School of Geosciences
University of Edinburgh
Abstract: This paper is about health, risk, and responsibility. Any discussion of a health risk inevitably involves attributing blame for its incidence and in this in part dependant upon whether a risk is considered to be voluntarily assumed or forcibly imposed. However, deciding whether a risk has been assumed or imposed is not straightforward, and is a highly contested part of any risk construction. This paper explores this in relation to one particular risk to health, that of contracting a deep vein thrombosis on a long haul flight, more commonly known as ‘economy class syndrome’. Different groups present the risk in distinct ways, and this paper focuses on the contrasting constructions developed of the role of the airlines – either contentious but absolved of blame, or imposing the risk and creating a conspiracy of silence about it; and the passengers – either responsible for the risk through their agency, or helpless victims. This paper uses discourse analysis to explore how this is achieved, and how the conceptions of risk as assumed or imposed are enacted by different groups.
Introduction This paper is about health, risk, and responsibility. In it, I consider how a health risk is constructed by different groups, and crucially, how responsibility and blame for this risk is ascribed. This paper follows a tradition of research focusing on the control and adoption of risk, including risks to health. What this paper adds is a detailed study of how this is enacted: how groups and individuals actually claim or deny responsibility for risks, and how they demonstrate that risks are voluntary or imposed, through a focus on the discourse used.
Previous work has examined various aspects of the voluntary or imposed nature of risks. For example, research has shown that hazards rated as voluntary are often rated as controllable: if people assume a risk, they feel in control of the consequences of it (Slovic, 1992, p. 121). Slovic, drawing on Starr (1969), found that people would accept risks that were a thousand times greater if they were voluntarily assumed, rather than being imposed upon them. Similarly, Benthin, Slovic, and Severson (1993) reported that when people voluntarily engage in ‘risky behaviour’, they report greater knowledge, less fear and more personal control over the risks, as did Sjoberg, Holm, Ulle, and Brandberg (2004). Lupton and Tulloch (2002) have rightly pointed out that people who voluntarily expose themselves to risks are not necessarily irrational, uninformed or foolish; not should such decisions necessarily be compared to the ‘neutral’ position of risk assessment experts. As they say, “in voluntary risk-taking, the activity in which individuals engage is perceived by them to be in some sense risky, but is undertaken deliberately and from choice” (2002, p. 114). What I am exploring in this research is not why people choose to engage in a particular risk or not; but how different groups attempt to establish a risk as either voluntarily assumed or forcibly imposed and the consequences this has.
This is important because the assumed or imposed nature of a risk relates to responsibility for avoiding it. While an emphasis on increased risk as a consequence of (post/late) modern society has been well documented (see for example, Giddens, 1990; Lupton, 1999; Jasanoff, 1999, p. 136; Okrent and Pidgeon, 1998), what is useful to consider is the notion of controlling these risks, and how this means allocating blame. As Beck (2000, p. 8) says, “risk always involves the question of responsibility”. Indeed, Singer and Endreny (1993, p. 104) argue that “[i]n a society like ours, the need to fix responsibility, to locate a cause, and preferably an agent, is pervasive” (1993, p. 104). This may be because, as Davidson and Baum (1991), Crouch and Kroll-Smith (1991), and Marris (1996) point out, unpredictable events threaten our sense of control, so assigning responsibility for them becomes a way of coping. If blame can be apportioned, it should be possible to avert similar events in the future. In this research I consider how these issues of responsibility and blame are addressed by the groups involved a particular health risk.
Also relevant here is the literature on illness distribution and health promotion, which has included a focus on responsibility for ill health. In the UK, the influential ‘Black Report’ (1980) cited individuals’ behaviour as the main cause of health inequalities between different social classes. Since then sociological work has demonstrated that this behaviour has to be considered in its wider social context; see for example Williams and Calnan (1994) on the social factors that GPs could not address when treating chronic heart disease; and Graham (1977) documentation of the stress prevented some working class women giving up smoking during pregnancy. Research has also noted that individuals do not see behaviour as the main determinant of ill health. Pill and Stott (1982) note that the most frequently cited cause of illness is ‘germs’, seen as external agents for which people cannot be blamed. Finally, research in this area has considered illness prevention as a ‘moral enterprise’. Graham (1989) for example notes that health promotion messages reinforce the guilt and confusion women feel; especially because they make parental responsibility equate to sacrifice and culpability for mothers. Indeed, according to Oakley (1989), health promotion messages construct appropriate behaviour. I am seeking to understand how different groups orient to these issues. If the risks of ill health can be constructed as an individual’s concern, the focus is then on their behaviour. If they can be constructed as being part of a wider social context, then there may be more of a moral responsibility to tackle them.
While there are many health risks that could be considered, I am focusing in this research on ‘economy class syndrome’ (ECS). There are several terms used to describe the issue, and which one is used, and why, is itself analytically interesting. For the present however, I will refer to it as ECS for simplicity. ECS is the risk of suffering a blood clot from sitting on an aeroplane, and attention has been paid to the apparent increased risk of developing this in the economy section, rather than business or first class where more leg room and movement is available. The term ‘ECS’ was first used in a research report in The Lancet, the journal of the British Medical Association, in August 1988. The report turned the possible link between long haul flights and thrombosis into an issue that demanded attention. It also explicitly warned of the dangers of the risk to passengers; and by stating that the airlines did little to inform them added an air of a ‘conspiracy of silence’ to it, implicitly blaming the airlines for their lack of action in failing to prevent the condition. A number of risk factors have since been highlighted as increasing the risk of a clot occurring, such as the lack of leg movement, but also poor cabin air quality, previous experience of clots or conditions such as heart disease, pregnancy, taking the contraceptive pill or smoking. Of course, the importance and relevance of many of these factors are hotly contested by the different groups who have an interest in the matter.
