The mass media is a critical component of response to a worldwide influenza pandemic. This is because the mass media -print, television, radio and internet -is able to reach such a large and diversified audience, [1] [2] [3] and is crucial to getting public messages out in a crisis. 4 However, it also exerts a powerful influence on the way a pandemic is represented or 'framed'; for example, as crisis, or mere beat up; or as well or poorly managed. These frames influence people's reactions. 5 Health experts are not immune to such 'framing effects', and in previous respiratory illness crises, such as the outbreak of severe acute respiratory syndrome (SARS) in 2003, were both reliant on and influenced by mass media reporting on events. 4, 6 Most commentators feel that it is therefore important that in addition to its commercial functions, the mass media does and should serve key civic functions. These include ensuring that citizens are sufficiently informed about significant issues as to be able to make appropriate decisions and to engage in forms of collective action against threats, such as infectious disease. Many studies of media ethics concentrate on identifying the ways in which coverage falls short of this ideal. The limitations of mass media reporting, mostly resulting from its commercial imperatives, have been repeatedly described since the 1960s. Among them are claims that the media is prone to sensationalism, sins of omission and sheer inaccuracy 7, 8 ; that in seeking to provide 'both sides of a story', it may perpetuate a problem or give unwarranted validity to wholly untenable views; that it leaves out complexity 8 and is the reverse of 'evidence based'. 9, 10 The perennial challenge for health policymakers, advocates, clinicians and researchers who respond to influenza and other infectious diseases is communicating extensively while avoiding these pitfalls. The unavoidable and critical effects of mass media coverage of epidemics and pandemics make it important that health experts who may play a role in responding to such events have a clear understanding of the factors that shape media reporting.
We present the findings of a study of the ways Australian journalists from all sectors of the news production process sought to represent pandemic influenza over the period when H5N1 avian influenza became publicly prominent.
This study adds to the relatively small pool of empirical literature on journalistic practices in health and medical contexts, 3, 8, [11] [12] [13] and is the only study to date, to have researched journalists' attitudes and practices specifically in relation to a threatened pandemic. It was conducted in view of, and supports, evidence that journalists and news editors are concerned about the quality and social impacts of the mass media 14, 15 and that their insights may be useful for public health and medical professionals and scientists to work more constructively with the media in future.
Before the emergence of H1N1 influenza 2009, many experts were concerned that H5N1 'avian' influenza had the potential to cause the next highly virulent influenza pandemic, which has been anticipated by concerned public health officials since the late twentieth century. 16, 17 Our study was conducted after fears about avian influenza had reached their peak and then declined again. This is the period in which risk issues can slip out of public sight, regardless of their long-term importance. 3 It occurred at a similar point in the cycle of public concern that we have recently experienced with regard to H1N1: a stage of post hoc questioning and judgement well known in the cycles of responses to crisis-like events. 1, 3, 18 It therefore sheds some light on the present post-pandemic stage.
Qualitative semi-structured interviews were conducted between October 2006 and August 2007. Ethics approval for the study was granted from the Human Research Ethics Committee at the University of Sydney. We have published a separate analysis, drawn from the data collected for this study, of media coverage of health issues in general, where we report the study methods in further detail. 19 We interviewed 16 journalists known to have reported significantly on pandemic influenza, drawn from a range of print, radio and television. We focused on journalists working in the traditional rather than online mass media, since the former still tends to be identified as setting the agenda for public discussion. The majority of the interviews were conducted via telephone, primarily by one researcher (JL). Our questions explored why avian influenza was covered or not covered and journalists' thoughts and reactions to the issue. All interviews were digitally recorded and transcribed. Coding in NVivo identified major themes. The coded text was reviewed by all researchers with the meanings and implications of the issues arising developed into higher order themes. Each theme was then reviewed by all authors to discuss general findings, exceptions and differences between participant groups.
Twenty-three journalists were approached. Three declined; three did not respond; and one interview recording failed. Sixteen interviews were analysed. The journalists were senior with a median of 14AE5 years in journalism (range: 5-37 years). Most had worked for multiple organisations and in differing roles although they usually continued in the one medium, for example, print. Ten were reporters and six were producers or editors. Seven of the 16 journalists were specialist health ⁄ medical reporters. An analysis of their roles and general reporting practices is reported elsewhere. 19 Why did journalists initially cover this story?
