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The War (on Terror) on Alzheimer's Daniel R George and Peter J Whitehouse Dementia 2014 13: 120 originally published online 2 July 2012 DOI: 10.1177/1471301212451382 The online version of this article can be found at: http://dem.sagepub.com/content/13/1/120
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Article
The War (on Terror) on Alzheimer’s Daniel R George
Dementia 2014, Vol 13(1) 120–130 ! The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1471301212451382 dem.sagepub.com
Penn State Hershey College of Medicine, USA
Peter J Whitehouse Case Western Reserve University, USA
Abstract In the decade following the tragedies of 9/11, a US-led ‘‘War on Terror’’ has coincided with a US-led ‘‘War on Alzheimer’s disease’’. Not only has the rhetoric from these two wars overlapped and produced similar practical and conceptual problems, the campaigns have also become interwoven through the emerging public health issue of war-related head injuries, as well as a shared neglect for environmental contributions to human suffering. This article first explores similarities in the framing and prosecution of both wars, and then considers the long-term consequences of traumatic brain injuries (TBI) and traumatic environmental injuries (TEI) in the context of a society facing the increased prevalence of dementia. Ultimately, it is argued that addressing the challenges of cognitive aging and preventing violent social conflict both require a vernacular of higher ideals and values – as well as new language patterns rising out of the ecological movement – to trump the more expedient war rhetoric that has disproportionately marked public discourse around terrorism and Alzheimer’s disease during the past decade. Keywords Alzheimer’s disease, metaphor, traumatic brain injury, public health
‘‘How good bad music and bad reasons sound when we march against an enemy.’’ Friedrich Nietzsche
Corresponding author: Daniel R George, Department of Humanities, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033, USA. Email: [email protected]
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Introduction The rhetoric of warfare has a primordial pull on the human mind. Evocations of war and crisis engender fear, create an obvious image of an enemy, and impel human groups towards the belief that aggression is necessary, noble, and even morally righteous. It has long been observed that war metaphors are deeply embedded in the rhetorical patterns of Western culture (Lakoff & Johnson, 1980), and that, in particular, biomedical knowledge is imbued with war metaphors (Annas, 1995; Jobst, Shostak, & Whitehouse, 2000; Kleinman, 1988). Scholars have documented war-related tropes that have come to define conditions such as AIDS, tuberculosis, and cancer (Ehrenreich, 2009; Martin, 1994; Sontag, 1978, 1989), mental illness (Kleinman, 1988; Martin, 2007; Whitehouse & George, 2008), and a multitude of other maladies that cause human suffering. Much more than a mere linguistic device, metaphor is a means by which humans come to understand, interpret, and act in the world, gaining knowledge about one thing by comprehending it in terms of something else (Lakoff & Johnson, 1980). Thus, for medical conditions rhetorically understood through war metaphors, the possibility of absolute victory (i.e. a cure) against a pathophysiological antagonist becomes the explicit goal, and this metaphorical positioning of subjects in relation to disease often overshadows less adversarial but no less important pursuits such as rehabilitation, basic care, and ecological prevention in public attention and funding (Ehrenreich, 2001). Indeed, war metaphors – whether applied towards other human beings in actual military conflict or to social challenges such as drugs, poverty, or disease – always represent a rhetorical choice that minimizes or excludes alternative ways of behaving towards worldly challenges. In the decade following the tragedies of 9/11, a US-led ‘‘War on Terror’’ has dovetailed with a US-led ‘‘War on Alzheimer’s disease (AD)’’. Not only has the rhetoric generated by these two wars overlapped and produced similar practical and conceptual problems for the executors of each campaign, the two events have also become linked through the emerging public health issue of war-related traumatic brain injuries (TBI) and the shared neglect of environmental contributions to human suffering, which we refer to here as traumatic environmental injuries (TEI). This article provides a constructivist overview (Gaines, 1992) of the historical, social, and cultural processes that have culminated in the concurrent wars against Terror and AD, and argues from the basis that disease development and other forms of human understanding represent ongoing social processes without terminus (Turner, 1969). It adds to the growing literature demonstrating how AD has gradually evolved into a global epidemic over time, particularly in the last three decades (Ballenger, 2006; Fox, 1989; Gubrium, 1986; Herskovits, 1995; Holstein, 1997, Whitehouse, Maurer, & Ballenger, 2000). We first explore similarities in the construction and prosecution of our contemporary wars on terrorism and AD, and then critically examine the unifying clinical threads between the two wars – TBI and TEI – while considering the long-term implications of these injuries. Lastly, we identify social and political changes already taking place in both wars that can reframe the respective challenges in more humane, ecological, and socially-productive ways that go beyond simple rhetoric of battle and victory.
