In this talk, medical anthropologist Samantha Gottlieb '00 explores how the vaccine Gardasil, which was developed to counter the common sexually-transmitted infection human papillomavirus (HPV), was marketed primarily as a cervical cancer vaccine. Prior to its market debut, Gardasil seemed to offer female empowerment, touting protection against HPV and potential cervical cancer.

It quickly became implicated in pre-existing debates about adolescent sexuality and pediatric vaccinations and Gottlieb questions the sales pitch’s promise, asking why marketing gendered the vaccine’s utility and thus undermined Gardasil’s benefit for men and women alike. Her book Not Quite a Cancer Vaccine: Selling HPV and Cervical Cancer explores why Gardasil’s low rates of public acceptance have their origins in the early days of the vaccine dissemination and addresses the expansion in U.S. healthcare of patients-as-consumers and the ubiquitous marketing of large pharmaceutical companies.

Gottlieb holds a Ph.D. in anthropology and a master's in health science from Johns Hopkins University. She has been a lecturer at California State University, East Bay, and a visiting scholar at the University of California, Berkeley. Gottlieb has worked in the non-profit, public, and private sectors for over 15 years and is currently conducting research with funding from the National Science Foundation and the Leonard Green Foundation.

Audio Transcript

Sunka Simon: It's my sincere and absolute pleasure to welcome our speaker for today. Dr. Samantha Gottlieb is a former student of mine and she and I shared the [00:00:16] of my first four years as faculty and her first four years, and only four years as a student here, but I'm still here. This is our perpetual blessing and curse. People move on but I'm especially grateful that once in a while they come back. I hope you do the same when you're beyond [inaudible 00:00:35].

Dr. Samantha Gottlieb was an honor student here. She graduated in philosophy and at that time it was still called women's studies which is now Gender and Sexuality Studies and was in the seminar with me when I first taught the seminar. We reminisced about a bunch of fun stuff we did in the seminar and again said how important it is the have honors seminars at Swarthmore and keep having them. Then after she was done here she went to get a Ph.D. at Johns Hopkins University in, correct me if I'm wrong, medical anthropology.

Samantha Gottlieb '00: I specialized in that [inaudible 00:01:13]. Just anthropology.

Simon: Anthropology. Right. She was the recipient of several grants. You can tell them more about those. Specifically the National Science Foundation grant which is one of the most lucrative and renowned grants that you probably should all have in mind if you're interested in this sort of studies and research. Also, she has a grant for her next project which I hope she gets into a little at the end.

So, today it's all about the book. Today is a book. It's so fantastic when students come back with their book in hand. This is the book that she just got published and it's her first book and not the last. I'm very convinced of that. Please give a warm welcome to Samantha Gottlieb.

Samantha: Thank you. Yes, so as Sunka said, my work has been on the new papillomavirus vaccine, the HPV vaccine. Before I get started I want to give a little of my own intellectual trajectory and contextualize my work.

In addition to Anthropology, I also did a public health degree, a master in Health Science. When the vaccine first became available in 2006 I came to it from this women's studies perspective. From thinking about, well great, we have this new technology to protect women's sexual health and how could it be bad? Right, to have something that is protective, that just seemed sort of no brainer.

Right before the vaccine review process with the FDA happened there were a lot of editorials and anxieties about whether the vaccine would even get approved because this was in the era of [inaudible 00:03:05] George W. Bush's administration and a lot of things, most notably the Plan B emergency contraception had just been held up through the FDA review process. Not for scientific reasons but very much for political and moral reasons that people should not have access to emergency contraception because of various [inaudible 00:03:22] about when life begins basically.

So when the HPV vaccine first started to appear in the popular conception in 2005. [inaudible 00:03:30] Anyways, there was one editorial by Catholic [inaudible 00:03:36] that said, Death!, and this was from a liberal perspective, progressive perspective. Why would anyone withhold this vaccine from anybody. Michael Specter in the New Yorker also wrote an article looking at sort of the political debates, as well as scientific through the moral tenor of these scientific debates. What is the values that are being discussed?

