Abstract

This article analyzes the coverage of Mozambican press, in particular, of the newspaper Notícias, regarding the topic of non-communicable diseases. The study uses a two-step approach; the first approach is embedded into the “contextualized” health communication theory, the second in the agenda-setting theory applied to the coverage of state-controlled press in limited democratic countries, such as Mozambique. This exploratory research adopted, as its methodology, firstly a quantitative analysis of the whole population of the articles on non-communicable diseases (NCD) that appeared in the newspaper Notícias for the period 2006-2018. A survey of the most meaningful articles was subjected to the discourse analysis, complemented by interviewing witnesses that had access to confidential information. The results showed a high politicization of the coverage of NCD. The incorporation of the interviews confirmed such conclusions, emphasizing the importance of a contextualized analysis: the editorial line of Notícias showed a dependency to the engagement of important public figures committed to combating such diseases; nevertheless, it was the only possible way to begin to approach DNT in public press.

Keywords:
Editorial Line; Health; Public Journalism; Agenda-Setting

Introduction

The present research sought to understand how non-communicable diseases (NCD) were covered by the Mozambican press, namely the country’s most widely circulated newspaper, the daily Notícias. It also intended to identify the mechanisms of power and political influences behind the newspaper’s editorial line.

The article presented here was based on exploratory research, considered adequate considering the low level of knowledge of the subject addressed (Theodorson; Theodorson, 1970THEODORSON, G.; THEODORSON, A. A modern dictionary of sociology. London: Methuen, 1970.). Such an approach allows a good interconnection between qualitative aspects and the possibility of quantifying them, expanding “the understanding of the phenomenon under study” (Piovesan; Temporini, 1995PIOVESAN, A.; TEMPORINI, E. R. Pesquisa exploratória: procedimento metodológico para o estudo de fatores humanos no campo da saúde pública. Revista de Saúde Pública, São Paulo, v. 29, n. 4, p. 318-325, 1995., p. 322).

The background investigation inspired by this article aimed to compare the coverage of NCD by the newspapers Notícias, Diário de Moçambique, and Wamphula Fax from 2006 to 2016.

The first two newspapers have a national circulation, while the third is local, circulating in the province of Nampula. The daily newspaper Notícias, founded in 1926, is the oldest and most diffused in Mozambique. Legally, it is a private newspaper, but it is still being controlled by public entities, such as the Institute for the Management of State Participation (IGEPE), the insurance company Emose, and the oil company Petromoc. The Prime Minister appoints the Director, and the ruling party dictates the editorial line.

The newspaper Diário de Moçambique, published in Beira (Sofala province, Central area) since Christmas 1950, has an editorial line similar to that of Notícias. However, it favors events that take place in the Center of the country.

Finally, Wamphula Fax, from Nampula (Northern Mozambique), was created on 10 Oct. 2001, belonging to CooperNorte-Jornalistas Associados,¹1See <https://bit.ly/3qO6jbe>. a cooperative of independent journalists, led by Vasco Fenita, who, after reforming the newspaper Notícias (where he was the focal point of the Nampula delegation), founded CooperNorte, giving rise to the first weekly newspaper published in Nampula (Bussotti, 2015BUSSOTTI, L. As doenças não transmissíveis na cobertura da imprensa em Moçambique: o caso dos jornais Notícias, Diário de Moçambique e Wamphula Fax (2006-2016). Comunicação & Sociedade, Maputo, n. 5, p. 25-47, 2015.).

The research mentioned above revealed that the highest coverage of NCD cases was made by Notícias, which led us to choose to deepen the type of editorial line in this daily newspaper, extending the time frame until 2018 (the previous study had ended in 2016). The analysis of this article was carried out starting from the previously acquired quantitative data, enriched by more recent ones and above all by a more qualitative approach, with discourse analysis and interviews with some key witnesses. Among them, the Director of the newspaper Notícias, Júlio Manjate, and Dr. Cesaltina Lorenzoni, Director of the Oncology Department at the Central Hospital of Maputo.

The reasons leading to choose the period in question were: as for the term a quo (2006), it was only from the mid-2000s that the Ministry of Health (Misau) began to collect statistical data on the occurrences of NCD in the country, starting with the Central Hospital of Beira. Consequently, the press, including Notícias, published articles on this subject based on that. The term ad quem (2018) was motivated by the willingness to observe the latest trends in this type of coverage by Notícias. The contextualized analysis constituted the main theoretical framework of the study (Maksimainen, 2016-2017MAKSIMAINEN, H. Improving the quality of health journalism: when reliability meets engagement. Oxford: University of Oxford, Reuters Institute for the Study of Journalism, 2016-2017. Disponível em: <Disponível em: https://bit.ly/3skvrGP >. Acesso em: 13 mar. 2019.
https://bit.ly/3skvrGP... ).

Health journalism: a brief theoretical framework

NCD, according to data from the World Health Organization,²2WHO - WORLD HEALTH ORGANIZATION. Non-communicable diseases. Geneva, 1 Jun. 2018. Available at <https://bit.ly/3aLRoIY>. Accessed on 14 Mar. 2019. are responsible for 41 million deaths per year, equivalent to 71% of total deaths worldwide. About 1/3 of such deaths occur in the age group 30-69 years, and 85% of these premature deaths occur in developing countries.

