‘War and Peace’ fighting the ‘invisible enemy’ –healthcare staff as the ‘new model(led) army’ on the front line of COVID-19 conflict
By: David Goldsmith
Tags: Covid 19, Medical, Metaphor, Media

Introduction:

As I review the first four months of the global struggle against COVID-19, sadly not yet at the beginning of the end of this ordeal, but, I hope, at the end of the beginning, one particular feature for me stands out. The militarisation, the arming, and the weaponising of much of the language used in reportage to describe the situation. Previous epidemics or plagues in contemporary chronicles tended to channel a connection with Biblical antecedents, reflecting the largely religiously-derived or nuanced, retributive, lens used by analysts and authors in the past (“black death, scourging angel, Divine retribution”). This practice derived from a strong belief that the plague was indeed Divine retribution for the sins of man, and that humanity could do little about it. Albert Camus (the French existentialist philosopher, author, and journalist, 1913–1960) in his well-known novel ‘The Plague’ (The Plague, New York: Alfred A. Knopf, 1947 pp. 95–6), which is a fictional account of bubonic plague in the town of Oran, in his birth country Algeria, makes such biblical comparison fodder for both irony and sarcasm in this florid, vividly metaphorical passage (said by Father Paneloux):

“If today the plague is in your midst, that is because the hour has struck for taking thought. The just man need have no fear, but the evildoer has good cause to tremble. For plague is the flail of God and the world His threshing-floor, and implacable He will thresh out His harvest until the wheat is separated from the chaff. There will be more chaff than wheat, few chosen of the many called.”

COVID-19 Dashboard from Johns Hopkins — 5th May 2020

Arnold Böcklin’s picture The Plague (1898) — Kunstmuzeum Basel

However, it is clear that, from around March 2020 onwards, in Britain, France, Russia and the United States, there is now a preferred source of metaphor-comparator- descriptor for our current existential challenge of containing and blunting the impact of COVID-19 on both individuals and society — namely conflict, battle, and the hue and cry of war!

This language has been very widely deployed, and, I would argue, abused — by politicians, commentators, much of the Press (both mainstream and on-line media) and even by healthcare workers themselves. I will argue in this paper that such practices are in the end detrimental, to those heroically struggling to save lives, to the wider public in affected countries, and finally to the global community at risk, and thus should now be dropped (nay, de-mobilised) with alacrity.

Cataclysms, catastrophes and calamities:

Threats to economy, prosperity, livelihoods and survival are not uniquely microbiological. The climate crisis, though clearly slower in pace, will provide just as real a threat of global societal collapse if ignored or mishandled. Equally, a major earthquake or tsunami, a nuclear disaster in war or peace (as so nearly seen in Cuba in 1962 or Chernobyl in 1976), a significant meteor strike, or a solar-flare could all create disruption, death, and destruction on a global scale, and considerably faster than this current, lethally-fast, viral scourge has done. First comes the primary shock of the lethality — the impact on the body-corporeal — and then, as the economic poison starts to work its chilling effect to compound the suffering — the impact on the body-politic.

Former single catastrophes such as the terrible flooding in Britain and Holland after a huge storm surge in January 1953, which caused over 2000 people to lose their lives, led to preventive measures (dams, barriers and co-ordinated weather prediction networks) being installed in both countries. The Sri Lankan tsunami of 2004 with the attendant loss of 250,000 lives, led to new global tsunami warning systems — both of these designed for “once in 500 years events”.

Given that typhus, cholera, typhoid, dysentery had wreaked havoc around the globe in the 18th and 19th centuries, in a slightly slower, more stealthy, but just as lethal extent as had natural disasters, it should not be surprising to learn that there were efforts in the 19th century to co-ordinate countries’ responses to epidemics.

Origin and development of international health cooperation: driven by the devastation from epidemic diseases:

International health cooperation began with the first International Sanitary Conference in Paris, which opened on 23 July 1851. The objective of this conference was to harmonise, and reduce to a safe minimum, the conflicting and costly maritime quarantine requirements of different European nations.