Really there was a lot of expectation that this vaccine was going to not go through it's FDA approval very easily mostly because it was expected to be a vaccine so HPV is a human papillomavirus, so it's a sexually transmitted infection. Well some types of human papillomavirus are sexually transmitted. It's only transmitted through sexual contact but more importantly it can lead to cancer. So, is this a cancer vaccine, is this going to be an HPV vaccine? And the expectation was that because it was going to be an HPV vaccine, and it was expected to be made available and focusing specially for young girls, there's a lot of anxiety about abstinent sexuality and particularly female sexuality.

So, I want to give you a little background about HPV just to contextualize the virus. As I said it's sexually transmitted. What's really interesting about HPV is that it's transmitted through contact. It doesn't necessarily mean fluids, as a lot of sexually transmitted infections and, I don't know if I have it up here or on the next page but condoms don't even protect against it so someone can use a condom and still transmit HPV.

So, it's this epidemic without demand because very few people actually knew about HPV before the vaccine became available. I would reckon you'd probably still, ten plus years later, still not know very much about it. When I would talk to doctor's about the HPV virus or HPV [inaudible 00:05:28], do you tell your patients about this? They sort of demurred and said, well you know it's not really that important because everyone gets it, it's so common. Equated in popular culture as the flu. Lie you're going to get it, not a big deal, most people clear it on their own.

HPV was sort of this funny thing where many people had it. Many people didn't know they had it but it also can lead to cancer. It had this sort of inflection point, this moment in which it becomes very risky. The work that I'm going to talk about is all done in the U.S. The other thing that I don't have on the slide here is that HPV leading to cervical cancer. Cervical cancer is I think the leading cause of women globally. So, in countries that are not the U.S., not highly industrialized countries, like Europe, Australia. Women die from cervical cancer at very, very, very high rates. In those countries an HPV vaccination is amazing. It's a really [inaudible 00:06:28] intervention because the pap smear, which has been historically used to identify cervical abnormalities, in some cultures it's not considered appropriate to be going into the gynecologist. Certainly there might not be resources to do the testing. There are some ways to do lower cost way to evaluate whether someone may have pre-cancerous activity on their cervix but as tool in certain places this is [new 00:06:53] idea. This is really fantastic.

The U.S. is probably not that instance and part of that has to do with the fact that we have really well established and institutionalized medical interventions so pap smears, and the HPV DNA typing test. We do not have the cervical cancer epidemic that is happening in other places. The thing that's interesting about HPV, that I started to say and moved on, is that HPV is often invisible. The types that cause genital warts manifest in [inaudible 00:07:29]. You get a wart, you go to the doctor, or the doctor says [inaudible 00:07:32]. It may be emotionally distressing bu it's not going to kill you.

The types that cause cancers are not necessarily visible. In fact, there are no symptoms until you have abnormalities in your cervix, or you have pre-cancerous growths or cancerous growths. It's this invisible phenomena that your body may be carrying that you don't know that you have and that requires a doctor to diagnose. That medical-ized kind of experience the only way to know if you have HPV is through medical care, made this HPV problem, again, this very strange phenomena that required intervention, medical knowledge and that people really didn't always know that they had, and because most bodies aren't able to clear the virus, if they no longer are detectable on their own most people don't even know they have it. If you don't go to the doctor for a couple of years for your pap smear the abnormality may never show up.

So there are people constantly falling in and out of information about whether they have the virus or not. And, one of my key points, is that men are not tested. There's no HPV test for men. That piece is really critical in actually influencing in how the HPV was marketed and represented to the general-public. Specifically and especially again in the U.S.

HPV related cancers are cervical, oral, anal, and penial cancers. The Oral Cancer Association happened within the last 20 years where that was confirmed. We've known about HPV association with cervical cancer for ... trying to do the math ... 40/50 years. The late 70's Harald zur Hausen was a researcher who identified that, of these [inaudible 00:09:21] on the jackalope is a rabbit with papilloma warts all over its body. So the recognition that this was a viral cancer has been something that has been common knowledge at least in the scientific and medical community for many, many years.

