Pain: The Science of Suffering

A friend was flying over wartime China when he was shot down. He parachuted down, broke his leg on landing, and lay in a ditch beside a road. Many peasants walked by with no signs of seeing or hearing him. Eventually a group picked him up, put him on a cart, and took him to the nearby village. He said he understood those who had walked by because the district was in the shambles of famine, where to take on the responsibility of one more being was a threat to all.

At the opposite social extreme, I came across a crowd standing round a man who had been knocked down on a London street. They stood silently watching as blood spread over the road from a cut artery on his head. I pushed in and jammed my thumb on the artery. After some minutes, the unconscious man opened his eyes and said, in deep Irish, “I’ve had a few jars” (pints of beer). His comrade, leaning on a lamppost, said, “He’s right. We have had a few jars.” The crowd began to laugh and to repeat what the two men had said. I understood their laughter. They had been standing in frozen awe, feeling incompetent to act. Their sense of guilt began to evaporate as the man woke up and declared his drunkenness. The police and ambulance men arrived and looked puzzled by the crowd’s hilarity. These two episodes encapsulate the question of the appropriateness of reaction.

Many of us are brought up shielded from other people’s miseries and drilled in respect for their sacrosanct privacy. At the same time, we are taught not to complain about our own miseries. I still suffer from that upbringing because it is not a good starting point in seeking help for oneself or for others. I am well aware that there are other cultures where complaint has been raised to a high art form. The problem of continued kvetching complaints, audible a block away, is that others come to judge them more for their form than for their content.

If you wish to see real professionals give first aid for pain, watch a football match. When a player is injured, the medics rush in. Their main weapons are massage and cooling. Pain-relieving sprays work only by cooling. Ice packs are applied and, for those without elaborate equipment, a bag of frozen peas from the freezer works wonderfully. It’s all common sense and folk medicine, but it requires a degree of confidence that comes from experience and learning. It is a mystery to me why first aid is not taught to everyone in school. Biology is taught and children end up able to name dinosaurs and identify pistils, stamens, and anthers on a flower, but they cannot tell you what blood is for or why they pee. The aim would not be to produce a gang of overconfident doctors: we have enough of those. It would be sufficient if we grew up with an intrigued awareness of our own bodies in health and an unflinching willingness to offer a hand to others in trouble.

Those who care for someone in pain are involved in a sequence of reactions that can stretch out for very long periods. It begins with fear, which can grow into terror and a sense of catastrophe. Fear is infectious. At first there may be anxiety about the pain and its meaning and consequences. This anxiety can generalize into the caregiver being anxious about everything and can show itself as agitation. We have seen the way the initial period of vigorous escape melds into a quieter period in which the victim guards the painful area and avoids movement. This can be a time of inactivity, loginess, loss of appetite, and a desire to be left alone. After operations or accidents, this phase can continue, even when the pain has gone, into a state where the patient feels flattened, with no energy and a feeling of apathy. This time had not been well studied until recently. It was believed to be the long period of healing and was certainly marked by surprise and frustration when the patients longed to get up and resume their normal activities. This stage of apathy certainly irritates the patients and their caregivers when expectation predicts recovery but it does not come. The condition is similar to chronic fatigue syndrome, although that state is not usually preceded by dramatic illness. Exercise seems to make the condition worse, and the patient is faced with a prolonged, irritating period of passivity with the fading hope that it will eventually go, although it normally does. Self-limiting and puzzling periods of stillness have in the past attracted little sympathy or attention from doctors and are trying times for patient and caregiver.

Professor Hall and his team in the Anesthetic Department at St. George’s Medical School in London recently began a special study of the phenomenon. They compared the course of recovery of patients who had had a hip replacement with those who had had an abdominal operation. Hip replacement these days may be thought of as a routine operation, but, in fact, it involves first the exposure of the hip joint, which is buried deep in the mass of muscle making up our upper leg, and then sawing off the top of the large femur bone and its joint, before replacing it with a plastic and metal prosthesis. By contrast, operations on the abdomen may seem minor in terms of the amount of tissue disturbed by the surgery. The abdominal wall, which is quite thin, is cut open to expose the viscera. These organs in the abdomen and pelvis have a limited supply of sensory nerves. The diseased parts are located and removed and the abdominal wall is sewn up. The speed of eventual full recovery was compared in the two types of operation and a striking difference was observed, with the hip replacement patient bouncing back far more quickly than those with abdominal operations. It is clear that the amount of damaged tissue cannot be the factor that leads to the prolonged exhaustion.

