Abstract
The World Health Organization (WHO) reports that routine immunization coverage has declined in Europe. In this article, we present the findings of a Norman Fairclough–inspired critical discourse analysis undertaken to explore how the Danish media came to suggest a possible linkage between the human papillomavirus (HPV) vaccine and serious side effects. The findings of the analysis highlight the social consequences of the controversy over the HPV vaccine, identified within the framework of three perspectives: (1) overall criticism of vaccine efficacy and safety, rooted in an ideological opposition; (2) a growing societal tendency to question the authority of the official health bodies; and (3) the specific controversy over the HPV vaccine. We suggest that the controversy over the HPV vaccine is rooted in an ideological conflict, and the declining acceptance implies that the perception that the vaccine causes serious side effects has gained currency among the general public.
Keywords
Introduction
Childhood vaccination is a much-debated subject. Despite organized routine vaccination programs in most Western countries, the World Health Organization (WHO) reports a decline in uptake of childhood vaccines in Europe over the past 5 years, leading to the risk of outbreaks of vaccine-preventable diseases (WHO, 2017). The WHO therefore recommends that health authorities work to gain a deeper understanding of the mechanisms behind decision-making among the general public to ensure the necessary vaccination coverage (WHO, 2017).
Immunization against human papillomavirus (HPV) was approved by the U.S. Food and Drug Administration (FDA) in 2006, and since then it has been implemented in vaccination programs in many countries worldwide (WHO, 2016). The WHO recommends HPV vaccination because of the vaccine’s effectiveness in preventing cervical cancer and other HPV-related cancer forms. Cervical cancer is the fourth most frequently occurring cancer among women worldwide, with most cases occurring in underdeveloped countries. Nearly, all cases are attributable to infection caused by the HPV (WHO, 2016). The HPV vaccine prevents the most common types of HPV. It is most effective if administered before sexual debut. Health authorities worldwide predict that cervical cancer could be almost eradicated if vaccination and screening programs were to be used widely (Sundhedsstyrelsen [SST], 2016a).
Since the approval of the HPV vaccine, more than 600,000 women have been vaccinated in Denmark. The uptake to the vaccine in Denmark was initially high, but in the past 5 years it has dropped dramatically. The Danish Health Authority (Sundhedsstyrelsen, SST) reported in 2017 that the uptake for fully vaccinated girls born in 2003 was 73% in Sweden and 88% in Norway; in Denmark, it was 29%. At the same time, fewer side effects have been reported in the other Nordic countries than in Denmark (SST, 2017). This disparity suggests that the HPV controversy as it has played out in Denmark may be specific to this country.
Internationally, a suite of studies has described public concern about the HPV vaccine. For various reasons, the vaccine has been a subject of controversy since the release. There were concerns that vaccinated women might not go for HPV testing (the cervical or pap smear), that vaccination might lead to a sense of false safety against sexually transmitted disease in general (Vanslyke et al., 2008). In Denmark, it has also been pointed out that the practice of offering the HPV vaccine only to young girls and women, and not to boys and men, is discriminatory. From September 2019 the Danish health authorities decided to include boys turning 12 in July or later to receive the HPV vaccine and added prevention against anal cancer (Statens Serum Institut [SSI], 2019).
Studies have debated whether the HPV vaccine is efficient, necessary, and safe (Patel & Berenson, 2013; Reiter et al., 2009), and finally, some studies also describe public concern about contradictions among medical experts (Carrion, 2018).
In Denmark, the HPV vaccine has been the subject of controversy in the media. Public acceptance of the vaccine has dropped dramatically since 2015, mainly owing to growing public concern about its serious side effects. The concern centers around two specific syndromes: postural orthostatic tachycardia syndrome (POTS) and complex regional pain syndrome (CRPS) 1 (European Medicines Agency, 2016). Both syndromes crucially affect the functionality of the young women and girls affected. Debate on social media and in the newspapers has for some time given the impression that there is major public concern that the risk of developing serious side effects from the HPV vaccine may be higher than that of developing cervical cancer.
In this article, we focus on how the relationship between the HPV vaccine and the risk of serious side effects is constructed in three communicative events. Our analysis was conducted between January and June 2016. We demonstrate how the knowledge gap between the health authorities and the general public is rendered legible through our analyses of material produced by the Danish health authorities and a Danish TV documentary that followed a group of girls who had experienced serious symptoms shortly after receiving an HPV vaccine. The documentary has been cited on several occasions as a contributing source to fear of the HPV vaccine and its declining uptake.
The analytical framework used in the article draws on the critical discourse analysis theory of linguistics professor Norman Fairclough, a theory that sees the use of language as a form of social practice and uses a three-dimensional analytical model to illustrate the relationship between text and social practice. Throughout the article, we elaborate on and explain the role of Fairclough’s concepts. The aim of our analysis was to elucidate the discursive struggles surrounding the HPV vaccine program and their consequent ideological implications for social practice.
According to Fairclough (1992), text analysis deals with the ideational function of language as a way of constructing a social reality. Therefore, we argue that the way the HPV vaccine has been discussed in public is of importance to the social reality that surrounds it. Our aim is to bring critical attention to bear on the ideological perspectives that emerge when the recommendations of the Danish health authorities are challenged by a growing public perception that the HPV vaccine can have serious side effects.