Again, this is why I think HPV is interesting because there was very low awareness of it and the vaccine became available and yet it was everywhere and also well established in medical and clinical care about what you do. There's a whole set of triage, I'm not going to get into all of that, but those things have changing and shifting and how that was managed in clinical practice. So it was both, there's was this ignorance and ubiquity simultaneously.

The final point that I, while I focus on all these details, is that annual U.S. cervical cancer deaths are quite low. They're at 4,000 people a year, and that is a true since at least the early 80's. Conversely, 40,000 women die annually from breast cancer. These are U.S. numbers. Bt it doesn't mean that we shouldn't prevent those 4,000 deaths. Absolutely we should but the reasons that those 4,000 deaths are still happening has to do with things like racially inequality or ethic inequalities. Very, very recently someone reexamined the cervical cancer mortality data and they found that if you controlled for ethnicity or race, as scientists would say, if you controlled for that, African-American women had rates that were comparable to the women in these countries like, Vietnam, where women are dying at incredibly high rates.

So, there's more in this 4,000 people per year numbers than it's obvious at first glance. But it also raises this question, so the morbidities that disease is associated with HPV is actually in the millions. Women who get annual pap smears are then thrown into this whole triage of screening and surveillance and a lot of medical interventions. Often unnecessary because HPV may never turn cancerous. Meanwhile, we have these male experiences that are made totally [inaudible 00:11:32]. There are researchers now, that are doing a fair bit of work around male ... men who have sex with men, HPV rates, but this narrative at the time the HPV vaccine availability was very much about women.

[inaudible 00:11:51] You can sort of see this gender disparity, or gender bias, in how the vaccine was approved. In 2006, they did receive approval for females nine to 26. This vaccine was manufactured by Merck and is still and was the only available vaccine. There was a competitor but they actually withdrew from the U.S. market a year or two ago. That vaccine is available in the U.K. and in other countries. In the U.S. Merck's vaccine virus was the only one available and is to this day. They did not approve the vaccine for boys until 2009. When they did that it was specifically for the indication for genital warts. So there was no discussion of cancer in the initial approval for boys.

The anal cancer indication for boys was approved in December 2010. Four and half years after the HPV vaccine was approved for women then it became what's called a universal vaccine, in men and women, both receive it. The vaccine was originally quadrivalent which protected against two types that caused genital warts and two types that cause cervical cancer. The most recent version was approved in 2014, adds seven more types of HPV associated with cervical cancer.

As you can see, all of these regulatory decisions were already getting a [inaudible 00:13:15] of what this vaccine is about. Cervical cancer. The work that I'm talking about is exclusively about the quadrivalent Gardasil because that is what was available when I was conducting my research. I was thinking when I was preparing this talk that I realize that this among the people here, many of you are probably some first people who were eligible for the vaccine. In 2006, when I was starting my research, I was a just a little to old for the vaccine, which gave me this nice semi-objective perspective. I couldn't get it. So anyway, it just occurred to me that here are, I may actually have some people in the audience who are possible the first people to receive the vaccine.

I want to start with some images of the early campaign for Gardasil. This was before the FDA approval, so there's an FDA approval process that affects how a pharmaceutical company can market its product. Before they get this FDA approval, they cannot mention the brand name. So, sometimes to create interest, pique your curiosity, pharmaceutical companies will release these campaigns pre-market approval. That are just sort of getting you talking.

These were three of about ten different postcards that were strategically placed around my bathrooms. I don't know if you guys follow, there's really only one presumably gender represented here. I always think this one with the faces is so bizarre, there's not even noses. It's just the mouths that are promoting this female-ness. They're not even faces, they're just lips floating on [inaudible 00:15:00]. It's so creepy right? They're really creepy. This was the campaign that was the first before the launch.

