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Pain and Its Transformations, The Interface of Biology and Culture Edited by Sarah Coakley and Kay Kaufman Shelemay Harvard Univ. Press, 2008 439 pp., $49.95

When I called a physician friend for advice on an adverse reaction to anesthesia after minor surgery, he made the offhand comment, "You know, veterinarians don't have that problem. They measure out the dosage, give the injection, and the horse or dog or whatever responds according to the book." That simple observation could serve as a summary of what prompted Harvard conveners to bring together molecular biologists, neuroscientists, pain clinicians, psychiatrists, anthropologists, musicologists, and scholars of religion for the conference that spawned this book. Physiologically, pain in humans may resemble that of horses and dogs, but there the similarity ends. In many ways, culture trumps biology.

Consider the phenomenon of Couvade, documented in many places worldwide. In some societies in Micronesia and the Amazon Valley, for example, the mother shows no indication of suffering during delivery. She may break from work a mere two or three hours to give birth, then return to the fields. By all appearances the husband bears the pain: during the delivery and for days afterward he lies in bed, thrashing about and groaning. Indeed, if his travail seems unconvincing, other villagers will question his paternity. A journalist or anthropologist who tried to explain, "Sir, there's no reason for you to feel pain because, after all, it was your wife who bore the child," would doubtless meet a hostile reaction. For months the father has struggled with such symptoms as nausea, weight gain, constipation, headache, and other signs of distress, not to mention the agony of the "delivery" itself. For him, the pain is as real as it is for the Manhattan socialite demanding her epidural.

Before attributing this cultural phenomenon to a primitive, unscientific world view, remember that placebos, nothing more than sugar pills and saline solutions, work well in developed countries. Around 35 percent of cancer patients report substantial relief after a placebo treatment, about half the number who find relief from morphine. Both cases, negatively with Couvade and positively with placebos, demonstrate that pain does not fit the Cartesian stimulus-response model that once prevailed.

Pain and Its Transformations reflects an admirable attempt to bring together experts who look at pain from the bottom up (neuroscientists, biologists) and those who look at it from the top down (anthropologists, scholars of religion). The Harvard conference, assembling 23 contributors from various disciplines, came as a climax to a two-year seminar series on the topic. The book includes fifteen main chapters as well as a series of discussions in which the other contributors get to respond. As in every compilation, quality varies. Some authors rely on the jargon of their specialty, whether science or theology. Mercifully, both points of view have presenters who can cut through the jargon and write in plain English.

One more complaint: Like most books on pain, this one gives a mere nod to pain's essential role in protecting from injury and turns quickly to the problems it presents (the root word for pain means "punishment" or "penalty"). To the contrary, I learned a high appreciation for pain's warning function while collaborating on three books with Dr. Paul Brand, the missionary surgeon who discovered that all the disfigurement that makes leprosy such a dreaded disease traces back to the loss of pain sensation. Theologians blithely attribute pain to the Fall, ignoring the marvelous design features of the pain system. Every square millimeter of the body has a different sensitivity to pain, so that a speck of dirt may cause excruciating pain in the vulnerable eye whereas it would go unreported on the tough extremities. Internal organs such as the bowels and kidneys have no receptors that warn against cutting or burning—dangers they normally do not face—but show exquisite sensitivity to distention. When organs such as the heart detect danger but lack receptors, they borrow other pain cells ("referred pain"), which is why heart attack victims often report pain in the shoulder or arm. The pain system automatically ramps up hypersensitivity to protect an injured part (explaining why a sore thumb always seems in the way) and turns down the volume in the face of emergencies (soldiers often report no pain from a wound in the course of battle, only afterwards). Pain serves us subliminally as well: sensors make us blink several times a minute to lubricate our eyes and shift our legs and buttocks to prevent pressure sores. Pain is the most effective language the body can use to draw attention to something important. The principle applies equally to animals, an aspect of pain for which C. S. Lewis had no satisfactory explanation.

