Dr. Paul Brand was known in medical circles for two major accomplishments. First, he pioneered the startling idea that the loss of fingers and toes in leprosy was due entirely to injury and infection and was thus preventable.
Leprosy attacks chiefly the nervous system, and resultant tissue abuse occurs because the patient loses the warnings of pain—not because of inherent decay brought on by the disease. The theory, radically new when Brand first proposed it as a missionary surgeon in India, has gained worldwide acceptance.
Second, he was hailed as a skilled and inventive hand surgeon, and most major textbooks on hand surgery contain chapters by him. Brand was the first to apply tendon transfer techniques to the specific problems of leprosy patients, whose hands often harden into rigid "claw-hands."
Philip Yancey interviewed Brand for the December 1, 1978, issue of Christianity Today after Brand was awarded the prestigious Albert Lasker Medical Award and made a Commander of the Order of the British Empire. At the time, Brand had spent ten years working at the Public Health Service Hospital in Carville, Louisiana.
There, he concentrated on rehabilitation techniques, designing shoes and tools for use by insensitive patients. He also developed the concept of "hand rehabilitation centers" where patients could live and work to get ready for normal life.
You once headed up a research project in which you tried to develop an alternate pain system for people who are insensitive to pain, such as leprosy patients. In a sense, you and your team of scientists and bioengineers were playing creator with the human body. What did this teach you about the creation process God went through?
Our most overwhelming response, of course, was a profound sense of awe. Our team worked specifically with the pain system of the human hand. What engineering perfection we find there! I could fill a room with volumes of surgical textbooks that describe operations people have devised for the injured hand: different ways to rearrange the tendons, muscles, and joints, ways to replace sections of bones and mechanical joints—thousands of operations. But I don't know of a single operation anyone has devised that has succeeded in improving a normal hand. It's beautiful. All the techniques are to correct the deviants, the one hand in 100 that is not functioning as God designed. There is no way to improve on the hand he gave us.
I think of the complex mechanical hands you see in nuclear labs for handling radioactive materials. Millions of dollars went into the circuitry and mechanical engineering to develop those hands. Yet, they are so bulky and slow and limited compared to ours.
Nearly everyone would acknowledge the marvelous structure of the human body. But what of the one in 100 abnormal hands? Why did God's creation include the potential for these exceptions that fill our hospitals?
A partial answer to that lies, I believe, in the inherent limitations of any medium that obeys physical laws. In his creation of the world, God chose to work with atomic particles that he made to operate according to physical and chemical laws, thus imposing certain limits. Those were the building blocks of creation. At the upper end of the whole process, for his highest creative achievement, God chose to make a human brain that would be independent and have freedom of choice. C.S. Lewis's example of wood illustrates the limitations of law-abiding material. To support leaves and fruit on a tree, God had to create a substance with properties of hardness and impliability. We use wood for furniture, and to build homes because of these qualities. Yet in a free world that characteristic invites abuse. Wood can be used as a club to bash someone's head. The nature of the substance allows the possibility of a use other than that for which it was intended.
I am glad that the world is governed by laws, that fire is hot and ice is cold, that wood is hard and cotton is soft. As a doctor and scientist, I must rely on those properties for my techniques of experimentation and surgery. If I could not rely on plaster to be firm, it would be useless as a splint for a broken bone.
We eventually had to abandon our own attempts at an alternative pain system partly because of these laws. The substances we tried to use—metal and electronic components—would break down after a few hundred uses, whereas the body requires millions of uses from each of its pain cells. We were unable to come close to duplicating the complexity and flexibility built into the simplest nerve cell.
As you studied the human body, especially in its sensitivity to pain, and as you tried to think like God, did you see any areas at all you would have arranged differently?
I would not be so bold as to express it like that, but I have contemplated the choices God must have considered in creating the body. One of the beauties of the pain system in the body is the way in which each pain ending in the tissues fires off its message at a level of stress appropriate to the preservation of that particular tissue. Your foot, for example, reacts dully to pain, since it must be tough enough to face a daily rigor of pounding and stomping. Yet your eye is incredibly sensitive. I visualize the Creator pondering the pain reflex in the cornea. Here is a tissue highly specialized for transparency and thus it must do without a regular blood supply (which would make it opaque). Therefore a wound is a special disaster and even a small wound could cause blindness. The pain endings are so sensitive that they call for a blink reflex when a thin eyelash touches the surface.
