THE OPEN MIND
Host: Richard D. Heffner
Guest: Norman Cousins
VTR: 9/24/83 Part I
I’m Richard Heffner, your host on THE OPEN MIND. Whenever today’s guest joins me here on the air – and the first time he did was three decades ago – my temptation is to introduce him at simply too great length. But only because I want so much to quote so much of what he’s recently written, for he is to me, and always shall be, not only one of the warmest, most decent human beings I’ve ever known, but the wisest as well. And after so many years of addressing the problems of war and peace, of international conflict, particularly in his long-time role as editor of The Saturday Review; now as faculty member of the University of California at Los Angeles School of Medicine, he directs his attention much more to each individual’s struggle for personal health and well-being. Norman Cousins’ “Anatomy of an Illness” made an incredible impression upon our country four years ago. Now his new volume, “The Healing Heart,” also published by W.W. Norton, promises to bring antidotes to panic and helplessness to even more of us.
Norman, thank you for joining me again.
Cousins: Thank you for your generosity.
Heffner: Well, you know, at some point in this extraordinary book, and it is, in its story of your heart’s healing after a massive attack in December 1980, you write about the disease of panic. And I wonder whether you found a cure for that disease?
Cousins: No, but I think there are blockers. And just as medicine has produced calcium blockers and beta blockers, chemicals that interrupt dangerous processes, so I think that there are blockers to panic. I think that love, faith, hope, laughter, the will to live, creativity, playfulness, all are correctives to the penalties of panic. And those penalties are very severe indeed, as I think you know. Anytime person is ill, there are two diseases that he has to combat: one is the disease that has the name attached to it when he gets his diagnosis, whether cardiac disease, or arthritis, or bronchitis, or malignancy, or any other; but there’s another disease that also takes place, inevitably, and that is the disease of the emotions. The panic that inevitably accompanies serious illness. And panic as a disease is devastating. And therefore, if you treat the first disease, the one with the formal name attached to it, and not the second, you’re treating only half the problem. Panic has physiological, biochemical effects. Panic will upset the endocrine system, change the balances. Panic will constrict the blood vessels, forcing the heart, which is already in precarious condition in the event of a heart attack, to work that much harder to get through the narrowed openings. And that is why I say there are two illnesses and not one, and we’ve got to give a great deal of attention to the second if we want to treat the first.
Heffner: You say “we.” But “we” you mean the medical profession?
Cousins: Not just the medical profession. Everyone. You see, Dick, I think that we’ve been so educated about certain aspects of health, that we tend to overlook some simple truths. In fact, I think we have not been served well by public education on health. I think that the general trend of thought makes us very timid about ourselves. The things that we read, the things that we’re told to do, all these things give us great insecurity about our bodies, and I think we’re becoming a nation of hypochondriacs and pill-poppers.
Heffner: Certainly if one looks at the bestseller list, almost every book if it doesn’t have to do with the stock market does have to do with the rise and fall of our blood pressure or other aspects of our physical well-being. You don’t object to that, do you?
Cousins: No, I don’t object to that. Because many of these books try to give the individual an increased sense of personal responsibility. And that is all to the good. What I do object to is the fear that people have about the slightest pain. We…there’s so much emphasis on annual checkups, for example, that physicians’ offices are clogged with people who have no business being there. Then, too, you turn on your TV set and it’s impossible to look at it for a few minutes without seeing this or that analgesic for this or that pain. And we’re almost made to feel subversive or un-American unless we begin to pop pills to take care of these pains. The curious thing is that we’re not taught to pay attention to the cause of the pain. Everything is geared to giving us labels. If you have symptoms, then you want a label. What is the name of the particular illness? But it’s not just what is wrong that is important. The question that has to be asked, the primary question, is “what is it that we are doing that we ought to stop doing?” because we don’t stop doing it. Then it’ll only be a matter of time before we have to take more pills. And that’s what I’ve been trying to address myself to in this book.
Heffner: It’s interesting you say “find out what we’re doing that’s wrong.”
Heffner: There is an assumption your part then that, to a large extent at any rate, when we’re ill it’s a function of the way we have been living. Is that a fair statement?
