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

Abstract

Purpose

The main aim of this article is to broaden the notion of strategic intent in public relations. It also develops an understanding of the social value of what can be defined as the first modern health communication campaign in Europe based on strategic intents and the development of modernity.

Design/methodology/approach

The study is based on both historical research and empirical material from the Norwegian tuberculosis campaign from 1889 up to 1913, when Norwegian women achieved suffrage. The campaign is analysed in the framework of modernity and social theory. The literature on lobbying and social movements is also used to develop a theoretical framework for the notion of strategic intent.

Findings

The study shows that strategic intent can be divided into two layers: (1) the implicit strategic intent is the real purpose behind the communication efforts, whereas (2) the explicit intent is found directly in the communication efforts. The explicit intent may be presented as a solution for the good of society at the right political moment, giving an organisation the possibility to mobilise for long-term social changes, in which could be the implicit intent.

Originality/value

The distinction between explicit and implicit strategic intent broadens our understanding on how to make long-term social changes as well as how social and political changes occur in modern societies. The article also gives a historical account of what is here defined as the first modern health communication campaign in Europe and its social value.

Citation

Dahlen, Ø.P. (2024), "The first modern health communication campaign in Europe: explicit and implicit strategic intents", Corporate Communications: An International Journal, Vol. 29 No. 7, pp. 74-91. https://doi.org/10.1108/CCIJ-08-2023-0106

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.

2.1 Strategic intent

To gain a general perspective of what PR is in a historical context, Lamme and Russell (2010) reviewed secondary literature about public relations history prior to 1900. They identified common functions of PR, over time and across sectors, as media relations, community outreach and reputation management. The institutions and individuals who performed the function tended to understand the power of persuasion and the strategies required to do things effectively (Lamme and Russell, 2010, p. 352). The communication activities were mainly driven by five motivations: profit, recruitment, legitimacy, agitation, advocacy, and fear (Lamme and Russell, 2010; Russell and Lamme, 2013, 2016). If the intent was to increase profit, the essential measurement of the effectiveness of the communication effort was “outcome – whether or not profits actually increased” (Russell and Lamme, 2016, p. 744). Russell and Lamme (2016) argue, therefore, that “rather than focusing on PR as a function or the functions of PR, public relations historians should consider the strategic intent of the practitioners” (p. 744). This is in line with a social-constructivist view of public relations in which “public relations can be understood as the strategic attempt to get the subjects of public relations activities to construct the intended meaning of the employing or commissioning entity rather than any other meaning” (James, 2009, p. 109). Melanie James defines strategic intent as “the intention to do something for the purposes of maintaining or gaining some kind of competitive advantage” (pp. 110–111), whereas Russell and Lamme (2016) defines it as the “expected outcome” (p. 746) and state that “communication tactics are employed with a specific outcome in mind” (p. 744).

2.2 The three modern sectors

Lamme and Russell (2010) divided PR into four sectors in their historical investigation into public relations: (1) religion; (2) education, nonprofit and reform; (3) politics and governments; and (4) business. This categorisation can be applied to the three formal institutions (or sectors) associated with modern PR and a modern society (Bentele, 2015, p. 29): (1) the state (governments); (2) business; and (3) civil society (nonprofit and reform), with religion and education can be potentially embedded in all three institutions. These three sectors have specific functions or strategic intents in modern societies, where Wagner (1994, p. 7) argues that the nation state is primarily an instrument to restrict practices and discipline individuals. (1) States want to control and govern societies, (2) civil society organisations want to change (or preserve) society either concretely (by organising activities for groups of people) or structurally (either locally, nationally or internationally) and (3) businesses want to accumulate profit. In modern states (health) care is provided within four different systems: (1) the state (national and local governments’ public health care), (2) the civil society (voluntary care), (3) commercial organisations (based on income) and (4) private, informal care (family, relatives and neighbours) (Blom, 1998, 1999), where the first three correspond to the three mentioned institutions of modern societies (see Table 1).

2.3 Societal changes and civil society

In civil society, activists attempt to inspire and mobilise others to join their cause to create long-term social changes (Anderson, 2017, p. 508). These changes can be achieved if they manage to frame the social problem right and at the right political moment. The latter is when “shifting political opportunities can influence a movement’s definition of itself” (Noakes and Johnston, 2005, p. 21), opening up new possibilities for mobilisation and change. A successful motivational frame should be consistent, attuned to the cultural stock of the target audience and political context and relevant to the target audience (Noakes and Johnston, 2005).

