If you’ve been watching television lately, you’ve probably seen Merck’s recent ads for Gardasil, the most widely used vaccine for human papilloma virus (HPV). The commercials begin with a young person in their 20s stating they have cervical cancer or have been infected with HPV. From there, we see them get progressively younger through family photos and home videos. They play, smile, and blow out birthday candles with heartfelt music playing in the background. In the voiceover throughout, the child continually wonders if their parents knew vaccination could have protected them from cancer or illness. Finally, we see the 12-year-old version of the young adult from the beginning, who looks directly at the viewer and asks, “Did you know?”
A quick search of Twitter tells me it’s not just my search history as a historian of sex and public health that prompts Hulu to play these commercials for me during every ad break. They’re part of a concerted effort to boost the lackluster adoption rates of the vaccine. In 2014, only 22% of boys and 40% of girls were vaccinated; this after almost a decade of the vaccine being available and a variety of advertising and educational campaigns by not only Merck, but also the CDC and state and local governments. In comparison, adoption rates for other vaccines range from 82-93%, in particular because many of them are required for children to attend school.
The HPV vaccine has stirred up debate since it was approved. While many see it as key to promoting sexual health and eradicating cervical cancer, anti-vaccination parents have resisted efforts to make it required for school children, and conservatives have argued that prophylactic measures will increase the sexual activity of young people. But the latest ad campaign has added another layer to this debate — the heavy-handedness of the commercial. Some see the guilt as a necessary way to get parents to take the vaccine seriously or to grab the attention of those unaware of the connections between HPV and cancer. But even many supportive of Gardasil have commented that the melodrama is a bit excessive. Particularly because a corporation is behind the commercial, we know the public’s best interest is not the only motivator for this advertising approach.
Perhaps surprisingly, there is a long history of using this type of parental guilt in the debate about sexually transmitted infections (STIs). At the turn of the twentieth century, public health officials estimated that 10% of the population would have syphilis at some point in their life and 20-40% would contract gonorrhea.1 The long-term effects of these illnesses if left untreated (which was far more common in the pre-penicillin era) included blindness, sterility, paralysis, insanity, and even death.
In spite of the prevalence and seriousness of these illnesses, their association with immorality, poverty, racial minorities, and prostitutes meant an uphill battle to convince the public that prevention was worthy of attention and resources. Then, as now, stereotypes, social inequality, and politics affect our ability to control disease as much as scientific technology and knowledge.2 Tapping into emotions about the family was a way to change the social, cultural, and political part of the equation.
Congenital syphilis, when the illness is transmitted to child in utero, accounted for less than 10% of total infections.3 However, concerns about the impact of venereal disease (VD) on children featured prominently in the discourses on control of these illnesses from the Progressive Era through WWII. Of course, we can understand the public relations strategy at work at here — children are “innocent” of any moral wrongdoing, and parents and society are both tasked with protecting children. Framing control of venereal diseases in this way, then, added urgency and legitimacy to the cause.
Progressive Era “Innocent Infections”
In the Progressive Era, parental guilt dominated the social hygiene movement’s conversation about VD control. Materials often used a melodramatic narrative — a white man contracted VD in a premarital sexual encounter with a prostitute or “loose woman” and spread it to his “innocent” wife and children.4 The serious effects of untreated syphilis or gonorrhea were often emphasized, as these family members were blinded, developed congenital deformities, or were disabled. Popularized through Upton Sinclair’s play Damaged Goods (1913), this “innocent infections” narrative was repeated in other materials like films, pamphlets, and posters. WWI posters also urged servicemen to remember their families at home and to avoid prostitutes and illness.
The goal of using parental fear and guilt in this era was to police the sexual behavior of young people and promote abstinence until marriage for both men and women at a moment when white, middle-class sex and dating norms were undergoing dramatic changes.5 In part, the concern about VD and family stability was a reaction to young people courting away from home and increased premarital sexual activity.6
Social hygienists in this era also used this concern about the family to push for the passage of state laws that would prevent gonorrhea-related blindness in newborns. By 1926, all but 2 states required the application of silver nitrate to babies’ eyes immediately after birth.7 After WWI, attention to venereal disease declined, as funding and wartime furor disappeared. But, the idea of VD would return a decade later as a threat to children and the family.
Protecting Children from VD in the 1930s
By the mid-1930s, the importance of controlling venereal disease gained steam again, in part due to the focus on children and the family. Tapping into parental guilt continued to be cornerstone of VD control, especially given the importance of family stability during the Great Depression.
