The existing structure of this field of study is weighted towards analyses of health representations (this point will be made more evident in the survey of abstracts that follows this section). Any general account of media and health, if it is to be based on an adequate body of evidence, must therefore take this as the primary object of analysis. But in order to understand media health representations it is necessary to know a little more about the media health audience. In the discussion that follows, little reference will be made to media production issues1 and, reflecting the balance of existing published work, the focus will be on traditional popular ‘mass’ media rather than the Internet or the more specialist media read by professional groups. They are nevertheless important areas and studies of the internet, as you will see, and are included in the papers in this volume because of their importance for the future of media health research.
Understanding the media health audience
This is necessarily brief, being the bare essentials of audience theory needed to understand the account of representations that follows (a fuller account that explains the underlying rationale for this selection is in Seale 2003: Chapter 1). In my view any general account of the media health audience should take account of the following five points, which I list together with references to works in which the particular perspective is best expressed:
- 1The audience may (or may not) seek health-promoting information as a part of rational risk profiling at fateful moments. The work of Giddens (1990, 1991, 1992) and to some extent Beck (1992) outlines this vision of the modern individual's relations to expertise, though not with particular reference to media audience theory.
- 2The audience seeks emotional stimulation through dramatised contrasts that have an entertaining effect; fear and anxiety, for example, may be aroused so that they are experienced as a contrast to security and pleasure. Hill's (2000) studies of ‘reality television’ brings this out effectively, as does Langer's (1998) account of the ‘other news’.
- 3Audience readings are diverse, involving ‘resistance’ as well as alignment with dominant ideas. The notion of the ‘active audience’ was designed to replace earlier conceptions of audiences as passive recipients of information, a conception often embedded in early health education studies of ‘effects’. The work of Hall (1980) and Morley (1986) has been influential here, although critical responses to over-enthusiastic depictions of audiences as always active and resistant have emerged to counter this (for example Philo 1999). This perspective is particularly important in any study of audiences where political issues are of concern.
- 4The audience participates in an imagined conversation with mediated ideas, and in an imagined community of other viewers, people ‘like me’. Anderson (1991) is responsible for this idea, relating it to the historical emergence of daily newspapers as the first such mass mediated conversation.
- 5People draw on media in order to construct themselves – the media are mirrors for narcissistic (self-regarding) experimentation with different potential selves. Abercrombie and Longhurst (1998) outline this view.
Beyond these points there is a general one – perhaps the sixth in the list – that I feel has not yet been well recognised, which concerns the nature of audience experience. This is not structured in the same way as the neat divisions of research studies require. A media analyst, in general, picks a particular issue on which to focus: BSE, for example, or depression, or HIV/AIDS, or the emergence of some new contested syndrome, and so on. Once chosen, data may be gathered about the way a range of media presents that particular issue. But audience experience is not like this – it is at once more fragmentary and in a sense more active. As we go about our lives we may at one point in the day hear a report about a health scare on a radio programme, then read about a health policy in the newspaper, then spend the evening channel hopping on the television, seeing a soap opera where characters eat a variety of health enhancing or damaging foods, a documentary where a medical breakthrough is described, finishing with reading a magazine where readers’ letters about health issues are answered. Nowhere do we decide to spend the day focusing on the way a variety of media present the topic of depression. As the result of this fragmentary experience, we learn the conventions of an overall media health story, which has certain regular features. Media audiences generally are well schooled in recognising media conventions (the discipline of media studies only formalises a tendency to critique and analyse these which we all have to a greater or lesser extent). Members of media audiences, in fact, are able actively to ‘fill in the gaps’ when they experience a fragment of an overall story, as Benthall (1993) has argued in relation to audience experience of disaster relief stories:
Even when only a part of a narrative relating to disaster is shown on television – for instance, pictures of starving babies, or an aeroplane setting off from a familiar airport bringing supplies, or an ambassador thanking the public for their generosity – viewers come to recognize it as part of the total narrative convention (Benthall 1993: 188–9).
It is in the context of this learned capacity of audiences to recognise narrative conventions (which media producers themselves may recognise and exploit) that we can understand media health representations.
