Politics, propaganda, and public health a case study in health communication and public trust

Politics, Propaganda, and Public Health


LEXINGTON STUDIES IN HEALTH COMMUNICATION
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Recent Titles in This Series
Politics, Propaganda, and Public Health: A Case Study in Health Communication and Public
Trust
By Laura Crosswell and Lance Porter
Communication Studies and Feminist Perspectives on Ovarian Cancer
By Dinah Tetteh
Reifying Women’s Experiences with Invisible Illness: Illusions, Delusions, Reality
Edited by Kesha Morant Williams and Frances Selena Morant

Politics, Propaganda, and Public Health
A Case Study in Health Communication and
Public Trust
Laura Crosswell and Lance Porter

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Copyright © 2018 by The Rowman & Littlefield Publishing Group, Inc.
“Inoculating the electorate: a qualitative look at American Corporatocracy and its influence on health communication” by L. Crosswell
and L. Porter, 2016, Critical Public Health, 26(2), p.207–220 Copyright 2016 by Taylor & Francis. Reprinted [or adapted] with
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Names: Crosswell, Laura, author. | Porter, Lance, 1969- author.
Title: Politics, propaganda, and public health : a case study in health communication and public trust / Laura Crosswell and Lance Porter.
Description: Lanham : Lexington Books, [2018] | Series: Lexington studies in health communication | Includes bibliographical references
and index.

Identifiers: LCCN 2018011190 (print) | LCCN 2018011813 (ebook) | ISBN 9781498553001 (Electronic) | ISBN 9781498552998 (cloth :
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Subjects: | MESH: Pharmaceutical Preparations—economics | Direct-to-Consumer Advertising | Health Knowledge, Attitudes, Practice |
Health Communication—methods | Patient Acceptance of Health Care | United States
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Contents
Contents
Acknowledgments
Preface
1 The Doctor, the Baker, and the Medicine Maker
2 An American System of Pharmaceutical Influence
3 Deconstructing Merck’s Awareness Campaign
4 Social Trust and Public Health
5 Consumer Perspectives
6 Pharmaceutical Conglomerates and American Politics
7 Global Implications of American Medicalization
8 The Genderization of a Vaccination
Conclusion
References
Appendix A: Commercial Transcripts for Pre-FDA Messages
Appendix B: Moderator Guide for U.S. Focus Groups
Appendix C: Additional Material/Questions for International Focus Groups
Appendix D: Moderator Guide for Co-Ed Marketing Focus Groups
Appendix E: Demographic Survey for all Focus Groups
Appendix F: Eye Tracking Materials

About the Authors


Acknowledgments
We would first and foremost like to thank Lexington Books for giving us a platform to share our work
and thoughts on commercial influence in the health care industry. Specifically, we would like to
acknowledge our acquisitions editor, Nicolette Amstutz, and her assistants, Jessica Thwaite and
James Hamill, as they were instrumental in bringing this book to fruition. We would also like to thank
the proofreaders at Lexington Books, as well as our anonymous peer reviewers for their valuable
contributions during the revision and editing process.
This work would not have been possible without the help and support from the Reynolds School of
Journalism at the University of Nevada, Reno, and the Manship School of Journalism at Louisiana
State University. We’d specifically like to thank the Center for Advanced Media Studies at the
Reynolds School and the Mary P. Poindexter Professorship in the Manship School, for providing us
with funding for this book’s production. In addition, we would like to express our appreciation to the
LSU Media Effects Lab for the administration of our experiments. We also want to extend our sincere
thanks to our colleagues, supervisors, and mentors for offering us guidance, advice, and feedback
throughout the publication process.
We would like to acknowledge the editors at Critical Public Health and Taylor and Francis .
Material included in chapter 6 of this book originally appeared in Critical Public Health and is
reprinted here with their permission (Inoculating the electorate: a qualitative look at American
corporatocracy and its influence on health communication, by L. Crosswell and L. Porter, 2016,
Critical Public Health, 26(2), p. 207–220. Copyright 2016 by Taylor & Francis. Reprinted [or
adapted] with permission. www.tandfonline.com). We thank both parties for allowing us to include
our previously published work in this book. The authors would also like to thank Dr. Meghan Sanders
for her work on the original publication of the data in chapter 5 (Crosswell, L., Porter, L. & Sanders,
M., 2018). Out of sight, out of mind?: Addressing unconscious brand awareness in healthcare
communication. In H. D. O’Hair, [Ed.] Risk and health communication in an evolving media
environment, New York: Routledge).
Additionally, we extend our sincerest gratitude to Kristi Barber for her copyediting work and moral

support during each stage of the manuscript’s development. We would also like to thank Joel
DesOrmeau for his extensive proofreading and Kari Barber for her help with photo editing and image
resizing.
Finally, we would like to thank our families and friends for their unconditional love, support, and
patience as we worked to finish this book. We could not have done it without you.


Preface
In his book Land of Desire, William Leach traces the conception of America’s consumption-based
culture back to the 1800s. The author documents the cultural rise of consumer capitalism in the United
States and exposes ways in which consumer-oriented institutions, democratized desire, and customer
imagination shape societal values. Mirroring Leach’s concern for America’s consumer-driven ethos,
this book takes an in-depth look at commercialized health messaging and the commodification of
public health as it relates to the free market enterprise.
Politics, Propaganda, and Public Health examines the profit-driven agendas, non-branded
marketing strategies, and consumer influences that induce public trust toward commercial interests.
Specifically, we investigate the ways in which Merck Pharmaceuticals engineered public
understanding of the human papillomavirus (HPV) and cervical cancer through social marketing and
product advertising. In examining Merck’s campaign as it relates to American capitalism, and more
closely investigating the vested interests feeding public awareness efforts, we attend to the social,
political, and commercial agendas driving today’s health care communication.
Big Pharma spends more money on advertising and lobbying than it does on researching medicine to
improve public health (Kantar Media, 2017; The Pew Charitable Trusts, 2017; Grantham, Ahern, &
Connolly-Ahern, 2010; Jaramillo, 2006). Yet, surprisingly, the commercialization of public health is
an under-examined topic. Politics, Propaganda, and Public Health investigates Merck’s
promotional messaging for the Gardasil vaccination as it relates to the medicalization process; a
practice in which health-related risks serve as marketing platforms for pharmaceutical companies. At
its most basic level, this work offers a multifaceted look at how one pharmaceutical company
gradually entered and quickly controlled a vaccination market. Concrete examples and case-specific
findings showcase the bigger picture, pointing to the commoditization, politicization, and