Birth and marriage rates had taken a nosedive, and dislocation and unemployment undermined traditional family dynamics. As in the Progressive Era, focusing on the family also aligned with easily understandable public health interventions that gained popularity across the country beginning in the late 1930s — premarital and prenatal testing laws. By 1944, over 30 states had passed legislation requiring such tests.8
VD materials continued to include images of blinded children and those on crutches along with new statistical visualizations that emphasized the seriousness of the threat to children if parents were ignorant of their status or failed to get proper treatment. The “innocent infections” narrative returned in a number of popular exploitation films that were all variations on Damaged Goods.
Though the 1930s campaign used fear and melodrama again, there were some shifts from the Progressive era version of this family theme. Depression-era efforts were less about policing sexual behavior and more about encouraging parents to practice proactive health care behaviors. (The literal and figurative policing of women’s social and sexual behavior would return during WWII.) This reflected changed social norms and politics as well as increased confidence in testing and treatment procedures, which had undergone study and refinement in the 1930s. Though prevention via abstinence was no longer the focus, parents still shouldered the responsibility if they failed to take these steps.
Parental Guilt Then & Now
The discovery of penicillin’s effectiveness against syphilis and gonorrhea in the 1940s, in addition to expanded infrastructure, meant that the dramatic effects of these illnesses that had been at the heart of the “innocent infections” narrative — blindness, deformity, disability — became exceedingly rare. The crux of parental guilt, responsibility for permanent disfigurement to children’s bodies, was no longer there. However, today’s Gardisil ads return to this fear of the scary, long-term effects of an STI, specifically cancer.
The commercial isn’t selling the vaccine as a way to maintain children’s future sexual health, but rather a surefire way to prevent them from getting cancer, an illness we still don’t have a “magic bullet” for. Emphasizing this connection doesn’t just play on imagined fears of cancer, but perhaps real and difficult experiences many families have likely had dealing with the illness. As a recent study showed that only 50% of parents surveyed knew the link between the two illnesses, educating people about this link might be a big part of getting vaccination adoption rates near those for polio, measles, whooping cough, and others.
However, the increased politicization of sexual health issues since the late twentieth century means that getting more parents to vaccinate their children for HPV is not simply a matter of education. Many Americans still see sexual health issues as moral concerns and not medical ones. Sex ed, birth control, and these vaccines are seen as promoting promiscuity rather than health. Whether or not guilt and fear can change people’s thinking in this regard remains to be seen.
- Thomas Parran, Shadow on the Land (New York: Reynal & Hitchcock, 1937), 7. Return to text.
- For a broad cultural and social history of VD in the US, see Allan Brandt, No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880 (Oxford: Oxford University Press, 1987). Return to text.
- William A. Brumfield, Jr., et al., “The Epidemiology of Syphilis Based Upon Five Years’ Experience in an Intensive Program in New York States,” American Journal of Public Health, 32:8 (August 1942), 794. Return to text.
- The mainstream social hygiene movement was concerned with the white middle-class. However, as Christina Simmons explains, there was a black social hygiene movement as well. Though they took notions of Victorian respectability from the mainstream movement, their rhetoric surrounding sex and disease was often different. Christina Simmons, Making Marriage Modern: Women’s Sexuality from the Progressive Era to World War II (New York: Oxford University Press, 2009), chapter 1. Return to text.
- Alexandra Lord, Condom Nation (Baltimore: Johns Hopkins University Press, 2009), chapter 2; Kristin Luker, “Sex, Social Hygiene, and the State: The Double-Edged Sword of Social Reform,” Theory and Society 27:5 (October 1998), 601-634. Return to text.
- Kathy Peiss, Cheap Amusements: Working Women and Leisure in Turn-of-the-Century New York (Philadelphia: Temple University Press, 1986). These changes in courting were first seen among working-class urban youth and then spread to middle-class young people. Return to text.
- R.J. Snowe and C.M. Wilfert, “Epidemic Reappearance of Gonococcal Ophthalmia Neonatorum,” Pediatrics, (1973), 111. Return to text.
- American Social Hygiene Association, “Progress in 1938,” Records of the ASHA, Social Welfare History Archives, University of Minnesota, box 173, folder 13; George Gould, State Laws to Guard Family Health, Records of the ASHA, box 175, folder 5. Return to text.