Pain (9 page)

Answering Orr's attack, Robert Bell, physician and medical consultant with the VFW, recalled the heroic memory of the men who had fought, sacrificed, and still carried the scars of their service. For Bell, fair compensation for heroic sacrifice was the key issue, not socialism and stigmatized identities: “the factor that has changed is the large increase in number of war veterans due to three great wars within the span of almost one generation.” Government's commitment needed to match its wartime demand on citizens, for, despite the three great wars, “it is difficult to perceive how anyone can read into this program a trend to socialism.” Bell characterized Orr's fears as grossly exaggerated. Furthermore, he insisted, the toll of chronic illness in the system was far lower than Orr alleged. In Bell's telling, the nation was deeply in the GI's debt; they “offered their maximum gift at a time when the country was endangered, and under this program they are only being accorded limited health benefits in their hour of individual need.” Not only were they worthy of care and compassion but it was “the height of folly to endanger a restricted but humane policy and program which so fully expresses the goodness, the humanity, and the moral leadership of this great country.”
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Orr responded by taking issue with Bell's liberal vision of the soldier's pain as worthy of the largesse of relief. Wasn't pain and sacrifice a normal duty of citizenship? “The performance of the duties of citizenship cannot be expected to be painless or free from sacrifice,” he contended. Here was the crux of the disagreement. Pain and sacrifice were expected of all citizens; to expect otherwise led the nation down a dangerous path. But disability relief now allowed the Trojan horse through gates; and, in its shadow, the ideological scaffolding of an American pain and disability debate came into view. Complicating the debate was the fact that the line between citizen and soldier had eroded. As the Bradley report eloquently noted in 1955, “Changes in the nature of warfare are making the old concept of ‘veterans' obsolete. Peacetime conscription, total war, and the threat of atomic warfare tend to blur or erase the line between the man in uniform and the civilian.”
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Now with the passage of SSDI, other groups (the elderly, children, women, African Americans, workers, and so on) who, critics charged, had even less of a claim for relief than veterans were swept into the controversy. The alleged character of
their
pains and disabilities (Were they heroic? How much had they sacrificed?) would become a moral and political battleground. All pain of course was
not equal, but now the medical expert was compelled to “rate” differences in disability and pain. The soldier's anguish and the aging citizen's complaints needed to be measured, using monetary yardsticks. New pain complaints would appear as well. Claims of pain specific to black Americans (such as sickle cell anemia, discussed in the following chapter) would carry yet another set of political meanings. Which of these complaints were real? Which deserved relief? How much relief? In the shadow of the disability law, these questions came to define a major political rift—with one side wishing to expand services in the name of compassion, and the other warning of a coddling, creeping loss of social vigor and values in society.

Pain became a signifier with potent political and psychological meanings. For many physicians writing in the late 1950s, the pain complainant became a tainted symbol of much that was wrong with society—a particularly vexing type of what sociologist Erving Goffman called “spoiled identity.” To California psychiatrist Henry Albronda, people who complained about chronic pain were maladjusted; they should be studied with caution and listened to with sympathy, but they should never be offered quick relief. Two political developments concerned him: not only had the federal government liberalized disability relief, but so too had his home state of California. Had the war years taught Americans nothing about pain? Studies showed, he said, that even during the war, the “psychosomatic backache” was the most common type of “functional backache among troops”—originating from anxiety and nervous energy. Speaking at a pain symposium in San Francisco in 1957, he grouped migraine headache, cardiospasm, and low back pain with all these vague “problems of psychogenic pain.”
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Albronda drew a direct line from the war to the postwar pain complaint—as if civilians had learned from the vets' poor example. He had emerged from years caring for soldiers at war with hardened skepticism. Compassion only made people in chronic pain complain more, he insisted. The hidden truth was this: many were simply maladjusted malingerers. He pointed to earlier studies showing that “all patients who complained of phantom limb pain had considerable psychopathic disturbances … Men who had dominant psychopathic traits and reacted poorly to their disability tended to be more demanding and complaining than those with sound personality before the injury.” In persistent chronic
pain sufferers, “masochistic self-punishment underlies [the] chronic painful condition.” Their sickness, in other words, went deeper, to a fundamental psychic imbalance.