medicalization of public health.
Merck’s pioneering promotional strategies, combined with the unique nature of the vaccination (a
preventative treatment for a sexually transmitted infection) and an unconventional target market
(young girls), make this case an appropriate one to analyze as we examine the changing nature of
pharmaceutical marketing in the United States. By deconstructing Merck’s issue awareness efforts, the
launch of the Gardasil vaccination, and the company’s ensuing lobbying strategies, we address
commercial agents that go far beyond the face value of standard product advertising. Politics,
Propaganda, and Public Health attends to symbiotic agents that regulate public health messaging,
and ultimately, issues a call for regulation realignment in the health care industry.
BOOK OUTLINE
In light of the paradigm shifts taking place in both academia and industry, Hartley (2012) suggests that
fields related to media and cultural studies re-direct focus toward the means and mechanisms of
change; centering an analytical lens on the overall dynamics of systems. This book pieces together the
various ways in which Merck Pharmaceuticals engineered public understanding of HPV and cervical
cancer, while drawing attention to the cultivated commercialization of public health. Through blended


methodologies, each chapter forges a globalized understanding of how corporatized health
communication and capital interests shape consumer perceptions, public trust, citizen efficacy, and
legislative policies.
In the early chapters of this work, we orient the reader with key terms, principal concepts,
regulation development, and company history. We then more fully introduce the campaign under
investigation following Hall’s (1977) method of textual analysis. By stripping campaign messages
down to fundamental elements of marketing semantics, we provide the groundwork for a basic, but
imperative, understanding of Merck’s health messages. Subsequent focus groups consider current
trends in health care communication and the implications of mixed-marketing models guiding public
awareness efforts. Eye tracking analysis later documents ways in which brand fixations correlate with
attitudes toward awareness messages. Through within-subject investigative design, we compare
physiological indicators of attention with self-reported measurements of awareness. We conclude this
body of work with in-depth interviews that more closely examine the role corporate funding plays in

legislation, regulation, and voter/consumer behavior. This final phase of research brings our
investigation full circle, showcasing the underlying nuances of product industry, government agency,
and consumer capitalism.
In sum, this book takes on multiple forms of research methods, data analysis, and writing styles; all
of which contribute to the crystallization of our broader argument (Richardson, 2000). As author and
researcher Laura Ellingson (2005) explains, holistic approaches to extensive, in-depth research
involve “collecting the data, making sense of them, and then writing about them; these processes do
not occur in a linear fashion, but are interwoven” (p.155). Indeed, each chapter of our text embraces
its own style and format, and through the inclusion of varied accounts and sociopolitical issues, we
present the reader with a triangulated, or interwoven, interpretation of Politics, Propaganda, and
Public Health. Our journey begins in chapter 1, in which we establish the foundation, direction, and
context for the case at hand.


Chapter One

The Doctor, the Baker, and the Medicine Maker
A dominant force in American culture, media act as both an economic and cultural institution; creating
marketable enterprises and social meaning through mass messaging systems (Cook, 2005). Guided by
the “invisible hand,” U.S. media nourishes consumer capitalism through advertiser-supported content,
and as a powerful social educator, advertising defines cultural norms and constructs social realities
(Buchanan, 2001). Therefore, as a profit-making business and a producer of meaning, the influences
of the U.S. media system go far beyond commercial interests, penetrating the core layer of societal
operations and human functioning.
America’s free market enterprise and dual-product marketplace provide fertile ground for the
commercialized exploitation of public health. For example, pharmaceutical advertising, also known
as direct-to-consumer advertising (DTCA), serves as both a major source of funding for the American
media system and a major source of health information for the U.S. public. As one of only two
Western countries to allow pharmaceutical advertising (New Zealand being the other), the United
States spends more on marketing prescription drugs than most countries spend on administering

medicine, with expenditures totaling $5.4 billion in 2015 alone. Notably, Americans also spent a
record $457 billion on prescription drug medications that same year (Llamas, 2016).
Health communication in the United States is largely a commercial enterprise, with many Americans
learning about important health issues through paid pharmaceutical advertisements (Donohue, 2006).
The system encourages intense competition among pharmaceutical companies to bring drugs to market
quickly with the most effective marketing communication plans. The question is, do successful paid
media campaigns bring about effective health communication?
Public opinion is divided. Proponents of DTCA claim pharmaceutical messages help publicize
available treatments for underreported conditions, such as depression (Sorofman, 1992). Others point
out that prescription drug advertising predominantly relies on emotional claims rather than
quantitative data; presenting consumers with vague and misleading information (Frosch, Krueger,
Hornik, Cronholm, & Barg, 2007; Woloshin, Schwartz, Tremmel, & Welch, 2001). Indeed, direct-toconsumer advertising is a topic ripe for discourse, as it unites matters of public health, consumer
culture, and a dual-product marketplace. While supporters suggest DTCA promotes a more educated,
healthier society, increasing overall consumer welfare (Mukherji, Raman, Dutta, & Rajiv, 2017),
critics argue such commercialized health communication drives consumer demand and ultimately
shifts the physician-patient relationship to a physician-consumer relationship (Bradley & Zito, 1997).
Though the controversy surrounding direct-to-consumer advertising is complex, it is certainly not
new. Debates over prescription drug advertising date back to the 1970s, when a trajectory of U.S.
Supreme Court cases drew attention to issues related to commercial canvassing, regulatory
intervention, and First Amendment violations (Beales & Muris, 1993; Perri, Shinde, & Banavali,
1999; Bates v. State Bar of Ariz., 433 US 350—Supreme Court 1977; Bigelow v. Virginia, 421 U. S.
809, 421 U.S. 817–818l; Virginia Pharmacy Board v. Virginia Consumer Council, 425 U.S. 748).


Perhaps most notably, in 1976, Shirley Terry v. California State Board of Pharmacy introduced
issues of consumer rights, information access, and commercial free speech into public consciousness
and onto political platforms.
In the California Supreme Court, consumer plaintiff Shirley Terry sued on behalf of persons needing
access to price information for prescribed medications, issuing “declarations of unconstitutionality
and permanent injunctions against the enforcement of California Business and Professions Code

insofar as they prohibit media advertising of the retail price of prescription drugs” (Terry v.
California State Board of Pharmacy, 395 F. Supp. 94—District Court, ND California 1975, p. 1798).
The District Judge ruled in her favor, granting prescription drug advertising limited commercial
speech protection in consideration of First Amendment rights and Federal Antitrust laws (Terry v.
California State Board of Pharmacy, 426 US 913).
While the First Amendment plays a vital role in America’s government system, privileged industry
allowances complicate the nature of constitutional protection within a free market enterprise. A 1993
Supreme Court opinion outlined the foundational principles for commercial free speech and protected
forms of advertising, explaining:
The commercial market place, like other spheres of our social and cultural life, provides a forum where ideas and information
flourish. Some of the ideas and information are vital, some of slight worth. But the general rule is that the speaker and the audience,
not the government, assess the value of the information presented. Thus, even a communication that does no more than propose a
commercial transaction is entitled to the coverage of the First Amendment. (Edenfield v. Fane, 123 L. Ed. 2d 543, 113 S. Ct. 1792,
1798, 1993)

