Introduction

Epidemics involve health problems that are seen as a threat, not only to specific groups but for entire populations. This produces enormous mobilizations, both of government institutions -viewed as ultimately responsible for protecting the population- but also of mass media, for which epidemics are a centrally newsworthy event. These kinds of events generate complex interaction and relationships among diverse social actors, both from the field of biomedicine and from the fields of politics, journalism and the mass media in general. In the face of an epidemic a wide range of potentially affected actors and sectors are mobilized and involved in the process of communication and circulation of information. The global character of epidemics increases even further the network of actors involved.

At the same time, many contemporary epidemics involve what can be classified as “emerging diseases”, that is, diseases caused by new types of pathogens. This means that both the responses of public health officials and those of the media, often must be elaborated before the slow process of scientific research has produced definitive knowledge about that which is affecting the health of populations. “Common sense” tells us that health knowledge is produced first in the realm of biomedical science, and then later transmitted by health institutions and professionals through various channels, including the mass media. However, epidemics are often created into objects of mediated public knowledge before they have been consolidated as objects of biomedical knowledge.

This article explores the mediatization of epidemics through a case study of the A (H1N1) influenza pandemic which occurred in 2009, popularly known as the “swine flu”. When we speak of mediatization, we are referring to the construction of a mediated public representation of something, in this case a pandemic. ^{Hjarvard (2013)} defines mediatization as:

The process through which the media acquire greater authority to define social reality and condition patterns of interaction… Media have become an integral part of other institutions’ operations, while also achieving a degree of self-determination and autonomy which forces other institutions... to submit to their logic (p. 3).⁶

The process we analyze is that of the A (H1N1) flu, which was declared a pandemic by the World Health Organization in June, 2009. At the time, public health authorities considered it a major potential threat, and it was an important focus both of the actions and statements of public health officials and of news media across the world. Nevertheless, this epidemic did not become the global catastrophe that many experts feared. One study estimated the global mortality as between 151 700 and 575 000 cases, though as this range suggests, estimating exact numbers is difficult (^{Dawood et al., 2012}). In fact, these figures are comparable to the annual figures for seasonal flu.

An “epidemic of fear”? alarm and “containment” in the mediatization of epidemics

News coverage of health and medicine has received relatively little attention in media and journalism studies. A large part of the existing research is rooted in the field of health communication. Within and beyond that field, research tends to be organized implicitly according to what can be called the “linear transmission model” (^{Seale, 2002}; ^{Biggs & Hallin, 2016}), which assumes that health knowledge is produced within the scientific field of biomedicine and later transmitted to audiences. This framework is often associated with the “two cultures” model, which understands science and the media as two separate realms, governed by opposing norms: science, by slow and careful evaluation of evidence; and journalism by the rapid generation of emotions and the drive to engage a mass audience. Accordingly, research is centered on evaluating whether the media faithfully transmit scientific information. The tone tends to be negative, that is, media are seen as a source of “distortion” in the process of transmission of scientific information. In the case of the 2009 A (H1N1) flu, some studies concluded that public discourse could be characterized as “media hype”, which was assumed to generate irrational fear and alarm in the general public (^{Krishnatray & Gadekar, 2014}; ^{Da Silva Medeiros & Massarani, 2010}; ^{Harding, 2009}). ^{Vasterman (2005)} defines “media hype” as a process of amplification and distortion generated by the media, that is, a “wave” of news coverage which results from a self-referential process inside the media sphere, without correspondence to real events.

Other researchers have proposed a more complex model of the media representation of epidemics. Sociologist Sheldon ^{Ungar (1998}, ²⁰⁰⁸⁾, in studies of the media coverage of the Ebola and bird flu epidemics, has proposed that media coverage of “emerging diseases” is typically characterized by three phases: in the first, it sounds the alarm about a grave potential threat to global public health. In the second, messages of alarm and reassurance are mixed. In the third, messages of “containment” tend to predominate, calming the public in order to ensure that the crisis can be managed and panic avoided (see also ^{Joffe & Haaroff, 2002}). In the cases analyzed by ^{Ungar (1998}, ²⁰⁰⁸⁾, containment is achieved centrally by externalizing the danger; the threat is associated with the “other”, with populations that are projected as distant from the receiver of the message. Consistent with this perspective, ^{Sánchez Maldonado, Terrón Blanco and Lozano Rendón (2016)} have found that the coverage of HIV/AIDS in Mexican newspapers used alarming language primarily in stories on foreign countries. Ungar does not emphasize differences between media and scientific cultures or media “distortion”, but suggests a consistency of journalistic and biomedical professional discourses in the trajectory from alarm to the containment phase.

