The HPV Vaccine Debate And The Unhealthy Corporatization Of Our Political Process And Public Policy Decisions
In his critique of the recent CNN/Tea Party sponsored Republican presidential candidates debate, The Daily Show’s Jon Stewart described the set as looking like the inside of Betsy Ross’s vagina. Crude but apt for a debate that saw two candidates stumble badly on the unlikely political football that the HPV vaccine has become. As has been well reported, Texas Governor Rick Perry has been trying to distance himself from his highly publicized effort to mandate the vaccination of all girls in Texas because in addition to sounding like the dreaded idea of government interference in our lives which strikes maniacal fear in the hearts of Tea Partiers, it has served to highlight the large donations Perry has received from Merck, the maker of the HPV vaccine Gardisil. Michelle Bachmann, not wanting to be left out, then claimed that she had heard from a mother whose daughter became mentally retarded because of the vaccine, a claim that is questionable and certainly not proven. All of which has served to kick up some major dust in the absurd debate about whether it is un-American big government at its worst to mandate vaccinations as opposed to being un-American to not vaccinate children because it imperils public health. Unfortunately, both stances not only lack subtlety, they completely miss the real issues involved that need to be addressed in regard to the HPV vaccine. In 2007, after Perry’s short-lived effort to mandate HPV vaccination, I pointed to some of the problematic issues in the debate about Gardisil: Cervical cancer is only expected to cause 3,670 deaths in the U.S. in 2007, a miniscule percentage (less than 2%) of the 270,000 deaths from the disease worldwide and only 1% of the total annual number of deaths from all cancers in the United States. While cervical cancer used to be one of the deadliest diseases for women in the U.S., the number of deaths it causes has dropped dramatically (by 74% from 1955-1992) and it continues to drop). Why then are so many states considering mandating a vaccine that costs $300-$500 per patient for a type of cancer that is already largely under control in this country and which can be almost entirely prevented by regular gynecological checkups and Pap smears? Merck & Co., the giant pharmaceutical company that makes the vaccine Gardasil, (spent) millions of dollars lobbying state legislators. In Texas… Gov. Perry received $6,000 from Merck’s political action committee during his last campaign. One of Merck’s key lobbyists in Texas is Perry’s former chief-of-staff, the mother-in-law of his current chief-of-staff, and the state director of Women in Government, a national advocacy group of female state legislators that has received substantial funds from Merck. It is important to note that low-income women and women who do not have health insurance are most at risk because they are less likely to get regular Pap smears. More than half of the diagnosed cases of cervical cancer are in women who have not had a Pap smear in three years. While Gov. Perry has mandated that the state of Texas foot the bill for those who can’t afford the expensive HPV vaccine, it is unclear where those funds would come from either in Texas or in other states that are considering making the vaccine mandatory. And obviously the cost of the vaccine makes it prohibitive in the countries where it is most needed and would potentially do the most good. What is clear is that Merck has a substantial financial interest in the vaccine becoming mandatory even though the added benefit to public health is both minimal and costly. With more than 10 million girls in the U.S. between the ages of 10-14, the drug company stands to make billions of dollars preventing a disease that is already treatable in the targeted population. Since the vaccine does not eliminate the need for regular Pap smears, it would appear that a far more appropriate and cost effective first step would be to make regular gynecological healthcare available for all women regardless of income and medical insurance, particularly since this step by itself would go a long way in reducing the few cases of cervical cancer that still occur in this country. There is however another significant public health concern in regards to the HPV vaccine, namely that it is a very new drug with no history. We are of course being told that it is perfectly safe and has few side effects, but we were also told that about Thalidomide, DES, and Hormone Replacement Therapy. Negative health concerns have also been raised about other children’s vaccines and the Anthrax vaccine given to those in the armed forces as well as drugs such as Vioxx, another Merck drug. While Merck says that Gardasil is 100% effective in preventing the two types of the HPV virus that cause 70% of all cervical cancer, questions have arisen about these results. In an article in Healthfacts, Maryann Napoli, associate director of the Center for Medical Consumers reports that according to Barbara Loe Fisher, president of the National Vaccine Information Center and a former member of the FDA Vaccines and Related Biologic Products Advisory Committee, the placebos in Merck’s studies contained aluminum (which is reported to cause inflammation and cell death in animals and humans) rather than saline solution, which according to Fisher “violates the