by Ian Leslie
There is no sensation more physical, visceral or immediate than pain; it requires no language skills or education to know the feeling of being slapped, or burned, or struck by a speeding lump of lead. Yet Beecher was suggesting that the pain we feel is deeply affected by the meaning we attach to it. The soldier and the civilian can suffer identical injuries, and their experience of it – their physical experience – depends on how they see the injury fitting into the story of their lives. The empirical truth or falsity of the story is less important than its potency – the power of the idea of a war hero, for example, or a crippled husband.
For years after World War II, America’s hospitals were dealing with its human cost. Wards, surgeries and beds were occupied by veterans lucky enough to have survived the war, but struggling to cope with the long-term injuries it bequeathed them. In the 1950s these patients were joined by men who had been injured fighting in Korea. All of them were attempting to put their lives back together while dogged by persistent, sometimes unbearable pain. While resting, or waiting to see the doctor, patients at Knightsbridge Veterans Hospital in the Bronx and, later, Mount Zion hospital in San Francisco, would find themselves approached by a slight, pale, softly spoken man with large, soulful eyes and a thick Russian accent, asking whether they would be prepared to take part in an interview about their condition. Although he worked for the hospital, the man explained, he wasn’t a doctor. He was an anthropologist.
Mark Zborowski was born in Ukraine in 1908. When he was a young boy his family moved to Poland to escape the Russian Revolution. As a student, Zborowski joined the Communist Party, to the dismay of his parents. In 1928 he left Poland, possibly to avoid imprisonment for radical activities, and travelled to France, where he studied anthropology at the University of Grenoble and worked as a waiter. In 1933 he moved to Paris and became deeply involved in anti-Soviet Trotskyite politics, working for a group led by Trotsky’s son Lev Sedov which agitated to undermine Stalin’s regime. Quiet, unassuming and a tireless worker, Zborowski became Sedov’s most trusted lieutenant.
In 1941, as Europe was torn apart by war, Zborowski moved to the United States, his path smoothed by wealthy New Yorkers sympathetic to Trotsky. One of them introduced Zborowski to the most prestigious cultural anthropologist of the day, Margaret Mead. Impressed by his first-hand knowledge of the culture of European Jewry, Mead offered him a post as her research assistant, a position from which he was able to launch a successful academic career.27 In the mid-1960s, with Mead’s support, he was appointed staff anthropologist at Mount Zion hospital, where he resumed work on a topic he had begun investigating in New York: the ways in which people from different backgrounds cope with pain. He later published his research in the form of a book, called People In Pain.
For the purposes of his study Zborowski classified his patients in four groups: Irish, Italian, Jewish and Old American, or what we’d now call WASP (White Anglo-Saxon Protestants). He was interested in how ex-soldiers coped with their pain, and whether or not their coping strategies reflected their cultural heritage. He expected a high degree of homogeneity in their responses to the pain itself: after all, they had all suffered injuries fighting for the same army, most of them in the same war, and it would seem a truism that a heart attack experienced by an Italian Catholic feels the same as one suffered by a Polish Jew. But as he carried out his interviews with patients and spoke to the hospital’s doctors and nurses, he found that something surprising: ‘People responded to their pain not only as individuals,’ he later wrote, ‘but also as Italians, Jews, Negroes, or Nordics.’
The Italians and Jews were often grouped together in the minds of the hospital’s staff, because they were regarded as highly emotional, and as having a ‘lower pain threshold’ (though Zborowski pointed out that previous research demonstrated such variations in pain thresholds were a myth). They were more likely to express their pain with theatrical gestures, florid language and loud cries, both at moments of peak intensity (when a nurse removed a bandage, for example) and in conversations with the doctor about their condition. Jews and Italians wanted and needed to talk about their pain, to describe the sensation of it but also its effect on their families and careers. They were demonstrative, unembarrassed to shed tears.
Zborowski found significant differences between the two groups, however. The Italian patients were mainly concerned with the immediate sensation of pain as it was experienced in the moment, while the Jews were more focused on its meaning. Italians expressed concerns about how their pain itself would affect their immediate situation (their job and family life); Jews were much more likely to talk, not about the pain itself so much as what it signified for their underlying condition, and for their future – they practised a hermeneutics of pain.
The two groups also had different attitudes to treatment. Italian patients would call out for relief when in pain, but once an analgesic had been administered they would forget their suffering immediately and display ‘a happy and joyful disposition’. Jewish patients were more reluctant to accept medication. They would express concern about side-effects and worry that the drug might be habit-forming, and that though it alleviated their symptoms it would not treat the underlying cause. Sometimes they would only pretend to take the pill, hiding it underneath the pillow. Even when they did take it, they remained anxious and downcast, waiting balefully for the pain to return. Whereas the Italians were sublimely confident in the ability of their doctors to banish their pain, Jewish patients worried that a doctor’s recourse to painkilling drugs meant he wasn’t skilful enough to cure the illness itself, and they frequently sought second and third opinions from specialists.
