Construction of death in H1N1 news in The Times of India

Abstract

Construction and meaning-making are central to the process of communication. Studying the way media frame a public health issue gives insight into how people are likely to perceive the information on that issue. Death is considered as the most significant contributory factor of fear in any public health crisis. In this article we analyze the H1N1 death coverage in The Times of India, the largest circulated English daily published from India. We describe and analyze the framing of H1N1 by reviewing 62 death-reporting news stories that appeared in the daily in 2009. Our analysis yielded four dominant frames: fear-panic, attribution of responsibility, action and human interest. We conclude that the newspaper framed H1N1 as a deadly disease and its coverage presented death in such a manner as to produce fear and panic.

Keywords

Content analysis death framing H1N1 flu crisis India qualitative analysis

Introduction

It can be said that the H1N1 virus entered India on 16 May 2009 when a person travelling from New York via Dubai and Delhi tested positive in Hyderabad (India). This was the first government-confirmed H1N1 positive case in India (Reuters, 2009). The first victim of H1N1 in India was a 14-year-old girl from Pune city in western India, who died on 13 August 2009 (Sinha, 2009). Since then the virus spread to various cities affecting a large number of people. In June 2009, the World Health Organization declared the H1N1 flu as first global flu epidemic in the last 41 years. The Indian Ministry of Health and Family Welfare declared the flu crisis a ‘national emergency’. By 3 October 2010, a total of 190, 990 persons were tested for H1N1 in India. Of these, 44,687 (23%) tested positive. A total of 2575 people died because of H1N1 infection (Government of India, 2010a).

Media worldwide covered the H1N1 flu epidemic as an international crisis. Indian media too ran several news stories about H1N1 infection, with coverage increasing from August 2009 after the first reported death because of H1N1. A series of H1N1-death events put the issue on the media’s agenda, including in The Times of India, an English daily published from Ahmedabad.

The media constitute an important source of information and attitude formation for the public (Kiousis, 2005; McCombs, 2005; Wanta et al., 2004). It sometimes determines the important issues beforehand and accordingly covers and presents them to the readers. The readers, in turn, learn about the issue and perceive its importance from the amount of information and its position (McCombs and Shaw, 1972).

Communication scholars have examined the role of the media in health crises and the influence it has on the public. Some scholars have argued that mass media tend to be increasingly full of death-related content (Liu and Smeesters, 2010) and that the death of a large number of people is considered newsworthy (McKenzie, 2005). A second group of scholars has examined how media present and portray health events and emergencies (Atkin et al., 2008; Campbell and Sato, 2009; Lowrey et al., 2006; Rankine and McCreanor, 2004), and a third group has examined the association between people’s knowledge and information about any crisis and exposure to media (Goffman, 1974; Riffe, 2006; Stryker et al., 2008) or type of media content (Lawrence, 2004; Swain, 2007).

In addition, scholars have studied ‘death’ in media coverage within various contexts such as war time (Silcock et al., 2008; Zelizer, 2005), conflicts (Wolfsfeld et al., 2008), custody (Bacon, 2005; Bacon and Mason, 1995), and physician-assisted suicides (Kalwinsky, 1998). However, our literature search did not yield research on framing of death caused by disease. In this article we try to understand why The Times of India featured a large number of H1N1-related death stories and how it framed H1N1 death-related news and presented it to its readers.

The Times of India

The Times of India is the largest circulated English publication in the world (The Times of India Group, 2012). The Indian Readership Survey 2012 shows that The Times of India is the most widely read English newspaper in India, especially amongst the growing urban middle class. Owned and published by Bennett, Coleman and Co. Ltd, its all-India average issue readership is 7.6 million – more than twice that of its nearest rival, the Hindustan Times (The Times of India, 2012). As one of India’s oldest newspapers, The Times of India has a pan-India presence in 41 centers with 15 main editions today. More than four decades old, the Ahmedabad edition of The Times of India was launched on 6 February 1968. The Ahmedabad city has two other mainstream English newspapers, the Daily News and Analysis (DNA) and Indian Express, but they rank a distant second and third in circulation.

Review of literature

Agenda-setting

Agenda-setting is one of the most widely used theories in the field of media and communication (Stromback and Kiousis, 2010). McCombs and Shaw (1972) first conceptualized the theory of the agenda-setting function of the mass media, and several studies subsequently found evidence of it (e.g. Kiousis, 2011; Lee, 2010). The original conception of agenda-setting posits that the mass media set the agenda of public opinion and influence the perception of media audiences about the issues and topics considered as being salient (Shehata, 2010). McCombs and Shaw’s (1972) original concept later came to be called first-level agenda-setting.

Recent studies have not only corroborated the original concept that the media tell the public what to think about, but have provided evidence that media also tell readers and viewers how they should think and feel about what they have been told to think about (Rill and Davis, 2008). The focus here is not on what media emphasize but on how media describe an issue (Coleman and Banning, 2006). The emphasis on how to think and feel about (rather than what to think and feel about) has been called ‘second-level’ or ‘attribute’ agenda-setting. While the first level of agenda-setting considers the transmission of issue salience, the second level of agenda-setting describes the transmission of attribute salience from the media to the public (McCombs et al., 1998). Second-level agenda-setting not only focuses on the attributes that news stories assign to issues but also examines the influence of such news stories on the media audiences’ perception of news stories. While the first level of agenda-setting is associated with opinion strength, the second level is associated with opinion direction (Lee, 2010). The agenda-setting approach is therefore appropriate for studying what agenda the media set for the public while covering the H1N1 crisis and how it wanted the readers to think about it. Specifically, this study attempts to unravel how The Times of India wanted people to think about the H1N1 crisis.

