What Strength Really Means When You’re Sick
The metaphors that Trump and others use when talking about COVID-19 are making the pandemic worse.
On Monday, as President Donald Trump left Walter Reed National Military Medical Center, Senator Kelly Loeffler of Georgia tweeted a doctored clip of the president tackling and punching the wrestler and WWE CEO Vince McMahon. In the edited version, McMahon’s face has been replaced with a picture of a virus. “COVID stood NO chance against @realDonaldTrump!” Loeffler wrote.
Similar sentiments, trumpeting Trump’s strength and fighting spirit, have poured forth since he tested positive for COVID-19. “#TrumpStrong,” Twitter users wrote. “Our president is strong and will beat the virus,” said House Minority Leader Kevin McCarthy. “He’s a fighter,” said former press secretary Sarah Huckabee Sanders. He has the “strength and stamina” of someone decades younger, said a urologist.
Such rhetoric is not unique to Trump. In the Western world, bouts of illness are regularly described as “battles.” Viruses and other pathogens are “enemies” to be “beaten.” Patients are encouraged to “be strong” and praised for being “fighters.” “It’s so embedded in our nature to give encouragement in that way,” says Esther Choo, an emergency physician at Oregon Health and Science University, “but it’s language that we try not to use in health care.”
Equating disease with warfare, and recovery with strength, means that death and disability are linked to failure and weakness. That “does such a disservice to all of the families who have lost loved ones, or who are facing long-term consequences,” says Megan Ranney, an emergency physician at Brown University. Like so much else about the pandemic, the strength-centered rhetoric confuses more than it clarifies, and reveals more about America’s values than the disease currently plaguing it.
The state of a person’s body and mind affects the course of a virus, but typically in subtle ways that aren’t captured by simplistic talk of “strength.” People who are infected with the SARS-CoV-2 virus are more likely to die or become severely ill if they are elderly, or have preexisting illnesses such as heart disease, cancer, or diabetes. But “we’ve seen very healthy, young, athletic, strong people get COVID-19 and die, or end up with long-term disability,” says Akiko Iwasaki, a Yale immunologist. College athletes have died from the disease. Some long-haulers, who have dealt with months of symptoms, were marathon runners and martial artists who have since struggled to walk up stairs. “I’ve seen not only elderly people with comorbidities, but also young people in their 30s, come in with visible respiratory distress,” says Uché Blackstock, an emergency physician and the founder of Advancing Health Equity.
Colloquially, people talk about having “strong” immune systems, easily boosted by good food and sufficient sleep. But immunity is famously complicated. Many people die because their immune system reacts to the coronavirus too forcefully for too long, creating a prolonged and sometimes harmful inflammatory state. “Some of the most distressing cases I have seen were young people who were fine and all of a sudden weren’t, and that was largely to do with how strong this immune overreaction was,” Ranney says.
These overreactions also explain some intriguing connections between a person’s mental and physical health. In several experiments, Sheldon Cohen at Carnegie Mellon University, who studies the connections between the nervous and immune systems, has found that volunteers who suffer from chronic stress — especially unemployment or long-running personal conflicts — are more likely to fall sick after inhaling small doses of common-cold or influenza viruses. That’s not because, as Cohen initially assumed, stressed people are more likely to take up unhealthy habits, but because stress makes their immune system more likely to overreact.
Cohen also found that people who are more emotionally positive are less likely to get sick from respiratory viruses. This fits with some other evidence (and a widespread belief) that optimists are more likely to recover from disease. But that connection is easy to misinterpret. It’s less that patients with viral diseases can will themselves better by putting on a happy face, and more that positivity reflects prior advantage. Optimists are more likely to have stronger social ties and adhere to medical advice. They’re less likely to have suffered the chronic stress that Cohen has linked to a higher infection risk. “I believe there are [psychological] factors that might extend your well-being,” says Choo, “but at the bedside, what I can tell you is that no one wants to die. Everyone is fighting to live with everything they have.”
A pandemic can tear away emotional resources that can help in that fight. “One of the things that’s so difficult about this virus is the fear and loneliness that accompanies it,” Ranney says. “People can’t have their normal support systems. They can’t have friends and family at their bedside. I look like an alien in full personal protective equipment, and I can’t do any of the things that would enhance a patient’s resilience, like hold their hands.”
As Susan Sontag wrote in 1978, it is difficult to enter “the kingdom of the ill unprejudiced by the lurid metaphors with which it has been landscaped.” Metaphors work by drawing connections between the familiar and the unfamiliar. This is useful when thinking about diseases, where unseen entities damage our bodies in largely unseen ways. By casting viruses as opponents, the immune system as defenders, and the course of illness as a fight, “we create a representation where we have control,” says Elena Semino, a linguist at Lancaster University.
Metaphors have downsides, though. In studying metaphors for cancer, Semino has seen patients blaming themselves for the spread of their tumors — casting themselves as failures for not winning their battles. And when we use “strength” to describe muscles, immune systems, personality, morality, and political power, meaning hops from one sense to another.
In the 19th century, a new movement called “muscular Christianity” deliberately connected moral and physical strength. Its proponents portrayed strenuous exercise and competitive sports as paths to hardy manliness, in opposition to what they saw as the softening feminization of Church and home. Muscular Christianity spurred the creation of the YMCA (and, by extension, basketball and volleyball). It became entwined with eugenics and imperialism, adding genetic and geopolitical “strength” to the metaphorical melting pot. It deeply influenced President Theodore Roosevelt, whose rugged persona was rooted in moving past the debilitating asthma of his childhood. “His effort to overcome the weakness of his youth instantiated itself through colonialism,” says Zoë Wool, a medical anthropologist at the University of Toronto. “He demonstrated strength through the claiming of nature in the name of the nation.”
