Impact of Social Media on Power Relations of Korean Health Activism

This case study explores how the Korea Leukemia Patient Group (KLPG) uses social media in its internal communication strategy and how that empowers its relationship with external counterparts. This study’s findings indicate that the communication strategy of the local health Non-Governmental Organization (NGO) is changing in response to the increased effectiveness and impact of social media. Using social media (e.g., Twitter) the KLPG can quickly and effectively construct an issue-based advocacy group. Consequently, more legitimacy and representativeness through collected support from the general public have further empowered the KLPG. Yet, the sustainability component in the relationships built through social media use was not evidenced in the current findings. The effects of social media use were analyzed based on data from interviews with top-level KLPG executive members and general members, and from documentation and archival materials. Limitations and suggestions for future research are included.


Background
In the arena of global health, local activism is of high importance to transnational corporations' issues management and community relations (Sriramesh, 2010).As huge expansions of social media (e.g., Facebook and Twitter) have facilitated the e-mobilization of local activist organizations, these new social media are particularly influential on their efficient, consistent and timely communication with the public and with their current and potential internal members (Seo, Kim, & Yang, 2009;Sriramesh, 2010).In this regard, the case study aims to investigate how social media use in a local health activists' organization, the Korea Leukemia Patient Group, shapes internal communication, how changing organizational routines affect inner culture, and how these changes ultimately affect its external communication strategy.
In particular, health activism (Zoller, 2005) draws significant attention from both private and public sec-tors of society.Redoubling efforts in symmetrical communication between private and public sectors is highly emphasized, considering that global health, being related to basic human rights and dignity, needs philanthropic efforts over financial ambitions.In addition, health activism rests on peculiar political dynamics (Zoller, 2005).For example, in the Korean context, major political driving forces exist in social activism, such as anti-Western sentiment and resistance to capitalistic reformation and policy implementation.
Although Korean health activism is viable as a forceful agenda setter in the Korean health landscape, many Korean health NGOs have lacked human and financial resources, thus have relied on a handful of active members or leader groups.Consequently, asymmetry in internal communication within organizationsembedded in Korea's closed and authoritarian organizational culture and its top-down decision-making process-often raises ethical issues (Bowen, 2010).Activists often tend to face conflicts of interest such as inappropriate corporate donations or government subsidies (Stuckler, Basu & McKee, 2011).Although many local health NGOs claim no strings are attached, this custom always presents obstacles to building organizational legitimacy and transparency (Stuckler et al., 2011).More, this criticism of seemingly inappropriate affiliations between health NGOs and corporations is not only a concern to health NGOs, but is also a problem confronting transnational corporations, in that their community relations might possibly be suspected of disguising marketing tactics (Stuckler et al., 2011).
Strikingly enough, the recent social media phenomenon has brought systematic and substantial change to the strategic communication of those health organizations in Korea.Increased e-mobilization has been accompanied by an increase in the volume of small donations and these now account for an ever-larger proportions of the organization's budget. 1 Constant participation of each individual small-donor eases the burden the organization bears in otherwise having to rely on a few deep-pocketed corporations.It thus is assumed that as social media are becoming incorporated into both health NGOs' routines and individuals' philanthropic efforts, two-way symmetrical and transparent communication between health NGOs and the public will also be further facilitated.
Under such assumptions, this study aims to explore how one specific Korean health NGO, the Korea Leukemia Patient Group (hereinafter KLPG), uses social media in its internal communication strategy and how that empowers its relationship with external counterparts.More broadly, this investigation can give multicultural public relations professionals better grasp of how local activism operates and how social media change their routines.

Research Problem
As social media occupy a major part of a health NGO's communication strategy with the public, how is the health NGO's inner culture and leadership benefited or changed?How do changing internal relations enhance its organizational ethics such as transparency, authenticity and responsiveness in decision-making processes?This set of inquiries also raises subsequent questions; does increased social media use really benefit activism?And how does this empowerment affect its strategy against external counterparts?Does more equal valence in the relationship contribute to mutual interests?And why and how does it do so?
Much academic investigation has been done into how transnational corporations run public relations to promote issue ascendance or Corporate Social Responsibility-CSR; however, little attention is given to how local activist organizations communicate with their internal audiences.The topic of this study question is particularly relevant to global Public Relations practitioners because organizational culture itself is essential to shaping an organization's outside activities.
In contrast to ample research investigations of corporate ethics (Bowen, 2010), NGO ethics have been marginalized in the realm of academia because more emphasis has been put on societal value and meaning, and legitimacy and power in activism (Smith & Ferguson, 2010) than communication openness and transparency in the organizational ethical construct (Ross, 2002).