principle of scientific method…making it hard to tell whether the many adverse events reported were due to the use of aluminum in both the placebo and the drug or to the Gardasil itself. And in an essay published in The New York Times in July 2006, Roni Rabin points out that most of the subjects in the Merck trials were women over the age of 16. Rabin found that the vaccine was only tested on 1,200 girls under the age of 16. In addition, the vaccine is so new that it is not yet known for how long it will be effective or whether a booster will be required. It is also important to note that Merck’s own literature states that Gardasil, “has not been evaluated for the potential to cause carcinogenicity or genotoxicity.” I also discussed Merck’s marketing campaign and the fast tracking of the FDA approval of Gardisil here, The New York Times ran several articles by Elizabeth Rosenthal (here and here) that finally address the points that I had raised. Rosenthal writes that, according to the New England Journal of Medicine: “Two vaccines against cervical cancer are being widely used without sufficient evidence about whether they are worth their high cost or even whether they will effectively stop women from getting the disease.” Those are rather serious issues considering that 16 million doses of the drug have already been distributed in this country alone, at a cost of $360 and upwards for a series of 3 shots, putting a serious crimp on the pocketbooks of parents and public health agencies and billions of dollars into the Merck coffers. And as Rosenthal points out, while cervical cancer is a major killer in developing countries: “In developed countries, Pap smear screening and treatment have effectively reduced cervical cancer death rates to very low levels already. There are 3,600 deaths annually from cervical cancer in the United States, 1,000 in France and 400 in Britain. Given that there are still serious unknowns about the effectiveness and safety of the vaccine, it is important to examine the sudden concern about HPV and cervical cancer. ”Merck lobbied every opinion leader, women’s group, medical society, politicians, and went directly to the people — it created a sense of panic that says you have to have this vaccine now,” said Dr. Diane Harper, a professor of medicine at Dartmouth Medical School. Dr. Harper was a principal investigator on the clinical trials of both Gardasil and Cervarix, and she spent 2006-7 on sabbatical at the World Health Organization developing plans for cervical cancer vaccine programs around the world. “Because Merck was so aggressive, it went too fast,” Dr. Harper said. “I would have liked to see it go much slower.” In receiving expedited consideration from the Food and Drug Administration,Gardasil took six months from application to approval and was recommended by the C.D.C. weeks later for universal use among girls. Most vaccines take three years to get that sort of endorsement, Dr. Harper said, and then 5 to 10 more for universal acceptance.” And as anyone who watches television, reads teen and women’s magazines or has been in a pediatrician or gynecologists office lately knows, the Merck marketing campaign was indeed quite impressive. The campaign has included such tactics as getting hundreds of doctors as unofficial spokesmen (paying them $4500 for each talk given about Gardisil), letting girls sign up to get text messages reminding them to get their next dose of the vaccine (as long as they let Merck use the information they provide for marketing purposes) and funding ‘awareness’ conferences, sometimes not so transparently. Merck also has provided substantive funding to legislative groups such as “Women In Government”, a group that suddenly appeared from nowhere to champion the vaccine (see this earlier post detailing the funding trail for this seemingly impartial group.) There are also serious questions about the use of health dollars on this very expensive vaccine, “(W)ith their high price, the vaccines are straining national and state health budgets as well as family pocketbooks. These were the first vaccines approved for universal use in any age group that clearly cost the health system money rather than saved it, in contrast to less expensive shots, against measles and tetanus, for example, that pay for themselves by preventing costly diseases.” “Looked at another way, countries that pay for the vaccines will have less money available for other health needs. “This kind of money could be better used to solve so many other problems in women’s health,” said Dr. (Abby) Lippman at McGill (University). “Some of our provinces are running out of money to provide primary care. I’m not against vaccines, but in Canada and the U.S., women are not dying in the streets of cervical cancer.”" Another concern is that since it is not yet known for how many years the vaccine provides protection, the vaccine could actually cause more deaths by, “giving girls false security that they are protected for life and no longer need to be screened.” To be very clear, it is should be obvious that we should be completely in favor of a vaccine that effectively saves lives. The uncomfortable truth however is that our health care decisions are all too often predicated by the corporate bottom line rather than the public good. When a large pharmaceutical company launches a huge advertising campaign and sprinkles huge campaign contributions around to secure