Our analysis identifies two opposing discourses of risk. The risk discourse of the Danish Health Authority focuses on the consequences of HPV leading to cervical cancer and the minimal risk of side effects from receiving the vaccine. According to the Health Authority, the benefits of vaccination greatly outweigh the possible harms. By contrast, the public risk discourse questions whether the public can trust the Health Authority, owing to the perception that HPV vaccination is associated with hidden risks of serious side effects. Our study identified this second discourse in our analysis of a television documentary that has been widely credited as a contributing source to the Danish HPV controversy and the decreasing uptake of the vaccine.
The HPV Vaccine in Denmark
The HPV vaccine has been a part of the Danish childhood immunization program since 2009; it is recommended for girls from age 12. The vaccine prevents the most common types of HPV infection, which cause 70% of cervical cancer cases.
Cervical cancer gradually develops over a long period of time. As the introduction of HPV vaccination is quite new, it is difficult to determine definitively whether the forecast prevention has taken effect. However, studies show that the incidence of HPV infection and dysplasia among vaccinated women has decreased since the introduction of the vaccine in Denmark (SSI, 2015). The health authorities predict that cervical cancer could be almost eradicated if vaccination were to be used widely (SST, 2016c).
There may be multiple reasons for the declining uptake of the HPV vaccine over the last 5 years, but the Danish health authorities point out that the media have played a significant role. The TV documentary we analyze in this article has been cited as a primary factor in the creation of doubt. The Danish health authorities are worried that the fall in vaccine uptake may lead to an increase in dysplasia and cervical cancer in coming years. Consequently, in 2017–2018, the authorities initiated a systematic public information campaign aimed both at parents and at health care workers.
Methodological Framework
In this article, we investigate the relationship between the HPV vaccine and side effects as presented in selected texts and in a television documentary. We analyzed not only particular texts issued by the Danish Health Authority, but also a documentary film about the public controversy. Our aim was to trace and identify any discursive struggles operating in both types of material, with the objective of exploring how these create challenges both for the affected girls and for the health authorities. We selected discursive events that illustrated both the chronology of the controversy and the processes of focus. We present these in the following section.
As it is widely accepted that the media play an important role in how public attitudes are formed, we initially examined newspaper headlines to determine when the current controversy over the HPV vaccine’s linkage with serious side effects began. This historical examination gave us contextual insight into the controversy and allowed us to select the empirical data that formed the basis of the analysis.
The Communicative Events
For the purposes of discourse analysis, Fairclough understands the term “text” broadly: It can also include a movie or an image (Fairclough, 1992). As we analyzed both texts and documentary material for this article, we referred to the empirical data we examined as “communicative events.” We selected three communicative events within a chronological framework in relation to the HPV controversy. These three communicative events consisted of health authority information texts about HPV vaccine, a TV documentary, and a set of guidelines for health professionals, released by the Danish health Board as a strategy to address growing public concern.
Health Authority information texts
We chose three texts to represent the Danish Health Authority’s public information about the HPV vaccine: (a) “The Danish Childhood Vaccination Program 2016,” with particular focus on the HPV vaccine (SST, 2016b); (2) a companion booklet dealing specifically with HPV, “HPV Vaccination: Part of the Childhood Immunization Program” (SST, 2016c); and (3) “HPV Protects Against Cervical Cancer”—an online fact sheet published by the Danish Health Authority and the Danish Medicines Agency (DMA) explaining the authorities’ rationale in the scientific investigation of adverse reactions to the HPV vaccine (DMA, 2016a).
We chose the Childhood Immunization Program, because it is the health authorities’ official informational guideline concerning immunization in general. The booklet and the fact sheet were published later. We view these additions as the health authorities’ response to the increasing public focus on HPV vaccine and side effects.
The TV documentary
We chose the TV documentary The Vaccinated Girls, which aired on Danish television in March 2015 (Bech & Daugbjerg, 2015) (Textbox 1). The documentary is about a group of girls who suspect they may be experiencing serious side effects after receiving an HPV vaccine. The program questioned both the Danish health authorities’ handling of the girls’ experiences and the girls’ suspicions about the vaccine.
Overview of the Documentary The Vaccinated Girls.
Including a documentary allowed us to examine measures specific to sound and pictures, wherein the relationship between the spoken and the visual language can be used to create meaning.
The “Single Admission” guidelines for health professionals
We selected the Health Board’s recommendations to hospitals in its “Single Admission program (En Indgang)” (SST, 2016d). This program, initiated in February 2016, launched a consistent cross-disciplinary package of examination and treatment for girls developing unexplained physical symptoms shortly after HPV vaccination in designated hospital departments across Denmark. We selected this communicative event because we consider it as the Health Board’s response to the public attention on side effects linked to HPV vaccine.
Data Analysis
Fairclough’s three-dimensional analysis model includes three levels. On the first level, the textual level of analysis, the researcher must capture how single words and grammatical formulations participate in the construction and reconstruction of social structures (Fairclough, 1992). On the second level, the discursive practice level of analysis, the researcher examines the processes through which the production, distribution, and consumption of texts came into being. These processes must be perceived as a form of social practice, forming a link between the text and the social surroundings. On the final level, the social practice level, the researcher analyzes the connection between discursive practice and the surrounding society. In this final process, both discursive and nondiscursive elements are identified, but the most important aim in the analysis of social practice is to consider whether the existing order of discourse—the structuring of different discourses, genres, and styles in a particular social ordering of meaning-making—is being reproduced or, alternatively, reconstructed (Fairclough, 1992).