The conditions were ripe for a psychological theory of pain complainants not as sympathetic heroes but as pathological; their indulgence emerged as a major social threat. For Albronda, Orr, and others, the soldier's professed pain had opened the way for government to become a destructive parent. Patients, doctors, politicians, and others were guilty, in this view, of nurturing the pain complaint, expanding access to free care, and exaggerating the severity of slight ailments. Reflecting also a Freudian turn in postwar psychiatry, Albronda saw excessive mothering in childhood as the real origin of the pain complaint. Parents (like government) needed to be on high alert lest chronic complainers get too much attention, gain easy relief, and grow to take advantage of others with their selfish dependence. “In most families,” Albronda stated to his colleagues at the pain symposium, “the young child soon learns that his cries of pain bring solicitude, and later he runs to his parents for comfort whenever he is hurt.”
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Whether in the family or in society, providing impulsive relief for every complaint was deeply misguided.

The expansion of disability benefits catalyzed this critical theorizing about pain, with doctors like Albronda describing the new pain persona as a thick web of repression, self-deceit, and fantasy. They had been conditioned by society to be plaintive, and they were being rewarded for this destructive behavior; this was the beginning of a conservative critique that would simmer and boil over the following decades. The pain complaint may develop, he noted, “in the child who secretly enjoys seeing the punishment of siblings, then punishes himself by fantasy for enjoyment … Or,” he added, “the child brought up to repress feelings of hatred may as an adult use complaints of pain to cover his hostile feelings toward an associate.” In contrast, “a well-integrated, adaptive person can disregard the not overpowering peripheral stimulus,” he wrote.
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Professional self-interest and frustration with the gatekeeper role led many such doctors to the same conclusion—that the pain complainant was a symptom of something deeply wrong with the government and society that produced him or her; pain was not a problem to be taken at face value or remedied impulsively with drugs or medicine. It symbolized what we might call a crybaby society.

