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Posted by steveneidman on February 16, 2010

How a New Jobless Era Will Transform America

 

Image credit: Fredrik Broden

By Don Peck

 

 

 

 

 

 

 

 

 

How should we characterize the economic period we have now entered? After nearly two brutal years, the Great Recession appears to be over, at least technically. Yet a return to normalcy seems far off. By some measures, each recession since the 1980s has retreated more slowly than the one before it. In one sense, we never fully recovered from the last one, in 2001: the share of the civilian population with a job never returned to its previous peak before this downturn began, and incomes were stagnant throughout the decade. Still, the weakness that lingered through much of the 2000s shouldn’t be confused with the trauma of the past two years, a trauma that will remain heavy for quite some time.

The unemployment rate hit 10 percent in October, and there are good reasons to believe that by 2011, 2012, even 2014, it will have declined only a little. Late last year, the average duration of unemployment surpassed six months, the first time that has happened since 1948, when the Bureau of Labor Statistics began tracking that number. As of this writing, for every open job in the U.S., six people are actively looking for work. 

All of these figures understate the magnitude of the jobs crisis. The broadest measure of unemployment and underemployment (which includes people who want to work but have stopped actively searching for a job, along with those who want full-time jobs but can find only part-time work) reached 17.4 percent in October, which appears to be the highest figure since the 1930s. And for large swaths of society—young adults, men, minorities—that figure was much higher (among teenagers, for instance, even the narrowest measure of unemployment stood at roughly 27 percent). One recent survey showed that 44 percent of families had experienced a job loss, a reduction in hours, or a pay cut in the past year. 

There is unemployment, a brief and relatively routine transitional state that results from the rise and fall of companies in any economy, and there is unemployment—chronic, all-consuming. The former is a necessary lubricant in any engine of economic growth. The latter is a pestilence that slowly eats away at people, families, and, if it spreads widely enough, the fabric of society. Indeed, history suggests that it is perhaps society’s most noxious ill. 

The worst effects of pervasive joblessness—on family, politics, society—take time to incubate, and they show themselves only slowly. But ultimately, they leave deep marks that endure long after boom times have returned. Some of these marks are just now becoming visible, and even if the economy magically and fully recovers tomorrow, new ones will continue to appear. The longer our economic slump lasts, the deeper they’ll be. 

If it persists much longer, this era of high joblessness will likely change the life course and character of a generation of young adults—and quite possibly those of the children behind them as well. It will leave an indelible imprint on many blue-collar white men—and on white culture. It could change the nature of modern marriage, and also cripple marriage as an institution in many communities. It may already be plunging many inner cities into a kind of despair and dysfunction not seen for decades. Ultimately, it is likely to warp our politics, our culture, and the character of our society for years. 

The Long Road Ahead

 

Since last spring, when fears of economic apocalypse began to ebb, we’ve been treated to an alphabet soup of predictions about the recovery. Various economists have suggested that it might look like a V (a strong and rapid rebound), a U (slower), a W (reflecting the possibility of a double-dip recession), or, most alarming, an L (no recovery in demand or jobs for years: a lost decade). This summer, with all the good letters already taken, the former labor secretary Robert Reich wrote on his blog that the recovery might actually be shaped like an X (the imagery is elusive, but Reich’s argument was that there can be no recovery until we find an entirely new model of economic growth). 

No one knows what shape the recovery will take. The economy grew at an annual rate of 2.2 percent in the third quarter of last year, the first increase since the second quarter of 2008. If economic growth continues to pick up, substantial job growth will eventually follow. But there are many reasons to doubt the durability of the economic turnaround, and the speed with which jobs will return. 

Historically, financial crises have spawned long periods of economic malaise, and this crisis, so far, has been true to form. Despite the bailouts, many banks’ balance sheets remain weak; more than 140 banks failed in 2009. As a result, banks have kept lending standards tight, frustrating the efforts of small businesses—which have accounted for almost half of all job losses—to invest or rehire. Exports seem unlikely to provide much of a boost; although China, India, Brazil, and some other emerging markets are growing quickly again, Europe and Japan—both major markets for U.S. exports—remain weak. And in any case, exports make up only about 13 percent of total U.S. production; even if they were to grow quickly, the impact would be muted. 

Most recessions end when people start spending again, but for the foreseeable future, U.S. consumer demand is unlikely to propel strong economic growth. As of November, one in seven mortgages was delinquent, up from one in 10 a year earlier. As many as one in four houses may now be underwater, and the ratio of household debt to GDP, about 65 percent in the mid-1990s, is roughly 100 percent today. It is not merely animal spirits that are keeping people from spending freely (though those spirits are dour). Heavy debt and large losses of wealth have forced spending onto a lower path. 

So what is the engine that will pull the U.S. back onto a strong growth path? That turns out to be a hard question. The New York Times columnist Paul Krugman, who fears a lost decade, said in a lecture at the London School of Economics last summer that he has “no idea” how the economy could quickly return to strong, sustainable growth. Mark Zandi, the chief economist at Moody’s Economy.com, told the Associated Press last fall, “I think the unemployment rate will be permanently higher, or at least higher for the foreseeable future. The collective psyche has changed as a result of what we’ve been through. And we’re going to be different as a result.” 

One big reason that the economy stabilized last summer and fall is the stimulus; the Congressional Budget Office estimates that without the stimulus, growth would have been anywhere from 1.2 to 3.2 percentage points lower in the third quarter of 2009. The stimulus will continue to trickle into the economy for the next couple of years, but as a concentrated force, it’s largely spent. Christina Romer, the chair of President Obama’s Council of Economic Advisers, said last fall, “By mid-2010, fiscal stimulus will likely be contributing little to further growth,” adding that she didn’t expect unemployment to fall significantly until 2011. That prediction has since been echoed, more or less, by the Federal Reserve and Goldman Sachs. 

The economy now sits in a hole more than 10 million jobs deep—that’s the number required to get back to 5 percent unemployment, the rate we had before the recession started, and one that’s been more or less typical for a generation. And because the population is growing and new people are continually coming onto the job market, we need to produce roughly 1.5 million new jobs a year—about 125,000 a month—just to keep from sinking deeper. 

Even if the economy were to immediately begin producing 600,000 jobs a month—more than double the pace of the mid-to-late 1990s, when job growth was strong—it would take roughly two years to dig ourselves out of the hole we’re in. The economy could add jobs that fast, or even faster—job growth is theoretically limited only by labor supply, and a lot more labor is sitting idle today than usual. But the U.S. hasn’t seen that pace of sustained employment growth in more than 30 years. And given the particulars of this recession, matching idle workers with new jobs—even once economic growth picks up—seems likely to be a particularly slow and challenging process. 

The construction and finance industries, bloated by a decade-long housing bubble, are unlikely to regain their former share of the economy, and as a result many out-of-work finance professionals and construction workers won’t be able to simply pick up where they left off when growth returns—they’ll need to retrain and find new careers. (For different reasons, the same might be said of many media professionals and auto workers.) And even within industries that are likely to bounce back smartly, temporary layoffs have generally given way to the permanent elimination of jobs, the result of workplace restructuring. Manufacturing jobs have of course been moving overseas for decades, and still are; but recently, the outsourcing of much white-collar work has become possible. Companies that have cut domestic payrolls to the bone in this recession may choose to rebuild them in Shanghai, Guangzhou, or Bangalore, accelerating off-shoring decisions that otherwise might have occurred over many years. 

New jobs will come open in the U.S. But many will have different skill requirements than the old ones. “In a sense,” says Gary Burtless, a labor economist at the Brookings Institution, “every time someone’s laid off now, they need to start all over. They don’t even know what industry they’ll be in next.” And as a spell of unemployment lengthens, skills erode and behavior tends to change, leaving some people unqualified even for work they once did well. 

Ultimately, innovation is what allows an economy to grow quickly and create new jobs as old ones obsolesce and disappear. Typically, one salutary side effect of recessions is that they eventually spur booms in innovation. Some laid-off employees become entrepreneurs, working on ideas that have been ignored by corporate bureaucracies, while sclerotic firms in declining industries fail, making way for nimbler enterprises. But according to the economist Edmund Phelps, the innovative potential of the U.S. economy looks limited today. In a recent Harvard Business Review article, he and his co-author, Leo Tilman, argue that dynamism in the U.S. has actually been in decline for a decade; with the housing bubble fueling easy (but unsustainable) growth for much of that time, we just didn’t notice. Phelps and Tilman finger several culprits: a patent system that’s become stifling; an increasingly myopic focus among public companies on quarterly results, rather than long-term value creation; and, not least, a financial industry that for a generation has focused its talent and resources not on funding business innovation, but on proprietary trading, regulatory arbitrage, and arcane financial engineering. None of these problems is likely to disappear quickly. Phelps, who won a Nobel Prize for his work on the “natural” rate of unemployment, believes that until they do disappear, the new floor for unemployment is likely to be between 6.5 percent and 7.5 percent, even once “recovery” is complete. 

It’s likely, then, that for the next several years or more, the jobs environment will more closely resemble today’s environment than that of 2006 or 2007—or for that matter, the environment to which we were accustomed for a generation. Heidi Shierholz, an economist at the Economic Policy Institute, notes that if the recovery follows the same basic path as the last two (in 1991 and 2001), unemployment will stand at roughly 8 percent in 2014. 

“We haven’t seen anything like this before: a really deep recession combined with a really extended period, maybe as much as eight years, all told, of highly elevated unemployment,” Shierholz told me. “We’re about to see a big national experiment on stress.” 

The Recession and America’s Youth

 

“I’m definitely seeing a lot of the older generation saying, ‘Oh, this [recession] is so awful,’” Robert Sherman, a 2009 graduate of Syracuse University, told The New York Times in July. “But my generation isn’t getting as depressed and uptight.” Sherman had recently turned down a $50,000-a-year job at a consulting firm, after careful deliberation with his parents, because he hadn’t connected well with his potential bosses. Instead he was doing odd jobs and trying to get a couple of tech companies off the ground. “The economy will rebound,” he said. 

Over the past two generations, particularly among many college grads, the 20s have become a sort of netherworld between adolescence and adulthood. Job-switching is common, and with it, periods of voluntary, transitional unemployment. And as marriage and parenthood have receded farther into the future, the first years after college have become, arguably, more carefree. In this recession, the term funemployment has gained some currency among single 20-somethings, prompting a small raft of youth-culture stories in the Los Angeles Times and San Francisco Weekly, on Gawker, and in other venues.