Within the prevention strategies, the media specialized in health matters plays a fundamental factor. Such communication uses an “integrated approach, considering the subject in his entirety, difficulties, desires, and not merely as the transfer of detailed information with the use of technical terms” (Ribeiro; Neves; Prado, 2013RIBEIRO, C. B.; NEVES, A. P. C.; PRADO, A. C. M. Comunicação em saúde: conceitos e estratégias, rumo à efetivação de direitos sociais. In: SIMPÓSIO MINEIRO DE ASSISTENTES SOCIAIS, 3., 2013, Belo Horizonte. Anais… Belo Horizonte: CRESS-MG, 2013. Disponível em: <Disponível em: https://bit.ly/3sKSP0H >. Acesso em: 3 jan. 2017.
https://bit.ly/3sKSP0H... , p. 9). Communication for health is not “neutral” but part of an ethical project that aims to redistribute symbolic and material powers based on access to health, one of the fundamental social rights (Araújo; Cardoso, 2007ARAÚJO, I. S.; CARDOSO, J. M. Comunicação e saúde. Rio de Janeiro: Fiocruz, 2007.).

There are many political and economic forces or lobbies that put pressure on social communication for health. This makes the health system very complex, and from this complexity, journalists are obliged to inform readers with professionalism and a high degree of independence from political power (Dentzer, 2009DENTZER, S. Communicating medical news: pitfalls of health care journalism. The New England Journal of Medicine, Boston, v. 360, n. 1, p. 1-3, 2009. DOI: 10.1056/NEJMp0805753
https://doi.org/10.1056/NEJMp0805753... ).

Health journalism has considerable impacts on public opinion worldwide (Guyatt et al., 1999GUYATT, G. et al. A journalist’s guide to writing health stories. AMWA Journal, Rockville, v. 14, n. 1, p. 32-42, 1999.). However, although “health journalism has a bad reputation” (Maksimainen, 2016-2017MAKSIMAINEN, H. Improving the quality of health journalism: when reliability meets engagement. Oxford: University of Oxford, Reuters Institute for the Study of Journalism, 2016-2017. Disponível em: <Disponível em: https://bit.ly/3skvrGP >. Acesso em: 13 mar. 2019.
https://bit.ly/3skvrGP... , p. 5, our translation), health journalism should be reliable and aimed at the local audience. The reliability is manifested in the fact that journalists ascertain the veracity of their information by using diversified sources and comparing the news obtained in its context with similar ones internationally. Then, the journalist has to know how to make a “technical” subject understandable (Maksimainen, 2016-2017MAKSIMAINEN, H. Improving the quality of health journalism: when reliability meets engagement. Oxford: University of Oxford, Reuters Institute for the Study of Journalism, 2016-2017. Disponível em: <Disponível em: https://bit.ly/3skvrGP >. Acesso em: 13 mar. 2019.
https://bit.ly/3skvrGP... ). News that is both reliable and contextualized constitutes the central axis for health journalism to support readers and positively impact them, overcoming the limitations of this genre of journalism (Cooper et al., 2012COOPER, B. E. J. et al. The quality of the evidence of dietary advice given in UK national newspapers. Public Understanding of Science, Bristol, v. 21, n. 6, p. 664-673, 2012.).

The responsibility of health journalism, which is essential in the global context, is even more relevant on the African continent. In fact, in Africa, the basic information that citizens have regarding their health conditions is deficient. Perceptions about diseases and their causes result from the complexity of factors that almost always call traditional beliefs into question. Many sometimes conflict with scientific knowledge.

In South Africa, for example, the incidence of hypertension is among the highest globally; however, few people take simple preventive measures, mainly due to the lack of information (Dugmore, 2014DUGMORE, H. Why does health journalism matter in Africa? European Health Journalism, [s.l.], maio 2014. Disponível em: <Disponível em: https://bit.ly/37J35hM >. Acesso em: 12 mar. 2019.
https://bit.ly/37J35hM... ). The same situation can be found in other African countries. In Eritrea, hypertension is spoken of as a silent epidemic (Mufunda et al., 2005MUFUNDA, J. et al. Noncommunicable diseases in Africa: a silent hypertension epidemic in Eritrea. Journal of Human Hypertension, London, v. 19, p. 255-256, 2005. DOI: 10.1038/sj.jhh.1001802
https://doi.org/10.1038/sj.jhh.1001802... ). A recent comparative study of six sub-Saharan African countries (Kenya, South Africa, Togo, Nigeria, Cameroon, and Malawi) demonstrates (despite national differences) that the weak health system and the scant training of human resources have already made the situation critical regarding the diffusion and management of NCD (Juma; Widsom, 2018JUMA, P. A.; WIDSOM, J. (Ed.). Non-communicable diseases prevention policies in six African countries. BMC Public Health, London, v. 18, 2018. Suplemento 1. Disponível em: <Disponível em: https://bit.ly/2NU0WJ2 >. Acesso em: 20 out. 2016.
https://bit.ly/2NU0WJ2... ). This set of factors makes the journalist’s responsibility even more significant within the African context when compared to the work of colleagues from other parts of the world.

