Silencing the virus? Government communication and MMR vaccination campaigns - the Australian case - UNSWorks
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
1014078
research-article2021
PRI0010.1177/2046147X211014078Public Relations InquiryDimitrov
Full Research Article
Public Relations Inquiry
1–35
Silencing the virus? © The Author(s) 2021
Article reuse guidelines:
Government communication sagepub.com/journals-permissions
DOI: 10.1177/2046147X211014078
https://doi.org/10.1177/2046147X211014078
and MMR vaccination journals.sagepub.com/home/pri
campaigns – the
Australian case
Roumen Dimitrov
University of New South Wales, Australia
Abstract
In this paper I analyse a series of Australian MMR (measles-mumpsrubella) vaccination
campaigns and policies from the last decade. Using the Bruno Latour’s Actor Network
Theory (ATN), I locate human and non-human mediators – including the virus and
vaccine – in the complex pro-vaccination alliance led by government campaigners. I
identify the vaccine hesitant parents – a large group that ‘sits on the fence’ between
the ‘vaccine confident’ and ‘vaccine refusing’ parents – as the main target of pro-
vaccination campaigns. PR literature on pro-vaccination campaigns has applied ATN
to the independence of the media as network agents. This paper contributes with
the problematisation of several more actors such as the health workers, medical
experts and the vaccine hesitant parents themselves. Even when they are keen
members of a pro-vaccination network, they cannot be taken for granted. This is where
understanding of stigma, silence and voice helps. To align their group interests and
discourses, government should know how to communicate strategically – including
how to communicate indirectly, avoiding stigma and keeping certain internal affinities
and communicative distances intact. In conclusion, I make suggestions about strategic
communication in pro-vaccination campaigns. Communication of statistical risks and
side effects should be central. It is a winning strategy because it establishes a more
credible balance between individual rights and collective obligations in achieving herd
immunity. And mandating vaccination cannot replace communication. Research shows
that legislating compulsory vaccination may have short-term and relatively small effects.
They are almost negligible in the long run. Mandate may trigger compliance, but it
also causes anger and mistrust. Mandating vaccine has negative side effects. It punishes
with economic and cultural sanctions the socially disadvantaged, who are not active
Corresponding author:
Roumen Dimitrov, University of New South Wales, Kensington Campus, Sydney, NSW 08025, Australia.
Email: r.dimitrov@unsw.edu.au2 Public Relations Inquiry 00(0)
refusers. It also has the opposite effect on vaccine hesitant parents. It does not weaken
but rather strengthens their resistance to the vaccine and pushes them to the lager of
antivaxxers.
Keywords
Public health communication, vaccination campaign, public relations, uncertainty,
strategic silence, stigma, measles, action network theory
Introduction
Except the new Covid19 coronavirus, measles has been the most contagious of all
vaccine-preventable diseases. Despite the availability of the MMR (measles, mumps and
rubella) serum, vaccination rates across the world have stagnated for the last decade. To
achieve herd immunity, that is the effect of the minimum of immunised people enough to
prevent an outbreak, a 95% coverage is needed. The World Health Organisation (WHO)
and Centres for Disease Control (CDC) in the US estimate that globally 86% of children
get the first dose and less that 70% the second. The MMR vaccination crisis is felt eve-
rywhere – in poor and rich countries. In 2018, WHO reported nearly 10 million cases and
142,000 deaths (UNICEF, 2019).
The Covid19 pandemic has repressed rather than replaced its prevalence. But it has
also highlighted some of the old problems. In 2019, the number of measles cases has
tripled (Boseley, 2019). There are poor countries where lack of availability of vaccine is
still a factor. But how about the decline of immunisation rate in the developed countries?
Europe, for example, has become the region with the lowest vaccine confidence and
higher vaccine hesitance in the world. According to a recent Eurobarometer poll, nearly
half of the people in the old continent – 48% – believe that vaccines often cause severe
side effects. In some countries such as France, Ireland, the United Kingdom and Romania
more than half of the population hold that belief (European Commission, 2019). Fewer
than 40% of the Europeans are aware that measles is still a cause of death in the EU,
although 72 people died in 2018 – twice as many as in 2017 (Jennings, 2019a).
There are consequences from vaccine hesitance and refusal. More children do not get
immunised. Epidemies break out more often than in the past. In 2019, measles epidemies
were raging from France and Italy to Romania and Bulgaria. In 2019, four EU countries –
Greece, the U.K., Albania and the Czech Republic – lost their measles-free status, while
only one, Austria, attained it (Wheaton, 2019). During the first half of the year, Europe
had 90,000 cases of measles – more than 17 times the number reported in the whole of
2016. ‘When immunization rates drop and herd immunity frays, it’s always measles that
comes back first’, says Paul Offit, a specialist in infectious disease at the Children’s
Hospital of Philadelphia, Pennsylvania. ‘Measles is the canary in the coal mine’ (Drew,
2019).
This paper deals with the issues of government pro-vaccination campaigns as a case
of health public relations. First, I identify the publics, which are key to the success of
such campaign. They differ depending on whether governments apply more communica-
tive (persuasion) or more coercive (legislation) tools. From a public relations perspec-
tive, not the active vaccine refusers but rather the so-called ‘fence sitters’ make up theDimitrov 3
largest and critical target group. At theoretical level, second, I apply the Action-network
theory (ATN) of Latour (1988, 1996) and its adoption by a few public relations scholars.
I also integrate the concepts of ‘natural history’ of a vaccine preventable disease (Chen
and Hibbs, 1998), which one needs for any case study of a pro-vaccination campaign. I
also borrow the category of ‘communicative distance’. It is instructive in cases of gov-
ernment communication, where certain publics have a degree of historical mistrust in the
public health institutions (Waymer, 2013).
Third, I study the case of the MMR vaccination policies and communication strate-
gies of various Australian governments from the last decade. In the centre of my atten-
tion are the strategies and tactics of the Labour government (2012–2013), which I
compare with those of later conservative governments. This period is especially instruc-
tive for public relations theory and practice. To achieve herd immunity, Labour preferred
to permanently campaign and persuade unconvinced parents instead of, what the next
governments did, legislate sanctions for those who refused to vaccinate their kids.
