Transcending the medical/media opposition in research on news coverage of health and medicine

Abstract

Health and medicine are major topics of news coverage, but research on health and medical reporting has remained mainly confined to specialist subfields, with less impact on broader academic fields, including journalism studies, than would seem warranted by its importance. This article argues that assumptions implicit in much of this literature have limited the development of a wider tradition of research on health journalism. We point particularly to what we call the linear-reflectionist perspective, which sees health journalism as an often-flawed mechanism for transmitting pre-existing medical knowledge to the mass public. We propose an alternative framework that seeks to illuminate the complexity and importance of this field of study.

Keywords

health health communication health news journalism science and technology studies sociology of medicine

Health and medicine are a prominent element of the contemporary news agenda. In 2009, according to the Tyndall Report (n.d. a), the two most extensively covered stories on network television in the U.S. were the health care reform debate and the outbreak of H1N1 influenza; in that year health and medicine followed only the economy as a focus of network news. Tyndall (n.d. b) also reports that the second most-used network correspondent during the first decade of the 21st century was NBC’s science correspondent, Robert Bazell, whose work, reflecting the ‘medicalization’ of science news in the post-Second World War era (Bauer, 1998), is largely focused on medical technology and research, and on health risks. The Kaiser Family Foundation/Pew Research Center (2008) found that in 2007–8 health news was eighth among major news topics in the U.S. across all media platforms.

Heavy news coverage of health and medicine no doubt reflects marketing factors – its appeal to audiences and advertisers and relatively low cost of production. It also makes sense given the centrality of this domain to social, economic and political life. The health sector constituted about 16% of GDP in the U.S. in 2011 and lower, though substantial percentages in all developed countries; as the debate on health care reform in the U.S. suggests, it is also a key political issue. Research in science-technology-society studies (STS) and explorations of ‘biosociality’ (Rabinow, 1992) have also made a strong case that medicine and medical technology have deep impacts on culture and society, shaping hierarchies of social value, defining social groups and changing conceptions of human life (e.g. Clarke et al., 2003).

There are growing bodies of research on news in health communication, among scholars interested in ‘public understanding of science’ and ‘risk communication’ and, in a more limited way, among scholars in medical sociology and anthropology, social psychology, and cultural studies. These literatures remain ‘scattered’, however, as Nelkin (1987: xi) once put it, dispersed in diverse disciplinary contexts and fragmented by disparate assumptions and methods. There has been little cross-fertilization, in particular, between journalism studies and health communication; the literature on health news is rarely cited by journalism studies scholars and, as Seale (2002) observes, health news has never received the sustained attention in the literature on news that has been devoted to other genres.

We believe there is a potential for a much broader and more integrated field of research on health journalism. Creating that field, however, requires re-examining some key assumptions about the nature of health journalism. In this article, we present a critical analysis of some of the most significant components of the research literature, examining key rhetorics and assumptions which have structured the formulation of research questions and the presentation of findings, and presenting ideas for transcending those assumptions.

The argument proceeds as follows. In the first section, we discuss a logic that positions medicine and public health on one side of a dichotomy and journalism on the other. This perspective privileges biomedical perspectives as providing authoritative representations of medical subjects and objects, and subordinates journalism to the role of circulating this pre-existing knowledge. We refer to this orientation as the linear-reflectionist perspective. It can be found particularly, though not exclusively, in the health communication literature and in research published in public health journals. This research tradition is most strongly developed in the United States, though not exclusive to that country. We suspect, however, that, reflecting the broad social and cultural influence of biomedicine, its assumptions are widely taken as common sense, both in the U.S. and, as we will argue in the conclusion, in other parts of the world, and may in part account for lack of interest in health journalism in fields like journalism studies or medical sociology and anthropology. If health journalism is ‘nothing more’ than an imperfect mechanism for transmitting health knowledge from scientists to the lay public, why is it interesting as an object of analysis, except to those whose focus is on health education?

