LAUGHTER: THE HEALTH TONIC; HEALTH

Laughing at the zany

antics of a clown will

make a sick child in

hospital feel good,

but could it actually

make them better?

Anne Woodham

on recent research

TUESDAY is Clown Day at Great Ormond Street Hospital for Sick Children. Dr Kiku, the humourologist, and Dr Leon, the laughologist (aka clowns Colin Maher and Leon Edwards), tour the wards in wigs, red noses and colourful travesties of doctors' coats, pockets bulging with magic tricks and lollipops disguised as giant pills. Their medicine is a gentle, zany humour that triggers smiles and giggles in the sickest children. Even a comatose seven-year-old takes a step towards recovery by opening her eyes in response to Dr Kiku's antics. For a while, the strain and fear of the young patients and their anxious parents is relieved.

At Great Ormond Street, the "clown doctors" add a humorous dimension to the play specialists' normal programme, but according to Colin Maher, at least, he and Leon Edwards are the only clowns in Britain who regularly visit hospitals. For a country that prides itself on its sense of humour, Britain has been remarkably slow to recognise the therapeutic value of mirth.

In Switzerland, clowns are found in most children's hospitals. In New York, the Big Apple Circus Clown Care Unit has a network of clowns in eight city hospitals. American patients can choose their favourite comic book or video from "humor rooms" or "comedy carts" that tour the wards. According to Dr Joel Goodman of The Humor Project Inc, a foundation dedicated to raising the profile of humour in our lives, such facilities give "a figurative shot in the arm to lift patients' spirits. They're not a miracle cure, but in conjunction with competent medical care, humour and laughter can be powerful additions to any health care plan."

Here in Britain, Robert Holden, a psychotherapist and stress consultant, is the closest thing to a laugh doctor. The author of Stressbusters and Laughter, the Best Medicine (both published by Thorsons), he says he is increasingly asked to lecture to health professionals on the healing applications of humour. "One of the sad legacies of our dependence on the NHS," he says, "is that we haven't got to grips with one key idea about healing: the way we think about ourselves has an impact on the body."

The very act of laughing has been described as a kind of internal aerobics, in which all the major systems of the body are exercised. American physiologist Dr William Fry, who studied the potential therapeutic effects of humour for over 30 years, calculates that 100 to 200 laughs a day is the equivalent of 10 minutes of jogging. But rolling around on the floor and shrieking with mirth every half hour is a tall order for most people. It would be bizarre, too, if medical staff felt obliged to crack running gags for the benefit of patients.

The part humour can play in healing is rather more subtle than that. Robert Holden describes it as something that can help cause a valuable shift in perception, from pessimism to optimism. Humour can be an affirmation of life, an expression of joy, compassion, hope, love and playfulness in the face of a potential threat.

Humour, of course, is a technique used in conventional nursing already. Jane Mallett, co-ordinator of nursing research and practice development at the Royal Marsden NHS Trust, has studied videos of nurses teaching kidney-disease patients haemodialysis techniques. On average, a humorous episode occurs nearly once a minute. "These aren't big jokes," she says, "but small utterances, gestures, spontaneous asides and laughter."

Such interactions serve various purposes. The nurses use humour to help develop a rapport with the people they are teaching; the patients use it to highlight anxieties about the procedure - and perhaps to regain, if not control then at least a measure of influence. Both parties found that humour helped them avoid conflict and cope better with the situation.

Research suggests that people who can see the funny side suffer less fatigue, tension, anger and depression in response to stress than others. The relaxing effects of humour are easy enough to demonstrate: easing of muscle tension, deepening of breathing, improved circulation and the release of endorphins (hormonal substances that are the body's natural painkillers). Is there any evidence, though, that humour can protect against disease, or even cure it?

Support for this argument is emerging in the relatively new field of psychoneuroimmunology (PNI), which explores the possibility that mind and body are more closely linked than has previously been thought. In 1974, the American psychologist Robert Ader first demonstrated a connection between the brain and the body's immune system in his experiments with rats. Subsequent studies in humans have shown that anxiety, emotional stress and loneliness can cause a slump in the body's natural killer cells. Traumatic life events such as divorce or bereavement can double the risk of catching a cold, for example.

