Politics, propaganda, and public health a case study in health communication and public trust

Contents Acknowledgments Preface 1 The Doctor, the Baker, and the Medicine Maker 2 An American System of Pharmaceutical Influence 3 Deconstructing Merck’s Awareness Campaign 4 Social Tru

Politics, Propaganda, and Public Health

LEXINGTON STUDIES IN HEALTH COMMUNICATION Series Editors: Leandra H Hernández and Kari Nixon

National and international governments have recognized the importance of widespread, timely, andeffective health communication, as research shows that accurate, patient-centered, and culturallycompetent health communication can improve patient and community health care outcomes Thisinter-disciplinary series examines the role of health communication in society and is receptive tomanuscripts and edited volumes that use a variety of theoretical, methodological, interdisciplinary,and intersectional approaches We invite contributions on a variety of health communication topicsincluding but not limited to health communication in a digital age; race, gender, ethnicity, class,physical abilities, and health communication; critical approaches to health communication; feminismsand health communication; LGBTQIA health; interpersonal health communication perspectives;rhetorical approaches to health communication; organizational approaches to health communication;health campaigns, media effects, and health communication; multicultural approaches to healthcommunication; and international health communication This series is open to contributions fromscholars representing communication, women’s and gender studies, public health, health education,discursive analyses of medical rhetoric, and other disciplines whose work interrogates and exploresthese topics Successful proposals will be accessible to an interdisciplinary audience, advance ourunderstanding of contemporary approaches to health communication, and enrich our conversationsabout the importance of health communication in today’s health landscape

Recent Titles in This Series

Politics, Propaganda, and Public Health: A Case Study in Health Communication and Public Trust

By Laura Crosswell and Lance Porter

Communication Studies and Feminist Perspectives on Ovarian Cancer

By Dinah Tetteh

Reifying Women’s Experiences with Invisible Illness: Illusions, Delusions, Reality

Edited by Kesha Morant Williams and Frances Selena Morant

Politics, Propaganda, and Public Health

A Case Study in Health Communication and

Public Trust

Laura Crosswell and Lance Porter

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Copyright © 2018 by The Rowman & Littlefield Publishing Group, Inc.

“Inoculating the electorate: a qualitative look at American Corporatocracy and its influence on health communication” by L Crosswell

and L Porter, 2016, Critical Public Health, 26(2), p.207–220 Copyright 2016 by Taylor & Francis Reprinted [or adapted] with

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Names: Crosswell, Laura, author | Porter, Lance, 1969- author.

Title: Politics, propaganda, and public health : a case study in health communication and public trust / Laura Crosswell and Lance Porter Description: Lanham : Lexington Books, [2018] | Series: Lexington studies in health communication | Includes bibliographical references and index.

Identifiers: LCCN 2018011190 (print) | LCCN 2018011813 (ebook) | ISBN 9781498553001 (Electronic) | ISBN 9781498552998 (cloth : alk paper)

Subjects: | MESH: Pharmaceutical Preparations—economics | Direct-to-Consumer Advertising | Health Knowledge, Attitudes, Practice | Health Communication—methods | Patient Acceptance of Health Care | United States

Classification: LCC HF6161.D7 (ebook) | LCC HF6161.D7 (print) | NLM QV 736 AA1 | DDC 659.19/61510973—dc23

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Contents

Acknowledgments

Preface

1 The Doctor, the Baker, and the Medicine Maker

2 An American System of Pharmaceutical Influence

3 Deconstructing Merck’s Awareness Campaign

4 Social Trust and Public Health

5 Consumer Perspectives

6 Pharmaceutical Conglomerates and American Politics

7 Global Implications of American Medicalization

8 The Genderization of a Vaccination

Conclusion

References

Appendix A: Commercial Transcripts for Pre-FDA Messages

Appendix B: Moderator Guide for U.S Focus Groups

Appendix C: Additional Material/Questions for International Focus GroupsAppendix D: Moderator Guide for Co-Ed Marketing Focus Groups

Appendix E: Demographic Survey for all Focus Groups

Appendix F: Eye Tracking Materials

About the Authors

We would first and foremost like to thank Lexington Books for giving us a platform to share our workand thoughts on commercial influence in the health care industry Specifically, we would like toacknowledge our acquisitions editor, Nicolette Amstutz, and her assistants, Jessica Thwaite andJames Hamill, as they were instrumental in bringing this book to fruition We would also like to thankthe proofreaders at Lexington Books, as well as our anonymous peer reviewers for their valuablecontributions during the revision and editing process

This work would not have been possible without the help and support from the Reynolds School ofJournalism at the University of Nevada, Reno, and the Manship School of Journalism at LouisianaState University We’d specifically like to thank the Center for Advanced Media Studies at theReynolds School and the Mary P Poindexter Professorship in the Manship School, for providing uswith funding for this book’s production In addition, we would like to express our appreciation to theLSU Media Effects Lab for the administration of our experiments We also want to extend our sincerethanks to our colleagues, supervisors, and mentors for offering us guidance, advice, and feedbackthroughout the publication process

We would like to acknowledge the editors at Critical Public Health and Taylor and Francis Material included in chapter 6 of this book originally appeared in Critical Public Health and is

reprinted here with their permission (Inoculating the electorate: a qualitative look at Americancorporatocracy and its influence on health communication, by L Crosswell and L Porter, 2016,

Critical Public Health, 26(2), p 207–220 Copyright 2016 by Taylor & Francis Reprinted [or

adapted] with permission www.tandfonline.com) We thank both parties for allowing us to includeour previously published work in this book The authors would also like to thank Dr Meghan Sandersfor her work on the original publication of the data in chapter 5 (Crosswell, L., Porter, L & Sanders,M., 2018) Out of sight, out of mind?: Addressing unconscious brand awareness in healthcare

communication In H D O’Hair, [Ed.] Risk and health communication in an evolving media

environment, New York: Routledge).

Additionally, we extend our sincerest gratitude to Kristi Barber for her copyediting work and moralsupport during each stage of the manuscript’s development We would also like to thank JoelDesOrmeau for his extensive proofreading and Kari Barber for her help with photo editing and imageresizing

Finally, we would like to thank our families and friends for their unconditional love, support, andpatience as we worked to finish this book We could not have done it without you

In his book Land of Desire, William Leach traces the conception of America’s consumption-based

culture back to the 1800s The author documents the cultural rise of consumer capitalism in the UnitedStates and exposes ways in which consumer-oriented institutions, democratized desire, and customerimagination shape societal values Mirroring Leach’s concern for America’s consumer-driven ethos,this book takes an in-depth look at commercialized health messaging and the commodification ofpublic health as it relates to the free market enterprise

Politics, Propaganda, and Public Health examines the profit-driven agendas, non-branded

marketing strategies, and consumer influences that induce public trust toward commercial interests.Specifically, we investigate the ways in which Merck Pharmaceuticals engineered publicunderstanding of the human papillomavirus (HPV) and cervical cancer through social marketing andproduct advertising In examining Merck’s campaign as it relates to American capitalism, and moreclosely investigating the vested interests feeding public awareness efforts, we attend to the social,political, and commercial agendas driving today’s health care communication

Big Pharma spends more money on advertising and lobbying than it does on researching medicine toimprove public health (Kantar Media, 2017; The Pew Charitable Trusts, 2017; Grantham, Ahern, &Connolly-Ahern, 2010; Jaramillo, 2006) Yet, surprisingly, the commercialization of public health is

an under-examined topic Politics, Propaganda, and Public Health investigates Merck’s

promotional messaging for the Gardasil vaccination as it relates to the medicalization process; apractice in which health-related risks serve as marketing platforms for pharmaceutical companies Atits most basic level, this work offers a multifaceted look at how one pharmaceutical companygradually entered and quickly controlled a vaccination market Concrete examples and case-specificfindings showcase the bigger picture, pointing to the commoditization, politicization, andmedicalization of public health

Merck’s pioneering promotional strategies, combined with the unique nature of the vaccination (apreventative treatment for a sexually transmitted infection) and an unconventional target market(young girls), make this case an appropriate one to analyze as we examine the changing nature ofpharmaceutical marketing in the United States By deconstructing Merck’s issue awareness efforts, thelaunch of the Gardasil vaccination, and the company’s ensuing lobbying strategies, we address

commercial agents that go far beyond the face value of standard product advertising Politics,

Propaganda, and Public Health attends to symbiotic agents that regulate public health messaging,

and ultimately, issues a call for regulation realignment in the health care industry

BOOK OUTLINE

In light of the paradigm shifts taking place in both academia and industry, Hartley (2012) suggests thatfields related to media and cultural studies re-direct focus toward the means and mechanisms ofchange; centering an analytical lens on the overall dynamics of systems This book pieces together thevarious ways in which Merck Pharmaceuticals engineered public understanding of HPV and cervicalcancer, while drawing attention to the cultivated commercialization of public health Through blended

methodologies, each chapter forges a globalized understanding of how corporatized healthcommunication and capital interests shape consumer perceptions, public trust, citizen efficacy, andlegislative policies.

In the early chapters of this work, we orient the reader with key terms, principal concepts,regulation development, and company history We then more fully introduce the campaign underinvestigation following Hall’s (1977) method of textual analysis By stripping campaign messagesdown to fundamental elements of marketing semantics, we provide the groundwork for a basic, butimperative, understanding of Merck’s health messages Subsequent focus groups consider currenttrends in health care communication and the implications of mixed-marketing models guiding publicawareness efforts Eye tracking analysis later documents ways in which brand fixations correlate withattitudes toward awareness messages Through within-subject investigative design, we comparephysiological indicators of attention with self-reported measurements of awareness We conclude thisbody of work with in-depth interviews that more closely examine the role corporate funding plays inlegislation, regulation, and voter/consumer behavior This final phase of research brings ourinvestigation full circle, showcasing the underlying nuances of product industry, government agency,and consumer capitalism

In sum, this book takes on multiple forms of research methods, data analysis, and writing styles; all

of which contribute to the crystallization of our broader argument (Richardson, 2000) As author andresearcher Laura Ellingson (2005) explains, holistic approaches to extensive, in-depth researchinvolve “collecting the data, making sense of them, and then writing about them; these processes donot occur in a linear fashion, but are interwoven” (p.155) Indeed, each chapter of our text embracesits own style and format, and through the inclusion of varied accounts and sociopolitical issues, we

present the reader with a triangulated, or interwoven, interpretation of Politics, Propaganda, and

Public Health Our journey begins in chapter 1, in which we establish the foundation, direction, and

context for the case at hand

Chapter One

The Doctor, the Baker, and the Medicine Maker

A dominant force in American culture, media act as both an economic and cultural institution; creatingmarketable enterprises and social meaning through mass messaging systems (Cook, 2005) Guided bythe “invisible hand,” U.S media nourishes consumer capitalism through advertiser-supported content,and as a powerful social educator, advertising defines cultural norms and constructs social realities(Buchanan, 2001) Therefore, as a profit-making business and a producer of meaning, the influences

of the U.S media system go far beyond commercial interests, penetrating the core layer of societaloperations and human functioning

America’s free market enterprise and dual-product marketplace provide fertile ground for thecommercialized exploitation of public health For example, pharmaceutical advertising, also known

as direct-to-consumer advertising (DTCA), serves as both a major source of funding for the Americanmedia system and a major source of health information for the U.S public As one of only twoWestern countries to allow pharmaceutical advertising (New Zealand being the other), the UnitedStates spends more on marketing prescription drugs than most countries spend on administeringmedicine, with expenditures totaling $5.4 billion in 2015 alone Notably, Americans also spent arecord $457 billion on prescription drug medications that same year (Llamas, 2016)

Health communication in the United States is largely a commercial enterprise, with many Americanslearning about important health issues through paid pharmaceutical advertisements (Donohue, 2006).The system encourages intense competition among pharmaceutical companies to bring drugs to marketquickly with the most effective marketing communication plans The question is, do successful paidmedia campaigns bring about effective health communication?

Public opinion is divided Proponents of DTCA claim pharmaceutical messages help publicizeavailable treatments for underreported conditions, such as depression (Sorofman, 1992) Others pointout that prescription drug advertising predominantly relies on emotional claims rather thanquantitative data; presenting consumers with vague and misleading information (Frosch, Krueger,Hornik, Cronholm, & Barg, 2007; Woloshin, Schwartz, Tremmel, & Welch, 2001) Indeed, direct-to-consumer advertising is a topic ripe for discourse, as it unites matters of public health, consumerculture, and a dual-product marketplace While supporters suggest DTCA promotes a more educated,healthier society, increasing overall consumer welfare (Mukherji, Raman, Dutta, & Rajiv, 2017),critics argue such commercialized health communication drives consumer demand and ultimatelyshifts the physician-patient relationship to a physician-consumer relationship (Bradley & Zito, 1997)

Though the controversy surrounding direct-to-consumer advertising is complex, it is certainly notnew Debates over prescription drug advertising date back to the 1970s, when a trajectory of U.S.Supreme Court cases drew attention to issues related to commercial canvassing, regulatoryintervention, and First Amendment violations (Beales & Muris, 1993; Perri, Shinde, & Banavali,1999; Bates v State Bar of Ariz., 433 US 350—Supreme Court 1977; Bigelow v Virginia, 421 U S

809, 421 U.S 817–818l; Virginia Pharmacy Board v Virginia Consumer Council, 425 U.S 748)

Perhaps most notably, in 1976, Shirley Terry v California State Board of Pharmacy introduced

issues of consumer rights, information access, and commercial free speech into public consciousness

and onto political platforms.

In the California Supreme Court, consumer plaintiff Shirley Terry sued on behalf of persons needingaccess to price information for prescribed medications, issuing “declarations of unconstitutionalityand permanent injunctions against the enforcement of California Business and Professions Codeinsofar as they prohibit media advertising of the retail price of prescription drugs” (Terry v.California State Board of Pharmacy, 395 F Supp 94—District Court, ND California 1975, p 1798).The District Judge ruled in her favor, granting prescription drug advertising limited commercialspeech protection in consideration of First Amendment rights and Federal Antitrust laws (Terry v.California State Board of Pharmacy, 426 US 913)

While the First Amendment plays a vital role in America’s government system, privileged industryallowances complicate the nature of constitutional protection within a free market enterprise A 1993Supreme Court opinion outlined the foundational principles for commercial free speech and protectedforms of advertising, explaining:

The commercial market place, like other spheres of our social and cultural life, provides a forum where ideas and information flourish Some of the ideas and information are vital, some of slight worth But the general rule is that the speaker and the audience, not the government, assess the value of the information presented Thus, even a communication that does no more than propose a commercial transaction is entitled to the coverage of the First Amendment ( Edenfield v Fane , 123 L Ed 2d 543, 113 S Ct 1792,

1798, 1993)

Though it may seem simple enough, commercial speech protection calls attention to conflicted capitalinterests in a democratic government system While some party lines support the notion that a healthydemocracy rests on that which is conducive to a properly functioning market, opposing views suggestcommercial speech protection is inherently antidemocratic, and symptomatic of America’s misguided

trust in a commercialized system (Jaramillo, 2006) Terry v California State provided the

pharmaceutical industry with privileged access to patients, and therefore prompted discussion overcommercial speech protection in the context of public health

The outcome of this seminal case undeniably transformed the nature of public health communication

and normative industry operations in the United States Previously reliant on sales representatives,medical journals, and physician recommendations for product promotion in years past, this newregulatory leeway allowed pharmaceutical marketers to directly communicate with consumers andfurther enhance product awareness Big Pharma quickly turned to periodicals as a means of moreeffectively promoting product interest and physician-generated prescriptions (Perri, Shinde, &Banavali, 1999) Though broadcast restrictions initially limited the scope of advertising reach andexposure, privileged speech protection eventually led pharmaceutics to the system that exists today,with a glut of prescription drug advertisements featured in almost all major media

Currently, the pharmaceutical industry is the seventh-largest advertised product category in theUnited States (Kantar Media, 2017) Pharmaceuticals are the leading advertiser for U.S magazines(Tadena, 2015), and Nielsen estimates that prescription drug commercials air at a rate of 80 ads perhour of TV programming Perhaps most notably, prescription drug ad spending today in the UnitedStates is often twice the spending on research and development (BBC, 2014).Today’s healthcommunication increasingly demonstrates a profit-driven orientation; leaving the public vulnerable tocommercial influence and market trends (Grantham, Ahern, & Connolly-Ahern, 2010; Jaramillo,

2006; Harnett, 2017).

Pharmaceutical powers arguably introduce unique hazards to public well-being, as the persuasivestrategies and induction techniques underlying direct-to-consumer advertisements largely inform thesocial understanding of specific health issues Ancient Greco-Roman philosophies seemingly speak to

the dubious nature of modern health messaging As Plato explains in Gorgias:

Pastry baking has put on the mask of medicine, and pretends to know the foods that are best for the body, so that if a pastry baker and a doctor had to compete in front of children, or in front of men just as foolish as children, to determine which of the two, the doctor or the pastry baker, had expert knowledge of good food and bad, the doctor would die of starvation (Plato, Kindle Location 3291)

Plato underscores the essence of pharmaceutical advertising, suggesting the beautification ofinformation merely impersonates that which is truly good for the soul

Platonic virtues call attention to the moral impasses underlying recent health communicationstrategies In a manner that mirrors the mask of pastry bakers, Big Pharma arguably replaces the role

of primary physician and commercial rhetoric increasingly defines what it means to be “sick” andwhat it means to be “healthy.” Indeed, studies show prescription drug advertisements can drivedemand for specific advertised drugs among consumers (Bell, Kravtiz, & Wilkes, 1999; Bell, Wilkes,

& Kravitz, 1999; Gellad & Lyles, 2007; Narayanan, Desiraju, & Chintagunta, 2004; Robinson,Hohmann, Rifkin, Topp, Gilroy, Pickard & Anderson, 2004; Wilkes, Bell, & Kravitz, 2000), as well

as influence physician diagnoses and prescription patterns (Friedman & Gould, 2007; Gellad &Lyles, 2007; Kravitz et al., 2005; Mintzes et al., 2002; Morris, Gadson, & Burroughs, 2007).Furthermore, pharmaceutical messaging predominately focuses on product promotion (at the expense

of raising awareness for health issues), and the advertisements themselves most often appeal toemotion-based reasoning rather than informed decision making (Frosch, Krueger, Hornik, Cronholm,

& Barg, 2007; Woloshin, Schwartz, Tremmel, & Welch, 2001)

Both modern research and Platonic dialogues seemingly speak to Big Pharma’s ability to enticeconsumers into medical treatment “through no other art than the rhetorical” (Plato, Kindle Location16294) Though scholars have examined prescription drug advertising in relation to doctor–patientrelationships (Murray, Lo, Pollack, Donelan, & Lee, 2004), public policy implications (Myers,Royne, & Deitz, 2011), medical compliance (Manika, Ball, & Stout, 2014), drug choices (Mintzes,Barer, Kravitz, et al., 2002), and patterns in message content/design (Macias & Lewis, 2003;Sumpradit, Ascione, & Bagozzie, 2004; Young & Cline, 2004), experts in the field indicate a need formore consumer-centric work that addresses the ultimate effects of pharmaceutical marketing inrelation to public interests (Royne & Meyers, 2008) Furthermore, while the literature on prescriptiondrug advertising is extensive, scholarly work on more subtle forms of for-profit health messaging isnot nearly as prevalent (Kim and Hancock, 2017)

As corporate agencies turn to less obvious means of commercial marketing, it becomes increasinglynecessary to examine public health knowledge as it relates to the “shadow of forms.” Accordingly,

we examine one particular case in which a pharmaceutical company and related media messagingseemingly manufactured the reality of a relatively unknown health threat, as well as the recommendedproduct solution Specifically, the following work details Merck Pharmaceuticals’ promotionalmessaging for the Gardasil vaccination, and the role it played in cultivating public knowledge of thehuman papillomavirus (HPV)

HEALTH ISSUE AT HAND

Today, one in four adults (approximately 80 million people) are infected with HPV The virus iscurrently the most common sexually transmitted infection (STI) in the United States (CDC, 2017), andthe National Center for Health Statistics indicates over 42 percent of Americans between the ages of

18 and 59 are carriers of HPV (Bakalar, 2017) The CDC further estimates that an additional 14million people will become newly infected with HPV each year The most abundant case of humanpapilloma infection, HPV 16, positively correlates with number of sexual partners (CDC, 2012).Such associative patterns suggest sexual activity elevates the risk of HPV exposure and infection.Indeed, studies show relational proclivities account for the foremost predictive influence of HPVinfection (Janicek & Averette, 2001; CDC, 2012), and studies confirm all women and men are at risk

of HPV infection once becoming sexually active (CDC, 2012)

Alarming trends and documented research further demonstrate direct ties between HPV infectionand certain types of cancer (CDC, 2012) Over 70 percent of all cervical cancer cases, for example,involve a strand of the human papillomavirus (CDC, 2011, 2012; NCI, 2017) While once named theleading cause of cancer-related deaths for women nationwide, mortality rates are declining Still,cervical cancer accounts for 15 percent of female cancers; claiming roughly 266,000 lives per yearworldwide (International Agency for Research on Cancer, 2012) Though HPV commonly surfaces inyoung women between the ages of 18 and 30, cervical cancer is more prevalent among females 35and older, indicating delayed development of precancerous cells Given that abnormal cervical cellchanges seldom generate symptoms, regular gynecological exams and Pap test screenings serve ascritical preventative health care behaviors (CDC, 2007) However, such measures are not guaranteed

to detect all precancerous lesions

While there is still no cure for the human papillomavirus or cervical cancer, scientific discoveriesand medical developments continue to advance the field of prevention Most recently, on June 8,

