George Eliot’s narrator in The Mill on the Floss (1860) reminds us that it is lamentable “that intelligence so rarely shows itself in speech without metaphor – that we can so seldom declare what a thing is, except by saying it is something else.”

But accuracy is not really the problem; it goes without saying that language is limited in its ability to reflect reality.

Eliot’s narrator in Middlemarch (1872) provides further insight: “we all of us, grave or light, get our thoughts entangled in metaphors, and act fatally on the strength of them.”

Metaphors do things in the world: they delimit as much as they expand; they make things thinkable and actionable, and vice versa; they have material histories that effect material consequences.

Acting “fatally on the strength” of what I call the martial metaphor is an unfortunate example of this. A statement such as “[COVID-19] is war and it needs a war-time plan to fight it,” registers immediately for most individuals; it is a scaled up version of “giving you something to help your immune system fight off this sinus infection.” But it is important to consider how this metaphor came to go without saying. A metaphor becomes rhetoric becomes argument becomes logic and becomes naturalized to the point where we no longer think of it as metaphor, and we uncritically invite all the connotative and historical baggage it carries. A metaphor then becomes inseparable from the thinking itself, and we become “fated” to not being able tell the difference or even consider how we got here. This is certainly the kind of conceptual closure that the martial metaphor lends itself to. But it is not just a matter of figure; it is also fatal in a more literal sense—a metaphor we live, cure, and kill by.

I cite works of Victorian literature here to frame a brief discussion of the martial metaphor because the intersection of the two has consumed my world for the past five plus years. I investigated how authors like Mary Shelley, Charles Kingsley, Arthur Conan Doyle, Bram Stoker, and Joseph Conrad circulated and reflected on the connections between militarism and medicine.

I had justified this research’s exigence by citing the continued uncritical use of the metaphor: the fact that it has been forgotten to be a metaphor, and that it has delimited other ways of imagining and experiencing health, disease, and medicine. The metaphor, then, has a number of discursive and material consequences. It enables xenophobic, racist rhetoric that incites violence and geographies of blame, where certain bodies’ movements are assumed dangerous while others are “presumed natural in the global order of things,” as Adia Benton has recently noted in a previous Somatosphere COVID-19 Forum article. It lends itself to promoting eugenic thinking and eliding negative social determinants of health for marginalized populations. The metaphor can be used to justify coercive, unethical political actions under medical auspices—that condone states of exception in the logic of nationalism. It abets heroic measures in extremis. In terms of treatments and technology, the martial metaphor facilitates a tunnel vision, focusing on moments of medical crises and their singular technofixes—“magic bullets” or pharmacological “torpedoes”—rather than the structures that catalyze them. The metaphor was central to promoting the expanseless industrialization and over-prescription of antibiotics, leading to resistance. It is a pretty long list.

This metaphor has a long history in Western culture, but in the nineteenth century it emerged to become the dominant frame for the human encounter with disease. This tends to be ascribed to the acceptance of germ theory in the late 1800s along with the rise of immunology, but it gained traction in medical, political, and popular discourse in the early nineteenth century as its specific use in military medicine (in particular during the first few cholera pandemics) was translated to the civilian sphere. Cholera was frequently figured as a “marching” and “invading army.” In his 1857 Condition-of-England novel Two Years Ago, Charles Kingsley uses this disease (that soldiers in Crimea and the population of England were encountering at the same time), to masculinize one character during a local epidemic: He declares that he will “meet cholera face to face, as one does with those Russians.” Literature, like Kingsley’s novel, played a significant role in this transmutation from the material grounding of military institutions (such as the role of the military in the development of tropical medicine) to figure in everyday speech.

Reading the martial metaphor as and in fiction lends itself to a number of productive lines of inquiry (that are by no means exclusive to historical, literary and cultural studies): denaturalize it as the sole interpretive frame to understand the human encounter with disease; query the historical conditions of its production, reception, and propagation across time; and consider its narrative and rhetorical configurations (what kind of stories it affords, who its protagonists are, what kind of meaning does it make, what effects does it produce in audiences).

Researching fictional, historical, and contemporary examples of its use in healthcare and politics, never did I imagine seeing events like those depicted in Shelley’s The Last Man live. Nor did I think I would see the president of the United States echo, on a near daily basis, the protagonists in Dracula. This is a novel where an Eastern vampire is described as a one-man army and a disease that invades England in a narrative of reverse colonization. As a degenerate, animal-human hybrid, Dracula threatens the imagined hermetic sanctity of the British empire, its racial purity, and its economy.

“We arrange our plan of battle with this terrible and mysterious enemy… [it] is of cunning more than mortal.”

“There’s a whole genius to it! We’re fighting… not only is it hidden but it’s very smart.”

