Critical Public Health

ISSN: 0958-1596 (Print) 1469-3682 (Online) Journal homepage: http://www.tandfonline.com/loi/ccph20

Inoculating the electorate: a qualitative look at American corporatocracy and its influence on health communication Laura Crosswell & Lance Porter To cite this article: Laura Crosswell & Lance Porter (2016) Inoculating the electorate: a qualitative look at American corporatocracy and its influence on health communication, Critical Public Health, 26:2, 207-220, DOI: 10.1080/09581596.2015.1026877 To link to this article: http://dx.doi.org/10.1080/09581596.2015.1026877

Published online: 01 Apr 2015.

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Date: 31 May 2016, At: 16:13

Critical Public Health, 2016 Vol. 26, No. 2, 207–220, http://dx.doi.org/10.1080/09581596.2015.1026877

RESEARCH PAPER Inoculating the electorate: a qualitative look at American corporatocracy and its influence on health communication Laura Crosswella* and Lance Porterb a Arizona State University, Lake Havasu City, AZ, USA; bManship School of Mass Communication, Louisiana State University, Baton Rouge, LA, USA

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(Received 13 August 2014; accepted 28 February 2015) This research examines the profit-driven agendas, non-branded marketing strategies, and commercialized propaganda that influence citizen trust in health communication messages. Specifically focusing on Rick Perry’s 2007 human papilloma virus vaccination mandate, we highlight the role that corporate funding plays in legislation, regulation, and voter/consumer behavior. Emergent findings from in-depth interviews with Texas residents, in combination with US media reports, illustrate the questionable communications contaminating consumer trust and public health. Our critical analysis of health promotion reflects the commodification of health consciousness in the United States. Keywords: public trust; health communication; Merck pharmaceuticals; Rick Perry; Gardasil vaccination; Merck; Texas; in-depth interviews

On 12 September 2011, Republican Presidential hopefuls Rick Perry, Michele Bachmann, and Rick Santorum went head to head during the Tea Party Express Republican Presidential Debate. Hosted in part by the American-based Cable News Network (CNN), the inaugural event presented issues to conservative candidates in an effort to determine a strong front-runner for the 2012 Republican Primaries. During the national broadcast, political mudslinging drew media attention to Governor Perry’s 2007 human papilloma virus (HPV) vaccination mandate and the heavily concealed industry ties that drove his executive order. Challenging accusations of ‘crony capitalism,’ Perry dismissed allegations that corporate funding influenced his administrative decision, stating: ‘it was a $5000 contribution that I had received from [Merck Pharmaceuticals]. I raised about $30 million dollars. And if you’re saying that I can be bought for $5000, I’m offended.’ Soon after the debate aired, financial reports showed Perry with even deeper ties to Merck Pharmaceuticals. Investigative reporters eventually linked the Texas governor to a decade’s worth of donations from Merck’s political action committee (PAC) in amounts that approached $30,000 (Murphy, 2011). The purpose of this study is to address the implications of the commercialized networks driving healthcare communication. By calling attention to the means by which Merck’s Gardasil lobbying budget framed vaccination conversations, we address the utilitarian ties driving public policy and the power plays propelling healthcare communication. Accordingly, the research question guiding this investigation asks how Rick

*Corresponding author. Email: [email protected] © 2015 Taylor & Francis

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Perry’s presidential campaign and related media reporting influenced local interpretations of HPV, cervical cancer, and the Gardasil vaccination. Commercial interests, political influence, and industry regulation in health communication Though we often assume that public policy and health communication promote citizen awareness, patient education, and medical discussion, questionable messaging strategies increasingly mitigate communication efficacy and consumer knowledge (Liang & Mackey, 2011). The recent rise in media capabilities, combined with the extensive latitude of corporate liberties, make the commercial increasingly indistinguishable from the non-commercial (McChesney, 2000). Such blurred boundaries bring into question the ethical standards guiding the political platforms and commercialized propaganda that inform health communication. Pharmaceutical lobbying efforts specifically showcase the dubious nature of corporate power and commercialized communication within the healthcare field. While the Federal Communications Commission regulates most broadcast messaging, and the Federal Trade Commission polices advertising accuracy, the Food and Drug Administration’s (FDA) mission focuses on monitoring the safety of health-related products (Beales & Muris, 1993). All three agencies participate in the regulation and jurisdiction of mass mediated health messages. However, ‘the overt cooperation ends with prescription drugs. In this area, the FDA has jurisdiction over both labeling and advertising’ (Jaramillo, 2006, p. 267). Scholars suggest the division’s role as the principal watchdog agency for healthcare marketing calls for greater public concern (Beales & Muris, 1993). Notably, pharmaceutical companies largely subsidize the FDA’s annual budget. Such close business ties bring the FDA’s regulatory ethos into question. Numerous legal proceedings document the ‘dynamic government guidelines’ that have shaped the industrialization of direct-to-consumer (DTC) advertising throughout passing decades, including cases that call into question professional virtues, advertising objectives, first amendment protection, and the individual right to informed decision-making (Bates v. State Bar of Ariz., 433 US 350 - Supreme Court 1977; Bigelow v. Virginia, 421 U. S. 809, 421 U. S. 817–818 l, 1975; Perri, Shinde, & Banavali, 1999, p. 1798; Virginia Pharmacy Board v. Virginia Consumer Council, 425 U. S. 748). Despite heavily documented legislative concerns over the effects of DTC advertising, commercial rights to free speech continue to thwart adequate safeguarding in the digital age (Cohen, 1998; Woodcock, 2003). Perhaps most conspicuously, in September of 2004, Merck’s top selling anti-inflammatory drug, Vioxx, was linked to more than 27,000 product-related deaths (MSNBC, 2004; Associated Press, 2004). Reports suggested that ‘the rise of Vioxx was due to ‘masterful public relations, aggressive marketing and ineffective regulation,’ with the FDA criticized for failing to take sufficient action in the interests of public health’ (McDougall & Popat, 2010, p. 898). In lieu of stringent federal oversight, legislative leaders have responded to lax standards by issuing their own recommendations (Hirson, 2005). Specifically, in 2004, US Senate Majority Leader Bill Frist encouraged manufacturers to wait for two years before advertising new drugs (Melillo, 2005). Financially wounded from Vioxx-related lawsuits and with its reputation at stake, Merck ignored government recommendations and directed attention toward a highly anticipated pharmaceutical breakthrough.

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While awaiting FDA approval for a groundbreaking HPV vaccination, Merck teamed up with non-profit agencies and proactively released a social marketing campaign that primed awareness for HPV and cervical cancer. In two nationally televised public service announcement-style television campaigns, ‘Make the Connection’ and ‘Tell Someone,’ Merck used several different 60-s commercials to urge women to ‘make the connection’ between HPV and cancer and then for ‘women’ to ‘tell someone’ about the importance of the HPV vaccination. Though Merck’s HPV awareness effort encouraged social vigilance, the pre-FDA approval messages sparked debate over corporate intentions, including accusations that the company created a health issue in the interest of product promotion (Eggen, 2011; Rubin, 2004). The company’s campaign messages seemingly fall into the category of ‘help-seeking ads,’ as defined by a collection of health agencies, which includes the FDA, the US Department of Health and Human Services, the Center for Drug Evaluation and Research, the Center for Biologics Evaluation and Research, and the Center for Devices and Radiological Health. The campaign qualifies as disease awareness communications ‘that discuss a particular disease or health condition, but do not mention any specific drug or device or make any representation or suggestion concerning a particular drug or device’ (FDA, 2004, p. 1). While the description fits, health agencies suggest the ‘FDA believes that disease awareness communications can provide important health information to consumers and healthcare practitioners, and can encourage consumers to seek, and healthcare practitioners to provide, appropriate treatment’ (FDA, 2004, p. 1). At the time of the campaign release, however, Gardasil had not yet received FDA approval, and the awareness messages focused little attention on preventative behaviors, such as abstinence, safe sex, or screening. Therefore, Merck’s pre-emptive efforts drove social consciousness of HPV and its connection to cervical cancer, but did little to promote self-efficacy. Immediately upon receiving FDA approval, however, the pharmaceutical company targeted the US market in full force. In addition to releasing two more direct television campaigns, ‘One Less’ and ‘I Chose,’ Merck heavily lobbied for nationwide mandates requiring HPV immunization. Starting in Texas, the company gradually began to monopolize state-ordered vaccinations (Schwartz, 2010). Vaccination requirements offered Merck an opportunity to funnel Gardasil profits into the crippling litigation costs stemming from the Vioxx recall and finally regain secure financial standing (Krumholz & Beckel, 2011). Reports further suggest that the immunization push was strategically engineered to position Merck ahead of pharmaceutical rival GlaxoSmithKline, a company likely to jeopardize Merck’s vaccination monopoly with alternative inoculation developments (Herper, 2012). The strategy was effective. By 2007, and less than one year after Gardasil received FDA approval, 23 states, as well as Washington D.C., had introduced vaccination legislation (NCSL, 2013). Accordingly, Merck now provides substantial contributions to influential agencies such as the US Chamber of Commerce and the Pharmaceutical Research and Manufacturers of America. Additionally, Women in Government, a non-profit organization credited with endorsing the Gardasil vaccination throughout multiple states, maintains tight connections to both Merck and the Perry administration (Fang, 2011). To be sure, Merck is not alone in corporate bankrolling efforts. Many more pharmaceutical companies are gaining political influence on US legislators through strategic government petitioning. Reports indicate that between 1998 and 2013, the pharmaceutical industry led all others by spending roughly $2.7 billion on lobbying expenditures (Drugwatch, 2015). Since 1990 alone, pharmaceutical industry-affiliated political action committees

