Metaphor and the Representations of Health and Illness among the Semai Indigenous Community in Malaysia

Diverse methods and approaches have been utilised in researching the cultural bases of health, illness and wellbeing. Understanding the cultural representation of health and illness of particular communities becomes urgent especially when the community concerned is underserved in healthcare. In this project, we sought to examine the representations of health and illness by members of the Semai indigenous community through the use of metaphor analysis, a qualitative method in applied linguistics that attend to how people use language in real-world discourses to understand their conceptualisations of abstract ideas and emotions. From semi-structured interviews with the indigenous Semai people in a village in Malaysia, metaphors of health and illness were identified from the oral stories told by participants. Metaphors were identified and analysed following Lakoff and Johnson’s (1980) conceptual metaphor theory that explains how people understand one idea in a conceptual domain through accessing resources in another conceptual domain. The results show that universal metaphors are dominant in representing embodied experiences while culturally influenced metaphors are important as vehicles of expression derived from their environment and folk beliefs. We argue that while culturally influenced metaphors may mark the participants as strange in their ways of thinking, a closer look at their underlying frameworks finds that they connect with universal bases that are intrinsic to all human experience. Understanding conceptual metaphors can contribute to the expansion of the locus of shared understanding between healthcare providers and the communities they serve.


BACKGROUND
Diverse methods and approaches have been utilised in researching the cultural bases of health, illness and wellbeing, ranging from examining individuals' underlying representations of illness to addressing larger sociocultural factors that affect the individual as part of a social network in his or her community (see Uskull, 2010, for an overview).Experiences of health conditions are said to be culturally-shaped, despite its physical cause that is attributed to some biological process.Researchers have sought to show the differences in the experience of and reaction to illness by people from different cultural backgrounds.They argue that differences in the perception of health and illness affect not only how patients actually experience the symptoms of diseases but also what actions they take to alleviate their suffering, including seeking healthcare.The kind of "deep" perception and expression of illness experience that is alluded to is often articulated as "mental representation" (Uskull, 2010; Skelton, Wearn & Hobbs, 2002; Skelton & Croyle, 1991; Bishop, 1991) which points to the existence of a cognitive schematic structure of meaning constructed and activated as a result of interaction between individuals and their environment.
Attempts to understand the representations of health and illness of particular communities become urgent especially when the community concerned is underserved in healthcare, and there exists health inequality between them and other adjacent communities.Indigenous communities in Malaysia comprise ethnic groups that are not very wellunderstood as they live in locations removed from other communities.Their economic, education and health status is also far below that of the general population (Bedford, 2013;Zainal, 2003), this making the indigenous people a marginalised minority in the country.This project involves the Semai community in Malaysia, an indigenous ethnic group living in the central region of the Malaysian peninsula.
Studies in health communication have shown that ethnic minorities evoke differential communication behaviours from healthcare providers of a different cultural background.Doctors tend towards demonstrating less affective behaviour (for example, less empathy, less expression of concern, and reduced social talk), and giving a lesser amount of explanation to patients about their health conditions.Particularly with ethnic minority patients, there was less shared understanding between patient and healthcare provider, and patients had fewer opportunities to ask questions (Schouten & Meeuwesen, 2006).At the same time, patients appear to be less verbally expressive and assertive.Research on medical encounters has identified culture as a significant factor affecting doctors' understanding of patients' nonverbal communication (Coelho & Galan, 2012), in doctors' rapport-building with and showing of empathy to patients (Ferguson & Candib, 2002), and also in the quality of healthcare provided to ethnic minority patients (Peck & Denney, 2012).
While resolving healthcare accessibility issues for ethnic minorities is a complex task, it cannot be denied that improving shared understanding between healthcare providers and the ethnic minority communities they serve must be part of the solution.In this project, we sought to examine the representations of health and illness by members of the Semai indigenous community through the use of metaphor analysis, a method in applied linguistics that attend to how people use language in real-world discourses to understand their conceptualisations of abstract ideas and emotions.We approach the analysis with particular reference to the universal and culture-specific aspects of these representations (Kövecses, 2005).In this regard, we depart from the current trend of research in cultural representations where differences attributed to culture are foregrounded to the relative neglect of similarities.We adopt the assumption that while illness experiences may be coloured by cultural attitudes and influences, there may well be base line universal ones that draw on the pool of common human experiences.In this article, we describe the universal and culture-specific representations produced by community members, and discuss how they might contribute to expanding the locus of shared understanding between healthcare providers and community members.

METAPHOR AND CONCEPTUAL REPRESENTATION
Traditionally, metaphor is regarded as a figure of speech used as a literary device in communication and self-expression.The emergence of theories that associate metaphor with a cognitive function apart from its communicative function changed the dynamics of the study of metaphor.The conceptual metaphor theory pioneered by Lakoff and Johnson (1980) explains the mechanism that integrates thought, language and experience in the creation of metaphor.
Studies on conceptual metaphors across languages and cultures have shown that metaphors are an essential and unavoidable part of language use, and that people use metaphors in their everyday communication with each other about their feelings, thoughts and life experiences (Lakoff & Johnson, 1999;Kövecses, 2005).Hence, the study of metaphor may be regarded as a study of how people structure their thoughts around particular concepts and how they communicate these concepts using language, straddling processes of both mental and discursive representations.Metaphors in discourse could reveal information about speakers such as their thoughts, the socio-cultural norms that they adhere to or flout, along with their emotions, attitudes and values (Cameron, 2010).

