‘자궁경부암 백신’ 국가예방접종 정책 과정 분석

Abstract

본 연구는 ‘자궁경부암 백신 국가예방접종(2016년-2021년)’을 연구 대상으로 삼는다. HPV 백신이 국가예방접종 사업으로 정책으로 결정되고 집행되는 과정을 분석했다. 자궁경부암 백신 국가예방접종 정책형성과 변화 과정을 다면적으로 분석하고, 정책을 둘러싼 맥락적 요인, 정책결정 행위자들의 인식 및 인식의 변화, 목표 달성을 위한 전략들을 조망한 것이다. HPV 백신 접종이 한국 사회가 당면한 저출산과 같은 사회적 조건과의 관계 속에서, 여성의 몸을 기반으로 어떤 보건의료적인 문제들을 설정하고 있는지 읽어낸다. 또한 과학과 의학의 결과인 HPV 백신 문제가 사회적인 상황과 조건에 의해 어떻게 역으로 규정되고 있는지 분석했다. 이 연구는 다음의 세 가지 질문을 중심으로 진행하였다. 글로벌 차원에서 HPV 백신이 개발되고 도입되는 과정은 무엇인가? 국가예방접종사업에 ‘자궁경부암 백신’이 포함되는 과정의 역동은 어떠했으며, 정책결정 행위자들 간의 각축과 논쟁의 지점은 무엇이었는가? 제약사의 시장 확대 전략과 정부의 저출산 대책은 어떻게 만나고 있는가? 국제사회에서 HPV 백신을 국가예방접종사업으로 포함한 경우들이 있는데, 제약사의 로비로 인한 이해충돌 문제, 청소년 성문란 우려 및 부작용 논란 등을 둘러싸고 각국에서 논쟁이 벌어진 것으로 볼 수 있다. 반면, 국내에서 HPV 백신 국가예방접종 도입 당시 큰 논쟁은 없었는데, WHO 권고와 저출산 대책과의 결합이 HPV 백신 도입에 충분한 명분을 준 것으로 보인다. 국내 HPV 백신 국가예방접종은 저출산 대책의 일환으로 기획되었고, 이 기획은 제약사의 시장 확대 전략과 만나면서 홍보 및 정책 담론이 변모해나간다. HPV 백신의 예방 범위가 확대되고 접종 대상이 넓어짐에 따라 제약사도 적극적으로 홍보를 펼친다. 자궁경부암의 위험성과 백신의 효과성을 과장하는 경우가 많았고, 성경험 전 접종이 가장 좋다고 말하는 동시에 성경험에 구애받지 않고 접종할 수 있다는 상호 모순된 언설이 있었다. ‘양성평등’의 맥락으로 남녀 모두 접종해야 한다는 주장이 강화되고 있는데, 이러한 맥락에서 제약사도 ‘남녀 모두 접종’을 강력히 홍보하고 있다. 정부는 ‘건강한 임신․출산’과 여성을 위한 ‘자궁경부암 백신’에서 ‘성‧재생산 건강권’과 모두를 위한 ‘HPV 백신’으로 정책 담론을 바꿨다. 이 과정은 제약사의 시장 확대 전략과 ‘양성평등’담론이 조우한 결과이다. 이런 제약사의 전략과 정부 정책의 결합이 접종 대상 연령과 성별이 확대되는 결과를 가져오지만, 자세히 들여다보면 여전히 백신 접종 대상의 우선순위는 여성이며, 무료접종 대상이 확대된 것도 여성이다. 이렇듯 백신 접종의 성별화로 남성은 여전히 여성 건강을 위해 권유되는 수준에 그치고 재생산 건강의 책임 또는 성적 권리 실천으로서 HPV 백신 접종이 결국 여성의 몫으로 돌아오는 것을 발견할 수 있다. HPV 백신은 자궁경부암의 예방으로 시작했으나, 백신 효능효과의 확장 및 저출산‧양성평등 담론들이 결합해나간다. 이를 통해 접종 대상을 확대해나가며 시장이 무한정으로 확장해나간다. 특히 여성의 몸을 접종 대상으로 한 유일한 백신이라는 것을 생각할 때, 여성의 건강을 위한 접종이 아니라, 제약사의 이해관계와 정부의 저출산 대책이라는 정책의 목표의 이해관계가 맞아서 추진된 이 예방접종이 공중보건의 측면에서 가장 적절한 결정이었는지 묻지 않을 수 없다. HPV 백신은 보건의료 정책이지만 보건의료 외적인 요소들에 의해 많은 영향을 받았고, 역으로 영향을 주기도 했다. 백신 접종과 같은 정책을 결정함에 있어 보건의료 전문가에 외에도 정책결정 행위자들을 다양하게 확장할 필요가 있다. 이 연구는 HPV 백신이 저출산 정책과 백신 제약사의 이해관계와 결합이라는 것을 밝혀내고자 했다. 이를 통해 여성의 몸과 관련된 정책이 입안되고 결정되는 과정에 여성과 시민사회의 더 많은 관심과 개입이 필요성을 제시하고자 한 것이다. ;This research microscopically analyzes the decision-making and enforcement process of a single policy called “National Vaccination of Cervical Cancer Vaccine(2016-2021).”HPV vaccine, commonly referred to as “cervical cancer vaccine,” has been has been in the spotlight for the fact that it prevents “cancer,”and has been strongly recommended to women, who has “uterus. This research does not put into question about the effectiveness of the ‘cervical cancer vaccine.’ Rather, it pursues the position of the HPV vaccine which is called the “cervical cancer vaccine.” The process of introduction and implementation of HPV vaccines as a national vaccination project policy, is microscopically analyzed from a feminine point of view while examining the strategies and competition of the various policy-making actors. A number of prior studies related to HPV vaccines have been conducted regarding health care, most of these studies focuses on increasing the vaccination rate. This research has a different perspective from the previous studies, as the research examines the “National Vaccination Project for Cervical Cancer,” as the collision of the pharmaceutical companies, which aims to expand the market, and the government’s low birth rate measures. The inquiry and result raised by this research are as follows. First, what is the process of the development and the introduction of HPV vaccines at the global state? As the main reason for the negative attitude towards HPV vaccine is the expensive vaccination cost, many countries include HPV vaccination in the national vaccination project. In the United States, lobbies by the pharmaceutical companies were