Three international sanitary conventions, addressing cholera and other threats, were held in the early 1890s. The conference in Venice in 1897 adopted a new international convention dealing with prevention of the spread of plague. All four of these conventions were consolidated into a single International Sanitary Convention in 1903; it was also agreed in principle that a permanent international health bureau should be established. At that time, the various American republics had already established the International Sanitary Bureau in 1902 in Washington- later renamed the Pan American Sanitary Bureau. At a meeting of government representatives in Rome in 1907 the final decision was taken to establish an Office international d’Hygiène publique (OIHP) in Paris, which was active up to the start of WW1.

After “the War to the end all Wars” and arguably “the Pandemic to end all Pandemics” had finally been extinguished, an exhausted international community had to try to pick up the many pieces and make efforts to prevent further catastrophes of this nature. The war had been concluded by a series of peace treaties out of which The League of Nations was formed in 1920 with the broad aim of preserving international peace and co-operation.

The League of Nations did have a small focus on international health issues through three bodies: the Health Bureau, containing permanent officials of the League; the General Advisory Council or Conference, an executive section consisting of medical experts; and the Health Committee. The main remit was to “endeavour to take steps in matters of international concern for the prevention and control of disease”. The Council focused on ending leprosy, malaria, and yellow fever (all endemic diseases) by starting an international campaign to eradicate mosquitoes. The Health Organisation also worked successfully with the government of the Soviet Union to prevent typhus epidemics, including organising a large education campaign.

As part of the United Nations, formed after WW2, the World Health Organisation (currently bearing the brunt of Trump’s opprobrium) acquired a leadership role in Global Health. For health emergencies, the WHO has specific responsibilities for which it prepares by identifying, mitigating and managing risks — acting to prevent emergencies and support development of tools necessary during outbreaks, to detect and respond to acute health emergencies and to support delivery of essential health services in fragile settings.

Whereas traditional approaches to containing outbreaks were historically defensive: trying to secure borders from the entry of infectious diseases — modern solutions, in addition to the development of new anti-infective drugs and vaccines, should be built on a combination of early warning surveillance systems, epidemic preparedness plans, stockpiles of essential materials, speedy communications and information-sharing (between people, agencies and others). The WHO was in a unique position to coordinate global outbreak alert and responses.

To this end, the Department of Communicable Disease Surveillance and Response (CSR), organised a major international meeting on “Global Outbreak Alert and Response” in Geneva, April 2000. The participants expressed the need for the establishment of a “Global Outbreak Alert and Response Network” and agreed on a series of principles and functions for the network. Much of the impetus for these revolutionary changes came from the Executive Director of the WHO Communicable Diseases Cluster, Dr David Heymann.

But all of this international collaborative achievement is of little utility if, when presented with the key early warning signs of global contagion risk, there is a sluggish global response to the impending danger, meaning that healthcare professionals are exposed to unnecessary and recurring risks, and the spread of the infectious agent risks is only partly checked. The “my nation first, international community second” isolationist approach which has characterised this pandemic smacks of a return to nation-state thinking, shying away from the critical international co-operation and collaboration vitally necessary to contain the virus, and to marshal resources to find new treatments, especially vaccines. The sheer number of vaccine projects underway (over 90), and the vast panoply of candidate drugs under test, by their very number still threatens to derail the pivotal research needed to establish both safety and efficacy of new products –trial statistical “power” mandates larger size of trials, not a vast smörgåsbord of smaller ones.

Saddle up those similes, mount those metaphors — it’s ‘away to the battle we go’ time:

We are described as being in the midst of a “battle”, a “war”, a “fight for survival”. In Britain, second-rate politicians are evoking both the Blitz and the Dunkirk spirit while trying to channel their best inner Churchillian mien. The Dunkirk debacle in 1940, was, we would do well to remember, a semi-organised retreat; Churchill at the time pointed out that you don’t win wars by retreating.

Initial reports of what was emerging from the Wuhan area were mainly distributed through the WHO and were sober and measured in terms of their language. On 31st January 2020 Italy was the first country in Europe to ban travel to China, and declared a state of national emergency (again, in measured language). The first mention of a “military aspect” to this global crisis that I can find are in early March, as the “tsunami” of COVID-19 cases began to overwhelm hospital capacity in Lombardy.