In setting the levels of sensitivity, the Designer must have recognized that if the eye were more sensitive it would be impossible to keep it open in a slightly dusty atmosphere, or in smoke, or perhaps when the wind is blowing. Yet as a doctor concerned primarily with disease and injury, I might have wished for that greater sensitivity.
The same is true with the lining of the trachea and larynx. We get impatient when we are forced to cough, but patients dying of lung cancer must sometimes wish that the Creator had made the mucosa of the trachea more intolerant of tobacco smoke. Even omnipotence cannot please everybody.
Let's talk for a moment about your concept of omnipotence. As I understand it, you view omnipotence in terms of the potential power, not the process it describes. For example, I can describe a Russian weightlifter as the most powerful man in the world. But his task of lifting the weights he attempts is not easier for him than lifting the weights that challenge me; he still has to grunt and sweat and exert. Is there an analogy there to the way you interpret God's omnipotence?
There may be. I don't even like the word omnipotence. The word conveys a simplistic view of the Creator and Sustainer of the Universe, as if he merely had to wave a magic wand and it all came into being. Man's creative effort in producing the Sistine Chapel or the lunar lander required tremendous planning and forethought, and I can envision God going through a similar process of planning and experimentation in his act of creation. The more I delve into the natural laws—the atom, the universe, the solid elements, molecules, the sun, and, even more, the interplay of all the mechanisms required to sustain life—I am astounded. The whole creation could collapse like a deck of cards if just one of those factors were removed. To build a thing like our universe had to require planning and thought, and that, I believe, is the strongest argument for the presence of God in creation.
From the chance collision of molecules you may sometimes derive a sudden, exciting pattern, but it quickly disperses. Some people really think that all the design and precision in nature came by chance, that if millions of molecules bombard each other for long enough, a nerve cell and sensory ending at exactly the right threshold will be bound to turn up. To those people I merely suggest that they try to make one, as I did, and see what chance is up against.
I see God as a careful, patient designer, and I don't think that the fact that I call him God makes it easy. There are billions of possibilities of ways in which atoms could combine, and he had to discard all but a very few as being inadequate. I don't think I can fully appreciate God unless I use the word difficult to describe the creative process.
I like to think of God developing his skills, as it were, by creating amoebae and then ants and cockroaches, developing complexity until he comes to people, the zenith of creation. Again, he was confronted with options at every decision. A person who breaks his leg skiing could wish for stronger bones. Perhaps bone could have been made stronger (though scientists have not been able to find a stronger, suitable substance for implanting) but he would have then made the bones thicker and heavier. If it were heavier you probably wouldn't be able to ski, because you would be too bulky and inert.
Take a model of the human skeleton and look at the tiny size of the bones in the fingers and toes. Those bones in the toes support all your weight. If they were larger and thicker, many athletic events would be impossible. If fingers were thicker, so many human activities—such as playing stringed instruments—would be impossible. The Creator had to make those difficult choices between strength and mobility and weight and volume.
And animals were given different qualities, based on their needs. Some are stronger and faster than man, and can see and hear better.
Right, you can only call creation perfect in relation to other options available. Even human types differ. Is an American better than a Vietnamese? The American is bigger, but it takes more food to sustain him. If food becomes short, the Vietnamese will survive because they can get by on a bowl of rice and the Americans will die out. So physical qualities are not good or bad but good in certain circumstances. I have tremendous admiration for the balance by which the world has come out with evidence of thought behind it. But every stage of development—moving from the inanimate to the animate, single-cell to multi-cell, developing the nervous system—required thought and choice. That's why I define omnipotence the way I do.
When you speak of pain, and even death, you seem to include these within God's overall design for this planet. These are generally seen as evidence of the twisted, or fallen, state of the world. How do you reconcile these elements with your belief in a wise, loving Creator?
