The first modern health communication campaign in Europe: explicit and implicit strategic intents

1. Introduction

Russell and Lamme (2016) argue that public relations (PR) exist when there is human agency (among the public), and the communicators have a specific strategic intent. This article expands this understanding of strategic intent as a (historical) characteristic of PR, and it brings PR histography further by connecting the analysis of strategic intent to modernity, public interests, and social change. This is accomplished by analysing the Norwegian tuberculosis campaign of 1889 as a micro-history with theoretical and historiographic significance. The campaign, which can be said to be the first modern health communication campaign in Europe, had three quite different communicators: the Norwegian Women’s Public Health Organisation, the Norwegian Doctors’ Union and the Norwegian government. Their different strategic intents are analysed to understand how these relate to the explicit communication on tuberculosis as a health issue. Unlike most historical analysis of concrete PR activities, or campaigns, the analysis is performed within a specific socio-historical context, by using general historical sociological and modernity theory and to investigate how the campaign might have affected wider society. The principal research questions in the article are therefore:

What were the (different) strategic intents of the Norwegian tuberculosis campaign of 1889, both for the organisations and wider society?

This article makes several contributions to our understanding of PR history: (1) it indicates a starting point for the first modern public health communication campaign in Europe; (2) it expands the understanding of strategic intent as a characteristic of PR; (3) it merges the notion of strategic intent with notions of modernity, societal change and the public interest (within PR) and (4) it expands our knowledge of the role of civil society and feminist groups in (Norwegian) PR history. By doing so, the article sheds new light on PR histography and the relationship between strategic intent, theories of modernity and societal change, where activist groups (civil society) often play a central role.

2. Theoretical framework

The aim of this article is to develop a deeper understanding of strategic intent as a concept within public relations. The theory of strategic intent is linked to the development of modernity, particularly around 1900, when there was a clearer division of society into different social systems. System theory (Luhmann, 1995, 2009, 2012, 2013) within modernity is therefore crucial to obtain a general understanding of a divided society and the specific time and the specific campaign, which includes female activism and social change. The division of society into different social systems, also created distinct logic for communication in the different systems, which is further discussed in paragraph 3.4.

3. Materials and methods

Jacquie L’Etang and Kate Fitch (L’Etang, 2014, 2015; Fitch and L’Etang, 2017, 2020) argue that the research on PR history should be centred upon larger processes of transformation and conflicts in society, as well as the power relations between dominant and subordinated groups (cf. Edwards, 2018, p. 6). The study of PR history has therefore much to gain from the theoretical concepts and issues of historical sociology and social theory (L’Etang, 2014).

One important task in understanding the development of PR history is, thus, to enquiry into the individuals who have pioneered the development of the relationships between and among organisations and their stakeholders. Examining “who these individuals were and what influenced them, informs our critical appraisal of their historical significance and that of their contributions” (Lamme, 2015, p. 49). Historian Yvonne Hirdman (1998, p. 12) warns however against an exaggeration of individual action that overlooks restricting structures. To analyse the campaign within the specific socio-historical context, historical sociology is therefore employed, within a modernity perspective. In historical sociology, we seek to understand historical processes by comparing them with other processes, combining sociology with history, through thorough investigations of things we cannot directly observe (Tilly, 2001, p. 6753). Social change is normally the main research subject in this approach (Lachmann, 2013, p. 140). The method of historical sociology is to use sociological categories and established historical knowledge to serve the sociological end (Stråth and Wagner, 2017, p. 28; Delanty and Isin, 2003, p. 3), which is here to analyse the women’s, the doctors’ and the government’s strategic intents of the early tuberculosis campaign in Norway from a modernity perspective. The analysis in this article is therefore mainly based on secondary sources (defined as established historical knowledge). A modernity perspective provides further a vertical view of the various dimensions of societies, such as democracy, politics and civil organisations. Modernity is also a universal topic, which makes it possible to analyse the development of PR and society in a global context (Hu et al., 2015, p. 263; Dahlen, 2019) and thus to compare different nations and developments (Dahlen and Skirbekk, 2021).