Indeed, ECS is a topical and fiercely debated issue. While airline security remains under the microscope across the world, claims are being made about ECS in the UK and European courts that will have significant ramifications for the whole of the industry. News headlines report on passengers who have collapsed in dramatic circumstances following a flight, a wide variety of merchandise is marketed as preventing an attack, and the often conflicting scientific research on the topic receives a high profile. It is clear from the controversy around the issue that ECS is not something that ‘just happens’. It is a risk that can be assessed and accounted for, and for which blame can be apportioned. What is interesting is that each of the groups involved in the issue do so differently. In the absence of established evidence to refer to, each of the groups make competing claims, hoping these claims will be seen as factual, accurate and compelling. I am studying how they do so, through an examination of the discourse used, and focusing in particular on how they present the risk as either assumed or imposed, and the implications that this has.
Methodology To do so, I am using discourse analysis. The “utility of discourse analysis to the community of risk researchers” has already been noted (Sarangi and Candlin, 2003, p. 116). This may be because, as Sarangi and Candlin say, “risk is always discoursally and dialogically constructed” (2003, p. 119). In this paper, I take a systematic approach to studying discourse, drawing on the principles of discourse analysis (DA) from social psychology (also known as discursive psychology).
In its broadest sense, DA is the study of talk and texts (Wetherell, Taylor and Yates, 2001, p. i), and the search for patterns in language use within them (Taylor, 2001, p. 10). Discourse analytic work has highlighted the value of addressing language use. It has shown that words used to describe things actively construct a version of what these things are. Edwards and Potter (2001, p. 13-14) for example emphasize that all words have associations and implications, even seemingly dull, neutral, or factual ones. Moreover, Wetherell and Potter (1988, p. 169) document the inevitable selection of words that takes place, as only some are chosen at any time. The necessary choices made about language use are made on the basis of the associations that words have. They present the world in a particular way, and have implications both for what they describe, and for whoever is doing the describing. Indeed, the focus that DA has on the constructive power of language means it is of “enormous value to social scientists whose concerns include the circumstances and experiences of people’s everyday lives” (Lawes, 1999, p. 17).
The method adopted here follows the principles outlined by Potter and Wetherell (1987) in Discourse and Social Psychology, described as “groundbreaking” (Gill, 1996, p. 141), and still almost universally drawn on by researchers in this field. This analysis follows the stages outlined by Potter and Wetherell (1987) of setting research questions and selecting and collecting a manageable and appropriate set of data, coding relevant themes, and moving back and forward between coding and analysis in the identification of patterns within the data and the verification of them. The process of analysis here followed two closely related activities identified by Potter and Wetherell; searching for pattern in the data; and a concern with function and consequence which “consists of forming hypotheses about these functions and effects and searching for linguistic evidence” (1987, p. 168). I have also followed Potter and Wetherell’s call that analysis can and should be of practical application. They cite of oft-levelled criticism that DA is “just looking at words – not real things” (1987, p. 174). What I aim to show in this analysis is that the discourse used to attribute assumption or imposition of the risk, and to apportion blame for it, has consequential effects both for the nature of that risk, and for those making the claims about it.
In terms of data, I analysed the information available on ECS from a number of airlines; this included information on websites, inflight magazines, advice cards given out with tickets, news releases. The collection of these data was governed by availability, and all the data that could be found from airlines were collected and analysed. Some major airlines – for example, United Airlines – did not provide any information on blood clots or related issues during the collection period.
For reasons that have been detailed elsewhere (see Potter, 2007), I have not carried out interviews with passengers, but instead analysed the published accounts of groups set up to represent and campaign for passengers. I identified three such groups, and collected the information they produce. The Aviation Health Institute, or AHI, is a British based group established in 1990. Although the group ostensibly has a broad remit, recently its focus has been more narrowly on the risks of ECS. A second group, VARDA (Victims of Air Related DVT Association), originally developed as an offshoot of the AHI, but was established in its own right in 2001. Their chair is Ruth Christoffersen, the mother of a British woman who died of ECS at Heathrow airport in October 2000. A final group, Airhealth, was set up in 2001, and proactively campaigns just on that issue. An American based organisation, it was established by the founder after he developed a blood clot following a flight. It aims to raise awareness of the risks of ECS, and to challenge the position of the airlines on the issue.
A third source of data was an online discussion forum for members interested in aviation health issues. This source was included because debates about ECS rage on the site, usually in the form of an initial question or comment which is followed up in a series of messages. As Richardson (2003) has demonstrated, discussion groups and mailing lists are rich resources for risk researchers; and further, DA is particularly appropriate to study them. Bordia argues that computer mediated communication offers “an exciting opportunity to researchers interested in studying linguistic and socio-psychological characteristics of verbal interaction in a naturalistic setting” (1996, p. 149). The data here are not a final polished article, but an indication of the current state of the controversy. Messages hotly debate and contradict each other on whether ECS exists, what can or should be done about it, and who is to blame. Myers (1985) notes that the criticisms and responses in the review process of scientific articles highlight details that are usually compressed and decisions that are usually unnoticed; so examining these groups accesses the discussion and presentation of opinions that are still being debated, in the way that a press release, magazine story or journal article does not allow. This allows a glimpse ‘behind the scenes’ in the construction of the issue, and an opportunity to see ‘facts in the making’.
To analyse this source, I anonymized the details and the addresses of the site, and all individual members. Dates have been given as these may be relevant to the content of the message (they show that one message follows on from another for example), and I have given initials to each member to distinguish them. In the analysis of the airlines, passenger groups, and online forum that follows, the data presented are intended to be illustrative of the analytical points being made, and are intended to be examples of exactly how various rhetorical schemes are enacted.
Firstly, I will consider the role of the airline industry, how they present ECS as a ‘controllable’ health risk, and how they absolve themselves of any blame for it. As I will discuss shortly, passenger groups construct ECS as something passengers are helpless against. Airlines however attempt to present ECS as a voluntary risk that passengers subject themselves to through their personal characteristics, their behaviour in-flight, and their choice to fly.
Airlines construct the issue by using offensive and defensive rhetoric. They place the emphasis on passengers; and consequently away from themselves. One way this is done is by outlining the responsible position that the airline has taken, and the information that they have provided; and it is therefore up to the passengers then to use this information. The airline has done all it can by providing it.