Research Questions
This case study will explore how the KLPG uses social media with its internal members and how this will affect its relationship with external counterparts.Accordingly, research questions are as follows:

RQ1: How does a local health NGO use social media to communicate with its internal members? RQ2: How does a local health NGO's use of social media change the relationship with external counterparts-such as transnational pharmaceutical companies and government authorities?
The study examines the way the use of social media changes the organization's culture in terms of the organization's leadership and ethics such as transparency and responsiveness.Also, the study further explores the effect of changing the organization's culture on its communication strategy as well as its relationships with external counterparts.

Organization to Be Studied
Founded in 2002, despite its short span of a little more than a decade, the KLPG has now become one of the representative patient groups in the local health activism landscape, with more than 8000 supporters and six paid executive activists.The KLPG's annual budget is approximately US$250,000.Sources of income consist of regular membership (45.5%), donations and fundraising (28%), government subsidy (16%), and miscellaneous (10.5%).
The KLPG's primary organizational goals are (1) to organize and offer emotional support and practical help to those who had or have leukemia or a blood disease, and their families and friends, (2) to promote blood donations needed after cancer treatment and transplants of hematopoietic stem cells, and (3) to devise alternative ideas to improve public health policy and protect patients' rights.
The KLPG has achieved notable success in enhancing patients' rights.In particular, Korean health activism and its lowering of the price of GLEEVEC, a unique treatment for certain forms of cancer, is a widely-cited successful case of price negotiation.After more than four years of three-party talks between the KLPG, the Ministry of Health and Wellness of Korea, and Novartis Korea, blood-cancer patients in Korea eventually gained free access to GLEEVEC with support from both the public health care plan and price reimbursements from Novartis Korea.
Apart from activism against its external counterparts, the KLPG is also implementing diverse health campaigns with support from a variety of non-profit and for-profit organizations.Three current areas on which the KLPG mainly focuses are (1) provision of consultation and education for patients needing medical treatment, (2) enhancement of anti-bacterial environments for patients fighting disease, and (3) organization of volunteer groups.

Health Activism
Many scholars have noted that health activism is defined as or understood as political action for (i) a cause that could save human lives, and (ii) those who would otherwise perish as a result of social injustice or unequal distribution of resources (Labonté, 2013;Laverack, 2013).Therefore, working against the tenets of capitalism and bureaucracy, health activism has become more empowered and has contributed to shifting power and norms to bring about substantial changes in culture and policy in the public health arena (Labonté, 2013;Laverack, 2013).To fulfill the aim of health activism, a successful strategy should be enacted to obtain "strong leadership, good media relations, a network of strategic alliances and sufficient, independent financial resources" (Laverack, 2013, p. 50).Particularly in the global context, ample successes have already been achieved through grassroots activism.A notable example is the interruption of monopoly rights of pharmaceutical companies, and of manufacturers of life-saving treatments; this was made possible as activists successfully mobilized support in the street as well as in courts in many countries (Labonté, 2013;Laverack, 2013;Lofgren, 2013;Magg, 2006;Vasella, 2003).

Activism and Local Politics in South Korea
Similarly, in Korean society, local health activism has grown into a significant political driver.The uniqueness of the Korean health market and culture should be considered for better understanding of Korean health activism as distinguished from health activism in Western society.Unlike the U.S. or other Western countries, in which privatization and individualism prevails in dealing with public health issues, the Korean public health sys-tem largely operates on the government system as seen in the universal health insurance policy and pricesetting system.In Korean society, medication is covered by public insurance and drug prices are set by the Health Insurance Review and Assessment Service under the umbrella of the Ministry of Health and Welfare (MHW) and pharmaceutical companies.Thus, the power relations of Korean health activism lie mainly in consideration of triangular relationships among global pharmaceutical companies, government health bodies, and activist organizations themselves.To be specific, in facing global pharmaceutical companies, the Korean government and activists may be on the same page in arriving at a price deal; at other times, health/patient activists may partner with global pharmaceutical companies as joint stakeholders when both parties can benefit from the public health insurance coverage.Therefore, ethics and public obligations that grassroots health activists aim for have a critical role in the Korean public health arena.