The analysis in this article is based on available research on the early Norwegian tuberculosis campaign from 1889 (Blom, 1998, 1999, 2002a, b, c, 2007; Rogstad, 1996; Ryymin, 2007, 2008, 2011; Melby, 2001). The study scrutinises three factors; (1) central actors, (2) how they communicated and (3) the (strategic) intent of their communication. Various materials, such as biographies and journals, have been examined and analysed to better understand the communication, regarding the three factors mentioned. This includes the first tuberculosis poster from 1889, the Medicinsk Revue from 1889, the anniversary outlets of the associations (Schram et al., 1946; Erichsen, 1960), the first 4 years of the journal of the National Association Against Tuberculosis (Notices from the Norwegian National Association Against Tuberculosis) and the biographies of Fredrikke Marie Qvam, who led the women´s association (Folkvord, 2013; Aune, 2002). This is all scrutinised to obtain a better understanding of the strategic intents behind the communication efforts.

To provide a comparative historical analysis of the Norwegian development, a contrast of context (cf. Skocpol and Somers, 1980, p. 178) is used to bring in historical experiences from other countries. Therefore, international research literature on tuberculosis and measures taken against tuberculosis have been consulted. Additionally, several historical reports from various countries have also been examined to test the hypothesis that the Norwegian campaign was the first in Europe.

Existing literature on the Norwegian tuberculosis campaign are mostly limited to the Norwegian context and does not address the international development of health communication or the evolution of modernity, strategic communication, PR, or social theory. This article makes a significant contribution to understanding this campaign as a communication project and as a part of European PR history by filling these gaps in the literature.

The theoretical contribution of this article to PR historiography lies in linking strategic intents to significant societal changes, which are also the focus of the modernity theories. This is specifically discussed in the article “Modernity and the development of PR in Norway: influences and interactions” (Dahlen, 2019), where important societal changes throughout Norwegian history are linked to the development of specific forms of communication. In this article, however, the development of nation-states, mass societies and divisions into different sectors or systems is in focus. The actual historical campaign is presented in the next section.

4. The information campaign on tuberculosis

Tuberculosis was the most threatening illness of the late 1800s. With a mortality rate of more than 0.03% of the population from the disease in one year, Norway had the highest mortality rate in Europe in 1900 (Smith, 1988, p. 219; Blom, 2002a, p. 73). There was not much that could be done about the threat before the discovery of the tubercle bacillus by Robert Koch in 1882 (Harrison, 2004, p. 125). This discovery strengthened the belief in the contagion theory: that the sputum of infected people was the main source of the spread of the disease (Blom, 1999, p. 212) through spitting and coughing. Now, it became possible to prevent and cure the illness and to reduce or eradicate the disease if the public understood the connection (Harrison, 2004, p. 126). Consequently, educating the masses became an important task, leading to global anti-tuberculosis campaigns. This marked a new era in public health, where intervention and treatment of the population became core activities (Teller, 1988; Bryder, 1988, p. 17), making health a public (and national) challenge, and tuberculosis (as one of a few diseases) was lifted out of the private sphere into the public sphere (Rogstad, 1996, p. 88).

The information campaign in Norway started in 1889 with a popular poster on the initiative of Dr Klaus Hansen and two colleagues. The poster included 11 specific precautions to prevent the spread of the disease [1]. The main points were disinfection and the isolation of those infected, and the danger of spitting was emphasised. The poster was printed with governmental funds in 10,000 copies (Grindheim, 2010, p. 26) and distributed to doctors and health commissions and posted in public places and schools around the country (Ryymin, 2009, p. 29; Blom, 2002b, p. 233).

In the same year as the Norwegian doctors formulated their tuberculosis poster in 1889, a public information campaign against tuberculosis was also launched in New York City (Teller, 1988, pp. 20–21; Holmboe and Hansen, 1895, p. 5). The US campaign is in recent research labelled “the first modern public health campaign” (Anderson et al., 2019, p. 147) and described as “the prototype of modern health campaigns” (Teller, 1988, p. 121), where both public health officials and other health and social welfare movements later “copied its methods” (Teller, 1988, p. 123).

