I won’t waste words refuting Bachmann’s ridiculous (and campaign-killing) claim that the HPV vaccine causes “mental retardation.” But here are the facts: The American Cancer Society estimates that about 4,000 women die from cervical cancer in the United States each year. Approximately $4 billion is spent annually on these conditions. The HPV vaccine is virtually 100 percent effective in preventing infection by strains of the virus associated with 70 percent of cervical cancers. A second HPV vaccine is also highly effective, preventing more than 90 percent of infections. Researchers estimate that if widespread vaccination is achieved, cervical cancer could drop by as much as 77 percent. That’s as close to a cure for cancer as we’ve ever had.

Yet even before Bachmann’s statements, the HPV vaccine has struggled to gain traction. A recent survey by the Centers for Disease Control showed that less than half of teen girls started the vaccine series, and less than one-third of those girls completed it. That leaves the promise of a cure for cervical cancer well out of reach. The question is why?

One myth to dispel right away is that parents believe the HPV vaccine will encourage sexual activity. Studies have never demonstrated this is a major factor that prevents vaccination. Parents do hesitate to give their teens the vaccine because they think it’s too new and needs more time in the marketplace (the vaccine was first licensed in 2006). Others worry their children are too young for this vaccine, though the vaccine is most effective before people become sexually active (on average, at age 15 in the U.S.). Education and time will help sort this misinformation out.

That out of the way, the common barriers — and solutions — to getting kids vaccinated are practical ones. First, the vaccine is primarily targeted toward teenagers. They’re healthy and busy — and hard to get into the doctor’s office. At best, we can get them in once a year for a checkup and immunize them there. But this vaccine is a three-dose series, and getting this group of kids — who go between home, school, friends, extracurricular activities, etc. — back isn’t so easy. Most teens also don’t feel physically vulnerable to illness, let alone a chronic or life-threatening disease. How do you motivate one to come in to stop a disease that might be three or four decades away?

If and when teens do come to the office, doctors present our own barriers to vaccination. First, we miss a lot of opportunities. While teens don’t usually develop devastating illnesses, they frequently come in with a cough, a sore throat or some other minor problem. If we’re not taking that opportunity to offer to vaccinate them, we’re missing the chance to save their lives. My practice uses something called the “Preventive Health Prompt,” which lists all vaccines a patient is due for. Our hope is that if the doctor doesn’t catch that the teen in front of him or her needs HPV, the parent or child will ask for it themselves, since we provide that list at every visit and online.

But there are also missed opportunities during routine visits. We know, for example, that it’s a strong influence when a doctor urges a patient to get the vaccine. Yet this doesn’t seem to happen as often as it ought to: In one study, among girls and young women who had planned to get the vaccine, a third who didn’t said that the most common reason was that their doctor did not offer it to them. Similar findings show up in other research.

When we do offer the vaccine, how we frame it can backfire. In many cases. the discussion of preventive HPV vaccination focuses on sex. That can be unsettling for parents and time-consuming for doctors. If it doesn’t go right, the myths of a child’s being too young for the vaccine or that it’s a ticket to sexual activity can easily surface. Finally, the vaccine’s cost is a major barrier, though not to patients. Rather, it’s doctors who get burned. The HPV vaccine is the most expensive of all recommended children’s vaccines. It costs $360 to vaccinate one child ($120 per dose). By comparison, most other recommended vaccines cost less than $50. Doctors have to pay the upfront costs, hoping that insurers will reimburse them. In some cases, doctors have only received $2 above the cost of the vaccine. This, and the tepid demand for it, makes it bad business to stock up.

The good news is that most of these barriers have solutions. Simple, straightforward education is a sure bet. In one study, the intent to vaccinate rose from 49 percent to 70 percent after doctors gave families educational literature about the vaccine. Making sure doctors frame the discussion about the HPV vaccine in terms of cancer prevention –  instead of sexual activity — has been shown to help improve uptake.

One way to get teens to come back for the full series is to reach them on their cellphones. In a recent study, researchers sent a group of patients text message reminders to come in for their HPV vaccine booster, and compared the results to a group that did not. The group that was texted was significantly more likely to return. Given that teens send an average of 3,000 text messages each month, the results are a good sign that this is one of the best channels to connect doctors and teen patients.

Then there are some more old-fashioned ways to get kids vaccinated. The first is to make them. In the U.K., rates of HPV vaccination hover around 80 percent. The reason for this staggering success is that the vaccine is mandated through a school-based program. School nurses get and administer the vaccine (if parents don’t want their child to receive it, they must opt out).

Yet, as the Republican debate highlighted, political and legal mandates are very divisive. Instead, we can also rely on some good old-fashioned “mandate” from Mom. It turns out a mother-daughter discussion can increase the rate of vaccination, even if the daughter is over 18 and no longer requires parental consent to get vaccinated. So moms, please help your kids to grow up cancer-free.

