Public relations and public health: The importance of leadership and other lessons learned from “Understanding AIDS” in the 1980s

Abstract

Public Relations Quarterly recognized Surgeon General C. Everett Koop as "Communicator of the Year" in 1988 for his work to inform the public about HIV/AIDS and reframe a then politically charged issue to focus on public health and education. Using a historical perspective, this study examines Koop's communication about AIDS during the 1980s, including press conference remarks, reminiscence notes, and an unprecedented mailing sent to all U.S. households. This study also explores media coverage at the time and framing throughout these materials to determine what lessons can be learned for today’s communication efforts. Two lessons relate to the importance of leadership in media advocacy and prioritizing public health over politics. Parallels are drawn between public relations and health and science communication practice and scholarship, and future research is suggested related to recent government communication surrounding the COVID-19 pandemic.

1. Introduction

In October 1986, United States Surgeon General C. Everett Koop released the first "Surgeon General's Report on Acquired Immune Deficiency Syndrome" (AIDS) to the media and the public. The report described what scientists and government agencies had discovered about AIDS, including information on how the disease could (and could not) be transmitted and how it could be prevented. Koop released the information to the media at a press conference, and the report "galvanized the media and allowed AIDS to achieve the critical mass to make it a pivotal social issue…. For one of the first times, the problem of AIDS was addressed in purely public health terms, stripped of politics" (Shilts, 2000, p. 587).

Less than two years later, in May 1988, the U.S. Government mailed an eight-page informational brochure, titled "Understanding AIDS," to 107 million households in the United States. Mandated by Congress in December 1987, the mailing was the first time the federal government attempted to reach every household about a health issue (The C. Everett Koop Papers, n.d.). In the first 18 days following the mass mailing, an AIDS hotline received more than 100,000 additional phone calls requesting information. A Centers for Disease Control and Prevention (CDC) poll revealed that 80 percent of respondents had received the mailing, and 80 percent of those who received it said they had read at least part of it and found it worthwhile (Lambert, 1988). Additionally, Gallup polls between 1986 and 1988 showed an increase in people reporting condom use (there was also an increase in condom sales), as well as an increase in the number of people expressing concern about AIDS as an epidemic for the public at large (Singer, Rogers, & Glassman, 1991).

The 1986 report and 1988 mailing were the result of Surgeon General C. Everett Koop's extensive efforts to change public understanding of AIDS. The purpose of this study is to examine how Koop helped create such change through public relations and media advocacy efforts, as well as how American media and some members of the public reacted to his efforts. Prior to 1986, the media and authorities such as the Institute of Medicine called President Reagan and the government's response to AIDS "woefully inadequate" (Shilts, 2000, p. 587). According to medical historian Brandt (1995, p. 126): "During the Reagan years it was difficult to get the President to utter the word 'AIDS,' let alone establish a coherent national policy…. Because of its particular meanings and politics, [AIDS] was anathema in the White House." Under this absence of leadership, Koop stepped in to educate the public about AIDS. Journalist and author Shilts (2000, p. 588) noted: "Unwittingly, the Reagan administration had produced a certifiable AIDS hero." For his efforts to inform the public about the deadly disease, Public Relations Quarterly recognized Koop as "Communicator of the Year" in the fall of 1988 (Grigg, 1988, p. 6).

Koop was a communicator at the time, of course, but he was also a medical doctor and did not consider himself a public relations practitioner. However, as a government employee tasked with communicating about one of the most important public health issues at the time, Koop’s efforts demonstrate the importance of media relations, or more specifically media advocacy, in communicating with the public about a health issue. Other political and government figures have been studied for working with media; U.S. presidents, in particular, have been recognized for understanding the power of the press for extending their influence (Lamme & Russell, 2009). However, Koop was effective because he combined many of the elements considered most important in evaluating credible health information sources - e.g., expertise, transparency, knowledge, years of experience (Avery, 2010); yet in many ways he went against the president and others in that administration at the time because he communicated clearly and openly about a health issue that was considered controversial.

Previous research studied the communication efforts of U.S. Surgeon General Thomas Parran, Jr. during the Great Depression (Anderson, 2018a, 2018b). Parran broke the silence among media in terms of communicating about venereal diseases (VD) such as syphilis and gonorrhea. Similarly, Koop brought HIV and AIDS out of the shadows during the 1980s; only, instead of simply getting the media to write about the issue more, he also communicated directly with the public with an unprecedented mailing to U.S. households. He also broke the silence on HIV/AIDS in terms of government communication, at a time when the president and others in the administration were not communicating about this deadly disease. As Taylor and Kent (2016) noted, people practicing public relations via a government entity don’t typically have “public relations” in their title. Because of the Gillett Amendment, most government communicators use terms such as “public information” or “public affairs.” Koop was more than a communicator, of course, but his work with the media, his role in creating the historic “Understanding AIDS” mailing with a public relations agency, and his leadership in other communication efforts demonstrate the importance of public relations in communicating about public health issues.

Indeed, Koop’s media relations and media advocacy efforts helped build the agenda for the issue of AIDS education in the United States in the 1980s (Kiousis, Mitrook, Wu, & Seltzer, 2006). He achieved message integrity in terms of press coverage of the issue (Carroll, Huang-Horowitz, McKeever, & Williams, 2014). He also demonstrated leadership and put public health before politics – something we could learn from in today’s highly partisan environment where we are dealing with new public health challenges like the COVID-19 pandemic. Koop’s leadership, including his initiative and focus on public education, and his willingness to go against the grain in the government administration at the time, are two of the most important lessons from this case study in terms of how public relations can impact public health. Before looking at the materials Koop helped produce and media coverage of his efforts, it may be helpful to understand the historical context of AIDS in the 1980s.