The first is from Dr. John Seward and Dr. Abraham Van Helsing from Dracula (1897); and, the second from President Donald Trump in a press conference from April 10 (2020), for the record.

In early March, I was beginning to second guess some of my conclusions. Maybe we do need a rhetoric of war for solidarity; maybe we do need it to encourage urgency; perhaps drawing on metonymic connection, military logistics could stop this. Moreover, I felt that my conclusions were not only wrong, but also that the work was inconsequential in our new reality.

Although COVID-19 has changed much of my thinking, it did not take long for the problematics the history and literature of the martial metaphor document to materialize. But it was not just the flood of recognizable negative effects of the metaphor that reinvigorated my conviction that humanistic inquiry matters.

More affirmatively, I never imagined the metaphor would become so recognizable as such in the public consciousness. Without a doubt, historians, cultural critics, anthropologists, health humanists, and bioethicists have discussed it in scholarship in different veins. But the amount of insightful public facing work, op-eds, and articles in news media is encouraging to say the least.

With the help of two dozen incredibly insightful medical students at USC in a narrative medicine class on the martial metaphor led by Pamela Schaff and Erika Wright, I had the unique opportunity to hear from those who are learning and will soon be practicing medicine in a very different world. There is so much more to say about the different biomedical registers of the martial metaphor and its scales in practice, but I’d like to conclude with what I learned and reflected on from talking with these second-year medical students. Out of respect for their time and engagement, I would like to quote rather than paraphrase some of their questions.

Can you expand on your statement that the medicine as war metaphor has caused healthcare professionals to over-prescribe antibiotics? Do you think switching to a different metaphor would help reduce antibiotic overuse, and how?

The relational framing of antibiotic—against life— in opposition to commensal or symbiotic relationality has imbued an almost Spencerian survival of the fittest between humans and microbes. Framing bacterial life as inimical and needing to be fought facilitates the thinking that we need eradication, even when we don’t know an infection is bacterial and is very likely viral. It’s not necessarily that practitioners have this metaphor in mind, but that patients might not have the model of coexistence readily available to them. The resistome, and its history at scale are not easy concepts to grasp, extending way beyond the single doctor and patient. The pressure patients can put on practitioners, and the fact that practitioners have little time with patients certainly makes prescribing a z-pack an easy course—in spite of stewardship efforts. Encouraging alternative metaphors when practicing stewardship came make the acceptance of not getting prescribed antibiotics a more amenable proposition. Or, if a practitioner wants to push on the metaphor’s logic, they might explain how a broad spectrum antibiotic can cause a “scorched earth’ effect in the gut, creating dysbiosis, and allowing C. diff to become pathogenic, when it was previously kept in check by other microbial life. This hypothetical exchange affords an opportunity to address two dimensions: showing some of the martial metaphor’s problematics (scorched earth) and encouraging alternative framing (correcting dysbiosis). There is also the case of practitioners making sure to hear patients who do not want antibiotics, and clarifying the risks and contexts, rather than assuming they are misinformed or combative.

 I found it interesting how you particularly point out the use of the martial metaphor specifically in infectious disease. What are your opinions on comments made by our political leaders/ Surgeon General saying things like “this is our Pearl Harbor” in reference to COVID. Do you think its benefits outweigh its drawbacks in using that rhetoric in an attempt to galvanize people? (Carissa Villanueva)

As I mentioned above, at first, I felt the immediate value of the metaphors call to urgency and solidarity. But the focus on those two imperatives, under the tenor of war, can cause harm. We are not all in this together, as much as some of us would like to be, at least under the current social configuration in the United States. Without question, underserved populations suffer differentially under this pandemic. Not everyone can do their part on the home front of social distancing and fulfilling the unachievable antimicrobial hygienic sublime; not everyone can wear masks in public without fear of being shot—especially under the current state of exceptional circumstance and state powers. Pearl Harbor was a surprise attack. Even in the logic of war or even the fictionalized conspiratorial bio war narrative of the pandemic’s origin, the invasion and attack by the so-called “Chinese Virus” (echoing characterizations of Asiatic Cholera and foreign vampiric contagion) was not: “Nobody Could Have Predicted Something Like This.” It is arguable that we had enough time to stop its entry into the United States, especially given the recent serological studies—still under evaluation as of this writing— but we did know something like this was possible and likely at some point. When this did begin, we had plenty of information to suggest the worst was yet to come, and there were actions we could have taken to mitigate and attenuate what was coming. Moreover, how long have we had to reconsider and build the medical infrastructure and social care to minimize the effect of an event like COVID-19, or climate change, or an economic downturn?

