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Copenhagen confer maldonado181012
1. Transits, regulation and mattering in the
Global-south
The production of Human Papilomavirus
(HPV) vaccination policies
Oscar Javier Maldonado Castañeda
Department of Sociology
Copenhagen, 18th of October 2012
2. According to WHO, there were an estimated 530.000 cases of
cervical cancer and 275.000 deaths from the disease in 2008.
Cervical cancer is the leading cause of cancer-related death among
women in Eastern, Western and Middle Africa; Central America;
South-Central Asia and Melanesia. The highest incidence rate is
observed in Guinea, with 6.5% of women developing cervical cancer
before the age of 75 years. India is the country with the highest
disease frequency with 134 000 cases and 73 000 deaths. Cervical
cancer, more than the other major cancers, affects women <45 years
(Natunen et al., 2011: 1).
3.
4. Analysis of HPV vaccines introduction in the
Global North
WHO/IVB database, 193 WHO Member States. Data as of April 2011 Date of slide: 03 August 2011.
Argentina started its programme in 2012.
8. Coproduction of the local and the Global: Interferences
and Travelling: Trials and Epidemology
From January 2002
through March 2003,
6463 women underwent
screening for eligibility;
of these, we enrolled a
total of 5455 (84%)
subjects between the
ages of 16 and 24 years
at 62 study sites in 16
countries” (Garland et
al., 2007: 1929).
9. Conclusions
National introduction of HPV vaccines is a good example of coproduction between
local and global in the circulation of health technologies, Global health is not a
homogeneous field; this is shaped for power relations, historical and material
features of multiple localities. Postcolonial STS approach is useful for describing
these asymmetries; the distinction between north and south may contribute to make
visible centres and peripheries of this “ order” . Global is produced through material
and institutional devices such standards, technologies and regulations.
This paper discusses the relation between policy orders and technical domains in the case of HPV vaccination global policy. The policies are engaged with different materialities in the establishment of control strategies for cervical cancer in local realities. In these realities national boundaries matter because of the restriction that the political orders can impose in the transit and circulation of persons and things. In this presentation I will deal with the problem of the relation HPV-Cervical Cancer and HPV vaccines as a global issue. I will describe some narratives, tensions and contradictions that are present in this case. An finally I would like to make some references to the role of sociotechnical arrangement in theproduction of this order. In the case of HPV vaccine I have identified different technical arrangement such as trials and epidemiological studies that have an important role in the international mobility of vaccines and in the production of HPV-Cervical cancer relation as a global problem.
The starting point is the relation between HPV viruses, Cervical Cancer (other cancer and diseases) and the presentation of HPV vaccines as a solution. This narrative is omnipresent, through policy institution of all the world. This relation that are presented as a well established causal relation and that is the support of policy strategies is the contested result of epidemiological studies and clinical trials around the world. Among the nearly 100 types of papillomaviruses molecularly identified, about 40 types can infect the genital mucosa following sexual transmission, and about 16 are highly carcinogenic
The relation HPV and Cervical cancer is depicted as a Global Public Health, but in this narrative immediately is introduced a global division regarding its incidence and burden. In spite of the division between global and local scenarios, the discourse about HPV vaccine is designed thinking in a Global scale. . 'Yet at the needle point the most global meets the most personal of worlds’ (Leach and Fairhead, 2007: 2) This kind of health policies and technologies are special in linking the most global with the most local and personal. The vaccines are produced, distributed and monitored within systems that are equally globalized (Leach and Fairhead, 2007: 2). The development of vaccination policies has been one of the most spread public health interventions. These have been defined as tools for reducing mortality in developing countries and as forms of providing long term health care through population immunisation. In 1974 the World Health Organization (WHO) launched the Expanded Program on Immunization (EPI) for the development of Global vaccination strategies. This narrative is produced on technological diffusion model. Although the disease, the research and the innovation are produced in local places these are presented as Global and dislocated. In the case of HPV vaccines, for example, the disease and the cure are defined such as global and universal. In this logic the references to the local and “national” are made after the Drug approval, in relation to marketing and policymaking. Moreover, this model conceives Gender/ women’s health, as well as technology and disease as something pre-existing and stable.
