2011 Center for Global Public Relations Research Conference UNCC Charlotte

March 15, 2011

[The Many Identities of Polio: Culture and Meaning in Global Health Communication Campaigns

Katie Stansberry, Ph.D., and Pat Curtin, Ph.D., University of Oregon] Abstract

This study determines the identities of polio that have arisen during the polio eradication campaign and examines what courses of action they legitimate. A discourse analysis of more than 500 primary documents is examined through the theoretical lens of the cultural-economic model of public relations practice. The results suggest that while communication may be considered a cornerstone of public health campaigns, there is much that public relations can contribute to global health diplomacy, but more interdisciplinary work is needed. Implications for practice and theory are discussed.

During the coming summer, thirty or forty thousand children will get polio. About fifteen thousand of them will be paralyzed and more than a thousand will die. If we have the capacity to prevent this, we have a social responsibility . . . it is our duty to save lives no matter how many difficulties may be involved.

Basil O’Connor, President, March of Dimes, 1954 (in Smithsonian, 2005)

Poliomyelitis, more commonly known as polio, is a viral disease spread by human contact and has no cure. Although 95% of cases are subclinical, meaning victims show few to no symptoms, in the other 5% the disease affects the nervous system and can result in crippling paralysis or death. The disease is ancient and worldwide; the earliest identifiable case of polio is on an Egyptian stele from about 1,500 B.C.

Ironically, polio did not cause major epidemics until the 19th century when sanitation improved in industrialized nations. Infants, no longer naturally exposed to the virus, failed to develop immunity. In the summer and fall, when temperatures rose and children played together in swimming pools and playgrounds, epidemics broke out across the industrialized world. Throughout the first half of the 20th century the epidemics grew increasingly worse. In 1952, almost 58,000 cases were reported in the United States alone. Although the disease primarily struck children, one-third of those infected were adults. Fear ruled: towns banned outsiders; affected individuals were strictly quarantined and their possessions burned (Smithsonian, 2005).

In 1938, President Franklin Delano Roosevelt, himself a crippled polio survivor, founded what became the March of Dimes to fund treatment and find a cure. In 1954, Jonas Salk developed a killed vaccine given by injection; in 1961, Albert Sabin developed the attenuated (live) form given orally. Vaccination proved effective, and the developed nations eradicated polio through public health vaccination programs. The last U.S. case was recorded in 1979.

In 1985, Rotary International began its PolioPlus campaign to eradicate polio worldwide. In 1988, 10 years after declaring victory in the smallpox eradication campaign, World Health Organization (WHO) members voted to join the eradication effort. The Centers for Disease Control and Prevention (CDC), and the United Nations Children’s Fund (UNICEF) also joined to form the Global Polio Eradication Initiative (GPEI). Its goal was to eradicate polio by 2000. In the 22 years since, the campaign has cut infections by 99%, but pockets of resistance remain in Afghanistan, India, Nigeria, and Pakistan that have led to flair ups and spread, pushing the target date back to 2013.

As the campaign to eradicate smallpox demonstrated, strategic communication efforts in support of global health campaigns cross national, regulatory, cultural, and social boundaries (Curtin & Gaither, 2007). This study uses the cultural-economic model of public relations practice and discourse analysis of campaign materials and coverage to examine the discourses that have arisen surrounding polio over the course of the campaign and the actions those discourses legitimate. Our purpose is to determine how public relations efforts have shaped the campaign around the globe and the consequences of those efforts.

Literature Review Global public relations practice and health communication are two burgeoning areas of

public relations scholarship (Sallot, Lyon, Acosta-Alzuru, & Jones, 2007), yet little has been written that examines their overlap. Much of the extant international public relations practice scholarship falls into three areas: (1) application of U.S. normative models and definitions of practice to which are then added cultural indices or values to explain cultural variations; (2) case study approaches that examine practice in a country as compared to U.S. practice as the norm; and (3) corporate-focused work that fails to account for the imposition of Western approaches, which results in neo-colonial approaches (Curtin & Gaither 2006). Bardhan and Weaver (2011) delineate three similar issues: the lack of complexity when addressing globalization issues, the meager theorizing addressing culture, and the predominance of functionalist theories.

In general, little work has stepped beyond geo-political determinations to address the globalization “scapes” defined by Appadurai (1996): ethnoscapes, technoscapes, financescapes, mediascapes, and ideoscapes. Such an approach realizes the very real connections in global health campaigns among peoples, technologies, money, communication, and ideologies. Some work, however, has used postcolonial theory to suggest the need for public relations practitioners to take a bottom-up approach and mobilize indigenous people to define how they would like to develop and what services they would value (Curtin & Gaither, 2007; Dutta & Pal, 2011). Despite theoretical work in this area, however, few case studies exist because little practice has embraced this approach.

In terms of health communication, public relations scholarship to date has focused mainly on crisis (e.g., Lee, 2009; Zhang & Benoit, 2009), agenda building (e.g,. Avery & Kim, 2009; Brunner & Brunner Huber, 2010; Campo, Askelson, Mastin, & Slonske, 2009; Lariscy, Avery, & Sohn, 2010; Len-Rios, Hinnant, Park, Cameron, Frisby, & Lee, 2009), and communication efficacy, particularly in terms of segmenting publics (Anderson, 2009; Avery, 2010; McMillan & Macias, 2008; Veil & Rodgers, 2010). Despite the assertion of the head of the CDC that “communication may well become the central science of public health practice” (CDC, 2008, p. 25), only one study has examined the particular skills needed by senior public health communicators (Gregory, 2009).

