Thursday, March 01, 2007

Public Health or Personal Choice?

Last week in the emergency department, I treated a 31 year old patient who is dying from cervical cancer. She has needed emergency care frequently during these past few months, not surprising given the advanced stage of her cancer. I took advantage of the familiarity that has developed between us, and asked her about the public debate over the HPV (human papilloma virus) vaccine. It is not surprising that she believes that all girls should be vaccinated.

Her own story is compelling. She married her only sexual partner at the age of 17. She had two daughters, one when she was 17 and one when she was 19. She had normal PAP smears every other year, as is now recommended for young women. At the age of 29, she was diagnosed with cervical cancer. She received standard therapy for her illness, and now is dying, leaving behind her husband and young daughters.

She asked me a question for which I have no answer. She asked, “Why don’t they vaccinate the boys?”

At first glance, the answer is that boys are not at risk for cervical cancer. However, if the goal of the vaccine is to prevent the spread of HPV, perhaps we should vaccinate everyone. Notice that I said everyone. Not just young girls. Not just young boys. How many adults have HPV and don’t know it?

I have listened to the debate rage between those who want the right to choose whether their daughters are vaccinated and those who would mandate vaccination. I understand both sides of the argument. Right now, for those who choose to have their daughters vaccinated, the cost is about $450. (The vaccine costs between $125 and $150, administered in three office visits.) Most commercial insurances do not cover the cost of the vaccine because it is “optional” in nature. Medicaid does not cover the vaccine for the same reason. Most health departments do not include the HPV vaccine in the sliding scale and many do not even stock the vaccine. Based on this information, it seems to me that the vaccine must be made mandatory if it is to be made available to more than a privileged few.

How can we as a society have in our possession a means to prevent cancer and then not promote it?

And yes, my daughters are vaccinated.

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