Pain (16 page)

Of course, in the United States pain and relief were political as well—but in a way that reflected America's political tensions. Here, sympathetic commentators in the early 1970s read the success of acupuncture as an affirmation of gate control theory and alternative medical trends. As one writer in the
Los Angeles Times
put it, “The gate [control] theory says that nerve signals from the body can be ‘gated' or blocked while on their way to the brain where the signals will be interpreted as pain. It is believed that the stimulation produced by acupuncture needles cause the gates to be closed, thus preventing the pain impulses from getting to the brain.” Unconventional theory and alternative practice reinforced one another. Gate control theory (still untested) legitimated the practice, and the practice suggested the logic of the theory—it was a neat logic born of these times. While Western researchers agreed that acupuncture worked, there was no consensus on why or how. There were also skeptics. As one observer noted, one theory that could not be ruled out was that “acupuncture analgesia is nothing more than old-fashioned hypnotism.” For adherents to gate control theory, the concept continued to show its value by mediating these clinical and political uncertainties surrounding orthodox and unorthodox relief.
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For Bonica (having built the pain field through the 1960s), acupuncture was also a threat, for it challenged the American pain managers' expertise and tested the field's openness to further liberalization. It also challenged Americans' openness to alternative medicine and further cultural diversity. When Bonica returned from his own China fact-finding tour, he faced an anxious public and a curious press. Fellow doctors wanted his views as well; the National Institutes of Health formed an ad hoc committee to study acupuncture's benefits, appointing Bonica as its chair. At the same time, state legislators and regulators wanted to know how they should regulate the acupuncture clinics that were popping up. In July 1973, the secretary of Health of South Dakota wrote to Bonica about the pressure he was facing to validate acupuncture in his state:

I am certain that there will be legislation introduced into our next Legislative Session which will deal with acupuncture … If you have any personal thoughts on what States should do regarding the control
of Acupuncture I would appreciate them … I know that Nevada has taken a step which is acclaimed by some and criticized by others [to permit independent practice by acupuncturists] … I am not certain that states or governments should take any such action at this time. However, the popularity and the great amount of publicity which the press gives the procedure may dictate action.

Bonica responded cautiously, at first: “The NIH Ad Hoc Committee on Acupuncture which I chair is not involved in legal matters … My own opinion … is to strongly urge everyone involved in legislation that we do not adopt laws which would permit the widespread use of the technique because it will result in exploitation of the American people.” Bonica's home legislature in Washington State took up the issue. The Seattle newspaper headline announced hopefully, “UW Medic Back from China with Prescription for the Future.” Was acupuncture that long-awaited pain prescription?
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If so, how should acupuncturists be licensed and regulated?

Policing now his profession's boundaries, Bonica warned that acupuncture in the wrong hands could lead to fraud and exploitation of people in pain, yet he allowed that the practice had some merits in liberalizing therapy and bringing relief. Interviewed in the Seattle newspapers, Bonica acknowledged that “the Communists have done a remarkable job of improving the health care of the nation” and that “the integration of traditional Chinese medicine, including acupuncture, with Western medicine is working.” At the same time, he praised Western medicine's impact in China, adding that about “70 percent of the operations involved Western ‘local' anesthesia” and “patients who submit to surgery under acupuncture are talked into it by the surgeon.” But, beyond these observations, Americans wanted more from Bonica—they wanted desperately to use his observations on acupuncture to speak to broader issues. For many Americans, the procedure was an opportunity to weigh in on Chinese Communism, on the state of East-West relations, or even on the hope of erasing Cold War divisions between capitalist democracies and Communist totalitarian regimes. For Bonica, however, the politics of acupuncture hinged on its challenge to Western medicine's scientific standards: “the Chinese doctors said they are ‘still experimenting'” with the technique, and he pointed to the “great lack of clinical research on the efficacy of
acupuncture” in the Western literature.
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For him, ultimately, this mysterious form of Eastern relief would have to submit to Western methods of scientific scrutiny.