Several examples of recent usage in Britain, France, Italy and the United States clearly display a common approach:

· In Britain, Queen Elizabeth II delivering a rare speech on Apr. 5 said “we will meet again” evoking a Second World War song, and reminding the very elderly of the 1939 children’s evacuation from major cities.

· Again, in Britain, the Herculean task of building a Public Health team of field operatives needed to track, trace and isolate cases was compared to needing an army.

· On March 9, Italian Prime Minister Giuseppe Conte also invoked the Second World War when he used Winston Churchill’s words to talk about Italy’s “darkest hour.”

· President Donald Trump has described himself as a “war-time president,” fighting against an “invisible enemy.”

· In New York, as residents faced the explosion of new cases and casualties, Governor Andrew Cuomo used the war metaphor extensively during a press conference:

o “The soldiers in this fight are our health care professionals. It’s the doctors, it’s the nurses, it’s the people who are working in the hospitals, it’s the aids. They are the soldiers who are fighting this battle for us.”

· The United Nations Secretary-General Antonio Gutiérrez embraced the comparison during his remarks at a G20 virtual summit on the COVID-19 pandemic:

o “We are at war with a virus — and not winning it. …This war needs a war-time plan to fight it.”

· Journalists have also been using the metaphor with abandon. A recent headline in the Globe and Mail read: “We are at war with COVID-19. We need to fight it like a war.”

· “We are at war,” declares French President Emmanuel Macron (probably wisely choosing to channel his inner Prime Minister Clemenceau of 1917 rather than say Maréchal Pétain of 1940).

· “Together we can win the war against COVID-19” declamed Dr. John Nkengasong, Director of Africa Centres for Disease Control and Prevention in April 2020.

· The U.S. government’s invocation last week of the Defense Production Act (DPA), a Cold War law allowing it to prioritise and allocate resources to help expand private industries in strategic sectors, is a step on this road to constructing a larger medical mass-production base.

Spoof of WW2 posters — here for COVID-19

Channelling Kitchener’s famous WW1 poster

Reasons that might explain, or underpin, militaristic linguistic choices in medicine:

Thomas Sydenham, the most famous physician of the 17th century, known as the English Hippocrates (noted for his studies of fevers, fluxes and gout), is often credited with introducing military language into Western medical discourse. Writing in the mid-17th century, Sydenham expounded that a “murderous array of disease has to be fought against, and the battle is not a battle for the sluggard.” His aim was to investigate illness, comprehend its character, and “proceed straight ahead, and in full confidence, towards its annihilation.” Describing his approach to venereal disease, he continued: “I attack the enemy within by means of cathartics and refrigerants.” [Quotes taken from Sydenham, Thomas, and Robert Gordon Latham. The Works of Thomas Sydenham, MD. Printed for the Sydenham Society, 1850.]

The change from mainly passive descriptions of disease (plague “lying upon” sufferers), to a vigorous, virile characterisation of diseases attacking patients comes mostly from Louis Pasteur, the father of vaccination, whose germ theory introduced the concept of invading armies of germs laying siege to the body, and then battle commencing.

Susan Sontag explored at length various linguistic concepts in her seminal 1978 essay “Illness as Metaphor,” which was collected in 1989 with her follow-up essay, “AIDS and Its Metaphors.” Sontag writes extensively of the war-like nature of metaphors used for cancer:

· The controlling metaphors in descriptions of cancer are, in fact, drawn not from economics but from the language of warfare: every physician and every attentive patient is familiar with, if perhaps inured to, this military terminology. Thus, cancer cells do not simply multiply; they are “invasive.” (“Malignant tumors invade even when they grow very slowly,” as one textbook puts it.) Cancer cells “colonize” from the original tumor to far sites in the body, first setting up tiny outposts (“micro-metastases”) whose presence is assumed, though they cannot be detected.

· And that has a warping effect in the “war on cancer,” Sontag wrote: “The bromides of the American cancer establishment, tirelessly hailing the imminent victory over cancer; the professional pessimism of a large number of cancer specialists, talking like battle-weary officers mired down in an interminable colonial war — these are twin distortions in this military rhetoric about cancer.”