Media scholars have discussed the similarities and differences between agenda-setting and framing (Entman, 1993; Maher, 2003; McCombs and Ghanem, 2003). Some researchers have posited that second-level agenda-setting research associates itself with the media’s framing of an issue and people’s understanding of the same (Lee et al., 2005; Rill and Davis, 2008). Melkote (2009) has argued that it is a small theoretical leap from attribute agenda-setting to the concept of news framing.

News framing

According to Entman, ‘Framing essentially involves selection and salience’. He defines the process of framing as:

To frame is to select some aspects of a perceived reality and make them more salient in a communicating text, in such a way as to promote a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation for the item described. (1993: 52, italics added)

Our enquiry into framing of the H1N1 issue is based on the second level of agenda-setting as well as on two major aspects of Entman’s definition. At one level, we seek to find out how H1N1 death was made salient in news reportage. For us, salience means making a piece of information more noticeable, meaningful, or memorable to audiences. The newspaper text contains frames, which use the presence or absence of certain keywords, stock phrases, stereotyped images, sources of information, and sentences that provide thematically reinforcing clusters of facts or judgments (Entman, 1993). Our study therefore seeks to identify keywords that are repeatedly used while reporting H1N1. Journalism production processes also assign salience to news stories by placement (front page or inside pages), position (upper or lower half of the printed page), emphasis (single or multi-column), or use of typefaces or illustrations. These editorial devices or techniques connote meanings that readers learn to understand and interpret (Middlestadt and Barnhurst, 1999).

The second aspect of Entman’s definition relates to promoting the issue in such a manner as to communicate a certain point of view. This relates to telling the story in ways to make the audience think and feel about it in a certain manner. For our purpose, this means how the death narrative was constructed, packaged and positioned in news stories and how some attributes or aspects of the issue were made salient. The assumption we make here is that news packaging and positioning are major strategies for framing of an issue. The way news media organize, treat and present issues, events and news objects such as death, offers interpretive frameworks for audiences to make sense of issues and events. In short, a news frame can be defined as the central story line or organizing idea of the news story that attributes specific meaning to issues, events and the actors involved (Fiske and Taylor, 1991; Melkote, 2009).

Communication scholars have explored how patients use narratives to create coherent understandings of illnesses (Andreas et al., 2010; Olsson et al., 2010), how stories affect the researcher and the subject (Caine, 2010), and how conversations between patients and physicians influence their relationships and behaviors (Cretchley et al., 2010). A common theme across the different streams of enquiry is that communication is a meaning-making exercise that is mutually constructed. A class of such communication studies relates to how media narratives frame news, imbue it with salience, and how people interpret it. A substantial part of audiences’ experience comes indirectly, through various forms of media exposure. If media reporting is biased, then much of their experience will also be biased (Combs and Slovic, 1979). Hence, it becomes important to study how media frame a health issue because it influences public perception and policy formulation.

Communication scholars worldwide have conducted several studies on news framing of public health issues such as Anthrax, SARS (Severe Acute Respiratory Syndrome) and bird flu, and have identified a variety of news frames (Semetko and Valkenburg, 2000). News frames related to health information determine the way people view or perceive disease and illness (Ziporyn, 1988).

The extant literature on health identifies the existence of some frames in health-related content, especially in news coverage. Bueno and Villar (2006) identified six frames in health news and advertisements: risk frame, medical management frame, faith frame, alternative frame, economic frame and social/political frame. A study of the coverage of SARS in China showed the presence of five frames: economic consequences, responsibility, conflict, leadership and human interest (Luther and Zhou, 2005). Hong (2007) also analyzed SARS coverage and identified five frames: attribution of responsibility, economic consequences, human interest, health severity and denial. Both Luther and Zhou (2005) and Hong (2007) adopted a similar strategy to identify frames: they pre-selected the frames based on a literature review and checked their existence in the coverage of SARS in the Chinese media. Some of the frames they selected were the most commonly identified frames in the health-framing literature (e.g. ‘attribution of responsibility’, ‘human interest’).

We were interested in finding out how H1N1-related news was packaged and presented to the public. Specifically, our primary motivation was to determine how the largest circulated English daily in India framed H1N1 death news. This led us to ask three specific questions:

RQ1: What frames were developed to construct the ‘H1N1 death’ narrative?

RQ2: What aspects of death news were ascribed most salience based on positioning?

RQ3: How did H1N1become newsworthy and significant?

Method

We chose to analyze framing of death news in the Ahmedabad edition of The Times of India, the largest circulated English daily in the state of Gujarat (India), because Gujarat stands second in the tally of total H1N1 deaths in different states of India (Government of India, 2010b).

We analyzed H1N1 death-related news from 4 August 2009 to 20 November 2009. The Times of India reported news of the first H1N1 flu death in the country on 4 August and around the third week of November news reports about H1N1 began to taper off. To illustrate, The Times of India published 90 H1N1 related news stories in the first week of the time frame and only three in the third week of November.