We carried out individual analyses of each communicative event on both textual and discursive levels by reading and viewing each event multiple times and then combined the analysis on these two levels with an analysis on the level of the social practice, as suggested by Fairclough (1992).
Fairclough argues that critical discourse analysis can be applied to documentary material as well as texts, but as his theory does not include direct guidance on how to do this, we decided to draw on Anne Jerslev’s (2015) suggestions on how to perform media analysis to gain a deeper understanding of the instruments used in documentary footage. We then used that understanding to translate concepts from Fairclough’s three-dimensional model and thus relate them to the purpose expressed at the beginning of the documentary.
Jerslev claims the documentary genre as a medium that is characterized by referring to actual events that now are communicated through both the content in the broadcast and the use of audiovisual language. As we drew on Fairclough’s concepts and guidelines for analysis, we have converted the visual language to text, which enabled us to access the analysis within a Fairclough framework.
We used this understanding to translate the visual elements of the documentary into the terms of Fairclough’s linguistic analysis.
Fairclough organizes text analysis under four main headings: “vocabulary,” “grammar,” “cohesion,” and “text structure.” These are viewed as ascending on a scale from the individual word to the larger organizational properties of text (Fairclough, 1992).
We analyzed grammar through the linguistic concepts modality and transitivity. Modality deals with the degree of affinity in a text by analyzing the use of verbs, adverbs, and adjectives (Fairclough, 1992). Modality can be either subjective or objective. Often objective modality where the “speaker” of the text projects a perspective as universal implies some sort of power (Fairclough, 1992).
Transitivity deals with the types of process coded in clauses and the types of participants or elements involved in them (Fairclough, 1992). We sought to find the processional relationship between HPV, cervical cancer, HPV vaccine, and side effects to understand how the individual communicative event relates to the context it emerged from.
According to Fairclough (1992), discursive practice focuses upon the production, distribution, and consumption of a text. On the discursive level, we chose Fairclough’s concepts of intertextuality and interdiscursivity to analyze each communicative event. We elaborate on the use of each concept in the presentation of the results.
Fairclough does not offer a specific explanation on how the social practice is comprehended. We understood social practice as a combination of both discursive and nondiscursive elements. Fairclough operates with the concepts of ideology and hegemony to discuss social practice (Fairclough, 1992, 2008). We chose to focus on the contradictory risk discourses presented in our communicative events, which made it possible for us to discuss some of the social consequences of the HPV controversy.
Results
Our analysis revealed that the configuration of knowledge and meaning associated with the perception of the HPV vaccine was very complex.
The wording of the texts by the Health Authority constructs a reality in which cervical cancer is a serious disease that must be combated. At the same time, the HPV vaccine is characterized as beneficial, effective, and safe, and these effects receive more attention than side effects. The texts present this reality without nuance or dilemma.
The TV documentary, however, casts doubt on this naturalized perception of reality and challenges the authorities’ truth monopoly. Because the focus on the HPV vaccine creates a linkage between the vaccine and the girls’ symptoms, the reality reflected in the film creates the impression that the girls portrayed were let down by the health authorities.
In the following sections, we illustrate our main findings on the textual and discursive level for each communicative event. The main findings on the textual analysis level are organized under three subheadings, in accordance with Fairclough’s terminology: Words and cohesion, Modality, and Transitivity. The main findings on the level of discursive practice are organized under two subheadings: “Intertextuality” and “Interdiscursivity.”
Part 1: The Danish Health Authority Information Texts
Our textual and discursive practice analysis found that the Danish Health Authority’s communicative events aimed to construct a reality in which the risk of cervical cancer outweighed that of the HPV vaccine. While the chronology of the texts reflected the public’s increasing focus on the side effects of the HPV vaccine, the transformation in these texts followed a predictable conventional pattern. Fairclough (2008) argues that the analysis of words focuses on how individual words reproduce a certain ideology. Although the information texts reflect the rising public concern, they produce a clear argument when put together. We perceived the texts as a part of an intertextual chain and identified a risk discourse in which cervical cancer was the primary predominant risk and HPV vaccine thereby became a necessity.
Words and cohesion
In the analysis of words and cohesion, we focused on the specific words used to represent the processes portrayed: HPV, cervical cancer, HPV vaccine, and side effects. By examining the words connected with each process, we were able to deduce the construction of the relationship between the processes (Table 1).
Words Used to Describe Key Processes in Danish Health Authority Information Texts.
Note. HPV = human papillomavirus.
HPV is generally described in sentences, but the words we extracted from those sentences were neutrally charged terms such as common, frequent, and invisible. These are linked to cervical cancer by the words cause, guilt, and risk. Cervical cancer, by contrast, is described as serious and deadly, and the relationship presented between virus and disease creates the impression that HPV in itself poses a threat because of its potential to cause cancer.
