India Today - - UPFRONT - By Leela Vis­aria Leela Vis­aria is hon­orary pro­fes­sor at the Gu­jarat In­sti­tute of De­vel­op­ment Re­search

In De­cem­ber 2017, the Union min­istry for health and fam­ily wel­fare de­cided to can­cel the in­tro­duc­tion of a vac­cine for the sex­u­ally trans­mit­ted Hu­man Papil­loma Virus (HPV). The vac­cine is used to pre­vent cer­vi­cal can­cer among women and, ide­ally, should be ad­min­is­tered be­fore the woman be­comes sex­u­ally ac­tive—to ado­les­cent girls. The de­ci­sion to can­cel its in­tro­duc­tion in the pub­lic health sys­tem was re­port­edly taken after the RSS-af­fil­i­ate Swadeshi Ja­gran Manch wrote to Prime Min­is­ter Naren­dra Modi ar­gu­ing that it was of doubt­ful util­ity, with ad­verse ef­fects, will di­vert scarce re­sources from worth­while ini­tia­tives, will erode con­fi­dence in the na­tional im­mu­ni­sa­tion pro­gramme and thus ex­pose chil­dren to the risk of more se­ri­ous vac­cinepre­ventable dis­eases.

The HPV vac­cine was launched in the global mar­ket more than 10 years ago and has been ac­cepted by sev­eral coun­tries as part of their health pro­grammes. Ac­cord­ing to the World Health Or­ga­ni­za­tion, India, with an age-stan­dard­ised in­ci­dence ra­tio for cer­vi­cal can­cer at 22 per 100,000 women per year (com­pared with 14 per 100,000 women glob­ally) and 25 per cent of HPV-re­lated deaths glob­ally, was per­ceived as the per­fect ground for the in­tro­duc­tion of this vac­cine.

After ob­ser­va­tional tri­als of the HPV vac­cine be­gan in Andhra Pradesh and Gu­jarat in 2009, mainly on tribal girls, seven girls died after vac­ci­na­tion. The deaths and the cir­cum­stances sur­round­ing them were in­ves­ti­gated by a stand­ing com­mit­tee on health and fam­ily wel­fare and an NGO work­ing in the health sec­tor. These pointed to sev­eral lapses—the way con­sents were ob­tained, ig­nor­ing the prob­lems re­lated to men­stru­a­tion faced by some girls after they were in­jected the vac­cine, and at­tribut­ing these deaths to un­re­lated causes. It was pointed out that since the ob­ser­va­tional stud­ies were car­ried out by an or­gan­i­sa­tion as­so­ci­ated with pharma com­pa­nies that man­u­fac­tured the drugs, there was also a con­flict of in­ter­est.

De­spite these con­cerns, in Novem­ber 2016, the Pun­jab gov­ern­ment went ahead and on a trial ba­sis ad­min­is­tered the vac­cine to all girls study­ing in grade six in gov­ern­ment schools across two dis­tricts with the pro­vi­sion to cover the en­tire state in a phased man­ner.

The op­po­si­tion to the in­tro­duc­tion of the HPV vac­cine has come from sev­eral quar­ters. Some Left-ori­ented health ac­tivists fear that the vac­cine could be used as a short-term so­lu­tion for all things re­lated to women’s health is­sues, leav­ing a host of gy­nae­co­log­i­cal con­cerns unat­tended. Fur­ther, the doc­tors’ fra­ter­nity feels that it is too early to de­ter­mine the vac­cine’s ef­fi­cacy and it is too ex­pen­sive an in­ter­ven­tion for most In­di­ans. (In the pri­vate sec­tor, the vac­cine costs Rs 2,800-3,300 per dose. The two doses needed will cost Rs 5,600-6,600.) Some pub­lic health ac­tivists have been ar­gu­ing that an im­proved per­sonal hy­giene, avail­abil­ity of run­ning wa­ter and bet­ter nu­tri­tion may be more cost-ef­fec­tive mea­sures to lower the in­ci­dence of cer­vi­cal can­cer. Ac­cess to screen­ing, aware­ness and ed­u­ca­tion pro­grammes would also pre­vent cer­vi­cal can­cer deaths, they ar­gue. How­ever, the con­trary view is that the vac­cine is a pre­ven­tion and not a cure for the dis­ease. There is no link be­tween poor hy­giene and HPV or cer­vi­cal can­cer. It is also ar­gued that the vac­cine is ad­min­is­tered to ado­les­cents be­tween nine and 14 years, but cer­vi­cal can­cer gen­er­ally strikes women who are above the age of 45-50. Does one have to wait for 30-35 years to es­tab­lish that the vac­cine is ef­fec­tive? There is also an un­spo­ken ‘moral’ ar­gu­ment against the vac­cine: it will en­cour­age pro­mis­cu­ous be­hav­iour among the youth since they will lose their fear of cer­vi­cal can­cer.

The health watch­dogs have im­por­tant roles to play in this de­bate. How­ever, when those hav­ing lim­ited sci­en­tific un­der­stand­ing jump on the band­wagon to op­pose ef­forts to in­tro­duce new in­ven­tions, the sit­u­a­tion be­comes murky. We need to sift through the ar­gu­ments for and against the HPV vac­cine with the help of good sci­ence.

When those of lim­ited sci­en­tific un­der­stand­ing op­pose ef­forts to in­tro­duce a cer­vi­cal can­cer vac­cine, the sit­u­a­tion is bound to turn murky

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