The critique of the linear-reflectionist perspective presented here draws on the ‘culture-centered critical health communication’ literature (Dutta, 2008, 2010; Zoller and Dutta, 2008), rooted in part in subaltern and postcolonial theory, which emphasizes cultural differences and social processes in examining whose health knowledge is validated and whose is marginalized. This literature, though it refers centrally to the classic work of Lupton (1994), has not focused in a central way on news; we try to address the issue here specifically in reference to the role of journalism. The mainstream health communication literature is rooted in a health education, not a media studies perspective. Our critique of this literature is not intended to imply that its research questions are unimportant or illegitimate, though we will make the argument that some of its formulations seem naive from the point of view of journalism studies or medical sociology/anthropology, and that it could often be strengthened by greater reflexivity. Our main intent, however, is to argue more broadly for critical scrutiny of the assumptions scholars make about the nature of health journalism as an essential move in developing a wider research agenda.

In the second section, we compare the health communication literature on news with the literature on public understanding of science, which is more international in its origins than the health communication literature, with strong European participation, in particular. Here we see interesting differences in conceptualizing what it means to communicate science to the public, that suggest some of the diversity and complexity of the roles of health journalism. In the third section we focus on some formulations of these literatures that seem problematic in their understanding of journalism. In the fourth section we outline elements of a wider interpretation of the role of health journalism, and suggest some ways in which we think approaches from journalism, media studies and political communication might contribute to a fuller analysis of what health journalists do. In the concluding section we locate health journalism in a wider theoretical context, drawing on the critical health communication literature, on the literature in medical sociology/anthropology on ‘biomedicalization’, and on Bourdieuian approaches to the sociology of news.

Our discussion of health journalism comes out of a research project that involves content analysis and discourse analysis of both print and television coverage of health and medical reporting, interviews with journalists and news sources, and some audience reception analysis. We will make occasional reference to this research to illustrate some of our points, though this article is intended as a critical commentary on the existing literature, not as a research article.

The linear-reflectionist perspective and ‘interreality distortion’

In health communication, and in a wide range of literature beyond it, including much that appears in medical and public health journals, research on health journalism tends to be dominated by a perspective centered around the concept of the news media as a means by which scientific information is transmitted to the mass public, which we call the linear-reflectionist perspective. Research is focused on the accuracy of this transmission and factors that ‘distort’ it. These factors are most often, though not exclusively, understood in terms of what Seale (2002: 51) calls the ‘two cultures’ explanation: as a result of differences between the cultures of science and journalism. News media are seen as a potential resource for public health promotion, but as a worrisome and often problematic one due to perceived limitations of journalists (their lack of scientific training, particularly) or contradictions between journalistic goals and those of health education, clinical medicine and public health.

‘The reality of cancer’, one typical article notes in its introduction, ‘does not always match public or individual perception of the disease.… One source with the potential to distort perception of cancer is news coverage’ (Jensen et al., 2010: 137). Summarizing the literature on cancer coverage, these authors write that ‘certain cancer sites were found to be covered disproportionate to their actual incidence and mortality rates, a phenomenon that came to be known as interreality distortion’ (2010: 139). Their primary research question is: ‘How do interreality distortions in the present study compare with previously observed interreality distortions?’ This literature has found that breast cancer is over-represented relative to actual incidence and mortality rates, while other cancers are under-represented. It has found – taking a standard biomedical division of the phases of medical attention to cancer, the ‘cancer continuum’ extending from prevention to detection/diagnosis, treatment, survivorship and end-of-life – that news coverage tends to focus most heavily on treatment, and decries the lack of attention to prevention and screening as problematic from the point of view of health promotion, as it ‘may cultivate the belief that cancer is something to be reacted to rather than prevented’ (Jensen et al., 2010: 149). Finally, it has found that coverage of risk factors focuses increasingly on lifestyle, which ‘corresponds nicely with cancer prevention research’ (2010: 149), though unfortunately it does not focus clearly on the three principal lifestyle choices – smoking, diet and exercise – that are seen in cancer prevention research as the largest risk factors.