Though it may seem simple enough, commercial speech protection calls attention to conflicted capital
interests in a democratic government system. While some party lines support the notion that a healthy
democracy rests on that which is conducive to a properly functioning market, opposing views suggest
commercial speech protection is inherently antidemocratic, and symptomatic of America’s misguided
trust in a commercialized system (Jaramillo, 2006). Terry v. California State provided the
pharmaceutical industry with privileged access to patients, and therefore prompted discussion over
commercial speech protection in the context of public health.
The outcome of this seminal case undeniably transformed the nature of public health communication
and normative industry operations in the United States. Previously reliant on sales representatives,
medical journals, and physician recommendations for product promotion in years past, this new
regulatory leeway allowed pharmaceutical marketers to directly communicate with consumers and
further enhance product awareness. Big Pharma quickly turned to periodicals as a means of more
effectively promoting product interest and physician-generated prescriptions (Perri, Shinde, &
Banavali, 1999). Though broadcast restrictions initially limited the scope of advertising reach and
exposure, privileged speech protection eventually led pharmaceutics to the system that exists today,

with a glut of prescription drug advertisements featured in almost all major media.
Currently, the pharmaceutical industry is the seventh-largest advertised product category in the
United States (Kantar Media, 2017). Pharmaceuticals are the leading advertiser for U.S. magazines
(Tadena, 2015), and Nielsen estimates that prescription drug commercials air at a rate of 80 ads per
hour of TV programming. Perhaps most notably, prescription drug ad spending today in the United
States is often twice the spending on research and development (BBC, 2014).Today’s health
communication increasingly demonstrates a profit-driven orientation; leaving the public vulnerable to
commercial influence and market trends (Grantham, Ahern, & Connolly-Ahern, 2010; Jaramillo,


2006; Harnett, 2017).
Pharmaceutical powers arguably introduce unique hazards to public well-being, as the persuasive
strategies and induction techniques underlying direct-to-consumer advertisements largely inform the
social understanding of specific health issues. Ancient Greco-Roman philosophies seemingly speak to
the dubious nature of modern health messaging. As Plato explains in Gorgias:
Pastry baking has put on the mask of medicine, and pretends to know the foods that are best for the body, so that if a pastry baker
and a doctor had to compete in front of children, or in front of men just as foolish as children, to determine which of the two, the
doctor or the pastry baker, had expert knowledge of good food and bad, the doctor would die of starvation. (Plato, Kindle Location
3291)

Plato underscores the essence of pharmaceutical advertising, suggesting the beautification of
information merely impersonates that which is truly good for the soul.
Platonic virtues call attention to the moral impasses underlying recent health communication
strategies. In a manner that mirrors the mask of pastry bakers, Big Pharma arguably replaces the role
of primary physician and commercial rhetoric increasingly defines what it means to be “sick” and
what it means to be “healthy.” Indeed, studies show prescription drug advertisements can drive
demand for specific advertised drugs among consumers (Bell, Kravtiz, & Wilkes, 1999; Bell, Wilkes,
& Kravitz, 1999; Gellad & Lyles, 2007; Narayanan, Desiraju, & Chintagunta, 2004; Robinson,
Hohmann, Rifkin, Topp, Gilroy, Pickard & Anderson, 2004; Wilkes, Bell, & Kravitz, 2000), as well
as influence physician diagnoses and prescription patterns (Friedman & Gould, 2007; Gellad &

Lyles, 2007; Kravitz et al., 2005; Mintzes et al., 2002; Morris, Gadson, & Burroughs, 2007).
Furthermore, pharmaceutical messaging predominately focuses on product promotion (at the expense
of raising awareness for health issues), and the advertisements themselves most often appeal to
emotion-based reasoning rather than informed decision making (Frosch, Krueger, Hornik, Cronholm,
& Barg, 2007; Woloshin, Schwartz, Tremmel, & Welch, 2001).
Both modern research and Platonic dialogues seemingly speak to Big Pharma’s ability to entice
consumers into medical treatment “through no other art than the rhetorical” (Plato, Kindle Location
16294). Though scholars have examined prescription drug advertising in relation to doctor–patient
relationships (Murray, Lo, Pollack, Donelan, & Lee, 2004), public policy implications (Myers,
Royne, & Deitz, 2011), medical compliance (Manika, Ball, & Stout, 2014), drug choices (Mintzes,
Barer, Kravitz, et al., 2002), and patterns in message content/design (Macias & Lewis, 2003;
Sumpradit, Ascione, & Bagozzie, 2004; Young & Cline, 2004), experts in the field indicate a need for
more consumer-centric work that addresses the ultimate effects of pharmaceutical marketing in
relation to public interests (Royne & Meyers, 2008). Furthermore, while the literature on prescription
drug advertising is extensive, scholarly work on more subtle forms of for-profit health messaging is
not nearly as prevalent (Kim and Hancock, 2017).
As corporate agencies turn to less obvious means of commercial marketing, it becomes increasingly
necessary to examine public health knowledge as it relates to the “shadow of forms.” Accordingly,
we examine one particular case in which a pharmaceutical company and related media messaging
seemingly manufactured the reality of a relatively unknown health threat, as well as the recommended
product solution. Specifically, the following work details Merck Pharmaceuticals’ promotional
messaging for the Gardasil vaccination, and the role it played in cultivating public knowledge of the
human papillomavirus (HPV).


HEALTH ISSUE AT HAND
Today, one in four adults (approximately 80 million people) are infected with HPV. The virus is
currently the most common sexually transmitted infection (STI) in the United States (CDC, 2017), and
the National Center for Health Statistics indicates over 42 percent of Americans between the ages of
18 and 59 are carriers of HPV (Bakalar, 2017). The CDC further estimates that an additional 14