UNIVERSAL BASES AND CULTURAL VARIATIONS OF METAPHOR
The understanding of the notions of universality and variation of metaphors is guided by several factors.Lakoff and Johnson (1999) discuss the notion of embodiment and its relation with metaphor creation.It is almost taken for granted that embodied experiences (which have a physical basis) would result in universal metaphors.However, Kövecses (2005) argues that embodied human experiences are not necessarily the only reason for the existence of universal metaphor; rather, the twin dimensions of "cultural considerations" and "cognitive processes" (p.4) dictate whether metaphors are interpreted universally or culturally.Shifting between these two dimensions, people are capable of using different metaphors when talking about the same thing, that is, the metaphors are not limited to a single source domain.
Often, emotions such as happiness or sadness could result in a variety of facial expressions.For example, the expression of a happy person is cheerful (often with an upturned mouth and lifted cheeks) while a sad person may appear downcast (with downward looking eyes and a downturned mouth), leading to the well-known metaphors HAPPINESS IS UP and SADNESS IS DOWN (Lakoff & Johnson, 1980).Such are examples of bodily experiences that could transcend the boundaries that differentiate one individual or culture from another.Still, people may express their emotions differently.For example, the conceptualisation of anger using the concept of a pressurised container (hence, AN ANGRY PERSON IS A PRESSURISED CONTAINER) has been found among speakers of English, Chinese, Japanese and Hungarian (Kövecses, 2000).Speakers of different languages (and therefore, different cultural backgrounds) seem to converge on the same anger metaphor probably because they share similar ideas concerning their bodies and the physiological processes that they undergo when the feeling of anger arises.However, despite the seeming universality of the pressurised container anger metaphor, at a more specific level, there are, too, cultural variations in the concepts used, such as qi (energy) in Chinese (ANGER IS EXCESS QI IN THE BODY) (Kövecses, 2000).Hence, while bodily experiences are generally universal in nature, they may themselves become the basis for the creation of alternative metaphors that prove to be culture-specific.The same may be said for the HUMAN BEINGS ARE ANIMALS metaphor which is regarded to be universal, as characteristics of animals have been mapped onto human beings in almost every existing language and cultural group; however, the selection of the animal and the particular aspect of it, as well as whether the comparison to humans is complimentary or derogatory is influenced by the cultural environment (see Wei & Wong, 2012).

METAPHORS IN HEALTHCARE
In the healthcare context, it is common for patients to use metaphor when talking about their illness when relating the traumatic experiences they have gone through or are going through.Metaphors are used to share their experiences more vividly and effectively with their hearers who are typically healthcare providers, support-group members, and therapists (see for example, Skelton, Wearn & Hobbs, 2002;McClelland & Huttlinger, 2012;Lanceley & Clark, 2013).Patients suffering from conditions such as asthma (Peterson & Sterling, 2009), epilepsy and psychogenic non-epileptic seizures (Plug, Sharrack & Reuber, 2009) and diabetes (Huttlinger et al., 1992) have been found to use a variety of metaphors when communicating about their experiences.More importantly, understanding how patients use metaphor has been shown to have crucial implications to healthcare delivery.We discuss four studies to illustrate the close connection between metaphor and healthcare.
The first study relates to the use of metaphor by children.Using an ethnographic approach, Peterson and Sterling (2009) interviewed African-American children who had asthma and found several metaphors used by the children when describing their asthma experience.The child asthma patients used metaphors such as "troll", "jellyfish", "cracker" and "guardian angel" to make sense of their condition.Of these four metaphors, the troll and the cracker metaphors are classified as internal while the jellyfish and the guardian angel metaphors are external to the child's body.The internal metaphors are significant for indicating that the child is aware of his or her own illness in terms of the early symptoms.As described by one child, the troll is the one who controls the airflow into her lungs if she wakes him up with her activities while another child described the experience as similar to chewing a cracker whereby the tiny pieces would fly around and cause him to cough and make a "crumbly" sound.
Use of metaphors is an attempt by children to express their experience of the illness in ways they know best, and to make sense of their confusion over what they are going through.At the same time, healthcare providers can understand more accurately the symptoms and hence, the severity of the illness suffered by the children.Also, metaphors may alert healthcare providers to a child's coping behaviour; for example a child may refuse to be active due to the fear of awaking the "troll".
A study on epilepsy patients (Plug, Sharrack & Reuber, 2009) highlights another important contribution of metaphor to medical practice.In interviews with epilepsy and psychogenic non-epileptic seizure (PNES) patients, it was found there was a significant difference in the way the patients conceptualise seizure.Epilepsy patients are more likely to use metaphors deriving from the agent/force (SEIZURE IS AN AGENT/FORCE) or event/situation (SEIZURE IS AN EVENT/SITUATION) categories while PNES patients use the space/place (SEIZURE IS A SPACE/PLACE) category more often.The metaphorical conceptualisation of seizure by epilepsy patients puts the patient as the experiencer of seizure which is represented as an event happening to them, whereas PNES patients experience seizure as a state or place that they have to pass through.These findings have important practical implications for healthcare as the type of metaphor used by patients can help physicians distinguish between the two conditions when diagnosing patients suffering from either epilepsy or PNES.
Another interesting study on metaphor in healthcare is a study conducted by Huttlinger et al. (1992) that may shed light on the notion of "non-adherence", a perennial problem that physicians have to deal with when treating patients from any cultural background.The group in the study, the Navajo people, communicated their illness experience using metaphors such as battles or war in coping with diabetes, using the weapon metaphor in referring to the treatments and interventions they needed to undergo.In most other contexts, when patients use the war metaphor, they often use it to suggest an on-going "fight" between them and their illness.However, the Navajo talked about being victimised and held as prisoners by both the illness and Western medicine.Some viewed Western medicine as the enemy in the battle.Cross-cultural conflicts that occur between healthcare seekers and providers due to differing worldviews add to the challenges in improving the health of the individual or the community.As Huttlinger et al. (1992, p. 711) conclude: Non-adherence to treatment plans is often the result of not clearly connecting the disease to the patient's ideas.If properly examined and used in communication, metaphors help the health professional and especially the occupational therapist respond not just to his or her ideas about the disease but also to the patient's ideas about the illness.
The final example, on metaphors created from a complex social and evolutionary system of survival of the collective at the sacrifice of the individual, is one related to infanticide.Scheper-Hughes (1990) in her controversial article posits that some societies that practice infanticide are motivated by the protection of limited resources for the most viable members of society at the expense of an anomalous or deformed infant who threaten to consume precious and scarce resources if it were allowed to survive.Metaphors equating an abnormal infant to such entities as "hippopotamus", "witch-babies", "fairy-children", "changelings", or "one who has no knack for life" have been reported by anthropologists from the 1950s to 1980s on communities from Africa, to Europe and South America (see Scheper-Hughes, 1990).These metaphors that dehumanise the infants arose in the communities to help members come to terms with the heartbreaking event of giving birth to an unacceptable infant and also to justify actions that would lead to its death.Scheper-Hughes goes on to urge public health officers to understand the conflict between the value systems of such communities and those of developed societies that are rich in resources and support systems for infants born with abnormalities.
The studies on metaphor discussed here show that metaphor as a representation of health and illness is not only psychologically real, but emerges in a dialectic process of reflecting and affecting consequences that impact the lives of individuals and societies.The implications of health metaphor research are far reaching in its effect on patients' well-being, patient care, therapy, medical assessment, public health and overall healthcare delivery.