Sampling

A total of 105 issues of The Times of India were published between 4 August and 20 November 2009. We counted and listed 381 H1N1-related news stories in these issues. Of the 381 news stories, we selected for analysis all the 62 news stories that reported death because of H1N1. Each of the 62 stories reported H1N1 death for the first time in the headline, the lead or the body of the news story. Aftermath (follow-up) death stories were not included in the study because these stories dealt with the consequences (how the family, the school or the hospital was coping with H1N1) of death and not the incident of death (how a H1N1-affected person died). The 62 news stories were then separately listed according to the date of publication, the number of columns occupied, and the number of accompanying photographs or illustrations.

Framing

Various approaches are available to identify and define news frames (Beaudoin, 2007). Semetko and Valkenburg (2000) discuss two possible approaches for content analyzing the news frames: inductive and deductive. In the inductive approach the researcher begins with loosely defined preconceptions of the frames and then arrives at the final frames. Working with an open mind, the inductive approach allows the researcher to find many possible frames. For example, Menashe and Siegel (1998) used the inductive approach in their analyses of newspaper coverage of tobacco issues in the USA between 1985 and 1996. They identified 11 dominant frames that tobacco industry and tobacco control advocates used to present their case to the public. The deductive approach to framing reverses the first approach. The researcher uses a predefined and established set of frames and then verifies the extent of occurrence of these predefined frames in the news. The researcher here has to deal with the possibility that the predefined frames might overlook the existence of other frames in the news content. In this sense, deductive approach can be problematic and can ignore the existence of some important frames.

We decided to use the inductive approach for a qualitative content analysis of framing of H1N1 death news in The Times of India. An important consideration for choosing to use the inductive approach was that disease-induced death frames had not been identified before. We adapted the procedure outlined by Winett (1995) for conducting the content analysis.¹

To identify the frames in the news coverage, we (both the authors) read all the 62 news stories at least three times. After each reading we shared our findings to achieve consensus. Our first reading enabled us to make sense of the coverage. It gave us a general idea about how death due to H1N1 is reported. The second reading enabled us to distance ourselves from the content and read it from a third person’s perspective. During the second reading, following Winett (1995), arguments (‘points’) mentioned in the news items were recorded. After discussion, the arguments showing common features were merged under a frame. Often a single complete sentence constituted an argument and a set of inter-related arguments spread across different stories constituted a frame. For example, two arguments – ‘the state government issued no communication about H1N1 resulting in delay in taking precautionary measures’ and ‘the hospital did not test for swine flu or administer Tamiflu despite [the woman] showing symptoms of swine flu’ – can be grouped under the ‘attribution of responsibility’ frame. Moreover, a frame included not just a series of arguments that share a common perspective of the problem, but also a set of catch phrases and visual images that can be readily identified as being a part of that frame. For example, catch phrases such as ‘shutting down’ of schools, ‘quarantining’ the patients and ‘taking preventive measures’, induce an ‘action’ frame.

The third reading was carried out to check the correctness and exhaustiveness of these frames. After the list of frames was identified, we conducted an in-depth analysis of all news stories included in the study and identified the dominant frames; that is, those frames that included maximum arguments.

We adapted a part of the framing matrix developed by Ryan (1991) and outlined by Winett (1995). In the framing matrix, each of the frames was characterized under five categories: (a) title of frame; (b) main arguments of frame; (c) implication; (d) catch phrases; and (e) example of sentences containing the frame.

Examples of analysis

We demonstrate here analysis of two news stories that show the existence of some of the dominant frames and arguments in the ‘death’ coverage. Both news stories are different in a variety of ways. In terms of placement, the first story (‘India’s first swine flu death’) appeared on the first page of The Times of India whereas the second (‘H1N1 claims fourth life in Vadodara’) appeared on the seventh page. In terms of date of publication, the two news stories appeared wide apart. The first story appeared on 4 August 2009 and the second appeared around the end of the study period, on 13 November 2009.

The first H1N1 flu death in India (Table 1) appeared on the front page of The Times of India on 4 August (as well as several other newspapers). It boldly announced at once the arrival and impact of the ‘deadly’ virus in the country. The ‘news’ narrative identifies the major actors (victim, school, hospital, federal and state governments, and a national scientific institution) and provides information about symptoms of the disease and the hospital people should visit (government) and not visit (private hospital).

Table 1.

Analysis of India’s first H1N1-related death news on the front page of The Times of India.

