There Is No Wealth But Life

What determines the difference between heartbreaking stupidity and a blazing, brazen act of hope which will save the world?

I don’t know.

In my recent post on Monogamy and Health Care I detailed a few of the differences in health care which are reasonable for the sexually monogamous (as opposed to the general population). My intention was to help some understand a bit more of the different assumptions that go into decisions regarding health, and another part of why it is absolutely abhorrent to suggest that it is somehow best for sexually unfaithful men¹ to expose their wives to STIs and silently carry on with life without informing the wives of their now compromised health.

But underlying all of this remains the question: is it ever actually reasonable for women to risk their health on the assumption of their spouses’ sexual fidelity? Can it be rational for a woman to tell her doctor that she is aware of the fact that she is betting her life on her husband’s honesty and fidelity, and she is quite willing to do so?

The answer to this is sometimes yes. Love of every type involves risk, and sexual love is no exception. We can do our best to minimize many risks in many ways, but ultimately there is always some risk. The only question is what degree of risk is acceptable to any given person. And that must be a personal decision.

Some of us must quite deliberately cultivate a seemingly naïve hope and make choices which reflect faith in the possibility of a life which is radically different from what most will experience on this earth. Others must realistically weigh their options and minimize the damage that inevitably comes in this life. To some extent we all create our own realities, and it is simply incorrect to suggest that one choice is best for all of us.

This is true in general, and it is true in the particular case of HPV vaccinations. Unfortunately, there is not a vaccine available against STIs which is either entirely effective or entirely harmless. If there were, I would have no hesitation whatsoever in supporting it wholeheartedly in every case. But that simply isn’t reality.

There is a vaccine against the two types of HPV that cause 70% of cervical cancers. To some it is clear that everyone who can be should be vaccinated.

But the numbers are more complicated.

HPV Facts (taken from CDC’s various fact sheets):

• HPV is so common that at least 50% of sexually active men and women get it at some point in their lives.
• Approximately 20 million Americans are currently infected with HPV. Another 6 million people become newly infected each year.
• Most people who become infected with HPV do not even know they have it.
• In 90% of cases, the body’s immune system clears HPV naturally within two years.
• Screening tests can find early signs of disease so that problems can be treated early, before they ever turn into cancer.
• Not having sex is the only sure way to avoid HPV.

Cervical cancer facts (taken from cancer.gov)

• Cervix cancer is rare in this country today because most women get regular Pap tests.
• Almost all women who have had sex will have HPV at some time, but very few women will get cervix cancer.
• Most cervix cancer can be prevented.
• Finding abnormal cell changes early with a Pap test can save your life.
• Cervix cancer is rare in women who get their Pap tests.
• There are treatments for the cell changes in the cervix that HPV can cause.
• Women who have their Pap tests as often as they should are least likely to get cervix cancer.
• Smoking and HPV infection may work together to cause cervical cancer.
• Diets low in fruits and vegetables are linked to an increased risk of cervical cancer.
• Women who are overweight are at a higher risk of one type of cervical cancer.
• Long-term use of birth control pills increases the risk of this cancer.
• If your mother or sister had cervical cancer, your chances of getting the disease are 2 to 3 times higher than if no one in the family had it.

Essentially HPV is very common, but cervical cancer is both rare and almost always preventable, even without vaccination. Furthermore, since one can know one’s relative level of risk for cervical cancer, one can choose to be hyper-vigilant about screening for precancerous cells if that is appropriate.

There remains the question of why one would allow any risk at all. Sure, an HPV vaccine may only reduce one’s risks of cancer ever so slightly, but why not take all of the protection that one can get?

And that brings us back to the fact that vaccines are not actually risk free. The value of vaccines comes from the fact that their benefits typically dramatically outweigh their risks, especially when considered from the perspective of the population as a whole. But no individual woman is the population.

As of February 14, 2011, approximately 33 million doses of Gardasil were distributed in the U.S. Since February 14, 2011, VAERS received a total of 18,354 reports of adverse events following Gardasil vaccination in the U.S. Of these reports, 92% were reports of events considered to be non-serious, and 8% were reports of events considered serious…

VAERS defines non-serious adverse events as those other than hospitalization, death, permanent disability, and life threatening illness.

The vast majority (92%) of the adverse events reports following Gardasil vaccination have included fainting, pain, and swelling at the injection site (the arm), headache, nausea, and fever. Fainting is common after injections and vaccinations, especially in adolescents. Falls after fainting may sometimes cause serious injuries, such as head injuries, which can be prevented by closely observing the vaccinated person for 15 minutes after vaccination.

Any VAERS report that indicated hospitalization, permanent disability, life-threatening illness, congenital anomaly or death is classified as serious. As with all VAERS reports, serious events may or may not have been caused by the vaccine.

There have been some reports of blood clots in females after receiving Gardasil. These clots have occurred in the heart, lungs, and legs. Most of these people had a risk of getting blood clots, such as taking oral contraceptives (the birth control pill), smoking, obesity, and other risk factors.

As of February 14, 2011, there have been 51 VAERS reports of death among females who have received Gardasil. Thirty two of these reports have been confirmed and 19 remain unconfirmed due to no identifiable patient information in the report such as a name and contact information to confirm the report. A death report is confirmed (verified) after a medical doctor reviews the report and any associated records. In the 32 reports confirmed, there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine and some reports indicated a cause of death unrelated to vaccination. Source.