The HPV vaccine itself is described in positive terms such as protect and prevent, whereas side effects are described in neutral terms such as common, expected, and rare. The fact sheet explains side effects in terms of subjective connotations such as reported and suspected side effects. This leads the reader to understand that reported and suspected side effects are subjective perceptions by individuals. The perception of side effects is based on a linkage between vaccine and symptoms.
Fairclough (1992) argues that relations between words are in fact structured by various forms of hegemony. We perceived the texts examined as isolated segments describing the processes being focused on. The words used to describe cervical cancer and the HPV vaccine were semantic oppositions. We perceived the words used to describe cervical cancer as “danger words”—serious, deadly—as opposed to the positive words used to describe the HPV vaccine.
On that basis, we argue that the texts are coherent; certain sections of the text are structured such that the texts appear to be valid arguments.
Modality and transitivity
Modality (also referred to as affinity) clarifies the extent to which the producers of texts commit themselves to their propositions (Fairclough, 1992). The Health Authority texts mainly use what Fairclough refers to as objective modality, which, according to Fairclough, often implies some form of power. Propositions expressed in objective modality are expressed as universal: for example, the statements “Cervical cancer is a serious disease” in the childhood vaccination program document (SST, 2016b) or “The vaccine works” in the fact sheet (DMA, 2016a).
Modality in grammar is associated with the use of modal auxiliary verbs such as must, may, and should. The most commonly used modal auxiliary verb in the texts analyzed is may. May implies that the affinity asserted in a proposition expresses a degree of uncertainty (Jørgensen & Phillips, 1999). We found that the use of may in the texts supported the abovementioned connection between virus and disease processes, as the following examples show: “It may take many years before precancerous lesions develop into cervical cancer” and “Cervical cancer may be almost eradicated by HPV vaccination.” The first example contains a form of ahistorical present tense that suggests that the individual has no influence on the progression. The second example focuses on the positive consequences of the vaccine, once again emphasizing that the vaccine is necessary because of the uncertainty associated with HPV.
Transitivity concerns the types of process portrayed in clauses. Fairclough (1992) distinguishes between “relational” processes, where the verb marks a relationship between elements in the text, and “action” processes, where an agent acts upon a goal. We understood transitivity as more than a grammatical term, and therefore focused on the effect of agency, which in Fairclough’s approach is concerned with how texts connect particular agents and processes as active (transitive) or passive (intransitive). In general, these texts tend to portray the HPV vaccine as a passive agent in the process between vaccine and side effects. On the contrary, the HPV vaccine is portrayed as an active agent in the process of preventing cervical cancer. The following examples illustrate that claim: “People are different, and some may develop rare and serious side effects from some types of medication” and “The vaccine works” both imply that the vaccine is the active agent in the process of protecting against and preventing HPV, and therefore also protecting against and preventing cervical cancer.
Discursive practice
Intertextuality
Intertextuality is the idea that a text draws upon preexisting texts that are to a greater or lesser degree embedded in the new text. Fairclough (1992) distinguishes between two types of intertextuality: manifest and constitutive intertextuality (which he also defines as interdiscursivity). These two types of intertextuality work in opposite ways. Manifest intertextuality operates when a text draws openly upon precursor texts, not only by directly referring to them, but also when texts are reproduced following a predictable pattern embedded in the discourse type, creating intertextual chains. We found that the reproduction of the discourse type in the three texts authored by the Health Authority showed that they formed part of the same intertextual chain. The “Childhood Immunization Program” text is based on guidelines from the WHO, which views public health in a collective perspective accommodating the majority of the population. The texts are aimed at the general public as the authorities’ recommendations on vaccines.
The chronology of the texts shows that the health authorities are addressing public concern. The fact sheet focuses mainly on side effects and explains the rationale in the authorities’ monitoring of reported side effects. We argue that the information in the fact sheet may be directed more at health care workers than at the general public, even though the information is publicly available. However, the fact sheet can be reproduced in other texts so as to reproduce the intertextual chain, for example, in newspaper articles or news programs.
Interdiscursivity
Interdiscursivity is a matter of how a discourse type is constituted within the orders of discourse (Fairclough, 1992). We found that the genre used in the information texts was “public information” aimed at parents deciding whether to give their daughters the HPV vaccine. Although we concluded that the chronology of the texts mirrors public concern about the vaccine, the ambivalence in the texts is very low, as is often the case in texts with manifest intertextuality (Fairclough, 1992). The texts are consistent in their use of discourse types. We identified one overall discourse type, which we labeled a risk discourse, although it is also a preventive discourse. We claim that both these discourse types belong to the same order of discourse, focusing on the risk of HPV/cervical cancer and the preventive nature of the HPV vaccine in the absence of doubt, creating the preventive discourse. The fact sheet also uses promotional discourse, because the information is intended to point out the efficacy and safety of the HPV vaccine, despite public doubts.
Part 2: The Television Documentary
The expressed purpose of the documentary was to investigate how the Danish health authorities had supported the girls who had been affected and additionally to investigate whether the girls’ suspicions about the HPV vaccine were justified.