1.1. Brief history of AIDS in the United States

The first accounts of AIDS surfaced in the United States in June and July of 1981 in the CDC's Morbidity and Mortality Weekly Reports, which described mysterious forms of pneumonia and cancer that were affecting homosexual men in California and New York. By the end of 1981, 298 cases had been reported in the United States. The number of cases escalated rapidly and proved fatal. In 1982, 1120 people were diagnosed with AIDS, and 60 percent of those diagnosed in 1981 had died. By 1983, diagnoses more than doubled to 3005 (Hombs, 1992). As a search for the cause of the deadly illness persisted, the disease was temporarily called Gay-Related Immune Deficiency (GRID), and research focused on the practices of homosexual men (Hays, 2005).

Although the disease was widespread and certainly newsworthy, the mysterious nature and politics surrounding AIDS seemed to keep serious media attention at bay. The Los Angeles Times and The Washington Post first reported on AIDS in 1982, while The New York Times did not publish a front-page story on AIDS until May of 1983. In 1985, media coverage was dominated by actor Rock Hudson's hospitalization and subsequent death from AIDS, as well as the case of Ryan White, a 13-year-old boy from Indiana who contracted the disease from a blood transfusion (Rogers, Dearing, & Chang, 1991). As noted, the White House remained mostly silent during this time. In fact, President Reagan did not give a public speech on AIDS until 1987 (Singhal & Rogers, 2003). By this time, there were more than 33,000 Americans living with AIDS, and yet the United States was the only major industrialized nation that had not launched a coordinated education campaign (Shilts, 2000).

Although much has been written about AIDS, additional attention and "rigorous historical inquiry and analysis might illuminate the policy debate," thus demonstrating the range of forces that have helped shape policy and public opinion surrounding the epidemic (Brandt, 1995, p. 124). While scholarly studies have focused on media coverage, public opinion, and behaviors related to AIDS (e.g., Rogers et al., 1991; Singer et al., 1991; Singhal & Rogers, 2003), few have used a historical perspective to examine this particular time period and Koop's public relations efforts on behalf of the U.S. government. One article looked at the impact of the “Understanding AIDS” mailing in Connecticut (Snyder, 1991), and a more recent study looked at what the authors called “authoritative metaphors” in the mailing (Jensen & King, 2013). However, now that we are more than 30 years from this historic mailing, with illnesses such as Ebola, Zika, and COVID-19 circulating recently, this study sought to understand what we might learn from these government communication efforts. Advocating for an understanding of the history, public opinion, policy and other myriad influences surrounding epidemics such as AIDS, Brandt states:

Only a sophisticated understanding of the social meanings of AIDS and the process by which they achieve attention and legitimacy offers potential pathways to a just public policy. This is the role in which historians may make a modest but important contribution. If the meanings of the epidemic are malleable and contingent, then it is necessary to give greater attention to working explicitly to shape them…. Only when we recognize the significance of social and cultural values in constructing disease will we be able to develop the effective, humane, and just social responses this epidemic demands (Brandt, 1995, p. 130).

2. Literature review

Like many issues, media contributed to the social and cultural construction of AIDS, and at a time when even public health officials framed the disease politically, Koop helped shift the conversation from whom to what causes AIDS. Koop's communication and the subsequent media coverage helped frame the epidemic in new and different ways. In doing so, Koop demonstrates keen public relations and media advocacy skills, which included building the agenda for AIDS and reframing the health issue for the media and the public.

2.1. Media advocacy

For those not familiar with the term, media advocacy is essentially public relations for public health. It is a way to advance public health goals by working strategically with those who help shape media content. In this way, it is similar to agenda building, which has been described as a process of making issues salient with influence from the media, the public, and policymakers (Lang & Lang, 1981). Similarly, Wallack, Dorfman, Jernigan, and Themba (1993) refer to media advocacy as “influencing public debate and putting pressure on policymakers by increasing the volume of the public health voice” (p. 2). Media advocacy focuses on how an issue is presented in the media and how media coverage affects public opinion and sometimes policy (Winett & Wallack, 1996). Media advocacy resembles agenda-building; however, media advocacy may go one step further because it consists of three steps: setting the agenda, framing an issue, and advancing specific solutions (Gibson, 2010; McKeever, 2013). These steps often involve influence from press conferences, news releases, interviews, or other information subsidies provided by public relations practitioners or others communicating on behalf of an entity (Gandy, 1982; Turk, 1986). Media advocacy has been studied by looking at content (Dorfman, 2003; McKeever, 2013) and has been found to influence policy related to issues like tobacco control (Niederdeppe, Farrelly, & Wenter, 2007), access to healthy foods and healthcare, and marketing activities related to alcohol and other products (Wallack et al., 1993).

Framing is an important part of media advocacy; and framing or reframing certainly played a part in the success of the Surgeon General’s efforts related to AIDS in the 1980s. Media framing of issues involves selection and emphasis of certain aspects of an issue, which promotes salience among the audience (Entman, 1993). Reese et al. (2001, p. 7) refers to framing as "the way events and issues are organized and made sense of, especially by media, media professionals, and their audiences." Framing has also been linked to agenda setting and building and is evident when we see media influencing how people think about an issue by placing emphasis on some attributes while ignoring others (Kiousis et al., 2006). When information subsidies have a clear influence on media coverage of an issue, message integrity has been achieved (Carroll et al., 2014). Message integrity refers to an organization’s messages remaining intact after going through an intermediary’s editorial process (Carroll et al., 2014).