The biggest contrast to the Jewish and Italian responses to pain was provided by WASPS, who were determinedly unemotional in their responses. They would refer to their pain in a way that minimised its impact. It’s just cramp, they would say, a sore muscle or a backache. They avoided all discussion of it whenever possible. They feared being seen as over-dramatic, and often made remarks to the effect that complaining ‘won’t help anybody’. When pressed, they might quietly admit that the pain sometimes became unbearable, even that it drove them to tears. But they would never cry in the presence of others, and so they sought out solitude. In Zborowski’s clinical but heartbreaking words, ‘Withdrawal from society seems to be a frequent reaction to strong pain.’
Unlike the Jews or Italians, the WASPs much preferred the impersonality of hospital treatment to home treatment. When with the doctor, they assumed the role of a detached observer of their own body, providing an objective description of their state so as to facilitate the correct diagnosis and treatment. Emotionalism was seen as a hindrance in a situation requiring knowledge and skill. WASPs talked about their bodies as if they were cars that needed to be checked periodically and, when out of order, taken to a specialist to be fixed. Their faith in doctors was formed from a respect for scientific knowledge. They were optimists – though their suffering continued, it would only be a matter of time before medical science found the answer for it.
The Irish, like the WASPs, preferred to suffer quietly, but their conception of pain was not without drama. When Zborowski asked Irish patients what they did to relieve their pain, they said things like:
– Well, what can you do? Have to take it.
– Just have to take it, that’s all.
– I don’t mind taking it. I can take it if I had to.
For the Irish, pain had to be ‘taken’ as a fighter must learn to take a punch; it was an opponent, worthy of respect. It would batter them, but it would never take them down. To absorb pain wasn’t passive suffering but a character-forming action in itself, one that bred courage and heroic endurance. ‘Taking it’ was a refusal to surrender, a redemptive act of overcoming. Zborowski contrasted this approach to that of Jewish patients. Here’s how one Jewish interviewee described his experience:
Well, I tell you what I think was pain – and to me I think it
’s a lot of pain. Do you know what a gall bladder attack is? Well, for eight months I took it. I rolled on the floor from this wall to that wall, chewing the carpet. For eight months! Now do you think that’s pain?
Although this patient refers to ‘taking’ pain, he means something very different from the Irish patients quoted above. Here, the pain is more like a demon or a ferocious animal at the throat of the patient. He doesn’t ignore his pain, or manfully soak it up; he wrestles with it, trying to throw it off. There is no morally ennobling contest of wills, just a desperate struggle to escape. In a commentary on Zborowski’s study, the writer David Morris points out that a prominent tradition within Judaism regards pain as evil, without any of the redemptive powers assigned to it in Christianity.
Zborowski’s study is rarely cited by scholars these days, in part because any assignation of characteristics to ethnic groups can be seen as racist. There is justification for such wariness, but it needn’t obscure the truth that our bodies are not just biological machines; they are embedded in social and cultural worlds. The physiology of pain, wrote Zborowski, must be looked at ‘not only in laboratories and clinics but also in the complex maze of society’.
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Days after the Royal Commission’s report on Mesmerism was published, Benjamin Franklin (a pronounced sceptic about religion) wrote a letter to his twenty-four-year-old grandson, Temple:
[The report] makes a great deal of talk. Everybody agrees that it is well-written; but many wonder at the force of imagination describ’d in it, as occasioning convulsions, etc, and some fear that consequences may be drawn from it by infidels to weaken our faith in some of the miracles of the New Testament. Some think it will put an end to mesmerism. But there is a wonderful deal of credulity in the world, and deceptions as absurd have supported themselves for ages.
Franklin might have been intrigued by a 1993 study that collected information on the deaths of twenty-eight thousand Chinese-Americans, together with a control group of nearly half a million white Americans.
In Chinese tradition, the five elements of wood, metal, fire, water and earth are thought to shape the relationship between the body and the natural environment, and each year is assigned to one of them. The researchers found that Chinese-Americans were significantly more likely to die earlier than normal if they had a combination of disease with a birth-year which Chinese astrology and medicine consider ill-fated. For example, those born in earth years are deemed more susceptible to diseases involving lumps or tumours, and Chinese-Americans born in those years who died from cancer did so, on average, nearly four years earlier than those who were born in other years and who suffered from the same condition. Chinese medicine considers the lung to be an organ of metal, and Chinese-Americans who were born in metal years and who suffered from lung disease died, on average, five years earlier than lung cancer patients born in other years. The same was true of a range of other conditions. In all cases, the same did not apply to the control group. What’s more, within the Chinese-American group, the intensity of the effect was correlated with ‘strength and commitment to traditional Chinese culture’. The more people believed in the story, the more likely they were to succumb to the death foretold by it.
People literally live and die by stories. Numerous other studies have found that religious belief is strongly associated with living longer. Even when you grasp the power of the belief effect, it’s still hard to comprehend that metaphors and symbols permeate the flesh as well as the spirit: that they can multiply blood cells, generate protein and disable nerve receptors. But an ability to create and respond to the lies we tell each other seems to be part and parcel of being a creature endowed with imagination, language and culture. Deception is essential to our well-being and, in some form or other, to all of our endeavours. Perhaps there is such a thing as Mesmer’s invisible fluid, surrounding and sustaining all of us.