As biochemists and endocrinologists have learnt more about hormones and neurotransmitters (chemical messages from nerve endings that lock on to target cells), they have began to understand more fully the links between stress and physiological change. Adrenaline and cortisol, hormones secreted in stressful situations, are known to suppress the immune response. Neurotransmit- ters, once believed to have been synthesised only in the brain, have been discovered throughout the body - including those immune-system cells that control production of antibodies and killer cells.

Dr Candace Pert, an American biochemist, has taken these findings a stage further. She believes the immune system can be boosted by a particular group of neurotransmitters known as neuropeptides, of which endorphins are the best-known example. These are triggered by our feelings, prompting a wave of chemical changes that could strengthen or weaken the body's immune system.

Does this mean we could literally laugh ourselves well? Dr Lee Berk of the department of preventive medicine at Loma Linda University, California, believes this to be the case. He has done extensive research into the effect on the immune system of "mirthful laughter" (a metaphor, he explains, for a physiological state of positive arousal called "eustress"). This state was provoked in his medical student subjects by watching videos of their favourite TV comedy series, Gallagher. In his most recent study, presented to the American Society of Behavioral Medicine in San Diego earlier this year, blood samples taken during a viewing of Gallagher showed an increase in cyto-kines (immune system hormones), particularly gammainterferon (which switches on natural killer cells).

But are the students getting fewer colds and other diseases as a result? Dr Peter White, of the department of psychological medicine at St Bartho- lomew's Hopital in London, says answering such questions isn't easy. "There's very good evidence that the immune system is affected by stress both directly, and indirectly by sleeping badly, increased smoking and alcohol consumption," he says. "What nobody has shown is that it makes people have more colds or gives them cancer."

If the evidence is slim for negative emotional states causing illness, it is even less substantial for positive states keeping illness at bay. Even if a link were proved, says nursing co-ordinator Jane Mallett, how would laughter therapy be best implemented? Comedy carts may not be the answer. She has made a proposal to study the cost-effectiveness of humour and laughter therapy among cancer patients at the Royal Marsden Hospital, and is looking for funding.

Even with such inconclusive answers, says Dr Peter White of Bart's, there is no harm in encouraging physical fitness and a positive mental outlook. Dr Lee Berk in California agrees. "I don't want to give the impression that laughter can cure all," he says. "It's part of a total lifestyle concept: a positive mindset and happiness have beneficial effects on physiology. You can laugh yourself well just as much as you can exercise or eat correctly to be well."

What about those who are not blessed with a riotous sense of humour? Can they teach themselves to be funny, or at least to see the bright side of life? Cognitive therapists, trained in replacing negative attitudes and emotions with positive ones, insist humour is a skill that can be learnt. It might be easier, however, simply to summon up a few cytokines; a prospect that is not as remote or as ludicrous as it appears. Dr Berk is working with a neurologist, Dr Barry Bittman, who has developed a biofeedback programme called Mindscope that can apparently access and condition specific parts of the brain. "If we can identify the various areas that interact with the immune system," says Dr Berk, "then we can train those areas to turn themselves on."

HARNESSING HUMOUR

l Don't take yourself too seriously.

l Don't set perfectionist standards for yourself.

l Don't identify to an exaggerated extent with one particular facet of your life (eg, work or family)

l Watch an entertaining film.

l Write down jokes you find funny.

l Spend time with uplifting people.

l Repeat affirmations such as "Life is too short to take too seriously".

l Try positive ways of looking at things. The phrase "I have so much to do" is far better than "I have too much to do".

l Remember that it's more important to have fun than to be funny.

(Taken from `The Wellness Book' by Dr Herbert Benson and Eileen Stuart, Simon & Schuster, $14, ISBN 0671 797506; not published here but can be ordered from bookshops)