The pollution of health discourse and the need for effective counter-framingBMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1128 (Published 04 May 2022) Cite this as: BMJ 2022;377:o1128
- Nason Maani, assistant professor1,
- May CI van Schalkwyk, NIHR doctoral fellow2,
- Mark Petticrew, professor3,
- Kent Buse, director4
- 1Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine and UK Prevention Research Partnership SPECTRUM Consortium, London, UK
- 2Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine
- 3Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine and UK Prevention Research Partnership SPECTRUM Consortium, London, UK
- 4Healthier Societies Program, The George Institute for Global Health, Imperial College London
The UK Health Foundation argues that to better communicate on the social determinants of health, we need to change our framing.1 Framing describes what we say about an issue or concept and how we say it, which in turn affects people’s understanding, reactions, feelings, and actions. For example, framing health as primarily a consequence of individual choice—as is often the case in public debate—deflects attention from ways that health is strongly shaped by other forces, such as the wealth of our parents, or the availability of education to us growing up.
Such engrained individualistic perspectives on health have consequences for the policies that the public and policy-makers support, and for political accountability, or lack thereof, when health declines. Framing helps explain why we celebrate and fund a new cancer therapy that extends life by several months, while gaps in life expectancy of nearly 20 years between different neighbourhoods in the same city, are afforded scant attention. How we frame problems then, can be “a matter of life and death,” as the Health Foundation describes. However, in order to change how issues are framed, we must understand who creates these frames and why.
There is now extensive evidence that large commercial actors actively shape how health issues are framed. They do so to further commercial interests, shield themselves from potential liability, and protect brand reputation. The scale and nature of these efforts contribute to a pollution of our discourse, including how we approach problems and solutions, that is rarely acknowledged.
Tobacco, provides the most obvious example, which sought to frame cigarettes as a symbol of masculinity,2 and later as a symbol of female emancipation.3 The same industry framed tobacco harms as being a matter of scientific controversy,4 and then, as evidence became insurmountable for such framing to persist, as being a matter of personal responsibility or freedom of choice,5 rather than a manufacturer’s legal responsibility not to harm the public. Public health research and advocates were also framed as “nanny staters” or “prohibitionists”6 engaging in “class warfare.”7 Leaked documents revealed the extent to which such messages were refined and tested, before being amplified through networks of industry funded scientists, journalists, spin doctors, scientific journals, newspapers, and politicians.8
These strategies are not unique to the tobacco industry, but are part of a playbook9 that has been replicated10 where the interests of a harmful product industry and society at large diverge. Such companies use a portion of their revenue to promote framings that protect future revenue and minimize the risk of regulation. Sugar sweetened beverage manufacturers frame obesity11 as being a matter of personal responsibility, a complex issue, and a matter of physical activity, going as far as funding major physical activity programmes, including through the US Centers for Disease Control and Prevention (CDC).12 Fossil fuel companies engaged over decades to frame global warming as a matter of scientific controversy, including through paid advertorials in leading newspapers,13 and personal responsibility.14
These well funded and carefully crafted efforts to frame health can have cumulative negative effects, including leading to a “downstream” emphasis on treatment and individual responsibility, rather than “upstream” prevention interventions. These framings also reduce faith in national and international regulatory agencies, undermine the public’s trust in science and evidence, and promote industries’ preferred solutions such as self-regulatory corporate social responsibility15 or “better regulation”16 as alternatives to effective public policy. A key strategy is increasing doubt. A recent randomised controlled trial found that industry framings that emphasised uncertainty, including about alcohol and breast cancer, fossil fuels and global heating, sugar-sweetened beverages and obesity, and tobacco and lung cancer significantly increased uncertainty in the minds of respondents about product harms compared to information from independent organisations.17
There is therefore a pressing need to not only acknowledge the significance of framing when communicating on the drivers of ill health, but to counteract the active pollution created by misleading framings from powerful stakeholders with conflicts of interest and no competence in public health. We suggest three ways forward:
First, we need greater awareness of the pollution of health discourses by industry actors. Industry framing on product harms is powerful, but predictable. A greater understanding of the framing strategies adopted by industries to deflect from their health-harming practices and products, and how these evolve in response to changing threats and contexts, is important in comprehending how distorted views of health and its causes come to be both so widespread, and so resistant to change.
Second, a greater focus on transparency and accountability of sources. Pro-industry framings are often spread through corporate social responsibility initiatives and through sponsored third-party organisations. Exposing the links of such messages to their corporate architects could diminish their impact and give a voice to more independent alternatives. For example, in Ireland a coalition of charities launched the “i-Mark,”18 a symbol to distinguish independent sources of health information from alcohol-industry funded charities.19
Third, beyond the reframing called for in the report by the Health Foundation, there is a need for the development and testing of counter-framing messages that successfully “inoculate” the public against industry-friendly framings, and denormalise6 them. The development of a WHO factsheet on the commercial determinants of health,20 which explicitly acknowledges such effects on public understanding, the publication of popular books on these topics (e.g. by Naomi Oreskes21 and David Michaels10) and the spread of terms such as “global heating”22 rather than “climate change,” are examples of what could become a more coordinated and strategic approach that acknowledges both the significance of framing, and the need to test and disseminate effective counter-framing.
Policy is to a large degree shaped by who prevails in framing problems and their solutions. All too often, the choices we make about what we say and how we say it are influenced by and reflect corporate interests. In this way, corporations can define the world of the possible and the impossible, the blameless and the guilty. We need to find better ways to tell the stories that matter, and better ways to counter the pollution of discourse on health.
Competing interests: None declared.
Provenance and peer review: not commissioned, not peer reviewed.