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have contributed nearly $150 million to government representatives through campaign contributions (Drugwatch, 2015). As Ayo (2011) suggests, ‘It is hard to ignore the supremacy of the free market in neoliberal states over matters pertaining to health promotion [ … ] There is no limit to the reach of the free market and its entrepreneurial role in the health industry’ (p. 103). In light of the far-reaching and widespread messaging capabilities of today’s informational age, it becomes ever more necessary to confront the corporate exploitation and product politicization corrupting public health communication. The Gardasil campaign offers a unique opportunity to examine the effects of this rapidly evolving environment for health awareness efforts. We draw upon in-depth interviews to highlight ways in which political corporate connections influence social trust in public health campaigns. At the most basic level, we demonstrate how one pharmaceutical company gradually entered and quickly controlled a vaccination market. In-depth interviews and case-specific findings showcase the bigger picture, pointing to the consumerization, politicization, and medicalization of public health. Specifically, we investigate the following research questions: (1) In what ways did media reporting of Rick Perry’s presidential campaign facilitate viewer sense making of the HPV health issue and the presumed cure, Gardasil? (2) In what ways did Merck’s involvement in Rick Perry’s executive order influence public trust in health communication and public healthcare policy?

Methods Jowett and O’Donnell (2005) explain that when investigating issues related to cultural propaganda, ‘the most important thing to look for is the behavior of the target audience. This can be in the form of voting, joining organizations, making contributions … or acting in crowds’ (p. 298). To become better acquainted with the lobbying efforts, legislative regulations, and political promotions buried deep beneath surface-level consumer marketing, we spoke with those directly influenced by vaccination mandates. Through in-depth interviews with Texas residents, and a review of media interviews with key actors, we examined how Rick Perry’s presidential campaign influenced local perceptions of HPV, cervical cancer, and the Gardasil vaccination program. Purposive sampling facilitated data collection of a specific and sensitive nature. Given our interest in collecting firsthand accounts of citizen reactions to Perry’s 2007 vaccination mandate, we interviewed state residents who lived in Texas over the past five years (2007–2012). This timeline provided the opportunity to ask participants about their initial reactions to the executive order, as well as their current understanding of Perry’s 2007 mandate and the HPV vaccination as discussions resurfaced throughout the 2012 Republican debates. We solicited participants through Craigslist, social media platforms, and snowball sampling. Participant incentives included $20.00 gift cards to large department stores. A wide variety of social media users (including industry professionals, department faculty members, research associates, and interview participants themselves) shared our call for participants, promoting diverse respondent involvement. Participants ranged in age, gender, and political affiliation. Though Merck’s promotional efforts and related political coverage largely focused on women’s healthcare behavior, men are often involved in medical decisions made by female family members