Most of the people interviewed in these stories seem merely to be trying to stay positive and make the best of a bad situation. They note that it’s a good time to reevaluate career choices; that since joblessness is now so common among their peers, it has lost much of its stigma; and that since they don’t have mortgages or kids, they have flexibility, and in this respect, they are lucky. All of this sounds sensible enough—it is intuitive to think that youth will be spared the worst of the recession’s scars. 

But in fact a whole generation of young adults is likely to see its life chances permanently diminished by this recession. Lisa Kahn, an economist at Yale, has studied the impact of recessions on the lifetime earnings of young workers. In one recent study, she followed the career paths of white men who graduated from college between 1979 and 1989. She found that, all else equal, for every one-percentage-point increase in the national unemployment rate, the starting income of new graduates fell by as much as 7 percent; the unluckiest graduates of the decade, who emerged into the teeth of the 1981–82 recession, made roughly 25 percent less in their first year than graduates who stepped into boom times. 

But what’s truly remarkable is the persistence of the earnings gap. Five, 10, 15 years after graduation, after untold promotions and career changes spanning booms and busts, the unlucky graduates never closed the gap. Seventeen years after graduation, those who had entered the workforce during inhospitable times were still earning 10 percent less on average than those who had emerged into a more bountiful climate. When you add up all the earnings losses over the years, Kahn says, it’s as if the lucky graduates had been given a gift of about $100,000, adjusted for inflation, immediately upon graduation—or, alternatively, as if the unlucky ones had been saddled with a debt of the same size. 

When Kahn looked more closely at the unlucky graduates at mid-career, she found some surprising characteristics. They were significantly less likely to work in professional occupations or other prestigious spheres. And they clung more tightly to their jobs: average job tenure was unusually long. People who entered the workforce during the recession “didn’t switch jobs as much, and particularly for young workers, that’s how you increase wages,” Kahn told me. This behavior may have resulted from a lingering risk aversion, born of a tough start. But a lack of opportunities may have played a larger role, she said: when you’re forced to start work in a particularly low-level job or unsexy career, it’s easy for other employers to dismiss you as having low potential. Moving up, or moving on to something different and better, becomes more difficult. 

“Graduates’ first jobs have an inordinate impact on their career path and [lifetime earnings],” wrote Austan Goolsbee, now a member of President Obama’s Council of Economic Advisers, in The New York Times in 2006. “People essentially cannot close the wage gap by working their way up the company hierarchy. While they may work their way up, the people who started above them do, too. They don’t catch up.” Recent research suggests that as much as two-thirds of real lifetime wage growth typically occurs in the first 10 years of a career. After that, as people start families and their career paths lengthen and solidify, jumping the tracks becomes harder. 

This job environment is not one in which fast-track jobs are plentiful, to say the least. According to the National Association of Colleges and Employers, job offers to graduating seniors declined 21 percent last year, and are expected to decline another 7 percent this year. Last spring, in the San Francisco Bay Area, an organization called JobNob began holding networking happy hours to try to match college graduates with start-up companies looking primarily for unpaid labor. Julie Greenberg, a co-founder of JobNob, says that at the first event, on May 7, she expected perhaps 30 people, but 300 showed up. New graduates didn’t have much of a chance; most of the people there had several years of work experience—quite a lot were 30-somethings—and some had more than one degree. JobNob has since held events for alumni of Stanford, Berkeley, and Harvard; all have been well attended (at the Harvard event, Greenberg tried to restrict attendance to 75, but about 100 people managed to get in), and all have been dominated by people with significant work experience. 

When experienced workers holding prestigious degrees are taking unpaid internships, not much is left for newly minted B.A.s. Yet if those same B.A.s don’t find purchase in the job market, they’ll soon have to compete with a fresh class of graduates—ones without white space on their résumé to explain. This is a tough squeeze to escape, and it only gets tighter over time. 

Strong evidence suggests that people who don’t find solid roots in the job market within a year or two have a particularly hard time righting themselves. In part, that’s because many of them become different—and damaged—people. Krysia Mossakowski, a sociologist at the University of Miami, has found that in young adults, long bouts of unemployment provoke long-lasting changes in behavior and mental health. “Some people say, ‘Oh, well, they’re young, they’re in and out of the workforce, so unemployment shouldn’t matter much psychologically,’” Mossakowski told me. “But that isn’t true.” 

Examining national longitudinal data, Mossakowski has found that people who were unemployed for long periods in their teens or early 20s are far more likely to develop a habit of heavy drinking (five or more drinks in one sitting) by the time they approach middle age. They are also more likely to develop depressive symptoms. Prior drinking behavior and psychological history do not explain these problems—they result from unemployment itself. And the problems are not limited to those who never find steady work; they show up quite strongly as well in people who are later working regularly. 

Forty years ago, Glen Elder, a sociologist at the University of North Carolina and a pioneer in the field of “life course” studies, found a pronounced diffidence in elderly men (though not women) who had suffered hardship as 20- and 30-somethings during the Depression. Decades later, unlike peers who had been largely spared in the 1930s, these men came across, he told me, as “beaten and withdrawn—lacking ambition, direction, confidence in themselves.” Today in Japan, according to the Japan Productivity Center for Socio-Economic Development, workers who began their careers during the “lost decade” of the 1990s and are now in their 30s make up six out of every 10 cases of depression, stress, and work-related mental disabilities reported by employers. 

A large and long-standing body of research shows that physical health tends to deteriorate during unemployment, most likely through a combination of fewer financial resources and a higher stress level. The most-recent research suggests that poor health is prevalent among the young, and endures for a lifetime. Till Von Wachter, an economist at Columbia University, and Daniel Sullivan, of the Federal Reserve Bank of Chicago, recently looked at the mortality rates of men who had lost their jobs in Pennsylvania in the 1970s and ’80s. They found that particularly among men in their 40s or 50s, mortality rates rose markedly soon after a layoff. But regardless of age, all men were left with an elevated risk of dying in each year following their episode of unemployment, for the rest of their lives. And so, the younger the worker, the more pronounced the effect on his lifespan: the lives of workers who had lost their job at 30, Von Wachter and Sullivan found, were shorter than those who had lost their job at 50 or 55—and more than a year and a half shorter than those who’d never lost their job at all. 

Journalists and academics have thrown various labels at today’s young adults, hoping one might stick—Generation Y, Generation Next, the Net Generation, the Millennials, the Echo Boomers. All of these efforts contain an element of folly; the diversity of character within a generation is always and infinitely larger than the gap between generations. Still, the cultural and economic environment in which each generation is incubated clearly matters. It is no coincidence that the members of Generation X—painted as cynical, apathetic slackers—first emerged into the workforce in the weak job market of the early-to-mid-1980s. Nor is it a coincidence that the early members of Generation Y—labeled as optimistic, rule-following achievers—came of age during the Internet boom of the late 1990s. 

Many of today’s young adults seem temperamentally unprepared for the circumstances in which they now find themselves. Jean Twenge, an associate professor of psychology at San Diego State University, has carefully compared the attitudes of today’s young adults to those of previous generations when they were the same age. Using national survey data, she’s found that to an unprecedented degree, people who graduated from high school in the 2000s dislike the idea of work for work’s sake, and expect jobs and career to be tailored to their interests and lifestyle. Yet they also have much higher material expectations than previous generations, and believe financial success is extremely important. “There’s this idea that, ‘Yeah, I don’t want to work, but I’m still going to get all the stuff I want,’” Twenge told me. “It’s a generation in which every kid has been told, ‘You can be anything you want. You’re special.’” 

In her 2006 book, Generation Me, Twenge notes that self-esteem in children began rising sharply around 1980, and hasn’t stopped since. By 1999, according to one survey, 91 percent of teens described themselves as responsible, 74 percent as physically attractive, and 79 percent as very intelligent. (More than 40 percent of teens also expected that they would be earning $75,000 a year or more by age 30; the median salary made by a 30-year-old was $27,000 that year.) Twenge attributes the shift to broad changes in parenting styles and teaching methods, in response to the growing belief that children should always feel good about themselves, no matter what. As the years have passed, efforts to boost self-esteem—and to decouple it from performance—have become widespread. 

These efforts have succeeded in making today’s youth more confident and individualistic. But that may not benefit them in adulthood, particularly in this economic environment. Twenge writes that “self-esteem without basis encourages laziness rather than hard work,” and that “the ability to persevere and keep going” is “a much better predictor of life outcomes than self-esteem.” She worries that many young people might be inclined to simply give up in this job market. “You’d think if people are more individualistic, they’d be more independent,” she told me. “But it’s not really true. There’s an element of entitlement—they expect people to figure things out for them.” 

Ron Alsop, a former reporter for The Wall Street Journal and the author of The Trophy Kids Grow Up: How the Millennial Generation Is Shaking Up the Workplace, says a combination of entitlement and highly structured childhood has resulted in a lack of independence and entrepreneurialism in many 20-somethings. They’re used to checklists, he says, and “don’t excel at leadership or independent problem solving.” Alsop interviewed dozens of employers for his book, and concluded that unlike previous generations, Millennials, as a group, “need almost constant direction” in the workplace. “Many flounder without precise guidelines but thrive in structured situations that provide clearly defined rules.” 

All of these characteristics are worrisome, given a harsh economic environment that requires perseverance, adaptability, humility, and entrepreneurialism. Perhaps most worrisome, though, is the fatalism and lack of agency that both Twenge and Alsop discern in today’s young adults. Trained throughout childhood to disconnect performance from reward, and told repeatedly that they are destined for great things, many are quick to place blame elsewhere when something goes wrong, and inclined to believe that bad situations will sort themselves out—or will be sorted out by parents or other helpers. 

In his remarks at last year’s commencement, in May, The New York Times reported, University of Connecticut President Michael Hogan addressed the phenomenon of students’ turning down jobs, with no alternatives, because they didn’t feel the jobs were good enough. “My first word of advice is this,” he told the graduates. “Say yes. In fact, say yes as often as you can. Saying yes begins things. Saying yes is how things grow. Saying yes leads to new experiences, and new experiences will lead to knowledge and wisdom. Yes is for young people, and an attitude of yes is how you will be able to go forward in these uncertain times.” 

Larry Druckenbrod, the university’s assistant director of career services, told me last fall, “This is a group that’s done résumé building since middle school. They’ve been told they’ve been preparing to go out and do great things after college. And now they’ve been dealt a 180.” For many, that’s led to “immobilization.” Druckenbrod said that about a third of the seniors he talked to that semester were seriously looking for work; another third were planning to go to grad school. The final third, he said, were “not even engaging with the job market—these are the ones whose parents have already said, ‘Just come home and live with us.’” 