The current study looked at content produced by the Surgeon General and U.S. government and the resulting media coverage through the lens of media advocacy, including framing, and considering the concept of message integrity. In terms of public relations history, this study contributes by focusing on non-corporate communication. While presidents and other politicians have been studied extensively (Lamme & Russell, 2009), the U.S. Surgeon General and other government individuals or entities that influence public health are less present in existing literature. This paper fills a gap by focusing on government communication about a public health issue, which was influenced by public relations in the form of media advocacy. VanDyke and Lee (2020) recently highlighted the parallels between public relations and science or health communication, and this study supports that thesis.

As the incidence of AIDS increased in the 1980s, media covered the issue more extensively - and the media and many individuals, including Surgeon General Koop, helped frame the issue for the public. How did Koop help build the agenda for AIDS, frame or reframe the issue, and what solutions did he advance in his communication efforts? And how did media and some members of the public react and frame Koop's actions in response?

This paper explores how Koop communicated about AIDS in the 1986 Surgeon General's Report, the 1988 “Understanding AIDS” mailing, and in related speeches and documents during that time. This study also examines how media and the public framed Koop's historic actions in response. In doing so, this study adds to existing research on the importance of public relations and the government’s role in communicating about important issues and ultimately impacting public health (Anderson, 2018a, 2018b; Taylor & Kent, 2016).

3. Method

This study employs what some historians have called "content assessment," a method involving "reading, sifting, weighing, comparing and analyzing the evidence in order to tell the story" (Marzolf, 1978, p. 15). In terms of analysis, the researcher relied on the process of emergence (Lamme & Russell, 2009; Startt & Sloan, 2003), looking for themes that emerged across the materials, keeping in mind “the concept of time and the notion of change in relation to larger processes of transformation” (L‘Etang, 2008, p. 321). Research focused primarily on documents and media coverage produced between 1986 and 1988, although additional materials help provide context. The C. Everett Koop Papers, housed at the National Library of Medicine, provide online access to primary sources, including the 1986 Surgeon General's Report on AIDS, the 1988 “Understanding AIDS” brochure, speeches, press conference remarks, "reminiscence" notes from Koop, and other documents related to these events. The online database can be sorted by subject files including AIDS, which holds materials from 1984 to 2005. Within these files, the researcher focused on 1986–1988 as well as Koop’s memoir documents from 2003 that focused on AIDS. In terms of document type or genre, this study focused on analyzing speeches, remarks and addresses, letters, memoirs or reminiscence notes, and official reports and brochures. Other types of documents in the files, such as audiovisual materials, were not included in this analysis. Approximately 185 documents were reviewed, though some were duplicates with slight variations (e.g., speeches).

These documents were analyzed and compared with appropriate media coverage of the events. Notable newspapers, specifically The New York Times, The Washington Post and The Los Angeles Times, were the focus of this study for several reasons. First, these newspapers are often recognized as agenda-setting newspapers with high circulations. They are produced in the most populous cities in California and New York, where the first AIDS cases were reported, as well as in Washington, D.C, where President Reagan, Koop, and other political figures resided at the time. Additionally, they were the newspapers used to represent the "media agenda" in a previous study of media coverage of AIDS in the 1980s for many of the same reasons noted in this study (Rogers et al., 1991). As such, these sources are highly appropriate for inclusion in this study’s analysis. LexisNexis and other academic databases were used to find newspaper articles, using the search terms “AIDS” and “Koop” and searching between January 1, 1986 and December 31, 1988. Focusing on the aforementioned three newspapers, approximately 244 articles were reviewed, though some were duplicates or short blurbs; editorials and letters to the editor were not included in this analysis.

4. Results

Results from analysis of the materials described above are presented in chronological order, for the most part, from 1986 to 1988. Headings reflect analysis of The C. Everett Koop Papers and media coverage. The major themes and organization of findings are presented as follows: Koop’s efforts to reframe HIV/AIDS and media coverage of AIDS as a medical (rather than moral) issue; his leadership in using unprecedented government communication tactics and media coverage of those efforts; and Koop’s remembrances and media coverage of his work going against the political administration at the time to impact public health.

4.1. Reframing AIDS in the 1980s

Examination of dozens of speeches by C. Everett Koop, along with the 1986 Surgeon General's Report, the 1988 Understanding AIDS brochure, and related documents and media coverage, show that Koop framed AIDS as a public health issue. More importantly, he helped reframe AIDS as a medical epidemic, rather than a moral debate. This may seem like common sense now, more than 30 years after these early efforts when almost everyone is familiar with HIV/AIDS and the ways in which it can be contracted, but it was a different way of looking at a deadly and initially mysterious and stigmatized disease. At a time when the government was not showing leadership in communicating about this issue, Koop helped focus the public’s attention and reframed the issue from whom to what causes AIDS.

On October 22, 1986, C. Everett Koop hosted a press conference on behalf of the U.S. Public Health Service in Washington, D.C. At this press conference, Koop informed the media that in February 1985, President Reagan had asked him to "prepare a report for the American people on AIDS," and that report was now complete (Koop, 1986, p. 1). Press kits were distributed to media, complete with a copy of the report and a list of the 26 health agencies and organizations Koop consulted with in preparing the report. The report was available by request, and Koop informed the media that there would be public service announcements on television prompting the public to call or write the government to receive a copy of the report. This by request method is how materials about VD were distributed in the 1930s (Anderson, 2018a). Koop told the media he had produced an objective health and medical report. Throughout the press conference and in the report, Koop used scientific language that reflects his objective stance as a medical doctor along with language that reflects his passion for educating the public about a "devastating" epidemic that "must be stopped" by providing information that is "vital to the future health of this nation" (Koop, 1986, p. 1–3).

