by Kim Krisberg
Broccoli. A nutritious green veggie of the cabbage family? Or a symbol of the federal government's over-reaching power grab? Like most things in life, it all depends on your perspective.
I've been thinking about that word -- broccoli -- since last month's Supreme Court hearings on the constitutionality of provisions within the Affordable Care Act (ACA). Specifically, I've been pondering this comment from Justice Antonin Scalia during arguments on the ACA's individual insurance mandate:
SCALIA: . . . could you define the market -- everybody has to buy food sooner or later, so you define the market as food. Therefore, everybody's in the market. Therefore, you can make people buy broccoli.
I'll leave it to the lawyers to parse out the difference between broccoli and insurance. (Jack Balkin also has a great post on this.) What intrigued me was the word itself -- broccoli. It certainly didn't invoke thoughts of salads and well-balanced diets; its meaning within this particular debate had already been solidly defined and framed. In the context of health reform, the broccoli comparison means one thing only: the threat of an encroaching nanny state. In other words, broccoli is a talking point and an emotionally powerful one at that.
So, what does it mean when this loaded word -- a favorite among reform opponents -- makes it all the way to the highest court of the land? Is it symptomatic of advocates' failure to use language -- to form a compelling, consistent narrative -- in support of health reform that resonates in the public mind? Can reform supporters, and public health advocates in particular, compete against the bogeyman of government-mandated broccoli consumption?
Public health researcher Patrick Remington, professor and associate dean at the University of Wisconsin School of Medicine and Public Health, thinks they can. But it might take fighting fire with fire.
"Scientists operate by the rules of logic, a series of 'if-then' statements," said Remington, author of "Communicating Public Health Information Effectively: A Guide for Practitioners." "The rest of the world operates not so much by logic, but by emotions and gut reaction, and therefore the use of terms like death panels or broccoli as a federal mandate turn out to be very effective ways to communicate to the average person. Oftentimes, scientists stick to their logic and believe if we simply provide information, then it will be processed appropriately and reasonable action will follow. But history tells us that's not the case."
The fear factor
If the long-term objective is to achieve good health outcomes and conditions in which people can live long, healthy lives, then advocates have a responsibility to be effective in their communication of those values, Remington told me. And while typically "we just don't use fear in public health as a motivating factor," it isn't unprecedented, he said.
For an example, he points to one of public health's most-prized accomplishments: the decline in tobacco use. Public health took on -- and continues to take on -- Big Tobacco with fiery rhetoric, instilling fear into people about the health effects of tobacco use and secondhand smoke and the insidious nature of tobacco marketing. (Remember popular statistics about how tobacco kills more people every day than three jumbo jet crashes?) That same element of fear, though, hasn't seemed to materialize in the language for health reform.
"It would be optimal to let logic prevail and have a civil discourse, however anybody that takes that approach will largely fail when the other side uses fear and appeals to the baser instincts of society," Remington told me. "When reason doesn't prevail, then I think it's not unreasonable to fight fire with fire."
Bob Crittenden said he cringed when he heard the broccoli question. Crittenden is the executive director of the Herndon Alliance, a nonpartisan coalition of more than 200 organizations that's working to find effective communication strategies for talking about the benefits of health reform. Opponents, he said, have been incredibly successful in framing the discussion about mandates as government intrusion. Ironically, it's an idea that resonates even though it comes from the very same group of thinkers that originally proposed individual mandates as an alternative to Hillary Clinton's reform attempts in the 1990s, he noted.
(Likewise, isn't it a tribute to the power of effective communication that the very same party that rails daily against the dangers of health reform will most likely pick a presidential candidate that did the very same thing in Massachusetts? How do you reconcile that, logically? You don't; you use good communications.)
Of course, Crittenden noted, it doesn't help that the progressive voice is often "outgunned and outmanned" when it comes to finances and advertising.
