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Cervical Cancer Is Strongly Associated with the Persistent and Untreated Infection with Specific Types of Human Papillomavirus (HPV)

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Cervical Cancer Is Strongly Associated with the Persistent and Untreated Infection with Specific Types of Human Papillomavirus (HPV) Making evidence, making legitimacy: The introduction of HPV (Human Papillomavirus) vaccines in Colombia Oscar Javier Maldonado Castañeda B.A. Sociology; M.Sc. Sociology Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy May 2015 Department of Sociology Lancaster University DECLARATION I declare that this thesis is my own work and that it has not been submitted in any form for the award of a higher degree elsewhere. Oscar Javier Maldonado Castañeda 13th May 2015 Calvin and Hobbes, 1985-1995 Abstract Cervical cancer is strongly associated with the persistent and untreated infection with specific types of Human Papillomavirus (HPV). There are currently two vaccines which protect against the HPV types associated with 70% of cervical cancers. In 2013 the Colombian government introduced Gardasil® (Merck’s HPV vaccine) into the Colombian Expanded Programme of Immunisation. Since that year, three million girls have received the vaccine in Colombia. This thesis offers an empirical analysis of the configurations of evidence, efficiency and anticipation that this intervention entails. Based on diverse sources including policy documents, scientific literature, memoranda, minutes and interviews with experts, consultants and members of the National Committee of Immunisation Practices, I show how evidence and efficiency are the result of different calculation practices. They constitute modes of ordering heterogeneous sets of objects, data and people. These orderings perform different values, including trust, efficiency, legitimacy, accountability and objectivity. I argue that evidence and efficiency are performed in health policy by means of calculation devices such systematic reviews, cost-effective analysis, statistical modelling and pharmaco-economics, and that these practices are not isolated from the political and cultural practices and discourses that constitute a policy. On the contrary, these elements constantly reshape calculation practices by configuring affective economies in relation to policy objects. Drawing on material semiotics of numbers, valuation studies and political sociology of science, I undertake a detailed analysis of the calculation and the transformation of data, figures and numbers in their movements between documents, technical committees, regulations and media. This exploration shows the contingency and the complexity in any claim regarding evidence and their role in contemporary policy legitimation. A central concern of this thesis is to ask: why do numbers and quantified expressions matter in healthcare policy? This thesis contributes to science and technology studies and sociology by devising methods to research the relationships between policy and calculation. These conceptual and methodological tools allow the practices of producing figures and numbers and their public use and political consequences to be traced and followed. This thesis extends social studies of evidence in healthcare by exploring the Colombian experience in the reception and adaptation of evidence based medicine in vaccination policy. Moreover, it contributes to the social science literature about HPV vaccines by analysing the process of selection and decision making undertaken in technical committees and the role of calculations in constituting the HPV vaccines as a matter of public interest. Table of contents Introduction ......................................................................................................................................... 14 Evidence, policy and anticipation regimes ............................................................................................. 20 Thesis summary ...................................................................................................................................... 23 Chapter One Cervical cancer, HPV vaccines and contemporary healthcare in Colombia. In search of a context for the production of evidence ........................................................................................................... 27 Introduction ............................................................................................................................................ 27 Introducing HPV vaccines in Colombia: a matter of evidence and efficiency ....................................... 28 Landscape of the disease: Cervical cancer: development, difference and sexuality .............................. 32 Cancer epidemiology and sexuality ................................................................................................... 33 HPV, sexuality and opening the edge to vaccines .............................................................................. 34 Locating difference: the cancer of underdevelopment ....................................................................... 36 Geographical enactments: tracing imaginaries in cervical cancer policy ........................................ 39 Landscape of the cure: Cervical screening programmes and vaccines ................................................... 42 From the complexity of cervical screening to the “simplicity” of vaccination .................................. 43 The world and body meet in a needle: risk, anxiety and geopolitics ................................................. 45 Moral calculation: Free riders, informed decisions and responsibility ............................................. 48 Geopolitical landscape: living in the middle and healthcare in Colombia ............................................. 50 Healthcare (market) reforms and the politics of evidence in Colombia ............................................. 53 Replicating global difference at national scale .................................................................................. 57 Conclusion: providing a context for the production of evidence ............................................................ 60 Chapter Two Textuality, calculation and value. Tools to study policy, quantification and governance in HPV vaccines introduction .......................................................................................................................... 62 Introduction ............................................................................................................................................ 62 Studying policy ....................................................................................................................................... 63 Policy as documents, telling stories through documents: an institutional cartography .................... 63 Textual analysis, intertextuality and genres in policymaking ................................................................. 67 Policy actors: committees, experts and decision makers ................................................................... 69 Studying calculation and quantification in policymaking: numbers and words ..................................... 72 Looking at devices .............................................................................................................................. 74 Performativity and calculation ........................................................................................................... 76 5 Material semiotics of numbers: indexes, symbols and icons .............................................................. 77 Thinking a strategy of ordering .......................................................................................................... 80 Studying value as enacted in policy........................................................................................................ 82 Pragmatist and axiological approaches to value ............................................................................... 83 To value is a question of method ........................................................................................................ 85 Conclusion: policy, modes of calculation and modes of ordering .......................................................... 86 Chapter Three Making HPV vaccines evident. Evidence, systematic review and other technologies of legitimation .............................................................................................................................................................. 88 Introduction ............................................................................................................................................ 88 Health policy based on evidence: promises for a system in crisis .......................................................... 90 Systematic literature reviews: calculating inside the HPV textual laboratory ........................................ 96 Systematic reviews outside the textual laboratory: the political and legal entanglements of the National Committee of Immunisations ............................................................................................................... 104 Technologies of legitimation, technical committees and consensus rhetorics ...................................... 105 New calculative spaces, minutes as literary technologies................................................................ 107 Evidence in controversy, extending calculation accounts and confronting valuation strategies .......... 109 Conclusion ............................................................................................................................................ 113 Chapter Four Making HPV vaccines efficient. Cost-effectiveness
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