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(i.e. daughters, wives, mothers). Beyond that, men are members of our consumer culture and actively participate in word-of-mouth marketing. Therefore, we did not issue gender-specific guidelines for participation. We interviewed six females and four males. Pilot interviews suggested male participants, though reluctant to admit disinterest, were minimally responsive to questions regarding Perry’s 2007 vaccination mandate. We attributed this trend to the nuances of a gender-specific issue, and accordingly ensured that male interviewers would conduct interviews with male participants. The participant age range was 27 to 41. Though political affiliation leaned left, responses spanned party representation, with four participants identifying as ‘democratic,’ three as ‘independent,’ one ‘center-left,’ and one ‘conservative.’ One participant did not respond to the open-ended question. We conducted interviews throughout the early fall of 2012 in San Antonio, Austin, and Houston. Interview settings included coffee shops, local restaurants, home visits, and the University of Texas student union. Discussions lasted an average of 46 min. After ten interviews, we reached thematic saturation and concluded data collection. In the interest of ensuring confidentiality, we identify all participants with pseudonyms in the following analysis. Data analysis Atlas Ti (a qualitative data analysis software program) helped organize the various stages of transcript coding. We examined emergent themes in relation to the context in which codes were mentioned and the relationships among references. Of the information sources identified, media demonstrated the heaviest grounded density (with specific sources including MSNBC, Fox, and CNN). Doctors followed second, though with far less weight. Friends, family, girlfriends, social media, and research were also listed as sources of information. Findings Political cronyism On 2 February 2007, Governor Rick Perry unilaterally issued an executive order requiring all 11- and 12-year-old girls to receive the Gardasil vaccination upon entering the sixth grade, making Texas the first state to mandate the $360 three-shot regimen (NCSL, 2013). Perry’s order granted immediate vaccination access to eligible females through Medicaid and the Texas Vaccines for Children program (Peterson, 2007). With roughly 165,000 children between the ages of 11 and 12 in Texas, the state offered a goldmine of profitable opportunity, with drug costs estimates approaching $55–60 million a year (PoliGu, 2011). Merck successfully secured mandate monopolization after strategically allocating a twofold budget increase to lobbying efforts in Texas (NCSL, 2013). Media reports further documented Merck’s intentions to bankroll mandates throughout twenty other states (Batheja, 2011). Though purportedly a nationwide lobbying effort, those directly interviewed reflected general skepticism regarding the oddity that ‘it was just Texas.’ Stephanie, a resident of Houston and medical professional in her early thirties, suggested, ‘it is strange that only one state would do that … you would think that the national department of health would mandate [the vaccination].’ Dave, originally from Albany, New York, indicated ‘As far as I know there was no other mandate like it in the United

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States. It seemed strange that Texas would do that … it doesn’t seem like a conservative thing to do.’ Interviewees further questioned the localization of the mandate, often relating speculation to political cronyism. While legislators in Texas quickly overrode the executive decision (superseding Perry’s directives within three months), Perry continued to aggressively endorse the HPV vaccination during his campaign for re-election as the governor of Texas, shocking religious conservatives across the state. Robert, a videogame developer in his early 40s and long-time resident of Austin, emphasized, ‘It wasn’t even bipartisan agreement. You know. He couldn’t get it passed in the legislature, so he issued an executive order. Both Republicans and Democrats were against it.’ Despite criticism from his conservative base, Perry remained loyal to Merck pharmaceuticals throughout statewide elections. Participants noted and questioned such behaviors, and further addressed what seemed to be a central concern across party lines. Interview responses suggested uncertainties regarding the vaccination’s inherent purpose. Peter, a financial advisor living in San Antonio, suggested ‘the idea to get a vaccine for a sexually transmitted disease is kind of strange because it seems like they might be overreaching their bounds a little bit. It’s interesting to me that this isn’t [the case] when I talk about polio or meningitis or tetanus.’ Mandate age further complicated the issue. Aaron, a software engineer in his mid-twenties, explained, ‘[the vaccination] is given to girls at the age of 12, which is part of the reason why it freaks people out. No one likes to think about 12 year olds having sex.’ Ashley, Aaron’s wife, supported this theory while being interviewed in a separate room. The professional fitness instructor ‘wondered if Gardasil would be as controversial if you got it at like age two instead of 12.’ Gender-related references were specifically relevant in terms of both Rick Perry’s 2007 vaccination mandate, as well as his short-lived presidential campaign run. Alex, a middle school teacher, explained, ‘As far as policy stuff, he’s another one who is not for a woman’s right to choose about what she does with her body … I don’t believe, especially a man, has that right to say that that’s the way it needs to be.’ Interestingly, respondents repeatedly referenced the state mandate as a female-specific problem. Without exception, male interviewees also referred to the health issue using the term ‘they.’ For example, ‘that was [Perry’s] idea – they must get the vaccination for HPV.’ With an already apprehensive (and arguably under-informed) audience, speculation of political cronyism snowballed as Perry vehemently campaigned for youth vaccination. Andrew Wheat, a research director at Texans for Public Justice, explained to the Washington Post that, ‘at the time that [Perry] did this, it just had everybody scratching their heads. He wasn’t known as a crusader for women’s health. There’s no explanation that seems to make sense other than that Toomey got his ear and he got Perry to do this favor for him’ (Eggen, 2011). Mike Toomey, Perry’s former chief of staff, was a close associate of Merck. Many interviewees referenced similar trends of cronyism when evaluating Rick Perry’s performance as their state governor. Aaron complained ‘He puts buddies in office. I was just reading in the Statesmen, that’s our local newspaper, that he’s got this guy that he just bounces around from place to place getting high profile jobs.’ While the mandate itself was the first of its kind, skepticism regarding Perry’s political stance is certainly not unique in the realm of American policy-making. Giving new definition to corporate power, societal leaders often operate on self-serving conventions, issuing laws that pander to the comforts and security of governing politics. Amanda, a paralegal assistant in her mid-twenties, offered, ‘you never know what’s going on

