Military language in healthcare
Metaphors are everywhere in communication. They help us make some form of sense of something that may be alien to us. The world of health and healthcare is complex, both to those working within it and those outside it. The military metaphor is an attempt to simplify communication around healthcare, especially in times of crisis. Quite simply, it is when issues of health are described in military language - think the war on cancer, fighting off disease, and healthcare heroes fighting on the front lines. But it has wide ranging implications. From dehumanising people receiving care and enforcing medical hierarchies; to normalising violence stoking the fires of racism - the military metaphor has many negative consequences for healthcare, both intended and unintended.
Militaristic language and rhetoric, and indeed militarism itself, have long been part of healthcare and medicine. Military metaphors in medicine are in the poetry of John Donne (1572 – 1631) and the writings of physician Thomas Sydenham (1624 – 1689), who proclaimed a “murderous array of disease has to be fought against, and the battle is not a battle for the sluggard”. However, this was the exception to the rule. Health and medicine was still discussed in terms of balance, based on humours and fluids within the body. By achieving harmony within these, health was achieved. Later we had Nightingale and Seacole, hailed as the founders of ‘modern’ nursing, rose to fame during the Crimean War (1853 – 1856) (though Seacole, as a British-Jamaican nurse, only received real recognition posthumously, and with great resistance by many Nightingale supporters, some of whom still oppose Seacole’s inclusion as a founder in nursing canon). Of course, nursing existed before Nightingale, with religious orders providing nursing care, providing a distinction between the increasingly powerful role of medicine and the role of nursing. Prior to Seacole, black women were also in nursing roles, with black nurses listed as “employed” (in reality, enslaved, with ‘wages’ going to slave owners) in records from British ships and Caribbean Naval Hospitals in the late 18th and early 19th centuries. Nurses, nursing bodies, the NHS and wider society view nursing as we know it being born with Nightingale and Seacole (though the latter to a far lesser degree). And while not directly linked to the war effort, the change in society and politics duringWW2 helped to pave the way for the NHS. Healthcare has military throughout its history.
Further bolstering military rhetoric in the 20th century were Reagan’s War on Cancer, and the HIV/AIDS crisis. Health professionals and researchers explained the action of disease in military terms, with the immune response fighting pathogens which invade the body. As Susan Sontag explores in her works, Illness and Its Metaphors and AIDS and Its Metaphors, this helped to solidify the military metaphor in healthcare. And as a nation was called to war, people became soldiers themselves in the fights against illness - either emerging victorious, or losing their battle, defeated. With illnesses framed as invaders that must be repelled, we can see how the military metaphor can demonise individuals and communities. In the context of heavily stigmatised diseases like HIV/AIDS, the military metaphor has helped to normalise this stigma throughout recent decades. The people who caught HIV, those that lost their lives, were held responsible for its spread, enabling an invasive force. With widespread racism, homophobia and classism, they were seen as not victims or worthy of care, but as something hostile.
Locating the individual within conflict
Sontag’s work highlights the implications for people described through military metaphor. How do we conceptualise the individual when our focus is on eliminating a disease? And what say does the individual have in what treatment and care they receive? There are alternative explanations.
Foucault’s description of the medical gaze helps us understand how the individual is viewed by medicine. Illness locates itself within the body, clinicians attempt to limit its spread, or hold, or to expel it completely. Advances in medical engineering mean that people are increasingly “transparent” in the medical gaze. as their bodies are viewed through X-ray, MRI, blood tests, et cetera. People are reduced to the datasets in which diseases are mapped, targeted, eradicated, or, in defeat, found to be too great in size or aggression. People cease to be people, but instead battlefields where the war against disease is waged.
Perhaps, the person can be seen as caught in the crossfire, and any damage caused to them - whether unintentional iatrogenic harm or damaging expecting side effects, is acceptable collateral in the fight against disease. This may apply particularly to people detained under the Mental Health Act, prescribed and forcibly administered medications against their will, which are often damaging to physical health. This is of course not to take away from the real benefit that some people experience from medication - indeed, many individuals attribute their wellbeing, in part or in full, to psychotropic medication given against their will while detained. In the military metaphor, this damage is presented as acceptable collateral to defeat a primary target - the disease, rather than considering the person as a whole. In doing so it reduces their agency in their own experience of health, and their own desires and perspectives are made secondary.
However, the military metaphor can also present people as active agents, locating them as combatants. Cancer care is one of the most widely examined areas for thinking on the military metaphor. With cancer being the enemy, the patient is the soldier themselves, whose fight against cancer will result in two possible outcomes: victory, or defeat. This call to arms can be demoralising for people, and cause anxiety, trepidation and fear. No one wants to go to battle, and I imagine the average person would not expect themselves to be combat ready nor combat proficient. Is a battle with an illness something that we expect to win?