Fourth, I discuss the findings and offer some ideas about the application of ANT in the
field of public relations. Previous contributions highlighted the own gravity of the media
as independent mediators and not automatic conduits of government communication.
They showed how even friendly media may turn against the government if their specific
interests are not appreciated. In my contribution, I analyse how by observing distance
and using indirect communication, the government can not only reach alienated publics
but also make even hostile media work for it. I also focus on the effects of other key
agents in the network such as the health workers, medical experts and vaccine hesitant
parents themselves – the main target of a pro-vaccination campaign. What has already
been said about the media, is also valid for those groups. Their relations with the govern-
ment in pro-vaccination campaigns is anything but unproblematic. I discuss, for exam-
ple, the systemic obstacles, which prevent health workers such as doctors and nurses
from becoming social media influencers.
Fifth, I return to the groups of vaccine-hesitant parents and their practical exclusion
as participants in the formation and intervention of pro-vaccination policies. I raise the
question whether engaging parents as consumers of health services with certain indi-
vidual rights but also collective obligations – for achieving herd immunity – would not
empower them as pro-vaccination agents.
I conclude with some suggestions about strategic communication in pro-vaccination
campaigns. Communication of statistical risks and side effects should be central in the
campaign. Speaking about risks and side effects is a winning strategy because it estab-
lishes a more credible balance between individual rights and collective obligations in
achieving herd immunity. One should not stigmatise – and politicise – vaccine hesitant
parents by confusing them with staunch antivaxxers. Research has repeatedly confirmed
that parents trust doctors and nurses more than any other authority on the matters of
public health, including of immunisation. But they could not be taken for granted either.
For example, health workers are more open about the risks and side effects of certain
vaccines, but they would talk about that with parents in person rather than in public.
They are lacking the necessary media, especially online presence. Eliminating the ‘con-
scientious objectors’ clause has only removed a main avenue of their work with vaccine
hesitant parents.4 Public Relations Inquiry 00(0) And finally, mandating vaccination cannot replace communication. Research shows that legislating compulsory vaccination may have short-term and relatively small effects. They are almost negligible in the long run. Mandate and communication are not inde- pendent from each other variables. Mandate may trigger compliance, but it also causes anger and mistrust. Mandating vaccine has negative side effects. It punishes with eco- nomic (family benefits) and cultural (access to school) sanctions the wrong parents – the socially disadvantaged, who are not active refusers. It also has the opposite effect on vaccine hesitant parents. It does not weaken but rather strengthens their resistance to the vaccine and pushes them to the lager of antivaxxers. What is the problem? Mandatory immunisation In theory, one must first define a problem to find then its solution. In practice, however, solutions sometimes precede and frame the problem. The trend of ever more govern- ments making the MMR vaccination compulsory illustrates the reflex of putting the solu- tion before the problem. Stricter legislation through litigating, penalising and limiting access to various resources seems to many politicians to be the quickest, one-fits-all and best serving the common good solution. In 2020, the voices clamouring for and against mandating of the (still in development) Covid19 vaccine, essentially replicate the argu- ments of the 2019 MMR debates (Knaus, 2020; Sanchez Hidalgo, 2020). But what difference mandated immunisation could make? An answer, at least a partial one is aim of this study. Early evidence is inconclusive. An EU-funded ASSET Project could not confirm any relationship between mandatory vaccination and rates of child- hood immunization in Europe (ASSET Reports, 2015). In Australia, Italy and France immunization coverage has slightly risen with the introduction of mandates (Drew, 2019). Yet Portugal and Sweden can boast vaccination rates over 95% without mandat- ing (Suárez and Villarreal, 2019). Over the past five years, Australia, France and Italy introduced quasi-mandatory mea- sles immunisation by restricting access to school for children who have not received the recommended by the health authority vaccination, including MMR. Germany, along France, Italy, the UK and US, used to be the stronghold of libertarian thinking, preferring informed parenting decisions to coercive vaccination measures. But not when the crisis struck. In November 2019, the Bundestag urgently passed a law that will fine parents (starting in March 2020) up to €2500 if children are not inoculated. Now, when I write this paper, it is not clear whether a ban from Kindergarten and school will also follow. Such implementation is flagged as ‘likely’ (Connolly, 2019). Even one of the last standing bastions of ‘consumer rights’, ‘vaccine safety’ and ‘vac- cine choice’ in public health started shaking when the UK Health Secretary, Matt Hancock, said ahead of the elections in December 2019 that the government was ‘look- ing very seriously’ at making vaccinations mandatory for state school pupils. ‘I don’t want to have to reach the point of compulsory vaccination, but I will rule nothing out’ (Mohdin, 2019). Early on, he had angered liberal ‘free thinkers’, including some in his own party, by telling the Times that ‘those who have promoted the anti-vaccination myth
Dimitrov 5
are morally reprehensible, deeply irresponsible and have blood on their hands’ (Mostrous
and Stoneman, 2019).
That was enough, and in an apparent rebuke of the Health Secretary, a spokesman for
the conservative Prime Minister, Boris Johnson, declared that ‘We’re not at the stage of
refusing admission. Our priority is on increasing vaccination numbers’. Instead, the
alternative plans included making it easier for parents to make GP appointments for vac-
cinations and keeping better records of children who have not been vaccinated (Walker,
2019). Such uncertainty in the recent German and UK vaccination policies are not by
accident, although perhaps not entirely deliberate either. I will later discuss similar ambi-
guity in the position of the Australian government. But here it makes more sense to think
that making threats of denying access to education for kids – unjust collective punish-
ment by any measure – without making such threats reality, may serve as a casual warn-
ing to parents of which effect politicians are no doubt aware.