quite active, while controversy over the mandatory vaccination was fierce. Controversy arose over the fact that HPV is not an airborne virus but rather sexually transmitted, the high vaccine costs, and unexpected side effects. In the UK, there have also been disputes regarding HPV vaccines, that HPV vaccine can give adolescents a “green light to have sex,”that there are lack of data on the long-term safety and the potential risk of the vaccines. Japan also suffered major disputes, such as withdrawing vaccination recommendations due to class action lawsuits related to side effects. In Korea, when HPV vaccine was developed in 2006, it attracted considerable attention, but due to lack of data and vaccine price, the introduction of vaccine did not obtain extensive consent. However, in 2014, WHO reduced the number of recommended vaccinations to two for HPV vaccine and emphasized the national mandatory vaccination which made the government to re-discuss this problem. Also, the “National Vaccination Project for Cervical Cancer” was planned and discovered as a countermeasure against low birth rate by the Ministry of Health and Welfare under the 3rd Basic Plan for Low Fertility and Aged Society. The combination of WHO recommendation and low birthrate measures gave sufficient justification for the introduction of the HPV vaccine. Second, what was the process of including the “cervical cancer vaccine” in the national vaccination project like, and what was the point of the debate and competition among the policy makers? Including the “vaccination of cervical cancer” campaigns led by the pharmaceutical companies and the medical community, there have been invisible but active interventions for the introduction and implementation of national vaccinations. Additionally, there were many insufficiency in the introduction process, such as the fact that HPV vaccines were pushed back on the priority list due to low cost effectiveness, and that related laws and notices were revised after the budget was passed, and that vaccination committe’s proposal of recommendation was released after the introduction of the HPV vaccination. Moreover, during the process of policy enforcement, the name “Cervical Cancer Vaccine” was changed to “Human Papilloma Vaccine,” which reveal who’s position was reflected. If there was a strategy to emphasize “cervical cancer” in the early stages of its introduction, it was necessary to highlight that it can prevent other infection disease such as anal cancer, vaginal cancer, vulva cancer, and genital warts. It seems that because the need for male vaccination was undermined due to the name “cervical cancer vaccine,”it has returned to the general name of HPV vaccine to solve this problem. The important point of controversies befor the incorporation of HPV vaccine in the national vaccination project ca be sorted out in to ① Is the vaccination budget cost effective? ② Who is the target of vaccine? ③ Is the safety of the vaccine secured? Despite it’s continuously low cost effectiveness, WHO’s recommendation for the number of vaccination was reduced to two, increasing the cost effectiveness and enabled it to be introduced as a national vaccination project. In contrast to other countries, there were no active debate about the vaccination age in Korea. The government stated that it is because “two vaccination is the most effective with two vaccinations before sexual contact,” but there were different claims about the starting age of the sexual intercourse in Korea. Nonetheless, it is speculated that most convincing reason that the vaccine is recommended to 12-year-olds