To see, as we do in many of the cases cited in this volume, the actions of a person known to be suffering from a serious, indeed potentially terminal, physical illness such as HIV-AIDS being categorised as criminal is, in principle, deeply shocking. On further investigation, however, it becomes clear that there has always been a close association between the concepts and categories ‘illness’ and ‘crime’ and that our thinking, and so our public policies, in the two domains run closely parallel. This chapter explores the nature of the association between them, employing a range of disciplinary perspectives. In addition, it highlights the extent to which an uncritical use of metaphor around both ‘crime’ and ‘disease’ contributes to a worrisome tendency towards a collapse of the conceptual boundary between the two domains.
The Shifting Boundary between Illness and Crime
As sociologists since Talcott Parsons in the 1950s have pointed out, illness and crime are regarded by most societies as forms of social deviance, in the sense that those who are sick and those who commit crimes disrupt normal social functioning in ways which are considered undesirable.Footnote 1 Correction of both kinds of deviance, as far as that is possible, is seen as a priority in most societies. Of course, the deviance of those who are sick is in most cases socially sanctioned, whereas the deviance of those who commit crimes is not.Footnote 2 Indeed, we often use the terms in a contrastive way, for instance, in judicial decisions about whether a person should or should not be held criminally responsible on the basis of their mental health for the act which brings them before the court. Debate in such cases has become increasingly complex.Footnote 3
As this last point suggests, it is not just that sickness and crime are close neighbours, but that the boundary between the two categories has been fluid over time and across cultures; interactions between the categories have been frequent and varied. Anthropologists, theologians, historians, political scientists and sociologists have much to say about the overlap between thinking around sickness and thinking around crime.Footnote 4
Blaming for Illness
In certain cultures and eras, sickness has been seen as stemming primarily from the commission of some kind of offence. In many indigenous cultures, sickness is viewed as the consequence either of the infringement of a taboo by the sick person or a member of their family or of a curse uttered by an enemy.Footnote 5 It was a fundamental tenet of ancient Jewish thought that sickness, whether individual or in epidemics, was a punishment sent by God for impurity or sin (Leviticus 26:21, 25; Numbers 16:49 and 25:9; Deuteronomy 28:22). Leprosy was singled out as unclean and a punishment for sin (Leviticus 3 and 14).Footnote 6, Footnote 7 In the Christian Middle Ages, syphilis, too, was viewed as retribution for sin.Footnote 8 In the modern period, such a belief has persisted among some religious groups in relation to HIV-AIDS, especially when it first manifested itself in the early 1980s in the male homosexual community in the United States. American preacher Jerry Falwell insisted that ‘AIDS is not just God’s punishment for homosexuals, it is God’s punishment for the society that tolerates homosexuals.’Footnote 9 More generally, it has been observed that stigma attaches to certain groups of physically ill people, as it does to criminals.Footnote 10 Stigma is usefully defined by Link and Phelan as involving ‘labeling, stereotyping, separation, status loss, and discrimination’ in a context where power is exercised.Footnote 11 Sick people often report that they find themselves labelled as ‘outsiders’.Footnote 12 The experience of stigma may well have a further negative effect on health.Footnote 13
What makes the question of blame around illness more complicated today is the increasing realisation that individual choices (to smoke, to eat badly, not to exercise enough, to use alcohol and other drugs to excess, to have unprotected sex) do indeed contribute greatly to poor physical health.Footnote 14 Although such behaviours are not generally referred to as ‘criminal’, those who undertake them may reasonably be held in part ‘responsible’ for their illness. There is, however, a danger that we will over-blame those who get sick for their plight. It appears that prejudice is particularly strong against those whose illness is severe and deemed to have been behaviourally caused.Footnote 15 As Richard Gunderman points out, even among medical professionals, there is an extraordinary tendency to blame patients unreasonably, for instance, for their ‘failure to respond to therapies which, from the physician’s point of view, should have worked’. He cites case notes which state that a woman with breast cancer ‘failed the standard breast cancer protocol, subsequently failed our newest investigational protocol, most recently failed autologous bone marrow transplantation, and now presents for palliative care with widely metastatic disease’.Footnote 16 Indeed, surgeons conventionally refer to surgical instruments or swabs that they have mistakenly left inside a patient during an operation as having been ‘retained’ by the patient, as if he or she could be blamed even for that!Footnote 17