million people will become newly infected with HPV each year. The most abundant case of human
papilloma infection, HPV 16, positively correlates with number of sexual partners (CDC, 2012).
Such associative patterns suggest sexual activity elevates the risk of HPV exposure and infection.
Indeed, studies show relational proclivities account for the foremost predictive influence of HPV
infection (Janicek & Averette, 2001; CDC, 2012), and studies confirm all women and men are at risk
of HPV infection once becoming sexually active (CDC, 2012).
Alarming trends and documented research further demonstrate direct ties between HPV infection
and certain types of cancer (CDC, 2012). Over 70 percent of all cervical cancer cases, for example,
involve a strand of the human papillomavirus (CDC, 2011, 2012; NCI, 2017). While once named the
leading cause of cancer-related deaths for women nationwide, mortality rates are declining. Still,
cervical cancer accounts for 15 percent of female cancers; claiming roughly 266,000 lives per year
worldwide (International Agency for Research on Cancer, 2012). Though HPV commonly surfaces in
young women between the ages of 18 and 30, cervical cancer is more prevalent among females 35
and older, indicating delayed development of precancerous cells. Given that abnormal cervical cell
changes seldom generate symptoms, regular gynecological exams and Pap test screenings serve as
critical preventative health care behaviors (CDC, 2007). However, such measures are not guaranteed
to detect all precancerous lesions.
While there is still no cure for the human papillomavirus or cervical cancer, scientific discoveries
and medical developments continue to advance the field of prevention. Most recently, on June 8,
2006, the Food and Drug Administration (FDA) approved the world’s first preventative vaccination
for the human papillomavirus. American pharmaceutical company, Merck & Co, Inc., subsequently
developed the Gardasil vaccine for widespread distribution, ultimately providing a promising means
of prevention for the predicted 80 percent of sexually active women who are at risk of acquiring an
HPV infection by age 50 (Schwartz, 2006; CDC, 2008).
Merck’s HPV vaccination consists of a three-dose series issued over a period of six months (CDC,
2012). As such, inoculation requires both initiation (receiving the first vaccine dose) and completion
(receiving all three vaccine doses). Given that the vaccination is most effective when fully
administered prior to virus exposure, many physicians recommend discussing preventative behaviors
and vaccination treatments with girls (and now boys) as young as nine years old (Center for Young
Women’s Health, 2012). Therefore, Merck faced the unique task of promoting a recently approved,

three-dose vaccination for a sexually transmitted virus to the parents of preteens.
Within four months of receiving FDA approval for the vaccination, Merck released a national print,
television and online advertising campaign for Gardasil (Petersen, 2006). However, prior to the
company’s official campaign launch (in November of 2006), and even before receiving FDA
approval for the Gardasil vaccination (in June of 2006), Merck teamed up with nonprofits Cancer
Research and Prevention Foundation and Step-Up Women’s Network in an unprecedented,
multitiered social marketing campaign for HPV and cervical cancer. The initial phase in Merck’s
rollout effort (“Make the Connection”) introduced a largely overlooked public health risk (HPV) and


established its connection to cervical cancer. The succeeding message sequence (“Tell Someone”)
urged women spread their knowledge and tell someone about the connection between HPV and
cervical cancer. Merck then released “One Less” upon receiving FDA approval for the Gardasil
vaccination. Advertisements in this final campaign phase promoted a medical (and proprietary)
solution for the now widespread public health concern.
While Gardasil offered promising hope in the fight against HPV/cervical cancer, and though
Merck’s vaccine was the first of its nature, the company’s early awareness messaging sparked debate
over corporate intentions. Reports characterized the social marketing campaign as a commercial
effort that primed the market for Merck’s new vaccine (Serono, 2013). Critics also suggested Merck
strategically engineered the awareness push to gain market lead, as GlaxoSmithKline was working on
alternative inoculation developments (Herper, 2012). Though Merck insisted, “this campaign is part
of a broad and longstanding public health commitment to encourage education about the disease”
(Merck representative K. Dougherty in Schwartz, 2006), the prereleased messages prompted
accusations of deceptive marketing agendas.
Proactive health care measures (such as screening or inoculation) can significantly reduce HPVrelated cancer rates (Janicek & Averette, 2001; National Cancer Institute, 2016). Vaccination
initiation, however, ultimately depends on citizens’ understanding of HPV, cervical cancer, and the
Gardasil vaccine; as well as widespread public trust and consumer buy-in (Briones, Nan, Madden, &
Waks, 2012). Therefore, Merck’s ability to effectively communicate risk messages to key audiences
is inherently tied to overall inoculation aptitude. As such, the company’s communicative efforts invite
ample opportunity for discourse evaluation and theoretical discussion.

While the Gardasil vaccine itself is a popular topic in academic literature, most of the work attends
to a singular facet/issue related to the vaccination, such as mothers’ and doctors’ opinions of the drug
(Head & Harsin, 2016), teen girls’ reactions to the campaign (Vardeman-Winter, 2012), and Merck’s
interpersonal tactics (Whidden, 2012). We aim to provide a more multi-dimensional and macro-level
understanding of Merck’s groundbreaking vaccination, and the surrounding sociopolitical issues that
influenced public deliberation and inoculation discourse. Through collaborative data analysis, this
book attends to the shifting health communication models, and the means by which cervical cancer
and the human papillomavirus became a matter of public interest. The following section details the
rationale that drove our unconventional research approach and the methodological components that
informed this investigation.
MERGING METHODOLOGICAL PARADIGMS
More often than not, the principles of media research are packaged and presented through a two-sided
interpretation of methodological strategies. In the 1970s, communication science divided into two
schools of thought; splitting the field into “humanistic” and “scientific” paradigms. This fault line
formed clear alliances to “quantitative” or “qualitative” scholarship, and such commitments to a
specific research style continue to distance those in the field today. As the nature of academic
scholarship evolves, however, it becomes increasingly important to assume a balanced, integrative,
and pragmatic investigative approach to research. As Johnson and Onwuegbuzie (2004) note,
Today’s research world is becoming increasingly interdisciplinary, complex, and dynamic; therefore, many researchers need to
complement one method with another, and all researchers need a solid understanding of multiple methods used by other scholars to
facilitate communication, to promote collaboration, and to provide superior research. Taking a non-purist or compatibilist or mixed


position allows researchers to mix and match design components that offer the best chance of answering specific research questions.
(p. 15)

Attending to this call for merged methodological progression, we unite the tenets of critical cultural
research with the methods of positivistic scholarship.
Chapters throughout this book integrate textual analysis, interviews, focus groups, and eye tracking
observation to create an informed account of the assorted influences driving public perception of

commercialized health messaging. Though data triangulation does not ensure truth or certainty, it is
recognized as a strategy that adds depth, richness, breadth, and rigor to scholarly investigation
(Denzin & Lincoln, 2000). Therefore, we use a wide range of investigative tools as we examine the
dynamic interplay between public messaging, for-profit health communication, and consumer
expectations.
Our grounded analysis unites modern marketing research with principles of message reception and
social trust, offering a contemporaneous account of corporate medicalization and pharmaceutical
consumerization. Though methodologically distinct and issue-oriented, each chapter of this book
concentrates on the means through which Merck Pharmaceuticals arguably commercialized cervical
cancer to promote the Gardasil vaccination. Through triangulated data, we provide a multifaceted and
more balanced account of the sociocultural, political, and economic significance underlying the
corporatization of public health communication.
Perhaps more broadly, the following work outlines ways in which pervasive health messaging often
serves corporate interests and can threaten consumer health information in a free market enterprise.
Channeling Lippmann’s (1922) concern for the pseudo environment in which society operates, we
delve into the commercialized networks driving health care communication to illustrate corporate
influence in public health messaging. The following chapter sets the stage for our book, as it
introduces the interconnected players and events that shaped the fruition of this manuscript.