Participants generally perceived three criteria as giving news value to avian influenza: it was potentially apocalyptic; it was perceived as 'close' to Australians; and trusted people in positions of authority were worried about it. These three criteria map closely to well-known factors that predict increases in perceptions of risk: catastrophic potential; unfamiliarity and uncertainty; salience; and trust in public figures. 20, 21 Journalists emphasised that the flu story was captivating because it predicted a potential catastrophe.
It's not just the mystery, it's that potential for it to be diabolical as well.
(Television news reporter)
The story increased in prominence because journalists viewed avian influenza as coming closer to Australia. Geographical proximity gave the story relevance as avian influenza spread through South-East Asian neighbours, and poultry culls and human deaths were reported in Indonesia and Thailand. However, a sense of cultural proximity could also give the story relevance:
It's like it hit Europe, or it hit Germany -that was like a step, like a doorstep that had been crossed or something. It's…I think also, it being in Indonesia, a lot of Australians have been to Indonesia, it's very close to us and people suddenly think 'oh-oh, it's close'.
(Television news reporter)
The degree of public trust and respect vested in the sources for the story gave it both importance and credibility. Concern expressed by authorities such as the World Health Organisation (WHO), government health officers and ministers, and independent, scientific experts -those who traditionally enjoy the highest levels of public trustguaranteed the story public coverage. Most journalists felt they were simply broadcasting the concern of these officials.
It really is the public health people and governments who are kind of creating the momentum for that public interest. We are in a sense fuelling it, but at the same time, we are just reporting on it.
(Newspaper medical reporter)
Why did the story lose its newsworthiness?
By April 2006, news coverage of avian influenza had tapered off dramatically, despite the continued potential for a pandemic. The primary determinant of this was a lack of novelty in the story; the topic was perceived as stale, and competition within the media made novelty a premier requirement for coverage.
Some also perceived avian influenza as a 'false alarm' that no longer justified news time. They expressed a degree of cynicism that the promised pandemic had failed to eventuate and was hence no longer worthy of attention.
Next time I hear people talking about bird flu or anything like it, I will pay less attention -bit like crying wolf.
(Newspaper editor)
There has been a lot of hyperbole. The world is going to end, everyone is going to die, so I think people are just bored by it now. (Newspaper medical reporter)
This was much more evident from general journalists. Specialist medical reporters conveyed a greater understanding of the uncertainty inherent in predicting a pandemic.
What did the story require to regain newsworthiness?
Even though media coverage had waned, the spread of avian influenza and bird to human infections continued to occur. Nevertheless, journalists were bald in stating that events would have to 'up the ante' for the story to regain news coverage. Within the context of avian influenza as it existed in 2007, this could only occur if a particularly startling human drama such as a large cluster of deaths or a significant scientific or technological development occurred, or, for television reporters, if particularly poignant images of death or grief became available.
…say the family, say a kid has died or something. People killing heaps of chooks; a hospital where somebody has been admitted; a laboratory where some tests have been carried out -just all of those [visual] elements can make a story.
(Television news producer)
I'm just looking on the wires, there is a woman from Surabaya critically ill. Now unless we had pictures of it, we probably wouldn't -I mean that could be a reason why they may not cover it.
(Television news reporter)
A renewal of media attention would only be generated by one of two events -human-to-human transmission or entry of the virus into Australia.
What issues did the journalists cover during avian influenza?
Besides reporting deaths and poultry culls internationally, journalists' focus was very strongly on the potential for pharmaceutical and technological responses to a potential pandemic. This strong focus left less room for coverage of community reactions, community preparedness, government preparedness planning, or public health actions centring on behaviours. Few would speak of public health measures like social distancing, quarantine, border control or personal protective equipment -all prominent in the government's pandemic plan. Although our respondents' focus on pharmaceutical solutions may in part have reflected the information they received from health experts, it also reflected their perception that biomedical developments were more newsworthy.
We may have reported on covering your nose when you sneeze, but I think the medical solutions perhaps are the ones we need to have, should there be an eruption that is difficult to contain.
(Television news producer)
I think the job of the media is to get as much hard factual information out about the danger; precautions you need to take; what you should do if you have the symptoms; how you get hold of the antiviral medication or vaccine or the reporting on those sort of factual things, and I think the speedy and efficient delivery of that information to the press will be most important in controlling any public panic that surrounds an outbreak of the pandemic.
(Newspaper medical reporter)
What is revealing in this statement is an unquestioned deference towards pharmacological solutions, and their perceived capacity to mitigate 'public panic'. For example, one television producer spoke of covering biomedical solutions as a response to his own sense of obligation to reassure the public, after having raised a degree of fear in reporting the pandemic threat.