Other studies regarding HPV vaccines in developing countries has been made from a medical perspective, these are focused on the feasibility of the vaccine delivery, and the knowledge of the relationship between cervical cancer and HPV in women, girls and policymakers (Garces -Palacio, 2012; Wiesner et al, 2010; Piñeros , 2007). Nevertheless, analysis about the political implications of HPV vaccines' introduction is not a common theme in these studies. The differences between north and south in the introduction of HPV vaccination programmes open the discussion about the relationship among development, medicine and globalisation
Europe, NorthAmerica and Australia. Middle-income countries. GAVI-PATH. World Health Organisation (WHO) has established a classification in different regions for promoting the introduction of vaccination programmes. These regions are: Americas (Latin America and Caribbean), Africa and South-East Asia. Moreover, through the GAVI Alliance has been defined a set of countries of priority attention. “GAVI aims to focus its support on the world's poorest countries. Eligibility is therefore determined by national income with all countries with a Gross National Income (GNI) per capita below or equal to US$ 1,520 (according to World Bank data for the latest available year) qualifying for support. There are currently 57 GAVI-eligible countries. However, not all of these countries qualify for every type of support because GAVI sets conditions for each type of support” (GAVI, 2012). GAVI has approved the support for HPV vaccines, the plan is introduce the vaccine into GAVI funding schema for 2020. The analysis about the introduction of vaccines in the Global south has been focused on the difficulties of generating this kind of policies. (Kane et al., 2006). On the other hand these studies have been made by policy institutions for providing recommendations. WHO and PATH developed with the support of Bill and Melinda Gates Foundation series of Pilot programmes for analizing the possibility of introducing HPV vaccines in developing countries. The pilot programme was developed in the following countries: Uganda, India, Vietnam and Peru (Wyttet, 2010). In the “south” the countries that have national vaccination programmes are sited in Latin America: Panamá (2010), México (2011), Argentina (2011) and Colombia (2012). These countries have been defined as middle-income economies. PATH, an international non profit organization that works in the development of health care programs in technologies in developing countries
The devices that make possible the mobility of the vaccines among national regulation and places are an important element in the study of co-production of local-global dynamics and medical technologies Science and technology studies have been very critical from this perspective. In particular because of informants and the “peripheries” are depicted as passive and without any meaningful influence on the metropolis. The idea of introduction is used at least in two senses. First, Gardasil is a product manufactured in United States, therefore, is an importation from colombian market perspective, There are practices and regulation regarding the importation of medicaments and health technologies, Gardasil® and Cervarix® licensing is framed in such context. Second, licensing and policy process are related with the mobilization of the vaccine from laboratory and trial context toward a public access and vaccination programmes. Trials are a very interesting place for trading the tension between scientifical and technological practices and regualtory culures.
There have been developed 2 prophilactic vaccines against HPV: Gardasil and Cervarix. (Key factor in the definition of vaccination targets) Trials are key in the coproduction of HPV vaccines an gender. This strengthens the disjunctive between the civic responsibility and the consumer choice that is framed into Health policy notion of efficacy as risk reduction and control of the disease. This has been particularly visible in the feminisation of the vaccine and in the exclusion of other targets such as gay men. The challenge is sited biomedicalisation, taking into account the features that have global reach, but also finding the local characteristics that made particular each national version. Trials are source of certainty... Projects for providing material support to the relation between disease and cure. IN the case in the estblishent of the “causality HPV-Cervical cancer”... Interferences of trials and policymaking But they are also sources of uncertainty... They are testing limits and boundaries. In the case of HPV vaccine trials there are 2 examples. The ban of India government to HPV trials in 2011... And the use made for antivacine organisations
The FUTURE (Females United to Unilaterally Reduce Endo/Ectocervical Disease) Program is sponsored by MERCK and is intended to demonstrate the efficacy and performance of the HPV vaccine (Gardasil). FUTURE is a double-blind study that uses placebos and HPV vaccine samples. Because of the ethical implications of the study, the samples are gathered from volunteer women who accept the conditions of the research. The FUTURE studies are a tool for expanding the populations targeted for vaccination. FUTURE I and FUTURE II defined the current target of HPV vaccination programs: teenagers and adolescents who had not yet had sexual relations. Currently a third stage of the Program aims to extend the vaccine target to women between 25-45 years old. These studies are very important in the global spread of the vaccine and in the co-construction of vaccine, disease, risk and gender. A revision of this kind of trials allows to understand the role of clinical trials and regulatory regimes in the co-production of disease and technology (Marks , 1997). Trials and control practices involve in their development are a medium for approaching to production of regulatory regimes and institutional mechanisms of Trust. The trials are important process for understanding the movements of things and facts from research to policy and vice versa (Petryna , 2011). Moreover, the trials are a key place for observing the production of technology and disease at global scale, as well as, for describing the role national regulations in the development of research objects. “The relationship between research and the provision of healthcare -and therefore public stakes in trials- becomes still more complicated when viewed on a global scale” (Will and Moreira , 2011: 7).
