Illness as Metaphor and AIDS and Its Metaphors

by Susan Sontag

The earliest literal definition of cancer is a growth, lump, or protuberance, and the disease’s name—from the Greek karkínos and the Latin cancer, both meaning crab—was inspired, according to Galen, by the resemblance of an external tumor’s swollen veins to a crab’s legs; not, as many people think, because a metastatic disease crawls or creeps like a crab.

Thus, from late antiquity until quite recently, tuberculosis was—typologically—cancer. And cancer was described, like TB, as a process in which the body was consumed.

Only with the microscope was it possible to grasp the distinctiveness of cancer, as a type of cellular activity, and to understand that the disease did not always take the form of an external or even palpable tumor.

Cancer is a rare and still scandalous subject for poetry; and it seems unimaginable to aestheticize the disease.

Other features of TB go to cancer—the agonies that can’t be romanticized. Not TB but insanity is the current vehicle of our secular myth of self-transcendence. The romantic view is that illness exacerbates consciousness. Once that illness was TB; now it is insanity that is thought to bring consciousness to a state of paroxysmic enlightenment. The romanticizing of madness reflects in the most vehement way the contemporary prestige of irrational or rude (spontaneous) behavior (acting-out), of that very passionateness whose repression was once imagined to cause TB, and is now thought to cause cancer.

(think of the disease’s recurrence in the families of Keats, the Brontës, Emerson, Thoreau, Trollope) and also believe that it revealed something singular about the person afflicted. In a similar way, the evidence that there are cancer-prone families and, possibly, a hereditary factor in cancer can be acknowledged without disturbing the belief that cancer is a disease that strikes each person, punitively, as an individual. No one asks “Why me?” who gets cholera or typhus. But “Why me?” (meaning “It’s not fair”) is the question of many who learn they have cancer.

The passive, affectless anti-hero who dominates contemporary American fiction is a creature of regular routines or unfeeling debauch; not self-destructive but prudent; not moody, dashing, cruel, just dissociated. The ideal candidate, according to contemporary mythology, for cancer. *

With the modern diseases (once TB, now cancer), the romantic idea that the disease expresses the character is invariably extended to assert that the character causes the disease—because it has not expressed itself. Passion moves inward, striking and blighting the deepest cellular recesses.

Both the myth about TB and the current myth about cancer propose that one is responsible for one’s disease. But the cancer imagery is far more punishing. Given the romantic values in use for judging character and disease, some glamour attaches to having a disease thought to come from being too full of passion. But there is mostly shame attached to a disease thought to stem from the repression of emotion

Theories that diseases are caused by mental states and can be cured by will power are always an index of how much is not understood about the physical terrain of a disease.

Psychological theories of illness are a powerful means of placing the blame on the ill. Patients who are instructed that they have, unwittingly, caused their disease are also being made to feel that they have deserved it.

Punitive notions of disease have a long history, and such notions are particularly active with cancer. There is the “fight” or “crusade” against cancer; cancer is the “killer” disease; people who have cancer are “cancer victims.”

“Metaphor,” Aristotle wrote, “consists in giving the thing a name that belongs to something else.”

As tuberculosis had been often regarded sentimentally, as an enhancement of identity, cancer was regarded with irrational revulsion, as a diminution of the self. There were also similar fictions of responsibility and of a characterological predisposition to the illness: cancer is regarded as a disease to which the psychically defeated, the inexpressive, the repressed—especially those who have repressed anger or sexual feelings—are particularly prone, as tuberculosis was regarded throughout the nineteenth and early twentieth centuries (indeed, until it was discovered how to cure it) as a disease apt to strike the hypersensitive, the talented, the passionate.

I didn’t think it would be useful—and I wanted to be useful—to tell yet one more story in the first person of how someone learned that she or he had cancer, wept, struggled, was comforted, suffered, took courage … though mine was also that story. A narrative, it seemed to me, would be less useful than an idea. For narrative pleasure I would appeal to other writers; and although more examples from literature immediately came to mind for the glamorous disease, tuberculosis, I found the diagnosis of cancer as a disease of those who have not really lived in such books as Tolstoy’s “The Death of Ivan Ilyich,” Arnold Bennett’s Riceyman Steps, and Bernanos’s The Diary of a Country Priest. And

Thinking about illness!—To calm the imagination of the invalid, so that at least he should not, as hitherto, have to suffer more from thinking about his illness than from the illness itself—that, I think, would be something! It would be a great deal!

To regard cancer as if it were just a disease—a very serious one, but just a disease. Not a curse, not a punishment, not an embarrassment. Without “meaning.” And not necessarily a death sentence (one of the mystifications is that cancer = death).

Considering illness as a punishment is the oldest idea of what causes illness, and an idea opposed by all attention to the ill that deserves the noble name of medicine.

A polluting person is always wrong, as Mary Douglas has observed. The inverse is also true: a person judged to be wrong is regarded as, at least potentially, a source of pollution.

It was years before AIDS that William Burroughs oracularly declared, and Laurie Anderson echoed, “Language is a virus.”

But the great influenza epidemic, which killed twenty million people, was an affair of fifteen months. With a slow-motion epidemic, these same precautions take on a life of their own. They become part of social mores, not a practice adopted for a brief period of emergency, then discarded.

We are not being invaded. The body is not a battlefield. The ill are neither unavoidable casualties nor the enemy. We—medicine, society—are not authorized to fight back by any means whatever.… About that metaphor, the military one, I would say, if I may paraphrase Lucretius: Give it back to the war-makers.