PART 1: 10 QUESTIONS FOR PUBLIC HEALTH ADVOCATES

Most fields of public health have objectives that are highly contested by opponents. Opposition can come from governments, industry, community and religious interest groups, and from within the public health field itself. Ever since John Snow removed the handle of the Broad Street pump and faced the scepticism and wrath of water suppliers and residents,¹ many public health initiatives have met with protracted, fraught, and often highly organised opposition. Road safety advocates have faced concerted opposition from the liquor and automobile industries, devotees of speed, and critics of government revenue raising. Immunisation campaigns have been opposed by diverse groups since Jenner.² Safe injecting rooms and heroin trials for narcotic addicts face virulent campaigns from sections of the churches, local residents, and businesses.³ The tobacco industry with its global resistance to meaningful controls has been described as the leading vector of the lung cancer epidemic: the industry is to lung cancer as mosquitoes are to malaria. Opposition can also take the form of indifference, with some public health issues being neglected because they are “off the political radar” and perceived as unimportant. Mental health has long suffered this fate.

The nature and impact of effective opposition to new public health laws, regulations, taxes, and policies and to greater resource allocation deserves both analysis and potent responses. Public health advocacy, particularly through media advocacy, is the strategic use of news media to advance a public policy initiative, often in the face of such opposition. Media advocacy seeks to develop and shape (“frame”) news stories in ways that build support for public policies and ultimately influence those who have the power to change or preserve laws, enact policies, and fund interventions that can influence whole populations.

CINDERELLA BRANCH

However, for all its importance, advocacy remains a Cinderella branch of public health practice. Advocacy is often incandescent during its limited hours on the stage, only to resume pumpkin status after midnight. Routinely acknowledged as critical to the project of public health, it is seldom taken seriously by the public health community, compared with the attention given to other disciplines.⁴ The status of advocacy as a legitimised discipline remains neophyte: few master of public health programmes formally address advocacy, there are comparatively few textbooks,^5–9 and no journals devoted to its exploration.

Yet like any public health initiative, effective advocacy requires careful strategic planning. Here, the following 10 questions are cardinal. In part 2 of this paper, a case study involving several of these elements is presented. The box provides a list of resources about the practice of public health advocacy.

1 What are your public health objectives with this issue?

Put simply, what do you want to change or preserve? All proposed advocacy strategies need then to be interrogated for their relevancy to achieving these objectives.

2 Can a “win-win” outcome be first engineered with decision makers?

Politicians and other key decision makers are naturally keen to avoid being pressured, and to be seen to lead initiatives. Wherever possible, advocates should try to first work with government to affect a marriage of interests. When obdurate government intransigence is the root problem, criticism is generally unavoidable but will often close doors. In such circumstances, divide your advocacy voices into the moderates who will continue to work the “inside route” with government and the vanguards who will take a critical public role in the media, setting the public agenda.

3 Who do the key decision makers answer to, and how can these people be influenced?

In all democracies, key health decision makers remain answerable to those who appoint or elect them. Political parties hang onto power by virtue of winning marginal seats in elections. If those marginal electorates vote differently at the next election, governments can fall. Health ministers are answerable to political cabinets and health bureaucrats are answerable to health ministers who will not relish their portfolio being criticised. Business executives are answerable to boards of directors. Advocates therefore need to study ways of accessing and influencing those whom key decision makers worry about or who endorse their policies.

4 What are the strengths and weaknesses of your and your opposition’s position?

You, your opposition, and the positions both are advocating require ruthless auditing for the ways in which they are perceived by those whose support and influence is being courted. What you learn here will be critical both to your own presentation and to the tack you take in discrediting your opponents. Know your opposition inside out and keep all manner of antennae alert for feedback about your own organisation’s public reception. Rehearse in role plays the worst questions you could face, and practice putting forward your most compelling points. Go to every interview with a maximum of three points you want to make, regardless of what you are asked.

5 What are your media advocacy objectives?

Your advocacy objectives must always serve your agreed public health objectives, and not be confused as ends in themselves (such as relentlessly pursuing media exposure with dubious connection to your agreed goals). Media advocacy objectives can include causing a neglected issue to become discussed or a much discussed issue to be discussed differently; discrediting one’s opponents; introducing pivotally compelling facts and perspectives into a debate; or introducing different voices in ways calculated to enhance the authenticity or power of an argument.

