Silly – poor people don't get choices

Brownfemipower has a really interesting post about the governer of Texas’s decision to make the HPV vaccine compulsory for all girls sixth grade or above. This would also make the vaccine available for free for those who were uninsured or whose insurance doesn’t cover the vaccine:

I’m really conflicted about the news that the governor of texas just wrote into law the requirement that all girls get vaccinated for HPV virus (the same one that causes cancer).

Unlike a lot of Texans who oppose the shot, I don’t for a minute think that this shot is going to cause girls to run out and screw anything that moves. But as a parent who has had to make the decision to vaccinate my child (or refuse to, depending) for anything from ear infections to polio–I’m really wondering if this governor is writing this requirement into law because he’s some big lover of women (as a lot of the leftist blogosphere seems to be thinking), or if he’s just gotten himself some pretty pocket money from the drug companies who make this vaccination (according to the article, at least 6000$ in campaign donations).

In New Zealand there is an immunisation schedule, and immunisations on the schedule are free (see we still have some tatters of a socialised medicine system left). However, there is no requirement for parents to get their child immunised, either before starting school, or at any other time. I am a strong supporter of the HPV vaccine going on the immunisation schedule, because I believe all women have the right to protect themselves from cancer. But here, we don’t have to make any trade-offs.

As I understand it the only way a vaccine can be available to all, and publicly funded in America is if it is compulsory before a child can attend school (there are exemptions available to parents for conscience reasons). I can understand the public health argument which says that a kid must be immunised from certain infectious diseases before they start school (I don’t necessarily agree with it, but I understand it), disease can travel very quickly among unorganised children at school and this can cause an epidemic. But this logic does not apply to the HPV vaccine, HPV is a lot harder to contract than measles, so it isn’t going to spread round a school in the same way (it is clear that the vaccine is as important for later in life as it is for 6th grade, unlike other vaccines) and any genuine worry about the disease spreading would require both boys and girls to be immunised. There appears to be two reasons to support compulsory vaccination, either because your in the pay of the drug company, or you believe that it’s important that poor women get access to the vaccine (or both). Neither of these are based on genuine health concerns, which would be solved by making the vaccine compulsory.

This puts feminists in an impossible position. I’ll leave it for American feminists to discuss how they deal with this problem; I’ll just be glad that I don’t have to choose between access and choice.

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127 Responses to Silly – poor people don't get choices

  1. 101
    Charles S says:

    We here in the US like our authoritarian system of handling immunizations.

    It clearly produces a higher rate of compliance, which leads to a lower chance of epidemics.

    Doesn’t make it not a more authoritarian system than an opt in system.

  2. 102
    mythago says:

    Indeed, it is a more authoritarian system. We don’t live in a consensus-based anarchical collectivist society, so the question is what the rules are going to be, not whether we have them.

    RonF, again, skepticism about Big Pharma is always healthy; the problem is that there is not really organized resistance to Gardasil from organizations that are purely anti-vaccine. It’s coming from professional right-wing Christians who think that viruses and cancer cells are intelligent actors seeking out the immoral to infect.

  3. 103
    Myca says:

    Sure, it may be slightly more authoritarian, but the difference between a system that says “hey, we’ll vaccinate your children if you ask us to” and one that says “hey, we won’t vaccinate your children if you ask us not to” is pretty damn small on the whole ‘tyrranical authoritarian government’ scale, doncha think?

  4. 104
    Charles says:

    Well, it would be if the process of “if you ask us not to” were something less than very opaque. Personally, I’m fine with the current system (I don’t trust my fellow Americans to have the sense to opt in with out the push of pretending that they don’t have the option to opt out), but I do think it is more than a technicality away from a clear opt in system.

  5. 105
    Charles says:

    In other words, poor people don’t get choices. ;)

    We have a crap system of health care that fails to provide functional health care to many millions of people. Given that, we need to have a system that forces them to at least participate in public health by getting vaccinated. Our system won’t provide for people to get cancer screenings, because who cares if they don’t, but at least it will force them to be vaccinated.