ORANG ASLI: THE INDIGENOUS PEOPLE IN MALAYSIA
The participants of this study are the Semai people, an ethnic group within the bigger collective of indigenous people of Peninsular Malaysia known as the Orang Asli (indigenous people or "original people" in Malay language).The Orang Asli are comprised of three ethnolinguistic groups which are the Negrito, Senoi and Proto-Malay which can be divided further into distinct ethnic groups.The Semai people are classified under the Senoi group and they populate two states in Malaysia, namely Pahang and Perak.As a minority section of the population in the country, the Orang Asli are underdeveloped in many areas with poverty being a key issue.In 2003, 76.9% of the various Orang Asli groups lived below the poverty line a , and 35.2% were deemed as hardcore poor (Zainal, 2003).In 2014, while the national poverty rate was at 0.6%, the Orang Asli living under the poverty linewas 30.4% (United Nations Malaysia, 2015).
Cultural conflict between members of the Orang Asli community and the "mainstream" community has resulted in the Orang Asli being regarded as "different", often with a negative connotation.It is not uncommon for healthcare personnel to describe the Orang Asli as having to "change their way of life" if they were to benefit from help provided (Mah, in Loh, 2015).The Orang Asli have been reported to be "ignoring" assistance given to them in public health programmes such as the distribution of nutrition (food) baskets to improve their nutritional status.They either refuse to collect the handouts, or do not consume the food after they have been given the baskets of food.In a health emergency that occurred in 2015, children of the Jahai Orang Asli community were reported to have died due to suspected thrush infection (Loh, 2015).Healthcare providers who were mobilised to the site reported that the Jahai people were suspicious of modern medicine and resisted treatment.
While the problems of the Orang Asli are complex and require resolution from multiple fronts, we believe that effective healthcare to the community should begin with developing trust between the Orang Asli community and the healthcare system and its personnel.This can happen only if the "culture factor" often cited as an obstacle to effective healthcare implementation is dealt with.We believe that alongside health promotion programmes instituted by public health experts, effort to promote understanding of how the Orang Asli make meaning of health and illness can help close the communication gap between the community and the healthcare providers who serve them.

