Ontario’s HPV Vaccination Program
In this paper, I present arguments that are supportive of the ethical inappropriateness of the Ontario government’s HPV vaccination initiative. I also aim at revealing the ineffectiveness of the program as a public health strategy constructed to combat cervical cancer. In addition, I will use the utilitarian approach to support my views.
The Ontario HPV Program Overview
In September 2007, the Ontario Liberal Government began a Human Papilloma Virus (HPV) vaccination intervention for female eighth-graders (Thompson, 2013; CIHR- IPPH, 2012). The federal government made an allocation of $ 300 million towards the intervention. Gardasil, the HPV vaccine, targets four subtypes of the virus. These strains are 6, 11, 16, and 18 (Thompson, 2013). Each child requires a minimum of three Gardasil doses, which cost approximately $400. This figure makes HPV the most expensive childhood vaccine.
The first three years of the school-based program involved girls only (CIHR- IPPH, 2012). The initiative registered an uptake rate of 51% in 2007/2008, 58% in 2008/2009, and 54% in 2009/2010 (Thompson, 2013). These statistics show that the program reached more or less half of the intended population. In 2010, the Ontario government expanded the vaccination intervention to incorporate boys following a regulatory approval for males (CIHR- IPPH, 2012). The inclusion of boys in the vaccination drive modified the intervention from an anti-cancer to an anti-STI strategy.
Why I Disagree with the HPV Vaccination Program in Ontario
In most cases, governments and public health agencies initiate vaccination programs with an objective of lowering harm or enhancing the greater good for an individual or a target population regarding contagious or infectious diseases (Dawson, 2011). At the inception of the HPV vaccination strategy, the Ontario government’s intentions were to reduce the incidence of cervical cancer by conferring immunity against four strains of HPV (CIHR-IPPH, 2012). Typically, vaccination programs have an eradication goal. This is not so for the HPV initiative because it only targets a limited number of HPV strains (6, 11, 16, and 18).
First, the vaccine provides immunity against only four strains of HPV whereas there are over a hundred strains of the virus. Second, the immunologic protection offered by the vaccine is reliable for only five years. It is still unclear whether the declining effectiveness of the vaccine necessitates the provision of boosters doses, and if so the number and interval of boosters are still unknown (CIHR-IPPH, 2012). Third, there is a risk of allowing other carcinogenic strains to become dominant. Fourth, the vaccination offers little or no benefits to the recipients. According to Thompson (2013) and CIHR- IPPH (2012) 90% of HPV infections clear within two years, meaning that these infections do not necessarily result in genital warts or cancer. As such, the vaccine offers little help to the recipients. Given the above considerations, it is clear that a paternalistic approach is not enough to justify the Ontario HPV project because the risk reduction potential of the vaccine is low.
Although the HPV-related health issues necessitate the provision of a vaccine, they are not enough to justify a compulsory vaccination approach. For instance, cervical cancer accounts for only 1.1% female cancer mortalities in Canada (approximately 140 women per annum) while breast and lung cause the death of 1951 and 2782 Canadian females each year respectively (Thompson, 2013; CIHR- IPPH, 2012). Compared to other public health menaces such as smallpox, HIV, and polio, HPV poses a low risk. Moreover, even a voluntary or intermediate HPV vaccination project calls for more supportive evidence on long-term effectiveness and the dominance of other strains (CIHR-IPPH, 2012). There is a possibility that providing immunological protection for some HPV strains could allow other carcinogenic subtypes to become dominant (CIHR- IPPH, 2012). Apparently, paternalistic ideals are not enough to justify the mandatory HPV immunization for eighth graders.
International health regulations give a mandate to jurisdictions to prevent harm to others when it comes to infectious diseases (Dawson, 2011). In addition, individuals have a moral obligation of protecting others from harm resulting from their actions or inactions (Dawson, 2011). In the Ontario case, the harm to others consideration does not hold water. The limited protection potential of Gardasil over time implies that vaccinated individuals have the likelihood of contracting and transmitting HPV after five years. Furthermore, the vaccination offers protection against 70% of cervical cancer cases related to the 6, 11, 16, and 18 HPV strains. As such, the whole population (including vaccinated individual) remains exposed to the other strains that cause 30% cervical cancer incidents. According to Thompson (2013), achieving significant outcomes in the reduction of cervical cancer mortality rates would require the use of a vaccine that provides protection against more HPV strain as opposed to the four subtypes that Gardasil targets. The inadequacies of Gardasil deprive the Ontario government the liberty of using the harm to others argument to justify its HPV project since it is not clear whether the intervention actually improves the well-being of an individual or the target population regarding HPV infection (Thompson, 2013).