Chapter Two

An American System of Pharmaceutical
Influence
Mass communication promotes an understanding of the creation, exchange, and interpretation of
human messaging. Research suggests the ways in which people verbalize and relay experiences to
others ultimately constructs human experiences and forms social realities (Carey, 2009; Littlejohn &
Foss, 2005). Unfortunately, in today’s age of immediacy, information is often communicated through a
radically distorted lens. The “truth” undergoes significant misrepresentation, in which “the complex
is made over into the simple, the hypothetical into the dogmatic, and the relative into an absolute”

(Lippmann, 1955, p. 27). In combination with app-driven packaging, political agendas and
competitive markets pollute the foundation of public information, making it all the more difficult for
the general public to obtain a full and accurate account of the issues at hand.
This chapter demonstrates the challenges of both relaying and consuming health information that is
free from special interests, hidden agendas, or strategic issue framing. Specifically, we provide an
account of the separate yet interconnected events that built the HPV/Gardasil narrative and shaped
public understanding of the health issue. The following section illustrates ways in which this case is
ultimately a microcosm of the overall system. Each component and specific event speaks to the
changing nature of health communication in the United States and the implications of commercial
influence in the public health field.
MERCK AND THE MEDIA
Merck’s unique corporate history offers numerous examples of how industry influence and related
media reporting can dramatically shape the nature of health information. The company’s story begins
(or at least, first enters the media scene) in 1981, with a strategic ad placement in Reader’s Digest
for Pneumovax, a pneumonia vaccine (Ventola, 2011). Though a seemingly ordinary event, the ad
purchase later defined an epic moment for the pharmaceutical industry and American capitalism, as it
marked the birth of direct-to-consumer advertising in the United States (Abel, 2006).
Roughly two decades after initiating what is now a pervasive advertising trend, Merck
Pharmaceuticals made nationwide headlines once again for matters directly related to its pioneering
role in prescription drug advertising. In September 2004, reports surfaced linking Merck’s top-selling
anti-inflammatory drug, Vioxx, to more than 27,000 product-related deaths (MSNBC, 2004). Experts
suggested that between the Food and Drug Administration’s (FDA) approval of Vioxx in 1999 and
initial negative media coverage in 2003, approximately 27,785 cases of sudden cardiac arrest could
have been prevented through alternative arthritis treatments and medications (Associated Press,
2004). Merck soon faced millions of dollars in legal costs, stemming from over 24,000 plaintiff
lawsuits (Huh & Becker, 2005). With media pressure mounting, Merck voluntarily withdrew the
arthritis treatment, prompting a 27 percent drop in company profits (equivalent to $26 billion in


market value) (Masters, 2004). In the end, authorities criticized the FDA for not taking appropriate

action. Reports indicated the agency failed to operate in the interest of public health, and further noted
the rise of Vioxx was ultimately due to “masterful public relations, aggressive marketing, and
ineffective regulation” (McDougall & Popat, 2010, p. 898).
The FDA’s involvement in pharmaceutical advertising regulation may seem somewhat
counterintuitive (especially given the roles of other federal agencies more directly tied to the U.S.
media system); however, the executive department gained full authority over prescription drug
labeling and advertising after passing the Kefauver Harris Drug Amendment in 1962. This amendment
positioned the FDA as the chief watchdog agency for all communications involving drug messaging
(Boden & Diamond, 2008). Therefore, though the Federal Communications Commission (FCC)
regulates most broadcast messaging and the Federal Trade Commission (FTC) polices advertising
accuracy, the FDA maintains complete jurisdiction over the release and marketing of pharmaceutical
medications (Beales & Muris, 1993). Scholars suggest the FDA’s independent regulatory role in the
pharmaceutical market warrants concern (Beales & Muris, 1993; Breton et al., 2007), as
pharmaceutical companies largely subsidize the agency’s annual budget. Given that conflicting
political and public interests inherently underlie core administrative operations, experts recommend
stronger watchdog focus on policy strategies.
Indeed, numerous U.S. legal proceedings document the FDA’s role in the industrialization of directto-consumer health messaging. In 1983, for example, the FDA publicly acknowledged that
prescription drug advertising failed to serve public health interests and even issued a brief
moratorium on direct-to-consumer marketing. However, the agency lifted the ban two years later,
indicating standards of “fair balance” (i.e., including both the risks and benefits of a drug) and “brief
summary” (addressing every risk in the product’s labeling) adequately protected informed decision
making (Ventola, 2011). Despite heavily documented concerns, the FDA once again further extended
pharmaceutical advertising protection near the turn of the 20th century (Cohen, 1988; Murray et al.,
2004), approving the use of radio, television, and internet for prescription drug marketing (Perri &
Nelson, 1997).
During the wake of Merck’s Vioxx controversy (which followed shortly after regulation
relaxations), both the FDA and the extended pharmaceutical advertising allowances fell under heavy
scrutiny. Critics called for stricter regulations, and the lax standards framing prescription drug
advertising prompted government leaders to issue their own policy recommendations (Saul, 2005;
Hirson, 2005). In 2004, U.S. Senate Majority Leader Bill Frist encouraged pharmaceutical

manufacturers to wait two years before advertising new drugs (Melillo, 2005). Despite being the
catalyst for such legislative intervention (Donohue, 2006), Merck seemingly ignored Frist’s
recommendations and moved forward with what appeared to be a strategic teaser campaign for the
company’s highly anticipated breakthrough vaccine.
While awaiting FDA approval for the Gardasil vaccination, Merck teamed up with nonprofit
agencies (the Cancer Research and Prevention Foundation and Step-up Women’s Network) and
proactively released a social marketing campaign that primed awareness for HPV and cervical
cancer. In two nationally televised public service announcement-style television campaigns (titled,
“Make the Connection” and “Tell Someone”), Merck released several different 60-second
commercials to urge women to “make the connection” between HPV and cancer and then for women
to “tell someone” about the health threat. More specifically, Merck introduced the deadly link


between HPV and cervical cancer in “Make the Connection.” The company remained in close contact
with audiences, quickly releasing the follow-up, “Tell Someone” campaign. This stage of
promotional messaging statistically emphasized the percentage of women who are unaware of the
threatening viral infection, and encouraged listeners to spread awareness to help prevent further
transmission. Fashioning a finish to what some suggested was a product endorsement operation,
Merck then offered viewers a solution to the well-publicized social crisis. The company presented a
call to action in the concluding tier of the social marketing effort, encouraging viewers to “get
vaccinated” to become “one less” statistic. The final phase suggested the “big picture,”
communicating the vaccination’s potential ability to freeze current cervical cancer statistics and
inoculate uninfected females.
The unique nature of Merck’s Gardasil campaign positions this case as one unlike any other.
Seemingly, the company’s messages fall into the category of “help-seeking ads”; defined by a
collection of health agencies (which include the FDA, the U.S. Department of Health and Human
Services, the Center for Drug Evaluation and Research, the Center for Biologics Evaluation and
Research, and the Center for Devices and Radiological Health) as disease awareness
communications, “that discuss a particular disease or health condition, but do not mention any
specific drug or device or make any representation or suggestion concerning a particular drug or