The few studies that examine international health issues from a public relations perspective tend to use individual nation or comparison case studies, concluding that culturally acceptable material works better, which is scarcely surprising (e.g., Al Khaja & Creedon, 2010; Baek & Yu, 2009). One study, however, notes that “health communication projects are certainly not immune from politics” and advocates for a participatory approach in health communication campaigns (Schneeweis, 2009, p. 23). Other studies have confirmed the need for a participatory approach (Servaes & Malikhao, 2010) and being cognizant of the larger social and cultural influences on participants (Vardeman-Winter, 2010). Similar to the call for more postcolonial work in international public relations practice, authors have also called for more work on health diplomacy as an area of praxis (Wise, 2009), noting that health is “a shared currency” (Ratzon, 2005, p. 198). Increasingly, global health campaigns are becoming lightning rods for issues of social justice, and scholars are debating their use to combat terrorism post 9/11. Vertical, single issue eradication campaigns have been particularly scrutinized because of the social justice issues they raise (Renne, 2006).

Eradication Campaigns Within the last year, articles have begun to appear concerning communication aspects

of the polio eradication campaign, including a special issue of the Journal of Health Communication devoted to it. From these mainly descriptive articles, several themes emerge. The first is that the GPEI originally adopted a top-down strategy, depending on mass media to raise awareness and believing that that would be enough, in and of itself, to bring about the required behavior in targeted publics (Obregon & Waisbord, 2010; Pirio & Kaufmann, 2010; Taylor & Shimp, 2010). Evaluation, then, consisted of measuring output objectives, rather than the actual impact of efforts (Taylor & Shimp, 2010). Media outreach strategies were lacking, with media treated simply as information conduits rather than as agents in their own right (Pirio & Kaufmann, 2010; Waisbord, 2008; Waisbord et al., 2008). More directed communication tactics were used only in developed nations for fundraising, whereas localized efforts seemed to be ignored, at least early in the campaign (Waisbord et al., 2010).

As the campaign progressed, GPEI realized that if eradication was to be achieved, it needed to employ more bottom-up communication strategies, even though government agencies perceived them to be time consuming and antithetical to standard operating procedures (Waisbord, 2008). Since the millennium, social mobilization has become a campaign theme, emphasizing coalition building and community participation (Obregon & Waisbord, 2010). This perspective has gradually granted more agency to the recipients of the polio vaccine, empowering them and their beliefs (Feek, 2010; Renne, 2006; Taylor & Shimp, 2010). As one set of researchers who have been on the ground in the campaign note: “The responses to global health initiatives are unpredictable. They are contingent on how goals and strategies resonate with local needs and demands” (Obregon & Waisbord, 2010, p. 43).

With eradication appearing more difficult, campaign organizers began to realize the efficacy of two-step flow in persuasive communication. Unless local opinion leaders were brought on board and interpersonal channels used, the campaign was not going to succeed (Obregon & Waisbord, 2010): “The roles of neighbors and friends, traditional and mainstream media, and traditional and religious institutions” took on increased import (Waisbord et al., 2010, p. 15).

What is interesting about these evaluations of the polio eradication campaign to date are the few references to the smallpox eradication campaign and what could have been learned from it. Although the two diseases are quite different, the efforts to eradicate them and the areas of the world affected are similar, which would seem to invite comparison. Bhattacharya and Dasgupta (2009) examined both efforts, noting that the smallpox eradication campaign taught WHO that micromanagement didn’t work; ground up techniques and adapting to local conditions were necessary for success. The polio effort, however, has been characterized in its earlier years by top-down efforts that have led to fatigue as deadlines have been missed, sapping morale. The lack, until recently, of a strong media relations policy and local community involvement have hurt the polio effort in comparison to the smallpox campaign (Bhattacharya & Dasgupta, 2009). The Theoretical Lens of the Cultural-Economic Model

Curtin and Gaither (2007) used the smallpox eradication campaign as an extended case study in their examination of international public relations. Using the cultural-economic model of public relations practice, they deconstructed the campaign using the circuit of culture (du

Gay, Hall, Janes, Mackay, & Negus, 1997; Figure 1). Theoretically, the model grounds particular situations in “reference to material practice and historical conditions” (Stuart Hall, in Grossberg, 1986b, p. 147).

[insert Figure 1 about here] The five moments of the circuit work synergistically; they are sites of dynamic discursive process and are not themselves cultural artifacts.

The moment of regulation embodies formal and informal controls, such as laws, social norms, and technological infrastructure. In the smallpox campaign, Cold War politics, geopolitical jurisdictional boundaries, applying moral suasion to shame noncompliant countries, adapting to local norms and customs, and establishing its own culture within the bureaucracy of WHO were keys to success (Curtin & Gaither, 2007).

