The Song of Our Scars

Pain is a fundamental truth. Pain might well be the first sensation a baby feels as it’s born, a gateway to the world of conscious experience, almost certainly becoming the sensation it most strongly associates with being alive. And indeed, every subsequent day of our lives, we experience pains of different types. These are often innocuous but can at times become intractable. Pain is one of the most consistent aspects of the consensus reality we all experience, a hallmark of consciousness among all beings, hardwired into our frames through evolutionary mechanisms millions of years in the making.

Yet pain is also the most fluid of all sensations. While how we see, hear, touch, and taste has likely remained unaffected by historical changes, how we perceive and tolerate pain has changed considerably just in the last century. Pain has transformed from a spiritual force, often the only language through which celestial agents could speak to mortal beings, into a corporeal corruption that can be entirely comprehended and conquered with biomedical advances. Yet other aspects of the place of pain in our society have remained unchanged. Pain—in how it is recognized, treated, and inflicted—has always been and remains an instrument of power, often used against the weak. For it is impossible to separate the assessment of pain from the assignment of supremacy.

Pain is imperialistic: European colonists often derided the pain of their Black and Brown subjects, chalking it up to feebleness, even as they capitalized on its affliction. As Britain operated the greatest opioid-production machine in the history of mankind, waging war simply to keep selling opium and addicting foreign populations to it, it banned the use of opiates for its own people, knowing just how addictive the poppy can be.

Pain is racial: Black slaves were often subjected to indescribable violence under the false pretext that they were too numb to feel pain the way their white masters did. Even to this day, otherwise sophisticated people, including some physicians, hold on to antiquated fabrications, including that Black people feel less pain because their skin is thicker than white people’s. This is one reason why the pain of Black people remains both underrecognized and undertreated.1

Pain is gendered: women are more likely to feel pain, but their pain is also more likely to be dismissed. Many women who seek relief are belittled and delegitimized by some of the very doctors they turn to for support.

And most of all, pain is personal, so personal that it is said to be the one thing truly our own, so inscrutable that it cannot even be communicated within the constraints of language. The only reason I mustered the gumption to write this book, to attempt to uncover the nature of our most complicated sensation, is that pain has been a part of my being for almost my entire adult life.

Pain is as sure a sign of life as the beating of the heart; its disappearance often signals death. It touches us from the tips of our toes to the crowns of our heads; it can even be felt in long-departed parts of our body, as in the phantom pains of those who have lost their limbs to landmines, diabetes, or flesh-eating bacteria. It is tempting to describe the evolution of weapons, from rocks and pointy branches to armed drones and tactical nuclear missiles, in terms of their ability to kill. But their primary aim is often to inflict pain—physical, psychological, cultural, racial, and economic.

And yet there are also those for whom pain is a ladder to the divine. In many religions, such as the Shiite sect of Islam, self-flagellation is a core ritual because of its supposedly redemptive qualities. Connoisseurs of spicy food set their palates on fire as they reach for peppers with ever-rising Scoville units, relishing the bodily chaos that ensues. For some, pain provides a sexual thrill that no amount of gentle stimulation can achieve.

Pain is also our most effective teacher. Most lessons fade, most sermons go unheard, but those taught by pain can last a lifetime. My baby daughter might not listen to anything I say, but the hot skillet only has to instruct her once for her never to touch it again. Not every lesson pain teaches is worth remembering though. Corporal punishment might be a poor tool for education, but it is very effective at creating lifelong trauma.

In the last two centuries, our understanding of how our bodies flourish and falter has advanced tremendously. And yet, even as the song of our scars reaches a deafening pitch, pain remains the sensation we comprehend the least.

It is not an accident that we fail to understand the very basics of pain—especially its more entrenched manifestation, chronic pain. The attempt to define pain beginning in the nineteenth century using clinical and scientific terms shrank its scope to fit the constraints of the tools and rituals of medicine. The corporatization of healthcare transformed people into consumers, transmuting human suffering into a lucrative opportunity to maximize capital. And profit-hungry pharmaceutical companies hijacked a movement to provide comfort to people with terminal illnesses, resulting in one of the most carefully engineered campaigns of distortion in human history.

As a physician I treat people who hurt every day. Yet my relationship with pain goes back to before I was the one people turned to for respite.

When I was a medical student in Pakistan, I would spend hours every day grinding at the gym. If I wasn’t playing basketball, I was lifting weights or running on the treadmill. I was no star athlete, but I labored joyously like a hamster on its wheel. Exercise was medicine for my body, therapy for my spirit.

One evening in the middle of a bench press, I heard a loud click in my back. All at once, my body went limp, and the metal bar I was holding aloft came crashing down, pinning me to the bench. Panic set in. With my torso compressed under more than two hundred pounds of steel, I began to suffocate. I tipped the bar over to one side, hoping the weights would slide off, but I quickly remembered that I had them clamped in place.