Cousins: Yes, it is. Yes. You see for a long time we had the germ theory of disease. The notion that we were in a crowded thoroughfare or crowded room, and one of our apertures happen to be open, and a bug spied the aperture, dove in and dove down and took up residence, and kicked up a fuss and we became ill. But a lot of people may have had their apertures open under those circumstances, but it didn’t happen to them. Why not? It didn’t happen to them because their bodies were equipped to take care of the problem. When you become ill it simply means that your immune system is not working as it was intended to work. Well, what is it that makes it difficult for that immune system to do its job? Here you have to look not just to disease germs, but you’ve got to look to the way we live, to our emotions, despair, depression, prolonged grief, frustration, exasperation, all have the effect on the body’s immune system and open us up to attack. So psychological factors play a very important part in bringing on disease. It’s not just the bug. Our bodies can handle the bugs. It’s the deterioration of the defense mechanisms in our body that we have to be concerned with.
Heffner: I gather in reading “The Healing Heart” that you have a lot of strong feelings about…you mention the annual exam. You mention the things that we’re concentrating on that perhaps we could focus on less intensely. How does the medical profession react to that suggestion?
Cousins: Well, I think that medical opinion now is coming around to the view that there’s been much too much attention paid to annual examinations. There was an interesting piece on this subject that was published the Journal of the American Medical Association a year or two ago, an excellent article, seeking some reconsideration of this particular fact. You see, at any particular point, we may have something wrong with us, and these are things that high technology, medical technology can pick up. But the important thing is not to do things about those problems prematurely. You don’t want to be treated prematurely for a problem that your body can handle by itself. In the New England Journal of Medicine, for example, Franz Inglefinger, not long before his death – he’s a great figure, I think, in contemporary…was a great figure in contemporary American medicine – wrote that 85 percent of the illnesses we have are self-limiting. By which he meant that the human body is perfectly capable of taking care of 85 percent of the problems.
Heffner: But, Norman, if you don’t go for that annual checkup, you don’t know then about the other 15 percent.
Cousins: One assumes that when Dr. Inglefinger was talking about the 85 percent of the illnesses that we bring to doctors, he was not talking about annual checkups. He was talking about the fact that there are symptoms and we bring these symptoms, as we should, to the physician. But the significant thing is that whether or not we bring these symptoms to the physician – and I certainly think that when you have symptoms you shouldn’t take them lightly – but it is interesting nonetheless, as he said that 85 percent of the time the human body is beautifully equipped to meet its own needs. And, given reasonable freedom from stress, given a reasonable level of good nutrition, given a reasonable level of emotional stability, your body will function as it was intended to function.
Heffner: What an incredible group of givens though, Norman. Do you want to name on the fingers on one hand the individuals who are sufficiently free from stress, who handle those problems, who are concerned about nutritional values? Before we went on the air you were asking me about nutritional matters; and I’m a fairly well educated person, but you know that I drew a blank. Now, what sense does it make to say, “With these things in check, with these things in hand, we’re okay,” when those things are seldom in check?
Cousins: Dick, that is why I emphasized a moment ago the need for reeducating the public about health. You see, most of the education about health is on the level of symptoms. Most of it has to do with pain; what you do about this or that pain. And a great deal of the treatment has to do with the relief of pain. But there’s not enough health education that teaches us how to avoid those things that produce the illness. I would hope that we would know at least as much about health habits as we know about CPR. And it is unfortunate, it seems to me, with respect to CPR, that so much attention is given to the physical things that we do to people when they have a heart attack. And very little is said about the psychological things that are important. Nothing is more important when a person has a heart attack than to produce an atmosphere of calm and reassurance. But almost everything we do tends to dramatize the fact the person is dying. And the panic that the person has anyway reverberates. And that represents a very real problem in heart attacks. I can’t think of anything more important to do when someone has a heart attack than to reassure this person that he or she does have a very good chance. And that is the truth, given reasonable degree of calm. But the thing that usually happens, if the heart attack happens at home, what happens? The wife starts screaming. And the husband with the heart attack, who is already terrified, is living in this echo chamber of his fears. And then the paramedics come and some of them take their Canadian Mounted image seriously. And then you have that ride to the hospital in the ambulance. And if you think that the shriek of that siren is terrifying from the outside, just imagine what it must sound like to the patient when you get this reverberating chamber on the inside.
Heffner: Is that why you told the driver to cut it off, cut it out?