How did journalists perceive the accuracy of reporting on avian influenza?
Participants in this study acknowledged the constraints of reporting, particularly the short time frames in daily news reporting.
On one axis you have maximum accuracy, integrity, detail -all of those wonderful things. And then on the other one you've got time. (Newspaper medical reporter) These constraints and, for non-medical reporters, a lack of familiarity with scientific terms could impact on the quality of reporting. In a period of media interest, such as an outbreak, junior or generalist reporters with little prior knowledge of the issues are assigned to the story, increasing the risk of inaccurate coverage. Having experts available to check stories was seen as a primary means of ameliorating this problem, along with encouraging health experts to provide clear, simple information in the first place.
Academics in particular need to accept that the reporters they will be talking to during a pandemic will not always be reasonably well-informed science or health journalists but could be a general reporter. They need to pare their message down to its basics -especially in a crisis. No reporter has time for long-winded background.
(Newspaper medical reporter)
On the other hand specialist medical reporters felt themselves to be highly informed and sophisticated in their coverage. One reporter commented on how 'invaluable' it was when reporters were invited to spend a day at a seminar, where they learned facts such as the number and characteristics of influenza strains. By the end of the day this journalist felt her understanding of the science to be solid and extensive, much better than 'most average punters'.
Medical journalists played a leadership role in shaping media coverage, and acted as 'gatekeepers' for which stories were let in and which were excluded, influencing the quality of coverage.
A mistake gets repeated again and again and again…So any specialist reporter will put out a national note, saying 'attention all, please ensure this is correct'.
(Radio news reporter) Some reporters were also concerned about the ability of the mass media to represent the complexity of infectious diseases. Others, however, were committed to offering sophisticated discussion of the issue -but their ability to do so was constrained by the audience and specific media organisation they worked for.
I do tend to put as much detail into the stories as I can, and try to be faithful to the people who I'm presenting -which often means [managers] don't like me because it's a bit too complex, you know. But I find the listener out there goes 'well I find them intelligent stories' so there is a bit of a divide between what managers think the public want to hear on the radio.
(Radio news reporter)
How did journalists perceive their role in an outbreak situation?
Journalists were placed in a dilemma when contemplating their response to a significant outbreak of influenza. They articulated a clear commitment to their roles as journalists: as public informants, independent and neutral -yet they also wished to support the public interests and efforts of public health officials. In envisaging a crisis event, some acknowledged that concerns about creating public panic or harmful public reactions would have an influence on the content, angle and style of their reporting. They perceived the speedy delivery of factual information as a premier tool in preventing public panic.
I always tried to say in my story that there had been these deaths overseas, but none here, kind of thing. I try to be well rounded, because we didn't want to scare people more than some people were already scared.
(Newspaper medical reporter) Some journalists expressed a less qualified perception of their role as public critics and investigators. Much as they intended to work in tacit support of governments handling a crisis event, they resisted the role of publicising the government agenda, and were wary of being exploited by either government or commercial interests. In particular, the more experienced medical reporters valued their independence and capacity for generating and maintaining discussions critical of government actions. (One commented drily, 'The media is not the public relations wing of the health department.') However, we note that despite this stated commitment, in practice, in crisis situations journalists are often either too much taken up with the outlook of those whose views they report or too busy to take a critical stance. See for example a critique of the reporting of air quality issues in the lower Manhattan district after 9 ⁄ 11. 22 In keeping with their strong commitment to their role as public informants, journalists were adamant that they would continue to work in a pandemic situation despite the dangers to themselves, although journalists with dependent family were more cautious. Journalists stated that competitive concerns and hence job insecurity might motivate them to continue to work. None were aware of any pandemic planning undertaken by their media organisation.
When prompted, journalists readily offered advice for how health experts could support the media in providing quality news coverage in the event of a pandemic. Their advice centred on their need for information to be accessible. As do risk communication experts, 23, 24 journalists reiterated the importance of health experts and governments being open and honest in dealing with the media. They wished particularly to underscore the strategic importance of openly acknowledging what is known, including uncertainty. Cautioned one:
Well I know this sounds sort of utopian, but, it is actually the best advice that I can give. It's to be completely open, share what you know with the qualifications, do it early. So that you sort of prepare people for what might happen… because otherwise, if something happens and you haven't indicated that is a possibility, then people won't be prepared and you will be found to be dishonest when there has been an enquiry. (Newspaper editor)
In crisis events, many of our participants saw the format of frequent mass media briefings as efficient and appropriate, but some warned that media competition would stimulate them to seek sources beyond such briefings. They emphasised the importance of health experts understanding media production processes and fitting into the constraints these processes imposed and advised health experts to be, or provide, good 'talent' as the primary sources of information. Being good 'talent' required being available at times of the day when journalists were newsgathering, and then to check their stories closer to publication. Preparing and providing fact sheets, pithy quotations and good quality 'vision' gave the maximum influence on the resulting coverage.
