Introduction

In an article published in 1990, ^{Nancy Scheper-Hughes (1990)} begins an academic joke about medical anthropology involving a doctor and three academics: Hans Baer, Michael Taussig, and Arthur Kleinman. In the story, as they stand by a river, they hear the screams of a man carried away by the water current, seemingly drowning. The doctor is the first to react, jumping into the river and attempting to save the man, but with no success. Soon, other bodies float on the water, and the doctor's efforts to rescue and revive them prove futile. Hans Baer heads towards the source of the current to investigate the contradictions of the capitalist mode of production responsible for the mass appearance of these corpses. Meanwhile, Taussig goes off alone in search of the enigmatic message in a bottle, a foresight one dying man might have sent to account for the deaths. Kleinman remains on the shore, facilitating the doctor-patient relationship.

From these three statements, Scheper-Hughes points out three key proposals for applying medical anthropology in a critical context: recognizing the influence of power and politics, questioning biomedical knowledge, and promoting social justice and ethical practices. Although the author insists on working on these three presuppositions together, it cannot be denied that this task still seems far from being completed. For example, some cultural elements, such as those that Taussig seeks to decipher in the joke, are often not considered on the grounds of biomedical biases. This last approach repeatedly forgets how certain everyday practices, symbols, language, and beliefs condition the perceptions and behaviors of individuals concerning disease¹ and health.

In this sense, it is important to turn our attention to the use of metaphors in the medical field. Metaphors play a crucial role in diseases. (^{Bleakley, 2017}) They make technical and sometimes abstract aspects of medicine more intelligible and often function as a bridge between this dimension and patients' particular and subjective experiences (^{Karska & Prażmo, 2017}; ^{Landau et al., 2018}). Metaphors frequently facilitate greater communication between healthcare professionals, patients, and their families (^{Margaryan & Petrosyan, 2016}). Methodological metaphors work in both directions. In other words, doctors and nurses are often better able to translate concepts, diagnoses, and procedures to their patients, and patients are better able to communicate their ailments more effectively. Thus, metaphors, understood as frames of reference and narrative structures, can encourage or modify behavior, promote making medical decisions, and even forge certain relationships or identities. Therefore, it is worthwhile to analyze their use critically and not to underestimate their function.

This article aims to analyze the role of metaphors concerning health and disease. By exploring the intricate ways metaphors are employed in the health field, starting with some metaphors used during the COVID-19 pandemic, I attempt to reveal how they both shape the conceptualization of health and become a political resource that guides a given public health policy. This article sheds light on the dual nature of metaphors, serving as linguistic tools that construct meanings and as instruments of power that influence the socio-political landscape. This exploration contributes to a deeper understanding of the complex interplay between language, health, and politics in health care.

Metaphors: Avoiding their reductionist use

Traditionally perceived as mere stylistic resources² (^{Karska & Prażmo, 2017}), metaphors extend beyond this narrow perspective. They embody the human ability to forge connections between seemingly unrelated concepts, processes, and objects. This capacity to establish similarities is not confined to the literary or artistic realm. Today, metaphors are study subjects in various fields, including psychology, technology, and health³. A tacit agreement exists that metaphors permeate all aspects of our daily lives, enriching our understanding of the world and communication beyond logic and literalism. Metaphors shape, nuance, and deepen our ideas, conversations, behaviors, and social bonds.

Establishing metaphorical relationships involves a conceptual process where one domain is represented with the characteristics or terms of another domain. This allows for precisely identifying source and target domains (^{Karska & Prażmo, 2017}; ^{Lakoff & Johnson, 2008}; ^{Thibodeau & Durgin, 2011}). The former serves as the point from which conceptual forms are imported to express the latter. The latter domain is often more abstract or difficult to intelligibly express. For instance, in the metaphor “marriage is a plant,” we can articulate the need to water or fertilize the marriage and describe it as withered or flowering. A solid understanding of the source domain generally enables the stipulation of sharper connections.

