Did the Media Help Manufacture HPV Vaccine Controversy?

Note: I have joined the “virtual class” component of Dan Kahan‘s Science of Science Communication course at Yale University. As part of this I am endeavoring to write a response paper in reaction to each week’s set of readings. I will post these responses here on my blog – the first such response is below. I will also be participating in the discussion on Kahan’s own blog. (The discussion on session 1 is here.) Comments are welcome are either site.


 

I wish to focus on the question of whether the media had some role in actually manufacturing the controversy around the Gardasil HPV vaccine, and specifically the debate about whether states should mandate the vaccine for school admission. In his class notes on Session 1, Dan Kahan raises some interesting points about the media’s behavior in the early days of the vaccine’s approval and introduction:

At this point, there is no meaningful dispute over Gardasil. Indeed, only a minute fraction of the U.S. population has ever heard of the vaccine or even HPV for that matter. Nevertheless, the prospect of controversy has already been anticipated in the national media. A government-mandated STD shot for adolescent girls, these sources predict, is certain to provoke confrontation between women’s rights groups and religious and social conservatives.

By referring to the “prospect of controversy,” and “prediction” of “confrontation,” does Kahan mean to imply that news outlets were engaged more in speculation then in reporting of actual disagreement? I’m not sure if this was his intention, but nonetheless I think it raises some interesting questions about reporting choices.

False balance

Certainly one of the most frequent and cogent criticisms of science reporting in recent years has focused on the problem of false balance – the notion that every story must provide “two sides.” This journalistic principle has shown itself to be most inappropriate when applied to matters of scientific fact (or theories supported by an overwhelming amount of evidence). Researchers such as Max Boykoff have shown how media outlets report the “question” of climate change in a “he said, she said” style, pitting one supporter against one opponent and creating the impression of a genuine scientific disagreement. The media has continued this harmful approach even as studies showed that a heavy majority of climate papers – most recently estimated at 97 percent – support the idea of anthropogenic climate change. (Some media outlets appear to be doing better at this – the BBC last year forswore the application of the balance principle to climate reporting – but sins are still committed regularly, as John Oliver pointed out in this entertaining segment.)

In the early HPV reporting, we may perceive another example of false equivalence, though not as egregious as in the climate case. While false balance in climate reporting tends to create the impression of disagreement over the science, HPV stories instead presented divergent views on policy, risk management and values. It’s still entirely possible, however, that the media’s presentation of these views distorted the true balance of opinion or even injected controversy where little existed. How can we evaluate whether this was the case?

Vaccine mandates: “the norm”

A full reckoning would require a much broader content analysis, but let me offer a few thoughts from the course readings. First, an important piece of background. I think one of the most important items in the reading was Kahan’s “Note on universal childhood vaccination schedules and mandates.” What I found extremely revealing was his assertion that:

The conventional practice is for state public health agencies simply to add vaccines to their state’s mandatory-immunization schedule consistent with CDC guidelines. See, e.g., Conn. Gen. Stat. § 9a-7f… Adoption is not instantaneous or automatic, but it is the norm for a CDC-issued guideline to be administrative incorporated into nearly every state’s immunization-mandates within several years…. This was the route that the hepatitis-b or HBV vaccine followed in being added to state mandatory- vaccination schedules after its approval by the FDA and the designation of it as a universal childhood vaccination by the CDC.

So if I understand correctly, prior to the HPV vaccine approval, there never was a controversy or debate over whether a state should mandate that children entering school have a certain vaccine. Whatever vaccines the CDC recommended physicians administer, the state mandated that children have before they could attend school. Now let’s look at some reporting on the HPV vaccine and see what justification the author had for painting a picture of controversy.

Washington Post article

Here’s Rob Stein’s Washington Post article of October 31, 2005. I’ve gone through the article and highlighted the key phrases I saw as conveying controversy/debate (higlighted in yellow) as well as language that had potential to polarize readers’ viewpoints by attaching positions to actors with particular ideological positions (orange). The most salient examples are excerpted below:

Stein HPV highlights 1 Stein HPV highlights 2

Reviewing this, I think we can agree that Stein certainly didn’t invent controversy out of whole cloth. There was indeed evidence that a public debate was brewing. Most notably, see points a) and b) above. Note, however, there isn’t much evidence in this article that conservative and religious groups were actually planning to oppose mandates. Statements such as those above could be read that way, but they don’t spell out an organized effort to prevent mandates. Nor do generalizations such as “activists on both sides have begun maneuvering to influence how widely the immunizations will be employed.”