Early on in his speech, Koop acknowledges that, "controversial and sensitive issues are inherent in the subject of AIDS, and these issues are addressed in my report;" he adds that value judgments are absent from the report (Koop, 1986, p. 2). Koop reminds the media: "From the start, this disease has evoked highly emotional and often irrational responses," which were compounded by "personal feelings regarding the groups of people primarily affected - homosexual men and intravenous drug abusers." He then coins a phrase that he repeats often in future speeches, a phrase that is also picked up and printed by the media: "We are fighting a disease - not people" (Koop, 1986, p. 4).

In his efforts to focus on public health and education, Koop focused on behaviors and prevention, rather than people and lifestyles. In the 1986 speech, Koop states that the risk of AIDS infection escalates with increased numbers of sexual partners - male or female. He states: "The best protection against infection right now - barring abstinence - is use of a condom" (Koop, 1986, p. 9–10).

The 36-page Surgeon General's Report elaborates on these messages with thorough details about how AIDS is and is not transmitted, including information on insects, pets, tears and saliva. There are section headings such as, "No Risk from Casual Contact," which is accompanied by an image of a hamburger and beverage, illustrating the fears and misconceptions that existed at the time (United States Public Health Service, 1986, p. 13 and 17). In other sections of the report, Koop seems to show his affinity for dramatic language once again, such as the introduction, which solemnly states, “this report could save your life” (U.S. Public Health Service, 1986, p. 3).

At times, Koop strays from his medical agenda and seems to revert to his conservative, religious roots, using the opportunity to preach values to the media and the public. At the press conference, he stated: "Couples who engage in free-wheeling casual sex these days are playing a dangerous game" (Koop, 1986, p. 9). In the report distributed to the media and public, he wrote: "From a social point of view, it may bring to an end the free-wheeling sexual lifestyle which has been called the sexual revolution" (U.S. Public Health Service, 1986, p. 27). In another section of the report, which could be a nod to Nancy Reagan's famous 1980s "Just Say No" to drugs campaign, Koop wrote:

Single teen-age girls have been warned that pregnancy and contracting sexually transmitted diseases can be the result of only one act of sexual intercourse. They have been taught to say NO to sex! They have been taught to say NO to drugs! By saying NO to sex and drugs, they can avoid AIDS which can kill them! The same is true for teenage boys who should also not have rectal intercourse with other males. It may result in AIDS (U.S. Public Health Service, 1986, p. 18).

In the 1986 speech and report, Koop also addresses two means of disease control that were discussed at the time - compulsory blood testing and quarantine. Koop states that mandatory blood testing is not necessary and would be unmanageable and cost prohibitive. He explains that people who test negative for the disease could actually be positive due to recent exposure, thus rendering mandatory blood testing ineffective against the spread of AIDS. He also acknowledges that, "quarantine has no role in the management of AIDS because AIDS is not spread by casual contact." Yet another section of the report titled, "Identification of AIDS Carriers by Some Visible Sign," suggests that some people wanted individuals with AIDS to somehow be marked or tattooed so they could be recognized. Koop closes this section and the report harking back to his message at the beginning of the speech and report: "AIDS must and will be treated as a disease that can infect anyone. AIDS should not be used as an excuse to discriminate against any group or individual" (U.S. Public Health Service, 1986, p. 34).

4.2. Media coverage of AIDS as a public health issue

The media and the public seemed to welcome Koop's reframing of AIDS as a medical rather than moral issue, as well as his focus on facts rather than fear. A Los Angeles Times article called the preparation of the 1986 report, “a watershed event in public thinking about AIDS” (Clift & Cimons, 1986, p. 17). The Washington Post published an almost verbatim version of the 1986 report, focusing on Koop’s clinical description of how AIDS is transmitted. The article includes Koop’s slogan, “’We are Fighting a Disease, Not People’” in the headline and ends with more of Koop’s words: “The spread of AIDS can and must be stopped” (Washington Post, 1986, p. Z7). As Koop requested at the press conference, the article also informs the audience how they can request a copy of the report, providing mobilizing information and a clear call to action for readers. These examples show evidence of message integrity (Carroll et al., 2014) because the key messages from Koop remained intact and some were printed verbatim in newspapers read by the public. It also shows evidence of agenda building and framing or reframing the issue with a focus on solutions, illustrating the media advocacy process.

Other media coverage shows support of Koop’s efforts from the scientific community. A “prestigious panel of scientists,” including members of the National Academy of Sciences and the Institute of Medicine, produced a report commending Koop’s efforts, calling for stronger leadership from President Reagan, and urging a “large-scale media, educational and public health campaign” (Russell, 1986, p. A1). Echoing the seriousness that Koop placed on the disease and the urgency of continued communication efforts, the panel voiced “major concern” about the lack of cohesiveness at the federal level and warned of impending catastrophe without further mass communication and public education about the AIDS epidemic (Russell, 1986, p. A1).

The media also recognized Koop’s other efforts, including television appearances and speeches at various conferences. A New York Times review about Koop's HBO Special, "AIDS: Everything You and Your Family Need to Know…But Were Afraid to Ask," portrayed Koop as a "medical man presenting medical facts" and called the show a "genuine public service" (Corry, 1987, p. 17). At a forum for business leaders preparing a corporate response to the AIDS virus, Koop stressed the importance of good science and strategic planning. A Wells Fargo executive who attended the conference where Koop spoke said the company was aware of 15–20 cases of AIDS among employees, but they had prevented panic through public education (Los Angeles Times, 1987a, p. 18).