This article presents the results of a content analysis of the coverage of the A (H1N1) pandemic in newspapers from three countries: the United States, Argentina and Venezuela. In the case of the United States, the research team carried out a broader study, including qualitative analysis of television and online coverage, interviews with journalists and public health officials, and an ethnography of “pandemic preparedness” exercises. We include some elements of that research to provide illustrations and to allow a more complete interpretation of the results.

The United States was one of the first countries in which a large number of cases of the virus emerged, while in Argentina the first cases appeared about a month later, and in Venezuela few cases before the month of June. The three countries also differ in their political context and the structure of the media system. Venezuela and Argentina were characterized in this period by a high level of political polarization between pro-government and opposition media. The United States was characterized by more limited polarization during the H1N1 epidemic. In this sense, the selection of cases (countries) makes it possible to explore whether these dimensions affect the coverage of the pandemic, the degree of politicization of the media, as well as the incidence of the virus at the national level.

The study is focused on four questions:

Methodology

Fourteen newspapers were analyzed, 5 from the United States, 5 from Argentina and 4 from Venezuela. This sample included influential print media with large circulations and made it possible to compare tabloids and “quality” newspapers, as well as regional and national newspapers. In the case of Argentina and Venezuela, media were chosen to include those with editorial lines both favorable to the government and those with more critical or oppositional positions. The samples for each country are the following:

All articles on the H1N1 virus were identified in a search, and then 50 articles were selected randomly for each newspaper in the United States and Venezuela, and 100 for each in Argentina (given the large number of articles on H1N1 published in that country). We used the quota sampling technique in order to have enough cases to compare newspapers, as some newspapers published more articles than others. The New York Post and Atlanta Journal-Constitution published slightly fewer than 50 articles.

All articles published from April through July, 2009, were analyzed. Initially, open coding was used to identify emerging themes, and an iterative, interactive process was used to reach consensus on dominant themes and synthesize higher-order constructions. The qualitative analysis guided the selection of variables for quantitative coding. We developed a common coding scheme for the three countries, translated from Spanish to English and then back-translated. The variables were the following:

The samples of U.S. and Venezuelan news were coded at the University of California, Berkeley by a team fluent in English and Spanish. The principal investigators, who were bilingual, verified the comparability of the categories between the U.S. and Venezuelan material. The Argentinian material was coded in Argentina by a principal investigator and two graduate students trained by them. The two teams exchanged coded materials during the training process to assure comparability. Coding discrepancies were resolved during training and, as coding proceeded, through periodic meetings. The two teams met once during the coding process to carry out the same procedure.

Results I: “Media Hype” or Containment

Certain elements of the coverage of the H1N1 flu appear consistent with the hypothesis of distortion and amplification of alarm on the part of the mass media. One frequent observation in the literature on “media distortion” in health coverage is that the emphasis media give to different illnesses fails to correspond with epidemiological data on incidence and mortality. Figure 1 shows the relation between media coverage and epidemiological incidence for the case of H1N1. News coverage in the United States reached its highest point at the end of April and beginning of May, 2009, but declined abruptly in June, while cases increased significantly in June. The coverage in Venezuela reached its highest point May 28^th, before the first case had been recorded in that country. Argentina shows two peaks in the number of news stories published on H1N1, the first, from April 26^th, to May 9^th, before the appearance of the first Argentinian case, the second, from the June 28^th to July 11^th, when the number of cases was high; nevertheless, when the number of cases increased even further, coverage declined (^{Sy & Spinelli, 2016}). Clearly in these three cases the volume of media coverage did not coincide with epidemiological data on the number of cases or deaths.