According to a recent Pew survey, 10 percent of adults younger than 35 have moved back in with their parents as a result of the recession. But that’s merely an acceleration of a trend that has been under way for a generation or more. By the middle of the aughts, for instance, the percentage of 26-year-olds living with their parents reached 20 percent, nearly double what it was in 1970. Well before the recession began, this generation of young adults was less likely to work, or at least work steadily, than other recent generations. Since 2000, the percentage of people age 16 to 24 participating in the labor force has been declining (from 66 percent to 56 percent across the decade). Increased college attendance explains only part of the shift; the rest is a puzzle. Lingering weakness in the job market since 2001 may be one cause. Twenge believes the propensity of this generation to pursue “dream” careers that are, for most people, unlikely to work out may also be partly responsible. (In 2004, a national survey found that about one out of 18 college freshmen expected to make a living as an actor, musician, or artist.) 

Whatever the reason, the fact that so many young adults weren’t firmly rooted in the workforce even before the crash is deeply worrying. It means that a very large number of young adults entered the recession already vulnerable to all the ills that joblessness produces over time. It means that for a sizeable proportion of 20- and 30-somethings, the next few years will likely be toxic. 

No young people were present at a seminar for the unemployed held on November 4 in Reading, Pennsylvania, a blue-collar city about 60 miles west of Philadelphia. The meeting was organized by a regional nonprofit, Joseph’s People, and held in the basement of the St. Catharine’s parish center. All 30 or so attendees, sitting around a U-shaped table, looked to be 40 or older. But one middle-aged man, one of the first to introduce himself to the group, said he and his wife were there on behalf of their son, Errol. “He’s so disgusted that he didn’t want to come,” the man said. “He doesn’t know what to do, and we don’t either.” 

I talked to Errol a few days later. He is 28 and has a gentle, straightforward manner. He graduated from high school in 1999 and has lived with his parents since then. He worked in a machine shop for a couple of years after school, and has also held jobs at a battery factory, a sandpaper manufacturer, and a restaurant, where he was a cook. The restaurant closed in June 2008, and apart from a few days of work through temp agencies, he hasn’t had a job since. 

He calls in to a few temp agencies each week to let them know he’s interested in working, and checks the newspaper for job listings every Sunday. Sometimes he goes into CareerLink, the local unemployment office, to see if it has any new listings. He does work around the house, or in the small machine shop he’s set up in the garage, just to fill his days, and to try to keep his skills up. 

“I was thinking about moving,” he said. “I’m just really not sure where. Other places where I traveled, I didn’t really see much of a difference with what there was here.” He’s still got a few thousand dollars in the bank, which he saved when he was working as a machinist, and is mostly living off that; he’s been trading penny stocks to try to replenish those savings. 

I asked him what he foresaw for his working life. “As far as my job position,” he said, “I really don’t know what I want to do yet. I’m not sure.” When he was little, he wanted to be a mechanic, and he did enjoy the machine trade. But now there was hardly any work to be had, and what there was paid about the same as Walmart. “I don’t think there’s any way that you can have a job that you can think you can retire off of,” he said. “I think everyone’s going to have to transfer to another job.” He said the only future he could really imagine for himself now was just moving from job to job, with no career to speak of. “That’s what I think,” he said. “I don’t want to.” 

Men and Family in a Jobless Age

 

In her classic sociology of the Depression, The Unemployed Man and His Family, Mirra Komarovsky vividly describes how joblessness strained—and in many cases fundamentally altered—family relationships in the 1930s. During 1935 and 1936, Komarovsky and her research team interviewed the members of 59 white middle-class families in which the husband and father had been out of work for at least a year. Her research revealed deep psychological wounds. “It is awful to be old and discarded at 40,” said one father. “A man is not a man without work.” Another said plainly, “During the depression I lost something. Maybe you call it self-respect, but in losing it I also lost the respect of my children, and I am afraid I am losing my wife.” Noted one woman of her husband, “I still love him, but he doesn’t seem as ‘big’ a man.” 

Taken together, the stories paint a picture of diminished men, bereft of familial authority. Household power—over children, spending, and daily decisions of all types—generally shifted to wives over time (and some women were happier overall as a result). Amid general anxiety, fears of pregnancy, and men’s loss of self-worth and loss of respect from their wives, sex lives withered. Socializing all but ceased as well, a casualty of poverty and embarrassment. Although some men embraced family life and drew their wife and children closer, most became distant. Children described their father as “mean,” “nasty,” or “bossy,” and didn’t want to bring friends around, for fear of what he might say. “There was less physical violence towards the wife than towards the child,” Komarovsky wrote. 

In the 70 years that have passed since the publication of The Unemployed Man and His Family, American society has become vastly more wealthy, and a more comprehensive social safety net—however frayed it may seem—now stretches beneath it. Two-earner households have become the norm, cushioning the economic blow of many layoffs. And of course, relationships between men and women have evolved. Yet when read today, large parts of Komarovsky’s book still seem disconcertingly up-to-date. All available evidence suggests that long bouts of unemployment—particularly male unemployment—still enfeeble the jobless and warp their families to a similar degree, and in many of the same ways. 

Andrew Oswald, an economist at the University of Warwick, in the U.K., and a pioneer in the field of happiness studies, says no other circumstance produces a larger decline in mental health and well-being than being involuntarily out of work for six months or more. It is the worst thing that can happen, he says, equivalent to the death of a spouse, and “a kind of bereavement” in its own right. Only a small fraction of the decline can be tied directly to losing a paycheck, Oswald says; most of it appears to be the result of a tarnished identity and a loss of self-worth. Unemployment leaves psychological scars that remain even after work is found again, and, because the happiness of husbands and the happiness of wives are usually closely related, the misery spreads throughout the home. 

Especially in middle-aged men, long accustomed to the routine of the office or factory, unemployment seems to produce a crippling disorientation. At a series of workshops for the unemployed that I attended around Philadelphia last fall, the participants were overwhelmingly male, and the men in particular described the erosion of their identities, the isolation of being jobless, and the indignities of downward mobility. 

Over lunch I spoke with one attendee, Gus Poulos, a Vietnam-era veteran who had begun his career as a refrigeration mechanic before going to night school and becoming an accountant. He is trim and powerfully built, and looks much younger than his 59 years. For seven years, until he was laid off in December 2008, he was a senior financial analyst for a local hospital. 

Poulos said that his frustration had built and built over the past year. “You apply for so many jobs and just never hear anything,” he told me. “You’re one of my few interviews. I’m just glad to have an interview with anybody, even a magazine.” Poulos said he was an optimist by nature, and had always believed that with preparation and hard work, he could overcome whatever life threw at him. But sometime in the past year, he’d lost that sense, and at times he felt aimless and adrift. “That’s never been who I am,” he said. “But now, it’s who I am.” 

Recently he’d gotten a part-time job as a cashier at Walmart, for $8.50 an hour. “They say, ‘Do you want it?’ And in my head, I thought, ‘No.’ And I raised my hand and said, ‘Yes.’” Poulos and his wife met when they were both working as supermarket cashiers, four decades earlier—it had been one of his first jobs. “Now, here I am again.” 

Poulos’s wife is still working—she’s a quality-control analyst at a food company—and that’s been a blessing. But both are feeling the strain, financial and emotional, of his situation. She commutes about 100 miles every weekday, which makes for long days. His hours at Walmart are on weekends, so he doesn’t see her much anymore and doesn’t have much of a social life. 

Some neighbors were at the Walmart a couple of weeks ago, he said, and he rang up their purchase. “Maybe they were used to seeing me in a different setting,” he said—in a suit as he left for work in the morning, or walking the dog in the neighborhood. Or “maybe they were daydreaming.” But they didn’t greet him, and he didn’t say anything. He looked down at his soup, pushing it around the bowl with his spoon for a few seconds before looking back up at me. “I know they knew me,” he said. “I’ve been in their home.” 

The weight of this recession has fallen most heavily upon men, who’ve suffered roughly three-quarters of the 8 million job losses since the beginning of 2008. Male-dominated industries (construction, finance, manufacturing) have been particularly hard-hit, while sectors that disproportionately employ women (education, health care) have held up relatively well. In November, 19.4 percent of all men in their prime working years, 25 to 54, did not have jobs, the highest figure since the Bureau of Labor Statistics began tracking the statistic in 1948. At the time of this writing, it looks possible that within the next few months, for the first time in U.S. history, women will hold a majority of the country’s jobs. 

In this respect, the recession has merely intensified a long-standing trend. Broadly speaking, the service sector, which employs relatively more women, is growing, while manufacturing, which employs relatively more men, is shrinking. The net result is that men have been contributing a smaller and smaller share of family income. 

“Traditional” marriages, in which men engage in paid work and women in homemaking, have long been in eclipse. Particularly in blue-collar families, where many husbands and wives work staggered shifts, men routinely handle a lot of the child care today. Still, the ease with which gender bends in modern marriages should not be overestimated. When men stop doing paid work—and even when they work less than their wives—marital conflict usually follows. 

Last March, the National Domestic Violence Hotline received almost half again as many calls as it had one year earlier; as was the case in the Depression, unemployed men are vastly more likely to beat their wives or children. More common than violence, though, is a sort of passive-aggressiveness. In Identity Economics, the economists George Akerloff and Rachel Kranton find that among married couples, men who aren’t working at all, despite their free time, do only 37 percent of the housework, on average. And some men, apparently in an effort to guard their masculinity, actually do less housework after becoming unemployed. 

Many working women struggle with the idea of partners who aren’t breadwinners. “We’ve got this image of Archie Bunker sitting at home, grumbling and acting out,” says Kathryn Edin, a professor of public policy at Harvard, and an expert on family life. “And that does happen. But you also have women in whole communities thinking, ‘This guy’s nothing.’” Edin’s research in low-income communities shows, for instance, that most working women whose partner stayed home to watch the kids—while very happy with the quality of child care their children’s father provided—were dissatisfied with their relationship overall. “These relationships were often filled with conflict,” Edin told me. Even today, she says, men’s identities are far more defined by their work than women’s, and both men and women become extremely uncomfortable when men’s work goes away. 

The national divorce rate fell slightly in 2008, and that’s not unusual in a recession: divorce is expensive, and many couples delay it in hard times. But joblessness corrodes marriages, and makes divorce much more likely down the road. According to W. Bradford Wilcox, the director of the National Marriage Project at the University of Virginia, the gender imbalance of the job losses in this recession is particularly noteworthy, and—when combined with the depth and duration of the jobs crisis—poses “a profound challenge to marriage,” especially in lower-income communities. It may sound harsh, but in general, he says, “if men can’t make a contribution financially, they don’t have much to offer.” Two-thirds of all divorces are legally initiated by women. Wilcox believes that over the next few years, we may see a long wave of divorces, washing no small number of discarded and dispirited men back into single adulthood. 