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Framing the fight ‘‘Our ‘War on Terror’ begins with al-Qaeda. But it does not end there. It will not end until every terrorist group of global reach has been found, stopped, and defeated.’’ Former US President George W. Bush
With these rousing words before a joint session of Congress on September 20, 2001, President Bush declared modern terrorism a unified threat that could be defeated through warfare. Similarly, leaders of the AD movement have often portrayed the fight against brain aging as a direct confrontation with a singular disease called ‘‘Alzheimer’s’’ despite its significant heterogeneity, mixed pathology, and overlaps with normal aging processes (Brayne, 2007; Hachinski, 2008; Schneider et al., 2007; Snowdon et al., 1997; Whitehouse and George, 2008). In fact, the US Alzheimer’s Association’s (AA) organizational vision for ‘‘a world without Alzheimer’s disease’’ suggests that AD – much like the conception of global terrorism espoused by the US government during the War on Terror – is a scourge that can be totally eradicated. Framed through various metaphors of warfare, AD is understood as an antagonist that ‘‘attacks’’ or ‘‘strikes’’ the brains of ‘‘victims’’. A 2011 AA publication reports: ‘‘Eventually, Alzheimer’s kills, but not before it takes everything away from you. It steals a person’s memories, judgment and independence. It robs spouses of lifetime companions and children of parents and grandparents. It destroys the security of families, [but] . . . this is a fight we can win’’ (Alzheimer’s Association, 2011). Such rhetoric, which is tinged with imagery that – perhaps intentionally – evokes public anxieties about terrorism, demonizes the human susceptibility to aging processes while personifying those processes as something external (George, 2010): a cruel marauder infringing on the brain that must be ‘‘stopped and defeated’’. However, if AD is in fact on a spectrum with normal brain aging processes, and if war metaphors guide feelings of enmity and fear towards those processes, then the War on AD may ultimately represent a rhetorical attack on ourselves in much the same way the War on Terror has elicited self-induced anxiety in the public sphere. In both wars, those who have dared to question the dogma of total victory have been marginalized – deemed either unpatriotic or scientifically nihilistic. Furthermore, war rhetoric has fomented powerful emotions that have led to unintended social damage. Just as the totalizing metaphors of the War on Terror contributed to a rise in discrimination against persons of Middle Eastern descent in the US – a cultural phenomenon that perhaps reached its most horrific nadir through the actions of a group of US soldiers during the Abu Ghraib scandal – the militaristic approach to AD has often engendered emotions of fear, disgust, and anguish towards persons affected by memory loss rather than fostering compassion, solidarity, and social inclusion. ‘‘With us or against us’’ – the Manichean tone of US foreign policy that so divided the post-9/11 global community – is also relevant to the contemporary landscape of AD in which the world has been clearly demarcated into those with ‘‘Alzheimer’s’’ and the cognitively normal. In recent AD literature, the demonization of the disease has actually led to advocacy groups such as the AA using the language of zombie films to refer to the hordes of ‘‘living dead’’ with dementia who will soon wander our streets and threaten social order unless the disease is cured (Behuniak, 2011). Such a blunt de-legitimization of a group’s humanity is reminiscent of
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the post-9/11 judicial assertion that captives in the War on Terror were ‘‘enemy combatants’’ who failed to play by the rules of international law and were thus not entitled to basic human rights as guaranteed by the Geneva Conventions. At stake on the rhetorical battlefield of both wars is what constitutes full personhood in contemporary Western culture, and at what point that status – whether through illicit terrorist actions or unintentional physical and mental decline – is forfeited.
(Mis)identifying the enemy ‘‘The British government has learned that Saddam Hussein recently sought significant quantities of uranium from Africa . . . Evidence from intelligence sources, secret communications and statements by people now in custody reveal that Saddam Hussein aids and protects terrorists, including members of Al-Qaida’’. Former US President George W. Bush
With the War on Terror declared, President Bush delivered a State of the Union Address on January 28, 2003 in which he linked Saddam Hussein to Osama Bin Laden’s Al-Qaida terror network, thus beginning the mobilization of resources to the Middle East for Operation Iraqi Freedom. Ridding the world of Hussein and Bin Laden became the pretext for prolonged combat operations in Iraq and Afghanistan that could ostensibly result in ultimate victory in the War on Terror. Similarly, the War on AD has been organized around the belief that two main enemies – the senile plaques and neurofibrillary tangles first noted by Dr. Alois Alzheimer in 1906 – are the primary perpetrators of neuronal death. Consequently, both protein-based structures have been assigned absolute negative value, with little regard for how this pathology might fit into the larger context of brain aging (D’Alton & George, 2011; Korczyn, 2012). As with the US government’s assurance that Hussein possessed weapons of mass destruction (WMDs) and formal links with Al-Qaeda that would eventually be rooted out as Iraq was liberated, the public has been told by AD advocacy organizations such as the AA that it’s only a matter of time and money before we discover an absolute cure for the ‘‘biological terrorism’’ wrought by plaques, tangles, and White Matter Disease (which possesses the somewhat ironic acronym of ‘‘WMD’’ and is often a hidden accompaniment of neurodegeneration). Whereas the US defense industry has provided firepower for the $1 trillion War on Terror, the pharmaceutical industry has positioned itself as the arms supplier in the War on AD, spending billions of dollars largely developing compounds to ‘‘attack’’ or ‘‘preempt’’ plaques even though it is not clear what amyloid or its precursor proteins do, and which forms, if any, are toxic. It is also emergently clear that brain pathology begins years before clinical symptoms of dementia (Morris & Price, 2001), casting doubt on whether intervening late in the progression of disease can affect meaningful clinical outcomes. However, this has not stopped nearly two dozen drug trials from being conducted over the past decade, all of which have failed to demonstrate cognitive or functional benefit, even in the cases where amyloid clearance has been achieved (Dimond, 2010; Korczyn, 2012; Selkoe, 2011). Such failures cast doubts on whether drugs that target amyloid pathways are a viable therapeutic option (Castellani et al., 2009; Castellani & Smith, 2011; Richards & Brayne, 2010; Whitehouse, George and D’Alton, 2011) or a biomedical misadventure akin to the search for WMDs in Iraq. Just as the deaths of Hussein and Bin Laden have failed to put closure to the War on Terror, the War on AD continues despite major pharmacological advancements in the removal and preemption of plaques.