    And, given that we have a crap health system, and no public will to fix that, it is indeed better that at least we have a system that protects us all from epidemics. Given our crap system, if we didn’t enforce vaccinations, the epidemics would hit mostly poor people (who would be more likely to have not gotten vaccinated) although it would hit everyone else too, as we would all get to find out how effective vaccinations are decades later.

    The crappier the civil society, the more authoritarianism is required to make it tolerable. Opt out vaccinations are probably one of the least problematic of our authoritarianisms here (how do they stack up compared to the 3 largest prison populations in the world, US, California, and Texas? Not very far).

  6. 106
    Charles says:

    Fair enough.

    I think I’d be for compulsory (or at least hidden opt out compulsory) vaccination even with a much better health care system too.

    And actually, small and isolated probably does make a bigger difference than I was giving it credit for on this issue. The ability of epidemics to spread goes way down when you have a population half the size of New York City’s spread out over an area 300 times as large (NZ = 268,021 SQ KM, NYC = 785 SQ KM), surrounded by a vast ocean, instead of embedded in a teeming nation of 300 million directly connected to another continent and a half of people. The same problem that makes opt in lead to epidemics in Europe.

    It’s still authoritarian, and I can see how someone unaccustomed to it would be shocked by it (like when I discovered that Britain version of Miranda warnings explain that you’d better fess up, because anything you fail to say now may be held against you later), but I’d still rather have it than polio epidemics.

  7. 107
    Barbara says:

    To sylphhead: vaccines are mandatory for public school attendance unless you are able to obtain a waiver consistent with state law guidelines. Most states permit waivers on prescribed bases. Most private schools also require vaccination (and some states might require private schools to adhere to the same schedule as public schools and daycare centers). Also, it’s useful to remember that many of those who “oppose” vaccines for their children are sometimes more concerned about the vaccine schedule than the vaccine itself — e.g., many people who object to giving the MMR in a combined vaccine at 15 months would give their children the MMR when they are older and their neurological systems supposedly better developed. As far as I am concerned, if these people keep their children out of daycare and other organized communal groups, it’s not something for me to worry about unduly. It’s still an issue for less formal “group” events like church daycares and playgroups, but a lesser one.

    Whoever said that this bit of authoritarianism in our civil society is quite a bit lesser of an evil than other bits — like the war on drugs, for instance, had it right. Think about the continuing threat to our freedom imposed by the reaction to 9/11. Now imagine the nature of the reaction if there were an epidemic that really COULD strike you personally. Viewed broadly from that perspective, mandating vaccines strike me as downright progressive.

  8. 108
    Original Lee says:

    Maia, damn straight I don’t trust my fellow parents to opt-in to vaccinations. I can’t even trust many of my fellow parents to think about their own children’s basic health, let alone anybody else’s. Also, many parents are under such financial pressure that they feel they must put keeping their jobs ahead of taking care of their sick kids. It is so common for both these sets of parents to send their kids to school sick that school professionals have a term for it: the Tylenol trick. The idea is to drug up your kid enough that you don’t get a phone call to pick him or her up until you’ve managed to put in at least half a day’s worth of work.

    My kids have caught some very nasty illnesses from the children of these people, including antibiotic-resistant staph, and the daycare we used when the kids were younger had to close twice in 2 years because parents brought their sick kids anyway. (I don’t think it’s realistic to keep kids home if all they have is a head cold, BTW, I’m talking about stuff like scarlet fever or strep throat.)

    So for selfish reasons I’m all for mandatory vaccinations. I’m also all for mandatory vaccinations because the poor and otherwise disenfranchised are more likely to be adversely impacted if herd immunity goes away. FTR, I’m also for quarantines enforced by people with guns, if anything exceptionally virulent and contagious should pop up (e.g., bird flu, major flu virus mutation, totally new bad disease spread by casual contact).

    It’s great that opt-in works for N.Z. Americans are just generally more self-centered and ornery, and for that reason opt-out works better for us.