Examples of this focus on distortion in the transmission of scientific information are common in a wide range of the literature within and beyond health communication. ‘Much of the research concerning how science is presented in the public press’, write Brechman and colleagues (2011: 496), ‘compares content between original science publications and mainstream news media.’ Titled ‘Distorting genetic research about cancer: from bench science to press release to published news’, this article involves the innovation of looking not only at the coverage of research in the media, but also at its representation in press releases. Statements culled from news reports and from press releases were presented to graduate students in genetics to be rated for their accuracy. ‘The findings’, they conclude, ‘suggest that as scientific knowledge is filtered and translated for mass consumption, there are slippages and inconsistencies that result in coverage that does not fairly represent the original science’ (2011: 506–7). Walsh-Childers, Edwards and Grobmeyer (2011) used doctoral students in medicine to code magazine articles for their inclusion of and accuracy in stating 33 ‘key facts’ about breast cancer. The hierarchical structuring of epistemologies and cultural fields involved in the linear-reflectionist perspective is evident in the procedure of using medical students to judge journalism. Da Silva Madeiros and Massarami (2010: 1–2) introduce an article on Brazilian television coverage of the 2009 H1N1 pandemic by noting that ‘various studies have shown that journalistic coverage of health/medicine issues tends to fail.… [P]reliminary results are highlighted rather than mature research … imprecise information based on scientific articles … exacerbation of the facts through images and special effects.’ The titles of many articles clearly announce the linear-reflectionist, or transmission/distortion perspective: ‘Misrepresentation of health risks by the mass media’ (Bomlitz and Brezis, 2008); ‘Relative risk in the news media: a quantification of misrepresentation’ (Frost et al., 1997). Seale (2002), who critiques this research perspective, summarizes many other examples.

In many ways, the linear-reflectionist perspective and the focus on ‘interreality distortion’ is reasonable and even obvious. Starting with Lippmann and Merz (1920), media analysts have used comparisons between news representations and alternative accounts of reality to foreground the constructed nature of news, to establish that news cannot be understood simply as a mirror of reality, and thus to open the question of the social processes that account for its emphases and silences. In the biomedical field there are highly developed bodies of knowledge that can serve as alternative accounts of reality. The media rely heavily on the authority of those bodies of knowledge to legitimize their representations and communicative authority, and it is reasonable to ask whether they are getting it right. It is clearly useful to document patterns in news coverage, like the focus on treatment over prevention, in an effort to make those involved in the process by which health news is produced aware of the patterns of emphasis and to generate reflection about the news decisions that produce them.

These comparisons also lead to hypotheses about processes that shape patterns of emphasis, which, as we will argue below, are potentially interesting for understanding the wider social process by which health knowledge is produced – though only, in our view, if we push beyond the confines of the linear-reflectionist perspective. Slater et al. (2008) and Jensen et al. (2010) argue that the differential representation of cancer types can be explained by the strength of organized media advocacy. Menéndez and Di Pardo (2009), coming from a very different intellectual tradition of medical anthropology and Latin American critical epidemiology, compare the content of Mexican newspapers with epidemiological data and find that in 2002 HIV/AIDS dominated media coverage, constituting almost 15% of the press coverage in Mexico City, though it represented less than 1% of deaths in Mexico that year. HIV/AIDS coverage also focused heavily on women, though they represented a small number of cases. Cirrhosis and related liver diseases ranked fourth as a cause of death but were essentially unreported in the media. These findings open the way for discussion of a number of factors that may influence health journalism, ranging from organized advocacy, as in the case of breast cancer, to policy priorities, to liquor advertising.

While a focus on ‘interreality distortion’ may be a useful starting point, however, it is extremely limiting if it serves in effect as a general paradigm for research; presented without qualification it essentially reproduces a folk theory or ideology about health communication, corresponding closely with what Briggs and Hallin (2007) call the ‘medical authority model’, which can be summarized as follows:

medical science produces an objective representation of reality with which news coverage can be compared;

knowledge consists of pieces of information which can be transported across social contexts (‘immutable mobiles‘, in the words of Latour, 1988);

the role of journalists is to transmit information from medical authorities to the lay public;

the lay public is ignorant about health, and the function of public health communication is to make up this deficit, displacing popular misinformation with correct information produced by medical science; and

in sum, health communication is a linear, non-recursive process; the production of biomedical knowledge is autonomous of the media, the public, and society in general, and any independent role the latter may play in the process is to be understood as ‘distortion’.