Crime Seen as Stemming from Disease
Alongside the tendency to view disease as, in some sense, stemming from a sin, or crime, or the inadequacy of the patient, there has been a tendency also to see crime as stemming from some sort of disease. Most notorious was the assertion of late-nineteenth-century psychiatrist Cesare Lombroso, widely accepted at the time, that criminals are distinguished by physical anomalies (which he interestingly named stigmata), consisting of abnormal forms or dimensions of the skull and jaw, asymmetries in the face as well as of other parts of the body).Footnote 18 In the 1920s, speculative research suggested that much crime might be caused by physical, as well as mental, illness.Footnote 19 Modern genetic research, employing rather more reliable scientific principles, examines the extent to which the predisposition to criminality may be genetically determined.Footnote 20 There has been discussion, too, about whether people experiencing such degenerative conditions as Huntington’s Disease are more prone than others to commit crime.Footnote 21
There have, nevertheless, been many critiques, by philosophers from Anthony Flew in the 1950s onwards, of the notion that crime should be regarded as a symptom of disease, in the sense of its deriving from the mental disorder of an individual. In his classic article, Flew asserted that clinicians often tacitly adopt a form of determinism in individual cases, in effect denying that their patients have been able to exercise any free will. He pointed out that such a belief has major implications for social and penal policy.Footnote 22 Mariana Valverde explores the related question of the role of free will in cases of alcoholism.Footnote 23 On a rather different track is research suggesting that the occurrence of infectious disease may actually contribute to the occurrence of property crimes and violent crimes. In a fascinating article, Shrira, Wisman and Webster argue that ‘[u]nder persistent disease threat, xenophobia increases and people constrict social interactions to known in-group members.’ In such circumstances, they suggest, inhibitions against harming and exploiting out-group members are reduced.Footnote 24
There has been much discussion, too, in a range of disciplines, about forms of correlation other than direct causal linkage, between sickness and crime. So Robert Peckham has drawn attention to the way in which disease and crime were often seen in nineteenth-century Britain as having common origins in derelict and dirty living conditions. ‘As the century progressed, disease and crime came to be increasingly located through the visualization of unsettled and unsettling metropolitan places and spaces.’Footnote 25 Current research in urban areas of Europe likewise shows a strong correlation between neighbourhood violent crime, poverty and potentially fatal conditions such as coronary heart disease.Footnote 26
Social Roles and Gatekeeping in Relation to Sickness and Crime
It was Talcott Parsons again who first drew attention to the way in which we attach distinct social roles to those in each domain, attributing a ‘sick role’ to those who deviate in one direction and a ‘criminal role’ to those who deviate in the other. In both cases, the role is, to a considerable extent, learned by individuals as they interact with the health system and the judicial system, respectively.Footnote 27 The attribution by society of a ‘sick role’ to the person experiencing illness imposes obligations and controls on those who become ill, just as the attribution of a ‘criminal role’ does on those convicted of crimes. The person who claims to be sick must be genuinely ill, is obliged to seek treatment, and, most importantly, is obliged to do their best to avoid transmitting the disease.Footnote 28 Failure to fulfil this last obligation is blameworthy and may be deemed criminal. Such a failure is, in a sense, at the heart of the issues discussed in this volume.