"On the reform side, we just don't have the financing to do it," Crittenden told me. "We have earned media and it's only effective if we really organize ourselves the right way."
In fact, Crittenden said that beyond the mandate, "if you look at the story we're telling, we win." People like many of the provisions in the ACA, he said, such rules that bar discrimination against people with pre-existing conditions or prohibit the pulling of people's insurance after they get sick. But breaking through the media's cluttered landscape takes discipline, which is why Crittenden said rallying around a single, consistent message is key.
"If you're not being disciplined, no one talks about what you're talking about," he said. "We have this opportunity...and a single message is important because once everybody starts using it, it can break into the public consciousness."
It's all in your head
The art of framing a conversation is an important one. And by many accounts, reform opponents have been wildly successful at framing the health reform discussion within a context of loss. Loss of freedom, choice, control and quality.
"One of the things we know from cognitive psychology is that people are likely to pay attention to frames that have to do with loss," said Brian Southwell, a senior research scientist with RTI International's Health Communication Program. "When you're talking about loss, people will pay more attention even if there's a good trade off. Opponents' messages really hone in on losses to freedom...there's all this emphasis on loss rather than pointing out that we're heading over a cliff."
Luckily, opponents don't hold a patent on the loss frame, he noted. Advocates, he said, have an "equally palpable" argument about loss if health reforms are rolled back -- loss of patient protections, loss of a real chance to curb out-of-control and crippling health care costs. But Southwell said he's hesitant to inject too much fear into the conversation.
"I personally struggle with not scaring people," he told me. "But we know we have narratives that are powerful...we need to think of a more compelling story and there's one to be told about the great opportunities to protect people."
When I talked to Lawrence Wallack, professor of public health and dean of the College of Urban and Public Affairs at Portland State University, about how to make a wider crack in the American psyche, he asked me a question about the movies. Who did an American Film Institute survey find was people's favorite all-time greatest film hero? (I couldn't guess.) Atticus Finch. The courageous lawyer in To Kill a Mockingbird who stood up for justice. To Wallack, the Finch example is a sign that people do respond to the "values of hope and aspiration that turn people toward each other."
"This is the view of the left in a sense...it's the values exemplified by Atticus Finch that we believe in and that drives us," Wallack said.
But first, he said, reform and public health advocates need to better define the values they share with people.
"You can't just say 'it's fair,'" he said. "You have to define what fairness is."
(To hear more from Lawrence Wallack, check out this video of a fantastic talk he gave about the language of health reform at APHA's 2011 Midyear Meeting.)
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for a decade.
The horror! Obama wants to pass a law to force us to eat ... broccoli !
That would never have happenend under Bush (1), he had a well-known dislike for broccoli.
Maybe the state-enforced eating of Solyent Green is just around the corner...
Great advice from Lawrence Wallack to explain what fairness is. I'll use that tip this week (and beyond) when a group of families will be visiting Washington DC and telling lawmakers and Administration officials why worker safety regulations are vitally important. Fairness means that a company that allowed dangerous workplace hazards to exist should pay more than a $1,500 penalty for three violations that led to a workers' death.
If penalties for unsafe work environments are ever going to have a deterrent effect, they have to be more than the "cost savings" that not implementing them produced.
For willful violations in other fields, there is the provision to triple actual damages as a deterrent for willful bad conduct.
Of course framing things in ways that others can easily use helps - but look at Michael Moore. He does an excellent job of reframing for us. The response to him is effective blacklisting. Sicko did a fantastic job of reframing the healthcare debate. He released it early in the national debate for the latest round of healthcare reform. The film was hardly shown, and he was maligned, as we say about voting, "early and often." And many progressives are afraid to defend him or stand in in solidarity with him - - and instead criticize him for framing instead of being more accurate with facts.
Coming up with frames that work is important. But the main frame that is used against the working class is blackmail - - support the rich or risk poverty, disease, and isolation - - and supporting the rich often gets you that anyway.