In Mozambique, some of the characteristics listed above are even more amplified. The distance between the information available and the news that the press conveys is very significant. There is a “news warehouse” unused by the media, demonstrated by the fact that the press generally ignores texts by Mozambican scientists. These texts are published in international journals about the relationship between NCD and sedentary life and physical activity (Prista, 2012PRISTA, A. Sedentarismo, urbanização e transição epidemiológica. Revista Cientifica da Universidade Eduardo Mondiane: Série Ciências Biomédicas e Saúde Pública, Maputo, v. 1, p. 28-38, 2012.), hypertension (Damasceno et al., 2009DAMASCENO, A. et al. Hypertension prevalence, awareness, treatment, and control in Mozambique urban/rural gap during epidemiological transition. Hypertension, Dallas, v. 54, n. 1, p. 77-83, 2009. DOI: 10.1161/HYPERTENSIONAHA.109.132423
https://doi.org/10.1161/HYPERTENSIONAHA.... ), smoking and alcoholism (Padrão et al., 2011PADRÃO, P. et al. Association between tobacco consumption and alcohol, vegetable and fruit intake across urban and rural areas in Mozambique. Journal of Epidemiology and Community Health, London, v. 65, n. 5, p. 445-453, 2011. DOI: 10.1136/jech.2009.099440
https://doi.org/10.1136/jech.2009.099440... ), and cancer (Lorenzoni, 2015LORENZONI, C. et al. Trends in cancer incidence in Maputo, Mozambique, 1991-2008. Public Library of Science, San Francisco, v. 10, n. 6, p. 1-12, 2015. DOI: 10.1371/journal.pone.0130469
https://doi.org/10.1371/journal.pone.013... ).

Another element that makes NCD coverage ineffective is represented by institutional and even partisan interference by the Front for the Liberation of Mozambique (Frelimo) in the editorial lines of the newspaper Notícias.

Such interference causes the omission of relevant information, which dissemination to local populations would be of great importance. Among the few studies carried out in Mozambique, one of them reveals the following:

Without arising a long and complex debate around the relationship between traditional beliefs and health, in Mozambique, official medicine is trying to collaborate with the Association of Traditional Doctors of Mozambique (Ametramo), created in 1992 (Acçolini; Sá Júnior, 2016ACÇOLINI, G.; SÁ JÚNIOR, M. T. Tradição-modernidade: a Associação de Médicos Tradicionais de Moçambique (Ametramo). Mediações: Revista de Ciências Sociais, Londrina, v. 21, n. 2, p. 49-70, 2016. Disponível em: <Disponível em: https://bit.ly/3slvSAN >. Acesso em: 15 mar. 2019.
https://bit.ly/3slvSAN... ). The studies confirmed that, especially in rural and peri-urban areas, such a dialogue has not yet produced satisfactory results, thanks to the low rate of access to official health (66%) (Unicef, 2017UNICEF - UNITED NATIONS INTERNATIONAL CHILDREN’S EMERGENCY FUND. Informe orçamental 2017: Saúde. Maputo, 2017.).

In this context, professionally prepared and influential health journalism could help improve habits and practices to prevent NCD; however, previous research has concluded why this did not happen: “Mozambican journalism is comfortable with the information provided by top sources and international organizations, such as, for example, the United States Agency for International Development (USAID), the World Health Organization (WHO), among others,” almost wholly ignoring background sources, such as patients and people who work in the health area (SADC…, 2011SADC: imprensa moçambicana com fraca cobertura aos assuntos de HIV/SIDA. A Verdade, Maputo, 10 maio 2011. ). The International Research and Exchanges Board (IREX) also concluded that “writing about health is still an incipient culture in Mozambique, being mainly international events and dates that motivate the approach of issues related to the sector” (Irex, 2013IREX - INTERNATIONAL RESEARCH AND EXCHANGE BOARD. Análise da cobertura da mídia moçambicana 2012. Maputo, 2013., p. 13). Except for A Verdade, a private online newspaper, no Mozambican newspaper of national circulation has a section primarily dedicated to health and good hygiene, physical, and food practices.

NCD in Mozambique

One factor that makes it difficult for the press to cover NCD in Mozambique is the limited veracity of the available data.

In the country, statistics on causes of death are still unreliable (Jembi Health Systems; Moasis, 2014JEMBI HEALTH SYSTEMS; MOASIS - MOZAMBICAN OPEN ARCHITECTURE STANDARDS AND INFORMATION SYSTEMS. Sistema de registo civil e estatísticas vitais de Moçambique: relatório de avaliação de registo de óbitos e causas de morte. Maputo: Ministério da Justiça, 2014.); in 2008, the survey method was changed, introducing the Hospital Death Registry Information System (SIS-ROH). According to the National Survey on Causes of Mortality in Mozambique, in 1997, the gross mortality rate was 210.2 inhabitants, while in 2007, it was 150.6 (INE, 2009INE - INSTITUTO NACIONAL DE ESTATÍSTICA. Mortalidade em Moçambique: inquérito nacional sobre causas de mortalidade 2007-2008. Maputo, 2009.). Although NCD (as well as traumas) have increased their spread, the leading causes of death in adults continue to be represented by AIDS (40%), malaria (14%), stroke (7%), diarrhea (3%), pneumonia (2%), and cancer (2%). For individuals under the age of 14, the picture is different, with a higher incidence of malaria (which comes in the first place, with almost 50%) and a lower incidence of AIDS (17%), and practically zero incidences of diseases such as cancer and stroke (INE, 2012INE - INSTITUTO NACIONAL DE ESTATÍSTICA. Moçambique: inquérito demográfico e de saúde 2011. Maputo, 2012.).

