‘Pain: A Political History’ by Keith Wailoo (Johns Hopkins University Press, 2014)
In Pain: A Political History Keith Wailoo surveys American social legislation since World War II in terms of its impact on people who experience pain. To organise his narrative he divides politicians and advocates in two groups: those who prefer self-sufficiency and minimal intervention by the government, and those who think the government should provide a safety net for its people (pp. 1-5). This classic division of conservative and liberal perspectives on the role of government predates the end of the War when returning veterans found they were eligible for the GI Bill which provided educational and housing benefits to ex-servicemen.
The veterans were also able to apply for benefits for service-connected disability. A designated body, The Veterans Administration, had devised criteria that allocated stipends based on a percentage of total disability. Loss of limb or sight counted more than headaches. Pain was a symptom that was included in the overall presentation. Since it was a complaint difficult to verify through tests and labs, pain became a target of those who objected to people seeking assistance.
Wailoo has a penchant for dichotomies. He places the liberal-conservative axis on top of a dependency-self-sufficiency continuum, which become destabilised in his attempt to link these divisions with Republican and Democratic Party affiliation. In the postwar period moderate Republicans could champion benefits for veterans. Dwight D. Eisenhower, the Supreme Allied Commander in Europe during the war, as a Republican president supported setting up a Social Security Disability programme as part of the Social Security retirement program begun during the administration of the Democrat Franklin D. Roosevelt in the Great Depression. Eisenhower also appointed General Omar Bradley to chair a commission to look into disability benefits for veterans.
After the war the Veterans Administration saw an increase in claims for housing and education followed by more claims for disability. The shift from benefits that would enhance independence to those that would acknowledge chronic infirmity led to debates about individual and collective responsibility for people’s way of life and misfortune. Symptoms like pain and fatigue could elicit the most derogatory comments about malingering. The debaters were advocates for patients and people who felt these experiences of health challenged fundamental American views about its role in history.
In these debates Wailoo found another polarity: veterans seeking benefits and the American Medical Association (AMA) which opposed government financing of health care (pp.20-22). His poles start to totter in the Sixties when Vietnam veterans protested the war older veterans championed. The hegemony of the AMA over physicians broke down. The AMA came to be seen as an organization of older doctors who did not represent the increased number of women and minorities entering the profession. Physicians championed their patients’ applications for disability benefits. The forms they learned to fill out became part of the system of reimbursement for services.
In his review of disability legislation that set up criteria to monitor pain and other symptoms that relied on patient’s accounts, X-rays, and laboratory results, Wailoo tends to rely on reports and newspaper articles about legislation. He does cite the case of Rosie Page, who sought relief and benefits for her arthritic pain. He is interested in the role of the patient in determining the degree of her pain and the impact of other symptoms such as anxiety and depression on her pain (pp. 57-59). Her pain can be seen as a cover for her anxiety while her anxiety can be a result of the pain.
Concurrent emotional and existential problems complicate the assessment and treatment of pain. People sometimes prefer to talk about back pain instead of their disappointment and worry about home and work. Simply prescribing an analgesic and recommending physical therapy can miss the larger point but also respects the patient’s request to acknowledge the pain and not attribute it to some other cause or motive.
In the latter half of the century psychoanalytic theories of pain and psychosomatic illnesses were replaced by a biopsychosocial model of illness and research based in patients’ answers to questionnaires about life changes and stress. These models and theories were obsolete by the end of the century when procedures such as CT scans and MRI’s facilitated research into the neuroanatomy and physiology of pain.
Wailoo’s study ends with the biopsychosocial era of the 1960’s and 1970’s. He suggests his position on the pharmacological treatment of pain by referring to medication as drugs pushed on patients and physicians by a pharmaceutical industry eager to increase its profits (p.169, pp. 173-175). He contrasts the work of Dr. John Bonica, a 1960’s pioneer in starting interdisciplinary pain clinics with physicians who performed lobotomies on patients with severe pain (pp.33-37). When introduced in the 1940s, lobotomies were usually recommended for patients with severe emotional ‘disorders’. They were replaced in the 1950’s by major tranquilizers such as chlorpromazine for the treatment of schizophrenia and other major illnesses.
As the century progressed, patients were but one of many who determined the character of their pain. Ironically those who objected to the role of government in healthcare could be the most determined to intrude into the life of the individual patient In fetal pain outside observers determine pain by noting movements of fetal extremities not reports by fetuses. When discussing end-of-life care Wailoo not surprisingly emphasizes pain rather than the loss of autonomy people face when terminally ill (pp.141-143).
Pain: A Political History is a useful introduction to a study of the role of pain in postwar American legislation on disability, physician-assisted suicide and fetal pain. As a discussion of political history, its focus is on public debates instead of personal accounts of the experience of pain. It is a short book (213 pages of text), and developments in the care of patients and research on neurophysiology and psychology are mentioned only briefly. The book’s relevance to the medical humanities may lie in its reference to concepts of agency, autonomy, and suffering in the political context of pain but does not discuss their meaning.
Reviewed by Anastasia Kucharski, M.D., a psychiatrist who has taught at Harvard, Tufts and Columbia medical schools. Her publications and lectures have been in the history of medicine, political psychology and applied philosophy.
Correspondence to Dr. Anastasia Kucharski