Pain (12 page)

If anyone could judge pain and analyze pain complaints, it was the young, disabled sociologist Irving Kenneth Zola. Echoing an emerging point of view, he insisted that “real” pain was as much a cultural construct as a scientific one. “Today's chronic disorders do not lend themselves to such easy conceptualization and measurement as did the contagious disorders of yesteryear,” Zola wrote. Stricken with polio at age sixteen, he walked with braces and was already on his way to developing disability studies as an academic field. His interviews with two groups of ethnic Americans (Irish and Italian) led him to appreciate the diversity of the pain complaint. Zola found that Irish subjects carried their burden stoically, tending to “deny that pain was a feature of their illness” far more than the Italian Americans. The study of illness and complaints thus merged into the study of cultural norms, for, as Zola put it, whether a symptom found acceptance in a particular society depended on “the ‘fit' of certain signs with a society's major values which accounts for the degree of attention they receive.”
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Pain behavior, in short, was cultural.

Across several expert communities, the pain debate was now fully engaged—and turning into a distinctive cultural debate. By focusing on the culture, psychology, and consciousness of the complainant, a tragic variety of human suffering came into view. “To most people, pain is a simple idea, offered readily but often difficult to define,” observed one neurosurgeon later in the 1960s. But “the physician must remember that pain is a concept, one with wide connotations” in which the anatomical transmission of the pain stimulus was “separate and distinct from its interpretation by the conscious mind.” As a surgeon put it, “The former represents pain, and the latter, suffering.” The legal world—with its battles over awards for pain and suffering and its systems for assessing damages in injury cases—was far ahead of the medical sciences. “In these respects,” the neurosurgeon observed, “courts of law, which clearly recognize these terms, appear to be more cognizant of the problem than the medical profession at large.”
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Theories of pain and disability were varied and unsettled, and they embraced fascinating questions of psychology, the human mind, and perception. As early as 1960, Henry Beecher had observed that placebos could actually be effective painkillers, under certain circumstances. The notion that pain could be controlled with a sugar pill took researchers deeper into the complexities of perception, individual personality, and how previously existing stress could accentuate someone's cry of pain. Forced to broaden its perspective, pain scholarship expanded to incorporate psychology, sociology, and other fields concerned with perception. Drug biology could never explain it all, since even when someone took a pharmacologically active drug like morphine, Beecher contended, “the power attributed to morphine is … presumably a placebo effect plus its drug effect.” This kind of scholarship suggested that faith, culture and belief, and positive personality traits could explain drug action; for, as Beecher noted, “Placebos work best when administered with an air of hope and confidence to an extroverted sort of patient who feels a real need for relief of his symptoms.” Beecher's view of pain as linked to personality and experience became a new standard reference in press accounts and medical writing and also in court arguments and rulings. Pain theory in the 1960s would move deliberately, relentlessly, toward appreciating the power of the subjective, the mind, psychology, and perception in pain and its control.
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Fascination with how people coped with pain and hardship ran the gamut from mundane interest in how a child learned when to complain to concern with spectacular feats of pain tolerance—issues equally of interest to parents, lawyers, scientists, and social commentators. On the mundane end, scientists speculated that average people acquired their pain tolerance from parental conditioning. Critics of the loosening of social mores wondered whether “permissive” parenting (for example like that apparently promoted by the popular pediatrician Benjamin Spock) laid the groundwork for indulgence and adolescent complaint. Or was it true,
Science Digest
wondered, that “a person's reaction to pain may often depend on how he saw his parents behave under similar circumstances when he was a child”? Through spanking, for example, a child was thought to acquire the “‘conditioned anxiety' that keeps his behavior as an adult within socially acceptable bounds.”
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The debate over spanking and pain (and Spock) was another dimension of a postwar debate that fragmented along
cultural, and often generational, lines. Wasn't imposed pain, in some ways, beneficial? Americans raised amid Depression-era hardship, war, and want might have recognized and even endorsed Judge Hand's view—that some degree of pain was essential to becoming a “normal” well-adjusted citizen—but in the postwar years, many Americans surely found the promise of a new pain-free life for children and adults to be appealing.