Jürgen Habermas has also emphasised that civil society’s primary function (or task) is to introduce problems into the public sphere, where the goal is to create change. Actors in civil society have in Habermas’s own words a “strategic intent” (1996, p. 364) and should have “political influence” (1996, p. 363) and “influence on institutionalized opinion – and will – formation” (1996, p. 352).

2.4 System theory

Niklas Luhmann (1995) emphasises also that social movements’ tasks (or function) are to introduce problems into society and create change according to their strategic intent. This is an example of how Luhmann defines different sub-systems with different intrinsic logics (Bruun, 2008): health, economic, political, scientific, religious, legal and artistic systems. Luhmann (1995, 2009, 2012, 2013) is mostly concerned with the function of – and the form of – communication within a system, which makes his theories even more useful when analysing the development of PR.

The systems have certain logics (binary codes) within a limited system with specific functions. The function of the health sub-system is, for example, to create health. The communication in each system is standardised through a dual-value positive and negative binary code. These binary codes differentiate, simplify and substantiate communication, and reduce complexity, with the creation of simple, standardised and predictable opportunities for the endorsement of further communication within the system, linked to the different strategic intents (see Table 2).

Their functions help to explain how specific systems work and why they are maintained. In this way, the systems create boundaries with other systems and their own logic for communication (Luhmann, 1995). Thus, “the system can develop its own boundaries and hold to them because the reasonableness and unreasonableness of communication in the system can be constrained” (Luhmann, 1995, p. 145). This formation of boundaries “interrupts the continuity of processes that connect the system with its environment” (Luhmann, 1995, p. 30), making the system self-referential and separated from its environment although it also depends on its environment.

There is no superior function that is above all other systems. Each sub-system has a specific main function, which belongs solely to that specific system, which together form modern societies. Luhmann (1995) points out that the concept of the state remains unclear in his theory, especially related to politics, because “it rendered too much complexity and too much heterogeneity when applied to issues important for the concept (especially national peoples, national territory, state authority)” (Luhmann, 1995, p. 463).

Luhmann’s sub-systems are not the same thing as institutions (or Bourdieu’s fields). Even if a business belongs to an economic system, where profit is the strategic intent, its communication is very often about other matters (belonging to another sub-system). This is also in line with Habermas’ general critique against public relations: A business very often mobilizes for the firm or branch or an entire system a quasi-political credit, a respect of the kind one displays toward public authority (…) for the “general interest” (Habermas, 1989, p. 194). The communication is then based on another system in order to gain respect in society. When a business leader appears on TV, he talks about the environment and family values, not about economy and profit, which is probably his main concern in the boardroom.

2.5 Public interests

Using an argument accepted in society is also in line with Jane Johnston’s (2017) statement that “public relations should engage with the public interest in a way that society will accept” (p. 17). Lobbyists tend also to appeal to the public interest to make their task or organisation more legitimate in society (Ihlen and Raknes, 2020), and organisations (increasingly) present their “policy positions as matters of public interests” (Uhre and Rommetvedt, 2019, p. 238) “in order to define the public interest according to their own interests” (Ihlen and Raknes, 2020, p. 2). As one of the basic strategic intents of PR is legitimacy (Lamme and Russell, 2010; Russell and Lamme, 2013, 2016), this could very well be based on how the organisation defines its public interest, which provides its “social license to operate” (Ihlen and Raknes, 2020, p. 7). Moreover, different actors in different fields bring in different ethical judgments and assessments of the (right) public interest (Johnston, 2017); and Luhmann also points to different intrinsic logics in different social systems and that there are different strategic intentions among different sectors (see Table 1). This will be illustrated with a historical example in the following.

