Health Promotion International, Vol. 30 No. 4
doi:10.1093/heapro/dau028
Advance Access published 19 May, 2014
# 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
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]
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
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Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
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
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
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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.
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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I. Basnyat and S. T. Lee
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
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.
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
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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
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).
RESULTS
Four themes emerged: (i) imported disease, (ii)
war/battle metaphors, (iii) social responsibility
War/battle
metaphors
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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I. Basnyat and S. T. Lee
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:
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.
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.
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
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:
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).
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).
947
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.
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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I. Basnyat and S. T. Lee
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:
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].
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.
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
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.
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).
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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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I. Basnyat and S. T. Lee
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:
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.
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
Framing of Influenza A (H1N1) pandemic in a Singaporean newspaper
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.
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
951
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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I. Basnyat and S. T. Lee
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.
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
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.
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