Illness as Metaphor and AIDS and Its Metaphors

by Susan Sontag

Any disease that is treated as a mystery and acutely enough feared will be felt to be morally, if not literally, contagious.

As long as a particular disease is treated as an evil, invincible predator, not just a disease, most people with cancer will indeed be demoralized by learning what disease they have. The solution is hardly to stop telling cancer patients the truth, but to rectify the conception of the disease, to de-mythicize it.

“I cough continually!” Marie Bashkirtsev wrote in the once widely read Journal, which was published, after her death at twenty-four, in 1887. “But for a wonder, far from making me look ugly, this gives me an air of languor that is very becoming.” What was once the fashion for aristocratic femmes fatales and aspiring young artists became, eventually, the province of fashion as such. Twentieth-century women’s fashions (with their cult of thinness) are the last stronghold of the metaphors associated with the romanticizing of TB in the late eighteenth and early nineteenth centuries.

Perhaps the main gift to sensibility made by the Romantics is not the aesthetics of cruelty and the beauty of the morbid (as Mario Praz suggested in his famous book), or even the demand for unlimited personal liberty, but the nihilistic and sentimental idea of “the interesting.”

Sadness made one “interesting.” It was a mark of refinement, of sensibility, to be sad. That is, to be powerless.

In contrast to the great epidemic diseases of the past (bubonic plague, typhus, cholera), which strike each person as a member of an afflicted community, TB was understood as a disease that isolates one from the community. However steep its incidence in a population, TB—like cancer today—always seemed to be a mysterious disease of individuals, a deadly arrow that could strike anyone, that singled out its victims one by one.

Such preposterous and dangerous views manage to put the onus of the disease on the patient and not only weaken the patient’s ability to understand the range of plausible medical treatment but also, implicitly, direct the patient away from such treatment. Cure is thought to depend principally on the patient’s already sorely tested or enfeebled capacity for self-love.

Illness expands by means of two hypotheses. The first is that every form of social deviation can be considered an illness. Thus, if criminal behavior can be considered an illness, then criminals are not to be condemned or punished but to be understood (as a doctor understands), treated, cured.4 The second is that every illness can be considered psychologically. Illness is interpreted as, basically, a psychological event, and people are encouraged to believe that they get sick because they (unconsciously) want to, and that they can cure themselves by the mobilization of will; that they can choose not to die of the disease. These two hypotheses are complementary. As the first seems to relieve guilt, the second reinstates it.

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.

Feelings about evil are projected onto a disease. And the disease (so enriched with meanings) is projected onto the world.

When travel to a better climate was invented as a treatment for tuberculosis in the early nineteenth century, the most contradictory destinations were proposed. The south, mountains, deserts, islands—their very diversity suggests what they have in common: the rejection of the city.

Both tuberculosis and cancer have been regularly invoked to condemn repressive practices and ideals, repression being conceived of as an environment that deprives one of strength (TB) or of flexibility and spontaneity (cancer). Modern disease metaphors specify an ideal of society’s well-being, analogized to physical health, that is as frequently anti-political as it is a call for a new political order.

The use of cancer in political discourse encourages fatalism and justifies “severe” measures—as well as strongly reinforcing the widespread notion that the disease is necessarily fatal.

But how to be morally severe in the late twentieth century? How, when there is so much to be severe about; how, when we have a sense of evil but no longer the religious or philosophical language to talk intelligently about evil? Trying to comprehend “radical” or “absolute” evil, we search for adequate metaphors. But the modern disease metaphors are all cheap shots. The people who have the real disease are also hardly helped by hearing their disease’s name constantly being dropped as the epitome of evil. Only in the most limited sense is any historical event or problem like an illness. And the cancer metaphor is particularly crass. It is invariably an encouragement to simplify what is complex and an invitation to self-righteousness, if not to fanaticism.

We study Health, and we deliberate upon our meats, and drink, and ayre, and exercises, and we hew and wee polish every stone, that goes to that building; and so our Health is a long and a regular work; But in a minute a Canon batters all, overthrowes all, demolishes all; a Sicknes unprevented for all our diligence, unsuspected for all our curiositie.…

written in 1627

The metaphor implements the way particularly dreaded diseases are envisaged as an alien “other,” as enemies are in modern war; and the move from the demonization of the illness to the attribution of fault to the patient is an inevitable one, no matter if patients are thought of as victims. Victims suggest innocence. And innocence, by the inexorable logic that governs all relational terms, suggests guilt.

Twelve years ago, when I became a cancer patient, what particularly enraged me—and distracted me from my own terror and despair at my doctors’ gloomy prognosis—was seeing how much the very reputation of this illness added to the suffering of those who have it.

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!

The purpose of my book was to calm the imagination, not to incite it.

My purpose was, above all, practical. For it was my doleful observation, repeated again and again, that the metaphoric trappings that deform the experience of having cancer have very real consequences: they inhibit people from seeking treatment early enough, or from making a greater effort to get competent treatment. The metaphors and myths, I was convinced, kill. (For instance, they make people irrationally fearful of effective measures such as chemotherapy, and foster credence in thoroughly useless remedies such as diets and psychotherapy.) I wanted to offer other people who were ill and those who care for them an instrument to dissolve these metaphors, these inhibitions.

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).

More and more linkages are sought between primary organs or systems and specific practices that people are invited to repudiate, as in recent speculation associating colon cancer and breast cancer with diets rich in animal fats. But the unsafe habits associated with cancer, among other illnesses—even heart disease, hitherto little culpabilized, is now largely viewed as the price one pays for excesses of diet and “life-style”—are the result of a weakness of the will or a lack of prudence, or of addiction to legal (albeit very dangerous) chemicals.

Infected means ill, from that point forward.

The most terrifying illnesses are those perceived not just as lethal but as dehumanizing, literally so.

But what may seem like a joke about the inevitability of chauvinism reveals a more important truth: that there is a link between imagining disease and imagining foreignness. It lies perhaps in the very concept of wrong, which is archaically identical with the non-us, the alien.

Illness is a species of invasion, and indeed is often carried by soldiers.

Epidemics of particularly dreaded illnesses always provoke an outcry against leniency or tolerance—now identified as laxity, weakness, disorder, corruption: unhealthiness.

It may be that some of the most feared events, like those involving the irreparable ruin of the environment, have already happened. But we don’t know it yet, because the standards have changed. Or because we do not have the right indices for measuring the catastrophe. Or simply because this is a catastrophe in slow motion. (Or feels as if it is in slow motion, because we know about it, can anticipate it; and now have to wait for it to happen, to catch up with what we think we know.)

With this illness, one that elicits so much guilt and shame, the effort to detach it from these meanings, these metaphors, seems particularly liberating, even consoling. But the metaphors cannot be distanced just by abstaining from them. They have to be exposed, criticized, belabored, used up.

But the effect of the military imagery on thinking about sickness and health is far from inconsequential. It overmobilizes, it overdescribes, and it powerfully contributes to the excommunicating and stigmatizing of the ill.