Vaccine hesitancy
There is an important – and underlying for this paper – difference between ‘vaccine hesi-
tancy’ and ‘vaccine refusal’. The World Health Organisation (WHO) defines vaccine
hesitancy as a ‘delay in acceptance or refusal of vaccines despite availability of vaccina-
tion services’ (MacDonald, 2015). The WHO Strategic Advisory Group of Experts
(SAGE) on Immunisation suggests that attitudes to vaccine should be conceptualised as
‘a continuum, ranging from total acceptance to complete refusal’ and that ‘vaccine hesi-
tant individuals are a heterogenous group in the middle of the continuum’ (WHO, 2014:
8). Accepters (vaccine confident) and rejecters (vaccine refusers) should be regarded as
belonging to this continuum, occupying its opposite ends. Following that terminology,
an Australian research team calls the vaccine hesitant individuals fence sitters who are
‘characterised by uncertainty and lack of confidence in vaccines, but who may still sup-
port vaccination in some respect’. They are not analogous to vaccine accepters who
‘strongly endorse vaccine practices’. Neither are they identical with the refusers (anti-
vaxxers) – ‘a small yet vocal group . . .’ who oppose the use of vaccine in all forms
(Rossen et al., 2019: 24).
Vaccine hesitancy and coverage (an informal term) are inversely related. The higher
the vaccine hesitancy – the closer it is to potential vaccine refusal – the lower the vaccine
coverage, although the former may be only one – among Western countries perhaps the
one – factor that impacts coverage. There may be other, more material and less attitudinal
obstacles such as a prohibitive cost of vaccine or limited access to immunisation. In other
words, there are unintentional hurdles to coverage, which may stop parents from immu-
nising their children although they do not reject to doing it (Yaqub et al., 2014).
This paper is concerned with government communication and its main target – the
vaccine hesitant individuals, the fence sitters, who in the middle of the continuum con-
stitute a group smaller than the accepters but larger than the antivaxxers. This is the
strategically important group to win – the sitters, which pro-vaccination campaigners
must and can pull out from the fence. As I will argue, their agenda of concern with the
health of their children and risks of the vaccine should not be confused with the political
agenda of the antivaxxers, which by addressing vaccine also has other things in mind.6 Public Relations Inquiry 00(0)
Parenting concern and health ideology influence each other but are not identical. The
vaccine-confidant parents have embraced the worldview of objective science and trust-
worthiness of its agents. This slants their parenting concern towards the risks for their
children from failing to vaccinate them.
The ideology – or ideologies – of the antivaxxers, who are in general well educated
and well-off people, has roots in various religious, libertine and New Age spiritual tradi-
tions (Wolfe and Sharp, 2002; Wolfe et al., 2002). They do not directly reject science but
rather mistrust its ‘hijacking’ by self-interested agents such as politicians, bureaucrats
and some experts. In the self-image of the antivaxxers, they are scientifically more
knowledgeable and critically minded than the ‘unaware’ and ‘gullible’ vaccine-confidant
parents. Thus, their parenting concern is focussed on the ‘unknown’ or ‘undisclosed’
risks of some vaccines for their children (Hobson-West, 2007).
The fence sitters – the vaccine hesitant parents – are perhaps a bit but not a lot affected
by those opposing ideologies. The agenda of their rather un-political concern as parents
is still prevailing over their ideological beliefs as citizens. Their political agenda – what-
ever it is – is weak, but their parental anxiety is high.
But if winning the vaccine-hesitant parents is the real problem, the question is what
highway to take in that journey. Is it possible to keep the argument un-political? Or is it
not better to find a more adequate translation between parental worry and political moti-
vation, because, in the end, there are no such things like policy-free solutions of public
health issues?
Theoretical framework
Stigma, voice and silence
A public relations theory of government public health campaign cannot go around the
category of stigma and process of stigmatising, in which both the pro-vaccination work-
ers and antivaxx activists are involved. Goffman (1990) defines stigma as a set of dis-
crediting characteristics to someone’s identity, which can be of a person or a group. The
advantage of his definition is that he is a sociologist and sees the process of stigma not as
an individual act but as a complex discursive event. Stigmatising takes place not when a
new word or a new collocation is introduced but when a whole language is changed. The
stigma ‘should be seen that a language of relationships, not attributes’ (p. 2).
In the mainstream media, the name of the person who started it all in 1998 with his
infamous publication in Lancet (later retracted) about the link between the measles vac-
cination and autism, Wakefield (1998), goes by default together with adjectives such as
‘discredited’ and ‘disgraced’ (scientist, expert). This is an example of stigma through
colocation. Minister Hancock gives another example of negative branding. (Branding is
the origin and literal meaning of stigma, the sign ancient Greeks burnt into the body of
a slave, criminal or traitor.) As cited above, he put together – or did not clearly differen-
tiate from each other – vaccine hesitant parents and anti-vaccination activists and
branded them as ‘morally reprehensible, deeply irresponsible and [with] blood in their
hands’. Stigmatising, in that regard, is the opposite of ‘normalising’. A stigma brands
the others as morally and noticeably inferior. Those in power need the stigma not toDimitrov 7
help the stigmatised, not to improve their moral, and not to change them into ‘normal’
people and return them to us, but to parade them as a living example and deterrence to
the others in the first place. Stigma silences by visibility.
Goffman’s term, however, only allows passive and static strategies for the stigmatises –
mostly of camouflage. They mimic the dominant group either by imitating (raising it a bit
too high) its voice of wisdom, or by making their own discredited Self more invisible.
Examples: hiding unemployment (Siebert, 1997) or masking sexual orientation (Lovaas,
2003). But research also unveils an opposite, resistant and transformative feature of
stigma (Smith, 2007, 2011). Passively and tactically, one can adapt to a dominant dis-
course; but actively and strategically, one can try to change it – weakening it (by deliber-
ate overuse, for example), imposing their own language, and, finally asserting their
dominance (Lakoff, 2004; Lakoff and Johnson, 2008). Both for the dominant and domi-
nated, stigma may have unexpected and unintended consequences.