Headline: India’s first swine flu death4 August 2009; page 1; 2-column story with photo along with a table
Sentence no.	Sentence (point)	Brief explanation of frame
1	India on Monday reported its first death due to H1N1 flu infection, with a 14-year-old girl from Pune succumbing to the deadly influenza virus.	Lethality of the virus Juxtaposition of innocence of childhood with cruelty of death
2	The girl, a student of class IX from St Anne’s High School first showed symptoms of H1N1 infection – sore throat, running nose and headache – on July 21.	Ordinariness of symptoms
3	But a crucial delay in being tested for H1N1 infection and being administered Tamiflu, because she was admitted in a private hospital instead of the stipulated government isolation ward meant for both suspected and confirmed H1N1patients, may have been the cause of her death.	Delay as cause of death Negligence Attribution
4	What’s bothering the Union health ministry is that the girl had attended school till July 23, raising serious fears that the virus may have jumped to other students and teachers in the school besides everybody she came in contact with from July 20–23.	Spread of infection – fear
5	Shockingly, Lymette Wilson, the school’s physical education teacher said the state health department had not even informed the school that a student was found to be infected with H1N1.	No information – negligence Attribution – blaming the health dept. Unsuspected victims (school members), victim (a girl) and villain (government) Unseemly situation
6	This is why the school hasn’t even started looking for similar H1N1symptoms in other students till now.	As 5 above
7	Wilson said, ‘Till yesterday, we were told it’s a lung infection.’	Incorrect information – negligence
8	The state health department on the other hand is upset with the National Institute of Virology for not informing them that a positive sample was sent to them by a private hospital.	Shifting of blame or responsibility – negligence
9	MS Devnikar, head of Pune’s joint co-ordination committee for containment of H1NI, told TOI (Times of India), ‘Till today, we were not aware that a patient with symptoms of swine flu was admitted to a private hospital.’	No information – negligence
10	The school meanwhile has decided to stay shut on Tuesday as a mark of condolence on the girl’s death.	Bereavement / condolence
11	However, it will open after that.	Show must go on
12	India recorded its first H1N1 case in Hyderabad on May 16 and since then the virus has spread to almost 22 cities and towns across the country.	Rapid spread of infection – adding to mysteriousness of H1N1
13	Explaining the series of events that led to the death of the girl, Maharashtra’s health secretary SharvariGokhale told TOI, ‘On July 21, the girl first showed symptoms.	Related to sentence (3) Quotation Sentence 1: symptoms
14	She then consulted a general practitioner and kept attending school till July 23.	Quotation Sentence 2: treatment
15	Two days later, she reported high fever.	Quotation Sentence 3 – symptom
16	She was then admitted to Jahangir hospital, a private nursing home on July 27.	Quotation Sentence 4 – hospitalization
17	Her condition worsened following which she was shifted to the Intensive Care Unit and was put on a ventilator on July 29.’	Quotation Sentence 5 – treatment
18	‘On July 31, her throat and nose swab was sent to National Institute of Virology (Pune) which confirmed that she was infected with H1N1.	Quotation Sentence 6 – H1N1 test
19	The same day, almost 10 days after her symptoms first appeared, she was administered the first dose of Tamiflu, which obviously was too late,’ Gokhale said.	Quotation Sentence 7 – Delay; denouement – death inevitable consequence

Importantly, the narrative construction of death embeds the ‘attribution of responsibility’ frame in the news story by using a series of arguments. For example, the third sentence of the news story ‘But a crucial delay in being tested … may have been the cause of her death’ (italics added) identifies the reason for the girl’s death. The news story then quotes the state’s health secretary in which he traces the entire process leading to the death of the girl. He concludes that by the time the first dose of Tamiflu was administered, it was ‘obviously too late’. Thus, a public health authority stamps his approval on the story’s claim that death was because of delay. However, this contradicts the unambiguous declaration in the news story’s lead that the girl’s death was because of H1N1 infection. The frame not only excludes the doctor’s voice from the news story but corroborates the claim of girl’s death due to delay by quoting the health secretary in seven sentences (sentences 13–19).

This frame also fixes responsibility for the girl’s death. The responsibility (or blame) for the girl’s death is tacitly attributed to the victim (or the caretakers) because she went to a private hospital instead of the ‘stipulated government isolation ward’. The responsibility for not providing or sharing correct information about H1N1 infection with the school or the joint coordination committee is attributed to the state health department and a national scientific institution respectively.

The second news story appeared on page 7 of The Times of India toward the end of study’s time period (Table 2). The dominant frame in this news story is one of ‘fear’. The manifest content of the news story is the death of a 30-year-old engineer from H1N1. However, at the connotative level, the story suggests that a young and educated person falls sick, visits doctors, is admitted into hospital, put on a ventilator, given medication, and yet he dies. That is, the young man did about everything correct, as possibly the reader of the news story would have. What else could he have done? The reader is left to dread flu-like symptoms.

Table 2.

Analysis of H1N1-related death news on an inside page of The Times of India.

Headline: H1N1 claims fourth life in Vadodara13 November 2009; page 7; 1 column
Sentence no.	Sentence (point)	Brief explanation of frame
1	A 30-year-old male software engineer from the city succumbed to swine flu on Thursday.	Young educated person infected Lethality of the virus
2	This is fourth swine flu death in the city.	Number of fatalities – mounting toll (fear)
3	Kamala Kannan, who lived in Sama-Savlilocality was admitted to SSG hospital on November 6 with flu like symptoms and respiratory problems.	Ordinariness of symptoms
4	His samples tested positive for H1N1 and he was kept on ventilator.	Seriousness of condition Adding to lethality of the virus
5	Kannan’s condition remained critical and he died at 10.20 am on Thursday.	Denouement – death Inevitability of death despite efforts to save him (fear)
6	Kannan had earlier visited several private clinics and was referred by a private practitioner to SSG.	Treatment
7	He was admitted at isolation ward complaining of cold, cough and respiratory problem.	Symptoms
8	As per hospital authorities, he had developed acute respiratory distress syndrome and his conditions remained critical despite medication.	Symptoms Drugs failed Adding to lethality of the virus (fear)
9	He died in the morning and was cremated at Khaswadi crematorium.	Death
10	As per Vadodara Municipal Corporation (VMC) health officials, Kannan had visited Chennai some time ago for professional reasons.	Travel to another city as possible source of infection – fear

However, differences in the framing of death can be observed between the first and the second news story. For one, the patient is not held responsible for delay in the second news story even though he had initially visited private clinics. The blame is shifted to another city, Chennai, where the victim travelled. However, the process of reporting and counting the number of fatalities in the city begins after the first death. The single column news story from 13 November reports the fourth death in Vadodara. The next section deals with the analysis of H1N1 ‘death’ news stories in The Times of India.

