Health Promotion International Advance Access published May 19, 2014 Health Promotion International doi:10.1093/heapro/dau028
# The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper ICCHA BASNYAT1* and SEOW TING LEE2 1
SUMMARY This study seeks to understand how public health messages provided by the government in Singapore during an Influenza A (H1N1) pandemic were framed by the news media for the public. News articles were analyzed to explore how the global pandemic was framed as a local event, providing a unique exploration of the dynamic involving public health communication, news media and the state. Thematic analysis (n ¼ 309) included the government-issued press releases disseminating public health information about H1N1 that were directly linked to news stories (n ¼ 56) and
news stories about H1N1 generated by the newspaper (n ¼ 253). Four themes were found: (i) imported disease, (ii) war/battle metaphors, (iii) social responsibility and (iv) lockdown policies. Frame analysis revealed that the news coverage during the H1N1 pandemic reflected how the newspaper framed and mediated the information flow, amplified a positive tone for the government response, emphasized individual responsibility and utilized gain frames to construct local messages about the global H1N1 pandemic that reified Singapore as a nation-state.
Key words: public health communication; news media; health framing; H1N1
INTRODUCTION On 11 June 2009, the World Health Organization (WHO) declared H1N1 a pandemic, as more than 70 countries reported cases of infection and ongoing community-level outbreaks. On 10 August 2010, the WHO declared the end of the pandemic. In Singapore, the first case appeared on 27 May 2009, when a 22-year-old woman returned from a vacation in New York (The Straits Times, 28 May 2009). On 18 July 2009, Singapore reported its first H1N1 casualty with the death of a 49-year-old man (The Straits Times, 19 July 2009). The Singapore Ministry of Health (MOH) stopped tracking severe cases and deaths related to H1N1 in 2010 when the WHO declared that the pandemic was over (The Straits Times, 15 March 2011).
MOH relies heavily on news media for disseminating health information, raising awareness about health and chronic diseases and communicating health initiatives and interventions (Jin et al., 2006). Particularly, The Straits Times, an English-language daily (circulation 400 000) and one of the most important sources of information for the public in Singapore (Ortmann, 2009), communicated public health information about H1N1 during the pandemic. Through a qualitative thematic analysis, recurrent patterns and themes used in the Singapore government-issued press releases and in The Straits Times news stories were identified to understand how a global pandemic was shaped and constructed as a local health issue. This article begins with a discussion of public health responses and their relationship to national security. Then the article discusses how H1N1 Page 1 of 12
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Department of Communications & New Media, Faculty of Arts & Social Sciences, National University of Singapore, Blk AS6, #03-41, 11 Computing Drive, Singapore 117416 and 2Department of Communications & New Media, National University of Singapore, Singapore 117416 *Corresponding author. E-mail: [email protected]
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health messages provided by the Singapore government during the pandemic were framed locally for the Singaporean public through news coverage. This is followed by a discussion of what the study reveals and how it can extend our current understanding of public health responses. PUBLIC HEALTH AS NATIONAL SECURITY
NEWS MEDIA FRAMING OF HEALTH Health news accounts for a significant portion of news coverage, and news media are important sources of health information for the public (Chang, 2012). Furthermore, how health is framed in the media shapes our understanding of health issues, the salience of health issues, and perceptions
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Scholars have argued that public health discourse plays a role in shaping ideas about national security when the state acts to protect its citizens against medical threats and emerging diseases (King, 2002; Wallis and Nerlich, 2005). Lupton (Lupton, 2003) argues that equating medicine and public health to national security enhanced the power of the state to police the public, which then allowed the state to communicate medicine and public health information top-down and paternalistically, acting as the necessary institution of social control. Furthermore, King (King, 2002) argues that colonial-era ideologies of medicine and public health symbolized rationality and modernity and sought to eliminate primitive indigenous medical beliefs. For instance, Arnold (Arnold, 1993) discusses how bodies were ‘counted’, ‘categorized’ and ‘disciplined’ in India ( p. 9) through public health policies under the rubric of protecting the citizens. Arnold (Arnold, 1993) argues that this ‘colonization of the body’ ( p. 8) justified the emergence of public health as an institution such that ‘force, if necessary, on an ignorant, superstitious, or simply lethargic population, as part of a top-down state-driven regime’, ( p. 114) could be undertaken. Historically, argues King (King, 2002), public health as national security to protect the citizens against emerging diseases originates from the USA and Western Europe as a modernist project of surveillance. King (King, 2002) further argues that colonial and postcolonial medical and public health ideologies are entangled such that even in the postcolonial era, colonial agendas, strategies and practices continue to be employed. The idea of public health as national security that protects citizens against imported disease has been implemented in South Asian public health responses (Arnold, 1993; Porter, 1999). For example, Karnik (Karnik, 2001) points out that even in the postcolonial era, Western ideologies and approaches to public health response have been imported into India’s response to HIV/AIDs. Importation of
Western-influenced public health responses that privilege certain ideologies serves as powerful policy-making tools within localized efforts to administer national public health (Karnik, 2001). Lupton (Lupton, 2003) argues that the dominant Western discourse of public health as an institution that protects the public, introduced into the Asian context, continues to justify dissemination of information with a top-down approach, with communication flowing from the centers of authority (i.e. nation) to peripheral locations (i.e. citizens). Unlike control of the public during the colonial and postcolonial era, public health in modern democracies requires health citizenship, a social health contract between the state and society (Porter, 1999). In this contemporary view of public health, the public is understood as citizens, and a healthy citizenship is a voluntary and active participation in social relationships between the citizen and the state such that morality is measured in terms of a citizen’s healthy habits (Petersen and Lupton, 2000). Petersen and Lupton (Petersen and Lupton, 2000) argue further that, rather than direct state control, contemporary public health continues to symbolize a modernist enterprise that calls upon citizens to regulate themselves as healthy citizens. This shift, Petersen and Lupton (Petersen and Lupton, 2000) argue, requires voluntary participation rather than the public health strategy discussed by King (King, 2002) of quarantine and forced medical treatments. Based on the idea of public health as national security that incorporates the emergence of public health as an institution, imported public health responses and the expectations of citizens in contemporary public health responses, this study explored the role of public health in Singapore. Particularly, this study examined how public health messages provided by the government during the global H1N1 pandemic in 2009– 10 were framed by the news media as local health messages for the public.
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
that health information in subsequent news coverage reveals how framing was used to construct public perception of a health crisis and to contribute to citizens’ understanding of the global H1N1 pandemic. Specifically, the following research question was asked: How are public health messages provided by the government in Singapore during the global Influenza A (H1N1) pandemic framed by local news media?
METHODS Data collection Singapore’s public health agency is the major source of health information for the news media, such that the primary information sources— press releases—were included in the analysis. Press releases related to H1N1 were obtained from the Singapore Ministry of Health (MOH) website. MOH issued 160 press releases related to the H1N1 pandemic from 2009 to 2012. Of the 160 press releases analyzed, 56 could be traced to 58 news stories, while 104 did not result in news articles. To determine whether a press release matched a news story, every news story on the pandemic published during the 3 days following each press release was assessed. A news story that was based on a press release would contain identifying information such as a specific set of statistics or an update in status, would directly attribute the information to the MOH and would contain verbatim words or phrases. For this study, press releases were considered successful in disseminating information if the intended message was transferred into news. In this preliminary analysis, it was found that when a press release was issued, many news stories were generated. In adding the source of the public health information, this study fills the gap in the literature on pandemic coverage by examining how the government-issued press releases were used by the news media to frame the pandemic. In this study, the press releases directly linked to news stories in The Straits Times and the news stories about H1N1 generated by the newspaper were included for analysis. News articles about H1N1 published between April 2009 and May 2012 in the Straits Times were retrieved from Lexis-Nexis using a keyword search for ‘H1N1’ or ‘swine flu’. An initial search yielded 936 articles. In all, 56 press releases linked to news articles, and 253 news articles (n ¼ 309) were analyzed.
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of the cause and solution of health issues (Berry et al., 2007). For instance, Wallis and Nerlich (Wallis and Nerlich, 2005) and De Souza (De Souza, 2007) have found the use of war metaphors in the construction of HIV/AIDS in the media. In fact, argues Sontag (Sontag, 1989), discussions of illness are often characterized by war metaphors. For instance, De Souza (De Souza, 2007) found the use of militaristic language such as ‘enemy’, ‘battle’, ‘combat’ and ‘defense’ to frame the discussion of HIV/AIDS in an Indian national newspaper. Metaphorical framing serves to control and police the population (Sontag, 1989) and to justify public health policies that curb individual rights as necessary for national security (Arnold, 1993; Porter, 1999). Public health communication that characterizes pandemics as emerging threats from elsewhere has helped shape discourse around national security (King, 2002; Wallis and Nerlich, 2005). King (King, 2002), Lupton (Lupton, 2003) and Petersen and Lupton (Petersen and Lupton, 2000) argue that states use national security to justify their responses to emerging global threats by locating the disease outside of national borders. For instance, Dong et al. (Dong et al., 2008) note that the Chinese media in their coverage define and represent AIDS as being pervasive overseas but not domestically. Similarly, Wu (Wu, 2006) found in a comparative analysis that the Chinese news media generally described the Chinese government’s response to HIV/AIDS as ‘positive and dynamic’, whereas American news depicted Chinese government officials as ‘dishonest and inefficient’. Wu (Wu, 2006) and Dong et al. (Dong et al., 2008) found that this local–global discourse aims to reinforce approval of the nation-state and local government’s efforts to manage public health. Similarly, economic consequences, individual responsibility, conflict, leadership and human-interest frames were found in both the USA and Chinese newspaper coverage of SARS (Luther and Zhou, 2005) that praised the Chinese government’s response to a public health crisis that originated from the outside. Few scholars have explored framing of a global health pandemic in Singapore or examined the dynamic relationship of public health communication, news media and state. Framing for the purposes of this study is defined as the journalist’s selection of which elements of a news story to include and emphasize and which to leave out or de-emphasize. Investigating how a national government health organization discussed a global H1N1 pandemic and how the media used
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Table 1: Example of coding illustrated Open coding
Axial coding
Selective coding
Imported, enemy, war, battle, inside, outside, came from, putting up a good fight, took our advice, behave responsibly, infected, infected travelers, returned from attackers, quarantine, traveled to Singapore, temperature screening, new enemy, fight, travelers, tourist, hostile, put up with inconvenience, track down, isolate, social spirit, bought valuable time, proud of our achievements, not to engage in, enter Singapore, vigilance, monitoring closely, fighting terrorism, heightened the risk, interventionist, such behavior, containment strategy, robust contingency measures, socially responsible, cross into, bring, defense, for your own good
Imported, inside, outside, came from, infected, attackers, travelers, tourist, traveled to Singapore, enter Singapore, returned from, infected travelers, cross into, bring Enemy, new enemy, fight, war, battle, putting up a good fight, heightened the risk, hostile, vigilance, fighting terrorism, defense Took our advice, behave responsibly, social spirit, bought valuable time, proud of our achievements, socially responsible, not to engage in, such behavior, took our advice, behave responsibly Quarantine, temperature screening, put up with inconvenience, isolate, monitoring closely, interventionist, containment strategy, robust contingency measures, for your own good
Imported disease
RESULTS Four themes emerged: (i) imported disease, (ii) war/battle metaphors, (iii) social responsibility
Social responsibility
Lockdown policies
and (iv) lockdown policies. These themes, which are reflective of the press release and the subsequent news stories, combine to produce a grand narrative about nationalism, constructed through news framing of public health messages. The global pandemic then is understood locally to be an imported disease that threatens our national borders such that we must fight against the enemy, but in order to win this war we must be responsible citizens who participate in health citizenship, remain vigilant and obedient, consider the health of the nation and appreciate the stringent public welfare measures created for surveillance. Imported disease H1N1 was initially framed as being ‘imported’, creating a need for vigilance. On 16 June 2009, an MOH press release stated: A number of the recent imported cases [infected persons] have engaged in extensive community activities. (. . .) Some have even travelled to Singapore even though they were already unwell prior to departure. (. . . ) Such behaviour has considerably increased the difficulty of contact tracing and significantly heightened the risk of community spread.