Among couples without college degrees, says Edin, marriage has become an “increasingly fragile” institution. In many low-income communities, she fears it is being supplanted as a social norm by single motherhood and revolving-door relationships. As a rule, fewer people marry during a recession, and this one has been no exception. But “the timing of this recession coincides with a pretty significant cultural change,” Edin says: a fast-rising material threshold for marrying, but not for having children, in less affluent communities. 

Edin explains that poor and working-class couples, after seeing the ravages of divorce on their parents or within their communities, have become more hesitant to marry; they believe deeply in marriage’s sanctity, and try to guard against the possibility that theirs will end in divorce. Studies have shown that even small changes in income have significant effects on marriage rates among the poor and the lower-middle class. “It’s simply not respectable to get married if you don’t have a job—some way of illustrating to your neighbors that you have at least some grasp on some piece of the American pie,” Edin says. Increasingly, people in these communities see marriage not as a way to build savings and stability, but as “a symbol that you’ve arrived.” 

Childbearing is the opposite story. The stigma against out-of-wedlock children has by now largely dissolved in working-class communities—more than half of all new mothers without a college degree are unmarried. For both men and women in these communities, children are commonly seen as a highly desirable, relatively low-cost way to achieve meaning and bolster identity—especially when other opportunities are closed off. Christina Gibson-Davis, a public-policy professor at Duke University, recently found that among adults with no college degree, changes in income have no bearing at all on rates of childbirth. 

“We already have low marriage rates in low-income communities,” Edin told me, “including white communities. And where it’s really hitting now is in working-class urban and rural communities, where you’re just seeing astonishing growth in the rates of nonmarital childbearing. And that would all be fine and good, except these parents don’t stay together. This may be one of the most devastating impacts of the recession.” 

Many children are already suffering in this recession, for a variety of reasons. Among poor families, nutrition can be inadequate in hard times, hampering children’s mental and physical development. And regardless of social class, the stresses and distractions that afflict unemployed parents also afflict their kids, who are more likely to repeat a grade in school, and who on average earn less as adults. Children with unemployed fathers seem particularly vulnerable to psychological problems. 

But a large body of research shows that one of the worst things for children, in the long run, is an unstable family. By the time the average out-of-wedlock child has reached the age of 5, his or her mother will have had two or three significant relationships with men other than the father, and the child will typically have at least one half sibling. This kind of churning is terrible for children—heightening the risks of mental-health problems, troubles at school, teenage delinquency, and so on—and we’re likely to see more and more of it, the longer this malaise stretches on. 

“We could be headed in a direction where, among elites, marriage and family are conventional, but for substantial portions of society, life is more matriarchal,” says Wilcox. The marginalization of working-class men in family life has far-reaching consequences. “Marriage plays an important role in civilizing men. They work harder, longer, more strategically. They spend less time in bars and more time in church, less with friends and more with kin. And they’re happier and healthier.” 

Communities with large numbers of unmarried, jobless men take on an unsavory character over time. Edin’s research team spent part of last summer in Northeast and South Philadelphia, conducting in-depth interviews with residents. She says she was struck by what she saw: “These white working-class communities—once strong, vibrant, proud communities, often organized around big industries—they’re just in terrible straits. The social fabric of these places is just shredding. There’s little engagement in religious life, and the old civic organizations that people used to belong to are fading. Drugs have ravaged these communities, along with divorce, alcoholism, violence. I hang around these neighborhoods in South Philadelphia, and I think, ‘This is beginning to look like the black inner-city neighborhoods we’ve been studying for the past 20 years.’ When young men can’t transition into formal-sector jobs, they sell drugs and drink and do drugs. And it wreaks havoc on family life. They think, ‘Hey, if I’m 23 and I don’t have a baby, there’s something wrong with me.’ They’re following the pattern of their fathers in terms of the timing of childbearing, but they don’t have the jobs to support it. So their families are falling apart—and often spectacularly.” 

In his 1996 book, When Work Disappears, the Harvard sociologist William Julius Wilson connected the loss of jobs from inner cities in the 1970s to the many social ills that cropped up after that. “The consequences of high neighborhood joblessness,” he wrote, 

are more devastating than those of high neighborhood poverty. A neighborhood in which people are poor but employed is different from a neighborhood in which many people are poor and jobless. Many of today’s problems in the inner-city ghetto neighborhoods—crime, family dissolution, welfare, low levels of social organization, and so on—are fundamentally a consequence of the disappearance of work.

 

In the mid-20th century, most urban black men were employed, many of them in manufacturing. But beginning in the 1970s, as factories moved out of the cities or closed altogether, male unemployment began rising sharply. Between 1973 and 1987, the percentage of black men in their 20s working in manufacturing fell from roughly 37.5 percent to 20 percent. As inner cities shed manufacturing jobs, men who lived there, particularly those with limited education, had a hard time making the switch to service jobs. Service jobs and office work of course require different interpersonal skills and different standards of self-presentation from those that blue-collar work demands, and movement from one sector to the other can be jarring. What’s more, Wilson’s research shows, downwardly mobile black men often resented the new work they could find, and displayed less flexibility on the job than, for instance, first-generation immigrant workers. As a result, employers began to prefer hiring women and immigrants, and a vicious cycle of resentment, discrimination, and joblessness set in. 

It remains to be seen whether larger swaths of the country, as male joblessness persists, will eventually come to resemble the inner cities of the 1970s and ’80s. In any case, one of the great catastrophes of the past decade, and in particular of this recession, is the slippage of today’s inner cities back toward the depths of those brutal years. Urban minorities tend to be among the first fired in a recession, and the last rehired in a recovery. Overall, black unemployment stood at 15.6 percent in November; among Hispanics, that figure was 12.7 percent. Even in New York City, where the financial sector, which employs relatively few blacks, has shed tens of thousands of jobs, unemployment has increased much faster among blacks than it has among whites. 

In June 1999, the journalist Ellis Cose wrote in Newsweek that it was then “the best time ever” to be black in America. He ticked through the reasons: employment was up, murders and out-of-wedlock births down; educational attainment was rising, and poverty less common than at any time since 1967. Middle-class black couples were slowly returning to gentrifying inner-city neighborhoods. “Even for some of the most persistently unfortunate—uneducated black men between 16 and 24—jobs are opening up,” Cose wrote. 

But many of those gains are now imperiled. Late last year, unemployment among black teens ages 16 to 19 was nearly 50 percent, and the unemployment rate for black men age 20 or older was almost 17 percent. With so few jobs available, Wilson told me, “many black males will give up and drop out of the labor market, and turn more to the underground economy. And it will be very difficult for these people”—especially those who acquire criminal records—“to reenter the labor market in any significant way.” Glen Elder, the sociologist at the University of North Carolina, who’s done field work in Baltimore, said, “At a lower level of skill, if you lose a job and don’t have fathers or brothers with jobs—if you don’t have a good social network—you get drawn back into the street. There’s a sense in the kids I’ve studied that they lost everything they had, and can’t get it back.” 

In New York City, 18 percent of low-income blacks and 26 percent of low-income Hispanics reported having lost their job as a result of the recession in a July survey by the Community Service Society. More still had had their hours or wages reduced. About one in seven low-income New Yorkers often skipped meals in 2009 to save money, and one in five had had the gas, electricity, or telephone turned off. Wilson argues that once neighborhoods become socially dysfunctional, it takes a long period of unbroken good times to undo the damage—and they can backslide very quickly and steeply. “One problem that has plagued the black community over the years is resignation,” Wilson said—a self-defeating “set of beliefs about what to expect from life and how to respond,” passed from parent to child. “And I think there was sort of a feeling that norms of resignation would weaken somewhat with the Obama election. But these hard economic times could reinforce some of these norms.” 

Wilson, age 74, is a careful scholar, who chooses his words precisely and does not seem given to overstatement. But he sounded forlorn when describing the “very bleak” future he sees for the neighborhoods that he’s spent a lifetime studying. There is “no way,” he told me, “that the extremely high jobless rates we’re seeing won’t have profound consequences for the social organization of inner-city neighborhoods.” Neighborhood-specific statistics on drug addiction, family dysfunction, gang violence, and the like take time to compile. But Wilson believes that once we start getting detailed data on the conditions of inner-city life since the crash, “we’re going to see some horror stories”—and in many cases a relapse into the depths of decades past. “The point I want to emphasize,” Wilson said, “is that we should brace ourselves.” 

The Social Fabric

 

No one tries harder than the jobless to find silver linings in this national economic disaster. Many of the people I spoke with for this story said that unemployment, while extremely painful, had improved them in some ways: they’d become less materialistic and more financially prudent; they were using free time to volunteer more, and were enjoying that; they were more empathetic now, they said, and more aware of the struggles of others. 

In limited respects, perhaps the recession will leave society better off. At the very least, it’s awoken us from our national fever dream of easy riches and bigger houses, and put a necessary end to an era of reckless personal spending. Perhaps it will leave us humbler, and gentler toward one another, too—at least in the long run. A recent paper by the economists Paola Giuliano and Antonio Spilimbergo shows that generations that endured a recession in early adulthood became more concerned about inequality and more cognizant of the role luck plays in life. And in his book, Children of the Great Depression, Glen Elder wrote that adolescents who experienced hardship in the 1930s became especially adaptable, family-oriented adults; perhaps, as a result of this recession, today’s adolescents will be pampered less and counted on for more, and will grow into adults who feel less entitled than recent generations. 

But for the most part, these benefits seem thin, uncertain, and far off. In The Moral Consequences of Economic Growth, the economic historian Benjamin Friedman argues that both inside and outside the U.S., lengthy periods of economic stagnation or decline have almost always left society more mean-spirited and less inclusive, and have usually stopped or reversed the advance of rights and freedoms. A high level of national wealth, Friedman writes, “is no bar to a society’s retreat into rigidity and intolerance once enough of its citizens lose the sense that they are getting ahead.” When material progress falters, Friedman concludes, people become more jealous of their status relative to others. Anti-immigrant sentiment typically increases, as does conflict between races and classes; concern for the poor tends to decline. 