Do you believe that the current ‘war’ against COVID-19 will reignite all countries to prioritize this research in order to prevent a future pandemic due to antibiotic resistance and other viruses? (Wendy Silva)

My suspicion is that it will be reactionary, once (hopefully) the proximate threat of the pandemic resolves, the cultural and governmental investment in public health more broadly will dissipate. Likely, there will be interest in funding research on emergent infectious disease and biodefense for some time to come, as far as attention and money toward failing medical infrastructure (technical, logistical, social, and economic) and the broader scopes of public health, I am not confident. I doubt there will be a significant interest and understanding of the different catalysts and mitigations with respect to antibiotic resistance, which, if you will forgive my figuration, is an entirely different animal (in the way of apology, consider the long history of the war against animal vectors: Framing Animals as Epidemic Villains).

Roger Cooter’s discussion of the “war-and-epidemic couplet” provides some insight on this question of a crisis moment versus its protracted cultural medium. He suggests that the use of war to describe something external and invasive to the normal operation of society—from civil to military—parallels the distinction from the epidemic and the endemic. The epidemic is exogenous, singular, discrete, like a war. But thinking of war (and epidemics) like this “detaches them from their political and social moorings.” In Jasbir K. Puar’s biopolitical framing, “the temporality of exception is one that seeks to conceal itself.”

What are the implications of using martial metaphors to describe healthcare workers (as soldiers, heroes, etc) in the current crisis? (Advaita Kanakamedala)

I worry about how easily the rhetoric of heroics used to describe not only medical practitioners, but the now visible essential workers (hospital cleaning staff, grocery store workers) makes so many of their inevitable deaths “not in vain.” So many have stated publicly that they—and their loved ones they cohabitate with—did not sign up for this. As in the case of those who die in war as military combatants or as “collateral damage,” the amount/disproportion of morbidity and mortality in the wake of COVID-19 did not have to play out this way. Necessary sacrifices, acceptable losses—this is the language that is sure to follow.

The development of the professionalization of medicine is also to important consider with respect to present metaphorical militarization and heroics. I’d refer readers to the work of Michael Brown and the work of Emilie Taylor-Brown who have discussed this topic more intelligently than I can summarize here. And for a more responsible accounting, I would also point to the role of heroics in the larger ontological questions of persevering humanity in the face of pandemic threats that Christos Lynteris analyzes.

In medical school we are taught about the importance of social determinants of health as an important predictor of the spread and incidence of disease. Typically, groups of lower social and economic status tend to have poorer health outcomes and higher rates of disease. Today in the age of COVID-19 we are seeing a disproportionate number of African American people affected by the virus. NPR reported that 33% of hospitalized patients were African American, even though only 13% of the population was considered African American. In light of this news, I have seen many headlines naming COVID-19 as a “racist” virus. My question is: what are your thoughts of these headlines? What are your thoughts about anthropomorphizing COVID-19, and its impact on the idea that we are at war with COVID? (Francis Reyes)

Who/what do you think gets left out when using the “medicine is war” metaphor? Who does it negatively impact? (Eleanor Patterson)

First, there are those that are blamed, overtly or subtly. Then there are the marginalized who do not have equal access to healthcare and consequently do not have the same resources to fight disease. They can be described as not doing their part. This is not unrelated to dominant medical narratives that frame those who choose not to accept the role as “fighters” in the face of serious illness (although socioeconomics is a clearer determining factor in the former versus the latter). Both of these groups often are cast into moralizing narratives for their failure to follow prescriptive roles of resilience. This logic contributes not to solidarity but individualism where everyone is in competition and/or at war with nature and the social, while at the same time the same society that incorporates them is also at war to sustain itself at the expense of letting some die, if not outright killing them. This implication is nothing new to biopolitical theorists, and certainly nothing new to those who have lived this generationally and in the present. Imagined communities have for some time naturalized the application of Social Darwinism to politics and economics which perniciously make their way into medical discourse. Those who can’t cut it, must be sloughed.

In case the above seems too theoretical or historically distant:

Anthropomorphizing the virus is without question inaccurate, but it is also a dangerous misconstrual of the relationship between the biological and the social (without getting into the entire problematic of that binary). Saying that infectious disease is “the great social leveler” is kind of like saying “all lives matter.” Yes, all humans live in the shadow of disease, but it is without question that COVID-19, like many other diseases, is affecting marginalized populations differentially, and this is not because some inherent biological susceptibility possessed by these groups. It is because structures inform pre-existing conditions, access to healthcare, and the ability to exercise all of the preventative architectures and practices that allow one individual or a particular group to “battle” disease.

Calling the disease itself “racist” deflects from the changeable conditions that mitigate the virus’s large-scale fallout. It ascribes the blame to nature, red in tooth and claw, rather than the social structures and how they have configured the lived experience of nature for some. The virus is not out to get us, and it is not out to get people of color. There are, however, people and institutions who are, or who at best, have enabled circumstances where the outcome is the same.