Social Media
The term "Social Media" is a broad concept encompassing diverse "interactive media channels that allow two-way interaction and feedback" (Kent, 2010, p. 645).To reduce ambiguity and clarify the concept as more relevant to this study, of the various types of social media (e.g., blogs, forums, podcasts, Wikipedia and YouTube; Helmond, 2009), this case study focuses on social networking sites (SNS) such as Facebook and Twitter as the most representative media reflecting the core nature of social media-in convenience as well as social utility.
It should be noted that SNSs are the social media most recently used by health activists to reach their internal audiences.One of the clear advantages of SNSs over blogs is the ability to get one's word out more effectively and quickly.Individual users access more validated and socially "significant" content through sharing posts or "re-tweeting."As a result, social media are tools that promptly and consistently facilitate a health NGO's internal members' and supporters' access to information relevant to their philanthropic motivation and health community concerns.

E-Mobilization and Activism
As with increased interactivity, interchangeability, propinquity, and responsiveness in digital media traits (Kent, 2010), publics have become more empowered and less restricted, bypassing traditional institutional controls of corporations (Bernoff, 2008).As Coombs noted (1998), technology contributes to building equal relationships between publics and organizations by facilitating a virtual organization designed by members of social media.
Reflecting these contentions in this case-study, it is assumed that social media also benefit a non-profit local activists' organization like the KLPG by providing effective means of communication for mobilizing support.Indeed, we have already seen such cases in the global activism landscape.Specifically, Chinese local activists were easily able to organize participants through e-mobilization when protesting against global corporations' business routines (Kent, 2010).This happened beyond geographical constraints and without the help of a system-based entity.Thus, it is clear that a local health NGO, the KLPG in this case study, can also make the best use of social media, reducing the burden of traditional media control for publicity by building direct, intimate and sustainable interaction with its supporters.

Internal Members
Given that a health NGO is a not-for-profit organization, its supporter group is the public who donates to, or psychologically advocates for, it.They are mobilized support (Bourland-Davis, Thompson, & Brooks, 2010) who share a relationship to the organization (Moffitt, 2001) with common worldviews and goals in the public health agenda.Stakeholder groups are the group with direct and financial interests in the NGO's activity.They financially and socially benefit by such outcomes as drug price negotiations and implementation of a public health care plan relative to treatment of the disease with which they work.Last, the employee group comprises activists paid by the health NGO.In terms of expected interests and shared values, this group is situated in the middle of both above groups in that they obtain both financial benefit as well as social recognition from the outcome of the health NGO's activities.

Dialogue and Responsiveness in Communication with Internal Partners
All the aforementioned concepts related to the research questions are pertinent to exploring the dialogue and responsiveness in organizational communicative culture.Although previously explored the organization's ethical frameworks mostly refer to forprofit organizations such as corporations, we can also apply the Kantian model of ethical decision making and communication considerations to non-profit settings because, whether an organization is for-profit or not, all organizations share common traits in that their ethics and public relations are significantly affected by the leadership and communicative process in which decisions are made (Bowen, 2002).According to Bowen (2010), dialogue and responsiveness are core elements in ethical public relations, "imbued with inherent goodness or moral worth" (p.574).Despite limited empirical exploration of NGOs' ethics and public relations, it is conjectured that health NGOs based on local activism are driven by the core leadership and funding structure.More importantly, because health NGOs serve philanthropic goals for public health (Zoller, 2005), ethics and legitimacy are even more crucial for them than for for-profit organizations.
Thus, as in a corporate setting, we can apply the Kantian model of ethical issues management to the context of local health NGOs' internal communication and external relationship-building processes.The model illuminates a symmetrical nature in practices for ethical and successful public relations (i.e., two-way communication with the public, formal and informal research, inspiration of change in organization and audiences, mutual understanding, and relationship maintenance) (Bowen, 2005, p. 193).In this respect, the KLPG's strategy regarding communication with its internal members, will drive the organizational decision-making process sequentially, thus affect the external relationship with its counterparts.

External Counterparts
External counterparts are the groups who have financial interests conflicting with, or the reverse of, those of the health NGO; these include pharmaceutical companies and government authorities.These external counterparts are organizations who perceive the health NGO as an issue to be handled, or in an academic description, "the capacity to understand, mobilize, coordinate and direct all strategic and policy planning functions, and all public affairs/public relations skills toward achievement of one objective: meaningful participation in creation of public policy that affects personal and organizational destiny" (Chase, 1976, p. 1).These external counterparts do not necessarily have conflicting relationships in terms of social values and meanings; after all, those entities share common values such as to defeat disease and to achieve better health treatment and welfare.Nonetheless, in details and with regard to specific aspects and/or methods of solving issues, external counterparts have disputes due to the negative impact of the issue on their profit gain or business routines (Jaques, 2010).