Analysis and results

The analysis of the 62 news stories of H1N1 death that appeared in The Times of India in the period 4 August to 20 November 2009 yielded four dominant frames: ‘fear and panic’, ‘attribution of responsibility’, ’action’ and ‘human interest’. The four frames appear to characterize the content of the news stories included in the study.

RQ1: What frames were developed to construct the ‘H1N1 death’ narrative?

The analysis of death coverage in 105 issues of The Times of India yielded four dominant frames. A brief description of the four frames is provided below.

Fear-panic frame

This frame is induced when news stories repeatedly bring up arguments about the lethality of the ‘deadly influenza virus’, ’mounting death toll’ and the ‘dreaded H1N1 virus’. In addition, use of catch phrases (strong adjectives) like ‘rapid spread of infection’, ‘flu death march’ and ‘government presses panic button’ induces fear and panic. Frequent references to H1N1 as a ‘mystery’, failure of doctors’ efforts, failure of preventive measures, and ineffectiveness of medication and treatment (‘Tamiflu does not work’) create fear and panic.

News stories also report fear and panic among people because of the death of an H1N1-affected person. News stories portray fear of H1N1 infection, death because of H1N1, spread of the virus to more places, ineffectiveness of the preventive measures and medication, lapses in public safety/security measures at institutional and government level, and the possibility of new infections (‘33% Indians likely to get H1N1: Azad’ – Azad is India’s health minister and this story appeared on the front page of the newspaper on 10 August 2009).

A consistent pattern of reporting the number of H1N1 deaths was found in the coverage. About 70 percent of the total 62 news stories mentioned the rise in the H1N1 death toll. Hong’s (2007) analysis of SARS coverage in Chinese media also highlighted the journalistic practice of reporting numbers and he classified it under the ‘severity’ frame

Attribution of responsibility frame

This frame fixes responsibility (blame) on an individual or organization for a specific set of actions related to H1N1. It does so by implicitly addressing two inter-related questions: who is responsible? and for what? News stories related to H1N1 deaths apportion responsibility for late admission of patients into designated government hospitals, late administration of Tamiflu and untimely communication. The implication of arguments in this frame is that death (or spread of infection) was due to someone somewhere not being responsible enough. Even though the affected person is held responsible for delay in getting to the government hospital, it is an institution (airport, hospital, government health department) that is taken to task for being negligent in either detecting H1N1 cases or providing prompt treatment. The implication in the news stories is that death could have been avoided if the victim was given prompt and appropriate care (Table 3). As indicated earlier, the ‘attribution of responsibility’ frame has been found in studies of health coverage (Luther and Zhou, 2005).

Table 3.

A matrix of H1N1 death news frames.

Serial no.	Frame	Main arguments of frame	Implication	Catch phrases used	Sentences containing the frame
1	Fear and panic frame	Public hospitals, doctors, government, even newspapers’ actions and pronounce-ments spread scare of H1N1 infection.	Its cause is mysterious and, if you are infected, H1N1 will most likely kill you.	Fear of the spread of the disease bothering the state officials, infection explosion in winter, death presses panic button, patient died despite of treatment and Tamiflu, doctors worried, people likely to get H1N1 infection, possibility of spread in lower middle class, mounting death toll, use of words like ‘deadly virus’, ‘dreaded virus’, and ‘flu death march’.	This after swine flu panic had taken the country and city by storm and even a child knew about the precautions. The death of Arya, the second swine flu casualty in Gujarat has left the government and doctors jittery and groping for answers because they debate the possibility that Tamiflu – the only medication for H1N1 world-wide – may not have worked in her case. Two deaths were reported from Karnataka, taking the total number of deaths because of H1N1 virus to 73. The nationwide toll climbed to 220.
2	Attribution of responsibility frame	Who is responsible for the delay or deaths? Victim, state government, hospital and institutions. Late access to treatment or not providing timely treatment or information about H1N1.	Irresponsible behavior. Delay, inefficiency is the cause of death.	The patient was admitted to private hospital instead of government hospital, state government did not provide information to school about the confirmation of H1N1 infection to a student, health body did not know a private hospital has admitted a H1N1 patient. Delay in accessing proper care, delay in administering the Tamiflu, negligence of hospitals in providing information, negligence in taking protective care by individuals, flights are not screened properly, hospitals goofing up in collection of samples.	Shockingly, Lymette Wilson, the school’s physical education teacher said the state health department had not even informed the school that a student was found to be infected with H1N1. My brother would have been alive had there been more vigilant action at the airport. The glaring negligence of Siddhivinayak hospital authorities in Maninagar in alerting civic body about a suspected swine flu case and eventually the patient’s death had the department doing a reverse tracking. It is reported that despite the swine flu scare, these doctors did not seem to have taken protective measures, like wearing a mask and other measures as per protocol while treating the woman. ‘Screening at the airport is non-existent. They just touched my forehead to check my fever and then let me go.’
3	Action frame	Steps taken to control the pandemic.	Prevention is important.	H1N1 test facility in government hospitals, shutting down of schools, quarantining the H1N1 patients, tracking persons released from hospitals. Government’s appeal to people and institution for precautionary measures.	Seven people have been identified who came in contact with the H1N1 patient. They have been quarantined and put on chemoprophylaxis. Seventeen deaths later, state health department finally cracked the whip on Surat Municipal Corporation (SMC) directing it to get copies of death records of all H1N1 patients and study them.
4	Human interest	Human side of the tragedy.	People react to and cope with it different ways.	Ganesha idols with flu masks, patients run away, wife’s ignorance of her husband’s death, emotional status of the relatives of H1N1 victim facing social exclusion.	A pall of gloom descended on Akota area with the mourning family locking itself in and not talking to anyone. Relatives console parents of the girl at Karelibaug cremation ground.