In addition to verbatim quoting from the above press release, the newspaper further highlighted the notion of cases being ‘imported’: All the latest 17 cases were imported—six of them had returned from the Philippines with another six from Melbourne. Three others flew here from the
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Data analysis Thematic analysis was utilized to derive themes that represented meanings within the data (Braun and Clarke, 2006). The analysis began with line-by-line open coding. This allowed for the range of categories to remain unrestricted, such that the researcher could freely consider meanings of words, phrases and sentences (Lindolf and Taylor, 2002). Open coding allowed ideas, events, actions, meanings and concepts to emerge unrestricted from the data. Line-by-line coding is important in the beginning of analysis because it enables the generation of categories that become the building blocks of meaning (Strauss and Corbin, 1998). Next, axial coding was employed to review, examine and group concepts into categories. Strauss and Corbin (Strauss and Corbin, 1998) note that axial coding allows the researcher to reassemble the data fractured during open coding to make connections between the categories and sub-categories. Therefore, at this stage, recurring words, repeated happenings, meanings and concepts were integrated, connected and grouped into broad categories. The purpose of this was to detect conceptual similarities, to refine differences between categories and to discover patterns (Simons et al., 2008). Finally, selective coding was conducted to further refine and unite categories based on overarching ideas and concepts and to derive themes (Table 1).
War/battle metaphors
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper United States and one each from Chile and Europe. They had all returned on various flights between June 11 and June 16 (ST, June 17, 2009).
The notions of ‘imported’, ‘travelled to Singapore’, ‘such behavior’, ‘heightened the risk’, ‘returned from’ and ‘not to engage in’ are reflected in the press releases and the subsequent news stories that distinguish spread (from an outside cause) and responsibility (as an inside solution). On 17 June 2009, the MOH issued a press release, stating:
The Straits Times carried the MOH press release with the above information the following day. In addition, the news article stated: MOH reminded travelers, especially those who recently returned from countries considered to have sustained community spread of the virus, not to engage in activities such as working and shopping or [to] participate in mass activities until they are well. (. . .) The Health Ministry said in a statement last night that seven of the new cases had proceeded with their travel, meetings and social activities despite having developed symptoms of flu. Contact tracing is ongoing for the 17 cases (ST, June 18, 2009).
From the beginning, emphasis was placed on the flu’s being ‘imported’ from outside, requiring measures inside national boundaries. Health Minister Khaw Boon Wan was quoted as saying that ‘Singapore was experiencing a third wave of imported H1N1 cases’ (ST, 23 June 2009). Other news stories reported: Mr Khaw stated that ‘it is only a matter of time before infected travellers, who do not show any signs of fever, enter Singapore. An infected person can transmit the virus even before he shows any symptoms. One in three does not have symptoms at all. Because of this, it is possible for an infected person to cross into Singapore’ (ST, April 30, 2009). Travellers who do not get themselves vaccinated and who get infected overseas could bring the virus back and infect children. Fever clusters could then form in schools and there could be possible school closures (ST, December 18, 2009).
‘Imported’, ‘infected travelers’, ‘enter Singapore’, ‘cross into’ and ‘bring’ are terms that distinguish them, those outside of the national boundary who are part of the problem, from us, those within the boundary who must be protected and who are prepared to collectively resolve the problem. Nearly 2 years later, the fear resurfaced that H1N1 may yet again be ‘imported’. Dr Asok Kurup, an infectious diseases specialist at Mount Elizabeth Medical Centre, said that the increase in last year’s figures compared to those in 2009 may have been due to more people travelling last year, given a more buoyant economy, and bringing the flu virus back with them (ST, January 6, 2011).
Frames that praise the government’s efforts and detail what goes into protecting the national borders from outside attacks promote feelings of gratitude and appreciation from us for being taken care of. For instance, two different Straits Times news articles on 24 June 2009 highlighted the government’s efforts and success through their continued undertakings. Contact tracing took place round the clock, to try to contain any possible local spread. These labour-intensive actions may have picked up only one in four imported cases, missing the rest. But those efforts helped keep the infected apart from the rest and prevent the virus from circulating in the community. For seven weeks, Singapore kept the H1N1 flu at bay, delaying the onset of local transmissions even after the flu was imported into Singapore by travelers. That is no mean feat given how globalised and densely packed the country is, with flights carrying possibly affected passengers arriving here from the world over.
The news media in Singapore play an important role in fostering and promoting the relationship between citizens and their government. These frames construct nation-building in subtle ways while employing rational strategies during a health crisis. The Straits Times news coverage reflected the sentiment expressed in the MOH press releases about addressing health needs during a pandemic but situated that discussion subtly around efforts that foster national identity. For example, the war/battle metaphors express actions that guarded and defended public welfare during a time of battle.
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With many Singaporeans returning from their June holidays or coming home for their summer vacation (. . .), we can expect an increase in the number of imported cases of H1N1. MOH will like to remind travelers (. . .) not to engage in extensive community activities (. . .) until they are well. This will help mitigate the risk of community spread in Singapore and make our containment efforts more effective.
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War/battle metaphors On 30 April 2009, a Straits Times news article quoted Minister Khaw Boon Wan: This is a new war now, and we have to adapt our approach to face this new enemy. The country is going into war better prepared to deal with the enemy. It will not be a short battle, but a long war of attrition against swine flu.
This sentiment of a fight against the enemy was reflected in other news stories:
Headlines also carried the notion of battle, such as: ‘Fighting H1N1 flu: Don’t go overboard’ (5 June 2009) and ‘Khaw: S’pore in last leg of fight against H1N1’ (12 July 2009). On 21 July 2009, Minister Khaw was quoted reminding the public about the enemy: We are now in the last leg of our battle against the first wave of the H1N1 outbreak. But the war is not over yet. The enemy is still out there.
Another senior minister, Goh Chok Tong, explained this war: I am reminded that in terms of vigilance, fighting terrorism is like fighting an external virus like Sars [sic] or Influenza A (H1N1). Notwithstanding our best efforts, an external terrorist or deadly virus may slip through our borders. Nevertheless, the best defense against terrorism is constant vigilance and having a domestic environment that is hostile to it. (ST, May 11, 2009)
‘New war’, ‘new enemy’, ‘vigilance’, ‘fighting terrorism’, ‘external terrorist’, ‘best defense’ and ‘hostile’, all communicated that the government was working to ensure public safety by fighting a war or battle on the people’s behalf. In addition to the ministers, physicians also shared similar sentiments about the fight against the enemy: Frederico Dimatatac, 37, doctor in the Infectious Diseases department in Tan Tock Seng Hospital: ‘I’m not afraid as it is part of my job. You know what you are dealing with, so you shouldn’t be afraid of it. In this case, I know the enemy, so there’s no need to be afraid. As long as you follow the infection control guidelines, it’s actually very safe (ST, June 28, 2009).
Social responsibility News articles reiterated that the ‘imported’ cases threatened the nation, reminding people to be socially responsible: doing their part to ensure the safety of those inside the national boundaries by complying with policies in the battle against outside attackers. In a press release issued on 16 June 2009, the MOH gave a detailed, chronological account of a Singapore-based researcher from Germany who was infected with H1N1: He took a taxi home from the airport, and stayed at home for the rest of the day. He went to work from 9 to 12 June. On 11 June evening, he went to a function at the French Ambassador’s Residence attended by about 70 persons. On 13 June, he went to a shopping mall and had social activities at Clarke Quay. On 14 June, he attended a concert and did more shopping. On 15 June, he did not go to work in the morning and called a 993 ambulance to send him to CDC around noon time. Laboratory results confirmed his infection at 2140 hours on 15 June.
The press release identified and detailed the actions of the foreign national as behavior that was not ‘socially responsible’, putting the entire nation at risk during a battle against attackers. The story was reported in the Straits Times under the headline, ‘H1N1-hit researcher attended concert’, covering the sequence of events verbatim as stated in the press release. In addition, the news article reminded individuals to put the needs of the nation ahead of their own: Dr Lam Pin Min, chairman of the Government Parliamentary Committee (GPC) for Health, said that Singaporeans needed to be more socially responsible and refrain from going to public or crowded places when they were unwell (ST, June 17, 2009).