This one ... I don't know how much you can read ... it says, think cervical cancer isn't an issue until you're much older? Millions of young women have a virus that they don't even know about. It's called human papillomavirus, HPV, and certain types can cause cervical cancer. It does acknowledge that most people with cervical cancer cures on its own, but in all these ads you really, I think this one is actually one of the creepiest because they kind of look like foul meats to me. But also the slogan, tell someone. Tell what? Tell that you have a disease? Tell that cancer is caused by a .. we'll see there's an ad about that ... [inaudible 00:15:47] but what is it to tell? It's a very nebulous, abstract message that doesn't really give the viewer who doesn't know what the HPV vaccine is, know anything about it, and there's not even any consistency of the messaging. The messaging is consistent, but the imagery ... they could be completely different things. It's the most bizarre ... when I started copying up, I was like this is the weirdest thing I have ever seen.

I've done a little work in pharmaceutical marketing, and it's just like, this doesn't even make ... it doesn't even seem clever, this just seems weird and [inaudible 00:16:20]. So, I'm really interested in this question of this, basically neutral objects. They seem like they're medical intervention, it's technology.

Thinking about myself at the beginning of this project in 2005 as a public health person, coming from public health, philosophy, and women's studies or gender studies, I expected, this is awesome. I was a central health counselor in college, I was so excited that this was available. But the complexity of who makes these vaccines, why are they being made, for whom? The HPV vaccine in certain countries would be an amazing asset, but the irony is that is was the most expensive and still is the most expensive vaccine on the market. It's not a good vaccine for women in less industrialized countries. It's not a good vaccine for women unless there are a lot of strategies that happen with pharmaceuticals to try to get those vaccines available to countries where there are fewer resources.

This vaccine is completely and utterly designed for the U.S. market. It was the most expensive, it was fast-tracked through the FDA review process, which we'll talk about in a minute. What does that mean, we have these objects, it's a tool, a technology, but we really need to think about this, and it's underlying meanings. The marketing, the who are there users? All of these thing are embedded in this seemingly innocuous [inaudible 00:17:58].

Again, you probably ...

Video: I don't know why people don't know about this?

I don't know why I didn't know.

I never heard of this, I'm just shocked.

I just found out that cervical cancer is caused by certain types of a common virus.

HPV human papillomavirus.

A cancer caused by a virus. I didn't know that.

Millions of people already have the types of HPV that can cause cervical cancer and other diseases.

You could have HPV and not even know it.

For most women HPV clears on its own but for some cervical cancer can develop. That's why it's important for you to talk to your doctor about pap tests.

Tell someone that cervical cancer is caused certain types of HPV.

I want to tell someone that I love.

I'd tell my daughter.

Tell someone. Tell someone. Tell someone.

Samantha: This is another example of who is this made for. This is again, before it was approved. You can see even before its approval that there was a very, very deliberate position of this vaccine. I'm especially interested in this early marketing, crew marketing materials because in the FDA approval process, the FDA brings, the pharmaceutical company brings their clinical data. The research they've done through the years and presents it to the FDA. So, there a whole performance, you could say, of giving data, how is it received? There's a question and answer, it's usually open to the public to comment on the vaccine or whatever the biological product is. Merck went to the FDA with the expectation, included data for boys.

They actually at least [inaudible 00:19:35] they said we would like this vaccine to also be available for boys and girls, but the clinical data they had for boys was much less robust. Very insufficient for approval for boys at that stage. They were told that they basically had to go back and collect more data. I think that's a really interesting moment because Merck is a very well-established pharmaceutical company. It's not like if I just said I'm going to make a drug, I'm going to get approval. They know what they need to do to get approval. They spend a lot of time in research and development. They would never go in front of the FDA, waste time and resources, to bring something like this to the FDA without having a certain amount of savvy about what they're doing.