Only then did I do what I should have done many long milliseconds before. With progressively thinning breaths, I cried for help.

A couple of medical students rushed over and lifted the weights awkwardly off my chest. Like me, they came to the air-conditioned sports center not just to escape the blistering Karachi sun but to zone out from the incessant memorization of pathologies and the drugs used to treat them. And yet my injury had turned their sanctuary into one of the bays in the emergency room close by. They grabbed me by my arms and tried to pull me up to my feet, but I screamed out in agony. One of them rushed outside and brought back a wheelchair.

Prior to that evening, I had made the walk from the hospital to the gymnasium several hundred times. It was short and typically forgettable. But I will always remember that ride back to the medical center in the wheelchair. Every small bump, even the fine clefts between pavement panels, shuddered through my body.

This was the day that pain became a part of my life. It changed my line of work. It took many of my friends from me. It also took away those precious hours at the gym, my sanctuary from the demands of medical school. And it could have taken away even more: more than once, my pain led me to believe that the only way to release myself from its vise would be to end my life.

On that day in the gym, pain settled in as a persistent presence in my body, an infestation that would come to shape the narrative arc of my life and a primary reason I wrote this book. And yet I know that my story is in fact quite unremarkable. Nothing is as important to our ability to survive as our ability to hurt.

Because I was a medical student who knew most of the staff, when I reached the emergency room, I was immediately taken to a secluded bed without having to linger in the overcrowded waiting room. The pain was most severe in my back, but it traveled all the way up and down my spine like a pendulum, shattering everything in its path. The emergency room physician jabbed me with a dose of intravenous ketorolac, an anti-inflammatory painkiller, and told me that I had sprained a muscle. It would get better in a week, he reassured.

That week went by, and then another, and then several more. My discomfort completely incapacitated me. Sitting hurt too much, but standing wasn’t any better. I could only sleep by lying on my side in the fetal position, with my knees up to my chest, a pillow in between them.

Walking made me exquisitely aware of how my body shifted its weight between the legs and the lower back. There wasn’t a special maneuver I could perform to be comfortable. There was no escape hatch. When I had previously torn my bicep muscle while lifting weights, it hurt only when I moved my arm in certain ways. Those movements I could easily avoid. Hurting my back offered no such out.

Sitting, standing, and walking: as a physician in training, these three activities constituted almost every waking moment of my day. When I was supposed to be attending to my patients during rounds with my team, I could think only of trying to find a chair to sit in or a wall to lean against. Of all the places in the hospital, I dreaded being in the operating room the most, as it meant standing possibly for hours. Medical students are usually assigned a position far from the action, performing tasks whose only purpose can seem to be to torture. I would find myself contorting at awkward angles, holding metal retractors to keep gaping incisions in the body open. I was supposed to be watching the surgeon’s hands, but all I could see was the side of the table or one of the operators’ backs. It quickly became clear that surgery was not a viable career path for me. Being a doctor required me to be empathic; yet my ceaseless pain had left me looking only inward, as I constantly introspected every aberrant alarm arising within my body. In my darkest days, I wasn’t even sure I could ever practice medicine at all.

Chronic pain has governed my life ever since. To this day, an atypical movement or a long day at work threatens to put me back at the beginning of this treacherous trail. But my story is not special, my adversity not exceptional. The back is in fact the part of our body we most commonly injure. And while most back injuries tend to heal, many become indomitable, making them the most common cause of both disability and chronic pain in the United States and around the world. And given that the condition is relatively invisible, with no bleeding wounds or bulbous tumors, and that most of us don’t really think about our backs until they bother us, only those who live with back pain can truly grasp what it wreaks.2

Many people’s lives will, at some point, be completely reorganized by chronic pain. Chronic pain is a truly global phenomenon, estimated to affect 1.5 billion people. Even so, it is a malady with a distinctly American bent: one study shows that Americans appear to feel aches and pains more frequently than people in other countries, and Americans are most likely to use opioids for their pain. One in five American adults—an estimated sixty-six million in total—experience chronic pain, resulting in $500 billion in direct medical costs and lost productivity. Chronic pain disproportionately affects those who are already disadvantaged in other ways: women, people of color, the poor, the elderly, the unemployed, and those living in rural areas are all more likely to experience it. Almost twenty-four million Americans are unable to participate in major life activities due to chronic pain. And the number of people who live with chronic pain is rising.3

We have always hurt. But how we hurt today—how it affects our lives, how we give it meaning, and how we attempt to overpower it—is nothing like how we have suffered in the past. Medical science is just one reason why how we hurt has changed: the confluence of several broader social, cultural, and economic movements has fundamentally altered how those of us alive today experience pain. We must learn to reckon and reconcile with the body on fire.