Case Study Method
This study uses the case study method, for two main reasons.First, case studies provide scientific evidence based on rigorous data collection from real-world contexts, which distinguishes such evidence from arbitrary interpretations of text or subjective observations (Yin, 2003).Also, as Yin noted, a case study is well suited to research questions as to how and why, focusing on contemporary events with no need to control behavioral events.This study's purpose is to explore one specific local health NGO's use of social media and its impact on the organization's communication with both internal and external members.This exploration cannot be pursued fully through experiments or surveys because the organization's social media use cannot be manipulated or measured on an absolute scale.In particular, social media use is the consequence of the organization's culture and strategies, rather than an independent variable that is frequently calculated and controlled in a typical quantitative approach.Accordingly, a case study is more appropriate to fulfill this study's aim.
Validity advantage derives from allowing for and facilitating in-depth descriptions and a thorough understanding of how and why the organization's characteristics, social media use, and relationships interact.We can avoid the reductionist pitfall of building relationships between social media and communicative change, thereby enhancing the validity of study via specific clarification of various forces when explaining social media impact on an organization.
To obtain theoretical power, this study will explore the exemplary case of one local health NGO, based on local health activism, whose financial and organizational structure is independent, mainly supported by its membership and charitable donations.Accordingly, the relationship between the KLPG and its external counterparts shows tensions typical among local health activism, government authorities, and transnational pharmaceutical companies.In this way, the study is expected to obtain replicability leading to generalizability of the findings.
Doubtless, the case study method has several limitations.Despite rigors in the clarification of this study's concepts and constructs, and the exemplar background around the KLPG reflecting the strained/cooperative relationship between local health activism and global pharmaceutical companies, the analysis and findings are yet restricted to within one specific organization, thus might not be able to be extended to other organizations.

Data Collection Procedures
As noted by Yin (2003), this study uses three sources of evidence: (1) telephone interviews, (2) documentation, and (3) archival records.Each of the following individuals were interviewed by telephone thrice: the KLPG's leader, the KLPG's PR strategy manager, and a KLPG member.Interviews were based on the script in the Appendix focusing on how the KLPG uses social media to communicate with internal members, how changes in the communication process influence communication effectiveness and transparency, and how and why these changes are important in external communication.
Data collected from interviews carries significant validity, since this is a case study on a small organization whose leadership is virtually a couple of people.Also, although this study collected data from a small number of interviewees, validity was not necessarily harmed as several studies on the organization's leadership (Bowen, 2002(Bowen, , 2005(Bowen, , 2010) ) focused on interview quality rather than on interviewee quantity.
In addition, documentation and archival records were used to obtain recorded or quantified evidence of actual campaign strategies implemented using social media and on their role in mobilizing members and attracting donations.

Data Analysis
To obtain a full picture of the impact of social media on the KLPG with particular reference to e-mobilization of support and publicity, this study will combine quantitative and qualitative evidence (Yin, 2003, p. 109) to explore the study's initial propositions, namely that social media bring about changes in transparency and responsiveness of the communication process.
Additionally, data will be analyzed based on logic models, an effective data analysis technique to clarify complex and repeated cause-effect-cause-effect patterns (Yin, 2003, p. 127).Although this case study is more exploratory than confirmatory, it aims to pursue a test of the theoretical proposition.Accordingly, this study will compare data collected on the KLPG's communication process and its external relationshipbuilding to the framework of collaborative decision making and also to the listening and appreciating elements in the ethical construct that Ross (2002) identified.The logic model presumes that the use of social media influences the KLPG's communication process and effectiveness, which in turn affects external relationship-building.It is important to note that this sequential model is more appropriate to exploring the interaction of variables than to one-way and simple pattern matching.

Results
The results section includes direct quotations from interviewees, information from archival materials, and documentation.From this point forward, items attributed to KLPG leader Ahn Ki-Jong, refer to the research interview of November 24, 2011.

