close quarters with that individual for many hours every day. That reasoning simply doesn't apply to HPV.

Because it doesn't, and because most families can't afford private school and must rely on the public system, the public school "hook" is just an attempt at government coercion. What next, a rule requiring students in public schools to submit to tests showing whether they drink alcohol over the weekend? Wait, that's already happening... what comes after that? It really SHOULD horrify everyone that public school enrollment is being used as the entry point to control so many behaviors that have nothing to do with school as such.
2.9.2007 9:50am
Questioning (mail):

Just a few questions, that perhaps someone can answer:

* How long does the immunity last?
* Are there any known effects upon fertility?
* What effects does Gardasil have on a fetus?
* What effects does Gardasil have on prepubescent girls?

Here's the catch: none of these questions can be answered, not one.

* Immunity lasts at least for two years, but we don't know how much longer. Does HPV mutate?
* HPV can affect fertility. Gardasil is manufactured using a genetic modification technique from fragments of HPV. We do not know if it can affect fertility or not.
* None of the testing subjects were pregnant.
* The youngest test subject in the Phase III trials was 16, we have no idea if there are any side effects on prepubescent girls or not.

What Rick Perry has done is essentially order thousands of girls in Texas to participate in a Phase IV test of Gardasil, without compensation. There is no scientific basis for mandatory vaccination of prepubescent girls with Gardasil, and several scientific reasons to hold off on that for at least a few years.

It is fascinating to me to see EV shed his libertarian cloak and reveal himself as yet another coercive utopian. Even more interesting is the experience of witnessing this reality-based commentatoriat devolve to a faith-based one: a guy in a white coat and a politician said "Vaccinate", and y'all snap to as one body, crying "Yes! We are all individuals here, and everyone must be vaccinated with Gardasil, whether they want it or not!"

It's always amusing to see EV's weblog devolve to Borg status...
2.9.2007 12:48pm
A.C.:
Most people are health nerds of one kind or another these days, so compulsory health-related things probably come off as less objectionable than other forms of compulsion. It's a tendency we should be fighting.

EVEN IF the vaccine turns out to be a terrific idea, I don't think it's acceptable to make it a mandatory or opt-out program connected to school enrollment. Same for any other health-related intervention, unless it is directly linked to school attendance or a school-related activity (polio vaccine, physicals before playing sports). Handing out information in schools is fine, as is providing services at a reduced price and in a convenient location, but I object to making any health intervention that isn't related to school a condition of school enrollment.

Or, to put it another way, letting the government herd a bunch of people together for one purpose does not mean the government should be allowed to do any old thing to them while they are herded together. Not even if it is meant to be for their own good. Why isn't this obvious?
2.9.2007 3:54pm
AK (mail):
AC:


Or, to put it another way, letting the government herd a bunch of people together for one purpose does not mean the government should be allowed to do any old thing to them while they are herded together. Not even if it is meant to be for their own good. Why isn't this obvious?


It's not obvious because, like I said at the very beginning of this discussion, we're Fair-Weather Libertarians here at the Volokh Conspiracy, and if there's something the government can do to make sex more consequence-free, by God we're going to have the government do it.
2.9.2007 10:24pm
Jay Myers:
Kovarsky:

Here, then I want to stop this exchange. From today's article to which you link:

Opposition from doctors was less expected. Virtually all hail the vaccine as a great breakthrough and call for the highest possible proportion of girls and women — and boys and men, eventually — to get immunized in hope of one day eliminating the virus.

"But education needs to come first," said Dr. Joseph Bocchini, chairman of the AAP's committee on infectious disease. "Much of the public doesn't know about HPV and its link to cervical cancer and other diseases. You can't put a mandate ahead of that."

Actually, I read this as saying that we must get people to understand why the immunization is important before requiring them to get it or to give it to their children. He says that most people don't "know about HPV and its link to cervical cancer and other diseases". If someone doesn't understand why the vaccine is a good thing then they are going to be more resistant or at least less compliant with any mandated immunization. And that statement makes sense. What reaction would you expect from a parent if you tell them: "I'm from the government and he's from big pharma and we want to have parents inject this substance into their kids. Don't worry about what it is or what it does. It's a good thing, trust us."

There is nothing in what you quoted that indicates that he opposes the vaccine or the requirement that children be immunized with it. Nor is there anything in what you quoted that indicates he is advocating abstinence-based sex education. He only mentions the connection between the virii and diseases. Sex or virus transmission is not even hinted at. Either you picked the wrong text to quote or you are reading things into this article that are derived from your prejudices of what "right-wingers" would say.
2.10.2007 3:36pm