This is illustrated in the following extract from Qantas, from a section about the health impacts of flying and ECS:
1 When you are flying you can be seated and inactive
2 for long periods of time. The environment can be low in humidity
3 and pressurised up to an altitude of 2440 metres above sea level.
4 Unlike other forms of transportation, air travel allows for rapid
5 movement across many time zones, causing disruption to the body’s
6 ‘biological clock’. Although these unique factors do not pose a health
7 or safety threat to most customers, there are guidelines you can
8 follow that will improve your comfort level during and after a flight.
9 We hope the following recommendations will help you
10 have a more pleasant flight today and in the future. (Quantas, n/d)
While this is ostensibly a description of the effects of flying, it actually constructs the passengers’ responsibility in the occurrence of ECS. It is written in terms of the passengers; “when you are flying” (line 1, emphasis added). This takes the emphasis away from the airlines and the consequences of being in a plane. It directly describes what passengers do: “you can be seated and inactive for long periods of time” (lines 1-2), rather than saying that ‘movement may be limited’. It is of course completely unexceptional that passengers will be seated, and largely inactive – they are onboard an aircraft. This seems obvious, but it must have been pointed out for a reason; and it clearly foregrounds the passengers and their actions in the development and prevention of ECS. There is also a responsibility on passengers; the airlines are providing the guidelines, but it is now up to passengers to improve their own health. The phrase ‘will help you have...’ (lines 9-10) is written with the emphasis on the passengers. It does not say ‘will make your journey more pleasant’, but is in terms of the things that passengers can do for themselves, and the ways that they can make their flight more pleasant through their own actions. Despite mentioning the conditions of the plane, it is still the passengers who have the ability to care for themselves and the airline is not to blame if they don’t; the attitude is ‘we’ve told you, it’s up to you now’.
This shifting of responsibility onto the passengers can also be seen in terms of the following extract from the Olympic Airways inflight magazine:
1 Any person who sits for a long time runs the risk of developing
2 small clumps of clotted blood in the lower legs.
3 Fatal clots can also occur in people who sit still for long periods
4 in buses, trains, cars, theatres, or at their desks. (Olympic Airways, 2008)
While again taking the focus away from air travel by mentioning these other forms of transport, using the phrase “runs the risk” further couches this in terms of action by individuals, not something that is imposed upon them. “Runs the risk” is a phrase that implies foolhardy and even reckless behaviour, knowingly engaged in. To “sit still” is presented as a choice. This is reiterated in a further extract from the magazine:
1 What preventative measures can be taken?
2 The Economy Class Syndrome may be deadly in some cases
3 but it is highly preventable.
4 Here are some steps you can take to avoid the condition. (Olympic Airways, 2008)
Again, the emphasis in on passenger action: “steps you can take”. There is also the element of passenger choice here: “can” take, rather than ‘should’ or ‘must’. This choice means that the responsibility for making this decision rests with passengers, and that therefore the onus of blame is shifted onto them. When the answer to this question states that “Here are some steps you can take”, this is interesting because at the beginning of this article it was stated that it was possible to prevent ECS with knowledge and education. Therefore by providing this to the passengers so that they can now take these steps, the airlines are absolving themselves of blame.
A further element to the construction of the risk by airlines is to emphasise the ‘risky’ characteristics that may make passengers more susceptible; and, if passengers do have these characteristics, the responsibility to defend themselves against ECS rests even more strongly with them. For example, the following extract from a British Airways (BA) factsheet stresses in some detail that it is a combination of inactivity and passenger characteristics that may cause ECS, and not being on a plane per se, shifting the emphasis away from themselves and very firmly onto the passengers:
1 Travellers’ Thrombosis: The Risks and the Researcha
2 Specific scientific studies examining traveller’s thrombosis have looked particularly at
3 how many DVT[] sufferers have travelled in the weeks preceding their diagnosis.
4 It is clear from the studies of which we are aware, that there is indeed an association
5 between long journeys and the occurrence of a DVT. However, thromboses can occur
6 after car, bus, rail or air travel, and there is no conclusive evidence that flying itself is
7 a specific risk factor. In addition, at least 75% of DVTs in these studies occurred
8 in passengers who already had at least one of the risk factors listed.
9 Some people are more susceptible to DVT than others. Generally, the risk of
10 thrombosis increases once you are over 40 years of age, but there are a
11 number of additional risk factors including:
12 Previous or family history of DVT
13 Abnormality of blood clotting factors
14 Certain forms of cardiac disease
15 Previous history or currently suffering from malignant disease
16 The oral contraceptive pill and HRT containing oestrogen
18 Recent major surgery or injury, particularly affecting the lower limbs or abdomen
19 Recent immobilisation for a day or more.
20 Some research has also suggested that, in addition, there may be an added risk
21 from tobacco smoking, obesity and varicose veins. (British Airways, n/d)
In this text, BA are describing that the risk exists and so defending themselves against any criticisms that they are ignoring it; but at the same time offensively orienting to the accusations that it is flying that causes it by stressing the impacts of travel generally. The text states this categorically, by detailing all the forms of travel (and listing air travel last) (lines 5-6). To actually list the different forms of travel that might bring on a DVT, rather than just saying that sitting still causes it, serves to direct attention away from the airline. Stating this in the sentence after one that mention “studies” (line 4) implies that this is a research finding, and adds greater credibility to it, although it does not actually say so.
The text points out that studies into DVT “looked particularly at how DVT sufferers have travelled in the weeks preceding their diagnosis” (line 3). Describing this directed focus (“particularly”) on the weeks leading up to a diagnosis emphasises the importance of what passengers do pre-and post flight, and removes attention from the experience of flight and the airline. Again, a presentation of acknowledging the issue of ECS is done in such a way that it takes the emphasis away from the airlines; DVT is caused by reduced blood flow, not specifically through the plane environment, but sitting still, and by what the passengers had been doing in the previous weeks.