Twitter and Celebrity Endorsement
The news article covering the KLPG's philosophy and identity through the interview with the KLPG leader was arranged in the headline page of OhmyNews, Korea's most-read Internet news channel, then viewed by approximately 10,000 readers (OhmyNews, 2011).However, when it was retweeted by the influential figure, liberal politician Lee Chung-Hee (having 100,000 followers), the interview article received an additional 11,000 readers.It also gained another 17,000 readers immediately after famous comedian Kim Mee-Wha's (having 160,000 followers) retweet.Ahn recalled the episode and cited the importance of social media to the KLPG.
"Merely two power-Twitter users' retweets of the news article on the KLPG issue brought about 'three times the effect of a traditional news media arrangement.'At that moment, I realized that-for the KLPG-it is more important to know how to circulate the information through social media rather than to just rely on traditional media exposure to push our issues to the public."2Another visible benefit through interaction with power-Twitter users comes from the ease and convenience in fundraising.The The Cost of a Meal Can Save Sodkoo campaign in 2011 might be a fitting example.Sodkoo, a three-year-old toddler from Mongolia had leukemia and visited Korea for treatment not feasible in his homeland due to lesser medical technical skill there.Although Sodkoo arrived with the equivalent of US$20,000 raised in Mongolia, that amount was insufficient for the full treatment.To assist him, the KLPG initiated a fundraising campaign and sought power-Twitter users to retweet the campaign website.Shortly after the KLPG contacted famous Korean actress Ku Hye-Sun through Twitter, she sent positive feedback.Particularly because the soap opera in which she had starred in 2007 was extremely popular in Mongolia, she is well known and admired there, so she willingly joined the campaign and visited Sodkoo in his hospital room.With Ms Ku's fans also joining, the KLPG raised US$30,000 for Sodkoo who could then be treated further and successfully return to health (Medigate News, 2011).Park Jin-Seok, the KLPG's Public Relations strategy manager, cited the effectiveness of social media in handling fundraising issues for the KLPG: "Thanks to Twitter, the KLPG can easily interact with celebrities or power-Twitter users on a real-time basis, easily building a direct communication channel with them, bypassing business contracts.It is also beneficial for celebrities to perform good deeds through retweeting or asking their fans to participate in charitable donations solely based on personal will.If we contacted celebrities through their agencies, there would be many constraints and the KLPG would need to pay for operating expenses.For example, major NGOs with relatively deep-pockets who invite celebrities to their events would pay more than $2,000 a time.This is not affordable for the KLPG."

Small Donations through Social Media Campaigns
One of the KLPG's constantly-running projects is the Clean Car Campaign, providing an anti-bacterial vehicle for blood cancer patients whose immune systems are vulnerable (Clean Car Campaign, n.d.).In 2011, the project stopped because a decrease in corporate donations forced budget cuts.So, rather than seeking corporate donations, the KLPG aimed to raise small donations for the project (Blood Talk, n.d.).The KLPG posted a news article on the issue on the organization's home page, and then asked 25 power-Twitter users in Korean society to retweet it.Of those 25, five were willing to retweet, and the result was that 135 people pledged to support the project and necessary funding raised minimum funds to continue the project.
Park Jin-Seok remarked on social media use as a communication vehicle for drawing public interest.
"I used to try to meet journalists in person and draw their attention to issues at hand.Unlike in the past, I can now write articles based on my own perspectives, considering audience interests and motivation.Also, these days, Korean companies' philanthropic efforts focus on global charity, not on patient organizations.Thus it is becoming even more important for us to draw small donations from the general public.To put it simply, I think social media are a sword and a shield for the KLPG."

Internal Members of the KLPG
Members of the KLPG comprise regular, associate, voluntary service, and supporting members.Regular and associate members are patients and patients' family members who are agreed on the KLPG's philosophy and action plan.If a member signs up for a monthly donation subscription, he or she is counted as a regular member; otherwise, he or she will be an associate member.Voluntary service members and supporting members are non-patient members who support the KLPG by regular donations or voluntary service.Additionally, two special celebrities-a Korean beauty pageant winner and a fashion model-officially endorse the KLPG.