So, I went back and looked through the transcript to see how many times they use the word boys, man, and girl and female. I should look at those numbers someday again just so I have them at the top of my head. Boys come up maybe 15, 20 times in a two-hundred page transcript and females, women, come up hundreds of times. Again, I also looked at this questions of sex and sexuality or sex and sexual, which is a little harder because of sexually transmitted infection and cancer. Again the language used in this presentation were very deliberate. These were all very constructed presentations to the FDA saying this is what we're asking for. Of course, the FDA is not itemizing how many times boys and males are being mentioned but it's very clear, even in the way that Merck asked the FDA, they say basically that w believe that this vaccine should be universal to protect women.

So the vaccine really came to the market as the cervical cancer vaccine. It was never designed as an HPV vaccine and infection that affects everyone regardless of sexual orientation, or sexual preferences. This was always positioned from the beginning of the market as a female vaccine. That does not mean that today that's what it is necessarily but the strategy that Merck decided on was that cancer is kind of an unimpeachable argument. Who is going to be upset if we have a cancer vaccine? So, Merck was able to fast-track this vaccine which means they went through much shorter regulatory time, they had much less data to get it through regulatory and also it was approved in a much faster process as a cervical cancer vaccine.

Again, sort of like these earlier marketing materials, Merck actually went to different family conservative organizations because again this was the era of Plan B, and talked to them about what they would be okay with. Most of them merits their interviews and articles about how Merck strategically went, mostly in marketing magazines [inaudible 00:22:32] pharmaceutical marketing magazines, talking about how Merck talked to Focus on the Family. One of the big conservative family groups. Basically, that conservative family organizations are always quoted as saying, were not against a cancer vaccine because again who can be against a cancer vaccine. But we don't this required, we don't want this a state law, we don't want our kids to have to get this vaccine.

There was this anxiety about it promoting promiscuity. That is would be condoning sexual behavior. There was sort of a, and I don't really think I have enough time to get into this, but there was a huge push in state legislature as to try and make this a required vaccine once the vaccine got approval and that completely bombed. It is required in I think three states out of 50. Twelve years later, twelve later there's only three states out of 50 that require the HPV vaccine for school entry. And school vaccination for school entry is a very common U.S. practice, that is how vaccination and immunization policies work. If you vaccine [inaudible 00:23:31] when state legislatures were pushing through, that it actually really undermined the vaccine.

I know that I'm starting to run out of time, does anyone want to ... I'm not going to get the chance to talk about the [inaudible 00:23:48] communication stuff as much as I would like, but there's this other interesting problem with this vaccine which is that it was both a sexually transmitted infection prophylactic, which means if you get vaccinated at least it will protect you against four out of 40 types of HOV, so a very imperfect prophylactic, but there was also this idea that as a vaccine. What actually happened by strategically positioning it as, A. a cancer vaccine and B. As a vaccine rather than a sexually transmitted infection intervention, they sort of ... instead of dealing as much directly with the sexuality, the young female bodies questions that I went into this project thinking this is totally going to be about adolescent female sexuality and we're such a puritanical country. What ended up happening was that as a vaccine Merck stepped totally into this fire of anti or vaccine resistance movements in the U.S.

They fought the thing which [inaudible 00:24:46] the gender, very deliberately positioning it as a gender vaccine but also side-stepping the sexuality and young female bodies and all of these ideas that are very hot in the U.S. And they just totally threw themselves into this other fire I think they just completely underestimated. They didn't even think about the implications of talking about a vaccine in the United States. In 2006 when they were getting approval, right now there's a lot of ... what's it called, some people call it vaccine movements, I prefer to use vaccine resistance because it's more complex that absolute.

Now it's a much more discussed topic but in 2006, 2007 most of the concern had been about the measles, mumps, rubella vaccine. In the U.K. in the late 90's there was a researcher who associated the measles, mumps, rubella vaccine with autism. So this autism myth anxiety, this researcher was found to be fraudulent, it was completely debunked, but the public health world really takes that moment as this fire that was set onto increasing peoples resistance, refusal to vaccinate their children. But Merck completely missed that debate and just not anticipate at all what this vaccine would do.

