You would not expect a physician who dedicated his life to alleviating suffering to call himself "a lobbyist for pain." Yet working as a missionary surgeon in India led Paul Brand to conclude that most of the ravages of leprosy—open ulcers, blindness, missing fingers and toes—can be traced to a simple loss of sensation. Without the warning signals of pain, leprosy patients were unwittingly destroying their bodies. Such observations gave Brand a view of both pain and pleasure that is at odds with our culture's conventional wisdom. Readers of Christianity Today may know Brand from his books Fearfully and Wonderfully Made and In His Image, and from his term as president of the International Christian Medical and Dental Society. His new book, Pain: The Gift Nobody Wants (Zondervan), from which this article is adapted, tells the story of Brand's career and how he came to his unusual approach to pain and pleasure.
My professional life has revolved around pain, and by living in different cultures I have observed at close hand the widely diverse reactions it elicits. I served my medical internship in London during the most harrowing days and nights of the Blitz, when the Luftwaffe was pounding a proud city into rubble. Physical hardship was a constant companion, the focus of nearly every conversation. Yet I have never lived among people so buoyant; now I read that 60 percent of Londoners who lived through the Blitz remember it as the happiest period of their lives.
After the war I moved to India. In that land of poverty and omnipresent suffering, I learned that pain can be borne with dignity and calm acceptance. It was there I began treating leprosy patients, pariahs whose tragedy stems from the absence of physical pain. The horrible disfigurement associated with the disease, we now know, has to do with the numbing of the sensation of pain. People with leprosy lack an internal system to warn them of danger, and they often wear their fingers, hands, and feet down to stumps.
Later, in the United States, a nation whose war for independence was fought in part to guarantee a right to "the pursuit of happiness," I encountered a society that seeks to avoid pain at all costs. Patients lived at a greater comfort level than any I had previously treated, but they seemed far less equipped to handle suffering and far more traumatized by it. Pain relief in the United States is now a $63 billion a year industry, and television commercials proclaim better and faster pain remedies. One ad slogan bluntly declares, "I haven't got time for the pain."
Each of these groups of people—Londoners who suffered gladly for a cause, Indians who expected suffering and learned not to fear it, and Americans who suffered less but feared pain more—helped to form my outlook on this mysterious fact of human existence.
From this vantage point, I now detect a profound uneasiness in the United States and much of the West. The good life does not seem quite so good as promised. Critics worry that Americans are becoming soft and weak, a "culture of complaint" more liable to whine about a problem or file a lawsuit than strive to overcome it. To me, at the heart of the issue lies a basic confusion regarding pain and pleasure. Affluence and overindulgence have made the modern industrialized West a difficult place to experience pleasure. This is a deep irony, because no society in history has succeeded so well in eliminating physical pain.
The Barber of Vellore
Encounters some years ago with two barbers, one in California and one in India, helped me see this vividly and gave me insight into the nature of contentment, a state of deep-seated pleasure. I visited the first barber in Los Angeles just before embarking on an overseas trip in the 1960s. He worked in a shop of gleaming tile and stainless steel that featured the latest equipment, including four hydraulic chairs that went up and down at the press of a foot pedal.
A crusty man in his late fifties, this owner used the occasion to grouse about the miseries of modern barbering. "I can hardly make a living these days," he said. "I can't get responsible help. The barbers who work for me gripe about their tips and demand raises. And everything I make I have to pay to the government in taxes." He went on with bitter commentary on the laggardly state of the economy and the ingratitude of his customers. When I arose from his chair, I felt like asking for a therapist's fee. Instead, I had to pay him five dollars, an excessive price in those days.
After a month of traveling, I had business in Vellore, India. I once again needed a haircut. This time I visited a storefront barbershop across the street from the Vellore hospital. The barber motioned me toward his single chair, a crude contraption of rusty metal and cracked leather that lacked all upholstery stuffing. When I sat down, he disappeared out the door and around the block, carrying a battered brass basin in which to fetch water. On his return, he laid out an array of scissors, combs, a straight razor, and hand-operated clippers. I was struck by his air of quiet dignity. He was a master of his craft, which he knew to be a worthy one.
Just as the barber was noisily stropping the razor, preparing to cut my hair, his ten-year-old son showed up with a hot lunch from home. The barber looked at me apologetically and said, "Sir, you'll understand that this is my lunch time. Could I cut your hair when I'm finished?"
