This article is co-authored by Miriam Yeung, Executive Director,  and Amanda Allen, Reproductive Justice Fellow/Georgetown Women’s Law
and Public Policy Fellow at National Asian Pacific American Women’s Forum.

This week the reproductive justice movement is celebrating a
significant victory. Effective
December 14, immigrant women and girls will no longer be
forced to get Gardasil, a vaccine developed by Merck and Company to prevent
transmission of the strains of human papillomavirus (HPV) linked to cervical
cancer.  This marks
the reversal of a harmful and discriminatory rule originally put in place in
July 2008 by the
U.S. Citizenship and Immigration Services (USCIS) that took away the ability of
immigrant women and girls to make informed choices of whether or not to get the
Gardasil injection. The National
Asian Pacific American Women’s Forum (NAPAWF), along with other
immigrant rights, reproductive justice, civil rights, public health and women’s
rights advocacy groups, led the effort to reverse the rule. The successful
outcome highlights the ways in which the reproductive justice framework is
essential to achieving equitable results for historically marginalized
communities. We believe this approach is also essential to securing accessible
and affordable health care for all.

Background
and Basics

There are more than 100
different strains of HPV, the most common sexually transmitted
infection in the United States, over
30 of which can be transmitted from person to person through sexual contact.
According to the Centers for Disease Control (CDC), approximately 20
million Americans are currently infected with HPV, and they estimate that at least half of
sexually active men and women become infected at some point in their lives.
 HPV transcends racial and
geographic boundaries, affecting men and women of all racial and ethnic
backgrounds across the U.S.   A number of strains of HPV have been
found to be the cause of virtually 100 percent of all cervical cancers.

On June 8, 2006, the Food and Drug
Administration (FDA) approved the use of Gardasil among
girls and women ages 9-26.  Gardasil
is administered through a series of three separate injections over the course
of six months. Like all vaccines, there are some side effects and risks, and
because Gardasil only recently entered the market, there are also possible
unknown risks.  Because it is so new, there is little research on how
long the vaccine remains effective and whether eliminating some strains of
cancer-causing virus will decrease the body’s natural immunity to other strains
of the virus. At the same time, many
reproductive health centers offer the HPV vaccine to their patients as a
part of primary, preventive care. 

Recommended
for Citizens, Required for Immigrants

In July 2008, USCIS added
Gardasil to their list of mandatory vaccinations for
green card applicants and immigrants applying to become U.S. citizens. The
requirement is the result of a 1996 change made to our immigration law that requires
all persons seeking to adjust their status to legal permanent resident in the
U.S., or applying for immigrant visas to enter the U.S, be immunized against
“vaccine-preventable diseases” recommended by an advisory committee at the CDC.
Thus, once that recommendation was made for the general public, the HPV
vaccination became an automatic requirement for immigrants, a change which was
likely unintended
by CDC officials.

The HPV vaccine mandate created an untenable
additional financial and administrative barrier to the immigration application
process. A significant percentage of immigrant women lack health insurance.  Asian and Pacific Islander (API) women,
for example, are less
likely than their white counterparts to have employer-based health insurance.  This is
due, in part, because many API women are concentrated in low-wage employment,
such as the garment and cosmetology industries, where employer-based insurance
is rarely offered. Uninsured women who lack access to benefits are the most
vulnerable to cervical cancer, and the least likely to obtain the vaccine. Thus,
the HPV vaccine mandate was particularly problematic for many immigrant women
because they are disproportionately un- or underinsured.  The full treatment of the HPV vaccine costs a
minimum of $360, or $120 per dose, excluding the additional fees and costs
of administering the vaccine. Moreover, most private health insurance plans
don’t cover immigration-related medical procedures—thus, regardless of whether
immigrant women have insurance, the likelihood that they would be required to
shoulder the burden of vaccination expenses was high. And, it’s important to
recognize that the costs associated with Gardasil were in addition to the more
than $1,000 required for application fees and the cost of meeting over a dozen
other mandatory immigrant vaccination requirements imposed on green card applicants.

Some advocacy groups also opposed the requirement because it
unfairly forced immigrant women to subject their bodies to a vaccine that is
new to the market and has unknown long-term efficacy rates. And, unlike the other infectious diseases addressed on the
list of required vaccinations, such as measles or chicken pox, HPV does not
pose an immediate threat to public health. Thus, requiring immigrant women to
obtain Gardasil did not comport with sound public health reasons provided for
requiring other mandated vaccines—namely, those that protect against a disease
that has the potential to cause an outbreak or to protect against a disease
that has been eliminated in the United States. At the time the Gardasil
decision was made, 12 of the 14
required vaccinations for immigrants were intended to combat infectious
diseases that are transmitted by respiratory route and are considered to be
highly contagious. Gardasil and the only available vaccine for shingles,
Zoster, were the only exceptions.

Additionally, progressive groups acknowledged that the
mandatory use of a medical procedure on a targeted population when it is not
required of the general population is discriminatory. Like their U.S. citizen
counterparts, all prospective immigrant women should have the opportunity to
make an informed decision about their use of the HPV vaccine, weighing both the
potential costs and health benefits of using the vaccine. While a pregnant U.S.
citizen can decide whether or not to be vaccinated, a pregnant immigrant woman
must be vaccinated without any opportunity to weigh the possible risks to
herself and her pregnancy.

