How do political measures reach maturity? Who are the players? What are the circumstances determining whether new strategies are introduced or not? How are decisions made at political level translated into practice? Using the example of health-policy measures, the political scientist Katharina T. Paul provides an insight into socio-political processes by concentrating on these and similar questions. Returning from Rotterdam to Vienna with a Lise-Meitner Fellowship from the FWF, Paul investigated the introduction of HPV vaccination as a measure for cancer prevention. The results have been published in the Social Science & Medicine journal.
A controversial issue
2006 and 2007 saw the first approval worldwide of vaccines designed to immunise women and girls in particular against certain strains of the sexually transmitted Human Papilloma Virus (HPV), including strains that lead to cervical cancer. “This medical innovation was not greeted with global enthusiasm”, comments project director Paul from the University of Vienna. Quite the contrary, the concept suggested by experts to protect children against sexually transmitted and carcinogenic viruses turned into a highly controversial political issue that had an impact on vaccination policy and existing cervical-cancer prevention programmes.
The path from hazard to innovation
Katharina Paul talked to stakeholders from medicine, politics, industry, civil society and government agencies to chronicle the controversial discussions that took place in Austria and identify the main players. She then compared the process in Austria to the introduction of the HPV vaccine in the Netherlands, where the vaccine had already been implemented on a national scale in 2008, after initial reservations had been overcome. While swift in other European countries, implementation took several years in Austria. Finally, the HPV vaccine was incorporated in the national immunisation programme for children in 2013 making Austria a “European frontrunner”. Unlike the Netherlands, where only girls (from the age of 13) receive the vaccine free of charge, both girls and boys from the age of 9 are immunised in Austria.
The criteria of success
The introduction of a medical technology is never easy, notes Katharina Paul, who is interested above all in preventive practices and in the marked differences from country to country in this respect. In the case under discussion, the researcher demonstrated how the decision-makers of the Austrian healthcare system, which is organised along federal lines, refined concepts, economic arguments and vaccination infrastructure in a way that was designed to achieve public acceptance for the HPV vaccine. “Three things were important in the process”, explains Paul. First of all, policy-makers succeeded in de-sexualising the topic by specifying the vaccine was to be administered to both girls and boys before they reached adolescence, thus transforming it from a gynaecological product to a vaccine for children. Secondly, incorporating it in the national immunisation programme for children made it easier to sidestep discussions with the parents. Thirdly, the vaccine was reduced from three to two doses so it could be completed within a single school year.
Culture and evidence
The decision about implementation or non-implementation of a national immunisation programme is the result of many discussions, held partly at informal level and not always very transparent, as Paul’s research has shown. Many factors determine whether progress in medicine, such as the HPV vaccine, is considered a promising innovation or a socially undesirable technology. “What constitutes common healthcare practice and what is considered self-evident in medicine is strongly influenced by social discourse, not only by scientific evidence”, says Paul and quotes the example of the Netherlands, where a PAP test every five years is recommended for all women aged 30 and over.
The fact that Papilloma viruses can also trigger other types of cancer, such as anal cancer, has not been a subject of debate at all in Austria, notes Paul. While the standard practice of screening for cervical cancer by means of PAP tests, viewed critically by some, was discussed again within the context of the new preventive measure, no result emerged. “Originally, improvements had been planned, but nothing much happened.” Overall, Paul would like to see more data collected on vaccination behaviour in general and would favour a central vaccination register. “When it comes to vaccination there are not only pros and cons, but also many uncertainties”, comments the researcher, who is convinced that the social sciences could make an important contribution in this respect.
Katharina T. Paul studied political science in Tel Aviv, Vienna, Essex and Amsterdam. An assistant professor at the Erasmus University Rotterdam until 2013, Paul currently teaches and conducts research at the University of Vienna’s Department of Political Science. In her research, Paul concentrates on interpretive policy analysis, healthcare policy, medicine and bio-policy, as well as science and technology research.