Download The war against dementia: are we battle weary yet?

Age and Ageing 2013; 42: 281–283
doi: 10.1093/ageing/aft011
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COMMENTARY
The war against dementia: are we battle
weary yet?
HEATHER PATRICIA LANE1, SUEANNE MCLACHLAN2, JENNIFER PHILIP1
1
Centre for Palliative Care, St Vincent’s Hospital (Melbourne), Melbourne, Victoria, Australia
Oncology, St Vincent’s Hospital (Melbourne), Melbourne, Victoria, Australia
2
Address correspondence to: H. P. Lane. Tel: (+61) 3 9416 0000; Fax: (+61) 3 9854 1671. Email: [email protected]
Abstract
Recently, the use of military metaphors when discussing dementia and in particular Alzheimer’s disease has increased, both
in medical literature and mainstream media. While military metaphors are a recent adoption when used to describe dementia, in oncology there has been longstanding debate about the usefulness of such metaphors. This article reviews the history
of military metaphors in medicine, literature discussing their use, and considers their use in describing dementia. While military metaphors are widely used in medicine, consideration should be taken in their use as they have the potential to influence the way we and our patients conceptualise and experience illness and treatment.
Keywords: dementia, Alzheimer’s disease, metaphor, military, older people
Introduction
Recently, the use of military metaphors when discussing dementia and in particular Alzheimer’s disease has increased,
both in medical literature and mainstream media. Titles including ‘Harnessing the immune system to battle Alzheimer’s
disease’ [1], ‘Developing the framework for the international
battle against Alzheimer’s disease’ [2] and ‘Dementia in Lewy
body syndromes: A battle between hearts and minds’ [3] are
found in medical journals.
Internationally, headlines reported President Obama declaring ‘War on Alzheimer’s disease’ early in 2012, after the
working group for the National Alzheimer’s Plan Act
announced the goal of finding a cure for Alzheimer’s
disease by 2025 [4], while the United Kingdom’s
Alzheimer’s Society website carries the banner: ‘Alzheimer’s
Society: leading the fight against Alzheimer’s disease’ [5].
Meanwhile, the ‘Fight Dementia’ campaign was launched in
2011 by Alzheimer’s Australia, aiming to make dementia a
national health priority [6].
While military metaphors are a recent adoption when
used to describe dementia and Alzheimer’s disease, in oncology there has been debate about the usefulness of these
metaphors dating back to Susan Sontag’s 1978 book ‘Illness
as Metaphor’ [7], debate which is relevant to other areas of
medicine including dementia care. This article reviews the
history of military metaphors in medicine, literature discussing their use, and considers their use in describing dementia.
Is discussion of metaphor of any importance to the medial
field? Lakoff and Johnson assert that metaphors represent
more than just the way a subject is described, also reflecting
conceptualisation and experience of the world, and therefore
having the potential to affect thoughts and actions [8].
Military metaphors are widely used when describing health
status and illness, and the mainstream media are frequently
accused of perpetuating them. Military metaphors are certainly prevalent in newspaper headlines, in reference to a broad
range of medical conditions including heart disease, obesity,
multiple sclerosis, depression and allergies. Pharmaceutical
companies use military metaphors and imagery in advertisements. An advertisement for the chemotherapy agent docetaxel features ‘Liberty Leading the People’, the 1830 Eugene
Delacroix painting with a woman, ‘Liberty’, leading an army
over the bodies of those fallen in battle [9].
However, these metaphors are not exclusively the
domain of the popular and commercial press. In the
medical literature, military metaphors are used in reference
to an extensive range of medical conditions, including: cardiovascular disease—‘The reperfusion wars’ [10]; medical
errors—‘The war against error’ [11] and psychological
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disorders—‘Are we winning the war against posttraumatic
stress disorder?’ [12].
Historical background
The use of military metaphor to describe illness dates back
to at least the seventeenth century when John Donne
described his illness as ‘a canon shot’ and ‘a siege’ [13], and
the physician Thomas Sydenham noted that ‘[a] murderous
array of disease has to be fought against, and the battle is
not a battle for the sluggard’ [14].
During the late nineteenth century infectious diseases
were increasingly referred to in military terminology. Otis
noted, ‘[w]hen … the disease [tuberculosis] is limited to an
apex, in a man of fairly good personal and family history, the
chances are that he may fight a good winning battle’ [15].
Worcester describing the physician’s duties wrote that ‘he
must lead the fight against all contagion and infection’ [16].