In an era of prosperity and growing middle-class comfort, cultural feats of pain tolerance could be graphic and shocking. As historian Karen Halttunen has argued, Anglo-American middle-class sensibilities have long been shaped by “spectatorial sympathy” for the pain of others. Watching Buddhist monks and nuns stoically burn themselves in Vietnam protests, American scientists marveled that mental training could so thoroughly sever the link between body and mind and between stimulus and perception. A science writer remarked on the “serenity” in their faces, asking, “Do they not feel the pain, or is their control so extraordinary that they can freeze their facial muscles into a mask of nonexpression?” In a context of war and social turmoil, the question (“How much pain can you stand?”) had no objective answers.
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How people handled their own pain, whether they faced discomfort with grim determination or with cries of anguish, protestation, and demands for relief—these matters wove hardship and tolerance seamlessly into pressing discussions of the era about protest, groups' rights, and social recognition.

Somewhere between the spectacular and the mundane, “new” pain syndromes migrated into popular discussion shaping and reflecting the sensibilities of the 1960s. Readers of the
Chicago Defender
in 1962, for example, were asked to consider the case of a boy named Calvin who suffered from sickle cell disease, an African American ailment defined by “recurring joint pains” that carried its own powerful political meanings. For fourteen years, Calvin carried his burden of recurring pain, then his ailment deepened, and he finally succumbed to it. By the mid-1960s, news of the condition had spread beyond medical journals or the black press. Sufferers with this “common Negro disease” had become symbols of a change in perception—their plight was covered in the mainstream media and turned into a broader plea for racial recognition, intersubjective understanding, and pain relief. “Nor is ‘suffer' too strong a term for what victims of sickle cell anemia go through during a crisis of the disease,”
noted the
New York Times
in 1965. With widening reports, the pain of this chronic disease became a metaphor tied to social recognition and political appeals for urgent relief. Sickle cell was only one example of “new” syndromes and disorders that became political in a cultural sense, linking clinical pain to the civic ideals and demands of African Americans. It was a public anguish calling not only for sympathy but also for the creation of new institutions (in health care and in government) where relief and compassionate care might take center stage.
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As a symbol of pain honestly felt, seeking true relief, Rosie Page was supported by and supported in turn what seemed like a legion of sufferers. A truly open society should be compassionate to their needs. Their subjective pains were real pains; their private ailing was now understood as social suffering. Public anguish appeared in a bewildering variety of forms—housewives, working men and women, athletes, African Americans with apparently “race-specific” complaints like sickle cell disease, and disabled warriors (from the Korean conflict and, after 1965, from Vietnam). Most notable of all was arthritis, which commanded a great deal of attention and provoked contradictory theories about another group, the elderly, and about the gates of relief and the capacity of a prosperous, liberal society to care for its people.
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The most prominent of the newly visible pain syndromes was arthritis, an ailment that cut a wide and worrisome swath through society. By middecade, it starkly illuminated the government's pain relief challenge. Not just a disease of aging, arthritis affected children, athletes, and poor people as well. The Los Angeles Dodgers star pitcher Sandy Koufax had “the most famous arthritic elbow in sports history,” receiving almost daily cortisone injections. When the illness forced his retirement in 1966, arthritis solidified its role as disability threat to the ablest of men. Former president Eisenhower (still an avid golfer) had it in his wrist. It was also diagnosed among children; the poor were said to suffer disproportionately. As the
New York Times
informed its readers in 1965 and as health officials warned, arthritis was a multifaceted crippler. As the
Times
put it, “Arthritis cripples more persons in low-income families than in other groups …
of the 13 million Americans with Arthritis, 50,000 were school-age or preschool children.”
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Despite arthritis's ability to cut across the life course, its impact on the elderly commanded special public concern in the early 1960s. The ailment illuminated a growing demographic challenge (the care of the elderly), and it framed the middecade debate about society's commitment to the aged. As this kind of pain rose to prominence among all the others, it called on government to act, even as the private sector (particularly the booming pharmaceutical economy) also promised relief. Both versions promised compassionate fast relief. At the same time, both stood accused of a deceitful fraud.

