“Superbugs” in the Risk Society: Assessing the Reflexive Function of North American Newspaper Coverage of Antimicrobial Resistance:

Gabriela Capurro

doi:10.1177/2158244020901800

“Superbugs” in the Risk Society: Assessing the Reflexive Function of North American Newspaper Coverage of Antimicrobial Resistance:

Capurro, Gabriela 2020-01-24 00:00:00 This article examines how antimicrobial resistance (AMR) is covered in four elite North American newspapers and whether the dailies act as sites of reflexive modernization. I draw on risk society theory to situate AMR as a modern risk and news media as key spaces for reflexivity. Through a qualitative content analysis of 89 news stories on AMR, this study shows that this risk is communicated through inaccurate definitions and oversimplified accounts of the causes, populations at risk, and preventive measures. Media representations of health risks affect public perceptions of risk and risk prevention. The dailies, however, seldom expressed reflexive modernization, a key function of “mass media” in the Risk Society, which I argue could be due to the very complexity of “modern risks.” Lack of reflexivity in the media regarding AMR could delay crucial policy and institutional changes necessary to tackle this risk. Keywords risk communication, qualitative content analysis, reflexive modernization, antibiotic resistance, health communication Furthermore, since the 1940s, antibiotics have been routinely Introduction used in farming by administering them in large doses to oth- Antibiotics are one of the most important technologies of erwise healthy livestock to promote growth. Currently more modern medicine. Without them, even a small scrap or rou- than 63,000 tons of antibiotics are used annually on livestock tine surgery can become life-threatening. Antimicrobial around the world (McKenna, 2017). The rise of antibiotic resistance (AMR) is one of the greatest public health risks, resistant infections, however, has led to debates over physi- threatening to make antibiotics useless. Resistance, the evo- cians’ prescription practices (e.g., Duane et al., 2016; lutionary defensive mechanism that allows bacteria to pro- Wilcock et al., 2016), recommended length of antimicrobial tect themselves against antibiotics’ power to kill them, treatments (e.g., Langford & Morris, 2017; Llewelyn et al., “threatens the very core of modern medicine” (World Health 2017; McGow, 2019), and the use of antibiotics in livestock Organization, 2015, p. VII) causing more than 1.5 million and crops for non-therapeutic purposes (e.g., Makary et al., deaths annually worldwide (Hall et al., 2018). In the last two 2018). decades, there has been an increase in multidrug resistant Emerging risks, such as AMR, bring a pervasive sense of bacteria, which cause infections that do not respond to mul- uncertainty, and in trying to make sense of them, multiple tiple antibiotics. Health authorities have described antibiotic narratives are generated that attempt to define the hazard, resistance, and more broadly AMR, as a public health emer- its causes, populations at risk, responsibility, and as well as gency caused by extensive antibiotic misuse, which has not preventive measures (Beck, 1992b, 2009; Douglas, 1992). been met with an equally prolific development of new antibi- otics (O’Neill, 2016). In addition, resistance to the few new drugs available is also being developed (Cassir et al., 2014). Carleton University, Ottawa, Ontario, Canada Today antibiotics are prescribed to treat a host of different Corresponding Author: bacterial infections but they are also consistently prescribed Gabriela Capurro, School of Journalism and Communication, Carleton when unnecessary—for example, to treat viral infections— University, Richcraft Hall, 1125 Colonel By Drive, Ottawa, Ontario, and are seldom taken by patients as indicated (Centers for Canada K1S 5B6. Disease Control and Prevention, 2015; Hall et al., 2018). Email: gabriela.capurro@carleton.ca Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open These definitions then become discourses that guide how success of industrialization (Beck, 1992b, p. 21; Shah, 2016). particular risks are understood and regulate risk behavior Similarly, AMR can be understood as a modern risk: exacer- (Beck, 1992b, 2009). News media are important sources of bated by the unregulated consumption of antibiotics, with scientific and health information (Nelkin, 1995) and they global effects, requiring international cooperation, and with contribute, along with other social actors, in the discursive repercussions that will extend to future generations. co-production of public health risks, affecting public per- Cultural theorists conceptualize risk as the combination ceptions of risks and risk behavior (Briggs & Hallin, 2016; of material conditions and sociocultural processes (Fox, Caulfield et al., 2019). In the theory of risk society, mass 1999; Lupton, 1999a, 2013) and risk definition, perception, media are described as key sites of risk definition and and estimation as dependent on values and cultural under- reflexive modernization (Beck, 1992b, 2009); however, standings (Bradbury, 1989, p. 2). In that sense, risk definition how the media achieve this reflexive function is not fully is susceptible to change, magnification, dramatization, or developed. minimization, that is, to social production through complex In this article, I examine how the risk of AMR is discur- claims-making processes by various social actors (Beck, sively constructed in North American newspapers and 1992b), who not only identify risks but also assign blame and whether the dailies act as sites of reflexive modernization, by responsibility (Tansey & O’Riordan, 1999). Processes of risk questioning expert knowledge and modern medical and definition can lead to reflexive modernization, a critique of industrial practices. I draw on risk society theory to situate the process of modernization given that the main institutions AMR as a human-made risk, a consequence of modern medi- of late modernity—government, industry, medicine, sci- cal and industrial practices with global repercussions extend- ence—have become the main generators of risk (Beck, ing in time, and news media as sites for risk definition and, 1992). Reflexive modernization supposes a process of “self- potentially, where reflexive modernization is expressed. This confrontation with the consequences of risk society which study sheds light on how news media’s reflexive function is cannot (adequately) be addressed and overcome in the sys- enacted when covering a “modern risk.” The analysis focused tem of industrial society” (Beck, 1996, p. 28). In this context, on five elements: risk definition, reported causes, popula- scientific progress does not reduce risks but make them more tions identified at risk, assigned responsibility, and preven- evident leading to the demystification of science and the tive measures suggested. demonopolization of scientific knowledge claims (Beck, 1992b), which not only multiply but also contradict one another and frequently lose their validity, leading to “reflex- Risk Society and Reflexive ive scientization” (Beck, 1992b, p. 166). Despite this, most Modernization modern risks cannot be perceived by the senses, so depen- Risk has been conceptualized in various ways, ranging from dency on expert knowledge increases (Beck, 1994), and sci- objectivist to constructivist approaches. Objectivist entists and experts maintain their definitional power (Beck, approaches borrowing from cognitive psychology tend to 2009). focus on how individuals’ form their perceptions of risk In the risk society, mass media are described as sites of through the information they receive about the risk and the risk definition and reflexive modernization. Media dis- heuristics they rely on to make sense of the risk, for example, courses and representations contribute greatly to the con- trust in institutions such as government and media (e.g., Choi struction of risk (Beck & Levy, 2013) by providing the et al., 2018; Fischhoff et al., 2000; Shin, 2010). Cultural definition and language that lay people will use to make approaches to risk, on the contrary, are constructionist in ori- sense of risks, assigning responsibility and blame, and vali- entation, conceptualizing risk as the outcome of a combina- dating some forms of knowledge while discrediting or ignor- tion of material conditions and sociocultural processes (Fox, ing others. Media discourses express reflexive modernization 1999; Lupton, 1999a, 2013) In this study, I draw on the criti- as experts, scientists, political leaders, advocates, policy cal theory of risk society, a constructivist approach to risk makers, and other stakeholders communicate and challenge that argues that in late modernity, social and political order each other’s views on the definition and causes of risks, and are threatened by unprecedented anthropogenic risks, result- how to manage them. ing from scientific and industrial development (Beck, 1992b, In this article, I examine how AMR is covered in four elite 2009). Modern risks are pervasive and not limited by time North American newspapers and whether the dailies act as (they will affect future generations) or space (global nature), sites of reflexive modernization. Through a qualitative con- and their management requires international cooperation tent analysis (QCA), I assess (a) how the risk of AMR is (Beck, 2009). The risks created by modernity are almost defined in the news coverage, (b) who is identified as respon- impossible to calculate and have unimaginable conse- sible for causing and/or managing the spread of AMR, (c) quences, making any attempts to manage their impact inad- who is said to be at risk, (d) which prevention measures are equate (Beck, 1992a; Giddens, 1997). For example, global suggested, and (e) whether the newspapers acted as sites for environmental degradation and accelerated spread of zoono- reflexive modernization by questioning expert knowledge ses are risks that emerged as a direct consequence of the and/or modern medical and industrial practices. Capurro 3 coverage was alarmist. The authors warn that apocalyptic Media Coverage of AMR media messages can increase skepticism of scientific exper- Media are important sources of scientific information and tise. Similarly, a study examining Australian media represen- health information, affecting public understanding of health tations of AMR found that the use of military metaphors, issues and risk (Nelkin, 1995; Vasterman et al., 2005; anthropomorphizing of bacteria, and doomsday framing Woloshin & Schwartz, 2006). News media play a crucial role were common rhetorical tools across media platforms in “producing and circulating information about health as (Bouchoucha et al., 2019). In addition, Collins and col- well as competing forms of knowledge and culture” (Briggs leagues (2018) found that in newspaper coverage of AMR in & Hallin, 2016, p. 77) that intersect with health and medi- the United Kingdom, not only are the resistant organisms cine. Studies in risk communication of AMR have mostly anthropomorphized but antibiotics are also depicted as focused on the use of the “superbug” frame in news cover- instilled with agency. age, that is, the use of hyperbolic language to refer to resis- Desilva (2004) examined antibiotic resistance in the tant organisms and to describe apocalyptic post-antibiotic Canadian press and compared it with U.S. coverage. They scenarios. Focusing mostly on how press and broadcast found that Canadian and U.S. media seldom mention the media describe the causes, incidence, and measures of con- causes of resistance or how to reduce exposure. Washer and trol and prevention, these studies draw on the information Joffe (2006) found a similar trend in British news coverage deficit and social amplification of risk models of risk com- of MRSA, which seldom offered an explanation of how bac- munication to examine whether enough expert information is teria evolve resistance to antibiotics or the role of physicians provided to the public (e.g., Bie et al., 2016; Desilva, 2004; overprescribing practices. Chan et al. (2010) showed that the Singh et al., 2016) and how media coverage amplifies feel- British media blamed “dirty hospitals” and the government ings of anxiety and risk (see Brown & Crawford, 2009; for the rise of MRSA but did not explain the evolutionary Nerlich & James, 2009; Washer & Joffe, 2006). process that leads to resistant bacteria or the human actions Washer and Joffe (2006) examined the coverage of meth- that accelerate that process or preventive measures. Similarly, icillin-resistant Staphylococcus aureus (MRSA) in the in the Swedish print media, the most commonly reported British press. They found that the coverage shifted from cause of antibiotic resistance was antibiotic over-prescrip- reproducing the rhetoric of the medical literature in the early tion, while risk-reduction measures at the societal level were 1990s, that is, explaining it as an infection resistant to antibi- more commonly reported than to the individual level (Bohlin otics, to depictions of a “killer superbug” since 1997. & Höst, 2014). Collins et al. (2018) found in newspaper cov- Apocalyptic predictions are now a common trope in the cov- erage of AMR in the United Kingdom that responsibility for erage of AMR, including the anticipation of both natural inappropriate use of antibiotics was multidirectional, and devastation and personal tragedy (Brown & Crawford, identified a tension between blaming doctors-as-prescribers 2009). The feeling of doom is emphasized by focusing on the or patients-as-users and the collectivization of the general ability of bacteria to evolve resistance to new antibiotics in a public as an unspecified “we.” Furthermore, they found that short period of time (Brown & Crawford, 2009; Washer & livestock farming and pharmaceutical industry were rarely Joffe, 2006). Media resort to the reification of resistant bac- reported as social actors with responsibility in the AMR teria as “superbugs” (Nerlich & James, 2009; Washer & crisis. Joffe, 2006) and depicting them as having human-like quali- Another recent study on newspaper coverage of AMR and ties, being “clever” and outsmarting the scientific commu- antimicrobial stewardship in the United Kingdom found that nity (Brown & Crawford, 2009; Washer & Joffe, 2006). In when covering sepsis, the newspapers preferred personal addition, the bacteria’s ability to move across space and cor- narratives which can generate greater public interest, which poreal boundaries is also recurrent in the media rhetoric, are rarely included in articles about AMR (Rush et al., 2019). highlighting its ubiquitousness and uncontrollability (Brown However, the articles usually did not balance messages about & Crawford, 2009). These depictions emphasize feelings of crucial early antibiotic treatment in sepsis with the need to danger and human vulnerability, and reinforce the idea of reduce unnecessary prescribing. The authors suggest inte- conflict between nature and medical progress (Washer & grating media discourses about AMR and sepsis to improve Joffe, 2006), a rhetorical tool used to raise public awareness, public understandings of the importance of antimicrobial but can also induce fear and promote misinformation (Nerlich stewardship (Rush et al., 2019). & James, 2009). Furthermore, unlike outbreak narratives that offer the promise of medical solution (Wald, 2008), the cov- Method erage of AMR contradict expert knowledge by suggesting The theory of risk society refers broadly to “mass media” alternative therapies, potentially leading to loss of trust in and “news media,” explaining that they have definitional medicine (Washer & Joffe, 2006). power through their agenda-setting function, identifying par- More recently, a study examined two decades of coverage ticular victims and laying blame on certain groups (Beck, of AMR in the German press (Boklage & Lehmkuhl, 2019) 2009; Beck & Levy, 2013), as well as a reflexive function; and found a similar trend, noting that the overall tone of the 4 SAGE Open however, how media achieve the latter is not fully developed. PostMedia, which owns several right leaning media outlets Furthermore, news coverage of health risks affect public per- throughout Canada. ception of risks and risk behavior (Briggs & Hallin, 2016; The analysis of the newspaper coverage of AMR was Caulfield et al., 2019). This study examines how the risk of guided by the following research questions: AMR is discursively constructed in four elite North American newspapers —The Globe and Mail and the National Post in Research Question 1 (RQ1): How do the newspapers Canada, and The New York Times and The Washington Post define AMR and its causes? in the United States—and whether the dailies expressed Research Question 2 (RQ2): Who is considered at risk reflexive modernization. of resistant infections? The global decline of news consumption in legacy news Research Question 3 (RQ3): Who is deemed responsible outlets, such as newspapers, radio, and television networks, for managing AMR in the news coverage? led legacy media to heavily invest in developing digital and Research Question 4 (RQ4): Which prevention mea- mobile news applications (Westlund, 2013). North American sures are suggested to minimize the risk of acquiring or newspapers have seen an increase in online readership (News spreading resistant infections? Media Canada, 2019; Pew Research Center, 2019). For Research Question 5 (RQ5): Does the newspaper cover- example, readership of Canadian newspapers is at an all-time age of AMR express reflexive modernization? high due to online news consumption, with 88% of Canadians reading a newspaper at least once a week (“Stop the Presses,” Through a QCA of 1 year of coverage, I examined how 2019). In this study, I examined news coverage in four North the risk of AMR was defined, how blame and responsibility American newspapers with print national daily editions as were assigned, and whether modern institutions and prac- well as strong online presence. The New York Times is based tices were questioned for their role in the exacerbation of in New York city and has a weekday print circulation of AMR and emergence of this public health threat. With QCA, 487,000 copies (Watson, 2019). Its presence online however the content and meaning of texts are systematically described continues to expand and the paper now makes 40% of its through the process of coding and the identification of revenue from online subscriptions (Benton, 2019). The New themes and patterns (Hsieh & Shannon, 2005; Schreier, York Times has around 2.33 million paid digital-only news 2012). Mayring (2015) defines QCA as a mixed-methods subscribers (Wang, 2018). Canadian subscribers make up approach consisting of two steps: first, a qualitative-interpre- around 27% of the Times international subscriber base with tative phase in which categories are assigned to text passages around 94,000 subscriptions (Wang, 2018). The New York through coding, and second, a quantitative analysis of fre- Times has a left-leaning media bias (AllSides, 2019). The quencies of those codes. Following Marying’s two-step newspaper is owned by The New York Times Company, approach, my analysis first identified the presence or absence which is publicly traded and is controlled by the Sulzberger of five topics—(a) whether the text explained what resis- family. The Washington Post is based in Washington, D.C., tance is (definition); (b) what causes it (cause and blame); (c) and has a weekday print circulation of about 293,000 copies who is at risk (population at risk); (d) who is responsible for (“The Washington Post Had 80.8 Million Readers in June managing it (responsibility); and (e) how it can be prevented 2018,” 2018), as well as a strong online presence with more (prevention)—and described how these topics were than 80 million unique visitors on their website per month in expressed in the news stories. Second, I determined the fre- 2018 (WashPostPR, 2018). The Washington Post is consid- quency with which those topics were expressed in the news ered a left-leaning newspaper (AllSides, 2019). The newspa- coverage to determine which angles were most prevalent in per is owned by Nash Holdings, a holding company the discursive construction of AMR. established by Jeff Bezos, owner of Amazon.com. The Globe On September 21, 2016, the United Nations (UN) General and Mail is based in Toronto, Ontario, and is considered the Assembly held a high level meeting on AMR, in which all “newspaper of record” in Canada. It is the largest newspaper the member-states committed to taking a broad, coordinated in the country with a weekday print circulation of 899,000 approach to address its root causes across multiple sectors, copies in 2019 (“Globe Weekend Edition,” 2019). The Globe especially human health, animal health, and agriculture. The and Mail has a center-right editorial line (Media Bias/Fact analyzed sample spans a year of coverage—6 months prior check, 2018). The newspaper is owned by The Woodbridge to the UN’s declaration on AMR (March 21, 2016) to 6 Company Limited, which is a Canadian private holding com- months after the declaration (March 21, 2017). The sample pany based in Toronto. The National Post is based in Toronto, was collected through Factiva database and the search terms Ontario. In 2016, it had a weekly combined print and online used were “antibiotic,” “antibiotic resistance,” “antimicro- readership of 4.5 million (“National Post Boosts Weekly bial resistance,” and “superbug.” There were 239 articles, of Print and Digital Readership to 4.5 Million,” 2016). The which 150 were duplicates and unrelated stories (e.g., stories National Post has a right-center bias, placing it further right about diseases that require antibiotic treatments but that did in the political spectrum than The Globe and Mail (Media not mention resistance, business reports that mentioned anti- Bias/Fact Check, 2019). The National Post is published by biotic-free meat, obituaries of scientists that contributed to Capurro 5 the development of various antibiotics, etc.). The final sam- war” with resistant bacteria, a common narrative that negates ple was composed of 89 articles published in the newspa- the symbiotic relationship humans have with bacteria. pers’ websites and in print. There were two peaks in coverage; However, 54% of the coverage did not use these anxiety- the first in May 2016 when an American woman was diag- inducing frames and instead chose to use more informative, nosed with a resistant urinary tract infection caused by colis- non-belligerent language. Below, I present the results for tin-resistant E.coli, and the second in September 2016 when each of the research questions. the UN held its high-level meeting on AMR. Legacy media still have an important definitional role in RQ1: How Is AMR Defined? health news (Greenberg et al., 2017), and they repurpose news content for their websites, mobile applications, and Antibiotic resistance was mostly covered as a health story social media (Westlund, 2013), thus reproducing the same (63%, n = 56), explaining how it affects human health and definitions and narratives online, which are later shared and the consequences of resistant infections for individuals, distributed among other social media users, including jour- sometimes recommending preventive measures. Other nalists (Russell et al., 2015). This study focused exclusively aspects of AMR that were salient in the news coverage were on newspaper print and online coverage due to archive acces- the need for political action (39%, n = 35), scientific discov- sibility, but future research could also include news coverage ery and development of new antibiotic treatments (35%, n = of AMR in radio and television, as these media formats could 31), and the economic impact of AMR and distribution of have specific implications on how AMR is covered and resources in prevention plans (21%, n = 19). Most stories reflexive modernization expressed. combined various angles. I created a codebook (Table 1) with five main codes that Although 88% of the stories described resistance as a express the definitional and reflexive function of the media health threat (n = 78), only 29% of the coverage (n = 26) as described in the theory of risk society: definition, cause, explained the evolutionary process that leads to it, that is, population at risk, responsibility, and prevention. In addition, that after prolonged exposure to antimicrobial treatments, a code was created to record how resistant bacteria were organisms evolve resistance to them in which case the tradi- qualified in the coverage (e.g., “superbug,” anthropomor- tional treatments become ineffective and the infection poses phism, etc.), and another one for whether the UN’s action a more serious threat. This is consistent with previous plan on AMR was mentioned or not. Sub-codes were gener- research showing that news coverage of AMR seldom use ated for each code after a preliminary reading of the sample, the word “evolution” or explain the evolutionary process and others were included as they emerged during the coding involved in it (Antonovics, 2016). In addition, 16% (n = 11) process. The sub-codes were not mutually exclusive, as the of the stories had no definition of AMR, why it is a public analyzed news stories could have more than one definition of health threat, or an explanation of the evolutionary process AMR, or mention more than one cause. Therefore, all the that causes it, thus leaving readers without basic information codes present in each story were recorded during the coding to understand the risk. process. I conducted the coding of the sample as an open For example, a story in the National Post warns that “a process, nine new codes were created as they emerged in the U.S. woman has died of an infection immune to virtually 5 6 coverage and the codebook was revised accordingly. The every antibiotic doctors could throw at it is adding to grow- publication date, newspaper, type of story (hard news, edito- ing concerns medicine is losing its standoff with superbugs” rial, column, etc.), and angle (political, economic, scientific, and adds that it “may not be the drug resistant ‘apocalypse’ etc.) were also recorded. some fear, but the case is raising new alarm over what has become one of the most serious public health threats world- wide” (Kirkey, 2017). Despite the dire description of the risk Results and mentioning the possibility of an “apocalypse,” the story Antibiotic resistance received greater coverage from newspa- does not define resistance or how bacteria become resistant pers in the United States (75%), with The Washington Post to antibiotics. publishing almost half of the news stories (n = 44), and The There were some instances in which the dailies published New York Times a quarter of the sample (n = 23). The two stories detailing the ordeal that patients with resistant infec- Canadian dailies published a similar volume of stories on tions go through, but missed the opportunity to explain what AMR comprising the last quarter of the sample. The Globe antibiotic resistance is and how organisms evolve it. For and Mail had 10 stories and the National Post had 12. Although example, The Globe and Mail published a story about a 65% of the coverage was composed by hard news (n = 58), woman who was kept alive for 6 days without lungs one quarter of the sample were opinion pieces (n = 22). (Ubelacker, 2017), describing in detail the novel medical pro- The analysis revealed that the newspapers had partially cedure used to save her life after a “superinfection” resistant drifted away from the “superbug” frame. AMR bacteria were to antibiotics had compromised her lungs; however, the story still referred to as “superbugs” in 43% of the coverage (n = did not explain what resistance is nor how it happens. 