2006, the Food and Drug Administration (FDA) approved the world’s first preventative vaccinationfor the human papillomavirus American pharmaceutical company, Merck & Co, Inc., subsequentlydeveloped the Gardasil vaccine for widespread distribution, ultimately providing a promising means

of prevention for the predicted 80 percent of sexually active women who are at risk of acquiring anHPV infection by age 50 (Schwartz, 2006; CDC, 2008)

Merck’s HPV vaccination consists of a three-dose series issued over a period of six months (CDC,2012) As such, inoculation requires both initiation (receiving the first vaccine dose) and completion(receiving all three vaccine doses) Given that the vaccination is most effective when fullyadministered prior to virus exposure, many physicians recommend discussing preventative behaviorsand vaccination treatments with girls (and now boys) as young as nine years old (Center for YoungWomen’s Health, 2012) Therefore, Merck faced the unique task of promoting a recently approved,three-dose vaccination for a sexually transmitted virus to the parents of preteens

Within four months of receiving FDA approval for the vaccination, Merck released a national print,television and online advertising campaign for Gardasil (Petersen, 2006) However, prior to thecompany’s official campaign launch (in November of 2006), and even before receiving FDAapproval for the Gardasil vaccination (in June of 2006), Merck teamed up with nonprofits CancerResearch and Prevention Foundation and Step-Up Women’s Network in an unprecedented,multitiered social marketing campaign for HPV and cervical cancer The initial phase in Merck’srollout effort (“Make the Connection”) introduced a largely overlooked public health risk (HPV) and

established its connection to cervical cancer The succeeding message sequence (“Tell Someone”)urged women spread their knowledge and tell someone about the connection between HPV andcervical cancer Merck then released “One Less” upon receiving FDA approval for the Gardasilvaccination Advertisements in this final campaign phase promoted a medical (and proprietary)solution for the now widespread public health concern.

While Gardasil offered promising hope in the fight against HPV/cervical cancer, and thoughMerck’s vaccine was the first of its nature, the company’s early awareness messaging sparked debateover corporate intentions Reports characterized the social marketing campaign as a commercialeffort that primed the market for Merck’s new vaccine (Serono, 2013) Critics also suggested Merckstrategically engineered the awareness push to gain market lead, as GlaxoSmithKline was working onalternative inoculation developments (Herper, 2012) Though Merck insisted, “this campaign is part

of a broad and longstanding public health commitment to encourage education about the disease”(Merck representative K Dougherty in Schwartz, 2006), the prereleased messages promptedaccusations of deceptive marketing agendas

Proactive health care measures (such as screening or inoculation) can significantly reduce related cancer rates (Janicek & Averette, 2001; National Cancer Institute, 2016) Vaccinationinitiation, however, ultimately depends on citizens’ understanding of HPV, cervical cancer, and theGardasil vaccine; as well as widespread public trust and consumer buy-in (Briones, Nan, Madden, &Waks, 2012) Therefore, Merck’s ability to effectively communicate risk messages to key audiences

HPV-is inherently tied to overall inoculation aptitude As such, the company’s communicative efforts inviteample opportunity for discourse evaluation and theoretical discussion

While the Gardasil vaccine itself is a popular topic in academic literature, most of the work attends

to a singular facet/issue related to the vaccination, such as mothers’ and doctors’ opinions of the drug(Head & Harsin, 2016), teen girls’ reactions to the campaign (Vardeman-Winter, 2012), and Merck’sinterpersonal tactics (Whidden, 2012) We aim to provide a more multi-dimensional and macro-levelunderstanding of Merck’s groundbreaking vaccination, and the surrounding sociopolitical issues thatinfluenced public deliberation and inoculation discourse Through collaborative data analysis, thisbook attends to the shifting health communication models, and the means by which cervical cancerand the human papillomavirus became a matter of public interest The following section details therationale that drove our unconventional research approach and the methodological components thatinformed this investigation

MERGING METHODOLOGICAL PARADIGMS

More often than not, the principles of media research are packaged and presented through a two-sidedinterpretation of methodological strategies In the 1970s, communication science divided into twoschools of thought; splitting the field into “humanistic” and “scientific” paradigms This fault lineformed clear alliances to “quantitative” or “qualitative” scholarship, and such commitments to aspecific research style continue to distance those in the field today As the nature of academicscholarship evolves, however, it becomes increasingly important to assume a balanced, integrative,and pragmatic investigative approach to research As Johnson and Onwuegbuzie (2004) note,

Today’s research world is becoming increasingly interdisciplinary, complex, and dynamic; therefore, many researchers need to complement one method with another, and all researchers need a solid understanding of multiple methods used by other scholars to facilitate communication, to promote collaboration, and to provide superior research Taking a non-purist or compatibilist or mixed

position allows researchers to mix and match design components that offer the best chance of answering specific research questions (p 15)

Attending to this call for merged methodological progression, we unite the tenets of critical culturalresearch with the methods of positivistic scholarship

Chapters throughout this book integrate textual analysis, interviews, focus groups, and eye trackingobservation to create an informed account of the assorted influences driving public perception ofcommercialized health messaging Though data triangulation does not ensure truth or certainty, it isrecognized as a strategy that adds depth, richness, breadth, and rigor to scholarly investigation(Denzin & Lincoln, 2000) Therefore, we use a wide range of investigative tools as we examine thedynamic interplay between public messaging, for-profit health communication, and consumerexpectations

Our grounded analysis unites modern marketing research with principles of message reception andsocial trust, offering a contemporaneous account of corporate medicalization and pharmaceuticalconsumerization Though methodologically distinct and issue-oriented, each chapter of this bookconcentrates on the means through which Merck Pharmaceuticals arguably commercialized cervicalcancer to promote the Gardasil vaccination Through triangulated data, we provide a multifaceted andmore balanced account of the sociocultural, political, and economic significance underlying thecorporatization of public health communication

Perhaps more broadly, the following work outlines ways in which pervasive health messaging oftenserves corporate interests and can threaten consumer health information in a free market enterprise.Channeling Lippmann’s (1922) concern for the pseudo environment in which society operates, wedelve into the commercialized networks driving health care communication to illustrate corporateinfluence in public health messaging The following chapter sets the stage for our book, as itintroduces the interconnected players and events that shaped the fruition of this manuscript

is made over into the simple, the hypothetical into the dogmatic, and the relative into an absolute”(Lippmann, 1955, p 27) In combination with app-driven packaging, political agendas andcompetitive markets pollute the foundation of public information, making it all the more difficult forthe general public to obtain a full and accurate account of the issues at hand.

This chapter demonstrates the challenges of both relaying and consuming health information that isfree from special interests, hidden agendas, or strategic issue framing Specifically, we provide anaccount of the separate yet interconnected events that built the HPV/Gardasil narrative and shapedpublic understanding of the health issue The following section illustrates ways in which this case isultimately a microcosm of the overall system Each component and specific event speaks to thechanging nature of health communication in the United States and the implications of commercialinfluence in the public health field

MERCK AND THE MEDIA

Merck’s unique corporate history offers numerous examples of how industry influence and relatedmedia reporting can dramatically shape the nature of health information The company’s story begins

(or at least, first enters the media scene) in 1981, with a strategic ad placement in Reader’s Digest

for Pneumovax, a pneumonia vaccine (Ventola, 2011) Though a seemingly ordinary event, the adpurchase later defined an epic moment for the pharmaceutical industry and American capitalism, as itmarked the birth of direct-to-consumer advertising in the United States (Abel, 2006)

Roughly two decades after initiating what is now a pervasive advertising trend, MerckPharmaceuticals made nationwide headlines once again for matters directly related to its pioneeringrole in prescription drug advertising In September 2004, reports surfaced linking Merck’s top-sellinganti-inflammatory drug, Vioxx, to more than 27,000 product-related deaths (MSNBC, 2004) Expertssuggested that between the Food and Drug Administration’s (FDA) approval of Vioxx in 1999 andinitial negative media coverage in 2003, approximately 27,785 cases of sudden cardiac arrest couldhave been prevented through alternative arthritis treatments and medications (Associated Press,2004) Merck soon faced millions of dollars in legal costs, stemming from over 24,000 plaintifflawsuits (Huh & Becker, 2005) With media pressure mounting, Merck voluntarily withdrew thearthritis treatment, prompting a 27 percent drop in company profits (equivalent to $26 billion in

market value) (Masters, 2004) In the end, authorities criticized the FDA for not taking appropriateaction Reports indicated the agency failed to operate in the interest of public health, and further notedthe rise of Vioxx was ultimately due to “masterful public relations, aggressive marketing, andineffective regulation” (McDougall & Popat, 2010, p 898).

The FDA’s involvement in pharmaceutical advertising regulation may seem somewhatcounterintuitive (especially given the roles of other federal agencies more directly tied to the U.S.media system); however, the executive department gained full authority over prescription druglabeling and advertising after passing the Kefauver Harris Drug Amendment in 1962 This amendmentpositioned the FDA as the chief watchdog agency for all communications involving drug messaging(Boden & Diamond, 2008) Therefore, though the Federal Communications Commission (FCC)regulates most broadcast messaging and the Federal Trade Commission (FTC) polices advertisingaccuracy, the FDA maintains complete jurisdiction over the release and marketing of pharmaceuticalmedications (Beales & Muris, 1993) Scholars suggest the FDA’s independent regulatory role in thepharmaceutical market warrants concern (Beales & Muris, 1993; Breton et al., 2007), aspharmaceutical companies largely subsidize the agency’s annual budget Given that conflictingpolitical and public interests inherently underlie core administrative operations, experts recommendstronger watchdog focus on policy strategies

Indeed, numerous U.S legal proceedings document the FDA’s role in the industrialization of to-consumer health messaging In 1983, for example, the FDA publicly acknowledged thatprescription drug advertising failed to serve public health interests and even issued a briefmoratorium on direct-to-consumer marketing However, the agency lifted the ban two years later,indicating standards of “fair balance” (i.e., including both the risks and benefits of a drug) and “briefsummary” (addressing every risk in the product’s labeling) adequately protected informed decisionmaking (Ventola, 2011) Despite heavily documented concerns, the FDA once again further extendedpharmaceutical advertising protection near the turn of the 20th century (Cohen, 1988; Murray et al.,2004), approving the use of radio, television, and internet for prescription drug marketing (Perri &Nelson, 1997)

direct-During the wake of Merck’s Vioxx controversy (which followed shortly after regulationrelaxations), both the FDA and the extended pharmaceutical advertising allowances fell under heavyscrutiny Critics called for stricter regulations, and the lax standards framing prescription drugadvertising prompted government leaders to issue their own policy recommendations (Saul, 2005;Hirson, 2005) In 2004, U.S Senate Majority Leader Bill Frist encouraged pharmaceuticalmanufacturers to wait two years before advertising new drugs (Melillo, 2005) Despite being thecatalyst for such legislative intervention (Donohue, 2006), Merck seemingly ignored Frist’srecommendations and moved forward with what appeared to be a strategic teaser campaign for thecompany’s highly anticipated breakthrough vaccine

While awaiting FDA approval for the Gardasil vaccination, Merck teamed up with nonprofitagencies (the Cancer Research and Prevention Foundation and Step-up Women’s Network) andproactively released a social marketing campaign that primed awareness for HPV and cervicalcancer In two nationally televised public service announcement-style television campaigns (titled,

“Make the Connection” and “Tell Someone”), Merck released several different 60-second

commercials to urge women to “make the connection” between HPV and cancer and then for women

to “tell someone” about the health threat More specifically, Merck introduced the deadly link

between HPV and cervical cancer in “Make the Connection.” The company remained in close contactwith audiences, quickly releasing the follow-up, “Tell Someone” campaign This stage ofpromotional messaging statistically emphasized the percentage of women who are unaware of thethreatening viral infection, and encouraged listeners to spread awareness to help prevent furthertransmission Fashioning a finish to what some suggested was a product endorsement operation,Merck then offered viewers a solution to the well-publicized social crisis The company presented acall to action in the concluding tier of the social marketing effort, encouraging viewers to “getvaccinated” to become “one less” statistic The final phase suggested the “big picture,”communicating the vaccination’s potential ability to freeze current cervical cancer statistics andinoculate uninfected females.