A Washington Post article not only recognized Koop’s efforts to stress public health and safety over morality and values, but also provides a glimpse into what Koop was facing in Washington at the time: “Meanwhile, in Washington, the puritans are engaging the pragmatists in the kind of rear-guard action on AIDS policy that is more appropriate to colonial New England than to the current public health crisis” (Mann, 1987, p. B3). Citing the fact that The New York Times and Time magazine would begin accepting condom advertising, not to mention Koop’s “giant step away from conservative orthodoxy” in the sex education debate, the article stated: “common sense is making a breakthrough in America’s epic struggle with sex” (Mann, 1987, p. B3). Some of the actions noted here are evidence of Koop’s media advocacy efforts; changes in advertising and in sex education seem to be the result of Koop pushing this issue onto the agenda, reframing it, and advancing more open communication and public education. Koop’s leadership was integral in advancing these solutions and in reducing stigma related to AIDS.

4.3. Leading government communication about “Understanding AIDS”

On May 4, 1988, Koop hosted another press conference about the upcoming AIDS brochure and historic national mailing. In the beginning of this speech, he referred to the 1986 press conference and report, stating that 19.2 million copies had been distributed at the request of individuals, corporate groups, and by congressmen who sent the report to their constituents. Additionally, he stated that the report had been reprinted in magazines and newspapers about 20 million times (Koop, 1988). The continuing requests and need for information about AIDS led to a Congressional mandate, enacted on December 22, 1987, "that the Department of Health and Human Services, through the Public Health Service's Centers for Disease Control distribute a national mailing of information on AIDS to all United States households" (Koop, 1988, p. 1). Koop acknowledged that this was the first time in U.S. history that the federal government sent information on a sexually transmitted disease to every home in America. He explained the need for this effort by citing a continued "epidemic of misunderstanding" about AIDS, noting that despite a steady flow of information from the government: "The American public has been whipsawed by publications from the private sector accusing the government of circulating inaccurate information and suggesting either that we have seriously over-estimated the problem on the one hand, or that we have withheld information on the transmission of AIDS on the other" (Koop, 1988, p. 2).

In this way, Koop framed the government's involvement in the fight against AIDS as a necessary public education campaign. He framed it as a community effort, in which he was leading the way, but in which the participation of everyone was necessary. He informed the media that the brochure was designed to provide facts, quiet fears, and lessen discrimination against those who had AIDS. Once again, Koop focused on prevention and behaviors, rather than people and politics. "We are endeavoring to make everyone understand that who you are has nothing to do with the danger you face of becoming infected with the AIDS virus. What does matter is what you do" (Koop, 1988, p. 5). Koop told the media directly: "This mailing speaks in frank, simple, clear language about oral, vaginal and anal intercourse as well as the proper use of condoms. This is information every sexually active American should know."

Koop led the way in separating politics from public health, stating: "A careful reading of this brochure should enable the reader to separate true health information from various political agendas promoted at the expense of the public's health" (Koop, 1988, p. 7). He referred to the brochure as an educational tool adding, "in the absence of a vaccine or a cure for AIDS, the only weapon we have is information and education." Koop called the historic mass mailing of the Understanding AIDS brochure, "the closest we can come to making something required reading in every American home" (Koop, 1988, p. 8). He recognized the role of family in his public education campaign, expressing his hope that parents and grandparents would sit down and review the information with children and teenagers. He said he hoped that friends and co-workers would discuss the brochure as well. By framing AIDS education as a community public health effort, Koop once again tried to bring the disease out of the shadows and into public conversation, attempting to reduce stigma not only for those who had AIDS but also for discussion of the topic among the general public.

The tactics Koop used, by hosting the 1988 press conference and releasing the brochure to the media months before the actual mailing, were somewhat unusual for sharing government and medical information at the time. Koop noted that typically when such information was released to the press, the contents would be under embargo until a certain date, but this mailing was being managed differently. He told media at the press conference:

We are giving you advance copies long before it will appear in the mail… Instead of asking you to hold it close until a later date, we are doing just the opposite and asking you to give it as much publicity as you possibly can because we want the American public to be aware of the brochure that will eventually be found in their mailbox, and we want them to be interested enough, concerned enough, and indeed curious enough to read it and read it carefully and share it in discussions with others as I have already suggested (Koop, 1988, p. 9).

Koop called upon the media directly to aid him in public education efforts: "No one can do this as well as you. We need you" (Koop, 1988, p. 9). He appealed to the media by praising them, admitting that the media had helped sustain public interest in AIDS, and he asked them to do that once again. "You've done a credible job in education… I hope that you will join me and get behind this effort and do everything you can to make the average American eager to find this brochure in his mail" (Koop, 1988, p. 16). In one of his reminiscence notes, Koop wrote that he "challenged the press" to help him (Koop, 2003a, p. 4). His leadership here, in terms of working with media, is likely one of the reasons for the success of these media advocacy efforts overall.

Beyond media, Koop also believed that schools should be involved in the public dialogue surrounding AIDS. He encouraged schools to begin sex education programs, which contrasted with his earlier conservative ideals. A full three pages of his 14-page press conference speech in 1986 focused on sex education for children. He stated: "We can no longer afford to sidestep frank, open discussions about sexual practices - homosexual and heterosexual. Education about AIDS should start at an early age so that children can grow up knowing the behaviors to avoid to protect themselves from exposure to the AIDS virus" (Koop, 1986, p. 6). Koop's 1988 speech also called for sex education in schools; this push for early and more explicit sex education is another example of focusing on solutions and pushing for policy change related to AIDS. This is an important distinction of media advocacy compared to public relations or media relations – solutions in the form of policy change(s) are an integral outcome of successful media advocacy.