Patients who will have a hip replacement have usually gone through a very long period of developing distress resulting from the slow onset of osteoarthritis. It begins with pain in the upper leg on movement and with aching at the end of the day. As it develops, movement becomes more and more limited and there is extreme difficulty in walking and a nagging pain at rest that begins to disturb sleep. Analgesics help to ease the pain in the early stages but have little effect on the movement, and eventually these patients become crippled and exhausted by their struggle and lack of sleep. They have a very positive attitude to the operation and have good reason to look forward to relief from pain and a return of movement. Many have already experienced the operation on their other hip, and most will have witnessed their fellow suffers make a splendid recovery.

By extreme contrast, people who have their abdomens opened and explored by surgeons have a far more worrying and doubt-provoking experience. They have suffered growing vague discomfort, sometimes not even frankly painful, seeming to originate from somewhere in the depths of their mysterious bodies. They feel unwell and frightened by the very vagueness of what is wrong and what the prognosis might be. Doctors peering into one’s various orifices can be a shaking invasion of one’s guarded personal space. Even more so, surgeons rooting around among one’s viscera is ultimately frightening by itself, and who knows what they found or missed?

The St. George’s group believes that it must be the fundamental difference in patients’ attitudes that explains the striking difference of their long-term postoperative recovery time. They may be right, but one must not forget that the nature of the tissue that has been disturbed by the operation is very different. It could be that the body’s recovery and defense mechanisms are very different when muscles and joints are damaged than when organs within our bodies suffer. It is crucial that we accept this phenomenon of malaise as a problem to be understood and controlled rather than ignored as it has been in the past. Apathy in growing children is famous for driving parents to distraction when their offspring exhibit contemptuous boredom with the very events that lit up the parents in their youth. Caring for a friend who sinks into a torpor of apathy and abandons former pleasures can be equally irritating.

Caregivers must take an attitude to a form of intense activity exhibited by some pain sufferers: the search for cure. This can become an obsession, with the patient being consumed with certainty that somewhere someone has the complete answer. When doctors are involved, this state can move from the sad to the frankly dangerous. The insistence of a pitiful wreck of a patient puts tremendous pressure on physicians and surgeons. Desperation breeds desperate measures. An escalation of invasion can result in the repetition of failed operations and the use of untested, dramatic new procedures. The Sloane-Kettering cancer hospital in New York believes that 23 percent of the pain problems they witness are caused by the therapy. It has been one of the clear advantages of the pain clinics to be discussed later that they have protected patients from excessive overenthusiastic therapy.

A more gentle and innocuous response of patients is to turn to the wide variety of complementary medicine after their physicians and surgeons have failed to relieve their pain. No matter how crazy the theory, these practices flourish. In chapter 9, I promoted the merits of the placebo. The effective alternative therapists have a number of advantages on their side. They can give more time to the patient than the overstretched health professionals. They often maintain an exuberant enthusiasm that has faded in their jaded academic colleagues. They can therefore offer more warmth, optimism, and attention to patients who are beginning to feel lonely and abandoned. The younger alternative therapists tend to be lovely people, whereas cynicism can settle on their seniors.

When pain persists, it is almost inevitable that depression is added to anxiety. With no end in sight and the progressive decrease of possible activity, the patients naturally turn in on themselves. They are sad, and it becomes more difficult for others to cope with the sadness. The patient becomes crotchety, particularly with the well-meaning efforts of others to get them out of their shells. This cycle leads to a sense of loneliness and alienation. “Why me?” they ask angrily. “No one cares.” ‘They don’t believe I am in pain.” “What is going to happen to me?” These descents into melancholy need professional treatment. In the meantime, those who care are themselves pushed to desperation and even anger and retreat. The caregivers face burnout and need relief, a break, and a community to share their problems.

I write as a warning to caregivers about what may happen, not about what inevitably happens. There are those in pain and their friends who have a built-in genius for coping. Their secret is never to deny the pain or its consequences but face both with reality. They observe and experiment with what makes it better, with no expectations of miraculous cure. They become expert at spotting diversions that give brief relief and then expand these periods of distraction until they become a way of life.

Medical, dental, and veterinary schools were set up to purvey the principles of their profession. The cause of disease and fundamental cures were the main target. Symptoms such as pain were mere signposts on the road to the main aim. Symptom control was historically not worthy of the attention of serious men so this task was assigned to denizens of the depths of the hierarchy, such as nurses and physiotherapists. Even dying was not a worthy subject because, by general medical agreement, there was nothing more to be done.