6 How will you frame what is at issue here?

Political debate is largely about multiple definitions of the same events and accordingly, advocates need to ensure that the way they define what is at issue in a health debate becomes the dominant definition circulating in the community. Framing strategy is the core skill of media advocacy. To frame is to “select some aspects of a perceived reality and make them more salient... in such a way as to promote a particular problem definition, causal interpretation, moral evaluation and/or treatment recommendation”¹⁰ for the issue under debate. For example, the tobacco industry seeks to frame tobacco advertising as freedom of speech, while tobacco control advocates try to reframe it as the highly researched effort at attracting children to smoking that will lead many of them into years of addiction and eventual disease. If the industry’s definition dominates, controls on advertising are unlikely. In Australia, opponents of mandatory fences around garden swimming pools spoke of the fences as Big Brother intrusions into private spaces, while child drowning prevention advocates tried to define fences as being like third party injury car insurance (“if you can’t afford the insurance, you can’t afford the car”).¹¹ As the protection of children frame came to dominate expressed concerns about backyard aesthetics, swimming pool fence laws were more easily embraced by political parties.

7 What symbols or word pictures can be brought into this frame?

The news media’s demands for brevity require that we maximise every opportunity to leave a lasting impression with readers and media audiences. Many public health issues appear arcane, technical, and impenetrable to ordinary people and unlikely to excite public or political interest. To gain their attention and to locate public health issues in shared value frameworks, the perspicacious and evocative use of analogy and metaphor is important. Think of how the change you want has parallels and precedents in other widely embraced areas of public life. Associate your cause with the same values that underlie these accepted issues.

Advocates also need to appreciate the dramaturgical dimension to news gathering.^12,13 Significantly, journalists refer to those appearing in the news as “talent” and audiences often assess news “performance” through criteria like believability, trustworthiness, and how likeable those in the news were. Decide which “role” you want to play and how you will seek to cast your opposition.

8 What sound bites can be used to convey 6 and 7?

The length of time given to newsmakers to speak in the media continues to shrink.¹⁴ Often, these “sound bites” are the only statements reported and so assume critical importance. The larger the audience for a news bulletin, the more truncated is the time devoted to each item. Those who disdain and eschew such news media should be disqualified as serious advocates. Every interview with a journalist should plan to inject at least one sound bite into the conversation. These are pithy, memorable, and repeatable summations that can come to epitomise a debate. A memorable example: “a non-smoking section of a restaurant is like a non-urinating section of a swimming pool”.

9 Can the issue be personalised?

A senior Sydney journalist once told me “experts are fine, but they are not actually a living thing”.¹⁵ Journalists hunger for ways to locate health stories within stories about real people who are affected by a health problem. Experts are typically stock embellishments to the “real” human story that is crafted to address the concerns and interests of ordinary readers. If journalists will try to ground the story via an ordinary citizen’s perspective, involving consumers in your advocacy group will be important as you will be seen as having both expertise and authenticity.

10 How can large numbers of people be quickly organised to express their concerns?

Statements from “the usual suspects” who always speak up for an issue risk being marginalised by politicians as predictable and unimportant. Efforts to build vocal constituencies for issues who are willing to speak up at strategically important times should therefore be given high priority. Newspaper letters pages are seen as key barometers of community concern. All politicians talk of the impression they gain from the reaction (or lack of it) of their electorate to issues in the news. Internet tools such as distribution lists, list servers, and chat rooms permit instant mass dissemination of “action alerts”: email templates that describe a problem, provide key pieces of information, outline suggested courses of action, and equip recipients with relevant facts and data. Within minutes, thousands of people can be mobilised to write letters to politicians and newspapers, call radio stations, vote in online opinion polls, or petition decision makers.

REORIENTING PUBLIC HEALTH AGENCIES TOWARD ADVOCACY

There is much that inhibits the development of more widespread and effective advocacy. Given that influencing government policy is often the object of advocacy, government funded public health workers mostly see advocacy as strictly off limits. Boards of charitable non-government agencies can also be inhibited by perceptions of heated debate with opposition groups distracting from their “community friendly” images. Conservative governments seeking ways of reducing criticism sometimes make charity status, essential in attracting tax deductible donations, conditional on agencies not engaging in advocacy.