Doctors were not alone in seeing the moral and economic stakes of illness and in theorizing pain; observers like economist Barbara Wooten, sociologist Talcott Parsons (writing on the “sick role”), and many others saw that shifts in the burden of responsibility were afoot. “The concept of illness expands continually at the expense of the concept of moral failure,” wrote Wooten in
Time
magazine in 1956, “The significance of this question of who is sick and who is sinful cannot be laughed off as ‘merely semantic'” The war experience of soldiers was one arena of debate, but now a new national debate about citizens was replacing it. There are “practical consequences” to “drawing the boundary between health and illness in one place rather than another,” Wooten observed. Were complainants sick or sinful? she asked. And who would carry the burden of their care?
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A bevy of specialists, new theories, and entire industries (not to mention new government programs) were emerging around the treatment and management of pain in this era; but if pain was being turned into profits and revenues, the process was a complex one. The case of arthritis highlights just how many economic interests and tensions this commodification of pain provoked. As the
New York Times
explained, arthritis “attacks the aged, the young and those in their middle years. It causes not only physical suffering but also economic and social hardships.” By some estimates, it affected eleven million adults and children, caused eighty million lost workdays, and (most troublingly) made “300,000 workers totally unemployable each year; it robs them of more than $1,000,000,000 a year in wages.” The search for pain relief, as the chair of the Arthritis and Rheumatism Foundation saw it, also drove millions of Americans into the arms of charlatans and quacks, where desperate people spent $250 million a year on fake cures and promises of relief. But even legitimate and proven pain relievers, like the booming tranquilizers, were subject to growing criticism, with
Time
magazine calling them “don't-give-a-damn pills” because of their ill effects on people's consideration of one another.
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With quacks selling false relief on one side and government offering disability benefits on another, doctors stood at the center of an often frustrating pain relief economy, but so too did lawyers. Thus, pain forced physicians to contend, for example, with personal injury attorneys like Melvin Belli (a man who earned the nickname the King of Torts for his pioneering work in personal injury law). Writing in 1951, Belli commented that “pain is not a readily measurable commodity. Trial juries and judges may never
be able to return verdicts for seemingly identical injuries with the precision that a cigarette machine vends an identical package for an identical coin.” Not only did pain thresholds vary from one individual to the next, Belli knew, but the economic consequences of pain varied and received different payouts: “a disabling injury to the wage earner may be more financially catastrophic than the same injury to a non-working housewife.” As an advocate for injured people in the private tort system, Belli had known for some time what doctors who had been pulled into the disability system were only just realizing—that “pain … may depend upon counsel's imagination and vividness of portrayal by demonstrative evidence.” As J. L. Barritt, the San Francisco-based medical director of the state's Industrial Accident Commission, noted, the doctor faced a dilemma when it came to assessing the thresholds, the character, and the evidence of subjective pain.
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With all these economic, moral, legal, and medical theories and agendas surrounding them, people in pain stood at a troubling political nexus; many were accused of a perverse and deceitful commodification that put the nation at risk. “No one but the patient himself knows exactly how severe his symptoms are. They are in a way his stock in trade—as yet unpriced,” noted Barritt. It was doctors and lawyers—called upon to study ailing people and characterize disability—whose theories, battles in the courts, and final judgments could turn this “unpriced” stock into a compensable disability. In dramatic courtroom settings, pain was becoming
commodified
—a term drawing our attention, as I've written elsewhere, “to the processes by which bodily experiences such as pain are assigned value (monetary and otherwise) by physicians, patients, insurance companies, and others.” Men like Barritt, however, voiced unease and resignation with this new task of “distinguish[ing] between the subjective
complaint
and actual subjective
disability
.”
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Who could blame physicians for being frustrated with policing pain and managing relief in postwar society? The new political economy asked much more of them than they could comfortably deliver, not only about the measurement of pain but also about monetary compensation for subjective illness. Writing in 1957, one Southern California doctor felt pressured by insurance companies for accuracy: “the increasing attention given in recent years to the question of insurance coverage for the expenses
of sickness has caused the public and insurance companies to be more conscious of the cost of medical care.” For insurers, the stakes were clear: defining where sickness ended and malingering began was a crucial business problem.
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The rise of both private insurance and public compensation of the VA variety raised worries over so-called perverse incentives—whether payment for sickness encouraged people to prolong their disability. For professionals, other incentive problems appeared. For surgeons now fighting with insurance companies to be paid for their procedures, few compensation issues were as contentious as whether operations for back pain would be reimbursed by insurance plans. This was the new pain relief economy at work, as doctors were drawn, by force of law, into the era's disability debates. In recoiling from these postwar trends, some physicians expressed their frustrations with government, private insurance, and the gatekeeper role through their disdain for the complainant.

“Pain presents us with a series of paradoxes,” wrote physician Louis Lasagna in introducing a special 1956 issue of the
Journal of Chronic Disease
devoted to the problem of pain. Pain is widely experienced, “yet pain is almost impossible for anyone to define adequately.”
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Absent consensus, the politics of pain meant that some medics like Lasagna gravitated toward compassionate relief while others like Albronda saw complainers (not pain per se) as the problem. Pain in all its confusing duplicity had arrived—a mysterious, worrisome presence in postwar society. Lawyers, insurers, drug marketers, and scholars, too, gathered around pain, regarding it with puzzlement and wonder, unable to see inside and worried about the dangers or profits lurking within. From this point forward, the question of pain would never stand apart from these economic and social interests—drug companies pushing their brand of relief, and private insurers and government administrators weighing their commitment to care against their fiscal concerns and the needs of veterans, the aged and other groups. But it was the physicians who worried loudly about the spoiled and suspect identity of the person in pain. In the shadow of two wars, contending with an aging society and fearing a postwar expansion of government many deemed to be a socialist threat, many of them saw the pain complainant as a tainted symbol of the indulgence, permissive social conditioning, easy access to welfare, and excessive
liberalism that was destroying the nation. In time, this argument became the cornerstone of a conservative critique.