is because they can be fully inoculated by two vaccinations, and that this secures cost-effectiveness. Meanwhile, the case of Japan triggered the controversy over side effects, but the voices of concern and criticism about the vaccine lost its strength due to the strong defense of the government and the medical experts. Third, how do pharmaceutical companies’ market expansion strategies meet the government’s low birth rate measures? The national HPV vaccination in Korea was planned as part of measures against low pirth rates, and this plan started to transform after it encountered pharmaceutical companies’ market expansion strategies. Pharmaceutical companies actively promotes the HPV vaccines regarding the expansion of the target vaccination. There were many exaggeration of the risk of cervical cancer and the effectiveness of vaccines, and also contradictory statements that pre-sex vaccination is the best while stating that one can be inoculated regardless of sexual experience. In the context of “gender equality,” claims that both men and women should be vaccinated are strengthened, and pharmaceutical companies are strongly promoting “vaccination for both men and women,” in this matter. In addition, this research tracks down the change in public relations discourse of pharmaceutical companies, the policy discourse under the planning measures for low birth rates and how two interact. The government transforms its policy discourse from “healthy pregnancy and childbirth” and “cervical cancer vaccine” for women to “sexual production health rights” and “HPV vaccine”for all. This process is the outcome of pharmaceutical companies’ market expansion strategies and “gender equality” discourse. The union of pharmaceutical companies’ strategies and government policies results in an expansion of vaccination age and gender, but the priority of vaccination target remains to be women, and free vaccination was expanded for women. The vaccination for men are still only recommended for women’s health, and HPV vaccinations are eventually found to be women’s responsibility for reproductive health or sexual rights. This research have revealed that HPV vaccination’s acceptance in not only on the medical problem, but depends on the cultural, historical, and political context of each country, and suggested that HPV vaccination is a political problem. Pharmaceutical companies have made immense impact on the policies on HPV vaccines, and the governement’s introduction of HPV vaccines was one of the measures against low birth rates and that it was a plan for their respective needs. The initiation of HPV vaccine was to prevent cervical cancer, but the vaccine’s efficacy and the discourse on low birth rate/gender equality are continuously combined. Consequently, it was found out that due to the expansion of the vaccination target, the market is also expanding infinitely. Specifically, considering that it is the only vaccine targeting women’s body, there remains a point of inquiry that it may not have been the most appropriate decision in terms of public health as it was not promoted for the women’s health itself, but was promoted to meet the interests of pharmaceutical companies and the goverment’s goal of overcoming low birth rates. Assuming that cervical cancer prevention is a problem, this research claims that vaccination is not the only solution to the problem, rather there needs to be a multilayered approach including cervical cancer screening, sex education, contraception, understanding of sexually transmitted diseases and medical accessibility, and sexual inequality in sex.