Both the sick and the criminal are crucially subject to gatekeepers, who define their status and control their actions: medical professionals serve as gatekeepers for the sick; and the police, the judiciary, and even juries serve a similar function in relation to those deemed criminal. In both cases, a significant degree of social control is exercised. (It should be noted that both sets of gatekeepers are concerned equally with admitting and with discharging the individuals in their care.) The two groups of gatekeepers are increasingly in competition over the boundary between their realms:
Now, the criminal justice system and medical profession compete for this authority – contending that their own definition over actions is the more proper. Behaviors once thought criminal can now be medicalized, ushered into the realm of medicine, and removed from their criminal implication by being redefined as a medical pathology. As the medical field grows and the criminal justice system defends its legitimacy – a contested space is created; actions can now become medicalized or criminalized.Footnote 29
Of course, medical practitioners interact with the penal system in other ways, too: treating prisoners for both physical and mental conditions and advising on whether prisoners have undergone sufficient psychiatric rehabilitation to merit parole.Footnote 30 Astonishing as it may seem to people living in other jurisdictions, doctors assist, in some US states, in the administration of lethal injections in judicial executions, despite warnings from the American Medical Association that to do so is unethical.Footnote 31
Medicalisation (and Demedicalisation) of Deviant Behaviour
The boundary between sickness and crime is especially blurred in relation to conditions and behaviours which have an obviously psychological dimension, for instance, actions resulting from psychosis or other major forms of psychiatric disorder, whether long-term or short-term.Footnote 32 Moreover, certain behaviours and conditions have oscillated historically between the two categories. Homosexual acts were, for many generations in the West, regarded in some contexts as a crime (and in some religious contexts as a sin) and in others as an illness. Indeed, the first two editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published from 1952 to 1974, defined homosexuality as a more or less treatable medical condition at a time when, in many of the countries where the manual was used, homosexual acts were also still illegal. Yet homosexuality is now regarded in most Western countries as neither criminal nor a disease, though it is estimated that over seventy countries worldwide have laws prohibiting homosexual acts, and many even prohibit education which treats homosexuality as ‘normal’.Footnote 33 On another front, there is vigorous debate in many countries about whether it is more appropriate for those addicted to drugs to be treated as criminals or as sick people.Footnote 34 The Secretary General of the United Nations Ban Ki-moon took a clear stand on this at the launch of the 2011 World Drug Report, when he declared: ‘Drug-dependent people should not be treated with discrimination; they should be treated by medical experts and counsellors. Drug addiction is a disease, not a crime.’Footnote 35
One might suppose that for a society to reassign a behaviour from the category of ‘crime’ to the category of ‘disease’ would be bound to indicate a greater degree of leniency towards it, but that is not necessarily the case. To be deemed ‘not guilty by reason of insanity’ for the killing of another person will, in many First World nations, result in incarceration in a psychiatric hospital for an indeterminate period, whereas conviction for murder might have resulted in imprisonment for a fixed period.Footnote 36 On a very different level, some totalitarian societies, including the former Soviet Union and the current People’s Republic of China, have classified various forms of opposition to the government/party line as evidence of mental disorder, rather than as a criminal act – let alone reasonable political behaviour.Footnote 37 Such people are thereby prevented from defending their actions in a court of law. To categorise individuals as sick permits the state to control them in ways and to a degree which sending them for criminal trial does not.
Inconsistency in Prosecutions for Spreading Disease
It is worth noting that criminal prosecutions relating to the transmission of infectious diseases are initiated much more often in the individual-to-individual context – as in all the cases referred to in the other chapters of this book – than in relation to actions by corporations, governments or international organisations, which actually damage the health of considerably larger numbers of people. So, though pharmaceutical companies and governments which continued to distribute blood products after they realised that those products could be infected with HIV and Hepatitis C have in some countries been belatedly required to pay civil damages to those infected or their families, the number of criminal prosecutions for these acts has been tiny (see the film Bad Blood: A Cautionary Tale).Footnote 38 Similarly, Haitians have had the greatest difficulty in obtaining any admission from the United Nations of its responsibility for the cholera epidemic brought to their country by Nepalese troops stationed there under the aegis of the United Nations after the 2010 earthquake and have, to date, received no compensation for it.Footnote 39 It has been argued that the prevalence of cholera in Africa should be treated as a crime against humanity, in that failure on the part of First World nations to introduce measures to treat and prevent the disease represents ‘one feature of an ongoing policy of genocide’.Footnote 40 On the other hand, it should be noted that many Western organisations have recently made large financial and professional contributions to the development of strategies for the prevention and treatment of cholera.Footnote 41 On a rather different front, while some governments, both national and local, are seeking to limit the distribution of foods and beverages overloaded with fats and sugars, which undoubtedly contribute greatly to the incidence of heart disease, diabetes and other diet-related diseases, none has taken criminal proceedings against their manufacturers.Footnote 42 Writer for the New York Times N. Cristof highlighted the anomaly posed by this inaction in the memorable statement: ‘Imagine if Al Qaeda had resolved to attack us not with conventional chemical weapons but by slipping large amounts of high fructose corn-syrup into our food supply. That would finally arouse us to action – but in fact it’s pretty much what we are doing to ourselves.’Footnote 43 Overstated though this statement may be, it highlights the tendency for blame around factors negatively affecting human health to be attached disproportionately to individuals rather than to corporations or governments or economic and social systems.