Our analysis of the documentary found that an oppositional relationship was constructed between the health authorities and the vaccinated girls. The exchange of knowledge presented in the documentary took place on uneven terms. The health authorities’ knowledge was generally subjected to critical questioning, while the subjective knowledge from the girls’ perspective was not. We found that this imbalance was part of the documentary’s overall agenda—to point out the uneven balance of power as between the authorities and the affected girls. The subjective perspective leads to a shift in the balance of power.
Words and cohesion
We searched for both verbal and visual representation of the identities constructed for the girls. We found that the words used to describe the girls before and after they received the HPV vaccine were underlined in the documentary by visual framing (Table 2).
Words Characterizing the Girls Before and After They Received the HPV Vaccine.
Note. HPV = human papillomavirus.
The physical symptoms of the girls were described as a mysterious disease, symptoms, and side effects. Those connotations reflected the complexity of the girls’ situation, emphasizing that no one knew why the girls were experiencing these symptoms.
The words used to describe the health authorities were betrayal and anger, as expressed in the following quote from a mother to one of the affected girls: “There is no help whatsoever as long as they will not recognize that there is a problem, and that makes me very, very angry” (Bech & Daugbjerg, 2015, 17:03).
Another way to express doubt in the health authorities is by using metaphors. Fairclough (1992) describes how metaphors express the perception of reality, often unconsciously. One example of the use of metaphor was “It seems like a smokescreen,” referring to the way the Health Authority had responded to growing public attention to side effects of the vaccination. The metaphors used in the documentary display an almost conspiratorial rhetoric, implying that the health authorities had a hidden agenda.
Modality
It is our perception that the modality in the various statements made in the documentary represented the overall modality. We grouped the statements into subjective and objective statements to establish the affinity with which the documentary expresses the represented reality. Throughout the documentary, the girls tend to express themselves with subjective modality but high affinity, as, for example, in the statement “I have no doubt that it is Gardasil . . . after my second jab I started to get really sick” (Bech & Daugbjerg, 2015, 16:01).
The various expert opinions called upon in the documentary were directed against the role of the health authorities, yet were generally characterized as objective.
Transitivity
In this section, we focus on the representation of the relationship between agents and subjects. In general, the documentary describes the HPV vaccine by using nominalization, described by Fairclough (1992) as a linguistic characteristic that makes a specific agent into something abstract. The HPV vaccine is described as the vaccine. For Fairclough, nominalization can assign to an agent a specific cultural meaning. The documentary uses the specific nominalization of generally mentioning the HPV vaccine as “the vaccine” or “the HPV vaccine” in everyday speech. We argue that this nominalization constructs a relationship between the vaccine and the girls in which the HPV vaccine becomes the active agent and the girls become the passive subject. The linguistic and visual articulation of the HPV vaccine throughout the documentary reproduces a specific understanding of the vaccine as an active agent that may be capable of making the girls ill.
Discursive practice
Intertextuality
When a documentary is analyzed, the main concern is the documentary’s argumentative reality. The Vaccinated Girls uses the “voice of God” strategy, explained by Jerslev (2015) as a narrative voice-over that navigates the viewer through the film and creates meaningful coherence between words and images. At the same time, the documentary also draws upon performative elements that allow the subjective perspective to dominate.
Fairclough (1992) uses the concept of meta-discourse as a kind of manifest intertextuality that allows the producer of a text to step outside his own discourse and thereby manipulate it. We found that the concept of meta-discourse does serve as a suitable concept to explain the editing of various statements throughout the documentary. In a scene in which the voice of God is talking about the background to the HPV vaccine in the Danish vaccination program, the documentary draws upon manifest intertextuality from an authoritative point of view. The same formulation is used here as in the Health Authority texts. However, the information is questioned in recurrent short interview clips interjected throughout the documentary. The following example is from a scene in which the journalist and producer of the documentary asks the unit head from the Danish Health Authority, “Is the Health Authority at all capable of assessing whether a product like Gardasil is safe enough?” (Bech & Daugbjerg, 2015, 19:25). This kind of questioning, by contrast, is absent when the opposing case is presented, when the two doctors who represent doubts about the vaccine and the girls’ health present their views. This pattern of casting doubt on the Health Authority is clearly identifiable in both the oral and the visual part of the documentary. We argue that this may leave the viewer doubting the Health Authority’s intentions.
Fairclough (2008) sees media texts as sensitive barometers of social and cultural changes in society. We argue that the Vaccinated Girls documentary is an example of how a creative practice of discourse becomes conventional, as the documentary establishes an alternative and dissenting view of the authorities’ recommendations regarding the HPV vaccine that previously enjoyed wide acceptance in a public setting.
Interdiscursivity
According to Fairclough (1992), the analysis of interdiscursivity can reveal hegemonic struggle. He argues that interdiscursivity reveals itself through the use of various genres. For Jerslev (2015), in turn, media analysis focuses on the types of communication that a documentary draws upon. The Vaccinated Girls uses various communication types. In our analysis of interdiscursivity, we treated genre (for texts) and types of communication (for the documentary) synonymously.
In many of the explanatory passages, the documentary is neutrally informative, but the most prominent type of communication is what Jerslev calls critical investigation, where the documentary constructs a certain reality through a critical approach. The documentary’s critical approach is sometimes accusatory, especially in the passages that question the health authorities’ care for the affected girls.