So, they pushed. They lobbied everywhere to try to get the vaccine in all of these different state legislatures. Again, this is one of those things, to me it's so amazing. It seemed obvious and then there were New York Times articles about how Merck's lobbying, what it took the [inaudible 00:26:26] I'm not sure which, was that in Texas the Governor, Rick Perry, who would eventually become a presidential candidate, push overrode the state legislature who were deliberating about whether the HPV vaccine should be required and he issued an executive order to preempt the discussion saying, all girls in Texas who are entering the seventh grade must have this vaccine.

He took a pro-life platform, this is to protect girls bodies in a sense women who have been abstinent till marriage, their partners may not have been abstinent. So we must protect their bodies. He literally said the word I think pro-life. To really align himself with what his intentions were. But it became very quickly, the Texans went crazy that he had done this without the traditional methods of getting legislation passed. During that process there was all this media coverage about he was somehow tangentially or indirectly affiliated with Merck and how he had received funds from Merck in some of his political campaigns. It also exposed very, totally explicitly, which is fairly rare in this pharmaceuticals machinations world, how much the pharmaceuticals company was lobbying for this vaccine. As a result it really turned people, I mean whether they would have been accepting of this if this had just been an HPV vaccine is hard to know, but I do think there was a public shaming and public revealing of corporate interests which are pervasive but somehow this was the flashpoint. Really made people distrust the vaccine overall and it's [inaudible 00:28:09] to this day.

So, for the last few minutes I wanted to talk about this idea, Merck was looking to get men and women vaccinated, it's a greater market-share, it's a lot of opportunity for them, they spent a lot of money on the campaign. One of the most expensive pharmaceutical marketing campaigns of the time. They clearly had very who they wanted to be a success. They weren't setting it up to make it unsuccessful and part of their strategy in making it a success I think was capitalizing on these ideas of women's bodies, which we see a little bit of mother with their daughters. Oh I didn't know this, we're vulnerable, we suddenly have this new information and most of this is empowerment. There's very much an empowerment strategy. Tell someone. You can own your body. Your sexual history. [inaudible 00:29:02]. There's so many things to unpack there.

But, this HPV virus serves at the beginning as the ignorance the HPV. The opportunity of peoples ignorance was really this opportunity to women, with this very long history as many of you know of how they [inaudible 00:29:21] sexual health is organized and it's literally on women's bodies. So there was a ready and waiting market right there. Women will get regular gynecological care, mostly. Women's reproductive histories, lead them when there's pregnancy or sexual activity or needing contraception, all of that gets [inaudible 00:29:41] at the clinical encounter. Women were kind of an easy sell. Except for this plaque of awareness about HPV. Some of my data in our research, women were like, I didn't know where my cervix was before I had cervical cancer. Which I just find fascinating. How do you forget an entire part of your body? How do you not know, even women who had babies, would have this sort of like confused relationship to [inaudible 00:30:08].

I think Merck had this really great opportunity to kind of very malleable and available [cogignition 00:30:15] it would have been very difficult the market this to both boys and girls, or men initially, because that conversation really doesn't, haven't, really existed. Part of this is very simple. I mentioned earlier, there is no HPV testing for men. This is not institutionalized standard male reproductive health practice. There's very little data on HPV in men that probably hasn't been somewhat corrected since but most of it is secondary. The HPV data when they show incidents or rates of HPV infection general population they're always extrapolated from women's infections. So it's always based on this ... I remember finding this article when I was starting the project [inaudible 00:31:03] aster ix next to the male data that was [inaudible 00:31:07]. But the women's data were not [inaudible 00:31:11], the male data was ... this was imagining what was happening in the male population.