Metaphors surpass their linguistic use; they are not merely embellishments or ornaments (^{Abrams & Harpham, 1998}; ^{Venkatesan & Saji, 2020}). In linking two domains, language assumes a secondary role. The critical aspect lies in the inference and connection of the two domains, followed by applying appropriate language codes. The discursive or lexical component aligns with a conventional mapping process (^{Lakoff & Johnson, 2008}), facilitating the conceptual representation of one concept by the other. This necessitates contemplation of the relationship, the epistemic correspondences, and not just the terms through which it is denoted (^{Karska & Prażmo, 2017}).

George ^{Lakoff and Mark Johnson (2008}) emphasize that metaphors extend beyond human thought to encompass the field of human action. According to this perspective, metaphors play a substantial role in conceptualizing the world, thereby shaping the behavioral ways in which we interact with it. In essence, metaphors organize our thinking and model our everyday behavior and decisions. Recognizing that the essence of metaphors is to understand and experience one kind of thing in terms of another underscores their significance beyond the stylistic use of language and intellectual reflection. Instead, they become a powerful instrument that frames and drives our perceptions and actions in the world (^{Venkatesan & Saji, 2020}). Lakoff and Johnson encourage us to view metaphors as an effective, dynamic, and transformative tool at both the levels of thought and action⁴.

The link established by human reason between two conceptually distinct domains proceeds through more than a simple comparison. Instead, in most cases, it is based on the correlation of individual experiences in both domains, wherein interactions with the physical environment, context, and culture play a transcendental role (^{El Refaie, 2016}). Metaphors, therefore, extend beyond indicating vague similarities; rooted in the routines and interactions of individuals in diverse environments and their capacity for abstraction, they are expressed through conceptual constructs. This process reveals that personal experiences in the physical and cultural worlds are reflected and represented through language. Even the simplest sensations carry sociocultural meanings, indicating that bodily experiences not only give rise to metaphors but also constitute their purpose (^{El Refaie, 2014}). These metaphors reflect and communicate these assumptions, transcending mere tropes. As ^{Frank expressed (2011}, p.193), “A metaphor is no longer a trope, in the sense of twisting language. Instead, reality is what is twisted, and language is a process of straightening.” In summary, metaphors and diverse cultural and social notions are interconnected to express and convey these notions and make sense of other experiences in specific cultural and social contexts.

From this perspective, metaphors offer an alternative way of understanding the truth about a fact or an experience, diverging from an exclusive adherence to an objective-logical view (^{Landau et al., 2018}). The notion of objectivity, driven by the pursuit of pure logic and data verification, involves a rational analysis of facts that tends to exclude the subjective or emotional dimension. In contrast, the concept of “imaginative rationality”⁵ (^{Lakoff & Johnson, 2008}) illustrates how metaphors can blend objectivity with subjectivity and logic with creativity. Metaphors, therefore, do not assert immovable truth claims but embody constantly changing and evolving concepts. Their interpretation depends on both the conceptual system of the enunciating subjects and the socio-cultural context in which human experiences unfold.

Metaphors in the medical field.

Metaphors in the medical field have been a recurrent theme. For instance, ^{Pena and Andrade-Filho (2010}) retrieve a series of metaphors in medical texts. ^{Tajer (2012}) explains how diseases are metaphorically modeled, and Elena ^{Semino and Demjén (2016}) demonstrate how pain, in both clinical and social literature, is represented through figurative language. David ^{Biro (2010}) delves into the power of metaphors to alleviate the pain of the sick. On the other hand, Susan Sontag⁶ (1978, ¹⁹⁸⁹) provides a poignant description of various images employed in literature and medical discourse, particularly representations of cancer and tuberculosis. She critically analyzes their effects on the collective perception of disease and argues for a discourse on disease purified of metaphorical thinking.

Regarding diseases, their existence, development, and effects are intrinsically dependent on the patient. This relationship is cardinal because a disease cannot be understood apart from the person experiencing it; it can only be conceptualized as a condition affecting an individual's body. These states often show themselves in the form of a series of symptoms, which can vary in degree of intensity and length, shaped not only by biological ailments but also by each patient’s lifestyle. Within this setting, examining how patients and clinicians represent diseases, ascribe characteristics and meanings to them, and define them is essential.