By the early twentieth century military metaphors were
being used in reference to cancer. Downing discussed
‘fighting cancer, leprosy, and tuberculosis’ [17], whereas
Cabot wrote of ‘a good fighting chance’ of reducing cancer
mortality [18]. In 1936 the Women’s Field Army was established by the American Cancer Society to engage in ‘trench
warfare with a vengeance against a ruthless killer’ [19], by
raising money and educating the public about breast cancer.
Following World War II, military metaphors were promoted in cancer care. Lerner suggests that this was due to
the increased profile of surgeons returning from war, many
of whom became involved in treating cancer [20]. Military
metaphors were used by Mary Lasker of the American
Society for the Control of Cancer in political lobbying for
the advancement of cancer research [21]. The military
metaphor was further promoted by President Nixon’s ‘War
on Cancer’, with signing of the 1971 National Cancer Act.
The use of military metaphors in the medical literature has
continued in recent decades, along with discussion of their
usefulness [22, 23, 24, 25].
Positive aspects of military metaphors
Military metaphors can be effective in raising the profile of
health issues, bringing them to public and media attention.
For example, prior to the establishment of the Women’s
Field Army, breast cancer was rarely discussed, with medical
attention often sought late through fear and embarrassment.
Military metaphors can also be used for marketing. For
researchers, such language can improve research profiles
and garner publicity. Charitable fundraising efforts are likely
to be enhanced by talk of battles and fighting, with winning
the battle held out as an incentive for contribution. For the
mainstream media, military metaphors are likely to grab the
reader’s attention and increase sales.
At the individual level, metaphors can aid understanding
and communication. Military metaphors appear to resonate
with both patients and doctors. For some, they come naturally
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and are helpful, imparting a sense of control at a time of uncertainty and powerlessness, and can assist in focusing attention
on completing investigative procedures, surgery, chemotherapy
or radiotherapy treatment. Menaker reports personally finding
military metaphors useful when following a complex treatment
regime and when facing surgery. He noted ‘it may be a kind of
self-delusion, but it may assist in self-preservation’ [26].
Negative aspects of military metaphors
A metaphor in itself is not harmful. However, military
metaphors can become pervasive, with a ‘fighting attitude’
expected. For some aggressive metaphors are unhelpful,
even distressing [22]. The pressure to maintain a fighting attitude, rather than discuss the real emotions they are experiencing, may become a burden, leaving the person isolated
from family and friends [27].
Military metaphors have been criticised for focusing attention on disease as ‘the enemy’, while the patient as an individual with their own physical, psychological and social needs is
forgotten [22, 23]. Such metaphors have also been criticised
for perpetuating hierarchy in the doctor–patient relationship,
with Fuks writing: ‘the battle cannot be won without following
doctor’s orders’ [23]. In a military context, the defiance of
orders is deemed ‘insubordinate’. This may limit a patient’s
ability to exercise judgement or question treatment options.
Military metaphors may inhibit conversations about alternative treatment options or prognosis. The focus on ‘battling’ encourages ‘taking action’, and discussion is centred on
treatment. The desire to ‘do everything possible’ could encourage doctors and patients to adopt burdensome therapies
which hold a very small chance of benefit [22]. Other conversations, such as planning for the future, may be impeded.
This may result in people with a limited prognosis, having insufficient time to accomplish other important tasks of life.
When military metaphors predominate, the outcome of an
illness becomes one of victory or defeat. If someone does not
‘win their battle’ with illness, have they failed? The implication
is that perhaps a person who is dying did not fight hard
enough. This could leave those with progressive disease,
feeling a sense of inadequacy or self-blame. Some people will
favour a ‘fighting’ approach, but perhaps physicians can be
complicit in the ongoing use of military metaphors, when promoting alternative metaphors or encouraging other ways of
viewing the situation might be useful.
The use of military metaphors in dementia
The profile of dementia and Alzheimer’s disease and
funding for research in these areas has been raised in
recent years. Campaigns using military metaphors may well
have contributed to this success in this traditionally poorly
understood and under-resourced area.
However, at an individual level a chronic illness such as
dementia is arguably not usefully conceived as a battle.
First, no curative treatments are available as ‘arsenal’.
The war against dementia
Secondly, many people with dementia are older and face
other medical conditions or disability. These people may
not be in a position to ‘fight’.
Dementia requires individualised multidisciplinary care
focused on supporting the individual and their family or
community network. However, military metaphors encourage disease focused, doctor led care. Future planning is a
core component of dementia care, as this progressive illness
is likely to limit capacity to make decisions at some point.