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With Sars [sic], there was a quick fight and it was over. But flu epidemics tend to come in waves. The first might be over in two months, but there is no telling when or how severe the next will be. (ST, April 30, 2009).
The war/battle metaphors set up two discussions: (i) being a socially responsible citizen and (ii) justification for increased surveillance and controls. Framing H1N1 as an outside attack that required individuals to act responsibly to aid the government in its fight against the enemy served to strengthen national identity as well as inculcate compliance. The lockdown policies that contained the spread of H1N1 and the remedies that restored normalcy and limited consequences of the outbreak were attributed to the Singapore government’s responding quickly, having contingency plans, issuing strong policies and unifying the populace for collective measures that were meant to protect against outside threat.
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
The researcher was ‘criticized sharply by many who called him irresponsible and inconsiderate for putting others at risk’ (ST, 18 June 2009) when the greater health of the country should have been put ahead of the individual. Calling on citizens to behave in a certain way, to participate in the national efforts, and calling attention to those who did not comply, all sent a definitive message about the government’s expectations of its citizens. Following the incident, MOH issued a press release on 19 June 2009, advising socially acceptable behavior:
The Straits Times the following day outlined the personal habits, hygiene and public manners specified in the press release, as well as stating: The accumulation of H1N1 flu cases in Singapore has been too rapid in too short a period, and ‘community’ spread looks imminent. Far from feeling relaxed about the flu because of its low severity and mortality rate, people should be on heightened alert concerning personal habits (ST, June 20, 2009).
On 24 June 2009, the following appeared in the Straits Times as prime news: Socially responsible behavior can slow the spread of H1N1 virus. For seven weeks, Singapore kept the H1N1 flu at bay, delaying the onset of local transmissions even after the flu was imported into Singapore by travelers. That is no mean feat given how globalized and densely packed the country is, with flights carrying possibly affected passengers arriving here from the world over. Some credit must go to the Government’s pandemic preparedness plan, which kicked in immediately once the H1N1 flu spread beyond Mexico in April.
The news coverage emphasized that individual behaviors can put others at risk, such that each person must be ‘socially responsible’ and do his or her part in reducing risk and increasing the protection of us. In addition, the news articles
emphasized the government’s efforts as being for the public welfare while praising its ability to act quickly and effectively. This frames the response, the policies and the efforts of the government in a positive tone aimed at fostering feelings of gratitude. Furthermore, the Straits Times reported that ‘Health Minister Khaw urges everyone to be socially responsible’ (ST, 30 April 2009) and that he also urged ‘Singaporeans to exercise care when attending large gatherings and to practice “social distancing” if anyone experienced flu-like symptoms’ (ST, 1 May 2009). In fact, the Straits Times provided ways of being ‘socially responsible’ and practicing ‘social distancing’ as prime news on 27 June 2009: Q: I’m in a crowded MRT train and the person standing in front of me is sneezing. What should I do? A: Offer him a clean tissue if he is not using one. Turn your face away when he sneezes. Cover your nose and mouth with a tissue. Q: I’m on home quarantine. What must my family members and I do to prevent the infection from spreading to them? A: Ideally, you should have your own room and toilet/bath facilities. If that is not possible, wear a mask if you need to be in a common area of the house near other people. Always cover your nose and mouth when you cough or sneeze. Make sure your hands are clean when you touch surfaces that others might touch— such as the toilet flush handle. Your family members should wash their hands frequently.
The newspaper reminded Singaporeans to do their part to be ‘socially responsible’ to ensure that their behaviors did not put others at risk, to be part of the efforts to ensure safety within national boundaries against outside attackers, and above all to put the health of the nation before their own needs in the battle against the enemy. It emphasized that during war, a unified dominant strategy within national boundaries to protect Singaporeans from attackers is necessary. The war/battle metaphors also served as justification for stringent measures such as lockdown policies that restricted personal freedom and mobility while increasing surveillance of the population.
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Singaporeans are reminded to maintain high standards of personal hygiene. This means covering your nose and mouth with a tissue when you sneeze or cough, and washing your hands frequently with soap and water, especially after contact with respiratory secretions (e.g., after sneezing and coughing). We also need the cooperation of everyone to be socially responsible. This means staying home and avoiding crowded places (including trains, buses, offices), putting on a surgical mask and seeing a doctor if you have flu symptoms [ parentheticals in original].
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Minister for Community Development, Youth and Sports Vivian Balakrishnan said the discovery of the H1N1 case was in a sense ‘an anticipated event’ and showed that robust contingency measures were working (ST, June 24, 2009).
This also furthered the national agenda by demonstrating strong commitment to public welfare, which further strengthened and amplified a positive government image. A Straits Times editorial voiced approval for the government’s containment measures: No wonder the H1N1 flu is holding few terrors, after initial worry, and play-safe governments like those of China and Singapore have been criticised by Mexico for ‘over-reacting’ in ordering quarantines and travel restrictions on Mexicans. Singapore should keep to the stringency. ( . . . ) WHO directorgeneral Margaret Chan said, ‘I’d rather overprepare (for a pandemic) than not prepare’. This newspaper concurs (ST, May 6, 2009).
News articles reiterated the government’s position by supporting the stringent measures, measures framed as being for the good of the people and necessary to protect the national borders. No, it does not matter if the returning traveler or tourist is feeling perfectly fine. This ‘interventionist’ approach is needed as the virus can slip past thermal screening at border checkpoints as symptoms may not have shown up yet in its victims (ST, May 1, 2009).
A Ministry of National Development (MND) spokesman said: ‘Being a quarantine center, there are rules based on health consideration, for their own good and that of other persons under quarantine as well as workers’ (ST, June 8, 2009).
The references to ‘monitoring closely’, ‘isolated’, ‘interventionist’, ‘rules on health consideration’, ‘for their own good’ and ‘containment strategy’, all communicate the power of the authorities to enforce regulations that may limit personal freedom but are framed as serving a greater good for the nation. This tone conveys a gain message through positively appreciating the actions taken by the government. In doing so, tough measures such as containment/quarantines and travel restrictions were framed as protection (i.e. gain) against threat (i.e. loss), even though such measures may restrict personal freedom and mobility. Three years later came a reminder of how well the ‘robust measures’ served the people: ‘Outbreak in Mexico in 2009 had left 1400 people dead. There were 30 deaths in Singapore due to H1N1’ (ST, 3 February 2012). Illuminating these contrasts further strengthened the government’s role as protector whose actions were meant to mitigate the outbreak for public safety. This framing of the H1N1 surveillance and containment played a crucial role in ensuring compliance and avoiding dissent for stringent measures. The government’s efficiency is dependent in part on the relationship between citizens and the state. For instance, the government issued the following press release at the end of the pandemic: Since its first outbreak here in May 2009, Singaporeans have put up a good fight against Influenza A (H1N1). We thank them and seek their continued support and cooperation. It is important that all of us maintain a high level of personal hygiene, be socially responsible and stay away from work or school if unwell (MOH, February 10, 2010).
Thanking the nation for complying with the national policies, rules and regulations serves the purpose of enhancing the people’s satisfaction with the actions undertaken. The government’s relationship with the people can be enhanced through the media’s positive framing of information that encourages citizens to support policies and to comply with efforts undertaken to protect us. Imparting advice, restating government’s efforts in serving the public, encouraging the public to make personal sacrifices and
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Lockdown policies The media played an important role in framing this communication in a positive tone that conveyed gaining something rather than losing something due to lockdown policies. For instance, the 4 May 2009, MOH press release has a loss frame: ‘Anyone who breaks the home quarantine order can be fined up to $10 000 and/or jailed for up to six months’. But rather than these measures creating discontent, the Straits Times in a 5 May 2009, article used a gain frame focusing on the benefits of home quarantine. The government’s reactions to the pandemic—quarantines, containment for travelers, restricting travel, placing personal responsibility on individuals, taking temperatures at arrival terminals (land, sea and air) and requiring public workers to log their temperatures daily— were framed as necessary and for citizens’ protection. All were framed as ‘robust contingency measures’ that protect citizens from outside attackers, for citizens’ protection.
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
emphasizing the war against attacks from outside national boundaries, all were aimed at evoking collective responsibility while building national unity. Mr Khaw was named one of the Faces of the Decade by the Straits Times on 31 December 2009, emphasizing his position of authority, power and credibility for managing national health issues. The following statement by Minister Khaw, reported on 23 June 2009, encapsulates the four framing strategies used to construct the global H1N1 pandemic as a local health issue:
Continual references to ‘came from’ and ‘imported’ attribute the cause of the problem to the outside, while references to ‘putting up a good fight’, ‘took our advice’, ‘behave responsibly’, ‘put up with inconvenience’, ‘home quarantine’, ‘track down’, ‘isolate’ and ‘promptly’, all communicate the positive impact of the government’s strategic control. Praising compliance and making references to ‘social spirit’, ‘bought valuable time’ and ‘proud of our achievements’ further evoke national identity and the feeling that ‘we’ were part of the solution, part of the win in this battle against outside attackers. Social construction of a nation mobilized around a health issue through the four frames presented by the news media supports the government’s actions, policies and regulations, and subtly mobilizes a nation towards unity. DISCUSSION This study aimed to explore the role of public health in Singapore by examining how public health messages provided by the government during a global H1N1 pandemic were framed by
the local news media. Government-issued press releases were identified as the source of the public health information for news stories. The four themes—imported disease, war/battle metaphors, social responsibility and lockdown policies—were found to be present in both the press releases and the news coverage. While the press releases provided factual information about the risk of infection, proper measures to take and the pandemic’s timeline, militaristic language was used in framing the public health information to emphasize social responsibility, imported disease and the need for vigilance through lockdown policies. Though not all news stories were linked directly to the press releases, subsequent news coverage reinforced, supported and extended the language, words, phrases and sentiments present in the press releases. The local news media’s framing of governmentprovided public health messages during the global pandemic suggests two lessons to be learned: (i) the news framing in Singapore is similar to the historical response of public health as national security, and (ii) the news framing in Singapore illustrates the relationship of health and political ideologies. The findings also suggest implications for public health educators who rely on news media for coverage and dissemination of health information. Lesson learned Similarities to historical public health response Similarities between studies of health framing in other nations in South Asia, particularly war metaphors in India (De Souza, 2007) and praise of the government actions in China (Wu, 2006; Dong et al., 2008), can be seen in the combined use of frames. The Straits Times used frames that emphasized the Singapore government as protector against outside attacker in times of war. This was constructed through the utilization of military metaphors such as war, battle, fight and enemy. News frames supported this war that needed to be fought and won by praises of the government’s response. The press releases highlighted the war metaphors, and the news stories extended this through amplification and praise of the public health response. The findings also suggest that the public health discourse in Singapore was similar to that found in King’s (King, 2002) analysis of the USA and Western Europe’s public health responses in the late 19th and early 20th centuries, which used
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There were three waves of exported cases to Singapore. The first wave came from the US. The second wave came from Australia ( . . . ). The third wave began last week, from fellow Asean countries, including the Philippines and Thailand. This will potentially be a big wave, given our close proximity. Against these challenging circumstances, Singaporeans are putting up a very good fight against the virus. Many took our advice and behaved responsibly. ( . . . ). Many more people put up with the inconvenience of home quarantine. I am grateful to them for their social spirit. As a result, we have bought ourselves valuable time. We can be very proud of our achievements. For seven weeks, there was no local transmission. All our confirmed cases were imported. We were able to track down every imported case and every one of their known close contacts and isolate them promptly.
