A “war frame” and the use of militaristic metaphors have dominated the way we understand diseases. We are caught up in a bio-militarist vocabulary by which our knowledge of diseases is filtered through notions of besiege, battles, resistance, combat and so on. Are there other ways to frame diseases? In #04 of his extended reading report, Rodriguez raises this question and stock-takes some alternative frames …

我們談細菌和病毒的入「侵」,我們要「戰勝」 SARS 、「擊退」 COVID-19,我們尋求「抗」體和「疫」苗。不知不覺間,這個以戰爭框架、戰爭隱喻去理解疾病的「日常」語彙構築了我們對病理的意識,成為主導的知識系統,定義我們的行動,規劃我們的回應,200 年了。已有不少學者指出這種生物軍國主義的局限;尤其它傾向廢病人的武功,把我們打進被動、無助的位置。戰爭,是醫生與病毒之間的事,我們(病人)是戰場,頂多是旁觀的途人;這問題在非傳染性或涉及精神狀態的疾病尤其值得商榷。除了「戰役」的框架外,還有別的嗎?有沒有別的「隱喻」?例如「體內平衡」(homeostasis) 、旅程 (journey)、協作探索 (collaborative exploration) 等所引伸一套語言及觀念又如何?放開「力」(force) 的框架,「存活在當下」(presence) 的框架又如何?二者一定要捨其一嗎?不能融合嗎?看來,是時候認真檢視「醫學人文學科」的發展了。羅海德繼續他的一連串讀書報告:如何述說 (narrativize) 疾病是尋求出路的起步。疾病作為敘事、有關疾病的敘事、敘事作為疾病。… …(中文翻譯撮要/黎肖嫻)

 

Framing Diseases #04 (updated 25 May 2020 at 11:20am)

Disease, Poetics, and Dwelling

A pervasive way of framing disease in the contemporary world is the “war frame” or war metaphor. [1] According to this frame, human beings are fighting a war against pathogens. In his study of The Scientific Voice, geologist Scott Montgomery has called attention to the prevalence of a militaristic metaphor in nineteenth century medicine. [2]  Referring to Louis Pasteur, Montgomery speaks of “biomilitarism.” Pasteur understood diseases as the result of germs attacking or invading people. Antibiotics were considered to be weapons in the war against this invading army. [3]

 

Pasteur’s theory of disease adopts the metaphor that germs were constantly besieging animals (battles in wars that were ultimately lost when bacteria overtook a corpse that decayed). [] Image: Pasteur from Munsey’s Magazine, May 1897. Found on https://uh.edu/engines/epi1210.htm

Pasteur was one of the pioneers of the germ theory of disease. One could suggest that this theory, which became a fundamental component of the modern disease picture, was very closely connected to the war metaphor. An infection is framed as an invasion. The pathogen is an aggressor. And the task of the clinician is to defeat this enemy. The process of working through the disease is viewed as a struggle against a foreign invader, whose only outcomes are victory or defeat. In that case, succumbing to the disease is viewed as a defeat. The disease, or the pathogen that caused it, is seen as the victor. This viewpoint, where disease is framed in terms of force, is connected to an important experience: our desire to be rid of pain, to bring an end to suffering, through active intervention. Biomilitariam understands this desire as a confrontation with an invading force.

The war metaphor remains prevalent even in the context of covid-19. Donald Trump often speaks of himself as a “wartime president”. This way of framing the disease is not unique or idiosyncratic. Two researchers used topic modelling techniques to analyze 200,000 tweets about the pandemic that appeared during March-April of 2020 onTwitter,  the treatment of the disease is often framed in terms of the war metaphor. Although other metaphors are present, for instance the storm metaphor or the tsunami metaphor, the researchers concluded that biomilitarism remains the dominant frame for covid-19. [4] 