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behind the scenes and how deep these ties are.’ Aaron admitted Perry made him ‘nervous because it seems like he has some big pocketbooks behind him.’ Given that most of the $30,000 contributed to Perry’s campaign by Merck’s political action committee preceded the Governor’s 2007 executive order, Texas state contribution records validate such concerns (Eggen, 2011). Peter, 29, suggested, ‘he was spending a lot of state money to do a lot of his campaigning and I think that did not go over very well here.’ As noted earlier, Mike Toomey, Perry’s former chief of staff, worked as a lobbyist at Merck and led one of the six super PACS endorsing Perry’s campaign. Super PACS provide an avenue for unlimited campaign donations under the condition that the political action group does not directly coordinate with candidates or officeholders. Though regulation prevents quid proquo strategizing, Super PACS provide opportunity for unspoken negotiations. Raised by politicians himself, Robert directly referenced Super PAC influence, explaining that people can funnel campaign money through Perry’s PAC, [or] hire his lobbyist friends … you can donate to his favorite charities, you can even put money in an offshore account that he has without any previous knowledge to the public – which I’m sure a number of those and more have happened. I mean, you don’t get a [mandate] like that passed with $30,000 in contributions.

While the exact degree to which pharmaceutical endorsements influenced Perry’s executive order is unknown, Minnesota Representative Michelle Bachmann indicated during the live debates in 2011, that, ‘the drug maker stood to make tens of millions off Perry’s order until the legislature overturned it’ (CNN, 2011). Seemingly accepting questionable politicking as the American way, Dave argued, The more you learn about politics, the more there are lobbyists going with recommendations to congressman, and this doesn’t mean they’re bad people or bad companies, but politicians need to get their ideas from somewhere and that’s where lobbyists come in. That’s just the pecking order. I think if you believe that that’s a bad thing, you’re going to have a whole lot of trouble understanding the American political system at all.

Dave’s feedback offers a representative account of the dismissive disposition sustaining a commercialized US democracy. Media framing and public trust Five years after issuing the vaccination mandate, Texas governor Rick Perry joined Minnesota Representative Michelle Bachmann and former Pennsylvania Senator Rick Santorum in the race to become the Republican Party’s 2012 nominee for president, challenging President Barack Obama on the democratic ticket. After announcing his bid in the 2012 election, Perry’s history with Merck quickly drew media attention to the 2007 executive order and corresponding allegations of political corruption. While the majority of participants expressed minimal recollection of the initial mandate, most indicated the 2012 campaign coverage brought Perry’s 2007 mandate and issues surrounding the Gardasil vaccination back into focus. Stephanie explained, ‘I didn’t really know that there was a mandate … that seemed to be talked about during the debates if I’m not mistaken.’ Almost in an air of exasperation, a few interviewees indicated hearing more reactions to the mandate as part of the 2012 election than at the time of the actual executive order in 2007. Media coverage made it increasingly clear

