Culture and pain
Last week I had to speak on “Asia’s languages of pain” at the 6th Association of Southeast Asian Pain Societies Congress. The participants are all experts on pain—not, I hope, on inflicting but on alleviating it—with all kinds of subspecializations (for example, some dealing mostly with children, others with the elderly).
We have common cries of pain that are recognized across countries. Even when expressed in a local language, there is amazing similarity: ay, ow, aiyo, aiya… and our aray.
But human language allows even more elaboration on pain. For Filipinos, sakit means both pain and an illness. We indicate where the pain is by naming the part of the body where the pain is, for example, sakit ng ulo (headache), sakit ng tiyan (stomachache). This localization of the pain is found across many languages.
We also have very specific terms for pain, with the late anthropologist Felipe Jocano naming several of the terms in his “Folk Medicine in a Philippine Municipality,” which is based on studies in Bay, Laguna. Three examples of the pain terminology are kirot (sharp, recurrent pain), hapdi (stinging pain) and antak (internal, continuous pain).
We find similar classifications of pain in all languages. In Chinese Mandarin, for example, you have qie tong (sharp pain), shan tong (stabbing flash pain), and jiao tong (gripping pain as in cramps or gas pain).
The anthropologist Emiko Ohnuki-Tierney had these descriptions of pain among the Ainu of Sakhalin, Japan, that reflect their environment. A “bear headache” is similar to heavy steps, a “deer headache” is similar to running deer. Pounding headache? It’s called “woodpecker headache.”
Physicians tend to ask patients to describe their pain on a linear scale—for example, if P100 means the most painful condition, how would you describe your pain? (I am told by older physicians that they used to ask patients to compare the pain to P1, but piso has become so insignificant that it’s not too useful for describing the degree of pain.)
I do remind physicians that pain cannot always be situated on a linear scale. There are just too many types of pain that go beyond intensity. The Chinese tong ku means pain and suffering. In Filipino, there are sakit ng loob (inner pain) and sakit sa loob (which might combine both the physical and the psychological).
Pain and suffering are inextricably related to sadness and misery. We suffer pain when we lose something, or someone. When I delivered my paper at that pain congress, I had no idea that in a few days I would feel the full weight of that pain, suffering and sadness with the death of a goddaughter, and my being reminded of how similar physical and psychological (or psychic) pain can be, for example, how the pain can be delayed, and then hitting full force when one least expects it.
“Ang bigat ng loob ko,” I told friends, literally reflecting how psychological pain can be a heavy (I was tempted to capitalize all the letters in that word) burden inside us.
Pain becomes suffering, too, because pain disables us, prevents us from doing what we want to do, what we need to do. An athlete who suffers an injury during a game will continue playing, with his or her determination allowing an endurance of the pain. After the game, the pain intensifies, but it becomes unbearable when coupled with a realization that he or she will not be able to compete.
Pain specialists should look then at alternative ways of getting patients to describe what they are feeling. In Chinese, patients are sometimes asked if they are suffering or having difficulty. I think something similar—“Nahihirapan ka ba?”—can be used locally, instead of “Masakit ba (Is it painful)?”
Culture comes into the picture, not just in terms of language but also in the “rules” around the expression of pain. Some cultures are more stoic than others, so much so that it can be considered impolite or rude to be too expressive of pain, as we find among East Asian cultures. Compare that norm with Filipinos, who are almost expected to be “OA” (overacting) when we express pain.
Cultural pain is existential, tied to philosophies of suffering. In many Asian cultures, women are expected to bear their pain: pagdudurusa or pagtitiis in Filipino. In Chinese, there is the expression chi ku—eating suffering, used often by women.
Many religions view pain both as punishment and as potential redemption. I remarked at the conference last week that maybe the organizers should have scheduled their meeting two weeks later, during Holy Week, so our foreign guests could see the “penitensiya”—religious devotees flagellating themselves or even having themselves crucified, sometimes to atone for sins. More often, though, this self-mortification is part of a panata or vow, a bargaining with God and the supernatural: Grant me my wish and I will pay back with pain.
We are not the only ones with such extreme displays of pain. Tamil Indians, both in their homeland in southern India as well as in other parts of the world where they have migrated in large numbers (for example, Singapore, Malaysia and Sri Lanka), observe a Hindu festival involving the bearing of kavadi or burdens. The most dramatic kavadi involve the piercing of the skin, tongue or cheeks with skewers. Another variation is to attach hooks to the back with the kavadi, like small pots of milk. That is mild compared with another form where the hooks are tied to ropes that are used to pull a vehicle.
Pain and pleasure
All societies “medicate” pain with all kinds of remedies, from poultices to pills. Some of the traditional remedies—acupuncture, say—are now being studied and used for pain alleviation.
We may have much to learn as well from our Holy Week penitents and Thaipusam kavadi bearers. These devotees prepare themselves for the rituals with weeks of fasting, meditation, and abstinence from sex. During the infliction of pain itself, they go into trance states.
At the conference there were exhibits for various pain remedies, usually to break or disrupt the nerve impulses that cause pain. I thought of how one could also break the psychological links that produce suffering. Psychologists use the term “cognitive restructuring,” or getting people to shift their mindsets. For pain alleviation, it’s teaching patients not to think so much of the pain, or to think of pain differently.
We could learn, too, from traditional comforting rituals that alleviate pain, from preparing comfort foods to just holding the patient.
Analgesia is not the opposite of pain; it is a clinical condition that is induced by pharmaceuticals. What our patients often need is not just analgesia but also a feeling of relief and wellbeing (ginhawa). “Nabunutan ng tinik” (a thorn has been removed) is one graphic description of the relief that patients want. Even better is relief that results in the patient saying, “Ang sarap (That feels so good)!” (or “Lami!” in Cebuano).
Pain and pleasure do overlap, and whether we are physicians or not, we are all often asked to dispel pain by allowing pleasure to take over.
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