Whether due to an aching knee or a throbbing head, pain has long been viewed as the work of supernatural forces strumming inflamed nerves like sitar strings. Pain always had a meaning, a greater context. According to the Bible, the pain of childbirth occurred because of Eve’s succumbing to the charms of the devil, which meant that until at least the eighteenth century in Western Europe, attempts to relieve labor pangs were punishable by death. The crime committed by the very first witch burned in Scotland was an attempt to ease the passage of a woman’s twins; the mother, too, was set alight at the stake. Pain relief was seen as an unnatural interruption of cosmic commandments.

As Western societies secularized, so did pain. The treatment of pain moved from the chapel to the clinic, and we began to seek prescriptions rather than prayers to ease the suffering. Yet, even as anesthesia and morphine were discovered in the nineteenth century, the primary aim of medicine continued to be prolonging life rather than providing relief.

In this, medicine succeeded. Yet the longer we survived, the more years we lived with disability and in pain. As noncommunicable diseases such as cancer and heart failure replaced infectious diseases as the leading causes of death, many people’s lives ended in excruciating agony, their bones moth-eaten by malignant tumors, their lungs flooded with their own secretions. Even this gruesome sight would not move physicians to ease the plight of their patients.

The twentieth century saw the rise of a broad movement that sought to give people more control over their bodies. This movement was manifested in many forms: it was cast in the women’s rights movement, the civil rights movement, and decolonization. And while medicine, given its long history of paternalism, was slower to change, these broader forces began to shift power from doctors toward patients, giving people more agency over their health. This shift, first manifesting within healthcare as the hospice movement founded by Cicely Saunders in the United Kingdom, implored physicians to avert not just death but despair and discomfort. Pain was no longer viewed as a symptom of sickness but understood as a syndrome in itself—not a metaphysical disturbance caused by the tipping of the balance between virtue and sin but a purely physical sensation caused by an anatomic disturbance that could be fixed as easily as a broken bone could be put back together. Yet pain is far more complex than that simplistic view, and this turn in the cultural understanding of pain did nothing to abate the rising scourge of chronic pain in the United States and around the world.

Perhaps the most visible sign of this transformation is the opioid epidemic. The Centers for Disease Control and Prevention estimates that between 1999 and 2019, this misery was triggered by a flood of opioid prescriptions to patients with chronic pain, many of whom went on to become addicted and some of whom began abusing street drugs like heroin and fentanyl. The public reaction to the opioid epidemic has focused mostly on the pharmaceutical companies that pushed these pills. Particularly intense attention has been laid on members of the Sackler family, the owners of Purdue Pharma, which manufactured OxyContin, the prescription opioid widely believed to have triggered the crisis.

Little attention, however, is paid to the entire healthcare system that abetted Purdue Pharma and other opioid manufacturers: the physicians who sold their sacrosanct status in exchange for profits, the medical journals that published highly flawed research, the federal regulators who failed to protect the public from dangerous drugs, the distributors that flooded every bit of the country with them, and the pharmacies that asked few questions before dispensing large quantities of dangerous pills to vulnerable individuals. An entire field of medicine centered on pain was created with scant evidence guiding its practice. The corporatization of medical care, coupled with the emergence of consumerism, created a pill-popping culture that placed all of our hopes and dreams for relief on drugs and procedures.

Yet, as we recognize the broad extent of this extraordinary tragedy, we have to consider something even more elemental, something at the heart of what we need to accomplish if we are to beat back the current opioid epidemic and prevent another from recurring in the future: almost everything we know about pain and how we treat it is wrong.

Pain is sensitive to context in a way no other human sensation is. The aches that engulf a marathoner’s entire body change meaning instantly when that marathoner crosses the finish line. During sex, pain can induce euphoria or leave lifelong scars. The pain in the belly that the devout believer feels during a religious fast is very different from that felt by someone starving because they cannot afford a meal. While some variation in pain sensitivity between individuals occurs due to biological differences, our response to pain is largely mediated by the surrounding circumstances we feel it in. In fact, even the genes that cause us to feel pain are deeply affected by the environments we grow up in.

We have been trying to understand the complexities of pain as long as we have been around. In Book 9 of The Republic, Socrates, speaking to his brother Glaucon, asks, “Do we not say that pain is opposite to pleasure?” To Socrates, pain was not merely the absence of pleasure; it was based on where a person started from: Did they move from pleasure to pain or simply from the tranquil middle? An individual’s baseline sets up the subsequent experience of either pain or pleasure, which Socrates considered to be on the opposite ends of a spectrum. Moving from pleasure to pain, according to this dictum, is more distressing than moving from pain to more pain. Are we any closer to understanding pain today?