"Certainly," I replied. I watched as the boy spread the lunch on a banana leaf. Sitting on the floor, his bony legs crossed at the ankles, the father partook of rice, pickles, curry, and curds while the son stood beside him.
"I suppose your son will become a barber after you," I said, observing the reverent way the boy treated his father. "Oh, yes!" the barber beamed proudly. "I hope to have two chairs by then. We can work together until I retire. And then the shop will be his."
As the boy cleaned up, the father began work on my hair. Occasionally it felt as if his ancient clippers were pulling individual hairs out by the roots, but all in all, I got a fine haircut. At the end, he asked for the fee: one rupee, the equivalent of an American dime. I glanced in the mirror, comparing this haircut with my last one, and as I did so I could not help comparing the two barbers as well. Somehow the one who earned one-fiftieth of the other's fee seemed to have the happier life.
From people like the barber in Vellore I learned that contentment is not the absence of discomfort or mere avoidance of pain. It is an inner state, a truth that easily gets lost in the jangle of high-pressure advertising in the West.
The Greek king Tantalus, as punishment for the crime of stealing ambrosia from the gods, was condemned to an eternal torment of hunger and thirst. Water receded as he stooped to drink, and trees lifted their branches as he reached up to pluck their fruit. From this myth, we get the word tantalizing; like most Greek myths, it offers a lesson worth contemplating. A double irony is at work: Just as a society that conquers pain and suffering seems less able to cope with what suffering remains, so a society that pursues pleasure runs the risk of raising expectations ever higher, so that true contentment always lies tantalizingly out of reach.
Straining to Hear Pain’s Signals
I readily admit that working among pain-deprived people may have given me a skewed perspective. But I regard pain as one of the most remarkable design features of the human body, and if I could choose one gift for leprosy patients, it would be the gift of pain. I also wish people in our culture would cease seeing pain as something to avoid at all costs. If we would, our lives would not only be richer, but our bodies would be healthier.
Any physician working in modern civilization cannot help noticing our culture's deafness to the wisdom of the body. In a village in India, I grew up in stern conditions of heat and cold, hunger and good food, birth and death. Now, living in a technologically advanced society, I am tempted to view all discomfort as a problem to be solved. We silence pain when we should be straining our ears to hear it; we eat too fast and too much and take a seltzer; we work too long and too hard and take a tranquilizer. (The three best-selling drugs in the U.S. are a hypertension drug, a medication for ulcers, and a tranquilizer.) In Western countries, an astounding proportion of health problems stem from behavior choices that show disregard for the body's clear pain signals.
Where has this disregard gotten us? We doctors sometimes shy away from interfering in our patients' lives. But if we were fully honest, we might say something like this: "Listen to your body. It is telling you that you are violating your brain with tension, your ears with loudness, your eyes with constant television, your stomach with unhealthy food, your lungs with cancer-producing pollutants. Listen carefully to the message of pain before I give you something to relieve those symptoms. I can help with the symptoms, but you must address the cause."
Each year representatives from the Public Health Service, including the Centers for Disease Control and the Food and Drug Administration, meet together to discuss health trends and to set priorities for new programs. In the 1980s, in the midst of one such weeklong conference, I started making a list of all the behavior-related problems on the agenda and the time devoted to each: heart disease and hypertension exacerbated by stress, stomach ulcers, cancers associated with a toxic environment, AIDS, sexually transmitted diseases, emphysema and lung cancer caused by cigarette smoking, fetal damage stemming from maternal alcohol and drug abuse, diabetes and other diet-related disorders, violent crime, and automobile accidents involving alcohol. These were the endemic, even epidemic, concerns for health experts in the United States.
A comparable gathering of experts in India, I knew, would have dealt instead with malaria: polio, dysentery, tuberculosis, typhoid, and leprosy. After valiantly conquering most of those infectious diseases, the U.S. has now substituted new health problems for old. And it is largely because we ignore or cover over our body's signals of discomfort and pain.
Prescription for Pleasure
Perhaps because I have had to repair so many physical problems caused by overindulgence, I take a long-term view of pleasure. I recognize that gluttony may give short-term pleasure even as it sows the seed for future disease and pain. Hard work and exercise, which may seem like pain in the short term, paradoxically lead to pleasure in the longer term. After living in several cultures, I am ready to diagnose promiscuity, an overindulgence in pleasure, as the disease of our modern age. To me, the word carries far more than a sexual connotation; it implies a kind of irresponsibility or hedonism, a spirit of "Have fun today, tomorrow will take care of itself."