In the complex yet fascinating process of representation, diseases manage to be seen through “inanimate or even personified forms.” (^{Karska & Prażmo, 2017}, p. 110) The range of images evoked is diverse. From one perspective, the disease is often perceived as an unwanted visitor invading our lives, a stealthy enemy lurking in the darkness, an insatiable animal devouring our energies, or a devious intruder disturbing every aspect of our personal lives. Alternatively, some individuals view diseases as tests, indulgent friends that help us grow, gifts reminding us of the value of life and the importance of care, or a form of training. Furthermore, not only disease is understood through metaphors but also the body and medicine itself. For instance, the body is conceptualized as a machine, and some treatments are likened to a battle (^{Bleakley, 2017}; ^{Buchbinder, 2012}).

Regardless of the characteristics and connections established, metaphors accumulate and synthesize people's attitudes toward disease and its hazards. In many cases, these concepts enable individuals to make sense of their ailments, process certain emotions, better understand the complexity of being ill, and become more interested in medical treatment or adopting healthier lifestyles. Metaphors are, therefore, a powerful tool revealing the intricate relationship between humanity and disease, together with the concrete and constant interest in understanding and controlling health, the fragility of life, and death. In this sense, both representations of diseases and therapeutic interventions reflect the sociocultural environment in which they are shaped and implemented (^{Unschuld, 1998}, p. 23).

Metaphors in the health field primarily stem from the everyday experiences of both patients and health professionals. To articulate their physical sensations, patients often draw on figures related to their jobs, culture, or level of education. Health professionals, including doctors, not only share these sources but also construct metaphors from visual contact with patients' symptoms, involving radiology data, laboratory images, and sensitive signs. ^{Rizzutto (2001)} suggests that doctors later link initial images with concepts by recognizing patterns, arriving at or converting the initial image into a familiar metaphorical term. In this context, medical metaphors can be seen as a discursive means of rationalizing the unknown or complex (^{Buchbinder, 2012}, p. 102).

The functionality of metaphors in the clinical field is diverse, serving various purposes. Some previously mentioned elements include facilitating the understanding of a diagnosis or enhancing communication fluency between doctors and patients (^{Bleakley, 2017}; ^{Margaryan & Petrosyan, 2016}). Metaphors are also employed for persuasive purposes, with some authors asserting that they stimulate imagination and innovation (^{Fauconnier & Turner, 2003}), contribute to disease prevention (^{Hauser & Schwarz, 2015}; ^{Landau et al., 2018}; ^{Landau et al., 2014}), and reinforce certain types of treatments (^{Mukherjee, 2010}). Understanding the functioning and effects of metaphors can help maximize their benefits and minimize their costs (^{Hauser & Schwarz, 2015}). Furthermore, it is recommended that research focus on the inferences people draw from metaphorical language to ensure that it does not undermine public health or science efforts (^{Landau et al., 2018}).

Some researchers caution that using metaphors in the medical field may not consistently encourage behaviors in patients that reduce the risk of disease (^{Hauser et al., 2017}; ^{Mukherjee, 2010}; ^{Sontag, 1978}). Even persuasive use can be inert and sometimes counterproductive (^{Kövecses, 2010}). For instance, military metaphors about cancer emphasizing its aggressive nature have been observed to make patients less motivated to adopt self-management behaviors (^{Hauser & Schwarz, 2015}). Additionally, some studies found that metaphors did not elicit more concern or stronger intentions than literal messages (^{Landau et al., 2018}). Explanations for these effects include the nature of the metaphors employed and the type of individuals with whom they were used. It could be that certain types of people may be more susceptible to the metaphorical effect. (^{Fetterman et al., 2016}; ^{Ottati et al., 1999})

Metaphors can not only generate misunderstandings and communication problems between doctors and patients but, despite their initial impact and persuasiveness, they may experience a decline in effectiveness over time. This phenomenon is attributed to what is described as “cultural shrinkage and atrophy.” (^{Bleakley, 2017}, p. 218) Over the years, these metaphors can become inoffensive, predictable, and meaningless due to changes in the context in which they originated or simply due to overuse. Moreover, when used in different contexts, metaphors can lead to misunderstandings and difficulties in memorization, highlighting the importance of using them sensibly and thoughtfully in persuasive communication (^{Masukume & Zumla, 2012}).