38), and in 10% of them, humans are described as being “at Similarly, both The Washington Post (Karidis, 2016) and The 6 SAGE Open Table 1. Code Book. Code Definition 1. Date 2. Newspaper Title of publication 3. Section Newspaper section 4. Title Title of the text 5. Type of unit a. News story Hard news b. Editorial Opinion piece by the editors of the newspaper c. Op-ed Opinion piece in the editorial section d. Column Opinion piece in any section e. Interview Interview f. Letter Letter to the editor 6. Angle a. Political Story highlighted political implications b. Economic Story highlighted economic implications c. Health Story highlighted personal health or public health or animal health implications d. Scientific Story highlighted scientific findings, scientific progress, scientific research 7. What is resistance? a. Evolutionary process AMR described as an evolutionary process b. Health risk AMR described as a health risk c. NA AMR not described as either an evolutionary process or a health risk 8. What causes resistance? a. Unnecessary/Prophylactic prescriptions AMR described as consequence of unnecessary and/or prophylactic antimicrobial prescriptions b. Not finishing the prescription AMR described as a consequence of patients not finishing their antimicrobial prescriptions c. Use of antibacterial products AMR described as a consequence of popular use of antibacterial products d. Use of antibiotic ointments AMR described specifically as a consequence of use of antibiotic ointments e. Use in farming/husbandry AMR described as a consequence of using antibiotics in farm animals f. Use in agriculture (crops specifically) AMR described as a consequence of using antibiotics in crops g. Extensive use/Overuse AMR described broadly as a consequence of “overuse,” “extensive use,” “generalized use” of antimicrobials or similar expressions h. NA No definition of AMR was given 9. Who is at risk? a. The general public Population at risk broadly described as “everyone,” “general population,” “the general public,” or similar b. Hospital patients Hospital patients described as at risk to develop resistant infections c. Patients in extended care Long-term hospital patients and patients in extended care facilities described as at risk of resistant infections d. People with weak immune systems People with immunodeficiency described as at risk of resistant infections e. Elderly The elderly in general described as at risk of resistant infections f. Infants Children less than 12 months of age described as at risk of resistant infections g. All of the above All of the populations above described as being at risk of resistant infections h. NA No populations identified at risk of resistant infections 10 Who is responsible for managing/solving it? a. Government Elected officials and policy makers b. Health authorities Public health authorities and international health organizations c. Medical community Health care professionals d. Pharmaceuticals Pharmaceutical companies e. NA No responsibility is assigned 11. How can it be prevented/controlled? a. Prescribing only when necessary Physicians prescribing antimicrobials only when necessary b. Taking antibiotics responsibly Patients taking antibiotics as prescribed c. Limiting use of antibacterial products General public reducing use of antibacterial products d. Limiting use of antibiotic ointments General public reducing use of antibiotic ointments e. Limiting use in farming/husbandry Reducing use of antibiotics in farm animals f. Limiting use in agriculture Reducing use of antibiotics in crops g. Antibiotic R & D Increasing research and development efforts for new antimicrobials h. Infection surveillance Implementing robust systems of infection surveillance in hospitals and in the community i. Hospital sanitation Reducing spread of infection in hospitals by adhering to infection prevention and control measures j. Vaccinations General public keeping immunizations up to date (continued) Capurro 7 Table 1. (Continued) Code Definition k. Hygiene/hand washing/proper cooking Adopting hygiene measures at home in general, and specifically when cooking l. NA No prevention measures were mentioned 12. Is the UN’s plan mentioned? a. Yes, and how the country will implement it The plan was mentioned and how the country will implement it b. Yes, but no how it will be implemented The plan was mentioned but there was no description of how it would be implemented c. No The plan was not mentioned 13. Description of resistant bacteria a. Superbug Resistant organisms were described as “superbugs” b. At war/battle with/fighting Resistant organisms were anthropomorphized and described using military language c. NA Resistant organisms were not described as “superbugs” and belligerent language was not used Note. AMR = antimicrobial resistance. New York Times (Rabin, 2016) published stories on the thus pointing to the need to correct this generalized practice Centers for Disease Control and Prevention declaring sepsis a across industries and countries and move toward judicious medical emergency and mentioned antibiotic resistance as a use of antibiotics. For example, a story in The New York cause of sepsis; however, neither explained what resistance is. Times explains, Infectious disease doctors have long warned that overuse of RQ2: What Causes AMR? antibiotics in people and in animals puts human health at risk by reducing the power of the drugs, some of modern medicine’s The three most cited causes of AMR were extensive use of 7 most prized jewels. The problem is global, because the bugs are antibiotics in farming and husbandry (n = 29), extensive mobile. Overuse in pig production in China, for example, has use or general overuse of antibiotics (n = 24), and unneces- spawned superbugs that have surfaced in the United States and sary antibiotic prescriptions for humans (n = 22). Other Europe. (Tavernise, 2016) causes mentioned were antibiotic use in agriculture, use of antibacterial products—such as gels and wipes—incomplete RQ3: Who Is at Risk of Contracting Resistant doses of antibiotics (not finishing the prescription), and use Infections? of antibiotic ointments. The following excerpts are examples of this: Lay citizens tend to look for information related to health risks and how to minimize exposure in legacy media either Concern has been growing among scientists, consumers and print or online (Greenberg et al., 2017). It is therefore crucial shareholders that the overuse of (antibiotics) is contributing to in risk communication to define populations at risk along rising numbers of life-threatening infections from antibiotic- with preventive measures (Abraham, 2009). However, in resistant bacteria dubbed “superbugs.” (Polansek & Baertlein, 45% of the coverage (n = 40), there was no mention of popu- 2016) lations at risk of AMR. In 38% of the articles (n = 34), popu- lations at risk were broadly defined—implicitly or The rate at which new strains of drug-resistant bacteria have explicitly—as “everyone” or the general public. Despite this, emerged in recent years, prompted by overuse of antibiotics in the newspapers still referred to AMR as a nosocomial risk, humans and livestock, terrifies public health experts. (McNeil, even though community-acquired strains of resistant bacteria 2017) are a common occurrence. Some investigative journalists have already sounded the alarm about the risk of community- Because the indiscriminate use of drugs in animals can destroy acquired strains of resistant bacteria that can cause lethal the drugs’ effectiveness for humans, the Food and Drug Administration has issued regulations that it says will reduce infections (see, for example, McKenna, 2010), an aspect that antibiotic use in livestock. (“The United Nations Takes on remains underreported in the dailies. Superbugs,” 2016) While portraying antibiotic resistance as a hospital-based risk, the newspapers identified five populations at risk of Reporting the causes of AMR indirectly lays blame on acquiring a resistant infection: hospital patients (n = 13), several actors. In this case, responsibility for causing and patients in extended care (n = 7), people with compromised spreading antibiotic resistance is laid principally on the farm- immune systems (n = 5), infants (n = 5), and the elderly ing industry and the medical community, and onto patients to (n = 3): a lesser degree for demanding antibiotics and not taking them responsibly. In addition, over a quarter of the stories Most of these deaths occur among older patients in hospitals or stated that antibiotics are being “overused” or “misused,” nursing homes, or among transplant and cancer patients whose 8 SAGE Open immune systems are suppressed. But some are among the young that requires a global response. (“The United Nations Takes on and healthy: A new study of 48 American pediatric hospitals Superbugs,” 2016) found that drug-resistant infections in children, while still rare, had increased sevenfold in eight years, which the authors called Although a portion of the coverage identified various “ominous.” (McNeil, 2017) actors as responsible or implicated in the management of the AMR crisis, almost half of it (n = 40) did not mention who The Public Health Agency of Canada says this is one of the should manage this public health hazard. In addition, the biggest public health risks facing the country, with 18,000 UN’s Global Action Plan on Antimicrobial Resistance Canadians contracting drug-resistant infections each year in (World Health Organization, 2015) was mentioned 8 times, hospitals and 700,000 dying from them annually around the five of them explaining how the plan will be implemented by world. (Bronwell, 2016) the national government. Reporters identified the obvious populations at risk of developing resistant infections, but they did not mention that RQ5: How Can the Spread of AMR Be antibiotic resistant bacteria also exist outside hospitals, in the Prevented? community, affecting healthy people who would not nor- mally be considered a vulnerable population. While hospitals Regarding risk prevention measures, over a third of the cover- are most often the epicenter of resistant-infection outbreaks, age did not mention any (n = 31), leaving readers uninformed community-acquired resistant infections are becoming more of how to avoid behaviors that put them at risk of contracting common and affecting a broader population (O’Neill, 2016). resistant infections and spreading them. Two thirds of the coverage, however, did identify preventive measures. This shows improvement since the study by Desilva (2004) who RQ4: Who Is Responsible for Controlling/ found preventive measures in only one fifth of the North Managing the Risk of AMR? American coverage of AMR. There were four preventive measures repeatedly mentioned: limiting the use of antibiot- The management of AMR is considered in the analyzed cov- ics in farming (n = 21), developing new antibiotics (n = 20), erage as a political task, and the government and policy- prescribing antibiotics only when necessary (n = 16), and makers are most frequently mentioned as responsible for it (n infection surveillance (n = 15). These four recurrent preven- = 31). Doctors were mentioned in relation to their prescrip- tive measures correspond to the actors identified as responsi- tion practices and expected to prescribe less antibiotics, ble for managing the risk: government, health authorities, while nurses were considered responsible for the hygiene of pharmaceuticals, and medical community. For example, medical settings which is a key infection prevention and con- trol measure (n = 20). Public health authorities were Through the use of good animal husbandry techniques, vaccines, expected to regulate antibiotic use across industries (n = 18), probiotics and other alternatives, the animal agriculture industry and pharmaceutical companies (n = 18) were mentioned as can and should move away from low-dose antibiotic use for responsible for developing new antibiotics. For example, an routine disease prevention and use antibiotics only to treat sick editorial in The Washington Post regarding a proposed health animals. (Heil, 2017) bill described members of the U.S. Congress as responsible for encouraging antibiotic stewardship: In addition, doctors and nurses need to take practices like hand washing and equipment sterilization much more seriously to Lawmakers should ensure that a proposed adjustment to rules on reduce widespread drug-resistant infections in hospitals. the approval and use of new antibiotics does not have the Consumers must make sure they and their children are unintended side effect of encouraging antibiotic overuse and vaccinated, which helps prevent infections in the first place. resistance—the very problem the provision is supposed to (“The United Nations Takes on Superbugs,” 2016) combat. (“A Bill Fit for Lame Ducks,” 2016) Other preventive measures mentioned in the coverage Similarly, an editorial in The New York Times highlights included taking antibiotics responsibly (n = 7), improved the role of the government in managing the risk of AMR as hospital sanitation (n = 4), vaccinations (n = 4), hygiene well as the need for global cooperation: (n = 3), and limiting the use of antibiotic ointments (n = 1). The newspapers suggested preventive measures that are This puts a burden on governments to invest more in research mostly out of the control of the individual; they depend on and development. Governments could also offer incentives— political action, scientific development, and improved medi- prizes have been suggested, for instance—to companies that cal practices. However, challenging the lack of regulation develop new vaccines and