For some observers defending Western standards and values, what seemed like a political infatuation with Eastern theories and practices had gone too far. The
Wall Street Journal
—well aware of the cultural politics of this Chinese invention—extracted only a political message from Bonica's findings. Seizing on his skepticism, they portrayed his lukewarm acupuncture assessment as a warning to liberal China admirers who were too easily infatuated “with China's political and economic wonders.” In an article entitled “Needling the China Watchers,” its editors opined that “one doctor who recently spent three weeks there reports that twirling those tiny needles isn't all it's made out to be.” Eight-five percent of their surgery relied on Western medicine, protested the conservative newspaper. Acupuncture “doesn't entirely remove the pain of an operation … and furthermore, the Chinese are getting irritated by the way the Americans exaggerate their use of this technique.” In much the same way that acupuncture's virtues were exaggerated, the editors determined that China's economic and political wonders were also exaggerated. “Who knows,” they concluded, “maybe in undergoing [so-called] Chinese miracles the patients do hurt after all.”
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It had only been a decade or so since Rosie Page won righteous relief. Within that span, what had begun as a story of bringing relief to her pain-laden life had blossomed into a sweeping cultural and political program of reform, professional growth, and social reinvention. When John Bonica came back from China in 1973, he returned to a liberal society prized for its openness and commitment to compassionate relief. Judge Learned Hand's dictum that all pain was not true pain was a thing of the past—a theory of pain and hardship that befit another, less forgiving time. But Hand's skepticism had not been forgotten entirely. Even in the era bringing Page, gate control theory, DMSO, Medicare, and acupuncture to the forefront of American politics, warnings about coddling, increasing dependence, the “pathological malinger,” and welfare
simmered—particularly among the more conservative members in the medical profession. Resentment about the era's swelling disability rolls festered. Frustration grew about the compassion-oriented therapeutic society charged with managing pain relief. By the early 1970s, the pain specialists themselves were vocalizing their concerns about hypnotism, methadone, LSD, disability, acupuncture, and other forms of “legitimate” pain relief. For critics, this excessiveness had acquired a name—that name was “liberalism.” In this context, the old fear articulated by AMA doctors in the 1950s about the undeserving pain complainant as a fraud resurfaced and took center stage.

Ironically, while in China Bonica rightly interpreted the ideologically charged character of pain and relief; it was obviously a product of that nation's political turmoil. In his field notes, he described how in the early 1960s the use of acupuncture was “abandoned in some (many?) hospitals. From the guarded comments made by several prominent anesthesiologists, I conclude that this disuse was the result of failures in a significant percent of patients, probably due to improper technique.” The 1960s in China, he noted, was a time of skepticism about the technique. But during the Cultural Revolution this “‘negative' trend of disusing of acupuncture was considered the work of revisionists and subsequently greater emphasis was given to the development and widespread use.” Acupuncture was part of Mao's program of reinvention, with purges and propaganda intended to instill faith in a particularly Chinese form of Communism and national virtue. Returning from this front, Bonica noted, “I gained the definite impression that many anesthesiologists are not so impressed by acupuncture but still extol its virtues and exaggerate the number of cases done … because this is in compliance with Chairman Mao's teachings and admonitions.”
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In China, Bonica was an outsider and an ethnographer; at home, he was a professional pain manager and a spokesman for the field. The political contours and hidden agendas of relief in his own country were not as obvious to discern as in China. In his time, a strong liberalizing wind had established his professional practice, in part by blowing open the gates of relief—the 1956 disability law (SSDI), the 1963
Page
ruling recognizing subjective pain as “real” pain, and gate control theory's validation of diversity and relief. Where there had once been no pain clinics, now there were hundreds across the country. These developments were
part of the formation of a liberal American pain standard. Gate control theory underwrote the era's therapeutic diversity, paying professional dividends for doctors like Bonica.
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Yet, there were limits to this diversity, and growing efforts to stem the liberalizing trend. Only a year before the China trip, Nixon had passed the Controlled Substances Act in 1970 declaring heroin, LSD, and marijuana to be Schedule 1 drugs—the highest form of “controlled substance,” having no recognized medical utility. Regardless of what advocates and physicians might say, the law commanded that they had no role in pain control. But even as the Nixon administration declared war on heroin, it sought a middle ground on pain—endorsing, and then later noting the problems with, methadone as form of relief.