Data from the Ministry of Health for ten hospitals (20% of all hospital units in the country), representing all provinces, except Tete and Maputo, point to a still evident prevalence of deaths caused by infectious and parasitic diseases (38%), affections in the perinatal period (19%), cardiovascular diseases (8%), respiratory diseases (5%), and neoplasms (also 5%). Therefore, it is possible to conclude that about 17% of intra-hospital deaths in Mozambique are caused by NCD, a figure with a moderate but constant increase in all hospital units subject to the survey (Moçambique, 2012MOÇAMBIQUE. Ministério da Saúde. Análise da mortalidade nacional intra-hospitalar: Moçambique. Maputo, 2012.).

Despite the severe statistical flaws related to epidemiological studies, the trends of NCD, over the last few years, seem clear. Compared to 2000, such diseases increased their spread by 45%, and, to 2010, 18% (Mozambique NCDI Poverty Commission, 2018MOZAMBIQUE NCDI POVERTY COMMISSION. Doenças crónicas e não transmissíveis em Moçambique: relatório nacional 2018. Maputo, 2018.). The record of diabetes points to an increase in the incidence in the population from 2.8% to 7.4% (Mozambique NCDI Poverty Commission, 2018MOZAMBIQUE NCDI POVERTY COMMISSION. Doenças crónicas e não transmissíveis em Moçambique: relatório nacional 2018. Maputo, 2018.), with almost two million Mozambicans suffering from this disease. Cardiovascular risk is also increasing, affecting more people in urban areas (40.6%) than in rural areas (29.8%). In 2015, the cardiovascular risk increased to 39% among the Mozambican population, against 33% in 2005 (Mozambique NCDI Poverty Commission, 2018MOZAMBIQUE NCDI POVERTY COMMISSION. Doenças crónicas e não transmissíveis em Moçambique: relatório nacional 2018. Maputo, 2018.). The cancer data are even more problematic: only in 1991 - at the end of the civil war, whose agreements were signed in 1992 between the government and the Mozambican National Resistance (Renamo) - the record was resumed at the Central Hospital of Maputo (HCM), Department of Pathological Anatomy. Therefore, from 1991 to 2008, the existing data refer only to this hospital unit, and nothing is known, in practice, concerning the national trends. For men, prostate cancer appears to be the most widespread one; for women, uterus câncer. Both figures align with trends in other countries in sub-Saharan Africa (Mozambique NCDI Poverty Commission, 2018MOZAMBIQUE NCDI POVERTY COMMISSION. Doenças crónicas e não transmissíveis em Moçambique: relatório nacional 2018. Maputo, 2018.). In parallel, cancers directly related to the spread of HIV-AIDS have steadily increased over the period considered in this research (1991-2008), supplanting, in fact, the primacy of liver cancer of the colonial era (Lorenzoni et al., 2015LORENZONI, C. et al. Trends in cancer incidence in Maputo, Mozambique, 1991-2008. Public Library of Science, San Francisco, v. 10, n. 6, p. 1-12, 2015. DOI: 10.1371/journal.pone.0130469
https://doi.org/10.1371/journal.pone.013... ).

In 2005, the Central Hospital of Beira began implementing a new registry. The data pointed to an initial cancer incidence rate of 62.9 per 100,000 inhabitants, going through an incidence of 63.5 per 100,000 inhabitants in 2006; still not very high, compared to the countries of Eastern Europe (300-400 for every 100,000 inhabitants), but already higher than that of countries like Thailand, with an incidence of 14.6 (Lopes, 2014LOPES, J. Mais de 6 mil mulheres padecem do câncer do colo do útero em Moçambique. Jornal Notícias, Maputo, 14 out. 2014. Notícias. Disponível em: <Disponível em: https://bit.ly/3aNyZeR >. Acesso em: 25 nov. 2016.
https://bit.ly/3aNyZeR... ).

There are no reliable data on the spread of cancer in Mozambique, except for the approximately 3000 cases detected in the three main hospital units in the country (Maputo, Beira, Nampula) (Júnior, 2016JÚNIOR, F. Moçambique, aumentam casos de câncer. Voa Português, Maputo, 31 maio 2016. Notícias. Disponível em: <Disponível em: https://bit.ly/2NR0wmz >. Acesso em: 29 dez. 2016.
https://bit.ly/2NR0wmz... ). Therefore, the incidence base is made assuming Globocan’s projections, with an average estimate of 10% of cancer cases in each country. Thus, by projection, Mozambique is expected to register around 22,000 new cases of cancer per year, of which about 17,000 will result in death (Lorenzoni et al., 2015LORENZONI, C. et al. Trends in cancer incidence in Maputo, Mozambique, 1991-2008. Public Library of Science, San Francisco, v. 10, n. 6, p. 1-12, 2015. DOI: 10.1371/journal.pone.0130469
https://doi.org/10.1371/journal.pone.013... ).