The first national association against tuberculosis in Europe was formed in France in 1891 (Harrison, 2004, p. 127). This organisation issued a popular instruction on precautions against tuberculosis in the same year. According to Norwegian doctors Holmboe and Hansen (1895, p. 12), its content was substantially in agreement with the mentioned Norwegian poster of 1889. Many other European countries followed suit with their anti-tuberculosis information campaigns in the following years (Smith, 1988; Bryder, 1988; Ryymin, 2009, p. 39). Fliers with advice and recommendations were published in Germany from 1891, followed by public lectures and readings from 1895 (Sanitize and Shengelia, 2015). The Danish Medical Association encouraged their government to produce a brief statement on tuberculosis and associated symptoms, risk of infection and precautions in 1895 (Danish Doctors Weekly Review, 1895, p. 28). National organisations against tuberculosis were established in Germany in 1895 (Fornet, 1911, p. 318), Britain and Belgium in 1898 (Bryder, 1988, p. 16; Ryymin, 2009, p. 39), Portugal and Italy in 1899, Denmark in 1900, Switzerland in 1902, Sweden in 1904, Iceland in 1906, the Netherlands in 1908, and Russia in 1910, where information measures were prioritised tasks (Notices, 1922, p. 19; April, 1922, p. 43; Blom, 2001, p. 86; Sanitize and Shengelia, 2015; Carrière, 1911, p. 378; Carlsson, 1911, p. 364; Gorkom, 1911, p. 395). The Women’s National Health Association of Ireland, which was founded in 1907, is said to have been inspired by both the “American and Scandinavian models in creating touring educational exhibitions promoting milk, fresh air, sanatoria, rest, and so on” (Smith, 1988, p. 221). This literature confirms that the Norwegian information campaign on tuberculosis was probably the first modern comprehensive public information campaign in Europe and therefore a landmark in European PR history. This is also mentioned by the Norwegian doctors in their journal:

We are the first nation that has taken up the fight in this way, but they are now working towards the same goal in many places in Europe. (Medicinsk Revue, 1889, my translation)

The campaign was modern in the sense of delivering what was believed to be true: scientific knowledge that was aimed at changing people’s behaviour and attempts to control nature. The campaign promoted a rational solution to what was perceived by many as a serious and current threat. A belief in the beneficial effects of information was further rooted in the enlightenment rationalism of the seventeenth century, the development of liberalism and emphasis on individual responsibility (Blom, 2002b, p. 232).

5. The Norwegian campaign

6. Different strategic intents

We have seen that the Norwegian authorities, the Norwegian Women’s Public Health Association and the Norwegian Medical Association had different strategic intents when they became involved in the fight against tuberculosis. It is even suggested that the Norwegian Women’s Health Association had a hidden agenda:

The organization made room for female independence and could legitimize the demand for political rights. It also had a hidden agenda, where the right to vote was central (Melby, 2001, p. 48, my translation).

The leader of the women’s organisation was clear that she wanted full citizenship for women, the Norwegian Medical Association wanted to mark a clearer scientific position in society and the authorities wanted control over and the assimilation of larger parts of the population within the framework of the nation state. They all, therefore, had strategic intents different from those directly communicated in the campaign, which was about health. We can thus say that the campaign chose tactics “with a specific outcome in mind” (Russell and Lamme, 2016, p. 744), which were focussed on preventing people from becoming infected. In addition, the three communicators had some implicit strategic intents: obtaining a more prominent position in society and controlling the population. To achieve these (implicit) strategic intentions, they sent out (explicit) messages that were in the public interest in line with general values (better health). The implicit strategic intents were, first and foremost, for the organisations’ own benefit (see Table 3), which is aligned with “the intention to do something for the purposes of maintaining or gaining some kind of competitive advantage” (James, 2009, p. 110–111). The understanding of the implicit intents is based on general theory, where states (governments) want to govern and control the population (Wagner, 1994, p. 7), and civil society organisations want to create change (Anderson, 2017, p. 508; Habermas, 1996, pp. 352, 363-4; Luhmann, 1995). The specific implicit intents in this article is mainly derived from established historical knowledge, where the Norwegian Women’s Public Health Organisation wanted suffrage (Melby, 2000, p. 90, 2001, p. 39; Folkvord, 2013, p. 149; Bjørnar, 2001, p. 64; Moksnes, 1984, p. 196), The Medical Association wanted to mark their societal value and position in society (Blom, 1999, p. 236; Rogstad, 1996, pp. 111–113), and the Norwegian government wanted to control and assimilate the Sami population (Ryymin, 2007).