Many people today resent a moral code like the Ten Commandments and regard it as an arbitrary list of rules—God's way of keeping us from having too much fun. I see it as exactly the opposite: a prescription for a joy-filled and healthy life, a life of well-being captured in the Hebrew word shalom. I believe that a society works best when a day is set aside to honor God, when children respect parents, when stealing, murder, and adultery are forbidden, when people do not lie to each other or covet others' possessions.
Indisputably, behavior choices affect health: obesity increases the risk of heart disease, drinking increases the risk of liver ailments, and sexual promiscuity increases the risk of venereal disease. I think back to Luther Terry, the surgeon general who had the courage to come out and say that a popular habit, smoking, was harmful to health and should be abandoned. The reason his pronouncement took courage is that people do not like to be told how to behave. They would rather hear that if you want to smoke, you should take a vaccine to prevent any possible harm, or that if you get lung cancer, we can fix it.
In the 25 years since Terry's pronouncement against smoking, other behavior-related sicknesses have moved in, even as smoking has begun to move out. AIDS is the latest and probably the worst of such illnesses. Many protest vigorously against the notion that AIDS is behavior-related, but in plain fact, AIDS would never have become the epidemic it is apart from such behaviors as intravenous drug abuse and sexual promiscuity.
God gave us a code of morality—whatever limitations it puts on us—for our benefit. Having celebrated my golden wedding anniversary last year, I can say without hesitation that the basic human virtue of faithfulness to one sexual partner is the most joyful way of life. That has meant forgoing illicit pleasures, to be sure, but I have thereby always lived free from any fear of sexually transmitted diseases. I have always trusted my wife completely, and she me. We have channeled love, commitment, and intimacy toward one person in a lifelong investment that is now, in old age, paying rich dividends.
The Oxford English Dictionary defines pleasure, in part, as the "opposite of pain." For much of my life, I would have agreed. But I have come to see that pain and pleasure come to us not as opposites but as Siamese twins, strangely joined and intertwined. Nearly all my memories of acute happiness, in fact, involve some element of pain or struggle: a massage after a long day in the garden, a scratching of an insect bite, a log fire after a hike in a snowstorm. Many include the element of fear or risk, such as my first time downhill skiing—I took up the sport at age 60—when by mistake I found myself flying down an expert run. The wind rushed past, my muscles tensed, my heart lept, but when I made it to the bottom, I felt for a moment like a champion.
I once read philosopher Lin Yutang's summary of the ancient Chinese formula for happiness. As I went through his list of 30 supreme pleasures in life, I was startled to find pain and ecstasy inescapably mixed. "To be dry and thirsty in a hot and dusty land and to feel great drops of rain on my bare skin—ah, is this not happiness! To have an itch in a private part of my body and finally to escape from my friends and go to a hiding place where I can scratch—ah, is this not happiness!" Each of the supreme happinesses, without exception, included some element of pain.
Later I read the following passage in Saint Augustine's Confessions:
What is it, therefore, that goes on within the soul, since it takes greater delight if things that it loves are found or restored to it than if it had always possessed them? Other things bear witness to this, and all are filled with proofs that cry aloud, "Thus it is!" ... The storm tosses seafarers about, and threatens them with shipwreck: they all grow pale at their coming death. Then the sky and the sea become calm and they exult exceedingly, just as they had feared exceedingly. A dear friend is ill, and his pulse tells us of his bad case. All those who long to see him in good health are in mind sick along with him. He gets well again, and although he does not yet walk with his former vigor, there is joy such as did not obtain before when he walked well and strong.
"Everywhere a greater joy is preceded by a greater suffering," Augustine concludes. This insight into pleasure is one that we in the affluent West need to remember. We dare not allow our daily lives to become so comfortable that we are no longer challenged to grow, to seek adventure, to risk. An internal self-mastery builds when you run farther than you have run before, when you climb a mountain higher than any other, when you take a sauna bath and then roll in the snow. The adventures themselves bring exhilaration; meanwhile, challenge, risk, and pain combine to bolster a confidence that may serve well in times of crisis.