Having demonstrated something of the diversity and fluidity of relations between our notions of disease and of crime, this chapter now approaches its central topic: the argument that metaphor plays a major part in the association of disease with crime.
Conceptual Metaphors and Public Policy
Since the ground-breaking work of linguist George Lakoff and philosopher Mark Johnson almost thirty-five years ago, it has been widely recognised that the metaphors we employ around any topic not only reflect, but even shape, the way in which we conceptualise, and so behave around, that topic: ‘Our ordinary conceptual system, in terms of which we both think and act, is fundamentally metaphorical in nature.’Footnote 44 To take a straightforward example, let us look at what a patient experiencing an intractable cancer says: ‘There have been times when I felt I was cutting my way through a jungle, other times when it’s been quite smooth sailing’. Here, the experience of cancer is what linguists call the ‘target domain’ of the metaphor and the references to journeys of different kinds represent the ‘source domain’. Metaphor links two domains or categories, implying that, while they remain distinct, certain features may be identified as common between the two and that the target domain (in this case, ‘cancer’) may usefully be seen through the lens of the other domain (‘journey’). Strengths of the metaphor include the way in which it captures the potential for the diagnosis to take the patient as readily to a positive outcome as a negative outcome and its emphasis on agency for the traveller. Thinking of cancer as a journey may impact significantly on the attitudes not only of those who experience cancer, but also of the wider public.
It was Donald Schön, also around thirty-five years ago, who argued more specifically that, when a particular metaphor or cluster of metaphors is selected to embody a given social issue, policymakers are inclined to come up with solutions which derive from that original metaphor.Footnote 45 He describes these as ‘generative metaphors’. Over the period since then, thinkers about issues of public policy such as Anthony Judge have pointed to the importance of metaphors in what Judge terms the ‘imaginal framework’ through which we view the topic under consideration.Footnote 46 Paul H. Thibodeau and Lera Boroditsky have argued more recently that the adoption of a given metaphor to refer to the challenge posed by a social issue will in large part determine not only the policies which officials will propose to deal with them, but also the attitudes of the public towards those policies.Footnote 47 The example they use is directly relevant to the current discussion. Thibodeau and Boroditsky found that, if crime in a given city is referred to as a ‘beast’ preying on the community, people will tend to support enforcement measures involving detection, capture and prosecution, whereas, if it is presented as a ‘virus’ infecting the city, they are more inclined to support preventive measures and treat the problem through social reforms.Footnote 48 As a number of commentators have suggested, there is a tendency for such metaphors to become literalised or concretised.Footnote 49
Crime as Disease
It turns out that the metaphor of crime as a disease is in widespread use and has been found in many circumstances to be highly productive. It has been most strikingly employed by Gary Slutkin who, on returning to Chicago in 1995 after working for years as an epidemiologist for the World Health Organization on the spread of diseases such as tuberculosis and HIV in Africa, observed similar patterns to be at work in the spread of violence in the city. He argued that it is productive to view crime as if it were an infectious disease and use similar strategies to overcome it. Violent crime, especially, he suggested was ‘contagious’ and measures should be introduced to limit the ‘epidemic’.
