AMERICANS more than just believe the health information they get from fictional television shows. Spurred by what they see on shows like "ER" or "The Bold and the Beautiful," surveys suggest, they take action. They go to the doctor. They tell a friend to have that cough checked. They ask a lover to use a condom.
Fans develop trusting relationships with the characters who come into their homes each week, and industry insiders can't betray that trust. "I'm aware of the number of people who are paying attention to the facts around the fiction," says Jan Nash, executive producer of "Without a Trace." Thanks in part to the Internet, where health sites consistently rank at the top of those most visited, more and more viewers know when something doesn't ring true.
They're getting a lot of chances to make such calls. Science is invading scripts. Disease is increasingly a backdrop to plots. The woes of the nation's healthcare system are punch lines. Heroic characters have mental diseases or incurable neurological disorders.
And behind the scenes, a body of communications research and an eager network of health and policy advocates are working with writers and producers to get the facts right. The shows milking medicine for back stories or main plot lines aren't limited to the medical genre such as "ER," " Grey's Anatomy" or " Scrubs." Sick, damaged or dying characters are showing up in shows about crime, politics, the legal profession, or wacky families and friends.
But seeing how profoundly true prime-time television can be was a shock, nonetheless, for Robert T. Brennan, a statistician at the Harvard School of Medicine and his daughter, Emma Brennan-Wydra, 13. On Jan. 3, 2006, they thought the night was winding down like hundreds of others, just another evening of TV viewing in their Somerville, Mass., home. It was 10 p.m., and Emma, a devotee of "Law & Order," was curled up watching the episode "Infected" with her father. "No popcorn. Nothing special, just uneventful viewing," says Brennan.
Little did they know, within their pajama-clad coziness on the other side of the country, that they were about to get an insider's glimpse into one of the latest trends in Hollywood.
Brennan and his daughter sat, mesmerized as the crime drama got closer and closer to home. It was about a grammar school-aged boy who, after seeing his mother shot to death, killed her murderer and went on trial as an adult.
"Annie Potts is addressing the jury," Brennan says, still amazed that his study, published in the May 27, 2005, journal Science, was quoted, statistic by statistic, by actress Potts, who played the boy's defense attorney, Sophie Devere. "She talked about kids being two to three times more likely to commit gun violence after they've been exposed to gun violence." As the character gave closing arguments, she referred to Science, gave the number of study participants and said the research took place in Chicago. There was no doubt. She was talking about Brennan's study.
"Emma and I looked at each other in total disbelief. Literally, I was flushed and my hair was standing up on my neck. The exact details of the study were on television," says Brennan. "And the accuracy of it was really amazing. I hate to say this, but it was more accurate than anything I've ever had covered in a newspaper."
His research ended up on the airwaves after Dr. Neal Baer, pediatrician and executive producer of "Law & Order: SVU," read the study on childhood violence by Brennan and coauthors Jeffrey Bingenheimer and Felton Earls. With all due respect, the paper was "wonky policy stuff, research that almost nobody reads," says Baer. But for a doctor who is also a television writer, it triggered an idea for a plot. "Just as you're exposed to flu when someone sneezes on you, this boy was exposed to violence. He was infected, and he committed a violent act," Baer says of his TV character.
What Baer did with a dry study illustrates the challenge to television writers: Take timely, important topics and make them entertaining. Accuracy and responsibility matter, industry insiders say, but their job is to attract and hold television viewers, not lecture or teach.
"Ultimately, our responsibility is to the drama of the show," says Nash. If writers start getting preachy, she says, viewers will hit the button on the remote.
At a time when reliance on traditional news media is slipping, entertainment communication becomes an important health issue. Prime-time television is where Americans gather, and it's where they learn. It makes sense to put the information where people are likely to get it.
The emphasis on the human and emotional drama behind the science, it turns out, is exactly what helps messages stick with viewers, according to communications research. Movies have a powerful effect too, but television fans come to know the characters they watch each week. Done well, the messages play out in the lives of familiar characters, and viewers learn something.
Premiering a theory
One of the first proofs that popular shows can educate large numbers of people came in 1977, in Mexico. Broadcast pioneer Miguel Sabido decided to make use of a classic learning theory, called social cognitive learning, in a soap opera. The theory, developed by Stanford social scientist Albert Bandura in 1961, holds that one way people learn is from watching others, particularly if they identify with the people and observe long enough to see a successful outcome. Sabido's telenovela was called "Acompaname," or "Accompany Me." The characters, including a poor but strong young woman who had two children and didn't want any more, grappled with family planning.
In its first year, it was apparent that the people who listened also learned -- and acted. The Mexican government's National Population Council reported that monthly phone calls requesting family planning information increased from next to none to 500. Contraceptive sales increased 23% the first year the show aired, compared with an increase of 7% the previous year.