  9. 109
    trillian says:

    Does anyone know (and apologies if this was already said) if Texan parents will be able to opt out of this vaccine specifically or if it’ll have to be part of a general refusal to vaccinate?

    Wingnuts are probably antsy about the prospect of opting out because it means having to explain their bizarre hangups to their cancer.

    I know you corrected this, sylphhead, but you had me cracking up picturing an oncology group therapy session where you have to talk things out with your tumor…that’s terribly insensitive, I’m sorry…

    Original Lee, I’ve been trying to get rid of MRSA for 6-7 months now, I can’t imagine dealing with it as a kid – my sympathies! Methacillin-resistant staph is a good example of what can come of other people’s stupid medical choices, since it’s largely a result of over/misuse of antibiotics. We’ve essentially bred certain bacteria out of the effectiveness range of our drugs. I’m not enough of a scientist to know if anything similar could happen to the HPV virus, but my impression is that spotty eradication can be worse than no measures at all.

  10. 110
    Elisabet says:

    I’m surprised that I had to read to the 71st comment to find what someone getting close to the facts on the ground here in Texas. Lu wrote:

    Another reason to make the vaccine compulsory is that it makes it guilt-free. If it’s compulsory, doctors don’t have to discuss with parents why yes, it really is a good idea and no, it will not turn your daughter into a slut. Parents who secretly think it’s a good idea but whose pastor told them it would turn their daughter into a slut don’t have to wrestle with their consciences.

    There’s more to it than that, though. Imagine you live in a smallish Texas town, have an 11 year old daughter, and, while you firmly believe that she is and will be a “good” girl, you also remember some of the mistakes you made, or nearly made, as a teenager, and want to get your daughter vaccinated, just in case, because – well, you never know. Besides, she will of course eventually get married and have unprotected sex then (so she can have kids) and there is always the possibility that her husband may have had a bit of, er, prior experience.

    Scenario 1: The vaccine is readily available and free or covered by your insurance. But you think about walking into the doctor’s office – where everyone on the staff and in the waiting room knows you from church or the PTA or the grocery store – and asking that your daughter be vaccinated for a sexually transmitted disease. You could not do that without feeling that they were judging you, even if no one says a word; they will know that you do not trust your daughter, that maybe you have a *reason* not to trust her. And what about her? How do you explain to your 11 year old that you think she might need this in the future, just in case she has unprotected sex with someone who has already slept around? What kind of message is that?

    Scenario 2: The vaccine is mandatory. You take your child to the doctor or clinic, complain to the nurse a little bit about how silly it is to require this for 11 year olds, apologise to your daughter that she has to do this because of that stupid law, and secretly sigh in relief on your way out the door.

    Making this vaccination mandatory provides social cover. Maybe those of you who live in other parts of the country (or world) don’t understand just how much a barrier “keeping up appearances” can be in small, conservative communities. (And before someone suggests crossing to a different county where no one knows you to get the vaccine – how would you explain *that* to your daughter?)

    And how easy is it going to be for that rare teenage girl who wants the vaccine (because we all know just how worried teenagers are about behaviors that can cause cancer, right) to get it, if she has to get her parent’s permission to receive medical care? Or risk being seen at a clinic, if that option is available?

    Someone brought up mandatory seat-belt laws. Well, I for one have invoked the mandatory seat-belt law many times over the years, as both a passenger and a driver – sometimes with a semi-fictional account of someone I knew who had just been ticketed for not being buckled up. It allowed me to indulge in my risk-adverse behavior without being a total prude, just as mandatory HPV vaccination allows parents and their daughters to indulge in risk-adverse behavior – that is, getting the shot – without appearing permissive/promiscuous.

    Here in Texas, there are a lot of places where that kind of cover is necessary.

  11. 111
    Ruhi says:

    I would have problems making the vaccine mandatory for boys even if it had FDA approval. There is some (admittedly probably very small) chance of a bad outcome and HPV won’t make them sick (aside from warts). This seems to violate the whole “First do no harm” thing.