METHOD
Participation in the study was voluntary.Participants were members of the Semai community who were residents of a Semai village in Perak.They were above 18 years of age b , and had given their consent to be interviewed.Information about the participants is provided in Table 1.The study adopted a qualitative design where stories of personal experience relating to health and illness were elicited in semi-structured individual and group interviews.Individual or group interviews were conducted depending on the convenience and availability of participants.Eight individual interviews and two group interviews with three and four participants were conducted.There were no discernible differences in terms of the participants' willingness to talk about their experiences whether the interviews were conducted individually or in a group.The authors conducted the interviews with the help of a research assistant, and at least two interviewers were present in each interview session.A total of ten sessions of interviews were conducted with 14 participants.The fieldwork which included preliminary visits to the village to get familiarised with the people and the environment as well as to have the villagers know the researchers and the purpose of their presence took place over a period of three months in 2014.
No question that explicitly asks participants for metaphors were asked.Instead, the questions were directed at eliciting accounts of events and perceptions related to health and illness.Interview questions were prepared as prompts but interviewers were not restricted to using only the prepared questions.The aim of the interview was to encourage participants to speak freely about their experiences related to health and illness.The interview questions are provided in Appendix 1.As the interviews proceeded, the participants were allowed the freedom to lead the conversation as long as they were sharing their views or information related to health, illness, and healthcare that were important and relevant to them.
The interviews were conducted and audio recorded at the homes of the participants in the village.Twelve hours of audio recording was transcribed in the language used in the interview which was the Malay language.The analysis of the talk was carried out on the data in the Malay language.The first author transcribed and translated the data, and conducted the analysis of the metaphors in consultation with the second author.All the authors checked the metaphors identified and provided feedback for refining the descriptions of the metaphors.
The interviews explicitly sought to elicit talk from participants about what they understood about health and illness through the telling of life experiences.All the excerpts presented in the article are expressions that were uttered in relation to health conditions.Utterances that were not related to health conditions, such as in participants' stories about frustration with service provided at hospitals, for example, were excluded.Linguistic expressions used by participants that could indicate conceptual metaphors need not explicitly state the target domain.For example, the expression "The road is blocked" may be interpreted literally as a road being obstructed by some physical object.However, if this utterance is produced in the context of talking about a love relationship, then the utterance, following conceptual metaphor theory, is a metaphorical expression sanctioned by the conceptual metaphor mapping A LOVE RELATIONSHIP IS A JOURNEY.Similarly, in this study, the topic of the conversations with participants had been established as "talk about health and illness".Hence, an utterance such as "Plants that creep" which was produced in the context of food taboos to keep one's illness from spreading, was interpreted as a metaphorical expression that draws from the understanding that illness can spread like a creeping plant.Through such a conceptual mapping, knowledge about creeping plants is applied to health conditions.
In conversations, utterances are often produced in fragments.Thus, one cannot expect to always find complete sentences in the form where linguistic expressions that draw from both the source and target domains are included.The metaphorical expressions derived from the conversations mainly indicate the source domain, as the target domain (health/illness) is understood from the context and inferred from utterances that may be several turns before.To identify a metaphor, words, phrases and clauses that are associated with a conceptual domain were extracted if they were applied (by participants) towards understanding or explaining health and illness conditions.
The scope of this study, and the space constraints in the article, does not allow an extended analysis of the data that incorporates analysis connecting metaphors with the demographic characteristics of participants such as their age or gender.

RESULTS
Metaphors were derived from accounts of health and illness events told by the participants of the study.Fifteen universal and five culture-specific metaphors are presented.Metaphorical expressions, which are the linguistic expressions that are drawn from the source conceptual domain, are provided in their English translations.The original utterances in Malay are provided in Appendix 2.

UNIVERSAL METAPHORS SPATIAL ORIENTATION -PHYSICAL ACTIVITY AND POSITION
The dominant metaphors used in the stories told by the participants were based on spatial orientation.Based on the participants' narratives, the metaphors HEALTH IS UP and ILLNESS IS DOWN present how bodily experience could influence one's metaphorical thought.When talking about being healthy, metaphorical expressions such as these were used by the participants: (1) A healthy person will not sit idle.He will always look for things to do.
(2) We're active and we want to do all kinds of work.
(3) …those who are healthy, they will walk around.(4) The characteristics of a healthy person are .. whether they are working or otherwise, they are active.
These expressions signify the spatial position of being up and about, hence, the metaphor HEALTH IS UP.On the other hand, expressions that conceptualise illness as being "down" are: (6) He is less healthy now.He cannot go anywhere and he just sits.(7) ... kids lose their weight when they have flu or fever.(8) … of course we must sleep….cannoteven get up.(9) … they just sit down and eventually lie down.
The universal experience such as being active when one is healthy and being passive when one is sick contributes to the basis for the up and down metaphors.Similar metaphors found in other studies such as HEALTH AND LIFE ARE UP, SICKNESS AND DEATH ARE DOWN (Nagy, 1974in Lakoff & Johnson, 1980) and SICKNESS AND MISFORTUNE ARE DOWN, HEALTH AND LUCK ARE UP (Joralemon & Sharon, 1993) are evidence that support the universality of the up and down metaphors that are also used by the Semai .

BRIGHTNESS -LIGHT IN THE FACE AND EYES
Another dominant concept associated with health and illness is light.The concept of light was used in the metaphors HEALTH IS LIGHT and ILLNESS IS DARKNESS.Expressions used to link brightness with good health are: (10) If his eyes are bright… (11) Work hard...radiant c In contrast, darkness or a lack of brightness indicates poor health: (12)… their eyes are not bright and they have pale finger nails.(13) When he walks he looks pale/dull and we know that he has a problem.(14) It is like being tired .. everything is pale/dull.
It is interesting to note that from the participants' point of view, the face, and in particular the eyes represent a person's state of health where words like "bright" and "radiant" describing both these specific body parts were mapped to the target domain "good health".When the source domain "darkness" is activated, illness expressions would include descriptions that depict a lack of light.Kövecses (2010) observes that the light domain that is often used in English is a result of our daily encounter with the weather.Good weather during the day will provide plenty of sunlight whereas bad weather turns the day dark.One's daily encounter with either good or bad weather provides the universal conceptual basis for the light metaphor.