An example: The COVID metaphors

Diseases are often associated with invisible or invading enemies, and treatments are likened to fierce battles. These and other images serve to express the frustrating experience of pain, the individual and collective challenges that a treatment may require, and the impacts that a disease may cause among the people involved. However, metaphors do not always aid in making both the tangible and intangible aspects of a disease more intelligible; in some cases, metaphors can also contribute to misunderstandings.

The COVID-19 pandemic was not an exception. In many countries of the world, due to the thousands of deaths caused by the contagion, metaphors about COVID have multiplied. Among the most prevalent metaphors are: “enemy,” “alien invader,” “fire,” “killer,” (^{Crespo-Fernández, 2021}; ^{Semino, 2021}; ^{Todorova, 2021}) “flood,” “marathon,” (^{Brugman et al., 2022}) “spiritual inoculation,” “acting like a hedgehog,” “glitter,” (^{Pérez-Sobrino et al., 2022}) “tanker,” “green shoot,” “storm,” (^{Garzone, 2021}) “lion,” “dragon,” “Israeli soldier,” “the via dolorosa,” “the cross,” “illegitimate son,” “king kong,” “bull,” “long dark tunnel,” (^{Abdel-Raheem, 2023})⁷ “monster storm,” “disaster,” (^{Lahlou and Rahim, 2022}) “attack,” “fight, “battle,” “hit,” “catch,” “burden,” “wave,” “earthquake.” (^{Rasool, Jan, & Noreen, 2021}) There was also prevalent talk of a “battle of humanity,” of a “fight against darkness,” of “trenches in hospitals,” of “heroes winning a battle” or “heroes on the front line”⁸ (^{Bartilotti, 2021}; ^{Cassandro, 2020}; ^{Charteris-Black, 2021}; ^{Costa, 2020}; ^{Musu, 2020}; ^{Semino, 2021}; ^{Xu, 2023}).

The authors have categorized metaphors in various source domains, including recurrent categories such as “the journey,” “natural phenomenon,” “person,” “game,” and “war.” (^{Pérez-Sobrino et al., 2022}, p. 137) These metaphors offer unique dimensions and perspectives on the pandemic and its effects, enriching our understanding without contributing to increased anxiety and pessimism. Despite intentionality, metaphors are expressions of knowledge (^{van Dijk, 2014}) closely linked to their originating and usage contexts. Therefore, it is crucial to consider both the individuals who propagate them and the contexts in which they circulate, as metaphors serve as models for understanding reality and the challenges they address (^{Abdel-Raheem, 2023}). The diversity of contexts implies many sources for metaphor generation, suggesting that metaphors are not static or predefined but continually evolve and adapt.

During the COVID-19 pandemic, metaphors serve various purposes. Firstly, they aim to instill courage in the population, acting as a moral incentive. Metaphorical discourse evokes emotions and values like hope, resilience, self-efficacy, solidarity, and care. Secondly, metaphors inform about the seriousness of the issue, warning citizens about the danger and magnitude of the virus, sometimes through exaggeration. Thirdly, they justify the measures taken. Political leaders, health authorities, and opinion leaders use metaphors to legitimize imposed rules and maintain a positive public image regarding their responsibilities (^{Castro Seixas, 2021}; ^{Crespo-Fernández, 2021}).

These predominantly military metaphors highlight several characteristics of the pandemic: its overwhelming and threatening nature, health workers’ collective and delicate efforts, and the urgency of an adequate and determined individual and collective response. Labeling COVID-19 as a war paints a dramatic picture resembling an armed conflict, where prevention actions become weapons, health professionals are likened to the military, and political leaders are portrayed as generals or war strategists, with hospitals serving as trenches. This metaphor invites the population of each country to unite against a common and invisible enemy. However, war metaphors can evoke feelings of co-responsibility and cohesion, as well as anxiety, discord, and uncertainty (^{Lahlou & Rahim, 2022}).

War metaphors, moreover, foster the need for a massive and determined mobilization against the virus, positioning health professionals at the forefront and depicting medicines and care as powerful weapons. These metaphors also evoke a sense of urgency and inevitability; thus, the call to combat the virus seeks to minimize the number of lives lost, interpreting them as collateral damage or casualties akin to military casualties. Similarly, they convey the binary idea of a defending “us” that must move to the front and an enemy that must be attacked with all available forces.