antibiotics, and they could regarding antibiotic use and infection surveillance, the eco- contractually agree to buy medicines to assure companies that nomic interests that dissuade pharmaceutical companies they will have a market for their products. The United Nations was right to ring the alarm about superbugs, a growing danger from developing new antibiotics, and questioning how Capurro 9 physicians prescribe antibiotics show evidence of some and whether these publications acted as sites for reflexive reflexive modernization in the coverage of AMR, particu- modernization, a necessary step for modifying our antibiotic larly in editorials, opinion pieces, and letters to the editor. consumption and assuming a stewardship mind-set. The For example, the National Post explained lack of economic results of this study show that AMR is being communicated incentive to develop new antibiotics: through inaccurate definitions and incomplete accounts of its causes, responsibility in managing the threat, preventive Another reason pharmaceutical companies have little incentive measures, and populations at risk, with potential negative to invest in research and development is that if researchers implications for public understanding of AMR and public discover an effective new antibiotic, public health officials want awareness efforts. Furthermore, this study shows that by to reserve it for use in emergencies to keep bacteria from oversimplifying this complex modern risk, the newspapers becoming resistant to it as well. As a result, only a handful of the seldom acted as sites of reflexive modernization, therefore world’s major drugmakers are pursuing antibacterial research obscuring the necessary changes to medical and industrial today. (Bronwell, 2016) practices required to tackle this threat. First, the newspapers preferred simplistic expressions, A reader, however, points out in a letter to the editor that such as “superinfection,” instead of explaining basic evolu- developing new antibiotics does not revert AMR and men- tionary processes and who is at risk, and did not explain why tions the continued use of antibiotics in modern farming as extensive use of antibiotics accelerates the evolution of resis- the main problem: tance either. Studies have shown that oversimplified accounts of AMR can lead to confusion regarding the way antimicro- As bacteria resistant to our existing drugs flourish, new classes bials function and perpetuate misconceptions, such as believ- of antibiotics are indeed needed. But introducing new antibiotics ing that the body becomes resistant to antibiotics and not the into a broken system won’t solve our problem; it merely buys bacteria (Davis et al., 2017; Kamata et al., 2018). Providing time. The overuse of antibiotics is the foundational problem, and the routine use of antibiotics on food animals is particularly a clear explanation of the biological process behind antibi- troubling. (New antibiotics, 2017) otic resistance could improve scientific literacy and public understanding of the risk, its causes, and potentially reduce Of all the preventive measures suggested, only the ones risk exposure. In addition, by presenting a limited and incom- mentioned on a few occasions—taking antibiotics responsi- plete account of who is at risk of resistant infections, the bly, getting vaccinated, proper hygiene, and reducing the use newspapers reinforced the idea that AMR is not a widespread of antibiotic ointments—can be done by individuals. health hazard, thus minimizing the crisis it represents and Furthermore, lay experience and public concerns were sel- potentially generating a false sense of security (Nisbet, dom considered in the newspaper coverage of AMR. For 2017). A low perception of risk can affect risk behavior and example, some letters and columns blamed patients for lead to the rejection of necessary changes in policy and med- expecting antibiotic prescriptions from their doctors or for ical practice to manage the risk. not finishing their prescriptions; however, there was no Second, half of the coverage did not mention any causes of explanation regarding antibiotics being useless for viral AMR, and the rest broadly identified “general overuse” of infections or why physicians will not prescribe them for mild antibiotics as the main cause. The persistent lack of clear bacterial infections, such as ear infections. causes of the risk is a common trend in media coverage of An interesting exception was a story written by a health AMR (e.g., Chan et al., 2010; Desilva, 2004; Washer & Joffe, reporter who narrates his experience with a tooth infection 2006). Broad explanations seldom acknowledged key politi- and his objection to take prophylactic antibiotics, describing cal and economic interests and activities that contribute to the how he negotiated his personal interest versus what he per- spread of resistant bacteria, thus ignoring necessary changes ceives as his societal responsibility: in current industrial and medical practices. Similarly, the newspapers suggested that governments and pharmaceutical Taking a series of single-dose antibiotics doesn’t seem like a industry should manage the risk, but mostly ignored other good idea: Surely my gut won’t thank me, and it seems like just actors who can also contribute to improve antibiotic steward- the sort of antibiotic use that contributes to the problem of ship. In doing so, other sources of responsibility remain resistance that everyone is concerned about. On the other hand, obscured, for example, government and policy makers who my tooth has an infection! [ . . . ] I’m not under any illusion that have failed to put in place adequate regulations regarding my personal actions will have great consequences for national antibiotic use. This contributed to a distorted perception of policy on antibiotic use. As Quinn puts it, “bacterial resistance is antibiotic resistance as being created by one or two industries a societal problem, not individual.” But I like to think I’m doing instead of describing this health risk as collectively caused by my bit. You’re welcome. (Lindley, 2016) various modern practices, from medicine and farming, to air travel and environmental degradation, as well as deficient Discussion and Conclusion health care systems and globalized economies. In this article, I examined how the risk of AMR is discur- Third, in almost half of the sample (42%), the dailies did sively constructed in four elite North American newspapers not explain what causes antibiotic resistance. This omission 10 SAGE Open was higher than the 33% found by Desilva (2004), showing on a few occasions as sites of reflexive modernization, ques- that over the past 15 years, the North American print media tioning expert knowledge (e.g., how physicians prescribe has not improved in terms of contributing to public aware- antibiotics) and modern practices (e.g., the use of antibiotics ness and understanding of this growing public health risk. In in industrial farming). most cases, the dailies failed to inform audiences about the My analysis suggests that this function was limited due to causes of AMR or laid all the responsibility on a few specific the complexity of AMR as a risk, which was impossible to actors or industries, therefore oversimplifying the complex address comprehensively in short newspaper stories. The networks of actors, practices, and interests that underpin the very complexity of modern risks (Beck 1992b, 2009), with acceleration of AMR. many layers of responsibility by a wide array of actors, could When suggesting preventive measures, the newspapers be hindering the reflexive function of news media, which focused on those that are out of the control of individuals, privilege fast news cycles and short stories, and thus mini- thus leaving citizens disempowered regarding how to pre- mize the feeling of risk instead of leading to the pervasive vent a resistant infection. Saliently, half of the coverage did feeling of it described by in the risk society theory. Future not mention any causes of antibiotic resistance, actors research could explore whether a more reflexive narrative is responsible for causing the threat, populations at risk, or pre- found in specialized publications, particularly online, that ventive measures, all crucial information that could poten- are more flexible with the length of their stories, thus inviting tially allow citizens to avoid risky behavior. Describing a their audience to critically think about the impact of modern risk and not identifying risk behaviors and explaining how to institutions and practices in human health. avoid them could lead to increased public anxiety. This study has two limitations that could be addressed in Furthermore, misinformation or incomplete information future research. First, the analysis did not differentiate about a health hazard could lead to false beliefs regarding between different types of stories (hard news, editorial, col- causes and prevention. umn, letter, etc.), an aspect that could be further explored as Fourth, the UN’s plan to tackle AMR, which outlines opinion pieces could be a more suitable space for question- infection surveillance systems, public awareness campaigns, ing industrial practices, policies, and lifestyles, while hard international cooperation, and other measures governments news could be a more likely genre to identify populations at can adopt, was mentioned only in eight articles in the sam- risk and suggest preventive measures. Second, the analysis ple, thus the newspapers oversimplified the global nature of was limited to four elite North American newspapers’ 1 year AMR by suggesting that this health hazard that can be dealt coverage of AMR, thus shedding light on current representa- with within the national borders. Fifth, in the risk society, tions and discussions of AMR. The sample could be expanded mass media are spaces for reflexivity, where scientific and to include more publications—for example regional cover- expert knowledge about hazards is discussed and challenged. age could vary—or a longer period of coverage. In addition, This, however, is not evident in the analyzed coverage, which further research could compare representations of AMR in for the most part follows a deficit model of risk communica- legacy newspapers with those in news websites with sections tion in which expert knowledge is reproduced as a way to dedicated to health-related and scientific topics. educate publics (Lupton, 1999b). Not acknowledging public Declaration of Conflicting Interests concerns while reiterating expert views can deepen public anxiety and reinforce the feeling of powerlessness, which The author(s) declared no potential conflicts of interest with respect can further reduce public trust in experts and decrease com- to the research, authorship, and/or publication of this article. pliance with prevention measures, such as using antimicrobi- als judiciously and vaccinating. Funding It is crucial to examine news media representations of The author(s) received no financial support for the research, author- health risks as they affect public perceptions of risk and risk ship, and/or publication of this article. behavior (Briggs & Hallin, 2016; Capurro et al., 2018; Caulfield et al., 2019). If news media are expressing reflex- ORCID iD ivity, this could potentially lead to political action. In this Gabriela Capurro https://orcid.org/0000-0002-2211-6229 case, reflexive news coverage of AMR could increase public awareness of the threat. This could lead to increased public Notes pressure for robust infection surveillance systems, additional 1. Antimicrobial resistance (AMR) is an umbrella term that refers efforts to increase public awareness of AMR and how to to bacteria, parasites, viruses, and fungi evolving resistance to reduce risk exposure, supporting initiatives to foster antimi- antimicrobial treatments that used to be effective against the crobial stewardship in medical practice, as well as push for wide range of infections they cause. Antibiotic resistance— increased political commitment at the national and interna- bacteria evolving resistance to antibiotics—is included in tional levels. This study, however, shows that the news media AMR. are not fulfilling their reflexive function as predicted in the 2. Elite newspapers have national distribution and are often theory of risk society given that the newspapers acted only regarded as agenda-setters for other national media. Capurro 11 3. Factiva is a current international news database produced by Australian perspective. Infection, Disease & Health, 24(1), Dow Jones. 23–31. https://doi.org/10.1016/j.idh.2018.09.084 4. The exact search phrase was (antibiotic) or (“antibiotic resis- Bradbury, J. A. (1989). The policy implications of differing con- tance”) or (“antimicrobial resistance”) or (superbug). cepts of risk. Science, Technology & Human Values, 14(4), 5. The following codes in Table 1 were added to the code book 380–399. https://doi.org/10.1177/016224398901400404 during the coding process: 5F, 8D, 8G, 10E, 11D, 11G, 11H, Briggs, C. L., & Hallin, D. C. (2016). Making health public: How 11I, and 11K. news coverage is remaking media, medicine, and contempo- 6. See Table 1. rary life. Routledge. 7. 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Giving legs to restless Vasterman, P., Yzermans, C. J., & Dirkzwager, A. J. E. (2005). legs: A case study of how the media helps make people sick. The role of the media and media hypes in the aftermath of PLOS Medicine, 3(4), Article e170. https://doi.org/10.1371/ disasters. Epidemiologic Reviews, 27(1), 107–114. https://doi. journal.pmed.0030170 org/10.1093/epirev/mxi002 World Health Organization. (2015). Global action plan on anti- Wald, P. (2008). Contagious: Cultures, carriers, and the outbreak microbial resistance. http://www.wpro.who.int/entity/drug_ narrative. Duke University Press. resistance/resources/global_action_plan_eng.pdf Wang, S. (2018, July 2). As The New York Times extends its reach across countries (and languages and cultures), it looks to Author Biography locals for guidance. https://www.niemanlab.org/2018/07/as- the-new-york-times-extends-its-reach-across-countries-and- Gabriela Capurro is a PhD candidate in Communication Studies languages-and-cultures-it-looks-to-locals-for-guidance/ at Carleton University. Her research interests include science and Washer, P., & Joffe, H. (2006). The “hospital superbug”: Social risk communication of (re-)emerging diseases, and the use of eth- representations of MRSA. Social Science & Medicine, 63(8), nomethodologies in the study of risk. Funded by a Social Sciences 2141–2152. https://doi.org/10.1016/j.socscimed.2006.05.018 and Humanities Research Council of Canada, her dissertation The Washington Post had 80.8 million readers in June 2018. (2018, analyses the social construction of “superbugs” as a public health July 16). The Washington Post. https://www.washingtonpost. risk. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png SAGE Open SAGE http://www.deepdyve.com/lp/sage/superbugs-in-the-risk-society-assessing-the-reflexive-function-of-SiBBOL02Uh