Stigma is an ambitious strategy. It may demoralise the victims or spoil them for a
fight. For example, one can undermine the stigma by doing the opposite of what it
enforces – by becoming instead of silent and visible – vocal and invisible. Cultural (mis-)
appropriation does exactly that – adopting dominant ‘cultural codes’ (Eyerman and
Jamison, 1991) to achieve something different from their origin or genesis (Aldredge
et al., 2009; Rogers, 2006). It is true that stigmatised groups do not have the cognitive
power to define their own identity imposed on them by primary definers, but they do
have the axiological power to subvert it by tweaking the value of who they are – from
negative to positive. ‘So you say, we, skinheads, are fascists. OK, you, smart alecks, we
are fascists. And this is good’. Changing the value sign is one of the strategies of how
resource-weak fringes may transform into core movements (Dimitrov, 2015).
Bruno Latour’s actor-network theory (ATN)
When we search for the effects rather than meanings in a vaccination campaign, Latour’s
(1996) actor-network theory (ANT) may lend us a hand. There are two main reasons for
that. First, Latour attempts an ontological and epistemological synthesis of social and natu-
ral science, in which he offers a material understanding of an actor – beyond the hermeneu-
tic and idealistic definition of (co-) producer of meaning (Dilthey, 2010 (1939); Weber,
2002 (1922)). According to Latour (1996), ‘anything that does modify a state of affairs by
making a difference is an actor’ (p. 71). And second, he developed and applied his theory
of the material constitution of the social in the field of epidemiology and immunology. In
The Pasteurisation of France, he dissects the combinations and alignments of social forces
that made the immunisation of the population in France possible on a grand scale. For
Latour (1988), both the virus and the vaccine perform as actors, who, if virtually silent
themselves, by sheer impact recruit and rally influential speakers on their behalf.
Latour’s ANT overcomes Cartesian dichotomies and move from the search for
meanings to the search for effects. Such understanding is easily applicable in public
relations campaigns. Practitioners are aware of the difference between (media) output
as a means and (public) outcome as an end. Although publicity effects may be a goal,
they are more often a means to achieving other, more material effects such as higher
attendance, increased sales or taking action (Hon and Grunig, 1999; Xavier et al.,8 Public Relations Inquiry 00(0)
2005). As collective intermediaries between groups, institutions and languages, public
relations practitioners and units are not only interpersonal mediators. Beyond that, at
the societal level, they are historical, institutional and cultural intermediaries. They
belong to promotional industries, which help keeping the fragmented and fragile global
society stay intact (Aronczyk et al., 2017; Davis, 2013).
The benefit from ANT is that it critically widens the understanding of communication
as historical and societal (above and below interpersonal) agency beyond the narrow
horizon of interpretative interaction. It focusses on material (action, communication)
outcomes instead of symbolic (expressive, hermeneutic) outputs (Umanski, 2019).
ATN and public relations
Only few researchers have adopted ANT in the field of public relations. Somerville
(1999) accepts Latour’s theory as an ‘amodern’ meta-theoretical and methodological
alternative to the ‘modern’ post-Kantian thinking in organisational theory, which works
with oppositions such as ‘subject/object’ and ‘self/others’. In contrast, ATN regards the
human subject as simply another actor in a network. The interconnectedness of the het-
erogeneous elements in a network triggers the process of ‘translation’. The latter means
that actors and forces within networks ‘will try to redefine the meaning of other actors,
‘speak’ on their behalf, and enrol (manipulate or force) the other actors into positions
with them. When an actor’s strategy is successful, and it has organised other actors for its
own benefit it can be said to have translated them’ (p. 41). ATN disputes a whole set of
presuppositions within organisational and public relations theories. Its methodological
allure is that it has the potential to identify new actors which have previously been
ignored in strategic communication scenarios.
Luoma-aho and Paloviita (2010) use ANT it to widen the stakeholder theory to include
non-human influences, which may reveal new, unexpected stakeholders into the complex
corporate world. Schölzel and Nothhaft (2016) discuss the relevance of the ANT in pub-
lic relations theory in their case study of the PhD-plagiarism of a German minister and
the ‘swarm’ of his anonymous ‘plagiarism hunters’. They appeal for a new understand-
ing of publics as actor-networks. They suggest looking not only into the ‘objective’ facts
but rather into the agency of facts – including the artefacts, which often act seemingly
disconnected from persons’ intentions. After a two-weeks of controversy, the minister
resigned. Decisive, however, were not the established ‘matters of plagiarism’ but the
‘matters of concern’ – that is the dynamic relations between hybrid elements such as the
role of the ‘swarm’, the reactions of the minister, the growth of a wiki investigating the
case, and so on. The authors conclude that, in lieu with Latour, ‘we need to systemati-
cally take into account as PR-scholars [. . .] that the fabrication of facts (or of non-fac-
tual claims, alternatively) as facts (i.e. in discourse) very rarely, if ever, can be undertaken
by one single actor. It almost always is ‘a collective process’’ (p. 58).
Verhoeven (2018) also calls for the reconceptualization of the public relations practi-
tioners as participants in the construction of actor-networks. If public relations is best
defined within in the organisations-publics network, a better understanding of the role of
the non-human in forming human alliances would only strengthen the formations for
which they work.Dimitrov 9
The virus as an agent
Of special value here is the paper of Aylesworth-Spink (2017) about the failures of public
relations during the swine flu outbreak in Canada. Latour’s theory explains how networks
consist of heterogeneous actors – human and nonhuman. What matters is not so much the
actors – people, organisations, or objects – but rather their actions and effects. ‘Entities
that do things’ were, for example, the government, the media, the parents, the organisa-
tions, the virus and the vaccine. Such network relations of ‘doing’ highlight that an actor
is ‘any element that bends space around itself, makes other elements dependent upon itself
and translates their will into language of its own’ (Callon and Latour, 1981: 286).
In 2009, during the influenza outbreak, the Canadian government took the mass media
for granted by assigning them the role of mere messenger for the health authority. It
presupposed that the interests of the sender (government) and translator (media) were the
in the same direction because most of the population was genuinely concerned about the
virus. It replaced the vernacular use of ‘swine flu’ with the scientific label of ‘H1N1’,
fetishizing the virus as laboratory-certified and brand-novel external agent in the rhetoric
of ‘germ theory’. It pitched measures affecting a simplified interaction between microor-
ganism and host. The human voices assigned to the invisible and silent virus its own
social life and somewhat mystical, ghostly features (Aylesworth-Spink, 2017: 6).
