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On 1st February 2010 the writer Terry Pratchett, author of what he self-mockingly referred to as ‘inexplicably popular fantasy novels’, gave the 34th Richard Dimbleby Lecture. Somewhat grimly yet playfully titled Shaking Hands with Death, Pratchett’s talk offered a touching and witty insight into living, as a writer, with Alzheimer’s (Pratchett had a rare strain of the disease known as Posterior Cortical Atrophy, which first manifested itself in difficulties accurately touch-typing), and set out a considered case for the right to choose, what he called, 'a good death'. I didn’t catch the original broadcast back in 2010, but read the script of the lecture much later, when it was first published in 2015. It made for wonderful reading.

But it was neither Pratchett’s account of his adjusting to life with PCA, nor his acute philosophical musings on assisted dying (memorable as these both were) that were, for me, the most interesting aspects of his talk. What caught my attention above all else, and has stayed with me since, was, very simply, the reason he gave for agreeing to deliver the lecture in the first place.

Prior to becoming a best-selling novelist, Pratchett was a newspaper reporter and, like many other reporters at that time, was an admirer of the pre-eminent journalist Richard Dimbleby. When Dimbleby died of cancer in 1965, Pratchett was struck by the candidness with which the journalist’s cause of death was announced in the British press. In those days ‘cancer’ was a forbidden word around which obituary writers fearfully tiptoed, preferring instead the vague and euphemistic expression ‘long illness’. The effect which this bold departure from linguistic convention had on public discourse, Pratchett recounted, was astonishing, and thereafter, spurred by this new verbal candour, the war on cancer began in earnest. ‘Before you can kill the monster,’ Pratchett opined, ‘you have to say its name.’ 

Respecting dementia, I fear that we are, linguistically at least, still stuck in a kind of benighted pre-Dimbleby era. Peruse any recent newspaper obituary, for example, and I suspect you’ll be hard pressed to find any explicit mention of dementia, regardless of the significance of its impact on the life of the deceased. Shortly after the death of Margaret Thatcher in 2013, I read as many obituaries as I could lay my hands on and, as far as I recall, not one of them discussed her having dementia. It was as though any mention of the disease would have been in some way incommensurate with a relevant and proper appraisal (positive or otherwise) of her life and legacy.

Another linguistic parallel between cancer and dementia is the way the two are described metaphorically. But here, as we shall see, dementia is by no means figuratively lagging behind in the 1960s. Metaphor (which literally means a carrying over, a transfer) relates to the process of describing one thing in terms of another: Juliet is the sun; he drowned in a sea of grief; all the world’s a stage; the rain came bulleting down, and so on.

In a marvellous and highly influential book, Metaphors We Live By, George Lakoff and Mark Johnson argue that metaphor is not simply some form of linguistic garnish – a poetic flourish designed to embellish an otherwise unremarkable stretch of discourse. Rather, they claim that metaphor is a means of seeing and making sense of the world, and hence something much more fundamental to human perception and experience than we have previously allowed for. We use metaphors all the time, often without realising that we are doing so. One of the most common kinds of trope depicts life as a journey, a metaphor which is realized in a variety of common expressions: We’ll cross that bridge when we come to it; there are a number of paths open to you; the baby has arrived! In fact, metaphor is so common in everyday language (not just literary discourse) that almost everything we say is in some underlying sense figurative. 

Metaphor certainly pervades the language of disease and medicine, particularly figures of speech that relate to war and warfare, although, here again, we might not readily apprehend their metaphorical essence. For example, terms such as heart attack and casualty (as in casualty department), and talk of wiping out disease and treating it aggressively, are so common as to have become almost unnoticeably conventional. Yet construing disease in martial terms, however conventionally, has its benefits. It allies patients and health practitioners against a common ‘enemy’ and can confer a sense of agency in a time of doubt and helplessness (feelings which are understandably common in serious illness).

Military metaphors also feature prominently in the promotional rhetoric of health charities and public health campaigns. One can see why. Such tropes are characteristically vivid and attention-grabbing and hence able to help raise the profile of a particular disease. Any mention of fighting disease, moreover, encodes the prospect of victory. In the case of cancer, with treatments (‘arms’?) becoming increasingly effective, and more and more people surviving (or indeed ‘beating’) the disease, the martial metaphor is, for some people, appropriate and effective: it can inspire genuine hope of personal recovery, the discovery of a cure, and stimulate charitable action.

But any talk of waging war on disease also intimates, of course, the possibility of defeat – of being ‘beaten’ by disease. And this is why conceiving dementia in military terms is, I think, inherently problematic. There is presently no cure for dementia (whatever the variant of this complex, multiform disease) and thus to 'fight' it is a potentially inaccurate and misleading form of representation, and one that has certain (negative) consequences. For how exactly does one fight a disease for which, unlike other serious diseases such as cancer, there is no effective and readily available treatment? Should people with dementia be encouraged to fight? Are they always well-placed to do so? And what is it to speak of people who have, as it were, ‘lost’ to the disease – does this entail construing them as somehow or in some way having failed?

I think that talk around health and illness has suffered for too long from ‘combat metaphor fatigue’. So here’s a rallying cry (a sporting rather than military one, I hasten to add): it is time for new metaphors – time for less aggressive and absolute ways of describing dementia and the experience of living with it. We need tropes that, in the words of the great Tom Kitwood, promote ‘personhood’ and living well with, rather than struggling against, the disease.  Changing the way we talk about dementia is not simply a token exercise in social etiquette, a means of being polite and respectful (important though this is). It is more fundamental than that. Updating our tropes affords us new, more enlightened, ways of thinking about and making sense of dementia – possibly shedding, in the process, some of the stigma which attends prevailing formulations of the disease. 

Suggestions for further reading 

George Lakoff and Mark Johnson (1980) Metaphors We Live By.

Paul Hodgkin (1985) Medicine is war: and other medical metaphors.