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Losing the war ‘‘They’re in the last throes, if you will, of the insurgency . . . So I think we’re making major progress.’’ Former US Vice President Dick Cheney
Although coalition forces in Iraq had ostensibly been drawn into a violent insurgency, Vice President Cheney appeared on the Larry King Show on May 30th, 2005 to argue that ‘‘major progress’’ was being made and that victory was imminent. Alzheimer’s advocacy groups have deployed similar platitudes to reinforce hope in biomedical progress and sustain fundraising in the face of continued failures. Commonly, the war against AD is conflated with the eradication of polio – a facile analogy that obscures the fact that AD has multifactorial, age-related pathways that make it difficult to ‘‘attack’’ the condition as if it were a virus. As the late geriatrician Robert Butler said in the first congressional hearings on AD in 1980: ‘‘In 1935, a March of Dimes was started. In 1961, less than 30 years later, the last polio epidemic occurred [. . .] Senility could fall the way polio did, if we invest now [. . .] We cannot wait until the first baby boomer turns gray in the year 2011 to declare war on senility’’ (in Ballenger, 2006). In later years, however, Butler came to realize that AD was not a single target to be conquered but rather a condition that emerges in several, perhaps many, different forms (in Butler, 2008, p. 457). Indeed, after several decades of war waged on AD, it is not clear that massive scientific investments have done anything more than expose the syndromal, age-related aspects of ‘‘AD’’, while dispatching millions of reluctant elderly ‘‘victims’’ and their caregivers onto the rhetorical battlefield of biomedicine. Even so, positivist imagery about polio abounds in mainstream AD discourse, implying that the ‘‘disease’’ will eventually yield to a technical solution. In 2009, US politician Newt Gingrich, a visible advocate for AD, implored the American public to: ‘‘Imagine . . . if we discovered a cure – a breakthrough for the disease like the vaccine for polio. The financial and social impact on this country and the lives of millions would be immense’’ (Gingrich, 2009, p. 13A). Similarly, former Chief Justice of the Supreme Court Sandra Day O’Connor, Nobel-prize winning scientist Stanley Prusiner, and aging expert Ken Dychtwald coauthored an editorial in the New York Times in 2010, writing: ‘‘If we could eliminate [AD], as Jonas Salk wiped out polio with his vaccine, we would greatly expand the potential of all Americans to live long, healthy and productive lives – and save trillions of dollars doing it’’ (O’Connor, Prusiner, Dychtwald, 2010). Rarely do such declarations delve beneath the rhetoric and consider just what such a cure would look like. Would it perhaps return people to the biological brains and memory states they possessed in adolescence? Would it restore memories that had been lost? Furthermore, the economic impact of such a powerful therapeutic is potentially problematic since ‘‘cured people’’ might live longer and consume more health care resources. Those promulgating a vision of an absolute cure do not often address these crucial issues. Thus, while it is perhaps well intentioned, rhetoric of medical triumphalism promotes exaggerated hope. It also ostensibly fails to learn from past failures in much the way the US government eschewed historical comparisons between Iraq and other imperial adventures such as Vietnam, while espousing Western values such as ‘‘liberty’’, ‘‘freedom’’, and ‘‘Jeffersonian democracy’’ in ways that obfuscated the complex tribal sectarianism that was suppressed under Hussein’s authoritarian rule. Ironically, those who continually seek to convince the public that we are getting closer to a ‘‘cure’’ for AD share rhetorical similarities not only with former Vice President Cheney, but also with the former Iraqi
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Information Minister, Mohammed Saeed al-Sahhaf (otherwise known as Baghdad Bob), who famously offered ludicrous exaggerations claiming Iraq’s army was defeating the US, even as American tanks meandered through Baghdad city streets during the initial invasion in March 2003.
Casualties of war ‘‘Military medical experts have designated TBI as the ‘signature injury’ of the wars in Iraq and Afghanistan’’. US Congressman Bill Pascrell
Combat theaters created by the War on Terror, into which hundreds of thousands of coalition troops have marched in the wake of 9/11, featured improvised explosive devices capable of inflicting tremendous concussive forces that cause the brain to move violently inside the skull, damaging tissue and leading to brain deformation in multiple regions in ways yet to be fully understood (MacDonald, Johnson, Cooper et al., 2011; Ropper, 2011). Sophisticated body armor and rapid access to emergency medical services have led to the survival of many soldiers in Iraq and Afghanistan who would have died from such explosions in previous eras. Consequently, TBI are the ‘‘signature wound’’ of the War on Terror, and have accounted for 22 percent of casualties overall and 59 percent of blastrelated injuries (Okie, 2005). To say nothing of the countless Iraqi and Afghani innocents who have been maimed or killed by coalition armaments, an estimated 350,000 US military personnel have experienced TBI (Tanielian & Jaycox, 2008). Studies on veterans from past wars – namely WWII (Corkin, Rosen, Sullivan, & Clegg, 1989) and Vietnam (Raymont et al., 2008) – have found evidence of more rapid cognitive decline in soldiers who suffered head injuries compared to soldiers without such injuries (Yaffe, 2011). This is likely because TBI inflict structural and functional damage that weaken one’s cognitive reserve, leaving the brain less resilient to age-related processes (i.e. further neuronal loss, oxidative stress, inflammation, altered glucose metabolism, vascular damage, etc.) over time. Therefore, upstream neurological and psychological damage wrought by the War on Terror will be felt in the dementia care field for decades to come. Not only must countries allied in the War on Terror provide appropriate healthcare coverage for affected veterans, communities will need to adapt to increasing numbers of persons who may experience the challenges of dementia earlier in their lifespan. Beyond the tragedy of damage to individual brains are the more hidden but perhaps even more profound ecological consequences of both campaigns. In our haste to destroy or contain the enemy in warfare, human beings have often ignored the damage to the environment caused by war-related destruction (e.g. burning oil wells, contaminated water and food supplies, and the residual presence of toxins from used munitions). We also are perhaps insufficiently reflective about the fact that competition over scarce natural resources has long been and still is a main cause of warfare (Pagel, 2012). Similarly, in the War on AD our rush to obliterate the disease with powerful biological weapons such as genetic and molecular approaches has caused public dialogue to minimize environmental contributions to brain aging. However, exposure to such heavy metals as lead, mercury, arsenic, and other toxins literally contribute to dementia by killing neurons and lowering cognitive reserve, and their influence may become even more of an acute public health issue in the future because of the widespread introduction of foreign chemicals to our
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environments through industry, warfare, or emerging processes such as natural gas ‘‘fracking’’. Thus, anthropogenic alterations to built and natural environments that subject populations to increased exposure to neurotoxic threats – which we refer to as ‘‘traumatic environmental injuries’’ – join actual TBI as non-genetic preventable causes of cognitive impairment that are too often overshadowed by the rhetoric concentrating public attention on a late-stage molecular cure. Presumably, the AD advocacy movement neglects environmental issues due to the perception that they distract from the movement’s politically-motivated focus on reductionistic scientific approaches, which generates the bulk of private and public funding. However, there is much wisdom in the argument advanced by George Annas (1995) who, two decades ago, declared that modern healthcare must move away from military (and market-based) metaphors and towards metaphors emerging from the ecological movement. In the context of brain aging, rather than fighting a ‘‘War against Alzheimer’s’’ in search of an absolute cure, a more ecological approach to AD can inform the use of words like ‘‘personhood,’’ ‘‘integrity,’’ and ‘‘dignity,’’ to refer to those who are aging (rather than considering them merely ‘‘victims’’), and words like ‘‘balance,’’ ‘‘quality of life,’’ ‘‘responsibility for future generations,’’ ‘‘community,’’ ‘‘prevention’’ and ‘‘conservation’’ to reframe individual and cultural priorities (Whitehouse & George, 2008). Such language can lead us away from the notion that the individual brain (or genome) is the site of a molecular war that can be won, and towards a consideration of population health that respects the vulnerability and limitations of human life and places a greater emphasis on preventing and caring for cognitive loss rather than ‘‘fixing’’ it. Money can and should be spent on basic research on brain aging, but it must be recognized that ‘‘basic’’ refers to much more than just biological research. Indeed, research allocations should be judged by a realistic understanding of the priorities that face society in the world today, and measured against other competing health priorities including caregiving and prevention. Besides lessening the need for control and conquest that has defined our approach in the War on AD, an ecological perspective can place greater emphasis on basic lifespan expansion and public health interventions and less on questionably effective and costly interventions at the end of life. Indeed, by thinking about AD as a late-life molecular disease we are focusing only on the downstream effects of cognitive aging and ignoring the cumulative insults that occur throughout life (many of which are drastically exacerbated by warfare and human conflict). Ecological metaphors will guide us in viewing brain aging as a universal process unfolding from womb to tomb, so that we can develop comprehensive strategies to protect brains from both TBI and TEI.