In the past twenty-five years, pain has regained a status worth consideration in these professions. However, there are new powerful, justified claims on the strictly limited time available for medical education. The hugely tempting developments of molecular biology, biochemistry, and genetics have considerable new claims on the time of the students and on the interests of the faculty. To make time, traditional subjects such as gross anatomy have been condensed to a wizened nugget of the former two-year absorption of medical students in the dissecting room. Despite the obvious fact that pain is the most common complaint and the reason why patients visit their doctors, the subject as such has made little progress in capturing jealously guarded class time. In the preclinical years, pain can be “explained” in fifteen minutes by mouthing the hundred-year-old myths that there are pain fibers in the peripheral nerves and a pain tract in the spinal cord with a pain center in the thalamus. A few hours of lecture have been inserted to cover the whole of psychology. The pharmacologist may give a one-hour lecture on analgesics. In the clinical years there may be just a single session on pain. This means that the fully qualified doctor usually emerges with only three to four hours of tuition on pain.

Deans and professors ritualistically bemoan the lack of time devoted to pain, but there has been little progress. It is true that elective courses on pain appear and are attended with enthusiasm by psychologists and pharmacologists as well as medical students. If the table is so bare in the medical school, it is not surprising that nurses, physiotherapists, occupational therapists, and psychologists fare little better in their need to understand the subject that will take up so much of their working life.

In most countries, the main specialities in medicine and surgery include no training requirements on pain management. However, the old neglect may be on its way out. In Britain, psychiatrists have just recognized pain as a worthwhile topic. But anesthesiologists from all over the world have taken up the challenge in a very hopeful way. I know of no other profession in any field that has twice succeeded in doing exactly what they set out to do. In their first fifty years, they aimed to provide pain-free operations and, by the turn of the century, had invented and applied several types of general anesthesia and produced local and regional anesthesia. For their second success, they tackled the problem that they were undoubtedly killing some of the patients with their anesthesia. Within another fifty years, they had made anesthesia astonishingly safe by applying great skill and ingenuity. Now they have refined anesthesia by training the controller to eliminate accidents and errors and to introduce methods while monitoring the patient’s condition breath by breath so that anyone, from early premature babies to centenarians, can be assured of safe anesthesia.

Their old masters, the surgeons, noticing that they seemed to have the patients under remarkable control, began surrendering more responsibility. Anesthesiologists should now keep the patients alive during the operation and see that they recover afterward. This led the anesthesiologists to take charge of the recovery room and move from there into intensive care units, which are more or less the same. Now they were faced with the major problem of pain in conscious patients, and from there it was only one more step to patients in prolonged pain and pain clinics. They now play the leading role in the clinical fight against pain, but the problem is too much for the time and skill of one specialty and the involvement of more is badly needed.

The picture is not pretty in any country. In what follows, I will use data mainly from Britain, which is a middling developed country with a fifty-year-old comprehensive national health service, although about 20 percent of the population also uses private medicine on some occasions. Britain spends 6 percent of its gross national product on health, while France spends 8 percent, Germany 9 percent, and the United States 12 percent.

Obviously, everyone has a fully trained anesthesiologist present during surgery. Some 80 percent of patients are visited for between five and twenty minutes before the operation by the anesthesiologist for examination, reassurance, and familiarization, but 20 percent first see their masked anesthesiologist in surgery. In 1997, the government audited the state of pain control. The Royal Colleges of Surgery and of Anaesthetics had declared that “failure to relieve pain is morally and ethically unacceptable.” The government survey found that 50 percent of patients in hospital had avoidable pain, largely attributable to disorganized guidelines for the staff. Financial pressures increase the frequency of day surgery and it was found that 10 to 20 percent of patients had quite unacceptable pain at home as a result of poorly planned relief. The newer methods of pain control require equipment, such as patient-controlled analgesia, or skilled staff attention, such as epidural anesthesia, but these were available for only a small minority. In order to provide a pain control service on the wards, for accident victims and for crises, hospitals have organized pain control teams that are ready to move to any patients. However, only 58 percent of hospitals had such a team.