Action frame

The action frame is created when news stories report steps or initiatives that public or private institutions undertake to arrest the spread of the virus. We came across two kinds of action frames: preventive and punitive. The preventive frame includes arguments that refer to steps taken by institutions and organizations to stop the spread of H1N1. Schools in several cities were shut down, airports became more vigilant, the state and federal governments launched awareness campaigns to educate people, and municipal or health authorities provided medication (Tamiflu) to the family of those who died because of H1N1. In such stories, the preventive frame was buried in the body of the story. The punitive frame, on the other hand, presents arguments that refer to strict action taken or threat of such action for negligence (‘17 deaths later, govt cracks whip on Surat civic body: To study death record, punish negligent hospitals’, The Times of India, 30 September 2009). The implication in the news stories is that the steps taken by any agency (hospitals, government or schools) to tackle the H1N1 pandemic or the fear or panic because of H1N1 were either adequate or inadequate.

Human interest frame

This frame features the patients’ or caretakers’ lives, giving a personal touch to the story by highlighting its affective dimensions (Luther and Zhou, 2005). Together the stories indicate how people react to or cope with sudden loss of near and dear ones and how their ways of dealing with tragedy are different from institutional responses to it (Semetko and Valkenburg, 2000). Some researchers also call it a personalization frame (Da Silva Medeiros and Massarani, 2010). While covering H1N1 death, the practice of dealing with the deceased’s personal details was evident. News coverage described the sad condition of the kin of the deceased; for example, ‘Wife unaware of Praveen’s death. Wants to go back home after getting out of hospital’, and ‘H1N1 victim Pravin Patel had played volleyball with friends recently’. Some stories reported the personal background of the infected or deceased person, such as their young age, occupation and marital status. If the deceased was a child, the parents’ grief was often quoted. In addition, the condition of the school and child’s friends was briefly but poignantly described.

The human interest frame also included news stories that were unusual. One such described the idols of lord Ganesha (a Hindu deity) wearing flu masks being displayed during the 10-day Ganesh festival season. Other stories featured instances of a H1N1-flu patient reluctant to be isolated in a hospital and a H1N1-affected student running away from the hospital but hospitalized by the caretakers.

RQ2: What aspects of death news were ascribed most salience based on positioning?

Newspaper practitioners routinely use position, emphasis, illustrations and other design and layout-related devices as strategies to attract attention and convey information and salience (Middlestadt and Barnhurst, 1999). Ample empirical evidence shows that such devices communicate connotative meanings (Morrison, 1986). Readers can judge the salience of news stories when these are printed on the front page (Ryan and Theodore, 2004). We define salience as news stories that are featured on the front page of The Times of India and thus became noticeable and memorable. Of the 62 stories related to H1N1 death, 18 appeared on the front page and are here specifically examined to identify and describe what aspects of death news were given salience.

Although death per se made news, there were aspects or characteristics of some deaths that made them sufficiently salient to be on the front page of the newspaper. Such news stories can be classified into four broad categories: news stories that featured: (1) the occurrence of the first death in a city, region, state or country; (2) the rising death toll due to H1N1; (3) a human interest angle; and (4) school and children. The first category comprised four stories. The defining characteristic of this category is that they relate to the occurrence of the first death in the city of Ahmedabad or the state of Gujarat (‘India’s first swine flu death’, ‘H1N1 claims first victim in Saurashtra’). Together these stories gain salience because of the firstness and nearness of death in the state of Gujarat (the state where The Times of India is published). We label the category the ‘novelty-proximity category’. The second category contained eight stories. The defining characteristic of this category is that they relate to the mounting death toll in the state (‘H1N1 claims 4 more’, Swine Flu kills 2 more in Gujarat’, ‘Wake up!: 3 more deaths take Gujarat toll rate 4 times higher than India’s’). Together these stories gain salience because of the increasing number of fatalities. The third category of human interest contained four stories. The defining characteristic of this category is that they relate to the death of women or pregnant women in the state. Together these stories gain salience because they evoke an emotional response in the readers. The last category of school and children contained two stories. These news stories relate to school closure and children’s susceptibility to the H1N1 viral infection.

It is interesting to note that all the 18 front page news stories appeared within two months from the first reported H1N1 death in the country (Table 4). The Times of India did not carry any H1N1 death-related news story on the front page for the next two months until the end of the study period. This underscores our argument that H1N1 death showed a decreasing degree of salience (moved from the front to inside pages) once its firstness began to fade and the toll began to mount in the state.

Table 4.

H1N1-related death stories on the front page of The Times of India.