Ending the wars ‘‘Since wars begin in the minds of men, it is in the minds of men that the defenses of peace must be constructed.’’ UNESCO Constitution
For too long, the wars on AD and terrorism have confounded the simple rhetoric of battle and victory; however, change is afoot. With regards to US policy, the term ‘‘War on Terror’’ has been officially retired as of January 2009, and the current US government has executed a phased withdrawal in Iraq with plans to leave Afghanistan by 2013. Similar conceptual changes are in motion in the Alzheimer’s field, where a growing counter-movement is arguing that so-called ‘‘AD’’ is not one entity to be defeated but is likely many biological
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processes that overlap with normal aging (D’Alton & George, 2011; Korcyzn, 2012; Plassman et al., 2010; Richards & Brayne, 2010; Whitehouse and George, 2008). Research informed by the values, principles, and methods of the ecological movement is establishing that these multi-factorial processes can include lifespan exposure to environmental toxins like lead and mercury, as well as TBI, insufficient nutrition, physical activity, and the gradual impact of psychosocial stress and depression (Stein, Schettler, Rohrer, & Valenti, 2008). Like terrorism, such processes will likely continue to be part of our lives; and while there is valuable humility in accepting that we cannot fully arrest them, we can attempt to delay, disrupt, and postpone their influence on ourselves and on others. As previous scholars have argued for conditions such as cancer (Ehrenreich, 2001), funds to study the intricate multisystemic and environmental interactions that lead to brain aging must increasingly be seen as a priority rather than continuing to overinvest in failing downstream reductionist theories and expecting a pharmacological deus ex machina. Assisting the public in dynamic, ecological, prevention-oriented thinking on diet, exercise, cognitive and social engagement, purpose, and participation in community, is an essential strategy for promoting brain health. Furthermore, investing in actively preventing domestic and foreign armed human conflicts over such issues as poverty, food and water shortages, and territorial expansion also represent a wise public health policy. Invariably, if the growing disparity between the economical haves and have-nots is not addressed, and if human rights abuses and illegal land- and resource-grabs are allowed to continue, it will lead to more conflict, environmental degradation, and reduced brain health (LaVeist, Pollack, Thorpe, Fesahazion, & Gaskin, 2011). Wise domestic and foreign investments can foster cultural conditions for healthier bodies and brains, thus reducing warfare and lowering the global burden of TBI and TEI. There are also humanistic implications to ending the War on AD and reframing the challenge of brain aging that is confronting both the developed and developing world (ADI, 2010). Liberated from the fear-driven rhetoric deployed by advocacy organizations such as the AA, societies might come to understand persons with dementia as existing on a continuum of age-related changes rather than being a separate category of person altogether. Just as a more latitudinarian foreign policy can mitigate the Manichaeism that defined the War on Terror and perhaps mend international diplomatic relations, a more humane approach to brain aging can lead to less warlike fractionation and greater intergenerational solidarity and interdependence with aging members of our communities. Such progress could serve to gradually desegregate the cognitively frail and restore the humanity that has been threatened by decades of escalating war rhetoric in the AD field. Ultimately, remediation of both wars will take time. As John F. Kennedy told the UN General Assembly in September 1963, just two months before his death: ‘‘Peace is a daily, a weekly, a monthly process, gradually changing opinions, slowly eroding old barriers, quietly building new structures.’’ In other words, advancing both causes – addressing the challenges of cognitive aging and preventing violent social conflict – requires a vernacular of higher ideals, values, metaphors, vignettes, and language patterns to incrementally trump the more expedient war rhetoric that has disproportionately marked public discourse in the past decade.
Authors’ contributions Both authors – Daniel R George and Peter J Whitehouse – have contributed significantly to the manuscript and consent to their names on the manuscript.
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Funding The authors report no funding sources for this manuscript.
Ethics committee approval No research data was collected for this opinion piece.
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Daniel R George teaches in the Department of Humanities at Penn State College of Medicine. He earned his PhD and MSc in medical anthropology from Oxford University. Dr. George is co-author of The Myth of Alzheimer’s: What You Aren’t Being Told About Today’s Most Dreaded Diagnosis (St. Martins Press, 2008). His research interests include brain aging, social influences on health, and the use of social media in contemporary education. Peter J Whitehouse, MD, PhD, is Professor of Neurology as well as current or former Professor of Cognitive Science, Psychiatry, Neuroscience, Psychology, Nursing, Organizational Behavior, Bioethics and History. He is clinically active at University Hospitals of Cleveland in the Joseph Foley Elder Health Center caring for individuals with concerns about their cognitive abilities as they age. He is also a member of the faculty associates of the Fowler Center for Sustainable Value at the Weatherhead School of Management and the Center for Aging and Health. In 1999 he founded with his wife, Catherine, The Intergenerational School, a unique public multiage, community school (www.tisonline.org).