Representation is the shared cultural space in which meanings are generated through discourse. Public relations practitioners, acting as cultural intermediaries, create materials (representations) that “define the norms, values, and realities that are regarded as legitimate in a particular context” (Edwards, 2009, p. 269). In particular, leaders represented eradication as a cost-benefit analysis, with obvious benefits accruing to eradication. The metaphor of a global war was used to motivate the troops in the field. To persuade the public, smallpox became a way to get rich—large rewards were offered to report cases (Curtin & Gaither, 2007).

Production is the process by which ideology informs meaning and the constraints on that process. During the process of production, public relations practitioners construct discourses to achieve organizational objectives. In the smallpox campaign, production was marked by technological advances, field innovations, proactive strategies, and efforts to recruit workers and maintain morale (Curtin & Gaither, 2007).

During consumption, audiences decode representations. Meaning doesn’t reside in objects but in how audiences make use of objects in their everyday lives. Consumption and production thus form an ongoing process of meaning making and negotiating. For consumers, smallpox was not only a fact of life for many peoples, it was a deity. Also of import was that for some peoples, lining up for vaccinations was a social norm, while for others it represented government control, and government wasn’t trusted. Many other issues were more important to the people than smallpox, which inhibited government efforts to eradicate it.

Identities are formed through relationships and “comprise a multitude of socially constructed meanings and practices, such as class, ethnicity, nationality, and gender” (Curtin & Gaither, 2005). As such, they are always in flux and often conflicting. Identity issues were among the most contentious during the smallpox campaign, engaging issues at all levels of the campaign. Leadership of the campaign, whether U.S. or international, was an issue, as was the identity of the disease itself. Was it a deity or a scientifically established fact? A fact of life, or the enemy to be abolished? Identity became, in many ways, the key to the campaign.

Overall, Curtin and Gaither (2007) conclude that the dominant discourses surrounding the campaign were that of a Cold War neocolonialism that drove competing political factions to show their support; a metaphor of a holy war, which enabled workers to use tactics that might otherwise be viewed as amoral; and a triumph of the rationality of Western science over ignorance and suspicion. Ironically, despite these dominant discourses, Curtin and Gaither (2007) concluded that the campaign succeeded in large part because of its reliance on ground-

up innovation, the lack of top-down standard operating procedures, and the empowering of field workers to respond to local conditions and bypass the bureaucracy. Summary and Research Questions

From the literature, it is apparent that research is lacking that combines the perspectives of postcolonial public relations, advocacy health communications, and cultural approaches. Such an approach would help span the global “scapes” in Apparudai’s (1996) terms and provide a better understanding of strategic communication efforts supporting global health campaigns. To further this line of cross-disciplinary research, we ask the following research questions:

1. What are the discourses that have arisen surrounding polio during the eradication campaign? What actions do these discourses legitimate?

2. How has the polio eradication campaign incorporated lessons from the smallpox eradication campaign?

3. What do these discourses tell us about the role of public relations in global health?

Method This study in large part replicates Curtin and Gaither’s (2007) examination of the

smallpox eradication campaign. It applies the same approach, discourse analysis, to examine the structural and semiotic perspectives used. We use principles from Hall (1992, 1997) and Foucault (1980, 1989, 1995) to inform our analysis. Discourse analysis requires intertextuality, that is a large number and variety of texts analyzed to understand the historical context that gives rise to particular discourses and to chart how “particular knowledges gain the status of truths by virtue of their relationship to power” (Motion & Leitch, 2009, p. 96).

We obtained primary texts from a variety of sources, including the Lexis/Nexis database, the Web sites of the many organizations involved, PR Newswire and Businesswire, and a Google search. These primary materials were supplemented by a variety of secondary sources, including material from anthropology, sociology, medicine, public health, communication studies, and public relations. To date, we have examined over 500 primary texts—and the number is growing daily as the campaign continues. We immersed ourselves in the texts to determine which discourses concerning polio appeared across a broad range of texts and in ways that prescribed cultural norms (Hall, 1997). The process was one of “a progressive form of saturation, from the consultation of ever more sources of origin” (Hook, 2001, p. 531). In keeping with Foucault, our approach was not so much on “reading the text . . . *but+ of engaging the discourse” (Hook, p. 526), examining discourses as events or processes and not simply content. We adopted Foucault’s methodological approach of problematization, that is, asking a series of questions to determine what these discourses presented as truth, what cultural norms they implied, how they constructed the subject, how they exhibited or gained authority, and how they were incorporated into institutional practices (Hall, 1997).

Results

The first finding is that our study supports the conclusions of earlier examinations of the campaign. The use of communication, even general mass communication, was limited prior to 1998, when communication efforts ramped up to explain why eradication was not going to be

achieved in 2000. After polio numbers surged again in 2003, greater communication efforts were geared toward not just governments and funders but also toward the actual consumers—the vaccination recipients—using both mass media and interpersonal channels. All too frequently, however, these were used reactively rather than proactively, as we explain below. Over the course of the campaign to date, we found six distinct yet related discourses: fighting a moral crusade, it’s just good business, stigma and pride, it’s not our fault, rumors and religion, and war and sport. Fighting a Moral Crusade Rotary International was not known for participating in worldwide humanitarian causes (Pirio & Kaufmann, 2010). Yet in 1985, Rotary International launched the PolioPlus campaign with the goal of raising funds to support polio eradication. Rotary estimates its financial contributions to the polio eradication effort will be nearly $1.2 billion by the time the world is certified polio-free (Rotary International, 2011).