Why are military metaphors so effective and widespread in the medical field? War metaphors are ubiquitous because they rely on “a basic and widely shared schematic knowledge that efficiently structures our ability to reason and communicate about various situations, expressing an urgent and negatively courageous emotional tone that captures attention and motivates action.” (^{Flusberg et al., 2018}) However, both elements are debatable, as most metaphors possess these qualities. Their basic structure generally enables memorability and the identification links they suggest while generating a reaction that can easily motivate action or attention. So, the question arises: Why might war metaphors be more effective than others?

The answer may lie in the argument put forth by ^{Flusberg, Matlock, and Thibodeau (2018}, p. 4), who contend that metaphors are effective when they meet three requirements: (a) the source domain recalls a relevant knowledge (or feeling) structure; (b) this knowledge is well known to speakers in the linguistic community; and (c) the comparison of the target with the source domain is appropriate in a given culture. These three criteria highlight the effectiveness of war metaphors, particularly in their relation to language and culture. In this sense, the figure of war becomes powerful firstly because battles generally have a strong basis in people's understanding and sensibility, secondly because they are a diffuse truth in most cultures, and thirdly because, despite having detractors and supporters, this subject always generates a particular responsiveness.

Research indicates that war metaphors used in the health field quickly attract financial resources for scientific innovation, vaccine investment, or medical treatments (^{Hartmann-Mahmud, 2002}; ^{Nie et al., 2016}). These images emotionally impact public opinion and decision-makers, prompting governments, international organizations, and philanthropists to act swiftly.

While metaphors are powerful tools for conveying ideas and feelings, effectively prompting action, we must recognize that they can also have limitations and risks, one of which is simplification (^{Amón, 2020}; ^{Cassandro, 2020}; ^{Elie, 2020}). By emphasizing particular characteristics, metaphors can lead to a biased or fragmented interpretation of reality, often reducing complex concepts to make them more easily understandable. For this reason, it is essential to analyze the cultural context and the circumstances in which they are used (^{Flusberg et al., 2018}; ^{Gibbs, 1999}, ²⁰¹¹).

However, such metaphors may have drawbacks at the individual level. Specific individuals facing diseases may experience feelings of guilt or defeat when their health does not improve, or medical treatment fails to produce the expected results (^{Semino and Demjén, 2016}; ^{Sontag, 1978}). In the context of a long-term disease or a pandemic, invoking such metaphors may be counterproductive, especially when it remains uncertain whether the battle can be won (^{Flusberg et al., 2018}). Additionally, some experimental research suggests that certain war metaphors may diminish individuals’ sense of individual responsibility, as they may hold the government accountable instead (^{Benzi & Novarese, 2022}).

Many war metaphors promote a positive view of political actors. Notions of sacrifice, honor, and heroism contribute to legitimizing disproportionate authoritarian measures and maintaining their power (^{Crespo-Fernández, 2021}; ^{Garzone, 2021}). Some governments, such as those led by Donald Trump and Boris Johnson, extensively utilize war metaphors for programmatic purposes, employing them as disciplinary devices (Garzone, 2021; ^{Todorova, 2021}). This becomes problematic when it divides the population into factions of winners and losers, masking and dispersing government responsibility (^{Benzi & Novarese, 2022}).

The use and effect of medical metaphors, particularly war metaphors, are not unidirectional. Some authors have shown that during COVID-19, war metaphors were effective primarily on individuals who declared support for right-wing political positions (^{Panzeri & Domaneschi, 2021}). This suggests that the impact of war metaphorical discourse varies among individuals and contexts. Individual reactions are also influenced by beliefs and attitudes toward the sources of dominance embedded in the metaphors (^{Brugman et al., 2022}). For instance, soldier metaphors may resonate with those with little fear of military presence and intervention. Still, they may be inappropriate for individuals for whom the military's presence is a constant threat. Therefore, caution is warranted when using these metaphors. Politicians and opinion leaders can manipulate us through war metaphors, influencing our attitudes or opinions during health crises. However, assuming the full effectiveness of such metaphors without evidence can also lead to misconceptions (^{Benzi & Novarese, 2022}).

The refusal to use Metaphors.