StoryNo.	Headlines	Date (all 2009)	Columns	Photos + sketches + data tables
1	India’s first swine flu death	4 August	2	2
2	H1N1claims Mumbai housewife	9 August	2	0
3	Atlanta-based NRI dies of H1N1 in A’bad	10 August	3	1
4	VIRUS IN VADODARA 7-Year-Old Treated For H1N1 For One Week, Dies	12 August	2	2
5	Mumbai Schools Closed: H1N1 toll 18	13 August	3	1
6	H1N1 claims 4 more	20 August	1	0
7	Flu death march picks up pace in Guj Two Deaths Stun A’bad, Suspect Dies In Vadodara H1N1 TIGHTENS GRIP IN GUJ	21 August	3	2
8	Swine flu claims 6th victim in Guj Bharuch Resident Dies In Vadodara; Positive Cases Climb To 92 In State	24 August	1	2
9	H1N1 claims first victim in Saurashtra	25 August	2	2
10	Maha doctors threatens stir	25 August	1	0
11	H1N1 kills pregnant woman in A’bad	30 August	3	1
12	H1N1 claims pregnant woman in Vadodara	4 September	1	0
13	Swine flu kills Surat woman	5 September	1	0
14	H1N1 kills woman in Ahmedabad	6 September	1	0
15	Swine flu kills 2 more in Gujarat	9 September	1	0
16	Swine flu claims 2 in Vadodara, Surat	13 September	3	2
17	Swine flu claims 3 in a day	29 September	3	2
18	WAKE UP! 3 more deaths take Gujarat toll rate 4 times higher than India’s	21 September	2	2

RQ3: How did H1N1 become newsworthy and significant?

Having analyzed framing of death, a fundamental question confronted us. How did H1N1 become newsworthy for such a long time (381 news items in 105 days in The Times of India)? What did the stories say that communicated that H1N1 was newsworthy and significant? To put things in perspective, about 1000 people on average die of tuberculosis daily in India. In the 100 districts across six states of the country, 42 percent of children under five are underweight and 59 percent are stunted (HUNGaMA, 2011). At least 4 million children are thought to migrate seasonally, whether by themselves or with their families, in search of work so that they can supplement family income (UNICEF, 2012 Report). But neither TB deaths nor hunger (or its consequences) have received the kind and extent of sustained newspaper coverage that H1N1 has done.

On reflection, we could attribute four categories of implied significance to the news stories. The first has to do with H1N1 itself and can be labeled ‘mysteriousness of disease’. From the local episodes scattered in a few places across the globe, H1N1 rapidly spread and became a worldwide scare. India might have been immune to the virus in the initial stages, but it was acutely aware of the scare it would create. However, this did not stop the political leaders and public health authorities from adding to it. The federal health minister unwittingly said that H1N1 would likely infect 33 percent of the Indian population in the next two years. Gujarat’s health minister publicly feared that the state must be prepared for an ‘infection explosion’. Government doctors openly wondered what would save lives if Tamiflu, the only known drug to prevent death, proved ineffective. The media added to the mysteriousness of the disease by calling it ‘swine flu’, ‘H1N1 flu’, ‘H1N1 virus’, ‘flu’, ‘Influenza A’, and ‘deadly virus’. In a rare instance, the newspaper attributed a death to H1N1 only to clarify later in a three-column story that this was not the case (‘Suspected H1N1 victim did not die of swine flu’, 17 August 2009). In another instance, the nonoccurrence of an event made a two-column splash in the newspaper (‘No fresh H1N1 case on Wednesday’, 27 August 2009). Confusion, uncertainty, panic and death pervaded the issue and the media promptly reported it all.

Another important category of explanation for extensive coverage was the ‘site of death’. Each of the deaths reported in the newspaper occurred in a hospital. The hospital’s case sheet became a source of news stories for the reporter covering the health beat and the medical doctors, experts and public health officials were often cited as sources of news. Moreover, several stories followed a predictable pattern in reporting the sequence of events leading to the death of the patient – appearance of symptoms, visit to private clinic(s), admission to private hospital, deterioration of condition, shift to government hospital, put on ventilator, administered Tamiflu, and death. News stories reporting this sequence of events occasionally informed readers about the symptoms and admonished them to visit government hospitals. In short, death became news partly because the doctor verified it and the hospital documented the cause of death, and the failure of the health system contributed to the significance of the crisis.

The third category that contributed to H1N1’s significance was the victim’s background. News reports quoted experts as saying that children in general and adults suffering from certain conditions (such as asthma) were susceptible to H1N1 infection. Several persons who died of H1N1 were schoolchildren and young men and women. Death robbed them of their future and life and the newspaper stories seemed to imply this (‘A 30-year-old male software engineer from the city succumbed to swine flu on Thursday’ or ‘… a 14-year-old girl from Pune succumb[ed] to the deadly influenza virus’). It was the suddenness with which the health of a person deteriorated and the untimeliness of death that made H1N1 newsworthy.

The fourth category of implied significance for H1N1’s newsworthiness has to do with how international news events influence national media agenda, and often public policy, and magnify its import. The Indian media and audiences were already primed about the pandemic even before the outbreak of H1N1 infection in the country. Television footage of mask-wearing Mexicans in early 2009 and the news of the mass slaughter of pigs made headlines in Indian media. Meanwhile, the World Health Organization declared the H1N1 crisis a global pandemic. This forced several governments, including the Indian government, to undertake a series of preventive measures including issuing travel advisories. In India, H1N1 became salient with the diagnosis of the first H1N1 case in the country on 16 May 2009. The coverage rose again when the first H1N1 death occurred on 3 August. Thus we observe that a serious outbreak of H1N1 virus in some parts of the world turned a health incident into a media issue, resulting in a slew of policy initiatives and announcements which again led to another round of media coverage. In short, when two or more agendas intertwine (in this case, public health and media) then the issue gains significance.