(Note: Dr. Parikh has no relationship, financial or otherwise, with the manufacturers of the HPV vaccine.)

She ought to have known better than to have heeded this column. “If Michele Bachmann can’t make an issue of [Rick Perry's] ill-fated executive order requiring sixth-grade Texas girls to be vaccinated against sexually transmitted diseases,” I had written, “she’s got no business running.”

The Texas governor’s political misstep was made-to-order for any self-styled Christian conservative. Ordinarily, it’d be easy to agree with former George W. Bush speechwriter Michael Gerson, writing in the Washington Post: “If Republican presidential candidates want to debate sexual health and hygiene, it would be nice if they displayed more collective knowledge and judgment than your average eighth-grade family-life class.”

Or with Gov. Perry himself, explaining that his motive was to protect women against a potentially fatal form of cervical cancer.

“We instigated, with HPV, a national debate, and I think appropriately,” Perry told Texas Monthly in 2007. “As a matter of fact, the more I know about this disease, the more I know that we are absolutely, unequivocally correct.” He added that Texas Medicaid spends $175 million per year on cancer treatments and hysterectomies.

Ah, but nothing’s ordinary where sexuality is concerned. Never mind that sexual intercourse comes close to being a human universal — ponder that next time you’re meandering through Walmart — nobody’s eager to popularize the practice among 12-year-old girls. Social conservatives resent the government taking over a solemn parental responsibility.

Or, as Bachmann said during the recent CNN/Tea Party debate, “To have innocent little 12-year-old girls be forced to have a government injection through an executive order is just flat-out wrong.”

Public health experts say waiting any longer risks being too late. Even so, Perry acknowledges he should have asked the Legislature.

Things got tricky for the Texas governor when Bachmann brought up payola. “The drug company gave thousands of dollars in political donations to the governor,” Bachmann said. “And this is just flat-out wrong.”

She flat likes that phrase.

“The company was Merck, and it was a $5,000 contribution that I had received from them,” Perry said with bemused condescension. “I raise about $30 million. And if you’re saying that I can be bought for $5,000, I’m offended.”

“Exactly what is your price?” Bachmann might have asked. Merck had actually given Perry $30,000. Not to mention that his former chief of staff and other aides had remunerative ties to the pharmaceutical company lobbying to have its Gardasil vaccine adopted nationally.

But that barely scratches the surface. Even in Texas’s pay-to-play political culture, Perry’s brazenness is a wonder to behold. His campaign donations from contributors seeking everything from nuclear waste dump permits to seats on the Texas A&M board reach into the tens of millions.

“When you are trying to figure out Rick Perry, you need to do two things,” Denton (Texas) Record-Chronicle‘s Mike Trimble advised out-of-state reporters. “Find the lowest common denominator and follow the money.”

Unfortunately, Bachmann got distracted by the innocent little girl issue, turning it into a characteristic blunder. On the “Today” show, she told about a crying mother who approached her after the debate.

“She told me that her little daughter took that vaccine, that injection, and she suffered from mental retardation thereafter. It can have very dangerous side effects … This is the very real concern.”

Needless to say, there’s no medical evidence whatsoever for this madly irresponsible statement. For religious zealots like Bachmann, the world is made of words. She’s made a career of crackpot pronouncements for which her sole authority is the last person she talked to. On the medical front, to cite one example among many, Bachmann once blamed a 1976 swine flu epidemic on Jimmy Carter. (Gerald Ford was president, not that it was his fault.)

But this time, conservative commentators turned against Bachmann as one. Not only Gerson, but the Wall Street Journal, Rush Limbaugh and her former campaign director Ed Rollins suddenly discovered that Bachmann’s a wackjob. “This is the nail in the coffin in her campaign,” a former Republican National Committee official told the New York Times.

In the New Republic, Walter Shapiro reported that on Fox News “Bachmann was almost entirely absent, like a Red Army general excised from the Great Soviet Encyclopedia after being purged by Joseph Stalin.”

I wonder if she’s gotten the message.

From the San Francisco Chronicle:

“I didn’t make any statements that would indicate I’m a doctor, I’m a scientist, or making any conclusions about the drug one way or the other,” she said, adding she was merely relating the concerns of a woman who was “very distraught” and who supported her view that Perry’s actions were wrong.

Asked specifically if she would apologize for the HPV comments, Bachmann said, “I’m not going to answer that question.”

So, no, she will not apologize for that. She won’t apologize because she still needs the HPV issue to hammer Rick Perry, which she is still attempting to do.

No more “retardation” talk! Just “mandates” and crony capitalism.