Understanding media health representations
One of the many insights of narrative analysts (for example Propp 1968, Labov 1973) is that stories often work by creating and then exploiting oppositions. These are common in the overall story of media health. To list just a few classic oppositions, such stories contain heroes and villains, pleasure and pain, safety and danger, disaster and repair, the beautiful and the ugly, the normal and the freak, cleanliness and dirt, female and male, lay and professional, orthodox and alternative. Perhaps most importantly, media health stories often oppose life with the threat, or the actuality, of death. This last opposition explains, for Turow (1989), the enduring appeal of TV medical soaps, as well as the reason for the overriding focus on doctors rather than nurses or other health care workers in such dramas. Doctors can be more easily depicted making life or death decisions. This means that medical soaps – perhaps like all media health stories at some level – explore the most fundamental anxiety that we all face as embodied, finite beings.
A perennial complaint of scientists considering media reporting of scientific discoveries is that journalists sensationalise their findings, thus introducing inaccuracies (Nelkin 1995). For example, a new drug is either a miracle cure, or a potential Frankenstein's monster such as thalidomide. There is no room for a drug that is good in some respects but bad in others. This tendency to generate dramatic effect through extrematised oppositions is an aspect of what some have called ‘tabloidisation’ (Sparks and Tulloch 2000). Whether there exists an increasing tendency in Western media towards ‘tabloidisation’ or not (and there are those who will argue both sides of this), opinion is also divided on whether such tendencies should be regarded as desirable. One view (seen for example in Livingstone and Lunt's (1994) analysis of daytime TV talk shows) is that tabloidisation is a route to greater democratic participation in the public sphere. It constitutes the popularisation of otherwise complex areas, thus drawing in more participants than otherwise. Others (for example, Franklin 1997) claim that the tabloid format represents a regrettable dumbing down in standards of public debate.
Clearly, popular mass media would cease to be popular if complexity were represented in a way that a scientist would find acceptable in a scientific journal. Some degree of simplification must be necessary if the dramatic oppositions that are the core device of story telling are to be created. Above and beyond this, though, the complaint of inaccuracy, with which the critique of tabloidisation is associated, reflects an inadequate understanding of the conditions of media production. People do not make TV programmes or publish newspapers solely in order to provide the public with accurate health information. The entertainment agenda (and this applies to news and current affairs as much, probably, as it does to ‘fictional’ products) is more dominant, and scientists, medical care providers and health educators have increasingly come to recognise this (Naidoo and Wills 2000).
Because audiences are well educated, through repeated exposure, in the standard oppositions and other forms that go to make up the media health story, they have certain expectations. But entertainment cannot be based solely on meeting expectations, otherwise the appetite for novelty suffers. Media producers know this, and through the phenomenon of the ‘twitch’ or the ‘reversal’ (Langer 1998) they play with audience expectations. This is also seen in the phenomenon of the media ‘template’ (Kitzinger 2000). I shall consider each of these in turn.
Kitzinger (2000) developed her idea of media templates in relation to child abuse stories. A famous case in Cleveland, UK in the 1980s involved the media-orchestrated vilification of a doctor and some social workers for removing children from families suspected of child sexual abuse, thus constructing a powerful sense of opposition between innocence and incompetence (or, even, evil). Later, events occurred in the Orkney Islands that, in the media reporting of the new case, were said to be ‘another Cleveland’. The imposition of the Cleveland template on the Orkneys case meant that a ready-made set of stereotypes, judgements and interpretations could be applied. The Cleveland case had set up a ‘template’ so that when new cases of removal of children from families occurred, they could be understood as further examples of the original story. This operated both at the level of production (how journalists researched, wrote and conceptualised the story) and carried through to audiences. Kitzinger's focus group work showed how people used their understandings of the Cleveland-Orkney association to help remember and interpret the more recent scandal.
Karpf (1988) explains how this used to happen in stories about heart transplants:
[Each one produces] perfect replicas of previous reports. They stress the desperation of those waiting for a heart, and the fear that time will run out. The fatal alternative is made plain. The operation is depicted as offering the chance of a new life or future, an opportunity to vanquish death. Grief and joy are voiced, and the press conference following the operation is an aria of hope (1988: 149).
We no longer see such heart transplant stories in Western media since the template that produced them has lost its currency with the proliferation and routinisation of the operation. A heart transplant story now needs an extra angle to become ‘news’ (for example, a dying Palestinian gives a heart to save the life of an Israeli). Templates, Kitzinger argues, can from time to time be reversed – indeed they must be when their currency begins to weaken. Thus stories of child abuse, in which adults were discovered to have committed abuse (a classic villain-victim opposition), became a tired format, the story being revived at one point by the reverse accusation of ‘False Memory Syndrome’, whereby the previously villainous father now became the victim, falsely accused by therapists and daughters (Kitzinger 1998).