What happened in 2009 with the campaign against H1N1 in Canada, partly repeated
what had already taken place there in 2003 with the fight against the Severe Acute
Respiratory Syndrome (SARS). As soon as the government rallied the media, alliances of
interested parties started assembling, fragmenting and realigning. Pursuing their interest,
the mass media pushed the moral panic button, overblew the SARS danger, exaggerated
the risk, and questioned the competence of the public health authorities to manage the
crises. Looking for sources corroborating their stories, they largely employed historians,
who delighted in making parallels with pandemic disasters in the past (Feldberg, 2006). In
result, the virus not only increased the mistrust in the government but also pushed the
myth of dangerous others and sponsored the fear, intolerance and hatred in the society
(Muzzatti, 2005). The risk communication exercise went awry, and an unwarranted per-
ception of the high risk of SARS materially impacted on the economy (Smith, 2006).
Back in 2009, the Canadian government visualised H1N1 as an actor with distinctive
behaviour to tangibly localise it in the social order and coordinate its siege with other
allies. Visualising made the virus remarkable. Its strength only grew as its self-appointed
speakers weakened. Instead an object, the microorganism became a mediator with its
own agency and autonomy, connecting and realigning various stakeholders. Again, the
imagined strength of its movement questioned the management and effectiveness of the
vaccination campaign. The media helped the virus and vaccine to mutually adjust their
roles. If the vaccine is scientifically tested and effective beyond any doubt, reasoned
many users, why do we not wait to see how it goes – and whether people around get sick.
If they do, we will immediately get the shot. Thus, not the virus but the vaccine was
identified as the greater risk.
Officials weakened themselves as actors when they inserted themselves into the news collection
process and undervalued the media’s free will. These leaders saw the media as a natural part of10 Public Relations Inquiry 00(0)
society at their disposal during a needy time. On the contrary, journalists begin from a place of
power and expand their size by gathering experts. As the media allied with other actors, this
expansion shaped and strengthened the pandemic narrative (Aylesworth-Spink, 2017: 9).
Again, the public health officials failed to recognise that the media were not mere instru-
ments but powerful actors – peculiar translators and independent mediators. And this is
the strength of Latour’s ATN. An association is strong when threatening one actor means
threatening others or, positively, when benefiting one actor is also benefiting others
(Latour, 1987). For that reason, the new association of the government with the media in
the Canada’s swine flu campaign grew not stronger but weaker.
The virus and vaccine are network entities, which can act as agents and cause effects.
Groups also make representations against them or on behalf of them. Some give the virus
and vaccine a voice, and some try to silence them. In October 2020, the former US
President Obama ridiculed the complaints of the incumbent President Donald Trump
about the media giving the coronavirus crisis, so to say, a higher rating than his efforts to
solve it with the famous ‘He’s jealous of Covid’s media coverage’ (Greve et al., 2020).
This was not only a good soundbite by an apt metaphor. It was true in a more profound
and material way. Trump and the virus were competitors. The strategy of dismissing,
silencing the virus – and by analogy of the then still undeveloped vaccine – was incon-
sequential, even counterproductive. Downplaying its invisible presence was not dimin-
ishing but only increasing its real effect.
Natural history of a vaccine-preventable disease
Following Latour, I consider virus and vaccine two agents, which mutually contribute to
the creation, composition, and realignment of coalitions of support or resistance. Trough
the circumstances they create, they both become prominent through their speakers.
Depending on the phase in the natural history of a vaccine-preventable disease, the
‘voice’ of the virus or the ‘voice’ of the vaccine alternately gets upper hand (Chen and
Hibbs, 1998; Ołpiński, 2012). At the same time, the other ‘voice’ (which is ascribed, dif-
ferent from material agency) gets silenced.
When analysing a case of immunisation-preventable disease – be it the Canadian or the
Australian one in the following pages – the phase of its natural history is important. And
the natural history of such disease – as any history – is not foreign to irony. In calm times
of relatively healthy communities, the virus loses visibility – it goes, so to say, undercover,
and lets the vaccine take centre stage. Vaccine then falls into the trap of the limelight. As
cases of infection become rarer, the number of people with first-hand experience of the
seriousness of the diseases diminishes. The vaccine becomes victim of its own success
(Janko, 2012). ‘When the disease isn’t around’, says Helen Bedford, a children’s health
specialist at Great Ormond Street Institute of Child Health, London, ‘half the equation has
been removed — all the risk is focused on the vaccine’ (Drew, 2019: 59).