Douglas Slobod and Abraham Fuks have noted that this war metaphor disempowers the patient. Biomilitarism replaces “the doctor-patient relationship with a doctor-disease interaction” wherein “patients are relegated to the status of ‘battlefield’ and become bystanders of their own care.” [5] Slobod and Fuks note that this way of thinking is extremely misleading, for instance, when applied to non-infectious diseases like mental illness. It also reproduces a masculinist, patriarchal, heroic conception of health care that is often aligned with hierarchical power structures. [6]

Susan Sontag famously argued against militaristic metaphors disease discourse. [7] One possible conclusion of this line of reasoning might be that metaphor has no legitimate place at all in the discourse and practice of health care. But other scholars claim that we ought not reject all metaphors. Instead, we ought to seek out and identify alternative ways of framing disease. Slobod and Fuks have pointed out that there exist other metaphors even within science itself. One example is the language of homeostasis, which understands health and disease as balance and imbalance.

Abandonment of biomilitarism need not always entail the abandonment of aggressive metaphors. In their careful analysis of disease metaphors employed by UK mainstream newspapers in their coverage of the SARS epidemic, Patrick Wallis and Brigitte Nerlich concluded that militaristic metaphors were largely absent. Although war metaphors did appear in several newspapers, Wallis and Nerlich noted the prevalence of the killer metaphor.  Mass media in the UK did not abandon the war metaphor in order to adopt less aggressive metaphors. Rather, the disease or the virus was viewed as a killer. The construction of this metaphor exploited familiar characteristics of our ordinary image of a killer: killers stalk and strike their preys and cause fear among the crowd; they are mysterious to us; and they are criminals. SARS was also regarded as a criminal and as a mysterious thing that stalks and attacks its victims. The onset of the disease was often framed as a physical force that would suddenly hit a patient. Moreover, SARS was not understood as an army of organisms but as a single, unitary entity.  Within the terms of this metaphorical system, epidemiology was framed as hunting. Scientists and officials were often described as struggling to hunt down the killer virus. Thus the killing metaphor was gradually elaborated into a systematic network of interconnected metaphorical meanings. “In this way a whole web of metaphors is cast over a certain domain of discourse and gives it coherence and illocutionary force.” [8] 

Additional metaphors mentioned by Slobod and Fuks include that of a “journey” or a “collaborative exploration”. These metaphors connect medicine with art and literature. Alan Bleakly refers to poet Wallace Stevens: “The world is presence and not force”. Instead of thinking of the world as an arena of violent struggle, we can see it as a realm of presence. We can also mix the two frames, force and presence. Bleakley writes: “A house of Force was built, within which I made a room of Presence. This house was a hospital made for treating aching bodies. Within it, you could attack your demons as if on a battlefield, or embrace the failings of the body as if in bed with a tender lover.” [9]

An important kind of work at the intersection of science and the humanities is the search for alternative metaphors, for novel ways of narrativizing disease. This search requires an understanding of metaphor and of narrative as media of understanding. In this context, Slobod and Fuks refer to the work of Carola Skott on cancer narratives. According to Scott, patients narrativize their diseases in ways that construct alternative “expressive metaphors” for the sake of making sense of the disease. From this standpoint, the narration of one’s own disease is a way of forming metaphors that reframe that disease from the standpoint of the patient. Metaphors are expressive. Someone might see cancer not as an invading aggressor but as “a thing in the air”. [10] It is in this context important to learn to listen to the patient’s own metaphors, since they can potentially expand our repertoire of ways of framing disease.

An important assumption that underpins research on metaphor and illness is that the patient’s own account expresses how the patient frames her/his own illness, and this framing is essential to health practice. The patient’s narrative accounts, her/his narrating actions, are integral moments in the unfolding of the disease. [11] Elaborating on this point, Lars-Christer Hyden has proposed a useful typology, according to which narrative and illness can be connected in three ways: “illness as narrative, narrative about illness, and narrative as illness”. [12] Note that these three types are not always sharply distinguished in practice.