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Relationship of health and political ideologies While the press releases were the source of public health information, The Straits Times constructed the H1N1 global pandemic as a local event
through strategies aimed at mobilizing citizens for nation-building. The government’s ability to subtly manage issues around a national agenda serves to inculcate respect for government policies, such that demarking boundaries, promoting public welfare, and praising and criticizing behaviors, all served to convey expectations of individual health and behavior. The media’s framing of H1N1 communicated public health messages with a subtle, underlying message of nation-building. Frame analysis of the news media coverage during the H1N1 pandemic revealed the role of media in defining, reinforcing and influencing national identity in Singapore, which reflected its relationship with the government. This study brings to the fore the relationship between public health communication and news media that serve the nation-state. It is important for public health educators to understand how framing health messages can be used in nationbuilding and the role that media play in that construction. Winning a war against imported attackers through public health preparedness, having ‘robust’ contingency plans in place, evoking national unity, demanding social responsibility and seeking support for new public health policies, limited mobility and increased surveillance, all communicate ideas about nation-state. This study brings to light the role of news media and its relationship with the state in Singapore, particularly using health as a way to communicate political ideologies. Public health response, particularly in a global pandemic, is used to reify nation-state. This was done through the news articles that imparted advice, taught socially acceptable behavior, reminded the public about the action taken on behalf of them, praised the government, reported the government’s public health response in a positive tone, converted loss frames to gain frames and conveyed officials’ praise of citizens for being ‘partners’ during the health crisis. The findings also suggest that nation-building strategies were not discussed explicitly during the dissemination of public health information about the H1N1 pandemic, but rather were imbedded within frames of a global pandemic as a local health issue that subtly pushed the government’s nation-building agenda. Selecting information that focuses on strengthening governance is reflective of the broader context of Singapore’s journalism profession, which aims to aid the government in its nation-building efforts. Although the Singapore media are close partners with the government in
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isolation and quarantines as public health measures. Quarantines and isolations framed in the press releases as well as in the news stories as for the greater good, communicated the power of the authorities to enforce regulations through surveillance. While the press releases reported policies, procedures and requirements of the quarantines, The Straits Times converted loss frames, such as personal leave and quarantine, to gain frames, such as the health of everyone in Singapore. The media’s positive support of the government’s stringent lockdown measures during the pandemic is reminiscent of the colonial-era ideologies. On the other hand, this modernist project was intermingled with contemporary ideas of health citizenship, as discussed by Petersen and Lupton (Petersen and Lupton, 2000). The social health contract between the state and society (Porter, 1999) asks Singaporeans to be active, to voluntarily participate in behaving responsibly, to accept increased isolation and surveillance and to support national public health security measures. Both the press releases and the news stories framed this in two ways: first, as the responsibility of government for solving the problem as well as of the individual to support those actions by being socially responsible; and secondly, by disseminating health information aimed at teaching the public how to: (i) behave responsibly, (ii) prevent risky behaviors and (iii) maintain hygiene. Additionally, the rhetoric of locating the pandemic as elsewhere, as discussed by King (King, 2002) and Wallis and Nerlich (Wallis and Nerlich, 2005), defines national boundaries and justifies measures for national security. Press releases emphasized that the threat of imported disease puts the nation at risk, such that the government must undertake surveillance and control on behalf of citizens. Concurrently, The Straits Times framed all these public health strategies, responses and actions by the government as protection for public safety against outside attackers and imported diseases, emphasizing the need for increased national security. The framing of H1N1 furthers the idea of public health as national security, demarking clear boundaries of expected and accepted behavior, sentiments and actions for the public in support of the government’s efforts.
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
nation-building, the findings raise the question of how journalists can subscribe to journalistic norms of balance and fairness while operating under extensive press controls, where nation-building is seen as the primary role for the news press. Particularly, in Singapore this also raises the question of the relationship between the source of public health information and the news media’s framing of that information.
to contain the outbreak, limit exposure and reduce morbidity and mortality, communication needs to include ways for people to manage their fears and anxieties. Today, with citizens’ having access to a complex media environment shaped in part by the Internet and social media, traditional notions of news framing that amplifies the power of the state will increasingly be challenged. Public health as national security can no longer remain a state-dominated discussion because: (i) the public has access to more information to help them make informed decisions; and (ii) decisions may be based on information originating outside local boundaries. Understanding the changing landscape of media can help the public health educator to significantly impact how health promotion is designed and implemented, particularly in times of crisis when communication is marked by urgency. More research is needed to understand how press releases issued by a powerful source and subsequent news coverage influence the public’s attitude and behavior. Future research should examine how news coverage shapes people’s understanding of a pandemic and influences the people’s cooperation. Future studies should also address the impact of health news framing and how such frames could shape audiences’ understanding of health, illness and disease. REFERENCES Arnold, D. (1993) Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-Century India. University of California Press, Los Angeles, CA. Berry, T., Wharf-Higgings, J. and Naylor, P. (2007) SARS wars: an examination of the quantity and construction of health information in the news media. Health Communication, 21, 35–44. Braun, V. and Clarke, V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. Chang, C. (2012) News coverage of health-related issues and its impacts on perceptions: Taiwan as an example. Health Communication, 27, 111–123. De Souza, R. (2007) The construction of HIV/AIDS in Indian newspapers: a frame analysis. Health Communication, 21, 257–266. Dong, D., Chang, T. and Chen, D. (2008) Reporting AIDS and the invisible victims in China: official knowledge as news in the people’s daily, 1986–2002. Journal of Health Communication: International Perspectives, 13, 357– 374. Jin, Y., Pang, A. and Cameron, G. (2006) Strategic communication in crisis governance: analysis of the Singapore management of the SARS crisis. The Copenhagen Journal of Asian Studies, 23, 81–104. Karnik, N. (2001) Locating HIV/AIDS and India: cautionary notes on the globalization of categories. Science, Technology, & Human Values, 26, 322–348.
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Implications for health promotion The study highlighted that the news media not only served Singapore’s national agenda but that the reaction to the pandemic was reflective of the historical responses of public health and of the contemporary expectations of public health. On one hand, a pandemic is a public problem that is solved through collective participation of citizens that support the government’s response. On the other hand, a pandemic is a problem that requires the government to step in on the behalf of the public to protect the nation-state by implementing new public health policies. Therefore, this study suggests that even in the contemporary context, Singapore’s public health responses reflect the colonial era of control but is also entwined with current expectations of public health responses that require active and voluntary citizen participation. Examining what frames were used to construct the global pandemic locally reveals how health issues are shaped for the public as well as the underlying ideologies. Singapore news media have a unique relationship with the government, where news information reiterates the government’s position, stance and messages. However, in today’s context, it is not enough to be contained within the historical contexts that reify political ideology through public health responses and/or ask citizens to voluntarily participate in those responses. Even in the context of Singapore, more research is needed to explore the relationship between the state and the news media on one hand, and on the other hand, this highly wired society’s access to a wide variety of news and information. Public health educators that continue to solely rely on traditional news media should consider: (i) providing more than basic information and (ii) accessing different forms of news media, such as weblogs and social media. Public health responses that attempt to change attitudes and behavior during a pandemic should include more than basic information. In addition to encouraging adoption of appropriate actions
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King, N. B. (2002) Security, disease, commerce: ideologies of post-colonial global health. Social Studies of Science, 32, 763–790. Lindolf, T. and Taylor, B. (2002) Qualitative Communication Research Methods. 2nd edn. Sage Publications Inc., Thousand Oaks, CA. Luther, A. and Zhou, C. (2005) Within the boundaries of politics: news framing of SARS in China and The United States. Journalism & Mass Communication Quarterly, 82, 857 –887. Lupton, D. (2003) Medicine as Culture. Sage Publication, Thousand Oaks, CA. Ortmann, S. (2009) Singapore: the politics of inventing national identity. Journal of Current Southeast Asian Affairs, 28, 23– 46. Petersen, A. and Lupton, D. (2000) The New Public Health: Health and the Self in the Age of Risk. Sage Publications, London, UK.
Porter, D. (1999) Health, Civilization, and State: History of Public Health From Ancient to Modern Times. Routledge, New York, NY. Simons, L., Lathlean, J. and Squire, C. (2008) Shifting the focus: sequential methods of analysis with qualitative data. Qualitative Health Research, 18, 120 –132. Sontag, S. (1989) Aids and its Metaphors. Farrar, Straus and Giroux, New York Strauss, A. and Corbin, J. (1998) Basic of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Sage Publications, Thousand Oaks, CA. Wallis, P. and Nerlich, B. (2005) Disease metaphors in new epidemics: the UK media framing of the 2003 SARS epidemic. Social Science & Medicine, 60, 2629–2639. Wu, M. (2006) Framing aids in China: a comparative analysis of US and Chinese wire news coverage of HIV/ AIDS in China. Asia Journal of Communication, 16, 251–272.