In the phase of relative vaccination success in the natural cycle, the virus still acts – but
in stealth. Then people take their time to have a long look at the only visible agent around –
the vaccine. Ironically, some start recognising it as the virus – or the remains of it. Some
parents – and political agendas can catalyse it from aside – start seeing in it more risksDimitrov 11 than benefits, more real danger than one from a hypothetical virus. Because of that, fight- ing a virus during the best phase when health services are closer to its eradication is not easier than in times of crisis. Mandating immunisation at this moment may appear the golden bullet, which can hit all targets. But how to persuade the public in the safety of the vaccine and credibility of its providers, when there is no sense of urgency and everything else in life reminds the people of the inadequacy of the public health services? Communicative distance What is the nature of relations between a pro-vaccination government campaign and the various actors – such as parents, media, scientists, health services, citizen groups and political movements – in the strategic alliance? A prominent theory in public relations puts relationships – organisations-publics relationships (OPRs) – front and centre (Ledingham and Brunig, 2001; Ledingham, 2006). Public relations, in that approach, is a management function, which goal is to establish and maintain mutually beneficial rela- tionships between organisations and publics. Five dimensions of those relationship make their strength empirically measurable: trust, openness, involvement, commitment and investment (Ledingham, 2003). An assumption of the theory is that it observes the inter- personal relationships through the prism of the organisation-customers relations. The authors are aware of the methodological problem here, especially when it comes to the identification and measurement of other kinds of relationships such as between the gov- ernment and its publics, when the values of democracy and citizenship are involved (Ledingham, 2001). Still, is it possible to understand, for example, government communication as political communication (democracy, competition, activism) and as public health communication (services, citizens as customers with rights)? How about the commodification of govern- ment services, including the application of public relations techniques developed in the commercial sector? Where is the place of sceptical or agonist publics? Are, for example, anti-government activists with low trust in the health services or in official science per definition anti-democratic? It becomes obvious that in a democratic society, there is no linear continuum of trust-mistrust, which can meaningfully measure government-publics relations. For example, government mistrust by a public can alone reflect neither the democratic quality of the government nor of the public. Not only in relation to a govern- ment, postulating positive relationships as the golden standard between organisations and their publics may be the shortest way to paternalist and authoritarian doctrines (Waymer, 2013). Publics, due to their historical troubles with a government, may desire not to be in any close relationship with it. Greater closeness may only intensify and seal the harm and injustice between two entities unequal in power. Relationship is an exclu- sive, more personal and, in a way, more unguarded relation. Only more distant relations are inclusive – inclusion, not exclusion defines the democratic public sphere. (Hess, 2000) introduces the term of ‘communicative distance’ to locate publics, who in non-voluntary relationships are happy not with closeness but with the non-violation of the distance from a power, which they historically do not trust. Waymer (2013) adopts this concept to problematise and further develop the OPRs paradigm in public relations, when he analyses lukewarm and unyielding reactions to the US Government’s official
12 Public Relations Inquiry 00(0) apology, administered by President Clinton, to the African-American survivors of the Tuskegee medical experiment in Alabama. For decades scientists observed untreated syphilis among uneducated Black men, keeping them at the same time unaware of their condition and already available methods to treat it. In his study, Waymer suggest further research about why distance is not more or less social (normal) than closeness, how pub- lics create and regulate distances, and, finally, how public relations should factor in strat- egies of effective communication without violating such norms of distancing (p. 329). Case: The Australian MMR vaccine campaign Notes about the method This section offers a case study of the MMR and HPV campaign by the Labor govern- ment in Australia in 2012 and 2013. I also discuss of the next period of conservative governments (from 2013 to the present), which have introduced more coercive and less communicative means of achieving higher vaccinations coverage. I compare the results and offer some conclusions. Case studies allow us to draw on previous models and experiences, learn lessons from both success and failure, and articulate solutions that have a broader relevance and may be applied in various situations (Patti, 2003; Yin, 2003). The type of this case is of the limits and potential of government health communication. I critically examine the deci- sions of the Health Minister, Tanya Plibersek, and her communicators when to act and when not – or, more precisely, when to recourse to stigma and when not to as well as when to act by speaking and when to act by remaining silent. For this purpose, I did document analysis of government sources. I have also con- ducted in-depth interviews (Legard et al., 2003) with two communicators who worked for the MMR campaign of the Minister for Health in 2012–2013. Caroline Turnour was then Senior Adviser for Plibersek’s office1. And Paul Perry was her Director of Communications2. They were not only insiders but also instrumental for that campaign. The interviews gave me valuable knowledge about the planning process, including research, dilemmas, ongoing decision making, objectives, strategies, implementation, and. I will cite them using their initials: C. T. and P. P. Lack of access or refusal? In 2012–2013, the communication team of the Australian Labor Minister of Health, Tanya Plibersek, decided to mount an MMR campaign by choosing a path unlike the Canadian one. Indeed, the situation was different from that in Canada. The natural cycle of measles in Australia was in the phase of further stabilisation, not of epidemic crisis. The immunisation rate for five-year old children in the country was satisfactory – 91.5%, albeit with measles still a concern (AIWH, 2014). The immunisation rate had been grad- ually climbing, but the herd immunity threshold of 95% was still some points away. This was the lull when the virus becomes invisible and the vaccine – its problematic safety, irrefutable risks and mistrusted providers – increasingly attracts public attention as the leading actor to deal with.
Dimitrov 13
There were some pockets in the country, where the share of immunised children was
notably lower – even below 70%. Two groups of the population defied the overall
uptrend. The first included some Aboriginal communities in Western and South Australia
as well as the Northern territories. In general, the Aboriginal and Torres-straight people
had an immunisation rate by 5%–6% lower than the average of the population. In gen-
eral, the causes for that were no different than those for the worse health situation and life
expectancy of the Aboriginal people in Australia. The leading negative factor is access to
health with both demand and supply issues.
The second group had a very dissimilar profile. It is safe to say that those are affluen-
tial, white and well (although not the highest) educated people with libertarian and anti-
authoritarian views. In Australia they are rather on the left than on the right, but otherwise,
they are of various political hues. Religious beliefs also were a certain, although not
dominant factor (Trentini et al., 2019; Ward et al., 2012). Statistical areas with lowest
immunisation rates were, for example, Inner Sydney (NSW), North Sydney-Mossman
(NSW) and the hinterland of the Sunshine Coast (Queensland). But the most striking low
(between 66% and 70%) was registered in the area of Richmond Valley-Costal (NSW).
Those are the communities around the famous – or notorious – Byron Bay, where old
hippy and new age sub-cultures mix with ‘sea-change’ and well-to-do intellectuals. They
include postcodes such as Broken Head and Byron Bay (2481), Brunswick Heads and
Ocean Shores (2483), and seventeen others around them (NHPA, 2014).
It is plausible to speculate that for the first group – for some but not all Aboriginal
communities in Australia – access to vaccine as an element of access to public health was
the main, albeit not only reason for not vaccinating their children. And it is also safe to
say that the second group of well-off libertarians produced a disproportionally larger
minority of active refusers, although its majority still consisted of vaccine-confidant and
vaccine-hesitant parents.
