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Illness as Metaphor

Catching up on my reading while “sheltering at home” in Chicago, Susan Sontag’s (1933 – 2004) book length essay, “Illness as Metaphor” (1977) is especially timely in view of the psychological dynamics around the Covid-19 pandemic.

The message of “Illness as Metaphor” is that human beings make things mean things. The

The look: Mayor Lightfoot clears the beaches and parks in Chicago

The look: Mayor Lightfoot clears the beaches and parks in Chicago

talent for doing this is metaphor. This means that – this is that.. That is sometimes called “art,” but other times, less inspirationally, it is called “magical thinking.” (“Magical thinking” is when not bringing my umbrella casues it to rain and vice versa.)

For example: Cancer is a death sentence. Tuberculosis (TB) is a source of genius. AIDS (acquired immune deficiency syndrome) is punishment from God. People who get sick have made a mistake – done something wrong, broken a taboo, committed a transgression against morality or community or both. Seems like problem, yes?

Any disease that is not well understood shows up as “The Plague!” and marks the person who has it. It is a stigma – literally, a mark – on the victim. Thus, the tendency of human beings to take a bad situation – and make it worse.

If Sontag were alive today, she would no doubt have something to contribute to the conversation about Covid-19 as another example of illness as metaphor.

Citing examples from literature, Sontag’s commitment is to drain the meaning from illness as a metaphor so that the patient can get treatment entirely independently of magical thinking about “what did I do to deserve this?” Even the victim blames the victim: “What did I do wrong?” Nothing in particular – follow doctor’s orders – take the treatment (if there is any).

Sontag collects diverse and entertaining literary anecdotes about the meaning of illness for the people impacted by it prior to the antibiotics that cure TB or the admittedly rougher chemo- and immuno-interventions that [often] cure cancer – that is, send it into long-term remission.

For example, TB was regarded and written about as the creative artist’s disease, an enhancement of identity. The disease itself becomes the mark of a creative personality. The disease is the source of creative genius. The list is long but Schiller, Chopin, Keats, Shelley, and Kafka top the list of artists whose lives and productivity were shortened by TB. Unlike such disorders as manic-depression where the boundary between productive creativity and uncontrolled acting out can vary problematically (and some of those on the list may have had some of that too), TB is just bad news. But it is not treated that way.

The tubercular character is both passionate and repressed. Literature is filled with romantic characters whose suffering from TB enhances their beauty when they are women – see Mimi in La Bohéme – or their intellectual vitality when they are men – see Hans Castrop in Thomas Mann’s Magic Mountain.

In contrast, according to Sontag, cancer is the metaphor for what is most ferociously energetic (p. 68). The uncontrolled multiplication of cells run riot. There are fewer narrative engagements in literature – see Tolstoy’s The Death of Ivan Illych as a notable exception – but the stigmatization is no less metaphorical. In Mann’s late novel The Black Swan the aging heroine, engaged in a romantic relationship, initially mistakes bleeding as the return of her menses whereas it is a hemorrhage due to cancer.

The link between moral disease and the underlying character is supposedly illustrated by Freud, who communicated brilliantly but was brought low by cancer of the mouth, chomping on his ever-present cigar long before the carcinogens in tobacco were understood. Wittgenstein was a carefully closeted gay person (in the UK where homosexuality was illegal at the time) and died when his prostate cancer spread.

This leads to the discussion of plague literature beginning with the setting for Boccaccio’s Decameron in the pestilence struck Florence of 1348. Thomas Mann’s “The Death in Venice” (1912) has its aging, celebrity hero, Gustav von Aschenbach, metaphorically plagued by an infatuation with a pubertal boy, who looks like Donatello’s statue of David.

The love affair unfolds across ninety pages without the lovers so much as doing more than exchanging an occasional remote glance on the beach across a distance of ten meters, but the animal magnetism on the part of Aschenbach is palpable, the references to Dionysius and Nietzsche compelling, and the ending unpredictable. Aschenbach eats the strawberries, and catches a version of the cholera epidemic that kills him before he so much as feels the slightest need to go to the bathroom. Hmmm. Might not have been cholera. Old age? A broken heart? An unscheduled cerebral event due to a hypertensive crisis brought on by stress?

Fast forward some ten years, in real life, and Sontag is herself a cancer survivor. She was realistic, did not romanticize her illness, did not mistakenly believe that aromatherapy, talk therapy or yoga would cure her cancer. She engaged with the chemotherapy, and lived to fight another day.