4.4. “Understanding AIDS:” a historic event

In creating the "Understanding AIDS" brochure on behalf of the U.S. government, Koop consulted with numerous experts and organizations as well as with well-known advertising and public relations agency, Ogilvy & Mather. In the 1988 press conference, Koop stated that there were four specific issues under constant discussion between him and the staff at Ogilvy & Mather. First, was what Koop called, a "paradox when it comes to consumer attention" (Koop, 1988, p. 10). He explained that while people are concerned about AIDS, it was not a true priority in the lives of most Americans. Thus, he said that everything about the brochure needed to encourage readership. Second, Koop stated that people were reluctant readers and tended to glance more than they read. Because of this, they tried to make the brochure appealing and easy to digest to both "glancing readers" as well as "serious students of AIDS" (Koop, 1988, p. 11). Third, Koop acknowledged that AIDS is a complex issue. He mentioned the struggle to not arbitrarily assign more importance to one topic than the other, and to ensure that all important information was presented equally and not buried. Fourth, Koop stated the importance of not sounding like researchers, preachers or even government officials:

We wanted this to be a chatty document not a medical seminar and indeed not a sermon. Certainly the content was critical but so was the tone of voice. The advice couldn't be impractical or unworkable and even though the scientists and moralists walk hand in hand in the control of AIDS, we could not make moral judgments (Koop, 1988, p. 13).

Working with Ogilvy & Mather, Koop seemed to accomplish his goals. The "Understanding AIDS" brochure began with a brief message from the Surgeon General, complete with Koop's photo and signature, and had individual sections broken out with clear headings, such as "How Do You Get AIDS?" and "The Problem of Drugs and AIDS" (U.S. Department of Health and Human Services, 1988, p. 2 and 6). The brochure directly addressed "you" consistently, making it clear that anyone can get AIDS, and headlines like, "You Won't Get AIDS from Insects - or a Kiss," followed by "What about Dating?" and, "What is All the Talk about Condoms" demonstrated the "chatty" language Koop sought to employ (USDHHS, 1988, p. 3–4).

In another attempt to show that AIDS could impact anyone, the brochure includes photos of men and women of various races and ethnicities, including two women identified as having AIDS, an AIDS counselor and AIDS volunteer, and two medical experts. At the 1988 press conference, Koop stated, "by introducing real living people in a credible human way… captions in the first person make a point, and in doing so, share a preventive idea or debunk a myth" (Koop, 1988, p. 15). A section titled, "What Does Someone with AIDS Look Like?" reiterated that there was no one type of person with AIDS in an effort to further reduce stigma and stereotypes (USDHHS, 1988, p. 5). This section features a photo and quote from Dr. Anthony Fauci, then coordinator of the National Institutes of Health AIDS Research. As Koop mentioned in a reminiscence note, this headline juxtaposed with the photo of Dr. Fauci was an error in brochure layout and design because it appeared as though Fauci was featured as an example of what someone with AIDS looks like. Koop noted of his relationship with Fauci following this mistake: "He took it in good grace and we are still good friends" (Koop, 2003b, p. 2).

Sections about "AIDS and Babies" and "Helping a Person with AIDS" were included to further reduce stigma and reiterate that AIDS can affect anyone. A section on "Talking with Kids about AIDS" provided a direct call to action, while a quiz about AIDS was included to test readers’ knowledge about the disease before they discussed it with others (USDHHS, 1988, p. 6–7). The brochure included a message in Spanish, informing Spanish-speakers that they could receive a copy of the brochure in Spanish by calling an 800-number. The brochure also included the number for an English-speaking AIDS hotline and an additional note in fine print: "Reproduction of the contents of this brochure is encouraged" (U.S. Department of Health and Human Services, 1988, p. 1).

Overall, the brochure is fact-based and informative. There are a few parts where the brochure took the opportunity to preach values. For example, the brochure stated that "no one should shoot drugs," and "children must be taught values and responsibility" (USDHHS, 1988, p. 6), but these types of statements were not nearly as frequent as in the 1986 report. Presumably, this may be due to the involvement of a public relations firm, as well as the scope of the 1988 mass mailing compared to the 1986 report, which was available by request.

4.5. Media coverage of “Understanding AIDS” and related efforts

Media coverage seemed to reflect Koop’s leadership of the government’s communication as necessary public education. The media also seemed to heed Koop’s advice and informed the public about Understanding AIDS before the brochure was mailed. Front-page coverage in the Los Angeles Times noted that the government had been criticized for taking too long to produce a national AIDS mailing, and that the forthcoming information from Koop was “highly regarded” (Cimons, 1988, p. 1). The article also included some sobering statistics: as of that week in 1988, 60,852 Americans had contracted AIDS, 34,088 of whom had died.

In response to Koop's calls to action for earlier and more explicit sex education in the classroom, the Conservative Digest published an eight-page article titled, "Sex Education is Just No Business of the Government" (Lee, 1987, p. 91). The article stated that Koop's 1986 report contains "much guesswork" about AIDS, refers to San Francisco as the "homosexual heartland," and urges conservatives to oppose increased sex education in schools without compromise (Lee, 1987, p. 91, 93, and 98). Much of the media coverage surrounding sex education highlighted the debate that seemed to be going on at the time between Koop and Secretary of Education William Bennett. Generally, Bennett wanted sex education to stress morals and abstinence, while Koop wanted more honest acknowledgement of adolescent awareness of sexual activities, including condom use and homosexual behaviors. A Los Angeles Times article juxtaposes Koop’s desire for schools to teach sex education as early as possible, including information that directly addresses AIDS, with Bennett’s belief in the importance of including moral values in sex education. Showing the clear dissimilitude between the two men, Bennett said that courses should teach heterosexual sex as the appropriate behavior. Meanwhile Koop responded, “We never addressed it” (Cimons, 1987, p. 2).