The unique nature of Merck’s Gardasil campaign positions this case as one unlike any other.Seemingly, the company’s messages fall into the category of “help-seeking ads”; defined by acollection of health agencies (which include the FDA, the U.S Department of Health and HumanServices, the Center for Drug Evaluation and Research, the Center for Biologics Evaluation andResearch, and the Center for Devices and Radiological Health) as disease awarenesscommunications, “that discuss a particular disease or health condition, but do not mention anyspecific drug or device or make any representation or suggestion concerning a particular drug ordevice” (FDA, 2004, p 1) Though the description fits, the FDA indicates ads that fall within thiscategory should provide relevant/pertinent health information that encourages consumers to seekappropriate treatment or engage in behavioral/lifestyle changes (FDA, 2004) At the time of thecampaign release, however, Gardasil had not yet received FDA approval and Merck’s awarenessmessages focused little attention on preventative behaviors, such as abstinence, safe sex, orscreening Therefore, preemptive campaign efforts drove social consciousness of HPV and itsconnection to cervical cancer, but did little to promote self-efficacy

Immediately upon receiving FDA approval, however, the pharmaceutical company targeted the U.S.market in full force In addition to releasing two more direct television campaigns, “One Less” and “IChose,” Merck heavily lobbied for nationwide mandates requiring HPV immunization Starting inTexas, the company gradually began to monopolize state-ordered vaccinations (Schwartz, 2010).Inoculation requirements offered Merck an opportunity to regain secure financial standing, as thecompany was still recovering from Vioxx-related litigation costs (Krumholz & Beckel, 2011) Mediareports further speculated that the immunization push allowed Merck to position itself ahead ofGlaxoSmithKline; a pharmaceutical company likely to jeopardize Merck’s vaccination monopolywith its impending alternative inoculation, Cervarix (Forbes, 2012)

Regardless of intentions, Merck’s strategy was effective By 2007, and less than one year afterGardasil received FDA approval, 23 states and Washington, DC, had introduced vaccinationlegislation (NCSL, 2013) Merck recently continued its lobbying focus, providing substantialcontributions to influential agencies such as the U.S Chamber of Commerce, the Business Roundtableand the Pharmaceutical Research and Manufacturers of America

Though Merck succeeded in its government petitioning, pre-FDA-approval marketing efforts andpoliticalized messaging prompted serious allegations against the company Vioxx-related civil suitsand legal hearings also cast a shadow on Merck’s corporate integrity Despite being held largelyresponsible for this event, in a 2001 report, the FDA did publicly condemn Merck for releasingmisleading claims in relation to Vioxx, maintaining that Merck failed to sufficiently address the

drug’s risks in the safety data submitted to the FDA Additionally, the FDA charged Merck withmisrepresenting potential health threats in the promotional material for Vioxx that was distributed toboth doctors and consumers (Business Wire, 2006).

As part of the settlement terms, Merck signed a corporate integrity agreement, pledging to carefullymonitor future product marketing However, as we argue throughout this book, the company seeminglycontinued to draw upon questionable advertising strategies in its marketing approach for the Gardasilvaccination We particularly focus on the ethical foundation of Merck’s campaign as it relates tocommercialized awareness messaging and product-driven social marketing

COMMERCIALIZING SOCIAL AWARENESS

Whereas direct-to-consumer advertisements promote prescription products to the general publicthrough profit-driven messaging (Bradley & Zito, 1997), social marketing campaigns “aim toinfluence human behavior in order to improve health or benefit society” (Kotler and Levy, 1969, p.98) In other words, these awareness efforts use the standard principles of marketing to prescribepro-social behavioral patterns rather than market an actual product The messaging approach isspecifically structured to disseminate information that promotes self-efficacy (through messages thatinform, motivate, and train audiences) to drive larger-scale societal changes (Bernays, 1928; Moore

& Greenwood, 2005) Merck followed the social marketing model, delivering messages that intended

to boost credibility, target salient beliefs, and motivate vaccination-seeking behaviors However,while most social marketing efforts aim to change a negative behavior (or “sell” people on pro-socialbehaviors), Merck’s campaign did not focus on the positive behavior of safe sex to avoid contractingHPV Instead, messages promoted the behavior of vaccinating yourself (or a loved one) with Gardasil

to avoid contracting HPV

While social marketing in the health care industry promotes an overall increase in consumerawareness, patient education, and medical discussion, current industry trends pose a threat to messagereception and communication efficacy (Liang & Mackey, 2011) More often, the burgeoning andincreasingly invisible commercialized structuring of health care efforts compromises the nature ofpublic health information and social awareness campaigns Indeed, the rollout campaign for Merck’sGardasil vaccination shows a trajectory in which the company gradually transformed cervical cancerdiscourse into inoculation rhetoric

Given the sensitive nature of the HPV health issue and the target market for the vaccination (younggirls), Merck needed to strategically reach household decision makers to abate vaccinationresistance Early messaging efforts appeared to be public service announcements, with prominentsponsorships showcasing the support of several worthwhile sounding nonprofit organizations.Merck’s branding, as we will illustrate in coming chapters, was comparatively inconspicuous,leaving non-discerning viewers with the impression that they were being presented with independenthealth messages Essentially, the company promoted Gardasil and its association with an HPV-freelife through a strategic roll-out campaign that spread awareness, cultivated concern, and, eventually,generated product demand

Keep in mind that Merck’s HPV vaccination not only provides medical utility to those at risk, butperhaps equally important, it extends opportunities to establish the connection between HPV andcervical cancer However, if the controversy surrounding Merck’s involvement in the awarenesscampaign compromises public trust, it becomes a lose–lose situation for both Merck Pharmaceuticals

and the public health initiative Promotional efforts for the HPV social awareness campaign highlightthe dubious nature of corporate influence in health messaging.

Health communication research indicates the level of consumer trust in vaccination messaginginfluences information-seeking behaviors (Nan & Madden, 2012; Manika, Ball, & Stout, 2014).Research further shows health awareness efforts that clearly and directly communicate causes ofdisease onset oftentimes facilitate extensive prevention (Janicek & Averette, 2001) Such literaturesuggests that, despite being the first to market with an HPV vaccine and securing numerous statewidemandates, Merck has had mixed success with its campaigning; as recent figures place vaccinationrates at only 50 percent of the target population, and 35 percent among boys, despite widespreadpromotion and a competing product in Cervarix (Crane, 2014)

Merck’s promotional canvass for the Gardasil vaccination highlights ways in which corporateagendas can threaten consumer trust in public health campaigns Throughout the years, Merck hasdemonstrated a commitment to disease and vaccine awareness through its longtime involvement withvarious educational organizations The pharmaceutical company also separately supports diseaseeducation through multilingual awareness programs, and reaches broad and diverse audiences throughgrant funding for national and local organizations that circulate medical information (MerckPharmaceuticals, 2007; 2017) Despite praiseworthy corporate missions, however, the circumstancessurrounding Merck’s product promotion gave rise to suspicion over vaccination discourse and relatedawareness messaging (as noted in earlier examples of media reporting)

Bear in mind that Merck’s marketing approach is not uncommon among the pharmaceutical sector.Because of the latest adjustments in direct-to-consumer advertising policies, and in light of today’sepochal interest in public policy issues, corporate agencies often assume social marketing approaches

to product promotion (Bosworth, Pardun, Taylor, & Taylor 2009) As consumers grow more mindfuland sensitive to corporate influence, however, the implications of commercial interests intensify.Davidson and Novelli (2001) speak to issues of corporatized health messages and public cynicism,explaining,

Society expects and accepts that business will promote its goods and services toward the end of making a profit It is confusing and skeptical, however, when business ventures into the area of social marketing to promote the improvement of social good by changing behavior This leads to an increase in the already worrisome level of cynicism about, and distrust of, business (p 90)

Considering the far-reaching and widespread messaging capabilities of the new millennium, model advertising1 makes it evermore necessary to understand the implications of profit-driven healthcare messages

mixed-Advertising in the digital realm is becoming harder to recognize, and the differences betweeneditorial content and persuasive messaging are difficult to ascertain in today’s news feed-dominatedenvironments Native advertising, by its very name, is meant to blend into whatever platform onwhich it is placed Commercial messaging in social media platforms is often paid messaging withoutdisclosure that money has changed hands In fact, Facebook, the most dominant social media platform,ensures through its algorithm that branded editorial messaging will not be widely distributed in theFacebook environment without the “boost” of an advertising expenditure

The recent rise in media capabilities, combined with the extensive latitude of corporate liberties,make the commercial increasingly indistinguishable from the noncommercial (McChesney, 2000;2013) These blurred boundaries bring into question current understandings of public awarenesscampaigns, nonprofit messaging, and corporately sponsored cause-related marketing Merck’s

exemplary model of blended health campaigning provides a rich foundation for examining the socialimplications of commercialized health care messaging Connecting modern medicine to questionableindustry trends, the question raised here is not whether Merck’s awareness efforts satisfy socialmarketing standards (as a review of literature clearly shows it does), but rather, whether thecompany’s marketing strategy is appropriate, or even ethical, in the health care arena.