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As the medical anthropologist Daniel Moerman has documented, one of the important determinants of a drug’s efficacy is the colour of the pill it comes in. When people suffering the symptoms of depression are given the same drug in different colours, they are most likely to get better when the pill is yellow. Sleeping pills, by contrast, tend to be more effective when they’re blue. This last is true of every country it’s been tested in, except Italy, where there is a puzzling difference between the genders. For women, blue sleeping pills are highly effective. For men, they’re much less likely to work than pills of other colours. Although it hasn’t been proven, Moerman’s explanation is that blue has a particular meaning for Italian men: it’s the colour of all Italian sports teams, including the national football team; instead of making them feel sleepy, blue makes Italian men think Forza Azzuri!
Other studies have shown that green pills are better at reducing anxiety, and white pills are best for soothing ulcers. Patients who take four sugar pills a day clear their gastric ulcers faster than those who take two sugar pills a day. Large pills work better than medium-sized pills, and very small pills work best of all. Placebos that patients believe to be expensive work better than those they think cost less. Fake surgery involving impressive-looking, excitingly-named machines works extremely well indeed.
Understanding that pills are not just pharmaceutical capsules, but symbols embedded in a shifting universe of stories helps to explain the mystery of the strengthening placebo effect. During the 1980s and 1990s the global pharmaceutical companies did very well out of the massive popularity of new mood-enhancing drugs. Taking a pill to make you feel happier went from being a science fiction fantasy to an unremarkable fact of life. At the same time, and aided by the loosening of advertising restrictions, the drug companies got much better at marketing their pills. The most powerful brands became instantly recognisable symbols of psychological uplift. As a result of the industry’s success at marketing itself, volunteers taking part in twenty-first century trials are more willing to believe that the pill they are taking will make them feel happier – and so, for increasing numbers, that is what happens. The ingredients of a placebo pill exert no effect; that hasn’t changed. What has changed is the cultural meaning of the act of taking a pill.
The Murderer at the Door
Is there any such thing as a white lie?
Perfection is one thing, and obligation another.
Henry Garnet, Treatise on Equivocation
The Hiding Place, by Corrie ten Boom, is a gripping account of life in a Dutch town under Nazi occupation. The ten Boom family of Haarlem were devout Christians, active in the local community, whose home had for years been known as an open house for those in need. When the Germans invaded in 1942 Corrie was living with her sister Betsie, her eighty-four-year-old father Casper and various other family members. One day a woman with a suitcase knocked on the door. Anxiously, she told Corrie’s father that she was a Jew whose husband had been arrested and whose son had gone into hiding. She had just been visited by hostile German soldiers issuing threats, and did not want to return home for fear of worse. She had heard that the Boom family was friendly to Jews and wondered if she might take refuge in their home. Corrie’s father welcomed her in. Within weeks, the family was harbouring a group of Jewish refugees in the cellar of their home, accessible only via a concealed trapdoor. From then on, their home became known as a safe house for Jews and members of the Dutch resistance.
One evening, two years later, there was another knock on the front door. This was the visit everyone in the house had been dreading. The SS had been tipped off about the Boom family’s illicit hospitality by a neighbour, and now they were demanding to know if there were Jews hiding in the house.
Versions of this scenario have been a recurring theme in the debates over lying for hundreds of years. It appears in various guises but is usually called ‘the murderer at the door’, and often takes the form of a simple question: is it right to lie to the murderer who asks you to tell them the whereabouts of your friend?
It’s an important dilemma, not because people are constantly being confronted with it, but because it frames a fundamental question about the morality of lying in the most stark and dramatic terms possible. Is a lie an inherently bad thing – or is it what you do with it that counts?
Corrie had no hesitation; she lied. The SS searched the house anyway, though they didn’t find what, or who, they were looking for. Two Jewish men, two Jewish women and two members of the Dutch underground remained undiscovered, hidden behind a false wall in Corrie’s bedroom. Corrie was arrested that day, and she and her family were imprisoned. Corrie and Betsie were sent to concentration camps. Betsie died in captivity, as did Casper. It is estimated that 800 Jews were saved by the actions of Corrie’s family and their friends
The Hiding Place also contains an example of somebody taking a very different attitude to telling lies. Corrie’s younger sister Nollie, a pious girl, rarely without her Bible, and known for her rigid honesty. Nollie believed strongly that the Bible condemned lying, and that God brooked no exceptions. One day, previous to the incident described above, Nollie was in the house when members of the SS charged in. She was in the living room with a refugee called Annaliese, whose blonde hair and flawlessly forged papers meant that the German authorities hadn’t discovered she was Jewish. The SS pointed at Annaliese and asked Nollie, ‘Is she a Jew?’ Nollie, unable to break with her principles, said yes. Both girls were arrested, and Annaliese was taken to an old theatre in Amsterdam where Jews were held before being transported to the concentration camps.28