Dennis Raphael is Professor of Health Policy and Management at York University, Toronto, and co-author of a new report about the social determinants of health, which recently featured on Croakey.
In subsequent email conversations, he mentioned his frustration about the difficulties of attracting media interest to such issues. For better or worse, as we all know, if an issue’s not prominent in the headlines, it’s unlikely to be high on government agendas.
So I asked if he’d write a piece exploring the reasons behind what he calls the “media blackout”.
Here it is:
“While Canada is seen as a world leader in developing health promotion and population health concepts that consider how living conditions shape health, the reality is that Canada has always been a laggard in applying these concepts in the development of public policy. Much of this has to do with the Canadian public’s profound lack of awareness which has been abetted by the media’s utter unwillingness to address these issues.
For 15 years I have been attempting to have the media in Canada address the broader — or social — determinants of health. My success can be counted on one hand in that a few columnists – not health reporters – have profiled my work on the impact of living conditions and poverty on health.
It was therefore both reassuring – and disturbing – to find that my perceptions of mainstream media coverage were accurate.
Simon Fraser University Health Sciences Professor Michael Hayes and colleagues carried out an extensive analysis of media stories in major Canadian newspapers over an eight year period.[i] Their results were disheartening.
Their analysis of 4732 newspaper articles concerned with health topics found a virtual black-out of stories concerned with the social determinants of health. Only 282 – 6% – newspaper stories were concerned with the socioeconomic environment. More specifically, a total of nine stories (2/10 of one percent) were concerned with how income – the primary social determinant of health – is related to health! There is no reason to think that radio and television coverage is any different.
In a follow-up study, Concordia University communications Professor Michael Gasher and colleagues interviewed twelve Canadian newspaper health reporters about how they went about reporting health stories.[ii]
The barriers to reporting on the social determinants of health as identified by the reporters included: a) lack of knowledge of the social determinants on their part; b) difficulty putting the social determinants into the immediate and concrete “storytelling” that comprises typical news reporting; c) a perception that the social determinants were not new and therefore not newsworthy; and d) concern about “stigmatizing the poor.”
That is the “rational” argument put forth by researchers for this media blackout. I offer a path dependency argument.
First, reporters are regular people. Why would we expect that their understandings of the determinants of health – focused on diet, exercise, and tobacco use — would be any different from the general public? For every one Dennis Raphael trying to communicate findings about the social determinants of health, there are at least 150 Mr and Ms fruit and vegetables researchers bombarding them with their stories.
Second, what are the implications for reporters – and their editors and publishers — suddenly pointing out that their last 1000 stories about fruits and vegetables, exercise, and tobacco use as the primary determinants of health were misguided at best and patently wrong at worst. Witness how the media maintains its saturated fat and heart disease fixation in spite of a decade of research disconfirming the link. Ditto for promulgating the fictions concerning PSA tests, weight, and cholesterol.
Third, reporters work for corporations who benefit from having the social determinants of health story kept secret. Most media – including newspapers – are now owned by large corporate entities whose ideologies and values are not consistent with a social determinants of health perspective. Reporters would probably be well aware of this and like most other salaried workers would hesitate to put their futures on the line by consistently presenting a social determinants of health perspective in their stories.
Fourth, newspapers in Canada have huge “Food” and “Living Sections” that generate significant reader interest and advertising dollars in maintain the fiction that life style choices will help readers live long and healthy lives.
I have given up on the mainstream media. I have no illusions that any message I may wish to communicate will be facilitated by it. Even if the odd story makes it into print, it then becomes lost in a continuing barrage of “healthy living” stories.
Set up your own networks. Use Facebook and Twitter. And besides, nobody between the ages of 16 and 30 watches, reads, or listens to the mainstream media anyway.”
[i] Hayes, M., et al. (2007). “Telling Stories: News Media, Health Literacy and Public Policy in Canada.” Social Science and Medicine, 54, 445-457.
[ii] Gasher, M., et al. (2007). “Spreading The News: Social Determinants of Health Reportage in Canadian Daily Newspapers.” Canadian Journal of Communication, 32(3), 557-574.
If you didn’t seen this already, here is a related post from Fran Baum, professor of public health from Flinders University, who was one of the Commissioners on the 2008 WHO’s Commission on the Social Determinants of Health.