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that political solicitation and Perry’s vaccination endorsement worked hand-in-hand to feed the vested interests driving legislation. News reporting and media framing further influenced public trust by propelling issues of political cronyism into the media spotlight. Throughout national debates, Perry’s message framing became unsteady and ambiguous as opponents challenged the motives behind his 2007 vaccination mandate. After receiving heavy criticism from his opponents, Perry eventually revised his stance on the statute. Nearly four years after bypassing the Texas legislature with an executive order, Perry went on record and admitted the mandate was ‘a mistake.’ ‘What was driving me was, obviously, making a difference about young people’s lives. Cervical cancer is a horrible way to die. You may criticize me about the way that I went about it, but at the end of the day I am always going to err on the side of life.’ Rendering his motives as pure, Perry offered, ‘If I had it to do over again, I would have done it differently’ (Mortada, 2011). He voiced a newfound support for the legislature’s overruling, explaining, ‘the fact of the matter is that I didn’t do my research well enough to understand that we needed to have a substantial conversation with our citizenry.’ Kaitlyn, a marketing professional in her late twenties, explained the ‘[media] highlighting Perry’s flip flopping on [the issue] was interesting because it really highlights that he, and really pretty much any politician, regardless of their political leanings, will say whatever they have to say to try to be in the right at the time.’ Medical facts quickly succumbed to theatrical political performances as presidential hopefuls engaged in negative campaigning during the presidential race. Minnesota representative Michele Bachmann went as far as to frame the HPV inoculation as a ‘very dangerous drug, [one] which could lead to mental retardation,’ (CNN, 2011; FactCheck.org, 2011). Chris Stolle, a member of Virginia’s House of Delegates, told US media reporters that, ‘we’ve taken what is a medical issue and politicized it, and it always bodes poorly for medicine when that happens’ (Huff Post, 2011). Interview transcripts support Stolle’s assessment, indicating participant concern that ‘it doesn’t become about issues anymore, it just becomes about sensationalism.’ Stephanie stressed, ‘it’s so convoluted … as far as any kind of news issue. I guess because I don’t take the time to go fact check these things … I don’t know who’s really telling the truth.’ Women’s health advocates, pediatricians, and cancer experts worried political turmoil would tarnish public perception of a potentially lifesaving vaccine. Risk communication scholars Ropeik and Slovic (2003) validate such concern, indicating ‘the less we trust the people who are supposed to protect us, or the people or government or corporate institutions exposing us to the risk in the first place, or the people communicating to us about the risk, the more afraid we’ll be’ (p. 3). Transcripts reflected general distrust for those charged with protecting the public, and indicated minimal faith in the integrity of American politicians. Amanda explained government leadership and mainstream news coverage ‘makes [her] leery. It makes me want to do the research on my own … and try to figure out what’s really going on.’ Commercialization of health communication Because corporatized health messaging threatens communication credibility, such commercialized strategies pose a potential breakdown in communication and collapse in overall societal advancement (Lundgren & McMakin, 2004). Bakan (2004), a scholar of economic law and socio-legal studies, suggests the ‘corporation’s legally defined mandate is to pursue, relentlessly and without exception, its own self-interest, regardless

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of the often harmful consequences it might cause to others’ (p. 2). Bakan argues that, ‘Over the last 150 years the corporation has risen from relative obscurity to become the world’s dominant economic institution. We are inescapably surrounded by their culture, iconography, and ideology’ (p. 5). One male respondent highlighted the industry’s ability to construct certain realities by indirectly addressing the implicit connection between Merck and HPV, reporting ‘I haven’t really thought about HPV since all that was going down, so probably if that company was brought up without its connection to HPV, I wouldn’t even know it.’ Interview transcripts reflected the implications of profit-driven healthcare communication. Dave, a business professional, reasoned that the healthcare industry ‘is different than making a car or making a computer, but the underlying motivations of why they’re there at all in the first place is the same – it’s to make money. That’s how corporations work.’ Speaking to the shared interests binding the FDA to commercial influences, Stephanie offered, You wonder what’s going on with drugs being developed and the FDA. You got to think that these companies are publically traded companies that need to make a profit, so that always makes me nervous. It just makes me nervous that companies like Merck or Pfizer- they have to turn a profit. So if they’re running out of drugs and their company is in jeopardy … maybe they’re not going to do due diligence.