Maps and graphs that chart the spread of violence look almost identical to those that chart infectious diseases with maps showing clusters and graphs showing wave upon wave.... The good news is, once we recognize violence as a contagious process, we can treat it accordingly, using the same methods that successfully contain other epidemic processes – interrupting transmission, and behavior and normative change.Footnote 50
He is one of the founders of the organisation Cure Violence, which has worked with city administrations in Chicago, Baltimore, New York, Philadelphia and beyond, appointing selected workers into communities to prevent violence and encourage behaviour change through outreach. Commentators and activists in other countries have used similar metaphors. Writing of the problem of violent crime in Jamaica, social commentator and entrepreneur Henley Morgan wrote an article in the Jamaica Observer with the headline: ‘Treat the crime epidemic like the disease it is’. He writes of the need to ‘understand the pathology of the disease’, ‘quarantine the constituencies ... against spreading the disease to unaffected areas of the population’, and concludes that ‘[i]f we approach fighting crime as if it were a deadly and contagious disease, we will find solving the problem is not beyond us.’Footnote 51 Mahatma Gandhi, it should be remembered, declared long ago that: ‘All crime is a kind of disease and should be treated as such.’Footnote 52
Reinforcing the crime as disease analogy, we frequently liken detectives to doctors in the way in which they analyse the evidence they find. It is no coincidence that author Sir Arthur Conan Doyle was trained in medicine at the University of Edinburgh and that he modelled the great fictional detective Sherlock Holmes, with his extraordinary powers of observation and deduction, on his medical lecturer Joseph Bell.Footnote 53 It should not be surprising that television series such as Bones, depicting teams of forensic medicine specialists working at the intersection of detective work and medicine, are so popular. House is another program which highlights the pursuit of clues in diagnosis. As Mariana Valverde has shown, public understanding of crime and the legal system is significantly shaped by the grossly simplified representations of detective work and forensic medicine we encounter in films and television series.Footnote 54
Nevertheless, some criminologists have expressed objections to the, sometimes uncritical, ways in which terms such as ‘predisposition’ and ‘rehabilitation’, commonly employed in the field of public health, have been borrowed for use in their discipline. Kaye Haw argues that concepts such as ‘risk factor’ and ‘pathway into crime’ have moved from being useful generative metaphors to the status of professional myth,Footnote 55 and Sarah Armstrong asserts that the concept of ‘risk management’ has undergone a similar shift.Footnote 56 She argues, in particular, that the metaphor promotes ‘the risk management process as all-seeing, permanent, delivered as an actual edifice, and coordinated into a coherent system of action’.Footnote 57 ‘Such a frame closes off critical conversations about definitions of problems in the first place ... It also treats human agency as relevant only at the margins.’Footnote 58 This critique illustrates the broad argument of Deborah A. Stone on the importance of teasing out the several kinds of causal explanation (mechanical, accidental, intentional, inadvertent) which may be employed around any social problem.Footnote 59
Direction of Meaning Flow in Metaphors
In general, the linkage between two domains through metaphor is perceived as working in one direction only. When a cancer patient refers to his or her experience of the disease as a journey, for instance, there is no suggestion that the equation is reversible and that it would be helpful to think of journeys as having some of the characteristics of cancer, via the metaphor journey as disease. Most of the metaphors studied by linguists and philosophers are ‘unidirectional’.Footnote 60 Nevertheless, it sometimes happens that the flow of metaphorical meaning does actually run in both directions. This occurs especially when the domains on which a metaphor draws are closely adjacent, as with disease and crime. So, alongside statements such as ‘violent crime is a cancer on the neighbourhood’, where crime (target domain) is viewed through the lens of disease (source domain), we find many instances of metaphors of crime being used to describe or explain disease, as in: ‘the HIV virus lurks in the ... glands and insinuates itself into the blood supply’, where the disease (target domain) is viewed through the lens of crime (source domain).Footnote 61 Both viruses and cancers are frequently referred to, even in professional literature, as if they are persons who have malevolent intentions. So, for instance, a report on a research programme at Vanderbilt University on potential vaccines against HIV comments: ‘The difficulty in developing a vaccine against the virus that causes AIDS testifies to its wiliness. The human immunodeficiency virus mutates rapidly to evade detection by the body’s immune system’.Footnote 62
While Conan Doyle saw that detectives needed to employ skills akin to those learned by students of medicine, the Vanderbilt report is only one of many reminders that doctors employ skills akin to those of detectives. So we find articles such as Lawrence K. Altman’s ‘The doctor’s world: A correspondent recalls his days as a medical sleuth’Footnote 63 and US television’s Dr Mehmet Oz bringing together a panel of ‘disease detectives’ to discuss new ways of diagnosing and treating key diseases.Footnote 64 The metaphor doctors as detectives is widely accepted and used.