Though patterns in public health communication increasingly tend toward profit-driven interests(Jaramillo, 2006), commercialized social marketing is, surprisingly, an under-examined topic Bydeconstructing cases of for-profit health communication, scholars and practitioners can moreeffectively consider how corporate agencies construct certain realities for health care consumers Assuch, this book looks at the commercial use of social marketing as it relates to public trust in healthcommunication Through both rhetorical and empirical analysis, we will illustrate the thin linebetween helpful health information and disguised forms of advertising Social cognitive theory, asoutlined in the following section, guides the interpretations and arguments we pose throughout thiswork

THEORETICAL FOUNDATION

Social cognitive theory (SCT) is largely recognized as the foundational framework from which toexamine symbolic modeling, individual action, and societal trends (Bandura, 1986) The theoryspeaks to media’s influence on personal agency, and the psychosocial influence of commercialmessaging In demonstrating how information processing mediates human behavior, social cognitivetheory frames how effective message design can motivate positive responses As such, the theory’smultidimensional scope fosters opportunity for critical evaluation of the promotional strategies thatdrive consumer behavior

Encompassing cognitive and behavioral ideologies, social cognitive theory addresses personalagency in terms of vicarious, self-regulatory, and self-reflective processes (Bandura, 1991) Thetheoretical framework outlines human performance in the context of socio-structural influences inwhich cognitions, behavioral patterns, and social surroundings operate as a bidirectional network ofinteracting determinants (Bandura, 1994) More simply, SCT recognizes individual cognition as thelocus for information reception and processing, while simultaneously acknowledging the influenceindividuals have over each other (Anderson, 1996; Bandura, 1986)

Albert Bandura (2001), the founder of SCT, suggested that external influences, such as socialapproval and disapproval, operate as a source for self-pride/censorship and therefore, oftenprescribe human behaviors By relating to another person, whether it be through direct interactions orparasocial connections, human beings can convert vicarious observations into personal life lessonsand positive decision making Bandura’s seminal work on social cognition is particularly applicable

to health care messaging, as it offers a platform for understanding interconnections among vicariouslearning, self-efficacy, and individual action (Bandura, 1986)

Early in his career, Bandura (1977) stressed the power of behavior modeling and vicarious learningexperiences, suggesting:

Learning would be exceedingly laborious, not to mention hazardous, if people had to rely solely on the effects of their own actions to inform them what to do Fortunately, most human behavior is learned observationally through modeling: From observing others one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action (p 213)

This notion offers insight to personal agency in the context of advertising’s cultural influence.

As technological advancements of the 21st century intensify the reach of symbolic modeling,audiences are increasingly exposed to and dependent upon vicarious learning Therefore, socialmores are largely transmitted through mediated experiences Bandura’s seminal work provides a firmfoundation for which to explore ways in which media and industry work in tandem to cultivate normsthat promote commercial interests

The power of commercial advertising operates under the understanding that message modelingguides knowledge and skill into a positive course of action (Bandura, 1997) Indeed, direct-to-consumer marketers often capitalize on the tenets of social learning, creating models and symbolicenvironments that promote “proper” or “ideal” health care behavior SCT therefore offers insight tothe relational, identity, and instrumental goals that pharmaceutical companies often appeal to inproduct messaging to drive consumer behavior (Young, Lipowski, & Cline, 2005) Bandura’s workspeaks to the ways in which media content (including product advertising) defines social norms andcultivates socially acceptable behaviors As such, SCT provides a strong philosophical frameworkfor which to examine the underlying dynamics that shape public health communication

Innovative marketing strategies and recent communication trends make it necessary for researchers,medical practitioners, and industry professionals to understand the relationship between commercialinfluence and consumer trust in the context of public health Ivan Preston (1974) examined therelationship between branding and trust extensively; developing a research agenda that largelyfocused on exposing consumer deception The scholar believed that any form of mass communicationessentially boiled down to an attempt at persuasion, suggesting that if communicators are not trying toinfluence behaviors or responses, they are at least trying to assure the audience that they are credible,dependable, and trustworthy (Preston, 1969) His work demonstrates the practical application oftheoretical concepts in relation to commercial health messaging

Indeed, rhetorical scholarship often positions audience value judgments at the heart of successfulcommunication, promoting a framework that guides the development of many advertisements andpromotional campaign trends (Foss, Foss, & Trapp, 2001) Message design must contain a means ofinfluencing the audience to “believe” for successful persuasion to occur (Preston, 1969; Root, 1987).Research indicates specific viewer behavior is socially context-dependent, and that advertisingeffectiveness largely depends on the messenger’s ability to effectively exploit the conative power ofsigns (Messaris, 1997) By understanding the psychological and sociological origins of the intendedaudience, campaign engineers can better discriminate between various arguments, employing only theclaims that a specific audience is most likely to understand and accept

Rapid changes in digital, social, and mobile media drastically transform the means of messagediffusion, calling attention to the dual paths of message influence and its role in the socialconstruction of reality As more media content moves into the realm of social media platforms, which

is supported by hybrid and even misleading forms of paid media content (such as native advertising),the sanctity of health information and its importance to the public at large becomes more and more atrisk

Scholars can better understand the social construction of public health issues through detailedexamination of the persuasive strategies and induction techniques in public health campaigns.Accordingly, the next chapter introduces an educated interpretation of how Merck’s campaignprescribed social meaning for HPV, cervical cancer, and the Gardasil vaccination We turn to the

principles of persuasion as we dissect the visual and verbal nuances of Merck’s campaign messages;and we adopt an interpretive lens as we consider the audience-specific motivators threadedthroughout marketing efforts Chapter 3 establishes the foundation for our overall body of researchand introduces the larger issues at stake.

NOTE

1 Mixed-Model advertising is defined throughout this work as a blend of public health messaging and product advertising.

Chapter Three

Deconstructing Merck’s Awareness Campaign

In this chapter, we will turn our attention to the actual content Merck produced, not only to legitimizeGardasil prior to FDA approval, but also to promote the vaccination further at product launch andbeyond To better understand ways in which media/commercial messaging actively influences thecultural construction of audience worldviews, it is necessary to first address ways in which viewersmake meaning out of “texts.” A “text” is a cultural product that informs one’s sense of environmentand surroundings circumstances More simply, it is something from which humans make meaning(McKee, 2001; 2003) The American media system, as we noted earlier, exists in a dual-productmarketplace; it is a powerful social educator with profit-driven interests Therefore, advertiser-supported content and commercial “texts” fuel citizen norms, values, and understandings Thoughmedia undoubtedly influence shared meaning, both the producers and consumers of content oftenchoose message frameworks unconsciously (Hall, 1976) Textual analyses help illuminate the latentnuances that often go unnoticed through casual content exposure

More specifically, methods of textual analysis provide a toolkit for systematically breaking downthe signs, codes, and rules that cultivate these worldviews (Stern, 1996) Much like a backwardsapproach to puzzle solving, textual analysts break apart message units to develop a clearerunderstanding of the smaller pieces of communication By searching for reoccurring patterns in style,imagery, and tone, and studying the periodic shifts in commercial rhetoric, textual analysts can

“discover intelligible patterns in the development of the art that otherwise may appear whimsical,haphazard, arbitrary, or merely verbal” (Buchanan, 2001, p 183) The research method offers criticalinsight to persuasive texts, and is therefore particularly relevant to the question at hand, which askshow Merck Pharmaceuticals facilitated viewer sense making of HPV and the Gardasil vaccination

In the following section, we examine the visual and verbal nuances underlying Merck’s ads, anddiscuss the audience-specific motivators integrated throughout the awareness-turned-productcampaign By analyzing text composition and dissemination, we put forth an interpretation of theideologies that informed Merck’s marketing efforts Social cognitive theory, combined with theprinciples of persuasion, frames our systematic investigation and subsequent reading of campaignmessages

MESSAGE DECONSTRUCTION

Effective advertising engineers semantic relationships (between signifier and signified, image andproduct) to ensure particular meanings are conveyed and received For that reason, textual analysesaddress matters related to both message production and audience reception to better interpret thepolitical and cultural significance of a particular commercial artifact (Curtin, 1995; Balasubramanian,1994) Relating ad deconstruction to, “the peeling of an onion in that it is taken apart layer by layer,”Frith (1998) suggests that, “moving from the surface message to the deeper social meaning allows one

to decode images using a comprehensive system of interpretation” (p 113) Therefore, only after

peeling back the layers of Merck’s campaign, can we begin to understand the company’s role inengineering public understanding of HPV and cervical cancer.

Merck’s social marketing approach for the Gardasil vaccination provides a unique platform fortextual investigation, as the three-tiered campaign seemingly pioneered a new model of health caremarketing In examining and deconstructing that which is both said and unsaid in campaign messages,

we put forth a range of reasonable interpretations regarding the cultural implications of Merck’scommercialized awareness messages While Stewart Hall’s framework loosely structures ourinterpretations, we adopt the postmodern belief that “there is no one ‘right’ way to read a text”(Silverman, 2004, p 27) This reading is just one understanding of the nuances underlying Merck’ssocial marketing effort; we do not presume it to be the only, the best, the most comprehensive, or eventhe most accurate We further suggest it is unproductive to measure our reading against other possibleinterpretations, as we see this text through a lens that is colored with our own unique experiences,perspectives, and interpretations

Campaign Overview

Merck worked with advertising agency DDB and public relations firm Edelman (Siers-Poisson,2007) to carefully craft a multistage “think-feel-do” campaign; which ranged from subtleinformational cognitive messaging to establishing preliminary product need, to the more affectiveresonance content aimed directly at the common emotions and feelings shared between mothers anddaughters, and finally moving to the hard sell in the final stages of the campaign As we noted earlier,the company first initiated the HPV conversation in September 2005, one year prior to receiving FDAapproval for the vaccination Through Merck’s financial contributions, the Cancer Research andPrevention Foundation and Step-Up Women’s Network managed the first phase of awarenessmessages in the “Make the Connection” campaign These messages introduced the link between HPVand cervical cancer Soon after, Merck launched a follow-up “Tell Someone” campaign, whichbridged the campaign’s cognitive and affective stages by emphasizing the reality of HPV infection andencouraging viewers to spread awareness Then, on November 13, 2006, one year after initiatingpublic mindfulness, Merck launched its final conative campaign phase, “One Less.” This segmentcompleted the company’s social marketing initiative with a product advertisement for the Gardasilvaccination

Though Merck’s campaign rolled out over a series of three phases, the marketing initiativeessentially breaks down into two major components The opening communication consisted ofunbranded, public service announcement-type messaging, fitting into a category of informational

“disease awareness/education” or “help-seeking” ads Once Merck received FDA approval forGardasil in 2006, the company redirected its focus toward more emotional branded, direct-to-consumer advertisements; pushing its product as a means for HPV protection This chapterdeconstructs the ways in which Merck’s commercial text seemingly aimed to spread publicawareness, motivate personal vaccination, and influence an HPV-free life through product promotion

In line with Stuart Hall’s method of campaign analysis, we identify categories of granted” commercial meaning through a “long preliminary soak” of Merck’s campaign messages.After addressing latent themes, we attend to the overlapping structures of meaning, place the workwithin the context of message production and consumption, and relate our findings to the larger socialcontext Our textual analysis begins with a detailed account of each campaign phase and commercial

“taken-for-sequence that informed public understanding of HPV, cervical cancer, and the Gardasil vaccination.

“Make the Connection”

“Make the Connection” ads initiated viewer awareness of the link between HPV and cervical cancer(Siers-Poisson, 2007) Kimberly Elise and Elisabeth Röhm starred in campaign messages, pioneeringAmerica’s mounting understanding of the public health issue Both spokeswomen carry recognizablenames and notable achievements; Elise earned an Outstanding Supporting Actress Image Award

nomination for her work in John Q, and Röhm is perhaps most known for her starring role in Law in

Order (IMDb, 2017).