MAINTENANCE -PREVENTING BREAKDOWNS
From the stories told, another metaphor emerged.The metaphor HEALTH IS MAINTENANCE is supported by expressions such as: (15) … we need to take care of its cleanliness.(16) Hmm ..health is like .. taking care .. we need to take care of our house cleanliness.(17) We need our surroundings to be well taken care of and clean.
In their effort to keep themselves healthy, the participants talked about the importance of keeping their houses and surroundings clean as their mothers and the doctors have advised.The idea of maintaining one's health may not be something new due to the common usage in both spoken and written discourses.This is an example of a metaphorical concept that most people are unaware of due to frequent use.The "maintenance" concept has been linked to the concept of machinery whereby a machine needs constant checking or maintenance.Extending the concept to the discourse of health, "maintaining" health requires maintenance, which implies good health cannot be taken for granted -it needs effort, regular care, and attention.
In the interviews, the topic on health seemed to be less "exciting" for the participants compared to illness stories, hence, fewer metaphors were found in the health discourse.In comparison, illness stories were told with more excitement and animation, resulting in many and varied metaphors on illness obtained.

PHYSICALLY REAL, YET UNSEEN
Referring to illness as though it is an entity stems from the stories about sakit kampung or "village illness", a euphemism for illness afflicted by supernatural elements.It refers to unknown illnesses believed to have arisen as a result of spells sent by an enemy or a person who holds a grudge against another.When the doctor is perceived to have "failed" to diagnose the illness that one is suffering from, sakit kampung is to be blamed.Often, such illness is "invisible", meaning it can be felt by the individual internally, but externally, there is no evidence that could be relied on to make a diagnosis.The following excerpts taken from the interviews invoke what we describe as the ILLNESS AS AN INVISIBLE PHYSICAL ENTITY metaphor: (18) … if we are coughing, we can cough right?Sometimes when we go to the hospital or clinic, the doctor will say, "Eh, you are fine."(19) Even if you undergo X-ray or blood test, it will show nothing.(20) It happens suddenly like that…That is village illness.I don't know because it is hidden.( 21) For example, if we go to the hospital and the doctor says that we don't have any illness but we feel the pain in our body, we know the cause because the doctor has examined our entire body and declared us healthy.
The perceived contrast between illnesses categorised as sakit kampung and those that are not is that for sakit kampung, tests and examinations conducted by the doctor would purportedly return results that are negative for any ailment, despite the pain or discomfort felt by the patient.Excerpts (18) to (21) show that the lack of a diagnosis from the doctors does not stop individuals from believing they are suffering from an illness, especially one that is hidden from the physician's gaze.Illnesses caused by supernatural elements are believed to be incurable.Although hidden from view, it is something to be feared.The physical existence of the illness in the form of suffering and pain often results in a tragic end for the sufferer.It is noted that the representation of illness as physically present but unseen (and therefore making the patient to appear well) is not peculiar to afflictions from supernatural causes.A similar metaphor DEPRESSION IS A PHYSICAL ENTITY as discussed by Semino (2008) has a similar source domain.Both sakit kampung and depression are viewed as illnesses that are physically present and can be felt, but are "invisible".

PERSONIFICATION OF ILLNESS -IT IS ALIVE
Talking about illness as though it is a living thing can result from one's observation of the effects of some illness or condition such as cancer, infected wounds and skin disease.In one of the interviews, a participant referred to a skin disease as a living thing as it spreads on the patient's body.In her story, the disease was described to have eventually "died" upon the patient taking her medication: (22) The skin disease has already died… Another participant characterised illness as something that is able to "eat" the patient, construing the abstract concept of illness as having the ability to perform an action associated with living things, as in excerpt ( 23): (23) …this one eats from the inside.
Understanding an illness by "giving life" to it shows how the speaker tries to make sense of the illness using a more concrete conceptual platform.The metaphor ILLNESS IS A LIVING THING provides a glance into the participant's perception regarding the illness.Bamber (1987) notices how the Thais use the living thing metaphor when speaking about illness which results from their belief that worms can cause illness when they enter the body.Illness is viewed as a living entity that invades the body.Other than the way the "living thing" works itself into the body, the concept of "life" in the conceptualisation of illness has something to do with the devastating effects of serious illnesses upon the afflicted.When one suffers from a major illness that can be fatal, either one of the patient or the illness "lives", and the other "dies".

WAR AND BATTLES
The advancement of modern medicine has changed society's view of illness, as Sontag (in Goatly, 2007) notes, the knowledge about bacteria entering the body to cause disease saw the widespread use of the military metaphor.War is one of the most commonly used source domains in metaphors, especially in the media.The war on drugs, crimes, diseases and epidemics are often used as headlines and emphasised in both spoken and written discourses.In a story about a man who suffered from sakit kampung related by participants in the study, the family members of the man recalled the experience of trying to cure the illness by seeking both modern and traditional treatments but sadly, the illness eventually "won".Using expressions such as in excerpts ( 24) and (25), they referred to the confrontation with the illness as a "battle to be won or lost", hence invoking the ILLNESS IS WAR metaphor: (24) We have given up.(25) Despite the specialist doctor's help, we have lost.
The ILLNESS IS WAR metaphor represents more than just the experience of illness, but the strong feelings associated with it.Another metaphor associated with the war domain was expressed by a participant who adopted the common biomedical view of asthma as an attack (ASTHMA IS AN ATTACK): (26) … he confirmed that my son is being attacked by asthma.