A service club organization with more than 1.2 million members, Rotary International’s motto is “service above self.” Yet it still seems remarkable that Rotary would undertake a global eradication campaign in 1985, three years before international agencies joined in. A few factors may have contributed to the timing and choice of topic. Other service organizations, such as the Lions, were taking on public health issues as causes. Additionally, the head of Rotary’s polio effort noted on more than one occasion that the success of the smallpox eradication campaign—formally announced in 1980—demonstrated that disease eradication was possible (e.g., Pigman, 1998). The coming millennium was certainly a factor; Rotary often used as a tagline in early communications that polio eradication would be “our gift to the children of the twenty-first century” (e.g., Sever, 1999). Finally, eradication in 2000 would mean certification of eradication in 2005—the organization’s 100th anniversary. This key message was picked up by the media. For example, Voice of America ran a five-part series on the eradication campaign, noting that the entire effort was about improving the well being of children (Skirble, 2002). More recently, Rotary has been the force behind many of the most visible international communications campaigns designed to bring attention to the continued presence of polio in the world. Its most recent campaign, End Polio Now, lit up several world monuments with polio awareness messages during February 2011, including the Trevi Fountain in Rome, India’s Charminar monument, and the New York Stock Exchange building (Figure 2). Rotarians also work on a more local level. Rotary clubs in Great Britain and Ireland plants purple crocuses in public spaces, which represent the color of ink dabbed on a child’s little finger to indicate they have been immunized against polio (Rotary International of Great Britain and Ireland, 2010).

[insert Figure 2 about here] The language used in recent communication pieces developed and distributed by Rotary

International, particularly its news releases and the section of its Web site devoted to polio eradication, presents its support of polio eradication as a moral duty. Polio is framed in terms of the crippling effect on children, as evidenced by this passage from the Web site:

The [money raised] will directly support immunization campaigns in developing countries, where polio continues to infect and paralyze children, robbing them of their futures and compounding the hardships faced by their families. As long as polio threatens even one child anywhere in the world, children everywhere remain at risk. (Rotary International, 2011)

Missing from this discourse is the fact that previous eradication efforts have failed; of six campaigns to date, only one—smallpox—has been successful. Also, many critics have noted that single issue health campaigns pull resources from other health issues, many of which are more pressing. For example, diarrhea and measles kill many more children each year than does polio (McKenna, 2000). But for Rotary (2011), anything other than eradication of polio is unacceptable and will rob the world’s children of their future. It’s Just Good Business

While Rotary has been using a moral argument to eradicate polio, organizational leaders also realized that as time went on, if progress were to be made, more monetary support would be needed. Consequently, organizational leaders pushed the cost-benefit analysis argument to world leaders, corporations, and philanthropic organizations. The figures used throughout the campaign from 1996 through the first part of this millennium were that eradication would result in savings of $230 million for the United States each year; for the world, the figure was $1.5 billion. Savings would come from the fact that routine vaccinations would no longer be necessary, nor would surveillance for imported cases. As the head of Rotary noted in testimony to Congress: “Few investments are as risk-free or can guarantee such an immense return” (Pigman, 1998, n.p.) A WHO news release declared that “governments around the world agree that polio eradication is a good investment” (“Planning for the last stages,” 1999, n.p.).

While the GPEI has acknowledged the moral argument, it has found the cost-benefit one even more compelling: “Saving children from the agony of polio is a great achievement, but the rewards for global public health are even greater” (Short, Herfkens, & Johnson, 2002, n.p.). But these savings can only be realized if polio is eradicated, for “Failure in one country is global failure” (“World health group,” 1998), but “eradication is the most powerful cost-saving device because its benefits will accrue forever” (Sever, 1995, n.p.). As a senior health specialist with the Canadian International Development Agency noted, eradication could be achieved for the cost of one fighter jet (“Polio eradication possible,” 1999, p. 21).

To raise support, the campaign is often held up as a model of private and public sector cooperation by many, including Senator Dale Bumpers (1998). Rotary members have spent much time pitching the cause to corporations, corporations, and NGOs—often with good effect. Successful recruits include Ted Turner and Bill Gates. In his 2011 annual letter to shareholders, Gates (2011) announced that he was placing the full weight of The Bill and Melinda Gates Foundation behind polio eradication efforts, clearly stating that eradicating polio was the organization’s top priority in 2011. Although Gates has faced substantial criticism for supporting a global health campaign that has exceeded all cost predictions and has dragged on far longer than expected (Roberts, 2006), he typically counters these arguments with a mix of humanitarian and economic justifications.