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Abstract

This article examines how antimicrobial resistance (AMR) is covered in four elite North American newspapers and whether the dailies act as sites of reflexive modernization. I draw on risk society theory to situate AMR as a modern risk and news media as key spaces for reflexivity. Through a qualitative content analysis of 89 news stories on AMR, this study shows that this risk is communicated through inaccurate definitions and oversimplified accounts of the causes, populations at risk, and preventive measures. Media representations of health risks affect public perceptions of risk and risk prevention. The dailies, however, seldom expressed reflexive modernization, a key function of “mass media” in the Risk Society, which I argue could be due to the very complexity of “modern risks.” Lack of reflexivity in the media regarding AMR could delay crucial policy and institutional changes necessary to tackle this risk. Keywords risk communication, qualitative content analysis, reflexive modernization, antibiotic resistance, health communication Furthermore, since the 1940s, antibiotics have been routinely Introduction used in farming by administering them in large doses to oth- Antibiotics are one of the most important technologies of erwise healthy livestock to promote growth. Currently more modern medicine. Without them, even a small scrap or rou- than 63,000 tons of antibiotics are used annually on livestock tine surgery can become life-threatening. Antimicrobial around the world (McKenna, 2017). The rise of antibiotic resistance (AMR) is one of the greatest public health risks, resistant infections, however, has led to debates over physi- threatening to make antibiotics useless. Resistance, the evo- cians’ prescription practices (e.g., Duane et al., 2016; lutionary defensive mechanism that allows bacteria to pro- Wilcock et al., 2016), recommended length of antimicrobial tect themselves against antibiotics’ power to kill them, treatments (e.g., Langford & Morris, 2017; Llewelyn et al., “threatens the very core of modern medicine” (World Health 2017; McGow, 2019), and the use of antibiotics in livestock Organization, 2015, p. VII) causing more than 1.5 million and crops for non-therapeutic purposes (e.g., Makary et al., deaths annually worldwide (Hall et al., 2018). In the last two 2018). decades, there has been an increase in multidrug resistant Emerging risks, such as AMR, bring a pervasive sense of bacteria, which cause infections that do not respond to mul- uncertainty, and in trying to make sense of them, multiple tiple antibiotics. Health authorities have described antibiotic narratives are generated that attempt to define the hazard, resistance, and more broadly AMR, as a public health emer- its causes, populations at risk, responsibility, and as well as gency caused by extensive antibiotic misuse, which has not preventive measures (Beck, 1992b, 2009; Douglas, 1992). been met with an equally prolific development of new antibi- otics (O’Neill, 2016). In addition, resistance to the few new drugs available is also being developed (Cassir et al., 2014). Carleton University, Ottawa, Ontario, Canada Today antibiotics are prescribed to treat a host of different Corresponding Author: bacterial infections but they are also consistently prescribed Gabriela Capurro, School of Journalism and Communication, Carleton when unnecessary—for example, to treat viral infections— University, Richcraft Hall, 1125 Colonel By Drive, Ottawa, Ontario, and are seldom taken by patients as indicated (Centers for Canada K1S 5B6. Disease Control and Prevention, 2015; Hall et al., 2018). Email: gabriela.capurro@carleton.ca Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open These definitions then become discourses that guide how success of industrialization (Beck, 1992b, p. 21; Shah, 2016). particular risks are understood and regulate risk behavior Similarly, AMR can be understood as a modern risk: exacer- (Beck, 1992b, 2009). News media are important sources of bated by the unregulated consumption of antibiotics, with scientific and health information (Nelkin, 1995) and they global effects, requiring international cooperation, and with contribute, along with other social actors, in the discursive repercussions that will extend to future generations. co-production of public health risks, affecting public per- Cultural theorists conceptualize risk as the combination ceptions of risks and risk behavior (Briggs & Hallin, 2016; of material conditions and sociocultural processes (Fox, Caulfield et al., 2019). In the theory of risk society, mass 1999; Lupton, 1999a, 2013) and risk definition, perception, media are described as key sites of risk definition and and estimation as dependent on values and cultural under- reflexive modernization (Beck, 1992b, 2009); however, standings (Bradbury, 1989, p. 2). In that sense, risk definition how the media achieve this reflexive function is not fully is susceptible to change, magnification, dramatization, or developed. minimization, that is, to social production through complex In this article, I examine how the risk of AMR is discur- claims-making processes by various social actors (Beck, sively constructed in North American newspapers and 1992b), who not only identify risks but also assign blame and whether the dailies act as sites of reflexive modernization, by responsibility (Tansey & O’Riordan, 1999). Processes of risk questioning expert knowledge and modern medical and definition can lead to reflexive modernization, a critique of industrial practices. I draw on risk society theory to situate the process of modernization given that the main institutions AMR as a human-made risk, a consequence of modern medi- of late modernity—government, industry, medicine, sci- cal and industrial practices with global repercussions extend- ence—have become the main generators of risk (Beck, ing in time, and news media as sites for risk definition and, 1992). Reflexive modernization supposes a process of “self- potentially, where reflexive modernization is expressed. This confrontation with the consequences of risk society which study sheds light on how news media’s reflexive function is cannot (adequately) be addressed and overcome in the sys- enacted when covering a “modern risk.” The analysis focused tem of industrial society” (Beck, 1996, p. 28). In this context, on five elements: risk definition, reported causes, popula- scientific progress does not reduce risks but make them more tions identified at risk, assigned responsibility, and preven- evident leading to the demystification of science and the tive measures suggested. demonopolization of scientific knowledge claims (Beck, 1992b), which not only multiply but also contradict one another and frequently lose their validity, leading to “reflex- Risk Society and Reflexive ive scientization” (Beck, 1992b, p. 166). Despite this, most Modernization modern risks cannot be perceived by the senses, so depen- Risk has been conceptualized in various ways, ranging from dency on expert knowledge increases (Beck, 1994), and sci- objectivist to constructivist approaches. Objectivist entists and experts maintain their definitional power (Beck, approaches borrowing from cognitive psychology tend to 2009). focus on how individuals’ form their perceptions of risk In the risk society, mass media are described as sites of through the information they receive about the risk and the risk definition and reflexive modernization. Media dis- heuristics they rely on to make sense of the risk, for example, courses and representations contribute greatly to the con- trust in institutions such as government and media (e.g., Choi struction of risk (Beck & Levy, 2013) by providing the et al., 2018; Fischhoff et al., 2000; Shin, 2010). Cultural definition and language that lay people will use to make approaches to risk, on the contrary, are constructionist in ori- sense of risks, assigning responsibility and blame, and vali- entation, conceptualizing risk as the outcome of a combina- dating some forms of knowledge while discrediting or ignor- tion of material conditions and sociocultural processes (Fox, ing others. Media discourses express reflexive modernization 1999; Lupton, 1999a, 2013) In this study, I draw on the criti- as experts, scientists, political leaders, advocates, policy cal theory of risk society, a constructivist approach to risk makers, and other stakeholders communicate and challenge that argues that in late modernity, social and political order each other’s views on the definition and causes of risks, and are threatened by unprecedented anthropogenic risks, result- how to manage them. ing from scientific and industrial development (Beck, 1992b, In this article, I examine how AMR is covered in four elite 2009). Modern risks are pervasive and not limited by time North American newspapers and whether the dailies act as (they will affect future generations) or space (global nature), sites of reflexive modernization. Through a qualitative con- and their management requires international cooperation tent analysis (QCA), I assess (a) how the risk of AMR is (Beck, 2009). The risks created by modernity are almost defined in the news coverage, (b) who is identified as respon- impossible to calculate and have unimaginable conse- sible for causing and/or managing the spread of AMR, (c) quences, making any attempts to manage their impact inad- who is said to be at risk, (d) which prevention measures are equate (Beck, 1992a; Giddens, 1997). For example, global suggested, and (e) whether the newspapers acted as sites for environmental degradation and accelerated spread of zoono- reflexive modernization by questioning expert knowledge ses are risks that emerged as a direct consequence of the and/or modern medical and industrial practices. Capurro 3 coverage was alarmist. The authors warn that apocalyptic Media Coverage of AMR media messages can increase skepticism of scientific exper- Media are important sources of scientific information and tise. Similarly, a study examining Australian media represen- health information, affecting public understanding of health tations of AMR found that the use of military metaphors, issues and risk (Nelkin, 1995; Vasterman et al., 2005; anthropomorphizing of bacteria, and doomsday framing Woloshin & Schwartz, 2006). News media play a crucial role were common rhetorical tools across media platforms in “producing and circulating information about health as (Bouchoucha et al., 2019). In addition, Collins and col- well as competing forms of knowledge and culture” (Briggs leagues (2018) found that in newspaper coverage of AMR in & Hallin, 2016, p. 77) that intersect with health and medi- the United Kingdom, not only are the resistant organisms cine. Studies in risk communication of AMR have mostly anthropomorphized but antibiotics are also depicted as focused on the use of the “superbug” frame in news cover- instilled with agency. age, that is, the use of hyperbolic language to refer to resis- Desilva (2004) examined antibiotic resistance in the tant organisms and to describe apocalyptic post-antibiotic Canadian press and compared it with U.S. coverage. They scenarios. Focusing mostly on how press and broadcast found that Canadian and U.S. media seldom mention the media describe the causes, incidence, and measures of con- causes of resistance or how to reduce exposure. Washer and trol and prevention, these studies draw on the information Joffe (2006) found a similar trend in British news coverage deficit and social amplification of risk models of risk com- of MRSA, which seldom offered an explanation of how bac- munication to examine whether enough expert information is teria evolve resistance to antibiotics or the role of physicians provided to the public (e.g., Bie et al., 2016; Desilva, 2004; overprescribing practices. Chan et al. (2010) showed that the Singh et al., 2016) and how media coverage amplifies feel- British media blamed “dirty hospitals” and the government ings of anxiety and risk (see Brown & Crawford, 2009; for the rise of MRSA but did not explain the evolutionary Nerlich & James, 2009; Washer & Joffe, 2006). process that leads to resistant bacteria or the human actions Washer and Joffe (2006) examined the coverage of meth- that accelerate that process or preventive measures. Similarly, icillin-resistant Staphylococcus aureus (MRSA) in the in the Swedish print media, the most commonly reported British press. They found that the coverage shifted from cause of antibiotic resistance was antibiotic over-prescrip- reproducing the rhetoric of the medical literature in the early tion, while risk-reduction measures at the societal level were 1990s, that is, explaining it as an infection resistant to antibi- more commonly reported than to the individual level (Bohlin otics, to depictions of a “killer superbug” since 1997. & Höst, 2014). Collins et al. (2018) found in newspaper cov- Apocalyptic predictions are now a common trope in the cov- erage of AMR in the United Kingdom that responsibility for erage of AMR, including the anticipation of both natural inappropriate use of antibiotics was multidirectional, and devastation and personal tragedy (Brown & Crawford, identified a tension between blaming doctors-as-prescribers 2009). The feeling of doom is emphasized by focusing on the or patients-as-users and the collectivization of the general ability of bacteria to evolve resistance to new antibiotics in a public as an unspecified “we.” Furthermore, they found that short period of time (Brown & Crawford, 2009; Washer & livestock farming and pharmaceutical industry were rarely Joffe, 2006). Media resort to the reification of resistant bac- reported as social actors with responsibility in the AMR teria as “superbugs” (Nerlich & James, 2009; Washer & crisis. Joffe, 2006) and depicting them as having human-like quali- Another recent study on newspaper coverage of AMR and ties, being “clever” and outsmarting the scientific commu- antimicrobial stewardship in the United Kingdom found that nity (Brown & Crawford, 2009; Washer & Joffe, 2006). In when covering sepsis, the newspapers preferred personal addition, the bacteria’s ability to move across space and cor- narratives which can generate greater public interest, which poreal boundaries is also recurrent in the media rhetoric, are rarely included in articles about AMR (Rush et al., 2019). highlighting its ubiquitousness and uncontrollability (Brown However, the articles usually did not balance messages about & Crawford, 2009). These depictions emphasize feelings of crucial early antibiotic treatment in sepsis with the need to danger and human vulnerability, and reinforce the idea of reduce unnecessary prescribing. The authors suggest inte- conflict between nature and medical progress (Washer & grating media discourses about AMR and sepsis to improve Joffe, 2006), a rhetorical tool used to raise public awareness, public understandings of the importance of antimicrobial but can also induce fear and promote misinformation (Nerlich stewardship (Rush et al., 2019). & James, 2009). Furthermore, unlike outbreak narratives that offer the promise of medical solution (Wald, 2008), the cov- Method erage of AMR contradict expert knowledge by suggesting The theory of risk society refers broadly to “mass media” alternative therapies, potentially leading to loss of trust in and “news media,” explaining that they have definitional medicine (Washer & Joffe, 2006). power through their agenda-setting function, identifying par- More recently, a study examined two decades of coverage ticular victims and laying blame on certain groups (Beck, of AMR in the German press (Boklage & Lehmkuhl, 2019) 2009; Beck & Levy, 2013), as well as a reflexive function; and found a similar trend, noting that the overall tone of the 4 SAGE Open however, how media achieve the latter is not fully developed. PostMedia, which owns several right leaning media outlets Furthermore, news coverage of health risks affect public per- throughout Canada. ception of risks and risk behavior (Briggs & Hallin, 2016; The analysis of the newspaper coverage of AMR was Caulfield et al., 2019). This study examines how the risk of guided by the following research questions: AMR is discursively constructed in four elite North American newspapers —The Globe and Mail and the National Post in Research Question 1 (RQ1): How do the newspapers Canada, and The New York Times and The Washington Post define AMR and its causes? in the United States—and whether the dailies expressed Research Question 2 (RQ2): Who is considered at risk reflexive modernization. of resistant infections? The global decline of news consumption in legacy news Research Question 3 (RQ3): Who is deemed responsible outlets, such as newspapers, radio, and television networks, for managing AMR in the news coverage? led legacy media to heavily invest in developing digital and Research Question 4 (RQ4): Which prevention mea- mobile news applications (Westlund, 2013). North American sures are suggested to minimize the risk of acquiring or newspapers have seen an increase in online readership (News spreading resistant infections? Media Canada, 2019; Pew Research Center, 2019). For Research Question 5 (RQ5): Does the newspaper cover- example, readership of Canadian newspapers is at an all-time age of AMR express reflexive modernization? high due to online news consumption, with 88% of Canadians reading a newspaper at least once a week (“Stop the Presses,” Through a QCA of 1 year of coverage, I examined how 2019). In this study, I examined news coverage in four North the risk of AMR was defined, how blame and responsibility American newspapers with print national daily editions as were assigned, and whether modern institutions and prac- well as strong online presence. The New York Times is based tices were questioned for their role in the exacerbation of in New York city and has a weekday print circulation of AMR and emergence of this public health threat. With QCA, 487,000 copies (Watson, 2019). Its presence online however the content and meaning of texts are systematically described continues to expand and the paper now makes 40% of its through the process of coding and the identification of revenue from online subscriptions (Benton, 2019). The New themes and patterns (Hsieh & Shannon, 2005; Schreier, York Times has around 2.33 million paid digital-only news 2012). Mayring (2015) defines QCA as a mixed-methods subscribers (Wang, 2018). Canadian subscribers make up approach consisting of two steps: first, a qualitative-interpre- around 27% of the Times international subscriber base with tative phase in which categories are assigned to text passages around 94,000 subscriptions (Wang, 2018). The New York through coding, and second, a quantitative analysis of fre- Times has a left-leaning media bias (AllSides, 2019). The quencies of those codes. Following Marying’s two-step newspaper is owned by The New York Times Company, approach, my analysis first identified the presence or absence which is publicly traded and is controlled by the Sulzberger of five topics—(a) whether the text explained what resis- family. The Washington Post is based in Washington, D.C., tance is (definition); (b) what causes it (cause and blame); (c) and has a weekday print circulation of about 293,000 copies who is at risk (population at risk); (d) who is responsible for (“The Washington Post Had 80.8 Million Readers in June managing it (responsibility); and (e) how it can be prevented 2018,” 2018), as well as a strong online presence with more (prevention)—and described how these topics were than 80 million unique visitors on their website per month in expressed in the news stories. Second, I determined the fre- 2018 (WashPostPR, 2018). The Washington Post is consid- quency with which those topics were expressed in the news ered a left-leaning newspaper (AllSides, 2019). The newspa- coverage to determine which angles were most prevalent in per is owned by Nash Holdings, a holding company the discursive construction of AMR. established by Jeff Bezos, owner of Amazon.com. The Globe On September 21, 2016, the United Nations (UN) General and Mail is based in Toronto, Ontario, and is considered the Assembly held a high level meeting on AMR, in which all “newspaper of record” in Canada. It is the largest newspaper the member-states committed to taking a broad, coordinated in the country with a weekday print circulation of 899,000 approach to address its root causes across multiple sectors, copies in 2019 (“Globe Weekend Edition,” 2019). The Globe especially human health, animal health, and agriculture. The and Mail has a center-right editorial line (Media Bias/Fact analyzed sample spans a year of coverage—6 months prior check, 2018). The newspaper is owned by The Woodbridge to the UN’s declaration on AMR (March 21, 2016) to 6 Company Limited, which is a Canadian private holding com- months after the declaration (March 21, 2017). The sample pany based in Toronto. The National Post is based in Toronto, was collected through Factiva database and the search terms Ontario. In 2016, it had a weekly combined print and online used were “antibiotic,” “antibiotic resistance,” “antimicro- readership of 4.5 million (“National Post Boosts Weekly bial resistance,” and “superbug.” There were 239 articles, of Print and Digital Readership to 4.5 Million,” 2016). The which 150 were duplicates and unrelated stories (e.g., stories National Post has a right-center bias, placing it further right about diseases that require antibiotic treatments but that did in the political spectrum than The Globe and Mail (Media not mention resistance, business reports that mentioned anti- Bias/Fact Check, 2019). The National Post is published by biotic-free meat, obituaries of scientists that contributed to Capurro 5 the development of various antibiotics, etc.). The final sam- war” with resistant bacteria, a common narrative that negates ple was composed of 89 articles published in the newspa- the symbiotic relationship humans have with bacteria. pers’ websites and in print. There were two peaks in coverage; However, 54% of the coverage did not use these anxiety- the first in May 2016 when an American woman was diag- inducing frames and instead chose to use more informative, nosed with a resistant urinary tract infection caused by colis- non-belligerent language. Below, I present the results for tin-resistant E.coli, and the second in September 2016 when each of the research questions. the UN held its high-level meeting on AMR. Legacy media still have an important definitional role in RQ1: How Is AMR Defined? health news (Greenberg et al., 2017), and they repurpose news content for their websites, mobile applications, and Antibiotic resistance was mostly covered as a health story social media (Westlund, 2013), thus reproducing the same (63%, n = 56), explaining how it affects human health and definitions and narratives online, which are later shared and the consequences of resistant infections for individuals, distributed among other social media users, including jour- sometimes recommending preventive measures. Other nalists (Russell et al., 2015). This study focused exclusively aspects of AMR that were salient in the news coverage were on newspaper print and online coverage due to archive acces- the need for political action (39%, n = 35), scientific discov- sibility, but future research could also include news coverage ery and development of new antibiotic treatments (35%, n = of AMR in radio and television, as these media formats could 31), and the economic impact of AMR and distribution of have specific implications on how AMR is covered and resources in prevention plans (21%, n = 19). Most stories reflexive modernization expressed. combined various angles. I created a codebook (Table 1) with five main codes that Although 88% of the stories described resistance as a express the definitional and reflexive function of the media health threat (n = 78), only 29% of the coverage (n = 26) as described in the theory of risk society: definition, cause, explained the evolutionary process that leads to it, that is, population at risk, responsibility, and prevention. In addition, that after prolonged exposure to antimicrobial treatments, a code was created to record how resistant bacteria were organisms evolve resistance to them in which case the tradi- qualified in the coverage (e.g., “superbug,” anthropomor- tional treatments become ineffective and the infection poses phism, etc.), and another one for whether the UN’s action a more serious threat. This is consistent with previous plan on AMR was mentioned or not. Sub-codes were gener- research showing that news coverage of AMR seldom use ated for each code after a preliminary reading of the sample, the word “evolution” or explain the evolutionary process and others were included as they emerged during the coding involved in it (Antonovics, 2016). In addition, 16% (n = 11) process. The sub-codes were not mutually exclusive, as the of the stories had no definition of AMR, why it is a public analyzed news stories could have more than one definition of health threat, or an explanation of the evolutionary process AMR, or mention more than one cause. Therefore, all the that causes it, thus leaving readers without basic information codes present in each story were recorded during the coding to understand the risk. process. I conducted the coding of the sample as an open For example, a story in the National Post warns that “a process, nine new codes were created as they emerged in the U.S. woman has died of an infection immune to virtually 5 6 coverage and the codebook was revised accordingly. The every antibiotic doctors could throw at it is adding to grow- publication date, newspaper, type of story (hard news, edito- ing concerns medicine is losing its standoff with superbugs” rial, column, etc.), and angle (political, economic, scientific, and adds that it “may not be the drug resistant ‘apocalypse’ etc.) were also recorded. some fear, but the case is raising new alarm over what has become one of the most serious public health threats world- wide” (Kirkey, 2017). Despite the dire description of the risk Results and mentioning the possibility of an “apocalypse,” the story Antibiotic resistance received greater coverage from newspa- does not define resistance or how bacteria become resistant pers in the United States (75%), with The Washington Post to antibiotics. publishing almost half of the news stories (n = 44), and The There were some instances in which the dailies published New York Times a quarter of the sample (n = 23). The two stories detailing the ordeal that patients with resistant infec- Canadian dailies published a similar volume of stories on tions go through, but missed the opportunity to explain what AMR comprising the last quarter of the sample. The Globe antibiotic resistance is and how organisms evolve it. For and Mail had 10 stories and the National Post had 12. Although example, The Globe and Mail published a story about a 65% of the coverage was composed by hard news (n = 58), woman who was kept alive for 6 days without lungs one quarter of the sample were opinion pieces (n = 22). (Ubelacker, 2017), describing in detail the novel medical pro- The analysis revealed that the newspapers had partially cedure used to save her life after a “superinfection” resistant drifted away from the “superbug” frame. AMR bacteria were to antibiotics had compromised her lungs; however, the story still referred to as “superbugs” in 43% of the coverage (n = did not explain what resistance is nor how it happens. 