The war-time imagery in current vogue around COVID-19 is at least superficially compelling and seems on first examination to have some purpose. It neatly identifies an enemy (the virus), a strategy (“flatten the curve,” and “save the economy”), the front-line warriors (health-care personnel), the home-front (people isolating at home), the traitors and deserters (people breaking the social-distancing rules). Furthermore, it highlights the urgency that underpins drastic policy decisions: the closing of schools, the imposition of travels bans, the grinding to a halt of economies around the world. It appeals to citizens’ sense of duty and obligation to serve in their country’s greatest hour of need.

There is also the obvious involvement, seen in all countries, of military forces for logistical and technical support for healthcare professionals, delivering PPE, building field hospitals, and supplementing others’ relief efforts; we should also remember the potential need for policing and maintaining civil obedience that lurks in the shadows (and may be more evident already in some more authoritarian regimes). And lest we forget, the League of Nations health efforts, and the WHO’s much more comprehensive efforts, all arose from the aftermath of two global wars after which these bodies were established, in a spirit of international collaboration (vide supra).

Have war metaphors been used in previous epidemics and pandemics, or indeed, in other “crisis” settings?:

This is certainly not the first time leaders and policy-makers have used the war metaphor to describe a threat that does not qualify as military. Think the war on poverty, on cancer, on illegal immigration, not to mention the war on drugs or on crime. And President Trump has gleefully made much of his tariff touting as part of his Trade War on China.

Defining the pandemic as war leads inevitably to the necessity of identifying an enemy. Crucially, this struggle against the enemy is not portrayed as an armed struggle. In a concerning element of mission creep, the enemy in 2020 while obviously being the coronavirus, has morphed somewhat into people — those not attuned to the prevailing political messages and instructions (making the phrase “The Enemy Within” pertinent to both political as well as microbiological discussions).

As alluded to in the first section of this paper, the use of military metaphors, and comparisons, is not a prominent feature of previous pandemics, or epidemics. Here below is an extended discussion of the use of metaphors and patriotic symbols, from a wonderful book by Mark Honingsbaum (A History of the Great Influenza Pandemics: Death, Panic and Hysteria, 1830–1920 Bloomsbury Academic Press, London, 2013) which covers the period of the Russian Flu (1888–1893) and the Spanish Flu (1918–1920):

“Another way of influencing emotions was through the manipulation of patriotic symbols and metaphors. These propaganda uses of metaphor are illustrated by the wartime advertisements for Bovril and patent medicines. A blended meat extract, Bovril’s origins date back to the 1870–1 Franco–Prussian war when the Scottish entrepreneur, John Lawson Johnston, won a contract to supply canned meat to French troops during the siege of Paris. From the start, Johnston sought to associate Bovril with ‘strength’ or what he called the ‘vital principle of prime ox beef’. To underscore the supposed vitality of his reduced beef tea, Johnston’s advertisements often juxtaposed jars of Bovril with virile images of lions and bulls [but not cannon or Dreadnoughts]. By WWI, the Bovril bull had become a symbol of national virility, with Bovril sponsoring a series of advertisements showing the bull standing guard outside an army recruiting tent above the copy line ‘British to the backbone’ and ‘Bovril recruits its strength through the power of beef’.

As a peculiarly fatiguing disease that depleted nervous energy, influenza lent itself readily to these somatic metaphors, hence Bovril’s claim that it could ‘prevent influenza and colds by fortifying the system against their attacks’ and that Bovril was ‘liquid life’. The problem was that, in order to sell Bovril as a preventive, the advertisements explicitly traded on consumers’ fears of exogenous pathogens, frequently drawing an analogy between the threat to individual bodies and the threat posed by Germany to the political and social body. In this way they raised the very fears that wartime propaganda was meant to obviate. In advertisement, dating from the German air raids on the east coast of England in 1915, a Zeppelin becomes a metaphor for the various germs waiting to attack stressed civilians. The copy reads, ‘More insidious than hostile aircraft are the enemies that fill the air in the shape of colds, chills and influenza, which are always “hovering to strike” the man or woman who is run down and out of sorts’. Similar contradictions bedevilled wartime advertisements for germicides, tonics, and disinfectants. Thus in an advertisement for the disinfectant Santol that appeared in the Salford Reporter in the early autumn of 1918, readers are warned that ‘the Germs of Influenza and other Diseases Attack at your Unguarded Moments, and only when the Grim Spectre of Illness or the Shadow of the Awful Reaper falls on your home do you realise the Danger’”.

