by Kayhan Parsi, JD PhD

Protest singer Edwin Starr powerfully asked in the early 1970s: “War, what is it good for?” Apparently, it’s good enough to use in a variety of metaphorical turns of phrase. The war on poverty. The war on cancer. The war on Alzheimer’s. The war on drugs. The war metaphor seems irresistible. How else to elevate a social problem and make it the object of our intense focus and attention, not to mention financial support? These metaphors figure prominently in many areas of public life. Take policing. As scholars Peter Kraska and Victor Kappeler have stated about the use of military metaphors in policing: “The ideological filter encased within the war metaphor is ‘militarism,’ defined as a set of beliefs and values that stress the use of force and domination as appropriate means to solve problems and gain political power”. Similarly, health care is replete with militaristic metaphors. Cancer garners the most intensely militaristic metaphors. We often say that someone lost their battle with cancer. Yet cancer is not alone. As Nie and colleagues argue in this month’s target article, such militaristic metaphors are commonly found in the world of HIV cure and research. Why do we continue to use such militaristic metaphors in health care?

Thinking and speaking in metaphors is such a part of being human that it’s almost unremarkable to us. Philosopher Mark Johnson and linguist George Lakoff have made significant contributions in our understanding of how metaphorical thinking shapes our morality and our moral understanding has persuasively argued that we think imaginatively about our moral problems and that our thinking is inevitably metaphorical. And Lakoff has made a career out of demonstrating how deeply entrenched our metaphorical thinking is—for instance, in a recent piece in the Huffington Post he wrote about how the major presidential candidates frame their respective campaigns through the use of metaphor. Health care is no different.

Nie and colleagues critically examine the use of military metaphors in the area of HIV treatment and research. They acknowledge the long history of such metaphors in Western medicine and their frequent use in the area of HIV cure and research. Although they realize the value of such metaphors, they also highlight the serious drawbacks that such metaphors pose. For instance, these metaphors reinforce the ascendancy of the biomedical model of medicine by focusing on the physiology of such diseases and the pharmacological response it engenders by the medical industrial complex. Such militaristic metaphors may also justify behavior that could be deeply problematic and even unethical: If the target of our “war” is a disease, can then patients become “collateral damage?”

Nie and colleagues realize the impossible task of completely abandoning metaphor when talking about disease. Contrary to the work of Sontag, they acknowledge that using metaphors in medicine is inevitable. The question, then, is to ask which metaphors are better suited for HIV research and cure. Instead of the militaristic metaphors that are abundant in Western medicine, the authors turn to more pacifistic metaphors found in non-Western traditions, specifically in Traditional Chinese Medicine and Sub-Saharan African tradition (acknowledging the vastness and diversity of traditions within such a large geographic area). They view the military metaphors used in Traditional Chinese Medicine to be dramatically different (and less aggressive) than the militaristic metaphors used in the West. The metaphors used in Sub-Saharan Africa are even less militaristic; rather, the metaphor of journey is what has become common (even “Africanized”).

I welcome the authors’ turn away from military metaphors as the dominant way to conceptualize HIV cure and research. The authors note the strange irony in using such metaphors when the ultimate goal is cure and healing. In his peer commentary, Chambers asks why we use such metaphors, citing the work of Kenneth Burke who views them as “equipment for living” (yet another metaphor). Chambers goes on to say that metaphors not only name an experience but provide an attitude as well. This reminds me of my recent experience this summer teaching a course on narrative ethics. My students and I were discussing the ubiquity of military metaphors during one week’s discussion when I directed them to view the MD Anderson website http://makingcancerhistory.com/gallery/. This site has a gallery of clinicians, patients, survivors, and board members all talking to an anthropomorphized version of cancer, saying things such as “Cancer, we’re not backing down,” “I will crush you, cancer,” and “MD Anderson will destroy you, cancer.” My students and I were startled by the aggressive nature of the metaphors used, and reflected upon what alternative metaphors could be used instead. Chambers (2016) argues that such metaphors persist because they are useful to some degree. Who would instead say, “Cancer, I’d like to propose a détente?” Yet some patients may in fact want to use a gentler kind of metaphor that doesn’t create such a heavy burden of constantly being at war.

Although Tate and Pearlman argue that military metaphors have their place and that they can even induce feelings of empowerment, the challenge with military metaphors is that they have become the dominant way to interpret various diseases. Although they argue that such metaphors should not be used indiscriminately, the problem is that such metaphors are used with such frequency that patients may not even think about how to interpret their illnesses in a different way. There is a stark contrast between an individual grappling with pain who wants to “annihilate” his or her pain, and our broader cultural metaphors in interpreting various diseases. Allowing a certain level of pluralism with the kinds of metaphors we use is appropriate. What’s troubling is when one metaphor (in this case, the military metaphor) becomes the only or dominant way we interpret various illnesses.

Thus, we need more and better metaphors. As George and colleagues state, we need new metaphors in the areas of social determinants in health that can have a pronounced impact upon health outcomes. They argue for an “ecological metaphor” that is more nuanced. In the age of the 140-character tweet, however, nuance is often lost. Arthur Frank has argued that we need to think with stories, becoming witnesses to our illnesses. Such witnessing requires that we create richer metaphors, not just one overarching metaphor. Perhaps some patients, clinicians, and institutions really do just want to wage ever-lasting war on diseases such as cancer and HIV/AIDS. But, the reality is that actual wars do much damage and even metaphorical wars can undermine serious public health goals. Knowing that we can never avoid metaphorical thinking and speaking, we should be more imaginative in our metaphors when dealing with disease and illness.