38), and in 10% of them, humans are described as being “at Similarly, both The Washington Post (Karidis, 2016) and The 6 SAGE Open Table 1. Code Book. Code Definition 1. Date 2. Newspaper Title of publication 3. Section Newspaper section 4. Title Title of the text 5. Type of unit a. News story Hard news b. Editorial Opinion piece by the editors of the newspaper c. Op-ed Opinion piece in the editorial section d. Column Opinion piece in any section e. Interview Interview f. Letter Letter to the editor 6. Angle a. Political Story highlighted political implications b. Economic Story highlighted economic implications c. Health Story highlighted personal health or public health or animal health implications d. Scientific Story highlighted scientific findings, scientific progress, scientific research 7. What is resistance? a. Evolutionary process AMR described as an evolutionary process b. Health risk AMR described as a health risk c. NA AMR not described as either an evolutionary process or a health risk 8. What causes resistance? a. Unnecessary/Prophylactic prescriptions AMR described as consequence of unnecessary and/or prophylactic antimicrobial prescriptions b. Not finishing the prescription AMR described as a consequence of patients not finishing their antimicrobial prescriptions c. Use of antibacterial products AMR described as a consequence of popular use of antibacterial products d. Use of antibiotic ointments AMR described specifically as a consequence of use of antibiotic ointments e. Use in farming/husbandry AMR described as a consequence of using antibiotics in farm animals f. Use in agriculture (crops specifically) AMR described as a consequence of using antibiotics in crops g. Extensive use/Overuse AMR described broadly as a consequence of “overuse,” “extensive use,” “generalized use” of antimicrobials or similar expressions h. NA No definition of AMR was given 9. Who is at risk? a. The general public Population at risk broadly described as “everyone,” “general population,” “the general public,” or similar b. Hospital patients Hospital patients described as at risk to develop resistant infections c. Patients in extended care Long-term hospital patients and patients in extended care facilities described as at risk of resistant infections d. People with weak immune systems People with immunodeficiency described as at risk of resistant infections e. Elderly The elderly in general described as at risk of resistant infections f. Infants Children less than 12 months of age described as at risk of resistant infections g. All of the above All of the populations above described as being at risk of resistant infections h. NA No populations identified at risk of resistant infections 10 Who is responsible for managing/solving it? a. Government Elected officials and policy makers b. Health authorities Public health authorities and international health organizations c. Medical community Health care professionals d. Pharmaceuticals Pharmaceutical companies e. NA No responsibility is assigned 11. How can it be prevented/controlled? a. Prescribing only when necessary Physicians prescribing antimicrobials only when necessary b. Taking antibiotics responsibly Patients taking antibiotics as prescribed c. Limiting use of antibacterial products General public reducing use of antibacterial products d. Limiting use of antibiotic ointments General public reducing use of antibiotic ointments e. Limiting use in farming/husbandry Reducing use of antibiotics in farm animals f. Limiting use in agriculture Reducing use of antibiotics in crops g. Antibiotic R & D Increasing research and development efforts for new antimicrobials h. Infection surveillance Implementing robust systems of infection surveillance in hospitals and in the community i. Hospital sanitation Reducing spread of infection in hospitals by adhering to infection prevention and control measures j. Vaccinations General public keeping immunizations up to date (continued) Capurro 7 Table 1. (Continued) Code Definition k. Hygiene/hand washing/proper cooking Adopting hygiene measures at home in general, and specifically when cooking l. NA No prevention measures were mentioned 12. Is the UN’s plan mentioned? a. Yes, and how the country will implement it The plan was mentioned and how the country will implement it b. Yes, but no how it will be implemented The plan was mentioned but there was no description of how it would be implemented c. No The plan was not mentioned 13. Description of resistant bacteria a. Superbug Resistant organisms were described as “superbugs” b. At war/battle with/fighting Resistant organisms were anthropomorphized and described using military language c. NA Resistant organisms were not described as “superbugs” and belligerent language was not used Note. AMR = antimicrobial resistance. New York Times (Rabin, 2016) published stories on the thus pointing to the need to correct this generalized practice Centers for Disease Control and Prevention declaring sepsis a across industries and countries and move toward judicious medical emergency and mentioned antibiotic resistance as a use of antibiotics. For example, a story in The New York cause of sepsis; however, neither explained what resistance is. Times explains, Infectious disease doctors have long warned that overuse of RQ2: What Causes AMR? antibiotics in people and in animals puts human health at risk by reducing the power of the drugs, some of modern medicine’s The three most cited causes of AMR were extensive use of 7 most prized jewels. The problem is global, because the bugs are antibiotics in farming and husbandry (n = 29), extensive mobile. Overuse in pig production in China, for example, has use or general overuse of antibiotics (n = 24), and unneces- spawned superbugs that have surfaced in the United States and sary antibiotic prescriptions for humans (n = 22). Other Europe. (Tavernise, 2016) causes mentioned were antibiotic use in agriculture, use of antibacterial products—such as gels and wipes—incomplete RQ3: Who Is at Risk of Contracting Resistant doses of antibiotics (not finishing the prescription), and use Infections? of antibiotic ointments. The following excerpts are examples of this: Lay citizens tend to look for information related to health risks and how to minimize exposure in legacy media either Concern has been growing among scientists, consumers and print or online (Greenberg et al., 2017). It is therefore crucial shareholders that the overuse of (antibiotics) is contributing to in risk communication to define populations at risk along rising numbers of life-threatening infections from antibiotic- with preventive measures (Abraham, 2009). However, in resistant bacteria dubbed “superbugs.” (Polansek & Baertlein, 45% of the coverage (n = 40), there was no mention of popu- 2016) lations at risk of AMR. In 38% of the articles (n = 34), popu- lations at risk were broadly defined—implicitly or The rate at which new strains of drug-resistant bacteria have explicitly—as “everyone” or the general public. Despite this, emerged in recent years, prompted by overuse of antibiotics in the newspapers still referred to AMR as a nosocomial risk, humans and livestock, terrifies public health experts. (McNeil, even though community-acquired strains of resistant bacteria 2017) are a common occurrence. Some investigative journalists have already sounded the alarm about the risk of community- Because the indiscriminate use of drugs in animals can destroy acquired strains of resistant bacteria that can cause lethal the drugs’ effectiveness for humans, the Food and Drug Administration has issued regulations that it says will reduce infections (see, for example, McKenna, 2010), an aspect that antibiotic use in livestock. (“The United Nations Takes on remains underreported in the dailies. Superbugs,” 2016) While portraying antibiotic resistance as a hospital-based risk, the newspapers identified five populations at risk of Reporting the causes of AMR indirectly lays blame on acquiring a resistant infection: hospital patients (n = 13), several actors. In this case, responsibility for causing and patients in extended care (n = 7), people with compromised spreading antibiotic resistance is laid principally on the farm- immune systems (n = 5), infants (n = 5), and the elderly ing industry and the medical community, and onto patients to (n = 3): a lesser degree for demanding antibiotics and not taking them responsibly. In addition, over a quarter of the stories Most of these deaths occur among older patients in hospitals or stated that antibiotics are being “overused” or “misused,” nursing homes, or among transplant and cancer patients whose 8 SAGE Open immune systems are suppressed. But some are among the young that requires a global response. (“The United Nations Takes on and healthy: A new study of 48 American pediatric hospitals Superbugs,” 2016) found that drug-resistant infections in children, while still rare, had increased sevenfold in eight years, which the authors called Although a portion of the coverage identified various “ominous.” (McNeil, 2017) actors as responsible or implicated in the management of the AMR crisis, almost half of it (n = 40) did not mention who The Public Health Agency of Canada says this is one of the should manage this public health hazard. In addition, the biggest public health risks facing the country, with 18,000 UN’s Global Action Plan on Antimicrobial Resistance Canadians contracting drug-resistant infections each year in (World Health Organization, 2015) was mentioned 8 times, hospitals and 700,000 dying from them annually around the five of them explaining how the plan will be implemented by world. (Bronwell, 2016) the national government. Reporters identified the obvious populations at risk of developing resistant infections, but they did not mention that RQ5: How Can the Spread of AMR Be antibiotic resistant bacteria also exist outside hospitals, in the Prevented? community, affecting healthy people who would not nor- mally be considered a vulnerable population. While hospitals Regarding risk prevention measures, over a third of the cover- are most often the epicenter of resistant-infection outbreaks, age did not mention any (n = 31), leaving readers uninformed community-acquired resistant infections are becoming more of how to avoid behaviors that put them at risk of contracting common and affecting a broader population (O’Neill, 2016). resistant infections and spreading them. Two thirds of the coverage, however, did identify preventive measures. This shows improvement since the study by Desilva (2004) who RQ4: Who Is Responsible for Controlling/ found preventive measures in only one fifth of the North Managing the Risk of AMR? American coverage of AMR. There were four preventive measures repeatedly mentioned: limiting the use of antibiot- The management of AMR is considered in the analyzed cov- ics in farming (n = 21), developing new antibiotics (n = 20), erage as a political task, and the government and policy- prescribing antibiotics only when necessary (n = 16), and makers are most frequently mentioned as responsible for it (n infection surveillance (n = 15). These four recurrent preven- = 31). Doctors were mentioned in relation to their prescrip- tive measures correspond to the actors identified as responsi- tion practices and expected to prescribe less antibiotics, ble for managing the risk: government, health authorities, while nurses were considered responsible for the hygiene of pharmaceuticals, and medical community. For example, medical settings which is a key infection prevention and con- trol measure (n = 20). Public health authorities were Through the use of good animal husbandry techniques, vaccines, expected to regulate antibiotic use across industries (n = 18), probiotics and other alternatives, the animal agriculture industry and pharmaceutical companies (n = 18) were mentioned as can and should move away from low-dose antibiotic use for responsible for developing new antibiotics. For example, an routine disease prevention and use antibiotics only to treat sick editorial in The Washington Post regarding a proposed health animals. (Heil, 2017) bill described members of the U.S. Congress as responsible for encouraging antibiotic stewardship: In addition, doctors and nurses need to take practices like hand washing and equipment sterilization much more seriously to Lawmakers should ensure that a proposed adjustment to rules on reduce widespread drug-resistant infections in hospitals. the approval and use of new antibiotics does not have the Consumers must make sure they and their children are unintended side effect of encouraging antibiotic overuse and vaccinated, which helps prevent infections in the first place. resistance—the very