Even those who would be expected to be chomping at the bit to promote this vaccine are holding back. "We haven't taken an official position on mandating the vaccine," says Amy Allina, program director for the National Women's Health Network. Though she acknowledges that "the data look excellent so far," she wavers, arguing with herself even as she speaks: "If you mandate the vaccine, this is how you get access for those with barriers to care--and if it's not mandated it's going to be much harder for many girls to get the vaccine. On the other hand, it's early to require this for such a huge population."

Almost all the major health organizations (American Academy of Pediatrics, the Society for Adolescent Medicine, the American College of Obstetricians and Gynecologists, the Institute for Vaccine Safety, the CDC, etc.), whatever they think about the aggressive push to require the vaccine immediately, are strongly recommending that girls be inoculated and are confident the vaccine poses no dangers. "This is a remarkably safe vaccine," says Dr. Neal Halsey, a professor in the department of International Health and Pediatrics at Johns Hopkins's Bloomberg School of Public Health, director of the Institute of Vaccine Safety and chair of the vaccine group at the Infectious Diseases Society of America. "There is no evidence of any increased risk of serious adverse events."

What worries him are logistics. "I think it's premature to require this for school entry, because we don't have good systems in place to make sure we can deliver this to all girls," he says. "We need to make sure the supply can be maintained, and we need to make sure we have good mechanisms in place to get this shot to all those who need it." According to Halsey, we do a great job of getting babies and little kids immunized in this country because well-baby visits insure regular contact with doctors and because the government has a system in place to make sure all young children--even those without insurance--can get the required shots free. "But we are doing a terrible job delivering vaccines to adolescents, due to a lack of infrastructure at the CDC and state health departments," he says. He worries that rushing school immunization requirements for the HPV vaccine will just overwhelm an already stretched system. "We're pushing too early, too fast." This troubles him: "It is a very valuable, very useful vaccine--our first for cancer--so let's do it right."

One of the biggest obstacles to the vaccine, even strong advocates acknowledge, is the swiftness with which it is being mandated. There hasn't been enough time to educate parents properly, and that has led Americans to react with all the nuttiness that any whiff of teen sexuality evokes--despite the assiduous effort of promoters to frame it as a "cancer vaccine," downplaying the issue of sexual transmission and never, ever emphasizing the vaccine's role in reducing genital warts. "When you educate parents, research shows, the numbers who say they are likely to give the vaccine to their kids shoot up," says Deborah Arrindell, vice president of health policy at the American Social Health Association. She cites a 2004 study published in the Journal of Lower Genital Tract Disease: Among 575 parents, only 55 percent thought the vaccine was a good idea before they read a one-page educational fact sheet about HPV. Seventy-three percent of them favored the vaccine after learning more about it. "If we had just a little more time, we would have a lot less controversy."

Even so, Arrindell still thinks it is vital to mandate the shots. That's because leaving the shots voluntary means some girls will get them, but a lot won't. And those who won't get the shots are those who can't afford them. Mandating the vaccine makes it much more likely that insurers will cover the costs, that Medicaid will pay and that federally funded vaccine programs will quickly offer free vaccines for uninsured children. All the experts agree on one thing: Any serious effort to address cervical cancer and genital warts has to target these populations. After all, these are the communities hardest hit. According to the Guttmacher Institute, African-American and Latina women are 1.5 times more likely to develop the cancer and are more likely to die of the disease as well. The explanation for this discrepancy is easy: More than half of those who develop cervical cancer in this country haven't had a pap smear in the previous three years, and these are disproportionately low-income and women of color who lack access to healthcare, Guttmacher reports.

"Unfortunately, there is a lot of distrust of the health community and their history of clinical trials among African-Americans," says Arrindell. For example, the Washington Afro-American, a local paper in DC and Baltimore, came out firmly against the vaccine in an editorial invoking the Tuskegee experiment and other efforts to restrict the reproductive rights of blacks, proclaiming that the government should "stop trying to shove it down our throats." Running with the piece was a cartoon featuring a young girl cowering from a huge syringe wielded by Uncle Sam in a Merck lab coat. "I'm really concerned that this controversy over the vaccine is causing the African-American community to shy away from a vaccine that can save women's lives," says Arrindell.

She says there are valuable lessons here. "Middle school may be the last public health gate we all walk through together, before kids begin dropping out of schools or get a crummy job without health insurance, or enter the workforce in general with its fragmented healthcare system."

"We should not get lost in the controversy over this," insists Arrindell, who would rather see a debate over the best ways of making this vaccine affordable and accessible--both to American girls and to those in developing countries who may never get the regular pap smears they need for early detection of cervical cancer. "This is the best public health news we've had for women in fifty years. It's huge. It's exciting. It's wonderful." She delivers a succinct epilogue: "It's a good thing."

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