Is cancer a noun, or is it a verb? In other words, is it something we have, or is it something we do? Thirty years ago in his essay titled ‘Culture is a Verb’, the anthropologist Brian Street asked whether it might be more beneficial to see culture as a verb instead of a noun. What he meant was, seeing culture not in terms of what it is, but instead in terms of what it does, and what we do to recreate it, can help us understand the proper nature of culture, that trickiest of concepts to define.
Culture is being constantly recreated by the actions that people in groups perform. ‘It’s the way we do things round here’ is one definition of culture, with a focus on ‘we’ (not ‘you’), ‘do’ (not ‘have’) and ‘round here’ (not ‘over there’). I wonder if we might see cancer in the same way, so rather than seeing it as something people have, it is something that people do. And given that one in two people will get cancer during their lifetime, it’s something we all do, some as carers, some as patients. I think seeing cancer in this way increases agency. If cancer is a noun, it’s very hard to change it; if cancer is a verb, it’s something we do, and we can change our actions to suit our aims. I hope this book will be helpful for those seeking ways of finding the appropriate actions.
Given that this book both draws on and seeks to extend applications of intercultural communication, it’s worth briefly clarifying what I mean by it (and there’s more in the Notes section). We can contrast two different approaches to intercultural communication, the predominant, mainstream approach, and the critical approach. The mainstream approach sees intercultural competence in terms of knowing a lot about other cultures, especially cultural differences with your own culture. ‘In Japan, take your slippers off when you walk on a tatami mat’ – that kind of thing. And such behaviours are often tied to values – ‘That’s because the Japanese are very polite.’ The critical approach takes the opposite view. Rather than seeing the focus on cultural differences and the use of stereotypes to explain behaviour as a solution, it sees the mainstream approach as a problem.
Let me give an example from my own experience. When talking to my wonderful Japanese oncologist ‘Dr Nishi’, I typically saw my identity as a research-engaged patient searching for evidenced answers as most relevant, but he tended to see my British, foreign, identity, and put my behaviour down to that. ‘Oh, you like to get dressed out of your pyjamas, that must be because you’re British … Oh, you keep questioning the treatment plan, that’s your Britishness I guess.’ As a result, I didn’t feel my queries were always dealt with meaningfully, and I didn’t feel I was being seen as a full person in all my admittedly diminished glory. He was a brilliant oncologist, whose expertise undoubtedly helped save my life, but to my mind he’d bought wholesale into the mainstream intercultural approach. So I learnt to work around his stereotypes, by explicitly framing my concerns in medical terms. Sometimes using the (Japanese) jargon of oncology worked, sometimes bringing in clinical studies helped. But sometimes nothing worked. I also realised that some of the ‘You’re so British’ stuff was intended as a way of building a relationship, banter in dark times, so I would laugh through my critical teeth.
I was applying insights from the critical intercultural approach to help me, a patient, navigate the healthcare system. The critical approach examines how power and stereotypes affect interactions, and is employed in this book, and in my research. The approach is critical in two ways: in the academic sense of seeking to ‘look under the carpet’ (or ‘under the tatami mat’ as the Japanese say) by questioning common beliefs about how society works, in this case about communication in society. In so doing, better ways of thinking and acting can be found. But it’s also critical of (as in negative towards) the mainstream intercultural approach. With the slippers, or my pyjamas, the focus is on behaviour in terms of national differences, and the mainstream approach explains the behaviour with a well-trodden stereotype. The critical approach argues that focusing on culture at the national level is often a distraction from what is really going on, and largely serves to reinforce stereotypes. By being aware of stereotypes and pushing against them, we can then improve things in society. In healthcare scenarios, for instance, this awareness can lead to better outcomes; lack of awareness has been shown to lead to very bad outcomes.
The difference between the academic mainstream and critical orientations is therefore also about the different stakes. Not knowing you shouldn’t wear slippers when walking on a tatami mat is the kind of mistake you can easily make, and which mainstream intercultural experts love to talk about, but you tend to make it only once. You apologise and move on (barefoot). The stakes of stereotyping people from some group can be much higher. In healthcare situations, for instance, differing survival rates for different ethnic groups can be partly explained by the stereotypes about such groups. But even among little children, stereotypes can cause damage and should be called out – though, as I’ll describe later, in our experience they may be swept under the school carpet.
Outside of this chapter, as I noted in the Preface, I’ve tried to make this book light on explicit theory, instead weaving in personal anecdotes and brief mentions of relevant concepts from critical intercultural communication and related fields. One such concept that runs through the book is othering, the way people can perceive someone from a different group as inherently separate and often less than ‘us’. It is something we can all be prone to. We reduce the other’s individuality by saying they do X because it’s their culture or they can’t help it, and may exaggerate their perceived threats or negative aspects. We know that sexism or racism are very much othering in action, but it can happen with any type of social category, such as profession, social class, school, and often nationality. And, as I discovered, it can happen when you become a cancer patient.
When you’re diagnosed with cancer, you may find yourself experiencing othering in multiple ways. Sometimes it comes from people who lack understanding of your situation. Sometimes it comes from medical institutions. And sometimes – perhaps most disturbingly – it comes from within yourself, as you begin to feel estranged from your own body.
