The definition of a crisis is dependent on the collective understanding of a problem. In her 1999 work How to Have a Theory in an Epidemic, Paula A. Treichler discusses the importance of meaning and definition in the context of the HIV/AIDS crisis. She states “scientists, physicians, and public health authorities argued repeatedly that AIDS represented an epidemic of infectious disease and nothing more...however, the AIDS epidemic is cultural and linguistic as well as biological and biomedical.” i This concept can be seen in the fact that the rate of diabetes has steadily increased in the United States for decades, yet its designation as a crisis or an epidemic has relied more on public discourse than medical definition. The narrative of health crises and the language used to describe them signify their collective importance and play a role in the agenda setting process. This paper explores these ideas by examining the content and frequency of public discourse surrounding diabetes in the United States.

The construction of a crisis is an inherently political act. In his study of the language of politics, David Eliot Green notes that “political vocabulary evolves in response to political need. Politics is a process of conflict resolution, conflict creation, and conflict management; and political language at once reflects and contributes to these processes.” ii Labeling a disease or an outbreak as a crisis communicates the seriousness of the problem to the public while directing interest and resources to the issue. Attention, defined by the volume of discussion, sends a message about the magnitude or urgency of an issue, whether it is real or perceived. The salience of a health crisis is paradoxically created and reflected by the amount of time devoted to discussing it, signaling its importance in the public agenda. In his book Agendas, Alternatives, and Public Policies, John Kingdon emphasizes the importance of problem recognition. He notes that “problems are often not self-evident by the indicators. They need... a focusing event like a crisis or disaster that comes along to call attention to a problem.” iii In the case of diabetes, labeling the disease as an “epidemic” in public discourse represents such an event, creating the cultural recognition of a crisis in addition to the biomedical circumstances.

Issue attention is also a competitive political process; when one problem is being discussed another is not. Though heart disease, stroke, diabetes, and cancer are among the deadliest diseases in the United States, the number of media stories devoted to these problems are often dwarfed by issues such as Ebola, H1N1, SARS, anthrax, and West Nile Virus, which have a comparatively miniscule impact on the population. The process of determining why some health problems are viewed as crises while others are not is highly dependent upon how they are portrayed. Diabetes presented a major health problem for millions of Americans prior to The New York Times and USA Today first labeling it an “epidemic” in 2000. That same year saw a spike in media coverage, a rise in crisis language, and nearly double the amount of diabetes legislation introduced in Congress. In their book A Cognitive Psychology of Mass Communication, Richard Jackson Harris and Fred W. Sanborn write that agenda setting does not necessarily shape what people think about an issue, but it decides what issues are important. They use the example of the extensive coverage given to presidential elections, noting “the public receives the implicit but unmistakable message that these campaigns are important. Similarly, when stories receive little coverage, a message is communicated that they are not important.” iv The same is true of threats to public health; the salience of a disease is paradoxically created and reflected by the amount of time devoted to discussing it, signaling its importance and urgency as part of the public agenda.

Crisis Language

In Deborah Stone's book Policy Paradox, she observes that “the way we think about problems is extremely sensitive to the language used to describe them...feelings of insecurity are connected to objective circumstances, but many other factors mediate between objective circumstances and psychological states.” v The use of crisis language to portray public health issues effectively associates medical realities with the perception and fear of emergency. The increasing prevalence of diabetes in the United States is a demonstrable medical issue, but the way it is framed, discussed, and perceived is subject to its portrayal. This is illustrated by the following news excerpts:

The number of Americans with diabetes increased by 15 percent in two years to 24 million, according to the Centers for Disease Control and Prevention. vi
Uncontrolled diabetes wreaks havoc on the body, often leading to kidney failure, blindness and death. A new study shows that the nation's unchecked diabetes epidemic exacts a heavy financial toll as well: $174 billion a year. vii

Both of these statements are entirely factual, yet the second quote elicits a strong emotional response which corresponds with the accurate information. The use of crisis language presents important information while sending underlying signals about the urgency and magnitude of the message. In essence, crisis language communicates information with higher intensity.