Social forces take time to grow strong, and time to dissipate again. Friedman told me that the phenomenon he’s studied “is not about business cycles … It’s not about people comparing where they are now to where they were a year ago.” The relevant comparisons are much broader: What opportunities are available to me, relative to those of my parents? What opportunities do my children have? What is the trajectory of my career? 

It’s been only about two years since this most recent recession started, but then again, most people hadn’t been getting ahead for a decade. In a Pew survey in the spring of 2008, more than half of all respondents said that over the past five years, they either hadn’t moved forward in life or had actually fallen backward, the most downbeat assessment that either Pew or Gallup has ever recorded, in nearly a half century of polling. Median household income in 2008 was the lowest since 1997, adjusting for inflation. “On the latest income data,” Friedman said, “we’re 11 years into a period of decline.” By the time we get out of the current downturn, we’ll likely be “up to a decade and a half. And that’s surely enough.” 

Income inequality usually falls during a recession, and the economist and happiness expert Andrew Clark says that trend typically provides some emotional salve to the poor and the middle class. (Surveys, lab experiments, and brain readings all show that, for better or worse, schadenfreude is a powerful psychological force: at any fixed level of income, people are happier when the income of others is reduced.) But income inequality hasn’t shrunk in this recession. In 2007–08, the most recent year for which data is available, it widened. 

Indeed, this period of economic weakness may reinforce class divides, and decrease opportunities to cross them—especially for young people. The research of Till Von Wachter, the economist at Columbia University, suggests that not all people graduating into a recession see their life chances dimmed: those with degrees from elite universities catch up fairly quickly to where they otherwise would have been if they’d graduated in better times; it’s the masses beneath them that are left behind. Princeton’s 2009 graduating class found more jobs in financial services than in any other industry. According to Princeton’s career-services director, Beverly Hamilton-Chandler, campus visits and hiring by the big investment banks have been down, but that decline has been partly offset by an uptick in recruiting by hedge funds and boutique financial firms. 

In the Internet age, it is particularly easy to see the bile that has always lurked within American society. More difficult, in the moment, is discerning precisely how these lean times are affecting society’s character. In many respects, the U.S. was more socially tolerant entering this recession than at any time in its history, and a variety of national polls on social conflict since then have shown mixed results. Signs of looming class warfare or racial conflagration are not much in evidence. But some seeds of discontent are slowly germinating. The town-hall meetings last summer and fall were contentious, often uncivil, and at times given over to inchoate outrage. One National Journal poll in October showed that whites (especially white men) were feeling particularly anxious about their future and alienated by the government. We will have to wait and see exactly how these hard times will reshape our social fabric. But they certainly will reshape it, and all the more so the longer they extend. 

A slowly sinking generation; a remorseless assault on the identity of many men; the dissolution of families and the collapse of neighborhoods; a thinning veneer of national amity—the social legacies of the Great Recession are still being written, but their breadth and depth are immense. As problems, they are enormously complex, and their solutions will be equally so. 

Of necessity, those solutions must include measures to bolster the economy in the short term, and to clear the way for faster long-term growth; to support the jobless today, and to ensure that we are creating the kinds of jobs (and the kinds of skills within the population) that can allow for a more broadly shared prosperity in the future. A few of the solutions—like more-aggressive support for the unemployed, and employer tax credits or other subsidies to get people back to work faster—are straightforward and obvious, or at least they should be. Many are not. 

At the very least, though, we should make the return to a more normal jobs environment an unflagging national priority. The stock market has rallied, the financial system has stabilized, and job losses have slowed; by the time you read this, the unemployment rate might be down a little. Yet the difference between “turning the corner” and a return to any sort of normalcy is vast. 

We are in a very deep hole, and we’ve been in it for a relatively long time already. Concerns over deficits are understandable, but in these times, our bias should be toward doing too much rather than doing too little. That implies some small risk to the government’s ability to continue borrowing in the future; and it implies somewhat higher taxes in the future too. But that seems a trade worth making. We are living through a slow-motion social catastrophe, one that could stain our culture and weaken our nation for many, many years to come. We have a civic—and indeed a moral—responsibility to do everything in our power to stop it now, before it gets even worse. 

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Just How Dysfunctional Is Our Healthcare System?

Posted by steveneidman on August 26, 2009

We buy thousands of dollars of it each year, but we know nothing about what it costs; we usually don’t even ask.  It brooks little competition. It doesn’t work as well in America as it does in many other countries, where it is much cheaper and available to many more people. It is responsible for 100,000 deaths in the U.S. each year, and is resistant to even simple changes that could make it much safer. And the “reform” that is the source of so much contention will barely change any of this. Welcome to the world of heathcare, American style. But it doesn’t have to be this way, as this long but worthwhile article points out. Extra benefit: reading it could save the life of someone you love.

-Steven Eidman

How American Health Care Killed My Father

by David Goldhill

ALMOST TWO YEARS ago, my father was killed by a hospital-borne infection in the intensive-care unit of a well-regarded nonprofit hospital in New York City. Dad had just turned 83, and he had a variety of the ailments common to men of his age. But he was still working on the day he walked into the hospital with pneumonia. Within 36 hours, he had developed sepsis. Over the next five weeks in the ICU, a wave of secondary infections, also acquired in the hospital, overwhelmed his defenses. My dad became a statistic—merely one of the roughly 100,000 Americans whose deaths are caused or influenced by infections picked up in hospitals. One hundred thousand deaths: more than double the number of people killed in car crashes, five times the number killed in homicides, 20 times the total number of our armed forces killed in Iraq and Afghanistan. Another victim in a building American tragedy.

About a week after my father’s death, The New Yorker ran an article by Atul Gawandeprofiling the efforts of Dr. Peter Pronovost to reduce the incidence of fatal hospital-borne infections. Pronovost’s solution? A simple checklist of ICU protocols governing physician hand-washing and other basic sterilization procedures. Hospitals implementing Pronovost’s checklist had enjoyed almost instantaneous success, reducing hospital-infection rates by two-thirds within the first three months of its adoption. But many physicians rejected the checklist as an unnecessary and belittling bureaucratic intrusion, and many hospital executives were reluctant to push it on them. The story chronicled Pronovost’s travels around the country as he struggled to persuade hospitals to embrace his reform.

It was a heroic story, but to me, it was also deeply unsettling. How was it possible that Pronovost needed to beg hospitals to adopt an essentially cost-free idea that saved so many lives? Here’s an industry that loudly protests the high cost of liability insurance and the injustice of our tort system and yet needs extensive lobbying to embrace a simple technique to save up to 100,000 people.

And what about us—the patients? How does a nation that might close down a business for a single illness from a suspicious hamburger tolerate the carnage inflicted by our hospitals? And not just those 100,000 deaths. In April, a Wall Street Journal story suggested that blood clots following surgery or illness, the leading cause of preventable hospital deaths in the U.S., may kill nearly 200,000 patients per year. How did Americans learn to accept hundreds of thousands of deaths from minor medical mistakes as an inevitability?

My survivor’s grief has taken the form of an obsession with our health-care system. For more than a year, I’ve been reading as much as I can get my hands on, talking to doctors and patients, and asking a lot of questions.

Keeping Dad company in the hospital for five weeks had left me befuddled. How can a facility featuring state-of-the-art diagnostic equipment use less-sophisticated information technology than my local sushi bar? How can the ICU stress the importance of sterility when its trash is picked up once daily, and only after flowing onto the floor of a patient’s room? Considering the importance of a patient’s frame of mind to recovery, why are the rooms so cheerless and uncomfortable? In whose interest is the bizarre scheduling of hospital shifts, so that a five-week stay brings an endless string of new personnel assigned to a patient’s care? Why, in other words, has this technologically advanced hospital missed out on the revolution in quality control and customer service that has swept all other consumer-facing industries in the past two generations?

I’m a businessman, and in no sense a health-care expert. But the persistence of bad industry practices—from long lines at the doctor’s office to ever-rising prices to astonishing numbers of preventable deaths—seems beyond all normal logic, and must have an underlying cause. There needs to be a business reason why an industry, year in and year out, would be able to get away with poor customer service, unaffordable prices, and uneven results—a reason my father and so many others are unnecessarily killed.

Like every grieving family member, I looked for someone to blame for my father’s death. But my dad’s doctors weren’t incompetent—on the contrary, his hospital physicians were smart, thoughtful, and hard-working. Nor is he dead because of indifferent nursing—without exception, his nurses were dedicated and compassionate. Nor from financial limitations—he was a Medicare patient, and the issue of expense was never once raised. There were no greedy pharmaceutical companies, evil health insurers, or other popular villains in his particular tragedy.

Indeed, I suspect that our collective search for villains—for someone to blame—has distracted us and our political leaders from addressing the fundamental causes of our nation’s health-care crisis. All of the actors in health care—from doctors to insurers to pharmaceutical companies—work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to the economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that—most important—remove consumers from our irreplaceable role as the ultimate ensurer of value.

These are the impersonal forces, I’ve come to believe, that explain why things have gone so badly wrong in health care, producing the national dilemma of runaway costs and poorly covered millions. The problems I’ve explored in the past year hardly count as breakthrough discoveries—health-care experts undoubtedly view all of them as old news. But some experts, it seems, have come to see many of these problems as inevitable in any health-care system—as conditions to be patched up, papered over, or worked around, but not problems to be solved.

That’s the premise behind today’s incremental approach to health-care reform. Though details of the legislation are still being negotiated, its principles are a reprise of previous reforms—addressing access to health care by expanding government aid to those without adequate insurance, while attempting to control rising costs through centrally administered initiatives. Some of the ideas now on the table may well be sensible in the context of our current system. But fundamentally, the “comprehensive” reform being contemplated merely cements in place the current system—insurance-based, employment-centered, administratively complex. It addresses the underlying causes of our health-care crisis only obliquely, if at all; indeed, by extending the current system to more people, it will likely increase the ultimate cost of true reform.

I’m a Democrat, and have long been concerned about America’s lack of a health safety net. But based on my own work experience, I also believe that unless we fix the problems at the foundation of our health system—largely problems of incentives—our reforms won’t do much good, and may do harm. To achieve maximum coverage at acceptable cost with acceptable quality, health care will need to become subject to the same forces that have boosted efficiency and value throughout the economy. We will need to reduce, rather than expand, the role of insurance; focus the government’s role exclusively on things that only government can do (protect the poor, cover us against true catastrophe, enforce safety standards, and ensure provider competition); overcome our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and rely more on ourselves, the consumers, as the ultimate guarantors of good service, reasonable prices, and sensible trade-offs between health-care spending and spending on all the other good things money can buy.