Other media coverage focused on Koop’s work to bring condom advertising to network television. In testimony before a House panel, Koop said he believed network television advertising for condoms would help prevent the spread of AIDS. "'The threat of AIDS is so great that it overwhelms other considerations, and advertising, I think, therefore is necessary in reference to condoms and would have a positive public health value,'" Koop said (Los Angeles Times, 1987b, p. 2). Shortly after this testimony, ABC announced that it would begin broadcasting 30-second public service announcements for condoms (Michaelson, 1987). Other news coverage cited an increase in condom sales around the same time as Koop’s testimony and the increase in network television advertising (Los Angeles Times, 1988, p. 4). These changes in advertising policies, and subsequent changes in individual behaviors (i.e., purchasing condoms), are indicators of the success of Koop’s media advocacy efforts, including agenda building, reframing the issue, and suggesting policy change as part of the solution to the problem of AIDS.

4.6. Koop’s leadership & the politics of public health

In many of C. Everett Koop's "reminiscence notes," and even in some of his more public communication, he framed himself as a maverick and a hero for pushing such an aggressive agenda of education and government action in the fight against AIDS. He also paints himself as a conservative martyr of sorts, because he was working in opposition to many of his conservative compatriots and even the President and the White House for a time. For the most part, Koop's view of himself seems to be reflected in media coverage and public response to his efforts.

In reminiscence notes about the 1986 press conference and report, Koop referred to the "unbelievable political undertones" of AIDS and the "reluctance of the administration to come to grips with AIDS" (Koop, 2003b, p. 1). He stated that he was never informed why the Surgeon General was not to discuss AIDS at any public forum (prior to 1986). "In retrospect, any fool would know that if there was ever a disease that needed the communication of a Surgeon General… it was AIDS." Koop stated that there were many unfilled posts in the Public Health Service during President Reagan's second term, and he stepped in to fill the void. He writes about the "constant pressure on me" as the "chief spokesperson for AIDS," a role for which he took part in innumerable radio and television appearances, documentary films (including an HBO special), and delivered "well over one hundred lectures in every conceivable forum" (Koop, 2003b, p. 1).

Between 1986 and 1988, Koop delivered speeches to numerous diverse audiences. He spoke at the Institute of Politics at the John F. Kennedy School of Government at Harvard University (Koop, 1987a). He delivered addresses at meetings of the National Religious Broadcasters in Washington, D.C. (Koop, 1987b) and the Christian Life Commission of the Southern Baptist Convention in Charlotte, NC (Koop, 1987c). He addressed the National School Board Association in San Francisco (Koop, 1987d), and the American Medical Association in Chicago (Koop, 1987e). He also spoke to the National Association for the Advancement of Colored People (NAACP) in New York (Koop, 1987f), and at a meeting of producers, writers and directors in Los Angeles (Koop, 1987g).

While the theme and focal points of these speeches varied depending on the audience, Koop consistently delivered a strong message about the importance of public education about AIDS. For example, when speaking to the National Religious Broadcasters and the Christian Life Commission, he did not abandon his beliefs about the importance of sex education in schools, nor did he gloss over the perceived religious and moral issues of homosexuality. However, he did tailor his message to his audience. In this case he focused on a principle of Christianity to "separate the sin from the sinner," reminding the audience: "You may hate the sin, but you are to love the sinner" (Koop, 1987b, p. 29). Again, he reminded the group, "we are fighting a disease - not people." He also stressed the fact that "more and more truly innocent people" were being affected by AIDS, including babies born to infected mothers and wives of promiscuous or bisexual husbands (Koop, 1987b, p. 31).

Koop's speeches seemed to be appreciated by many audiences, and letters from the groups he addressed indicate that he may have won some friends through these efforts, despite the difficult topics he was covering. The director of the Christian Life Commission wrote a letter to Koop, thanking him for offering to meet with the group and addressing "the AIDS nightmare." The letter assures Koop that the Christian Life Commission "will strive to contextualize the problem within our Christian tradition's emphasis upon monogamy, sexual fidelity, drug-free living, and resistance to promiscuous life-styles" (Braidfoot, 1986). The executive director of the National Coalition of Black Lesbians and Gays also sent Koop a letter following the release of the 1986 report indicating the group’s appreciation of his efforts. The letter states that while they wish the report had elaborated on "the issue of AIDS in Black and Brown communities," nonetheless, "the report and your statements exceeded our expectations" (Gerald, 1986).

In a reminiscence note, Koop wrote about his struggle with the conservative right in his work to push AIDS and sex education onto the public agenda. As noted, conservatives at the time wanted a continued focus on morals and abstinence (Braidfoot, 1986; Lee, 1987). Koop "lost some ultraconservative old guard Republicans, because they thought I was coddling homosexuals" (Koop, 2003a, p. 1). Regarding his push to make sex education a priority in schools, he was accused of "leading the children of America down the garden path to immorality." Koop wrote: "I lost fearful parents who didn't have the courage to teach their own children what they should know about sex education and instead condemned me for trying to help. It was from this group, I presume, that the threats on my life arose from time to time" (Koop, 2003a, p. 1). From the 1986 press conference and report to subsequent communication efforts, Koop learned that almost any health warning issued by the Surgeon General "divides the populous into those who agree with him and those who do not. There are always zealots on each side; and they always make themselves heard" (Koop, 2003a, p. 2).

4.7. Media coverage of Koop’s leadership in putting public health before politics

The media echoed Koop's sentiments about working against the grain both in the White House and among the larger conservative community. Highlighting Koop's conflicts with previous conservative supporters, one article discussed Republicans Jack Kemp and Bob Dole dropping their support of a banquet honoring Koop, "who was once a favorite of conservatives and anti-abortion groups but has come under criticism in such circles" (New York Times, 1987, p. A16). Yet another article titled, "Doctors Who Shun AIDS Patients are Assailed by Surgeon General," highlighted Koop's struggle against misconceptions and discrimination of information even among some members of the medical community. In an address to the Presidential Commission on the HIV Epidemic, Koop provided the "strongest condemnation yet by any Federal health official," and "denounced doctors and other health workers who refuse to treat AIDS patients as a 'fearful and irrational minority' who are guilty of 'unprofessional conduct'" (Boffey, 1987, p. A1).