device” (FDA, 2004, p. 1). Though the description fits, the FDA indicates ads that fall within this
category should provide relevant/pertinent health information that encourages consumers to seek
appropriate treatment or engage in behavioral/lifestyle changes (FDA, 2004). At the time of the
campaign release, however, Gardasil had not yet received FDA approval and Merck’s awareness
messages focused little attention on preventative behaviors, such as abstinence, safe sex, or
screening. Therefore, preemptive campaign efforts drove social consciousness of HPV and its
connection to cervical cancer, but did little to promote self-efficacy.
Immediately upon receiving FDA approval, however, the pharmaceutical company targeted the U.S.
market in full force. In addition to releasing two more direct television campaigns, “One Less” and “I
Chose,” Merck heavily lobbied for nationwide mandates requiring HPV immunization. Starting in
Texas, the company gradually began to monopolize state-ordered vaccinations (Schwartz, 2010).
Inoculation requirements offered Merck an opportunity to regain secure financial standing, as the
company was still recovering from Vioxx-related litigation costs (Krumholz & Beckel, 2011). Media
reports further speculated that the immunization push allowed Merck to position itself ahead of
GlaxoSmithKline; a pharmaceutical company likely to jeopardize Merck’s vaccination monopoly
with its impending alternative inoculation, Cervarix (Forbes, 2012).
Regardless of intentions, Merck’s strategy was effective. By 2007, and less than one year after
Gardasil received FDA approval, 23 states and Washington, DC, had introduced vaccination
legislation (NCSL, 2013). Merck recently continued its lobbying focus, providing substantial
contributions to influential agencies such as the U.S. Chamber of Commerce, the Business Roundtable
and the Pharmaceutical Research and Manufacturers of America.
Though Merck succeeded in its government petitioning, pre-FDA-approval marketing efforts and
politicalized messaging prompted serious allegations against the company. Vioxx-related civil suits
and legal hearings also cast a shadow on Merck’s corporate integrity. Despite being held largely
responsible for this event, in a 2001 report, the FDA did publicly condemn Merck for releasing
misleading claims in relation to Vioxx, maintaining that Merck failed to sufficiently address the


drug’s risks in the safety data submitted to the FDA. Additionally, the FDA charged Merck with
misrepresenting potential health threats in the promotional material for Vioxx that was distributed to

both doctors and consumers (Business Wire, 2006).
As part of the settlement terms, Merck signed a corporate integrity agreement, pledging to carefully
monitor future product marketing. However, as we argue throughout this book, the company seemingly
continued to draw upon questionable advertising strategies in its marketing approach for the Gardasil
vaccination. We particularly focus on the ethical foundation of Merck’s campaign as it relates to
commercialized awareness messaging and product-driven social marketing.
COMMERCIALIZING SOCIAL AWARENESS
Whereas direct-to-consumer advertisements promote prescription products to the general public
through profit-driven messaging (Bradley & Zito, 1997), social marketing campaigns “aim to
influence human behavior in order to improve health or benefit society” (Kotler and Levy, 1969, p.
98). In other words, these awareness efforts use the standard principles of marketing to prescribe
pro-social behavioral patterns rather than market an actual product. The messaging approach is
specifically structured to disseminate information that promotes self-efficacy (through messages that
inform, motivate, and train audiences) to drive larger-scale societal changes (Bernays, 1928; Moore
& Greenwood, 2005). Merck followed the social marketing model, delivering messages that intended
to boost credibility, target salient beliefs, and motivate vaccination-seeking behaviors. However,
while most social marketing efforts aim to change a negative behavior (or “sell” people on pro-social
behaviors), Merck’s campaign did not focus on the positive behavior of safe sex to avoid contracting
HPV. Instead, messages promoted the behavior of vaccinating yourself (or a loved one) with Gardasil
to avoid contracting HPV.
While social marketing in the health care industry promotes an overall increase in consumer
awareness, patient education, and medical discussion, current industry trends pose a threat to message
reception and communication efficacy (Liang & Mackey, 2011). More often, the burgeoning and
increasingly invisible commercialized structuring of health care efforts compromises the nature of
public health information and social awareness campaigns. Indeed, the rollout campaign for Merck’s
Gardasil vaccination shows a trajectory in which the company gradually transformed cervical cancer
discourse into inoculation rhetoric.
Given the sensitive nature of the HPV health issue and the target market for the vaccination (young
girls), Merck needed to strategically reach household decision makers to abate vaccination
resistance. Early messaging efforts appeared to be public service announcements, with prominent

sponsorships showcasing the support of several worthwhile sounding nonprofit organizations.
Merck’s branding, as we will illustrate in coming chapters, was comparatively inconspicuous,
leaving non-discerning viewers with the impression that they were being presented with independent
health messages. Essentially, the company promoted Gardasil and its association with an HPV-free
life through a strategic roll-out campaign that spread awareness, cultivated concern, and, eventually,
generated product demand.
Keep in mind that Merck’s HPV vaccination not only provides medical utility to those at risk, but
perhaps equally important, it extends opportunities to establish the connection between HPV and
cervical cancer. However, if the controversy surrounding Merck’s involvement in the awareness
campaign compromises public trust, it becomes a lose–lose situation for both Merck Pharmaceuticals


and the public health initiative. Promotional efforts for the HPV social awareness campaign highlight
the dubious nature of corporate influence in health messaging.
Health communication research indicates the level of consumer trust in vaccination messaging
influences information-seeking behaviors (Nan & Madden, 2012; Manika, Ball, & Stout, 2014).
Research further shows health awareness efforts that clearly and directly communicate causes of
disease onset oftentimes facilitate extensive prevention (Janicek & Averette, 2001). Such literature
suggests that, despite being the first to market with an HPV vaccine and securing numerous statewide
mandates, Merck has had mixed success with its campaigning; as recent figures place vaccination
rates at only 50 percent of the target population, and 35 percent among boys, despite widespread
promotion and a competing product in Cervarix (Crane, 2014).
Merck’s promotional canvass for the Gardasil vaccination highlights ways in which corporate
agendas can threaten consumer trust in public health campaigns. Throughout the years, Merck has
demonstrated a commitment to disease and vaccine awareness through its longtime involvement with
various educational organizations. The pharmaceutical company also separately supports disease
education through multilingual awareness programs, and reaches broad and diverse audiences through
grant funding for national and local organizations that circulate medical information (Merck
Pharmaceuticals, 2007; 2017). Despite praiseworthy corporate missions, however, the circumstances
surrounding Merck’s product promotion gave rise to suspicion over vaccination discourse and related

awareness messaging (as noted in earlier examples of media reporting).
Bear in mind that Merck’s marketing approach is not uncommon among the pharmaceutical sector.
Because of the latest adjustments in direct-to-consumer advertising policies, and in light of today’s
epochal interest in public policy issues, corporate agencies often assume social marketing approaches
to product promotion (Bosworth, Pardun, Taylor, & Taylor 2009). As consumers grow more mindful
and sensitive to corporate influence, however, the implications of commercial interests intensify.
Davidson and Novelli (2001) speak to issues of corporatized health messages and public cynicism,
explaining,
Society expects and accepts that business will promote its goods and services toward the end of making a profit. It is confusing and
skeptical, however, when business ventures into the area of social marketing to promote the improvement of social good by changing
behavior. This leads to an increase in the already worrisome level of cynicism about, and distrust of, business. (p. 90)