In many cases, research and public education on diseases and their treatments are clearly illuminated by the use of metaphors from the domain ‘crime’. So a fascinating article from 2005 in the journal Nature, titled ‘Cancer: Crime and Punishment’,Footnote 65 illustrates the way in which human cells use ‘exile, execution and lifetime imprisonment’ as strategies to prevent mutant cells from turning into fully fledged cancers.
The metaphors which view disease through the lens of criminality are a subset of what Scott Montgomery identifies as the dominant metaphors in the West around disease, the biomilitary (deriving from Pasteur) and the bioinformationist (deriving especially from the discovery of DNA and research in genetics).Footnote 66 He shows that these dominant metaphor clusters feature not only in popular discourse but also in technical and professional discourse and that ‘they have provided organizing images, even image systems, whose own internal logic later became the guiding basis for inquiry’.Footnote 67 The subset of metaphors which represent disease as crime refers to diseases as attacking, by stealth, and making use of covert communication systems. Many of the metaphors used suggest spying, invasion and even terrorism, rather than simple criminality. Montgomery acknowledges that the adoption of such metaphors has shaped professional understanding of, and research in, many fields of medicine in ways which are fruitful.
It may well be, however, that this tendency to view illness through the lens of criminality stems also in part from the etymology of the English words ‘health’, ‘healing’ and ‘illness’. ‘Health’ and ‘healing’ are cognate with both ‘whole’ and ‘holiness’, with the implication that the person who lacks ‘health’ is less than whole and may indeed be ‘unholy’. Moreover, the ‘ill’ of ‘illness’ is a contraction of the word ‘evil’, which means that the term ‘illness’ suggests that an evil has been done – and that, as we have already seen, begs the question of whether it has been committed to or by the person who is sick.Footnote 68 This possibility may start to bring into question the appropriateness of the disease as crime metaphor.
Metaphors of ‘Self’ and ‘Other’
Rather than just a matter of popular belief, the notion that sickness involves some intrusion from the outside has, to a considerable extent, become fixed in the professional conceptualisation of both cancer and diseases of microbial origin. A central feature of the notion of the ‘immune system’, as it emerged in the late nineteenth century, is the ‘self-other’ distinction. So, the opening paragraph of a standard text on immunity and immunology states:
The human organism, from the time of conception, must maintain its integrity in the face of a changing and often threatening environment. Our bodies have many physiological mechanisms that permit us to adjust to basic variables such as temperature, supply of food and water, and physical injury. In addition, we must defend ourselves against invasion and colonization by foreign organisms. This defensive ability is called immunity.Footnote 69
Yet, as several commentators have pointed out, the self-other distinction is somewhat misleading. In particular, the assumption that ‘bacteria’, as ‘other’ to the human organism, are in principle to be feared and, as far as possible, removed, is inaccurate, since the physiology of the body is highly dependent on the presence, especially in the gastro-intestinal system, of large numbers of ‘positive’ bacteria. To suggest, likewise, that cancer cells originate outside the bodily system is also misleading, given that they are actually mutations of cells internal to that system.Footnote 70 The metaphorical leap involved in borrowing the term ‘immunity’ from legal language is obscured in most textbooks where the concept is presented as if it had literal validity. This is one of a number of areas in which doubt has been raised about the appropriateness of military and criminal metaphors as they are used in relation to sickness.