The money that will be saved by eradicating polio far exceeds what we are spending on eradication efforts now. The long-term benefits of the last couple of billion dollars spent on eradication will be truly phenomenal. A recent estimate added up the cost of treatment that won’t be necessary and the enhanced economic contribution of adults who won’t get polio. Eradication could save the world up to $50 billion over the next 25 years. (Gates, 2011)

Other arguments frequently used to justify campaign costs are that the campaign will leave a legacy of a better global healthcare system and that eradication will free up funds to fight other diseases and increase enthusiasm for vaccinations worldwide (Hull, Tangermann, Aylward, & Andrus, 1999; Satcher, 1998; “The Rotary Foundation,” 2000). Many sources, however, have noted that there has been much resentment that so much funding has been earmarked for one disease—and that it’s a disease that is less deadly than many others (e.g., Renee, 2006). But eradication campaigns are often considered a sexier sell to private donors than are campaigns directed to general infrastructure. And for governments, the cost-benefit analysis can prove compelling (Curtin & Gaither, 2007), making costs incurred an investment, rather than a loss. Stigma and Pride The start of the polio eradication campaign was characterized by a series of quick successes. The global polio eradication initiative focused first on areas that had strong health infrastructures and the financial resources necessary to fund mass vaccination campaigns (Pirio & Kaufmann, 2010). Advocacy messages in the early campaign were successful in the Americas, leading to pressure on other countries to also eradicate the disease.

For those nations with active polio cases, achieving official eradication became a point of pride. For example, early in the campaign Indonesia was said to be “coveting” a polio-free certification (“Government begin final,” 1997), and Rotary noted that India was making progress, which meant that any country should be able to (“Worldwide eradication,” 1998). The Philippines celebrated certification in 2000, congratulating itself for “skillful use of mass communication strategies” (“Political will,” 2000). China celebrated its polio-free status in 2001 by declaring itself a “shining example” of what could be done (“China wins,” 2001).

For others, the stigma of being among the last has been felt. A Pakistani news report noted that while 170 countries were polio free, Pakistan was not among them (“Nazim Karachi,” 2001). In 2004, after suffering a resurgence, Nigerian officials lamented “risk*ing+ being the last nation in the world” (Olatunji, 2004, n.p.). WHO’s Director General berated many countries for “lagging behind” (“Intensify polio war,” 1998).

Although only four countries (Pakistan, Afghanistan, India, and Nigeria; often referred to as P.A.I.N.) shelter the bulk of current polio cases, there is posturing among those countries as to who is most likely to end polio first (Oyeniran, 2011). Indian health officials have admitted that polio in India is a stigma for the country as it seeks recognition as a global power (Nessman, 2011). In Pakistan, the Secretary of Health called polio eradication “not only our national necessity but . . . our national commitment to international partners”; the government of Pakistan is facing international pressure to ramp up its vaccination efforts (Ahmed, 2011). Nigeria has been openly and frequently blamed for polio resurgence in Western Africa (Egburonu, 2011).

In turn, Rotary has distributed Polio Eradication Champion Awards each year since 1995 to political and humanitarian leaders. The national leaders often appear to have been carefully targeted for political reasons, however, more so than for evidence of progress toward eradication. Early recipients of the award, for example, included the presidents of Nigeria and Pakistan—two of the four countries where polio is still endemic. Since then, Nigeria has been accused of rampant corruption in handling campaign supplies and a lack of commitment

(Oghifo, 2003); Pakistan’s Musharaff received the award in 2002 at a time when the United States was depending on his support in the “war on terror.” It’s Not Our Fault A recent news article equated trying to eradicate the last 1% of polio cases to “trying to squeeze Jell-O to death” (McNeil, 2011). While early eradication efforts successfully decreased polio cases by 99 percent, the last bastions of polio tend to be found in individuals who live migrant lifestyles, populations in war zones, and communities isolated by geographic barriers. Polio infection is also difficult to track because 95% of the people who contract it exhibit no symptoms. Early in the campaign, however, officials expressed with certainty that they were “within reach of completely eradicating the disease—the goal is achievable” (Sever, 1995). In 1998, several key campaign messages stressed that the campaign was “in the home stretch,” in the “final stages,” and was directed at only a “few areas” (“WHO polio eradication,” 1998). In 2000, when more cases were reported worldwide, officials said the increase was not a setback but indicative of better surveillance techniques (Slager, 2000). Officials often point to the smallpox campaign as proving that eradication is possible, despite the fact the diseases have two very different etiologies. Wild polio virus (as opposed to the live virus contained in the oral vaccine) can be transported in water systems tainted by raw sewage as well as through person to person contact. Polio’s complete disregard for geographic or political boundaries is one of the primary arguments made in strong support of continuing polio eradication efforts (Gates, 2010).

But smallpox eradication proved “the war against polio is winnable” (Sandrasanga, 2000). An oft-repeated phrase has been “We have the tools and we have the strategies to finish this job” (“WHO Director-General,” 2003; see also, e.g., Sandrasanga, 2000). Interestingly, the tools include the use of the live oral vaccine, which is controversial, but campaign leaders insist that only the oral vaccine, rather than the killed vaccine given by injection, is capable of achieving eradication (Hull & Wook, 1996; “Rotary International endorses,” 1995). The four campaign strategies, which are often listed, are use of the oral vaccine; National Immunization Days (NID), when mass vaccination of all children five and under takes place; surveillance for children suffering from the paralysis than can accompany a polio case; and “mopping up” operations, which involves going house to house to find any children not vaccinated during NID.

