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CulturalResponsestoPainbyMarkZborowski

Thewaysthatwerespondtoillnessarestronglyinfluencedbyculturalfactors.Inthisarticle,
MarkZborowskishowsthateventhephysicalsensationofpainisofteninterpreted
differentlybymembersofdifferentAmericanethnicgroupswhotendtorespondtopainin
termsofmeaningstheylearnedintheirownfamilies.

CulturalDifferencesandPain
Inhumansocietiesbiologicalprocessesvitalforman'ssurvivalacquiresocialand
culturalsignificance.Intakeoffood,sexualintercourseoreliminationofwaste
physiologicalphenomenawhichareuniversalfortheentirelivingworldbecome
institutionsregulatedbyculturalvaluesandsocialrules.Humanbeingsexperiencehunger
forfoodandsexualdesire,butcultureandsocietydictatethekindoffoodpeoplemayeat,
thesocialsettingforeating,ortheappropriatepartnerformating.
Moreover,theroleofculturalandsocialpatternsissogreattheymayinspecific
situationsactagainstthedirectbiologicalneedsofindividuals,eventothepointof
endangeringtheirsurvival.Onlyahumanbeingmaypreferstarvationtothebreakingofa
religiousdietarylawormayabstainfromsexualintercoursebecauseofspecificincest
regulations.Voluntaryfastingandcelibacyexistonlywherefoodandsexfulfillmorethan
strictlyphysiologicalfunctions.
Membersofdifferentculturesmayassumedifferingattitudestowardsthesevarious
typesofpain.Intheprocessofinvestigatingculturalattitudestowardpainitisimportantto
distinguishbetweenpainapprehensionandpainanxiety.Painapprehensionreflectsthe
tendencytoavoidthepainsensationassuch,regardlessofwhetherthepainisspontaneous
orinflicted,whetheritisacceptedornot.Painanxiety,ontheotherhand,isastateof
anxietyprovokedbythepainexperience,focuseduponvariousaspectsofthecausesof
pain,themeaningofpainoritssignificanceforthewelfareoftheindividual.
Moreover,membersofvariousculturesmayreactandbehavedifferentlytovarious
painexperiences,andthisbehaviorisoftendictatedbytheculturewhichprovidesspecific
normsaccordingtotheage,sexandsocialpositionoftheindividual.
Thefactthatotherelementsaswellasculturalfactorsareinvolvedintheresponse
toaspontaneouspainshouldbetakenintoconsideration.Theseotherfactorsarethe

Cultural Responses To Pain Sociology101

pathologicalaspectofpain,thespecificphysiologicalcharacteristicsoftheexperience,such
astheintensity,thedurationandthequalityofthepainsensation,andfinally,the
personalityoftheindividual.Nevertheless,itwasfeltthatintheprocessofacareful
investigationitwouldbepossibletodetecttheroleoftheculturalcomponentsinthepain
experience.

TheResearchSetting
WiththeseunderstandingsinmindtheprojectwassetupattheKingsbridge
VeteransHospital,Bronx,NewYork,wherefourethnoculturalgroupswereselectedforan
intensivestudy.ThesegroupsincludedpatientsfromJewish,Italian,IrishandOldAmerican
stock.ThreegroupsJews,Italian,andIrishwereselectedbecausetheyweredescribed
bymedicalpeopleasmanifestingstrikingdifferencesintheirreactiontopain.
ItaliansandJewsweredescribedastendingto"exaggerate"theirpain,whiletheIrish
wereoftendepictedasstoicalindividualswhowereabletotakeagreatdealofpain.The
fourthgroup,the"OldAmericans"[orAngloAmericans]werechosenbecausethevalues
andattitudesofthisgroupdominateinthiscountryandareheldbymanymembersofthe
medicalprofessionandbymanydescendantsoftheimmigrantswho,intheprocessof
Americanization,tendtoadoptAmericanpatternsofbehavior.Themembersofthisgroup
canbedefinedaswhite,nativebornindividuals,usuallyProtestant,whosegrandparents,at
least,werebornintheUnitedStatesandwhodonotidentifythemselveswithanyforeign
group,eithernationally,sociallyorculturally.
TheKingsbridgeVeteransHospitalwaschosenbecauseitspopulationrepresents
roughlytheethniccompositionofNewYorkCity,thusofferingaccesstoafairsampleofthe
fourselectedgroups,andalsobecausevariousagegroupswererepresentedamongthe
hospitalizedveteransofWorldWarl,WorldWarllandtheKoreanWar.Inonemajor
respectthishospitalwasnotadequate,namely,innotofferingtheopportunityto
investigatesexdifferencesinaltitudetowardpain.
Insettingupthisprojectweweremainlyinterestedindiscoveringcertainregularities
inreactionsandattitudestowardpaincharacteristicofthefourgroups.Themain
techniquesusedinthecollectionofthematerialwereinterviewswithpatientsofthe
selectedgroups,observationoftheirbehaviorwheninpain,anddiscussionoftheindividual
casewithdoctors,nursesandotherpeopledirectlyorindirectlyinvolvedinthepain
experienceoftheindividual.Inadditiontotheinterviewswithpatients,"healthy"members
oftherespectivegroupswereinterviewedontheirattitudestowardpain,becauseinterms
oftheoriginalhypothesisthoseattitudesandreactionswhicharedisplayedbythepatients
ofthegivenculturalgroupsareheldbyallmembersofthegroupregardlessofwhetheror
nottheyareinpainalthoughinpaintheseattitudesmaycomemoresharplyintofocus.In
certaincasestheresearchershaveinterviewedamemberofthepatient'simmediatefamily

Cultural Responses To Pain Sociology101

inordertocheckthereportofthepatientonhispainexperienceandinordertofindout
whataretheattitudesandreactionsofthefamilytowardthepatient'sexperience.
Thediscussionofthematerialpresentedinthispaperisbasedoninterviewswith
103respondents,including87hospitalpatientsinpainand16healthysubjects.According
totheirethnoculturalbackgroundtherespondentsaredistributedasfollows:"Old
Americans,"26;Italians,24;Jews,31;Irish,11;andothers,11.Inaddition,therewerethe
collateralinterviewsandconversationsnotedabovewithfamilymembers,doctors,nurses
andothermembersofthehospitalstaff.

PainAmongPatientsofJewishandItalianOrigin
TheJewsandItalianswereselectedmainlybecauseinterviewswithmedicalexperts
suggestedthattheydisplaysimilarreactionstopain.Theinvestigationofthissimilarity
providedtheopportunitytocheckaratherpopularassumptionthatsimilarreactionsreflect
similarattitudes.ThedifferencesbetweentheItalianandJewishculturearegreatenoughto
suggestthatiftheattitudesarerelatedtoculturalpatterntheywillalsobedifferentdespite
theapparentsimilarityinmanifestbehavior.
Membersofbothgroupsweredescribedasbeingveryemotionalintheirresponsesto
pain.Theyweredescribedastendingtoexaggeratetheirpainexperienceandbeingvery
sensitivetopain.Someofthedoctorsstatedthat,intheiropinion,JewsandItalianshavea
lowerthresholdofpainthanmembersofotherethnicgroups,especiallymembersoftheso
calledNordic[orAnglo]group.Thisstatementseemstoindicateacertainconfusionasto
theconceptofthethresholdofpain.Accordingtopeoplewhohavestudiedtheproblemof
thethresholdofpain,forinstanceHaroldWolffandhisassociates,thethresholdofpainis
moreorlessthesameforallhumanbeingsregardlessofnationality,sexorage.
Inthecourseoftheinvestigationthegeneralimpressionsofdoctorswereconfirmed
toagreatextentbytheinterviewmaterialandbytheobservationofthepatients'behavior.
However,evenasuperficialstudyoftheinterviewshasrevealedthatthoughreactionsto
painappeartobesimilartheunderlyingattitudestowardpainaredifferentinthetwo
groups.
WhiletheItalianpatientsseemedtobemainlyconcernedwiththeimmediacyofthe
painexperienceandweredisturbedbytheactualpainsensationwhichtheyexperiencedina
givensituation,theconcernofpatientsofJewishoriginwasfocusedmainlyuponthe
symptomaticmeaningofpainanduponthesignificanceofpaininrelationtotheirhealth,
welfare,andeventually,forthewelfareofthefamilies.TheItalianpatientsexpressedin
theirbehaviorandcomplaintsthediscomfortcausedbypainassuch,andtheymanifested
hisemotionswithregardtotheeffectsofthispainexperienceuponhisimmediatesituation.

Cultural Responses To Pain Sociology101

TheJewishpatientsexpressedprimarilytheirworriesandanxietiesastotheextentto
whichthepainindicatedathreattohishealth.Inthisconnectionitisworthmentioningthat
oneoftheJewishwordstodescribestrongpainisyessurim,awordwhichisalsousedto
describeworriesandanxieties.
AttitudesofItalianandJewishpatientstowardpainrelievingdrugscanserveasan
indicationoftheirattitudetowardpain.WheninpaintheItaliancallsforpainreliefandis
mainlyconcernedwiththeanalgesiceffectsofthedrugswhichareadministeredtohim.
OncethepainisrelievedtheItalianpatienteasilyforgetshissufferingsandmanifestsa
happyandjoyfuldisposition.
TheJewishpatient,however,oftenisreluctanttoacceptthedrug,andheexplains
thisreluctanceintermsofconcernabouttheeffectsofthedruguponhishealthingeneral.
Heisapprehensiveaboutthehabitformingaspectsofthepainkillers.Moreover,hefeels
thatthedrugrelieveshispainonlytemporarilyanddoesnotcurehimofthediseasewhich
maycausethepain.Nursesanddoctorshavereportedcasesinwhichpatientswouldhide
thepillwhichwasgiventothemtorelievetheirpainandwouldprefertosuffer.These
reportswereconfirmedintheinterviewswiththepatients.Itwasalsoobservedthatmany
Jewishpatientsafterbeingrelievedfrompainoftencontinuedtodisplaythesamedepressed
andworriedbehaviorbecausetheyfeltthatthoughthepainwascurrentlyabsentitmay
recuraslongasthediseasewasnotcuredcompletely.
FromtheseobservationsitappearsthatwhenonedealswithaJewishandItalian
patientinpain,inthefirstcaseitismoreimportanttorelievetheanxietieswithregardto
thesourcesofpain,whileintheseconditismoreimportanttorelievetheactualpain.
AnotherindicationastothesignificanceofpainforJewishandItalianpatientsistheir
respectiveattitudestowardthedoctor.TheItalianpatientseemstodisplayamost
confidentattitudetowardthedoctorwhichisusuallyreinforcedafterthedoctorhas
succeededinrelievingpain,whereastheJewishpatientmanifestsaskepticalattitude,
feelingthatthefactthatthedoctorhasrelievedhispainbysomedrugdoesnotmeanatall
thatheisskillfulenoughtotakecareofthebasicillness.Consequently,evenwhenthepain
isrelieved,theJewishpatientstendtocheckthediagnosisandthetreatmentofonedoctor
againsttheopinionsofotherspecialistsinthefield.
SummarizingthedifferencebetweentheItalianandJewishattitudes,onecansay
thattheItalianattitudeischaracterizedbyapresentorientedapprehensionwithregardto
theactualsensationofpain,andtheJewtendstomanifestafutureorientedanxietyasto
thesymptomaticandgeneralmeaningofthepainexperience.
IthasbeenstatedthattheItaliansandJewstendtomanifestsimilarbehaviorin
termsoftheirreactionstopain.Asbothculturesallowforfreeexpressionoffeelingsand
emotionsbywords,soundsandgestures,boththeItaliansandJewsfeelfreetotalkabout
theirpain,complainaboutitandmanifesttheirsufferingsbygroaning,moaning,crying,etc.

Cultural Responses To Pain Sociology101

Theyarenotashamedofthisexpression.Theyadmitwillinglythatwhentheyareinpain
theydocomplainagreatdeal,callforhelpandexpectsympathyandassistancefromother
membersoftheirimmediatesocialenvironment,especiallyfrommembersoftheirfamily.
Wheninpaintheyarereluctanttobealoneandpreferthepresenceandattentionofother
people.
Thisbehavior,whichisexpected,acceptedandapprovedbytheItalianandJewish
culturesoftenconflictswiththepatternsofbehaviorexpectedfromapatientbyAmericanor
Americanizedmedicalpeople.Thusthemedicalprofessionalstendtodescribethebehavior
oftheItalianandJewishpatientsasexaggeratedandoveremotional.Thematerialsuggests
thattheydotendtominimizetheactualpainexperienceoftheItalianandJewishpatients
regardlessofwhethertheyhavetheobjectivecriteriaforevaluatingtheactualamountof
painwhichthepatientexperiences.Itseemsthattheuninhibiteddisplayofreactiontopain
asmanifestedbytheJewishandItalianpatientprovokesdistrustinAmericancultureinstead
ofprovokingsympathy.
DespitetheclosesimilaritybetweenthemanifestreactionsamongJewsadItalians,
thereseemtobedifferencesinemphasisespeciallywithregardtowhatthepatientachieves
bythesereactionsandastothespecificmanifestationsofthesereactionsinthevarious
socialsettings.Forinstance,theJewsandItaliansdifferintheirbehaviorathomeandinthe
hospital.TheItalianhusband,whoisawareofhisroleasanadultmale,tendstoavoid
verbalcomplainingathome,leavingthistypeofbehaviortothewomen.Inthehospital,
whereheislessconcernedwithhisroleasamale,hetendstobemoreverbalandmore
emotional.
TheJewishpatient,onthecontrary,seemstobemorecalminthehospitalthanat
home.TraditionallytheJewishmaledoesnotemphasizehismasculinitythroughsuchtrails
asstoicism,andhedoesnotequateverbalcomplaintswithweakness.Moreover,theJewish
cultureallowsthepatienttobedemandingandcomplaining.Therefore,hetendsmoreto
usehispaininordertocontrolinterpersonalrelationswithinthefamily.Thoughsimilaruse
ofpaintomanipulatetherelationshipsbetweenmembersofthefamilymaybepresentalso
insomeothercultures,itseemsthatintheJewishculturethisisnotdisapproved,whilein
othersitis.Inthehospitalonecanalsodistinguishvariationsinthereactivepatternsamong
JewsandItalians.Uponhisadmissiontothehospitalandinthepresenceofthedoctor,the
Jewishpatienttendstocomplain,asksforhelp,beemotionaleventothepointofcrying.
However,assoonashefeelsthatadequatecareisgiventohimhebecomesmore
restrained.Thissuggeststhatthedisplayofpainreactionserveslessasanindicationofthe
amountofpainexperiencedthanasameanstocreateanatmosphereandsettinginthe
pathologicalcauseofpainwillbebesttakencareof.
TheItalianpatient,ontheotherhand,seemstobelessconcernedwithsettingupa
favorablesituationfortreatment.Hetakesforgrantedthatadequatecarewillbegivento
him,andinthepresenceofthedoctorheseemstobesomewhatcalmerthantheJewish

Cultural Responses To Pain Sociology101

patient.ThemerepresenceofthedoctorreassurestheItalianpatient,whiletheskepticism
oftheJewishpatientlimitsthereassuringroleofthephysician.
TosummarizethedescriptionofthereactivepatternsoftheJewishandItalian
patients,thematerialsuggeststhatonasemiconsciousleveltheJewishpatienttendsto
provokeworryandconcerninhissocialenvironmentastothestateofhishealthandthe
symptomaticcharacterofhispain,whiletheItaliantendstoprovokesympathytowardhis
suffering.IntheJewishcasethefunctionofthepainreactionwillbethemobilizationof
theeffortsofthefamilyandthedoctorstowardscompletecure,whileintheItaliancase
thefunctionofthereactionwillbefocuseduponthemobilizationofefforttoward
relievingthepainsensation.
OnthebasisofthediscussionoftheJewishandItalianmaterialtwogeneralizations
canbemade:(1)Similarreactionstopainmanifestedbymembersofdifferentethno
culturalgroupsdonotnecessarilyreflectsimilarattitudestopain.(2)Reactivepatterns
similarintermsoftheirmanifestationsmayhavedifferentfunctionsandservedifferent
purposesinvariouscultures.

PainAmongPatientsofOldAmericanOrigin
ThereislittleemphasisonemotionalcomplainingamongOldAmerican[orAnglo
American]patients.Theircomplaintsaboutpaincanbestbedescribedasreportingon
pain.Indescribingpain,theOldAmericanpatienttriestofindthemostappropriateways
ofdefiningthequalityofpain,itslocalization,duration,etc.Whenexaminedbythe
doctorhegivestheimpressionoftryingtoassumethedetachedroleofanunemotional
observerwhogivesthemostefficientdescriptionofhisstateforacorrectdiagnosisand
treatment.Theintervieweesrepeatedlystatethatthereisnopointincomplainingand
groaningandmoaning,etc.,because"itwon'thelpanybody.However,theyreadily
admitthatwhenpainisunbearabletheymayreactstrongly,eventothepointofcrying;
buttheytendtodoitwhentheyarealone.Withdrawalfromsocietyseemstobea
frequentreactiontostrongpain.
Thereseemtobedifferentpatternsinreactingtopaindependingonthesituation.
Onepattern,manifestedinthepresenceofmembersofthefamily,friends,etc.,consistsof
attemptstominimizepain,toavoidcomplainingandprovokingpity;whenpainbecomestoo
strongthereisatendencytowithdrawanexpressfreelysuchreactionsasgroaning,
moaning,etc.Adifferentpatternismanifestedinthepresenceofpeoplewho,onaccount
oftheirprofession,shouldknowthecharacterofthepainexperiencebecausetheyare
expectedtomaketheappropriatediagnosis,advisethepropercure,andgivetheadequate
help.Thistendencytoavoiddeviationfromcertainexpectedpatternsofbehaviorplaysan
importantroleinthereactiontopain.Thisisalsocontrolledbythedesiretoseekapproval
onthepartofthesocialenvironment,especiallyinthehospital,wheretheOldAmerican

Cultural Responses To Pain Sociology101

patienttriestoavoidbeinga"nuisance"ontheward.Heseemstobe,morethananyother
patient,awareofanidealpatternofbehaviorwhichisidentifiedas"American,"andhe
tendstoconformtoit.Thiswascharacteristicallyexpressedbyapatientwhoansweredthe
questionhowhereactstopainbysaying,"IreactlikeagoodAmerican."
Animportantelementincontrollingthepainreactionisthewishofthepatientto
cooperatewiththosewhoareexpectedtotakecareofhim.Thesituationisoftenviewedas
ateamcomposedofthepatient,thedoctor,thenurse,theattendant,etc.,andinthisteam
everybodyhasafunctionandissupposedtodohisshareinordertoachievethemost
successfulresult.Emotionalityisseenasapurposelessandhinderingfactorinasituation
whichcallsforknowledge,skill,trainingandefficiency.Itisimportanttonotethatthis
behaviorisalsoexpectedbyAmericanorAmericanizedmembersofthemedicalornursing
staff,andthepatientswhodonotfallintothispatternareviewedasdeviants,
hypochondriacsandneurotics.
AsinthecaseoftheJewishpatients,theAmericanattitudetowardpaincanbebest
definedasafutureorientedanxiety.TheOldAmericanpatientisalsoconcernedwiththe
symptomaticsignificanceofpainwhichiscorrelatedwithapronouncedhealth
consciousness.ItseemsthattheOldAmericanisconsciousofvariousthreatstohishealth
whicharepresentinhisenvironmentandthereforefeelsvulnerableandisproneto
interprethispainsensationasawarningsignalindicatingthatsomethingiswrongwithhis
healthandthereforemustbereportedtothephysician.Withsomeexceptions,painis
consideredbadandunnecessaryandthereforemustbeimmediatelytakencareof.Inthose
situationswherepainisexpectedandaccepted,suchasintheprocessofmedicaltreatment
orasaresultofsportsactivitiesthereislessconcernwiththepainsensation.Ingeneral,
however,thereisafeelingthatsufferingpainisunnecessarywhentherearemeansof
relievingit.
ThoughtheattitudesoftheJewishandOldAmericanpatientscanbedefinedaspain
anxiety,theydiffergreatly.ThefutureorientedanxietyoftheJewishintervieweeis
characterizedbypessimismor,atbest,byskepticism,whiletheOldAmericanpatientis
ratheroptimisticinhisfutureorientation.Thisattitudeisfosteredbythemechanistic
approachtothebodyanditsfunctionsandbytheconfidenceintheskilloftheexpertwhich
aresofrequentintheAmerican,inthatthebodyisoftenviewedasamachinewhichhasto
bewelltakencareof,beperiodicallycheckedfordysfunctioningandeventually,whenoutof
order,betakentoanexpertwhowill"fix"thedefect.Inthecaseofpaintheexpertisthe
medicalmanwhohasthe"knowhow"becauseofhistrainingandexperienceandtherefore
isentitledtofullconfidence.Animportantelementintheoptimisticoutlookisfaithinthe
progressofscience.Patientswithintractablepainoftenstatedthatthoughatthepresent
momentthedoctorsdonothavethe"drug"theywilleventuallydiscoverit,andtheywill
givetheexamplesofsulfa,penicillin,etc.
TheanxietiesofapainexperiencingOldAmericanpatientaregreatlyrelievedwhen
hefeelsthatsomethingisbeingdoneaboutitintermsofspecificactivitiesinvolvedinthe

Cultural Responses To Pain Sociology101

treatment.Itseemsthathissecurityandconfidenceincreaseindirectproportiontothe
numberoftests,Xrays,examinations,injections,etc.,thataregiventohim.Accordingly,
OldAmericanpatientsseemtohaveapositiveattitudetowardhospitalization,becausethe
hospitalistheadequateinstitutionwhichisequippedforthenecessarytreatment.AJewish
andanItalianpatientseemtobedisturbedbytheimpersonalcharacterofthehospitaland
bythenecessityofbeingtreatedthereinsteadofathome,whiletheOldAmericanpatient,
onthecontrary,prefersthehospitaltreatmenttothehometreatment,andneitherhenor
hisfamilyseemstobedisturbedbyhospitalization.
TosummarizetheattitudeoftheOldAmericantowardpain,heisdisturbedbythe
symptomaticaspectofpainandisconcernedwithitsincapacitatingaspects,buthetendsto
viewthefutureinratheroptimisticcolors,havingconfidenceinthescienceandskillofthe
professionalpeoplewhotreathiscondition.

SomeSourcesofIntraGroupVariation
Inthedescriptionofthereactivepatternsandaltitudestowardpainamongpatients
ofJewishandOldAmericanorigincertainregularitieshavebeenobservedforeach
particulargroupregardlessofindividualdifferencesandvariations.Thisdoesnotmeanthat
eachindividualineachgroupmanifeststhesamereactionsandattitudes.Individual
variationsareoftenduetospecificaspectsofpainexperience,tothecharacterofthe
diseasewhichcausesthepainortoelementsofthepersonalityofthepatient.However,
therearealsootherfactorsthatareinstrumentalinprovokingthesedifferencesandwhich
canstillbetracedbacktotheculturalbackgroundsoftheindividualpatients.Suchvariables
asthedegreeofAmericanizationofthepatient,hissocioeconomicbackground,education
andreligiositymayplayanimportantroleinshapingindividualvariationsinthereactive
patterns.Forinstance,itwasfoundthatthepatternsdescribedaremanifestedmost
consistentlyamongimmigrants,whiletheirdescendantstendtodifferintermsofadopting
AmericanformsofbehaviorandAmericanattitudestowardtheroleofthemedicalexpert,
medicalinstitutionsandequipmentincontrollingpain.Itissafetosaythatthefurtherthe
individualisfromtheimmigrantgenerationthemoreAmericanishisbehavior.Thisisless
truefortheattitudestowardpain,whichseemtopersisttoagreatextentevenamong
membersofthethirdgenerationandeventhoughthereactivepatternsareradically
changed.AJewishorItalianpatientborninthiscountryofAmericanbornparentstendsto
behavelikeanOldAmericanbutoftenexpressesattitudessimilartothosewhichare
expressedbytheJewishorItalianpeople.Theytrytoappearunemotionalandefficientin
situationswheretheimmigrantwouldbeexcitedanddisturbed.However,intheprocessof
theinterview,ifapatientisofJewishoriginheislikelytoexpressattitudesofanxietyasto
themeaningofhispain,andifheisanItalianheislikelytoberatherunconcernedaboutthe
significanceofhispainforthefuture.

Cultural Responses To Pain Sociology101

Theoccupationalfactorplaysanimportantrolewhenpainaffectsaspecificareaof
thebody.Forinstance,manualworkerswithherniateddiscsaremoredisturbedbytheir
painthanareprofessionalorbusinesspeoplewithasimilardiseasebecauseofthe
immediatesignificanceofthisparticularpainfortheirrespectiveabilitiestoearnaliving.It
wasalsoobservedthatheadachescausemoreconcernamongintellectualsthanamong
manualworkers.

Cultural Responses To Pain Sociology101

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