the fast-track approval and use of a very expensive vaccine with known efficacy and safety issues (for an informed discussion of this, please see Marcia G. Yerman’s series on the HPV vaccine that begins here), we need to raise a caution flag. The key issue that we need to keep sight of is how large corporations are framing (and funding) our political debate and the harm that does to our health and well-being. Addenda: For more on Perry’s links to Merck, see this. And while I don’t totally agree with her viewpoint on vaccines, Ayelet Waldman points to the issue of sexual control which is most definitely part of the rightwing argument against the HPV vaccine. While I have questions about the vaccine, this kind of thinking is obviously harmful and should not be a factor in making decisions about this vaccine. Martha Kempner, RH Reality Check: "In 2007, Governor Rick Perry shocked both public health officials and his conservative base when he signed an executive order mandating that female students in Texas be vaccinated against human papillomavirus (HPV) before entering the sixth grade. The order referred to Gardasil, a vaccine that had been approved by the FDA only a few months earlier after having been found to prevent infection with four strains of HPV, including two strains that account for 70 percent of cervical cancer and two that account for 90 percent of genital warts. The FDA approved the three-shot regimen for young women ages nine to 26 and the Centers for Disease Control and Prevention (CDC) recommended that this become part of the routine vaccinations of girls at ages 11 or 12 because 'it is important for girls to get HPV vaccine before their first sexual contact - because they won't have been exposed to human papillomavirus.'"Read the Article In 2007, Governor Rick Perry shocked both public health officials and his conservative base when he signed an executive ordermandating that female students in Texas be vaccinated against human papillomavirus (HPV) before entering the sixth grade. The order referred to Gardasil, a vaccine that had been approved by the FDA only a few months earlier after having been found to prevent infection with four strains of HPV, including two strains that account for 70 percent of cervical cancer and two that account for 90 percent of genital warts. The FDA approved the three-shot regimen for young women ages nine to 26 and the Centers for Disease Control and Prevention (CDC) recommended that this become part of the routine vaccinations of girls at ages 11 or 12 because “it is important for girls to get HPV vaccinebefore their first sexual contact – because they won’t have been exposed to human papillomavirus.” Public health advocates argued that because HPV is so easily spread through sexual contact, universal or near-universal vaccinations would be the only the way to eradicate the disease. They pointed out that, although cervical cancer can be prevented through early detection using Pap Smears and other medical tests, approximately 10,000 women in the United State do become infected each year. As a result of these arguments, a number of states considered legislation and rules similar to Perry’s order which would make the vaccine a requirement for school attendance. (It’s worth noting that many public health advocates stopped short of supporting these types of mandates because of the fear that such requirements and the steep price of the vaccine –- about $390 for the series -– would be too much of a burden on the Vaccines for Children program, “a federally-funded program that provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay.”) On the flip side, social conservatives and proponents of abstinence-only-until-marriage programs argued that vaccinating young girls against a sexually transmitted disease was morally questionable and dangerous. They suggested that such a vaccine would give young women a false sense of security and lead to promiscuity. They also took issue with the young age at which vaccine was recommended and complained that at the very least this would cause parents to have to have uncomfortable and age-inappropriate conversations with their daughters. Ultimately, they said that this was a parental issue in which the state should not become involved. When it came to issues around sexual and reproductive health, Governor Perry sided with these factions far more often that with public health experts. So, people on both sides of the debate were surprised when Governor Perry bypassed his state legislature and issued the executive order which not only required all female students to be vaccinated but also “directed state health authorities to make the vaccine available free to girls 9 to 18 who are uninsured or whose insurance does not cover vaccines,” and ordered Medicaid to offer Gardasil to women ages 19 to 21. At the time Perry argued that “the HPV vaccine provides us with an incredible opportunity to effectively target and prevent cervical cancer,” and that it was no different than the vaccine for polio. According to one blog he had this to say to his critics: “I understand the concern some of my great and dear friends have about requiring this vaccine, which is why parents can opt out if they so choose…I refuse to look a young woman in the eye who suffers from this form of cancer and tell her that we could have stopped it, but we didn’t. Others may focus on the cause of this cancer. I will stay