Should vaccines for only semi-communicable disease be mandatory?

Joe points our attention to a post/article over at TAPPED that tackles some of the issues regarding the HPV vaccine and its intersection with state power & public health. Since TAPPED is from the 'progressive' viewpoint, the desirability of universal vaccination (for, I presume, anything) is taken as a given. But as Joe intuits, that premise needs to be checked at least once before we grant it.

The usual public health rationale for mandatory/universal vaccination is usually composed of the "herd immunity" effect and references to externalities of individual sickness (you get sick and through no fault of my own, you make me sick, thus imposing a cost on me, etc). A key assumption behind this is that these relatively easily communicable diseases have a roughly equal probability of infecting any other given person in close/proximate connection to the currently infected individual, and thus its a numbers/mass probability game. And as far as it goes for the usual suspects like smallpox and tuberculosis and measles and such, the argument and the assumption are on solid ground, and it covers Joe's points 1-3.

But when it runs up to diseases that *aren't* easily transmissible, we start to hit a snag. For instance, the HIV infection risk for a monogamous, heterosexual, non-drug-injecting male is in the "chance of getting hit by lightning/terrorists" zone. The behavior of a straw-man combination of the highest risk categories for HIV infection (highly promiscuous gay dirty/shared-needle heroin using man, for instance) will have little to no impact on the first man's risk. Joe's 3 points start to look suspect, and so does a rationale based on easily and unintentially communicable diseases that have no significant behavioral modifier to infection probability.

This is where it gets dicey for diseases/pathogens like the type of HPV that causes cervical cancer. Cervical cancer HPV strains are highly specific to certain tissues; they don't infect the skin on your hand, or your mouth, or other places that could spread the disease by common social contact. They strictly infect genital skin & mucosal tissue. Thus Kip (at his place and in the comments) is absolutely correct in pointing out that while one student can casually pass smallpox or influenza to his neighbor one desk over, the same is simply not true for HPV. There is a large and substantial behavioral aspect (i.e. engaging in sexual contact) that radically affects the chance of infection.

So Jane Galt is somewhat off base with most of her objection to the vaccine objectors, as this isn't a case of polio or mumps or smallpox where just being contact with *anything* related to the infected might infect you.

So absent the usual externality argument (positive and negative), I find it harder to justify the extension of government in the face of the countervailing issues, not simply as Joe breezily puts it "my liberty to get sick," but important considerations such as the old saw "keep your laws off my body," (reproductive & bodily autonomy & liberty from paternalist intervention), respect for individual & familial autonomy and culture, general liberal concern with state coercion in general, etc. These are important considerations that push against a paternalist/humanist concern for the greatest general well-being of society.

But on the other hand, unlike with the case with the vastly different risk profiles for HIV infection[1], HPV is (a) easily transmissible via pretty much any sexual contact (no hetero/homo distinction), (b) is somewhat commonplace in the general population and (c) and has a disproportionate impact on women. Unlike with HIV, the at-risk population does start to resemble the "herd," and also unlike HIV the behavioral needle for most people points them *into* harms way (save for the sex-free zero-drive individuals, we all have some urge to merge), and the subpopulation least likely to control their behavior given the power of hormone & instinct (young teenagers) is at the highest risk for infection. These considerations do a great deal of the heavy lifting needed to push the argument back into the public health justification, but not quite all the way.

So for me, while the behavioral/intentional aspect of the disease rules out *mandatory* vaccination, there is still a partially compelling social interest in helping to curb transmission via vaccination, and a compelling personal/familial interest to protect daughters from cancer/infertility. And as the TAPPED post points out, there are welfare implications as well. To thread the liberal needle then, my gut response is to make the vaccine easily available, through means-tested subsidy if necessary, but voluntary. Perhaps add some extra incentives (via charity) to help push vaccination among the poor, like a March of Dimes or its equivalent.

(edited to add links to Kip's posts - thanks!)

fn1. Where in the case of, say, hetero vs. gay men, the biggest behavioral risk there (unprotected anal sex with an infected man) is one where biological sexual orientation will do the heavy lifting in protecting the heterosexual men.

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