John Bonica in Seattle in the 1950s invented the idea of a pain clinic. The idea was that patients referred by other doctors would be seen by a board of experienced pain doctors. Too often, in any country, patients make their own diagnosis and seek one specialist who might be an orthopedic surgeon or a gynecologist or a neurosurgeon. The chosen specialist then does his thing and, if it fails to work, the patient seeks another specialist. This process is clearly expensive, time-wasting, and potentially dangerous. The ideal pain clinic was to eliminate “doctor shopping,” to present the patient to a variety of specialists with a concern for pain problems, and to permit a coordinated treatment plan that could include psychotherapy and physiotherapy. Although this was the aim, it soon became apparent that patients seen in a pain clinic had already seen other specialists who had failed. Furthermore, providing access to many pain specialists was very expensive or impossible.

In Britain, there are some very impressive pain clinics that fulfilled the original ideal. The Royal College of Anaesthetists made it compulsory for training anesthesiologists to spend time in a pain clinic. The result is that 87 percent of hospitals have something called a pain clinic, but 30 percent of these are staffed by a single anesthesiologist, 40 percent have one anesthesiologist and one aide, and only 20 percent approach the multidisciplinary ideal. There is a great need for these understaffed clinics and so there are very long waiting lists. The question now arises of the cost-effectiveness of these less than ideal clinics. The evidence is good that they save money because they decrease the costs of very expensive surgery, drugs, visits to doctors, and home care.

The origin of the modern hospice movement can be attributed to Dame Cicely Saunders. She had learned as a young woman that care of the dying was left entirely in the hands of immensely kind-hearted people who had no training and no support from doctors. The lack of pain control was the most obvious tragedy. By the 1960s, she had set up St. Christopher’s Hospice in London with a staff dedicated to the patients and to pragmatic research on how to ease their misery. It has been a wonderful success story, achieving particularly good pain control without reducing the patients to zombies. It has been widely imitated all over the world, with variations including resident hospices, palliative care wards in hospitals, and maintenance at home with visiting expert teams.

Some patients, most commonly those with back pain, have been in pain for years and have not responded to any of the conventional treatments. There are large numbers of such people hidden away, a perpetual misery to themselves and to those who care for them. Ten years ago, a program was developed for just such people at St. Thomas’s Hospital in London. Groups of ten to twenty people are invited to take part in a program lasting three to four weeks in the hospital. Patients are selected who have been in disabling pain for more than a year, have had complete diagnostic studies, and have not been substantially helped by any of the standard treatments. They enter as a group and organize to look after themselves in a nursing home. For four to five days a week, they become involved in progressive guided programs where they learn about pain and their thinking, decrease the amount of medicine they take, and relax better. The immediate outcome and six-month follow-up has been studied in more than a thousand patients. The aim is carefully explained to them. It is not to abolish their pain but to make them sufficiently confident to liberate them from immobility and from dependence on medicines and on others. It works. By the end of the course, they are walking faster over longer distances, climbing more stairs, and taking less medicine.

It is not at all clear which component of this complex mix is the effective one, and it may well be that the mixture combines with synergy to liberate them. It may be that the group itself is therapeutic with its infectious interactive mimicry. The long-term cost-effectiveness of this labor-intensive and therefore costly course is apparent to the patients’ doctors, as they use less medical care and experience more independence. The goal of complete pain relief and a return to work is a completely unrealistic outcome measure that may occur but that hides the very real improvement in the quality of life experienced by most of these chronic pain patients.

Variations on this type of treatment have spread widely around the world as teams explore the practical possibilities of how to help. The full-time inpatients’ course may seem prohibitively expensive and disruptive, so outpatient visits are used instead. These schemes vary from daily highly programed courses to less and less frequent applications of fewer and fewer varieties of therapy. Eventually these programs become so diluted that they differ little from the old boring routines and are patently ineffective.

The situation I have described leaves a scattered, invisible, underground population of people seriously disabled by their ongoing pain and yet abandoned and ignored. It is not surprising, in this situation, that self-help groups spring up all over the world as patients revolt at their neglect. A typical example was one called SHIP (Self-Help in Pain), founded by Rosalie Everett, a former nurse who had wrecked her back while lifting patients. Realizing that even good-hearted conscientious doctors had little to offer her, and having made her way through the smorgasbord of complementary therapies, including the Alexander technique, she realized that her experience had made her something of an expert. She was determined to share her experience with others and, with the help of local doctors, began to invite fellow sufferers to small group meetings. Such groups could easily turn into moaning misery sessions, where each patient competed with the others to determine who suffered most. Not with Rosalie Everett! She is a positive woman, determined to share useful resources and to offer mutual support. Lecturers were invited, visits were organized, and a community who knew each other was established. A telephone hotline was set up, manned by an experienced person who could talk to people in crisis. A newsletter was published with gleanings from the medical press, government regulations, pension advice, and so on. These groups now appear and flourish in many districts and countries. I am in awe of them. Their success and frequency proves their need. They remind the rest of us how far we still have to go.