I cannot easily imagine life on this planet without pain and death. Pain is a helpful, essential mechanism for survival. I could walk with you through the corridors of this leprosarium and show you what life is like for people who feel little pain. I see patients who have lost all their toes simply because they wore tight, ill-fitting shoes that caused pressure and cut off circulation. You or I would have stopped wearing those shoes or adjusted our way of walking. But these patients didn't have the luxury of pain to warn them when they were abusing their flesh.
You're familiar with the stereotyped image of leprosy, with its loss of fingers. That abuse comes because the leprosy bacillus destroys pain cells, and the patients are no longer warned when they harm their bodies through normal activity. On this world, given our material environment, I would not for a moment wish for a pain-free life. It would be miserable. I mentioned earlier that 99 of 100 hands are perfectly normal. The statistics are exactly reversed for those people insensitive to pain: Nineteen of each twenty of them have some sort of malformity or dysfunction, simply because their pain system is not working properly.
As for death, when I look at the world of nature, its most impressive feature as a closed system is the lavish expenditure of life at every level. Every time a whale takes a mouthful he swallows a million plankton. Every garden pond is a scene of constant sacrifice of life for the building up of other life. Death is not some evil intruder who has upset beautiful creation; it is woven into the very fabric and essence of the beautiful creation itself. Most of the higher animals are designed so that they depend for their survival on the death of lower levels of life. Having created this food pyramid, and placed man at its apex, the Creator instructed him to enjoy and to use it all responsibly. In modern, Western culture, we tend to see a certain ruthlessness and lack of love in nature, but I believe that viewpoint comes from a civilization whose main contact with animal life is through domestic pets and children's anthropomorphic animal stories.
Just a minute, now. It is true that pain and death fit into the present system of life on earth, but weren't these factors introduced as a result of man's rebellion and fall? Are you saying that the Garden of Eden contained pain and death?
Well, anything I say about the Garden of Eden must be conjecture, because we've been given very little data about it. I feel reasonably sure that Adam felt pain, if his body was like mine. If there were sharp rocks on which he could have hurt himself, I hope he had a pain system to warn him. The pain network is so inextricably tied to the functions of the body—it tells you when to go to the bathroom, how close you may go to the fire, and carries feelings of pleasure as well as pain—that I could not imagine a worthwhile body in this world without it.
And I believe physical death was present before the fall also. The very nature of the chain of life requires it. You cannot have soil without the death of bacteria; you couldn't have thrushes without the death of worms. The shape of a tiger's teeth are wholly inappropriate for eating plant matter (and even vegetarians thrive off the death of plants, part of the created order). A vulture would not survive unless something died. I don't see death as being a bad thing at all.
But the explicit warning given Adam was "In that day you shall surely die."
I think the precise phrasing is important: "in that day." The whole story strongly indicates to me that God was speaking of spiritual life—the breath of God, the image of himself that he reserved exclusively for human beings. I believe Adam was biologically alive before God breathed into him the breath of life; the Hebrew suggests a spiritual life, a direct link of communication and fellowship between God and man. And after Adam's rebellion, I think immediately "in that day" that link was broken. God had to search out Adam after his sin. I don't think his curse referred to physical death at all, and I assume Adam would have died biologically if he had not rebelled. As for thorns and thistles and the pain of childbirth, I'm not really adequately prepared to interpret those. We're given so few details of the creation before and after the fall.
It still sounds strange to hear someone vigorously defending pain. You work in a hospital populated by people insensitive to pain. Having met leprosy patients, I can easily agree to the void created in their lives by the absence of pain. But if you worked in a cancer ward, say, among people who feel constant, unrelieved pain, could you praise pain so confidently there?
I have worked in places of great suffering: the clinics treating victims of the London bombings during the war, surgical wards in Indian hospitals. The one legitimate complaint you can make against pain is that it cannot be switched off. It can rage out of control, as with a terminal cancer patient, even though its warning has been heard and there is no more that can be done to treat the cause of pain. I'm sure that less than 1 per cent of pain is in this category that we might call out of control. Ninety-nine per cent of all the pains that people suffer are short-term pains, correctable situations that call for medication, rest, or a change in a person's life style.