Code appropriation
The Australian Vaccination-risks Network Inc. (AVN), previously known as The
Australian Vaccine-sceptics Network Inc., the most organised anti-vaccination pressure
group, has its headquarters in the same NSW area – in Bangalow, a few kilometres from
Byron Bay. The online group was established in 1994 by an American, Meryl Dorey,
who moved to Australia and had claimed that her son, when he was a child, was badly
affected by DPT (diphtheria, pertussis and tetanus) and MMR (Vines and Faunce, 2012).
The strength of the network, depending on who counts, has been between 2000 and 3500
members (Hansen, 2014; Watt, 2009). The group has been heavily criticised by doctors,
experts and health authorities as ‘misleading, inaccurate and deceptive’ (Health Care
Complaints Commission (HCCC), 2010). All former governments and most civil society
organisations in Australia had called for zero tolerance against AVN. There had been
various actions against it – from a petition to deport Meryl Dorey (Change.org, 2013) to
a government decision to strip AVN from its charitable status – that is, to ban the organi-
sation to raise funds (Stewart, 2010). Such jolts do not seem to have decreased the other-
wise limited influence of the group. Administering stigma is often a step too far.14 Public Relations Inquiry 00(0)
A string of events is also noteworthy. In 2012, the NSW Office of Fair Trading ordered
the pressure group to change their name or de-register (Burns, 2012). AVN then made
such name change two times. In 2014, it first scrapped from its name ‘-sceptics,’ which
had so much affronted the government. And in 2018, it settled on ‘Vaccination-risks’
instead. AVN declared that it had not been comfortable with the world ‘sceptics’ anyway
because it was associating it too close with the Australian Sceptics – an unrelated group,
which represents the international chain of Scientific Scepticism. As many other anti-
vaccination groups, AVN positions itself not as anti-science. On the contrary, it insists
that it is closer to science than those who mindlessly let their children immunise. Thus,
its mission is to scrutinise sloppy laboratory methods and standards, vested bio-techno-
logical and multi-national interests, and corrupt health authorities, who align in a power-
ful cabal that compromises the safety of vaccines (Tasha, 2018). In other words, the
legislatively enforced rechristening of the organisation made its mark even sharper and
more persuasive. AVN managed to appropriate the cultural code of the government
(Merry, 1998; Rao and Giorgi, 2006) and use it back its own argument against its vacci-
nation logic and policies.
‘Apolitical’ politics
Each phase in the natural cycle requires different communication strategies. In 2012–
2013, the challenge before Minister Tanya Plibersek was – also with a view to the
Canadian experience – about how to walk the tightrope between persuading more hesi-
tant parents in the safety of MMR and, at the same time, not to overblow its power – not
to push them towards the refusers. In contrast to Canada, there was no illusion around the
tabloid and mostly right-wing media as a mouthpiece of government communication.
The media is always after conflict – possibly with the government. The opposition is
always after conflict – necessarily with the government. Now, how to involve diverging
political and commercial interests without alienating pivotal actors? And how not to take
the bait of sought adversity – how not to embolden the dissenting groups with a dispro-
portionately strong response?
The Department’s silent mantra was: ‘We are not going to be in conflict with you’
(C.T.). Prioritising health was the right choice to tame the conservative opposition, which
main concern had been the fight the government’s policy of Emission trading scheme,
which it dubbed ‘carbon tax’ – an ideological label that tainted the carbon emissions
trade as a hidden tax. ‘Carbon tax’ was a confrontational – and successful, as it proved
later – discursive strategy, which used the neoliberal presupposition of ‘tax is bad’ against
an otherwise sound real-policy (Dimitrov, 2014). Pro-vaccination, however, enjoyed a
bi-partisan support, which let the opposition no other choice but to silently align with the
government. Here Labor momentarily won with the apparent more consensual and ‘apo-
litical’ positioning in ‘health’ – although health and vaccine are, of course, political
trough and trough3 (Blume, 2006; Epstein, 1995; Hobson-West, 2007).
At this phase of the natural history of the virus – especially of measles – the media
were not going to make much trouble either. Because vaccination was a shared value
in the Australian political public sphere, the legacy media were rather tempted to criti-
cise the failure of the government to vaccinate rather than the campaign itself. EvenDimitrov 15
influential digital media, such as MamaMia (www.mamamia.com.au), which feeds on
informed cultural gossip and conflict, would question Minister Plibersek whether she
had not missed to immunise her own children rather than directly attack her policy
(Plibresek, 2012). For a scoop one would assail the government for double standards
rather than bad faith. And the antivaccination pages such as those of the AVN, had a
limited, albeit ardent fellowship.
A dog whistler by proxy
Another move by the government was to distribute to the media internal information
about the vaccination inequalities between the statistical geographic areas in Australia.
For that purpose, the Minister asked the National Health Performance Authority, which
collects the vaccination statistics, to add to its bi-annual report all local information,
including of the smallest areas – the postal codes. The artful design of the report, usually
a bland administrative sheet, was also a lucky strike. Clear and colourful figures allowed
a layperson to look for certain geographic places, compare them and see the picture as a
whole – including, the ‘winners’ un blue and the ‘losers’ in red (NHPA, 2012). The gov-
ernment sent it to the news outlets even before officially publishing it. The media liked
it; the contrasts between the post codes stroke a cord with them. The shared facts were
newsworthy. What is more, they allowed chasing moral narratives – from sensitive to
scandalous, depending on who the pundit was.
The Daily Telegraph of Murdoch’s News Limited Ltd. is the largest newspaper circu-
lation in Australia. It got not only involved but it also wanted to run a campaign about it.
On one hand, it did not sympathise with the Labor government – only a year later it
would lead the most vicious election campaign against it (Dimitrov, 2014). On the other,
it had recognised that campaigning on a value shared by almost all Australians would
increase its sale. There was an ideological reason as well. The tabloid saw the Byron Bay
type of people as ‘elitist lefties’ – which, of course, is a violent simplification of the local
demographics – who were the perfect enemy, against which it could energise its populist
and rather conservative base. It started a campaign, called ‘No Jab, No Play’, which
required a ban of unvaccinated children from childcare centres and withdrawing child-
care rebates and family benefits from their parents (Hansen, 2013; Leask and Willaby,
2013). Other media followed suit, although in a less agitated, finger-pointing manner.