By the turn of the century, large pharmaceutical companies began to appear, often spinning off from chemical companies. Now, with growth and mergers, giants dominate. In their beginnings, innovative research with the best brains in the universities established the new pharmacology. In the nineteenth century, Robert Koch proposed that dyes that stained bacteria might kill them. The dye companies set to work, including I. G. Farben (Farben is German for “color”), the traditional fabric dyers in Basel, CIBA, Sandoz, and Hoffman-La Roche. Claude Bernard proposed that plant poisons were clues to important body processes. Henry Dale at the Wellcome Company set about on the analysis of ergot, a fungal infection of wheat that set off lethal epidemics when people ate bread containing “rusty” wheat, which produced St. Anthony’s Fire and Dancing Madness, St. Vitus’s Dance. From this he extracted and analyzed the major classes of compounds that are neurotransmitters. Brown-Sequard pointed out that the glands and the endocrine system are a source of body control, and the Parke-Davis Company isolated adrenaline.

These heady days of adventurous exploration and innovative research have faded from the drug company scene. Hard-headed accountants have taken control and, while profits have soared, fundamental research has shrunk. It is sad to scan the annual reports of these giants and note that the advertising and marketing budgets far outstrip the research budgets. Even the research departments are consumed with the scramble to invent “me too” varieties of drugs marketed by rivals. Caution along with an analysis of sales potential dominates planning. A new aspirin would be ideal, but the gamble to find a treatment for a relatively rare condition would not. A new treatment for diabetes would be a goldmine, but the painful neuropathy of diabetics is too uncommon and short lasting to be worthy of major investment. Only two major advances have appeared in the treatment of pain from the major drug companies in the past fifty years and they are both coincidental side effects: some antiepileptic drugs are effective in neuropathic pain and some antidepressant drugs are usefully analgesic.

But the picture is not all grim. While the old giants play a very cautious game, some of the new biotechnology companies are full of vigor. They are in intimate contact with the frontier of basic research and contribute by making astonishing new tools. Effects on pain have yet to appear, but these companies are hugely inventive and intelligent.

Given the slow start of the professions in facing the challenge of pain, it is not surprising that most governments have trailed behind. The largest medical research center in the world is the National Institutes of Health in Bethesda, Maryland. The size of at least ten medical schools, it contains institutes dedicated to the major conditions such as cancer, heart disease, and so on but not even a section concerned with pain. The French national medical research organization has one excellent unit on pain problems, the Germans have two, but the British have none.

Charities are crucial in the support of medical research. In Britain, the Wellcome Trust alone funds as much research as the government’s Medical Research Council, and the cancer charities support more cancer research than the government. In any country, a multiplicity of charities finance research and the well-being of those with many types of illness, including some with very obscure diseases. Yet no country in the world has a major charity devoted to those in pain. Why is that so? It could be that people wish to see their money spent on fundamental cures, not on symptoms. There are societies that reasonably seek a cure for arthritis, knowing that if they succeed the pain will go. The Multiple Sclerosis Society does not divert funds to determine why those who suffer multiple sclerosis are in pain. The International Spinal Research Trust has in its charter that money may be used only for research on the regeneration of nerves in the spinal cord and may not be applied to symptom relief. There are headache and migraine societies, but headaches could be considered self-contained entities.

This insistence on fundamental cure may be a partial explanation for the absence of pain charities, but I believe that it cannot be complete. After all, there are many excellent, powerful charities for the blind, the deaf, or amputees with the side intention of enriching their daily lives and with no talk of cure or restoration. I suspect that the entire subject of pain encompasses one of the last taboos. It is not a topic of easy conversation. Better to speak of something else that offers a chance of control. I have written this entire book with trepidation. Has it skimmed over an abyss of dark horror that hides a terrible threat? Presumably the reader who has reached this far has found some method of coping with their own distaste of so disturbing a topic. One may read about cancer from a psychologically isolated refuge even if you have cancer, as I do. When I see someone in pain, I confess that I still react with horror and would prefer to retreat. My response is the occupational therapy of working on the topic. I do not believe one can ever be familiar with pain. It is too deep.