focused on the cure.” Today, as he makes his bid for the Republican Presidential nomination, it seems that Rick Perry has something different to say. When the issue of Gardasil came up in last week’s Republican debate he acknowledged that he probably didn’t handle the situation correctly but argued that he wanted to bring the issue to the attention of people in his state and said that he would always err on the side “saving lives.” He was even more contrite in an Iowa radio interview in which he said: “I readily stand up and say I made a mistake on that.” Exactly what Rick Perry really believes when it comes to HPV, sexually transmitted diseases, and prevention remains unclear. Unfortunately, what is very clear in looking closely at the Gardasil debate is what the governor believes about, well, campaign contributions. The Toomey Connection His fellow primary candidates seemed anxious to bring up the Gardasil issue as an example of Perry breaking with his anti-choice, pro-abstinence, conservative base on a social issue. What they didn’t mention (perhaps for fears of similar skeletons in their own closets), was the connection between the executive order and Perry’s relationship to the vaccine’s manufacturer. This connection, however, was a large part of the controversy and seems very indicative of how he does business. Gardasil is manufactured by the pharmaceutical company Merck, which donated $16,000 to Perry’s campaign in the two-and-a-half years before the executive order was signed. Moreover, as part of an aggressive lobbying campaign for laws and rules just like the mandate Perry signed, Merck hired the Governor’s former chief of staff, Michael Toomey, as one of its top lobbyists in Austin. Between 2005 and 2010, “Merck paid Toomey between $260,000 and $535,000 in lobbying fees.” Andrew Wheat, research director at Texans for Public Justice, a watchdog group in Austin explained: At the time that he did this, it just had everybody scratching their heads. He wasn’t known as a crusader for women’s health. There’s no explanation that seems to make sense other than that Toomey’s got his ear and he got Perry to do this favor for him.” It seems this isn’t the only time that Toomey “got his ear.” Last week, Mother Jones reported on a plan that Rick Perry had floated to privatize the state’s prison health care system. Toomey (who the article says is referred to in Austin as “Mike the Knife”) now lobbies for the Corrections Corporation of America (CCA) which “provides health care services to male and female inmates and youthful offenders who are housed in local jails, detention facilities, and correctional institutions around the country.” Toomey is not only Perry’s former chief of staff but also a campaign contributor having given $20,000 to the 2010 gubernatorial campaign. And, Toomey is not the only donor who cares about this issue: Thomas Beasley, the founder of CCA, has given $17,000 to Perry’s campaigns over the last decade; Luis Gonzales, a lobbyist for another private prison firm, the GEO Group, gave $50,000 to the campaign; and Geo Group itself gave another $15,000. Mother Jones points out that Perry has been a fan of privatizing everything from “public lands to highways” but had been largely quiet on the issue of prisons until the influx of funds from these interested parties. The article goes on to say: Perry’s rush to privatize prison health care is consistent with the approach he’s taken throughout most of his 10 years as governor: slashing public services under the guise of austerity, and then contracting those services out to the well-connected businesses that have made his rise possible. Toomey is still a close friend of the governor and is running the newly formed super-PAC, Make Us Great Again, which was created to support Perry’s presidential campaign. (For those of us who aren’t in full-on election mode yet, a super-PAC, technically known as an “independent-expenditure only committee,” is a new kind of political action committee made possible by the recent Supreme Court decision which lifted some campaign finance restrictions. These committees can raise unlimited amounts of funds from corporations, unions, and individuals.) Toomey, is not, however, the only friend, colleague, or donor who has been rewarded for his contributions to Perry’s political career. Political Appointees There are over 600 boards, commissions, authorities, and departments in Texas to which Perry has made almost 4,000 appointments in his 11 years as governor. And, his campaigns seem to have profited from many of these. Governor Perry’s Patronage, a report released in September 2010 by Texans for Public Justice found that between 2001 and June of 2010 “Perry’s campaign received $17,115,865 from 921 of these appointees or their spouses.” For example, in August of this year, Perry “named James Lee, president of JHL Capital Holdings, to the Texas Higher Education Coordinating Board. Lee, who served on Perry’s 2011 inaugural committee, has donated more than $190,000 to Perry’s campaigns during the last decade.” Similarly, he appointed, Dan Friedkin, chief executive officer of The Friedkin Group, as chairman of the Texas Parks and Wildlife Commission. Friedkin contributed more than $750,000 during the last decade. In fact, the report concluded that “gubernatorial appointees accounted for an impressive 21 percent of the $83.2 million that Perry’s campaign has raised since 