Highlighting the accepted presence of commercialized and politicized communication, Peter suggested, ‘profits almost always come ahead of the general public.’ In terms of health messaging, ‘you just kind of have to let it go through one ear and out the other.’ Aaron more or less applauded the healthcare industry for what seem to be reversed priorities, explaining ‘healthcare is unique in the fact that they’re not only there to make money but they’re there to improve the livelihood of the society. To some degree, that’s part of their charter.’ Directly referencing the Rick Perry–Merck connection, Amanda submitted that ‘someone’s going to benefit, and either way, I suppose some pharmaceutical company is going to make millions of dollars.’ While participants explicitly indicated a general tolerance for the commercialized corruption driving the US political system, discussion subtly shifted gears when interview questions gradually became more apolitical. Indicative of public distrust in healthcare communication, Dave advised to ‘talk with your doctor and just hope your doctor is not just pushing drugs … there’s always that concern that you doctor is going to be in the backdoor.’ Such noted themes speak to ways in which corporate interests drive the commercialized medicalization of health communication. The medicalization of public health While the mandate itself sparked controversy worthy of deeper examination (including topics related to funding, availability, safety, parental control, and moral objections), emergent themes outline the bigger picture, unearthing greater implications of commercialized government policies and public health communication. Interviews and transcript analysis link responses with a call for clearer healthcare marketing regulations. Though interviewees largely accepted the political power granted to the pharmaceutical industry, responses to broader health communication questions painted a different picture.

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Transcripts indicated a majority of interviewees had ‘a real adverse attitude towards Western medicine.’ Aaron said, ‘It seems like every year they figure out a new disease out of thin air.’ Alex further developed such thought, explaining, ‘Drugs are abused all the time that have been later recalled because there hasn’t been enough studies done over enough years like there needs to be.’ Stephanie, a healthcare professional, said she ‘would just like to see more accuracy and more testing.’ She added,

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There [needs to] be an independent group not financially tied to any of the people. But there is not an independent group. That independent group is able to have waivers … and continue to be a part of the evaluation process. That’s a guaranteed market. Lots of money there. I know that it takes a lot of money to do the research and prove these drugs are safe. But I feel like it’s a process that doesn’t have enough stops in place or people watching the process who are independent to make sure things like this don’t happen – to make sure that special interest isn’t part of deciding whether or not a vaccine’s going to be mandated.

Adele, a mother and homemaker, emphasized the dangers of mixed agendas and blended communication models, voicing concern that ‘drug companies target consumers and push that to the very line where they’re not crossing it, but they’re treading it. Western medicine has made tremendous breakthroughs for diseases, and viruses and bacterial things … but [consumerism] can get in the way of communication.’ Suggesting healthcare communication has gradually morphed into healthcare commodity, Dave explained, Pharmaceutical companies can say whatever they want, you know, to a point where they’re not lying – in a very clever way. Just like Republicans when they try to put a bill past the American legislature they’ll name it something clever like the Patriot Act, right? So if you vote against it then the message is ‘you’re not a patriot.’ You know, a great example would be Prilosec, OTC. Prilosec is an anti-gastric drug. Instead of encouraging consumers to eat better foods or, to you know, drink certain things like milk or something that’s less acidic, they market a profitable remedy.

Aaron asserted, I don’t like prescription drug ads that try to have you self-diagnose yourself. I think it’s one thing when they’re like, ‘hey you’re not able to have sex with your wife because you have ED.’ It’s another thing when they’re like, ‘do you have mysterious pains all over your body?’ And they’re trying to get you to be like, ‘well, am I hurt in this way?,’ or ‘Am I depressed?’ Should I be self-diagnosing myself? And you know, they always throw in as a lip service, ‘oh you need to go and talk to your doctor to make a final decision.’ But at the same time, a lot of people’s doctors could, for better or worse, just prescribe to people what they want. So I don’t like the idea of ‘hey in the first part of this ad we’re going to educate you on how to self-diagnosis yourself.’ If it has a real scientific term of what the problem is, just refer to it as that.

Contemplating the connection between capitalism and the medicalization of public health, one participant surmised ‘Is there a connection? I don’t know. Is that quite possible? Well, hell yeah.’ Marxist scholars commonly suggest the general public overlooks the industry peddling and political bankrolling that occurs across the nation (Lasn, 2012). Findings throughout this work support such arguments, indicating trends of unconscious dismissal. We expand the range of current research by connecting DTC messaging and health communication to the driving forces of American capitalism. While pharmaceutical

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marketing may foster consumer awareness, patient education, and healthcare discussion, such promotional efforts can also yield gratuitous physician prescribing, patient misuse and abuse of medications, and escalated healthcare expenses (Calfee, 2002; Liang & Mackey, 2011; Myers, Royne, & Deitz, 2011). Additionally, lax broadcast regulations and political influence complicate the nature of information, misinformation, and disinformation driving healthcare communication. As such, deliberative democracy and informed citizenry necessitate a more robust public awareness and understanding of pharmaceutical influence and commercialized wellness.