Following Mexico's success, the entertainment-education movement spread to India, China and Africa, where people in even the most remote villages tune their portable radios to soap operas. Characters routinely deal with the reality of AIDS. "You put up a billboard saying 'AIDS Kills, Use a Condom,' and it doesn't tell a woman how to approach her husband to talk about condoms," says Sonny Fox, whose Studio City consulting company works internationally to advise media and public health advocates. "In a radio drama, you put that right into the story. The listener has to be able to say, 'If she can do it, I can do it.' "
At a recent workshop in Johannesburg, South Africa, a survey presented Nov. 6 by researchers from Johns Hopkins Bloomberg School of Public Health examined the effect of one such program. It found that reported condom use during the last sexual encounter increased from 34% among people who did not tune into a soap opera called "Tsha Tsha" to 60% among those who watched 10 or more of the programs.
Third World successes got the attention of the federal Centers for Disease Control and Prevention. If people in poor countries learn from radio and television entertainment shows, maybe Americans would too.
The CDC analyzed U.S. health survey data in 1999. Researchers concluded that of the 38 million Americans who regularly watch daytime soap operas, almost half said they learned something about diseases and how to prevent them. Even better, about a third of viewers said they took some action based on what they saw on a soap opera, including 7% who visited a doctor and 6% who did something to prevent a health problem.
A year later, the CDC looked at prime-time television. It found that of Americans who tuned in twice a week or more, 52% said they trusted the health information they see to be accurate, and 26% said that prime-time TV was among their top three sources for health information.
Inspiring ideas, facts
Inspired by such research, health advocates are figuring out how to work with entertainment television, without raising the hackles of creative types. The Kaiser Family Foundation and CBS and Viacom, for example, hold annual briefings in which writers and producers hear the real-life stories of people living with HIV.
Writers listen, awaiting the muse. And advocates cross their fingers, hoping that truth morphs into broadcast fiction.
Just such a briefing sparked the imagination of Nash and Greg Walker, executive producers of "Without a Trace." "We heard these testimonials, and we were moved by the accounts," says Walker. Adds Nash, "We would drive home and think, 'We have to figure out a way to do this.' " In the 2005 HIV-AIDS briefing, they heard the true story of Jennifer Jako, a pregnant HIV-positive woman who felt the judgment of people who thought she shouldn't have risked passing the virus to her child.
Her story inspired an April 13, 2006, episode called "Expectations," about a pregnant HIV-positive woman who resents the judgmental comments of a nurse, who tells her she should never have gotten pregnant. The character disappears shortly before her baby is due. The suspense builds as the missing woman calls from her cellphone to say she is in labor. She needs a cesarean section, and she needs it now.
To get the AIDS facts straight, Nash and Walker worked with Tina Hoff, director of the Media Entertainment Program of the Kaiser Family Foundation. "We're not the creative visionaries," Hoff says. "But once a story line is developed, we can help ensure that it's accurate."
In reality, the baby of an HIV-infected mother has a less than 2% chance of being born with the disease provided the mother has taken appropriate medications during pregnancy and the delivery is cesarean. If the audience didn't know that before they saw the show, they did after.
In the show, the woman was found in time to deliver a healthy baby by cesarean section. In real life, Jako gave birth -- C-section of course -- to a healthy daughter in July.
The influence of a popular television show can make physicians' everyday advice pale, says Dr. Mark Morocco, an emergency room physician who was a technical advisor to "ER." "I might see 20 to 30 people a day," he says on his morning shift at the real emergency department of Brotman Medical Center in Culver City. "A show like 'ER' at one time was reaching 30 million people a week. You just can't beat that for power."
The magnitude of the impact of that one show was measured in classic studies by the Kaiser Family Foundation and the CDC. They surveyed "ER" viewers before and after specific episodes. One episode included a vignette on date rape. The victim was advised that she could take a morning-after pill to prevent pregnancy. Before it aired, the study found that only 10% of viewers were aware that high-dose birth control pills were an option to prevent pregnancy. In the week after the episode aired, 33% of viewers were aware of the morning-after option. Another episode dealt with HPV as a cause of cervical cancer, and before the show ran, 24% of "ER" viewers knew about HPV. A week after the show aired, 47% said they had heard of HPV.
"That research reinforced that you just can't ignore the role of entertainment media in people's lives," says Hoff.
Such studies have encouraged shows to use the expertise of real doctors to go deeper than helping actors correctly pronounce medical words, or showing them how to attach electrocardiographic leads. Morocco helped the show's writers figure out how to write Anthony Edwards, who played Dr. Mark Greene on "ER," out of the script after Edwards announced he'd be leaving the show. "What could we give him that would be accurate, that could kill him in 15 months?" says Morocco. The answer: glioblastoma, an aggressive brain tumor whose sufferers have a life expectancy of about 18 months.
Viewers watched, week after week, the dramatic arc of Dr. Greene's diagnosis, treatment success, relapse and decline. "We were able to show what people with a bad brain tumor really go through," Morocco says. "How it affects your family, the real roller coaster ride you're on when you get this kind of diagnosis." Until, finally, the fictional Dr. Greene died, in the May 9, 2002, episode.
