Scientists and public health practitioners blame the media system for being careless in presenting research findings and insensitive to its impact on the public. Journalists in turn accuse the medical community and its institutions of being obscure and uninterested in the public implications of their work. In fact, we know little of how much the supposed flaws of the news media on reporting public health issues depend on the quality of reporting or its sources.
Factors endogenous to the production of the news media include motivation and the organizational routines and practices of the media industry. Since the first rule of journalism is that what is published must be read, reports of an immediate menace to the daily life of the readers (such as food scares) is easier to relate to the readers’ personal experience and more likely to get the readers’ attention than some distant, long-term risk (Laurance, 1998). The techniques use a number of discursive strategies, including personalization and vocabularies emphasizing fear and danger, as well as an extensive use of the ‘rhetoric of quantification,’ through the repetitive citing of extremely large numbers of potential victims and persons at risk (Miller, 1999).
Time and space always make the top of the long list of organizational constraints over the production process of the news. The time factor seems to be the major difference between the print media and television, where reporting is usually limited to a few sound-bites. Lack of context comes as a crucial difference between medical and other news, where journalists can safely assume readers’ common background. Occasional and fragmented coverage of medical discoveries makes medical research appear as a series of unrelated breakthroughs, instead of an ongoing effort with frequent turnarounds. This is particularly the case with television coverage, which usually focuses on episodic events, in contrast to newspapers, which tend to frame their stories more thematically (Iyengar, 1991). Journalists’ professional norms of fair and balanced reporting can also confuse the public, since the rule of presenting both sides of a story implies legitimizing opposing views that are at the margins of mainstream science (Dearing, 1995; Boykoff and Boykoff, 2004).
A fundamental study of the interface between medical journals and the news media industry analyzed the making of medical news, examining the characteristics of medical articles published in The Lancet and the British Medical Journal that the journals’ editors highlighted in their press releases and that were subsequently reported in two British newspapers (The Times and The Sun) at the extremes of the market of the print media (Bartlett et al., 2002). ‘Bad’ and ‘good’ news were proportionally represented in the press releases, but bad news was more likely to make both newspapers. Findings from randomized controlled studies were more likely to be press released, but less likely to be covered in newspapers. Both newspapers were equally selective regarding specific topics: studies of women’s health are over-represented in press releases and even more so in the newspapers; whereas cancer and elderly studies were proportionally represented in press releases but over-represented and entirely ignored, respectively, by both newspapers.
This study is important for the analysis of the production process of medical news in showing that the editors of both medical journals press-released a similar proportion of published papers (45.4% for The Lancet and 41.1% for the BMJ ) and that all medical news that made the newspapers had been press-released – although the poor quality of the press releases, when compared with their original papers, has been repeatedly demonstrated. For example, out of the press releases from six consecutive issues of nine different leading medical journals, only 65% quantified study results, 23% mentioned study limitations, and 22% of studies funded by the industry reported such disclosure (Woloshin and Schwartz, 2002).
Medical reporters are cognizant of the intrinsic limits of their instruments, concerned about the impact of their work on the general public, and willing to take responsibility for false or premature hopes; moreover, their suggestions for improving medical reporting are similar to scientists’ proposals (Winsten, 1985; Entwistle and Watts, 1999). Commonality of analyses and intents directs the attention toward external factors affecting both the products of medical news and their original scientific sources.
Cozy Relationships
Medical journals and their press releases, along with health-care and research institutions and individual researchers, have long been the primary source of information for the news media, which frequently push for publication (Einsiedel, 1992).
The use of popular media by individual scientists to seek visibility for their research was first analyzed in Nelkin’s groundbreaking book Selling Science:
Increasingly dependent on corporate support of research or direct congressional appropriations, many scientists now believe that scholarly communication is no longer sufficient to maintain their enterprise… . They see gaining national visibility through the mass media as crucial to securing their financial support (Nelkin, 1999: 133)
To prevent premature diffusion of scientific news to the public and to maintain the primacy of peer review for legitimization and recognition of the scientific validity of research findings, the Ingelfinger Rule proscribed the publication of articles in medical journals after their content had first appeared in the lay press (Altman, 1996). However, the funding of research by private corporations and the patentability of scientific discoveries have further expanded the interest of scientists and their institutions for media coverage. Competition for press coverage among research and health-care institutions increasingly interlocked with the corporate world, combined with obvious efforts by drug and devices manufacturers, as well as by a host of other industries with corporate interests in the public health field (such as tobacco and food industries), resulted in aggressive marketing of research findings by corporate sources, academic institutions, medical journals, and professional organizations (Etzowitz, 1998; Brennan et al., 2006).