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

5.1 Female activists

Female activists got involved in the campaign against tuberculosis at the end of the century. The Norwegian Women’s Public Health Association was originally established in 1896 to provide sanitary material and teach women first aid in case of a possible armed conflict between Norway and Sweden. Increasingly more Norwegians argued for independence and to dissolve the union between the two countries, which had a joint monarch. However, the fear of war subsided, and the organisation expanded its strategic intents into other areas. It took up the fight against tuberculosis on the initiative of their president, Fredrikke Marie Qvam, from 1899 (Schiøtz, 2003, p. 71; Rogstad, 1996, p. 93; Folkvord, 2013, p. 171).

The women’s campaign began with a nationwide fundraising effort to establish institutions for tuberculosis patients. To carry out this fundraising, they received 9,000 copies of a brochure by Dr Klaus Hanssen, and they printed another 20,000 copies. In the capital, 227 ladies went door-to-door to collect support for the organisation’s work. They raised funds to send campaigners to travel around the country, to inform people about the dangers of tuberculosis and how to fight the disease. The organisation produced brochures on diet and a book on childcare distributed to women. Local branches of the organisation across the country also got involved. They created posters against spitting and promoting hygiene, and organised evening talks, where the local doctor would give an introductory talk about the disease. The sale of a Christmas stamp from 1906 and the Mayflower (a charity pin sold at the beginning of May) from 1909 brought more attention to the Women’s Health Association and their fight against tuberculosis. They built and operated tuberculosis homes and supported tuberculosis families financially and with nursing supervision. Accounts of their practical work and the results of this work were made known to the public through notices and press releases in local and national newspapers (Blom, 1999, p. 234; Blom, 2002a, p. 74; Melby, 2001, p. 40; Rogstad, 1996; Schram et al., 1946, pp. 61–62; Hamran, 2007, p. 416).

At the time, Norwegian women did not have suffrage. Consequently, they used ways to exert their influence other than through regular political channels (Melby, 2000, 2001; Bjørnar, 2001; Berven, 2001). Qvam was the strategic mastermind behind the link between the public information campaign on tuberculosis and the fight for women’s suffrage by demonstrating the usefulness of women’s contribution to the public good:

I will not hide the fact that I hope that women’s work in the Women’s Public Health Association will enable them to eventually meet the requirements that citizenship will demand of them. (Fredrikke Marie Qvam, 1921, quoted from Rogstad, 1996, p. 113, my translation)

The initiative to establish the Women’s Health Association was taken by the board of the Norwegian Association for Women’s Rights, of which Qvam was the leader and an otherwise prominent member. From the start, there were clear links with the women’s rights movement and activist women placed themselves in the leadership of the new association. They also rejected becoming a subdivision of the Red Cross, as was the original plan, and they refused to cooperate in this regard. The Red Cross was led by men and the women in the health association would not submit to their authority (Melby, 2001, pp. 46–47; Berven, 2001, p. 84; Moksnes, 1984, p. 197). By supporting the Liberal Party’s fight against the union between Norway and Sweden, the organisation also became a channel for political activity, via which the women could show their political commitment. This included a fight for national independence, political rights for women – and thus also women’s suffrage. Many of the members of the first board of the health organisation also had prominent positions in the Norwegian Association for Women’s Rights and Fredrikke Maria Qvam was elected leader off both. It is therefore suggested that the creation of the health association was part of a strategy for female suffrage (Melby, 2000, p. 90; 2001, p. 39; Folkvord, 2013, p. 149; Bjørnar, 2001, p. 64; Moksnes, 1984, p. 196).

The information campaign demonstrated women’s philanthropic intents and showed how women’s experience and skills had societal value and contributed to the common good of society (Rogstad, 1996, p. 114; Blom, 1999, p. 236). The fight against tuberculosis was a so-called respectable field, one in which women could participate in the public sphere at the beginning of the twentieth century (Melby, 2005, p. 271) given their experiences in the private and informal care system. Thus, women demonstrated political initiative before they had achieved political rights (Melby, 2001, p. 40, 48), and they did so based on the private and informal care system as providers of family care. They practised democratic rights with such conviction that it represented a powerful argument for political equality (Melby, 2000, p. 90; Melby, 2005, p. 271). It legitimised their role in public life and membership in the organisation “can be interpreted as a practice of democratic rights and was a practice that, on the other hand, effected the process of democratisation” (Melby, 2000, p. 91). The health organisation made more women conscious of their rights and it recruited activists to work for suffrage, including conservative women. Local branches of the National Association for Women’s Suffrage were established in the aftermath of the establishment of the Norwegian Women’s Public Health Association (Melby, 2000, p. 90; Melby, 2001, p. 46; Moksnes, 1984, p. 197). The organisation attracted female activists, and more women gained knowledge of organisational work (Aune, 2002, p. 112) as it became a school for women, providing them with an understanding of democracy and preparing them for participation in public life (Steen, 1948, p. 593; Bjørnar, 2001, p. 64; Melby, 2001, p. 46).