Source: Own elaboration.

Figure 1 Number of de Stories and Confirmed Cases of H1N1, By Country 

The initial coverage of the outbreak did also have an alarming tone: “Scientists have spent a lot of time worried that bird flu could become a pandemic”, reported Robert Bazell, the science correspondent for the U.S. television network NBC (April 24^th, 2009). “But they have always known that any new virus to which humans have no natural immunity holds that possibility. That is what happened in 1918, killing some 50 million people worldwide”. While Bazell pronounced these last words, black and white images of a patient in bed and rows of crosses appeared on the screen. A few days later, the San Diego Union-Tribune (April 29^th, 2009) reported: “If the swine flu crisis reached pandemic proportions in San Diego County, this is what it would look like: nearly 1 million people, or one-third of the county’s population, sickened and as many as 3 000 dead”. In Argentina, La Nación on April 30th recounted, “The last time the who [World Health Organization] raised the level of alert to 5 [the maximum] was in 1968, when the Hong Kong flu killed 700 000 people”. The next week, Página 12 reported, “The World Health Organization warned that the swine flu could be devastating if it interacted with bird flu”. In the three countries, the media frequently referred to the virus using terms such as “killer”, and “deadly”, and used expressions like “fear” and “threat” with considerable frequency. At the same time, the high volume of coverage, often with large headlines, reinforced a sense of urgency.

Nevertheless, when we examine the coverage more closely, the hypothesis of “media hype” appears too simplistic. For example, immediately after showing the black and white images of the 1918 flu, the April 24^th broadcast of NBC news moved on to an image of Dr. Richard Besser, interim director of the Centers for Disease Control (CDC), who appeared in front of a calming blue background, projecting an image of control of the situation. Two days later, a report on the television network CBS included a statement by a high school student in New York, where some of the first cases appeared, saying, “I think it’s really scary… you could die from it”. But the report concluded with the medical correspondent, Dr. Jon La Pook, saying, “Well, clearly there’s concern, okay… But to put it in perspective, in the United States, the cases of swine flu so far have been mild. Okay, nobody has died. Officials have been thinking about this for years... they are all over this”. References to 1918 were frequently qualified with phrases like, “as the experts have noted, in 1918 there was no Tamiflu, there were no antibiotics to combat pneumonia, there were no electric ventilators”, in all three countries. This type of coverage is consistent with the argument of ^{Ungar (1998}, ²⁰⁰⁸⁾, that epidemic coverage contains alarm by externalizing the threat, except that in these cases externalization situates the danger not in the “other” or in “underdeveloped” countries, but in the historical past.

Table 1 shows the results of the analysis of the tone of the stories in the three countries. Only in Argentina was the number of alarming stories higher than the number of balanced, positive, humorous and skeptical stories, though in that case the majority of stories were still neutral.

Table 2 shows the characterization of the virus for the U.S. case, and how it changed over time. The use of alarming adjectives such as “killer” or “deadly” declined notably after the initial phase of coverage, shifting to more reassuring, less dramatic characterizations. The data are consistent with the findings of Ungar for other epidemics: a shift is seen from an alarm phase to another phase in which messages with different valences coexist, but those of containment or moderation prevail. One difference seen in the coverage of H1N1 analyzed here is that the mixture of messages of alarm and containment was present from the beginning. Fourteen interviews we carried out between June 9^th, 2009 and March 5^th, 2013 in the United States confirmed that journalists were concerned about balancing messages of alarm and containment (see also ^{Klemm, Das & Hartmann, 2019}). One editor in the health section of The New York Times commented in an interview that “it’s a tough call” deciding how much emphasis to put on this kind of story, particularly given the fact that a novel virus can “put in motion all sorts of alarm”, that in the end can end up being out of proportion to the impact of the epidemic. The editor suggested that public health authorities were working under “a lot of unknowns and so we were operating with a lot of unknowns at the paper as well”. The journalists feared that, if they amplified official concerns, this could exaggerate potential deaths. In effect, the editor wondered, “the next time this happens, will anyone take authorities seriously if they’re shouting too loud”.