Do you think the medical community has responsibility to explicitly disavow this connection and do you have any ideas on how that could be effectively done? (I think of your “War on Drugs” example) (Katherine Halper)

I’d suggest the metaphor is something that needs to be addressed rather than prescribed. Change ways of thinking rather than giving single answers (“don’t say medicine is war”). It is encouraging to see that we have an increased investment in health humanities and social science in medical education. Health humanities broadly—not only narrative medicine and not only focus on metaphor—inculcates these ways of looking at medical practice and encouraging self-reflection. Humanistic methods, broadly, encourage this way of thinking without explicit medical thematics. Medical humanities requirements in medical school have been expanding for some time now. The interest in undergraduate health humanities has more recently been increasing, which shows equal if not more promise. Encouraging different ways of thinking about health and the body apart of and within biomedical disciplines at any educational stage is ideal.

I would suggest including an exchange on language and narrative as testable knowledge within the medical curriculum. In my zoom visit, I proposed having one or more simulated patient encounters that require attention to language and narrative that can be assessed by proctors with practical and theoretical knowledge on the subject. This seemed favorably received by the students and their professors.

I think anyone should use whatever metaphors they like to describe their experience with illness. I do not think practitioners should disavow, necessarily and stop patients from using the martial metaphor. I think practitioners could encourage other metaphors if they deem it appropriate—or at the very least—talk through what patients take their metaphors to mean. Practitioners, I think, would be served by reflecting on how they understand disease process and treatment; they might create a repository of different figurations based on the situation and patient that is open to modification and the spontaneity of each exchange.

When the scale moves from the doctor-patient to public health, and especially to a large audience, and especially in a crises, I think those with a voice that reaches and influences decision makers and so much of the public have a responsibility to exercise restraint in using this metaphor as the go-to explanatory framework and rallying call. In writing releases and statements, and op-eds, care and thought should go into alternative ways of framing and serious considerations into the consequences of particular choices of words. The difference between cleaner, sanitizer, disinfectant, and sterilizer matter—even though those terms are used loosely even within medical discourse. The difference between war, encounter, mitigation (I realize the latter is also a technical term), and managing also matter.

What is the alternative? (everyone)

As an expansion on the earlier question related to resistance, thinking about this in terms of other microbial life, I, and many others before and with me had been thinking in terms of coexistence and living with, rather than against. Charlotte Brives has recently proposed the helpful frame of amphibiosis in an article for the COVID-19 forum. Having been focused on bacterial life, I had not considered sufficiently or conceptualized viruses in the same sort of coexisting ecology within the larger environment and the individual human body, but as Brives notes, and Devin Griffiths has recently discussed, there is plenty of research that complicates the inimical framing of viruses and looks to the beneficial roles they might be playing in the holobiont. Iona Walker, who researches alternatives to thinking of medicine as war and interdisciplinary frames to mitigate antimicrobial resistance, recently pointed me to the #reframecovid initiative and document which contains hundreds of cited alternatives in multiple languages.

With respect to figuration itself, I have seen really helpful frames such as dance, balance (these have long been used in Eastern cultures), and with respect to the immune system, recently, I have found the comparison of the immune system to an orchestra quite compelling.

It also occurs to me that we could make a conscious effort to move from metaphor to simile. Simile draws attention to itself as figure with the prepositions like or as. “It is as if we are at war with a virus,” or it is “like a war in the emergency room.” On the one hand, this approach, with a little effort, over time by many, could produce a conscious recognition of the figurative construction in audiences, and implicitly recognizes it is not the single explanation nor the sole figuration. On the other hand, it reinscribes the problematic split between figure/material, and thus while drawing attention to the martial metaphor as a fictional construction, the very signaling of figuration can occlude the material grounding with military institutions and logics immersed in its historical and present use.

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The martial metaphor’s history and literary representation helps us think about what structures not only doctor-patient interactions, but medicine as a larger system that is bound up in social and political—as much as histological and microbial—relations. Such a line of inquiry suggests we are not fated by the martial metaphor, but rather that we have the cognitive and imaginative strength to think differently.

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Lorenzo Servitje is assistant professor of literature and medicine, dually appointed in the Department of English and the Health, Medicine, and Society program at Lehigh University. His monograph Medicine Is War: The Martial Metaphor in Victorian Literature and Culture, (Forthcoming from SUNY University Press 2021) traces the metaphorical militarization of medicine in the nineteenth century. His most recent work is on the history and culture of antibiotic resistance and can be found in Osiris’s 2019 issue. He serves on the editorial board of the Journal of Medical Humanities and as an associate editor for Literature and Medicine. He can be reached on twitter @kilojoule_or  by email at los317@lehigh.edu.

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