Advocates of social insurance for the elderly (emboldened by the election of President Kennedy in 1960) saw the elderly arthritic sufferer—alone and vulnerable to exploitation—as the strongest case for continued health-care reform. In their name, liberal Democrats pushed Eisenhower's disability relief to new levels. The political maneuvering that ultimately produced Medicare and Medicaid legislation in 1965, with its health coverage for people over age sixty-five and for people living in poverty, preserved this image of arthritis. As Democrats pressed for reform in the early 1960s, frequent congressional hearings highlighted how the elderly with arthritis were viciously victimized by both pain and by health quackery. As the chair of the Senate Special Committee on Aging stated in January 1963 hearings, in the “era of the hard sell … the senior citizen is particularly vulnerable to the spiel of the pitchman. When he is ailing and in pain … he will listen to a glib promoter who has ‘the sure cure' for arthritis … The young have time to recoup from financial folly … The results of fraud upon the elderly are particularly tragic.”
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Lacking health insurance (and often uninsurable), older Americans tended also to be poorer and were thus the primary face of health vulnerability.

While new programs like Medicare and Medicaid absolutely expanded the scale of government's concern about elderly pain, other initiatives of the era focused on preventing pain-relief fraud. Liberal concern about pain fraud in this era extended to the predatory danger of marketed relief and thus focused on the private sector and the need to protect vulnerable citizens. The challenge of pain relief was multilayered. Midway through the decade, the U.S. surgeon general labeled arthritis “a billion dollar crippler”—doing damage on two fronts, first because of lost work
hours and second by turning these productive citizens into disabled dependents of the state. Furthermore, such problems of disability and poverty were intimately intertwined, as two legal analysts observed: “Not all who are poor are physically handicapped, and not all who are handicapped are poor. But the two conditions—poverty and disability—are historically so intermeshed as to be often indistinguishable,” explained Floyd Matson and Jacobus tenBroek. For some other experts, echoing the conservative critique, it was the specter of fraud perpetrated
by
the complainant, not
upon
him, that warranted attention. For such critics, the person with arthritis had underlying psychological problems—repressed hostility, poor social adjustment, and obsessive-compulsive character. But for Democratic legislators pushing for Medicare legislation in 1964 and 1965, the fraud of deepest political concern was the more heinous problem of hucksters and drug marketers promising fast relief and preying on poor, gullible older Americans. For those involved in the government of pain relief, arthritis sufferers constituted both a multimillion dollar drug market—and also a problem keeping regulators on their toes alerting “the public to what was termed ‘the $250,000,000 racket in misrepresented drugs and products for arthritis.'”
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The worry over pain-relief fraud originated in the era's relentless and wide-ranging drug innovation—with the pharmaceutical industry boom in drugs provoking a good deal of regulatory worry. Americans' reprieve from the 1962 thalidomide scandal highlighted the wisdom of robust regulation; in that case, a drug promising nausea relief for pregnant women instead caused thousands of birth defects in Europe but not in the United States, where the drug had not been approved by the Food and Drug Administration (FDA). Still, the existing FDA regulations required only that drug manufacturers demonstrate safety, not that drugs—for pain or anything else—be effective. With the government now in the business of acknowledging pain and regulating on the basis of drug effects, distinguishing between legitimate pain relievers and fraudulent remedies was a new problem for regulators, not just for consumers. A wide range of products from large and small drug houses (such as Liefcort, chloroquine, dipyrone, dimethyl sulfoxide (DMSO), and indo-methacin) sat on the fringes of the legitimate market.
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The market itself was unsteady. As the
New York Times
reported in 1966, of the thirteen drug companies that had sold “dipyrone under various trade names as a pain killer and antirheumatic
drug,” most had left the market by late 1964 when the FDA reported on the drug's side effects. Complicating the situation and turning the tables on government as protector, a subset of users desperate for relief were leaving the U.S. to find the drug elsewhere; their supporters now warned that government regulation (in the name of protecting the public's health) was actually keeping wonder drugs out of the hands of those who needed relief the most.
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This burgeoning market, with its capacity for both relief and exploitation, kept federal agencies busy, kept lawyers active, and pulled consumers in multiple directions. As Daniel Carpenter has noted, these controversies slowly strengthened the hand of government regulation. A year could not pass in the 1960s without either FDA warnings or Federal Trade Commission (FTC) threats to pain relief hucksters for misleading advertisements.