AUTONOMY AND CONTROL -ILLNESS TAKES AWAY ONE'S INDEPENDENCE
A patient or a sick person may undergo physical as well as psychological changes when they are sick.The changes that a caregiver saw in her husband led to the conceptualisation of A SICK PERSON IS A CHILD metaphor.Expressions such as in (27) to (29) were used: (27)We give him diapers he removes them.He acts like a child…and it was difficult to take care of him.(28) They bathe him, put some powder, feed him.( 29) When he walks he falls down like a child.
Describing her experience as similar to taking care of a child, the participant recalled the challenges of caring for a sick person who is unable to care for himself.The PATIENT IS A CHILD metaphor is one of the parent metaphors discussed by Coulehan (2003).A sick person or a patient is viewed as someone whose decision-making authority has to be compromised, and who would require "parental" supervision.This can be especially distressing if a role reversal within the familial social structure takes place, where a previously dominant decision-maker in the family has to relinquish decisions about his or her existence to a less powerful member of the family, due to illness.Interestingly, biomedical ethics has cautioned against the influence of this universal metaphor and advised caregivers to be respectful of the patient as an autonomous adult.

THE WHOLE AND ITS PARTS -FIXING THE BROKEN PARTS
The mechanical metaphor such as THE BODY IS A MACHINE shows how the human body is perceived as a machine with its constituent parts that enables the participants to talk about their experiences using congruent metaphors like THE HEART IS A MACHINE and THE BRAIN IS A MACHINE.Lexical units that are related to the MACHINE domain were found in the participants' stories: (30) ...they say his heart is already damaged.(31) …finally it leaves him with an asynchronous heart and blood.(32) …his heart and blood are not in sync.(33) …once our brain can function a bit then only we can understand.
The excerpts (30) to (33) were taken from two stories, told by a participant talking about the illness suffered by her husband, and another participant sharing her experience in a consultation with a doctor at a clinic.Objectifying or dehumanising the human body by using the machine analogy creates a sense of understanding that is simpler compared to the complex biomedical processes that may be confusing to non health professionals.The use of the metaphor THE BODY IS A MACHINE is widespread not just in patients' or caregivers' talk.Health professionals are also known to use the machine metaphor (THE BODY IS A BIOCHEMICAL MACHINE) which is said to represent the very heart of biomedicine (Kirmayer, 1988).In the most basic sense, the Semai participants have expressed an understanding of health congruent with the values of biomedicine, that is, parts of the body need to function in synchrony and can break down to cause illness.

BLOOD AS A SYMBOL OF LIFE
The idea that illness is caused by the imbalance in the blood is one of the many folk theories that some communities still refer to when someone is sick.From the account of one participant in the study, the ILLNESS IS DIRTY BLOOD metaphor was found in a story about jaundice.In relating the episode when her son was diagnosed with jaundice, the participant made the following references to the concept of "dirty blood": (34) ... but then he kept crying, apparently his blood was dirty.(35) He felt the pain here because his blood vessel was carrying dirty things to his brain.(36) ...maybe because the vein is carrying the dirty blood, right.
The blood metaphor in which blood is used as a metonymy for life is a common metaphor used by people in different parts of the world.Courtens (2008) points out that the West Papuan people who use the metaphor convey the belief that illness can be caused by polluted blood, and Mathews, Lanninv and Mitchell (1997) who analyse narratives of patients with advanced breast cancer show that "dirty" or "bad" blood is believed to be the cause of the cancer.Metaphorically, the word "dirty" is used to replace medical facts about the illness, and can be interpreted as saying there is something in the blood that has gone wrong.Using the dirty blood concept, two congruent metaphors, JAUNDICE IS DIRTY BLOOD and STROKE IS DIRTY BLOOD were also identified in the participants' stories.

CULTURE-SPECIFIC METAPHORS ILLNESS SPREADS IN THE BODY
The first culture-specific metaphor encountered is ILLNESS IS AN UNCONTROLLED PLANT.From expressions such as: (37) Things that creep, right.Like the type that climbs.(38) ...don't eat this or else your illness will worsen (39) If we don't abstain [from eating the creeping plant], it will come back.
The metaphor ILLNESS IS AN UNCONTROLLED PLANT resembles the living thing concept used in the ILLNESS IS A LIVING THING metaphor.However, the selective conceptualisation of the experience creates the plant metaphor instead.According to the participants, one of the taboos that must be followed when undergoing traditional treatment is to abstain from consuming creepers (creeping plants) as they can worsen one's illness.They believe that when a sick person consumes the creepers, the illness will spread in the body, similar to the idea of creepers creeping uncontrollably on the ground and up the fences if not monitored.The underlying concept of the plant metaphor also suggests that when the sick person respects the taboo, the illness can be controlled, similar to a gardener pruning a plant.The origin of the metaphor may be attributed to the fact that creepers are planted as a common vegetable by the community and the behaviour of creepers are well-known to the members of the community.The semantic property of the creeping plant is then transferred to the concept of the worsening of one's health condition.

