Thank you

I’m so touched by the emails in response to my last in the FT: I will reply to each one (just back from a September weekend in wild woods, no batteries on iphone) over the next few days. In the meantime, here’s a quickie from the Times today about risks and benefits of aspirin (or is it behind a paywall?) and a reprint of the battle metaphor column which some people want to see again.

The war on illness – whose battle is it anyway?

By Margaret McCartney

Published: November 10 2006 19:45 | Last updated: November 10 2006 19:45

We’ve had the war on terror, the war on drugs and the war on anti-social behaviour. Read the obituaries or death notices, however, and it is clear there is another, rather more subtle war going on.

This is the war on illness. People die after a long “fight” with cancer. Or they lose the “battle” against leukaemia. Illness is discussed in these and many other military terms. “Fighting spirit” is something ill people need copious stocks of, ready to draw on, should they be tired, fatigued or war-worn. They “struggle” against death, draw up “battle plans” and mount their “resistance”. And they must never “give up”. There are educational groups for cancer patients called “Fighting Spirit” and treatments are described as “magic bullets”. Patients want to “beat” illness. Doctors talk of “targeting” therapy.

I loathe the military analogy and not just because it is ubiquitous. It also places a peculiar strain on people. Got sick in the first place? Well, she didn’t exercise very much. She didn’t really fight it. A relapse? Well, he just gave up, turned his back to the wall. Someone has died? Well, she did her best. She battled right to the very end.

There are things we can do to exert some control over our health. But non-smokers can get lung cancer, teetotallers can get liver disease, young fit women can get multiple sclerosis. Not smoking, exercising regularly, eating a varied Mediterranean diet and keeping our weight reasonable – these things have an impact. But where you were born, your social class, your education and your genes also have large implications for your health. And bad luck happens too.

The desire to think that our health might be within our total control is a mistake. Logically, it is just a small step from there to believing that bad health only comes to those who deserve it. So when we “battle” against cancer, it is almost as though there is some fault in our morality that must be compensated for. And unless we now show fortitude and courage, we deserve to die. This is not true, of course.

Is there room for any other way of thinking about how we face serious illness? I prefer the analogy with a journey: one where it’s OK to take companions and make detours; where there are decisions to be made about routes and speed and where people help to carry your bags. Roads intersect as well as broaden and wind and it’s fine to rest a while. As one person diagnosed with cancer told their doctor: “There is not much you can do about the length of your life but you can make it wider and deeper.” And this, as their oncologist remarked, is “a wonderful thought”.

Anyway, it seems that a large dose of fighting spirit is overrated. And several studies show that it doesn’t protect people against cancer recurrences either. A large study from the Royal Marsden Hospital last year found that “longer follow-up [study] also indicates that a high fighting spirit confers no survival advantage”.

This means that people who don’t have much fighting spirit can stop feeling guilty about it and that the terrible situation where a death is followed by a family’s belief that they, or even the patient, somehow “didn’t do enough” can be dismissed. Though what we know logically and what we feel emotionally can be two distinct things.

It isn’t simply the urge to find and apportion blame that the war analogy leads to. Battles involve brutality, not care and compassion and tenderness. On the battlefield of illness, we are so afraid of what will happen if we stop fighting that we often lose sight of what we are fighting for. Is another round of chemotherapy going to be worth it? Would it be better next time, rather than going in to hospital, to simply be treated with comfort at home? Caught up in battle, there is no room for contemplation or even acceptance. Even an unquestioning faith in “positive thinking” means that fears often don’t find a voice.

In fact, only the brave – to use another “military” analogy – admit how terrified they are. The striking way in which many people can accept the imminence of death is profound and humbling. The war on illness may be culturally embedded but these people are not losers in anyone’s battle.

Further reading

Cancer as metaphor

Fighting Spirit: a psychoeducational group for younger women with breast cancer.

Influence of psychological response on survival in breast cancer: a population-based cohort study.

6 Responses to “Thank you”

  1. Vicky April 13, 2013 at 12:18 am #

    Thanks for this. I’m being treated for breast cancer at the moment. The only time I ever use a phrase like ‘battling cancer’ is when I want an excuse to get my boyfriend to do something I can’t be bothered with. I am not brave. I am not fighting this disease. I am lucky to have great medical care. To imply, however subtly, that someone who dies just wasn’t trying hard enough is shameful.

  2. Bobby April 13, 2013 at 12:33 am #

    When I first saw the title of your post I thought, ‘oh wait, she’s anti-cancer treatment?’ But (thankfully) your blog touches on a certain denial of the nature of illness – masking the true nature with the ‘military’ analogy and as if it is battle after battle on an endless war. The journey and realising that there are ups and down (ie, like life itself) is invaluable.

  3. Shirley Wishart April 13, 2013 at 1:33 am #

    Totally agree. 32 years ago I had bone cancer. I felt different every day, sometimes scared, sometimes positive, manic, fed up, tired, energetic, happy, sad. I hated the think positive lobby. I knew it was ok to face my fears. In the end they removed a bone and I survived – disabled but – what the hell – alive.

  4. Karen Leonard April 13, 2013 at 9:26 am #

    Iam an anaesthetist with an interest in palliative care. I completely agree with you

  5. Stuart December 26, 2013 at 9:01 pm #

    Danny Baker put it well:

    “You are the battleground,” Danny Baker told BBC Radio 4’s Desert Island Discs. “You are the Normandy Beach, you are Hastings in 1066. You don’t fight it. It’s nice if that helps you. You don’t battle it. You’re helpless. Science is fighting it.”

  6. Mike Stewart May 3, 2014 at 10:21 pm #

    I couldn’t agree more. I work as a physiotherapist specialising in persistent pain and see so many people struggling to ‘beat’ their pain. Move away from the battlefield and look for the light at the end of the tunnel. Here are my recent articles about metaphors and pain reconceptualisation: