Has the Spread of HPV Vaccine Marketing Conveyed Immunity to Common Sense?
by Glenn McGee, Summer Johnson
2007. The American Journal of Bioethics 7(7):1

Approximately 20 million men and women in the U.S. are infected with human papillomavirus (HPV). For those whose infections are not transient, genital warts are the least objectionable problems caused by several versions of this sneaky virus, comprised of more than 200 permutations. HPV accounts for at least 65% of cervical cancer cases. It has become a scourge for sexually active women killing hundreds of thousands worldwide, most in the developing world, and more than 3,000 in the U.S. each year.

You would think that developing and introducing a vaccine that could prevent most if not all uninfected women from contracting those strains of HPV associated with cervical cancer would be a no-brainer. Ignore for a moment the ethical imperative to improve public health that governs biomedical science. From a strictly financial perspective, it is cheaper to prevent cancer than to treat it. Moreover, if the sale of such a vaccine resulted in mammoth savings in terms of the cost of treating cancer, and in rising stock prices for the tens of millions who hold pharmaceutical stock in their mutual fund retirement accounts, that wouldn't anger anyone either. But all of those health and financial benefits depend on the public's use of the vaccine, so another ethical principle is at stake: should corporations become part of the public health system when their interests are so conflicted, lobbying to make their interventions mandatory, for minors and without informed consent?

It is easy to see why Merck, makers of the vaccine Gardasil, has to fight to get its vaccine approved. Crusaders against premarital sex argued against the vaccine on grounds it would increase promiscuity. Crusaders whose attention is focused on the risks of vaccines more generally have argued for delay after delay, arguing that the safety of the vaccine cannot be determined at this time. In May, the conservative group Judicial Watch surfaced three FDA reports of deaths of young patients who had recently taken the vaccine, and 1,637 other adverse events reported to the agency. The revelation hits Merck right where it hurts: the company, still reeling from the Vioxx scandal, has created with Gardasil what should be the safest vaccine ever made, but which now may pose significant risks.

But the really hard-hitting criticism of Merck is coming, not from conservatives, but from mainstream journalists and liberals who argue that the vaccine costs too much. The New York Times, Wall Street Journal, Associated Press, Philadelphia Inquirer, Atlanta Journal-Constitution and more have carried stories or editorials in the past year in which Merck is hammered for the fact that it is spending huge lobbying dollars to make the vaccine mandatory. Even those who strongly favor the vaccine, such as Dr. Joseph A. Bocchini, chairman of the committee on infectious diseases of the American Academy of Pediatrics, are stunned at the degree to which Merck has pushed its $400 vaccine as a mandatory measure, rather than opting to phase in the vaccine at lower cost and with measures for informed consent and tiered pricing.

Merck suffered mightily from the Vioxx scandal, but Gardasil isn't a blockbuster pain medication nor a lifestyle drug. Vaccines are not Viagra. We all know that vaccine development is not going to easily yield a blockbuster. We learned this with pandemic flu vaccination, as the world asked why no corporation had worked to protect the public against such a threat. It just isn't a sustainable business model. But can't Gardisil make money for Merck without this high price? They clearly did not think so. After plumbing the depths of the direct to consumer market with Gardisil, it quickly became clear that the only lucrative strategy for dispersion of this life-saving vaccine was to mix metaphors: on the one hand, Merck deployed and paid for a traveling PR effort of female legislators who proclaimed that Gardasil was an unadulterated boon for public health - at any cost. On the other hand, Merck has positioned itself as the Halliburton of cervical cancer - Gardisil has, critics say, become akin to the $1000 toilet seats on military aircraft. Merck also dispatched lobbying teams across Washington, but more notably into the offices of governors and leading legislators across the entire United States, to carry the message that the cure for cervical cancer will save money, but only after the premium of an incredibly expensive vaccine is paid up front. In short, pay now, save later.

If pharmaceutical companies are going to fund lobbying to improve public health, they also need to support public health. A pharmaceutical company that can set aside billions in case it had to pay out big settlements or spend tens of millions to lobby government officials to order mandatory inoculation, also can afford to cut the cost of the vaccine. In addition, just as pizza bearing cheerleader drug reps are a poor substitute for medical education, pharmaceutical company lobbying is a poor substitute for well-reasoned public health policymaking. Merck should fund public health science, education and services so that, for example, we can learn more about who needs the shot, how to price it, and how to build a healthy relationship between the government, the public and corporate biomedicine.