Many studies from critical anthropology tend to disregard disease metaphors, primarily focusing on the political-structural aspects of these phenomena. Symbolic representations, practices, and cultural meanings that human groups use to explain and cope with disease are often neglected. This type of analysis overlooks both subjectivity and other aspects of individual character. Although some cultural aspects are occasionally considered, they are typically relegated to macro-sociological research, often deemed merely anecdotal. By exclusively concentrating on the economic and political forces that constrain the lives of entire populations and individuals, we overlook that most social science theories and concepts are laden with metaphors. Categories such as the social body, network, and biosocial are just a small example of this common usage (^{Tootle et al., 2015}). Given our linguistic and epistemological limitations in addressing the relations between the world and everyone, between what we call objective and subjective, metaphors not only evidence this precariousness and disconnection but also serve as a means for our knowledge and language to describe and explain what is happening in society, in our history, and each of our bodies.

Susan ^{Sontag (1978}, ¹⁹⁸⁹) is among the researchers who have sharply criticized the use of metaphors in the medical field. She emphasizes that all diseases have a material and objective dimension expressed in the body through signs and symptoms. Additionally, all diseases have a “double” that manifests itself in cultural representations, particularly in metaphors, as an attempt to understand and cope with something that appears absurd and tragic. However, instead of providing relief or a solution, this "double" ends up reproducing stigmas and prejudices, generating more pain, fear, and exclusion in patients.

^{Nancy Sheper-Hugues and Margareth Lock (1986)} criticize Sontag’s work in which she advocates for a “de-poeticization and de-metaphorization of disease.” They argue that not employing these resources would not only mean, in the medical field but at the level of all human experience, the acceptance of crude materialism that would entail the medicalization and reification of human misery or a form of “self-alienation or false consciousness.” (^{Taussig, 1980}) Although numerous scholars agree on the need to eliminate metaphors, our minds depend on them; thus, we cannot escape them (^{Lakoff & Johnson, 2008}). We use them to understand suffering and disease. These alternatives are problematic because, firstly, metaphorical discourse is part of our way of understanding the world. Secondly, these processes of interpretation generally come from various sources, follow paths that are difficult to control, and often stem from very intense and personal human experiences.

Instead, we could take this “double” or “other” of diseases seriously (^{Scheper-Hughes & Lock, 1986}). If both diseases-illness and metaphors are social constructions, the duty of the researcher should be to describe their production, the interests at stake, who benefits from them, how they are reproduced and perpetuated, and what effects they have on society and on the experience of those who suffer from diseases. By proceeding in this way, the influence of metaphors on the perception and treatment of disease and the stigmatization or dehumanization of those who experience it could be uncovered, exposing the power relations that influence health policies and medical practices that reflect their use.

Three proposals.

Metaphors offer something to think about, talk about, and work with. (^{Flusberg et al., 2018}) In this sense, I propose to explore three elements to unravel their meaning at political, cultural, and ethical levels.

Conclusion

This article has delved into the significance and utility of metaphors as cognitive tools and drivers of action. It has particularly emphasized the role of metaphorical discourse within the realm of health. The exploration has highlighted that metaphors extend beyond mere linguistic expressions and are inseparable from our cognitive processes and daily experiences. Their constructive and detrimental impact in the medical domain is unmistakable. Metaphors play a pivotal role in shaping the perceptions, experiences, communication, and coping strategies related to diseases for healthcare professionals and patients.

This reflection, inspired by Scheper-Hughes’ story, puts forward three propositions to unravel the meaning and function of metaphors at the political, cultural, and ethical levels. From a political perspective, metaphors are scrutinized for their influence on shaping perceptions and decisions in the public sphere, particularly in normalizing inequalities within the health domain and legitimizing the taxonomies that govern this space. From a cultural standpoint, metaphors are seen as cultural sediments, reflecting alternative ontologies and diverse worldviews concerning health and disease. This provides a means to challenge the dominance of biomedical knowledge and offers alternative perspectives on social issues that are often narrowly medicalized. Finally, from an ethical vantage point, metaphors prompt an examination of the moral implications embedded in the narratives they construct, raising questions about their contribution to justice and equity in decision-making and the formulation of social policies. Exploring these three dimensions enhances our understanding of the intricate interplay between language, cognition, and the lived experience of diseases and suffering, facilitating the development of more holistic health approaches.