Nothing annoys media more than if they can't get someone, that is when things go pear shaped, because no-one is there to answer their questions.
(Television current affairs reporter)
Journalists' views about reporting avian influenza and a potential pandemic ª 2011 Blackwell Publishing Ltd
Our analysis, undertaken prior to the pandemic, offers other insights into the response of the mass media to H1N1. Human-to-human transmission and clusters of deaths provoked an initial resurgence in media coverage, which was then driven by cultural and geographic proximity and swiftly thereafter by expert response, dominated by attention to technological and scientific solutions. Lack of novelty was the chief determinant of when the issue receded from mass media coverage. One of the chief findings from this study is reassuring: that in an actual crisis situation, local journalists at all levels of the production process expressed explicit commitment to the public good: communicating infection control messages, and being concerned about the potential to cause public over-reactions, being accurate, and being concerned about oversimplifying complex scientific issues. Specialist health reporters anticipated playing leading roles in a pandemic and in becoming rapidly educated about the relevant basic scientific information and technical issues. Evidence from previous outbreak events suggests that local media has handled these concerns well during crisis situations. 4, 25, 26 However, this situation is only sustainable so long as (i) the acute phase of the crisis persists, in which unified public action is perceived as integral to infection control, and (ii) journalists feel themselves to be getting full and frank information from government sources, sufficient to meet the requirements of media competition. Our study suggests that as time passes, journalists resume their role as critics of government and prioritise news values such a dissent and novelty above other public goods. 'Postmortem' reflections from government and community leaders on the handling of an outbreak have high news value and will be given considerable coverage, quite likely regardless of their intrinsic merits. Such reflections regarding H1N1 influenza, for example, have been evident since late 2009. 27, 28 Therefore we suggest media strategies in pandemic plans should anticipate this post-acute, 'reflective' phase.
Our respondents considered that the best insurance against media critiques of official handling of a pandemic threat to be the provision of full, accurate and clear information for journalists, along with full acknowledgement of the uncertainties inherent in decision making in such situations. 29 We agree, and suggest that actively providing good 'vision' and 'talent' to media organisations may mitigate the effects of competition in the media, which tends to drive sensationalist and intrusive reporting. During the H1N1 threat, journalists sought to diversify their sources as part of providing new and interesting angles, but found that at exactly this time many of those best qualified to comment were tied up at the coalface and ⁄ or constrained in speaking to the media because of their government role. Being sensitive to media timetables and being available to check stories would have offered health officials more influence on the quality of coverage. 8 However, we note that uncertainties are not always clearly reported, or may tend to amplify perceptions of risk. Emphasising that there is a range of possibilities may help.
Some issues did not appear to concern our respondents. One was constant deference to highly medicalised solutions, such as vaccine and antiviral medications or thermal scanners, rather than on community based infection control methods, such as handwashing, wearing masks, neighbourhood support and social distancing. As these sorts of responses are often among the most critical in early pandemic responses, their under-representation would certainly influence the way a pandemic and its solutions were framed and hence affect public and government responses. The H1N1 influenza 2009 pandemic has played out such dynamics. Early media reports focusing on upcoming biomedical solutions were met with assurances from many governments of an adequate and fasttracked supply of vaccine for the entire population. Now, in the face of a mild pandemic, there are post hoc criticisms about cost to the public purse, timing and delivery mechanisms. 27, 30 Limitations
The restriction of the sample to Australian journalists may limit the generalisability of findings to other countries. The study is limited by a relatively small number of editors and producers not allowing the full exploration of how a particular role or medium influenced news production. However, it afforded an opportunity to look beyond the reporter and explore news selection among those who have this as their core task.
Clearly, there is much that health experts can do to help ensure that local mass and mainstream media coverage of outbreaks, epidemics or even pandemics is both accurate and publicly useful. 18, 31, 32 It may be possible to express concerns about the accuracy of media coverage or about public responses to media coverage directly with specialist reporters, while respecting their autonomy and judgement. In building such partnerships between science, medicine and the mass media, it may be possible to move beyond the commonly adversarial critiques of the media to a more constructive engagement with them.