Cousins: Well, when they took me to the hospital I wanted to have a leisurely ride. I didn’t want to be disturbed. And another thing is that I felt that speeding through the streets that way may endanger other people, creating the need for yet more ambulances, more sirens, and so on, ad infinitum. But I felt that the mood of the patient after a heart attack is as vital as any medicine you can give the patient. Certainly you can give the patient morphine, and tranquilizers to affect that mood, but there’s the deep layer in the subconscious that is never really touched. For example, they’ve discovered that patients who were told just before going to surgery what the risk of the anesthesia was have a far higher rate of death, cardiac arrest on the surgery than those who went into the surgery with a great deal of confidence. You see, the subconscious did carry burden of that knowledge of what the risk was. And that’s why I think that we’ve got to start giving a great deal more emphasis to the mood of the patient, and to all those things that are addressed to the uniqueness of human beings and not to people as machines.
Heffner: It’s interesting that you say that, and it’s so easy to agree with you. But that comes at the same time that we’ve been talking about informed consent. And there seems to be a conflict between asking the physician to handle the emotions and the psyche of his patient and at the same time give his patient the opportunity to make real decisions for himself.
Cousins: This is a real dilemma for the physician. He’s required by law to inform the patient. Also, the physician knows that if something should happen that he did not alert the patient about, or the family of the patient about, that he may be subject to a malpractice suit. And so, because of the fear these malpractice suits…or I should say the fact of these malpractice suits – the fear may be genuine in many cases – because the fact of these legal problems, the physician feel she has to be as unambiguous as possible, and has to tell the worst, because the worst might happen and he might be sued if he didn’t inform the patient in advance. But the difficulty about telling the worst is that it tends to bring on the worst. The human body has a tendency to follow the path of its expectations. This is how the placebo works. If you take a pill thinking it’s going to have a certain effect, more than half the time it will even if that pill may have nothing more in it than let’s say sugar, weakened sugar. So, the physician does have a dilemma. And this calls for a great deal of artistry in how to inform the patient about risk without at the same time increasing the very risk you want to avoid.
Heffner: You say it calls for artistry at a time again when we’ve become more and more dependent upon technology, which doesn’t lend itself to artistry.
Cousins: Another dilemma. One of the melancholy things I’ve observed in the last five years at the medical school – and I’ve had a chance to study, I think, almost 300 patients who have malignancies – nothing to me is more striking about those cases than the large number of them that became suddenly and severely worse coincident with the diagnosis. Their symptoms may have been depending at a certain rate, slow but not precipitant. And then suddenly they get a label to attach to those symptoms and swoosh, the disease takes off. How we think about ourselves, the panic, conscious or subconscious, that we carry, has a powerful effect on illness. And that’s why I say that any physician who treats a serious illness is really treating two diseases. He’s treating the disease where he’s able to get verification through his various tests; but he’s also treating another disease that is not so easily diagnosable by high technology. And that disease is the deep underlying apprehension and tension. Because that tension, that apprehension, can affect the vital balances of the body, can indeed depress the immune system that you need to help fight the problem. And also those psychological effects can limit the usefulness of whatever it is the physician may want to do for you. That’s why I say you’ve got to have two people involved in any attack on disease. You’ve got the physician with all his science. And that science today has made tremendous strides. But you’ve also got another part of the problem, equally important, which is what does the patient do for himself or herself? What is the patient’s responsibility? What are the patient’s resources? What about the patient’s healing system? How can that healing system be activated in order to make optimum use of whatever it is that science has to offer? Otherwise, you’re just bringing half your point total to the game.
Heffner: When you talk about what you, yourself – when you write in “The Healing Heart” – about what you, yourself brought to your heart attack in terms of the determinations that you made, you knew a great deal about your own physiology. You knew a great deal about your own structure. You knew a great deal about medicine. And you made a great many decisions. They were not decisions that were always met with approval by your doctors. Is that a fair statement?
Cousins: By some of the doctors.
Heffner: Well, okay, by some of the doctors. Doctors whom you respected.
Heffner: All right. And I…now on this, it’s such a fascinating technique that you use in “The Healing Heart” to conclude with comments…
Cousins: I want to give the doctors their innings. Let them say what they think.
Heffner: So seldom does that happen. But you’ve included what they think in your book, not…your own paraphrase…
Cousins: That’s right. Each of them writes a separate chapter.
Heffner: Okay. And in Dr. Shein’s comments – he was initially your…
Cousins: He’s one of the world’s leading cardiologists.
Heffner: Okay. He says, in talking about your getting better, he says, “Complicating the matter, however, is the extent to which Norman’s involvement in his own care limits the physician’s ability to apply data obtained from his situation to those derived from other patients.” And…
Cousins: Absolutely true. And that’s my central point, which is that you can’t go at any case statistically. If you attempt to treat patients only on a statistical basis, what happens, according to the statistics in the vast majority of cases, you may be right the vast majority of times, but that’s not good enough.