The implicit strategic intents (self-interest) may explain why the organisations and authorities launched and spent a great deal of resources on the tuberculosis campaign; it was an important motivation. Alternatively, the explicit intents, in line with society’s values, points to some opportunities that organisations could use to approach the implicit strategic intents. It was the right political moment to mobilise for long-term changes (cf. Anderson, 2017, p. 508; Noakes and Johnston, 2005, p. 21). The new knowledge about the threat (the disease) and the solution (better hygiene) indicated that it was possible to fight tuberculosis (based on science) and gave the authorities and organisations opportunities to launch a campaign that could support their self-interest strategic intents, in which also could be called implicit strategic intents. We have also seen how Norway’s struggle for independence gave women an extra opportunity (as we have seen that the First World War was an opportunity in other countries) in that the Norwegian Women’s Public Health Association was originally established to help possible injured Norwegian soldiers. Women claimed special expertise in the management of social welfare from their experience in the private, informal care system and further used the voluntary and charitable organisations (civil society) to gain full political rights at the beginning of the twentieth century as their implicit strategic intent.

The potential war with Sweden during the first crises of modernity was an opportunity for Norwegian women to establish an association in which they could make evident their national mentality and societal role in creating something society could accept as a public good (national feelings, health and care). No war materialised, but a referendum was arranged, which provided a new opportunity. By collecting signatures in support of the dissolution of the union, the explicit strategic intent was to support the dissolution of the union, while the implicit strategic intent was suffrage. The means were showing their national mentality and that women could understand politics, whereas the goal was full citizenship. In Norway, as in many other Western European countries, the nation became the important framework for the organisation of society, which was applied by women who fought for their civil rights and doctors who argued for their position in society when there was “a disembedding process of giant scale” (Wagner, 2001, p. 84, see also Luhmann, 2013, pp. 286–289). The state used the possibility to take better control of minorities when it could clarify the national commonalities within the (national) state just as the women and doctors could organise national associations that explicitly worked for the good of the entire nation’s public interests, even if their implicit intents was to play a more import role in society.

In many other countries, women also played an important role in the fight against tuberculosis and thus demonstrated their role in society and what they had to offer. By making their work as carers into a public matter, they also turned this traditionally female quality (private/family health care) into a skill that served the public in a broad sense. Similar developments could also be observed in other countries, such as the US, Italy and Britain, around the turn of the twentieth century:

In Britain, Europe and the United States, within the context of local government and organized philanthropy women used a language of service and duty to identify a type of gendered citizenship which allowed them to participate in the public sphere. (Porter, 1999, p. 174)

But they obviously needed something more. Despite campaigns against tuberculosis, which included women at an early stage in the United States, Great Britain, Italy and Ireland, women in these countries did not get the right to vote until after the First World War (1918 in Great Britain, 1920 in the United States, 1922 in Ireland, 1945 in France, and 1946 in Italy). This can probably be explained by the fact that they were not included in any international struggle before the First World War, unlike the Norwegian women, who marked a clear (national) position in 1905. Women showed their societal value when they kept the country going while the men fought in the war. The fight for national independence and democracy thus explains why the legitimation phase was so short for Norwegian women (Melby, 2001, p. 41). Others have also emphasised the fact that national questions have given women a chance to act as political individuals (Melby, 2000, 2001; Smith-Rosenberg, 1993; Scott, 1996, p. 163). In France, granting women the right to vote was a way of resolving the national political differences that had plagued the previous republic and asserting national unity (Scott, 1996, p. 163). Norway was not involved in the First World War, but the country had a conflict with Sweden that culminated with the referendum on the dissolution of the union in 1905. Women in Norway communicated that they also supported the dissolution and could make independent political decisions in support of the nation.