Military/Criminal Metaphors in Relation to Disease
More broadly, there has been ongoing concern since the 1980s about the implications for social attitudes towards sickness of the widespread use of metaphors with military and criminal connotations to characterise disease. It was novelist and essayist Susan Sontag who raised concerns first in relation to cancer, then to HIV. According to Sontag, the ascribing of military or criminal associations to those diseases tends in the first instance to demoralise the patients. In addition, there is a tendency for the notion of guilt to be somehow transferred from the disease to the patient. ‘Ostensibly, the illness is the culprit. But it is also the cancer patient who is made culpable.’Footnote 71 This may well indicate, in part, a kind of hangover of earlier assumptions about the origins of disease lying in criminal or sinful actions by the person who gets sick, or those around them. As Sontag also suggested, focus on the ‘otherness’ of cancer, HIV-AIDS and certain other infectious diseases may engender prejudice against the social other, in the shape of both xenophobia and homophobia. ‘This is the language of political paranoia with its characteristic distrust of a pluralistic world’,Footnote 72 the kind of paranoia which fosters representations of Muslims or Asian immigrants or homosexuals as toxic.
A complicating factor in this is that several of the most serious diseases to have surfaced in the world in recent years such as HIV, Severe Acute Respiratory Syndrome (SARS), avian influenza, and now Ebola, emerged first in non-Western countries, with HIV-AIDS and Ebola originating in Africa, and SARS and avian flu in East Asia. Indeed, all of these viruses appear to have been first transmitted to human beings from other animals, thereby doubling their ‘otherness’. These facts have made it only too easy for commentators in Europe and the United States to adopt melodramatic metaphors derived not just from the military domain, but from the domains of individual criminality and of terrorism. Referring to the geographical spread of avian flu, two New York Times journalists wrote: ‘like enemy troops moving into place for an attack, the bird flu known as A (H5N1) has been steadily advancing’,Footnote 73 to which other writers added ‘the virus lurks’ and another still ‘it is a serial killer’ which ‘did not need one of the host’s own enzymes to turn traitor and cleave apart the hemagglutinin protein to help the virus infect a cell ... the virus toted its own cleaving mechanism into the host on that gene, like a butcher who brings his own knife’.Footnote 74
In reference to public health responses to these threats, Western leaders seem to have thought mostly in terms of defending their own territories and population against ‘invasion’ by these viruses, rather than seeking to treat them and the people whose lives are devastated by them in Asia and Africa directly. The rhetoric of President George W. Bush in relation to avian flu was particularly remarkable in that it was almost indistinguishable from his rhetoric on international terrorism and ‘homelands security’, with references to ‘insufficient surveillance’, the importance of ‘stockpiling Tamiflu’ (the antiviral medication) not only at the national level, but also at the level of individual households and his promise to give Americans ‘the protections they deserve’.Footnote 75 It does seem, however, that the response from rich countries to the current Ebola outbreak in 2014 is somewhat more positive, in that it is focusing primarily on the problem as it presents itself in the countries of West Africa.Footnote 76 In this context, it is all too easily forgotten that, through history, it has been much more often the case that diseases have been transmitted from the first, colonising world to the populations of the third, colonised world, than the reverse.Footnote 77
It is, of course, relevant, too, that diseases, notably anthrax, cholera and typhus, have actually been used as weapons of warFootnote 78 and are contemplated as weapons of terrorism.Footnote 79 Following the establishment of the Biological and Toxin Weapons Convention in 1972, which has been signed by the governments of 120 countries, to use diseases for military or terrorist purposes is in fact criminal.Footnote 80 In this specific sense, therefore, the characterisation of disease as criminal is not wholly metaphorical.