It is evident this model is out of step with contemporary scholarship, both on journalism and on science and medicine. The field of journalism studies long ago moved beyond the idea that media analysis was about exposing ‘bias’ in media representations (Schudson, 2003), just as the field of communication in general moved beyond understanding communication exclusively in terms of the transmission of information. STS, meanwhile, has developed a large body of research that demonstrates that the production of scientific knowledge is shaped by politics, economics and culture, and that lay understandings of science and health cannot be reduced to misunderstandings or partial assimilations of scientific knowledge (Jasanoff et al., 1995). Few of the scholars we cite above, we assume, would endorse the model laid out above if it were made explicit; nevertheless it seems to be implicit in the way much research on health journalism is formulated and presented.

Communicating science or shaping behavior?

The public understanding of science (PUOS) literature on health news is similar in many ways to the health communication literature, concerned about how the news media communicate scientific knowledge to the mass public. When we compare the two, however, there are interesting differences in how they conceive public understanding of science that begin to suggest some of the reasons it might be important to think through the role of journalism in the construction and circulation of health and medical knowledge more systematically.

Much of the PUOS literature on health news employs the linear-reflectionist perspective in whole or in part; some of the articles cited above fall within this research tradition. Because of its disciplinary diversity, however, this literature includes more extensive debate about the kinds of epistemological and theoretical questions raised here. The Social Amplification of Risk Framework (SARF), for example, has been criticized in recent literature for relying on a ‘transmission or transportation model of communication in which “authoritative messages” travel from the centre of expertise and legitimated power to lay publics’ (Murdock et al., 2003: 158) and on a ‘deficit model’ of lay understanding (Hom et al., 2011).

A key question we have not yet explored is why it matters that scientific knowledge is accurately conveyed to the mass public. The PUOS literature includes many perspectives on this question, from the role of information in individual behaviors related to risk (a common focus in SARF), to the judgments citizens will make about policy issues related to science and technology, to support for science as an institution (including support for research funding), to appreciation of science as a knowledge-producing practice. A policy perspective in Public Understanding of Science in 2001 distinguished between public understanding of science, in the sense of understanding the results of established science, and public understanding of research, in the sense of understanding the process of research ‘as it is happening, including the set-backs, detours and disagreements, as well as the positive aspects of new discoveries and exciting new directions for exploration’ (Field and Powell, 2001: 423)

In the mainstream health communication literature, there is a much more consistent assumption that faithful transmission of medical science matters because it will influence individual behavior and hence affect health outcomes, and the news media are commonly described in this literature as a ‘health education service’ (Brechman et al., 2011: 496) or as a ‘vehicle for dissemination of cancer control messages’ (Stryker et al., 2007: 24). In part – it seems reasonable to assume – this perspective reflects the institutional interests of the funders of health communication research, government agencies and foundations concerned with health education, and hence interested in research which would make possible more effective ‘use of the news media to disseminate [disease] control research’ (Stryker et al., 2007: 20). This is a worthy objective to be sure; it clearly also involves a very different understanding of what it means to communicate science than is found in other branches of literature. Niederdeppe and colleagues (2010: 246), for example, criticize local TV news coverage of cancer for focusing on research which is ‘novel or controversial’, rather than emphasizing ‘well-documented causes and known prevention methods’ – a clear contrast with Field and Powell’s (2001) stress on promoting public understanding of ‘the positive role of controversy’ in science.

Another illustration of this difference can be seen in a comparison of cancer coverage in mainstream and ethnic newspapers (Stryker et al., 2007), which refers to a National Cancer Institute recommendation that educational material use no higher than a fifth grade writing level, and assesses news stories on this variable. The PUOS literature, meanwhile, is peppered with complaints that media coverage does not represent science in its full complexity. These differences point to the complexities and contradictions apparent in what are often taken to be common-sense and unstated assumptions regarding health and medical journalism, and what it is expected to accomplish. Disseminating disease control messages may work with writing at a fifth grade level; explaining complex science probably will not (Hinnant & Len-Ríos, 2009). Even to the extent that we accept that media coverage of health and medicine is mainly to be understood in terms of the communication of scientific knowledge to the mass public, that communication takes place in the context of different social processes, with different purposes.