Furthermore, the text goes on to list in some detail the various characteristics or conditions that increase the risk. All of these are about passengers and not about the various factors onboard a plane that airlines are responsible for and passengers have little control over, such as cramped conditions, limited leg room, reduced access to fluids and so on. The text presents the risk as being something that passengers bring on board with them. The comprehensive list would cover a wide proportion and cross section of the (passenger) population – being over forty, taking the pill, being a smoker, and/or previous ill-health or inactivity are commonplace. This list serves to increase the possibility therefore that anyone who contracts ECS has a high chance of having one or more of these characteristics, and further de-emphasises the impact of the airline. Further, the claims here – that passengers’ characteristics and behaviour preceding a flight are responsible for the risk – are presented as being from both independent and authoritative sources, and not from the airline itself. It is not that the airline is attributing the risk to passengers, but that others have done so; ‘research’ and ‘studies’ have found this. Here, BA are not directly pointing the blame at passengers, but build the picture of risky people engaging in risky behaviour by merely relaying the ‘facts’ that ‘research’ has found; but which of course are presented in such as way as to entirely substantiate their case.
Secondly, I will consider passenger groups. While the airlines attempted to make the risk of ECS more acceptable by associating it with passengers’ behaviour and characteristics, here it is presented as an involuntary risk imposed upon them. Airlines are constructed as subjecting passengers to the risk through the conditions of the aircraft, which passengers can do nothing about, and knowingly concealing from them information that could lead to its prevention.
For example, this extract from the Aviation Health Institute (AHI) constructs the involuntary nature of the risk:
1 There is no doubt that flying is by far the safest form of transport.
2 But there will always be a residual risk attached to flying, particularly if you
3 decide to spend your next vacation in Hawaii or visit your business partners
4 in Hong Kong. You will be forced to sit in the same place for hours, practically
5 without moving, and the narrow seats often mean you spend your entire flight
6 with your knees bent – and that’s when the danger of a thrombosis arises (Aviation Health Institute, 2009)
This is not a risk that passengers bring on themselves through their increased propensity to fall ill or their behaviour – it is “forced” upon them. The text presents a list of contributory factors, all of which are caused by flight – and moreover, by the particular conditions of it. Passengers are forced to sit, they cannot move, they have to endure cramped conditions – all of these are the responsibility of the airline. It may be a passenger’s choice to fly – they “decide”, but then are faced with these conditions – which are not presented as being part of that choice. They are imposed upon the passengers, and the casual link with ECS is made clear – it is “when” these conditions have been experienced that a clot develops. The extreme case formulations (Pomerantz, 1986) emphasise the depravity of these conditions – they may last an “entire” flight. Passengers cannot escape them at all. As the type of journeys that have been described are long haul (to Hawaii or Hong Kong) this means many hours at the mercy of a “danger” because of the conditions of that flight.
The airlines are presented as even more reprehensible because they deliberately keep the information about ECS from passengers. It is not that they knew nothing or could not help, but that they consciously acted to prevent passengers from finding out the truth. The following extract from a VARDA press release illustrates this:
1 Mrs Christoffersen accused the airline industry and the government of being
2 indifferent to the tragic deaths. She cited that fact that neither Lord Macdonald
3 the Transport Minister or Bob Ainsworth the Aviation Minister attended the
4 House of Commons meeting. They, as well as Sir Richard Branson of Virgin,
5 Rod Eddington of BA, and Sally Martin of Qantas were invited.
6 “It was been swept under the carpet by the very people how knew about the
7 risks of air related DVT and are still in a state of denial” she added (VARDA, n/d)
The text makes it clear that the airlines do know about the risks of ECS – they are not undecided or it is not a topic that the information is not available on – they “knew about the risks”. The past tense is interesting here too – the airlines “knew”. This information is not new or currently being debated, they already have all the facts of it. Further, the text presents the idea that the airlines should have been relaying information about the risks – they were the “very people” who knew about them – but that they have not done so. The issue was “swept under the carpet”, a deliberate action to avoid doing anything about it, not a lack of knowledge of it. Further, that they are “in denial” about the risk presents the airlines both as consciously ignoring it, and also gives the risk an existence. It has a reality beyond the claims the group are making about it if it is something that can be chosen to ignore. The airlines have been given the opportunity to address the issue, but they are presented as deliberately choosing not to – the text states that they were “invited” to the meeting at the House of Commons (the seat of the UK Government); in such a venue, this was surely an important meeting. No reason is given why they did not attend, and the reader is only left with the impression of their “indifference” and “denial”. Their non attendance is given as an example of their indifference, and it is “cited as a fact” by Mrs Christoffersen. It is not something “that she said” but a reference to external facts to emphasise the way that the airlines are deliberately failing to address the issue and are making every effort to keep it quiet.
This attempt to cover up the facts is stressed again in terms of airlines denying their importance. This extract from Airhealth describes the extremely minimal number of injuries from turbulence recorded:
1 Serious injuries from turbulence average five per year. But the airlines
2 want you to think that this is the biggest risk.
3 American Airlines inflight magazine says that turbulence is the biggest danger,
4 even though the risk of ECS is at least 8,000 times greater (Airhealth, 2009)
The airline is presented as being deliberately misleading about this in an attempt to cover up the truth. Their magazine only “says”; their defence is outlined as merely an opinion that they are trying to present as true. In contrast, “the risk of ECS” (line 4, emphasis added) is presented as a fact. The group describes the airline as “wanting you to think” (line 2, emphasis added) – this implies that are specifically attempting to persuade people about their version – this is not the same as their text being accidentally inaccurate. The use of quantification and a contrast really emphasises this (following Potter and Wetherell, 1995; and Herschell, 2001). Not only is the risk of ECS greater than that of turbulence injuries but it is “8,000 times” greater. Putting a figure on this implies they it is a measured fact. That the figure is so high, especially compared to “five” turbulence injuries, emphasises the reprehensible position of the airlines in deliberately trying to conceal this.