Issues in Internal Relations
The KLPG major goal is to pursue the health rights of blood cancer patients, and to provide mental and financial support for them.However, some issues require internal handling.Overall, the KLPG's highest priority is the rights of blood cancer patients, so if a government health agency or other health service provider stands against patient members' rights and interests, the KLPG tends to criticize those external counterparts.Yet the response might be different if blood cancer patients' interests and the general public's interests are trade-offs.For example, drug prices are settled in negotiations between the National Health Insurance Corporation (NHIC) and the pharmaceutical companies.When considering only patients' interests, patient organizations typically tend to push the NHIC to an agreement with pharmaceutical companies as soon as possible because, no matter what the price, patients can be covered by insurance.Moreover, if the price is not finalized, the pharmaceutical company cannot sell the drugs, so patients' treatments can be delayed.However, the KLPG's philosophy and action plan does not uphold only patients' interests.According to KLPG leader Ahn, considering that NHIC's budget should be spent on the general citizens' health rights, not solely on a specific disease group, as often as not, blood cancer patients' needs and demands should be checked for fair and balanced use of national insurance funds (Jinbonet, 2008).
As such, in sensitive issues entailing conflicts of interest, organizational ethics and leadership become critically important to build organizational identity and an action strategy for dealing with external counterparts.KLPG executive office members do not see twoway communication as absolutely beneficial to the organization's ethics and leadership.Leader Ahn's comment below outlines the ambivalent role of two-way communication in internal communication.
"One of the possible concerns anticipated from the executive office's side is the immediate controversy over our prioritization of public interests over blood patients' interests.If new members are not aware of our original identity, they might extensively advocate patient-centeredness.In this case, two-way communication is a two-edged sword.To be specific, the KLPG was initiated to pursue social and humane justice, such as protesting against overlyexpensive drug prices, but was not intended to pursue private and selfish interests of patient groups.If we care only about patients' financial and medical interests, we would not need to support the government in price negotiations with pharmaceutical companies, because no matter how much the drug cost will be, national insurance will cover it.However, the KLPG appreciates government efforts to save public funds, so we are not pushy on making fast deals just to get drugs as soon as possible.Two-way communication might cause confusion and inefficiency instead of transparency and sustainability."By far, organizational identity and major decisionmaking are not fully discussed and agreed upon through social media platforms.First, there has not been a major political issue, so the KLPG has shifted its focus to patients' welfare rather than to the political issue.Next, not until recently did social media become extensively used for internal communication.Often, bottom-up decision-making was processed through phone calls or interpersonal contact with executive members.However, executives recognize the importance of social media in encouraging dialogic communication, thereby building organizational authority, transparency and representativeness in issues management in the future.It is because without social media, only enthusiastic members use the interpersonal channel to deliver their opinions to executive members.

Transparency and Responsiveness in Future Trends
Although KLPG executive members might be concerned by possible limitations of social media's effectiveness in internal communication, they believe that dialogue and agreement on the KLPG's philosophy-via social media platforms-will enhance organizational representativeness and legitimacy.Also, the executives see it as a major future goal in internal communication.Leader Ahn outlined it so: "Especially for a small-sized NGO like the KLPG, there is considerable concern about isolating the executive office from its internal members.The KLPG holds a meeting only annually with internal members, so the executive office might tend to be the dominant driver of the major decision process.But since early 2011 the organization has extensively used social media like Twitter, so we expect to gather members' opinions quickly and spontaneously." It seems that the frequent and easy access of general members to the decision-making group would elevate ethics in organizational communication and its leadership by balancing patients' group needs and interests, and the common public good, where non-patient members' opinions and interests are also involved.

External Counterparts of the KLPG
The first significant external counterparts to consider are government health agencies, councils and Congress as the public sectors with whom the KLPG interacts or negotiates on public policy.For example, if government reduces health benefit coverage for blood cancer patients and discriminates based on blood cancer type, the KLPG works to stage a protest against the proposed cutback of benefits.However, the relationship between the KLPG and government started to change in 2007 as the KLPG grew into a qualified health NGO; in several health campaigns, such as the hematopoietic stem cell donation campaign and the organ donation campaign, the KLPG and the government collaborated.Other external counterparts are a group of health service providers' organizations, including the Korean Medical As-sociation, the Korean Hospital Association, the Korean Pharmaceutical Association, the Korean Pharmaceutical Manufacturers Association, and so on.The relationship with medical service providers varies based on mutual financial interests and the extent of invasion of patient rights.With regard to the high expense of blood cancer treatment, the Right to Life, and the Right to be Informed, the relationship might be strained, yet for issues such as the procurement of medical services for those in poverty, rebates for medical expenses, and patients' Declaration of Rights, the relationship is likely to be harmonious.In addition, Corporate Social Responsibility (CSR) programs are major counterparts of the KLPG; examples include the La-Mi cosmetic company, and Ozone Phytoncide Solution (an air cleaning service firm).When and where those corporations have genuine motives in CSR, the relationship would be cooperative, but in situations where patient rights are violated for commercial purposes, the relationship would be frictional.