Liberal relief would win other victories in the early 1970s, further opening the gates for palliation. Most striking was the advent of ondemand analgesia and patient-controlled analgesia—the stunning notion that hospitalized patients should determine their own level of relief, rather than request relief from doctors and nurses. Its rise signaled that professionals were ceding control to patients, albeit in contained institutional settings. Patient-controlled analgesia advocates saw the simple act of putting the morphine drip into the patient's hand as the surest step to relief; it was also a political shift undermining the traditional authority of the doctor. By 1968, an apparatus Philip Sechzer invented was being used in New York, allowing patients in postoperative pain to treat themselves. As he saw it, every patient could become his or her own controlled experiment. In England at the same moment, researchers were developing a similar “self-service” concept for women in labor pain; in Palo Alto, California, other researchers developed the Demand Dropmaster; and in Canada, another apparatus for demand analgesia was being created.
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Across these contexts, then, doctors were literally handing the power to patients, so that they might decide how to relieve their own pain. Other innovations, such as Ronald Melzack's widely used McGill Pain Questionnaire, prompted patients to speak for themselves and to describe their pain—was it radiating? spreading? cruel? annoying? terrifying?—and so on.

Skepticism about the claims of people like Page had never disappeared; it lingered and slowly spread among those frustrated with liberalized relief. Bonica's younger colleague, Stephen Brena, had become a
skeptic after building a pain clinic in Atlanta. Every city, of course, had its own pain politics shaped by local views on dependency, drugs, and so on. Atlanta (home of a Democratic governor, Jimmy Carter, with eyes on the presidency) was a cauldron of urban-suburban anxieties about race and liberalism's excesses. Working in this context, Brena began writing about a new problem he called “the learned pain syndrome” and described many people at his clinic as exhibiting a kind of “learned helplessness.” The concept of “learned helplessness” gave a theoretical grounding to the critique of liberal relief. In seeking to relieve the pain of others, Brena suggested, society had created new forms of dependent behavior (learned pain) and fostered welfare. When Brena shared his concerns with Bonica in 1982, the aging founder of the field responded sympathetically: “I share your concern about the proliferation of so-called pain centers throughout the U.S. and other countries.”
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Bonica, like many Americans, was having second thoughts about bringing relief to so many lives burdened with pain.

The topic of pain, in all its complexity, now contained many of the elements that fractured the political Left and the Right. Calling themselves “neoconservatives,” skeptics of social liberalism in the 1970s recoiled against cultural relativism, the expansion of disability benefits and welfare, the false infatuation with Chinese society, and the rise of liberal relief everywhere. Critics charged that American liberals condoned every complaint. They had little patience for those on the far left, like pain reformer Helen Neal, who pushed to bring back heroin as an acceptable form of pain relief.
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The endorsements of subjective pain as real pain had gone too far, skeptics insisted. The disability rolls were exhibit A in the case against pain. To say that pain was politicized anew in this era is to draw attention to the explicit way in which social suffering—ailments that had defined the post–World War II epidemiological landscape—became an index of party ideology in the 1970s.

How should the people's pain be accommodated? How should their plight be managed? And what price would society pay for compassionate relief? These were no longer veiled political questions; they were explicitly articulated positions defining the political Left and Right. In prosperous times, society would tolerate and even champion liberal relief, but, as the American economy faced inflation, rising unemployment, and fiscal uncertainty, the investigative media (like much of the public) swung toward
a hard-edged critique of liberal policies. In a 1972 segment on “low back losers,” for example,
NBC News
endorsed the legitimacy of subjective pain and the pain clinic's importance yet also voiced angry frustration about the “losers … whose learned pain cost the state of California $102 million a year in compensation.” Judges too, sought to moderate liberalism's perceived excesses. In a case involving Manuel Miranda's disability claim, two Republican appointed judges (Bailey Aldrich, a 1959 Eisenhower appointee, and Levin Campbell, appointed by Nixon in 1972) along with Frank Coffin (appointed by the Democrat Lyndon Johnson in 1965), teamed up to articulate a new pain standard. Compassion for subjective pain should have limits, they warned, putting aside the
Page
precedent: “pain is not easily diagnosed, but the Secretary is not at the mercy of every claimant's subjective assertions of pain” when determining eligibility for disability.
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People in chronic pain were now put on legal and political notice—the gates of relief would not stay open.