There is one further illustration of pain and pleasure working together that I must not overlook. Some people voluntarily take on suffering as an act of service, and these, too, find that pain can serve a higher end. I have met a few "living saints" in my time, men and women who at great personal pains and sacrifice have devoted themselves to the care of others.
As I have watched these rare individuals in action, though, any thought of personal sacrifice fades away. I find myself envying, not pitying them. In the process of giving away life, they find it and achieve a level of contentment and peace virtually unknown to the rest of the world.
I think of a man we all called "Uncle Robbie," a New Zealander who turned up at Vellore one day, unannounced. "I have a little experience in shoemaking," he said. "I wonder if I could be of help to your leprosy patients. I'm retired now, and don't need money. Just a bench and a few tools."
The facts of Uncle Robbie's life leaked out slowly. We were amazed to learn that he had been an orthopedic surgeon, had, in fact, been chief of all orthopedics in New Zealand. He had given up surgery when his fingers began trembling. Then he had learned how to work with leather, how to dip it and stretch it over a mold, then fill in all the hollow places with tiny scraps glued together. He would spend hours on a single pair of shoes and keep making custom adjustments until the patient's foot showed no more stress points. Uncle Robbie lived alone in a guest room at the leprosarium—his wife had died some years before. He worked with us three or four years, training a whole platoon of Indian shoemakers. Watching him labor so tenderly over the damaged feet of leprosy patients, I could hardly imagine him in the ·prestigious, high-pressure environment of orthopedic surgery back in New Zealand. He was an utterly unassuming man, and nearly everyone he met came to love him. No one ever felt sorry for Uncle Robbie—he was perhaps the most self-contented person I have ever known. He did his work for the glory of God alone.
I think of Sister Leela, who, like Robbie, showed up at Vellore with no advance notice. She wore a plain sari in an odd style, rather like a nun's habit. She was indeed a Catholic nun, though not connected to any particular order.
"I think I know how to heal ulcers on a leprosy patient's foot," she said to me, rather matter-of-factly. She needed only some felt, adhesive, and an antiseptic called gentian violet. I supplied these materials and assigned her some patients. Watching her at work was like watching a master sculptor. First she would shave the felt into very fine layers. After treating the ulcer on a foot, she dabbed glue around the sore and then meticulously built up the felt in various thicknesses, depending on the contours of the foot.
Somehow, in this small, unpleasant, but essential task, she had learned to find true joy through service. (Unless you have treated the ulcerous foot of a leprosy patient, you cannot imagine what a remarkable statement that is.) She stayed with us several years and then felt the urge to move on. I lost track of Sister Leela for almost a decade, until I visited a leprosarium in Israel. There I saw a patient wearing an insole support formed of fine layers of felt. Sure enough, Sister Leela had stopped there. Several times later, in diverse parts of the world, I saw the same trademark felt treatment, and I knew that Sister Leela had passed by.
A cobbler shop and a foot clinic may seem like unpromising settings in which to learn about pleasure. Nevertheless, these are some of the people I look back upon as happy in the deepest sense. They achieved a shalom of the spirit powerful enough to transform pain—their own pain as well as others'. "Happy are they who bear their share of the world's pain: In the long run they will know more happiness than those who avoid it," said Jesus in J. B. Phillips's paraphrase.
Mother Brand’s Bequest
What I learned from Uncle Robbie Robbie and Sister Leela reinforced one of the earliest lessons from my parents, who served as missionaries in the Kolli Malai range of India. I lived with my parents for nine happy years before going away to England for schooling. There I stayed with two aunts in a majestic house in a suburb of London, the estate home my mother had grown up in. It was furnished in mahogany, its cabinets filled with priceless heirlooms.
My aunts told me that Mother used to dress with a certain flair, and showed me some of her silks and laces and long plumed hats still hanging in the closet. She had studied at the London Conservatory of Art, and I saw the watercolors and oils she had painted years before. There were portraits of my mother as well; my aunts told me that the men students used to compete for the privilege of painting beautiful Evelyn. "She looks more like an actress than a missionary," someone had remarked at her farewell party before the voyage to India.
When my mother came back to England, though, after my father died at age 44 from blackwater fever, she was a broken woman, beaten down by pain and grief.
Could this bent, haggard woman possibly be my mother? I remember thinking at the time.