2001.” Apparently, the State Parks and Wildlife Commission is one of the most lucrative for Perry as is the board of regents of Texas A & M University, Governor Perry’s alma mater. Over the years, the individuals he has appointed to these posts, including Friedkin, have collectively donated more than $4 million to his campaign. But while a campaign contribution may be enough to get you onto one of these boards, donor beware: it takes absolute loyalty to keep you there. The New York Times reports: In 2009, two members of the Board of Regents of Texas Tech University said the Perry administration pressured them to resign because they supported Mr. Perry’s challenger in the gubernatorial race, Senator Kay Bailey Hutchison. One regent, Windy Sitton, told The Austin American-Statesman that she was given a choice to disavow Senator Hutchison or resign; when she refused, she was replaced. Mark Griffin, the other regent, said he was told by Mr. Perry’s chief of staff that the governor “expects loyalty out of his appointees and if you can’t be loyal, it’s probably not best to be on the team.” If Not an Appointment, Perhaps a Grant If you donated to the Perry campaign but were not among the lucky 4,000 who could call themselves an appointee, there is no need to despair. You see the governor has a number of pots of money at his disposal that frequently seem to make it into the hands of his contributors. The Texas Emerging Technology Fund, for example, is an economic development effort designed to create jobs in the state. Since 2005, the fund has distributed nearly $200 million to companies. Not surprisingly, a New York Times analysis found that: [M]ore than a quarter of the companies that have received grants from the enterprise fund in the most recent fiscal year, or their chief executives, made contributions to either Mr. Perry’s campaign dating back to 2001 or to the Republican Governors Association since 2008, when Mr. Perry became its chairman. The Times points to the case of G-Con, a pharmaceutical start-up that received a three million dollar grant from the technology fund. Not only did the head of G-Con, John McHale, contribute $100,000 to Perry’s campaign, a number of other individuals affiliated with the company are also donors. Michael Shanahan, whose biotech company Gratalis owns 10 percent of G-Con and received a separate $1.75 million grant from the technology fund, gave Perry $10,000 just a month before G-Con submitted its applications. In addition, San-Antonio business man James Leininger, who has a minority stake in Gratalis, has given Perry more than $230,000. Of course, there are also less direct ways in which state funds are funneled to contributors. One example involves the Teacher Retirement System, a $110 billion pension fund that is among the nation’s largest. The New York Times reports that Perry has appointed at least four top donors or fund-raisers to that board, and that some of the appointees have “leaned on the fund to invest more money with hedge funds and private equity firms” and “in some cases, the appointees appear to have pushed for firms whose investors, officers, or partners were Perry donors.” When an investment manager at the fund complained about this he was told simply: “This is the way business is done.” When Donors Impact Policy Sure, that is the way it is done. “You scratch my back, I’ll scratch yours,” is not a new concept in business or politics though Perry’s brand of it does seem a bit more conspicuous than many. What is more disturbing, however, than the direct tit-for-tat exchange of appointments, grants, or state contracts for donations, is the more indirect ways in which this system of favors impacts how the state of Texas does business. Perry’s contributors have certainly left their mark on the state. Take the case of Waste Control Specialist LLC which applied for permits to build a radioactive waste dump in Andrews County. Waste Control is owned by the holding company Contran Corp., whose chairman, Texas billionaire Harold Simmons, is the governor’s second largest donor having given over $1.2 million. In 2003, Perry laid the ground work for Simmons’ company to open such a dump by signing “legislation allowing a private company to build and run a low-level disposal site that would be owned by the state.” In 2004, Waste Control applied for permits to build three facilities that would take waste from labs, military bases, nuclear plants, and hospitals as well as other radioactive “by-products.” The permits had to be approved by the Texas Commission on Environmental Quality (TCEQ). Not surprisingly, all three commissioners on the TECQ were appointed by Perry. TCEQ’s review of the application raised concerns because initial maps from the Texas Water Board showed the site to be on top of an aquifer that fed drinking and agricultural water to five states. Interestingly enough, in 2006, the water board (five of the six members of which were also appointed by Perry) released new maps that moved the boundaries of the aquifer. To make a long story short (or at least not as long), TCEQ eventually voted 2-1 to grant the permits despite the fact that its own review committee recommended against doing so. That wasn’t the end of the controversy, however: At least three commission employees resigned in protest At least three commission employees resigned in protest and [one commissioner] voted against the permit. Meanwhile, a state employee