These ideas stand well outside the emerging political consensus about reform. So before exploring alternative policies, let’s reexamine our basic assumptions about health care—what it actually is, how it’s financed, its accountability to patients, and finally its relationship to the eternal laws of supply and demand. Everyone I know has at least one personal story about how screwed up our health-care system is; before spending (another) $1trillion or so on reform, we need a much clearer understanding of the causes of the problems we all experience.

Health Care Isn’t Health (Or Happiness)

“Money is honey,” my grandmother used to tell me, “but health is wealth.” She said “health,” not “health care.” Listening to debates over health-care reform, it is sometimes difficult to remember that there is a difference.

Medical care, of course, is merely one component of our overall health. Nutrition, exercise, education, emotional security, our natural environment, and public safety may now be more important than care in producing further advances in longevity and quality of life. (In 2005, almost half of all deaths in the U.S. resulted from heart disease, diabetes, lung cancer, homicide, suicide, and accidents—all of which are arguably influenced as much by lifestyle choices and living environment as by health care.) And of course even health itself is only one aspect of personal fulfillment, alongside family and friends, travel, recreation, the pursuit of knowledge and experience, and more.

Yet spending on health care, by families and by the government, is crowding out spending on almost everything else. As a nation, we now spend almost 18 percent of our GDP on health care. In 1966, Medicare and Medicaid made up 1 percent of total government spending; now that figure is 20 percent, and quickly rising. Already, the federal government spends eight times as much on health care as it does on education, 12 times what it spends on food aid to children and families, 30 times what it spends on law enforcement, 78 times what it spends on land management and conservation, 87 times the spending on water supply, and 830 times the spending on energy conservation. Education, public safety, environment, infrastructure—all other public priorities are being slowly devoured by the health-care beast.

It’s no different for families. From 2000 to 2008, the U.S. economy grew by $4.4 trillion; of that growth, roughly one out of every four dollars was spent on health care. Household expenditures on health care already exceed those on housing. And health care’s share is growing.

By what mechanism does society determine that an extra, say, $100 billion for health care will make us healthier than even $10 billion for cleaner air or water, or $25 billion for better nutrition, or $5 billion for parks, or $10 billion for recreation, or $50 billion in additional vacation time—or all of those alternatives combined?

The answer is, no mechanism at all. Health care simply keeps gobbling up national resources, seemingly without regard to other societal needs; it’s treated as an island that doesn’t touch or affect the rest of the economy. As new tests and treatments are developed, they are, for the most part, added to our Medicare or commercial insurance policies, no matter what they cost. But of course the money must come from somewhere. If the amount we spend on care had grown only at the general rate of inflation since 1970, annual health-care costs now would be roughly $5,000 less per American—that’s about 10 percent of today’s median income, to invest for the future or to spend on all the other things that contribute to our well-being. To be sure, our society has become wealthier over the years, and we’d naturally want to spend some of this new wealth on more and better health care; but how did we choose to spend this much?

The housing bubble offers some important lessons for health-care policy. The claim that something—whether housing or health care—is an undersupplied social good is commonly used to justify government intervention, and policy makers have long striven to make housing more affordable. But by making housing investments eligible for special tax benefits and subsidized borrowing rates, the government has stimulated not only the construction of more houses but also the willingness of people to borrow and spend more on houses than they otherwise would have. The result is now tragically clear.

As with housing, directing so much of society’s resources to health care is stimulating the provision of vastly more care. Along the way, it’s also distorting demand, raising prices, and making us all poorer by crowding out other, possibly more beneficial, uses for the resources now air-dropped onto the island of health care. Why do we view health care as disconnected from everything else? Why do we spend so much on it? And why, ultimately, do we get such inconsistent results? Any discussion of the ills within the system must begin with a hard look at the tax-advantaged comprehensive-insurance industry at its center.


Health Insurance Isn’t Health Care

How often have you heard a politician say that millions of Americans “have no health care,” when he or she meant they have no health insurance? How has a method of financing health care become synonymous with care itself?

The reason for financing at least some of our health care with an insurance system is obvious. We all worry that a serious illness or an accident might one day require urgent, extensive care, imposing an extreme financial burden on us. In this sense, health-care insurance is just like all other forms of insurance—life, property, liability—where the many who face a risk share the cost incurred by the few who actually suffer a loss.

But health insurance is different from every other type of insurance. Health insurance is the primary payment mechanism not just for expenses that are unexpected and large, but for nearly all health-care expenses. We’ve become so used to health insurance that we don’t realize how absurd that is. We can’t imagine paying for gas with our auto-insurance policy, or for our electric bills with our homeowners insurance, but we all assume that our regular checkups and dental cleanings will be covered at least partially by insurance. Most pregnancies are planned, and deliveries are predictable many months in advance, yet they’re financed the same way we finance fixing a car after a wreck—through an insurance claim.

Comprehensive health insurance is such an ingrained element of our thinking, we forget that its rise to dominance is relatively recent. Modern group health insurance was introduced in 1929, and employer-based insurance began to blossom during World War II, when wage freezes prompted employers to expand other benefits as a way of attracting workers. Still, as late as 1954, only a minority of Americans had health insurance. That’s when Congress passed a law making employer contributions to employee health plans tax-deductible without making the resulting benefits taxable to employees. This seemingly minor tax benefit not only encouraged the spread of catastrophic insurance, but had the accidental effect of making employer-funded health insurance the most affordable option (after taxes) for financing pretty much any type of health care. There was nothing natural or inevitable about the way our system developed: employer-based, comprehensive insurance crowded out alternative methods of paying for health-care expenses only because of a poorly considered tax benefit passed half a century ago.

In designing Medicare and Medicaid in 1965, the government essentially adopted this comprehensive-insurance model for its own spending, and by the next year had enrolled nearly 12 percent of the population. And it is no coinci dence that the great inflation in health-care costs began soon after. We all believe we need comprehensive health insurance because the cost of care—even routine care—appears too high to bear on our own. But the use of insurance to fund virtually all care is itself a major cause of health care’s high expense.

Insurance is probably the most complex, costly, and distortional method of financing any activity; that’s why it is otherwise used to fund only rare, unexpected, and large costs. Imagine sending your weekly grocery bill to an insurance clerk for review, and having the grocer reimbursed by the insurer to whom you’ve paid your share. An expensive and wasteful absurdity, no?

Is this really a big problem for our health-care system? Well, for every two doctors in the U.S., there is now one health-insurance employee—more than 470,000 in total. In 2006, it cost almost $500 per person just to administer health insurance. Much of this enormous cost would simply disappear if we paid routine and predictable health-care expenditures the way we pay for everything else—by ourselves.

The Moral-Hazard Economy

Society’s excess cost from health insurance’s administrative expense pales next to the damage caused by “moral hazard”—the tendency we all have to change our behavior, becoming spendthrifts and otherwise taking less care with our decisions, when someone else is covering the costs. Needless to say, much medical care is unavoidable; we don’t choose to become sick, nor do we seek more treatment than we think we need. Still, hospitals, drug companies, health insurers, and medical-device manufacturers now spend roughly $6 billion a year on advertising. If the demand for health care is purely a response to unavoidable medical need, why do these companies do so much advertising?

Medical ads on TV typically inform the viewer that a specific treatment—a drug, device, surgical procedure—is available for a chronic condition. Many also note that the product or treatment is eligible for Medicare or private-insurance reimbursement. In some cases, the advertiser will offer to help the patient obtain that reimbursement. The key message: you can benefit from this product and pass the bill on to someone else.

Every time you walk into a doctor’s office, it’s implicit that someone else will be paying most or all of your bill; for most of us, that means we give less attention to prices for medical services than we do to prices for anything else. Most physicians, meanwhile, benefit financially from ordering diagnostic tests, doing procedures, and scheduling follow-up appointments. Combine these two features of the system with a third—the informational advantage that extensive training has given physicians over their patients, and the authority that advantage confers—and you have a system where physicians can, to some extent, generate demand at will.

Do they? Well, Medicare spends almost twice as much per patient in Dallas, where there are more doctors and care facilities per resident, as it does in Salem, Oregon, where supply is tighter. Why? Because doctors (particularly specialists) in surplus areas order more tests and treatments per capita, and keep their practices busy. Many studies have shown that the patients in areas like Dallas do not benefit in any measurable way from all this extra care. All of the physicians I know are genuinely dedicated to their patients. But at the margin, all of us are at least subconsciously influenced by our own economic interests. The data are clear: in our current system, physician supply often begets patient demand.

Moral hazard has fostered an accidental collusion between providers benefiting from higher costs and patients who don’t fully bear them. In this environment, trying to control costs is awfully tough. When Medicare cut reimbursement rates in 2005 on chemotherapy and anemia drugs, for instance, it saved almost 20 percent of the previously billed costs. But Medicare’s total cancer-treatment costs actually rose almost immediately. As The New York Times reported, some physicians believed their colleagues simply performed more treatments, particularly higher-profit ones.

Want further evidence of moral hazard? The average insured American and the average uninsured American spend very similar amounts of their own money on health care each year—$654 and $583, respectively. But they spend wildly different amounts of other people’s money—$3,809 and $1,103, respectively. Sometimes the uninsured do not get highly beneficial treatments because they cannot afford them at today’s prices—something any reform must address. But likewise, insured patients often get only marginally beneficial (or even outright unnecessary) care at mind-boggling cost. If it’s true that the insurance system leads us to focus on only our direct share of costs—rather than the total cost to society—it’s not surprising that insured families and uninsured ones would make similar decisions as to how much of their own money to spend on care, but very different decisions on the total amount to consume.

The unfortunate fact is, health-care demand has no natural limit. Our society will always keep creating new treatments to cure previously incurable problems. Some of these will save lives or add productive years to them; many will simply make us more comfortable. That’s all to the good. But the cost of this comfort, and whether it’s really worthwhile, is never calculated—by anyone. For almost all our health-care needs, the current system allows us as consumers to ask providers, “What’s my share?” instead of “How much does this cost?”—a question we ask before buying any other good or service. And the subtle difference between those two questions is costing us all a fortune.

There’s No One Else to Pay the Bill

Perhaps the greatest problem posed by our health-insurance-driven regime is the sense it creates that someone else is actually paying for most of our health care—and that the costs of new benefits can also be borne by someone else. Unfortunately, there is no one else.

For fun, let’s imagine confiscating all the profits of all the famously greedy health-insurance companies. That would pay for four days of health care for all Americans. Let’s add in the profits of the 10 biggest rapacious U.S. drug companies. Another 7 days. Indeed, confiscating all the profits of all American companies, in every industry, wouldn’t cover even five months of our health-care expenses.

Somebody else always seems to be paying for at least part of our health care. But that’s just an illusion. At $2.4 trillion and growing, our nation’s health-care bill is too big to be paid by anyone other than all of us.

In 2007, employer-based health insurance cost, on average, more than $12,000 per family, up 78 percent since 2001. I’ve run several companies and company divisions of various sizes over the course of my career, so I can confidently tell you that raises (and even entry-level hiring) are tightly limited by rising health-care costs. You may think your employer is paying for your health care, but in fact your company’s share of the insurance premium comes out of your potential wage increase. Where else could it come from?

Let’s say you’re a 22-year-old single employee at my company today, starting out at a $30,000 annual salary. Let’s assume you’ll get married in six years, support two children for 20 years, retire at 65, and die at 80. Now let’s make a crazy assumption: insurance premiums, Medicare taxes and premiums, and out-of-pocket costs will grow no faster than your earnings—say, 3 percent a year. By the end of your working days, your annual salary will be up to $107,000. And over your lifetime, you and your employer together will have paid $1.77 million for your family’s health care. $1.77 million! And that’s only after assuming the taming of costs! In recent years, health-care costs have actually grown 2 to 3 percent faster than the economy. If that continues, your 22-year-old self is looking at an additional $2 million or so in expenses over your lifetime—roughly $4 million in total.

Would you have guessed these numbers were so large? If not, you have good cause: only a quarter would be paid by you directly (and much of that after retirement). The rest would be spent by others on your behalf, deducted from your earnings before you received your paycheck. And that’s a big reason why our health-care system is so expensive.

The Government Is Not Good at Cost Reduction

Every proposal for health-care reform has featured some element of cost control to “balance” the inflationary impact of expanding access. Yet it goes without saying that in the big picture, all government efforts to control costs have failed.

Why? One reason is a fixation on prices rather than costs. The government regularly tries to cap costs by limiting the reimbursement rates paid to providers by Medicare and Medicaid, and generally pays much less for each service than private insurers. But as we’ve seen, that can lead providers to perform more services, and to steer patients toward higher-priced, more lightly regulated treatments. The government’s efforts to expand “access” to care while limiting costs are like blowing up a balloon while simultaneously squeezing it. The balloon continues to inflate, but in misshapen form.

Cost control is a feature of decentralized, competitive markets, not of centralized bureaucracy—a matter of incentives, not mandates. What’s more, cost control is dynamic. Even the simplest business faces constant variation in its costs for labor, facilities, and capital; to compete, management must react quickly, efficiently, and, most often, prospectively. By contrast, government bureaucracies set regulations and reimbursement rates through carefully evaluated and broadly applied rules. These bureaucracies first must notice market changes and resource misallocations, and then (sometimes subject to political considerations) issue additional regulations or change reimbursement rates to address each problem retrospectively.

As a result, strange distortions crop up constantly in health care. For example, although the population is rapidly aging, we have few geriatricians—physicians who address the cluster of common patient issues related to aging, often crossing traditional specialty lines. Why? Because under Medicare’s current reimbursement system (which generally pays more to physicians who do lots of tests and procedures), geriatricians typically don’t make much money. If seniors were the true customers, they would likely flock to geriatricians, bidding up their rates—and sending a useful signal to medical-school students. But Medicare is the real customer, and it pays more to specialists in established fields. And so, seniors often end up overusing specialists who are not focused on their specific health needs.

Many reformers believe if we could only adopt a single-payer system, we could deliver health care more cheaply than we do today. The experience of other developed countries suggests that’s true: the government as single payer would have lower administrative costs than private insurers, as well as enormous market clout and the ability to bring down prices, although at the cost of explicitly rationing care.

But even leaving aside the effects of price controls on innovation and customer service, today’s Medicare system should leave us skeptical about the long-term viability of that approach. From 2000 to 2007, despite its market power, Medicare’s hospital and physician reimbursements per enrollee rose by 5.4 percent and 8.5 percent, respectively, per year. As currently structured, Medicare is a Ponzi scheme. The Medicare tax rate has been raised seven times since its enactment, and almost certainly will need to be raised again in the next decade. The Medicare tax contributions and premiums that today’s beneficiaries have paid into the system don’t come close to fully funding their care, which today’s workers subsidize. The subsidy is getting larger even as it becomes more difficult to maintain: next year there will be 3.7 working people for each Medicare beneficiary; if you’re in your mid-40s today, there will be only 2.4 workers to subsidize your care when you hit retirement age. The experience of other rich nations should also make us skeptical. Whatever their histories, nearly all developed countries are now struggling with rapidly rising health-care costs, including those with single-payer systems. From 2000 to 2005, per capita health-care spending in Canada grew by 33 percent, in France by 37 percent, in the U.K. by 47 percent—all comparable to the 40 percent growth experienced by the U.S. in that period. Cost control by way of bureaucratic price controls has its limits.

Uncompetitive

In 2007, health companies in the Fortune 1,000 earned $71 billion. Of the 52 industries represented on Fortune’s list, pharmaceuticals and medical equipment ranked third and fourth, respectively, in terms of profits as a share of revenue. From 2000 to 2007, the annual profits of America’s top 15 health-insurance companies increased from $3.5 billion to $15 billion.

In competitive markets, high profits serve an important social purpose: encouraging capital to flow to the production of a service not adequately supplied. But as long as our government shovels ever-greater resources into health care with one hand, while with the other restricting competition that would ensure those resources are used efficiently, sustained high profits will be the rule.

Health care is an exceptionally heavily regulated industry. Health-insurance companies are regulated by states, which limits interstate competition. And many of the materials, machines, and even software programs used by health-care facilities must be licensed by state or federal authorities, or approved for use by Medicare; these requirements form large barriers to entry for both new facilities and new vendors that could equip and supply them.

Many health-care regulations are justified as safety precautions. But many also result from attempts to redress the distortions that our system of financing health care has created. And whatever their purpose, almost all of these regulations can be shaped over time by the powerful institutions that dominate the health-care landscape, and that are often looking to protect themselves from competition.

Take the ongoing battle between large integrated hospitals and specialty clinics (for cardiac surgery, orthopedics, maternity, etc.). The economic threat posed by these facilities is well illustrated by a recent battle in Loma Linda, California. When a group of doctors proposed a 28-bed private specialty facility, the local hospitals protested to the city council that it was unnecessary, and launched a publicity campaign to try to block it; the council backed the facility anyway. So the nonprofit Loma Linda University Medical Center simply bought the new facility for $80 million in 2008. Traditional hospitals got Congress to include an 18-month moratorium on new specialty hospitals in the 2003 Medicare law, and a second six-month ban in 2005.

The hospitals’ argument has some merit: less complicated surgical cases (the kind specialty clinics typically take on) tend to be more profitable than complex surgeries and nonsurgical admissions. Without those profitable cases, hospitals can’t subsidize the cases on which they lose money. But why are simple surgeries more profitable? Because of the nonmarket methods by which Medicare sets prices.

The net effect of the endless layers of health-care regulation is to stifle competition in the classic economic sense. What we have instead is a noncompetitive system where services and reimbursement are negotiated above consumers’ heads by large private and government institutions. And the primary goal of any large noncompetitive institution is not cost control or product innovation or customer service: it’s maintenance of the status quo.

Our Favored Hospitals

In 1751, Benjamin Franklin and Dr. Thomas Bond founded Pennsylvania Hospital, the first in America, “to care for the sick-poor and insane who were wandering the streets of Philadelphia.” Since then, hospitals have come to dominate the American medical landscape. Yet in recent decades, the rationale for concentrating so much care under one roof has diminished steadily. Many hospitals still exist in their current form largely because they are protected by regulation and favored by government payment policies, which effectively maintain the existing industrial structure, rather than encouraging innovation.

Between 1970 and 2006, annual Medicare payments to hospitals grew by roughly 3,800 percent, from $5 billion to $192 billion. Total annual hospital-care costs for all patients grew from $28 billion to almost $650 billion during that same period. Since 1975, hospitals’ enormous revenue growth has occurred despite a 35 percent decline in the number of hospital beds, no meaningful increase in total admissions, and an almost 50 percent decline in the average length of stay. High-tech equipment has been dispersed to medical practices, recovery periods after major procedures have shrunk, and pharmaceutical therapies have grown in importance, yet over the past 40 years, hospitals have managed to retain the same share (roughly one-third) of our nation’s health-care bill.

Hospitals have sought to use the laws and regulations originally designed to serve patients to preserve their business model. Their argument is the same one that’s been made before by regulated railroads, electric utilities, airlines, Ma Bell, and banks: new competitors, they say, are using their cost advantages to skim off the best customers; without those customers, the incumbents will no longer be able to subsidize essential services that no one can profitably provide to the public.

Hospitals are indeed required to provide emergency care to any walk-in patient, and this obligation is a meaningful public service. But how do we know whether the charitable benefit from this requirement justifies the social cost of expensive hospital care and poor quality? We don’t know. Our system of health-care law and regulation has so distorted the functioning of the market that it’s impossible to measure the social costs and benefits of maintaining hospitals’ prominence. And again, the distortions caused by a reluctance to pay directly for health care—in this case, emergency medicine for the poor—are in large part to blame.

Consider the oft-quoted “statistic” that emergency-room care is the most expensive form of treatment. Has anyone who believes this ever actually been to an emergency room? My sister is an emergency-medicine physician; unlike most other specialists, ER docs usually work on scheduled shifts and are paid fixed salaries that place them in the lower ranks of physician compensation. The doctors and other workers are hardly underemployed: typically, ERs are unbelievably crowded. They have access to the facilities and equipment of the entire hospital, but require very few dedicated resources of their own. They benefit from the group buying power of the entire institution. No expensive art decorates the walls, and the waiting rooms resemble train-station waiting areas. So what exactly makes an ER more expensive than other forms of treatment?

Perhaps it’s the accounting. Since charity care, which is often performed in the ER, is one justification for hospitals’ protected place in law and regulation, it’s in hospitals’ interest to shift costs from overhead and other parts of the hospital to the ER, so that the costs of charity care—the public service that hospitals are providing—will appear to be high. Hospitals certainly lose money on their ERs; after all, many of their customers pay nothing. But to argue that ERs are costly compared with other treatment options, hospitals need to claim expenses well beyond the marginal (or incremental) cost of serving ER patients.