Elise starred in the first two “Make the Connection” messages Though nearly identical in design,the similar yet separate campaign messages uniquely targeted two different audiences (young womenand mothers of young women) The ads placed female viewers into separate groups and, in doing so,encouraged viewer attention through audience-specific communication strategies In the “Make theConnection” public service announcement created for mothers, Elise appears comfortable andrelaxed as she lounges barefoot on a white couch In one of the commercial frames, the actress is onthe telephone (presumably with her daughter), firing a series of questions to a person on the other end

of the line; “What time will you be home? Will you be driving? Who are you going with?” Parentalencouragement and motherly wisdom is also conveyed through lines such as, “Be true to yourselfbaby,” and “I am so proud of you.”

The commercial transitions from the light-hearted parody of a typical mother–daughter conversation

to a more important, less discussed message about cervical cancer The actress directly addressesviewers as she confides with mothers that there is something else she is talking about with herdaughters; it is “the connection between cervical cancer and some types of HPV, the humanpapillomavirus.” The actress reminds parents that, “even if they don’t always admit it, our daughtersare depending on us.” The final frame features the names of campaign sponsors, the campaignwebsite, and, in a font smaller than that of cosponsors, the words, “with support from Merck & Co.”

As information is displayed on the screen, Kimberly is heard in a voice-over explaining, “‘Make theConnection’ is a public education campaign sponsored by the Cancer Research and PreventionFoundation and the Step-Up Women’s Network Cervical Cancer and HPV—make the connection.That’s maketheconnection.org.”

Elise’s second “Make the Connection” ad is nearly identical in design and offers similarinformation, however, the script is noticeably molded for a younger audience There is a clear shift invernacular as Kimberly transforms her identity from a concerned, protective parent to her role as afun, confiding girlfriend Again, Elise lounges barefoot on the couch, this time asking the audience,

“Last time you got together with your girlfriends, what’d you talk about?” Elise is featured on thephone, engaging in what is assumed to be typical banter with a girlfriend: “When are we gettingtogether?” “Mmm yeah, I loved him in that movie.” “Those are my shoes!” “Trust me.” “Can youbelieve it?!” “Love you in that dress, look at you.” The ad mirrors the previous commercial structure,progressing from facetious conversation to a more urgent tone, with Kimberly suggesting to youngwomen that, “the next time [they] get together, [there’s] something more important to talk about.” Sheintroduces the connection between HPV and cervical cancer, and explains that it is “a virus thatcauses cervical cancer in thousands of American women each year.” Elise indicates that she is talkingabout it with her girlfriends and encourages the audience to “help someone [they] care about.” The

commercial’s conclusion mirrors that of its sister ad.

The third awareness ad in the “Make the Connection” campaign features Law and Order actress,

Elisabeth Röhm Unlike Elise’s messages, Röhm’s ad immediately establishes the virus’s link tocervical cancer The message begins with the actress sitting outside on paved steps, elbows on knees,leaning into the camera Röhm explains, “There’s something I want to tell you that could save yourlife.” The camera scans left, bringing two businesswomen into view As the women pass Elizabeth,they take charge of spreading awareness, explaining that cervical cancer is, “a cancer diagnosed inthousands of American women each year.” The camera returns to Röhm, and the speaking role shifts

to a female jogger as the actress and runner cross paths Simulating a baton hand-off at a high schooltrack meet, the ad forwards information from one woman to another Within 30 seconds, viewers hearfrom two businesswomen, a female jogger, a policewoman, and what appear to be a mother anddaughter walking through a scenic garden (see figure 3.1); all of whom address the relationshipbetween HPV and cervical cancer

Figure 3.1 Mother and daughter discuss HPV and cervical cancer in the “Make the

Connection” ad.

Elizabeth Röhm returns to the camera’s lens in the final frame and encourages viewers to visit thecampaign’s website Like preceding ads in the “Make the Connection” campaign, the URL, campaignsponsors, and words “Merck & Co.” are superimposed across the bottom of the screen during thefinal seconds of the ad Figure 3.2 features the final frames for the “Make the Connection” messagesfeaturing Kimberly Elise

Figure 3.2 Final frame in the “Make the Connection” ads starring Kimberly Elise.

While Elise’s message offered the public a warm welcome into campaign conversation, Röhm’s adartfully and subtly shifted the overall campaign tone The spokeswoman’s immediate and directapproach more strongly conveys issue importance, and helps drive campaign momentum as Mercktransitions into the next stage of the awareness movement, “Tell Someone.”

“Tell Someone”

The second tier of Merck’s campaign included two ads, also both similar in their emotional nature.Through slightly different scripts (full commercial transcripts for pre-FDA ads are provided inappendix A), campaign messages encouraged viewers to spread awareness of HPV and cervicalcancer The ads feature a diverse cast of women, many of whom are wearing “Tell Someone” t-shirts(see figure 3.3)

Figure 3.3 Still frame of Merck’s branding & the “Tell Someone” T-Shirt.

In an interview-like fashion, females express their shock after learning about HPV; one woman tellsthe audience: “I just found out that cervical cancer is caused by certain types of a common virus.Cancer caused by a virus HPV, human papillomavirus I didn’t know that.” Another indicates, “Iwas stunned at how many people have HPV I was stunned Mill—Millions? That’s insane.”Commercial frames often feature a well-kept community park in the background An actress portrayal

of a female physician momentarily appears outside a hospital building to explain that, “for mostwomen, HPV clears on its own, but for some, cervical cancer can develop.” The commercial returns

to the park setting and audiences hear from female interviewees once again: “I feel like myresponsibility is to just tell everybody that I know.” “I just want to tell someone I love I want to tell

my sister I want to tell my mom.” “I want to tell everyone I know.” Though the commercials do notspecifically mention Merck, the company’s logo briefly appears in the upper right-hand corner duringone of the final frames in the first commercial, rotating to the upper left-hand corner in the followingversion The two advertisements provide the campaign’s website (www.tellsomeone.com), a number

to call for more information, and conclude with a white screen featuring the “Tell Someone” tag line.Through strategic commercial choreography, “Tell Someone” ads generated a “real world”representation of the dissonance between palpable risk and awareness level The second phase of theawareness campaign presented the audience with a call to action and a way to reduce that dissonance,asking viewers to “tell someone [they] love.” In doing so, the “Tell Someone” messages encouragedviewers’ emotional involvement with prevention efforts and set the stage for the third phase inMerck’s rollout campaign

“One Less” and “I Chose”

Arriving at phase three, Merck made a clear shift from an educational awareness campaign to adirect-to-consumer messaging strategy that focused on increasing intent to purchase “One Less”introduced Merck’s breakthrough vaccination through a heavily branded, 60-second direct-to-consumer advertisement First in the series of post-FDA product commercials, “One Less” adsfeatured a medley of girls engaged in a variety of healthy activities (including a skateboarder, soccerplayer, horseback rider, basketball player, a musician playing the drums, a group of females dancing,

and frozen snapshots of women posing with friends and family) The young actresses are featuredsaying, “I want to be one less woman who will beat cervical cancer,” and toward the end of the firstadvertisement, a group of girls chant “O-N-E -L-E-S-S, I want to be one less One less.” The finalframe features “Gardasil” in bold, white letters against a black background The vaccination’sinsignia, the pharmaceutical company’s name, and Merck’s logo appear in the lower right-handcorner The frame includes the product’s website, gardasil.com, and a phone number for viewers tocall with questions or concerns.

In a slightly different version of the “One Less” commercial, mothers assume the featured role.Commercial frames include a mother and her daughters looking over an informational cervical cancerpamphlet at the breakfast table, a family discussing the risk of cancer in what appears to be the familycamping trailer, and a mother braiding her daughter’s hair on the beach The script remains relativelythe same, though it takes on a more family-oriented tone Specific lines include, “one less familyturned upside down,” “one less daughter,” and “one less friend whose life might be affected bycervical cancer.” A black screen with the words “Get Vaccinated” written in large, white font acrossthe dark background completes the final conative phase of Merck’s social marketing mission

“I Chose” offered a sequel to the awareness narrative, but mirrored the “One Less” ads Thecommercial features different women and girls explaining why they chose to get vaccinated The “IChose” and “One Less” ads completed the three-tiered social marketing campaign; which establishedthe problem, created emotional and intense feelings around the problem, and then left the audiencewith a preventative product for the heavily advertised health threat

DECODING THE TEXT

The first phase of the campaign rollout tapped into the power of fame transferal and directed messages to initiate viewer interest Research indicates easily recognizable, relatable, andculturally iconic cues facilitate message recall Indeed, celebrity endorsements often secure audienceattention and engender consumer trust Industry logic also suggests famed testimony candidly verifiessupport for the awareness effort, which further facilitates message impact (Lindstrom, 2011).Accordingly, “Make the Connection” ads reinforced message credibility through recognizable andrelatable celeb personage As both mothers and actresses, the “Make the Connection” spokeswomenfurther enhanced endorsement authenticity and source credibility While unique star credentialsseemingly functioned to wed viewers to campaign messages and awareness efforts, commercialmodeling operates on the “understanding that it is others, like oneself, who provide the mostinformative social criterion for comparison” (Bandura, 1986, p 421) Therefore, by categoricallyplacing female viewers into separate groups, opening “Make the Connection” messages moreeffectively and efficiently appealed to two, diametrically opposed consumer segments (mothers anddaughters)

audience-The first two “Make the Connection” ads each lasted 60 seconds, included 16 different commercialframes, and used comparable camera techniques Both messages featured the same spokeswoman(Kimberly Elise), in the same outfit, delivering the same information, from the exact same setting.However, the two advertisements feature considerably different messages despite such similarities.The “Make the Connection” campaign created a sense of exclusive membership through viewer-specific ads Besides the obvious purpose of providing more direct and relevant information toaudience groups, research shows that “eliciting the interest and approval of a specific type of person

is one of the principal goals of commercial advertising; giving viewers a sense that only people likethem can discern a particular message may be an effective way of reaching that goal” (Messaris,

1998, p 189) The company identified with the target market through specialized segment messaging,and capitalized on audience-specific emotional appeals to prompt consumer-specific behavior

Both “Make the Connection” messages carry a feminine undertone Pink rippling curtains, colored pillows, and color-coordinated apparel established the campaign’s focus on gender-centrictactics, and further appealed to the instinctive responses of both viewer groups (again, mothers andyoung women) Indeed, Lee-Wingate (2006) explains that in terms of ad design, color choices arestrategic, intentionally chosen, and speak to one’s innermost feelings and emotions Pink’s emotionalcharacter conveys a sensitive and gentle tone; often personifying womanliness, tenderness, comfort,security, and innocence Principles of color psychology further suggest that the warm and caringindividual favors the color pink (Feig, 2006) Merck arguably “pink-washed” the initial two “Makethe Connection” ads to further connect with the company’s consumer base We will later argue inchapter 8 that Merck’s emphasis on feminine constructs complicated co-ed vaccination efforts oncethe U.S Advisory Committee on Immunization Practices (ACIP) recommended Gardasil for bothwomen and men in 2011

rose-The campaign’s color choice further capitalized on intrinsic associations tied to female healthcrusades, as it relayed an official sense of women’s health Arguably, the Susan G Komen foundationcolor-coded women’s health in 1982, when the organization designed a pink ribbon logo for the

Komen Race for the Cure (Susan G Komen, 2017) The symbol grew to represent breast cancer

awareness, and the “pink-washing” that followed early cause-marketing efforts set the stage for the

socially constructed coloration of female health (Brainerd Dispatch, 2007) Merck’s strategic array

of pink tones in campaign messaging calls forth implicit and deeply ingrained color connections tofeminine well-being Indeed, many participants in our focus groups and eye tracking research(presented in later chapters) reported “pink” as a memorable part of campaign communication.Notably, many also incorrectly identified the Susan G Komen Foundation as a campaign sponsor ofMerck’s public awareness effort

“Make the Connection” messages demonstrated strategic reliance on the power of semiotics, socialconstructs, as well as strategic geometric design Recall that Elise welcomes viewers into a stagedliving room, in which silky pink curtains blow softly in the background Three oversized, decorativepears rest in an equally oversized ornamental dish (see figure 3.4) Though seemingly irrelevant, therippling curtains and pears’ curvature promote female identification with the campaign’s message, assoft curves and flowing contours are visually (and loosely) analogous to a woman’s body Indeed,such design forms function as a gender-specific ad strategy (Jeffries, 2007)

Figure 3.4 "Make the Connection" capitalized on strategic colors, shapes, body positioning,

and the power of semiotics to entice female interest.

