Wailoo, Keith. Pain: A political history. Baltimore, MD: Johns Hopkins University Press. 2014. 284 pages. Hardback. USD $29.95. ISBN 978-1-4214-1365-5
Reviewed by S.B. Barak
Critical Disability Studies, York University
I read Keith Wailoo’s latest book through my lens as an emerging critical disability studies scholar who was born in the United States, and completed my undergraduate work and commenced my early career there. Having sustained multiple injuries in motor vehicle accidents and sports-related injuries, requiring surgery and extensive rehabilitation, I am all-too-well personally acquainted with the topic of pain.
Locating himself as a person of colour, Wailoo’s previous works primarily concentrated on the politics of race and health, whereas this book pivots a constellation of various intersectionalities around the central dilemmas connected to and engendered by pain. It captures the political drama surrounding those individuals directly experiencing pain as disability as well as the range of stakeholders throughout the political, legal, and medical realms of the United States. With Pain, Wailoo, an accomplished and well-connected professor in history and public affairs, primes himself to become a recognized voice in other academic domains, including disability studies.
A heads-up to “international” readers: Pain would have been more aptly subtitled “An American political history,” as it depicts the ongoing battle between liberalism and conservatism in the United States from World War II onward. Wailoo himself points out how from a global perspective this issue has disproportionately consumed Americans, further framing this work as illuminating a uniquely American history. Fraught with irony, Wailoo’s account squarely places the major players and their parts in addressing pain’s political issues in the American arena, providing a critical analysis from a variety of perspectives, from organizational and systemic levels to the individuals impacted, repeatedly describing aspects of this topic as “fractious” and “fractured.” He positions his work alongside the body of scholarship detailing the emotional undercurrent accompanying shifts away from welfare-oriented policies in the liberal–conservative debate, citing the assessment that “it is not dependency that is the problem, but fear and hatred of dependency” (p. 4), and “Rather than championing the disabled and dependent, Eisenhower (like many Americans) chose to valorize those who fought through the worst distress (p. 24). Wailoo also notes that “All pains are not the same or equally deserving of relief” (p. 7). Perhaps it is here that he finds the heart of the connection that leads him to specifically claim that his work contributes to “the diverse and rich scholarship in disability studies” (p. 219), positioning himself amidst Longmore and Umansky (2001), Rosemarie Garland Thomson (1997), and Ruth O’Brien (2001). Wailoo also acknowledges other related recent work in other disciplines, such as Moscoso’s (2012) Pain: A Cultural History.
In this work, as the author addresses the question of whose pain matters and examines the players who alternate centre-stage, from veterans to workers to women to African Americans, correlating with other headlining events taking place historically in terms of rights advocacy. A key question in the pain debate has been how to determine the legitimacy of chronic pain and what might be fair treatment and compensation – for ultimately these questions hinge on the right to benefits. In addition to economics, this history of pain notes the close connection between medicine and politics – a factor all too well-recognized by proponents of the social model of disability.
Organized into five core chapters, each opening with a quotation, the book highlights gender issues in the context of injured soldiers in Chapter 1, “The Trojan Horse of Pain.” From the perspective of psychiatrists after World War II, Wailoo poses the question, “If it is true that ‘angry, regressed, anxiety-ridden, depending men’ were returning to civilian life in large numbers, the future appeared dark indeed. Would they cripple society?” (p. 18). Then, as now, it seems there was a larger stigma and problematization of those with invisible disabilities that are more difficult to measure and therefore for which to calculate appropriate compensation. The scale of veterans’ injuries made this a significant budgetary issue when one considers that in addition to returning veterans, there were still aging World War I veterans to be accounted for, not to mention those who then followed from fighting in Korea. There were significant debates that saw disability to be compensated based on a contract of military service, with these debates bleeding into arguments about socialized medicine and broadening welfare and disability services. Unsurprisingly, conservatives viewed pain complainants as a liberal Trojan horse seeking to coddle its citizenry and condone dependency. This could also be seen in the shift in popular pharmaceutical products and what Wailoo depicts as “the slippage from pain relief into personality and mood management” in the “drug revolution” (p. 31). The rest of this chapter delves further into the development of high profile specialists in the medical industry as well as looks further into the issues around stigma with reference to the sociologist Goffman’s work on the management of spoiled identity.