ILLNESS EATS YOU UP
Another metaphor that reflects the cultural influence of the community is ILLNESS IS A FEEDING INSECT.The metaphor appeared in one of the participants' story about her husband who was afflicted with sakit kampung.In describing the illness, she said: (40) We don't know, from the outside it looks okay, but apparently the inside is like the wood is being eaten by termites.His bones at the back were full of holes.(41) … this one eats from the inside.
The selection of the source domain A FEEDING INSECT used by the participant is an example of how elements in specific environments can affect one's metaphorical conceptualisation.The choice of representing the effect of illness as the damage caused by termites reveals the dominance of the insect in the lives of community members.Living in an area surrounded by oil palm trees, the Semai village is exposed to threats from termites whose infestation of the villagers' wooden houses would prove to be economically disastrous.Instead of explaining the illness using complicated concepts, the ILLNESS IS A FEEDING INSECT metaphor enables the participant to share her experience as vividly as possible using a simple to understand concept derived from her surroundings.
The two culture-specific metaphors, ILLNESS IS AN UNCONTROLLED PLANT and ILLNESS IS A FEEDING INSECT conjure up frighteningly vivid images of illness ravaging the body.Unlike the universal metaphors discussed in the earlier section, culture-specific metaphors appear to utilise more creative source domains harvested from concrete elements in the speaker's cultural environment.In the same way, the last four metaphors, A BLOOD CLOT IS A LIVING THING, ILLNESS IS THE BODY WITHOUT THE SOUL, ILLNESS IS THE BODY WITH A WEAKENED SOUL and THE SOUL IS FLOWING WATER seem to be constructed using source and target domains that people from a different cultural environment may find a little unsettling.

BLOOD CLOTS ARE ALIVE -THEY CAUSE PROBLEMS
The BLOOD CLOT IS A LIVING THING metaphor was extracted from a story told by a mother whose son had been diagnosed with asthma.According to the mother, the boy was cured from his asthma after attending a two-day healing session organised by the local religious organisation.She believes that the blood clot is the cause of the illness.As narrated by the participant: (42) … the blood clot is alive.When it comes out he feels better.(43) It is a blood clot but it is alive.It is like.. it has pulse.
The "living" blood clot that makes its way out of the body during the healing session provides a conceptual basis for the culture-specific metaphor to be created.The diverse and individualised experience during spiritual healings creates alternative source domains found in the personal stories.Contrary to other blood metaphors that regard blood as a symbol of life, this cultural metaphor specifically targets the "clotted" form of blood as a dangerous bearer of disease.

SOUL WITHIN THE BODY
Illness is described as having a connection with the supernatural world which involves one's soul.The soul metaphor used by the participants in the study reveals that folk theories are still relevant to the community.When talking about illnesses caused by supernatural entities, the participants commented on the relationship between illness and the soul.Without the soul, a person will eventually die.They relate how the absence of the soul can be fatal: (44) How can we retrieve it [the soul] and put it back into his mortal body?We can't.It's like that.That is why from day to day we become more sick and there is no end to it.(45) It means that our soul has been weakened.(46) … it is related to other spirits.. when we are shocked/scared, our soul weakens The metaphor invoked appears to be ILLNESS IS THE BODY WITHOUT THE SOUL or alternatively, ILLNESS IS A WEAKENED SOUL.The metaphor accompanied the story of a man whose health was deteriorating as a result of the "loss of soul", and a story from another participant who asserted that illnesses related to the "loss of soul" cannot be cured by modern medicine.In 1968, Dentan commented on the use of the ruai (soul) metaphor among the Semai people in the discourse of illness.Today, the soul metaphor is still relevant as the community relies on folk wisdom and remedies to deal with some types of illnesses.
Other than using the soul as the source domain, the concept of soul was also used as the target domain in a related metaphor, THE SOUL IS FLOWING WATER.When describing how the soul leaves the body due to an illness, one of the participants said: (47) We are doomed if we are afflicted by spells.Our soul … has left us like smoke floating in the air.It has already spread everywhere like water, right.
According to the participant, when the soul is lost, the chances of recovering from the illness are very slim because like water, there is no stopping it from flowing away in all directions.Dealing with illnesses caused by spells or supernatural elements involve not just men and medicine, but a host of other supernatural entities who must be appeased or negotiated with to enable the return of the soul: (48) …during the ceremony all, like the spirits will come.Then someone will speak to them and ask them what they want for the return of the soul.
The soul is believed to be a central part of one's health which is why the loss of the soul can be fatal and the characteristic of the soul which is "like water", makes it hard for the bomoh (shaman or traditional medicine man/woman) to retrieve it.Hence, THE SOUL IS FLOWING WATER tells of the vulnerability of life which can be snatched away easily just as the soul can just flow away.