Thanks to WHO and the Southern African Development Community (SADC) requests, Mozambique has begun to include NCD as one of the priorities of its global health strategy. ³3Among the fundamental documents in the design of the strategy against NCD, the following can be recalled: SADC, Protocol on Health, 1999; Misau, Plano Estratégico Nacional de Prevenção e Controlo das DNT, 2008-2014, 2008; OMS, Declaração de Brazzaville sobre a prevenção e o Controlo das Doenças Não Transmissíveis na Região Africana, signed by the Mozambican Government; Misau, Programa Nacional de Prevenção e Controlo do Cancro do Colo do Útero e da Mama, Maputo, 2009; Misau, Plano Estratégico do Sector da Saúde PESS 2014-2019, 2013, with a part especially dedicated to NCD; Misau, Plano Nacional de Controlo do Cancro 2019-2029, Maputo, 2018

The reference points of the new national strategies against NCD are derived from a series of documents and positions of the leading international organizations. The long-term action plan developed by the WHO (2013-2020), for example, focuses on the fight against the four diseases with the most significant impact on deaths around the world (cardiovascular accidents, cancers, chronic respiratory diseases, and diabetes) and against the four causes supposedly more linked to the outbreak of these diseases, namely: tobacco, diet, physical inactivity, and alcohol. In this context, urbanization will be the decisive element for these diseases to spread and gain a space previously unknown in the African context (Prista, 2012PRISTA, A. Sedentarismo, urbanização e transição epidemiológica. Revista Cientifica da Universidade Eduardo Mondiane: Série Ciências Biomédicas e Saúde Pública, Maputo, v. 1, p. 28-38, 2012.).

Specific programs were launched recently: for example, for diabetes and hypertension, the World Diabetes Foundation (WDF), Cuamm (an Italian non-governmental organization, specialized in health), Amodia (Mozambican Diabetes Association), and the Ministry of Health of Mozambique managed to implement the first project in 2017 only and limited to three provinces out of 11 (Maputo, Sofala, and Cabo Delgado). However, the first global program for non-communicable diseases started in 2018, called NDCs Capacity Project: Support to the Fight Against Non-Communicable Diseases in Mozambique, covering 2.6 million people, with funding from Italian Cooperation (Carleton, 2018CARLETON, G. In Mozambique an integrated approach to NCDs. World Diabetes Foundation, Bagsværd, 23 mar. 2018. Notícias. Disponível em: <Disponível em: https://bit.ly/37CNrEj >. Acesso em: 12 mar. 2019.
https://bit.ly/37CNrEj... ).

Considering the Southern African Development Community (SADC, founded in 1980 as SADCC and in 1992 transformed into the current SADC, with 16 member states), the Protocol on Health was signed in Maputo in 1999. Its art. 13 invites the adoption of an appropriate strategy to prevent and control NCD, which is the first indication appropriate to the new WHO policies.

However, the health sector in Mozambique continues to be fraught with serious structural problems, almost entirely neglected by the press, especially the public one. Until 2014, the national public health network had 1252 health units; however, only 3% of this group can face complex clinical situations. In terms of human resources, of the approximately 25,000 workers in the health sector, doctors represent less than 1%, with only 478 specialists (Mozambique NCDI Poverty Commission, 2018MOZAMBIQUE NCDI POVERTY COMMISSION. Doenças crónicas e não transmissíveis em Moçambique: relatório nacional 2018. Maputo, 2018.). There is one doctor for every 22,000 inhabitants and only three general oncologists, three hemato-oncologists, two radiotherapists, one oncology pediatrician, and no oncology surgeon in a country that ranks 180 out of 187 nations on the human development index (UNDP, 2018UNDP - UNITED NATIONS DEVELOPMENT PROGRAMME. Human development reports: Mozambique, 2018. Disponível em: <Disponível em: https://bit.ly/3aKc0kU >. Acesso em: 5 mar. 2020.
https://bit.ly/3aKc0kU... ). Significantly, such data were first released in a report written by a Portuguese journalist (Sá, 2016SÁ, S. Moçambique: quando para tratar câncer só há… paracetamol! Visão, Lisboa, 22 maio 2016. Notícias. Disponível em: <Disponível em: https://bit.ly/2QnS0ga >. Acesso em: 7 abr. 2016.
https://bit.ly/2QnS0ga... ) and confirmed by internal sources in an interview in Notícias in 2018 with Dr. Cesaltina Lorenzoni (Cancro…, 2018CANCRO mata anualmente 17 mil pessoas no país. Jornal Notícias, Maputo, 11 fev. 2018. Notícias. Disponível em: <Disponível em: https://bit.ly/3pGeRzy >. Acesso: 15 mar. 2019.
https://bit.ly/3pGeRzy... ).

Based on the assumptions above, the hypothesis that was the background of this work was that both the political context and the still incipient training of journalists results in NCD coverage that responds much more to a logic centered on political influences than one that favors the correct information with the citizen-reader.