In our experiments with alternative pain systems, we learned it was self-defeating to attach a cut-off switch. We had a glove that, when pressed too hard, would emit an electric shock. But if the patient was turning a screwdriver too hard and the electric shock went off, I have seen him overrule the pain signal and switch it off. As a result, he might injure himself. To make a useful system we would have to eliminate the cut-off switch, or place it out of the patient's reach. I can see why God didn't allow a cut-off switch.
Don't forget, the absolutely best pain-relieving drug in the world is the opium seed of the poppy, which people have used throughout recorded history. God did make allowances for pain that rages out of control. There are many ways open to us to relieve a dying person with terminal cancer.
Have you given any thought to the resurrected world of the afterlife? Little evidence is given about it in the Bible specifically, and yet you insist so strongly on the necessity of pain in this world. What about the next? The Bible hints that it will be radically different in heaven in regards to pain.
I really don't know. Jesus could walk through a solid door in his resurrection body, so it seems clear the afterlife will be governed by a different set of physical laws. There will be some continuity. His body, and those of the three on the Mount of Transfiguration, were recognizable, and it's true that Jesus even bore the scars of his pain from this world. Thomas touched them.
It's a spiritual world, and it's difficult to conjecture what it will be like when our spiritual forms are fully developed. Will children still have resurrection bodies of children? I think of my mother, Granny Brand, who lived to be ninety-five. She struggled as a missionary for seventy years under harsh conditions in India. Gradually the decades of poor sanitation and Indian diseases and poor nutrition caught up with her, and her body was bent and twisted. She thought herself so ugly that she would not allow a mirror in her house. Yet when she rode her donkey into a village, the people who knew her saw her as a beautiful person, a messenger of love. Perhaps we will relate in heaven so much on that basis that physical appearance will become irrelevant. I don't know how pain fits in. If the verse "tears shall be no more" is to be taken literally, then our eyes will be very different, for in this world we quickly go blind without tears.
What about some of the psychological parallels to physical pain? I'm thinking particularly of emotions we generally view as negative, such as guilt and fear. Do you see these as contributing to health in the same way that physical pain does?
Guilt has some spiritual value in that it impels you toward cleansing. It is a pain to the conscience that something is wrong that should be dealt with. Two steps are necessary. First, the person must find the cause of the guilt, just as a person must find the cause of his pain. Much of modern counseling deals with this process of rooting out reasons for guilt.
But then there must be a further step—a pathway out of the guilt. Unless it is aimed at cleansing, guilt is a useless encumbrance. Guilt as such doesn't lead you anywhere, just as pain does not: They both simply point out a condition that needs attention. In this sense, guilt is certainly a good thing, if it is directional, pushing you toward something. The perceived purpose of it is for you to get rid of the sense of guilt, which you don't like. Underlying that is the more significant purpose of uprooting and dealing with the cause of guilt. It's the same with pain.
In modern society the tendency has been to approach pain as if it were the enemy. We get rid of the pain without asking why did the pain come. Pain-killing medicine can quiet the pain, but that can be bad if its cause is not determined. I believe modern psychology has concentrated on guilt as an evil and attempted to suppress or excise guilt. Just stop feeling guilty, they say. Live your life as you want. But in the Christian context, guilt is very valuable. It pushes you to right the wrong that is the cause of your guilt, and gives you the outlet of forgiveness to purge it.
When used properly, fear, too, is an absolute essential element of human life, a protective instinct without which the human race would never have survived. A mother isn't happy to leave a baby alone until it has grown to have a healthy fear of fire or fear of heights. Fear also supplies, through adrenalin, increased heart rates and other mechanisms to tap abnormal reserves of strength. The trick is to have the right amount of fear, and to control it properly.
We know that pain and struggle produce character, that often in the realm of music and art the tensions of childhood result in creative genius. Do you think the tendency in America to try to balance everyone out through self-help books, counseling and advice, and so forth can be unhealthy? I often wonder how a psychiatrist would have handled Beethoven.
There are problems in this area. One is a trend to eliminate variety. I think variety is exciting and lovely, yet we set up norms and tend to reject people who do not match. If one does not hit the proper standard of height, weight, figure, shape of nose, outgoing personality, and extroversion, his psyche is bruised and he loses the will to succeed. Anyone who doesn't conform to our artificial goals does badly. When a child is bookish and is clumsy with sports and doesn't shine in conversation, society tends to discard him. But that's the material from which research scientists come. I feel we try too much to push people into molds.