So, looking back over the last few centuries, the use of military comparisons for epidemic or pandemic waves of illness was rare, and really only evident to a limited extent at the very end (April to November 1918) of the Great War, for obvious reasons.

Poster from 1918 Brasil, a trope of Germany being the source of “Spanish” flu as a bioweapon (similar to current concerns over China)

Arguments to support the “militarisation” of COVID-19 discourse:

When faced with a huge, sudden unknown threat, it is normal to make sense of it with reference to what has come before. The deployment of metaphorical language can aid navigation of unfamiliar and frightening challenges by transferring ideas about the known on to the unknown.

War is a concept of rare potency, one that commands universal understanding. It is, of course, important that leaders use this for good rather than ill. But not to use it at all would be potentially to deny ourselves a useful tool — one that might if used judiciously help us come together and prevail against the virus. Used in the right way, some argue that war contextualisation could focus our response to Covid-19. This pandemic has required us to accept huge disruption in the face of a deeply unfamiliar threat. The only comparable experience in (just) living memory is the Second World War; by invoking it leaders could persuade us of the urgency of the crisis, of the lives at stake and of the need for collective sacrifice.

However, war comes loaded with an array of universally explicable feelings and associations. Few ideas have more potency, which is why it can feel cheap when leaders use this idea to sell their policies. The war on drugs, for example, reduced a complex and ill-defined policy into a binary conflict with clear winners and losers — a simplification leading to a distortion. Even positive war references risk being misapplied in certain situations. Still, to say that this pandemic, in which draconian government intervention has safeguarded millions of lives, does not warrant a carefully calibrated comparison to some kind of global warlike mobilisation, does requires some thought, and justification.

Pifalls and Pratfalls inherent in choosing jingoistic linguistics:

Invocations of war don’t have to feel cheap but that depends on the credibility of those using them, and the frequency with which these invocations are made. The Queen, in her broadcast to the nation, compared the trauma of the wartime child evacuees to today, when many, trapped in isolation, are unable to see their relatives. As someone who lived through the Second World War, and is widely respected in the UK (and beyond), she was able to draw out those resonances powerfully. But the speed and frequency with which these jingoistic linguistic tics have been used, and the type of people all too fond of using them, have seriously degraded their effectiveness, in a form of advertising impact tachyphylaxis. This is partly I believe down to the propensity of war language to (col)lapse into cliché all too readily.

In general terms, I believe that by using war metaphors we distort and shuffle definitions, identifications, and categorisations in curious and insidious ways. Our citizenship is now sublimated as we become soldiers in battle. As such, politicians call for obedience rather than awareness and appeal as much if not more to our patriotism, rather than to our solidarity.

And, as we find ourselves at war, we, as soldiers under arms, may be irresistibly drawn to an inward-looking, my-country-first beggar-my-neighbour attitude. Arguments over essential supplies have already erupted, with countries blocking shipments of items like masks and other protective equipment or life-saving ventilators. Within the European Union an initial failure of solidarity has made many suggest that the pandemic might eventually claim another victim: the EU itself.

While highly appealing as a tool of political rhetoric, the war metaphor hides several pitfalls that, in the case of the COVID-19 pandemic, are particularly dangerous and unwelcome. I shall discuss these in turn.

In the case of society, I feel that there are serious dangers in the sweeping generalised centralised powers now contained in the Executive:

· dangerous authoritarian power-grabs, as in Hungary, where Prime Minister Viktor Orbán seized wide-ranging emergency powers and the ability to rule by decree with no time limit.

· in the Philippines President Rodrigo Duterte, in the context of a national emergency bill, gained the right to punish people spreading “false information” about the outbreak, a right that could easily be used to silence political dissent.