Legitimacy and Representativeness in External Communication
Potentially, social media are highly influential in mobilizing support in dealing with external counterparts.In particular, the transparent and effective nature of social media helps in increasing legitimacy and representativeness of the mobilized support.An illustrative anecdotal episode was the mounting of a recall of government policy in response to the cutback of health benefits for cancer treatment (Policy Recall, 2011).The Special Favor Policy for cancer patients, allowing them to pay only 5% of treatment costs for the first five years of treatment, was called for to offer an extension for those suffering severe symptoms in the aftermath of treatment.To push government health authorities to reflect public opinion, the KLPG uses a special online application tool to gather signatures through the Short Message Service (SMS).A person can send a text message via his or her mobile phone to the designated number, whereby his or her signature is registered online via text/phone identifiable personal information.KLPG PR strategy manager Park Jin-Seok has mentioned several aspects of the value of the combined use of Twitter and online signature applications: "First value of the application is to help in tracking down signature validities through mobile phone numbers and addresses.Thus, signatures collected through the application can carry more weight with authorities or health service providers.Second, Twitter and the application reduce much of the burden in a signature-seeking campaign.We gathered more than 10,000 signatures through the online application.But if we attempted to do that offline, we would have to turn to the street and put extensive time and labor into meeting people and persuading them to sign up.In response to this, government authorities have started to research the possibility of a policy recall, and policy reform is now expected soon." As noted, social media provide the most cost-effective methods ever in gaining public support, even for changing policy minutiae-which, often, is not easy for general populations to understand.While some scholars (Labonté, 2013) doubt the potential and actual contribution of social media in building organizational power in health activism it is anticipated that 'Clicktivism' will flourish as a form of more public-driven action than have other methods in the past.

Benefits and Limitations of Social Media use from Members' Perspectives
Both patient and non-patient members commonly perceive benefits in the KLPG's use of social media.Un-Young Lee, a patient member, commented that social media are more effective for quick updates and dissemination of information to like-minded people.Jeon Ju-Hyun, a non-patient member, also noted that social media enables the KLPG to disperse the organizational agenda into a variety of populations, creating more sympathy for any individual issue.However, the member interviewees shared a common view that not all communication through social media necessarily leads to a sustainable and long-term relationship with participants in the issue.This point was also made by the leader of the KLPG Ahn Ki-Jong, that celebrities or power-Twitter users who endorse the KLPG through retweeting or supporting a fundraising campaign often are not aware of its organizational philosophy and identity, so regard their brief support as merely an act of charity rather than becoming involved in a sustainable relationship with the KLPG.This minimal association is also reflected in interaction from the general public.Thus, future organizational communication strategies need to focus on a new communication strategy to overcome the current limitation, thereby turning the speedy yet short-term linkage with the public into a more sustainable dynamic.

