Where Does it Hurt?

By Joanna Bourke

Pain compels sufferers to “pay attention.” Suddenly, the person in pain becomes aware of her body—the clutching at the throat, the rough thump-thump in the region of the heart, the rumbling of the stomach, or the piercing spasm in the lower spine. Witnesses to suffering are also part of the drama of pain. They watch, listen, and judge. Is her pain real? Is it mild or severe? On a scale of one to ten, in which “one” represents “no pain” and “ten” is “the worst pain possible,” is it a two or an eight? The suffering person knows that worlds of unhappiness rest on the way she communicates her pain to these witnesses. As an author known simply as “A Mother” advises her children in Hints on the Sources of Happiness (1819), if a person enduring “bodily torture” comports herself correctly, she could stimulate in witnesses “a pity, a love, a veneration that binds him perhaps for ever after to the sufferer.” Implicit in such instructions is the assumption that sympathetic communities could be forged only if the person in pain followed certain rules of comportment. People in pain need to follow the appropriate pain script: they need to learn to “suffer well.”

Sufferers have always sought to communicate their pain. However, they have repeatedly been dismayed not only by how difficult it is to find the right words to talk about their disruptive body but also by the often-dismissive attitude of those people who profess to wish to help them. It is no exaggeration to say that a political and cultural war is being waged against people in pain. And not just any sufferers: those whose aches are most likely to be disparaged or even ignored altogether tend to be poor or female. In contrast, the people who decide who deserves to be relieved of pain are those with power: physicians, pharmaceutical companies, politicians, lawyers, and judges.

This is the problem that Keith Wailoo addresses in his book Pain: A Political History. It is a brilliant exposition of the political function of physical suffering in the second half of the 20th century. Wailoo, the Townsend Martin Professor of History and Public Administration at Princeton University, has a reputation as one of the most distinguished commentators on the health of Americans and the politics of medicine. This latest book is a forensic analysis of the political realities of pain in America.

Although the book is about polemics, Wailoo is relentlessly even-handed. He shows how Republicans and Democrats, conservatives and liberals, seek to appropriate pain to their cause. In the aftermath of the Second World War, U.S. health policy was forced to undergo a major overhaul. Universal military service had changed the relationship between citizens and the state. The battleground was decided when President Truman fought for a “fair deal” for wounded veterans, arguing for the establishment of compulsory health insurance, and the American Medical Association disputed him by evoking fears about “socialized medicine.”

The clash between those who fear the provision of public relief on the grounds that it creates “Big Government” and dependent people, against those who reiterate the duty of governments to their citizens, has contributed to the neglect of suffering Americans. Certain themes return time and again: health commissioners, politicians, and physicians debate how they can truly know whether a complaint of pain is real or simply an excuse for shirking. How can pain be objectively calibrated? How much was each ache or sting worth in dollars? Crucially, who should be allowed to decide?

Unsurprisingly, physicians found themselves at the forefront of these debates. But they often turned out to be reluctant assistants to people in pain. For example, in 1955, General Omar Bradley’s Commission on Veterans’ Pensions asked 153 eminent physicians whether pain and mental anguish should be taken into account when calculating pension entitlements. These doctors fretted over the reality of “subjective symptoms;” they confidently declared that many veterans were malingerers; they were concerned that pensions would penalize the stoical ones; and they worried about the lack of an objective way to measure pain. These anxieties recurred throughout the century.

People in pain were made into convenient symbols for what was thought to be wrong in society more generally. In the 1960s, for instance, “permissive parenting” was blamed for the lack of forbearance among youth. In the 1970s, there were fears that suffering was a form of “learned dependency.” As Steven Brena argued in his influential book Chronic Pain: America’s Hidden Epidemic (1978), people who fixated on their suffering ended up hurting more. Those who had less of a stake in their pain seemed to feel less agony and respond better to medication. Whatever the period, “dependency” and “addiction” were the twin goblins to be feared above all else.

The socio-political nature of these debates was especially evident in the rapid adoption of the “gate control theory” of pain. Introduced in 1965 by Ronald Melzack and Patrick Wall, this new theory drew on research in computer science to argue that people were processors of information. Melzack and Wall proposed that there was a “gating mechanism” in the dorsal horns of the spinal cord that allowed the perception of pain to be modified. In other words, cognitive and affective processes (as well as physiological ones) influence how people actually experience pain, and non-painful stimuli could “block” or suppress the sensation of pain. It was a theory that was receptive to more “alternative” treatments, including hypnosis. Crucially, it endorsed subjective feelings—resonating, Wailoo notes, “with the era’s legal battles, cultural critiques, pain relief practices, and liberalizing political commitments.” Even scientists who were ambivalent about gate control’s scientific underpinnings ended up endorsing it. After all, it worked. As senior pain researcher P. W. Nathan rather grumpily concluded, “although the theory has led to the successful treatment of chronic pain, this does not mean that it is correct…. Ideas need to be fruitful, they do not have to be right.”

Wailoo’s book should be read alongside Daniel S. Goldberg’s The Bioethics of Pain Management: Beyond Opioids (2014), who shares Wailoo’s dismay at pain medicine in the United States. Both scholars lament the failure of the health care system and practitioners to take account of the social and cultural contexts in which real people in the real world suffer. They acknowledge that both the problem and the solution are political. Access to effective pain relief is stratified. Wailoo shows that Americans are “overmedicated and undertreated.” The problem, though, is that it is the rich who are overmedicated; the poor, undertreated. As Wailoo observes, in the Reagan era “the pain of the taxpayer was true pain; the pain of the disabled or the addict was suspect. The pain of the fetus outranked the alleged pain of the disabled housewife or injured worker.”

Wailoo castigates both conservative and liberal positions. He calls on readers to pay more attention to the political motives of people who make claims about pain, whether they are politicians, spokespeople from the pharmaceutical industries, physicians, or even pain-sufferers themselves. Wailoo’s subtle and critical exploration of these claims illuminates the contested ground that pain occupies in U.S. political culture.