Parentalism mandates parents to make vaccination decisions on behalf of their children, with the best interest of the minors at heart (Dawson, 2011). Essentially, Gardasil is a childhood vaccine against an adult disease caused by adult behaviors. It offers the best protection when it is inoculated before individuals become sexually active. Since the Ontario program targets school going minors from the age of nine years, it is possible that the protection power of the vaccine wears off before the first sexual encounter for many recipients (CIHR-IPPH, 2012). As such, it is unjustifiable to quote parentalistic arguments in support of childhood HPV vaccination, as the vaccine may not offer the required protection when needed (at a time when recipients become sexually active). Given the limited immunologic protection that Gardasil confers, one might wonder whether the HPV Initiative is an appropriate utilization of parentalism.
According to Gostin & Powers (2006), justice is s central to public health that it emerges as one of its core values. It is imperative for public health interventions to disburse common advantages and burdens fairly (Gostin & Powers, 2006). Although social justice does not give all the answers to the controversies that arise when public health collides with civil liberties, it is necessary for policies and intervention to commit to certain principles that promote legitimacy. According to Gostin and Powers (2006), a social justice approach to public health is helpful in dealing with socioeconomic disparities and addressing health determinants. The first and the second phases on the Ontario HPV vaccination violate various principles of social and gender justice. The initial episode of the initiative targeted school going girls aged between nine and fifteen years. Although epidemiological statistics show that women suffer the consequences of HPV infection more than men, focusing vaccination efforts on girls shifts the responsibility of HPV health issue to the female gender. It might imply that women are solely responsible for the transmission and spread of the virus. The public might perceive cervical cancer as a consequence of women’s sexual responsibility despite the fact that men too suffer from HPV-related illnesses. According to CIHR- IPPH (2012), HPV also causes genital warts, anal, and throat cancer in both males and females. Clearly, focusing on girls contradicts the core characteristic of justice that calls for fair distribution of benefits and burdens because it paints the issue as a female problem (Gostin & Powers, 2006).
The Ontario school-based initiative presents Gardasil as an anti-cancer vaccine. According to Thompson (2012), this presentation is wrong and ethically incorrect because it deliberately portrays cervical cancer as a public crisis. Although the vaccine campaign is aimed at informing the public and enhancing adherence, the wrongful presentation of the health problem is morally unethical because it deliberately and incorrectly equates HPV infection to cervical cancer (Thompson, 2013).
The second phase of the HPV vaccination involved both girls and boys. The incorporation of both genders in the program shifted the approach from an “anti-cancer vaccine” for girls to an “anti-STI vaccine” for both sexes (CIHR-IPPH, 2012). This model might wrongfully and unjustly imply that the most-at-risk populations (such as girls from low-income households or gay men) are sexually promiscuous and irresponsible, thus enhancing stigmatization of these groups. Also, vaccinating both sexes while communicating the high risks that HPV poses to women may paint men as disease vectors other than victims who also transmit the virus and suffer from the health complications of HPV infections. It also downplays the health concerns for men. Such a risk communication strategy propagates gender injustices, as it seems to shift blame to the female sex.
The Utilitarian Approach
Utilitarianism applies cost-effectiveness in the formulation of public health policies (Thompson, 2013). The utilization of cost-effectiveness analysis allows for allocations that maximize social utility. This approach aims at achieving the greatest good for the greatest number using the available resources (CIHR-IPPH, 2012; Thompson, 2013). In the Ontario case, the Provincial Infectious Disease Advisory Committee for Immunization (PIDAC-I) carried out cost- effectiveness and utility analyses in evaluating the program (Thompson, 2013). Scholars indicate that cost-effectiveness and cost utility are the most relevant factors that need to be examined when formulating public health priorities.