The two conceptions of the media that are assumed in these literatures – what we might call the representational and instrumental variants of the linear-reflectionist perspective, of media as representation of reality and media as tool of public health policy – are potentially contradictory in a number of ways. As another example, consider the 2009 H1N1 epidemic. H1N1 coverage dwarfed that of any other health problem at the time and was particularly heavy in the first week after the virus was identified. If we look at the epidemiology, this would clearly be a massive ‘interreality distortion’, as H1N1 was far from the leading cause of mortality or morbidity in the United States, and the peak of U.S. coverage occurred when there had been only a handful of cases and no deaths in the country. In this case, however, ‘interreality distortions’ reflected not a cultural gap between journalism and medicine, but the fact that public health authorities were using communication, with the cooperation, to a large extent, of journalists, as a means of prevention. As Richard Besser, Acting Director of the Centers for Disease Control during the H1N1 epidemic (later medical correspondent for ABC News), put it to us, ‘if you start small, if you start incrementally with a new outbreak … you’d have no chance whatsoever.… You have to hit it hard … hit it early.’ One might call this phenomenon ‘productive interreality distortion’; it dramatizes the fact that what is at stake in health reporting is not simply the representation of ‘reality’ but social purposes. Disseminating ‘disease control messages’ is one of these purposes, but certainly not the only one. Besser’s statement could point us in the direction of seeing news coverage as part of a complex, multi-sited process in which researchers, clinicians, public health professionals, journalists, advocacy groups and audiences co-construct medical subjects and objects.

Taking health journalism seriously

To a journalist, or to a scholar in journalism studies, the kinds of phrases quoted above about the ‘use of the news media to disseminate control research’ raise red flags immediately. Journalists are resistant to the idea that it is their role to be ‘used’ by anyone, whether it is military leaders who believe the media should help them win wars, police officials who believe they should help them catch criminals, or central bank officials who believe they should help them calm jittery markets – at least professional norms say they should be wary of this idea. Health and medical reporting is to a degree different: reporters covering this ‘beat’ often express more didactic and instrumental conceptions of their role than other journalists. Some of them, in fact, are medical and public health professionals: the U.S. television networks all employ practicing physicians as chief medical correspondents. This hybrid character of medical reporting, its combination of communicative norms of journalism with those of medicine and public health (in contrast to the ‘two cultures’ interpretation), is one of the things that makes health and medical reporting interesting from the point of view of journalism studies. Even medical correspondents who are also physicians, however, and still more so the wide range of their colleagues who cover health and medical issues across many genres of journalism, are doing something more active and complex than simply disseminating disease control messages or ‘cultivating accurate illness representations’ (Jensen et al., 2010). Nucci and colleagues (2009), for example, in a study of network television coverage of the spinach recall of 2006, note that while the Food and Drug Administration’s press releases emphasized health education, in the sense of disseminating information about how to avoid the risk of illness, news coverage focused more heavily on why contamination occurred and whether issues with the food production system needed to be addressed. Food safety stories – a common category of health news – typically involve a wide range of social issues, from industrial agriculture and its regulation to migrant labor, global trade, and understandings of racial, ethnic and national identities related to these.

Much of the existing literature on health and medical journalism, rooted as it is in the field of public health, puts journalism in the background, or on a low rung of an assumed knowledge hierarchy, and this results in formulations that can be fundamentally problematic if we seek to understand the role of journalism in the circulation of health knowledge. Consider the complaint in Niederdeppe et al. (2010: 246), quoted above, that in local TV coverage of cancer ‘many of the causes described were novel or controversial and yet likely to be relevant to many individuals (e.g. cell phone use, beef consumption, dry cleaning and exercise)’, and that the news media covered these at the expense of focusing on ‘well-documented causes and known prevention methods’. Niederdeppe and colleagues show that local TV news viewers tend to have more ‘fatalistic’ attitudes toward cancer, and they believe this is a result of extensive coverage of studies and treatments that ‘cultivate beliefs that everything causes cancer or that there are too many recommendations about cancer prevention’ (2010: 246). Local TV news has often been criticized for lack of context and perspective, and it would not be surprising if its cancer coverage were open to criticism as confusing and alarmist. Reporting things that are ‘novel or controversial and yet likely to be relevant to many individuals’, however, is at the core of what journalism is as a social practice and a form of knowledge production. Do we really want to imply that journalists covering health and medicine should drop it in the interest of disseminating disease control messages? This sounds reminiscent of paternalistic versions of the old concept of ‘development journalism’. If it is our goal to understand health and medical journalism as a social and cultural practice, we need to take it seriously as an object of study (Zelizer, 2004), to look at it on its own terms as well as from the point of view of public health authorities. Even if our purpose is to reform the way health journalism carries out one of its many functions, that of shaping individual behavior to achieve better health outcomes, a formulation that reflects a greater consciousness of the complexity of journalists’ roles might have more potential.