Body language also acts as an agent of persuasion Kimberly Elise positions herself in various waysthroughout both ads, but remains facing the camera at all times This attention-getting kinesics strategyserves to capture interest and inspire trust; summoning our real-life tendency to look back when beinglooked at (Messaris, 1997) Notably, this specific body manipulation is also a common targetingtactic for messages directly seeking to influence women (Messaris, 1998) As a case in point, the

“Make the Connection” ad featuring Elisabeth Röhm similarly embraces the physical approach.Toward the start of the message, Röhm points her finger toward the camera as she explains theconnection between HPV and cervical cancer

Her noteworthy body language evokes physical similarities to the “I want you!” Uncle Sam ads,prominent throughout World War I (see figure 3.5) Though created decades apart, both Röhm and theUncle Sam caricature seem to reach into the audiences’ space and actively involve the viewer(Messaris, 1997) Röhm’s body orientation toward the camera and head-on eye-to-eye deliveryfurther simulates the connection between interpersonal closeness and involvement that often occurs inreal life The kinesics language models a straightforward, nothing-to-hide approach and serves topromote message attendance and stronger viewer engagement (Messaris, 1997)

Figure 3.5 Elisabeth Röhm uses strategic body language in “Make the Connection” ad.

Perhaps recognizing the social and financial value of targeting preteens, young women, and mothers,Merck Pharmaceuticals adapted the commercial text of risk messages to fit the tendencies of thedefined audience and the social norms of the 21st century Though “Make the Connection”strategically integrated colors, shapes, and cultural constructs to connect with a female audience,limited character diversity curbed opportunities for message identification among Merck’s targetaudience Indeed, evidence shows a viewer’s perceived similarity to character representationenhances modeling effects; therefore, assorted actors often boost advertisement persuasiveness(Bandura, 2001) While “Make the Connection” integrated celebrity endorsements and other designtactics that seemingly served to attract viewer attention, the campaign’s character representationfailed to identify with a vast female audience

Relatable/effective character representations are typically perceived as trusted predictors ofmodeled outcomes, and therefore drive the self-efficacy needed to convert knowledge into behavior

As is the case for most social marketing efforts, the first campaign phase concentrated on attractingviewer attention with relevant information to effectively drive consumer engagement in subsequentphases Merck’s opening commercials favored celebrity sponsorships over diverse charactermodeling, and provided minimal context regarding the HPV health threat (such as means oftransmission, preventative behaviors, or viewer susceptibility) Therefore, other than establishing thevirus’s connection to cervical cancer and encouraging viewers to talk with their doctor, the ads failed

to relay effectual information Merck’s evasive messaging in the first campaign phase may have beenintentional “Make the Connection” ads arguably advanced a need for knowledge and effectivelycreated dissonance among the target audience through a tease of limited health information and subtlethreats to personal well-being Indeed, focus groups later indicated the strategic bait of information inthe preliminary “Make the Connection” campaign, combined with the unresolved nature of the healthrisk, left concerned audiences reaching for more

As D’Silvia and Palmgreen (2007) note, “PSAs are created with the intention that the audiencewould at some point in the future respond positively to the information Hence, apart from attention,encoding and recall become an integral part of developing appropriate messages” (p 67) In line withthe standard stages of public awareness efforts, “Make the Connection” promoted awareness and

perhaps initiated consumer concern Retention, recall, and behavioral responses, however, typically

require strategic character modeling (Bandura, 2001) As Messaris (1997) indicates:

Encouraging viewers’ identification with the people in images may be the most common way in which visual advertisements exploit their iconic relationship to our real-world visual and psychological experiences In our real-world social interactions, our psychological capacity to identify with other people enhances our ability to predict their actions toward us, and it also allows us to learn through observation By identifying with someone else, we turn the observed consequences of her or his actions into lessons for our own lives (p 44)

In other words, people are not limited to direct learning experiences; they can also gain knowledgethrough secondhand experiences (such as actions, outcomes, and events in the lives of others).Therefore, while Merck’s first campaign phase served to gain viewer attention by providingimpactful and unexpected information, the second tier of messages arguably functioned to establishpersonal relevance through emotional cues

Characters perceived to share similarities with the viewing audience often enhance both sociallearning and behavioral modeling “Tell Someone” messages encouraged broader audienceidentification through a more diverse representation of actresses/characters As an attention-gettingstrategy, commercials featured head-on, or direct, interviews with a collection of women The candidcamera-like simulation stressed virus prevalence and showcased women’s shocked reactions afterlearning more about the connection between cervical cancer and HPV Though seemingly innocuous,

as noted earlier, the campaign’s eye-to-eye interview approach is a distinctive and deliberate designtactic for ads targeting women (Messaris, 1998) Moreover, emotional expressions often activatesimilar feelings and responses in engaged viewers As Bandura (2001) indicates, people are easilyinfluenced, or stirred, by the emotional expressions of others In other words, watching individualsrespond emotionally to inciting circumstances often motivates emotion-stirring thoughts and implicitsimulations in oneself Innate mirroring tendencies suggest viewers will react to the modeledexpressions in a similar surprised fashion, and in doing so, become more engaged with the issue

The community park “interviews” also cleverly promoted a sense of joint responsibility and

“togetherness.” Semiological frameworks suggest the viewer is a masterful decoder, movingproficiently from signifier to signified (Bordwell, 2012) Though the effect may not be consciouslyrecognized, specific commercial elements oftentimes deliver a nuance of meaning that resonate withthe viewer psyche Accordingly, the architectural style of buildings, the attire of characters, and otherseemingly irrelevant commercial elements are often intentionally chosen to reinforce thecommercial’s message Communication strategists commonly integrate physician portrayals intohealth campaigns to foster message credibility, and images of hospitals are thought to induce fear,apprehension, and anxiety The color green may also impart notions of flourishing health, cleanliness,innocence, and youth (as green often implies nạveté)

Therefore, fused commercial imagery in “Tell Someone” ads (a physician standing in front of ahospital; shocked women speaking from a grassy park) arguably conveyed a threat to women’s health.Tactical juxtaposition of the “Tell Someone” mantra further encouraged communal responsibility inspreading awareness (see figure 3.6 for a still frame featuring the modeled interviews from the “Tell

Someone” campaign).

Figure 3.6 Mother and daughter model word-of-mouth behavior in “Tell Someone” ad.

“Tell Someone” engineered a psychological environment conducive to establishing direct relevanceand elevating viewer concern During this campaign stage, the company conceptualized civic duty andurged women to believe that, as members of the female community, they have a social responsibility

to “tell someone” about the HPV virus Strategic character modeling in the “Tell Someone” campaignalso provided a “real-world” representation of misaligned risk perceptions Whereas “Make theConnection” repeatedly indicated that HPV is “a virus that causes cervical cancer in thousands ofAmerica women each year,” “Tell Someone” ads stressed that millions of people have HPV.Commercial rhetoric artfully aligned risk perceptions and infection likelihood, reminding viewersthey are the primary stakeholders in the awareness effort (as focus groups later indicate in chapter 4,the second stage of the rollout campaign more effectively communicated with viewers, largely in partdue to model diversity) This phase seemingly intended to encourage word of mouth marketing amongviewers and non-viewers, setting the stage for the third phase in Merck’s campaign, “One Less.”

The company released the “One Less” and “I Chose” Gardasil advertisements in 2006, heavilypromoting its product through multimedia platforms In doing so, Merck made a very clear move from

educational awareness (meant to influence women cognitively and affectively) to direct-to-consumeradvertising during the third and final phase of the social marketing effort (seemingly to influencepurchasing behavior) Fashioning a finish to an endorsement operation, post-FDA product approvedmessages communicated a sense of urgency and offered a preventative solution for the heavilyadvertised health crisis “One Less” and “I Chose” completed the three-tiered social marketing effort,leaving the audience with a call for immediate action.

Evolutionary scholarship, along with tenets of social cognitive theory, demonstrates the marketvalue and social power underlying Merck’s rollout campaign Identified as the strongest of allconsumer motives, the human drive for survival often dictates the nature of communication reception,cognitive processing, and health care behavior (Maddock & Fulton, 1996) Leon Festinger’s seminalwork on cognitive dissonance suggests that the greater the discord between health knowledge andbehavior, the greater the need to balance thoughts and action Festinger (1957) maintained that “soft”social pressures are particularly powerful at driving dissonance and inciting subsequent behaviormodifications Seemingly, Merck’s early awareness campaigns served as a “soft” messaging strategy.Preemptive communication heightened viewer knowledge/awareness, which in turn, propelledinternal conflict among audience members when presented with the preventative, yet controversial,solution (Gardasil)

Based on the principles of cognitive dissonance, Merck’s strategic timing and design of campaignphases encouraged consumers (specifically mothers) to accept/seek out the vaccination to easeheightened anxiety Prescription drug companies commonly play on audiences’ primary fears tomotivate consumer behavior, and women are particularly reactive to natural protective instincts(Main, Argo, & Huhmann, 2004) As Lee-Wingate notes:

Self-reported guilt in consumption contexts is categorized into guilt arising from either actions or inactions related to a) others in close and distant relationships, b) societal standards, and c) oneself Mothers are affected by all three categories of the consumptions [of] guilt, not just one [when] it entails the children who are in an extremely close relationship to themselves (p 262)

Accordingly, “One Less” messages focused on the threat of youth infection, and in doing so,capitalized on the universal, and very powerful, maternal drive Specifically, messages that showchildren at play or “imply a worst-case scenario” are often successful targeting strategies (Feig,

2006, p 211) Feig (2006) warns, however, worst-case scenario is only effective if the negative isimplied, without actually being said Merck’s strategic ad design, young commercial cast, andcleverly constructed tag line (“One Less”) promoted parental dissonance, ultimately suggesting thatwithout the vaccination, the viewer’s child will very likely be “one more.”