The coverage of non-communicable diseases by the Mozambican public press: the case of Notícias (2006-2018)

The Notícias newspaper lives in a privileged condition, compared to other newspapers. Despite the liberalization of information (Moçambique, 1991MOÇAMBIQUE. Lei nº 18/91. Lei de imprensa. Boletim da República, Maputo, n. 32, 10 ago. 1991. Série 1.), this daily vehicle continues to have no competitors. As the most widely circulated newspaper in the country, all public notices and tenders from public and private companies must be published in Notícias. Also, it is acquired by all Mozambican civil service departments, central and provincial. The set of these elements guarantees financial stability to the newspaper, to the detriment of its quality and autonomy (Chichava; Pohlmann, 2010CHICHAVA, S.; POHLMANN, J. Uma breve análise da imprensa moçambicana. In: BRITO, L. et al. (Org.). Desafios para Moçambique 2010. Maputo: IESE, 2010. p. 127-138.).

The news criteria adopted by Notícias must be framed within the contextual elements that characterize it, avoiding the categories and priorities defined by the literature (Traquina, 2005TRAQUINA, N. Teorias do jornalismo: porquê as notícias são como são. Florianópolis: Insular, 2005. 1 v.). The newspaper’s editorial line responds to extra-commercial and, we might say, extra-journalistic criteria, with news filtered and selected according to the ruling party’s interests.

Part of this study was based on indicators of analysis of the quantitative part, considering the following: number of articles published by Notícias on NCD, distributed by year; location of published articles, distinguishing between “noble” pages (the first four, starting from the cover) and the others; and space occupied by the article.

Within the quantitative analysis, reference was made to two more categories: the subdivision of articles published according to each type of disease; and, above all, according to the journalistic genres, which, in this case, were limited to three: the news, the report, and the opinion of columnists. In general, the reports were considered the elements of the newspaper’s most significant commitment to the subject addressed, profiling journalism potentially closer to the principles of health journalism (Lage, 2006LAGE, N. Linguagem jornalística. 8. ed. São Paulo: Ática, 2006.).

Despite being “the report” of the fact and not the fact itself (Lara, 2008LARA, J. Os gêneros jornalísticos com conteúdo informativo (a notícia, a reportagem e a entrevista) nas aulas de língua portuguesa: desvelando a linguagem pretensamente neutra. 2008. Disponível em: <Disponível em: https://bit.ly/3sjJL2d >. Acesso em: 13 mar. 2019.
https://bit.ly/3sjJL2d... , p. 12), the news seeks to provide primary and, in general, shallow information. Therefore, the prevalence of news in a newspaper indicates an editorial choice that tends to reproduce (using slightly diversified sources) more information than to question it.

Finally, opinionated texts have their structure, intending to arouse the reader’s interest on the part of specialists, journalists or not, on a particular subject and with a “polemic” bias (Silveira; Figueiredo, 2013SILVEIRA, A. C. F.; FIGUEIREDO, M. F. A retórica no jornalismo: o caso do artigo opinativo. Anais… Uberlândia: EDUFU, 2013. Disponível em: <Disponível em: https://bit.ly/2NR9QXB >. Acesso em: 15 mar. 2019.
https://bit.ly/2NR9QXB... , p. 3).

The coverage entity: quantitative analysis

The coverage made by Notícias on NCD was relatively homogeneous over the period considered, totaling 194 articles, with an annual average of almost 15 points achieved in 2006, 2008, and 2018, and minimum values in 2009, 2017, and 2013 (Table 1).

This is a very modest coverage, with a high condensation level in the final part of the newspaper, starting on page 10. However, about 16% of the total articles are placed on the cover (Table 2).

A relevant and recent aspect is the largest highlight of the news about NCD in 2018: 10 articles, out of 33 from the entire period considered here, are on the cover of the 2018 editions.

In terms of size, articles on NCD are almost always reduced, rarely exceeding half a page. This happens in nine cases: Notícias presented two half-page articles and seven full-page articles. In all cases but two, the articles are placed on the newspaper’s page two, therefore in a noble position. There is a positive correlation (although “weak” due to the low number of texts) between the articles’ size and their “noble” location.

As for the type of diseases, the picture of coverage is as follows: cancer is the most addressed NCD (about 45% of selected articles). Then there are the heart and cardiovascular diseases (about 13.5%), obesity (about 10%), diabetes (about 5%), and asthma (4%). Many other diseases are treated sporadically, until even once in 12 years, such as polio, leukemia, depression, anorexia, Parkinson’s disease, etc.

A revealing subdivision of the newspaper’s editorial line is related to the typology of articles (Table 3).

As is evident, it is almost entirely news, with only nine reports and two opinion pieces, which reveals an editorial line that favors mere information without deepening or criticizing it.

The first conclusion is that the NCD-related article is usually relegated to a secondary position in the newspaper, little covered, with a modest space and a location that is not generally noble. There is an associated tendency to privilege news, to the detriment of almost absent reports and opinion texts. Such provisional conclusions were verified in the qualitative analysis, presented in the following point.

Discourse analysis: first interpretative hypotheses

The brief qualitative analysis of the selected material is based on two modalities: above all, the contents of the articles on the first page of the last year (2018) are considered, by the way, the year in which news about NCD appeared most frequently on the newspaper’s cover; secondly, discourse analysis applied to some of the few reports found over the 12 years of research coverage.