The interview is used as both a direct and an indirect genre. The passages portraying the girls are an example of the indirect interview, because the girls’ monologues work rather like reality television. One of the reasons why the documentary has been accused of affecting the development of the HPV controversy is the very powerful verbal and visual representation of a group of girls who have been seriously affected in their daily lives.
The documentary articulates various types of discourses. One of the exercises involved in the analysis of interdiscursivity is to assess whether the discourses reproduce or restructure the order of discourse (Fairclough, 1992). We argue that a legible risk discourse can be seen throughout the documentary, articulated partly in the girls’ narratives, but also in the way the health authorities are presented. The visual presentation of the girls drowns out the health authorities’ message, leaving the perceived risk of the HPV vaccine more present than that of cervical cancer. The representation of the girls also creates a victim discourse in which the girls play the role of victims of vaccine injury. This victim discourse constructs a certain identity for the girls, leaving them with different rights than if their disease had been psychological, mental, or even idiopathic in character. We argue that the discourses expressed in the documentary can be perceived as a counter-discourse against the health authorities.
Fairclough argues that a high degree of interdiscursivity reflects discursive change. The documentary presents several different coexisting orders of discourse defined not only by the health authorities but also by society. It can therefore be concluded that the documentary constitutes creative configurations of the existing order of discourse. At the same time, Fairclough (1992) points out that creative configurations of various elements from different orders of discourse can create new types of manifest intertextuality, in which a certain type of knowledge becomes naturalized and conventional.
We argue that the TV documentary is voicing a discourse in which it has become naturalized that the HPV vaccine has side effects that have not been recognized.
Part 3: The “Single Admission” Guidelines for Health Professionals
The following section reports on the findings from the analysis of the “Single Admission” guidelines for health professionals (SST 2016d).
On June 1, 2015, selected hospital departments in each region were tasked with implementing the “Single Admission [En Indgang]” program and thus with taking on responsibility for carrying out investigations of persons with unexplained symptoms that had occurred shortly after being administered an HPV vaccine. The guidelines provided recommendations for a uniform and appropriate organization of the initiative.
Words and cohesion
The aim of the “Single Admission” text was to establish recommendations for a cross-disciplinary approach to the investigation and management of the girls’ symptoms. In the following, we illustrate the constructed reality surrounding the HPV vaccine and possible side effects as presented in the text.
First, we note that the term “side effects” is never used in this communicative event. Rather, the girls’ condition is described as symptoms or disease. We then note that the text establishes a group of patients—young girls who have experienced “unexplained symptoms that have occurred closely following an HPV vaccine”—and assimilates that group with a group of patients experiencing the same symptoms who had not received an HPV vaccine. The words used to describe the symptoms in both groups are unexplained, unspecific, multifarious, and long-lasting. This approach establishes a wider patient group, characterized by symptoms rather than causality.
Modality
Initially, the Health Authority states, “With these recommendations the Health Authority wishes to establish that patients with unexplained symptoms are offered a cross-disciplinary overall assessment” (SST, 2016d). We found that the subjective intention and the use of the word wishes together created an impression of personal involvement with the patients and high affinity to the overall message of the text as a whole.
The text is generally written in present form. The occurrence of the symptoms in close proximity to the HPV vaccine is stressed several times, as is the point that the same symptoms were identified in a group of patients who had not received the HPV vaccine.
The use of objective modality, especially in the sections constructing the patient group, effectively constructs a larger group of patients that is characterized by symptoms rather than by possible causes.
The text is a set of recommendations for health professionals, and we note several examples of “hedging,” a concept that Fairclough explains as a way of expressing affinity by establishing a distance from the reality being discussed. The sentence “The information material can hopefully help to remedy this apparent disparity” refers to a discrepancy between the patients’ expectations and the care offered by the selected hospital clinics. We argue that the words hopefully and apparent express both a hope for improvement and surprise at the mistrust.
Transitivity
We searched for processes of agency between the HPV vaccine and side effects, but we found that the specific wording of the text deprives the vaccine of agency, as the term “side effects” is never used. The use of a term such as disease enables the possibility of an underlying idiopathic cause for the symptoms, best treated using the cross-disciplinary approach. The health authorities are thus characterized as the active agent in the process of helping their patients.
We found that the overall tendency throughout the text was to distance the idea that the HPV vaccine is capable of causing the symptoms. Instead, the focus was on the character of the symptoms and the possibilities for treating them. In this sense, the girls became passive recipients of the health professionals’ help. However, we also found one example in the text in which the girls were given partial agency: “The intention is to give the patient and their own doctor whatever they need to deal with further developments together” (SST, 2016d). On one hand, the girls are passive recipients of the treatment from the health authorities; on the other, the purpose of the initiative is to give the patients coping strategies to deal with their symptoms.
Discursive practice
Intertextuality
The intertextuality analysis revealed to us that the intertextual chain surrounding this text draws upon the conventional medical perception inherent in the health authorities’ order of discourse. The specific context in this communicative event is treatment, rather than prevention. The objects in the processes are patients, rather than girls. Thus, at the same time, we find references to a holistic perspective, because this recognizes that disease can be a multicausal “body and mind” deficit.