Finally, there is an issue about the extent to which passengers with ‘risky’ characteristics are to blame if they have a DVT. The airlines tend to make these people seem culpable if they smoke or have a medical condition that makes them increasingly susceptible. However, when campaign groups list the characteristics of passengers that may increase their risk, there is no blame inferred; rather these people should be better looked after by the airlines and it is particularly tragic that they are not. It is therefore implied that there is a moral dimension to the responsibility that airlines have. Groups present them as undermining or ignoring this to protect themselves, and this casts the airlines in a worse light still:
1 We trust the airlines. We trust them to do their best to deliver us
2 unharmed to our destinations. Instead, US airlines are doing their best
3 to conceal the biggest danger in air travel. This is especially tragic
4 for the weakest and the most vulnerable travellers, those with heart disease,
5 cancer, diabetes, pregnancy, and other risk factors. They trust the airlines
6 and their trust is sorely abused.
7 All the needless suffering and deaths could be stopped at the cost
8 of less than a cent per passenger for a leaflet telling them what they need
9 to know. Millions are spent to recover and reconstruct crashed airliners.
10 Millions are spent to foil possible terrorist attacks. If the DVT and PE injuries
11 were caused by terrorists putting something in the food, there would be
12 no expense spared to stop them. But when thousands of air travellers
13 all over the world stagger into hospitals with blood clots caused by air travel,
14 it is simply business as usual. (Airhealth, 2009)
The position of the airlines is constructed through the assumptions of their membership category (Sacks, 1992). The group presents the category of ‘airline’ as having the activity of ‘unharmed delivery of passengers to destination’ associated with it. Passengers have a right to expect this, and trust that it will be so. This disjuncture with the reality presented here makes the airlines seem calculating, grasping, and merciless. The continued repetition of the word “trust” makes this very clear. The contrast of the weak and vulnerable victims with the massive resources available to these huge companies emphasises this, especially in terms of the pitiful amount that would be needed to save them. While airlines describe people with these characteristics as being more susceptible to ECS, here these people deserve extra care because of their vulnerability, which the airlines deny them. Using the phrase “doing their best” twice (lines 1 and 2) characterises the airlines as perfectly capable of helping these people and keeping their trust, but instead actively choosing not to. The scale of the issue makes this seem worse, as “thousands” of people “all over the world” are suffering in this way, and the airlines could so easily prevent it if they wanted to. It is clear again that the risk is avoidable. Clots are caused by air travel but they could be simply prevented by a leaflet (line 8). The airlines have a moral duty to their passengers that would be so easy for them to uphold, but they are doing everything that they can not to.
Finally, I will briefly consider discussions of the risk by participants in an online aviation health forum. Members of these groups develop constructions of the risk and those involved. A key issue in the construction of the passengers is whether any risk is assumed voluntarily or is imposed upon them. Do passengers knowingly subject themselves to the risk of a DVT or is it something they are held hostage to by a secretive and uncaring airline? For example:
1 If you were ill or harbouring some ailment prior to your flight, then don’t fly –
2 nobody is forcing you. The ‘lack of leg movement’ is as much your fault for not
3 getting your bum off the seat and having a wander about; you are not tied in or
4 handcuffed you know – there is no extra charge for taking a walk up and down
5 the aisle. The ‘lack of exercise’ is a bit thick; 99% of people do not take proper
6 ‘exercise’ anyway, never mind having the facilities for such ‘exercise’. I’m sure
7 there are some good books you can buy on seated exercise manoeuvres. (Member TG – Online forum, 12/03/09)
In this message, avoiding an inflight DVT is presented as passengers’ responsibility, not the airlines’. Not only do passengers voluntarily assume the risk when they choose to fly, but they could take precautions against it if they wanted to. In a thread in the forum, it had previously been stated that the airlines make this difficult or impossible (such as not giving passengers the opportunity to move about), but these reasons are summarily dismissed and causes are instead couched in terms of passenger laziness. The message is structured in terms of the passengers’ agency to emphasise their responsibility: “if you are ill”; “getting your bum off the seat”; “you are not tied in”. The member also puts the issue into a wider context to detract from the seriousness of it. Instead of it being a scandal that the aircraft does not permit room for sufficient exercise and the crew actively discourage it, this is a ridiculous criticism when people do not exercise anyway, especially when they point to a situation in which they perceive they are being deliberately prevented. The reference to books on exercise states very clearly that it is the passengers’ responsibility not only to avoid a DVT, but to find out the information themselves that they need to be able to do this.
Passengers are also presented as assuming the risks of ECS themselves because they choose to sit in cheaper seats where the risk is greater. They could have more room, but deliberately decide not to. The airlines cannot be held responsible for this:
1 If it’s more leg room that you’re really after, then buy a seat in a class which
2 gives you the leg-room that you want. You pay for what you get. How much
3 leg movement/exercise area does your car give you? Do you spend more time
4 in your car than on an aircraft? Dehydration is self induced– if you do not drink
5 what do you expect? Does the airline you are talking about not give you
6 a cup of tea or coffee, or a glass of water every time you ask for one?
7 Be prepared is a good old motto. (Member BL – Online forum – 12/03/09)
The member presents the airlines as doing all they can, but that it is up to passengers to be prepared – and it is reasonable to expect them to be: a “good old motto” is an interesting phrase. This is a use of what Edwards and Potter (1993, p. 37) describe as the ‘vagueness of idioms’. They note that such phrases may be used because they are difficult to challenge whilst giving the impression of a “distillation of a common wisdom”. Here, the phrase implies that being ready for eventualities is something that people should think about, this is not a new or controversial idea. This also makes it harder to undermine, as it is presented as something that no one could argue with. This therefore also applies to flying. The duty of care that an airline has is also brought into question here, but it is clear that the onus rests with the passengers. They choose where they sit, and how much they would like to pay. They put a price on how much they value their health and comfort, and it cannot be up to the airlines to do anything more about this, if passengers only value their safety up to a certain point. The leg room on an aircraft is compared to that of a car, and the point is made that these things are comparable. It is not the case that when someone is onboard an aircraft, the airline assumes responsibility for how much room they have, how comfortable they are, and what arrangements there are for them. These are all still the choice of the passenger, and how much they choose to pay for them.