  12. 112
    Myca says:

    What bad outcome would that be, Ruhi?

  13. 113
    sylphhead says:

    Elisabet, the scenario also works in reverse, which I think is why some people oppose opt-out so vehemently.

    “Have there been any side effects with previous vaccinations that you forgot to tell us about, Mrs. Johnson?”

    “Well, no, that’s not it, exactly.”

    “Have there been any noticeable changes in your daughter’s behaviour since her last vaccination. I’ve got… an MMR taken last – ”

    “No, it’s not that! It’s just – what if Sally thinks this means it’s okay to have sex?”

    “Well, Mrs. Johnson, I understand your concern, but recent studies have not shown this causal link. Besides, I’ve seen what cervical cancer can do, and isn’t keeping your daughter safe from it our number one concern?”

    “No, it’s not.”

    “I see… ”

    “Let me quote the Good Book… ”

    Makes me want to be a doctor.

  14. 114
    sylphhead says:

    I should correct that. I’ve yet to encounter very many people who publicly oppose opt out vehemently. Rather, they pretend the option doesn’t exist – it’s either Statists sneaking into your backyard, snatching her from the swings, and jamming a ten inch needle into her while another guy stamps ‘premarital sex #6269374′ on her forehead, or giving wingnut parents free reign to bless their kids with cancer.

  15. 115
    Individ-ewe-al says:

    Ruhi and others who think it’s not worth vaccinating boys because they get the risk of the vaccine without the benefit: the HPV virus causes not only warts but also anal cancer and in rare cases, penile cancer. And yes, you can get anal cancer from heterosexual sex. Not of course that you would be happy to expose gay men to a potentially lethal cancer for the sake of protecting boys from the sore arm they might get from the vaccine, but just so you know.

  16. 116
    sailorman says:

    It’s clear HOV vaccination has some benefit to boys. It’s also fairly clear that the benefit to boys exceeds the risk of the vaccine.

    Nobody really seems to dispute that. It’s just that there’s MORE benefit to girls, so if (as here) we don’t have time/money/political capital to vaccinate everyone, it makes more sense to vaccinate girls first.

    A lot of the “not only girls!” arguments seem to be based on a general (understandable) emotional complaint vis a vis sex, punishment, morality plays, etc. OK. But from a public health perspective (HPV has no political views; it’s just a virus) those arguments don’t work

  17. 117
    sailorman says:

    ah. Let me rephrase “nobody” to be “nobody who I have encountered who has read and understands the relevant science”

    The question of whether it is a ‘good idea’ or not; whether it ‘sends the wrong message’ or not; whether it is ‘fair’ or ‘patriarchal’ or ‘nosy’ or ‘appropriate’…. all those questions involve moral issues and no opinion is really ‘worth’ more than another.

    a distinct factual question like “does the projected benefit to men from hpv vaccine, taking into account those diseases known to be caused by hpv, exceed the projected risks” aren’t opinion issues. They’re factual issues. and unless you can and have read and understand the science involved, your opinion is worth less. So I didn’t count Ruhi.

  18. 118
    sailorman says:

    ’cause i missed it earlier. sorry.

  19. 119
    RonF says:

    In my experience 10-12 year olds take any decision they have to make very serious (because they get to make so few).

    I wish I could agree, but I can’t. I’ve run into a lot who do, and I’ve run into a lot who don’t. I can very easily see a bunch of 11-year old kids who would be very selfish and foolish and say, “I hate needles, and since everyone else is vaccinated against measles I don’t need to be.” I work with kids in that age range every week, and they can be incredibly self-centered and irrational.

    You can’t realistically give medical attention to an eleven year old who doesn’t agree.

    Depends on the medical care. I’ve had to force kids to get medical care. And then there’s the concept of “force”. There’s physical force. There’s “no more soccer team for you this semester unless you let the doctor give you this shot.”

    I’m saying that that process should be formalised and children should be taken seriously.

    I can certainly agree with ensuring that a patient of any age is fully informed of their medical care options and that their opinion is taken and taken seriously. But kids just don’t always make rational choices and sometimes you have to override them.