In all conceptualisations of the military metaphor, biomedicine is the primary modality. It reduces the individual to being forcibly located in the battle between medicine and disease. There is little room for holistic discussion of health - of emotions, of meaning, of spirituality, of relationships. The person’s own narrative and story is reduced to the success or failure of medical intervention and disease.
Covid-19, Wartime Leaders and Healthcare Heroes
Faced with a new global health emergency in Covid-19, we again employed the military metaphor. Across the world, leaders declared war on the disease. Boris Johnson must have been relishing the prospect of now positioning himself as a wartime leader, tasking himself with the biggest challenge a prime minister has faced since WW2 and his hero, Winston Churchill. And so came the outpour of WW2 imagery from the Tory government and its ideologues. Matt Hancock evoked the Spirit of the Blitz, calling on the nation to put in a national effort just like their grandparents before them. Healthcare heroes were described fighting in the trenches against Covid-19. Even at the start of 2022, Johnson has made public his desire for the NHS to be on a “war footing”, achieved through calling up reserves and volunteers.
What purpose does this evocation serve? Perhaps it was a genuine attempt to rally a nation to the severity of the issue at hand. Maybe it was an attempt to bring the nation together, to call for differences to be put aside, and for all to share in the common sacrifice. This was done effectively in some countries. Vietnam, hailed by much of the media and the left, but carefully ignored by many Western governments, took a very strong approach to lockdowns, and deaths were low. Military metaphor was centre-piece to their response, and was cited as key to building a sense of nationhood and identity. Given Vietnam’s history of resisting imperial invasion, national propaganda campaigns portraying the virus as an invader helped to build a sense of national pride and resilience against the disease, alongside clear and consistent health messaging. Independent research found it worked - 94% of people trusted Vietnam’s response to Covid-19. Their deployment of military metaphor was focused and consistent. Crucially, their rhetoric matched their outcomes.
Despite Vietnam’s success, there is evidence that comparing public health crises to military conflict can create undue
pessimism in public opinion. Given what would be an, at times, lackadaisical, at others, treacherous, and, overall, downright disastrous response from the UK and devolved parliaments to Covid, perhaps that pessimism was justified. Rather than bringing the nation together in shared sacrifice, Tory ministers and the Prime Minister partied, potentially, and likely, breaking their own rules. Clearly, military metaphors were not being used as a genuine attempt to bring the nation together in shared sacrifice.
The use of the military metaphor also helped to strip the debate over the Covid-19 response of nuance and context. It set up NHS workers as healthcare heroes whose deaths, while unfortunate, were justifiable in the nation’s response to Covid-19. While many felt a sense of duty, it is not what we signed up for. Healthcare workers are workers, and workers are entitled to protections. The lack of PPE, the lack of proper strategy and containment, placed workers at risk. This risk was fatal.
The government’s own insistence on healthcare heroes was challenged by healthcare staff, who demanded fair pay, fair protections and that the government stop gaslighting them with praise and Thursday night claps, after years of austerity which increased waiting times and damaged the health of the nation. By using the military metaphor, the government and media sought to normalise the state of crisis in the NHS, as part of a necessary struggle, of which little could be done. There are stressors inherent to healthcare, but the majority of difficulties faced by healthcare workers are the result of political decisions - decisions on funding, staffing and policy. Staff working 24 hours because of shortages. Teams relying on bank staff overtime to fill their rotas each week, and then being stuck if they cancel last minute. Cleaners, security staff and porters being forced to strike - successfully - just to be paid same as direct NHS employed counterparts. These are not stressors inherent in healthcare. Importantly, increasing funding and pay are crucial to fixing these issues. But, as healthcare heroes, it reinforces the idea that healthcare is a job of duty, one that is done based on the personal qualities of the individuals rather than for a fair wage for a fair day’s work. Like all of our key worker colleagues, from bin workers to posties to delivery drivers, we did not sign up for this. We signed up to work.
Further helping to justify the dire situation was that it became increasingly clear that the objective of the war was not to eradicate Covid-19 from the country and to minimise infection rates. The objective of the war quickly became preventing Covid-19 from impacting the economy for too long. Deaths became acceptable if the economy was opening up. While prolonged economic and societal damage would be harmful to the nation’s health and wellbeing - take the increase in mental health referrals as an example - the government had made the decision when refusing to lockdown early, that vulnerable people were second-class citizens, and risking their health to justify their victory marker - re-opening of the economy and return to ‘normality’. Odd, perhaps, given that WW2 helped to create one of the biggest societal upheavals and redistributions of wealth the UK has seen. Selective memories, perhaps.
