Usually when we think of a gift, we think of something pleasant, like a bunch of flowers, a box of chocolates or a book voucher. I doubt that any one of us would consider pain to be a gift. The niggling pain in the middle of my back can be annoying sometimes. The blinding pain of Bec’s migraines is often quite disruptive to her daily life. Fortunately for us, though, we are not one of those whose entire lives are marred by chronic and debilitating pain. Still, we would hardly consider pain to be a gift.
Imagine though, if you never experienced pain at all. Ah, bliss, you might exclaim. A life without pain would be heaven! But what if we never felt the pain of a sprained ankle and kept on walking, putting our full body weight on the injury. What untold damage could we do? Or, if wandering around barefoot, as I am prone to do, we didn’t feel the pain of that rusty nail in the bottom of our foot? Or the pain of an appendicitis attack? While pain can be unpleasant or even crippling at its worst, it has a very important role to play in our overall health and well-being and this is one of the central themes of Dr Paul Brand’s book, The Gift of Pain.
Paul Brand (1914-2003) spent in his early life growing up in India where his parents were Christian missionaries. Although his mother had hoped he would consider a medical career, he was inspired to follow in his father’s footsteps and become a builder – missionary. He confidently claimed that “medicine was not for me,” however he didn’t bank on falling in love with medicine during a medical preparatory course for missionaries. You know what they say about famous last words. After completing his medical training he returned to India in 1946.
Brand’s book, co-written with Philip Yancey, is essentially a memoir about his life in medicine across three countries, England, India and the United States and his life-long fascination with the body’s pain system. It is often amusing as he recounts the challenges of practising medicine in India where one of the greatest challenges was the lack of clean water. He describes conducting outdoor surgery in villages and using coconut water as a sterile fluid. Medicine in India, he notes, required a good deal of creativity and improvisation. Having specialised in orthopaedics, Brand opened a foot clinic where one of the major conditions he treated was club foot, as well as the ongoing impact of leprosy. It was leprosy that led Brand to discover the “incredible gift of pain.”
When I was growing up we learned about the terrible consequences of leprosy, how lepers were shunned and had to live in colonies and how their body parts just rotted away and fell off. Turns out, most of that was not true. Apparently leprosy is not as contagious as we were led to believe. Most of the population have a degree of natural immunity, leaving about 20% who have no immunity and are significantly impacted by the disease. Leprosy attacks the nerves and while drug therapy can halt the progression of the disease, it cannot return the lost sensation to dead nerves. Brand discovered that fingers, toes and other body parts do not just drop off, but are shortened due to infection. The lack of sensation leads to injuries and wounds, and if undetected, causes infection in the bone and tissue. As the bone fragments, the body absorbs the bone and tissue, leading to a shortening of digits and appendages. It is the lack of sensation, the absence of pain, that causes the disfigurement and disability, not the disease itself. Even when the disease was dormant, infection, disfigurement and disability would continue throughout the rest of the patient’s life. However Brand realised that with an ongoing intensive program of rehabilitation and health care, much of the disfigurement could be prevented.
Brand slowly put together a medical team and the story of the medical procedures they developed through trial and error is absolutely fascinating. While many patients were technically “free” of the disease, they were left with clawed hands and physical deformities. They were unable to earn a living and shunned for their appearance. Brand developed a surgical technique that involved transferring healthy tendons to restore movement to hands. The funny thing about leprosy is that it can attack some nerves while leaving others untouched. It turns out, that leprosy is sensitive to temperature. It attacks the nerves closer to the skin’s surface while leaving nerves deeper within untouched. These untouched and healthy nerves could be re-assigned. It sounds so simple, and yet it had such a major impact on a patient’s life as they saw fingers coming to life again. Of course, the surgery could only return movement, it could not restore feeling, so vigilance was essential in detecting injuries and wounds. Even a minor wound could lead to infection and disability if left undetected and untreated.
While Brand started publishing papers and promoting the rehabilitation and preventative measures they were implementing In India, the rest of the medical world was uninterested. After all, what could a hospital for leprosy in India possibly teach the progressive medical world of the West? While the World Health Organisation (WHO) continued to fund drug therapy and research, they also were uninterested in preventative or rehabilitative measures. The ongoing disfigurement and disability was just “regrettable.”
But as Brand quite pointedly notes,
“A person free of active leprosy who is left with crippled hands and feet hardly thinks of himself as cured, no matter what WHO or any doctor claims.”
Eventually this did change with a documentary produced in 1957 and suddenly the “experts” recognised the importance of prevention and rehabilitation measures. Ironically, WHO even ended up hiring Brand as a consultant!
Brand’s work with leprosy patients highlights how much we take for granted in the West. We grumble about our aches and pains despite the fact that most of our health issues are actually caused by our lifestyle. We want a quick fix and a pain-free life not realising that those pains are telling us something is wrong. Brand likens pain to a “loyal scout announcing the enemy.” It is telling us to stop, pay attention and prevent further damage or ill health. The interesting thing about pain is that it is all in our head. I don’t mean that it is imaginary, but that it is only when the signal reaches the brain that we feel the pain. Leprosy has a lot to teach us about how vulnerable our body would be to injury and disease, if it were not for pain.
If you are at all squeamish, this book might not be for you. There are descriptions of autopsies and surgical procedures and the treatment of leprosy patients in some places is pretty awful. One of the major causes of injury to leprosy patients in India was also due to rodents… There is also reference to animal research conducted before the days of animal rights, not undertaken by Brand, but which could be distressing to some readers.
However, I found The Gift of Pain to be a fascinating and informative read and Brand’s reflections on the difference in attitude toward pain and suffering across different cultural and national contexts was very thought provoking. While the book was written in the early 1990s and Brand’s work in India was during the 40’s, 50s and 60s, the difference in access to health services is still relevant today. The COVID 19 pandemic has highlighted, once again, the difference between developed and developing nations. We might well ask why it is that some nations will be waiting much longer for access to vaccines than others.
On Wednesday (April 7th) it was World Health Day and the theme for this year was “building a fairer, healthier world.” As WHO points out, our world is not equal. While some people have access to good health services, employment and living environments, there are many who do not and it leads to “unnecessary suffering, avoidable illness and premature death.” And yet, just as Brand showed that the ongoing effects of leprosy are preventable, this inequity in health outcomes is also preventable – if we have the will.