The first mode of linkage between narrative and illness essentially involves the first-person. The patient who encounters an experience of suffering attempts to make sense of this experience, so that “suffering is given form” through narrative. [13] This form essentially involves the patient’s own lived bodily experience. [14] Here narrative helps to shape the manner in which the illness, experienced as suffering, is absorbed into the life of the person, so that from thid first-person perspective the illness is no longer separable from the narrative. We can in tis sense think of illness as narrative. In many instances, illness is experienced as a disruption in the flow of time. In extreme cases, the illness is traumatic. The patient’s narrative enunciation attempts “to knit together the split ends of time, to construct a new context and to fit the illness disruption into a temporal framework.” [15]

In the second mode of linkage, “narrative about illness”, the story is constructed by other people, mostly health professionals, about the patient’s disease. These narratives reflect the assumptions, resources, and goals of the clinical professional. They do not always, perhaps not often, prioritize the patient’s own account. In some cases, however, the patient’s own narrative, the illness as narrative, plays a role in the formation of narratives about the illness, and so the two modes of linking narrative and illness enter into a meaningful dialogue. The doctor or health professional essentially depends on the patient’s own report, and so on the understanding embedded in that report.

The third mode of linkage is one where a certain narrative in a sense generates, or helps to generate, the illness. An example is neurosis, where the patient’s own narrative, which can leave out or distort key events in their own lives, becomes a central aspect of the illness. In many cases, the first-person narrative becomes crucial. Narratives of other people in the social or cultural context, for instance dominant ideologies like homophobia or sexism, also play a generative role in the person’s illness. The narrative generates the illness because it supplies a model (a way of thinking, a picture) that is already taken for granted and that underpins and dominates our entire way of living. The narrative generates neurotic activity, for instance. [16] In this case, the work of narrative analysis involves helping the patient to recognise, understand, take a distance from, analyze, and transform the narrative framework from which the illness originates.

In these three types, narrative constitutes a medium wherein the illness is in a sense articulated. It is given form and structure. The discipline of narrative and hermeneutic analysis in health case focuses on this work of articulation. This discipline involves the cultivation of listening skills, the ability to listen to what the patient says. [17] These accounts are to be approached through the techniques of artistic and narrative analysis.

This involves the effort to imagine, or attempt to imagine, what it is like to experience something painful or traumatic. This project arises not only in the context of illness but also trauma, for instance sexual assault. In her excellent book about trauma and selfhood, Susan J. Brison has called attention to the challenge of “finding a language” wherein the traumatic experience, something lived but not spoken, can be said. [18]

Refusal to acknowledge the discourse of the victim and the experience articulated therein might, for instance, lead a philosopher to say that rape is like “normal” sexual intercourse minus consent.

This effort at articulation often involves finding apt metaphors for what cannot be literally said. The metaphors in this sense are not mere decorations or rhetorical devices, designed to express more elegantly or persuasively something that could be expressed in a more literal way. The metaphor itself is essential to the content being expressed. The metaphor is indispensable. Any enterprise wherein metaphor is essential is poetic. This enterprise partly aims to develop a “poetics of illness experience”. [19]

To understand how the patient makes sense of her disease through narrativization and metaphorization requires an interpretative method that aims to understand what the patient says using narrative analysis. There are various approaches rather than one single methodology. Inger Ekman and Carola Scott, for instance, develop a hermeneutic approach inspired by the work of Paul Ricoeur. [20] One subdiscipline of this research field focuses on literature and medicine. [21] A super-discipline of narrative and health is medical humaniites, which argues for the introduction of humanistic understanding into the discourse and practice of health. For instance, Bleakely argues that medicine can in a sense be understood and configured as a “poetic practice” geared towards articulating modes of presence (and of absence). [22]

For instance, we could pay attention to the ways in which time is organized in the narrative. A classical distinction in narrative theory is that between the plot and the discourse or story, the content that is narrated and the manner of narrating it. Certain episodes might, for instance, be compressed or extended. By making these and other decisions, the narrative act generate an organisation of time, which can be understood as expressing a sense of what matters or does not matter, and why it matters. It expresses the import of the story for the person who is constructing it.