The result is that much advocacy suffers from being concentrated in poorly resourced grass roots community groups who can struggle to have their voices heard. Colleges and professional associations have therefore a special responsibility to join with citizens in embracing advocacy for evidence based objectives. Members who may be government employees can participate in advocacy efforts wearing their professional hats.

PART 2: ADVOCACY IN ACTION: KEEPING TOBACCO COMPANIES OFF CAMPUS

On 4 August 2003, the University of Sydney’s vice chancellor announced that a former premier of NSW and current chairman of British American Tobacco Australia, Nick Greiner, was resigning from the chair of the advisory board of the university’s new Graduate School of Government. The announcement culminated several weeks of advocacy among staff, students, and university senate members to achieve this end. Below, I review the core strategies used, illustrating several of the principles described above.

WHAT WAS THE PROBLEM?

As a pariah industry¹⁶ under siege from the WHO, governments and an ever-growing section of the public angered at its conduct, the tobacco industry has sought to diffuse this criticism by promoting itself as socially responsible.¹⁷ Benefaction of programmes for the homeless and domestic violence prevention¹⁸ and support of university research¹⁹ including the provocative establishment of a centre of business ethics²⁰ are among recent strategies designed to “enhance our position within the socio-political environment.”²¹ Engaging in the affairs of government, the business and wider community is another, where spin off commercial benefits for the industry are always paramount. As a 1995 BAT memo put it: “Systematic contact should be maintained with key audiences whose goodwill and co-operation can help companies achieve their business objectives... Steps should be taken to ensure that non-executive directors are given the opportunity to play a full and appropriate role in relationships with government and other appropriate audiences.”²²

On learning of Greiner’s appointment, a contradiction was obvious of the spirit of the university’s 1982 policy²³ that has since prevented any member of the university from accepting support from a tobacco company. I immediately protested about the appointment to the Chancellor (web link 1, see journal web site http://www.jech.com/supplemental). His response emphasised that the appointment had “no connection whatsoever with any tobacco company or any role Mr Greiner may have on the Board of such a company.” (Web link 2 http://www.jech.com/supplemental). This was to become the central argument advanced by the appointment’s defenders.

GOALS

The appointment held potential to become a vital symbolic increment in the social and political rehabilitation of the tobacco industry that has long occupied bottom feeder status as the nation’s least trusted industry.²⁴ Leaving it unchallenged risked allowing the corporate strategy to flourish, expanding the tobacco industry’s vital elite to elite communication opportunities with the expected pay offs in achieving the company’s euphemistically phrased “business objectives”. Our goal was to overturn the appointment and thereby signal to other institutions that such appointments were inappropriate and would risk infecting universities with the opprobrium of tobacco industry collusion. A leading university showing the nation’s most senior tobacco official the door would ignite public debate that promised to consolidate Australian universities’ resolve in this matter (web link 3 http://www.jech.com/supplemental).

STRATEGIES: NETWORKING AND THE INTERNET

It was vital that the complaint be not dismissed as the predictable response of well meaning but zealous individuals. I therefore emailed my letter to the chancellor to hundreds of colleagues, including several listservers, urging recipients to protest about the appointment and attend a dignified demonstration outside the inauguration. Dozens wrote to the chancellor. Email, in rapidly disseminating “action alerts” at virtually no cost, can mobilise thousands within minutes of being sent.

NEWSWORTHINESS

The conflict was pregnant with compelling news narratives that promised to unfold as the episode evolved. Elementary ethical subtexts abounded: the 1982 policy suggested the university was ignoring the spirit of its own long established principle (hypocrisy). Would the university place principle above its short term embarrassment at having to withdraw its ill considered invitation to Greiner (expediency)? Would staff and students succeed in overturning an appointment made by the university’s highest official (the mouse that roared)? How would Greiner react to the news that many found his vaunted presence on campus obnoxious (the emperor’s new clothes)?

Lead stories of morning newspapers influence radio and television news agenda during the day, so I provided a print journalist with an exclusive. The next day it was front page news,²⁵ rapidly becoming a favoured radio topic for specialist political panels and talk back callers. Instead of an arcane internal university policy tiff, it had become a big public story.