In 1989 Sontag updates her work in a separate essay entitled “AIDS and Its Metaphors.” Ten years on (roughly 1987) the AIDS (acquired immune deficiency syndrome) epidemic is in getting going and would continue accelerating until 1995. Antiretroviral treatments would start emerging in 1996 that ultimately would substantially reduce AIDS-related mortality.

Here the stigma of being gay loomed large as the Reagan administration and Evangelical Christians led the way in blaming the victims. Drug addicts who used infected needles also formed a marginalized population that, according to the some versions of the Christian right, did not deserve treatment, never mind the sayings of Jesus of Nazareth about what one does to the least of the brethren one also does to Him.

Never was it truer that we are all related – and the least of the brethren eventually and unwittingly started infecting the heterosexual population. Indeed even the credible threat of such infection was game changing, along with the gay rights growing protests, political power, and the participation of fellow travellers of integrity of diverse persuasions.

What Sontag may not have appreciated as much as we do today (Q1 2020) is that it is a cognitive design defect of human thinking to take responsibility for things for which we have responsibility as well as no responsibility, because it is adaptive to do so from the point of view of survival in the face of the unknown. This “taking responsibility” is “making it mean that I did something = x to cause this.” In turn, this “x” is often “I did something wrong.” Not necessarily – unless you consider “being born” to have been a mistake.

When the solution [or cure] is known one has to shift the responsibility and just take the medicine or when there is no medicine just follow evidence-based doctor’s orders. Thus, Sontag’s self-described mission is to treat disease as disease – not as a curse, embarrassment, punishment, or stigma. “Without meaning.”

It is a design defect of human cognition that in the face of the unknown causes of TB, cancer, AIDS, Ebola, or Covid-19, people’s imaginations ran riot with meaning-making about the causes, expressive value, symbolic portend, possible treatments and cures, and outcome of illness.

The lesson? As Sontag surely appreciated, Psychology 101 teaches us that the most fearsome thing is – the unknown. The unknown is a source of meaning generation as one tries to comprehend it, structure it, control or at least manage it. But meaning making itself has its own risks and break downs.

As of this writing (Q1 2020) we do not know if or how readily the Covid-19 virus can be aerosolized – hang in the air and be contagious – twenty minutes (not so bad?) – twenty hours (no so good!). The rapid spread of the community contagion suggests the coronavirus is more contagious than was at first suspected. Bad news. Yet it is the unknown takes one’s power away and unworkably leaves one with the thought, “Maybe I should hold my breath.”

You know how in the vintage back and white monster movies, once you actually see the guy dressed up as Swamp Thing, it is a lot less scary? The creature may still be disgusting, but it is no longer nearly as scary? The scary part is when the heroine is innocently combing her hair and the swamp thing (which is “off camera” and the audience cannot yet see) is silently sneaking up behind her.

You know that scenario? Well, that’s what we’ve got here with the World Health’s Declaration of a pandemic. I will not further comment on the details as numerous resources are available from WHO and the Center for Disease Controls (CDC), frequently updated as we learn more and more about what to do or not do.

I hasten to add that “following doctor’s orders” does not mean abandoning critical thinking. It means following the light, but it does not mean following the light off a cliff. How to know the difference?

Medical “science” makes mistakes. George Washington got a fever, and bleeding him to reduce the imagined excess of blood contributed to his untimely death. In the 1960s, thalidomide was a horrific episode that lead to the strengthening of the Food and Drug Administration’s (FDA) requirements for validating the uses of medications. Yet in the face of political pressure to “do something” even the FDA bows to the bully pulpit to approve an unproven treatment against malaria for use against Covid-19. Well, at least it doesn’t cause birth defects – we think, we hope.

Sontag does not touch the fraught matter of psychiatric treatments, and some psychiatric treatments that have been applied in certain places and times are indistinguishable from human rights violations, especially seen with the benefit of 20-20 hindsight. For example, the prefrontal lobotomy destroys the personality, rending the acting-out patient compliant and docile – and sometimes incontinent. While some patients have benefited from electro shock therapy (ECT), its use remains controversial, and it has not always been used (as it should be) as a treatment of last resort. (For example, at a time when ECT was the first line treatment because it was arguably the only treatment, see Marsha Linehan’s memoir Building a Life Worth Living of the damage it did to her.)