· In the United Kingdom, a country with robust democratic institutions, the Coronavirus Bill gave government ministries the power to detain and isolate people, ban public gatherings including protests and shut down ports and airports. Health Secretary Matt Hancock put it this way: “The measures that I have outlined are unprecedented in peacetime. We will fight this virus with everything we have. We are in a war against an invisible killer and we have to do everything we can to stop it.”

The doctors’ dilemma: a battle too far?

In the case of healthcare workers there is a tremendous doctors’ dilemma which faces everyone directly involved or those sitting it out on the side-lines:

The flurry of 2020 headlines about healthcare workers themselves treating people with COVID-19 have chosen to utilise a wide array of military metaphors over the last 2 months: Doctors are fighting on the frontlines without sufficient ammunition. They are battling the enemy. They are at war.

But we healthcare professionals are not at war; we certainly have neither enlisted nor been called-up in this struggle. We are doctors. What we are doing is our job — working extraordinarily hard in difficult and dangerous circumstances to keep our patients alive. While there are obvious similarities between treating an enormous number of patients with a rapidly spreading, potentially fatal virus, and armed conflict against an enemy invader, the differences between these situations are just as, if not more, important.

To adopt a wartime mentality is fundamentally to allow for an “all-bets-are-off, anything-goes” mentality to flourish. And while there may very well be a time for slapdash tactics in the course of weaponised encounters on the physical battlefield, this is never how one should endeavour to practice medicine. Under normal circumstances, such behaviour would bring the healthcare worker to the attention of the appropriate regulatory body overseeing safe practice and standards.

Ominously, in its guidance issued to “returnees” (something that the Cygnus exercise from the Autumn of 2016 in the UK had made clear was the hopeless under-staffing of the NHS under normal conditions, with no reserves, necessitating the “calling-up” of retired doctors under pandemic conditions), the medical regulator, the GMC solemnly warned that while volunteer re-registered doctors would be working under great stress, and in unfamiliar circumstances, that the risk of being accused of negligence and being struck off or prosecuted was just as great it would be under normal conditions.

Especially now doctors and nurses from every specialty have been redeployed in new situations, locations and contexts, with severe attendant risks to their physical and mental health, it is incumbent upon the media to tread lightly with language suggesting that sacrificing either our lives or our careers to this pandemic is now required. Of course, we all want to contain the virus, post haste, and to treat as many as patients as possible. But to do so under the “banner of war” might be seen to imply the necessity of a heedless approach, which approach would leave both doctors and patients open to an indefensible level of risk.

In medicine, emergencies — even pandemics — are never an excuse for shortcuts. If the careful study of, and reflection on, of our own mistakes and oversights (reflective self-analysis being a cornerstone of current medical practice) has taught us anything it is that, even in the most critical of situations, we must confirm the birthdate on every wristband and review every item on the checklist. In day-to-day practice, these procedures may begin to feel redundant and banal, but they keep us from operating on the wrong patient or prescribing the wrong medicine for the wrong patient. In times of crisis such as this, when cortisol and catecholamine levels are super-high, and health care workers are particularly susceptible to distraction and exhaustion, our reliance on basic safety protocols is more important than ever, for both for ourselves, and our patients.

Wartime rhetoric, the kind that pervades nearly every news article about those of us who are involved in the care of COVID-19 patients, calls this logic into question. It makes a desperate appeal to the necessity of chaos. It argues for the inevitability of abandoning the rule of law in exchange for the promise of a swift resolution. In so doing, it sends a precarious if not dishonest message.

Excess deaths in Bergamo, Italy comparing March 2019 with March 2020

The shocking human toll from COVID-19 in March 2020, Lombardy, Italy

Conclusions:

Using militaristic diction to describe doctors’ and nurses’ sense of duty conflates and confuses the reality of our responsibilities. Until a few months ago, those involved in the practice of modern medicine could be reasonably confident that, regardless of the patients’ ailments, the provider was not putting their own life at risk in the process of proffering treatment (although of course, with regard to infectious, communicable diseases, some chance of contagion has always existed, but mitigated by access to PPE).