Results II: The two cultures in conflict or harmony?

The literature on two cultures, which provides a framework for exploring the relation between public health authorities and the media during the H1N1 pandemic, suggests that reporters may fail to attend to information produced by public health authorities. Table 3 shows that, in fact, public health authorities and health professionals were the dominant sources: they represented 54.5% of sources in Argentina, 51.3% in the United States, and 61.2% in Venezuela. Foreign and international public health authorities were cited with greater frequency in Venezuela, which could reflect the later appearance of H1N1 in that country and the lower number of local cases. Politicians and other government officials were relatively little cited in the three countries: they represented about 12% of the citations in the U.S. and Argentina and 24% in Venezuela. U.S. newspapers cited ordinary people more often than the South American newspapers, although those ordinary people, for the most part, recounted personal experiences, rather than offering alternative interpretations of the institutional response to the pandemic.

The predominance of biomedical authorities and biomedical experts, and the relative absence of politicians or other types of social actors, indicates that the media treated the pandemic as a “sphere of consensus” story (^{Hallin, 1986}) located apart from the sphere of political debate. The consensual character of the presentation of the stories is also reflected in Table 4, which shows the tone of the media representations of health authorities. For the most part, despite the “watchdog” orientation normally attributed to the U.S. press and the understanding of the media in Argentina and Venezuela as participants in political “media wars”, criticisms of health authorities in the three countries was generally absent. Argentine health authorities were represented negatively 31.8% of the time; 66.2 % of the coverage was neutral. A 69% of the U.S. coverage and, notably, 84.9% of Venezuelan coverage was favorable or neutral with respect to the representation of health authorities, and in both countries positive representations outweighed negative ones.

The “media war” between the government and opposition in Venezuela sometimes does produce negative images of officials of the Ministry of Health. In the case of the H1N1 epidemic, this polarization could be seen primarily in citations from medical associations, especially when opposition media cited sources from the Venezuelan Medical Federation (Federación Médica Venezolana), which was an anti-government organization. Nevertheless, the great majority of representations of health authorities was positive. Negative images varied from 4.8% in El Carabobeño to 12% in El Nacional, both opposition newspapers. One article in El Nacional (June 1^st, 2009, “Detectan tercer caso de gripe AH1N1”) reported on official assurances with a subtle touch of critical distance: “The Ministry of Health, as we have been informed, has taken the indicated measures”, and the National Institute of Health, in the words of its director, is the “only institution with the equipment, supplies and personnel, capable of carrying out laboratory diagnosis”. In Argentina, criticisms of health authorities was more frequent, and was published normally in the opposition press. Criticism centered on the Minister of Health, Graciela Ocaña, a controversial public official before the pandemic, given that Ocaña is not a medical or public health professional.

In general, the interpretation of the H1N1 pandemic in the news media of the three countries was in harmony with the perspectives and communication policies of public health officials, both in their emphasis on the potential danger of the virus, and in the assurance they sought to transmit. This message of control and containment was also the tone of the director of the World Health Organization, Margaret Chan, who said: “No previous pandemic has been detected so early or watched so closely” (New York Times, June 11^th, 2009). On April 24^th, NBC, in the news story cited previously, the anchor began with the following words, “You can tell by the tone of what federal officials are saying, on and off the record, that they’re concerned about a new strain of flu, never before seen”. Public health authorities put the H1N1 pandemic on the public agenda in an effort to mobilize a global public health response. When we asked the former interim director of the Centers for Disease control, Dr. Richard Besser (later named the Chief Medical Correspondent for ABC News) whether public statements on H1N1 had been “exaggerated” he responded: “You only have one chance to get out ahead of a new outbreak. You have to hit it hard, hit it early, and then you can back off”. In this sense, the lack of correspondence between the epidemiological data and news coverage in the case of H1N1 did not represent distortion on the part of the media but a preventative measure on the part of public health authorities. Studies of coverage of H1N1 in other countries have also found close relations between the media and the statements of authorities. ^{Vasterman and Ruigrok (2013)} in a study of Dutch coverage of H1N1, found that “who and scientific experts were very alarming in their statements with an emphasis on worst-case scenarios, triggering massive media attention all over the world”, and suggest that the decision to activate pandemic preparedness plans was an important stimulus to extensive media coverage (see also ^{Staniland & Smith, 2013}). In a study of the coverage of H1N1 in Mexico, ^{Menendez (2010)} suggests that health professionals and journalists collaborated in the production of a sense of alarm.