(19 May 2020, Hong Kong)

 

CITATIONS

[1] Elliott, Richard 2009: Communicating Biological Sciences. Routledgen/p.

[2] Montgomery, Scott 1996: The Scientific Voice. New York: the Guilford Press, chapter 3.

[3] See also: Alan Bleakley, Thinking with Metaphors in Medicine, pp. 60ff.

[4] Wicke, Philipp; and Bolognesi, Marianna M. 2020: “Framing COVID-19: How we conceptualize and discuss the pandemic on Twitter,” preprinthttps://arxiv.org/pdf/2004.06986.pdf 

[5] Slobod, Douglas; and Fuks, Abraham 2012: “Military metaphors and friendly fire,” Canadian Medical Association Journal, 184(1), January, p. 144.

[6] See also:Bleakley, Alan 2017: “Force and Presence in the World of Medicine,” Healthcare 5: 58.

[7] Sontag, Susan 1978: Illness as A Metaphor. Allen Lane: London, UK.

[8] Patrick, Wallace; and Brigitte Nerlich 2005: “Disease metaphors in new epidemics: the UK media framing of the 2003 SARS epidemic,” Social Science and Medicine, Volume 60, Issue 11 (June 2005), pp. 2629-39.

[9] Same as [6].

[10] Skott, Carola, 2002: “Expressive Metaphors in Cancer Narratives,” Cancer Nursing: June, Volume 25 – Issue 3, pp. 230-35.

[11] Hyden, Lars-Christer 1997: “Illness and narrative,” Sociology of Health and Illness; 19(1), pp. 48–69.

[12] See [11].

[13] See [11], p. 53.

[14] Toombs, S.K. 1998: “Illness and the paradigm of lived body,” Theoretical Medicine, n.9, 201-26.

[15] See [13].

[16] Wisdom, John 1957: Philosophy and Psychoanalysis; Blackwell, p. 275.

[17] Greenhalgh, T.; and Hurwitz, B. 1998: Narrative Based Medicine: Dialogue and Discourse in Clinical Practice. London: BMJ Books.

[18] Brison,Susan J. 2002: Aftermath: Violence and the Remaking of a Self; Princeton University Press, Princeton, p. xi.

[19] Kirmayer, LJ. 2000: “Broken narratives. Clinical encounters and the poetics of illness experience”; in Mattingly C, Garro L.C. (eds). Narrative and the Cultural Construction of Illness and Healing. University of California Press, Berkeley, pp. 153-81.

[20] Ekman, Inger; and Skott, Carola 2005: “Developing Clinical Knowledge through a Narrative-Based Method of Interpretation,” European Journal of Cardiovascular Nursing, September 1, Volume: 4 issue: 3, pp. 251-56.

[21] Charon, Rita; Banks,Joanne Trautmann; Connelly, Julia E.; Hawkins, Anne Hunsaker; Hunter,Kathryn Montgomery; Jones, Anne Hudson; Montello, Martha; and Poirer, Suzanne 1995: “Literature and medicine: contributions to clinical practice,” Annals of Internal Medicine 122: 599-606.

[22] Bleakley, Alan 2017: “Force and Presence in the World of Medicine,” Healthcare 5: 58.

 

RELATED READINGS

Hector Rodriguez / <Framing Diseases> series

Rodriguez, Framing Diseases 03: COVID-19 and the cooperative society 建構疾病 三:COVID-19與協作的社會 (2020.05.18)

Rodriguez, “Framing Diseases 02: Disease and the Cooperative Society” (2020.05.17)

Rodriguez, “Framing Diseases 01: Disease Pictures” (2020.05.16)