A wartime mindset demands death, suffering and sacrifice in the service of one’s country. A global pandemic should not demand the same of its medical and extended healthcare workforce. Young doctors who have not yet finished medical school should not feel pressured (but some did) into risking their own lives in response to an illusory promise of martyrdom or glory, or from peer-pressure (shades of August 1914 and legions of fresh-faced young men rushing to enlist to fight in WW1). Older doctors, or those with conditions that put them at greater risk of becoming seriously ill, should be encouraged to stand up for their own needs without fearing any form of “dishonourable discharge” or being denounced as “moral cowards”. In times of war, following orders may mean every single recruit charging ahead, even in sub-optimal conditions, even without proper equipment (as we have seen, with PPE). But applying such a framework to our current situation would do more harm than good. War is inevitably unavoidably dangerous, but danger should never be inherent to the hospital. The loss of well-over 100 healthcare workers to date, the majority of whom were older, and from a BAME background, shows only too clearly that more marching speed can be less healthcare safety.

In medicine, the use of metaphor is pervasive. The words we choose to describe illness can be potent. They carry both weight and valence, creating the milieu in which goals of care are discussed, treatment plans designed, and thus allow some relief from worry and uncertainty, if done in a holistic and intuitive fashion. This while true is only pertinent to the private domain of the “doctor-patient” relationship. Few patients would relish the prospect of fighting, then losing, a battle, feeling guilt for letting their own side down, being scared, or just not being able to fight harder.

When I consider these matters, I do so from the perspectives of four cohorts, but these cohorts are not all of the same importance. First come the patient, carers, family. Second, the doctor, and broader healthcare team. Third, the non-affected public and fourth and finally, the press, politicians and others of their ilk. I feel that these pseudo-aggressive martial medical messages so much in vogue in the latter two cohorts have little or no value for, or locus to, the former two cohorts. Imagine, if you will, knowing that you as a patient or healthcare worker that has COVID-19, that you need to be admitted to hospital. Unimaginable concern, worry, and anxiety are all to be expected. Heedlessly and recklessly then throwing jingoistic linguistic fuel on the fire of patients’ natural fears and dread is both crass and unforgivable.

I believe that such practices are in the end detrimental, to those heroically struggling to save lives, to the wider public in affected countries, and finally to the global communities at risk, and should thus now be dropped with alacrity.

David Goldsmith, Retired Physician and Academic, London, May 2020

5343 words

Bibliography:

(1) https://www.theatlantic.com/health/archive/2014/08/the-trouble-with-medicines-metaphors/374982/

(2) https://blogs.scientificamerican.com/observations/military-metaphors-distort-the-reality-of-covid-19/

(3) https://theconversation.com/war-metaphors-used-for-covid-19-are-compelling-but-also-dangerous-135406

(4) https://www.bbc.com/future/article/20200430-covid-19-what-we-can-learn-from-wartime-efforts

(5) https://aspeniaonline.it/covid-19-at-war-between-metaphor-and-reality/

(6) https://www.theguardian.com/books/2020/apr/16/frontline-is-it-misleading-to-apply-military-metaphors-to-medicine

(7) https://www.alternet.org/2020/04/war-metaphors-used-for-covid-19-are-compelling-but-also-dangerous/

(8) https://rcni.com/nursing-standard/opinion/comment/covid-19-why-we-need-to-ditch-military-terms-160071

(9) https://www.vox.com/culture/2020/4/15/21193679/coronavirus-pandemic-war-metaphor-ecology-microbiome

(10) https://www.project-syndicate.org/commentary/trump-putin-covid19-war-rhetoric-by-nina-l-khrushcheva-2020-04

(11) http://www.historyandpolicy.org/policy-papers/papers/the-real-lessons-of-the-blitz-for-covid-19

(12) Mark Honingsbaum (A History of the Great Influenza Pandemics: Death, Panic and Hysteria, 1830–1920. Bloomsbury Academic Press, London, 2013)

(13) Albert Camus. The Plague, New York: Alfred A. Knopf, 1947

(14) Susan Sontag. Illness as Metaphor and AIDS and Its Metaphors. Picador Press, Macmillan, New York, 2001

(15) Alan Bleakley. Thinking with Metaphors in Medicine: The State of the Art. Routledge (Taylor and Francis), New York and London, 2017