The consensual nature of the coverage of H1N1 and the pattern of respect for authorities is also manifested in the fact that alternative interpretations of the pandemic and of health policies were for the most part marginalized in the mass media. Those alternative discourses took many forms. In the United States, conservative political commentators connected the epidemic with immigration issues, calling for stricter control of the border with Mexico. This theme appeared in major media during the early days of the outbreak; but geographical containment was rejected by authorities, and the theme was rapidly marginalized. Other alternative perspectives included the question of whether the origin of the virus was connected with industrial agriculture and whether public health authorities were overly influenced by pharmaceutical companies that would benefit from the global alarm about the pandemic. This last theme grew in importance at the global level, and in 2010 the British Medical Journal and the Bureau of Investigative Journalism detailed “conflicts of interest” involving advisors to the World Health Organization who had ties with pharmaceutical companies (^{Cohen & Carter, 2010}). Nevertheless, that negative coverage was limited in our sample. There was some debate in the United States about whether budget cuts had undermined the public health infrastructure that would be necessary to confront a really dangerous pandemic. In Venezuela, the government-aligned newspaper Diario VEA adopted a strong anti-neoliberal and anti-imperialist stance, and often included content that was marginalized by global mass media. That newspaper published, for example, an article arguing that military laboratories in the United States had created the H1N1 virus as a form of biological warfare, and that the pandemic was being promoted in order to enrich North American politicians who wanted to increase sales of antiviral drugs. Nevertheless, even Diario VEA in general was close to the standard pattern of reporting on H1N1 with reproductions of official reports, statistics, clinical recommendations and preventive measures rather than political debates.

Discussion

In the three countries included in this study the news coverage of the H1N1 pandemic was dominated by the perspectives of public health authorities and biomedical specialists, following for the most part their interpretations of the importance of the novel virus, and the response of the public health sector was presented generally as appropriate. The fact that a strongly consensual discourse attuned to the perspectives of global public health officials, even across the great political differences that characterize the media in Argentina and Venezuela, is strong evidence for what anthropologists and sociologists of medicine define as “medicalization” (^{Zola, 1972}) or “biomedicalization” (^{Clarke et al., 2003}), that is:

[T]he processes through which aspects of life previously outside the jurisdiction of medicine come to be construed as medical problems… The extension of medical jurisdiction over health itself (in addition to illness, disease and injury) and the commodification of health… Biomedicine has become a potent lens through which we culturally interpret, understand, and seek to transform bodies and lives (p. 162).

In this case, the authority of biomedicine was strong enough to dominate the flow of information and to displace important elements of the typical media logic, including partisanship in Venezuela and Argentina.

At the same time, if we ask how this result was produced, how H1N1 was produced as a public object largely in the terms intended by biomedical authorities, even in the absence of established scientific knowledge about an emerging health threat, another dimension of the story comes into focus. In the interview we carried out with Besser, he explained in this manner:

We made a decision on the first day that communication was going to be a critical part of what we did... that we were going to make sure that if any news outlet wanted information about the outbreak they were going to be able to get it from us... That we would practice the principles of emergency risk communication... a lot of us had been trained in (New York, March 3^rd, 2012).