Considering the far-reaching and widespread messaging capabilities of the new millennium, mixedmodel advertising1 makes it evermore necessary to understand the implications of profit-driven health
care messages.
Advertising in the digital realm is becoming harder to recognize, and the differences between
editorial content and persuasive messaging are difficult to ascertain in today’s news feed-dominated
environments. Native advertising, by its very name, is meant to blend into whatever platform on
which it is placed. Commercial messaging in social media platforms is often paid messaging without
disclosure that money has changed hands. In fact, Facebook, the most dominant social media platform,
ensures through its algorithm that branded editorial messaging will not be widely distributed in the
Facebook environment without the “boost” of an advertising expenditure.
The recent rise in media capabilities, combined with the extensive latitude of corporate liberties,
make the commercial increasingly indistinguishable from the noncommercial (McChesney, 2000;
2013). These blurred boundaries bring into question current understandings of public awareness
campaigns, nonprofit messaging, and corporately sponsored cause-related marketing. Merck’s


exemplary model of blended health campaigning provides a rich foundation for examining the social
implications of commercialized health care messaging. Connecting modern medicine to questionable
industry trends, the question raised here is not whether Merck’s awareness efforts satisfy social

marketing standards (as a review of literature clearly shows it does), but rather, whether the
company’s marketing strategy is appropriate, or even ethical, in the health care arena.
Though patterns in public health communication increasingly tend toward profit-driven interests
(Jaramillo, 2006), commercialized social marketing is, surprisingly, an under-examined topic. By
deconstructing cases of for-profit health communication, scholars and practitioners can more
effectively consider how corporate agencies construct certain realities for health care consumers. As
such, this book looks at the commercial use of social marketing as it relates to public trust in health
communication. Through both rhetorical and empirical analysis, we will illustrate the thin line
between helpful health information and disguised forms of advertising. Social cognitive theory, as
outlined in the following section, guides the interpretations and arguments we pose throughout this
work.
THEORETICAL FOUNDATION
Social cognitive theory (SCT) is largely recognized as the foundational framework from which to
examine symbolic modeling, individual action, and societal trends (Bandura, 1986). The theory
speaks to media’s influence on personal agency, and the psychosocial influence of commercial
messaging. In demonstrating how information processing mediates human behavior, social cognitive
theory frames how effective message design can motivate positive responses. As such, the theory’s
multidimensional scope fosters opportunity for critical evaluation of the promotional strategies that
drive consumer behavior.
Encompassing cognitive and behavioral ideologies, social cognitive theory addresses personal
agency in terms of vicarious, self-regulatory, and self-reflective processes (Bandura, 1991). The
theoretical framework outlines human performance in the context of socio-structural influences in
which cognitions, behavioral patterns, and social surroundings operate as a bidirectional network of
interacting determinants (Bandura, 1994). More simply, SCT recognizes individual cognition as the
locus for information reception and processing, while simultaneously acknowledging the influence
individuals have over each other (Anderson, 1996; Bandura, 1986).
Albert Bandura (2001), the founder of SCT, suggested that external influences, such as social
approval and disapproval, operate as a source for self-pride/censorship and therefore, often
prescribe human behaviors. By relating to another person, whether it be through direct interactions or
parasocial connections, human beings can convert vicarious observations into personal life lessons

and positive decision making. Bandura’s seminal work on social cognition is particularly applicable
to health care messaging, as it offers a platform for understanding interconnections among vicarious
learning, self-efficacy, and individual action (Bandura, 1986).
Early in his career, Bandura (1977) stressed the power of behavior modeling and vicarious learning
experiences, suggesting:
Learning would be exceedingly laborious, not to mention hazardous, if people had to rely solely on the effects of their own actions to
inform them what to do. Fortunately, most human behavior is learned observationally through modeling: From observing others one
forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action. (p.
213)


This notion offers insight to personal agency in the context of advertising’s cultural influence.
As technological advancements of the 21st century intensify the reach of symbolic modeling,
audiences are increasingly exposed to and dependent upon vicarious learning. Therefore, social
mores are largely transmitted through mediated experiences. Bandura’s seminal work provides a firm
foundation for which to explore ways in which media and industry work in tandem to cultivate norms
that promote commercial interests.
The power of commercial advertising operates under the understanding that message modeling
guides knowledge and skill into a positive course of action (Bandura, 1997). Indeed, direct-toconsumer marketers often capitalize on the tenets of social learning, creating models and symbolic
environments that promote “proper” or “ideal” health care behavior. SCT therefore offers insight to
the relational, identity, and instrumental goals that pharmaceutical companies often appeal to in
product messaging to drive consumer behavior (Young, Lipowski, & Cline, 2005). Bandura’s work
speaks to the ways in which media content (including product advertising) defines social norms and
cultivates socially acceptable behaviors. As such, SCT provides a strong philosophical framework
for which to examine the underlying dynamics that shape public health communication.
Innovative marketing strategies and recent communication trends make it necessary for researchers,
medical practitioners, and industry professionals to understand the relationship between commercial
influence and consumer trust in the context of public health. Ivan Preston (1974) examined the
relationship between branding and trust extensively; developing a research agenda that largely
focused on exposing consumer deception. The scholar believed that any form of mass communication

essentially boiled down to an attempt at persuasion, suggesting that if communicators are not trying to
influence behaviors or responses, they are at least trying to assure the audience that they are credible,
dependable, and trustworthy (Preston, 1969). His work demonstrates the practical application of
theoretical concepts in relation to commercial health messaging.
Indeed, rhetorical scholarship often positions audience value judgments at the heart of successful
communication, promoting a framework that guides the development of many advertisements and
promotional campaign trends (Foss, Foss, & Trapp, 2001). Message design must contain a means of
influencing the audience to “believe” for successful persuasion to occur (Preston, 1969; Root, 1987).
Research indicates specific viewer behavior is socially context-dependent, and that advertising
effectiveness largely depends on the messenger’s ability to effectively exploit the conative power of
signs (Messaris, 1997). By understanding the psychological and sociological origins of the intended
audience, campaign engineers can better discriminate between various arguments, employing only the
claims that a specific audience is most likely to understand and accept.
Rapid changes in digital, social, and mobile media drastically transform the means of message
diffusion, calling attention to the dual paths of message influence and its role in the social
construction of reality. As more media content moves into the realm of social media platforms, which
is supported by hybrid and even misleading forms of paid media content (such as native advertising),
the sanctity of health information and its importance to the public at large becomes more and more at
risk.
Scholars can better understand the social construction of public health issues through detailed
examination of the persuasive strategies and induction techniques in public health campaigns.
Accordingly, the next chapter introduces an educated interpretation of how Merck’s campaign
prescribed social meaning for HPV, cervical cancer, and the Gardasil vaccination. We turn to the


