Book Review
Book Review | Pain: A Political History by Keith Wailoo (Johns Hopkins University Press, 2014)
Indiana University Bloomington
oliadams@iu.edu
The ubiquity of pain as an enduring medical problem reflects Keith Wailoo’s argument for its enduring politicization in Pain: A Political History, an investigation of US twentieth- and early twenty-first-century pain policy. Throughout the text, he stresses that pain emerged not as a uniquely medical affair, but rather an issue of morals, ethics, governing, and legality. As a result, legislatures, federal and state courts, as well as patients and medical providers contributed to the issue of managing pain relief technologies and providing monetary support for chronic pain patients through disability insurance benefits. Furthermore, the largely partisan debates surrounding pain policies gave rise to a number of larger issues; pain became a lightning rod for pointed debates regarding trust, ideal citizenship, and consent.
Wailoo utilizes the first two chapters of this book to ground his primary arguments. In Chapter 1, he explains the roots of Republican and Democratic antagonism regarding pain policy. The return of veterans, combined with rapid advancements in pain medication and the beginning of pain treatment as a specialization within medicine, raised important questions about the role of pain in formalized constructions of disability. Republicans feared that the stoic, independent veterans returning from military service were left behind while their complaining counterparts took advantage of liberal attitudes that sought to expand access to pain relief and support through the inclusion of pain as a recognized disability. Chapter 2 continues this debate, introducing the idea of pain fraud and increasing Republican anxieties around disability benefits and the legitimacy of chronic pain. Medical expertise also was not as clear cut as Republicans may have hoped, as physicians on either side debated best approaches for treating chronic pain. The development of gate control theory reinvigorated the pain debate and bolstered ongoing efforts to liberalize pain policy; according to Judge John R. Brown, “if pain is real to the patient,” then disability benefits administrators should believe them (quoted in Wailoo 2014, 62).
With the arrival of the Reagan administration in Chapter 3, the decades-old battle between stoicism and dependency arose again, this time in an effort to demonize people with chronic pain and weed so-called fraud out of the disability benefits system. Wailoo makes clear, however, that the basic fear regarding pain fraud and mismanagement of the disability benefits system transcended political parties as reducing fraud was first a goal of Democratic President Jimmy Carter. Ronald Reagan’s stance towards pain fraud was decidedly more aggressive than Carter’s, however, and included a masterful political strategy to illustrate the evils of pain fraud and the larger disability system as rewarding the wrong kind of citizen. The Reagan administration and other like-minded Republicans were soon deemed “extreme” and lacking compassion by Democrats in a counterattack to the pain fraud narrative. The battle over disability claims would continue to play out in earnest within the state and federal court systems with patients once again caught in the middle.
Chapters 4 and 5 grapple with patient consent and physician obligation, focusing on debates over the regulation of powerful analgesics. Much of Chapter 4 focuses on physician-assisted suicide (PAS), a controversial approach to pain relief and compassionate care. This approach was championed by physician Jack Kevorkian, nicknamed “Dr. Death” for his advocacy work as well as his engagement in PAS with several patients throughout the 1990s (Wailoo 2014, 131). PAS ignited a fiery debate over both a physician’s moral obligation to their patients or to God as well as issues of governance—Should the legality of PAS lie in state or federal jurisdiction? The issue of pain management is again taken up by multiple actors, namely physicians like Kevorkian and state court systems. The actions of disability and patient advocacy groups also grows in significance, with battle lines drawn between patient consent and “death with dignity” to fears over abuse of disabled and elderly people.
While Kevorkian represented an extreme side of the analgesia debate, many more physicians found themselves in precarious positions regarding their ability to prescribe powerful opioids to their patients. Wailoo takes up this issue in Chapter 5, with a careful look at the confluence of large pharmaceutical companies, decreased FDA regulations, and direct-to-consumer advertising. The arrival of OxyContin to the market—advertised as a miracle pain killer with no relationship to addiction—sparked debates concerning pain, trust, and consent that carry throughout the previous chapters. Surveillance structures designed to manage the ballooning opioid problem reflected previous political narratives regarding the stereotyped victims and perpetrators of pain fraud. As a result, drugs such as OxyContin were stocked sparsely in pharmacies located in poor and of color communities while white, affluent ones enjoyed wide availability. Wailoo points out that the manipulation of people in pain was taken up not only by politicians but pharmaceutical companies as well. In reference to consumers’ strategy of crushing OxyContin to bypass its seemingly non-addictive formula, he writes, “for drug companies, this argument served a broader goal—feeding their argument that conniving customers, not the drug itself or improper marketing, were to blame for the abuse” (184).
