On the other side of the globe, in contrast, the US death rate from cervical cancer has been steadily declining at a rate
of about four percent each year, according to the American Cancer Society—and has experienced an overall drop of 74 percent
between 1955 and 1992. But Barr disagrees that pap tests have reduced the need for a vaccine here. "The number of people who
are told they need to have invasive procedures in a sensitive area of the body not only has costs from a dollar perspective,"
says Barr, "but also has psychological costs."
In fact, the vaccine's value proposition—both social and economic—has been Merck's key pitch to managed care plans to achieve
the same sort of widespread coverage that is necessary in poorer countries. But even Merck insiders admit that it was ACIP's
coverage recommendation that really put things in motion. Within five months of ACIP's decision, and by the time Merck launched
its big consumer push, CDC had added Gardasil to its Vaccines for Children Contract, providing it free of charge to uninsured
girls ages 9 to 18. Most states took up the cause by establishing cervical cancer task forces, and all but one pledged to
cover the prophylactic vaccine. The private sector followed their lead, with 95 percent of plans adding Gardasil to their
Facing the Opposition
Getting the vaccine on formularies only solves the riddle of how to pay for a vaccine that costs around $300 to $500 for three
doses. It still leaves open the question of how to get girls to the doctor in the first place.
California, Kentucky, and the District of Columbia are among the jurisdictions that are debating whether to make the vaccine
mandatory as a condition for enrolling in school. Yet compulsory vaccination is where Merck and lawmakers are likely to face
their stiffest opposition from conservative and religious groups—a constituency that has been largely, perhaps surprisingly,
accepting of the vaccine's approval. But their concerns linger. At the center of their opposition is the belief that inoculating
girls against an STD might come across as an endorsement of risky sexual behavior—by giving youngsters a false sense of security.
They want parents, not the state, to have the final say about when and if to vaccinate to their daughters.
These groups have been no less an audience for Merck's outreach than professional societies or policymakers. "We recognize
that there are different voices out there, and we want to make sure that we hear the perspective of those different groups,"
Still, it remains to be seen how effective Merck can be against vocal opposition. It is facing not only an organized conservative
movement, but also heightened public awareness—and fears—about drug safety and risk. In a recent discussion on The Washington Post's Web site, two groups objected to Washington, DC's proposal for compulsory vaccination: those who objected on the grounds
that the shot might encourage promiscuity, and those who worried about long-term risks and side effects that might not be
seen until years and thousands of vaccinations later.
Helping Women Find the Words
Some of Merck's most important and exciting work came from reaching out to women themselves, many of whom had never even heard
of the human papillomavirus, let alone its link to cervical cancer. "In the past, women thought you developed cervical cancer
like any other cancer—they didn't know why it happened," says Jill Rogers, director of marketing research services at AllPoints
In AllPoints' independent Women's Health Study, conducted before Gardasil's launch, only 60 percent of women had heard of
HPV. And even if they knew what it was, only 52 percent knew that it could cause cervical cancer or genital warts.
The findings were echoed in other parts of the study. Nearly 60 percent of women who had symptoms of possible sexually transmitted
diseases didn't discuss those complaints with their clinicians. Doctors weren't bringing up the subject either; 85 percent
of women said their doctors had never raised the issue of how to protect themselves from an STD like AIDS, for instance.