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Discussion This research relays the opinions and perceptions of various state residents, offering an intimate portrayal of government administration and its role in vaccination communication. Field interviews offer first-hand accounts of ways in which the politicization of the HPV health issue shaped resident assessment of Rick Perry, Merck Pharmaceuticals, and the Gardasil vaccination. Our analysis suggests that despite diminishing levels of public trust, commercialism may simply be understood and accepted as a realized component of American culture. If citizens are in fact resigned to the commercial influences that flood day-to-day experiences, concern needs to shift to the social dynamics driving corporate control and the industry legacy in government legislation. Though nearly four decades have passed since the pharmaceutical industry secured commercial speech protection, the rapidly changing political economy, and expanding abilities of global communications heighten debates over industry regulation and accountability. Most recently, US lawmakers attempted to provisionally freeze prescription drug advertising in 2007. Again, legislative efforts failed due to constitutional protection of commercial free speech (Liang & Mackey, 2011). Given that governmental censorship undermines the principles of a democratic system and poses a threat to the free market enterprise, healthcare messaging becomes increasingly vulnerable to profitdriven agendas and big business corruption. Both legal and financial documents expose the market-driven interests that point toward the medicalization and trivialization of public health in the US. Consumer reports highlight the methodical commoditization of healthcare communication, showing that in 1997, the pharmaceutical industry landed 13th among 360 advertised product categories. This ranking came one year prior to the finalized relaxation of DTC regulations (Jaramillo, 2006; Med Ad News Staff, 1998). Furthermore, DTC advertisements are among the most common forms of health communication, and prescription drug ad spending is nearly eight times higher than research and development (Grantham, Ahern, & Connolly-Ahern, 2010; Jaramillo, 2006). The circumstances surrounding the Gardasil vaccination, the social marketing campaign, and the executive mandate introduce several key issues to the health communication regulation conversation. Though Merck’s Gardasil vaccination offers promising potential to reduce rates of cervical cancer, consumer knowledge ‘hinges on widespread public acceptance of HPV vaccination, especially among decision makers’ (Nan, 2012, p. 10). In the presented case, pre-emptive marketing efforts and politicalized messaging compromised the informative value of HPV awareness efforts. Industry agendas, company transgressions, and sensationalist media coverage further complicated consumer trust in healthcare communication Though commercialism forms the foundation of America’s market economy, certain sectors of society require stronger protection against the laissez-faire system. The

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underlying dynamics of corporatized politics, unlimited commercial speech, lax corporate social responsibility, limited FDA regulation, and a de-emphasis on consumer well-being all support an increase in commercialized healthcare messaging. Without questioning the legitimacy or purpose of profit-driven communication, the implications of corporate control intensify as business agendas infiltrate public health sectors. These issues become exponentially more complex when it starts to become unclear whether the ends justify the means. US Supreme Court Justices (White, Brennan and Marshall) attest that industry privileges have ‘placed [companies] in a position to control a vast amount of economic power by which they may, if not regulated, dominate not only the economy but also the very heart of our democracy, the electoral process’ (Lasn, 2000, p. 160). Knowingly or not, corporations have systematically conditioned public acceptance of industry presence across all levels of communication, coercing the masses into believing the ‘bottom line’ is a standard part of societal operations. By allowing corporations to price every aspect of their lives, US citizens forfeit personal autonomy and assume a completely commercialized existence by default. The US can mitigate these threats by raising awareness of these agents of social control. While informed communication begins with mass media, the responsibility of social awareness falls upon the entire community. As Breton, Richard, and Gagnon (2007) suggest, Significant actors in basic public policy change are not, strictly speaking, confined to the political sphere, but also include actors in the social sphere such as journalists, academics and representatives of civil society. These actors are part of an elite concerned with decisions and policy directions that affect a specific domain in society. The members of this elite are distinguishable from the general population by their means of action, e.g. budgets, legitimacy and scientific data, and their opportunities for access to the decision- making process through their network of contacts and access to the media. (p. 358)

Once key communities start recognizing and challenging the legitimacy of corporately funded healthcare systems, they can start building a more informed and actively aware society – one in which constituents exercise ownership over personal wellbeing, and the US electorate assumes its rightful place in American democracy. Acknowledgements We would like to thank the anonymous reviewers, associate editor, and editor for their considerate feedback and invaluable recommendations regarding this manuscript.

Disclosure statement No potential conflict of interest was reported by the authors.

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