The media coverage of the 1992 dispute over regulation of silicone breast implants, devices suspected of causing autoimmune disorders and neurological diseases, became in itself a part of this bitter controversy. Many physicians were angry at the coverage, accusing journalists of projecting their personal opinion, of irresponsible sensationalism, of jumping to conclusions without listening to experts. They blamed the media for creating unnecessary fear. A review of this case suggests some of the dilemmas involved in risk communication.
Media reports on the breast implant controversy were influenced by several factors that more broadly characterize risk events. First, despite Food and Drug Administration (FDA) mandates requiring that the device be systematically tested, no adequate data were available. The Advisory Panel, meeting in 1992 to assess the risk had to make decisions about regulating the implants mainly on the basis of anecdotal evidence and individual testimony. The media also had to rely on these anecdotes.
Second, many dimensions of the risk from implants were complex, controversial, and poorly understood. Scientists themselves did not fully agree about the nature and extent of risk. Were the cases of leaking silicone aberrant or inevitable? Were the damaged implants defective or would all implants eventually fail? What was the effect of silicone on the body? Were the reported cases simply anecdotes from women seeking money from malpractice suits, or were there significant patterns? In light of the debates over these questions, who were reporters to believe?
Third, like so many questions of risk, this issue was socially and politically controversial. In the deregulatory climate of the Bush Administration, David Kessler as an activist FDA commissioner, was an anomaly, and, in an election year, a publicized risk controversy was threatening. Moreover, the issue became a media event at a time when the American medical profession was under attack for its neglect of the diseases of women. A National Institutes of Health initiative to remedy the situation had called public attention to the history of this neglect, creating awareness of the problems of using a device on women that had never been adequately tested. The case also followed the much publicized dispute over the Dalkon Shield. The risk of silicone breast implants, then, became one more issue in a parade of uncomfortable incidents.
Finally, the reporting of the risk of silicone breast implants, was bound to have a direct and immediate effect on the behavior of women. Some use implants for breast augmentation -- that is, for cosmetic surgery that some regard as frivolous, but others as essential. Implants are also used as reconstruction after mastectomy, and are considered essential for the psychological and even physical recovery of cancer patients.
Like so many risk disputes, the reporting of the silicone breast implant controversy took place in a context of technical uncertainty and political controversy about social and clinical implications. The complaints of physicians about overblown media reports resembled those of a chemist some years ago who accused the press of reporting that modern technology is poisoning America. "If there is any poisoning of America going on, it is not chemicals that are the culprit, it is the media which seem intent on burying us in purple prose -- a sort of verbal poison. Journalists have helped to create crises where none exist (the cancer epidemic), have blown out of proportion legitimate stories (Three Mile Island) and avidly hunted for crises to come (acid rain)."
The physicians' irritation with the media reports reflected the controversial implications of risk reporting. By their selection of news, journalists set the agenda for public policy. They can point the finger of blame -- in the implant case towards the product manufacturer -- and imply responsibility for remedial action. They can define an issue as an urgent problem or reduce it to an aberration. By creating public issues out of particular events, the media can force regulatory agencies to action simply out of concern for public image. The media interest in the drama of the silicone breast implant controversy was important in encouraging the appointment of a commission to decide on regulation.
Through their disclosure of new discoveries the press can also affect consumer behavior. We know this from many cases. After extensive media reports on the dietary studies relating cholesterol-producing foods with heart disease, consumption of beef, eggs and fatty milk products declined. Similarly, the media attention to the risks of the silicone implants have greatly increased the use of saline implants though this is a far more complex and costly procedure.
Given the impact of reporting, control over the information and images, the values and views, the signs and symbols conveyed to the public are understandably a sensitive issue. Industries, political institutions, professional groups and aspiring individuals all want to manage the messages that enter the cultural arena. Public relations efforts are a growing aspect of every field of science, technology and medicine, but they are most elaborate in the promotion of dramatic medical interventions, promising new discoveries or therapeutic techniques. Recall the extraordinary publicity over the artificial heart, promoted as a "revolutionary development," a miraculously effective solution for heart patients, a medical milestone.
Sometimes firms try to market products by defining them as newsworthy discoveries. Silicone breast implants had been widely promoted by the company and by some private physicians as a panacea for women who, for reasons of vanity, or for post operative reconstruction, were extremely vulnerable to such sell. This, however, was hardly the first instance of such promotion. In the 1970's physicians and drug firms promoted estrogen replacement therapy by claiming it would reduce the biological effect of aging. Promotional materials on estrogen were designed to attract the press, which was, of course, attracted in any case to stories on a therapy that promised eternal youth. Thus news articles on estrogen replacement therapy were headlined: "Science Paints Bright Picture for Older Women." Eager for copy, journalists uncritically accepted the claims of interested experts who debunked the growing set of studies that suggested a relationship between estrogen and endometrial cancer, well after the FDA issued warnings to that effect. The press uncritically cited estrogen proponents who dismissed the concern about risk: "When we drive down the freeways, we take a risk."
Drug companies use "science-based press agentry" to market their products, in effect pushing products as newsworthy discoveries. Lilly's arthritis drug, Oraflex, was initially marketed this way as the firm's public relations office sent out press kits promoting the drug as a scientifically proven way to relieve arthritis. When the media covered the product as science news, in prescriptions increased from 2,000 to 55,000 a week. Twelve weeks later, a report showed its harmful side effects and it was withdrawn from the market. Similarly, silicone breast implants had been marketed for many years without significant testing despite uncertainty about long term risks. In the course of investigation, Dow-Corning admitted misleading the FDA and the public about its data on the possible problems of implants, and other companies had not collected data at all. Meanwhile, the media encouraged the use of implants by playing up to women's concerns about image and capitalizing on the belief that large breasts mean sex appeal.