Interestingly and worryingly, the passages that most strongly seem to demonstrate controversy come, I believe, from those who would least desire it: health advocates and the vaccine manufacturer. For example, the article says cancer experts and women’s health advocates are “pushing the view” espoused by Merck, that school mandates “have been one of the most effective ways to increase immunization rates.” (Point c above.) This statement may sound innoccuous on the surface, but suggesting that it is a “view” and that school mandates are one of several ways we might seek to increase immunization – rather than just an automatic step taken for all vaccines recommended for children – implies there is a debate to be had.

This is followed up by a quote from Juan Carlos Felix of the University of Southern California and the National Cervical Cancer Coalition, who says, “I would like to see it that if you don’t have your HPV vaccine, you can’t start high school” – a reasonable statement to be sure, and probably one that Felix though nothing of uttering to a reporter. But again, in context, it suggests this is just one reasonable point of view of several.

Given research on the role of cultural cognition in risk perception (see for example Kahan, et al., Who Fears the HPV Vaccine, Who Doesn’t, and Why?), it’s highly likely that the views expressed in this piece caused readers to take stances on the vaccine where they didn’t previously have any. They likely then made health decisions that were not as rational as they could have been.

What should change?

For that reason, should or could Stein have written his story any differently? In retrospect, I would like to have seen more evidence that ideologues really were gearing up to fight mandates, rather than just mumbling idly about misgivings. But I think the most important thing the author could have done would have been to situate those concerns in the proper regulatory context: that is to say, fairly high up in the story, “here is the path that vaccines usually take, from FDA approval to CDC recommendation to school mandate; and here is why Gardasil may not have such an easy ride.”

There are many other questions reporters should ask themselves when approaching these kinds of stories – and that we should be asking about the reporting process. Some to consider (perhaps in a future reaction piece, or class discussion?):

  • News stories often create the idea of a “balanced” debate, with perhaps 2 or 3 voices pro, 2 or 3 voices con. Is that appropriate if one side is a minority view?
  • How can journalists even figure out what the majority view is?
  • If certain political groups are taking a stand on an issue, but the reporter can establish that their view is definitely in the minority, should he still report that stand?
  • Whose views “count more” in these types of stories – doctors? Politicians? Regulators? Advocates? Patients?
  • In this type of story, do questions of values even matter? Does health trump all? Or are values inescapable?
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2 Replies to “Did the Media Help Manufacture HPV Vaccine Controversy?”

  1. This is a really good question & an admirably let’s-take-a-look-at-the-evidence assessment.

    We need more evidence, as the post implies.

    A couple things to note:

    1. There were definitely other media stories at this time that had this same theme. E.g., Guyon, J. The coming storm over a cancer vaccine. CNN Money (2005). Available at http://money.cnn.com/magazines/fortune/fortune_archive/2005/10/31/8359188/index.htm.

    2. Early on, before approval of Gardasil, prominent religious conservative activists signaled they would not seek legislation to block approval or distribution of the vaccine. Indeed, the Family Research Council, a leading religious-right activist group that had led opposition to instruction on birth control in public schools, issued a statement declaring that “media reports suggesting that [it] opposes all development or distribution” of Gardsil “are false,” and that it in fact “welcomed” approval of the vaccine. http://www.cfcidaho.org/family-research-council-statement-regarding-hpv-vaccines. This was significant b/c before then there was (as the FRC’s statement suggests) would seek congressional action blocking introduction of Gardasil. However, the group also made plain that it “would oppose any measrues to legally require vaccination” as contrary to parents’ “inherent right to be the primary educatory and decision maker regarding their children’s health.”

    What to make of this?

    Not any *one* particular thing, obviously. But here are some observations:

    I. For Tamar is for sure right that Tamar is right to say that the Washington Post reporter wasn’t “inventing” a controversy. The prospect of controversy was in the air for sure. The FRC statement staked out its position — that it would not seek to block the vaccine but would fight any campaign, also already anticipated, to push for rapid state legislative mandates. That campaign came, led ostensibly by “Women in Government,” a women’s rights advocacy group, but funded by Merck, initially in a manner designed to disguise its involvement.

    II. Nevertheless, I think one could still take the position that the media played an “agent provocateur” role. The argument would be that anticipation that the media would frame the advent of the vaccine as a “culture war battle” essentially “forced the hand” of advocacy groups: once framed in that way, sitting on the sidelines would not be an option for either women’s advocacy groups or the conservative religious ones. In a world in which the media wasn’t stirring things up, those groups might not have gotten involved. Generating evidence to test/support this conjecture would be pretty complicated, obviously.