However, other members use ideas of voluntary and imposed risk to argue that passengers have little choice over the service they receive or the behaviour they can engage in. This post describes the impracticality of exercising during a flight:
1 For those who are very tall, the notion of being able to do ‘at the seat’
2 exercising is a joke (and the airlines know it), when the knees are
3 pinned hard against the seat in front. (Member FP - Online forum - 14/03/09)
The member is clear that there is little choice over whether to take exercise or not, and it is not a case of laziness or ignorance but the physical confines of the aircraft restricting any movement at all. It is made clear that exercising is simply not possible – it is ridiculous enough an idea to be “a joke”. As a ‘notion’ it is only a view or opinion, and is only vague and insecurely based – not a ‘possibility’ or even an ‘idea’. The member presents the image of having no choice about carrying this out. Further, knees are “pinned hard”, an ‘extreme case formulation’ (Pomerantz, 1986) that carries a lot of force. “Pinned” is a word that implies being fixed in that position without any choice or possibility of movement – it is not just that conditions are ‘cramped’ or ‘uncomfortable’. It is also phrased in terms of being something that happens to one’s knees – the passenger has no agency here in what happens to them or to do anything about it. This is contrasted with the image of “being able to do” exercises – the ability of passengers to take action has been denied them. What makes this worse is that this situation is presented as a risk definitely imposed by the airlines, who are well aware of this problem. The presentation given is that the airlines say one thing but know another – they may advocate exercising but this is contrasted with their actual attitude. The implication of course is that they choose to do nothing about it.
Personal experience is also used to challenge the constructions about passenger behaviour and their ability to avoid DVT:
1 On a recent flight I tried to stand in/near the back galley because I had
2 leg cramp, I was told to sit down, the stewardess told me I was in the way
3 and there was nowhere for me to stand on the aircraft. I refused, and an
4 argument ensued to the point where I was afraid that I will become accused
5 of instigating an air rage incident, and I decided to sit down, still with leg cramp. (Member PR - Online forum - 15/03/09)
The member describes trying to take action to avoid ECS, and being very clearly prevented from doing so. The member was prohibited from standing and describes being told that there was “nowhere” to stand – so the airline allows passengers no opportunity to move about at all. What is more, the airline will make determined and continued efforts to ensure that passengers do not move about – staff will instruct passengers, explain to them, ‘argue’ with them (in what is implied to be a heated manner), and make them feel intimidated enough to sit down. The member presents this as passengers being “in the way” if they try to look after themselves – the airline does not value them and their concerns. Passengers are denied any opportunity to help themselves. They can “try” but this agency is taken from them and the only decision they are allowed to make is which is the greater risk – accusations of air rage or cramp and possible ECS. The member therefore presents the issue as a case of an imposed risk that passengers are not given any opportunity to avoid. This particular post opened up an interesting thread of messages. The following is a message that was given in response:
1 Unfortunately, the legal situation is that you must obey the lawful instructions
2 of the Flight Crew. I would imagine that they had work to prepare or carry out
3 and that you would have been in the way. (Member BS - Online forum - 15/03/09)
While this message is seemingly sympathetic to the plight being described in the previous post, it carefully dismisses any blame being directed at the airlines. It does this subtly, for as Potter (1997, p. 109) says, actions that are delicate or sensitive are often be carried out indirectly. The member describes ‘imagining’ that the crew had work to do. This has the effect of softening the comment, rather than baldly stating ‘the crew had work to do’. The member also starts off with “unfortunately”, implying support and sympathy for the plight of the passenger, but very quickly constructs the airline crew as behaving exactly as they should have done, stressing twice the “legal” requirements behind their actions – something that is hard to argue with. The member goes on to emphasise that the crew were trying to carry out procedures as part of the airline service (“they had work to do”), so the member’s behaviour was interfering with the operations of the crew. Interestingly, the staff are called “flight crew” here, in contrast to the “stewardess” in the previous message. ‘Stewardess’ implies someone who only serves refreshments to passengers, while flight crew is a more generic term and could encompass the pilots, inflight staff manager or any member of the team. While refreshments might not be a priority if someone has a cramp, the safe flight of the aircraft might be. Using this term, a more modern one for inflight staff, brings with it assumptions about the importance of their role and the need to obey their instructions. The presentation in this second message is of the crew not being difficult or unusually awkward but merely trying to get on with their job, issuing “lawful” instructions - and the passenger as preventing that.
Other messages also attempt to counter claims about DVT being the fault of passengers because they are not prepared to pay for what the service costs:
1 And I’d be happy to pay a little more for human conditions, but don’t necessarily
2 want (and can’t always afford) Business Class. We’re talking about expecting
3 a reasonable, tolerable degree of comfort and safety when we travel, not luxury.
4 The last time I flew to the West Coast with BA, I had even less space than I’ve
5 ever had in a bus, train, or even the back seat of many cars, and that simply isn’t
6 good enough. On that particular route (Phoenix) there is no competition, and
7 £520 should have bought me something closer to a proper standard. (Member JN - Online forum - 15/03/09)
This message invokes ideas about what it is reasonable to expect and to pay for on a flight. It talks in terms of “human conditions”, clearly emphasising that what is available at the moment does not even reach this most minimal of standards. The member also uses terms such as “tolerable” implying that not much more is being asked for here; and in terms of such basic things as “safety”, requests that can hardly be dismissed as unreasonable. Using such ‘extreme case formulations’ (Pomerantz, 1986) as “less space than I have ever had” really stresses the poor quality of the service in relation to other forms of transport, and this comparison is used to emphasise the reprehensible position of the airlines. This is compounded by mention of the cost of the flight, on a route where “there is no competition”. This implies that the airlines are not charging what the service costs but the highest price that they feel they can get away with. It is not therefore a case of passengers being too irresponsible to pay for a service which gives them decent conditions, but that the airlines charge prices that most people would not be able to “afford” to pay and give a substandard service for it.