Another danger is the tendency of modern culture to remove risk and adventure from life. Most of our excitement happens to us vicariously, as we watch it on TV. We shelter our kids, removing them from risky situations, and as a result stunt their growth. I always maintained that of our six children, I would much rather have four survivors who truly lived, with adventure and self-determination in the face of risk, than end up with six fearful, timid youngsters. Fortunately, all six have survived, but each one of them could tell you some hair-raising tales of what they went through in finding their own independence.
This tendency to eliminate risk is compounded upon the old. I visited a very tidy hospital for old people, where the superintendent showed me with great pride how each person had a separate room and a clean bed. They lie there all day. I asked why they were not allowed to get up and walk about. He said, "Well if they do, we find that they sometimes fall and break their hips. If they go outdoors they catch cold and if they meet each other they exchange infections. By keeping them in their separate little rooms they don't get infected, they don't break their legs, they don't catch cold." I carried away from there a memory of bodies that were alive, but of spirits that were caged.
Your emphasis on restoring the human spirit brings up an interesting line of questions. In rehabilitation, you work with very few patients, lavishing in each one thousands of dollars and man-hours a year. In fact, at Carville the ratio of staff to patients is almost one-to-one, isn't it? Does it bother you that in India millions of people are going without the most primitive kind of medical treatment while these patients receive so much?
I don't like the juxtaposition of the two cases—people in India and patients here. I work with quadriplegics and other disabled persons who require lavish expenditures of money, yes. The opportunity to work with a person and to help set his spirit free is one of my most inspiring challenges. No effort is too great and no expense should be spared to restore activity to such a one or to help the spirit rise above its physical limitations.
Even in India I was faced with terrible choices of priorities. After I applied hand surgery techniques to the specific case of leprosy, our staff was able to remake hands. We could turn a rigid, frozen claw-hand into a flexible, usable hand and allow a beggar to find work. But our time and resources were limited, so we had to make choices, just as hospitals in the U.S. must make choices among their kidney dialysis patients. Did we give a hospital bed to one long-term case for a year, or to twelve short-term cases for one month each, or fifty cases for one week each? Did we repair an older patient with gross deformities or a younger one with his whole life ahead of him? The most pathetic cases—those with missing limbs and exposed bones—were often the last we would treat; we tried to focus on less—developed cases to prevent further abuse. These were wrenching choices. Yet in no way did that background of alternatives devalue the worth of the human spirit we did choose to treat.
I have heard it said, by an Indian in fact, that Western medical advances applied to India upset the natural balance. Years ago, the birth rate was high, but only a third of the babies survived infancy. Now the birth rate remains high, but most of them live. He accused the West, and missionaries in particular, of causing India's overpopulation because of their charitable aid.
And in a real sense he's right. Missionaries on the whole have not been the chief offenders. They're too inefficient and localized. But the World Health Organization comes in with massive resources and wipes out killing diseases. I would have to say I would not go to India with a life-saving mission without tying it at least to education for limiting population. While in India, my specific task was with crippling diseases; I helped remake human spirits, and that, I think, is wholly legitimate. The expense required by one of our operations could have saved 100 people from cholera, but I still maintain that spirit-saving activity was worth it.
Jesus said, "Love your neighbor as yourself." Modern media has made that command infinitely more complex and burdensome. Because of television, the whole world is our neighbor. On evening news programs we watch the progress of famines, wars, end epidemics. How can we possibly respond to all of these disasters?
You can't, not in the sense in which Jesus meant it, at least. You must remember the context in which he was speaking. He meant family, nearby villages, Capernaum. Jesus healed people, but in a very localized area. In his lifetime he did not affect the Celts or the Indians or the Aztecs. And I think an intolerable burden of guilt such as you describe merely numbs us and keeps us from responding. We must have a sense of touch to those we love.