Young females modeled typical adolescent behaviors, and appeared blissful and healthy throughoutcommercial spots Ads also implicitly signified a youthful orientation through a more rapid editingspeed (Messaris, 1997) Nearly a full second shorter than the average length of a commercial frame(MacLachlan & Logan, 1993), “One Less” commercials featured over 17 different girls engaged invarious activities Bordwell (2012) argued that cutting shots together can encourage associations andbuild emotional overtones that ultimately structure viewer perceptions, thoughts, and mindsets High-speed tempos can help boost an ad’s perceived energy level—and high energy is an attribute of youth(Messaris, 1997) Fast cuts also promote a more emotional reading of texts, as the audience does nothave time to cognitively process the message Therefore, through both visual and verbal commercialtext, “One Less” communicated the importance of early vaccination

However, the messages were never purely emotional or informational “One Less” commercials

emphasized the vaccination’s medicinal utility, spelling out (letter by letter) Gardasil’s instrumentalvalue The message design appealed to human emotions, promoted female health, and promptedviewer motivation through vicarious learning opportunities Merck subtly emphasized the rewardsassociated with modeled behaviors, and in doing so, stifled associations between the vaccination andpremarital/preteen/promiscuous sex.

Indeed, the suppression of presence is a particularly noteworthy phenomenon in advertising strategy(Perelman & Olbrechts-Tyteca, 1971) In describing the value in implicit communication andmessage construction, Hall (1982) explained that symbolic representation “implies the active work ofselecting and presenting, of structuring and shaping: not merely the transmitting of an already-existing

meaning, but the more active labor of making things mean” (p 64) Merck arguably initiated

conversation through a preliminary tease of risk information, and secured consumer buy-in throughideological discourse that defined social practices In doing so, Merck seemingly masked deepersocial issues through clever campaign design and commercial text

It is important to note that despite profitable incentives or corporate intentions, Merck’s campaignultimately served to abate HPV transmission and cervical cancer rates through vaccine promotion.Regardless of utilitarian outcomes, however, the fact remains that message content concentrated onpharmaceutic/consumer-based solutions rather than precautionary behavioral approaches to riskmitigation As such, text deconstruction speaks to the foundational campaign content that informed ourreading of campaign messages

CONNECTING THEMES AND STRATEGIES

Merck’s effort to drive public awareness and encourage viewer engagement artfully unfolded throughboth classic persuasive strategy and unconventional social marketing The three phases in Merck’stiered campaign reflect the corresponding stages in an integrated awareness approach The companyemployed the fame and credibility of relatable spokespersons in initial campaign messages tointroduce the connection between HPV and cervical cancer After initiating HPV awareness in thefirst campaign phase, the company released the “Tell Someone” initiative to better secure stakeholderinterest through more emotional tactics “Tell Someone” messages targeted salient beliefs, balancedinconsistencies between concern and risk, and modeled social responsibility The campaign furtherserved to control health issue framing and generate a wide consumer base through word of mouthdirectives The closing campaign, “One Less,” promoted the highly anticipated, FDA approved,Gardasil vaccination as the “cure” to the problems established early in the campaign

Early campaign phases manufactured an opportunity for Merck Pharmaceuticals to enter the market

in a demagogue-like manner with a preventative vaccination for HPV Collectively, “Make theConnection” and “Tell Someone” introduced the HPV health threat and encouraged concernedviewers to spread awareness of the risk to prevent societal infection The word of mouth strategy, inturn, allowed Merck to solicit the survival motives of a much larger audience Negative emotionalappeals and task-oriented goals relayed a powerful message that encouraged prevention andpromoted product demand The overall tone and agenda of Merck’s initial messaging, combined withsuggestive enthymemes in the final campaign phase, essentially encouraged vaccination preventionthrough a play on consumer dissonance

Merck’s initial pre-FDA approval campaign phases followed the standard formula for promotionalhealth communication, with texts that included celebrities, diverse character representation, and

actress portrayals of medical professionals Campaign messages also incorporated set designs,commercial props, and modeling strategies that specifically appealed to female-oriented messageprocessing Through gender-oriented texts, the “Make the Connection” and “Tell Someone” messagesencouraged audience engagement, and compelled female viewers to remain involved in learning moreabout the health threat Though thematically distinct, Merck’s structured follow-through of the socialmarketing campaign offered solid reference points for female viewers’ evolving understanding of theHPV health issue.

While each individual campaign maintained a specific marketing tagline, the uniform focus oncervical cancer and female solidarity homogenized the rollout effort and connected eachadvertisement to the need for and value of Merck’s HPV vaccination Merck’s campaign themesencouraged females to take control over personal well-being, and reminded the consumer base thatthey are the primary stakeholders in nationwide inoculation efforts Tag lines offered a blueprint forliberation and action, suggesting women “make the connection,” “tell someone,” and become “oneless” through Gardasil inoculation (see figure 3.7 for visual references) A close deconstruction ofcampaign text, however, suggests Merck’s strategic campaign design manufactured an artificial (orcommercialized) notion of female empowerment

Figure 3.7 Commercial tag lines in Merck’s three-tiered campaign provide blueprint for action.

Essentially, Merck constructed a profitable pseudo-reality in which its target audience perceivedthemselves to be the driving force behind vaccination development This campaign speaks to theincreasing medicalization of American society, and appeals to a public that often relies onpharmaceutical treatment rather than positive life-style choices/changes See, for instance, theongoing debate around ADHD diagnosis and treatment (Comstock, 2015) for another example of thisphenomena As noted earlier, while most successful social marketing campaigns aim to change anegative behavior, Merck’s marketing initiative did not promote safe sex or other autonomousbehaviors as a means for HPV prevention Instead, the company’s commercialized social marketingencouraged vaccination as the primary means to avoid contracting HPV Merck ramped up messageintensity throughout each stage of the rollout effort Though the first two phases of the campaignemphasized HPV awareness and protection, the third and final phase put forth a commercial solution

to the health threat (at one point in time, the “One Less” advertisements went so far as to faultily

present Gardasil as a vaccination for cervical cancer) Merck proficiently satisfied the imperiledconsumer with a pharmaceutical solution (Gardasil) Therefore, campaign directives essentiallypromoted self-efficacy and female empowerment through medicalized treatment and productpurchase.

Merck’s commercial cinematography also served to steer audience attention away from thecompany’s branding in early awareness efforts Merck solicited nonprofit proxies to deliver theawareness messaging in the early stages of the campaign rollout Through this “third-party technique,”

“Merck reached audiences that could have rightly been suspicious of the message if it had comedirectly from a pharmaceutical company” (Siers-Poisson, 2008, p 242) Merck’s strategic, subtle,and revolving logo in the “Tell Someone” ads provides further opportunity to dismiss notions ofrandom or haphazard brand placement Shifting brand location suggests conscious consideration overcorporate markings Merck’s messaging strategy and commercial aesthetics arguably distractedviewers from pharmaceutical involvement, and in doing so, redirected viewer focus on personalresponsibility to share information, or “tell someone.”

Effective health communication relays information, targets risk perceptions, and promotes efficacy (Meyerowitz & Chaiken, 1987) In line with the notion that advertising can be madememorable through brief, three- to five-word, declaratory statements (Maddock and Fulton, 1996),the titles of Merck’s campaign phases in and of themselves model the principle tenets of for-profithealth communication Each marketing phase engaged in memorable messaging strategy throughsuccinct, simple summaries of not-so-simple issues Arguably, each campaign tier advanced viewerresonance through medical consumerization rather than knowledge building and information delivery.Assuming behavior is learned through observation, imitation, and identification, Merck’s campaigncommunicated a commercialized understanding of HPV and cervical cancer

self-Socratic scholarship suggests that beautifying health information distorts the essence of civicdiscourse and threatens the quality of human knowledge Though public health and media ethics areclosely related, “discussions about ethics are seldom heard in daily health communication practice”(Bouman & Brown, 2010, p 42) This campaign deconstruction outlined our informed interpretation

of the persuasive strategies underlying Merck’s vaccination communication The following chapterenhances message readings with consumer feedback, and highlights ways in which Merck’s rolloutcampaign informed viewer understanding of HPV and cervical cancer Specifically, chapter 4supplements this interpretive analysis with focus group feedback, offering firsthand accounts ofviewer understanding, awareness, and attitudes regarding HPV health messages and the Gardasilvaccination

Chapter Four

Social Trust and Public Health

Now that we have fully examined the materials used in Merck’s launch of Gardasil, we turn ourattention toward audiences What are the effects of Merck’s method of establishing the marketplacefor a public health need? How do audiences perceive commercialized health messaging? Shore(2003) explained, “Just as trust is good medicine, it is also good business; high levels of trust bothfurther an organization’s mission and help build its margin Indeed, it may not be too much to say thatthe organization that owns trust owns its marketplace” (p 36) Though there is a case to be made forutilitarian outcomes, the unique nature of campaign development, networked agendas, and vaccinationefficacy calls Merck’s marketing ethics into question In this chapter, we take a close look at howviewers perceived Merck’s social marketing efforts and the company’s eventual launch of theGardasil vaccination By talking directly to audience viewers, we investigate public reception ofcampaign communication and the overlapping motives that merge social marketing withcommercialized strategy How does viewer awareness of corporate involvement influence thereception of campaign messages, and how do participants distinguish between pharmaceuticalmarketing and social awareness campaigns?

OUR RESEARCH APPROACH

As demonstrated in chapter 3, Merck’s rollout campaign presents a subtle, but clear-cut example ofhow a social marketing campaign can artfully evolve into a direct-to-consumer product promotion.Given that much of our own behavior stems from both conscious and unconscious reactions toenvironmental stimuli, the next logical step is for us to consider the thoughts of the people affected bythe campaign Focus groups provide a way for us to more deeply explore participants’ knowledge,attitudes, and beliefs regarding different topics (Lindlof & Taylor, 2002) Accordingly, we turned togroup discussion to examine viewer interpretations, perceptions, and attitudes toward the Gardasilcampaign Our group panels specifically concentrated on pharmaceutical marketing in relation to theefficacy of health care communication After reviewing and discussing three campaign messagesincluded in Merck’s nationwide marketing operation, collaborative participant feedback offeredinsight to audience perceptions of pharmaceutical advertising and the HPV social marketingcampaign

Procedure

This chapter expands upon earlier research, specifically examining three of the messagesdeconstructed in chapter 3 Having an intimate familiarity of the commercial text threaded throughouteach phase of Merck’s social marketing effort, we were better able to select appropriate messagestimuli for a university-based participant pool We discussed two HPV awareness messages releasedprior to FDA’s authorization of the Gardasil vaccination (the “Girlfriend” version of “Make theConnection” and the “Tell Someone” awareness message) We also included a post-FDA approved