Against all advice, my mother returned to India after a year's recuperation, and there her soul was restored. She poured her life into the hill people, nursing the sick, teaching farming, lecturing about guinea worms, rearing orphans, clearing jungle land, pulling teeth, establishing schools, preaching the gospel. While I was staying in the manor house of her childhood, she was living in a portable hut, eight feet square, that could be taken down, moved, and erected again. She traveled constantly from village to village.
Mother was 67 when I first went to India as a surgeon. We lived only a hundred miles apart, though it took a full 24- hour journey to reach her place up in the hills. Her active years in the mountains had taken a toll. Her skin was weather-beaten, her body infested with malaria, and she walked with a limp. She had broken an arm and cracked several vertebrae being thrown off a horse. I expected she would be retiring soon. How wrong I was.
At the age of 67, still working in the Kolli hills, Mother fell and broke her hip. She lay all night on the floor in pain until a workman found her the next morning. Four men carried her on a string-and-wood cot down the mountain path to the plains and put her in a jeep for the agonizing hundred-mile ride over rutted roads. I was out of the country when the accident occurred, and as soon as I returned, I scheduled a trip to the Kolli Malai with the express purpose of persuading Mother to retire.
"Mother, you're fortunate someone found you the next day," I began my rehearsed speech. "You could have lain there helpless for days. Shouldn't you think about retiring?" She stayed silent, and I piled on more arguments.
"It's not safe for you to live alone up here where there's no medical help within a day's journey. Surely you realize that even the best of people do sometimes retire before they reach 80. Why don't you come to Vellore and live with us? We have plenty of good work for you to do, and you'll be much closer to medical help. We'll look after you, Mother."
My arguments were absolutely compelling—to me, anyway. Mother was unmoved. "Paul," she said at last, "you know these mountains. If I leave, who will help the village people? Who will treat their wounds and pull their teeth and teach them about Jesus? When someone comes to take my place, then and only then will I retire. In any case, why preserve this old body if it's not going to be used where God needs me?" That was her final answer.
For Mother, pain was a frequent companion, as was sacrifice. I say it kindly and in love, but in old age, Mother had little of physical beauty left in her. The rugged conditions, combined with the crippling falls and her battles with typhoid, dysentery, and malaria, had made her a thin, hunched-over old woman. Years of exposure to wind and sun had toughened her facial skin into leather and furrowed it with wrinkles as deep and extensive as any I have seen on a human face. Evelyn Harris of the fancy clothes and the classic profile was a dim memory of the past. Mother knew that as well as anyone—for the last 20 years of her life she refused to keep a mirror in her house.
And yet, with all the objectivity a son can muster, I can truly say that Evelyn Harris Brand was a beautiful woman, to the very end. One of my strongest visual memories of her is set in a village in the mountains, possibly the last time I saw her in her own environment.
When she approached, the villagers had rushed out to take her crutches and carry her to a place of honor. In my memory, she is sitting on a low stone wall that circles the village, with people pressing in from all sides. Already they have listened to her praise them for protecting their water supplies and for the orchard that is flourishing on the outskirts. They are listening to what she has to say about the love of God for them. Heads are nodding in encouragement, and deep, searching questions come from the crowd. Mother's own rheumy eyes are shining, and standing beside her I can see what she must be seeing with her failing vision: intent faces gaze with trust and affection on one they have grown to love.
No one else on earth, I realized then, commanded such devotion and love from those villagers. They were looking at a bony, wrinkled old face, but somehow her shrunken tissues had become transparent, and she was all lambent spirit. To them, and to me, she was beautiful.
It was a few years later that my mother died, at the age of 95. Following her instructions, villagers buried her in a simple cotton sheet so that her body would return to the soil and nourish new life. Her spirit, too, lives on, in a church, a clinic, several schools, and in the faces of thousands of villagers across five mountain ranges of South India.
A coworker once remarked that Granny Brand was more alive than any person he had ever met. By giving away life, she found it. Pain she knew well. But pain need not destroy. It can be transformed—a lesson my mother taught me, and one I have never forgotten.
Paul Brand is a world-renowned hand surgeon and leprosy specialist. Now in semiretirement, he serves as clinical professor emeritus, Department of Orthopedics, at the University of Washington and consults for the World Health Organization. His years of pioneering work among leprosy patients earned him many awards and honors.
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