We must be careful with how we use disease metaphors

Seeing illness as punishment has caused suffering in past,

“I should, I think, like to die of consumption … because the women would all say, `see that poor Byron — how interesting he looks in dying!'” — Lord Byron on tuberculosis

Not everyone feared the 19th-century European tuberculosis epidemic. As many artists contracted the disease — including Lord Byron's contemporary, John Keats — it became a symbol of great passion and elevated sensibility.

It was as if passion itself consumed those infected — hence the alternative name, “consumption” — as they gradually wasted away. People therefore began mimicking the symptoms of TB, especially the pale skin and emaciation, in what was essentially an anticipation of the 1990s' “heroin chic.”

The glorification of TB reveals that we don't see diseases as mere medical conditions, but as metaphors, as symbols of one's moral or emotional triumphs or failings. This was the thesis of Susan Sontag's famed 1978 monograph Illness as Metaphor, which she wrote while being treated for breast cancer.

Sontag notes, however, that the 20th-century perception of cancer was the opposite of the 19th century's treatment of TB. While cancer was, like TB, interpreted as a comment about one's personality, cancer was seen as afflicting those who lacked passion.

In fact, psychotherapy became a popular fad treatment for cancer, as the disease was attributed to patients' ostensibly inhibited personality.

The past four decades reveal that we haven't abandoned seeing disease as a product of one's character. The AIDS epidemic, which early on primarily affected heavily stigmatized groups, including gay men, sex workers and injection-drug users, provided plenty of opportunity for judgment, something that prompted Sontag to write a followup, AIDS and Its Metaphors.

Sontag argues that the AIDS epidemic resuscitated an old, largely disused metaphor: illness as punishment. In so doing, ostracized communities became further isolated. And now we're at risk of doing it all over again, this time with monkeypox.

Both the World Health Organization and the Public Health Agency of Canada have noted that many cases of monkeypox have been observed in men who have sex with men, and both organizations have urged them to limit the number of their sexual partners.

That's not an unreasonable suggestion given that the risk of infection increases with the number of people with whom you come into close physical contact. But that's true of anyone, regardless of sexual orientation.

To their credit, the WHO and PHAC have emphasized that anyone can contract monkeypox and that, while transmissible through sexual contact, it can also be spread through contact with contaminated objects such as towels and bedsheets.

It's critically important that public health messaging — and media reports, some of which have been a lot less careful — stress these facts for two reasons. First, as we learned during the AIDS epidemic, using the “gay disease” metaphor causes further stigmatization of individuals and communities, creates distrust in the health-care system, and discourages people from seeking testing and treatment.

And second, the gay disease metaphor sends the message that no one else need take precautions against contracting the illness. This messaging likely resulted in infections among straight people during the early days of AIDS.

Sontag argues that given the harm done by disease metaphors, we ought to abandon them altogether and view illness in purely concrete, physical terms.

That, however, hasn't happened in the nearly half-century since Illness as Metaphor was published, and it's not going to happen in the next half-century either.

The fact is, we think with metaphors. Metaphors help us to understand an impossibly complex world and to make sense of ourselves. Metaphors can therefore help our efforts to fight disease just as easily as they can hinder it.

Instead of the fool's errand of abandoning metaphors, then, we need to examine the metaphors we use — sometimes without even being aware of them — and ask: Does the metaphor lead us to blame individuals for becoming infected or create a false sense of security? Or does it help us to understand and combat the disease?

Or to mix some metaphors: It's always better to rally the troops against disease than to cut off your nose to spite your face.