principles of persuasion as we dissect the visual and verbal nuances of Merck’s campaign messages;
and we adopt an interpretive lens as we consider the audience-specific motivators threaded
throughout marketing efforts. Chapter 3 establishes the foundation for our overall body of research
and introduces the larger issues at stake.
NOTE

1. Mixed-Model advertising is defined throughout this work as a blend of public health messaging and product advertising.


Chapter Three

Deconstructing Merck’s Awareness Campaign
In this chapter, we will turn our attention to the actual content Merck produced, not only to legitimize
Gardasil prior to FDA approval, but also to promote the vaccination further at product launch and
beyond. To better understand ways in which media/commercial messaging actively influences the
cultural construction of audience worldviews, it is necessary to first address ways in which viewers
make meaning out of “texts.” A “text” is a cultural product that informs one’s sense of environment
and surroundings circumstances. More simply, it is something from which humans make meaning
(McKee, 2001; 2003). The American media system, as we noted earlier, exists in a dual-product
marketplace; it is a powerful social educator with profit-driven interests. Therefore, advertisersupported content and commercial “texts” fuel citizen norms, values, and understandings. Though
media undoubtedly influence shared meaning, both the producers and consumers of content often
choose message frameworks unconsciously (Hall, 1976). Textual analyses help illuminate the latent
nuances that often go unnoticed through casual content exposure.
More specifically, methods of textual analysis provide a toolkit for systematically breaking down
the signs, codes, and rules that cultivate these worldviews (Stern, 1996). Much like a backwards
approach to puzzle solving, textual analysts break apart message units to develop a clearer
understanding of the smaller pieces of communication. By searching for reoccurring patterns in style,
imagery, and tone, and studying the periodic shifts in commercial rhetoric, textual analysts can
“discover intelligible patterns in the development of the art that otherwise may appear whimsical,
haphazard, arbitrary, or merely verbal” (Buchanan, 2001, p. 183). The research method offers critical
insight to persuasive texts, and is therefore particularly relevant to the question at hand, which asks
how Merck Pharmaceuticals facilitated viewer sense making of HPV and the Gardasil vaccination.
In the following section, we examine the visual and verbal nuances underlying Merck’s ads, and
discuss the audience-specific motivators integrated throughout the awareness-turned-product
campaign. By analyzing text composition and dissemination, we put forth an interpretation of the
ideologies that informed Merck’s marketing efforts. Social cognitive theory, combined with the

principles of persuasion, frames our systematic investigation and subsequent reading of campaign
messages.
MESSAGE DECONSTRUCTION
Effective advertising engineers semantic relationships (between signifier and signified, image and
product) to ensure particular meanings are conveyed and received. For that reason, textual analyses
address matters related to both message production and audience reception to better interpret the
political and cultural significance of a particular commercial artifact (Curtin, 1995; Balasubramanian,
1994). Relating ad deconstruction to, “the peeling of an onion in that it is taken apart layer by layer,”
Frith (1998) suggests that, “moving from the surface message to the deeper social meaning allows one
to decode images using a comprehensive system of interpretation” (p. 113). Therefore, only after


peeling back the layers of Merck’s campaign, can we begin to understand the company’s role in
engineering public understanding of HPV and cervical cancer.
Merck’s social marketing approach for the Gardasil vaccination provides a unique platform for
textual investigation, as the three-tiered campaign seemingly pioneered a new model of health care
marketing. In examining and deconstructing that which is both said and unsaid in campaign messages,
we put forth a range of reasonable interpretations regarding the cultural implications of Merck’s
commercialized awareness messages. While Stewart Hall’s framework loosely structures our
interpretations, we adopt the postmodern belief that “there is no one ‘right’ way to read a text”
(Silverman, 2004, p. 27). This reading is just one understanding of the nuances underlying Merck’s
social marketing effort; we do not presume it to be the only, the best, the most comprehensive, or even
the most accurate. We further suggest it is unproductive to measure our reading against other possible
interpretations, as we see this text through a lens that is colored with our own unique experiences,
perspectives, and interpretations.
Campaign Overview
Merck worked with advertising agency DDB and public relations firm Edelman (Siers-Poisson,
2007) to carefully craft a multistage “think-feel-do” campaign; which ranged from subtle
informational cognitive messaging to establishing preliminary product need, to the more affective
resonance content aimed directly at the common emotions and feelings shared between mothers and

daughters, and finally moving to the hard sell in the final stages of the campaign. As we noted earlier,
the company first initiated the HPV conversation in September 2005, one year prior to receiving FDA
approval for the vaccination. Through Merck’s financial contributions, the Cancer Research and
Prevention Foundation and Step-Up Women’s Network managed the first phase of awareness
messages in the “Make the Connection” campaign. These messages introduced the link between HPV
and cervical cancer. Soon after, Merck launched a follow-up “Tell Someone” campaign, which
bridged the campaign’s cognitive and affective stages by emphasizing the reality of HPV infection and
encouraging viewers to spread awareness. Then, on November 13, 2006, one year after initiating
public mindfulness, Merck launched its final conative campaign phase, “One Less.” This segment
completed the company’s social marketing initiative with a product advertisement for the Gardasil
vaccination.
Though Merck’s campaign rolled out over a series of three phases, the marketing initiative
essentially breaks down into two major components. The opening communication consisted of
unbranded, public service announcement-type messaging, fitting into a category of informational
“disease awareness/education” or “help-seeking” ads. Once Merck received FDA approval for
Gardasil in 2006, the company redirected its focus toward more emotional branded, direct-toconsumer advertisements; pushing its product as a means for HPV protection. This chapter
deconstructs the ways in which Merck’s commercial text seemingly aimed to spread public
awareness, motivate personal vaccination, and influence an HPV-free life through product promotion.
In line with Stuart Hall’s method of campaign analysis, we identify categories of “taken-forgranted” commercial meaning through a “long preliminary soak” of Merck’s campaign messages.
After addressing latent themes, we attend to the overlapping structures of meaning, place the work
within the context of message production and consumption, and relate our findings to the larger social
context. Our textual analysis begins with a detailed account of each campaign phase and commercial