This connection between physicality and righteousness created, as its dark corollary, a link between disability and moral failing. That explains why presidents like Woodrow Wilson and Franklin D. Roosevelt tried to cover up their disabilities, on the misguided notion that “someone with a disability can’t be a good decision maker,” says Wool. It explains, she adds, why “we take it for granted that every villain in every classic story will be physically marked in some way,” including Captain Hook, Darth Vader, multiple Bond villains, and Scar from The Lion King (who, for extra measure, is also coded as queer).
American society has long portrayed strength “as the opposite of disability and feminization,” Wool says. “Those go together, and are seen to be incapacitating. This is relevant in the case of Donald Trump.”
As a patient, Trump has physical traits that place him among the riskiest categories for dying from COVID-19. He is also emotionally brittle, requiring constant validation and reassurance. But as his niece Mary Trump recently wrote, among Trump’s family, “weakness was the greatest sin of all.” So, in lieu of actual strength, Trump excels at performing a specific masculinized version of it, in which aggression, volume, stubbornness, overconfidence, and mockery are stand-ins for might. This is a man who sees wounded veterans and casualties of war as “suckers” and “losers.” “He’s a caricature of masculinity,” says Rosemarie Garland-Thomson, an emerita disability scholar at Emory University.
But the leaky nature of metaphor allows displays of strength to be mistaken for its presence. “Strongman characterizations seem to revolve around the dispositional, temperamental features of a leader,” says Martha Lincoln, a medical anthropologist at San Francisco State University, “but I think there’s some magical thinking about the physical resilience of such a person too.” Even when Trump himself fell sick, he and his supporters couched his experience in the language of strength, victory, and courage. “Don’t let it dominate you,” he said in a video.
This strength-centered rhetoric is damaging for three reasons. First, it’s a terrible public-health message. It dissuades people from distancing themselves from others and wearing a mask, and equates those measures with weakness and cowardice. “The more you personify the virus, the more one version of heroism is to ignore it,” says Semino. “When people take that idea to extremes, they say, I’m strong. I’m not going to be cowed by this.”
Second, it ignores the more than 210,000 Americans who have died from COVID-19, and the uncounted thousands who have been disabled. Such dismissals are already common. In recent years, the ideologies of eugenics, where “if you’re sick, it’s your own fault and you don’t deserve support, [have] become more and more blatant,” says Pamela Block, an anthropologist at Western University. As the pandemic progressed, many saw the deaths of elderly people, or those with preexisting conditions, as acceptable and dismissible. And as COVID-19 disproportionately hit Black, Latino, Indigenous, and Pacific Islander communities, “people who believed in the idea of white supremacy felt like the virus was doing their work for them, and could promote the idea that they’re genetically stronger,” Block adds. One of Trump’s supporters recently predicted that the president would beat COVID-19 because of his “god-tier genetics”; Trump himself recently told a largely white audience that they have “good genes” before warning about incoming Somalian refugees.
Third, “metaphors redirect our attention,” says Wool, the medical anthropologist, and create “dead zones” in our thinking. “The idea of fighting a disease creates this dyad between you and the illness” and distracts us from everything that affects that fight. Trump was born into wealth. He is white. He is the president of the United States. He had regular access to COVID-19 tests. He was given supplemental oxygen at the White House — his home — before being airlifted to Walter Reed, where he received dedicated medical care on taxpayer funds that he himself contributed nothing to in 10 of the past 15 years. When he apparently felt lonely, he left the hospital in a motorcade so he could wave to his supporters, exposing the Secret Service agents riding alongside him. He received three treatments — remdesivir, dexamethasone, and an experimental antibody cocktail from the biotechnology company Regeneron, whose CEO is an acquaintance of Trump’s and a member of one of his golf courses. “He received a level of care that no patient has received in this country, and a combination of medications that has probably never been given to another patient,” Blackstock, the emergency physician, says. “He’ll probably end up doing well because of his access to resources.”
By contrast, many Americans have struggled to get tested for COVID-19 throughout the year — a problem that still dominates the lives of long-haulers who lack the diagnostic certainty needed for benefit claims or participation in research. Nearly 30 million Americans lacked health insurance last year, and that number has undoubtedly risen further amid record unemployment. Because of the combined burden of historical and everyday racism, many people of color must cope with chronic stress — the same stress that Cohen, the Carnegie Mellon researcher, showed makes them vulnerable to respiratory viruses in general. Many worked “essential jobs,” risking infections in unprotected workplaces and crowded public transport to make hourly wages that they couldn’t afford to lose. Acknowledging none of this, a defiant Trump told the country, “Don’t be afraid of it. You’re going to beat it. We have the best medical equipment. We have the best medicines.”
Trump is hardly the first American to mischaracterize his own privilege as fortitude, but from his lips, that error is uniquely and doubly pernicious. It distracts not only from the massive advantages that he enjoys, but also from his singular role in America’s pandemic year. The horrors that others have endured are in large part the result of his ineptitude, and the same empty strength that he now claims has defeated the disease. Trump is both beneficiary and engine of the unequal, broken systems that have led to the deaths of more than 210,000 Americans, but have thus far averted his own. In the time since his diagnosis, more than 300,000 other people in the U.S. have tested positive. More than 4,000 have died. Their fates were not a matter of weakness, but their numbers should make the self-described most powerful nation in the world consider how strong it truly is.
Originally published at www.theatlantic.com on October 9, 2020.