We are finding similar challenges in our Communities of Health work (www.communitiesofhealth.org) in the United States. While people intuitively grasp the idea of social determinants of health, it is difficult to sustain ongoing awareness and attention on these factors sufficient to do anything about them.
A number of barriers exist. First, it is difficult to break from the prevailing frame, which views health primarily as a function of individual behavior and medical care. The individual-medical model of health dominates our systems, beliefs and language, and is continually reinforced in the way our nation thinks about, talks about and acts on health. And, when health is discussed in a broader context, counter-narratives tend to appear, overwhelming the potential for an expanded view of health.
A second challenge has been demonstrating how social determinants impact specific stakeholder groups. For instance, it has been difficult to draw a direct causal linkage between harmful community conditions and the rising costs of health care paid for by an employer.
Finally, even for those who are motivated to act, specific strategies for addressing the social determinants of health may seem elusive, impractical or insurmountable. As more than a few Communities of Health participants have expressed: “This is like trying to solve world hunger – what do you want me to do about it?”
What we are learning is that nothing changes until people have the opportunity to discover for themselves what matters to health, and what we can do about it together. In short, we must un-learn and re-learn “health” as a direct, ongoing and collective experience of it.
This is happening in a growing number of cities where people are coming together to uncover the broad set of factors driving health and illness in their communities. What they discover together forms the basis of collaborative action among an expanding group of stakeholders – citizens, business, government, education, health and other sectors – who realize the collective strengths, needs, and possibilities inherent in their community.
I appreciate the frustration and futility of working with the media on the social determinants of health. I am reading A While New Mind by Daniel Pink who reinforces what is not a new concept – science sees anecdote as the lowest form of science/evidence, which is true when researching causation, etc – but anecdote is the highest form of communication. Exhibit A would be Malcolm Gladwell and his gift in telling stories of science across themes that resonate with the public. While the things identified on the path dependency argument in this blog post are undoubtedly true, they lead one to wave the proverbial towel and say “what’s the use”. The reasons identified by Professor Gasher offer some light to work within, specifically storytelling as it relates to the SDOH. Sometimes we hope the media will tell the story for us – that’s their job. But since they’re obviously not doing it very well as this post relates, perhaps the profession of public health needs to take more ownership of this. As I have delivered lectures to university students, the story is always more effective than the graph in helping them receive a concept (stick figure art vs full color art). Daniel Pink mentioned also that the London Telegraph newspaper once sponsored a mini-saga contest (not sure if they still do). Mini-sagas are extremely short stories – just fifty words long. In his book are examples of how much creativity can be packed into fifty words. Perhaps we could do something similar for the SDOH? Hold a contest (I’m also reading Punished By Rewards by Alfie Kohn so this contest would need to be appropriately incentivized) for stories related to the SDOH and begin the wheel moving in this new direction. I would be willing to make a donation (I’m a regular joe, not a philanthopist – but think this is important enough to put my money where my mouth is) to see something like this happen to increase our capacity to tell the stories of the SDOH.
I doubt if Australia’s mainstream media is much different to Canada’s in this respect but I don’t know of any studies in Australia on media barriers to reporting on the SDH? But when you think about it, the SDH isn’t exactly headline grabbing stuff, well at least the way its currently presented to the media by most health professionals. I don’t believe it’s all about media disinterest or values, I think it has a lot do with the subject itself. Jargon, no doubt is a big part of the probelm. I mean, the term ‘social determinants of health’? Ask anyone in the street what they think this is, or means, or has to do with them? I’d be very interested in their response. It probably also has a lot to do with the way health professionals engage with the media. Approaches to the SDH often rely on changing systems, public policy and organisational practices and these types of conversations can quickly glaze the eyes of even the most seasoned jounalist. We need to use succinct, plain English that expalins the causal lnkages between SDH and health status.
I think Raphael’s arguments against the mainstream media apply equally to a large chunk of Australia’s health system, which appears to have a distinct disinterest in the SDH and probably for similar reasons as the media and more – lack of understanding and knowledge about the ways SD impact on health and wellbeing; difficulty in placing the context of SDH within a disease framework; not seeing the relevance of the SDH to everyday health care; outcome focused, quick fix treatments that measure indiviual ‘wellness’; vested clinical interest etc.
The problem is that for people who work in the social area of public health, to ‘give up’, as Raphael apparently has, means ‘giving in’ to ignorance and vested interests whether they be media or the health system. No one ever told me that working in public health would be easy.