October 18, 2015

A Shot in the Arm

Juggling multiple projects, it is perhaps unsurprising that one sometimes tries to catch all the knives in one hand. The release of a policy position-paper from the World Health Organisation on pain mitigation during child-vaccination procedures brought everything into focus recently, making me think there’s a unifying principle to my work after all.

The release of Edward Jenner is only two weeks away (that makes him sound like a hell hound, which maybe is apt), so I’ve become a sort of vaccine activist in the form of Jenner’s ghost (@EdwdJenner on Twitter). In the meantime I’m finishing off a book on pain for Oxford University Press, due in December. Lurking in the background is the daunting prospect of writing the first textbook on the history of emotions for Manchester University Press, due at the end of next year. And my book on the practical applications of Darwinian sympathy is done, dusted and on its way to the University of Illinois Press, replete with a chapter on the evolutionary rationale for compulsory vaccination.

Concerned that anxiety increases the pain of childhood vaccination, which in turn leads to fall-off rates for immunization programmes, the WHO sets out guidelines for a smooth and pain-reduced process. Interestingly, they don’t think that topical anaesthetics are worth the cost and find no evidence that orally ingested painkillers make any difference to the pain of being injected. Rather, a programme of calmness, distraction and neutral language is promoted. Caregivers are to be present throughout. Where appropriate, infants should be breastfed immediately prior to injection. Vaccinators should be even-tempered and well-informed. They should stick to straightforward speech that neither alarms nor falsely reassures (we can all see through it). There ought to be a plentiful supply of toys. It’s essentially a recipe for anxiety elimination for the reduction of pain.

Probably not what the WHO has in mind: Major and Mrs Padmore inoculating against plague in the bazaar in Mandalay, Burma, now Myanmar, 1906. Wellcome Library, London
What is striking about the WHO’s advice is the degree to which they accept and endorse a working definition of pain that includes, in fact depends on, emotion. I’ve been beating a drum for a while now about the way humans make meaning out of pain, arguing that things hurt according to the extent to which we fear them. Pain is not simply a mechanical nervous circuit, where pain experience is directly proportional to painful stimulus. Humans make pain according to emotional appraisals of the meaning of bodily harm, and this dynamic involves both the affective processes of the brain and an understanding of the world and its particular and contingent articles of anxiety. There is no universal elicitor of fear; no object that is intrinsically fearful. Meaning is made – pain is made – in cultural and historical context.

David Hume knew all this in the 1730s:
Were I present at any of the more terrible operations of surgery, ’tis certain that even before it begun, the preparation of the instruments, the laying of the bandages in order, the heating of the irons, with all the signs of anxiety and concern in the patients and assistants, wou’d have a great effect upon my mind, and excite the strongest sentiments of pity and terror. No passion of another discovers itself immediately to the mind. We are only sensible of its causes and effects. From these we infer the passion: And consequently these give rise to our sympathy.
Watching someone about to endure pain is, in itself, painful to the witness. Anxiety is well known to be ‘contagious’. In turn, the subject of the ‘terrible operation’ sees only victimhood, feeding on the anxious atmosphere at hand. In such circumstances, without something to deaden the sensibilities, doubtless the pain would be heightened. It is heartening to know the WHO has a handle on this, with a complex understanding of the ways in which the management of anxiety will diminish the likelihood of painful experience.

Vaccines, Pain, Emotions: my world to a tee, in an episode from the doctors WHO.

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