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The War (on Terror) on Alzheimer's Daniel R George and Peter J Whitehouse Dementia 2014 13: 120 originally published online 2 July 2012 DOI: 10.1177/1471301212451382 The online version of this article can be found at: http://dem.sagepub.com/content/13/1/120
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Article
The War (on Terror) on Alzheimer’s Daniel R George
Dementia 2014, Vol 13(1) 120–130 ! The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1471301212451382 dem.sagepub.com
Penn State Hershey College of Medicine, USA
Peter J Whitehouse Case Western Reserve University, USA
Abstract In the decade following the tragedies of 9/11, a US-led ‘‘War on Terror’’ has coincided with a US-led ‘‘War on Alzheimer’s disease’’. Not only has the rhetoric from these two wars overlapped and produced similar practical and conceptual problems, the campaigns have also become interwoven through the emerging public health issue of war-related head injuries, as well as a shared neglect for environmental contributions to human suffering. This article first explores similarities in the framing and prosecution of both wars, and then considers the long-term consequences of traumatic brain injuries (TBI) and traumatic environmental injuries (TEI) in the context of a society facing the increased prevalence of dementia. Ultimately, it is argued that addressing the challenges of cognitive aging and preventing violent social conflict both require a vernacular of higher ideals and values – as well as new language patterns rising out of the ecological movement – to trump the more expedient war rhetoric that has disproportionately marked public discourse around terrorism and Alzheimer’s disease during the past decade. Keywords Alzheimer’s disease, metaphor, traumatic brain injury, public health
‘‘How good bad music and bad reasons sound when we march against an enemy.’’ Friedrich Nietzsche
Corresponding author: Daniel R George, Department of Humanities, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033, USA. Email: [email protected]
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Introduction The rhetoric of warfare has a primordial pull on the human mind. Evocations of war and crisis engender fear, create an obvious image of an enemy, and impel human groups towards the belief that aggression is necessary, noble, and even morally righteous. It has long been observed that war metaphors are deeply embedded in the rhetorical patterns of Western culture (Lakoff & Johnson, 1980), and that, in particular, biomedical knowledge is imbued with war metaphors (Annas, 1995; Jobst, Shostak, & Whitehouse, 2000; Kleinman, 1988). Scholars have documented war-related tropes that have come to define conditions such as AIDS, tuberculosis, and cancer (Ehrenreich, 2009; Martin, 1994; Sontag, 1978, 1989), mental illness (Kleinman, 1988; Martin, 2007; Whitehouse & George, 2008), and a multitude of other maladies that cause human suffering. Much more than a mere linguistic device, metaphor is a means by which humans come to understand, interpret, and act in the world, gaining knowledge about one thing by comprehending it in terms of something else (Lakoff & Johnson, 1980). Thus, for medical conditions rhetorically understood through war metaphors, the possibility of absolute victory (i.e. a cure) against a pathophysiological antagonist becomes the explicit goal, and this metaphorical positioning of subjects in relation to disease often overshadows less adversarial but no less important pursuits such as rehabilitation, basic care, and ecological prevention in public attention and funding (Ehrenreich, 2001). Indeed, war metaphors – whether applied towards other human beings in actual military conflict or to social challenges such as drugs, poverty, or disease – always represent a rhetorical choice that minimizes or excludes alternative ways of behaving towards worldly challenges. In the decade following the tragedies of 9/11, a US-led ‘‘War on Terror’’ has dovetailed with a US-led ‘‘War on Alzheimer’s disease (AD)’’. Not only has the rhetoric generated by these two wars overlapped and produced similar practical and conceptual problems for the executors of each campaign, the two events have also become linked through the emerging public health issue of war-related traumatic brain injuries (TBI) and the shared neglect of environmental contributions to human suffering, which we refer to here as traumatic environmental injuries (TEI). This article provides a constructivist overview (Gaines, 1992) of the historical, social, and cultural processes that have culminated in the concurrent wars against Terror and AD, and argues from the basis that disease development and other forms of human understanding represent ongoing social processes without terminus (Turner, 1969). It adds to the growing literature demonstrating how AD has gradually evolved into a global epidemic over time, particularly in the last three decades (Ballenger, 2006; Fox, 1989; Gubrium, 1986; Herskovits, 1995; Holstein, 1997, Whitehouse, Maurer, & Ballenger, 2000). We first explore similarities in the construction and prosecution of our contemporary wars on terrorism and AD, and then critically examine the unifying clinical threads between the two wars – TBI and TEI – while considering the long-term implications of these injuries. Lastly, we identify social and political changes already taking place in both wars that can reframe the respective challenges in more humane, ecological, and socially-productive ways that go beyond simple rhetoric of battle and victory.