A steady stream of empirical studies have documented the effects of the industry links on scientific outcomes, providing extensive evidence of the complex web of influence corporations wield over biomedical research, medical education, and health care. This is the focus of extensive analyses in the medical literature (see, e.g., Angell, 2004 and Kassirer, 2004) as well as of concern for governmental bodies. Discussing the ‘lax oversight’ of the Department of Health of the British government over the pharmaceutical industry, the Select Committee of the House of Commons stated that ‘‘pharmaceutical companies will inevitably continue to be the dominant influence in deciding what research is undertaken and conducting that research, publishing it and providing information to prescribers’’ (House of Commons Health Committee, 2004–05: 3).
Empirical research has clearly proved that conflicts of interest (financial or otherwise) are associated with greater chances of pro-industry biased research, increased secrecy, and inappropriate publication practice, such as keeping less favorable results secret and/or publishing positive results from studies of poor quality in symposium proceedings and medical journals’ supplements, with no peer review (Rochon et al., 1994; Bekelman and Le Yan, 2003; Bhandari et al., 2004; Ridker and Torres, 2006). Members of panels in regulatory agencies maintain industry ties, influencing their decisions on regulatory issues (Steinbrook, 2005; Lurie et al., 2006). These empirical findings are consistent with the tobacco industry strategies revealed by the analysis of the ‘tobacco papers,’ that is, the internal documents whose disclosure was forced by the U.S. tobacco settlement and the U.K. Health Select Committee Inquiry (Bero, 2003). These documents have provided the first significant exposure of industry practices, which are being used as a template for studying the role of the industry and the business community in other fields, such as the food industry.
Of course, industry sponsors have no absolute obligation to science or to the health of the public, since corporations maintain a fiduciary duty only to their shareholders, under the axiom that ‘the business of business is making business’ (Friedman, 1970). However, the solid evidence for the significant effects of conflicts of interest in individual scientists and their parent organizations should have called for a strong policy of full disclosure. Most leading medical journals have adopted such policies but their enforcement is inadequate and their effectiveness is limited (McCrary et al., 2000; Krimsky and Rothenberg, 2001).
Peer-reviewed journals aim at providing the most reliable and unbiased scientific information, under the assumption that science is operating according to the Mertonian norms of communality, universality, disinterestedness, and organized skepticisms. However, because of what Horton (current editor of The Lancet) defines as ‘‘the privatisation of knowledge,’’ ‘‘medical journals have become an important but unrecognised obstacle to scientific truth-telling’’ (Horton, 2004). According to Richard Smith (former editor of the BMJ), they currently are just ‘‘an extension of the marketing arm of pharmaceutical companies’’(Smith, 2005). In fact, medical journals are not only repositories of medical knowledge for a small circle of specialists, but also businesses that generate substantial income for their owners (frequently, a medical association) and, usually, fat salaries for their editors (Smith, 2006a).
The role of peer review has rapidly changed from ‘‘a crude and understudied, but indispensable’’ instrument (Ingelfinger, 1977) to a ‘‘smokescreen’’ and ‘‘an empty gun’’ (Goldbeck-Wood, 1999; Smith, 2006b). In fact, Lawrence describes ‘‘the politics of publication’’ of top scientific journals as a riddle of forces between authors, editors, and reviewers which ‘‘all combine to create an antiscientific culture in which pushiness and political skills are rewarded too much, and imaginative approaches, high-quality results and logical arguments, too little’’ (Lawrence, 2004). Hype, which scientists use to place blame on sloppy reporters, seems also to go hand in hand with publication politics: ‘‘Hyperbole has become a common and accepted practice in science nowadays … the purpose being to persuade editors, other scientists and even ourselves that our results mean more than they do.’’
The obvious conclusion is that medical research and media industry institutions, as well as individual researchers and journalists, share a mutually reinforcing and usually undisclosed motivation for ‘stretching the boundaries of truth’ in framing the outcomes of research. Alternatively, interdependencies between research, health-care organizations, and corporations may silence scientists when their findings run against corporate interests, as with the famous Olivieri case in Canada (Viens and Savulescu, 2004).