Racism, Invaders and the Hostile Environment
The founding principle of the NHS is free healthcare for all, free at the point of access. Within a few years of its founding,
this was already subject to restrictions, with free glasses and dentures being stopped. One example is reports of people ordering several sets of dentures for upcoming weddings, as the state of the nation’s teeth was so poor. Supply could not meet demand. Since its inception, there have been debates, often highly polarised, about what should be included on the NHS taxpayer bill.
Racists and anti-migrant forces have used this area of contention to fan flames of racism, claiming the NHS is overrun by immigrants and asylum seekers. While obviously factually incorrect, the NHS itself would collapse without the input of migrant workers. Many asylum seekers and refugees themselves take up positions in the NHS. Successive Tory governments have used this to help justify the creeping of the hostile environment into healthcare services. Healthcare workers are now expected to check entitlement to care. This has led to thousands of people being wrongly turned away from treatment, many with life-threatening conditions, despite guidance that no one should be turned away if they cannot pay if they require urgent or immediate treatment. Asylum seekers have regularly been charged when they were entitled to free care.
The military metaphor is relevant to this because it frames healthcare as a battle, in which resources must be conserved to protect one’s own and achieve the objective. As such, people seen as “alien” - ie, non-white, are seen as not worthy of resources. Note that there are far less who are calling for Ukrainian refugees to be paying for NHS services than other people fleeing conflict. They become detrimental to the nation’s war effort against disease.
With Covid–19, racist hate crimes and abuse against South Asian people and communities increased, aided by Trumpian rhetoric about a “Chinese” virus. People were verbally abused, intimated and physically assaulted to the point of hospitalisation. The Government were painfully silent on the issue and did not do enough to stem what was a predictable rise in xenophobia. Just as racism and homophobia blamed black and LGBT people for ‘spreading’ ‘invasive’ HIV during the AIDS crisis, Asian people were held by racists as being responsible for Covid-19 invading the UK. By framing the debate through the military metaphor, it enables this type of thinking by posing the issue as a nation not being responsible for its own poor Covid-19 response, but instead appropriating the blame on a foreign actor. A nurse going to work in the very system where she was held as a healthcare hero by the Government,was assaulted by racists for being Asian.
This racism was not reserved for the wider public. We know there was a disproportionate number of deaths for BME staff. Inside the NHS, the recent Nursing Narratives report is just one of many papers and research projects highlighting the endemic racism faced by black and minority ethnic (BME) staff which contributed to the death rate. Black nurses report disproportionately being sent to high-risk Covid-19 red zones. In some units, only black and brown nurses were being reallocated to Covid-19 wards. Staff reported being threatened with being fired and losing their work visas if they are refused. One black agency nurse found her contract terminated for questioning discriminatory procedures over the distribution of PPE. This was not new, but a continuation and exacerbation of widespread culture and systemic racism within the NHS.
Moving forward - telling it as it is?
How do we move forward? Sontag advocated ditching metaphorical thinking entirely. Her critique of metaphorical communication in healthcare found that it stopped seeing disease for what it was - disease. But is this helpful, or even possible? Disease is not just disease. What is important is how it impacts an individual - whether that is their body and their actual physical health, or their sense of purpose and their social functioning. Metaphorical thinking is fundamental to human communication.
After war, comes peace. A possible solution is to change violent and combative military terms to the language of peace-making. This is already commonplace - people ‘living with’ cancer as opposed to in a battle with it. By focusing on acceptance, tolerance, and understanding, it can help foster realistic expectations, and build optimism in quality of life while experiencing illness or disease. The fight does not need to be won or lost - but we need to live out the rest of our lives in a peace that is acceptable to us. Some have advocated for the journey metaphor, popular in Sub-Saharan Africa, and now increasingly used in Westernised healthcare, which, similar to the peace-making metaphor, focuses on the experience of ill-health. How did we get here? How do we move forward? Rather than fighting an illness, we talk about our health journey.
And while metaphorical language helps us to communicate - not every aspect of healthcare requires it. By demystifying what healthcare workers do, being open about how we deliver care, how we work in compassion, and crucially, how stressors and poor conditions within healthcare are not inherent to healthcare itself but political decisions, healthcare workers can show that we are not heroes We are normal people, doing a normal job.
One of my lecturers of mental health nursing was very fond of quoting Orwell’s seminal Politics and the English Language - “but if thought corrupts language, language can also corrupt thought”. I don’t think the class considered this as much as he hoped, and I hope that is me being over-cynical. But, just as Orwell lambasted the function of automatic and non-critical use of language in enabling oppression, the military metaphor helps to normalise, reinforce and promote a healthcare model we proclaim to have moved beyond. It is one of violence, of medical, and without care nor comparison. It is time we defeated the military metaphor, and made peace with a new rhetoric.