I recently had the honor to get to give a keynote at the Comics & Medicine conference in Riverside, CA, hosted by the Graphic Medicine collective and the amazing Juliet McMullin. I thought it might be fun to share my talk, "Beyond Metaphor," in serial fashion. Here is Part 1...

A year ago in Baltimore I had a chance to give a paper about time and illness at this conference, my first tentative steps towards what I hope will be my next monograph. At the time, I fondly believed I was on the far side of illness: surely this latest surgery meant I was now fully on the road to health. Having “beaten” my disease, I set out on a course of “healthy living,” energized by my “new lease of life.”

As Susan Sontag famously demonstrated, metaphors cling to illness like flies—but the same is true for the more challenging category in this binary: health. My lease allowing me to live in my body renewed, I now had a moral responsibility to fix the place up. My employer, my physician and my insurer (which are for me one and the same, because what could go wrong?) set me up with a phone coach and plugged me into their online “plan for health” program that promised to give me keys to this mysterious, ever-elusive kingdom of the well. Some of the tips were clear and I followed them dutifully: lose weight, exercise regularly, eat the right foods in the most disciplined of portions. I entered my data online and was rewarded periodically with that most magical marker of accomplishment: an Amazon gift card. I was told to “get in the flow,” to lose myself in my work, to find deeper meaning in life. I was to be more resilient, to bounce back from difficulties and not dwell on the past, and to journal about the person I would like to become in order to develop a more positive goal-oriented self-image. Mostly, I was told to monitor myself—not just my calorie, water, and alcohol intake but, even more importantly, my mood, my efficiency in managing tasks, my equipoise with colleagues, my spiritual well-being and my positive outlook. And most especially my balance.

“Balance” is our most pervasive metaphor for health today. Today we must balance not our humours as in traditional Galenic medicine but our hormones, our pH, our mind/body, and our work/life. While balance is an operative metaphor in both pre-modern and contemporary medicine, the effect of the metaphor is profoundly different. To be out of balance before modern medicine was to be subject to “heroic medicine”—the “hero” here being the doctor and the “medicine” being the bloodlettings, sweatings, purgings designed to restore balance on the unwitting and often unconscious patient. In our age of patient-centered care the “hero”—or more often, the villain when it comes to “balance”—is the patient. I did my best, I swear. I mean, I really wanted those gift cards. But as I stared at the images I felt strangely alienated from their promised land of healthy balance. When, not long after our gathering last year, I found myself suddenly sick again, there was, I confess, a brief moment of relief at no longer having to compare my physical, social and emotional well-being against these images.

Also, of course, I felt guilt. After all, I had never really gotten with the program—never monitored my “self-talk” or “timeboxed” my tasks. If I was sick again, it was almost certainly my fault. The website didn’t exactly say so, but my lack of progress in accumulating points was there for me (and my employer/physician/insurer) to see. That I was now finally officially chronically ill, having run out of organs to remove in the hopes of a surgical solution, did not get me off the hook. Far from it.

When Sontag wrote Illness as Metaphor she was in the midst of chemotherapy for stage-4 breast cancer. In her book, Sontag famously preached against the tendency in our discourse of illness to think of illness through not metaphor, metaphors that shaped the thinking of all who came in contact with illness—doctors, loved ones and patients themselves. Sontag was militating especially against the military metaphors that had first emerged in the 19th century as modern medicine finally saw the pathogenic enemy in the microscope: now doctors had something to fight, to kill, to defeat. And they did: today most of us have to turn to literature of the past to understand the devastations of smallpox, yellow fever, polio, bubonic plague. A cough or a wound in Act 1 no longer means an inevitable deathbed scene in Act 2. What happens however when modern medicine and its military metaphors encounter illnesses for which it has no solution? In the case of cancer, for which we can have the pathogenesis but only occasionally an etiology, we can see it, we can fight it, declare war on it… but we haven’t come close to defeating it. Here, especially with the shift to patient-centered medicine in the 1970s, the military metaphors begin to cut in new ways, as Sontag pointed out: in the absence of a nuclear option, it is the patient who loses the fight against cancer—not fighting hard enough, not strong enough, brave enough. And in the absence of etiology (and often even in its presence), it is the patient who brought it on herself—insufficiently disciplined, conditioned…balanced.

Though we might think of the figure of balance as being drawn exclusively from pre-modern and non-western medical traditions, it is in fact also a military term: “balance of power,” balanced forces, a well-balanced soldier. Each year the International Institute for Strategic Studies publishes Military Balance, a measure of the world’s weaponry and war footing. In the Cold War, the anxieties about balance moved increasingly from the balance of armed forces as a whole to the balance of individual soldiers—especially after the brainwashing hysteria during the Korean War, in which, as Edward Hunter, cheerleader of the hysteria in the 1950s put it, “The Reds [used] … medical science to take balanced minds and to make them unbalanced.” In the mid-50s, the big story was not that brainwashing of POWs could work, but that so very many of our young soldiers were in fact sufficiently unbalanced that it worked on them—as if they wanted to be brainwashed by the Reds. As if they wanted to be sick.

All of which is to say, the pirouette from military metaphor to blaming the victim is hard-wired in the very metaphors medicine borrowed in the first place— and it continues to shape so much of our discourse about global health. And if these metaphors had potentially devastating effects for patients with cancer, for Sontag in the quintessential “modern disease” of the late 20th century, how much more so when turned in the direction of the rising tide of chronic illness in this generation. How do we tell our stories when our illnesses not only have no cure, no known etiology, but in many cases not even a name. What might it mean to move beyond metaphor, as Sontag demanded, in communicate the experience of often “invisible” disease?