Political scientists have long portrayed political news reporting as a story of continuous interaction between reporters and government officials who serve as the crucial resource for a steady supply of raw material for the production of their news (Schudson, 2002). The cozy symbiosis in press–government relationships where ‘‘news gathering is generally an interinstitutional collaboration between political reporters and the public figures they cover’’ (Schudson, 2002: 250) results in a press made captive by the government in charge through cash subsidies and in-kind services from spin doctors and press officers. This same coziness can be usefully considered in explaining the ‘miscommunication’ between medicine and the news media (Ransohoff and Ransohoff, 2001). To capture media attention in order to successfully compete for private and public funding, researchers and research institutions tend to oversimplify and dramatize preliminary findings, ‘jumping the gun’ on research and reporting. Stretching the truth of scientific findings to make newsworthy pieces produces tensions within the norms of balanced reporting and drives conflicts between scientists’ responsibilities to the norms of science and their personal or institutional interests.
Active Audiences
A common and implicit assumption in the analysis of the media impact on public health is that the public is generally defenseless against the media’s influence and gullible populations are traditionally portrayed as easy prey for hype and false hopes. In fact, audiences are far from being passive receivers of the messages of the news media and may prove resistant to the messages of mass campaigns.
The social amplification of risk (SAR) concept pioneered by Slovic has long recognized the active role of the audience in the social construction of risk to health and well-being (Slovic, 1987). Perception of risk has been constructed as a continuous process of blending scientific information and judgment with psychological, social, cultural, and political factors, including social values, trust in regulatory agencies, and the credibility of the sources of information. Messages communicated by newspapers as well as by scientific articles may therefore be received by different audiences in unintended ways, and risk communication alone cannot make a significant contribution to reducing the gap between technical risk assessment and its public perception. The theory of the ‘active audience’ and the concept of ‘lay epidemiology’ have much in common with SAR.
The ‘active audience’ theory emphasizes the polysemy of the message, which is open to interpretation by those to whom the message is addressed, bringing into play their own personal and collective experiences and beliefs (Philo, 1999). According to the concept of lay epidemiology, people interpret health promotion messages by integrating observations and discussions of cases of illness and death in their personal networks with the more formal and objective evidence provided by educational messages (Frankel et al., 1991). This concept has been brought to bear in explaining why the public tends to give more credence to information received from relatives, friends, and people they trust than from anonymous and more formal sources, including the media and governmental organizations, and why they show skepticism and resistance to educational messages.
The observation that people resist the message does not imply that the media are ineffectual. Sociologists and political scientists have long recognized that the identification of social problems emerges from the competition of different issues in the ‘‘marketplace of ideas,’’ under the constraint of the ‘‘carrying capacity’’ of social institutions (Hilgartner and Bosk, 1988). Miller (in Philo, 1999), in examining ‘food scares’ in the British press, has argued that news media serve as public fora where a number of interest groups (including government organizations, the industry, medical scientists, etc.) both compete for public attention in terms of how they frame medical issues, making certain aspects salient and marginalizing others, and prime emotional responses.
Frames convey the relative importance of the issue for the different audiences and interest groups, and define causal connections and the range of acceptable solutions, identifying who is to blame and who is responsible for the solution. Medical errors, for example, were originally framed as an issue for the courts under the tort law before the landmark Institute of Medicine report To Err Is Human re-framed them as a public health issue, amenable to preventive intervention (Institute of Medicine, 1999). Alternative frames compete, but can also be interactive and dialogical, so that competing interest groups may occasionally share common aspects of different frames. Obesity has been alternatively framed as a medical and a public health issue, emphasizing individual health risk and/or collective problems; an aesthetic issue, against the accepted model of a thin body; a social justice issue, in terms of nondiscrimination of the obese; and a market choice issue, where responsible consumers are free to make their own informed decisions about eating behavior. Different stakeholders, including the government (mostly interested in the public health and cost-containment angle of the problem), the food industry (promoting the informed free choice approach), and citizen organizations (taking either a public health or a social justice stance), are the major agents competing for the dominant frame resulting from different combinations of the original versions (Lawrence, 2004). The emergent frame for obesity combines the public health frame, portraying a global epidemic nurturing an impending disaster, with aesthetic and moral arguments, emphasizing personal responsibility and individual failings against the corporate greed of the food industry.