Wailoo’s Pain offers an accessible, jargon-free account of pain as a political phenomenon. His decision to ground the first chapters of the book in his primary arguments—that pain is a legislative, moral, ethical, and legal issue taken up by many different actors and catalyzed larger discourses regarding trust, citizenship, and consent—effectively guides the reader along a critical narrative that chronologically demonstrates the enduring battle between pain and legitimacy. Wailoo works to critically consider the motivations and actions of several interest groups, not only the politicians driving legislation regarding pain as a thing to be managed. These roles are also not examined within a vacuum—each group’s political and material circumstances are deeply interrelated.
The argument in Chapter 3 effectively demonstrates this interrelatedness. In “The Conservative Case against Learned Helplessness,” Wailoo focuses on the Reagan administration and its political maneuvering that created both monstrous and innocent scapegoats for the pain debates. These stereotypes implicated real people suffering from debilitating pain and gave important context to the battles that disability activists fought for the recognition of their pain, as they were oftentimes caught between competing moral arguments of the Left and the Right. Similarly, the Reagan-era fine-tuning of the dependent pain fraud and the innocent pain victim figures implicated physicians as well—What kind of physician prescribes addictive medications? On the other hand, what kind of physician denies patients needed opioids to manage their pain? This chapter deftly unites the forces of Wailoo’s primary arguments, showing both how the pain debates evolved from the 1940s soldier and how discourses regarding the opioid crisis may develop.
This book demonstrates the depth of pain as an object of study. Wailoo takes care to maintain a narrow focus on the US twentieth- and early twenty-first-century political history of pain while also touching upon varied and complex concepts like the notion of pain as culture and the administrative implications of pain management. Both areas could have received greater development in Wailoo’s work, however. The issue of pain and culture in Chapter 2 receives no critical race analysis (although Wailoo does address its modern implications in his concluding remarks). Harriet Washington’s work on US surgical theaters of the late nineteenth century sheds light on the important confluence of pain, culture, race, and doctoring; she writes, “Blacks were believed to sleep more, feel pain less, endure heat better and cold worse…Yet in a familiar but illogical leitmotiv, treatment for whites were devised, adopted, or rejected based upon the black response to therapeutics” (Washington 2006, 108). Furthermore, additional context regarding the waning power of the American Medical Association, the arrival of managed care systems in the 1980s, and the role of these two events on medical authority would enrich Wailoo’s arguments regarding doctoring in the OxyContin era. (Paul Starr’s The Social Transformation of American Medicine [1982] would be useful here.) More recent work may also prove useful, such as a 2010 study from Matthias et al. on provider attitudes towards treating chronic pain in Veterans’ Association clinics, which reflects an ongoing struggle between chronic pain treatment and maintenance of medical authority. Readers interested in these three areas should peruse the endnotes and bibliography of Pain for more specific analytical, political, and historical projects.
Wailoo’s Pain: A Political History presents pain as a multidimensional phenomenon, acting at once as a physical manifestation, medical condition, source of fraud, moral crusade, and policy issue. His analysis remains salient today, with threads of the questions regarding pain and its management in the 1940s and 1950s linking through to the present-day opioid epidemic and the role of the pharmaceutical industry. This book also offers an interesting analysis of the relationship between normative masculinity and pain policy, where the former served as an important cultural backdrop against which issues of legitimate or illegitimate pain and proper or improper citizenship were cast. Wailoo’s text also works as a starting point for a great deal of other projects related to the opioid epidemic, the Republican Party’s stance towards science and medicine, and chronic pain medical education. For these reasons, Pain is a useful entry for feminist science study scholars interested in how US politics has approached questions of deservedness and legitimacy regarding pain, including what kinds of pain are legitimate, and perhaps more importantly, on what kinds of bodies is pain legible as either a source of fraud or honest suffering.
References
Matthias, Marianne S., Amy L. Parpart, Kathryn A. Nyland, Monica A. Huffman, Dawana L. Stubbs, Christy Sargent, and Matthew J. Bair. 2010. “The Patient-Provider Relationship in Chronic Pain Care: Providers’ Perspectives.” Pain Medicine 11 (11): 1688–97. https://academic.oup.com/painmedicine/article/11/11/1688/1933849.
Washington, Harriet A. 2006. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. New York: Harlem Moon.
Author Bio
Olivia Adams is a PhD student at Indiana University Bloomington in the Department of Gender Studies. Her research focuses on chronic vulvovaginal pain, provider communication, and racial disparities in healthcare access, outcomes, and experiences.