Premiering this week may be one of the most intense efforts to get the science right. A new series, "3 Lbs.," named for the weight of the average human brain, is about two neurosurgeons. The pilot shows symptoms, brain scans and neurosurgery wrapped around the lives of two patients shocked that their brains have gone haywire. "It's all research-based," says executive producer Peter Ocko. "There's not a neurological condition we deal with that's not documented in research. We consult with two neurosurgeons. We gather case histories. There's a doctor and a nurse on the set for every medical moment. And we do just as much research on the patient's perspective." From there, poetic license comes in.
Even nonmedical shows are hiring researchers whose job it is to ferret out what's new and true in multiple sclerosis, Alzheimer's disease, obsessive-compulsive disorder, cancer, diabetes or even policy issues such as the growing number of uninsured Americans or the vast disparity between donated organs and the need for organ transplants. All those topics have made their way into recent prime-time shows.
The effort to educate while entertaining goes beyond doctors and staff researchers working within television.
The granddaddy of the industry-science collaboration is probably the Entertainment Industries Council, started in 1983, just about the time John Belushi died of a drug overdose and Richard Pryor set himself ablaze freebasing cocaine. Created to promote health and social issues via entertainment, the council first tackled drug abuse. It quickly expanded. "We're the folks who got actors to put their seat belts on for driving scenes," says Larry Deutchman, executive vice president of marketing and industry relations for the council.
Now there is a growing industry in Hollywood made up of advocates who are neither entertainers nor insiders, but who want their disease or issue to get dramatic play before a mass audience. Similar to product placement, it's a kind of ideas placement. A group called the Entertainment Professionals Resource Assn. pulls dozens of these groups together, including the American Cancer Society, Down Syndrome in Arts and Media, the American Heart Assn. and the Mental Health Media Partnership.
"We're trying to shift the norm," says Deborah Glik, director of the UCLA Health and Media Research Group, who is affiliated with the entertainment group. "When you're going to portray a health issue anyway, and you're working with a platform that reaches millions of people, you should do it accurately."
Members make themselves available with scientific facts and a bank of real citizens willing to tell their stories. They carefully push their causes, knowing they walk a delicate line between sparking creativity and triggering annoyance.
David Sampson, director of media relations at the American Cancer Society, has learned that it's better if his organization stays away from pitching specific plots. Policy wonks, it turns out, aren't so good at recognizing the germ of a compelling story line. "Writers come to us," he says, "and almost invariably, they'll pick up on some bit of information that we had no intention of relaying."
But the society doesn't hesitate to advise, when asked. When Alexis on the soap opera "General Hospital" was diagnosed with lung cancer despite being a nonsmoker, Sampson heard that writers wanted to attribute her disease to asbestos exposure. "About 4,000 non-smokers a year come down with lung cancer," he says. "But short of working in a mine, you only get lung cancer from asbestos exposure if you're also a smoker." Exposure to second-hand smoke, the society suggested, was a far better explanation.
The idea is to present entertainment insiders with powerful real stories, inundate them with facts, and then sit back and hope the creative juices take over. "I believe the writer is king or queen," says Lisa Allen, director of the Media Project, which provides entertainment industry professionals with information on reproductive issues. "We don't preach, we don't proselytize."
But sometimes, when the people who understand the power of the medium watch TV, they do a slow burn. Glik recalls one of those moments. She was watching a prime-time drama in which a character had hepatitis. "I got so upset," she says. "They should have talked about immunizations. It was a missed opportunity."
Missed opportunities and programs that are just plain wrong persist. Soap opera characters can still come out of comas as though they simply took a long nap. Prime-time shows can still depict death as though it's as quick and painless as fainting.
And while television may have become more daring in portraying how disease affects real people, network television pulls its punches on some controversial topics. Abortion, for example, has become more taboo over the years. In 1972, Maude, played by Bea Arthur, had an abortion, a decision that unfolded over two episodes on the sitcom "Maude," watched by 65 million viewers. Thirty years later, Claire Fisher, played by actress Lauren Ambrose on the HBO drama "Six Feet Under," whose viewership peaked at 5 million, had an abortion. In between the two shows, almost all unplanned television pregnancies ended either in miscarriage, adoption or a decision to keep the baby.
No issue unaired
But because truth can be stranger, and more entertaining, than fiction, increasingly even the most tedious of topics -- the economics of the healthcare delivery system, for example -- are finding their way onto the airwaves. What "Friends" fan will ever forget the time that Joey, an aspiring actor, faced losing his health coverage, an all too real dilemma for 46 million Americans? In the Oct. 14, 1999, episode, Joey's coverage through the Screen Actors Guild was going to lapse unless he chalked up more work hours. Then he got a hernia, the pain of which required treatment but also interfered with his ability to work the hours he needed to remain insured.
Joey does solve his problem, recalls Kate Langrall Folb of Nightingale Entertainment, who works to get stories on health policy, including the uninsured, onto television shows. "He gets a gig portraying a dying guy in pain," she says. He earned his hours, kept his insurance and got his hernia treated.
It was, after all, television. Everything must be tidied up within 30 to 60 minutes.
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