The main conclusions of the analyses of the agenda-setting function of the news media were popularized with the statement that media are not saying ‘what to think’ but ‘what to think about,’ which clearly rejected persuasion as the central organizing paradigm of the relationship between media and the public. The twin concepts of framing and priming (both of which imply an active role for the audience) are captured by a further twist of the phrase, where the news media do not just focus the public attention but also define the problems and their acceptable solutions (‘how to think about’) (Kitzinger, 1997, 2000). This opens the way for the news media and public health campaigns to become part of the policy-making process.
Health Policy And The Media
The public arena function of the news media and the theory of the active audience suggest that the media are more than a passive conduit through which people learn about scientific advancements and government initiatives; the media can also influence policy making by sending messages to politicians and administrators, calling them to responsiveness and public accountability (Page and Shapiro, 1983). Media politics, that is, the role of the media as actors in the political arena, has greatly increased with the historic decline of political parties as instruments of political advancement (Page, 1996). An increasing number of important social decisions, such as genetic engineering and stem-cell research, are made on the frontier of science, and the news media could serve as public fora for fostering democratic debate. Media attention has contributed to change in health behaviors, both directly and by facilitating a supportive environment, pushing local and central governments toward tougher policies aimed at preventing smoking, promoting traffic safety, and so on. Public outrage provoked by aggressive reporting and media campaigns has forced new regulations on medical practices (such as with the politics of ‘drive-through’ deliveries) and entire industries (for example, by supporting the managed care backlash in the United States) (Blendon et al., 1998). The ‘public shaming’ of doctors by elite newspapers and television news has been credited with pushing both policy makers and the profession’s leaders to adopt a systematic approach to error prevention which eventually led to the patient safety initiative (Millenson, 2002).
Health-care system reforms are more difficult stories to cover, because of the complexity of the health-care system and the lack of consensus among the experts on how to fix it (Otten, 1992). However, the mass media played a significant role in the rise as well as the demise of the Clinton Health Plan, first placing the problem of the uninsured at the top of the public policy agenda, and then helping the government plan to fail, under the attack of a devastating barrage of TV ads (Skocpol, 1996). The TV campaign used commercial-style advertising which borrowed heavily from the soap operas, featuring a middle-class couple, Harry and Louise, discussing the government proposal at the kitchen table (West et al., 1996). While not directly attacking the goal of providing universal coverage, these discussions aimed at raising anxiety about what pursuing this collective end would imply for those already insured. Both the format and the effects of this campaign are important in understanding the new ‘policy making by commercials.’ The political campaign worked less by directly mobilizing public opinion against the plan than by persuading political leaders that the government plan was producing uncertainty and anxiety in the public. This novel approach in the strategic use of the media as part of the policy-making process has subsequently been used in general election campaigns and issue-specific initiatives (Goldstein et al., 2001).
A further innovation in the use of public information as an integrated part of the policy-making process is in the making in the UK. The Wanless report on health policy introduced the idea of a ‘‘fully engaged patient,’’ one who undertakes ‘‘health-seeking behavior,’’ including the management of his/her health and health care through reasonable and informed choices (Wanless, 2001). It is the government’s task to provide appropriate information to help consumers make choices, empowering the citizen/ client to navigate a health-care market designed for active consumers. Information is the core content of the new politics of health care, not just an instrument for framing the issues and their acceptable solutions.
This goes well beyond the strategy of imposing public disclosure of standardized, comparative reports on the outcomes of health-care organizations in order to secure government control of their performance and/or to shame providers into action to improve the quality of their care. Although lay media have been shown to be able to influence health services utilization when covering health-related issues (Grilli et al., 2002), disclosure to the public of comparative performance of providers has failed to show the anticipated effects on consumers’ choices among individual health-care providers (Marshall et al., 2000).
Concluding Comments
Mass media are the principal sources of information about the advancement of knowledge in health and health care and the main conduit of information from expert sources to the lay people. Formal communication campaigns superimpose on normal media coverage, competing in a media-crowded world with opposite messages. This is why examining the political economy of the production of the news media and its interplay with public health campaigns is of both practical and theoretical importance for public health practitioners and advocates.
Since medical journals are the most important sources of ideas and information for journalists writing about medicine, a substantial part of the blame – usually placed on the news media for the poor quality of medical reporting – should be shared by the research community and its scientific institutions. The reasons for and the implications of such a state of affairs are best summarized by two medical journalists who lucidly saw the impending changes more than 10 years ago: