Guest: Cousins, Norman
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The Open Mind
Host: Richard D. Heffner
Guest: Norman Cousins
Title: World Peace
HEFFNER: I’m Richard Heffner, your host on The Open Mind. Fifteen years ago Norman Cousins was ill, suffering from what he was told was an irreversible disease. He survived. He believes because he tapped what is literally, physiologically, the therapeutic value of the will to live; because his physician helped him develop his own capacity to overcome his illness; because together they nurtured his right, and indeed his responsibility as a patient for his own well-being. As a friend, the simple fact of this great, good man’s survival meant the most to me. But what may ultimately loom largest for all of us concerned with the growing impersonalization of American medicine, and with the compelling need for health experts to join with their patients in a more humane and positive assessment of the capacity of the human mind and the body to regenerate, what may be particularly telling is the fact that a prestigious New England journal of medicine has printed Norman Cousins’ layman’s reflections on his health and regeneration. Medical experts don’t usually suffer well the luminations of their patients. But his insights were embraced by many physicians who perhaps feel most acutely the genuine need for a more holistic approach to the healing arts. Now W.W. Norton has published Norman Cousins’ reflections as a book, a most extraordinary book, Anatomy of an Illness as Perceived by the Patient, and I’ve asked him to talk about it today on The Open Mind.
Mr. Cousins, thank you for joining me here on The Open Mind. I know that you’ve requested that I not drag out the matter of your own illness, and I won’t, because I know that in this brilliant book, Anatomy of an Illness, you direct yourself to what we might all learn from your experience. I really wanted to turn, to ask you to comment on a quotation in your book from a very dear old friend of yours, Albert Schweitzer; you quote him as saying: “The witch doctor succeeds for the same reason that all the rest of us succeed. Each patient carries his own doctor inside him. They come to us not knowing that truth. We are at our best when we give the doctor that resides within each patient a chance to go to work”. What did you mean by that? What did he mean by that?
COUSINS: Well, see, one night at dinner in his hospital in Lambarene I said the wrong thing. I said that the natives in that part of Africa were very lucky that they had Dr. Schweitzer and didn’t have to take their chances on the witch doctors. He turned and asked me “What do you know about witch doctors?” and I realized that I had said the wrong thing, so I confessed that I knew very little. And he said “I thought so”. He said “Let me take you to see the witch doctor tomorrow”. So the next day we walked about a mile through the jungle to a witch doctor, who greeted his colleague very amiably, Dr. Schweitzer, and Dr. Schweitzer said that his friend from the United States was curious about how witch doctors work and that he hoped that he wouldn’t mind if we stand by as his patients came in for their treatment. Well, the patients would arrive in three categories: The first category consisted of those natives who had the transient pain, the self-limiting illnesses, colds or the like, and these were treated with herbs or folk medicine that the doctor put in a little brown bag and gave to them. The second consisted of illnesses that the witch doctor felt appeared translated into Western medicine as psycho-somatic, which is to say that these were induced by a strain of one sort or another or fears. And so the witch doctor would exorcise the fears by beating his drums and swooping around the patient and chanting, and the patient went away feeling much better. The third category consisted of those who really had something wrong with them. Those were the ones he sent to Schweitzer.
COUSINS: So commenting on the (???) Dr. Schweitzer said that for the most part that the witch doctors were no different from the rest of us. We realize that our greatest ally is the healing force within the patient, and that is where the real doctor resides. We know this. This is our secret. And now you know it, too.
HEFFNER: Norman, after many years as editor of The Saturday Review you are now at the University of California at Los Angeles on the medical faculty. Does that mean that you are teaching Dr. Schweitzer’s lesson about the doctor inside each one of us to young will-be doctors?
COUSINS: For the most part, Dick, I’m trying to talk humanities to medical students, liberal arts. See, medical students to a very large extent are well trained, but not always well educated. And what happens is that when they go to college knowing that they want to go to medical school they tend to concentrate on those subjects which can be quantified and where they know by and large that if they give the right answer they’ll get a good mark. They don’t take their chances on the liberal arts; philosophy, history or literature or a language. And so, by the time they get to college they’re well trained in sciences. They do get good grades, they do get into medical school, and in medical school they stay with the sciences to a very large extent. Consequently, they tend to be expert in knowledge that is not real hard, despite the fact that science can be described as hard. All you have to do is look back on changes that have come about in medicine in the last 25-50 years and you recognize that the factual base in medicine has changed. Therefore what we describe as the sciences, or the so-called “hard” subjects really turn soft. But the so-called “soft” subjects, the liberal arts, the philosophy, the language; in short, what human beings are all about, the art of dealing with human beings, the sensitivity, the compassion that doctors need, the sense of a tradition in medicine, all of these that are considered soft, these are the ones that live. These are the ones that endure and therefore these are really the hard subjects. So you do get this curious inversion. But you also get a disparity, which is that in medical school, about 95% of the attention is given to the so-called “hard” subjects which turn soft and 5-10% to the “soft” subjects which are really hard.
HEFFNER: Well, has that been responsible for…let’s call it a failure…the failure generally of many physicians to recognize that doctor inside ourselves? Inside of his patient…
COUSINS: Well, the closer I get to the medical profession…the more I’m able…the teachers of medicine…the students…the more respect I have for the profession. It’s very difficult to get it all in. And, for example, when I’m able to talk to the Curriculum Committee to discuss the need for more attention to medical models of great doctors who were very well rounded human beings; men like (???) or Walter Cannon or Oliver Wendell Holmes; I…as I say, an attempt to talk to the Curriculum Committee about this and more…the greater my respect for the difficulty they have…the members of the Curriculum Committee…to get it all in. Knowledge is increasing expedientially, and so they do have this problem. But I’m very gratified at the fact that the Curriculum Committee, not just at UCLA, but at medical schools around the country are giving an increased emphasis to ethics, to tradition, to philosophy, to the humanities.
HEFFNER: Norman, why did you write Anatomy of an Illness? I know that it first appeared in the New England Journal…why did you write it? You didn’t write it for doctors, I’m sure. It wasn’t published by Norton for Doctors. What did you want us to learn?
COUSINS: I wrote it originally for doctors. I wrote it because it happened to be described in the public press. The story got out and it was made to appear that I laughed my way out of it. While laughter was an important ingredient, so were all of the positive emotions, but that wasn’t the whole story. And I felt that perhaps I might give a more balanced account than what had appeared in the public press. But I didn’t write about it for a long time because honestly I was afraid that it might give false hopes to people who were similarly afflicted. And I honestly didn’t know whether the reason I pulled out of it as well as I did was because of my understanding of what the illness was all about and I knew that one instance was just…of medicine, and it became necessary to have a great deal more experience before you could attempt to tell other people what to do. But in the end, it seemed to me that there were aspects of it which ought to be talked about, the most important was the fact that the individual has to accept a large amount of responsibility.
HEFFNER: For what?
COUSINS: For his or her own illness. I think that it’s not the doctor’s fault. The doctor didn’t make you ill. And I think it’s a mistake to expect the doctor to do the whole job himself. The most successful recoveries that I’ve been witness to in the past year at the medical school are those in which doctor and patient work together. Because the doctor’s not the healer, you are, the individual’s the healer. And you have built in you a superb, a magnificent healing mechanism. And the wise doctor tries to put that to work. The wise doctor tries to potentiate the patient. The wise doctor knows that the medicine he may prescribe is only part of a total attack on the problem, and what the patient brings to the illness, the attempt to overcome the illness can be every bit as important as the medication. Indeed, it’s quite possible that in many cases that medication would work best only when the patient, himself or herself, creates a mood in which the doctor can go to work. I wrote the book, therefore, in the first instance, for the physician to talk about a doctor/patient relationship that did have something to offer, to talk about the need for the acceptance by the patient of a proper measure of responsibility. I then wrote the book for the…for people, because I feel that the most important thing in illness, as in life, is the maintenance of hope. And I believe that the will to live is therapeutic. I believe, too, that stress, or the negative emotions in general…fear, panic, uncertainty, exasperation, frustration, all produce negative effects on the body’s chemistry, as (???) and Walter Cannon…have very beautifully described, and it just didn’t seem to be reasonable to believe that only the negative emotions have an effect on body chemistry. Quite the contrary, it seemed to me to be axiomatic that negative emotions produce harmful changes in body chemistry, but the positive emotions would have to produce benevolent changes in body chemistry. The body just doesn’t work one way. And so I wrote this book with the hope that people who were combating illness might take heart, might recognize that no one really knows enough to make a pronouncement of doom, and the fight is worth making whatever the odds may be. Not everyone will succeed, but it seems to me that the attempt to battle the illness itself is a manifestation of human uniqueness.
HEFFNER: Norman, you said before that you did not want to be in a position in which you were encouraging people in a false way, referring specifically to your own disease. But don’t you do so when you refer to that extraordinary need for cooperation that you describe between doctor and patient? Aren’t you describing something that you were so fortunate in having or in creating? Something that’s not given to the rest of us.
COUSINS: Well, one of my reasons for going out to UCLA, Dick, was not just to teach but to learn. I wanted to find out whether my hunches had any basis in fact. I want to find out whether it’s possible for the same thing to happen to others. So I’ve studied the literature, and I’ve gone out to the hospitals and talked to doctors, and I’ve found out enough to convince me that my experience is not unique, that every day patients are able to put their will to live to work, a will to live in a way that does help. And that the doctor’s greatest ally in combating serious disease is the patient’s confidence in the doctor, the patient’s confidence in himself or herself, and the patient’s understanding of this magnificent mechanism that we…that’s built into us, that’s been honed by a million years of human evolution – to combat disease. And that’s the mechanism we tend to disparage and bypass.
HEFFNER: You say that the doctor’s greatest ally in this is the patient himself…
HEFFNER: …in willing and understanding…What is the patient’s greatest ally? And I ask that because I always assumed that a good hospital was a fine place to be in a time of concern and yet I turn to page 29 of Anatomy of an Illness and you write: “I had a fast-growing conviction that a hospital is no place for a person who’s seriously ill”. Now…I know you didn’t say it laughingly or jokingly. So I come back to the question of if the patient is the doctor’s greatest ally, is the doctor the patient’s? Today, as medicine’s…
COUSINS: I thought I’d pick up on a few things. Illness is not a laughing matter. Perhaps it ought to be. In respect to hospitals, I believe that hospitals in the last 10 years have changed substantially. I’ve attended conventions with hospital administrators where we’ve discussed very frankly the objections that I had at that time. I’d like to review them very briefly now. First, I had a feeling that the patient was being managed rather than being treated, and the main thing was to keep that patient’s finger off that call button. And when that nurse travels with that cart with the medications, the emphasis was on pain killers, on sleeping pills. Those things would keep the finger off the call button. Perhaps you can understand that since the hospitals have been short of help, but that didn’t help the patient necessarily. Second, I felt that the hospital could do a better job of coordinating. It’s a tax on the patient. One day I had four different separate departments of the hospital come to take samples of my blood, each for different specialized areas. Well, if I were a healthy patient, I might consider making these donations to separate parts of the hospital, but for a sick person, I didn’t think it was a good idea to take that much blood. And so I posted a sign on my door saying that I’d be very happy to give one sample of my blood every three days, just one, and to the different departments, please coordinate the demands into the same file. And another thing that bothered me was that the food was not very good, frankly, not very nourishing. I was amazed to see the extent in which sugars were used in food. I was amazed at the greasiness of some of the food. I was astounded at the fact that they used white bread with the dyes and preservatives. And I could reflect that the White House Conference on Nutrition made a very important observation when it called attention to the fact that this was one of the, perhaps, great failures of modern medicine. This, of course, was some years ago. By this time, I trust that all’s well. I haven’t been to the hospital in a long time.
HEFFNER: Norman, you say “I trust by this time all is well”. Now, I know that with the glare of the lights and the television camera one tends, and I’m sure with your position at the medical school, one tends not to knock, rap those with whom one works. But are you serious that this is something you identify as ten years old?
COUSINS: No, I’m quite serious about this because in the hospitals I’ve visited recently, and I’ve visited quite a few, I do find greater respect for the rights of the patient, and the comfort of the patient, and less attempt to manage the patient in the hospital’s interest. Although now and then I run into something that bothers me. For example I went into a very important hospital in the Los Angeles area not long ago to visit a patient who was dying of cancer. And I asked the patient if there was anything I could do. And she said, “Yes, I just can’t get this food down that the hospital gives me.” And she said, “They give me hamburgers and fried foods. I would just love”, she said, “to have a simple baked potato and raw carrots and raw vegetables”. And I said, “Well, that shouldn’t be so difficult, especially at this particular hospital”. So I went up to the doctor in charge of this particular patient and discussed this case and I said “Your patient would very much like to have a baked potato.” And he said, to my great amazement, “We can’t give her heavy foods”. And I said “Doctor, a baked potato is heavy food?” And I said the patient is getting hamburgers and I don’t think the patient can get this food down. If nourishment is important, I’m sure he’d want to know about this. Then he said something to the effect that the kitchen couldn’t be run for the convenience of a patient. Well, I’m glad that he said it, you see, because it probably was the truth. I went back to UCLA and I called the student employment service and I found a student who lived near this hospital and I hired him to bake a potato each day and to bring a potato and the raw carrot and the raw vegetables over to the hospital. But you do find now and again people who dig in, but on the other hand, let me give you someone who is a good example of what is right to be done. Occasionally I make the rounds with the Dean of the UCLA Medical School, Dr. Sherman Mellinkoff, and on one day we visited a patient, a Guatemalan, 38, who was dying of a combination of tuberculosis and hepatitis, a most gruesome combination. And when we went up to see him Dr. Mellinkoff established contact. He put his hand on the shoulder of the man, and the sense of touch immediately gave the patient reassurance. He was huddled in his little blanket in a wheelchair in the hall waiting for an x-ray, and then he had the residents and the interns there and he said to the interns, “Is this man able to get nourishment?” And the intern said, “Well, he’s not eating, so we have to feed him intravenously.” And so Dr. Mellinkoff turned to the patient and in Spanish said “Tell me, are you eating food?” And he shook his head. He said, “Tell me, do you get the food you like?” The patient looked at the other doctors somewhat apprehensively. Dr. Mellinkoff said, “Please, speak frankly. I’m the Dean here, and you won’t be punished for this.” And the patient shook his head. And he said “Tell me what you like”. And he rattled off a string of Spanish dishes, you see, and then Dr. Mellinkoff turned to the interns and residents and said “Tell me, is this man getting this food?” And they said “No”. And he said, “Well, how do you know he can’t eat if he doesn’t get the food he likes?” “Well”, they said, “You know how the kitchen is. We can’t get food like this from the kitchen”. “We can”, said the Dean. Let me tell you something. When you write a prescription at the pharmacy, you insist that you get that prescription that you want for the medicine you need, knowing that that’s the medication that patient needs. Yes. Well, food is every bit as important as medicine. If you can’t get that food out of the kitchen, write a prescription and get it from the pharmacy. Well, two weeks later I revisited this patient. He was now getting the food he liked and getting attention, you see, because the Dean set the model, and he felt that he was important. He felt that someone cared.