The demonstration coincided with student exams and drew about 50 participants, almost outnumbered by security staff and news media²⁶ (fig 1). Serendipity dealt her kind hand by arranging for the first raucous chorus of “Nick off, Nick-otine Nick” to rise at the precise moment Greiner took to the podium inside the ceremony.

BEHIND THE SCENES LOBBYING

The university senate, as the university’s supreme policy forum, comprised half elected staff, student and alumni members and half government appointments. Several elected members angered by the appointment requested it be put to a vote at the next senate meeting. From 21 voting members, lists were compiled of those who could be relied on to vote for and against the appointment, with a third being those whose votes were considered unpredictable. The predilections of each in the third group were reviewed, and appropriate people designated to make contact with each to sell the case against endorsing the appointment.

Greiner’s supporters also lobbied the same group, but wasted energy trying to convince obvious members of the opponent camp of their folly, thus telegraphing their punches for the senate debate and allowing the preparation of anticipatory responses.

I wrote a letter outlining the case against endorsing Greiner to all senate members (web link 4 http://www.jech.com/supplemental) and circulated an article from a leading Sydney ethicist (web link 5 http://www.jech.com/supplemental), who pilloried the notion that people could somehow avoid being the sum of their parts. Greiner, he said, was unavoidably a tobacco boss and so the connection would need to be confronted.

The vice chancellor’s motion to the senate read “that while deploring Mr Greiner’s continued involvement as Chair of British American Tobacco in Australia, Senate endorse the appointment to the Advisory Council”. It was defeated 10–7. Jubilation at the expected announcement that Greiner would stand down was then dampened by a cryptic statement from the vice chancellor that it was unclear whether the senate in fact had any jurisdiction in the matter. The episode now threatened to metamorphose into one of senate authority, which might erupt into a wider confrontation.

SOUNDBITES

Thirty six days passed between the initial protest to the chancellor and the resignation. In this period, the issue was extensively covered in the media. A newspaper commissioned an opinion piece (web link 6 http://www.jech.com/supplemental). The repeated insistence that Greiner’s appointment reflected his political experience but not his tobacco pedigree threatened to become the dominant definition of what was at issue and thus required memorable rebuttal within the constraints of news media soundbites. Examples included:

• “this is today’s version of the Jeckyll and Hyde defense: the upstanding citizen by day, who strenuously denies his evening persona has any relevance to his overall reputation”

• “the mafia boss who places $500 in the church plate fools no one”

Similarly, the notion that universities should embrace free speech in the “marketplace of ideas” and not subject tobacco—always described as a “legal product”—to a politically correct witch hunt was countered with examples of other entirely legal benefaction or association that any self respecting university would instantly eschew without debate. For example:

• a wealthy holocaust denier wanting to establish a school of war history

• a chain of brothels offering to fund a chair in erotic literature

The tobacco industry would have liked nothing more than for the appointment to be seen as utterly routine: tobacco chiefs are like any other corporate official. These analogies and word pictures sought to anchor people’s assessments of what was at issue to readily understandable and apposite comparisons, thus affecting a denormalisation of the appointment.

CONTINGENCY PLANS

With the hiatus between the senate vote and the announcement of the resignation at the August senate meeting, contingency plans were made on the assumption he would not resign. Revelations made in the interim period that BAT had knowingly destroyed documents that would have assisted dying litigants were to be emphasised.²⁷ Did the university really want the head of such a company in its ranks? Medical students promised to keep the heat up, and the future shaped as a highly undesirable saga for the university.

All fears of community backlash appeared unfounded. An online newspaper poll recorded 89% approving of the outcome of the senate vote, further eroding concerns expressed by Greiner’s supporters that the action would make the university look foolish. The episode inspired a student representative of senate to ratchet up the policy even tighter. At its September meeting, the senate voted unanimously to support a revised policy that read “the university shall not accept funding or other forms of support, other than by taxation of government levies, from any tobacco manufacturing company or foundations primarily funded by such companies, or agents known to be acting on their behalf.”

The tobacco industry is now on notice around Australia that attempts at integrating with respected community institutions may turn ugly. The chairman of the American Cancer Society, John Seffrin, once said “politicians don’t like standing next to a social pariah in the next photo opportunity.” Tobacco lobbyists have their access to policy makers greatly diminished by this process. Campaigns like this one aim to keep it that way.