Reversals of this sort, then, play on existing audience expectations to achieve a dramatic or entertaining effect. They confirm the existence of standard narrative conventions, their recognition by an ‘active’ audience, and the response to this by media producers. Langer (1998) presents some particularly subtle examples in his account of ‘twitches’. Certain items become news because they disrupt expectations in an emotionally stimulating way. Langer suggests the following:
a safety barrier impales a car driver;
a schoolboy (rather than an engineer) builds a hovercraft;
the Queen and Prince Philip visit a theme park and take a ride in a ‘tunnel of love’.
The first of these is a very common format in media health stories that involve risks to health. An everyday object turns out to be dangerous – in this case something that is supposed to promote safety. Food scares can work like this – food is an everyday object, necessary for life. Yet food can kill.
The other two twitches also work by disrupting expectations. Schoolboys are not supposed to be able to do the things that engineers do; royals are supposed to maintain their dignity by not engaging in popular pleasures. This last example reminds us that media celebrities can themselves set a media agenda by initiating twitches and reversals. Thus Princess Diana shook the hand of a person with HIV/AIDS in order to disrupt then-dominant negative stereotypes; the footballer Pele, a hero of masculinity, nevertheless advertises the benefits of Viagra; the royal family now sit uncomfortably through rock concerts trying to look as if they enjoy them, so that previous images of aloofness may be disrupted.
A meta-narrative that runs through contemporary mass media health representations, containing a series of opposed elements, arranged in a way that allows a range of sub-plots, templates, twitches and reversals to be placed, can now be described. Its five key elements are listed below, with explanations and examples of each following the list. They constitute a series of core oppositions:
- 1the dangers of modern life;
- 2villains and freaks;
- 4professional heroes;
- 5lay heroes.
The first of these is a collection of stories that generate fear, and a concomitant ‘culture of safety’ (Furedi 1997, Reinharz 1997) that is a marked feature of life in advanced industrialised societies with a highly developed mass media. In a variety of ways, popular mass media emphasise the dangers of modern life. Food scares (salmonella, BSE) are vehicles for such scares (as well as identifying potential villains – farmers, big business). Environmental dangers – nuclear power, acid rain, climate change, power lines and cancer – are also much emphasised in health-related scare stories, as are, from time to time, a variety of infections (for example, herpes) or ‘killer bugs’ (necrotising fasciitis, ebola fever). Images of medical and scientific activity gone wrong – GM foods, breast implants, tampon-induced toxic shock syndrome, contraceptive pill scares – are also important in generating a climate of insecurity.
The second of these (villains and freaks) also concerns things that can threaten health and the sense of normality with which health is nowadays associated (Petersen 1994). In this case though, the threats come from threatening kinds of people. A classic example of this, in some areas of the media, was the treatment of HIV carriers in the early stages of the emergence of this virus, whereby prostitutes, injecting drug users and gay communities were stigmatised and feared (Watney 1997). A similar level of stigmatisation can be found in the media treatment of mental illness (Philo 1996). From time to time, scientists or representatives of big business (for example, ‘agribusiness’, tobacco manufacturers, nuclear power station operators) may be vilified (though not often personally) if they can be associated with harmful developments. The history of depictions of people with disabilities in film is replete with negative stereotyping.
Unlike harmful objects, ‘harmful’ or threatening people can have their reputation defended or restored. Because of the overwhelming interest in subjectivity in media accounts, it is hard to present any person, or group of people, as irredeemably evil over a sustained period of time. Perhaps the only group whose subjectivity is largely deleted from media representations are those of child molesters, who appear to be a securely stigmatised category of person. Most other categories, in due course, attract stigma champions (as in the case of Princess Diana and HIV/AIDS), or they organise to resist media stereotyping (as in the case of the very successful disability movement).
With threats established and continually regenerated by a steady supply of stories, we can all imagine ourselves as potential victims. Yet, from time to time, media producers like to depict victimhood and for this they tend to choose people who represent ourselves at our most vulnerable. Thus the most effective victim portrayals in contemporary media are generally of children. Much concern with safety therefore focuses on child safety. Classically, stories of child abuse have served media producers well in this respect. A less common genre, but one that is more centrally located within the media health field, is the story of the sick child. The dimensions of this story and the way in which it compares with families’ reported experiences of sick children (there are many disjunctures) have been analysed in a study by Dixon-Woods et al. (2003).