Discussion This paper has been a discussion of the risk to health of ECS, and the different ways it can be constructed. If airlines are presented as responsible, this has huge legal, financial and organisational ramifications for the industry. If passengers can be presented as responsible for ECS, then it is up to them to modify their behaviour to avoid the risk. It is clearly crucial for groups to establish where blame for ECS should be apportioned, and defend themselves against counter-accusations.
In this paper, I have discussed the differing constructions of ECS used by airlines, passenger groups, and in an online aviation health forum. The differences in these demonstrate the contested nature of the risk and responsibility for it. The point is not to judge between these constructions, to argue that one is ‘right’ or more accurate, but to highlight how groups draw on ideas about blame, imposition, and control to both defend their own position and attack that of others.
For the airlines, it is imperative to persuade that risks to health inflight are the fault and responsibility of the passengers. There have already been several high profile court cases in the UK and around the world where survivors and victims’ families have sought to prove airline culpability for ECS, and more are upcoming. The construction that the airlines develop is one of concern and contentiousness about the issue. They provide passengers with the necessary information about it, and it is then up to passengers to listen to and act on this advice – and the airlines cannot be to blame if they don’t. Passengers with extra risk factors have even more of a responsibility to take care of themselves.
Further, there is an interesting balancing act that airlines have to strike here, between making passengers aware of the risks to their health, giving them preventative information, and emphasising the dangers so that they will take notice – and making the risks seem directly correlated to air travel and appear so bad that passengers will be dissuaded from flying. Again, the way they attempt this is through emphasising the agency of passengers, to draw attention away from the location of the risk. This is not about flight, being in the air, or the confined conditions of the cabin, but about passengers choosing not to move or to protect themselves. If ‘you’ as a passenger have any of these conditions that are recognisable and medically known, and you take these precautions or actions, it can be prevented. ECS is not constructed as a random accident or as something stealthily creeping up on unsuspecting victims. It is possible to know about it, it is possible to avoid it, but the responsibility for doing so rests with the passengers and their actions. Indeed, the preferred term for the risk among airlines is ‘traveller’s thrombosis’ rather than ‘economy class syndrome’. Using ‘economy class syndrome’ locates the cause of the condition very specifically, and focuses attention on air travel. The term ‘traveller’s thrombosis’ makes the condition something that anyone who is travelling may contract. It is not location specific, but about peoples’ actions and agency. The very phrasing of the term portrays it as belonging to the passengers; it is their responsibility, not the airlines’.
In contrast, passenger groups place the blame for the condition very firmly with the airlines; not only is it being onboard an aircraft that causes ECS, but the airlines know this, and actively chose to cover it up. The risk is imposed on passengers when they fly, through the lack of information and conditions of the flight. These are not risks that they can choose to adopt or avoid, or use their experience to weigh up for themselves. The actions of the airlines give them no control at all. For passenger groups, ‘economy class syndrome’ is an appropriate label for a risk that is very much centred on the location and actions of airlines.
ECS is therefore presented as essentially very simple by the passenger groups. The risk is real and serious, but it can be avoided – but airlines refuse to acknowledge the risk or give accurate information. This makes the deaths and suffering from it all the more tragic because they are needless, and the airlines directly responsible. This sets up a classic dualism, of the poor vulnerable unsuspecting passenger, a victim upon whom the pernicious ECS stealthily creeps, against the might of the resource laden airlines. In the midst of this, the groups are the passengers’ champion, providing information, advice and facts, and attempting to bring those responsible to justice.
I have included some data and analysis from the online aviation health forum to further highlight these contrasting conceptions. Members differ in their constructions of the risk, placing the responsibility with either the airlines or the passengers, and use similar rhetorical devices to do so. What including these data allows is an insight into a ‘live’ discussion rather than a published document. Here, in this more informal context, members respond to each other and negotiations over meaning take place. Analysis of these messages allows a sense of how this is achieved. The constructions of the risk of ECS and the positions of the passengers and the airlines in these forums are in many ways a microcosm of the views presented by the passenger groups and airlines themselves. In the messages here, the responsibility of the passengers is presented in terms of their risky characteristics and behaviour, or in terms of the information given or agency allowed by the airlines for them to protect themselves. Similarly, airlines are presented either as being responsible for the risk, or at the mercy of litigious claims from disingenuous passengers.
What I have shown in this study is that notions of the assumed or imposed nature of a health risk are a crucial part of its construction, and that they are fiercely contested. I have demonstrated how these notions are actively used and oriented to, and the effects that they have, through a study of the discourse and rhetoric that different groups use. This focus on the detail of accounts highlights exactly how groups develop their constructions, and allows an appreciation of just how crucial such details are. A body of valuable research has demonstrated that the adoption or imposition of a risk is a highly significant part of its construction, and fundamental when attributing blame for it. What I have intended this paper to contribute to this debate is a focus on just how this is enacted and achieved.
Airhealth (2009). Index and Rankings. Retrieved on February 21, 2009 from www.airhealth.org/index.html
Aviation Health Institute (2009). Health Advice. Retrieved on February 13, 2009 from http://www.aviation-health.org/health_advice.html
Beck, U. (2000). World Risk Society. Cambridge: Polity Press.
Benthin, A.C., Slovic, P. & Severson, H.H. (1993). A psychometric study of adolescent risk perception. Journal of Adolescence, 16, 153-168.
Black, D., Morris, J., Smith, C., and Townsend, P. (1980). Inequalities in Health: Report of a working group. London: The Stationery Office (DHSS).
Bordia, P. (1996). Studying verbal interaction on the internet: The case of rumor transmission research. Behaviour Research Methods, Instruments and Computers, 28, 149-151.
British Airways (n/d). Travel Health and DVT. Retrieved on January 31, 2009 from http://www.britishairways.com/travel/healthdvt/public/en_gb
Crouch, S.R. and Kroll-Smith, J. S (1991). Communities at Risk: Collective Responses to Technological Hazards. New York and London: Peter Lang.
