By Stephen Kramer, MD, Attending, Department of Psychiatry at SBH
The global coronavirus epidemic of 2020 has generated a multitude of iconic images, perhaps none more ubiquitous than people banging pots and pans and clapping in salute of the health care worker as hero. The pandemic was often framed in warlike terms, with the metaphor of health care workers as soldiers on the “front lines.” Here at St. Barnabas Hospital, we experienced these developments firsthand, and have the fleece sweaters (provided by the hospital to all staff) to prove it.
The health care worker-as-hero phenomenon during Covid generated extensive ethical inquiry into the physician’s duty to treat in a pandemic or disaster. Epidemics over the past 40 years, such as AIDS, SARS, and Ebola, have raised the issue of the physician’s obligation to continue working in an environment of significant personal risk. The consensus has been mixed, with many bioethicists examining the particular characteristics of the disease or disaster in question, such as route of transmission, fatality rate, as well as individual factors such as family obligations, medical history, etc. Legal and sociological perspectives related to individual and broader social contracts also have informed the “physician duty to treat” discussion.
The hero narrative bears deconstruction, both from the perspective of the hero, as well as the hero worshipper. The modern inquiry into the ethics of heroism is considered to have been ignited with J. O. Urmson’s essay “Saints and Heroes” in 1958. While moral action had traditionally been informed by Old and New Testament derivatives (the obligatory, the permitted, and the prohibited) he proposed a fourth category termed “supererogatory”: actions that are good to do, but not bad not to do.
George Goethals and Scott Allison provide a comprehensive yet concise analysis of the hero concept in culture, in their article, “Making Heroes: The Construction of Courage, Competence, and Virtue,” at the Jepson School of Leadership Studies, University of Richmond in 2012. Their essay cites important work from diverse scholars of philosophy, history, sociology, psychology and related disciplines. The authors recall the Greek myth from which the word “hero” is derived. Hero was a female priestess of Aphrodite, who had a lover Leander. Though she had a vow of chastity and could not marry him, he convinced her to make love to her, and he swam across the Hellespont regularly so they could be together, until one day he was lost at sea. Consumed with sorrow and grief, she drowned herself. Hero’s story may be where the idea of heroism came to involve sacrificing one’s life for someone or something.
Goethals and Allison identify two key characteristics of heroes that have evolved over thousands of years. Heroes are moral with “nobility of purpose.” Martin Luther King Jr., Mother Teresa, and Joan of Arc are among those typically and easily considered heroes. In addition, heroes are highly competent and exceptional. Athletes, actors, and entertainers can all become heroes to their fans and admirers. The combination of morality and exceptionalism are amplified when action occurs at a critical, key moment. For example, a basketball player making the clutch basket in the final seconds, or Winston Churchill delivering his iconic radio address to frightened Britons in World War II (very different situations but equally illustrative of the timeliness element of the universal hero narrative).
In some of their recent research, Goethals and Allison found that individuals frequently name family members as heroes. They suggest a kinship/evolutionary advantage to viewing one’s genetic relations in this way. Another significant percentage of chosen individuals were celebrities, many perceived as underdogs. The aspect of overcoming great odds seems to be an additional aspect of how heroes are widely recognized. Yet another large proportion of those named as heroes were fictional. In the authors’ estimation, it may be easier for the hero “worshipper” to internally manipulate fictional characters to conform to the hero ideal, without the flaws or inconsistencies which necessitate qualification in real people.
Another framework for considering hero narratives cited by Goethals and Allison are Jungian archetypes. Carl Jung referred to the collective unconscious as a repository of forms without inherent content. They cite Jung’s comment: “There are as many archetypes as there are typical situations in life. Endless repetition has engraved these experiences into our psychic constitution, not in the form of images filled with content, but only as forms without content, representing merely the possibility of a certain type of perception or action.” In addition to the hero archetype, Jung identified several important and interconnected archetypes: mother, demon, magic, power, and wise old man. The hero archetype is described as an individual who overcomes a villain or dark force; “only one who has risked the fight with the dragon and is not overcome by it wins the hoard, the treasure hard to attain,” from Essential Writings of Carl Jung.
The importance of identification (from psychoanalysis) and moral development (sociology) are also reviewed by Goethals and Allison, toward a comprehensive understanding of how heroism and hero worship may develop in a culture. Regarding the latter (morality), while development of a conscience and a sense of right and wrong is in the trajectory of “conventional” development, there may exist a “post conventional” stage as described by sociologists, that is characteristics of leaders and/or those who take action based on their ideals (citing the work of Kohlberg). This post conventional morality may be related to altruism, which is sometimes equated with supererogation in the philosophy literature (though not always agreed upon).
The psychoanalytic mechanisms of identification and transference are seen as instrumental to hero worship. There may be an unconscious positive or negative transference to heroes and villains operating on a societal/cultural level. The idea of human struggle and identification with the underdog, and how powerfully attractive these narratives are to the collective spirit, is highlighted. The death or sacrifice of the candidate hero enhances the heroic script (martyrdom).
The social influence model is discussed as yet another way to conceive of the importance of heroes to a culture or society. Heroes have influence on emotions, thoughts, and behavior. People are moved by the stories of heroes (i.e., Martin Luther King Jr., Nelson Mandela). Heroes can influence and challenge large groups of individuals’ thoughts or belief systems (Confucius, Mohammed). Heroes affect people’s behavior (Oprah Winfrey, Tiger Woods), and inspire them to change.