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# The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper ICCHA BASNYAT1* and SEOW TING LEE2 1
SUMMARY This study seeks to understand how public health messages provided by the government in Singapore during an Influenza A (H1N1) pandemic were framed by the news media for the public. News articles were analyzed to explore how the global pandemic was framed as a local event, providing a unique exploration of the dynamic involving public health communication, news media and the state. Thematic analysis (n ¼ 309) included the government-issued press releases disseminating public health information about H1N1 that were directly linked to news stories (n ¼ 56) and
news stories about H1N1 generated by the newspaper (n ¼ 253). Four themes were found: (i) imported disease, (ii) war/battle metaphors, (iii) social responsibility and (iv) lockdown policies. Frame analysis revealed that the news coverage during the H1N1 pandemic reflected how the newspaper framed and mediated the information flow, amplified a positive tone for the government response, emphasized individual responsibility and utilized gain frames to construct local messages about the global H1N1 pandemic that reified Singapore as a nation-state.
Key words: public health communication; news media; health framing; H1N1
INTRODUCTION On 11 June 2009, the World Health Organization (WHO) declared H1N1 a pandemic, as more than 70 countries reported cases of infection and ongoing community-level outbreaks. On 10 August 2010, the WHO declared the end of the pandemic. In Singapore, the first case appeared on 27 May 2009, when a 22-year-old woman returned from a vacation in New York (The Straits Times, 28 May 2009). On 18 July 2009, Singapore reported its first H1N1 casualty with the death of a 49-year-old man (The Straits Times, 19 July 2009). The Singapore Ministry of Health (MOH) stopped tracking severe cases and deaths related to H1N1 in 2010 when the WHO declared that the pandemic was over (The Straits Times, 15 March 2011).
MOH relies heavily on news media for disseminating health information, raising awareness about health and chronic diseases and communicating health initiatives and interventions (Jin et al., 2006). Particularly, The Straits Times, an English-language daily (circulation 400 000) and one of the most important sources of information for the public in Singapore (Ortmann, 2009), communicated public health information about H1N1 during the pandemic. Through a qualitative thematic analysis, recurrent patterns and themes used in the Singapore government-issued press releases and in The Straits Times news stories were identified to understand how a global pandemic was shaped and constructed as a local health issue. This article begins with a discussion of public health responses and their relationship to national security. Then the article discusses how H1N1 Page 1 of 12
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Department of Communications & New Media, Faculty of Arts & Social Sciences, National University of Singapore, Blk AS6, #03-41, 11 Computing Drive, Singapore 117416 and 2Department of Communications & New Media, National University of Singapore, Singapore 117416 *Corresponding author. E-mail: [email protected]
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health messages provided by the Singapore government during the pandemic were framed locally for the Singaporean public through news coverage. This is followed by a discussion of what the study reveals and how it can extend our current understanding of public health responses. PUBLIC HEALTH AS NATIONAL SECURITY
NEWS MEDIA FRAMING OF HEALTH Health news accounts for a significant portion of news coverage, and news media are important sources of health information for the public (Chang, 2012). Furthermore, how health is framed in the media shapes our understanding of health issues, the salience of health issues, and perceptions
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Scholars have argued that public health discourse plays a role in shaping ideas about national security when the state acts to protect its citizens against medical threats and emerging diseases (King, 2002; Wallis and Nerlich, 2005). Lupton (Lupton, 2003) argues that equating medicine and public health to national security enhanced the power of the state to police the public, which then allowed the state to communicate medicine and public health information top-down and paternalistically, acting as the necessary institution of social control. Furthermore, King (King, 2002) argues that colonial-era ideologies of medicine and public health symbolized rationality and modernity and sought to eliminate primitive indigenous medical beliefs. For instance, Arnold (Arnold, 1993) discusses how bodies were ‘counted’, ‘categorized’ and ‘disciplined’ in India ( p. 9) through public health policies under the rubric of protecting the citizens. Arnold (Arnold, 1993) argues that this ‘colonization of the body’ ( p. 8) justified the emergence of public health as an institution such that ‘force, if necessary, on an ignorant, superstitious, or simply lethargic population, as part of a top-down state-driven regime’, ( p. 114) could be undertaken. Historically, argues King (King, 2002), public health as national security to protect the citizens against emerging diseases originates from the USA and Western Europe as a modernist project of surveillance. King (King, 2002) further argues that colonial and postcolonial medical and public health ideologies are entangled such that even in the postcolonial era, colonial agendas, strategies and practices continue to be employed. The idea of public health as national security that protects citizens against imported disease has been implemented in South Asian public health responses (Arnold, 1993; Porter, 1999). For example, Karnik (Karnik, 2001) points out that even in the postcolonial era, Western ideologies and approaches to public health response have been imported into India’s response to HIV/AIDs. Importation of
Western-influenced public health responses that privilege certain ideologies serves as powerful policy-making tools within localized efforts to administer national public health (Karnik, 2001). Lupton (Lupton, 2003) argues that the dominant Western discourse of public health as an institution that protects the public, introduced into the Asian context, continues to justify dissemination of information with a top-down approach, with communication flowing from the centers of authority (i.e. nation) to peripheral locations (i.e. citizens). Unlike control of the public during the colonial and postcolonial era, public health in modern democracies requires health citizenship, a social health contract between the state and society (Porter, 1999). In this contemporary view of public health, the public is understood as citizens, and a healthy citizenship is a voluntary and active participation in social relationships between the citizen and the state such that morality is measured in terms of a citizen’s healthy habits (Petersen and Lupton, 2000). Petersen and Lupton (Petersen and Lupton, 2000) argue further that, rather than direct state control, contemporary public health continues to symbolize a modernist enterprise that calls upon citizens to regulate themselves as healthy citizens. This shift, Petersen and Lupton (Petersen and Lupton, 2000) argue, requires voluntary participation rather than the public health strategy discussed by King (King, 2002) of quarantine and forced medical treatments. Based on the idea of public health as national security that incorporates the emergence of public health as an institution, imported public health responses and the expectations of citizens in contemporary public health responses, this study explored the role of public health in Singapore. Particularly, this study examined how public health messages provided by the government during the global H1N1 pandemic in 2009– 10 were framed by the news media as local health messages for the public.
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
that health information in subsequent news coverage reveals how framing was used to construct public perception of a health crisis and to contribute to citizens’ understanding of the global H1N1 pandemic. Specifically, the following research question was asked: How are public health messages provided by the government in Singapore during the global Influenza A (H1N1) pandemic framed by local news media?
METHODS Data collection Singapore’s public health agency is the major source of health information for the news media, such that the primary information sources— press releases—were included in the analysis. Press releases related to H1N1 were obtained from the Singapore Ministry of Health (MOH) website. MOH issued 160 press releases related to the H1N1 pandemic from 2009 to 2012. Of the 160 press releases analyzed, 56 could be traced to 58 news stories, while 104 did not result in news articles. To determine whether a press release matched a news story, every news story on the pandemic published during the 3 days following each press release was assessed. A news story that was based on a press release would contain identifying information such as a specific set of statistics or an update in status, would directly attribute the information to the MOH and would contain verbatim words or phrases. For this study, press releases were considered successful in disseminating information if the intended message was transferred into news. In this preliminary analysis, it was found that when a press release was issued, many news stories were generated. In adding the source of the public health information, this study fills the gap in the literature on pandemic coverage by examining how the government-issued press releases were used by the news media to frame the pandemic. In this study, the press releases directly linked to news stories in The Straits Times and the news stories about H1N1 generated by the newspaper were included for analysis. News articles about H1N1 published between April 2009 and May 2012 in the Straits Times were retrieved from Lexis-Nexis using a keyword search for ‘H1N1’ or ‘swine flu’. An initial search yielded 936 articles. In all, 56 press releases linked to news articles, and 253 news articles (n ¼ 309) were analyzed.
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of the cause and solution of health issues (Berry et al., 2007). For instance, Wallis and Nerlich (Wallis and Nerlich, 2005) and De Souza (De Souza, 2007) have found the use of war metaphors in the construction of HIV/AIDS in the media. In fact, argues Sontag (Sontag, 1989), discussions of illness are often characterized by war metaphors. For instance, De Souza (De Souza, 2007) found the use of militaristic language such as ‘enemy’, ‘battle’, ‘combat’ and ‘defense’ to frame the discussion of HIV/AIDS in an Indian national newspaper. Metaphorical framing serves to control and police the population (Sontag, 1989) and to justify public health policies that curb individual rights as necessary for national security (Arnold, 1993; Porter, 1999). Public health communication that characterizes pandemics as emerging threats from elsewhere has helped shape discourse around national security (King, 2002; Wallis and Nerlich, 2005). King (King, 2002), Lupton (Lupton, 2003) and Petersen and Lupton (Petersen and Lupton, 2000) argue that states use national security to justify their responses to emerging global threats by locating the disease outside of national borders. For instance, Dong et al. (Dong et al., 2008) note that the Chinese media in their coverage define and represent AIDS as being pervasive overseas but not domestically. Similarly, Wu (Wu, 2006) found in a comparative analysis that the Chinese news media generally described the Chinese government’s response to HIV/AIDS as ‘positive and dynamic’, whereas American news depicted Chinese government officials as ‘dishonest and inefficient’. Wu (Wu, 2006) and Dong et al. (Dong et al., 2008) found that this local–global discourse aims to reinforce approval of the nation-state and local government’s efforts to manage public health. Similarly, economic consequences, individual responsibility, conflict, leadership and human-interest frames were found in both the USA and Chinese newspaper coverage of SARS (Luther and Zhou, 2005) that praised the Chinese government’s response to a public health crisis that originated from the outside. Few scholars have explored framing of a global health pandemic in Singapore or examined the dynamic relationship of public health communication, news media and state. Framing for the purposes of this study is defined as the journalist’s selection of which elements of a news story to include and emphasize and which to leave out or de-emphasize. Investigating how a national government health organization discussed a global H1N1 pandemic and how the media used
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Table 1: Example of coding illustrated Open coding
Axial coding
Selective coding
Imported, enemy, war, battle, inside, outside, came from, putting up a good fight, took our advice, behave responsibly, infected, infected travelers, returned from attackers, quarantine, traveled to Singapore, temperature screening, new enemy, fight, travelers, tourist, hostile, put up with inconvenience, track down, isolate, social spirit, bought valuable time, proud of our achievements, not to engage in, enter Singapore, vigilance, monitoring closely, fighting terrorism, heightened the risk, interventionist, such behavior, containment strategy, robust contingency measures, socially responsible, cross into, bring, defense, for your own good
Imported, inside, outside, came from, infected, attackers, travelers, tourist, traveled to Singapore, enter Singapore, returned from, infected travelers, cross into, bring Enemy, new enemy, fight, war, battle, putting up a good fight, heightened the risk, hostile, vigilance, fighting terrorism, defense Took our advice, behave responsibly, social spirit, bought valuable time, proud of our achievements, socially responsible, not to engage in, such behavior, took our advice, behave responsibly Quarantine, temperature screening, put up with inconvenience, isolate, monitoring closely, interventionist, containment strategy, robust contingency measures, for your own good
Imported disease
RESULTS Four themes emerged: (i) imported disease, (ii) war/battle metaphors, (iii) social responsibility
Social responsibility
Lockdown policies
and (iv) lockdown policies. These themes, which are reflective of the press release and the subsequent news stories, combine to produce a grand narrative about nationalism, constructed through news framing of public health messages. The global pandemic then is understood locally to be an imported disease that threatens our national borders such that we must fight against the enemy, but in order to win this war we must be responsible citizens who participate in health citizenship, remain vigilant and obedient, consider the health of the nation and appreciate the stringent public welfare measures created for surveillance. Imported disease H1N1 was initially framed as being ‘imported’, creating a need for vigilance. On 16 June 2009, an MOH press release stated: A number of the recent imported cases [infected persons] have engaged in extensive community activities. (. . .) Some have even travelled to Singapore even though they were already unwell prior to departure. (. . . ) Such behaviour has considerably increased the difficulty of contact tracing and significantly heightened the risk of community spread.