    RonF, again, skepticism about Big Pharma is always healthy; the problem is that there is not really organized resistance to Gardasil from organizations that are purely anti-vaccine. It’s coming from professional right-wing Christians who think that viruses and cancer cells are intelligent actors seeking out the immoral to infect.

    “Professional” right-wing Christian? ? But I personally do agree that a religious or moral objection to this vaccine seems quite absurd. After all, one’s daughter could stay a virgin until after marriage and still have what’s apparently a pretty high likelihood of being exposed to this virus by her husband. And in all the discussions I’ve been party to and the materials I’ve seen regarding sexual abstinence and education, I bet that if you ask kids what the risk factors are in having non-marital sex damn few will have any awareness that they include getting cervical cancer. They’ll all be thinking about HIV, gonorrhea, syphilis, genital herpes and, of course, pregnancy. Giving a kid a vaccine for cancer when they’re 12 years old is not going to encourage them to become sexually active.

  20. 120
    AB says:

    I think how one views mandatory HPV vaccinations probably revolves around two unstated attitudes:

    (1) How normative you believe it is for (young) adults to be sexually active–is sexually active the default status, or is abstinent the default status; and

    (2) What the basis is for parents to have control over medical decisions for their children is.

    #1 has been covered above, I think. #2 is more interesting to me.

    I believe (and I think this gets more to the feminist question) that the basis of parental rights is not one of ownership (“they’re *my* kids, so I get to say what they do!”) but rather because many medical decisions are in a gray area, and since the child can’t make those decisions herself, a parent is the one with the most relevant facts on-the-ground to make the decision. States shouldn’t make medical decisions not because it’s a fundamental incursion on liberty (after all, the child has no liberty in the decision either way) but because the state cannot possibly have a nuanced-enough view of the kid’s prior medical history, and no basis for saying one side of any trade-off is better than another, to make that decision. A parent isn’t a perfect solution; but he or she is the best one available to weigh the pros and cons and make the ultimate judgement.

    So in any situation where the pros and cons are obviously stacked on one side or the other, I don’t really have a problem with the state stepping in and making a blanket rule. The pros–protection from a highly communicable and very prevalent disease that can occasionally have fatal complications–so far outweigh the cons that I don’t see a reason that parents should have a choice. Any more than parents should have a choice about strapping their kids into a car seat. It’s not an infringement on the child’s rights, who after all does not have a choice one way or the other, and as far as I see there’s no rational basis for saying it’s enough of a gray area that the parent needs discretion.

    Incidently, I don’t think this is a view that is necessarily anti-libertarian (although Robert will probably come through and tell me why I’m wrong). You can be pro-mandatory-child-vaccination and anti-mandatory-adult vaccination. You can be pro-mandatory-child-seats and anti-seatbelt-laws. I think the onus is on those arguing for opt-in to explain why this is a sensitive enough decision to warrant the careful weighing of pros and cons that only a parent can do. And I haven’t seen anyone able to adequately articulate why this vaccine would fall into that category.

  21. 121
    Ruhi says:

    I certainly admit that I’m uninformed about the subject. I got the impression that
    HPV wasn’t a large health problem for men from an old article in Science. Here is the relevant section

    The two vaccines do have marked differences. Merck has included two additional genotypes, HPV 6 and 11, which cause genital warts in both sexes. Merck added these two types in part to create an incentive for males to receive the vaccine; vaccinated males, in turn, might reduce viral spread to women. “Men are very worried about genital warts because they’re highly visible,” explains Eliav Barr, head of Merck’s HPV vaccine clinical trials program. “Why in the world would a young adult male or an adolescent male want to get vaccinated with a vaccine that would not in general help him out?”

    Science 29 April 2005:
    Vol. 308. no. 5722, pp. 618 – 621

  22. 122
    RonF says:

    It seems to me that a large part of parental rights over their children comes from their responsibilities. If something bad happens to a child, it was the responsibility of the parents, not the State, to protect their child from that bad thing in the first place, to the point that they can be prosecuted if they were neglectful. It will also be the parent’s responsibility, not the State, to deal with the financial and other consequences of anything the child does or has happen to it. With responsibilities come rights.