Communication, however, has not been a listed strategy to date. In Brazil, where the Pan American Health Organization ran a successful campaign in 1980 before the start of the GPEI, the first NID involved a 15-day media campaign prior to the event, encompassing 123 television stations, 1,200 radio stations, and 3,900 mobile loudspeakers (Smithsonian, 2005). In the current campaign, however, studies suggest that many people remain unaware of the vaccination event, leading researchers to suggest that “constructive communication is needed at all levels of the health system” (Razum, Liyanage, & Nayar, 2001, p. 476).

As eradication efforts have failed year after year, the campaign is becoming increasingly aggressive. Volunteer vaccinators have been replaced by per diem workers (Pirio & Kaufmann, 2001), and 2013 is the new target date. Massive vaccination projects in India, for example, frequently kick off with rickshaw rallies sponsored by the health department. Gaily decorated rickshaws travel through areas frequented by migrant workers to bring the attention of these vulnerable publics to the campaign (“UP progress against polio remarkable,” 2011).

Communication efforts are becoming increasingly directed to consumers and using more interpersonal communication channels (Dugger, 2010; Shoichet, 2003). The failure to reach the targeted date, however, has hurt the campaigns’ credibility with governments, volunteers, and funders (“Polio,” 2002; Shoichet, 2003). Only that fact that so much has already been invested in the campaign appears to be keeping the money flowing for eradication. In turn, officials have blamed local health officials, lack of adequate funding, and civil unrest for blocking progress (Collins, 2000; Picard, 2001; “UN urges parties,” 2002). The refrain remains that with the current technology and proven strategies, victory can be had, if only lack of funding doesn’t stand in the way (Crawford & Buttery, 2010). Rumor and Religion Early in the campaign, the primary objective of GPEI communication efforts was to inform people of the availability of the vaccine. The organizations leading the eradication effort assumed that if the vaccine was made available and the expertise was in place to administer it, that would be enough for widespread adoption (Waisbord, 2009). However, global health officials quickly learned that a mass media campaign coupled with vaccine delivery would not be enough to achieve eradication (Waisbord, Ogden, & Morry, 2010). The cultural distinctiveness of countries where polio has proved difficult to quash has contributed to the reemergence of polio in many parts of the world. On early reporting forms, vaccinators had few options to check. All children missing from vaccination attempts were listed as nonvaccinated because of “fear associated with rumors.” For those people who actively refused vaccination, the box available to check was “ignorance” (Taylor & Shimp, 2010). Throughout, campaign officials have stated that the issue is one of social justice and that anyone who blocks the campaign—actively or passively—is threatening a “global public good” (Aylward & Heymann, 2005, p. 773). From the official perspective, only fear and ignorance could account for refusing the benefits of vaccination.

This discourse, however, does not take into account religious beliefs, such as those of the Hausa people in West Africa. There, polio is known as “Shan Inna,” a spirit who sucks the blood from a victim’s limb as punishment for the family having offended the gods (Akrasi, 2003; Renne, 2006). Persons with polio are marginalized and thought to have brought their fate unto themselves. One of the more recent successful vaccination programs in Nigeria demonstrates a change in tactics. Vaccination teams partnered with polio survivors to speak directly with families about the realities of the disease (Wilder & Adamou, 2008). Of the four countries where wild polio remains endemic, the majority of the populations in the affected areas are Muslim. The campaign’s provide-it-and-they-will-come approach to polio eradication has failed to take into account global tensions since September 11, 2001. Muslim leaders have wondered why Western doctors have taken an interest in them, particularly when the campaign is geared toward supposedly just one disease that is seldom life threatening. It also seems odd that medical treatment is free and given in the home, rather than costing money as a health facility (Silberner, 2004). Gender has also raised issues. Some female volunteers have refused to veil (Renne, 2006), and boys are isolated for 40 days after birth, which has impeded early vaccination (Obregon & Waisbord, 2010). More than 325 cases of polio were reported in India in 2006, and 70% of those infected were Muslim even though Muslims accounted for only 13% of India’s population at the time (Adiga, 2006). In certain areas

of India, fatwas were issued against the vaccination campaign, and Muslim parents in some rural areas refused to allow health workers into their homes (Adiga, 2006).

The heavily Muslim northern regions of Nigeria have exhibited the most defiance against the campaign. In 2003, the polio eradication campaign was brought to a standstill there as political and religious leaders responded to widespread fears that the vaccine caused infertility and contained the HIV virus (“Nigeria polio vaccine,” 2003; Yahya, 2007). “No More Rotary” was spray painted on walls, and the organization was accused of representing Zionist interests (Renne, 2006). With the halt in vaccination, polio spread, ultimately reinfecting 21 countries at a cost of $500 million (Waisbord et al., 2010). In response, WHO brought Dr. David Heymann on board to negotiate directly with religious leaders, including Nigeria’s Supreme Council for Shariah (Antai, 2009) and the Organization of the Islamic Conference, which ultimately lent its endorsement to the campaign. The Nigerian government led an independent investigation of the vaccine, demonstrating it to be safe. But production was moved solely to the Indonesian facility so that it would originate in a predominantly Muslim country (Smithsonian, 2005).

The official line, however, is that “local media were full of conspiracy theories” and that local leaders used “false rumors” to their own gain (Aylward & Heymann, 2005, pp. 773, 775). Never mentioned was that Pfizer had used people in this area for drug testing earlier, causing much harm and creating a well-founded distrust of Western medicine (Renne, 2006). Instead, Dr. Bruce Aylward, in charge of the effort, stated that when a few people turned the situation to their own uses, the only answer was to respond with open dialogue and transparency “and then . . . begin a communication program” (in Block, 2004).