The fight for national independence, which dominated the political agenda during these years, provided opportunities for feminist claims because they were found to be in the national interest. The national question gave women a chance, which they eagerly took, to act politically to extend their political rights (Melby, 2000, p. 95)

The Norwegian Women’s Public Health Association was a part of this feminist movement, in which the goal was social change (suffrage), the function (in Niklas Luhmann’s terms) was to introduce problems in society (women’s lack of influence), the communication took place through mobilisation (the medium) and protest (the programme) and the binary codes of communication are affected or not affected, with all women being affected by a lack of suffrage. But to get there, the Women’s Public Health Association used another system, as a tool: the health system. The Norwegian Women’s Public Health Association communicated within the health system, where the goal is to make people healthy, the binary codes are healthy and sick and the medium is treatment. Through communication campaigns and health institutions, they showed their social value with their engagement in making people healthy. For the leadership of The Norwegian Women’s Public Health Association, this type of communication served as a sort of (rhetorical) cover-up for the real goal (for the social movement) – in the same way as politicians (and lobbyists) communicate solutions (explicit intents), while their (real) goal (implicit intents) is power and influence (cf. Ihlen and Raknes, 2020).

At the same time, Norwegian doctors wanted to take control of the health system with their scientific (modern) knowledge. They communicated within the scientific system, where knowledge (about diseases) is important, and there is something that is true (scientifically proven) and something that is untrue (quackery). The medium is knowledge, which emerged through scientific research (the programme), and its function is the production of knowledge (about diseases). This knowledge is linked to the health system, so they created a new system, a scientific health system, in which only those who use scientific knowledge have access. The unscientific health system is rendered incompetent, so the doctors could take full control of the health system, which has become synonymous with the scientific health system today. The unscientific health system lost much of its credibility in the modern society, where science and rationality are prevailing values.

The Norwegian state had an explicit strategic intent for better health in the population, while the implicit strategic intent was governance, control, assimilation, and nation building – in line with Peter Wagner’s (1994, p. 7) thesis that the national state is primarily an instrument for limiting practice and disciplining individuals. This may also explain why Niklas Luhmann (1995) finds it difficult to fit the state into his systems theory. The state has a clear function (implicit intent) regarding management and control, but the state consists of many different functional systems and, thus, various types of communication tactics, with explicit intents, which we have also seen an example of in this article (e.g. health and law). Explicit intent refers therefore first and foremost to communication tactics used “with a specific outcome in mind” (Russell and Lamme, 2016, p. 744), as a common good or public interest, whereas implicit intent is concerned more with self-interest and “maintaining or gaining some kind of competitive advantage” (James, 2009, pp. 110–111) for the organisation itself.

7. Conceptual and practical implications

The distinction between explicit and implicit strategic intents can give us an understanding of how both PR and other forms of strategic communication work in practice. Some offer a solution (to a problem of the time) for the good of society, built on society’s prevailing values attuned to the cultural stock (public interest), through an explicit message, where the real (implicit) strategic intents is linked to self-interests. As the leadership of the Norwegian Women’s Public Health Association could talk about women’s position in society and voting rights internally, the organisation had an explicit message to the general public about health and national independence. The Norwegian Doctors’ Union had an (explicit) message about health, while the leadership’s implicit strategic intent was achieving more prominent positioning in society and greater respect for the (scientific) medical system. Finally, as the authorities wanted increased control over the population (implicit intent), there is an explicit intent regarding better health for the population, which is communicated to the general public.

So, if PR has a strategic intent to work for profit, recruitment, legitimacy, agitation and advocacy and to reduce fear (Russell and Lamme, 2013, 2016; Lamme and Russell, 2010, p. 335), we may add that there could be both explicit and implicit strategic intents, where the explicit intent normally points to some public interests (attuned to the stock of the target audience and political context and relevant to the target audience), and the implicit intent points to some self-interests that could benefit the organisation behind the communication efforts.

This way of thinking can also explain changes in society on a general level. The right political moment leads to opportunities that can be used to mobilise for long-term change (implicit intentions), such as the discovery of the tubercle bacillus and the First World War creating an opportunity for women in Europe to show their national mentality and societal value and mobilise for influence and suffrage. There are events in society that can be used by organisations and individuals to change society’s values (implicit intent), with the arguments (the explicit message) used being based on society’s prevailing values and challenges, to achieve their real (implicit) strategic intent. Historian Yvonne Hirdman (1998, p. 12) also warns against an exaggeration of individual action that overlooks restricting structures. Even if Fredrikke Marie Qvam was one of the important actors in the Norwegian fight for women’s suffrage, there were crucial new structures (national mobilisations and conflicts) and material development (the discovery of the tubercle bacillus), which provided some new opportunities for change.