Discussion

We have presented here what we believe is the first systematic analysis of frames used in an Indian daily in portraying H1N1 deaths beginning from the day when the first H1N1 death was reported in the country. One of the most important findings from the analysis of news stories in The Times of India is our observation of the existence of four dominant frames: fear and panic; attribution of responsibility; action; and human interest. Two of the four frames (attribution of responsibility and human interest) inductively derived in the study exist in literature. This study contributes to the health-framing literature, especially from the ‘framing death’ perspective.

During the coverage of H1N1 death, the editorial team of The Times of India chose to define H1N1 as a ‘deadly’ issue, invoking anxiety, fear and panic. By focusing on the ‘attribution of responsibility’ frame, the newspaper reports underscored the need to establish medical emergency protocols, including procedures for inter-agency coordination and communication with various stakeholders. By focusing on the occurrence of deaths in government (public) hospitals, the newspaper inadvertently created an impression that they are ineffective.

Framing leads media to make editorial choices in what gets reported and what does not (or who is quoted and who is not). A careful examination of the H1N1 death news stories in The Times of India showed that several private clinics first admitted patients and later sent them to government hospitals where they eventually died. However, the newspaper stories hardly ever reported the delay in transferring patients to government hospitals. The ‘attribution of responsibility’ frame did not pay attention to the role of private clinics or to what institutions and organizations (health department, airport, and schools) were doing.

The concept of framing has implications for public opinion formation. Readers form opinions and attitudes based on how media portray news events. Because a large number of H1N1 deaths occurred in public (government) hospitals, what attitudes and images would individuals have formed about public hospitals? News frames would have reinforced negative impressions people might already have about public hospitals and would have dissuaded others from visiting them (and, therefore, visiting private hospitals) when in fact their survival depended on visiting the public hospitals at the earliest.

Fear and panic are the result of people’s perceptions of risk. Media influence people’s risk measurements in two ways: qualitative and quantitative. Qualitative risk measures represent the low end of the continuum of contextual precision (Dudo et al., 2007). Qualitative measures refer to repeated use of strong adjectives (‘deadly virus’, ‘flu death march’, ‘dreaded H1N1 virus’, ‘big threat’, deadly disease’, mysterious disease’, ‘infectious disease’), references to events such as failure of life support systems, failures of preventive measures, ineffectiveness of medication and treatment, even failure of doctors, and emphasize vague claims and information with less precision (e.g. Federal health minister’s statement that 33% of Indians are likely to get infected with H1N1). Taken together, we argue, based on previous literature, embedding such phrases and references in the broad death narrative added to the sense of anxiety and fear (Gudykunst, 1995; Hume, 2000).

Quantitative risk measurement refers to reporting the numbers of deaths with or without a contextual denominator (Dudo et al., 2007). Several news stories reported the number of H1N1 deaths but did not report ‘out of how many’. For example, of the total number of 65,803 samples tested for H1N1, only 12,334 people were affected with the virus. Of these, 400 cases died of H1N1 virus until 15 October 2009 (H1N1 Toll Nears 400 in India, 15 October 2009). In other words, fewer than 20 percent of the samples tested were found to be positive and of those who tested positive only 3.24 percent succumbed to the H1N1 virus. By choosing not to provide contextual information – percentage of dead or recovery cases – the newspaper framed the H1N1 virus into a ‘deadly disease’ and created an exaggerated sense of uncertainty, anxiety and fear. Had the newspaper featured stories about those (an overwhelming 96% or so) who did not succumb to the virus, the heightened sense of fear and panic people experienced would have abated. We argue here that providing quantitative risk information allows for informed, rational decision-making (Roche and Muskavitch, 2003) and minimizes people’s sense of risk of infection and possible death. In terms of editorial practice, journalists should report percentages rather than frequencies of those affected or dead.

Media’s influence is not limited to the readers; rather it extends to policy makers too. Framing organizes and presents events and issues in such a manner as to offer public policy decisions (Wallack et al., 1993). Specifically, media exposure has an impact on policy decision in two ways: by shaping public perception of risk (rather than of policy), and by shaping policy makers’ perception of public opinion (Bakir, 2006). Policy agenda-setting literature suggests that the policy makers sense public opinion through media, as they believe that the media influence people’s understanding of issues (Herbst, 2002; Linsky, 1986; Rogers and Dearing, 1988: 579; Soroka, 2003). In the present case, the media coverage of H1N1 may have contributed, along with other factors, to declaring it a ‘national emergency’. This analysis suggests that, while media professionals report on issues such as deaths from H1N1, they should pay attention to the selection and presentation of information, and the implications of the agenda they are going to set, through framing of an issue, in their coverage. To be fair to journalists, framing can be an unintentional source of bias in reporting an issue; ‘unintentional’ because framing might occur for any number of reasons: meeting deadlines, work pressure, availability of information, availability of space, selection of some facts over others, inefficiency or lack of experience of a journalist or simply the way news is written.

One could argue that the identification and classification of frames has been subjectively arrived at in the study. Other analysts could come up with a very different set of frames from those presented here. Framing, by its very nature, is the result of a series of subjectivities and the interpretive nature of framing analysis could be considered both its strength and weakness. This study represents only a first attempt to identify frames for H1N1 death-related news. Despite this limitation, our findings do provide some important lessons for media professionals who play an important role in health crisis.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Notes

Author biographies

Pradeep Krishnatray is Professor at the School of Media and Communication Studies, Galgotias University, India

Rahul Gadekar is a Research Associate at the Mudra Institute of Communications, Ahmedabad, Gujarat, India.

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