Beyond linear-reflectionism: the communicative work of health and medical journalism

In this section we summarize four perspectives on the communicative work of health journalism we see as particularly fruitful to pursue as part of an expanded research agenda for research on health journalism.

Health journalism as mediation

Let’s return here to the finding of Jensen et al. (2010), that ‘interreality distortions’ in coverage of cancer are the result of processes of public advocacy: social groups intervene in the public sphere to draw attention to particular health issues, resulting in more coverage of some forms of cancer than others. This is indeed a central part of the process by which health news is generated. It takes many forms, ranging from cases where new research is released and patient advocacy groups help journalists to get access to individuals whose stories can provide human interest, to stories about regulatory debates in which conflicting alliances of scientists, pharmaceutical companies, patient advocacy groups and other actors debate whether a particular treatment should be approved or reimbursed. If, instead of dismissing this advocacy process and the journalists’ interaction with the social actors who participate in it as a source of ‘distortion’ in the proper linear transmission of information, we put it at the center of the analysis, the role of health journalism suddenly comes into focus in a different and richer way.

Journalists do not simply transport scientific ‘information’ or translate what appears in scientific journals into lay language. Like other journalists, health and medical reporters operate in an environment where many interests are at stake, and conflicting perspectives contend. The diversity of perspectives journalists encounter reflects the fact that health and medical news is not simply about human biology, but concerns institutions and practices that are complex and socially embedded: medicine and public health are science, commerce, public policy, social relations, and more, and implicate a range of interests, values and knowledges. The work of the health journalist, therefore, might be seen less as transmission of information than as mediation among contending perspectives and interests. The results of these mediations, the emphasis journalists give to different issues and points of view, are important for many reasons, and their character varies considerably among media, issues, and genres of health reporting. News coverage may be important for its effects on individual health behavior, or on the stock prices of pharmaceutical companies, or on research funding or regulatory policy. If, then, we return to the question of whether health journalists reporting on cancer research are putting the news in the ‘proper context’, we have to think about the choices they have to make about which context that will be: The context of health education? The context of understanding how science advances? The context of debate about research priorities and how they are set? The context of environmental or consumer safety regulation?

Mediation and popularization

The journalists’ role of mediation, we have argued, is not simply a matter of translating science for lay audiences. Their audiences include policymakers, investors, scientists and health professionals, among others. But one of their most important tasks is certainly to mediate between lay audiences and the worlds of science, medicine and public health. This is evident in the structure of television health stories where the anchor typically follows a film report by asking the correspondent, ‘What does this mean for the rest of us?’ As we have argued, the linear-reflectionism perspective is often associated, at least implicitly, with a ‘deficit model’ of lay understandings. Jensen et al. state:

Research on illness representations has demonstrated that people ‘formulate their own representations of illness’.… This helps explain why actual cancer risk and perceived cancer risk are often different; that is, people frequently miscalculate the likelihood that they will contract a certain type of cancer … (2010: 137)

They go on to address ‘personalization bias’, closely tied to the journalists’ concern to address lay understandings, as one of the causes of interreality distortion.

Strong arguments have been made in STS and in the ‘critical culture-centered’ literature on health communication, however, against the deficit model of lay understanding (e.g. Epstein, 1996; Rapp, 1999). If we assume that lay understandings of health have their own logics and significance, then the journalist’s role of mediating between medical science, health policy, and audience perspectives can be conceptualized in a richer and less dismissive way. It is true that the need of journalists to personalize news can produce blind spots in coverage. Klinenberg (2002) shows that during the Chicago heat wave of 1995, death rates were highest among people who were socially isolated. Journalists generally missed this story, in part because they covered victims of the heat wave by interviewing friends and relatives, so those who didn’t have them remained invisible. But, of course, there is also such a thing as ‘depersonalization bias’; our research suggests that journalists often accept the same linear views of the flow of health information we have outlined here, and ‘distortions’ can result from privileging administrative perspectives at the expense of looking seriously at lay experience and understanding.