    Those rights can be overridden by the State if the State can demonstrate that the parents are being neglectful, that they are taking an unacceptable risk with their child or that they are endangering society as a whole. The concept that people should not be a reservoir of disease that endangers the public is a powerful one. I’m not automatically against the concept of mandatory vaccination. But parental rights are real and should not lightly be set aside.

  23. 123
    Robert says:

    Part of the feeling that we should defer to parents on this issue, even when we think they’re wrong, comes from the fact that many folks recognize that it’s parents who are the last line of defense against bad/terrible/wrong ideas hitting their kids. Although immunizations are a good thing, someday we know the schools are going to want everyone to submit to something that will turn out to be a bad thing – and it’s important to maintain the tradition that parents have the right to say “nyet” and pull the plug, as far as their kid is concerned. The existence of the right puts a damper on some harebrained schemes from the get go, I have no doubt.

  24. 124
    trillian says:

    Although immunizations are a good thing, someday we know the schools are going to want everyone to submit to something that will turn out to be a bad thing – and it’s important to maintain the tradition that parents have the right to say “nyet” and pull the plug, as far as their kid is concerned. The existence of the right puts a damper on some harebrained schemes from the get go, I have no doubt.

    Robert, that would be what my 10th grade debate teacher would have referred to as the fallacy of the slippery slope.

  25. 125
    mythago says:

    RonF, I’m sure you know that your first paragraph is extremely oversimplified.

  26. 126
    RonF says:

    Sure, but how far do you want to go? I was trying to generalize, I didn’t want to make up a lengthy post on parental rights. I just wanted to point out that the rights of a parent to control their child’s behavior and status and to control the State’s involvement with their child’s behavior and status is based at least in part on the fact that the parent, not the State, is ultimately responsible for the child’s behavior and status (health, education, etc.).

    The State can force a child to attend an educational institution, although they can’t force a child to forsake private schooling or home schooling and go to a public school. The parent has a responsibility to ensure that their child gets an education, and has a right to make a choice as to where that will happen. The State can force the parent to send their kid somewhere for an education, but the parent has latitude on how that will happen. The State can force the kid to take a test so that it can determine how well the job is being done, but it cannot discipline either the parent or the child if the kid flunks all his classes. The State has powers, but there are constraints.

    The State does have the power to intervene in the parent-child relationship. I won’t deny that, and I’ll even go so far as to say that it’s a good thing. But that power must be limited to certain constraints, and those constraints should not be changed lightly.

  27. 127
    sylphhead says:

    “I believe (and I think this gets more to the feminist question) that the basis of parental rights is not one of ownership (”they’re *my* kids, so I get to say what they do!”) but rather because many medical decisions are in a gray area, and since the child can’t make those decisions herself, a parent is the one with the most relevant facts on-the-ground to make the decision. States shouldn’t make medical decisions not because it’s a fundamental incursion on liberty (after all, the child has no liberty in the decision either way) but because the state cannot possibly have a nuanced-enough view of the kid’s prior medical history, and no basis for saying one side of any trade-off is better than another, to make that decision. A parent isn’t a perfect solution; but he or she is the best one available to weigh the pros and cons and make the ultimate judgement.”

    Exactly, as far as the parental rights/privileges are concerned. I object that because some kids have medical complications, we should condone blanket laws that come down to ensuring that the percentage of girls who flop in the hay and get cancer doesn’t get unacceptably low. These medical complications, which are surely a minority for most vaccines, are exactly why opting out exists. Parents with children who have these specific medical conditions, after all, are probably more informed of the medical and legal options out there. There are parents who never really bother to find about these things precisely because their children never had these conditions, and their children would be first on the chopping block with an opt in system. The children in question could always yank on their own sneaker straps and get themselves better parents, but I think our society is too politically correct and socialist for that at this point.