Medical science makes mistakes. But medical science still makes fewer mistakes than do politicians appearing on TV and pretending to be doctors, touting unproven anecdotal remedies.  Alternative facts, half truths, and dangerous nonsense are readily projected onto the unknown.

Thus Albert Camus writes in his novel The Plague (translation by Stuart Gilbert 1947/1948): “The evil that is in the world always comes of ignorance, and good intentions may do as much harm as malevolence, if they lack understanding. On the whole, men are more good than bad; that, however, isn’t the real point. But they are more or less ignorant, and it is this that we call vice or virtue; the most incorrigible vice being that of an ignorance that fancies it knows everything”

The management and overcoming of epidemics is difficult under the best of circumstances. As well as deep medical and public health expertise, it requires leadership, communication, and political skills. Not for the faint of heart.

For example, Albert Camus’s The Plague provides the paradigm structure of an epidemic. The epidemic is a social drama is three acts. The first act contains hints that all is not right. Most of the tourists pack up and leave. No one dares say the word “cholera” or “plague.” The commercial class of businesses and shop-keepers are in denial out of a combination of economic interests and outright fear for their own health and well-being. Then a rising number of illnesses and deaths requires people to confront the fact.

The second act consists in the search for causes. When science does not have the answer (or as in medieval times science is not quite what we mean by “science”), people substitute value judgments for causal accounts. In medieval times, Jewish people and practices were blamed. In our own time with Covid-19, some are pointing a finger at Chinese people, projecting their fears. I hasten to add there are Covid-19 lessons to be learned in the breakdown of the early warning system for disease under diverse political and economic stressors not further analyzed here.

At this point in the drama, act three, the social and political strengths and weaknesses of the community are exposed. The poor suffer disproportionately whereas the rich leverage their access to resources to survive. The ultimate voter suppression opportunity? The ruling class uses the opportunity to thin the ranks of the opposition; though to be sure, the disease is a great equalizer, arbitrarily carrying away rich and poor, indiscriminately.

Other individuals and groups – first responders – step up and perform heroic acts of self-sacrifice for the good of the community. The latter also exposes the weaknesses of the response of the authorities as people are asked to “step up” without adequate personal protective equipment and systems.

Finally, the disease runs its course when it runs out victims susceptible to its action and intervention by the authorities – medical and social – succeeds in stemming its tide.

Sontag is clear. Disease is the result of pathogens such as bacteria, viruses or toxic chemicals such as tobacco and arsenic, so follow doctor’s orders, take the medicine (if available), in our own current predicament, maintain social (physical) distance, shelter in place, and live to fight another day.

By 1977 tuberculosis (TB) had long been curable. Innovative chemo- and immuno-therapies for cancer were supplementing radiation therapy. So cancer no longer equaled a death sentence. But the inertia of thinking, judging, moralizing, politicking is such that TB and cancer were rich sources of metaphor – commentary, comparison, and expressive discourse about relationships, community, and politics. In literature and historical narrative illness is not mere disease, it is metaphor. Illness gathers together, activates, and occasions meaning making about life, death, morality, merit, transgression, finitude, and mortality.

Sontag’s method is based on her breakthrough approach in “Against Interpretation” (1964), which is directed against the accumulations of meaning that stick to modern art. Her recommendation? Instead of trying to figure out what it means, let it be what it is.

This is the existentialist moment in Sontag. Disease is a reminder of human finitude – mortality. That is one of the few things that can be said to be the truth with a capital “T” – no one gets out of this thing – that is, life – alive. Everyone dies – but the manner of coming and going is highly diverse. We humans work mightily to negotiate and postpone the exit – that is called modern medicine. Go back to the top of this post and substitute “modern medicine” for “illness”; and, while that does not change the guidance, it puts in perspective just how much trouble we really are today.



David S. Jones, MD PhD History in Perspective – Lessons for Covid-19


March 12, 2020: March 12, 2020
DOI: 10.1056/NEJMp2004361

Megan Molteni, (3/4/2020), Everything you needed to know about a coronavirus vaccine:


Politico: Coronavirus Will Change the World Permanently. Here’s How (03/19/2020): https://www.politico.com/news/magazine/2020/03/19/coronavirus-effect-economy-life-society-analysis-covid-135579

Note this material is highly time sensitive. All the usual disclaimers apply.

© Lou Agosta, PhD and the Chicago Empathy Project