According to the official view as late as 2004, then, communication is only necessary as a reactive technique when a few people who aren’t serving the cause of social justice block progress. Recent work has been more sensitive to local beliefs, however, and social mobilization of community and religious groups has proven vital to the final push for polio eradication (Waisbord, 2009). For example, health workers in Pakistan carry a letter from Mullah Mohammad Omar, the supreme leader of the Taliban, requesting people to cooperate "for the benefit of our next generations" (Trofimov, 2010, p. A14). War and Sport One final discourse that emerged encompasses the metaphors of war and sport. War or battle is a frequent metaphor in health campaigns (Weiss, 1997), so it is not surprising to find it in this one as well. WHO’s Director-General called the campaign “a fight to the finish and the terms are unconditional surrender” (in Foy, 2001, p. 1B). News releases from UNCEF speak of a “call to arms” (“Polio eradication partners,” 2000) and the need to “close in on the remaining strongholds” (“Polio eradication: Final 1%,” 2001). Somewhat unusual, however, is the peacetime language used. In conflict areas, the organizations organized “Days of Tranquility” to allow NIDs to proceed, with UNICEF asking that children be seen as “zones of peace” (“Polio eradication: Final 1%,” 2001). Also evident was a strong sports theme, making polio the object of a hard fought, but ultimately friendly, contest. The sports metaphor appears to have begun when Nelson Mandela launched the “Kick Polio Out of Africa” campaign in 1996, which featured football (i.e., soccer; Figure 3). The campaign has since recruited a number of sports stars to serve as campaign ambassadors and spokespeople, including Martina Hingis, who declared “match point against

polio . . . play to win” (in “Polio eradication partners,” 2000). A 2001 public service announcement featured world champion Kenyan runners, and in 2004 the cricket match between India and Pakistan was used to raise awareness of the campaign and included ads featuring star cricket players (“India, Pakistan to cooperate,” 2004). Somewhat ironically, two doctors leading the campaign noted that the funding needed to achieve eradication was “less than several professional athletes contracted salary” (“Can polio be defeated?”, 2004).

[insert Figure 3 about here]

Discussion Before addressing the research questions, the first thing to note is that although we have pulled examples from only some of our sources, those singular examples are representative of the discourses shared across many texts. The lack of more than any one cite to support a point should not be taken as evidence that the discourse was not dominant throughout the wealth of materials examined.

The first research question asked, what are the discourses that have arisen surrounding polio during the eradication campaign? What actions do these discourses legitimate? The six discourses—fighting a moral crusade, it’s just good business, stigma and pride, it’s not our fault, rumors and religion, and war and sport—legitimate particular perspectives and actions. That the campaign is a moral crusade, an issue of obvious social justice, means that to question the campaign is to be inherently ignorant or unjust. A certain hubris or naiveté is evident from the assumption throughout the campaign until quite recently that simply offering such an obvious public good would lead to compliance from consumers. The fact that the smallpox campaign proved eradication possible seems to also mean that because single disease eradication can be done, it should be done.

Yet for people suffering from malaria and measles, diarrhea and malnutrition, a disease that only shows symptoms in 5% of all cases is not a priority item. Single disease campaigns also take resources away from other health issues, making them a “double-edged sword”: as an USAID official noted, “Ironically, unless eradication efforts are carried out in the right times and in the right way, they can actually result in a worsening of the overall health situation of the people they are supposed to serve” (Daulaire, 1998, n.p.).Additionally, for people lacking many basic resources, polio is a bargaining chip. Community groups in India have traded access to their children for vaccination for local development projects, such as roads, bridges, and food distribution systems (Bhattacharya & Dasgupta, 2009). At the same time as the moral argument has been used with consumers, the financial argument has been used to justify the campaign to funders and governments. The cost-benefit evaluations provided by the campaign, which have not varied throughout the course of the campaign, have been repeated by politicians, journalists, and philanthropists as fact—not as best guess estimates. Only one person testifying before Congress ever questioned how accurate the numbers might be. Instead, these numbers represented a necessity to fund the campaign. At issue was not human suffering but the savings to be had. The argument is pure Milton Friedman corporate social responsibility applied to government—the only responsibility of the government is to its taxpayers. This same discourse is keeping the campaign afloat 11 years after the target date. At this point, too much money has been invested to allow governments to pull out now—to do so would appear wasteful of taxpayer funds.

