Where public health means private responsibility.

Gardasil, the vaccine that protects against the most common strains of the STD HPV, has been approved to cover five more strains in addition to its current 4, and for use in people up to 45 years old. Since HPV can cause cervical cancer (and, less commonly, throat cancer), this is a really incredible advancement. But because of the stigma of an STD-caused cancer, Gardasil has had a hard time convincing parents to vaccinate their children, and I think this struggle was a precursor to the larger anxiety around vaccines recently. Both ultimately stem from a lack of understanding of what vaccines are and how they work, both medically and socially.

My first college class was an economics course called “How the Black Death Changed Europe”, which was really a public health class in disguise. While the first half really was about the economic impact of the fourteenth-century plague on Western Europe, the second half built on the conceptual models of the Black Death to explain the potentially destructive impact of modern diseases and how an economics-based understanding of public health concerns can prevent disaster. This class was hugely influential for me, since I ended up going into history of medicine, and it also gave me a foundational understanding of the issues of public health. This combination of medieval theory and modern issues is really important when you’re studying pre-modern diseases because it’s easy to say “that just doesn’t happen anymore because we’re civilized now.” But while we as a society expect modern medicine to do a lot of work for us, we often don’t consider our individual roles in putting modern medicine to use because a lot of us haven’t seen this in practice. It’s easy to say that the plague isn’t an issue now because we have antibiotics and we don’t throw shit in the streets, but people who contract plague today still die from it, and hygiene was never really the cause. Or diseases like leprosy or scurvy, which seem lost to time, never actually went away, and in the case of leprosy still presents something of a medical mystery. When we move into the modern era, diseases that become disasters (or at least grab the public’s attention) come to be more about society-wide habits than individual exposure. Cholera, for instance, is an issue of contaminated water, usually caused by poor sewage removal, and it’s a particularly insidious disease because the cure is also the prevention: clean water. But everything changed with vaccines, right?

A formative moment for me in the Black Death class was during a discussion about vaccines. We had been talking about whether or not individuals should be able to choose whether or not to receive a vaccine. On the one hand, there is the benefit of herd immunity, when diseases become eradicated simply because enough of the population is immune that the disease is backed into a corner and dies out. On the other hand, there is the abuse of over-prescription in cases where herd immunity isn’t necessary, as in the overuse of antibiotics causing the development of antibiotic-resistant bacteria (helpfully termed “superbugs”), and it’s not always clear that doctors know how to judge one versus the other. This debate is about systemic solutions, a popular strategy of the 19th and early 20th centuries that has now become the hallmark of self-identified progressives. But then one girl in my class made the debate about personal choice. She said that individuals should be able to decide for themselves whether it’s a good idea for them personally to get a vaccine, not out of any particular health concern, but out of a general distrust of the medical establishment and a sense of personal freedom. And she gave as an example that she had opted not to receive the Gardasil vaccine the year before, praising her parents for allowing her to make that decision for herself. Now, I should just get out of the way that since this was in a time before I learned restraint I laid into this girl in front of the whole class and told her it was a stupid, selfish decision and that she had missed the point of the vaccine. But to be more diplomatic, I think she would have chosen differently if she had understood that getting the vaccine was not just about protecting herself, but about protecting everyone of her generation, and that by doubting the validity of herd immunity, she was delegitimizing a real public health concern.

This all happened right when the Gardasil vaccine was first approved, but even now only half of teenagers get the vaccine. Gardasil, as I said, has a hard time convincing parents to vaccinate their children against an STD, because parents want to assume that their kids will “be smart” about sex. Except that HPV is extremely common and easy to catch, and, in a case of dramatic irony, typically only displays symptoms in women. So Gardasil was only approved for use in girls and young women because typically men don’t know they have it and don’t develop more severe conditions from it. It’s as if it doesn’t matter that men can spread it, if it doesn’t affect them, it doesn’t apply. Echoes of this ideology in the development of male birth control, which has been halted multiple times due to side effects considerably less severe than what women experience. To add insult to injury, there is a significant population of men that contracts throat cancer from HPV, and it’s gay men. Eventually, Gardasil was approved for boys as well as girls, so progress, I suppose. But why does it matter that only girls were getting the vaccine? Why isn’t half the population good enough? You could theorize that for an STD half the population would be enough to corner the disease, but only if everyone is straight and monogamous, which we know they’re not. Because otherwise, as happened with the original spread of HIV, you could have a single vector (point of dissemination), or patient zero, who personally infects a large number of other people. And since only women typically know that they have HPV, men couldn’t even implement safer sex practices once they were infected.

But herd immunity isn’t how vaccines always work. The flu vaccine, for instance, maybe shouldn’t be given to everyone. Since the flu evolves every year, you can’t develop permanent immunity to it and certain groups (people with chronic illnesses, the very young, and the very old) are at risk of dying from it. The important difference here from the case of HPV is that there is an identifiable group that is more likely to be negatively affected by it, whereas the rest of the population will not be any worse off getting it. And because the disease mutates quickly, it’s possible that shielding the entire population will actually encourage it to become drug resistant. Instead, people who are susceptible and those who are in frequent contact with them can get the vaccine and feel reasonably safe. In both the case of the flu and HPV, everyone can be better protected with better hygiene. But the stupidest reason not to get the flu vaccine is the myth that it doesn’t work “because I got sick anyway.” This comes from two things – 1) people don’t know what the flu actually feels like and think that their cold is the flu and 2) people don’t realize that the vaccine is the dead virus injected into the body to trigger an immune response, and the immune response can feel like (but not have the same life-threatening impact as) the real thing. The point of preventing a disease isn’t primarily so you can feel great (i.e. not sick) all the time – it’s to keep people alive. We vaccinate against diseases that kill people, not just diseases that are annoying. Which is why people are suddenly surprised by the resurgence of measles now that a swath of the parent population has decided to stop vaccinating against it – measles used to kill children. The reason it doesn’t anymore isn’t because modern medicine waived a magic wand and slayed the dragon (to mix fantasy metaphors), but because it created a solution that then needed to be implemented. Implementation is the key, and that requires a coordinated action, a team effort. So don’t just decide whether or not to get a vaccine because of what might happen to you – consider whether your action is required to help protect other people.