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Framing the fight ‘‘Our ‘War on Terror’ begins with al-Qaeda. But it does not end there. It will not end until every terrorist group of global reach has been found, stopped, and defeated.’’ Former US President George W. Bush
With these rousing words before a joint session of Congress on September 20, 2001, President Bush declared modern terrorism a unified threat that could be defeated through warfare. Similarly, leaders of the AD movement have often portrayed the fight against brain aging as a direct confrontation with a singular disease called ‘‘Alzheimer’s’’ despite its significant heterogeneity, mixed pathology, and overlaps with normal aging processes (Brayne, 2007; Hachinski, 2008; Schneider et al., 2007; Snowdon et al., 1997; Whitehouse and George, 2008). In fact, the US Alzheimer’s Association’s (AA) organizational vision for ‘‘a world without Alzheimer’s disease’’ suggests that AD – much like the conception of global terrorism espoused by the US government during the War on Terror – is a scourge that can be totally eradicated. Framed through various metaphors of warfare, AD is understood as an antagonist that ‘‘attacks’’ or ‘‘strikes’’ the brains of ‘‘victims’’. A 2011 AA publication reports: ‘‘Eventually, Alzheimer’s kills, but not before it takes everything away from you. It steals a person’s memories, judgment and independence. It robs spouses of lifetime companions and children of parents and grandparents. It destroys the security of families, [but] . . . this is a fight we can win’’ (Alzheimer’s Association, 2011). Such rhetoric, which is tinged with imagery that – perhaps intentionally – evokes public anxieties about terrorism, demonizes the human susceptibility to aging processes while personifying those processes as something external (George, 2010): a cruel marauder infringing on the brain that must be ‘‘stopped and defeated’’. However, if AD is in fact on a spectrum with normal brain aging processes, and if war metaphors guide feelings of enmity and fear towards those processes, then the War on AD may ultimately represent a rhetorical attack on ourselves in much the same way the War on Terror has elicited self-induced anxiety in the public sphere. In both wars, those who have dared to question the dogma of total victory have been marginalized – deemed either unpatriotic or scientifically nihilistic. Furthermore, war rhetoric has fomented powerful emotions that have led to unintended social damage. Just as the totalizing metaphors of the War on Terror contributed to a rise in discrimination against persons of Middle Eastern descent in the US – a cultural phenomenon that perhaps reached its most horrific nadir through the actions of a group of US soldiers during the Abu Ghraib scandal – the militaristic approach to AD has often engendered emotions of fear, disgust, and anguish towards persons affected by memory loss rather than fostering compassion, solidarity, and social inclusion. ‘‘With us or against us’’ – the Manichean tone of US foreign policy that so divided the post-9/11 global community – is also relevant to the contemporary landscape of AD in which the world has been clearly demarcated into those with ‘‘Alzheimer’s’’ and the cognitively normal. In recent AD literature, the demonization of the disease has actually led to advocacy groups such as the AA using the language of zombie films to refer to the hordes of ‘‘living dead’’ with dementia who will soon wander our streets and threaten social order unless the disease is cured (Behuniak, 2011). Such a blunt de-legitimization of a group’s humanity is reminiscent of
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the post-9/11 judicial assertion that captives in the War on Terror were ‘‘enemy combatants’’ who failed to play by the rules of international law and were thus not entitled to basic human rights as guaranteed by the Geneva Conventions. At stake on the rhetorical battlefield of both wars is what constitutes full personhood in contemporary Western culture, and at what point that status – whether through illicit terrorist actions or unintentional physical and mental decline – is forfeited.
(Mis)identifying the enemy ‘‘The British government has learned that Saddam Hussein recently sought significant quantities of uranium from Africa . . . Evidence from intelligence sources, secret communications and statements by people now in custody reveal that Saddam Hussein aids and protects terrorists, including members of Al-Qaida’’. Former US President George W. Bush
With the War on Terror declared, President Bush delivered a State of the Union Address on January 28, 2003 in which he linked Saddam Hussein to Osama Bin Laden’s Al-Qaida terror network, thus beginning the mobilization of resources to the Middle East for Operation Iraqi Freedom. Ridding the world of Hussein and Bin Laden became the pretext for prolonged combat operations in Iraq and Afghanistan that could ostensibly result in ultimate victory in the War on Terror. Similarly, the War on AD has been organized around the belief that two main enemies – the senile plaques and neurofibrillary tangles first noted by Dr. Alois Alzheimer in 1906 – are the primary perpetrators of neuronal death. Consequently, both protein-based structures have been assigned absolute negative value, with little regard for how this pathology might fit into the larger context of brain aging (D’Alton & George, 2011; Korczyn, 2012). As with the US government’s assurance that Hussein possessed weapons of mass destruction (WMDs) and formal links with Al-Qaeda that would eventually be rooted out as Iraq was liberated, the public has been told by AD advocacy organizations such as the AA that it’s only a matter of time and money before we discover an absolute cure for the ‘‘biological terrorism’’ wrought by plaques, tangles, and White Matter Disease (which possesses the somewhat ironic acronym of ‘‘WMD’’ and is often a hidden accompaniment of neurodegeneration). Whereas the US defense industry has provided firepower for the $1 trillion War on Terror, the pharmaceutical industry has positioned itself as the arms supplier in the War on AD, spending billions of dollars largely developing compounds to ‘‘attack’’ or ‘‘preempt’’ plaques even though it is not clear what amyloid or its precursor proteins do, and which forms, if any, are toxic. It is also emergently clear that brain pathology begins years before clinical symptoms of dementia (Morris & Price, 2001), casting doubt on whether intervening late in the progression of disease can affect meaningful clinical outcomes. However, this has not stopped nearly two dozen drug trials from being conducted over the past decade, all of which have failed to demonstrate cognitive or functional benefit, even in the cases where amyloid clearance has been achieved (Dimond, 2010; Korczyn, 2012; Selkoe, 2011). Such failures cast doubts on whether drugs that target amyloid pathways are a viable therapeutic option (Castellani et al., 2009; Castellani & Smith, 2011; Richards & Brayne, 2010; Whitehouse, George and D’Alton, 2011) or a biomedical misadventure akin to the search for WMDs in Iraq. Just as the deaths of Hussein and Bin Laden have failed to put closure to the War on Terror, the War on AD continues despite major pharmacological advancements in the removal and preemption of plaques.