Discussion
This case study pursues a clear understanding of social media's effectiveness, especially for transparency and responsiveness when fighting for issues and mobilizing support from the public whereby a local health NGO can be empowered substantially.Laverack (2013) pointed out critical elements of successful social movements such as access to human and financial resources and leadership and participation sharing a common world view and philosophy.Aligned with this perspective, the KLPG successfully seems to utilize social media to strengthen elements critically important to an ethical and efficient health community.This study's findings suggest that social media are incorporated into an effective campaign strategy helping empower activists dealing with the complicated political relationship with institutional authorities.
This finding about social media use in organizational internal communication is consistent with Kent's prediction (2010) that social media bring effectiveness and convenience, especially in drawing the general public's attention to KLPG issues.In addition, by bypassing traditional and institutional control of corporations (Bernoff, 2008), social media spawns easy access to celebrities who might endorse the organization and/or its aims.Consequently, the social media phenomenon affects organizational PR strategies so as to focus on information circulation by power-Twitter users, rather than by relying solely on traditional media coverage.Thus, analysis revealed that after the KLPG adopted Twitter use, it changed the organizational communication dynamic, rendering it more effective via endorsement of celebrities and power-Twitter users on specific issues.This finding is consistent with the notion of powerful and effective activism through e-mobilization (Kent, 2010).Dialogue and responsiveness in communication with the general public empowers the KLPG by enabling it to obtain more trust-and more thrustagainst external counterparts.
However, overall transparency and effectiveness in social media communication among internal members does not necessarily mean two-way communication in decision-making.To be specific, research results found there to be limited use of social media in internal communication, particularly for sensitive and debatable political issues such as patients' self-centered interests or organizational philosophy.In the organizational decision-making process, the KLPG has not had the opportunity to experience a two-way symmetrical communication strategy among internal members.The KLPG's leaders prioritize social good rather than organizational self-interest, being consistent with the Kantian model of ethical decision-making (Bowen, 2002).Hence, although the KLPG often relies on a one-way decision-making process in internal communication, its ethical leadership remains intact.This finding is inconsistent with previous studies' assertions on the correlation between organizational ethics and two-way communication in the decision-making process in corporate settings (Bowen, 2002(Bowen, , 2005)).
In this case-study, the KLPG's ethical decisionmaking was driven by organizational leadership pursuing a common good apart from prioritization of patient groups' interests.Thus, it is not counted as a bottomtop, two-way symmetrical approach.Rather, the KLPG showed a one-way decision-making process, yet the decisions were supported by the public and were con-stantly and promptly communicated among internal members, as well as to the general public through social media.Social media are effective tools for use by organizational leadership to bring about responsiveness and to transform the general public into advocates.
Taking all these elements into consideration, executive members have wisely come to value and embrace the importance of transparency and responsiveness through the dialogic nature of two-way communication additionally for internal decision-making.Effort invested in a communication strategy through social media also builds more sustainability in not yet fully developed internal relationships.Executive, patient, and non-patient members alike shared a common view of the role of social media in making an internal communication strategy work to that end.
Therefore, consistent with the logic model proposed in this study, social media first help to broaden the scope of internal participants' responses to the nature of an issue, then, in turn, help to broaden the transparency and responsiveness of both internal communication and external communication.However, sustainability in internal communication is not evidenced in the current communication strategy, although it apparently will be pursued in the KLPG's not yet fully developed future strategy.
This research study is somewhat diluted by several limitations.The first is in the lack of generality in the KLPG case findings because, globally, individual local health NGOs are situated in different social, cultural, and media environments.More specifically, the analysis on social media use of the organization presents a limitation on validity in that social network sites such as Twitter and Facebook have been introduced in Korea later than in the U.S.This time-frame discrepancy might inhibit results within the Korean context.Also, given that the KLPG is considered a minor NGO with a small membership, other major NGOs in Koreaoperating on a much larger scale-might use social media in ways different from the KLPG.
A small number of interviewees and outdated data might raise methodological concerns and thus further investigation into this area is needed to address these issues.However, since the 2011 period during which I collected data was the initial stage for the organization to incorporate social media into its strategy, I think this paper, depicting that period, is profoundly relevant to the research question of this study, and eminently worthy of academic investigation.Interview data mainly comprise anecdotal rather than quantifiable information, so the current study's value might be more exploratory than confirmative.Of course, current findings could be complemented by subsequent quantifiable information to transform findings into theoretical concepts with increased validity.Accordingly, future studies should build upon the model proposed by this study and further investigate the contribution of social media use on local NGOs' PR strategies in a longitudinal approach.Also, future studies should address how sustainability in PR can be achieved beyond the quick-yet effective-communication in current findings.To obtain more generalizable credibility in measuring constructs this study proposes and explores, factor analysis might be pursued using subjects from the population who engage in NGOs.It is hoped that this study's framework can be extended into studies of organizations worldwide, in terms of scale, nationality, and internationalization.

Conclusion
In sum, this study's findings indicate that the local health NGO communication strategy is changing in response to the increased effectiveness and impact of social media.Rather than relying on a small group of enthusiastic members, the KLPG can construct an issuebased advocacy group quickly and effectively.In the social media era, by pushing external counterparts with more legitimacy and representativeness through collected support from the general public, the KLPG sees itself as more empowered, and as independent from external counterparts.Based on these findings, a prediction: a local health NGO's use of social media in its internal communication strategy renders its relationship with external counterparts more symmetrical, more independent, and more effective.
Social media can be strategic tools, especially for local health activism in enlarging their resources, power and leadership.In this sense, the KLPG case is surely a benchmark for many other global health practitioners and activist groups.The case is brimful of insights into the use of social media to access and mobilize a wide swath of individuals via a more intimate, yet casual, and remarkably rapid means to deliver sensitive or shocking public health issues.This social media communication approach also helps in reducing possible worries and concerns about 'too radical activism,' which could often draw attention away from main issues, and could reduce the general population's support for expert-led and specific health issues at hand (Laverack, 2013).
More important is that the empowerment of grassroots health activism can contribute to building more independent, sound and equal relationships with external counterparts.Activists should pay special attention to built-in applications on social media that swell the total volumes of small donations.This offers health activism better financial stability, thus more effective offset of-and counteraction to-social injustice and inequality where greedy corporations and complacent governments might otherwise endanger the lives of marginalized groups in the global health arena (Laverack, 2013).