Interestingly, the mirror image of the disease as terrorism metaphor is to be found in the frequent contemporary references to terrorism as a cancer or contagious disease.Footnote 81 A vivid example is to be found in the words of President Obama on 20 August 2014, when he spoke of the murder of an American journalist in Syria: ‘From governments and peoples across the Middle East, there has to be a common effort to extract this cancer so that it does not spread.’Footnote 82
The Crime of Disease and the Disease of Crime
The widespread use of both the disease as crime metaphor and the crime as disease metaphor derives not just from the general contiguity of the two fields that I referred to at the start of this chapter. More specifically, it springs from the long-established dual conventions whereby we view society as a body and the body as a society. The society as body metaphor has been widely used in the West, but with different emphases, for 800 years or more. Whereas, in the Middle Ages, the emphasis was on the detailed anatomy of the ‘body politic’, with the prince being regarded as ‘the head’, and every social group corresponding to one or another necessary part of the body, right down to the peasants and craftsmen, who were ‘the feet’,Footnote 83 in the modern era the tendency has been to focus on the question of the ‘health’ or ‘sickness’ of the society and, specifically, its vulnerability to some kind of ‘infection’ from other communities or nations.Footnote 84 The body as society metaphor has an equally long history, which depends broadly on our identifying the organs as playing different roles in the normal functioning of the body, with, at different times, the heart, the brain and the liver being perceived as ‘in charge’.Footnote 85 In the modern era, the emphasis has shifted to the processes by which the organs ‘communicate’ with each other and, as has been seen, the tendency to view the body as subject to ‘invasion’ and ‘colonisation’ by outside forces. At a microscopic level, the whole body is depicted as a vast and complex community of citizen cells, not unlike a community of bees or ants (or humans). Discussion of the mechanisms by which the body responds to infection depicts the cells of the body as citizens with specialised roles. For instance, a recent article on the immune system for a general interest magazine refers to the way in which a virus will:
do its best to infect a host cell and keep out of the way of the immune system, which may, in turn, identify the viral material and sound the alarm. Antiviral elements are then released; uninfected cells are cautioned to bolster their defences against viral intrusion, and cells that have already been infected are coaxed towards committing suicide.Footnote 86
Subsequently, the article refers to ‘helper T cells (that mostly help other immune cells by directing them to the right spot and providing guidance and encouragement)’.Footnote 87
The conclusion that follows is that the closeness, in so many ways, of the domains ‘crime’ and ‘disease’ and, especially, the widespread use of dual direction metaphors between the two domains leads to a worrisome tendency towards a collapse of the conceptual boundary between them. As a result, rather than the one being seen as analogous to the other, they come to be seen as more or less identical. When we are aware that we are using metaphors, we realise that only some of the features of the source domain are transferable to the target domain; however, when the boundary between the domains collapses, we assume that all features are shared between the domains. When, as we saw earlier, the concepts of ‘predisposition’, ‘pathway’, ‘risk factor’ and ‘rehabilitation’ are employed in an undifferentiated way across both the public health sector and the field of criminology, it becomes very easy to suppose that all the key concepts in the two domains are mutually interchangeable. In the words of Sarah Armstrong: ‘The boundary between the literal and the metaphorical can become obscured when a cross-domain mapping occurs between domains that are very near to each other.’Footnote 88 While Armstrong’s concern, given that she is a criminologist, is with the misleading tendency for offenders to be regarded as patients, the concern of Sontag and her successors, whose preoccupation is with medicine, has been that the patient may too easily be regarded as an offender.
In conclusion, therefore, it is imperative that the issues discussed in the other chapters of this book concerning the criminalisation of people suffering from a potentially terminal illness, who engage in behaviour which may put others at risk of contracting the disease, be viewed against the linguistic and cultural background outlined in this chapter. Although not recommending for a moment, as Susan Sontag did, that we should entirely abandon the use of metaphor in relation to either domain, I do suggest that there is a great need for more critical thinking around just how we refer to the relationship between the two domains, especially in terms of the uncritical use of metaphors derived from the one domain in relationship to the other.