Just as the media have been used as a tool to market new products by defining them as scientific discoveries, so there are efforts to manage the media's reporting of risk from technologies. Efforts to control the communication of risk was evident in the nuclear industry's use of the media to project positive images of nuclear power to allay public fear. The chemical industry employs similar strategies, using scientific expertise in their public relations as a means of damage control in risk disputes. So too in the silicone implant controversy, both the industry and the women who suffered disorders from the implants engaged both scientific experts and public relations practitioners to support their conflicting claims.
Journalists are vulnerable to such public relations strategies, for they are constrained by intense competition, tight deadlines, limited budgets and the need to cover complex and often technical material within limited space and time. Pressed for time, they are inclined to rely uncritically on material that is conveniently packaged by public relations staffs. This gives an unusual degree of power to those sources best organized to provide facts in a manageable and efficient form. Thus institutions skilled in organizing timely and lucid material have considerable influence on the media. Though ambivalent about public relations and aware of efforts to subordinate journalism to private interests, journalists are still influenced by it -- a fact which prompted Upton Sinclair to define journalism as "a business in the practice of presenting the news of the day in the interest of economic privilege."
By now, with 20 years of experience in risk reporting, reporters approach the subject with greater independence and, indeed, a certain cynicism about corporate behavior. The silicone implant fiasco followed on the heels of a series of cases in which companies have been found to obfuscate known risks -- for example, the risks of asbestos, of dioxin and of cigarette smoking. Investigations, sometimes by journalists, had uncovered many cases of products that were marketed even when known to be harmful.
Reporters are especially skeptical of the increasing pressures from science-based institutions: "I get calls from Dr. Knowledge, the world's leading authority on X disease or Y technology, who is also president of Z society." They refer to "pesky PR types," or "the flacks." Irritation is not limited to corporate public relations. "They're all grinding the same axe, from breakthrough university to wonder pharmaceuticals to the National Institute of Nearly Cured Diseases."
The physicians' anger at the media coverage of the risks of silicone breast implants reflect less the actual content of the media coverage than the broader tensions between the medical and journalist communities. These groups hold fundamentally different views on the appropriate behavior and role of journalism. First, there are differences in judgments about what is news. In the medical community, research results become reliable and therefore newsworthy through the endorsement of professional colleagues. Research findings are provisional -- and therefore not newsworthy -- until certified by peers to fit into the existing framework of knowledge. The physicians could not see this issue as newsworthy because there were no adequate data, and without such data they felt that no public judgments should be made about risks and how they should be balanced against the benefits to their patients. They did not regard the testimony of individual women who had been harmed by the devices as news. As one critic put it starkly: "Distraught women are not news."
A related source of tensions concerns when to release information to the public. In the case of suspected risk, how much evidence is necessary before informing the public? How certain must the evidence be? How much scientific consensus must there be before problems or potential problems are widely disclosed? Are there situations when reporting risk may cause unnecessary panic or counterproductive behavior when nondisclosure of risks would be desirable? Most journalists believe that risk data should be promptly available to the public. But the doctors, facing patients who were even reluctant to have mammograms if they thought they might be disfigured, believed that releasing information before risks were well understood was irresponsible. While their desire for definitive knowledge is understandable, if certainty was a condition for disclosure there would be no public information at all.
A further set of conflicts follows from different assumptions about how to communicate risk. Journalistic conventions may violate the norms of the scientific and medical community. To create a human interest angle, journalists will focus on conflict and create polarities; technologies are either risky or they are safe. Their quest for simplicity, drama, and brevity preclude the nuanced and complex positions that scientists prefer. Moreover, journalists follow the principle that verity in reporting disputes can be established by balancing conflicting claims. This clearly contradicts the scientists' view that claims can be verified only by empirical evidence.
A related source of tension lies in the conflict between the professional practices of journalism and scientific expectations about appropriate styles of communication. Constrained by the interests of their readers, journalists must select and simplify technical information. This often precludes the precautionary qualifications that scientists feel are necessary to accurately present their work. Readability in the eyes of the journalist may be oversimplification to the scientist. Indeed, many accusations of inaccuracy follow less from actual errors than from efforts to present complex material about risk in a readable and appealing style.
Differences in the use of language contribute to strain. The language of science is precise and instrumental. Information is communicated for a purpose -- to indicate regularities and aggregate patterns, and to provide technical data. In contrast, journalistic language is often chosen for richness of reference and suggestiveness. Scientists or, in this case, physicians are used to directing their professional communication to an audience trained in their discipline. They often forget that some words with special meanings in a scientific context may be interpreted quite differently by the lay reader. Take, for example, the word "evidence." Biostatisticians use the word "evidence" as a statistical concept. For biomedical researchers, the critical experiment is also defined as evidence. Most laypersons accept as evidence anecdotal information or individual cases. Thus the media considered the experience of the individual women as news. While physicians wanted aggregate data, reporters wrote of the immediate concerns of their readers.
Finally, an important source of strain between scientists and journalists lies in the ambiguity about the appropriate role for the press. Many professionals talk about the press as a conduit or pipeline, responsible for converting technical information into a form where it may be easily transported to the public. Regarding the press as a technique to further technical or medical goals, they expect to control the flow of information to the public just as they do within their own domain, and feel betrayed when their views are challenged. Physicians are especially aggrieved when the issue has immediate policy or clinical relevance.
The silicone breast implant controversy was marked by such strains. The tensions over the coverage of this dispute illustrate the important role of the media in risk disputes and the difficulties that are intrinsic to this role.
* Dorothy Nelkin is University Professor at New York University, teaching in the Department of Sociology and the School of Law.