Three main categories determine the noblest location of NCD news in the newspaper: those that refer to the figure of the first lady, engaged in the fight against cancer (total of three); news announcing governmental initiatives on NCD (six); and news about the alarming situation of cancer in Mozambique (one). The sources used to spread this news are all governmental and tend to convey an idea of tranquility to readers, thanks to the government’s commitment to the fight against NCD. The article announcing the 17,000 annual deaths from cancer (interview with Dr. Cesaltina Lorenzoni, oncologist at the Central Hospital of Maputo) partially breaks this logic. Both the title and the doctor’s statements point to all the gaps in the country regarding oncology specialist availability. However, in the text body, the alarm is mitigated, announcing an awareness campaign in the fight against cancer. The journalist’s conduct is limited to reporting the doctor’s statements without further comment.

The editorial line of the “first pages” that the newspaper assigns to NCD confirms the results of the quantitative analysis: the value-news does not follow the usual criteria of commercial journalism or the ethical commitment to public health issues. The focus is on government personnel or executive actions and campaigns. Consequently, this option omits the critical elements and cases that hinder the government’s performance. The most eloquent among them is the case of the former first lady Maria da Luz Guebuza. While she started the national campaign against cancer, she has been investigated since late 2018 by the American justice. This investigation is due to an alleged diversion of clinical equipment donated by the American government (for a value of about 280 million dollars) in favor of private clinics she owns in Maputo, Chimoio, and Nampula. Notícias made no mention of this complicated case, preferring the international press and the private national press to deal with it (Maria…, 2019MARIA da Luz Guebuza na investigação dos EUA: e impõe sanções contra Moçambique na área da saúde. MK Africa, [s.l.], 9 jan. 2019. Disponível em: <Disponível em: https://www.youtube.com/watch?v=rcBGM0Pyv1Q >. Acesso em: 20 mar. 2019.
https://www.youtube.com/watch?v=rcBGM0Py... ).

The analysis of one of the few reports made by Notícias makes clear there is a considerable gap, mainly concerning the principles of health journalism. In the 12/12/2014 edition, Joana Macie presents a report entitled “Enaltecendo o trabalho da primeira-dama.” (Praising the work of the first lady). Here, this public figure is exalted, as a farewell to her role (the article is written shortly after the elections that brought Nyusi to Ponta Vermelha, replacing Guebuza) through interviews with several individuals, who testify to the commitment of the wife of the President for the fight against cancer. The use of the photo - an element familiar to many of the published articles - corroborates the report meaning, which focuses on the public person and the “gala” in her honor, much more than talking about the illness (Photo 1).

Therefore, it is a “minimalist” use of the report. There is no thematic deepening nor critical bias concerning the subject addressed, but only the celebration of the public personality through diversification of questionable sources, which were also handpicked. In the same vein, the article (this time a news item), published in 2016, should be read, with the following lead “Aconselha Primeira-dama” (The first lady advises) and title “Auto-exame para reduzir mortes por cancro da mama” (Self-examination to reduce deaths from breast cancer) (Photo 2).

Moving from one first lady to another, the type of journalism remains the same: the article is structured according to a circular criterion: the lead refers to the first lady’s advice; the title emphasizes the message to be communicated; and the photo again highlights the importance of the (new) first lady, Isaura Nyusi.

The editorial line of Notícias on cancer has undergone some changes over the past two years: not that the basic principle (praising public figures and government action) changes; however - as already noted above - there is an evident tendency (especially in 2018) to make the headline with news about the disease, seeking, on the one hand, to start to inform better about it and, on the other, to show the (supposed) progress of the country in its fight, for example, with the introduction (precisely in 2018) of radiotherapy. Photo 3 is a demonstration of the partial change in the editorial line. Here, the entire second page of the newspaper is dedicated to the cancer theme, accompanied by four photos (of doctors and equipment) and designed according to the report style. Such new elements are mixed with an old approach, with the celebration of the results achieved by the Mozambican government and the new opportunities for curing cancer.

If cancer represents Notícias’ most covered non-communicable disease, the other diseases had an even less professional and more improvised coverage.

The coverage on cardiovascular diseases was “instantaneous” and very superficial, with a concentration of articles on the traditional World Heart Day, 29 Sep. 2016SÁ, S. Moçambique: quando para tratar câncer só há… paracetamol! Visão, Lisboa, 22 maio 2016. Notícias. Disponível em: <Disponível em: https://bit.ly/2QnS0ga >. Acesso em: 7 abr. 2016.
https://bit.ly/2QnS0ga... (two articles), and on the trip to Maputo, at the Heart Institute (ICOR), a private hospital in the Coop neighborhood, central Maputo, of American specialists who would operate 406 patients in Maputo (also two articles).

In all other cases, Notícias uses almost exclusively foreign sources, publishing short articles with low news value and, therefore, with little impact on its readers. An isolated diabetes service represents a partial exception, referring to World Diabetes Day (14 Nov. 2016).

Possible provisional conclusions

A first conclusion is that there is a scheduling of information “the other way around.” It is the political power that dictates the editorial line of Notícias regarding NCD, making this body something very similar to a mere reproducer of government propaganda. The representation of the prominent figures of the ruling party becomes the central axis of coverage in merit to the NCD and its first criterion of news.