In addition to verbatim quoting from the above press release, the newspaper further highlighted the notion of cases being ‘imported’: All the latest 17 cases were imported—six of them had returned from the Philippines with another six from Melbourne. Three others flew here from the
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Data analysis Thematic analysis was utilized to derive themes that represented meanings within the data (Braun and Clarke, 2006). The analysis began with line-by-line open coding. This allowed for the range of categories to remain unrestricted, such that the researcher could freely consider meanings of words, phrases and sentences (Lindolf and Taylor, 2002). Open coding allowed ideas, events, actions, meanings and concepts to emerge unrestricted from the data. Line-by-line coding is important in the beginning of analysis because it enables the generation of categories that become the building blocks of meaning (Strauss and Corbin, 1998). Next, axial coding was employed to review, examine and group concepts into categories. Strauss and Corbin (Strauss and Corbin, 1998) note that axial coding allows the researcher to reassemble the data fractured during open coding to make connections between the categories and sub-categories. Therefore, at this stage, recurring words, repeated happenings, meanings and concepts were integrated, connected and grouped into broad categories. The purpose of this was to detect conceptual similarities, to refine differences between categories and to discover patterns (Simons et al., 2008). Finally, selective coding was conducted to further refine and unite categories based on overarching ideas and concepts and to derive themes (Table 1).
War/battle metaphors
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper United States and one each from Chile and Europe. They had all returned on various flights between June 11 and June 16 (ST, June 17, 2009).
The notions of ‘imported’, ‘travelled to Singapore’, ‘such behavior’, ‘heightened the risk’, ‘returned from’ and ‘not to engage in’ are reflected in the press releases and the subsequent news stories that distinguish spread (from an outside cause) and responsibility (as an inside solution). On 17 June 2009, the MOH issued a press release, stating:
The Straits Times carried the MOH press release with the above information the following day. In addition, the news article stated: MOH reminded travelers, especially those who recently returned from countries considered to have sustained community spread of the virus, not to engage in activities such as working and shopping or [to] participate in mass activities until they are well. (. . .) The Health Ministry said in a statement last night that seven of the new cases had proceeded with their travel, meetings and social activities despite having developed symptoms of flu. Contact tracing is ongoing for the 17 cases (ST, June 18, 2009).
From the beginning, emphasis was placed on the flu’s being ‘imported’ from outside, requiring measures inside national boundaries. Health Minister Khaw Boon Wan was quoted as saying that ‘Singapore was experiencing a third wave of imported H1N1 cases’ (ST, 23 June 2009). Other news stories reported: Mr Khaw stated that ‘it is only a matter of time before infected travellers, who do not show any signs of fever, enter Singapore. An infected person can transmit the virus even before he shows any symptoms. One in three does not have symptoms at all. Because of this, it is possible for an infected person to cross into Singapore’ (ST, April 30, 2009). Travellers who do not get themselves vaccinated and who get infected overseas could bring the virus back and infect children. Fever clusters could then form in schools and there could be possible school closures (ST, December 18, 2009).
‘Imported’, ‘infected travelers’, ‘enter Singapore’, ‘cross into’ and ‘bring’ are terms that distinguish them, those outside of the national boundary who are part of the problem, from us, those within the boundary who must be protected and who are prepared to collectively resolve the problem. Nearly 2 years later, the fear resurfaced that H1N1 may yet again be ‘imported’. Dr Asok Kurup, an infectious diseases specialist at Mount Elizabeth Medical Centre, said that the increase in last year’s figures compared to those in 2009 may have been due to more people travelling last year, given a more buoyant economy, and bringing the flu virus back with them (ST, January 6, 2011).
Frames that praise the government’s efforts and detail what goes into protecting the national borders from outside attacks promote feelings of gratitude and appreciation from us for being taken care of. For instance, two different Straits Times news articles on 24 June 2009 highlighted the government’s efforts and success through their continued undertakings. Contact tracing took place round the clock, to try to contain any possible local spread. These labour-intensive actions may have picked up only one in four imported cases, missing the rest. But those efforts helped keep the infected apart from the rest and prevent the virus from circulating in the community. For seven weeks, Singapore kept the H1N1 flu at bay, delaying the onset of local transmissions even after the flu was imported into Singapore by travelers. That is no mean feat given how globalised and densely packed the country is, with flights carrying possibly affected passengers arriving here from the world over.
The news media in Singapore play an important role in fostering and promoting the relationship between citizens and their government. These frames construct nation-building in subtle ways while employing rational strategies during a health crisis. The Straits Times news coverage reflected the sentiment expressed in the MOH press releases about addressing health needs during a pandemic but situated that discussion subtly around efforts that foster national identity. For example, the war/battle metaphors express actions that guarded and defended public welfare during a time of battle.
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With many Singaporeans returning from their June holidays or coming home for their summer vacation (. . .), we can expect an increase in the number of imported cases of H1N1. MOH will like to remind travelers (. . .) not to engage in extensive community activities (. . .) until they are well. This will help mitigate the risk of community spread in Singapore and make our containment efforts more effective.
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War/battle metaphors On 30 April 2009, a Straits Times news article quoted Minister Khaw Boon Wan: This is a new war now, and we have to adapt our approach to face this new enemy. The country is going into war better prepared to deal with the enemy. It will not be a short battle, but a long war of attrition against swine flu.
This sentiment of a fight against the enemy was reflected in other news stories:
Headlines also carried the notion of battle, such as: ‘Fighting H1N1 flu: Don’t go overboard’ (5 June 2009) and ‘Khaw: S’pore in last leg of fight against H1N1’ (12 July 2009). On 21 July 2009, Minister Khaw was quoted reminding the public about the enemy: We are now in the last leg of our battle against the first wave of the H1N1 outbreak. But the war is not over yet. The enemy is still out there.
Another senior minister, Goh Chok Tong, explained this war: I am reminded that in terms of vigilance, fighting terrorism is like fighting an external virus like Sars [sic] or Influenza A (H1N1). Notwithstanding our best efforts, an external terrorist or deadly virus may slip through our borders. Nevertheless, the best defense against terrorism is constant vigilance and having a domestic environment that is hostile to it. (ST, May 11, 2009)
‘New war’, ‘new enemy’, ‘vigilance’, ‘fighting terrorism’, ‘external terrorist’, ‘best defense’ and ‘hostile’, all communicated that the government was working to ensure public safety by fighting a war or battle on the people’s behalf. In addition to the ministers, physicians also shared similar sentiments about the fight against the enemy: Frederico Dimatatac, 37, doctor in the Infectious Diseases department in Tan Tock Seng Hospital: ‘I’m not afraid as it is part of my job. You know what you are dealing with, so you shouldn’t be afraid of it. In this case, I know the enemy, so there’s no need to be afraid. As long as you follow the infection control guidelines, it’s actually very safe (ST, June 28, 2009).
Social responsibility News articles reiterated that the ‘imported’ cases threatened the nation, reminding people to be socially responsible: doing their part to ensure the safety of those inside the national boundaries by complying with policies in the battle against outside attackers. In a press release issued on 16 June 2009, the MOH gave a detailed, chronological account of a Singapore-based researcher from Germany who was infected with H1N1: He took a taxi home from the airport, and stayed at home for the rest of the day. He went to work from 9 to 12 June. On 11 June evening, he went to a function at the French Ambassador’s Residence attended by about 70 persons. On 13 June, he went to a shopping mall and had social activities at Clarke Quay. On 14 June, he attended a concert and did more shopping. On 15 June, he did not go to work in the morning and called a 993 ambulance to send him to CDC around noon time. Laboratory results confirmed his infection at 2140 hours on 15 June.
The press release identified and detailed the actions of the foreign national as behavior that was not ‘socially responsible’, putting the entire nation at risk during a battle against attackers. The story was reported in the Straits Times under the headline, ‘H1N1-hit researcher attended concert’, covering the sequence of events verbatim as stated in the press release. In addition, the news article reminded individuals to put the needs of the nation ahead of their own: Dr Lam Pin Min, chairman of the Government Parliamentary Committee (GPC) for Health, said that Singaporeans needed to be more socially responsible and refrain from going to public or crowded places when they were unwell (ST, June 17, 2009).