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Losing the war ‘‘They’re in the last throes, if you will, of the insurgency . . . So I think we’re making major progress.’’ Former US Vice President Dick Cheney
Although coalition forces in Iraq had ostensibly been drawn into a violent insurgency, Vice President Cheney appeared on the Larry King Show on May 30th, 2005 to argue that ‘‘major progress’’ was being made and that victory was imminent. Alzheimer’s advocacy groups have deployed similar platitudes to reinforce hope in biomedical progress and sustain fundraising in the face of continued failures. Commonly, the war against AD is conflated with the eradication of polio – a facile analogy that obscures the fact that AD has multifactorial, age-related pathways that make it difficult to ‘‘attack’’ the condition as if it were a virus. As the late geriatrician Robert Butler said in the first congressional hearings on AD in 1980: ‘‘In 1935, a March of Dimes was started. In 1961, less than 30 years later, the last polio epidemic occurred [. . .] Senility could fall the way polio did, if we invest now [. . .] We cannot wait until the first baby boomer turns gray in the year 2011 to declare war on senility’’ (in Ballenger, 2006). In later years, however, Butler came to realize that AD was not a single target to be conquered but rather a condition that emerges in several, perhaps many, different forms (in Butler, 2008, p. 457). Indeed, after several decades of war waged on AD, it is not clear that massive scientific investments have done anything more than expose the syndromal, age-related aspects of ‘‘AD’’, while dispatching millions of reluctant elderly ‘‘victims’’ and their caregivers onto the rhetorical battlefield of biomedicine. Even so, positivist imagery about polio abounds in mainstream AD discourse, implying that the ‘‘disease’’ will eventually yield to a technical solution. In 2009, US politician Newt Gingrich, a visible advocate for AD, implored the American public to: ‘‘Imagine . . . if we discovered a cure – a breakthrough for the disease like the vaccine for polio. The financial and social impact on this country and the lives of millions would be immense’’ (Gingrich, 2009, p. 13A). Similarly, former Chief Justice of the Supreme Court Sandra Day O’Connor, Nobel-prize winning scientist Stanley Prusiner, and aging expert Ken Dychtwald coauthored an editorial in the New York Times in 2010, writing: ‘‘If we could eliminate [AD], as Jonas Salk wiped out polio with his vaccine, we would greatly expand the potential of all Americans to live long, healthy and productive lives – and save trillions of dollars doing it’’ (O’Connor, Prusiner, Dychtwald, 2010). Rarely do such declarations delve beneath the rhetoric and consider just what such a cure would look like. Would it perhaps return people to the biological brains and memory states they possessed in adolescence? Would it restore memories that had been lost? Furthermore, the economic impact of such a powerful therapeutic is potentially problematic since ‘‘cured people’’ might live longer and consume more health care resources. Those promulgating a vision of an absolute cure do not often address these crucial issues. Thus, while it is perhaps well intentioned, rhetoric of medical triumphalism promotes exaggerated hope. It also ostensibly fails to learn from past failures in much the way the US government eschewed historical comparisons between Iraq and other imperial adventures such as Vietnam, while espousing Western values such as ‘‘liberty’’, ‘‘freedom’’, and ‘‘Jeffersonian democracy’’ in ways that obfuscated the complex tribal sectarianism that was suppressed under Hussein’s authoritarian rule. Ironically, those who continually seek to convince the public that we are getting closer to a ‘‘cure’’ for AD share rhetorical similarities not only with former Vice President Cheney, but also with the former Iraqi
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Information Minister, Mohammed Saeed al-Sahhaf (otherwise known as Baghdad Bob), who famously offered ludicrous exaggerations claiming Iraq’s army was defeating the US, even as American tanks meandered through Baghdad city streets during the initial invasion in March 2003.
Casualties of war ‘‘Military medical experts have designated TBI as the ‘signature injury’ of the wars in Iraq and Afghanistan’’. US Congressman Bill Pascrell
Combat theaters created by the War on Terror, into which hundreds of thousands of coalition troops have marched in the wake of 9/11, featured improvised explosive devices capable of inflicting tremendous concussive forces that cause the brain to move violently inside the skull, damaging tissue and leading to brain deformation in multiple regions in ways yet to be fully understood (MacDonald, Johnson, Cooper et al., 2011; Ropper, 2011). Sophisticated body armor and rapid access to emergency medical services have led to the survival of many soldiers in Iraq and Afghanistan who would have died from such explosions in previous eras. Consequently, TBI are the ‘‘signature wound’’ of the War on Terror, and have accounted for 22 percent of casualties overall and 59 percent of blastrelated injuries (Okie, 2005). To say nothing of the countless Iraqi and Afghani innocents who have been maimed or killed by coalition armaments, an estimated 350,000 US military personnel have experienced TBI (Tanielian & Jaycox, 2008). Studies on veterans from past wars – namely WWII (Corkin, Rosen, Sullivan, & Clegg, 1989) and Vietnam (Raymont et al., 2008) – have found evidence of more rapid cognitive decline in soldiers who suffered head injuries compared to soldiers without such injuries (Yaffe, 2011). This is likely because TBI inflict structural and functional damage that weaken one’s cognitive reserve, leaving the brain less resilient to age-related processes (i.e. further neuronal loss, oxidative stress, inflammation, altered glucose metabolism, vascular damage, etc.) over time. Therefore, upstream neurological and psychological damage wrought by the War on Terror will be felt in the dementia care field for decades to come. Not only must countries allied in the War on Terror provide appropriate healthcare coverage for affected veterans, communities will need to adapt to increasing numbers of persons who may experience the challenges of dementia earlier in their lifespan. Beyond the tragedy of damage to individual brains are the more hidden but perhaps even more profound ecological consequences of both campaigns. In our haste to destroy or contain the enemy in warfare, human beings have often ignored the damage to the environment caused by war-related destruction (e.g. burning oil wells, contaminated water and food supplies, and the residual presence of toxins from used munitions). We also are perhaps insufficiently reflective about the fact that competition over scarce natural resources has long been and still is a main cause of warfare (Pagel, 2012). Similarly, in the War on AD our rush to obliterate the disease with powerful biological weapons such as genetic and molecular approaches has caused public dialogue to minimize environmental contributions to brain aging. However, exposure to such heavy metals as lead, mercury, arsenic, and other toxins literally contribute to dementia by killing neurons and lowering cognitive reserve, and their influence may become even more of an acute public health issue in the future because of the widespread introduction of foreign chemicals to our
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environments through industry, warfare, or emerging processes such as natural gas ‘‘fracking’’. Thus, anthropogenic alterations to built and natural environments that subject populations to increased exposure to neurotoxic threats – which we refer to as ‘‘traumatic environmental injuries’’ – join actual TBI as non-genetic preventable causes of cognitive impairment that are too often overshadowed by the rhetoric concentrating public attention on a late-stage molecular cure. Presumably, the AD advocacy movement neglects environmental issues due to the perception that they distract from the movement’s politically-motivated focus on reductionistic scientific approaches, which generates the bulk of private and public funding. However, there is much wisdom in the argument advanced by George Annas (1995) who, two decades ago, declared that modern healthcare must move away from military (and market-based) metaphors and towards metaphors emerging from the ecological movement. In the context of brain aging, rather than fighting a ‘‘War against Alzheimer’s’’ in search of an absolute cure, a more ecological approach to AD can inform the use of words like ‘‘personhood,’’ ‘‘integrity,’’ and ‘‘dignity,’’ to refer to those who are aging (rather than considering them merely ‘‘victims’’), and words like ‘‘balance,’’ ‘‘quality of life,’’ ‘‘responsibility for future generations,’’ ‘‘community,’’ ‘‘prevention’’ and ‘‘conservation’’ to reframe individual and cultural priorities (Whitehouse & George, 2008). Such language can lead us away from the notion that the individual brain (or genome) is the site of a molecular war that can be won, and towards a consideration of population health that respects the vulnerability and limitations of human life and places a greater emphasis on preventing and caring for cognitive loss rather than ‘‘fixing’’ it. Money can and should be spent on basic research on brain aging, but it must be recognized that ‘‘basic’’ refers to much more than just biological research. Indeed, research allocations should be judged by a realistic understanding of the priorities that face society in the world today, and measured against other competing health priorities including caregiving and prevention. Besides lessening the need for control and conquest that has defined our approach in the War on AD, an ecological perspective can place greater emphasis on basic lifespan expansion and public health interventions and less on questionably effective and costly interventions at the end of life. Indeed, by thinking about AD as a late-life molecular disease we are focusing only on the downstream effects of cognitive aging and ignoring the cumulative insults that occur throughout life (many of which are drastically exacerbated by warfare and human conflict). Ecological metaphors will guide us in viewing brain aging as a universal process unfolding from womb to tomb, so that we can develop comprehensive strategies to protect brains from both TBI and TEI.