Although not dwelling on pain's contribution, everyone in this volume acknowledges the complexity and mystery surrounding our experience of pain, which provides a common ground for discussion. The reductionists describe how a stimulus at the most basic level—a cut finger or stubbed toe—begins a cascade of biochemical reactions which are then filtered through the spinal cord and referred to the brain. In a recent development, functional MRIs can even detail the brain activity responsible for phenomena such as phantom-limb pain, which involves no external stimulus. The brain has a representation, or mental picture, of individual body parts based on their sensory history, and interprets reality based on that picture; an amputation dramatically alters the representation, confusing the brain. Or, in the case of someone who has undergone a frontal lobotomy, the patient can describe intense pain in precise detail but have no emotional reaction: "Yes, the pain is acute and nearly unbearable," she says with a broad smile.

To its credit, this collection provides a wide variety of cultural models for understanding and managing pain. A Harvard professor describes an operation in Shanghai in which a woman has a tumor removed from her thyroid with no anesthesia or medication, only traditional chi gong therapy. At one point the sheet covering her shoulder irritates her and has to be adjusted, but when blood spurts across the room onto the white coat of a surgeon, she gives no reaction. The devout in Sri Lanka dangle from hooks, and Shi'ites in Iraq flagellate and slash themselves with swords, giving no indication of pain sensation. In a fascinating section, two musicologists describe the analgesic quality of music and trance in Finland and Bali, Indonesia.

Religion, of course, plays a crucial role in ascribing meaning to the pain experience. At the risk of oversimplification, I might suggest the following pattern: acceptance (Islam, Hinduism, Buddhism), mastery (advanced practitioners of Hinduism and Buddhism), and protest (Judaism). Christianity at various points reflects each of these streams. Early in its history martyrs sang in the flames, stylites sat on poles exposed to weather, and desert monks lived on a diet of bread and water. Later, fatalistic Christians argued against inoculations for smallpox, which would interfere with God's will, and warned against relieving the God-given pain of childbirth. Sarah Coakley, one of the editors of this volume, contributes a chapter examining the relationship between pain and contemplation in the spirituality of two 16th-century Carmelites, Teresa of Avila and John of the Cross. She admits that in some ways these two reflect a strand of valorization of pain—a tradition familiar to parochial school students drilled on martyrs' tales. Yet, paradoxically, meditation also offers its own analgesic possibilities, as Dr. Herbert Benson has long maintained. Perhaps most important, the Christian mystics presume that no pain is devoid of spiritual meaning. It can serve a redemptive purpose, and in that sense pain can be transformed.

The philosopher Nicholas Wolterstorff suggests that early Christian thinkers introduced a radical departure from their contemporaries, the Stoics and Neoplatonists, so much so that the two viewpoints on pain are profoundly alien. Stoics and Neoplatonists strove to live a life in which one's well-being is not hostage to fortune; the absence of pain is thus not desire-worthy, being by and large outside one's control. Citing Augustine, Wolterstorff points to a major divergence in approach: human beings should grieve over their miseries as well as those of their neighbors and friends. The word "compassion" means, simply, to "suffer with." Augustine emphasized two ages, a present age and an age to come. The age to come holds out the promise of no suffering, death, or wrongdoing, which implies that their existence in the present age represents evil not yet overcome. Pain serves only a temporal purpose, by contributing to soul-making. Christ himself gave the template: ministering to the afflicted, embracing pain with both protest and acceptance, then transforming it through resurrection.

Complementing Wolterstorff, the Jewish scholar Jon Levenson affirms that "being happy in this world is not necessarily a good sign." The believer lives as a sojourner, with eyes on a blissful world to come. He admits, "Moderns often think of the latter as pie in the sky, a crude consolation prize, rather like the candy bars that were dropped on a village during the Vietnam War after it was learned that the wrong site had been bombed." Perhaps it is this modern myopia that makes pain such a problematic experience. If one has no hope in a future balancing of the scales, whether through reincarnation (Hinduism), absorption (Buddhism), or divine judgment (the Abrahamic faiths), one can only sort through the capricious and cruel distribution of pain and suffering in this life and strive to eliminate it.

Those who study pain from the bottom up keep uncovering layers of complexity, in the pain receptors themselves and especially in the networking systems within the human brain. Those who study pain from the top down have no easier task. For the Christian pain represents, at various times and from various angles, a design feature worthy of praise and gratitude, an affliction to be overcome, a potential vale of soul-making, and a spur to hope in a painless future. The Harvard seminar, and this book which resulted, hardly reduce the complexity, but at least the two sides are talking.

Philip Yancey is the author most recently of Prayer: Does It Make Any Difference? (Zondervan).

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