Interdiscursivity
We found that this communicative event expresses public ambivalence surrounding the HPV vaccine. We identified a holistic medical discourse and a classic medical discourse, and the relationship between the two was ambivalent.
The holistic discourse was expressed through the recognition of a bio/psychosocial dimension to treatment that explicated coping strategies as important measures. The medical discourse was reflected in statements that compared vaccinated and non-vaccinated groups to establish the concept of causality. We therefore concluded that this text is an example of how the order of discourse can be constituted both creatively and conventionally, contributing to both the transformation and the reproduction of the discourse.
Social Practice
In this section, we bring together our findings from the textual analyses and those of discursive practice to inform the social structures. The three communicative events examined present a range of examples of how an order of discourse may be both reproduced and restructured. They reflect the discursive struggles operating, both in defining the correlation between the HPV vaccine and side effects and also in the determination of truth.
Fairclough draws upon Marxist tradition in his understanding of social practice and therefore sees the development of power relations as a hegemonic struggle. Our focus was on the effects that both hegemonic and ideological factors had on the knowledge systems in the discourse surrounding the HPV vaccine.
Ideology and Hegemony
Fairclough uses the theoretical terms ideology and hegemony as a way to theorize changes in power relations in society. Hegemony, in Fairclough’s understanding, is power over a society as a whole, but it is never achieved more than partially and is more about winning consent through ideological means than about dominating. Hegemonic struggles therefore take place on a broad front in society, and discursive changes have their roots in these hegemonic struggles, where uneven power relations are located. Fairclough’s understanding of ideology focuses on the implicit and unconscious materialization of ideologies that are manifest in individual and collective life. He uses Althusser’s concept of interpellation—the idea that the individual internalizes values and ideologies from the surrounding society and acts upon them—to explain how ideology constitutes the subject (Fairclough, 1992).
We found that the Health Authority’s ideology was based on a long-standing tradition in public health whereby the objective is to maximize the health of as many people as possible. Within the field of vaccines, the desired objective is herd immunity, a state in which the vaccinated majority protects the unvaccinated minority. Side effects are accepted to a certain degree, because the benefits of vaccination exceed the disadvantages. In this sense, the Health Authority ideology is expressed through the childhood immunization program.
However, when interpellation comes from different ideological positions, it leads to uncertainty and confusion, causing discursive change to begin. The three communicative events analyzed in the present article illustrate a contradictory interpellation of this kind, whereby the HPV vaccine has been articulated from different positions within the medical domain and the public domain. This ambivalence makes it difficult for parents to make a well-informed choice based on fact.
Discussion
Vaccine skepticism is an international phenomenon: As already noted, the WHO describes a general tendency toward declining uptake in routine immunization. The HPV controversy, however, seems to be a primarily Danish phenomenon. Other countries do not report declining acceptance of the HPV vaccine (SST, 2017).
The controversy is not only a hegemonic struggle between a commonsense rationality among the general public and the authorities’ factual knowledge. There are examples of medical experts who have disagreed in public over the scientific methods leading to the conclusion that the HPV vaccine is safe (Ehrenskjöld, 2018; Thorup, 2016). This has left the public to make a difficult choice. A few named individuals have played a critical role here, but their voices can be of major importance to public opinion, because of the existing public doubt. The health authorities want the population to make an informed decision, but for the ordinary citizen, it can be hard to decide what the right decision is when experts do not agree on the safety or necessity of the HPV vaccine.
We therefore suggest that the HPV controversy mirrors a paradox among both the population and the authorities.
Following the broadcasting of the TV documentary, the Danish Medical Authority published an information video. This video pointed out that large population-based studies have not been able to prove a connection between the HPV vaccine and the focused-on side effects, but it also acknowledged that no study is large enough to discover very rare side effects (DMA, 2016b). This fact in itself gives both the authorities and the affected girls the right to relate to “their” knowledge. It opens up the possibility of discussion about the proper range of science. Truth is no longer a scientifically detectable truth. The “what if” scenario is very real for the general public. Traditionally, the monopoly on truth has always been on the side of the health authorities. However, as we have illustrated in this analysis, this monopoly is under pressure. As a consequence, the health authorities are now required to introduce new ways of communicating information to their populations, new ways of adjusting to the mechanisms of public decision-making.
Viewing the material produced by the Health Authority in a chronological perspective, we found that the texts had undergone a transformation in the specific intertextual chain that connects them. In line with the increased focus on side effects among the general public, the three texts also displayed an increased focus on side effects. This was the result of a rearticulation of the existing discourse within the health authorities’ order of discourse. On that ground, we argue that the health authorities attempt to gain hegemony in defining the relationship between vaccine and side effects.
In the present controversy as it has developed since 2013, we find three prominent perspectives.
First, the discourses surrounding vaccine skepticism have become clearer and more visible in the current debate. Vaccine skepticism has existed since vaccinations began, and it is not the primary issue in the case of the HPV controversy. Vaccine opponents articulate the natural perspective. Studies show that some parents believe in natural immunization because they are afraid of poisonous additives (Hilton et al., 2007; Leask et al., 2011). Even though cervical cancer is a feared disease, the risk of actually falling ill can seem rather abstract, whereas the narratives of girls suffering serious side effects from the HPV vaccine are prominent on various media platforms.