    III. An alterantive to the “agent provocateur” view of the media’s role would be “canary in the coalmine.” An issue doesn’t *already* have to be a major cause of public controversy for smart reporters *correctly* to anticipate the likelihood that it will become one. The news stories, which as Tamar points out were covering activities by the players involved, were doing that. And they were thus *putting on notice* all those other actors, from the FDA & CDC to public health professional groups to science communication researchers, that advent of the vaccine might well be attended by such controversy. They were doing this *yrs* before the public controversy in fact materialized. So why didn’t researchers, who were at that time doing studies that showed only that parents would “accept” the vaccine if advised by their pediatricians that it was effective, *do more studies* (one was done, actually) to model what would happen if parents learned about the vaccine in a context filled with cultural controversy? Why didn’t public health regulators intervene to try to steer the players– including Merck and the advocacy groups pushing for legislative mandates–to back off of actions that would trigger this sort of controversy? Why didn’t other members of the public health establishment, such as medical associations, do so?

    With hindsight, the HPV vaccine controvrersy looks “inevitable.” But it wasn’t; the peaceful itnroduction of the HBV vaccine is convincing evidence of that. Indeed, it’s more plausible to suggest the controversy caught responsible actors “by surprise” — nothing like this had ever happened before, and there was so much research suggesting that parents would simply follow the advice of physicians. But *that would be wrong* too: the controversy was both looming — yet not clearly unavoidable…

  2. In these discussions, the media is not some neutral party, but rather owned and influenced by corporate interests.
    The point of the principal communication operation here is Public Health. Specifically, the reduction of the incidence of HPV virus instigated cancers.
    (I think that that analysis changes once the vaccine is expanded beyond just females, and the potential for cancers not screened for by Pap Smears or as readily treated, are included. But this vaccine was originally introduced for use by girls and the aim was reduction of HPV infections leading to Cervical Cancer.)
    Tamar Wilmot gives a great analysis of whether or not the media created the vaccine controversy. I believe that analysis can be expanded. I think that this is not just a matter of whether or not the media created the controversy regarding the use of the HPV vaccine with 12 year old girls, but also, why such a controversy might actually have been a way of diverting attention away from other, more scientifically pertinent issues.
    Prior to the vaccine, awareness of HPV was limited by the fact that the linkage between Cervical Cancer and Pap smears was what was discussed. And so women who regularly saw their gynecologist, if they were following protocols, did so once yearly to have a pap smear. A Pap Smear indicating abnormal cells is a reason for further investigation, but at that point the cause of the abnormalities was not particularly relevant. Precancerous abnormal cells on the cervix, if found by Pap Smear, can be removed, by biopsy or cutterage. Cervical cancer, if caught in its early stages can be treated. The key is regular Pap Smears.
    At best, the vaccine will only impact incidence of cervical cancer decades from now. Cervical Cancer forms very slowly. And since this vaccine does not immunize against all forms of HPV, Pap smears will still be necessary. While the vaccine targets the forms of HPV most implicated in cervical cancer cases today, it is not clear how that carries through to the future ecosystem of HPV viruses. For older, non- immunized women, HPV infection during one’s life is likely. Whether or not a woman gets cervical cancer depends on whether or not the HPV infection(s) create immunity, or go on to cause cancer. Not enough is known about HPV variants to really know whether or not the vaccine is knocking out HPV virus types that are more likely to confer immunity along with those likely to cause cancer. Or, what happens to the remaining HPV types, not affected by the vaccine. Will they cause cancers of the future? The reason for selecting age 12, is to vaccinate girls before they are sexually active. But obviously, many girls and women are not sexually active until much older than that. What is not known is how long the immunity from the vaccine lasts. In the case of cervical cancer, if that immunity does not last for decades, is the vaccine really helping? Also, Pap Smears are still needed.
    I think we also need to look more closely at Tamar Wilmot’s statement here:
    “Interestingly and worryingly, the passages that most strongly seem to demonstrate controversy come, I believe, from those who would least desire it: health advocates and the vaccine manufacturer. For example, the article says cancer experts and women’s health advocates are “pushing the view” espoused by Merck, that school mandates “have been one of the most effective ways to increase immunization rates.”
    What are Merck’s motivations? For economic success, vaccines need a business model, not just a medical need. This is for example, why the world has been slow about thinking about Ebola.
    In particular, getting onto the CDC childhood immunization schedule is highly desirable from an economic point of view. Not only does this give a large client base, but also access to coverage under National Childhood Vaccine Injury Act of 1986, VCIP, or the National Childhood Immunization Program. http://www.hrsa.gov/vaccinecompensation/index.html. And, of course, once on the schedule, the Pharmaceutical company needs to get Pediatricians to administer the vaccine. And states to add them to their requirements.