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With Sars [sic], there was a quick fight and it was over. But flu epidemics tend to come in waves. The first might be over in two months, but there is no telling when or how severe the next will be. (ST, April 30, 2009).
The war/battle metaphors set up two discussions: (i) being a socially responsible citizen and (ii) justification for increased surveillance and controls. Framing H1N1 as an outside attack that required individuals to act responsibly to aid the government in its fight against the enemy served to strengthen national identity as well as inculcate compliance. The lockdown policies that contained the spread of H1N1 and the remedies that restored normalcy and limited consequences of the outbreak were attributed to the Singapore government’s responding quickly, having contingency plans, issuing strong policies and unifying the populace for collective measures that were meant to protect against outside threat.
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
The researcher was ‘criticized sharply by many who called him irresponsible and inconsiderate for putting others at risk’ (ST, 18 June 2009) when the greater health of the country should have been put ahead of the individual. Calling on citizens to behave in a certain way, to participate in the national efforts, and calling attention to those who did not comply, all sent a definitive message about the government’s expectations of its citizens. Following the incident, MOH issued a press release on 19 June 2009, advising socially acceptable behavior:
The Straits Times the following day outlined the personal habits, hygiene and public manners specified in the press release, as well as stating: The accumulation of H1N1 flu cases in Singapore has been too rapid in too short a period, and ‘community’ spread looks imminent. Far from feeling relaxed about the flu because of its low severity and mortality rate, people should be on heightened alert concerning personal habits (ST, June 20, 2009).
On 24 June 2009, the following appeared in the Straits Times as prime news: Socially responsible behavior can slow the spread of H1N1 virus. For seven weeks, Singapore kept the H1N1 flu at bay, delaying the onset of local transmissions even after the flu was imported into Singapore by travelers. That is no mean feat given how globalized and densely packed the country is, with flights carrying possibly affected passengers arriving here from the world over. Some credit must go to the Government’s pandemic preparedness plan, which kicked in immediately once the H1N1 flu spread beyond Mexico in April.
The news coverage emphasized that individual behaviors can put others at risk, such that each person must be ‘socially responsible’ and do his or her part in reducing risk and increasing the protection of us. In addition, the news articles
emphasized the government’s efforts as being for the public welfare while praising its ability to act quickly and effectively. This frames the response, the policies and the efforts of the government in a positive tone aimed at fostering feelings of gratitude. Furthermore, the Straits Times reported that ‘Health Minister Khaw urges everyone to be socially responsible’ (ST, 30 April 2009) and that he also urged ‘Singaporeans to exercise care when attending large gatherings and to practice “social distancing” if anyone experienced flu-like symptoms’ (ST, 1 May 2009). In fact, the Straits Times provided ways of being ‘socially responsible’ and practicing ‘social distancing’ as prime news on 27 June 2009: Q: I’m in a crowded MRT train and the person standing in front of me is sneezing. What should I do? A: Offer him a clean tissue if he is not using one. Turn your face away when he sneezes. Cover your nose and mouth with a tissue. Q: I’m on home quarantine. What must my family members and I do to prevent the infection from spreading to them? A: Ideally, you should have your own room and toilet/bath facilities. If that is not possible, wear a mask if you need to be in a common area of the house near other people. Always cover your nose and mouth when you cough or sneeze. Make sure your hands are clean when you touch surfaces that others might touch— such as the toilet flush handle. Your family members should wash their hands frequently.
The newspaper reminded Singaporeans to do their part to be ‘socially responsible’ to ensure that their behaviors did not put others at risk, to be part of the efforts to ensure safety within national boundaries against outside attackers, and above all to put the health of the nation before their own needs in the battle against the enemy. It emphasized that during war, a unified dominant strategy within national boundaries to protect Singaporeans from attackers is necessary. The war/battle metaphors also served as justification for stringent measures such as lockdown policies that restricted personal freedom and mobility while increasing surveillance of the population.
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Singaporeans are reminded to maintain high standards of personal hygiene. This means covering your nose and mouth with a tissue when you sneeze or cough, and washing your hands frequently with soap and water, especially after contact with respiratory secretions (e.g., after sneezing and coughing). We also need the cooperation of everyone to be socially responsible. This means staying home and avoiding crowded places (including trains, buses, offices), putting on a surgical mask and seeing a doctor if you have flu symptoms [ parentheticals in original].
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Minister for Community Development, Youth and Sports Vivian Balakrishnan said the discovery of the H1N1 case was in a sense ‘an anticipated event’ and showed that robust contingency measures were working (ST, June 24, 2009).
This also furthered the national agenda by demonstrating strong commitment to public welfare, which further strengthened and amplified a positive government image. A Straits Times editorial voiced approval for the government’s containment measures: No wonder the H1N1 flu is holding few terrors, after initial worry, and play-safe governments like those of China and Singapore have been criticised by Mexico for ‘over-reacting’ in ordering quarantines and travel restrictions on Mexicans. Singapore should keep to the stringency. ( . . . ) WHO directorgeneral Margaret Chan said, ‘I’d rather overprepare (for a pandemic) than not prepare’. This newspaper concurs (ST, May 6, 2009).
News articles reiterated the government’s position by supporting the stringent measures, measures framed as being for the good of the people and necessary to protect the national borders. No, it does not matter if the returning traveler or tourist is feeling perfectly fine. This ‘interventionist’ approach is needed as the virus can slip past thermal screening at border checkpoints as symptoms may not have shown up yet in its victims (ST, May 1, 2009).
A Ministry of National Development (MND) spokesman said: ‘Being a quarantine center, there are rules based on health consideration, for their own good and that of other persons under quarantine as well as workers’ (ST, June 8, 2009).
The references to ‘monitoring closely’, ‘isolated’, ‘interventionist’, ‘rules on health consideration’, ‘for their own good’ and ‘containment strategy’, all communicate the power of the authorities to enforce regulations that may limit personal freedom but are framed as serving a greater good for the nation. This tone conveys a gain message through positively appreciating the actions taken by the government. In doing so, tough measures such as containment/quarantines and travel restrictions were framed as protection (i.e. gain) against threat (i.e. loss), even though such measures may restrict personal freedom and mobility. Three years later came a reminder of how well the ‘robust measures’ served the people: ‘Outbreak in Mexico in 2009 had left 1400 people dead. There were 30 deaths in Singapore due to H1N1’ (ST, 3 February 2012). Illuminating these contrasts further strengthened the government’s role as protector whose actions were meant to mitigate the outbreak for public safety. This framing of the H1N1 surveillance and containment played a crucial role in ensuring compliance and avoiding dissent for stringent measures. The government’s efficiency is dependent in part on the relationship between citizens and the state. For instance, the government issued the following press release at the end of the pandemic: Since its first outbreak here in May 2009, Singaporeans have put up a good fight against Influenza A (H1N1). We thank them and seek their continued support and cooperation. It is important that all of us maintain a high level of personal hygiene, be socially responsible and stay away from work or school if unwell (MOH, February 10, 2010).
Thanking the nation for complying with the national policies, rules and regulations serves the purpose of enhancing the people’s satisfaction with the actions undertaken. The government’s relationship with the people can be enhanced through the media’s positive framing of information that encourages citizens to support policies and to comply with efforts undertaken to protect us. Imparting advice, restating government’s efforts in serving the public, encouraging the public to make personal sacrifices and
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Lockdown policies The media played an important role in framing this communication in a positive tone that conveyed gaining something rather than losing something due to lockdown policies. For instance, the 4 May 2009, MOH press release has a loss frame: ‘Anyone who breaks the home quarantine order can be fined up to $10 000 and/or jailed for up to six months’. But rather than these measures creating discontent, the Straits Times in a 5 May 2009, article used a gain frame focusing on the benefits of home quarantine. The government’s reactions to the pandemic—quarantines, containment for travelers, restricting travel, placing personal responsibility on individuals, taking temperatures at arrival terminals (land, sea and air) and requiring public workers to log their temperatures daily— were framed as necessary and for citizens’ protection. All were framed as ‘robust contingency measures’ that protect citizens from outside attackers, for citizens’ protection.
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
emphasizing the war against attacks from outside national boundaries, all were aimed at evoking collective responsibility while building national unity. Mr Khaw was named one of the Faces of the Decade by the Straits Times on 31 December 2009, emphasizing his position of authority, power and credibility for managing national health issues. The following statement by Minister Khaw, reported on 23 June 2009, encapsulates the four framing strategies used to construct the global H1N1 pandemic as a local health issue:
Continual references to ‘came from’ and ‘imported’ attribute the cause of the problem to the outside, while references to ‘putting up a good fight’, ‘took our advice’, ‘behave responsibly’, ‘put up with inconvenience’, ‘home quarantine’, ‘track down’, ‘isolate’ and ‘promptly’, all communicate the positive impact of the government’s strategic control. Praising compliance and making references to ‘social spirit’, ‘bought valuable time’ and ‘proud of our achievements’ further evoke national identity and the feeling that ‘we’ were part of the solution, part of the win in this battle against outside attackers. Social construction of a nation mobilized around a health issue through the four frames presented by the news media supports the government’s actions, policies and regulations, and subtly mobilizes a nation towards unity. DISCUSSION This study aimed to explore the role of public health in Singapore by examining how public health messages provided by the government during a global H1N1 pandemic were framed by
the local news media. Government-issued press releases were identified as the source of the public health information for news stories. The four themes—imported disease, war/battle metaphors, social responsibility and lockdown policies—were found to be present in both the press releases and the news coverage. While the press releases provided factual information about the risk of infection, proper measures to take and the pandemic’s timeline, militaristic language was used in framing the public health information to emphasize social responsibility, imported disease and the need for vigilance through lockdown policies. Though not all news stories were linked directly to the press releases, subsequent news coverage reinforced, supported and extended the language, words, phrases and sentiments present in the press releases. The local news media’s framing of governmentprovided public health messages during the global pandemic suggests two lessons to be learned: (i) the news framing in Singapore is similar to the historical response of public health as national security, and (ii) the news framing in Singapore illustrates the relationship of health and political ideologies. The findings also suggest implications for public health educators who rely on news media for coverage and dissemination of health information. Lesson learned Similarities to historical public health response Similarities between studies of health framing in other nations in South Asia, particularly war metaphors in India (De Souza, 2007) and praise of the government actions in China (Wu, 2006; Dong et al., 2008), can be seen in the combined use of frames. The Straits Times used frames that emphasized the Singapore government as protector against outside attacker in times of war. This was constructed through the utilization of military metaphors such as war, battle, fight and enemy. News frames supported this war that needed to be fought and won by praises of the government’s response. The press releases highlighted the war metaphors, and the news stories extended this through amplification and praise of the public health response. The findings also suggest that the public health discourse in Singapore was similar to that found in King’s (King, 2002) analysis of the USA and Western Europe’s public health responses in the late 19th and early 20th centuries, which used
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There were three waves of exported cases to Singapore. The first wave came from the US. The second wave came from Australia ( . . . ). The third wave began last week, from fellow Asean countries, including the Philippines and Thailand. This will potentially be a big wave, given our close proximity. Against these challenging circumstances, Singaporeans are putting up a very good fight against the virus. Many took our advice and behaved responsibly. ( . . . ). Many more people put up with the inconvenience of home quarantine. I am grateful to them for their social spirit. As a result, we have bought ourselves valuable time. We can be very proud of our achievements. For seven weeks, there was no local transmission. All our confirmed cases were imported. We were able to track down every imported case and every one of their known close contacts and isolate them promptly.