Personalization, moreover, and other forms of popularization, including narrative techniques, are fundamental to the way popular journalism engages audience attention; this is why health educators have often found entertainment media to be important vehicles for communicating health messages (Kreuter et al., 2007). As many scholars writing on infotainment have observed (e.g. Eide and Knight, 1999; Langer, 1998; Seale, 2002), if we start from the assumption that news must be purely didactic and that any deviation from this is a source of distortion, we will not be able to analyze its actual role in the production of knowledge and culture nor its potential to contribute to popular education and mobilization.

Journalism as a creator of frames and narratives

As Schudson (2003) notes, the sociology of journalism has for the most part abandoned the concept of ‘bias’ in favor of the analysis of framing and the way journalists turn events into cultural narratives. This is consistent with Carey’s (1989) broader argument against the reduction of communication to the transmission of information. From this point of view, health journalism is important because it does not merely transmit information, but participates in establishing the frames and narratives through which knowledge about health and medicine is understood and circulated. There is a fairly large literature that approaches health and medical reporting through some variant of this perspective (e.g. Joffe and Haarhoff, 2002; Lupton, 1994, 1998; Ungar, 1998), and it represents the main alternative to the linear-reflectionist literature. It is large and diverse enough that it cannot possibly be summarized here; but two examples should suffice to give a sense of the kinds of findings it includes.

Clarke and Everest (2006) argue that the ‘medical model’ dominates cancer coverage, in the sense that the focus is on technological intervention as a response to individualized fear of disease; the dominance of a medical model, which understands health in terms of individual-level biological pathology and intervention through medical technology, has been observed in many studies over the years (e.g. Signorielli, 1993). Seale (2002) explores narratives of heroism that prevail in reporting on childhood cancer, and argues that these narratives imply a view of health care as an unlimited resource which society has an obligation to use to the fullest extent possible, to honor the heroism of cancer sufferers. Narratives of this sort, Seale argues, affect not only lay understandings of disease and health care, but also the cultural context in which professionals and policymakers operate. Often the nature of these frames reflects considerable mutual influence between entertainment media and news. In the subfield of political communication, the analysis of media frames has provided a link joining the literatures in critical media studies and in media effects; we suspect that could probably also be the case in health communication (as for example in Goodall et al., 2013; Major, 2009).

The pre-mediatization of health issues

Journalists play central roles in constructing the frames and narrative structures referred to in the last section, but they do not create them all by themselves. They are, to a significant degree, co-constructed by a wide range of actors, both lay and professional, including people trained as journalists ‘embedded’ in health institutions. In political communication, the effect of the news media is understood not only in terms of the effects of media coverage on other actors and institutions, but also in terms of what we could call ‘pre-mediatization’, that is, the way media logics come to be built into the practices of other political actors (Strömbäck, 2008). The same is true of health and medicine. The initial public health response to the H1N1 epidemic, for example, was largely a communication response. Work was started on a vaccine, but its use remained months in the future. The main public health response was to alert the public through the media and urge people to wash their hands, stay home from work if they were sick, avoid panic, go to the doctor only if their symptoms were severe, etc. This response followed elaborate risk communication plans and was carried out by officials with extensive experience dealing with the news media.

The development of a new drug, to take another kind of example, often involves extensive public relations planning for a ‘disease awareness campaign’, which serves both to create a market – in some cases to reframe the condition as a treatable ‘disease’ (Dumit, 2012) – as well as to create the kinds advocacy efforts often crucial to getting a drug approved and covered by insurance. In cases of this sort, science does not exist first, later to be transmitted by the media; instead, media logics are implicated in medical research and in public health from the beginning.