    I think that the following two articles aimed at medical professionals are instructive:
    http://journals.lww.com/co-pediatrics/Abstract/2009/02000/Human_papillomavirus_vaccine__a_paradigm_shift_for.16.aspx
    The above indicates that as late as 2009, there was still reluctance on the part of pediatricians, to actively participate in this vaccine program and for whom further education on the importance of the HPV vaccine still needed to be directed. Pediatricians were already under fire from parents concerned about other childhood immunizations, and the increasing numbers of those immunizations.
    A more direct challenge to the wisdom of utilizing this vaccine on the part of medical professionals is contained in this article:
    http://jama.jamanetwork.com/article.aspx?articleid=184404
    This article challenged the cost effectiveness of the vaccine approach to cervical cancer reduction as opposed to greater use of Pap Smears.
    Remember that Gynecological practices have long been established on the pattern of yearly visits by their patients, for the purpose of obtaining a Pap Smear. At this time, other medical issues could be addressed with patients as well. But it was the Pap Smear that got patients in the door. (Recently, the technology of Pap Smears has greatly improved, and the need for repeating the test reduced accordingly.) The above article raises many points, but a significant one is that encouraging greater access to Pap Smears would be a much more cost effective mechanism for reduction of cervical cancer than this vaccine, which after all, can not possibly reduce cervical cancers for decades, and it is not entirely proven that it will do even that.
    Gynecological practices have been based on women coming in on a yearly basis for a Pap Smear. Most 12 year olds have mothers, many of whom would be expected to have a personal gynecologist. In theory, Merck might have wanted mothers to ask their Gynecologists about the HPV vaccine and recieve information endorsing having their daughter get it. But is that answer what Merck could have reliably expected from Gynecologists?
    The current CDC website contains the following page:
    http://www.cdc.gov/std/hpv/pap/default.htm
    One of the interesting things to note is that currently, HPV infections themselves can be tested for (and not noted here) immunity for specific types covered by the vaccine can be demonstrated.
    This website contains the following information:
    “The Pap test is a screening test for cervical cancer. It looks for abnormal cells on your cervix that could turn into cancer over time. That way, problems can be found and treated before they ever turn into cancer. An HPV test may also be used with the Pap test for women 30 years or older, as part of routine screening.”
    “Most of the time, the body’s immune system fights off HPV naturally within two years– before HPV causes any health problems. It is only when HPV stays on a woman’s cervix for many years that it can cause cervical cancer. Experts do not know why HPV lingers in certain cases but not others.”
    “HPV is very common in women under age 30. But it is not useful to test women under age 30 for HPV, since most HPV that is found in these women will never cause them health problems. Most young women will fight off HPV within a few years.”
    “HPV is less common in women over the age of 30, who are at increasing risk for cervical cancer. HPV is also more likely to signal a health problem for these women, who may have had the virus for many years. Doctors may use the HPV test with the Pap test to tell if these women are more likely to get cervical cancer in the future, and if they need to be screened more often.”
    In my opinion, we should be hearing a lot more about the continuing need for Pap Smears for all women. The fact that the media discussion centers on the vaccine when women face decades of cervical cancer risk without obtaining a simple test ought to be a major issue for those interested in effective health science communication. We ought to be discussing the need for development of analogous tests to the Pap Smear for cancers of the throat and anus. We ought to be investigating whether or not HPV infections could be treated in older adults when they are more likely to be a problem. We ought to consider testing adults for the forms of HPV that cause cancer and are covered by the vaccine, and consider giving the vaccine to those that do not yet have immunity.
    I think that we ought to look at the current media controversy as one that may be being utilized by pharmaceutical corporations as a diversionary tactic.
    It is one of many “science communication” discussions that come in the form:

    Private corporations carry the flag of science in a battle against the completely ignorant.

    In the process, many issues that are actually vital to authentic communication of science are never raised in a manner that reaches the general public. Scientists need a better way to communicate.

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