Even the use of seemingly rigid labels can be used to portray a crisis. The word “epidemic” itself can have subjective interpretations. Building on Treichler’s notion that health crises carry both medical and cultural elements, Mitchell and McTigue observe that “the term ‘epidemic’ has a double quality—it is a medical term with a technical meaning, but it also functions as a metaphor in public discourse—an approach that blends epidemiology with rhetoric.” viii The definition used by the Centers for Disease Control and Prevention (CDC) describes an epidemic as “an increase, often sudden, in the number of cases of a disease above what is normally expected in that population,” based on specific calculations which determine the epidemic status of a disease. For instance, in the case of influenza, “an increase of 1.645 standard deviations above the seasonal baseline of deaths is considered the ‘epidemic threshold.’ ” ix Yet, invoking an “epidemic” in discourse is more commonly used metaphorically to portray the seriousness of a public health issue. This may or may not meet official CDC criteria, but it sends a message about the prevalence and associated risk. In fact, the CDC has noted that the terms “outbreak” and “epidemic” are almost interchangeable, but that the former is preferable because it's a less frightening characterization. x

Advocacy groups play an important role in the discursive politics surrounding diabetes. The American Diabetes Association (ADA) is a patient group which provides information, supports and conducts research, and publicly advocates on behalf of individuals with diabetes. While they are a highly-regarded organization, they are by definition a stake-holding interest group. As a political organization, the language and narratives used by the ADA can provide insights into their attempts to spread awareness while increasing support for positive policy change regarding diabetes. As a common provider and subject of news coverage, the language and narratives presented by advocate groups provide a major contribution to the nature of public discourse. Due to their position as trusted sources and experts in the field of diabetes, advocacy groups are viewed as authority figures.

A strong majority of ADA publications are highly technical, relaying medically-centric information to health care professionals and diabetics managing their treatment. Still, the use of crisis language plays an important role in the overarching ADA narratives. Examining archives going back to 1952, ADA publications initially appear to use the word “epidemic” carefully, relying on a narrow and strictly medical definition. In 1972, there is a small, but important change in linguistic approach. In an article about the impact of premature vascular disease on diabetes, the report refers to the situation as a major public health problem which had reached “epidemic” proportions. The difference was that quotation marks were used around the word epidemic, implying that it was being used metaphorically rather than medically. In addition, the term was applied to a large-scale public health issue. xi This trend progressed, and in 1980, ADA first describes obesity and diabetes as national epidemics, predating the media usage of the phrase by 20 years. xii In 1991, an article about gestational diabetes placed blame on the “fast food epidemic.” xiii Clearly, this was not a medical prognosis, but a linguistic device for arguing that dietary habits contribute to the prevalence of diabetes. The organizational trend toward crisis language increased with the rate of diabetes and the frequency of media coverage. As of 2014, the term is most readily applied in the context of a worldwide epidemic of type 1 and type 2 diabetes as well as cancer and obesity. Crisis language is a powerful framing device which creates emotional associations and a sense of urgency, while still conveying information. While ADA remains a highly-reputable organization whose publications are at the forefront of medical research, the language they use to portray the disease is also strategic.

Framing and Metaphors

Beyond the use of crisis language, framing impacts how crises are discussed and understood. In their work on framing in politics, Karen Callaghan and Frauke Schnell argue that the process of highlighting an issue inevitably involves “promoting a particular interpretation.” xiv Epidemics provide a powerful metaphor. Labeling a social problem as an epidemic instantly conjures a sense of urgency. Metaphors of struggle and war are frequently invoked to describe health crises. A February 2006 editorial in the New York Times was entitled “Declare War on Diabetes.” xv The subject of the article does not involve a war, but rather a series of policy problems, such as the lack of viable exercise options in New York neighborhoods, the inaccessibility of healthy food, and the high financial cost to uninsured groups. These are productive observations with a specific vision of needed policy change; however, the headline frames these proposals as a literal battle, and ends with the warning that “waiting for this epidemic's fuller toll is foolhardy.” Another instance comes from an April 2007 USA Today article entitled “Obesity is the Enemy; 2 Soldiers Take Up the Fight” about an elementary school principal and a nutritionist trying to improve conditions in their school. xvi The Washington Post also ran an article in 1996 discussing a new “six-year study designed to test the effectiveness of treating people who have impaired glucose tolerance.” The headline put the article's content in a different context, declaring “NIH Opens Offensive on Type II Diabetes.” xvii In addition, words such as “combat,” “fighting” and “facing threats” are frequently used in the discussion about public health crises.

An increasingly common metaphor revolves around an economic framing of diabetes. This portrayal goes beyond the price of individual treatment and frequently refers to “cost” of diabetes to the United States as a whole. Framing health crises as economic threats is not inaccurate, but it changes the dialogue from a matter of medicine to money. A particularly striking article published in USA Today is entitled “Diabetes Costs Nation More Than Wars, Disasters, Study Says.” In addition to the national “$170 billion price tag,” the article also warns that “diabetes will handicap both state and local economies.” xviii A similar tactic was used in a 1997 article in The Washington Post. Entitled “Vital Statistics.” The article presented the problem by noting that “Diabetics make up about 5 percent of the U.S. population but account for nearly 15 percent of health care costs.” xix This frame projects an image of diabetics as employees losing their financial potential, and consumers of medical devices rather than patients with a chronic disease.

Even when framed in the context of disease, diabetes discourse has taken on the connotation of very different medical conditions. The rhetoric used to portray health problems often takes the form of comparing respective conditions to plagues and outbreaks. For instance, The Washington Post published an article regarding medical privacy entitled From Typhoid Mary to Diabetes Debbie.” xx While the author was careful to note the differences in contagious disease and non-communicable diabetes, he also deems the latter a “fearsome epidemic” that warranted “strategic interventions” such as the historic quarantine of typhoid carriers. Dr. Mark Hyman, author of The Blood Sugar Solution further adds to this line of discussion when he declared obesity and diabetes to be “the modern plague.” xxi While they did not use direct comparison to the bubonic plague, The New York Times posed the question to its readers “Is Sugar Toxic?” xxii The answer, though literally “no” was intended to link one of diabetes’ determinants to a lethal substance. While attempting to raise awareness about the seriousness of diabetes, these authors demonstrate the tendency to use the image of sickness, poison, and plague to construct a crisis. Framing shapes the way the disease is perceived by the public, shifting away from the confines of medical details and creating images of war, economic panic, and plague. Deborah Stone’s work suggests that these rhetorical devices create a cultural narrative about diabetes that parallels the growing rate of the disease itself. The way information is presented creates narratives of war, economic threats, and plague that shape how diabetes is perceived.

Attention and Frequency of Coverage

In addition to the use of crisis language and framing, issue attention is a fundamental element in public discourse. An analysis of the frequency and content of media coverage demonstrates how diabetes is portrayed in the United States. The principal source of data comes from a content analysis of media stories about diabetes. The data was collected from Lexis Nexis searches of print media archives from The New York Times, The Washington Post, and USA Today. In order to sufficiently observe patterns in the coverage from these newspapers, a longitudinal approach was adopted. Every diabetes-related article appearing in these publications over the thirty-year period from 1985 to 2014, was examined. In total, 2,718 articles were reviewed and coded based on the language used to describe diabetes. The quantity of articles was measured, as well as the usage of crisis language. In this context, crisis language was categorized by the use of specific words such as “epidemic” and “crisis” to describe diabetes in America. Additionally, while one story could note that the rate of diagnosed diabetes rose 15 percent over a two-year period, a crisis-language article might describe the same trend as “skyrocketing” or “soaring” rates of diabetes.

An analysis of 2,718 diabetes-related articles from 1985 to 2014 revealed several important insights. As the rate of diagnosed diabetes steadily increased over the period of observation, the frequency of media coverage rose dramatically. At the outset of the study in 1985, roughly 6.1 million Americans had been diagnosed with either type 1 or type 2 diabetes. Eighteen articles about the disease appeared in the selected newspapers that year, only two of which contained crisis language. By 2000, the frequency of coverage increased to 98 articles, with 21 incidents of crisis language. The first occurrence of the phrase “diabetes epidemic” came in 2000 when the New York Times and USA Today invoked the term. The pinnacle of frequency came in 2007, when 178 articles relayed information about diabetes. A year earlier in 2006, 175 diabetes articles were published and 64 specifically employed crisis language, the peak of the 30-year study. Following this spike, the rate of diagnosed diabetes continued to rise, but media frequency moderately declined while still remaining well above the mean of 91 articles per year. In the final year, 2014, there were 149 articles, and 46 instances of crisis language. In total, 593 articles containing crisis language constituted 22 percent of all the diabetes-related news stories.

Media coverage and diabetes in the US

When observing the trend of diabetes coverage from 1985-2014, it is clear that the rising prevalence of the disease contributes to increased attention, however the window of salience from the late 1990s through the late 2000s confirms what Anthony Downs referred to as the issue-attention cycle. xxiii Downs writes that the perception of crisis “does not reflect changes in real conditions as much as it reflects the operation of a systematic cycle of heightening public interest and then increasing boredom with major issues.” The frequency of newspaper coverage related to diabetes was initially responsive to the actual rate of the disease in the population, suggesting that the media's overall attention to diabetes in America differs from other public health threats like Ebola or H1N1 which received a disproportionate ratio of coverage to the number of people affected. However, as diabetes gained salience, it began to be labeled as a crisis or an epidemic. Increased media attention and heightened advocacy from interest groups created punctuation in diabetes discourse. This suggests that even a chronic illness can evoke moments of salience without major changes in the disease’s trajectory. The years 1999 to 2007 represented a window where the growing problem of diabetes appeared to be high on the public agenda. However, following the apex of 2006 and 2007, the level of salience declined. While the increase in attention had previously mirrored the rising rate of diabetes, the drop in interest diverged from the steadily growing disease.