The “absences” of the editorial line of Notícias on NCD are striking: public policies on the sector are never questioned; except in a highly incidental way, there is no analysis of the situation the country faces in the fight against NCD, reports are never made with in loco visits, interviews with health operators and especially patients, and journalists never question statements by public figures. There has been a partial change in this dismal picture in the last two years, especially concerning cancer. The importance of the context determined that the newspaper devoted more and better space to themes that were almost entirely neglected.

If compared with the theoretical framework described above, such provisional conclusions lead to the determination that Notícias ignore the fundamental principles of health journalism.

However, without radically altering these conclusions, some interviews with key witnesses contributed to enriching and problematizing these conclusions. The interviews provided a more contextualized perspective and anchored to the Mozambican reality, confirming the importance of the aforementioned theoretical framework.

The problematization of the conclusions from the point of view of the key witnesses

After analyzing the selected material, the research focused on verifying the provisional conclusions drawn in the previous point. This was done by interviewing the Director of the newspaper Notícias, Júlio Manjate, and the Director of the Oncology Department at the Central Hospital of Maputo, Cesaltina Lorenzoni.

The two essential points discussed with the interviewees were the politicization of health information, with particular reference to NCD, and the overuse of official foreign and internal sources.

On the first question, the provisional conclusions were more than denied, read from a different perspective. Júlio Manjate, Director of Notícias, explaining the historical genesis of the production of NCD news in the newspaper he directs, wanted to recall that they began to appear in the 1990s, with a reference above all to cardiovascular diseases, which were immediately perceived as the “diseases of the wealthy,” as he highlighted. Then, in the 2000s, cancer arose, with a greater and less characterized spread in social terms. The coverage has multiplied, confirmed Manjate, with the first lady’s initiative, who even became the first source of information for the newspaper due to the reticence of clinical and hospital sources that wanted little to communicate with the press.

Manjate explained that the way Notícias approaches NCD, and especially cancer, is highly politicized, but that is due to a specific reason, typical of the Mozambican context: it was thanks to the first lady that the newspaper was able to start publishing about NCD: she enabled us to address an important and sensitive issue that, without her help, we would not have been able to cover (Manjate, 7 Mar. 2017).

Dr. Cesaltina Lorenzoni proposed the same perspective. She admitted that without the contribution of the first lady, cancer information would be, today, in Mozambique, at an even more basic level, and that even within Misau, any initiative on NCD will be influential only if the first lady is involved. This approach is very political, but we use it to bring concrete benefits in terms of spreading knowledge to the population about this disease. The first lady’s involvement only benefits us (Lorenzoni, 30 Mar. 2017).

Another element that stood out in the research, the overuse of foreign sources by Notícias, led to quite similar conclusions. The two interviewees explained that the level of knowledge on health-related issues by journalists is so low that it is necessary above all to avoid mistakes that could damage the newspaper’s credibility. Júlio Manjate admitted this circumstance, stressing that there are no journalists in Notícias trained in communication for health, so everything is in the news and in the immediacy (Manjate, 7 Mar. 2017). The limited availability shown by Misau, as well as doctors, would be, according to him, one of the reasons for the poor quality of coverage on NCD, a fact that left him dissatisfied.

On the other hand, Dr. Cesaltina Lorenzoni comes to opposite conclusions: according to her, journalists only call to talk about policies and are not rigorous (Lorenzoni, 30 Mar. 2017); hence the doctors’ difficulty in communicating with the press.

The two interviews answered, albeit indirectly, another question observed during the empirical work: the modest use of clinical sources, whether direct (interviews with doctors) or indirect (critical analysis and dissemination of published scientific articles on NCD in Mozambique). Such a phenomenon must be framed in the distrust that health professionals have towards those in communication, which closes the normal channels of information flow between the two parties. As seen earlier, throughout 2018, this trend appears to be partly reversed with more significant interaction between doctors and journalists.

Final remarks

Following the example of the Notícias newspaper, health journalism in Mozambique is outside the two internationally accepted pillars, based on an ethical commitment to public health and professionalism. It is journalism that overlaps, to a large extent, with political propaganda favoring the government and its supposed achievements, in the face of a situation that, as seen, is not at all rosy. The research revealed the use of very dubious sources, including in the reports, with photos that portray, in most cases, illustrious political figures.

However, the interviews carried out impelled to deepen the reasons for an editorial line so markedly politicized and deprived of quality. Journalists and management of Notícias are fully aware of the limitations of the coverage carried out on non-communicable diseases. However, in the context in which they operate, taking the “ride” from public figures (such as the first lady) to talk about cancer and other relatively “new” diseases in Mozambique is one of the few possibilities for getting these issues started to be addressed.

Finally, it is difficult to say whether the context justifies such a cautious and little investigative editorial line. What seems to emerge from the analysis made in the most recent editions of the newspaper is that there are new spaces to inform Notícias’ readers about NCD, with an increasingly accentuated propensity for cancer. An option, also this one motivated by the political context, national and international, more than by the effective situation in which the country is, where cardiovascular diseases have a higher incidence in terms of deaths when compared to cancer, but with inferior journalistic coverage.

References

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