With the stakes so high and the issues so contentious, the political powers-that-be established a commission to assess issues around pain and compensation, as a tactic to manage the situation. To illustrate the conservative position opposing liberal compensation and its threat to bankrupt the social security system, Wailoo writes:
Hedwig S. Kuhn dismissed the idea of disability outright: “I doubt if there are very many people of the world who are truly disabled,” he barked. Technology and medical innovation, he thought was lightening the burden of the afflicted people: “Even a polio victim in an iron lung is not truly disabled if he has imagination. He can even support himself by writing music, writing books, talking into dictaphones and what not. (p. 43)
Using the trope of an animalistic descriptor (“barked”) to dismiss Kuhn in relaying these obscure comments, Wailoo’s editorializing ironically injects a common pejorative device often levelled at those being Othered. Yet Kuhn’s viewpoint could have something to be said for it from a social model standpoint, implying that disabling is a discrete phenomenon apart from impairments. Is Wailoo assuming that a medical doctor and authority must have been a man? Hedwig is a woman’s name and in fact, a look at the final published report lists several women as professional experts – however Dr. Kuhn is not among them, so perhaps was less influential than Wailoo suggests. Therefore, though creditable that either Wailoo or some of the archivists he has acknowledged went back into the original files of the Commission, the fact that none of this quoted material was ultimately used in the published report is in and of itself telling. This is but one example of those littered throughout the entire book revealing the author’s bias, raising the suspicion of a fair amount of cherry-picking in the book’s composition.
Chapter 2, “Opening The Gates of Relief,” reviews key precedent-setting legal cases in the wake of Eisenhower’s signing into law the new federal social security disability insurance (SSDI) in 1956 and covers the surrounding debates over when pain warranted government relief. It outlines issues around appropriate treatment trends that would follow subsequent presidencies from Kennedy to Nixon and carry through to Reagan, at which point the conservatives began making a concerted effort to begin closing the gate on those claiming pain as the basis for their disabilities (p. 97). The next chapter [3] looks at “The Conservative Case against Learned Helplessness.” Although the Democratic president Jimmy Carter had already begun the process of reviewing all disability claimants, within a mere two months of his inauguration, Republican president Ronald Reagan escalated both the rhetoric and draconian action towards whittling the welfare rolls as much as possible, framing this purge as eliminating illegitimate, that is, fraudulent, claimants. Although “gate control theory” and the idea of “learned helplessness” featured large in the spotlight at this time, Reagan backed off his extreme measures in this endeavour to avoid the appearance of callousness, due to a pending re-election campaign (p. 113). Subsequently, both Bush presidents positioned themselves as “compassionate conservatives” (p. 125), as pain continued to polarize the political sphere, enduring as a key issue in the courts as well as in Congress.
Cleverly titled “Divided States of Analgesia”, Chapter 4 observes that the treatment of pain not only remained controversial, but expanded into the complex issues of physician-assisted suicide and even fetal pain. Doctors increasingly participated in the ongoing exchanges about healthcare reform, with the debates intensifying, particularly from the period of Clinton’s public focus on these matters. The medical establishment faced competing demands from patients and prosecutors, challenged by principles of religion and ethics as well as appropriate medical treatment. The question of physician-assisted suicide was particularly contentious and “fractured” both the political left and right. As Wailoo comments, “When these vexed questions of pain relief arrived yet again at the US court, the nine justices were ruling on far more than pain; they were deciding fundamental legal, moral, political, and philosophical questions that had long been refracted through the question of pain, compassion, and relief” (p. 164).