problem the provision is supposed to (“The United Nations Takes on Superbugs,” 2016) combat. (“A Bill Fit for Lame Ducks,” 2016) Other preventive measures mentioned in the coverage Similarly, an editorial in The New York Times highlights included taking antibiotics responsibly (n = 7), improved the role of the government in managing the risk of AMR as hospital sanitation (n = 4), vaccinations (n = 4), hygiene well as the need for global cooperation: (n = 3), and limiting the use of antibiotic ointments (n = 1). The newspapers suggested preventive measures that are This puts a burden on governments to invest more in research mostly out of the control of the individual; they depend on and development. Governments could also offer incentives— political action, scientific development, and improved medi- prizes have been suggested, for instance—to companies that cal practices. However, challenging the lack of regulation develop new vaccines and antibiotics, and they could regarding antibiotic use and infection surveillance, the eco- contractually agree to buy medicines to assure companies that nomic interests that dissuade pharmaceutical companies they will have a market for their products. The United Nations was right to ring the alarm about superbugs, a growing danger from developing new antibiotics, and questioning how Capurro 9 physicians prescribe antibiotics show evidence of some and whether these publications acted as sites for reflexive reflexive modernization in the coverage of AMR, particu- modernization, a necessary step for modifying our antibiotic larly in editorials, opinion pieces, and letters to the editor. consumption and assuming a stewardship mind-set. The For example, the National Post explained lack of economic results of this study show that AMR is being communicated incentive to develop new antibiotics: through inaccurate definitions and incomplete accounts of its causes, responsibility in managing the threat, preventive Another reason pharmaceutical companies have little incentive measures, and populations at risk, with potential negative to invest in research and development is that if researchers implications for public understanding of AMR and public discover an effective new antibiotic, public health officials want awareness efforts. Furthermore, this study shows that by to reserve it for use in emergencies to keep bacteria from oversimplifying this complex modern risk, the newspapers becoming resistant to it as well. As a result, only a handful of the seldom acted as sites of reflexive modernization, therefore world’s major drugmakers are pursuing antibacterial research obscuring the necessary changes to medical and industrial today. (Bronwell, 2016) practices required to tackle this threat. First, the newspapers preferred simplistic expressions, A reader, however, points out in a letter to the editor that such as “superinfection,” instead of explaining basic evolu- developing new antibiotics does not revert AMR and men- tionary processes and who is at risk, and did not explain why tions the continued use of antibiotics in modern farming as extensive use of antibiotics accelerates the evolution of resis- the main problem: tance either. Studies have shown that oversimplified accounts of AMR can lead to confusion regarding the way antimicro- As bacteria resistant to our existing drugs flourish, new classes bials function and perpetuate misconceptions, such as believ- of antibiotics are indeed needed. But introducing new antibiotics ing that the body becomes resistant to antibiotics and not the into a broken system won’t solve our problem; it merely buys bacteria (Davis et al., 2017; Kamata et al., 2018). Providing time. The overuse of antibiotics is the foundational problem, and the routine use of antibiotics on food animals is particularly a clear explanation of the biological process behind antibi- troubling. (New antibiotics, 2017) otic resistance could improve scientific literacy and public understanding of the risk, its causes, and potentially reduce Of all the preventive measures suggested, only the ones risk exposure. In addition, by presenting a limited and incom- mentioned on a few occasions—taking antibiotics responsi- plete account of who is at risk of resistant infections, the bly, getting vaccinated, proper hygiene, and reducing the use newspapers reinforced the idea that AMR is not a widespread of antibiotic ointments—can be done by individuals. health hazard, thus minimizing the crisis it represents and Furthermore, lay experience and public concerns were sel- potentially generating a false sense of security (Nisbet, dom considered in the newspaper coverage of AMR. For 2017). A low perception of risk can affect risk behavior and example, some letters and columns blamed patients for lead to the rejection of necessary changes in policy and med- expecting antibiotic prescriptions from their doctors or for ical practice to manage the risk. not finishing their prescriptions; however, there was no Second, half of the coverage did not mention any causes of explanation regarding antibiotics being useless for viral AMR, and the rest broadly identified “general overuse” of infections or why physicians will not prescribe them for mild antibiotics as the main cause. The persistent lack of clear bacterial infections, such as ear infections. causes of the risk is a common trend in media coverage of An interesting exception was a story written by a health AMR (e.g., Chan et al., 2010; Desilva, 2004; Washer & Joffe, reporter who narrates his experience with a tooth infection 2006). Broad explanations seldom acknowledged key politi- and his objection to take prophylactic antibiotics, describing cal and economic interests and activities that contribute to the how he negotiated his personal interest versus what he per- spread of resistant bacteria, thus ignoring necessary changes ceives as his societal responsibility: in current industrial and medical practices. Similarly, the newspapers suggested that governments and pharmaceutical Taking a series of single-dose antibiotics doesn’t seem like a industry should manage the risk, but mostly ignored other good idea: Surely my gut won’t thank me, and it seems like just actors who can also contribute to improve antibiotic steward- the sort of antibiotic use that contributes to the problem of ship. In doing so, other sources of responsibility remain resistance that everyone is concerned about. On the other hand, obscured, for example, government and policy makers who my tooth has an infection! [ . . . ] I’m not under any illusion that have failed to put in place adequate regulations regarding my personal actions will have great consequences for national antibiotic use. This contributed to a distorted perception of policy on antibiotic use. As Quinn puts it, “bacterial resistance is antibiotic resistance as being created by one or two industries a societal problem, not individual.” But I like to think I’m doing instead of describing this health risk as collectively caused by my bit. You’re welcome. (Lindley, 2016) various modern practices, from medicine and farming, to air travel and environmental degradation, as well as deficient Discussion and Conclusion health care systems and globalized economies. In this article, I examined how the risk of AMR is discur- Third, in almost half of the sample (42%), the dailies did sively constructed in four elite North American newspapers not explain what causes antibiotic resistance. This omission 10 SAGE Open was higher than the 33% found by Desilva (2004), showing on a few occasions as sites of reflexive modernization, ques- that over the past 15 years, the North American print media tioning expert knowledge (e.g., how physicians prescribe has not improved in terms of contributing to public aware- antibiotics) and modern practices (e.g., the use of antibiotics ness and understanding of this growing public health risk. In in industrial farming). most cases, the dailies failed to inform audiences about the My analysis suggests that this function was limited due to causes of AMR or laid all the responsibility on a few specific the complexity of AMR as a risk, which was impossible to actors or industries, therefore oversimplifying the complex address comprehensively in short newspaper stories. The networks of actors, practices, and interests that underpin the very complexity of modern risks (Beck 1992b, 2009), with acceleration of AMR. many layers of responsibility by a wide array of actors, could When suggesting preventive measures, the newspapers be hindering the reflexive function of news media, which focused on those that are out of the control of individuals, privilege fast news cycles and short stories, and thus mini- thus leaving citizens disempowered regarding how to pre- mize the feeling of risk instead of leading to the pervasive vent a resistant infection. Saliently, half of the coverage did feeling of it described by in the risk society theory. Future not mention any causes of antibiotic resistance, actors research could explore whether a more reflexive narrative is responsible for causing the threat, populations at risk, or pre- found in specialized publications, particularly online, that ventive measures, all crucial information that could poten- are more flexible with the length of their stories, thus inviting tially allow citizens to avoid risky behavior. Describing a their audience to critically think about the impact of modern risk and not identifying risk behaviors and explaining how to institutions and practices in human health. avoid them could lead to increased public anxiety. This study has two limitations that could be addressed in Furthermore, misinformation or incomplete information future research. First, the analysis did not differentiate about a health hazard could lead to false beliefs regarding between different types of stories (hard news, editorial, col- causes and prevention. umn, letter, etc.), an aspect that could be further explored as Fourth, the UN’s plan to tackle AMR, which outlines opinion pieces could be a more suitable space for question- infection surveillance systems, public awareness campaigns, ing industrial practices, policies, and lifestyles, while hard international cooperation, and other measures governments news could be a more likely genre to identify populations at can adopt, was mentioned only in eight articles in the sam- risk and suggest preventive measures. Second, the analysis ple, thus the newspapers oversimplified the global nature of was limited to four elite North American newspapers’ 1 year AMR by suggesting that this health hazard that can be dealt coverage of AMR, thus shedding light on current representa- with within the national borders. Fifth, in the risk society, tions and discussions of AMR. The sample could be expanded mass media are spaces for reflexivity, where scientific and to include more publications—for example regional cover- expert knowledge about hazards is discussed and challenged. age could vary—or a longer period of coverage. In addition, This, however, is not evident in the analyzed coverage, which further research could compare representations of AMR in for the most part follows a deficit model of risk communica- legacy newspapers with those in news websites with sections tion in which expert knowledge is reproduced as a way to dedicated to health-related and scientific topics. educate publics (Lupton, 1999b). Not acknowledging public Declaration of Conflicting Interests concerns while reiterating expert views can deepen public anxiety and reinforce the feeling of powerlessness, which The author(s) declared no potential conflicts of interest with respect can further reduce public trust in experts and decrease com- to the research, authorship, and/or publication of this article. pliance with prevention measures, such as using antimicrobi- als judiciously and vaccinating. Funding It is crucial to examine news media representations of The author(s) received no financial support for the research, author- health risks as they affect public perceptions of risk and risk ship, and/or publication of this article. behavior (Briggs & Hallin, 2016; Capurro et al., 2018; Caulfield et al., 2019). If news media are expressing reflex- ORCID iD ivity, this could potentially lead to political action. In this Gabriela Capurro https://orcid.org/0000-0002-2211-6229 case, reflexive news coverage of AMR could increase public awareness of the threat. This could lead to increased public Notes pressure for robust infection surveillance systems, additional 1. Antimicrobial resistance (AMR) is an umbrella term that refers efforts to increase public awareness of AMR and how to to bacteria, parasites, viruses, and fungi evolving resistance to reduce risk exposure, supporting initiatives to foster antimi- antimicrobial treatments that used to be effective against the crobial stewardship in medical practice, as well as push for wide range of infections they cause. Antibiotic resistance— increased political commitment at the national and interna- bacteria evolving resistance to antibiotics—is included in tional levels. This study, however, shows that the news media AMR. are not fulfilling their reflexive function as predicted in the 2. 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SAGE Open – SAGE

Published: Jan 24, 2020

Keywords: risk communication; qualitative content analysis; reflexive modernization; antibiotic resistance; health communication

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“Superbugs” in the Risk Society: Assessing the Reflexive Function of North American Newspaper Coverage of Antimicrobial Resistance:

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“Superbugs” in the Risk Society: Assessing the Reflexive Function of North American Newspaper Coverage of Antimicrobial Resistance:

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