Goethals and Allison offer a system of subcategories of heroes. Trending heroes may rise up or down depending on their sphere of influence and societal changes (Lady Gaga). Transitory heroes are those whose narratives may capture the imagination for a short time and then fade from view (but nevertheless may have objectively accomplished important things – Andy Warhol’s “15 minutes of fame” quotation). Transitional heroes reflect different developmental levels’ preferences (i.e., Power Rangers, Buzz Lightyear, Elsa in Frozen). Tragic heroes derive from antiquity, proliferated in Western literature but exist in real life: great men who have some major flaw that leads to their downfall/death (King Lear, Hamlet, Brutus, Bill Clinton, and Dimmesdale in the Scarlet Letter). Transposed heroes may flip from hero to villain (Harvey Two Face, LeBron James when he left Cleveland, Sue Ellen in Dallas). This is distinct from tragic heroes in that the transposed hero makes a conscious choice and may not be unsuccessful in the new role. Transparent heroes are typically unseen in their roles (parents, health care workers). Traditional heroes follow a typical narrative of a rise from obscurity to greatness (Luke Skywalker, Batman, Abraham Lincoln). Transfigured heroes are those whose narrative is initially seen as that of the inspiring underdog, with the usual moral elements; however, details may eventually emerge that damage the heroic narrative (Chilean miners). Transforming heroes may be the most important subcategory and are generally leaders that shift the beliefs on a national/cultural or global scale (Martin Luther King Jr., Nelson Mandela, Gandhi). Transcendent heroes may move or belong to more than one category.
THE WAR METAPHOR IN DISEASE
There has been increasing discussion and debate in recent years in sociology, psychology and philosophy about the use of the war metaphor in health care systems. Metaphors offer health care providers a powerful tool for communicating complex and overwhelming medical information in digestible form, both at the individual patient and group/collective public health level. With the “war on cancer” declared with the National Cancer Act in 1971, the proliferation of military terminology became standard. Kristine Harrington, author of “The Use of Metaphor in Discourse About Cancer: A Review of the Literature,” cites another writer’s example (Camus Williams) of the common usage: “After the cancer’s invasion of the body, the immune system launches an offensive to beat the disease. The army of killer T-cells and stealth viruses fight the tumor cells. However, this is not enough to wipe out or eradicate the invader completely, especially if it has spread throughout the body becoming lethal. Thus a bigger arsenal of weapons, consisting of magic bullets and blunt instruments, target the enemy. If the cancer is still resistant to the cancer-fighting tools, other weapons are injected to attack the disease or to boost the body’s own defenses. This attack may eventually lead to defeating the disease, although it also involves serious side-effects as healthy cells are also destroyed by the weapons.”
BMH Larsen and others discuss the use of military metaphors in infectious diseases. The “invasiveness” of microbes can be a useful analogy for an era of increasing globalization and the introduction of non-native organisms
across the world with potentially catastrophic consequences (like a war). Climate change also captures the collective imagination as a growing catalyst for these hostile “invasions.” They are particularly interested in the public embrace of the metaphor of “the other” as some infectious diseases arriving from foreign lands. The native environment is seen as stable, and “defenseless,” “delicate,” “fragile,” “susceptible,” “vulnerable,” and “weaker,” than the invader(s). The invading species may be described as “thugs,” “running rampant,” “out of control,” creating “havoc”. Even in 2005, the use of nationalistic rhetoric in the characterization of emerging epidemics was noted as an increasingly favorite tactic of the media in some collusion with institutional/governmental objectives (Larsen, 2005).
Adrian Scribano and Angelica de Sena (2020) investigated the phenomena of applause for health care workers in Argentina and other South American countries in the spring of 2020 as Covid rapidly spread through the region, from a sociological perspective. A critical substrate/backdrop for the hero/ hero worshipper dynamic as it played out in Covid, is the normalization of consumption-oriented societies within the developed world. When this way of life faced an existential threat in the virus, the “stage” was set for the “spectacularized” phenomena of citizens expressing their appreciation for the targeted group through their banging, clanging and applause. An additional backdrop has been the dysfunctional health care systems in these same countries, which further amplified the drama and urgency of the public outpouring (though generally not articulated in the moment of crisis and emergency). The authors surmised through a study of videos made throughout the country, there was a correlation between the intensity of applause and militaristic/nationalistic rituals, and degree of urbanization.
THE HERO/HERO WORSHIP/WAR METAPHOR IN COVID-19
As the coronavirus epidemic unfolded in early 2020, initially in Wuhan, China, then spreading quickly to Europe, North America and throughout the world, health care workers were from the beginning referred to as doing “battle,” on the “front lines”, willing to make the ultimate sacrifice (often without the proper armor and weapons). They were “transparent” heroes, heretofore unrecognized, thrust into the limelight, endowed with many of the characteristics of heroes mentioned earlier: moral, exceptional, and at the right place (or wrong place?) at the right time. The collective unconscious hero archetype shaped their role: David’s combatting Goliath (the dark monster). The unsettling details that did not comply with this narrative/schema were mostly discarded (not really having a choice, not being adequately protected, falling apart/committing suicide).
The world continued (and continues) to search for heroes and villains. The George Floyd murder drew attention around the world; he and others who had met similar fates, became heroes in the struggle against structural racism (which was also becoming apparent in the health care disparities contributing to and distorting the trajectory of the pandemic). Law enforcement/police assumed the role for many (but not all) as the villains. The U.S. election season and Donald Trump’s flouting of, taunting, succumbing, eventually prevailing against Covid, the contrast of Joe Biden in his Delaware bunker wearing his mask: the collective splitting, demonizing, extolling that repeated itself over and over, as the world faced an indefinitely altered way of life.