In this book I discuss some instances of othering I’ve seen, experienced and been guilty of. I do this for two reasons. One because the topics in this book allow for some original reflection on the topic of othering, but more importantly because I argue this concept may help us understand the new, brutal reality of a cancer diagnosis, the emotional chaos accompanying it, and some avenues out of the chaos. And as I’ll say towards the end of the book, there are some parallels between racial othering, cancer-related othering, and how we might push back against them. This is the value of a critical intercultural orientation: by shining a light on problems, it can guide us towards solutions, sometimes solutions relevant to one problem (e.g. discrimination) and applied to another (e.g. cancer).
Perhaps surprisingly, being othered can open certain avenues – the less well-signposted ones. You may be motivated to find healthcare providers who see you for who you are; you may build connections with others who share your experiences; and you may find a sense of unexpected freedom by subverting or ignoring the opinions of others. And while I’d say Dr Nishi lightly othered me when he kept attributing my behaviour or requests to my being British, that did partly motivate me to become a particularly engaged type of patient. And that, in turn, also improved my Japanese. As I’ll recount in later chapters, my family being racially othered has eventually led to outcomes of which they, we, can be proud.
In ‘normal’ times, when we’re in what Susan Sontag in her book Illness as Metaphor refers to as the Kingdom of the Well, I think we can look at communication in at least three ways. There’s interpersonal communication (for instance between friends, or loved ones, or strangers we don’t perceive as different), intercultural communication (which can also be between doctors and patients), and the emotional and cognitive communication within each of us (including the stories and metaphors we use to see ourselves and the world), called intrapersonal communication.
As I’ve said, as a patient we might feel like an ‘other’ sometimes, depending on how we are treated. But my argument is, with a cancer diagnosis, you may feel like an other in all three communicative situations: you may feel distanced from strangers, acquaintances, or even loved ones, and they may struggle to understand you. Sometimes no words seem appropriate. But you can also feel a sense of otherness within, like you are no longer at home in your own body. You have a thing inside you that may kill you, and yet you cannot get away from this most genuine of threats.
As a person with cancer, you may be othered, sometimes by people who may lack empathy for, or are ignorant of, your plight. This may involve blaming you for your cancer, for example, or dismissing you as a person because your ability to communicate has been affected by the treatment, or even dismissing you from your job. Perhaps you are physically marked, following radical surgery to your face or body. You may have less control over your bodily functions, which in public can lead to disgust on the part of strangers. I remember being rather revulsed on a train in Tokyo because a young woman was constantly hacking up green mucus and spitting it slowly into a paper cup. A year later, soon after the radiation treatment had started, I found myself doing the same.
But this is not the only conception of othering that I mean: it is that as someone either with cancer, or if someone we care about has been diagnosed with cancer, we may well see the cancer itself as the ultimate other. What do I mean by that? Cancer is not a person, it’s a physical growth, so how can we otherise something that is a non-thinking collection of cells? The thing is, we do. We have an emotional reaction to a cancer diagnosis, one that may never fully leave us, even if our treatment finished years before and we’ve long returned to our pre-cancer lives. Cancer threatens our very existence, and the trauma of its diagnosis can require many retellings. These retellings are often of our relationship with this other that once almost killed us and may one day return.
Long after it has left the bodies of those who have survived, cancer can linger in our minds. In terms of how this relates to cancer as ‘the other’, this book will show that having cancer does not necessarily entail seeing it as something horrific; nor does its lingering shadow need to be horrific. I’m not saying you should love cancer (although some people do develop such a relationship with it). But as intercultural communication training can help us reduce the way we perceive people different from us as other, I think it is possible to have a relationship with your cancer that is nuanced and potentially positive, at least in some ways.
Many of the world’s religions stress that our over-attachment to this world is a cause of suffering, and that accepting the transitory, impermanent nature of life can allow us to achieve some peace. I’m an atheist, but I wholly believe this to be the case. And something like a cancer diagnosis brings that message crashing home, crashing into our home, breaking down the front door and the walls in the process. But the deep, personal realisation that things like cancer or earthquakes can threaten the permanence of our existence is often followed by another realisation. Life itself is fleeting, transient, despite our sustained strutting and fretting.
We cannot will away cancer: moving beyond seeing cancer as a threatening, malignant, unknowable thing will not remove cancer cells from our bodies. It can, however, help give you more freedom, more agency during your journey or battle or time with cancer. In the preceding sentence you’ll notice I frame cancer in three ways: as a journey, a battle, and as something we spend time with. The first two are clearly metaphorical, in that they help us understand our relationship with cancer by seeing it as something we travel with or something we fight against. They are two of the most common ways of describing cancer.
In later chapters I’ll be discussing these different metaphors in much more depth, because metaphor sits at the heart of this book. I’ll outline the way I made my own cancer metaphor, and how it helped. I’ll also discuss some of the recent research on the topic of metaphor-making when you have cancer. The metaphor can define the relationship we have with cancer, and therefore how we think about dealing with this new reality. This is one of the ways we can move beyond seeing cancer as the threatening, potentially disabling other, and instead have more control over our lot. A little metaphor can quieten, even momentarily, the overwhelming mental chaos a cancer diagnosis begets.