The expression people in pain most dread hearing is that their agony is “all in their head.” It is often used to diminish that agony, to erase their very personhood. Yet our brain does have a central role in shaping how we hurt. After a pain signal reaches the brain, it undergoes significant reprocessing. The brain, based on previous experiences and current expectations, can modulate pain to be felt either more or less severely. How much something hurts can vary depending on factors like one’s mood and level of distraction. The human brain is not just staffing the ticketing booth at the circus—it is the ringleader. Without the brain’s permission, no tigers jump through burning hoops, no trapeze artists fly around, no swords are swallowed.4

The brain is particularly involved in the experience of chronic pain. Most people assume that when pain lasts long enough, usually more than three months, it transforms into chronic pain. This is how people like me who live with pain have come to think of it and how doctors also like me have been trained to treat it: chronic pain is essentially acute pain prolonged. Yet, if you dive deep into the science only now emerging, a very different picture comes together: acute and chronic pain are entirely distinct phenomena, and there is no justification for treating them the same way.

The siloed nature of science means that at present there is no single working theory for what chronic pain is. Yet my journey poring over thousands of research studies and speaking to dozens of experts and patients, as well as my own odyssey aboard this faltering body, makes one thing clear: most chronic pain is not just a physical sensation. To our nervous system, chronic pain is most often akin to an emotion we feel in a part of our body, an overlearned traumatic memory that keeps ricocheting around in our brains, often long after the injury it rehearses has fully healed. Unlike acute pain, which ascends up the spinal cord to the brain from a nick on the shin or a frayed nerve in the foot, chronic pain descends down from the brain, often with no need for an incitement from below.

Pain remains a difficult matter to approach primarily because of the gulf between the people who experience it, the clinicians who treat it, and the researchers who study it. This gulf means that many common notions are about as grounded in reality as magical fairy dust. It is said that what doesn’t kill you makes you stronger. Yet research actually suggests the opposite, that people who have chronic pain are even more sensitive to pain than those for whom pain is a stop but not a terminal destination. It is said that pain is inevitable but suffering is optional. Yet I cannot imagine that anyone who has experienced persistent pain personally or cared for someone in unflagging agony would ever believe such hogwash. When pain arrives and refuses to leave, suffering is as inevitable as death itself. The only thing I have gained from pain is the lived experience so essential to knowing how ceaseless suffering can wring a human spirit dry.

Standing on this island, I feel pain coming at me from all directions. It comes to me from within when I wake up in the middle of the night in affliction. It comes to me from my patients, who often have disease eating their insides out, leaving them up to their nostrils in pain. And it has come to me from the papers, books, and articles I have read and the scientists, clinicians, and patients I have spoken to about all that hurts.

To understand pain is to know the human body and the human mind and how they are interweaved. It is the strongest riposte to how clinical medicine artificially divides them.

To understand pain is to recognize how race, gender, ethnicity, and power come to indelibly mark what it means to inhabit the human frame.

To understand pain is to learn how the greatest medical tragedy in history came to be, how corporate greed and academic naivete and corruption fueled the opioid epidemic, and how it could recur again.

To understand pain is to explore the true nature of human suffering, how religion and spirituality have often been our most potent balms, and how movements such as existentialism, feminism, and consumerism have changed not only our core beliefs but also our senses.

Yet the need to understand pain is not just a scientific curiosity for me. It has given deeper meaning to the pain that I feel. And while this knowledge may not always grant me complete relief, it has allowed me to find a new way to live in my body.

Broadening the lens through which I see pain has helped to defog the window through which I see the pain of others, an essential part of my work as a clinician. Even as physicians and nurses are almost constantly face-to-face with suffering, that existential leap known as empathy, the act of feeling another’s pain, is especially important as we increasingly rely on blood tests and imaging to tell us what ails a patient, while pain continues to elude such quantification. Relieving pain is one of the most gratifying feelings a clinician can ever get in the course of their vocation. Yet the drive to label pain as a physical sensation, as a vital sign similar to heart rate or blood pressure, was not an organic movement founded by clinicians. It was in fact engineered by the pharmaceutical industry, appealing to clinicians’ deep desire to relieve suffering to sell trillions of dollars’ worth of products. And while the drugs and devices they sold provided comfort in the short term, for people with chronic pain they were ineffective for most and deadly for many.

If you twist your ankle or bump your head, or if you live with torment that never ebbs, what you feel and how you respond is not just the aggregate of nerve signals bombarding your brain stem. It is the sum product of your entire existence and the entire history of human beings encapsulated in the multidimensional experience we call pain. Reaching a new understanding of how we hurt will change how we live with our aching selves. Synthesizing our knowledge about the fundamentals of pain could move us closer to a future in which even if we hurt, we don’t suffer. And recognizing the many layers of pain and how we respond to the agony of others could lay the foundation for a just and equitable society.