Ending the wars ‘‘Since wars begin in the minds of men, it is in the minds of men that the defenses of peace must be constructed.’’ UNESCO Constitution
For too long, the wars on AD and terrorism have confounded the simple rhetoric of battle and victory; however, change is afoot. With regards to US policy, the term ‘‘War on Terror’’ has been officially retired as of January 2009, and the current US government has executed a phased withdrawal in Iraq with plans to leave Afghanistan by 2013. Similar conceptual changes are in motion in the Alzheimer’s field, where a growing counter-movement is arguing that so-called ‘‘AD’’ is not one entity to be defeated but is likely many biological
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processes that overlap with normal aging (D’Alton & George, 2011; Korcyzn, 2012; Plassman et al., 2010; Richards & Brayne, 2010; Whitehouse and George, 2008). Research informed by the values, principles, and methods of the ecological movement is establishing that these multi-factorial processes can include lifespan exposure to environmental toxins like lead and mercury, as well as TBI, insufficient nutrition, physical activity, and the gradual impact of psychosocial stress and depression (Stein, Schettler, Rohrer, & Valenti, 2008). Like terrorism, such processes will likely continue to be part of our lives; and while there is valuable humility in accepting that we cannot fully arrest them, we can attempt to delay, disrupt, and postpone their influence on ourselves and on others. As previous scholars have argued for conditions such as cancer (Ehrenreich, 2001), funds to study the intricate multisystemic and environmental interactions that lead to brain aging must increasingly be seen as a priority rather than continuing to overinvest in failing downstream reductionist theories and expecting a pharmacological deus ex machina. Assisting the public in dynamic, ecological, prevention-oriented thinking on diet, exercise, cognitive and social engagement, purpose, and participation in community, is an essential strategy for promoting brain health. Furthermore, investing in actively preventing domestic and foreign armed human conflicts over such issues as poverty, food and water shortages, and territorial expansion also represent a wise public health policy. Invariably, if the growing disparity between the economical haves and have-nots is not addressed, and if human rights abuses and illegal land- and resource-grabs are allowed to continue, it will lead to more conflict, environmental degradation, and reduced brain health (LaVeist, Pollack, Thorpe, Fesahazion, & Gaskin, 2011). Wise domestic and foreign investments can foster cultural conditions for healthier bodies and brains, thus reducing warfare and lowering the global burden of TBI and TEI. There are also humanistic implications to ending the War on AD and reframing the challenge of brain aging that is confronting both the developed and developing world (ADI, 2010). Liberated from the fear-driven rhetoric deployed by advocacy organizations such as the AA, societies might come to understand persons with dementia as existing on a continuum of age-related changes rather than being a separate category of person altogether. Just as a more latitudinarian foreign policy can mitigate the Manichaeism that defined the War on Terror and perhaps mend international diplomatic relations, a more humane approach to brain aging can lead to less warlike fractionation and greater intergenerational solidarity and interdependence with aging members of our communities. Such progress could serve to gradually desegregate the cognitively frail and restore the humanity that has been threatened by decades of escalating war rhetoric in the AD field. Ultimately, remediation of both wars will take time. As John F. Kennedy told the UN General Assembly in September 1963, just two months before his death: ‘‘Peace is a daily, a weekly, a monthly process, gradually changing opinions, slowly eroding old barriers, quietly building new structures.’’ In other words, advancing both causes – addressing the challenges of cognitive aging and preventing violent social conflict – requires a vernacular of higher ideals, values, metaphors, vignettes, and language patterns to incrementally trump the more expedient war rhetoric that has disproportionately marked public discourse in the past decade.
Authors’ contributions Both authors – Daniel R George and Peter J Whitehouse – have contributed significantly to the manuscript and consent to their names on the manuscript.
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Funding The authors report no funding sources for this manuscript.
Ethics committee approval No research data was collected for this opinion piece.
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Daniel R George teaches in the Department of Humanities at Penn State College of Medicine. He earned his PhD and MSc in medical anthropology from Oxford University. Dr. George is co-author of The Myth of Alzheimer’s: What You Aren’t Being Told About Today’s Most Dreaded Diagnosis (St. Martins Press, 2008). His research interests include brain aging, social influences on health, and the use of social media in contemporary education. Peter J Whitehouse, MD, PhD, is Professor of Neurology as well as current or former Professor of Cognitive Science, Psychiatry, Neuroscience, Psychology, Nursing, Organizational Behavior, Bioethics and History. He is clinically active at University Hospitals of Cleveland in the Joseph Foley Elder Health Center caring for individuals with concerns about their cognitive abilities as they age. He is also a member of the faculty associates of the Fowler Center for Sustainable Value at the Weatherhead School of Management and the Center for Aging and Health. In 1999 he founded with his wife, Catherine, The Intergenerational School, a unique public multiage, community school (www.tisonline.org).
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