The fourth and fifth components of the media health meta-narrative are stories about professional and lay heroes. These, in their different ways, are set up to rescue the victims threatened by danger and villainy. Yet there are important tensions between these two kinds of hero, and understanding this helps us understand why villains cannot easily be securely stigmatised – their subjectivity comes through too often, as the elevation of the lay hero involves a quite pervasive media celebration of the subjectivity of the ordinary person that has gathered pace in recent years. This in turn generates an obligation to be tolerant and inclusive of difference, something which can test the ingenuity of media producers obliged to replace old hate figures with new ones, all the time risking the alienation of important media audience constituencies, should vilification be taken ‘too far’.
Sociologists of health and illness are independently interested in the changing nature of professional-lay relations. For example, the ‘proletarianisation’ and the ‘deprofessionalisation’ theses (Elston 1991) assess the argument that there is a decline in the social and cultural authority of medicine. Karpf's (1988) study of media and health took this as its theme, concluding that in spite of some knocks, medical prestige was as strong as ever on the television. Perhaps if she was writing now, her view might have changed, as it is now quite routine for media health stories to appear announcing medical authority to be bankrupt (see also Bury and Gabe 1994). For example, in Britain in recent years individual doctors have been taken to task in a variety of scandals – the Cleveland child abuse scandal mentioned earlier, the case of the murderous family doctor Harold Shipman, a scandal concerning the storage of dead children's organs at Alder Hey hospital, another involving heart surgeons (again concerning children, significantly enough) in Bristol, whose mistakes were said to have cost lives. Entwistle and Sheldon (1999) list some typical headlines: ‘Patients claim they woke during surgery’, ‘Therapy error in cancer cases’, ‘Surgeon is suspended over breast operations’, ‘Disease could be spread by surgical tools’. There are vestiges of the unassailable Dr Kildare in contemporary representations, though, and media health stories – particularly medical soaps – commonly contain images of doctors acting to rescue threatened victims. But in general this source of rescue is as likely to turn sour or dangerous as the villain is to turn good. Like the villain, the professional hero is no longer a secure category.
Instead, emerging in media health stories with particular force in recent years is the figure of the lay hero. Powers are often conferred on this figure that are at least as ‘unrealistic’ as those conferred on Dr Kildare in an earlier generation. The confessional narrative has become popular over a range of media genres. In relation to cancer and terminal illness, for example, personal accounts abound in which people recount their tribulations and successes in the face of life-threatening disease (McKay and Bonner 1999). These often contain a significant anti-medical component, in which orthodox medicine is cast as unhelpful or flawed. Additionally, lay heroism possesses a significant gendered component, as my own studies of cancer stories in the news have shown (Seale 2002). Women are generally portrayed as more skilful than men in managing their own health, confirming Giddens’ observation that women have pioneered the transformation of intimacy that self-identity now involves, largely through the appropriation of emotional skills so that women are ‘the emotional revolutionaries of modernity’ while men experience a ‘lapsed emotional narrative of self’ (Giddens 1992: 130). Media health representations have played an important part in this shift, which is associated with a demagogic alliance of media organisations with the supposed interests of ordinary viewers and readers, championing Everyman or woman in the risky environment of modern life. Increasingly widespread involvement by lay people in producing Internet health sites seems likely to increase this tendency.
If sociological studies of health in the media were to become more oriented to understanding production and reception issues, it is likely that a pressing concern would be to understand the consequences of the increased emphasis on lay powers. Analysts might ask, for example, how institutional and governmental interests seek to exploit this apparent ‘empowerment’ of ordinary people. The development in the United States of ‘direct to consumer’ advertising by pharmaceutical companies is an example of such commercial exploitation of lay empowerment (Yamey 2001). No longer passively following medical advice, consumers are expected by pharmaceutical companies to respond to media advertisements by demanding particular products from their doctors. The paper by Kroll-Smith in this volume also shows an important way in which mass media, including the Internet, may bypass the influence of health care interests, showing how a new syndrome has been constructed in large part by lay activists with low levels of involvement by medical authorities. The papers in this volume that relate to the Internet show, too, how active consumers may behave, potentially placing the traditional advice of health care system representatives in a less dominant position. In this changing power relation between professional and lay interests, it is important to understand how media producers and audiences relate to health-related media messages. This is an important project for sociologists and media studies specialists alike.