Michele Bachmann, by the way, did used to campaign around Minnesota as “Dr. Michele Bachmann.” Bachmann called herself “Dr.” because she has a J.D. from Oral Roberts University. (While some lawyers argue the point, “Dr.” is generally reserved for medical doctors and people with Ph.D.s.) But she hasn’t called herself “Dr.” recently, so make sure not to take any medical advice from her.

Lieberman, the “model purple senator” and avowed champion of moderation, is surely praising centrist Republican Jon Huntsman and pragmatic former blue-state governor Mitt Romney, right? Nope. Lieberman instead has kind words for Michele Bachmann and Rick Perry, the 2012 race’s two most outspoken conservatives.

Why does Joe Lieberman, former Democratic candidate for vice president, like Bachmann and Perry so much? (I mean besides because those two are the ones who inspire the more liberal fear and loathing?) Because Bachmann and Perry share Joe Lieberman’s love of constant sanctimonious religious moralizing, of course.

Lieberman respects Michele Bachmann and Rick Perry, two Republican presidential contenders who have spoken up about their faith on the trail. “I know this got controversial recently, with Governor Perry and Congresswoman Bachmann. But they didn’t give up their First Amendment right to free expression and freedom of religion when they decided to run for president,” he says. “I like it when a candidate, if they feel comfortable, talks about their faith. It’s very interesting to me; it tells me more about the candidate, giving me one more factor to evaluate about what kind of president they would be.”

“Others may be turned off by it, even by the very fact that you’re talking about it, or the way you’re articulating it,” Lieberman says. “That’s the risk you take.” But he emphasizes that while some may find Perry’s public prayers troubling, or Bachmann’s Christian declarations strange, many Americans find such words “reassuring.” In this sense, he urges all politicians, if they are so inclined, to speak up, even if they are not religious experts, in order to make politics more hospitable to religious discussions.

Yes, a lot of work still needs to be done to make politics more hospitable to constant pious invocations of The Lord. It is a good thing Joe Lieberman is standing up for the First Amendment right of all politicians everywhere to be an outspoken evangelical Christian who uses religious arguments to justify political decisions.

“This is classic America,” Lieberman says. “The Constitution promises freedom of religion, not freedom from religion. The whole history of the country is intertwined with religion. The founding documents are premised on a world view, actually a very creationist world view.” Since then, “We have found a way to invite religion into the public square without pushing all but one religion out. It’s remarkable.”

Classic America.

The Constitution actually “promises” that the government “shall make no law respecting an establishment of religion,” which is arguably closer to “freedom from religion” than the other way around, but that’s splitting hairs. What’s important is that we all agree that the Constitution is “creationist” (?!) and Rick Perry and Michele Bachmann are Classic America.

(Does Joe Lieberman know that there are actually a couple members of a religious minority in the GOP race, by the way? Wouldn’t the Mormon candidates be a better example of America “inviting religions into the public square without pushing all but one religion out” than the dominionist Protestants?)

You could tell when the Politico/MSNBC-sponsored debate began that the moderators wished there were fewer people onstage. Almost the first 15 minutes of the debate were spent on an argument solely involving the only two people with a shot at the nomination: Rick Perry and Mitt Romney. Brian Williams and John Harris clearly preferred addressing their serious questions to those two, and many of the questions aimed at the others onstage were about one of those two ex-governors. Poor Michele Bachmann, heretofore the only credible non-Romney candidate, seemed barely to be present. Huntsman got a lot of airtime, but he’s been getting plenty of press attention this whole time.

The lovable third-tier candidates — the guys who were never, ever going to win this — will have fewer and fewer chances to share their madness with America after last night. Newt Gingrich, Herman Cain, Rick Santorum and Ron Paul will remain in the race for a while longer (or a lot longer, in Ron Paul’s case), but going forward, they’ll be less likely to be invited to debates, less likely to inspire “dark horse” fantasy analysis stories, and less likely to inspire blog posts documenting crazy things they said. (Well, fine, they’ll continue inspiring blog posts until I stop writing them because people have stopped clicking on them.)

The debates do lose something when the candidate pool coagulates into two very slightly different people. Ron Paul will occasionally bring up the few things he is right about, like the drug war. Herman Cain is the funniest person on the stage, without fail. Rick Santorum is fun to have around as a reminder that sometimes assholes aren’t rewarded for their awfulness. And Newt Gingrich can still nail an applause line — he got love from the (deplorable) audience by demanding an English-only law and rather pointlessly attacking the media for … asking him to debate his colleagues.

Of course Bachmann is still in third place. But the data indicate she could still win the Iowa caucuses in January. So it was truly weird that the moderators ignored her in favor of hopeless cause (and liberal favorite) Jon Huntsman. Neglecting Bachmann does help the press create the “narrative” of her impending collapse now that Perry’s in the race. But that’s premature. We’ve got a year to watch Perry and Romney beat each other up; there’s no reason to prematurely push everyone else out. Even if everyone else is laughable.