Westerners, with our opulent life styles, are very sensitive on this point. But I really don't believe that kids born in Bangladesh amid poverty suffer all that much more than a spoiled child in a rich country. In Plato's Cane he pictured people being born and brought up entirely in darkness, and as a result their range of appreciation of beauty, light, and joy was very different from that of a person on the ground. When they come up to the light, dazzled, they learn to appreciate a new range of happiness. This, to me, is a deep perception of the human spirit. A child develops a norm, above which is happiness and below which is suffering.
Not long ago I was in Bombay, among the awful refugee villages between the airport and the city. Children live in stinking, ghastly shacks, held up by sticks, reeking with human excrement, fleas, and lice. Yet you'll see a child coming out of the hovel and playing tag and hopskotch with a light-hearted air. Their ability to enjoy the basics of life seems greater than that of a spoiled kid the day after Christmas, whining and smashing his new toys out of boredom.
How do you maintain a sense of Christian compassion in your work? In India you saw thousands of patients regularly with the same afflictions. After examining 3,000 abused hands, how can you maintain your compassion?
I don't know that I do it very well. In India I did learn the importance of a sense of touch. Sometimes when we were treating a serious case and had prescribed some drug, the relatives of the patient would go and purchase the medicine, then come back and ask me to give it to the patient "with my good hands." They believed the medicine was more able to help the patient if it were given by the hand of the physician. Interesting, isn't it, that Jesus always touched his patients?
I probably remember a persons hands better than his face. I connect a person's occupation with his hands—often you can read it by the hand. I try to individualize what the loss of sensation or the stiffness in his hands means in his work. When I return to India to teach, I can often remember a patient's hands with startling vividness. I'll recognize someone and say right off, "You've lost some more of your ring finger."
Doesn't your emphasis on the personal aspect of mission run counter to some of the trends in missions today, where we isolate which groups are most responsive to the Gospel and go after those groups with a specific approach?
Yes, it does contradict those trends. I don't believe mission work is necessarily more effective as it becomes more specialized. My father moved into a mountain community in India to preach the Gospel. Within a year his tasks were part medical, part agricultural, part education, evangelism, and translation. He responded to the needs of the people around him. I think that's missions at its best.
The Christian way of multiplying is the biological way, not the arithmetical way: One becomes two and two becomes four and four becomes eight. I have seen good Christian medical works in India gradually lose their original mission. They become institutionalized, with a building and staff to support, and soon they have to charge fees for their patients. To make the work more self-supporting, they branch out into specialized surgery techniques. Soon they're doing brain surgery with all sorts of sophisticated equipment, and the people they actually came to reach, the poor, malnourished Indians, cannot afford the hospital. Christian witness shines when a young person goes out to work among villagers, working with their sanitation, diarrheal disease, improving nutrition, cutting down on child birth. Eventually more good is done through this kind of personal ministry, I believe.
Jesus Christ did not have to touch people as he healed them. He could easily, with that same power, have waved a magic wand. In fact, a wand would have reached more people than a touch. He could have divided the crowd into groups: paralyzed people over there, feverish people here, people with leprosy there, and raised his hands to heal each group en masse, but he chose not to. No, his mission was to people, individual people who happened to have a disease. They came to him because they had a disease, but he touched them because they were humans and because he loved them. You can't readily demonstrate love to a crowd. Love is generally person to person.
This article appeared in the December 1, 1978, issue of Christianity Today.
Other stories appearing on our site today:
Noted Surgeon and Author Paul Brand Dies at Age 89 | Connected his pioneering work with leprosy and his missionary faith.
A Surgeon's View of Divine Healing | Do doctors waste their time by doing slowly and painstakingly what could have been done in the twinkling of an eye? (November 25, 1983)
Blood, Part 1: The Miracle of Cleansing | We moderns are repelled by the thought of blood cleansing, but biologically and spiritually the precious liquid does exactly that. (February 18, 1983)
Blood, Part 2: The Miracle of Life | A well-known surgeon talks about that miraculous red river within us as an emblem of life. (March 4, 1983)
Blood, Part 3: Life in the Blood | If Jesus had been born in the twentieth century, would he have chosen the image of transfusion for his forgiveness, love, and healing? (March 18, 1983)
The Scars of Easter | He knows the wounds of humanity. His hands prove it. (April 5, 1985)
A Handful of Mud | Soil is life. Can we preserve it for future generations? (April 16, 1985)