Military metaphors focus on the immediate ‘fight’ and may
impede conversations about the future. Additionally, fighting metaphors may leave some individuals feeling they have
‘lost’ as the disease progresses, an unnecessary burden for
someone facing illness and disability. Finally, from a
broader perspective, focus on ‘battling’ dementia, may distract from discussion about how our communities best care
for and support an increasing number of people with
dementia and their families as the population ages.
The adoption of military metaphors in healthcare may
aid in raising awareness of illnesses and in fundraising.
However, the metaphors we use in medicine potentially influence the way we and our patients conceptualise illness
and treatment [8]. Therefore, consideration must be taken in
their use to ensure individual harms are not forgotten.
References
The very long list of references supporting this commentary has meant that only the most important are listed here
and are represented by bold type throughout the text. The
full list of references is available on the Supplementary data
in Age and Ageing online.
Supplementary data
4. Gleckman H. The Obama Administration’s War on Alzheimer’s.
New York: Forbes Magazine, 2012 Available at: http://www.
forbes.com/sites/howardgleckman/2012/01/11/the-obamaadministrations-war-on-alzheimers/ (accessed 8 October 2012).
5. Alzheimer’s Society: Leading the fight against dementia.
London: Alzheimer’s Society, 2012 http://alzheimers.org.uk
(accessed 12th Aug 2012).
6. Alzheimer’s Australia; 2012; Available at: http://www.
fightdementia.org.au/default.aspx (accessed 8 August 2012).
7. Sontag S. Illness as metaphor. New York: Farrar, Straus and
Giroux, 1978.
8. Lakoff G, Johnson M. Metaphors We Live By. Chicago:
University of Chicago Press, 2003.
9. Scott T, Stanford N, Thompson DR. Killing me softly: myth
in pharmaceutical advertising. BMJ 2004; 329: 1484–7.
13. Donne J, Raspa A. Devotions Upon Emergent Occasions.
Montreal: McGill-Queen’s University Press, 1975.
14. Sydenham T, Grenhill WA, Latham RG. The Works of Thomas
Sydenham, M.D. Vol 1. London: Printed for the Sydenham
Society, 1848. Available at: http://ia700300.us.archive.org/16/
items/worksofthomassyd01sydeiala/worksofthomassyd01
sydeiala.pdf (accessed 26th Aug 2012).
15. Otis EO. Pulmonary tuberculosis with especial reference to
its prophylaxis, hygienic and climatic treatment. Boston Med
Surg J 1893; 129: 337–40.
19. Black ME. What did popular women’s magazines from 1929
to 1949 say about breast cancer? Cancer Nurs 1995; 18:
270–7.
20. Lerner BH. The Breast Cancer Wars: Hope, Fear, and the
Pursuit of a Cure in Twentieth-century America. New York:
Oxford University Press, 2001.
22. Reisfield GM, Wilson GR. Use of metaphor in the discourse
on cancer. J Clin Oncol 2004; 22: 4024–7.
23. Fuks A. The Militray Metaphors in Modern Medicine.
Freeland, Oxfordshire: Inter-disciplinary.net, 2009. Available
at: http://www.inter-disciplinary.net/wp-content/uploads/2009/
06/hid_fuks.pdf (accessed 9 August 2012).
26. Menaker D. Cancer: fighting words. New York: The
New York Times, 2011 August 27. Available at: http://www.
nytimes.com/2011/08/28/opinion/sunday/cancer-fightingwords.html (accessed 9 August 2012).
27. Amsterdam S. No Battle Lines in the Cancer Ward.
Melbourne: The Age, 2012 Mar 24. Available at: http://www.
theage.com.au/opinion/society-and-culture/no-battle-linesin-the-cancer-ward-20120323-1vpi4.html (accessed 9 August
2012).
Supplementary data mentioned in the text is available to
subscribers in Age and Ageing online.
Received 28 October 2012; accepted in revised form
19 December 2012
Key points
• Military metaphors are widely used in many areas medicine
and have a long history of use in reference to medical
conditions.
• Military metaphors can aid in raising the profile and
improve fundraising for a medical condition.
• Some individuals find military metaphors help them
manage a medical condition.
• Military metaphors may encourage a disease focused approach and suggest to patients that a fighting attitude is
expected.
Conflicts of interest
None declared.
Funding
H.L. is funded by an Australian Postgraduate Award.
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