Despite women’s increasing role in public matters, they were still denied participation in the referendum on the dissolution of the union with Sweden in 1905. Consequently, women were mobilised to sign a petition to dissolve the union, and almost 300 000 signatures were sent to the Norwegian parliament. The Women’s Public Health Association was strongly involved in the mobilisation of its members together with national suffrage organisations. This campaign would later be said to have had a significant influence on the parliament’s decision to grant women suffrage in 1913 (Melby, 2001, 2000, p. 89; von der Lippe and Tønnesson, 2013, p. 38; Aune, 2002, p. 105; Moksnes, 1984, p. 196) when Norway became the first sovereign state to give women suffrage [2].

5.2 The doctors’ profession

The discovery of the tubercle bacillus may also be viewed as a battering ram for those who wanted a scientific modernisation of the medical profession and a more practical orientation. Norwegian doctors wished to increase their influence and recognition in society and to assert their position as tuberculosis specialists had done abroad. Doctors had still not gained control over the medical field by the end of the 1800s in the same way that priests had gained control in religious matters and lawyers in the administrative field. The health field was first and foremost a legally managed field (Haave, 2014, p. 277), especially when the sanitary project became a question of law and order (Schmidt and Kristensen, 2004, p. 50). The doctors were also concerned about excluding potential competitors, such as folk healers and others using non-scientific methods (Bliksrud et al., 2002, p. 349). It was important for the doctors to mark their territory and emphasise their societal value at a time when the government was debating the economic value of doctors and the medical profession (Blom, 1999, p. 236; Rogstad, 1996, pp. 111–113).

The idea of a new national association was put on the agenda at the Norwegian Doctors’ Union meeting in 1909. Many doctors felt quite distanced from the work of the women’s organisation because men could only be passive members. The Norwegian National Association against Tuberculosis was therefore established in 1910 in an attempt to coordinate the work against tuberculosis (Blom, 1999; Rogstad, 1996). The doctors wanted to incorporate the Norwegian Women’s Public Health Association into the new union, but this worried Qvam and her associates since the fight against tuberculosis by the women’s association also functioned as an instrument for recruitment, equal rights and suffrage for women, which they were unwilling to relinquish. They therefore declined to become a subordinated part of the doctors’ association. It may be said that these strategic intents became more important to Qvam and her board than the united national fight against tuberculosis, and the two groups continued working as separate entities (Rogstad, 1996; Folkvord, 2013, pp. 173–180).

5.3 The Government’s efforts

The Norwegian government was not really directly involved in the information work on tuberculosis until it introduced a special law on tuberculosis in 1900, which continued the advice from the doctors’ tuberculosis poster from 1889. The new law was also the first of its kind in the world (Grindheim, 2010, pp. 26–27) and opened up for strong interventions in individuals’ freedom and signalled that the disease was no longer a private matter but something that concerned the whole nation (Blom, 1998, p. 15). The law required all doctors to report tuberculosis, and the authorities could force an infected person to be hospitalised (Blom, p. 1998, p. 14; Ryymin, 2007, p. 146). The government also issued a special law on cleanliness in churches in 1910, in which information measures are mentioned in paragraph 6:

Information will be posted at conspicuous places, and especially at church entrances, encouraging churchgoers not to spit on the church floor or on the stairs. (Notices, January 1911, pp. 35–36, my translation)