Narrowing its focus on pain relief, Chapter 5, “OxyContin Unleashed,” looks closely at the multi-faceted ramifications resulting from the insidious reformulation of oxycodone (Percodan) into a time-release formula, repackaged as OxyContin, and approved by the FDA in 1998. Wailoo expounds that the notorious conservative Rush Limbaugh’s secret addiction to OxyContin “conjoins the personal and political” (p. 168), and signaled the turn toward “a new liberal-conservative consensus…around the need for market surveillance” (pp. 168–169). Examining problems with deregulation and the aggressive marketing of the pharmaceutical industry, in particular the burgeoning of direct-to-consumer advertising, the author points out the uncomfortable irony that Americans were faced with overmedication and under-treatment. While noting the gender discrepancies in pain assessment, and that race and other differences played into disparities in pain relief (pp. 197–197), Wailoo underlines pain relief per se as “a seemingly enduring American ideal” (p. 172), and that pain medications are the drug industry’s “financial lifeblood” (p. 172). A 2008 United Nations report documented that “in 2007, while other countries tightened regulations, the United States accounted for over 99 percent of global consumption of hydrocodone and 83 percent of global consumption of oxycodone” (p. 191). From this Wailoo concludes that, “As with so many of the drug stories of the decade, the US stood alone” (p. 191).
Wailoo posits that questions around pain have been a source of drama in the American political theatre, and carries this metaphor throughout the concluding “Theatres of Compassion,” remarking that pain belongs to all players: not only those who suffer, but also those who observe and respond to suffering (p. 212). He declares that prior to this book, no other scholarly work has considered the ways that “seemingly separate cultural, biological, social science, legal, and administrative views on pain have intersected and informed one another,” nor has any shown “how the topic of pain in proper relief underpins American political debates” (p. 221). In his analysis of the various media as well as scholarly literature examined, Wailoo makes a thought-provoking contribution to all these fields; however, Wailoo does not highlight addiction as disability per se, nor does he tie that into the discussion around stigma. While he states that this work fits into the purview of the work of major disability scholars, the reader might be hard-pressed to view disability studies as a discipline directly incorporated as an overarching focus. This book, however, could be useful for those wishing to take Wailoo’s observations on politics, medicine, economics, and law further in that direction.
A relatively easy read that would be accessible to a general readership as well as the academic community, Pain is sprinkled with a number of illustrations from cartoons to photographs to tables; however, there is no listing as one might find in a purposefully academic work, and all graphics are on the same recycled paper and in the same black and white/gray scale as the text. Typos, incomplete references, and repetitive language reveal perhaps too many hands in the product’s creation, making haste under deadline. To quote Wailoo’s old nemesis, Reagan, it might behoove the author to “trust but verify” outsourced work. Three pages of acknowledgements illuminate the current modus operandi in academia where it takes a village to crank out publications funded by multiple major grants – in this case one for research in the history of science and another for health policy. Cultivating relationships with colleagues and students, archivists, authors, editors, and friends and family, Wailoo has delivered another work on a prolific path, with eight previous book titles to his credit and more pending publication. Despite concerns with rigour, this book is an engaging read; Wailoo clearly conveys that popular approaches to treating disability ─ and pain specifically ─ are deeply embedded in political economy, in terms of both profits and social protection.
References
Bradley Commission. (April 1956). Findings and Recommendations: Veterans' benefits in the United States. Retrieved from http://www.veteranslawlibrary.com
Garland Thomson, R. (1997). Extraordinary bodies. New York: Columbia University Press.
Longmore, P. K., & Umansky, L. (Eds.). (2001). The new disability history: American perspectives. New York: New York University Press.
Moscoso, J. (2012). Pain: A cultural history. New York: Palgrave.
O’Brien, R. (2001). Crippled justice: The history of modern disability policy in the workplace. Chicago: University of Chicago Press.