These numbers look good when considering the entire population, but that is because the entire population consists of many women who are at significant risk for contracting HPV, including those who receive inadequate health care and are unlikely to receive Pap tests frequently enough.

But for an individual woman who is at unusually low risk of contracting HPV, the risks of the vaccine suddenly look worse. A headache and fever may not be that bad if it is the price to pay for significantly reducing one’s risk of cervical cancer, but if the risk of cancer is negligible to start with, then the added risk of  “non-serious adverse events” becomes at the least an unnecessary nuisance.

And then there is the question of cost. The HPV vaccine was determined to be worth the financial cost based once again on the general population. The Catholic Medical Association asserts that:

Cost-effectiveness models have estimated about that, overall, a program of universal vaccination of adolescent girls will cost $23,000–$45,000 per quality-adjusted life year saved. These cost-benefit ratios fall within the range generally deemed acceptable for preventive medicine.

Which is, of course, all well and good for the general population. Yet once again, no individual woman is the general population. And while the experts who determine the cost-benefit ratios simply cannot pull out individual women as exceptions, the women themselves–with the help of their personal health care providers–can. Thus it is entirely reasonable both to provide a general recommendation for a vaccine, and still recommend against it for an individual patient.

Unfortunately, while HPV vaccines can save some lives, the costs savings of the vaccine is limited because women who have had an HPV vaccine still need routine Pap tests. The vaccines currently available are only effective against a few of the many strains of HPV, and it is not currently known how long the vaccine will be effective without a booster shot. Hypothetically, a 12-year-old could be vaccinated, but then not be protected at all once she is 35.

What does all of this mean for you? I have no idea. Only you, your doctor, and those you love can figure out what the risks and benefits are for you as an individual.

What does this mean for me?

I am 25. I have not yet been vaccinated. No medical professional has recommended that I be vaccinated, presumably because I am at abnormally low risk for contracting HPV. I am well aware of the fact that I could dramatically change my sexual practices in the future, or that I could be raped. While I have a high dose of self-skepticism and unhealthily high fear of sexual abuse, I seek to make medical choices rationally rather than out of fear.

I personally find the idea of vaccinating out of concern about rape to be incredibly troubling. I know that I cannot personally make a difference as I cannot tell my insurance company to redirect $400.00 toward rape prevention programs rather than vaccines for me. But I am still a part of a larger system. It is positively revolting to me to participate in encouraging that system to spend money on what turns out to be an exorbitant cost-benefit ratio for protection against consequences of rape rather than investing the money in reducing rape.

It is highly likely that I will enjoy good access to health care for the rest of my life. Should my risk for HPV change, I will simply increase my vigilance by having regular Pap tests and prompt treatment for any cervical cell changes caused by HPV.

Because of all this it seems clear to me that it would not be wise for me to request vaccination against HPV. If my irrational fear were significant, then I would think the vaccine worth it simply for mental health reasons. But given the fact that I am not afraid and the cost-benefit ratio is drastically different for me than for the general population, I will not seek to be vaccinated.

In the future I expect to have children and be faced with the question of vaccinations for them. I suspect that a vaccine against HPV will be standard for a 12-year-old girl and readily available, though more optional, for a boy. Given the greater uncertainties about my children’s futures, I would most likely choose to have them vaccinated.

The CDC has chosen to promote vaccinations for girls rather than for boys, but because of the subculture in which we live, my son would be more likely than average to end up marrying a woman who had not been vaccinated. We will seek to promote not only sexual monogamy as a part of chastity for our children, but also responsibility and concern for the well-being of one’s sexual partner.

It is important for young men to grow up knowing that any sexual activity will put them at risk for contracting infections, and that these infections could ultimately both prevent them from having children and even kill a woman whom they love. While I do not think that fear of STIs is an effective promoter of abstinence for most young people, I do think that it is important for young people to have a realistic understanding of risks, and vaccinations can provide a time for discussion of all the things that cannot be vaccinated against. Like your heart! ::sniff sniff:: I’m sure I’ll be the type of mother who tells her children that the number one cause of death is broken hearts– so they’d better run from sex!. Ehem, what I meant to say was that even if the benefits of protection against male cancers are smaller, warts are still gross, and as long as boys are carriers of STIs, it makes sense for them to be part of the vaccination solution.

Since my children will be perfect, they will not only be perfectly chaste, but also loving, generous, and forgiving. That means that they are likely to marry people who have different sexual histories and risk factors. The future will be much less clear for my child as a pre-teen than it is for me as a married 25-year-old, so vaccination will make a lot more sense statistically.  It is possible that we will know more about the risks of vaccinations in 5-15 years and they will not be universally recommended, but if they are, I see no reason to object to my children being vaccinated.

Fear is a powerful motivator when it comes to decisions such as whether to vaccinate against HPV. One can have an irrational fear of HPV and cervical cancer, and one can have an irrational fear of sexual activity and promoting teenage licentiousness. I cannot always control my fear, but I can seek to understand which choices I am making out of fear, and which are based on the evidence relevant to me and my situation in life.

I know that many of you will disagree with me on this, so please do comment (with lots of links to legit sources!) and explain your view and why it makes sense for you to make different choices.

1. For some reason the discussion seemed to keep returning to the idea that the husband would be the unfaithful one (despite my best efforts to not suggest that) and there is also the fact that the female reproductive system is more vulnerable to disease than the male reproductive system. Currently, there is no test to find HPV in men so it is impossible to simply test and then inform one’s spouse after the fact if the results are positive in a negative way.