Besser himself, who was hired by ABC News following the H1N1 pandemic, has a long history of moving between the worlds of medicine, public health and news media. The response of public health authorities in the face of the appearance of swine flu was above all a communication response, given the fact that it would be several months until there would be a strictly biomedical intervention, in the form of a vaccination campaign. The relative success of this communication response had its roots in a long history of preparation in which health authorities were trained in the principles of risk communication, learning logics rooted in journalism and public relations, formulating plans and working together with journalists, both in “risk communication exercises” and in the coverage of previous epidemics and public health crises. In this sense, the H1N1 pandemic illustrates not only the process of biomedicalization, but also the importance of another process of largescale social change: the process of “mediatization” (^{Hjarvard 2013}; ^{Couldry & Hepp, 2017}).

In this case, the field of public health appears to have incorporated media logics into its own practices. Contrary to the perspective of “two cultures” and of linear transmission, according to which biomedical objects are first produced by science, and then transmitted to mass audiences, the H1N1 pandemic was co-produced as a public object by biomedical professionals and journalists simultaneously. This did not represent a simple linear transmission of biomedical science nor a displacement of biomedicine by media hype, but an intertwinement and hybridization of media and biomedical logics.

The success the strategy of the health authorities achieved in the case of H1N1 is not something automatic, and the relation of interdependence between the media and biomedicine is not always harmonious. Up to a certain point, pandemics represent a special situation, similar in many respects to a “national security” crisis, as in events like terrorist attacks and wars, in which political divisions are eclipsed to a significant extent by the feeling of threat to the community. Nevertheless, this does not happen in a completely consistent way with epidemics. Research on coverage of A (H1N1) in various countries shows patterns similar to those found for the U.S., Argentina and Venezuela in many respects, but with some variation. Cornia et al. (2015), for example, found that Swedish coverage was dominated by the perspectives of professionals and public health officials, as with U.S. coverage. But the coverage in Italy showed characteristics similar to what we found for Argentina, more politicized, with more partisan debate regarding the performance of the Health Minister. The British coverage, for its part, showed more the character of watchdog journalism, including substantial debate about whether officials were evaluating the threat correctly and whether the response was managed effectively. In the case of the U.S., critical coverage of public health officials, similar to the British coverage, emerged later during the H1N1 pandemic, with the introduction of the vaccine and debates about how to manage its scarcity. In the same way, during the Ebola epidemic in 2015, which took place during an election year in the United States, there was much more partisan polarization over the public health response and more criticism on the part of the media of public health authorities. Nevertheless, once again in that case, the dominant news media for the most part moved in parallel with public health officials, above all in rejecting calls to restrict travel (see ^{Briggs & Hallin, 2016}).

How do we evaluate the largely cooperative relationship between the news media and public health authorities during the H1N1 pandemic? On the one hand, we can probably celebrate the fact that public health authorities are learning increasingly to use communication effectively and building relationships with journalists, as well as the fact that many journalists, particularly those specializing in health reporting, come to have deep knowledge of the perspectives of biomedical science. Health authorities -and the major news media- in general terms were successful in their response to the H1N1 flu pandemic, putting the issue on the public agenda and at the same time avoiding widespread panic or harmful forms of overreaction. Probably we can also celebrate the fact that the public health response to H1N1 was not strongly politicized: party politics was for the most part absent, and the most extreme politicized proposals, like closing the border between the U.S. and Mexico, were marginalized. At the same time we might question whether the heavy predominance of public health officials in the reporting of H1N1 and the dominance of the biomedical perspective narrowed the range of relevant questions in the discussion of the pandemic. Structural issues posed by advocates of social medicine, critical epidemiology and social epidemiology, related to economics and the capitalist mode of production which relegates to second place the state of the ecology of populations (^{Breilh, 2003}; ^{Waitzkin, 2011}) were eclipsed by narrower biomedical perspectives. Critical issues related to priorities for public health expenditure, political and social influences on health policy, and possible economic interests behind the appearance and spread of new diseases were not even discussed. One of the areas of discussion that was marginalized during the H1N1 pandemic was the debate about whether the public health infrastructure would have been adequate to respond to a really dangerous pandemic, and the role of public health in relation to the private sector. Today, in the context of the coronavirus pandemic, this issue proves to be central.

In closing, we believe that the central lines of argument of this article can become into possible lines of inquiry into what is occurring and how we can best interpret the new state of pandemic unleashed by COVID-19.