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Relationship of health and political ideologies While the press releases were the source of public health information, The Straits Times constructed the H1N1 global pandemic as a local event
through strategies aimed at mobilizing citizens for nation-building. The government’s ability to subtly manage issues around a national agenda serves to inculcate respect for government policies, such that demarking boundaries, promoting public welfare, and praising and criticizing behaviors, all served to convey expectations of individual health and behavior. The media’s framing of H1N1 communicated public health messages with a subtle, underlying message of nation-building. Frame analysis of the news media coverage during the H1N1 pandemic revealed the role of media in defining, reinforcing and influencing national identity in Singapore, which reflected its relationship with the government. This study brings to the fore the relationship between public health communication and news media that serve the nation-state. It is important for public health educators to understand how framing health messages can be used in nationbuilding and the role that media play in that construction. Winning a war against imported attackers through public health preparedness, having ‘robust’ contingency plans in place, evoking national unity, demanding social responsibility and seeking support for new public health policies, limited mobility and increased surveillance, all communicate ideas about nation-state. This study brings to light the role of news media and its relationship with the state in Singapore, particularly using health as a way to communicate political ideologies. Public health response, particularly in a global pandemic, is used to reify nation-state. This was done through the news articles that imparted advice, taught socially acceptable behavior, reminded the public about the action taken on behalf of them, praised the government, reported the government’s public health response in a positive tone, converted loss frames to gain frames and conveyed officials’ praise of citizens for being ‘partners’ during the health crisis. The findings also suggest that nation-building strategies were not discussed explicitly during the dissemination of public health information about the H1N1 pandemic, but rather were imbedded within frames of a global pandemic as a local health issue that subtly pushed the government’s nation-building agenda. Selecting information that focuses on strengthening governance is reflective of the broader context of Singapore’s journalism profession, which aims to aid the government in its nation-building efforts. Although the Singapore media are close partners with the government in
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isolation and quarantines as public health measures. Quarantines and isolations framed in the press releases as well as in the news stories as for the greater good, communicated the power of the authorities to enforce regulations through surveillance. While the press releases reported policies, procedures and requirements of the quarantines, The Straits Times converted loss frames, such as personal leave and quarantine, to gain frames, such as the health of everyone in Singapore. The media’s positive support of the government’s stringent lockdown measures during the pandemic is reminiscent of the colonial-era ideologies. On the other hand, this modernist project was intermingled with contemporary ideas of health citizenship, as discussed by Petersen and Lupton (Petersen and Lupton, 2000). The social health contract between the state and society (Porter, 1999) asks Singaporeans to be active, to voluntarily participate in behaving responsibly, to accept increased isolation and surveillance and to support national public health security measures. Both the press releases and the news stories framed this in two ways: first, as the responsibility of government for solving the problem as well as of the individual to support those actions by being socially responsible; and secondly, by disseminating health information aimed at teaching the public how to: (i) behave responsibly, (ii) prevent risky behaviors and (iii) maintain hygiene. Additionally, the rhetoric of locating the pandemic as elsewhere, as discussed by King (King, 2002) and Wallis and Nerlich (Wallis and Nerlich, 2005), defines national boundaries and justifies measures for national security. Press releases emphasized that the threat of imported disease puts the nation at risk, such that the government must undertake surveillance and control on behalf of citizens. Concurrently, The Straits Times framed all these public health strategies, responses and actions by the government as protection for public safety against outside attackers and imported diseases, emphasizing the need for increased national security. The framing of H1N1 furthers the idea of public health as national security, demarking clear boundaries of expected and accepted behavior, sentiments and actions for the public in support of the government’s efforts.
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
nation-building, the findings raise the question of how journalists can subscribe to journalistic norms of balance and fairness while operating under extensive press controls, where nation-building is seen as the primary role for the news press. Particularly, in Singapore this also raises the question of the relationship between the source of public health information and the news media’s framing of that information.
to contain the outbreak, limit exposure and reduce morbidity and mortality, communication needs to include ways for people to manage their fears and anxieties. Today, with citizens’ having access to a complex media environment shaped in part by the Internet and social media, traditional notions of news framing that amplifies the power of the state will increasingly be challenged. Public health as national security can no longer remain a state-dominated discussion because: (i) the public has access to more information to help them make informed decisions; and (ii) decisions may be based on information originating outside local boundaries. Understanding the changing landscape of media can help the public health educator to significantly impact how health promotion is designed and implemented, particularly in times of crisis when communication is marked by urgency. More research is needed to understand how press releases issued by a powerful source and subsequent news coverage influence the public’s attitude and behavior. Future research should examine how news coverage shapes people’s understanding of a pandemic and influences the people’s cooperation. Future studies should also address the impact of health news framing and how such frames could shape audiences’ understanding of health, illness and disease. REFERENCES Arnold, D. (1993) Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-Century India. University of California Press, Los Angeles, CA. Berry, T., Wharf-Higgings, J. and Naylor, P. (2007) SARS wars: an examination of the quantity and construction of health information in the news media. Health Communication, 21, 35–44. Braun, V. and Clarke, V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. Chang, C. (2012) News coverage of health-related issues and its impacts on perceptions: Taiwan as an example. Health Communication, 27, 111–123. De Souza, R. (2007) The construction of HIV/AIDS in Indian newspapers: a frame analysis. Health Communication, 21, 257–266. Dong, D., Chang, T. and Chen, D. (2008) Reporting AIDS and the invisible victims in China: official knowledge as news in the people’s daily, 1986–2002. Journal of Health Communication: International Perspectives, 13, 357– 374. Jin, Y., Pang, A. and Cameron, G. (2006) Strategic communication in crisis governance: analysis of the Singapore management of the SARS crisis. The Copenhagen Journal of Asian Studies, 23, 81–104. Karnik, N. (2001) Locating HIV/AIDS and India: cautionary notes on the globalization of categories. Science, Technology, & Human Values, 26, 322–348.
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Implications for health promotion The study highlighted that the news media not only served Singapore’s national agenda but that the reaction to the pandemic was reflective of the historical responses of public health and of the contemporary expectations of public health. On one hand, a pandemic is a public problem that is solved through collective participation of citizens that support the government’s response. On the other hand, a pandemic is a problem that requires the government to step in on the behalf of the public to protect the nation-state by implementing new public health policies. Therefore, this study suggests that even in the contemporary context, Singapore’s public health responses reflect the colonial era of control but is also entwined with current expectations of public health responses that require active and voluntary citizen participation. Examining what frames were used to construct the global pandemic locally reveals how health issues are shaped for the public as well as the underlying ideologies. Singapore news media have a unique relationship with the government, where news information reiterates the government’s position, stance and messages. However, in today’s context, it is not enough to be contained within the historical contexts that reify political ideology through public health responses and/or ask citizens to voluntarily participate in those responses. Even in the context of Singapore, more research is needed to explore the relationship between the state and the news media on one hand, and on the other hand, this highly wired society’s access to a wide variety of news and information. Public health educators that continue to solely rely on traditional news media should consider: (i) providing more than basic information and (ii) accessing different forms of news media, such as weblogs and social media. Public health responses that attempt to change attitudes and behavior during a pandemic should include more than basic information. In addition to encouraging adoption of appropriate actions
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King, N. B. (2002) Security, disease, commerce: ideologies of post-colonial global health. Social Studies of Science, 32, 763–790. Lindolf, T. and Taylor, B. (2002) Qualitative Communication Research Methods. 2nd edn. Sage Publications Inc., Thousand Oaks, CA. Luther, A. and Zhou, C. (2005) Within the boundaries of politics: news framing of SARS in China and The United States. Journalism & Mass Communication Quarterly, 82, 857 –887. Lupton, D. (2003) Medicine as Culture. Sage Publication, Thousand Oaks, CA. Ortmann, S. (2009) Singapore: the politics of inventing national identity. Journal of Current Southeast Asian Affairs, 28, 23– 46. Petersen, A. and Lupton, D. (2000) The New Public Health: Health and the Self in the Age of Risk. Sage Publications, London, UK.
Porter, D. (1999) Health, Civilization, and State: History of Public Health From Ancient to Modern Times. Routledge, New York, NY. Simons, L., Lathlean, J. and Squire, C. (2008) Shifting the focus: sequential methods of analysis with qualitative data. Qualitative Health Research, 18, 120 –132. Sontag, S. (1989) Aids and its Metaphors. Farrar, Straus and Giroux, New York Strauss, A. and Corbin, J. (1998) Basic of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Sage Publications, Thousand Oaks, CA. Wallis, P. and Nerlich, B. (2005) Disease metaphors in new epidemics: the UK media framing of the 2003 SARS epidemic. Social Science & Medicine, 60, 2629–2639. Wu, M. (2006) Framing aids in China: a comparative analysis of US and Chinese wire news coverage of HIV/ AIDS in China. Asia Journal of Communication, 16, 251–272.
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