Society is not kind to people in pain. Fifty million Americans are partly or totally disabled for periods ranging from a few days to weeks or months. Some are permanently disabled. A significant proportion of chronic pain problems relate to the lower back. Some 60 percent of the British population take more than a week off work for back pain during their working life. In a telephone survey of 1,254 adult Americans, 56 percent reported some back pain in the preceeding year with 3 percent reporting lower back pain for more than a month. Surveys of this type have been carried out in many countries and always show the presence of very large numbers of people in trouble with pains, of which back pains, headaches, and arthritis are the most common. The fact that a proportion are suffering from very prolonged episodes means that available treatment must be ineffective.

One might think that such a vast problem would be a subject worthy of media attention, but in practice there is a wall of silence. The reason for this neglect may be that everyone is so familiar with the problem in themselves or in their friends and relatives that the unpleasant facts are ignored in favor of something new and the evanescent breakthroughs that enchant the press. It may also be an example of a taboo subject from which we cringe.

While silence reigns in public, some doctors have been paying close attention and some label lower back pain as an epidemic. Attacks of low back pain are usually of sudden onset. In a ten-year survey of all workers in the Boeing aircraft factories, attacks were found to be equally common in shopfloor workers engaged in heavy lifting and in clerical workers whose occupation involved only light work. Some 80 percent of the victims had a relief of pain within two weeks but 10 percent were still in pain five months later. Even the brief episodes tend to recur and may become more frequent and prolonged. Very careful testing of people with sudden-onset lower back pain reveals up to 15 percent may have one of five disorders that may explain the pain: slipped discs, displaced vertebrae, overgrowth of bone, unstable vertebrae, and fractures, tumors, and infections. This leaves 85 percent of the victims in the highly unsatisfactory category of “nonspecific lower back pain.”

Many countries have set up commissions to give official guidelines on how to cope with these people. The most recent and infamous is entitled Back Pain in the Workplace: The Management of Disability in Nonspecific Conditions and was written by an international team of experts. Society intrudes to form an unholy coalition of employers, insurance companies, lawyers, and workers’ compensation departments with puzzled doctors. They emphasize the ruinously rising costs of lost work hours, health benefits, and insurance plans. Because the doctors could define no traditional cause for the pain and disability, many of the inspecting alliance were eager to turn to the attitude of the victims as the cause of their pain. A recent survey of the British civil service showed absenteeism to be relatively low among the top-grade executives and the lowest grades, such as postmen, whereas the middle ranks, who face daily hassles, had the highest rate. The Boeing survey identified job dissatisfaction as predicting those most likely to complain to the company of back pain. It seems to me such obvious common sense that those who hate their job and the company will complain to the company. It is hardly worth the trouble of a vast survey.

Ignoring this commonsense explanation, the report on back pain in the workplace concludes that dissatisfied workers cause their own pain. In order to treat this common problem, the report proposes specific treatment. For the first six weeks, the victim of nonspecific lower back pain is permitted only a day or two of bed rest, after which movement is vigorously encouraged with professional help and with minimal analgesic medication. It is quite true that the majority recover during this conservative regime, at least until their next episode. The commission is even more specific about the proper treatment of those still in pain after six weeks. The diagnosis of back pain is to cease and the patients are now to be labeled “movement intolerant.” I take this phrase to be a politically correct neologism implying a work-shy shirker. Furthermore, it recommends a cessation of all further medical treatment on the grounds that it positively encourages patients to consider themselves sick. In order to reinforce this, it proposes an abrupt end to the payment of health benefits and the relabeling of workers as unemployed.

This report is the considered opinion of a very eminent international grouping of establishment experts. They conclude that the problem is no longer for traditional medicine but is instead a social, psychological epidemic and should be treated as such. The Canadian Pain Society objected strongly to the report. All societies contain large numbers of “experts” who have precisely diagnosed the causes of what is wrong with their societies. Immigrants, minorities, and criminals are popular explanations for society’s ills.

One popular idea is that society is sinking under a mass of people who live a life of ease and luxury supported by social benefits. The Australian psychologist Issy Pilowsky invented the term hypochondriophobia to label the tendency in our population to suspect and fear the validity of people on prolonged disability benefits. For example, Italians love to repeat a press fabrication about a man who was on a pension for the blind while also being paid as a traffic policeman. In this atmosphere, in which social and disability benefits are considered mainly in terms of cheating, fraud, hypochondria, and lack of moral fiber, governments concentrate on ways to reduce their social security budgets. This is not a good atmosphere in which to mobilize the mass of good-hearted citizens who would love to take part in social action to help and encourage the lonely abandoned folk who live in pain.