I guess just to think about, this vaccine came out of this perfect moment of the opportunity to capitalize on [inaudible 00:31:30] arguments there people did not know about HPV. So, Merck could create whatever they wanted, but they weren't just creating this out of nothing, oh suddenly we have a computer or people don't know what a computer is or cell phones et cetera, consumer good. It was built on this very historical notion of vulnerable bodies and the Rick Perry pro-life strategy sort of encapsulates that so perfectly. Here's this opportunity to tell women, as part of your basic reproductive health, as a responsible consumer, as we saw these moms saying I want to tell my daughter and tell everyone, suddenly I have this enlightened empowered knowledge. The vaccine is the answer to that which is a very interesting, direct consumer opportunity. I don't think there are a lot of other things that I've seen out there, pharmaceutical marketing is a very messy, problematic [inaudible 00:32:28] but this vaccine really just tipped the [inaudible 00:32:32] really deliver. What I think is so fascinating is how spectacularly it failed.

So, this data that I have ... let's move this slide if I can .. this is older data so I think there's more up-to-date data, the rate are a little higher. But you can see that in another [inaudible 00:32:52] public health data is that there's always a lag. So it's really hard to know what's happening now but we can look retrospectively. At the time, they were recommending three full doses of the vaccine, they now can choose up to two, but these rates of vaccination are very low. Even the measles, mumps, rubella vaccine which is considered a very controversial vaccine has 95% or 98% get vaccinated. Those rates may have dropped in the last ten years or so, but overall it's really fascinating to me that this vaccine did not gain acceptance.

When I was finishing the book, I was, in June 2016, I don't remember it's all a fog. June 2017, there was a number of editorials that were really like, why are we still not getting kids vaccinated with the HPV vaccine? There was about 60 some odd cancer centers that sign on to this letter like , this is urgent. Part of that is that it's an adolescent vaccine and cancer happens much later in life, so there's a disconnect. Most of the other vaccines we get in our youth are pediatric, so you children vaccines. These are adolescent vaccines, so this adolescent sexuality is totally there. I don't want to minimize it's presence or importance, but I do think that Merck's positioning of the vaccine and somewhat deceptive practices because the vaccine did not protect against all types of HPV but still get vaccinated and ended up with cancer or HPV because there were so many other types.

So, it wasn't really a vaccine in the way that people may have thought about a vaccine as really excluding you from risk. This ambiguous, not committed vaccine. They were calling it a cancer vaccine and the truth is I really still take this position that it's not a cancer vaccine. It's an HPV vaccine and by not calling it an HPV vaccine we have just avoided discussing what this is about. We've avoided saying, everybody gets HPV. Would people be more receptive, it may not be in this country, it may just mean this country is not willing to do that. There's a problem with vaccine messaging more generally which I think has affected the public's acceptance and trust in vaccines. So by calling it what it isn't, as a cervical cancer vaccine, I think that Merck really fostered distrust in a population that is already weary of corporate interests, or selectively worried of corporate interests and interventions.

I like to think that this counter [inaudible 00:35:39] what would have happened if it had just started out as an HPV vaccine. If we just said, educate ... what is Merck had educated people? And this cancer narrative too, as I was saying, as recently as the last couple of years, there's still this great push, oh this is a cancer vaccine. You need to emphasize it's utility as a cancer vaccine. What are we doing wrong, why aren't people talking, don't talk about sex, talk about cancer has been the mantra of a lot of public health officials. The irony is this has never been about sex. This has never been discussed as a sex vaccine. It's always been discussed as a cancer vaccine. So to say that this is, again this is not a very popular position among the public health world, but I think that it really merits this closer examination on both what happened historically on what it has been premised, but also having this longitudinal perspective that 10 years later or 12 years later, people are still not accepting the vaccine.

I just wanted to thank my [inaudible 00:36:43] who made this possible. I think I [got to talk to 00:36:45] most of them but I've actually talked to a lot of non-vaccinating parents and cancer advocacy organization as part of my ethnography. My research was funded by the National Science Foundation and the Leonard Green Foundation which is an anthropology foundation. I'm very grateful to all of the departments and studies programs that are in here. Thank you.