Conclusion

The prevalence of the linear-reflectionist perspective across wide swaths of the literature on health journalism and, more generally, the prevalence of research questions that center around the idea of journalism as a disseminator of health control messages from scientists to the lay public, is an excellent example of what sociologists and historians of medicine have referred to as the ‘biomedicalization’ (Clarke et al., 2003) of society and culture. It reflects the extension of biomedical authority and logics into wider areas of social life and knowledge production – here into both journalism and communication research. Scholars of ‘biomedicalization’ have stressed that it is far too complex a social phenomenon to be understood simplistically as ‘good’ or ‘bad’, and an ‘administrative’ research tradition, in Lazarsfeld’s (2011) terms, centered around the promotion of health education through the news media, is perfectly legitimate. If, however, we seek a wider understanding of health journalism as a social institution and as a practice of knowledge production, an analysis that would make contributions not only to public health but also to journalism studies and to the sociology and anthropology of medicine, we need to step outside this framework, to understand it as something that is itself produced by ‘political, economic, and cultural spaces of knowledge production’ (Dutta, 2010: 534), and analyze where it fits in a wider set of processes.

As noted in the introduction, the subfield of health communication which produced much of the ‘linear-reflectionist’ research is especially strongly developed in the U.S., and its development there may be related to particular characteristics both of the American biomedical field and of American academia, including the role of funding agencies such as the National Institutes of Health. We have encountered the assumptions of this perspective quite widely, however, both in research literatures in many parts of the world, and in public discourse, and we suspect it cuts across differences in media and public health systems to a large extent. Briggs (2011) tested this proposition for the case of Cuba, finding that even in a system in which neither the media nor the public health system had the commercial structure that characterizes the United States, similar assumptions about the circulation of biomedical knowledge were strongly entrenched.

The fundamental insight developed by scholars in the sociology and anthropology of medicine as well as in the critical tradition within health communication is the idea that clinical medicine, biomedical science and public health are more than bodies of knowledge about nature and how to control it. They are social institutions and cultural systems, embedded in complex sets of relationships with the state, the market, media and the structure of social stratification, deeply affected by their relationships with those structures and in turn shaping them.

One way to forge links between the literatures on news and on medicine is to make use of Bourdieu’s field theory. In these terms, we can think of what is constructed as the biomedical field as having logics and structures of its own, but also as being deeply affected by its relations with other social fields, including, especially, those Bourdieu calls the fields of power – those of politics, economics and the media. The media field similarly has its own logics, and its own set of relations with other fields, including health and medicine. The role of journalism is important because journalism is ‘a crucial mediator among all fields’ (Benson and Neveu, 2005: 6). Health and medical journalists mediate among many actors that intervene in the process of public discussion of health-related issues, as well as between domains of knowledge and value that these issues involve – the biomedical, the economic, the political, the moral. As Marchetti (2010: 160) puts it, in a broad sociological study of French health journalism: ‘The idea of a form of information confined solely to a specialist realm … has been progressively challenged; the journalistic field retranslates new expectations linked to general transformations in the social structure of the medical field.’ This mediating role is active, complex, and very much deserving of study. It involves negotiating between the authority of medical science and public health, and the perspectives and needs of media audiences. It also involves co-producing, along with other actors, through framing and narration, structures of meaning through which we understand health, medicine, and disease. The media field is significant not only for its effects on mass audiences, but also because it has effects backward onto the structure of the biomedical field itself; this is one of the key points in the analysis of the transformation of the biomedical field in Clarke et al. (2003), the idea that the production and circulation of biomedical knowledge is increasingly a complex public process that takes place through the news, advertising, public relations, technologies, etc.

One might make a normative argument that health and medical journalism ought to be subordinate to the biomedical field, and the transmission of information essentially linear. As a basis for empirical analysis of health and medical reporting, however, such a perspective will clearly be a poor starting point. Even from a primarily normative point of view, it is not clear that it is adequate. Given the range of interests and values at stake in the production of biomedical knowledge, there is probably a wider range of questions we will want to ask beyond the question, ‘Are the journalists getting the (established) science right?’ We probably also want to ask, as with other genres of reporting, whether they are opening proper spaces for public debate, giving proper scrutiny to powerful institutions, and similar questions that are central to journalism studies in general.

Footnotes

Funding

This article emerged from research funded by the Salus Mundi Foundation and supported by the University of California, Berkeley and University of California, San Diego. It grew out of discussions that took place while Daniel C. Hallin was a Fellow at the Center for Advanced Study in the Behavioral Sciences at Stanford University.

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