CONCLUSION
In this article, we have described the metaphorical representations of health and illness obtained from the narration of stories by Semai participants.From the metaphors gathered from the stories, it is clear that the participants' general conceptualisation of health and illness is constituted by both traditional and modern ideas, and universal as well as culturespecific representations.Health is assessed through visible physical displays such as movement, position, brightness and maintenance of physical surroundings (HEALTH IS UP, HEALTH IS LIGHT, HEALTH IS MAINTENANCE), all of which are expressed as universal metaphors.This shows that in describing health, the Semai participants draw on universal bases, the pool of experiences that are intrinsic to all humans.
The representations of illness are more varied, and straddle the use of both universal and culture-specific metaphors.The high emotion and variety of experiences surrounding illness contribute to the larger number of illness metaphors found.As experience with illness is complex and involves abstract ideas that are not easily understood, the lengthy stories narrated provided more opportunities for metaphorical expressions to emerge to aid the participants in sharing their respective stories.
The many universal illness metaphors affirm the considerable extent of shared understanding of the nature of illness between the Semai participants with other people around the world.This optimistic evaluation is preferred over exoticizing an indigenous community about the way they make sense of the world.Consider the metaphor ILLNESS IS AN UNSEEN PHYSICAL ENTITY, for example.Although the metaphor was expressed in the context of the participant's belief in the supernatural cause of illness, the experience is comparable with patients suffering from any condition that causes discomfort, but cannot be easily diagnosed without further observation and investigation.One such example is connected to mental health, as discussed by Semino (2008) in her DEPRESSION IS A PHYSICAL ENTITY metaphor.Given the resource-scarce situation of the Semai community, it is not inconceivable that complaints of ailments may be neglected due to lack of access to secondary and tertiary medical services.In the face of a perceived dead-end point where biomedical help is concerned, beliefs in folk treatment provide the only solace to sufferers.Extending this further, the reality is that many people around the world turn to prayer or alternative medicine when they have reached their terminal point for medical treatment (the threshold where the terminal point resides differs among patients and is dependent on the amount of resources (economic and knowledge) the patient possesses).This fact has been acknowledged by mental health specialists in Malaysia who agree that mental illness such as schizophrenia may take some time to diagnose and many patients, regardless of level of formal education, turn to traditional healers (see Badarudin, 2015).In order to convince patients to seek treatment from mental health professionals, they suggest that the co-existence model be adopted, whereby mental health professionals should find ways to accept and work with traditional healers to reach out to patients to enable detection of early psychosis.
The Semai participants are not alien to the concept of the body as machine, the metaphor that represents the crux of biomedical practice (Kirmayer, 1988).The conceptualisation of the body as being made up of individual parts that work together for a healthy body and that the role of doctors is to repair broken parts, is well within the psyche of the participants.A question may be asked about whether the participants' belief in the role of the soul in illness is in contradiction with the concept of the body as machine.We argue that the belief in a damaged or weak soul should be interpreted within the broader framework of the soul as a part of the whole being of the person, such that when the soul is broken or gone, it must be repaired or retrieved.To the best of the community members' knowledge, the "healthcare specialist" most able to perform this work is the traditional healer in the village.When seen from this perspective, the participants' understanding of the body and its individual parts among which the soul is one, is thus not entirely incongruent with modern medicine's "a-part-of-the-whole" scheme of thought.
The culture-specific metaphors, in comparison to the universal ones, appear to conjure very vivid images that would seem strange to non-members of the community, but are perfectly logical to insiders.Influences of traditional beliefs in the illness domain are unavoidable as it is ingrained in the accumulated socio-cultural experiences of the participants.The creeping plant, insect, soul, water, and blood clot metaphors are products of metaphorical thought that are shaped by the community's interaction with their cultural environment and their folk beliefs.In cross-cultural communication settings, the overt expression of these metaphors from patients marks them as a "cultural Other" which may become a barrier to building mutual understanding.People are consciously or subconsciously affected by the overt expressions of culture-specific metaphors, especially if those metaphors appear to be in conflict with their own worldviews of what is true or false, right or wrong.A lack of effort to understand the value-system of communities such as that discussed by Scheper-Hughes (1990) could lead to insensitive treatment of or ineffective public health interventions for disadvantaged communities.In the case of Malaysia, members of the Orang Asli communities have rejected interventions by healthcare providers (see Loh, 2015).Conversely, embracing culturally-derived metaphors offered by patients can enhance medical care through more effective communication, as shown in Peterson and Sterling's (2009) asthma experience metaphors and Plug, Sharrack and Reuber's (2009) epilepsy metaphors.
The aim of this article is not to prove or extend the theory of metaphor, but rather to put the theory and its method of metaphor analysis to practical use, that is to apply it in an investigation of a community's representations of health and illness.Particularly, the article makes a contribution to the discussion of universal and culture-specific metaphors in terms of their implications to cultural understanding and healthcare communication with regard to service to diverse communities.
Awareness of metaphor as a process of meaning-making, and not a fixed attribute or mental state of individuals is the first step towards breaking down preconceptions and misconceptions about differences in diverse communities.Healthcare providers' awareness of the underlying meanings of conceptual metaphors can raise their sensitivity to the fears and concerns of the patient and address them by invoking appropriate empowering metaphors.Culture-specific metaphors can alert healthcare providers to the environment and cultural practices patients are accustomed to and address their needs more effectively.
There can be no recipe-book recommendations for effective intercultural communication.However, healthcare providers who are sensitised to interpreting, responding to and invoking metaphors would make competent intercultural communicators as they appropriate metaphors to empower patients towards dealing with their illness and understanding treatment plans.This is possible because metaphors do not only reflect conceptual thought patterns of the user, but are powerful tools in shaping the thinking of users as they adopt and internalise metaphors.
Engaging with culturally diverse patients need not be a painful affair for both healthcare providers and patients if they can be brought closer within the common ground of shared understanding, and as this article has shown, unpacking the deeper meanings of metaphors used by members of diverse communities has the potential to enhance intercultural understanding.It is suggested that further research on metaphor and health investigate healthcare providers' interpretation of metaphors used by patients, and further, towards a more practice-oriented goal, to investigate the extent to which metaphor tracking as a communicative tool for healthcare providers can lead to better communication with culturally diverse patients.

TABLE 1 .
Participants' age, gender, marital status and occupation Note: Names of the interviewees were changed for confidential reasons.