The law was also an important basis for the educational campaigns of the Women’s Public Health Association and later the Norwegian National Association against Tuberculosis (Ryymin, 2008, pp. 347–348), and the government supported the organisations with funds. The national association could therefore produce and post “Do not spit on the floor” signboards around the country and in shops, assembly houses and other public rooms (Notices, 1912a, b, p. 74). Brochures and posters such as “Do not spit in the church” and “Do not spit on the boat deck” were published, and “Use the spittoons” posters were posted in churches, trains and train stations around the country; additionally, hundreds of lectures were arranged around the country (Notices, January 1911, p. 32; November 1911, p. 4; November 1912, p. 22; Blom, 2002a, pp. 73–74; 2002b, pp. 232–235; Erichsen, 1960, p. 25). The national association published their own magazine, Notices, from 1911, which was sent to all doctors, priests, veterinaries, midwives and teachers as well as most newspapers in Norway, and they even established their own press agency, which distributed information to the Norwegian press about tuberculosis infection and precautions (Grindheim, 2010, pp. 44–45; Blom, 2002b, p. 234).

It is, however, claimed that the Norwegian medical profession and its government placed more emphasis on the protection of society than on the curing of individual patients (Ryymin, 2009, p. 11). The public information campaign was very much directed towards the poor and irresponsible, with the intent of persuading or frightening them to act in a civilised manner. The poor were regarded as the most important carriers of the disease and those most in need of information and education (Blom, 2007, p. 125). This perception emphasised preventive work aimed at the individual’s behaviour and lifestyle, with less focus on their living conditions and opportunities (Porter, 1999, p. 165).

The governmental control function regarded especially the Sami population, which is defined as indigenous in official documents today. The traditional areas of the Samis (and Kven) in the North were acknowledged as a national problem, with twice as many infected as the national average in 1907 (Ryymin, 2007, p. 146). The general state policy at the time was to integrate this northernmost part more firmly into the national state and to assimilate the ethnic groups into the supposedly superior Norwegian culture (Ryymin, 2007). It was said that the Sami population had to become Norwegians to be able to take part in the new knowledge and become modern people (Nielsen, 2011, p. 177). This is consistent with the dominant perception of the Norwegian modernisation process as constituting “civilisation”, where civilisation came through the education of the population – Bildung zum Menschen – and through the instrumental and rational control of nature. Most of the information material from the state and the national tuberculosis organisation was therefore conducted in Norwegian even though a large part of the population did not read or speak Norwegian. The campaign against tuberculosis therefore also (openly) promoted cultural assimilation and civilisation (Ryymin, 2007, 2011). This was moreover a question of state security, where the children should learn – and use – Norwegian (Ryymin, 2011, p. 49).

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.

Table 1

The three modern sectors and their strategic intents

The three modern sectors	Strategic intents	Historical sectors (Lamme and Russell, 2010)
1 State (governments)	Govern and control	Governments, religion, education
2 Civil society	Create change	Nonprofit, reform, religion, education
3 Business	Accumulate profit	Business, religion, education

Source(s): Table by the author

Table 2

Some of society’s functional systems (Luhmann, 1995, 2009, 2012, 2013) and their strategic intents

System	Binary codes	Programme	Medium	Function	Strategic intent
Health/medical	Healthy/sick	Hippocratic oath	Treatment	Create health in the population	People’s wellbeing/health
Social movements	Affected/not affected	Protest	Mobilisation	Introduce social problems	Create change
Politics	Position/opposition	Political ideas and ideologies	Competition for power	Create collectively binding decisions	Keep or achieve power
Science	Truth/not truth	Research methods	Knowledge	Produce knowledge	Accumulate knowledge
Economy	Pay/not pay	Price, scarcity	Money	Material production	Accumulate profit

Source(s): Table by the author

Table 3

Explicit and implicit strategic intents in the tuberculosis campaign

	General strategic intents	Implicit strategic intents for the tuberculosis campaign	Explicit strategic intents for the tuberculosis campaign (public interest)
Norwegian Women’s Public Health Association	Civil society: Change	Suffrage for women	Better health
Norwegian Doctors’ Union	Civil society: Change	Position in society (for the profession)	Better health
Norwegian government	Authorities: Control and governing	Control, nation building, assimilation	Better health and protect the healthy

Source(s): Table by the author

Notes

1. https://web.archive.org/web/20060204185351/http://arkivverket.no/originalbilder/m_april2003_2.jpg

2. Other places with universal suffrage at that time were Finland (as an autonomous Grand Duchy in the Russian Empire), Australia and New Zealand (as a part of the British Commonwealth Empire) and four US states.