Rotary has been the one organization able to espouse both the moral crusade and the it’s just good business arguments. By using an “ends justify the means” approach, Rotary has continued to present the cost-benefit analysis to Congress to obtain the necessary funding for its crusade to save the children. For the other organizations involved, particularly members of WHO and the CDC, the argument has been one of the triumphs of Western science. Again, hubris or naiveté is evident in the faith placed in science and technology—the “we have the tools and we have the tactics” tagline. Science and technology, however, do not take into account differing contexts, including geography, culture, and religion. Campaign leaders seem affronted that civil war, often in areas trying to fight off years-long dictatorships, has gotten in the way of the campaign. House-to-house searches as part of the mopping up strategy fail to take into account the sheer difficulty of getting from house to house in many parts of Africa (Egashira, 2003), India, and Pakistan. And the continued difficulty eradicating polio in mostly Muslim areas demonstrates the reality of politics. Science and technology do not operate in political and cultural vacuums, although the campaign leaders have seemed to assume that they do. Given these discourses of the obvious benefits of social justice, cost savings, and Western science and technology, it is not surprising that communication has been a low priority. The first real mention of communication as a strategy at all is in the September 1998 testimony of Rotary’s chairman (Pigman) to Congress, stating that the private sector, namely corporations, has expertise in “communications” (quotes in the original). By placing communications in quotes, it diminishes its role, making it almost an aside to the campaign. Only recently has the value of communication been realized in the campaign. The question is whether it comes too late as people now ask whether eradication is feasible or whether containment should be the goal. The second research question asked what lessons from the smallpox campaign have been incorporated into this campaign. Some of the discourses are the same—the cost benefits to be attained and the triumph of Western science over ignorance. The Cold War neocolonialism that marked the smallpox effort appears to have been replaced by an East/West divide, with discourse marginalizing Muslim beliefs and culture. On the positive side, the metaphor of a holy war, which enabled the use of force and subjugation during the smallpox campaign, has been replaced with a discourse marked more by the language of peace and sport. The result is more of a friendly struggle than strife. Although a few instances of the use of force have arisen during the polio campaign, these occasions are far fewer than they were during smallpox eradication. It should also be noted, however, that the results have been much less effective so far. Curtin and Gaither (2007) concluded that the success of the smallpox campaign was due to its reliance on ground-up innovation, the lack of top-down standard operating procedures, and the empowering of field workers to respond to local conditions and bypass the bureaucracy. To date, all of these approaches appear to be lacking in the polio campaign. The GPEI has been marked by top-down management, one set of strategies to be applied in all regions, and a lack of flexibility to adapt to local conditions. Dr. D. A. Henderson, who led the smallpox campaign and was instrumental in its success, was an avid supporter of the polio campaign in its early years. Now, however, he is an outspoken critic of polio eradication. In a recent New York Times story, he said: “Fighting polio has always had an emotional factor — the

children in braces, the March of Dimes posters. But it doesn’t kill as many as measles. It’s not in the top 20” (McNeil, 2011, p. D1). While some dominant discourse has remained the same, then, this study concludes that those in charge of the polio eradication campaign have not incorporated the lessons of the smallpox campaign, which may explain the current lack of success. Finally, we asked what these discourses tell us about the role of public relations in global health. The lack of strategic communication in this campaign speaks volumes. Public relations has much it can offer the global public health community, from effective use of communication to the need for culturally sensitive approaches. From a purely practical perspective, more crossover between the disciplines could result in better health diplomacy, improving relations in a post 9/11 world rather than aggravating them (Wise, 2009). Such work, however, would have to take a bottom up approach, empowering indigenous peoples and making them full partners in determining what services they need and how they can be best delivered (Schneeweis, 2009; Servaes & Malikhao, 2010). To date, most global public relations efforts have not embraced this approach (Bardhan & Weaver, 2011). It waits to be seen if the advent of social media, with its concomitant relative empowerment of consumers, makes global practice more open to participatory approaches. In terms of theory, the dominant discourses that have arisen during the campaign fall into three of Appadurai’s (1996) five scapes: technoscapes, financescapes, and ideoscapes. The singular belief in Western science and technology occupies the technoscape; eradication as good, cost-effective business practice territorializes the financescape; and the inherent social justice of a vertical eradication campaign colonizes the ideoscape. Besides writing out other perspectives in these scapes, as if their very real connections don’t matter, the discourses also leave unexamined the integral role of affected peoples (ethnoscape) and communication (mediascape). In terms of public health, these latter two would seem to be of most import (CDC, 2008), yet they are written out of consideration in this campaign. More work examining how the integration of all five realms, including ethnoscapes and mediascapes, can inform global health campaigns is needed. The cultural-economic model of practice (Curtin & Gaither, 2007) also lends perspective on these findings. The regulatory environment of the global health agencies has produced a culture that ignores the very real role of human agency in creating meaning and shared identities. The GPEI has imposed identities of polio as a child killer, a money drain, and a problem easily conquered by Western science. That consumers may view polio as a small problem compared to others, as a deity, as a bargaining chip to obtain services, or as a Western tool of conquest is a lesson that has been lost on the campaign’s producers. Yet production and consumption work in tandem—one is never complete without the other. Until the GPEI realizes this connection, the campaign is likely to fail. Global health campaigns are inherently political, and trying to remove them from that context is bound to lead to failure. The role of public relations practitioners is to create shared meanings between producers and consumers within the political context, but public relations expertise has been sorely lacking in this campaign. This study is limited by the documentation available. Consumers, particularly marginalized ones, seldom create such documentation for scholars to examine. Participant observation and interviews would greatly strengthen their voices in this study. But our object was to establish the dominant discourses inherent in the campaign materials themselves. What

is apparent is that as eradication keeps eluding the campaigners, communication is taking on a more crucial role in the campaign. The next few years of the campaign will be instructive in how strategic communication can work to benefit global health.

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