Heffner: Yes, but there’s another angle to that, Norman. Your book, as I read your book, and I think of all the times I’ve said “no” to doctors, I couldn’t help but cheer you on. I’m not so sure though that I’ve been right. I’m always sure that you’re right. But I was thinking here that what the good doctor was indicating was that, by saying “No,” by insisting that when you take a stress test – it may be Mozart, it may be Bach playing as you take the stress test – you’re messing up the statistical capacity of medicine to treat others in the future.
Heffner: Well, why do you say “Fortunately”?
Cousins: Because medicine evolves. Medicine is an evolving science and an evolving art. And we cannot assume that at any point we have reached the pinnacle of wisdom. It’s only a few years ago, for example, when people who had a massive heart attack would have been treated substantially differently from the way I was treated. They would have, only ten to twelve years ago, for example, or a little more than that, you would have had sustained bed rest for six weeks, almost no exercise. And now they discover that that is precisely the wrong thing to do. And now, you think back, therefore, on all the people placed in jeopardy by what was considered to be the conventional wisdom. I don’t think we have yet reached, nor will ever reach, a point at which wisdom will become absolute. And wisdom evolves in interaction with changing circumstances. And each individual has something to give to that total evolving lesson that emerges.
Heffner: When you say that “each individual” does – and in this very wonderful book by Anatol Bortard of your book in The New York Times, he says, “because of these special circumstances” – talking about you; the fact that in the hospital they knew who Norman Cousins is. You’re a celebrity, as he points out. You’re a teacher at the medical school. Everyone knew your name, knew your previous book – he says, “because of these special circumstances, another of his attendant physicians observes in his afterword that ‘We have to be careful about generalizing on Mr. Cousins’ case,’ which presupposes both extraordinary doctors and an extraordinary patient.” And I worried, as I read your book, about the fact that you were because you’re an extraordinary person doing things that the rest of us might not be able to do and that you are also – and I wonder if you’ve thought about this – detracting from the accumulation of statistics necessary to change modalities of treatment?
Cousins: But there are other doctors who have something to say about that same question. Dr. Bernard Lamb, a world-famous cardiologist at Harvard, Dr. David Catham from Yale, and the two internists on the case, Dr. Fried and Dr. Hitzig, come up with a different conclusion based on this experience. And what they say is that there are aspects of this case which can be applied on a very broad scale, and that they, themselves, believe that the experience can be usefully applied in a great number of cases. What Dr. Shein, who wrote that caveat, was thinking about, as I said before, was that there is a process that one goes through even in evolution, before the statistics may be changed. But at a given point in that process, especially at the start of the process, you can’t rush into it. I would not dream of suggesting that people do what I did. I wouldn’t dream of suggesting that. But I do believe that there are some aspects what was done which may be useful to others. Number one, I think that everyone has to take some responsibility for his or her own illness and recovery.
Heffner: No matter how unknowing, no matter how ignorant?
Cousins: I think it’s the doctor’s job to help educate the patient in a way that enables the patient to share in that responsibility. The patient should be involved, because the healing system is activated by the believe system. You just can’t superimpose on a human being. You don’t fix illnesses just by dumping pills into a stomach. You don’t fix known illnesses by going in there with a knife. The fact of the matter is that each individual is a totality. And that individual has to be involved in the process. And that’s what I mean by a sharing of responsibility. Dr. Shein himself made that point about the need for individuals to be involved; he advocates that. The second thing…
Heffner: He didn’t advocate what this individual sitting across from me at the table did.
Cousins: Well, let’s talk about the nature of those differences, because I was fascinated by them. And I’ve got great respect for him and for the position he took. But the second point that I try to make in the book, in response to your earlier question, was that we can recognize that panic and helplessness can intensify an underlying disease, and that we’ve got to give at least as much attention to that second disease as we do the first. And this is something the individual can…
Heffner: Norman, you don’t want me to feel panic now or helplessness, so I’m going to have to say to you we have to end our conversation now, but if you’ll stay where you are, we’ll do another program, okay?
Cousins: All right.
Heffner: Thanks very much.
Cousins: Is the program over?
Heffner: The program is just about over. When I say goodbye to you now and then turn to the camera, it’s over.
Cousins: One half hour?
Heffner: Stay where you are, Norman.
Heffner: Thanks, too, to you in the audience. I hope that you will stay where you are, and join us again next week on The Open Mind. Meanwhile, as another old friend used to say, “Good night and good luck.”