who advanced the permit became a lobbyist for the company a month after it was approved. In a similar example, the TXU Corporation, a utility based in Dallas, sought permits in 2005 to build coal-fired power plants. Perry used an executive order to “fast-track” the application. According to the New York Times: In the months that followed, current and retired TXU executives, as well as the company’s political action committee, sent Mr. Perry more than $100,000 in donations, including one check dated the same day as Mr. Perry’s order. In this case, a state judge blocked the fast-track order saying that the governor had overstepped his authority. In what seems to me like another gubernatorial over-reach, the Governor created a brand new state board in, the Texas Residential Construction Commission, because apparently the 600 or so he already had weren’t enough to hold all of his contributors. The Commission was, in part, created to deal with a series of mold-related lawsuits against construction companies: “the legislation creating the board also sharply limited the rights of homeowners to sue contractors for faulty construction, shunting most disputes to the commission.” According to theNew York Times, this commission was a priority of Bob Perry (no relation) a home builder who has contributed more than $2 million to Perry over the years. After the legislation creating the commission was passed, Bob Perry and his wife sent two $50,000 checks to the governor’s campaign and: Three weeks later, the governor appointed an executive of Perry Homes, Bob Perry’s company, to the commission. This one gets to me, maybe because in the wake of Irene I’m growing mold in my basement or maybe because it just seems like such a flagrant disregard for even the appearance of impartiality. Selling Out I remember being surprised when I learned that Texas was one of the few states that followed through with efforts to mandate the HPV vaccine (though other states proposed legislation, only Virginia and the District of Columbia actually passed mandates). After all, having followed abstinence-only-until-marriage programs there since then-Governor George W. Bush founded his Lone Star Leaders, I considered it one of the birth places of the chastity movement. Sure, I was as cynical as everyone else when the news of Merck’s relationship with Toomey as well as the pharmaceutical company’s own contribution to Perry’s campaign came to light. But, I was willing to give the man the benefit of the doubt as he fought his legislature’s attempts to overturn his order. He (almost) sounded genuine when he discussed the issue. After state lawmakers were successful, Perry held a news conference during which “he was flanked by several women who had contracted the virus, including one who had been raped,” and gave this impassioned plea: “I challenge legislators to look these women in the eyes and tell them, ‘We could have prevented this disease for your daughters and granddaughters, but we just didn’t have the gumption to address all the misguided and misleading political rhetoric.’ ” Maybe he really was thinking outside the strict parameters set by social conservatives. Maybe even though he supported abstinence before marriage, he rejected the idea that a vaccine could promote promiscuity. Maybe he realized that no matter how badly you want to control woman’s behavior, you can’t deprive them of a vaccine that prevents cancer. And maybe he really was just trying to “save lives.” But since declaring his intention to be our next president he has put that passion aside, apologized, and backtracked. He toldreporters: “The fact of the matter is that I didn’t do my research well enough to understand that we needed to have a substantial conversation with our citizenry.” Maybe he was just willing to sell women’s health out to the highest bidder after all. |
 The GOP Establishment’s Rick Perry ProblemE.J. Dionne Jr., Op-Ed: “Here’s the problem: There is no Republican establishment. It squandered its authority by building up the Tea Party’s brigades and then fearing them too much to do anything to check their power. Worse for those who think Perry would be a general-election disaster is the growing confidence among conservatives that President Obama will be easy to beat. This feeling will be bolstered by Tuesday’s special election that sent a Republican to Congress from New York’s 9th District for the first time since 1923. If Obama is going to lose anyway, many conservatives reason, why not go with their hearts?” The Republican Party is split down the middle between tea party supporters and those who don't support the movement, a new CNN/ORC International poll suggests. Forty-nine percent of Republicans and independents who lean Republican say they support the tea party movement or are active members; 51% say that they have no feelings one way or another about the movement or that they oppose it. Demographically, tea party Republicans are more likely to be male, older and college-educated; non-tea party Republicans are younger, less-educated, women and less likely to say they are born-again Christians or evangelicals. On many issues, the two wings of the GOP are in accord, but they aren't in agreement on issues such as the deficit, global warming, evolution, abortion, same-sex marriage, the Federal Reserve, the Department of Education or Social Security.  |
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