Conclusion

Paula Treichler argues that health crises are not limited to disease or biomedical threats, but also include linguistic and cultural “parallel epidemics.” xxiv Overall, this research supports her claim, finding that the frequency and content of public discourse shapes the way public health crises are defined and addressed. Issue attention is one of the strongest factors in determining the salience of a disease, and institutions like the media and advocacy groups play a critical role in deciding what problems are elevated on the public agenda. In the case of diabetes, attention rose gradually until it began to be framed as an epidemic, leading to a window where the disease was viewed as an urgent health crisis. Following the apex of attention in 2006 and 2007, the frequency of diabetes discourse fell, reflecting the systematic cycle of issue attention described by Anthony Downs. In addition to the quantity of discussion, the content of discourse shapes how health problems are understood. The increasing use of crisis language in the media and from advocacy groups underscores an attempt to convey information as well as evoke an emotional response that highlights the urgency of an issue. The evolving use of the word “epidemic” demonstrates how medical information can be appropriated metaphorically in order to communicate the seriousness and anxiety associated with widespread outbreaks. In the case of advocacy groups, the American Diabetes Association introduced the phrase “diabetes epidemic” decades before the disease met CDC criteria. Eventually, media sources adopted this narrative and increasingly used the metaphor to present both information and message intensity. Ultimately, diabetes represents a single case that holds larger implications for the nature of discourse surrounding public health threats. Crises are not created solely by medical conditions or epidemiological data; issue attention, public discourse, and the perception of an emergency are all necessary components in the construction of a crisis.


i Treichler, Paula. 1999. How to have theory in an epidemic: Cultural chronicles of AIDS. Durham: Duke University Press.

ii Green, David Eliot. 1987. Shaping political consciousness: The language of politics in America from McKinley to Reagan. Ithica: Cornell University Press.

iii Kingdon, John. 1984. Agendas, alternatives, and public policies. Boston: Little, Brown.

iv Harris, Richard Jackson, and Fred W. Sanborn. A cognitive psychology of mass communication. Routledge, 2013.

v Stone, Deborah. 2002. Policy Paradox: The Art of Political Decision Making. New York: Norton.

vi “Diabetes Cases Increase 15 Percent in 2 Years.” New York Times, June 25, 2008.

vii Szabo, Liz. “Diabetes Costs Nation More Than Wars, Disasters, Study Says.” USA Today, January 24, 2008.

viii Mitchell, Gordon R., and Kathleen M. McTigue. “The US obesity ‘epidemic’:Metaphor, method, or madness?” Social Epistemology 21, no. 4 (2007): 391-423.

ix “Introduction to Epidemiology,” Centers for Disease Control and Prevention. 2012. http://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section11.html.

x Koerner, Brendon. “Outbreaks vs. Epidemics.” Slate, December 19, 2003.

xi Fajans, Stephan S. 1972. “Current Unsolved Problems in Diabetes Management.” Diabetes, 21(2), 678-684.

xii West, Kelly M., Linda J. Erdreich, and Judy A. Stober. 1980. “A Detailed Study of Risk Factors for Retinopathy and Nephropathy in Diabetes.” Diabetes, 29(7), 501-508.

xiii Beischer, Norman A., Jeremy N. Oats, Olivia A. Henry, Maryt T. Sheedy, and Janet E. Walstab. 1991. “Incidence and severity of gestational diabetes mellitus according to country of birth in women living in Australia.” Diabetes 40 (2): 35-38.

xiv Callaghan, Karen, and Frauke Schnell. Framing American politics. University of Pittsburgh Press, 2005.

xv “Declare War on Diabetes.” New York Times, February 5, 2006.

xvi Wickham, DeWayne. “Obesity is the enemy; 2 ‘soldiers’ take up the fight.” USA Today, April 17, 2007.

xvii Squires, Sally. “NIH Opens Offensive on Type II Diabetes.” Washington Post, June 11, 1996.

xviii Szabo, Liz. “Diabetes Costs Nation More Than Wars, Disasters, Study Says.” USA Today, January 24, 2008.

xix “Vital Statistics.” Washington Post, April 1, 1997.

xx Longman, Phillip. “From Typhoid Mary To Diabetic Debbie.” Washington Post, February 15, 2006.

xxi Hyman, Mark. 2012. The Blood Sugar Solution: The Ultra Healthy Program for Losing Weight, Preventing Disease, and Feeling Great Now! New York, NY: Little, Brown.

xxii Taubes, Gary. “Is Sugar Toxic?” New York Times, April 17, 2011.

xxiii Downs, Anthony. 1972. “Up and Down with Ecology: The Issue Attention Cycle.” National Affairs 28.

xxiv Treichler, Paula. 1999. How to have theory in an epidemic: Cultural chronicles of AIDS. Durham: Duke University Press.

Copyright (c) 2016 Michael McPhie