Plibersek watched the development with mixed feeling. She was happy with the value
of vaccination as the frame of the media campaign. But she did not agree with the
#NoJabNoPlay demands and shrill, aggressive tone of the Daily Telegraph. The strong
value element was tempting. Politicians prefer to campaign on values shared by every-
one. The value of community safety and herd immunity were such strong values. But
values are not policies. Her communication team were watching and thinking:
The Daily Telegraph were very much onto values. . .The vast majority of Australians would
hold the same values. It is a great campaign to run if you are to sell news, to engage readers and
to create moral outrage. But it’s not actually a great campaign to run if you want to increase
vaccination rates. By being morally outraged you’re actually inflaming and giving oxygen to a
group whose profile you don’t want to increase (C.T.) So they’re talking to their base but,16 Public Relations Inquiry 00(0)
giving greater attention to that issue, they’re actually advantaging the people they don’t agree
with. That is the moral conundrum. (P.P.).
Advertising the vaccination campaign, the government stayed in the background and let
the media step forward and exploit the pros and contras of the value debate. The bully
pulpit was not the business of the executive. Daily Telegraph, however, had taken this
position. The government, however, needed to stay focused on what it could do best,
which in many ways is also what no one else could do. It needed to carry on its less vis-
ible but closer to parents policies and measures. What were they like?
We want to encourage people to be vaccinated and we will do as many public policy things as
we can to get all those people who are not vaccinated just because they are too busy, or they
haven’t had the opportunity to get to the doctor, encourage them to do that, but not, you know,
demonise people which was what Daily Telegraph was trying to do. . .It would have been very
easy to jump on [its] campaign, but that is not the role of the Health Minister. The Minister’s
role and leadership is to promote best policies and promote the best considered debate (C.T.)
As long as a broad alliance of media and agencies, led by Daily Telegraph, was after the
Byron Bay vaccine refusers, the government was left, so to say, ‘off the hook’. This
helped it concentrate on its work on the ground.
Silence as not engaging the antivaxxers
The Health Minister evaluated the anti-vaccination activists as relatively week and wanted to
see them staying so. He who targets is also targeted. Nowadays, one targets many, and many
target one. Nowadays, strategies are not primal but responses to other strategies. Agendas try
to highjack agendas. Thus, even more often silence is the right response to voice. Strategic
silence is the answer to being strategically targeted, especially when this would strengthen
someone else’s agenda and weaken your agenda (Dimitrov, 2018: 163–170).
Thus, the psychology of government communication:
You don’t want to be talking to the community action group down the road, because whoever
you’re talking to, you’re going to be essentially brought down or brought up to their level. That
is part of the decision who you engage with in an debate, and also whether people are pushing
an agenda that you don’t want to be pushed and they don’t have enough currency in the current
media world or they’re not getting enough of attention. If you are a serious player and you
engage with them, you raise them up. So why would you want to raise up someone who does
not agree with your position? That is a strategic question that doesn’t necessarily have to have
a moral component. It is just about a strategic decision what our agenda is. We are pushing our
agenda and we don’t want your agenda cutting us out’ (C.T.).
Not to give them the conflict, the government preferred strategic silence. Silence as the
opposite of engagement with the anti-vaccination activists – neither acting as Daily
Telegraph ‘who run against those guys and painted them in the most radical sort of way’
nor by giving them a place at the table, where ‘the more you give voice to the small
minority, the more they will actually influence and take people from the majority’ (P.P.).Dimitrov 17 HPV for boys – how much above the line? The introduction of the vaccine against human papilloma virus (HPV) for boys was another interesting subcase of the campaign. Previously, only girls were vaccinated because the main possible harm from HPV – otherwise a relative harmless sexually transmitted disease – was warts that may lead to cervical cancer in women. Hence girls had been its main beneficiary. But there were two main reasons to put it also to boys. First, in a limited number of cases of HPV boys may get anal and throat cancer if they have anal sex in the future. And second, girls would indirectly become even greater ben- eficiaries, because they would not get the disease from immunised boys (Stanley, 2014). The big question was how to sell it to parents of boys who get vaccinated before they are sexually mature. How to persuade parents who have never entertained the possibility of their boys having anal sex in the future? There was an intensive internal debate in the Department of Health with strong and conflicting opinions about the message and media strategies. Which message would tell it all without saying much? Which medium would give it the right format and tone? How to custom tailor the messages for various groups of parents? For example, how much money to spend to advertise above the line, so that everyone can appreciate the universal benefits of HPV for both genders? How much detail to leave to the GPs and health workers for their more personal or confidential con- versations with parents? What should be done first – setting up a favourable public opin- ion or getting the process to work through school nurses and public health units? It was a stark dilemma: ‘And we can either promote the benefits to a small proportion of boys who will potentially go on to practice anal sex or we were sort of saying, let’s promote it as universal because of the [scope of] community we were talking to’ (C.T.). The term we [finally] used was ‘Cancers that boys can get’. The view of the Department was that we did not need a multi-million advertising campaign, that we could remain silent and let out some parts of the debate. We launched it. Tanya did a press conference, and we got good national media. We used the systems that are in place just to get it out there so that we just could get on with it’ (P.P.) ‘Indeed it was almost universally accepted. It was also Ian Fraser, the clinician who initially developed the original vaccine. We were saying that it was an Australian success story. And it was framed by the media as equity – finally boys had access to the vaccine’ (C.T.) Discursive silence The Australian Department of Health had also contributed to the battle of languages. One of the things the minister was very keen on was that in the past these people who refused to have their children vaccinated were called ‘conscientious objectors’. And we changed the name to ‘vaccine refusers’ in all Government documents because the Minister was very clear that she didn’t want to be about a conscientious sort of moral decision but just about ‘refusing’ (C.T.) Indeed, ‘conscientious objectors’ has gained currency since the very beginning of the anti- vaccination protests. Even since Edward Jenner had success in preventing smallpox, coined the word ‘vaccine’ and promoted the first vaccination campaign in 1796, anti-vaccination
You can also read