A recent study showed that parents often supported vaccines until a particular cue motivated them to refuse one or more vaccines: perceived adverse events, endorsements from medical staff, or perceived contradictions among medical experts (Carrion, 2018). This aligns with our assumption that the controversy in the media has triggered those various reasons to refuse the HPV vaccine.
We suggest that the HPV controversy has some similarities to the MMR controversy from 1998 in which Andrew Wakefield published a series of papers that linked the MMR vaccine to autism. The vaccine uptake began to drop, and though the papers were later retracted because of ethical violations and scientific misrepresentation, the MMR controversy still flares up periodically (Eggertson, 2010; Lindgreen, 2019).
Second, we view the HPV controversy as a part of a wider context in which the general public is questioning the authorities’ position in defining truth. Knowledge-sharing on social media is significant in shaping parents’ attitudes toward vaccination, and the knowledge shared is often of personal experiences (Brunson, 2013; Penţa & Băban, 2014). The production of knowledge on social media in the presence of divergent opinions voiced by health professionals can make it difficult for parents to navigate the large amounts of information facing them, which moreover constantly changes. The consequence may be that the choice of individual parents comes to be based on personal belief rather than on the health authorities’ understanding of solid fact. Many parents make reflective choices about vaccination, whether or not they choose to vaccinate (Kennedy et al., 2014; Whyte et al., 2011).
The third perspective is the controversy about the HPV vaccine and the question of causality. We view the “Single Admission” program as an answer by the health authorities to the TV documentary and thus as part of a strategy to address the controversy. This was demonstrated in our analysis of the “Single Admission” recommendations, which we found downgraded the agency of the HPV vaccine in several respects. This represents an attempt to focus the public’s attention in a different direction. Rather than focusing on the HPV vaccine, the text creates a new focus, viewing the girls holistically and including their demand for investigation and treatment of the symptoms, regardless of cause.
The WHO’s principles for effective communications function to reach decision makers in various ways. The communication has to be accessible, actionable, credible and trusted, relevant, timely, and understandable to decision makers (WHO, 2019). We suggest that one of the key elements in the Danish HPV controversy is the question of trust, or the lack of trust.
According to the WHO (2019), to ensure trust from decision makers, health communication has to be transparent. To reach that goal, it is important to acknowledge any uncertainties.
The documentary asks whether the Health Board listened to the (small) group of girls who believed the vaccine made them ill. That statement became an important factor in the public perception of the health authorities.
We suggest that the chronology of the health authorities’ informational texts follows a pattern of trying to ensure trust. As an example, the fact sheet explains how data are analyzed, and “One Admittance” addresses the girls’ concerns by acknowledging their symptoms.
Fairclough (1992) argues that the relationship between discourse and social structures is dialectic. Our study of texts with divergent constructions of knowledge and truth has enabled us to deduce patterns in the discursive change. One of the strengths of discourse analysis as an analytical strategy is the possibility it offers to perceive statements from other discourses as meaningful within their specific context (Nexø & Koch, 2013).
Conclusion
In this article, we have explored the complex discursive network surrounding the administration of the HPV vaccine in Denmark. We suggest that the HPV controversy is a controversy over what constitutes truth and knowledge, and that decision-making among the general public may have additional sources besides traditional science. Thus, this is an example of a societal tendency for health authorities’ recommendations to be challenged by the public.
The Health Authority’s ideology has its roots in the idea of collective disease prevention. The increased public focus on young girls suffering serious adverse events following the HPV vaccine is, however, a powerful voice in the public mind-set. It supports a growing degree of mistrust in the health authorities. This situation challenges the health authorities’ ability to reach the public with scientific information. The traditional collective information has come under challenge, and the health authorities have been forced to acknowledge that they cannot take for granted that public opinion will follow authoritative recommendations.
One aspect of the HPV controversy consists of an exchange of perspectives: the struggle is over the truth of anecdotes compared with research-based information. The present controversy shows that the power of anecdote exerts a strong hold over public opinion.
Closing Remarks
Since we conducted our analysis, the Danish Health Board and its partners have presented a comprehensive information campaign regarding the HPV vaccine and cervical cancer, intended to uphold the recommendations on the HPV vaccine (SST, 2017).
The goal is to increase the coverage of the vaccine by communicating information to the population and to health professionals about the HPV vaccine and cervical cancer. The health authorities wish to communicate with the population, rather than, as formerly, to give one-way information. Part of the campaign is a Facebook page that makes it possible for the health authorities to engage in dialogue and share information in real time. There is also a series of short films showing young women who have undergone operations for dysplasia or cervical cancer, explaining the impact on their lives. The Danish national vaccination research institute (Statens Serum Institut, SSI) recently declared that the number of girls vaccinated has doubled since 2016 and is now at its highest since 2012. The SSI (2018) interprets the rise in the number of girls vaccinated as a clear sign of restored confidence in the health authorities and also concludes that the comprehensive campaign has worked as intended.
It is true that there are signs that the uptake of the HPV vaccine is rising. Whether this is due to the campaign is hard to say in our opinion, because the debate over the HPV vaccine continues to evolve.
However, the HPV vaccine controversy does provide a clear example of the challenges faced by national health authorities in a society where social media and the viral spread of opinion are unstoppable.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