Viewing the Ontario HPV vaccination project through the utilitarianism lenses reveals several flaws in the appropriateness of the initiative. To maximize public health benefits of HPV protection, the program needs to target the most at-risk populations such as girls from socially and economically marginalized backgrounds. The first phase of the initiative that involved girls only used a partial application of cost-effective principles in allocating the available resources to a population where optimal prevention yields could have been realized. According to Thompson (2013), a Canadian meta-analysis revealed that the quadrivalent HPV vaccine for girls was a cost-effective option in preventing cervical cancer as well as other HPV infections like genital warts. As a result, the health sector was positioned to gain from reduced treatment costs. Unfortunately, the first leg of the publicly funded program only managed to reach half of the intended population (CIHR- IPPH, 2012). Furthermore, the inclusion of boys in the second part of vaccination program exceeded the cost-effective threshold of $ 50,000 per Quality-Adjusted-Life- Years (QALY) (Thompson, 2013). The above instances indicate that the financial allocations for the vaccination initiative were not used to give maximum outcomes. Thus, the utilitarian model is inadequate to support the Ontario strategy.
Vaccinating adolescent school goers appears unnecessarily expensive because the majority of the recipients may not have needed the intervention (CIHR- IPPH, 2012). The federal government gave an allocation of $ 300 million for the initiative, and the four doses required for each child costs approximately $400 (Thompson, 2013). This makes Gardasil the most costly immunization protocol for children in Canada (Thompson, 2013). Targeting adolescents leaves out other age groups creating an equality problem. According to CIHR- IPPH (2012), public health initiatives should focus on three factors, that is utility, equality, and need. In most cases, it is impossible to maximize the three, so one of the factors is usually compromised. However, the Ontario case seems to undermine all of them. The cost of the program is unnecessarily high, and the intervention focuses on adolescents only, who do not fall in the most at-risk group when it comes to cervical cancer.
Thompson (2013) argues that targeting older women who are more likely to die from cervical cancer could have been a better utilization of public resources since it could have yielded better public health outcomes compared to the school-based program that focuses on a small population. Thompson (2013) raises the question why the Ontario did not design an initiative that targets the women who are most likely to perish due to cervical cancer.
The cost-ineffectiveness of the second phase revealed by the Canadian meta-analysis, in conjunction with the inadequacies of the immunological protection of Gardasil as discussed earlier, shows that the Ontario program is unjustifiable by the utilitarianism principles that emphasize the use of social utilities for optimal benefits (Thompson 2013; CIHR-IPPH, 2012).
One might argue that the inclusion of boys in the vaccination project, though cost-ineffective, eliminates the social and gender injustice that targeting girls only perpetuates. As seen earlier, directing protection efforts towards girls might create an impression of shifting responsibility and the burden of cervical cancer and other HPV-associated illnesses on the female gender. Also, this approach might enhance the stigmatization of women as sexually promiscuous and irresponsible. The incorporation of both genders in the vaccination strategy the above injustices by distributing public health burdens and benefits equitably between the two sexes.
However, I still believe that focusing on boys and girls does not offer significant protection benefits that justify the cost-ineffectiveness of the second part of the Ontario HPV vaccination initiative. The hiccups of reducing immunological security over time and the need for boosters nullifies the fair distribution of benefits and burdens argument because both genders attain partial and diminishing protection against HPV at the end of the day.
Conclusion
In conclusion, it is clear that the application of utilitarian, parentalistic, paternalistic and social justice models is inadequate to justify the Ontario HPV school-based vaccination program as it is. As such, the Ontario government should consider a redesigning the program to address ethical and cost-effectiveness issues with an aim of maximizing the public health benefits of the fight against HPV.
References
Canadian Institutes of Health Research – Institute of Population and Public Health (2012). Population and public health ethics: Cases from research, policy, and practice. Toronto, ON: University of Toronto Joint Centre for Bioethics.
Dawson, A (2011). Public health ethics. Cambridge: Cambridge University Press.
Gostin, L. O. & Powers, M. (2006). What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Affairs, 25 (4): 1053- 1060.
Thompson, A (2013). Human Papilloma Virus, vaccination, and social justice: An analysis of a Canadian school-based vaccine program.” Oxford University Press. Vol 6. No.1: 11-20.