Interestingly, the lack of opposition to the immigrant HPV
vaccine requirement from conservative religious groups demonstrated that a
double standard continues to apply to citizen versus immigrant girls and
young women. By the end of 2007, legislators in at least 27 states and the
District of Columbia had introduced legislation to mandate the HPV vaccine for
school entrants. Conservative advocacy groups opposed the state proposals and
claimed that the mandatory vaccination of citizen girls and young women would
encourage teens to engage in more risky sexual behavior and disrupt
their abstinence-only message. Yet, no such outcry arose
when USCIS announced the requirement of the HPV vaccine for immigrant girls and
women. This notable difference in response raises
the troubling question of whether certain bodies are still seen
as more deserving than others of “protection,” even if it is of the wrong kind.

Reproductive
Justice Response

NAPAWF and the National
Latina Institute for Reproductive Health, as co-chairs of the National Coalition of Immigrant Women’s
Rights, as well as other allied organizations, opposed the requirement from
the outset and applied a reproductive justice lens to address the rule’s
shortcomings and advocate for a just outcome. The reproductive justice
framework seeks to place those most marginalized at the center by highlight the
overlapping forms of oppression faced by the communities whose voices are least
heard. The reproductive justice framework demands that individuals be given the
information and resources necessary to make the best choices for their bodies,
families and communities. The immigrant HPV vaccine mandate, then, was a
textbook example of reproductive injustice—dictating
to a particular group of women what they must do to their bodies.

Additionally, the reproductive
justice movement offers an example of social justice practice that is
cross-movement and intersectional. Just as those most affected by an HPV
vaccine mandate — young immigrant women –do not experience their lives, or the
discrimination they face as separate issues, our movements must also learn to dismantle
the barriers that often divide us. The working group that NAPAWF spearheaded
consisted of nearly 40 national and state organizations representing civil
rights, reproductive health, public health, youth, immigrant rights and
reproductive justice organizations. This working group was tasked with creating
a cross-movement reproductive justice framing of the issue that did not
undermine any group’s position. The working group also researched and developed
a policy advocacy and organizing strategy that proved to be successful. California Latinas for Reproductive
Justice, for instance, built partnerships with key California immigrant
rights organizations and mobilized women of color activists on the ground in
California to voice their opposition to the mandate.

One of the most remarkable aspects of the campaign’s success
in reversing the CDC’s decision was the strong collective response that
developed among progressive organizations. Over
100 groups representing different constituencies and even differing
views about the vaccine itself joined together to send a clear message to the
CDC that the singling out of immigrant women would not be tolerated. The
working group’s success in removing the Gardasil mandate for immigrant women,
then, signals the importance of continuing to build and sustain a movement that
addresses the intersections between immigration statuses, class, and access to
health care.

Changing
the Conversation

The immigrant HPV vaccine mandate illustrates the need for
health care reform that meets the needs of poor women, immigrant women, and
women of color. Mandating the use of a particular medical procedure does not
address the root of the problem, i.e. the fact that the women most likely to
develop cervical cancer are the least likely to have the resources to access
preventive care. Research that disaggregates data based on
race and ethnicity shows that cervical cancer has a disproportionate impact on
certain immigrants, particularly Latina, Vietnamese, Korean and Hmong women. However,
for many immigrant women, the
high expense of medical care, the lack of health insurance, and the difficulty
in finding culturally competent services means that they forego routine
preventive health care services such as pap smears that could identify cervical
dysplasia before cancer develops. It is these
inequalities in access that contribute to the high rates of death and illness
from cervical cancer among immigrant women.

While it is obviously important to increase access for all immigrant
women to safe medical technologies such as vaccines, mandating the use of medical procedures will not fully improve
immigrant women’s lives.  Reducing
health disparities faced by immigrant women requires greatly expanded access to
culturally competent medical services and effective measures to make health
care more affordable.  In addition,
expanding access to and encouraging voluntary use of a vaccine like Gardasil among
immigrant populations requires a combination of genuine, informed consent and efforts
to increase the affordability for immigrant women of the vaccine.

Moreover, immigrant
women cannot access public health programs including Medicaid
because of the five-year waiting period imposed on legal immigrants before they
can apply for such benefits.  Even the best proposals in the current health care reform bills do nothing
to address this problem—currently, neither the House or current Senate bills
eliminate the five-year bar, and the Senate bill even goes so far as to
prohibit undocumented immigrants from using their own money to purchase health
insurance through the exchange. The CDC’s and USCIS’s decision to mandate
Gardasil for immigrant women would not have resolved these types of health
disparities known to affect certain immigrant communities.

The CDC’s decision to reverse the HPV vaccine mandate is a
step in the right direction to recognizing that immigrant women need to be
treated fairly.  However, much more
needs to be done to address immigrant women’s health needs.  The current health care reform debate
ignores the needs of immigrant women at best, and penalizes them at worst by
prohibiting them from accessing affordable health care in the exchange.  Moreover, political debates suggesting
that immigration reform should happen after health reform imply that immigrants
do not need health care and that identities can be precisely and tidily
segregated.

The reproductive justice framework recognizes that people
experience a multiplicity of identities, and it is the intersections of those
identities that shape their needs; immigrant women may be in poverty,
uninsured, or caring for elderly family members as well as their own children. Recognizing
the reproductive injustice of the HPV vaccine mandate was a start; now we need
to relocate the conversation into other political realms to fight for the right
of self-determination for everyone.