Davidson, L.M. and Baum, A. (1991). Victimisation and self blame following a technical disaster. In S. R. Crouch and J. S. Kroll-Smith (Eds.), Communities at Risk: Collective Responses to Technological Hazards (pp. 33–52). New York and London: Peter Lang. Edwards, D., and Potter, J. (1993). Language and causation: a discursive action model of description. Psychological Review, 100, 23-41.
Edwards, D., and Potter, J. (2001). Discursive psychology. In A. McHoul and M. Rapley (Eds.), How to Analyse Talk in Institutional Settings: A Casebook of Methods (pp. 12-24). London: Continuum.
Giddens, A. (1990). The Consequences of Modernity. Cambridge: Polity Press.
Gill, R. (1996). Discourse analysis: practical implementation. In J. T. E. Richardson (Ed.), Handbook of Qualitative Research Methods for Psychology and the Social Sciences (pp. 141-156). Leicester: BPS Books.
Graham, H. (1977). Smoking in pregnancy: the attitudes of expectant mothers. Social Science and Medicine, 10, 399-405.
Graham, H. (1989). Prevention and health: every mother’s business – comment on the child health policy of the 1980’s. Sociological Review Monograph, 28, 160-185.
Herschell, K. (2001). Howard’s way: naturalizing the new reciprocity between the citizen and the state. In A. McHoul and M. Rapley (Eds.), How to Analyse Talk in Institutional Settings: A Casebook of Methods (pp. 124-134). London: Continuum.
Jasanoff, S. (1999). The songlines of risk. Environmental Values, 8, 135-152.
Lawes, R. (1999). Marriage: an analysis of discourse. British Journal of Social Psychology, 38, 1-20.
Lupton, D. (1999). Introduction: risk and sociocultural theory. In D. Lupton (Ed.), Risk and Sociocultural Theory: New Directions and Perspectives (pp. 1-12). Cambridge: Cambridge University Press.
Lupton, D., and Tulloch, J. (2002). ‘Life would be pretty dull without risk’: voluntary risk-taking and its pleasures. Health, Risk and Society, 4 (2), 113-124.
Marris, P. (1996). The Politics of Uncertainty: Attachment in Private and Public Life. London: Routledge.
Myers, G. (1985). Texts as knowledge claims: the social construction of two biology articles. Social Studies of Science, 15, 593-630.
Oakley, A. (1989). Smoking in pregnancy – smokescreen or risk factor? Towards a materialist analysis, Sociology of Health and Illness. 11 (4), 78-92.
Okrent, D. and Pidgeon, N. (1998). Editorial: Risk perception versus risk analysis. Reliability Engineering and System Safety, 59, 1-4.
Olympic Airways (2008, summer). Motion. Inflight magazine, Travel Health section, p.98.
Pill, R., and Stott, N. (1982). Conceptions of illness causation and responsibility, Social Science and Medicine, 16, 43-52.
Pomerantz, A. (1986). Extreme case formulations: A way of legitimizing claims. Human Studies 9, 219-229.
Potter, J. (1997). Representing Reality: Discourse, Rhetoric and Social Construction. London: Sage.
Potter, J. (ed.) (2007). Discourse and Psychology (Vol I. Theory and Method). London: Sage.
Potter, J. and Wetherell, M. (1987). Discourse and Social Psychology: Beyond Attitudes and Behaviour. London: Sage.
Potter, J. and Wetherell, M. (1995). Analyzing discourse. In A. Bryman and R.G. Burgess (Eds.), Analysing Qualitative Data (pp. 47-66). London: Routledge.
Qantas (n/d). Your Health Inflight. Retrieved January 28, 2009 from http://www.qantas.com.au/info/flying/inTheAir/yourHealthInflight
Richardson, K. (2003). Health risks on the internet: establishing credibility on line. Health, Risk and Society, 5 (2), 171-184.
Sacks, H. (1992). Lectures on Conversation (Vol. I and II). Oxford: Basil Blackwell.
Sarangi, S., and Candlin, C. N. (2003). Categorisation and explanation of risk: a discourse analytical perspective. Health, Risk and Society, 5 (2), 115-124.
Singer, E. and Endreny, P.M. (1993). Reporting on Risk: How the Mass Media Portray Accidents, Diseases, Disasters, and other Hazards. New York: Russell Sage Foundation. Sjoberg, L., Holm, A., Ulle, H., and Brandberg, Y. (2004). Tanning and risk perception in adolescents, Health, Risk and Society, 6 (1), 81-94.
Slovic, P. (1992). Perception of risk: reflections on the psychometric paradigm. In S. Krimsky, and D. Golding (Eds.), Social Theories of Risk (pp. 117-152). Westport: Praeger.
Starr, C. (1969). 'Social benefit versus technological risk: what is our society willing to pay for safety?' Science, 165, 1232-1238.
Taylor, S. (2001). Locating and conducting analytic research. In M. Wetherell, S. Taylor, and S. J. Yates (Eds.), Discourse as Data: A Guide for Analysis. London: Sage and The Open University.
VARDA (Victims of Air Related DVT Association) (n/d). Introduction and Aims. Retrieved December 14, 2008 from http://www.varda.org/about.htm
Wetherell, M. and Potter, J. (1988). Discourse analysis and the identification of interpretative repertoires. In C. Antaki (Ed.) Analysing Everyday Explanation: A Casebook of Methods (pp. 168-183). London: Sage.
Wetherell, M., Taylor, S. and Yates, S. J. (2001). Discourse as Data: A Guide for Analysis London: Sage and The Open University.
Williams, S., and Calnan, M. (1994). Perspective on prevention: the views of general practitioners. Sociology of Health and Illness, 16 (3), 372-393.
A version of this article appeared in eä journal.
 See Potter and Wetherell (1987, pp. 160-179) for a full exposition of these stages.
 Line numbers added
 Line numbers added
 Line numbers added
 DVT or ‘deep vein thrombosis’
 Line numbers added
 Line numbers added
 Line numbers added
 Line numbers added
 Line numbers added
 Line numbers added
 Line numbers added
 Line numbers added
 Line numbers added
 Line numbers added
 Line numbers added