In a particularly colorful article about Koop and his crusade against AIDS, columnist Maureen Dowd referred to Koop as a lighting rod for one of the most sensitive moral issues in the country, noting that Democrats who used to define the Surgeon General as a "scary" "right-winger," now call him "a man of heroic proportions" (Dowd, 1987, p. B8). Dowd acknowledged, "the 70-year-old Dr. Koop spreads the graphic gospel of AIDS prevention," even while President Reagan and most White House officials either avoid the issue or preach sexual abstinence (Dowd, 1987, p. B8).

Dowd highlighted accolades Koop received from the gay community, calling him an unlikely hero who came along when he was really needed. She reminded readers that the man who once made decisions based on religious beliefs, who toured the country with a film featuring an image of him standing in the Dead Sea preaching against abortion, had certainly changed. When it came to AIDS, Koop emphasized science rather than values. In response to this assessment, Koop commented (behind his "Captain Ahab beard"): "'I am not afforded the luxury of bringing ideology or morals into my job, especially with the sort of threat we have with AIDS…. I guess what I'd like people to say about me, when the controversy dies down, is that I handled the job with integrity and didn't bow to pressures'" (Dowd, 1987, p. B8). In this column and elsewhere, Koop’s work to improve public health, despite political pressures and previous lack of government communication about AIDS, is acknowledged and seems to be appreciated.

5. Discussion and conclusions

Overall, Koop seemed to accomplish his mission. Although he may have lost some conservative friends along the way, Koop helped build an agenda and reframed the issue of AIDS in America at a time when it needed to happen, and when no other government official seemed willing to take the political risk. By reframing AIDS as a medical rather than a moral issue, Koop put aside politics in favor of public health. By repeating his mantra about fighting a disease, rather than people, Koop helped reframe the conversation from focusing on whom to what causes AIDS, helping to reduce stigma. Furthermore, by offering scientific and explicit fact-based information and continuously stressing the importance of education and public participation, Koop framed the government's involvement in the fight against AIDS as a necessary public education campaign. He shed light on a disease that had previously been shrouded in fear, and the media and the public recognized Koop for his efforts.

In recognition of Koop's AIDS efforts in the 1980s, the National Association of Government Communicators (a group made up of press and public affairs representatives of federal, state and local governments) named Surgeon General C. Everett Koop "Communicator of the Year" in 1988. An article about the award in Public Relations Quarterly states that Koop worked boldly and tirelessly, more or less on his own: "Our group pays tribute to his energy and his willingness to travel anywhere, anytime and to speak and consult. And to tell it the way he sees it" (Grigg, 1988, p. 6–7). Indeed, Koop was recognized as a leader and as a "doctor-communicator" and a "medical missionary" who "decided to save lives now - and souls later." In summary, Koop's media advocacy efforts to educate the public about a deadly disease, to separate public health from politics and medical facts from moral judgments earned him the "mark of a good man, a fine doctor and a great communicator" (Grigg, 1988, p. 6–7).

Current and future government communicators, public relations practitioners and students can learn from Koop’s leadership and example, particularly when communicating about health issues or controversial topics. His media advocacy efforts helped change perceptions, norms, and public health. His leadership, particularly in the face of partisan politics, is an important lesson for those working in Washington and elsewhere. In terms of research, this work shows evidence of media advocacy at work, with media relations and coordinated, multi-faceted communication leading to real change in terms of sex education, advertising policies, and more. Koop clearly helped build an agenda for AIDS in the 1980s. He took a risk in reframing the issue, achieved message integrity by challenging and working with media, and he called for solutions that eventually made a difference in terms of policy and individual behaviors.

Future research should consider leadership as an important part of media advocacy efforts and seek to determine if/when an individual or organization leads successful efforts. Because media advocacy is a complex process, which is probably best understood in hindsight, historical research may be particularly useful for continuing to explore and understand the concept. Message integrity is another concept that could be useful in examining media advocacy efforts from a historical perspective. Knowing how policy and social changes take place is important for organizations, and knowing what worked in terms of communication is an integral part of that process. Though limited in scope, this study sheds light on media advocacy related to AIDS in the 1980s. It reveals the importance of leadership, of putting aside politics in favor of public health, and the specific strategies and tactics that helped achieve not only individual behavioral but also large-scale policy and social changes. Future research could look at communication efforts by President Donald Trump, Dr. Anthony Fauci, Surgeon General Jerome Adams and/or other individuals communicating with the public during the COVID-19 pandemic.

As noted, a recent article discusses the parallel and interwoven trajectories of public relations and science communication theory and practice (VanDyke & Lee, 2020). This study further provides evidence of some of the similarities between public relations and health and science communication. What has been referred to as agenda building in public relations is similar to media advocacy, as described in health communication. The concept of message integrity is a useful supplement to research in these areas, as it enables researchers to look at the transfer of messages from organizations and individuals (such as Koop) to media; in turn, these messages may become salient among the public. As VanDyke and Lee (2020) note, more research is needed in these areas. This study also highlights the complexities of public relations and communication from individuals employed by government entities, as noted in previous work by Anderson (2018a, 2018b) and Taylor and Kent (2016) and suggests the need for more research on the nuances of communicating about controversial issues in partisan environments. This historical case study adds to existing literature in many areas, but future research should continue to explore such parallels and contrasts to help us better understand the impact of public relations on public health.

Funding

This research did not receive any grant funding from agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The authors report no declarations of interest.