HEFFNER: Okay, now…
COUSINS: Caring was a form of treatment. Now, just let me finish here, because a month later that patient walked out of the hospital. The patient was expected to die. And no one can tell me that the compassion, the care, and the attention to the things that were necessary from the patient’s point of view did not have a role in strengthening that patient’s will to live.
HEFFNER: All right, Norman, what’s the matter…
COUSINS: It’s a good example.
HEFFNER: What’s the matter with American medicine that the Dean has to go walking those rounds, that there has to be in a sense an ombudsman? What’s the problem with our delivery of health care now that that should be such an extraordinary…
COUSINS: Well, two things. I don’t think it’s accurate to think that the Dean should…you do have doctors like that. I’ve seen an awful lot of them since I had one of them. I’ve got to believe that there are many more. Second: You use the word “health delivery system”. I can think of nothing that symbolizes more what’s wrong with medicine today of the entire concept of illness in the United States than the term “health delivery system”. I don’t want to use it. It symbolizes what is wrong because we assume that health is something that can be wrapped in a package and delivered. One wrapped package and you’re healthy. And this cure is the external view of what I think represents a view of what is wrong with the concepts of health, or the concepts of the breakdown of health. Now, we grow up with the notion, you see, that the only time we become ill is if we happen to bump into some disease germs and the disease germs invade the body. And there is the external view that the disease is “out there”, you see, and we have a collision with the disease and the disease comes inside. So we externalize and reach out for the medication to put inside to get rid of the disease that is there when you…the intruder, then we’re well. But all this is related to this concept of the delivery system, the fact that health can be externalized, or that disease is something that invades. The important thing to recognize, it seems to me, is that we’re dealing with internal medicine, that each person has the capacity to resist disease, the immunological system. And it’s only when that immunological system is not functioning that the disease can take hold. Therefore the problem is not with the disease germ. The problem is with the basic system itself. The problem is that the individual has been doing many things that are wrong that weakens the body and that opens the floodgates, whether this is drinking too much or smoking too much, or too much noise, or too much congestion, or too much worry or too much fear – all these things tend to weaken the immunological system. It’s at that point that the disease germs enter. But you don’t just deal with that problem by going after the intruders. You go after the problem by strengthening the body. You go after the problem by raising that threshold. You go after the body by everything that’s involved in regeneration and healing, and not just dumping in some potion. Now, there are times when medications are absolutely necessary, make no mistake about it. If I had bacterial meningitis I would want to take antibiotics because I know it would be the difference between life and death. But not all illness requires heroic medication. Indeed heroic medication can be dangerous in many instances. Therefore the wise doctor deals with the patient, the wise doctor tries to persuade the patient that not every illness requires a prescription. The wise doctor tries to get the patient to concentrate and to think about those things in the patient’s life that results in the stress which in turn results in the weakening that in turn results in the encounter with the bugs.
HEFFNER: Norman, we have about 20 seconds left. Just…I mean to apologize for talking about health delivery and I understand what you’re saying…
COUSINS: No, no, no, I talk about it too, but that’s what’s wrong with the whole system.
HEFFNER: I, I understand that. Some day, though, we’re going to have to come back and talk about the health care preservation system. Call it what you will, we’re going to have to talk about what help has to be given to the patient.
You are an extraordinary person. You did what needed to be done, and I’m glad you did, and that you’re here and you can come back and talk with me again.
COUSINS: Do I have ten seconds?
HEFFNER: Go ahead.
COUSINS: Jonas Salk said the other day that we have a degree called Doctor of Medicine, where we train people to study disease. He wants a degree called “Doctor of Health”, where medical students study health, not just disease.
HEFFNER: Thanks very much for joining me today, Norman Cousins, and thanks, too, to you in the audience. I hope that you’ll join us again on The Open Mind. Meanwhile, as an old friend used to say, “Good night, and good luck”.
This is Richard Heffner, your host on The Open Mind. We would like to know your ideas and your opinions on the subject we discussed. Please send your comments to me care of this station.