In a recent IRS survey of almost 500 nonprofit hospitals, nearly 60 percent reported providing charity care equal to less than 5 percent of their total revenue, and about 20 percent reported providing less than 2 percent. Analyzing data from the American Hospital Directory, The Wall Street Journal found that the 50 largest nonprofit hospitals or hospital systems made a combined “net income” (that is, profit) of $4.27 billion in 2006, nearly eight times their profits five years earlier.

How do we know whether the value of hospitals’ charitable services compensates for the roughly 100,000 deaths from hospital-borne disease, their poor standards of customer service, and their extraordinary diseconomies of both scale and scope? Might we be better off reforming hospitals, and allowing many of them to be eliminated by competition from specialty clinics? As a society, couldn’t we just pay directly for the services required by the poor? We don’t know how many hospitals would even survive if they were not so favored under the law; anyone who has lost a loved one to a preventable hospital death will wonder how many should.

You Are Not the Customer

What amazed me most during five weeks in the ICU with my dad was the survival of paper and pen for medical instructions and histories. In that time, Dad was twice taken for surgical procedures intended for other patients (fortunately interrupted both times by our intervention). My dry cleaner uses a more elaborate system to track shirts than this hospital used to track treatment.

Not every hospital relies on paper-based orders and charts, but most still do. Why has adoption of clinical information technology been so slow? Companies invest in IT to reduce their costs, reduce mistakes (itself a form of cost-saving), and improve customer service. Better information technology would have improved my father’s experience in the ICU—and possibly his chances of survival.

But my father was not the customer; Medicare was. And although Medicare has experimented with new reimbursement approaches to drive better results, no centralized reimbursement system can be supple enough to address the many variables affecting the patient experience. Certainly, Medicare wasn’t paying for the quality of service during my dad’s hospital stay. And it wasn’t really paying for the quality of his care, either; indeed, because my dad got sepsis in the hospital, and had to spend weeks there before his death, the hospital was able to charge a lot more for his care than if it had successfully treated his pneumonia and sent him home in days.

Of course, one area of health-related IT has received substantial investment—billing. So much for the argument, often made, that privacy concerns or a lack of agreed-upon standards has prevented the development of clinical IT or electronic medical records; presumably, if lack of privacy or standards had hampered the digitization of health records, it also would have prevented the digitization of the accompanying bills. To meet the needs of the government bureaucracy and insurance companies, most providers now bill on standardized electronic forms. In case you wonder who a care provider’s real customer is, try reading one of these bills.

For that matter, try discussing prices with hospitals and other providers. Eight years ago, my wife needed an MRI, but we did not have health insurance. I called up several area hospitals, clinics, and doctors’ offices—all within about a one-mile radius—to find the best price. I was surprised to discover that prices quoted, for an identical service, varied widely, and that the lowest price was $1,200. But what was truly astonishing was that several providers refused to quote any price. Only if I came in and actually ordered the MRI could we discuss price.

Several years later, when we were preparing for the birth of our second child, I requested the total cost of the delivery and related procedures from our hospital. The answer: the hospital discussed price only with uninsured patients. What about my co-pay? They would discuss my potential co-pay only if I were applying for financial assistance.

Keeping prices opaque is one way medical institutions seek to avoid competition and thereby keep prices up. And they get away with it in part because so few consumers pay directly for their own care—insurers, Medicare, and Medicaid are basically the whole game. But without transparency on prices—and the related data on measurable outcomes—efforts to give the consumer more control over health care have failed, and always will.

Here’s a wonderful example of price opacity. Advocates for the uninsured complain that hospitals charge uninsured patients, on average, 2.5 times the amount charged to insured patients. Hospitals defend themselves by contending that they earn from uninsured patients only 25 percent of the amount they do from insured ones. Both statements appear to be true!

How is this possible? Well, hospitals bill according to their price lists, but provide large discounts to major insurers. Individual consumers, of course, don’t benefit from these discounts, so they receive their bills at full list price (typically about 2.5 times the bill to an insured patient). Uninsured patients, however, pay according to how much of the bill the hospital believes they can afford (which, on average, amounts to 25 percent of the amount paid by an insured patient). Nonetheless, whatever discount a hospital gives to an uninsured patient is entirely at its discretion—and is typically negotiated only after the fact. Some uninsured patients have been driven into bankruptcy by hospital collections. American industry may offer no better example of pernicious “price discrimination,” nor one that entails greater financial vulnerability for American families.

It’s astonishingly difficult for consumers to find any health-care information that would enable them to make informed choices—based not just on price, but on quality of care or the rate of preventable medical errors. Here’s one place where legal requirements might help. But only a few states require institutions to make this sort of information public in a usable form for consumers. So while every city has numerous guidebooks with reviews of schools, restaurants, and spas, the public is frequently deprived of the necessary data to choose hospitals and other providers.

The Strange Beast of Health-Care Technology

One of the most widely held pieces of conventional wisdom about health care is that new technology is relentlessly driving up costs. Yet over the past 20 years, I’ve bought several generations of microwave ovens, personal computers, DVD players, GPS devices, mobile phones, and flat-screen TVs. I bank mostly at ATMs, check out my own goods at self-serve supermarket scanners, and attend company meetings by video conference. Technology has transformed much of our daily lives, in almost all cases by adding quantity, speed, and quality while lowering costs. So why is health care different?

Well, for the most part, it isn’t. Whether it’s new drugs to control previously untreatable conditions, diagnostic equipment that enhances physician productivity, or minimally invasive techniques that speed patient recovery, technology-driven innovation has been transforming care at least as greatly as it has transformed the rest of our lives.

But most health-care technologies don’t exist in the same world as other technologies. Recall the MRI my wife needed a few years ago: $1,200 for 20 minutes’ use of a then 20-year-old technology, requiring a little electricity and a little labor from a single technician and a radiologist. Why was the price so high? Most MRIs in this country are reimbursed by insurance or Medicare, and operate in the limited-competition, nontransparent world of insurance pricing. I don’t even know the price of many of the diagnostic services I’ve needed over the years—usually I’ve just gone to whatever provider my physician recommended, without asking (my personal contribution to the moral-hazard economy).

By contrast, consider LASIK surgery. I still lack the (small amount of) courage required to get LASIK. But I’ve been considering it since it was introduced commercially in the 1990s. The surgery is seldom covered by insurance, and exists in the competitive economy typical of most other industries. So people who get LASIK surgery—or for that matter most cosmetic surgeries, dental procedures, or other mostly uninsured treatments—act like consumers. If you do an Internet search today, you can find LASIK procedures quoted as low as $499 per eye—a decline of roughly 80 percent since the procedure was introduced. You’ll also find sites where doctors advertise their own higher-priced surgeries (which more typically cost about $2,000 per eye) and warn against the dangers of discount LASIK. Many ads specify the quality of equipment being used and the performance record of the doctor, in addition to price. In other words, there’s been an active, competitive market for LASIK surgery of the same sort we’re used to seeing for most goods and services.

The history of LASIK fits well with the pattern of all capital-intensive services outside the health-insurance economy. If you’re one of the first ophthalmologists in your community to perform the procedure, you can charge a high price. But once you’ve acquired the machine, the actual cost of performing a single procedure (the marginal cost) is relatively low. So, as additional ophthalmologists in the neighborhood invest in LASIK equipment, the first provider can meet new competition by cutting price. In a fully competitive marketplace, the procedure’s price will tend toward that low marginal cost, and ophthalmologists looking to buy new machines will exert downward pressure on both equipment and procedure prices.

No business likes to compete solely on price, so most technology providers seek to add features and performance improvements to new generations of a machine—anything to keep their product from becoming a pure commodity. Their success depends on whether the consumers will pay enough for the new feature to justify its introduction. In most consumer industries, we can see this dynamic in action—observe how DVD players have moved in a few years from a high-priced luxury to a disposable commodity available at discount stores. DVD players have run out of new features for which customers will pay premium prices.

Perhaps MRIs have too. After a long run of high and stable prices, you can now find ads for discount MRIs. But because of the peculiar way we pay for health care, this downward price pressure on technology seems less vigorous. How well can insurance companies and government agencies judge the value of new features that tech suppliers introduce to keep prices up? Rather than blaming technology for rising costs, we must ask if moral hazard and a lack of discipline in national health-care spending allows health-care companies to avoid the forces that make nonmedical technology so competitive.

In 2002, the U.S. had almost six times as many CT scanners per capita as Germany and four times as many MRI machines as the U.K. Traditional reformers believe it is this rate of investment that has pushed up prices, rather than sustained high prices that have pushed up investment. As a result, many states now require hospitals to obtain a Certificate of Need before making a major equipment purchase. In its own twisted way, this makes sense: moral hazard, driven by insurance, for years allowed providers to create enough demand to keep new MRI machines humming at any price.

But Certificates of Need are just another Scotch-tape reform, an effort to maintain the current system by treating a symptom rather than the underlying disease. Technology is driving up the cost of health care for the same reason every other factor of care is driving up the cost—the absence of the forces that discipline and even drive down prices in the rest of our economy. Only in the bizarre parallel universe of health care could limiting supply be seen as a sensible approach to keeping prices down.

The Limits of “Comprehensive” Health-care Reform

A wasteful insurance system; distorted incentives; a bias toward treatment; moral hazard; hidden costs and a lack of transparency; curbed competition; service to the wrong customer. These are the problems at the foundation of our health-care system, resulting in a slow rot and requiring more and more money just to keep the system from collapsing.

How would the health-care reform that’s now taking shape solve these core problems? The Obama administration and Congress are still working out the details, but it looks like this generation of “comprehensive” reform will not address the underlying issues, any more than previous efforts did. Instead it will put yet more patches on the walls of an edifice that is fundamentally unsound—and then build that edifice higher.

A central feature of the reform plan is the expansion of comprehensive health insurance to most of the 46 million Americans who now lack private or public insurance. Whether this would be achieved entirely through the extension of private commercial insurance at government-subsidized rates, or through the creation of a “public option,” perhaps modeled on Medicare, is still being debated.

Regardless, the administration has suggested a cost to taxpayers of $1 trillion to $1.5 trillion over 10 years. That, of course, will mean another $1 trillion or more not spent on other things—environment, education, nutrition, recreation. And if the history of previous attempts to expand the health safety net are any guide, that estimate will prove low.

The reform plan will also feature a variety of centrally administered initiatives designed to reduce costs and improve quality. These will likely include a major government investment to promote digitization of patient health records, an effort to collect information on best clinical practices, and changes in the way providers are paid, to better reward quality and deter wasteful spending.

All of these initiatives have some theoretical appeal. And within the confines of the current system, all may do some good. But for the most part, they simply do not address the root causes of poor quality and runaway costs.

Consider information technology, for instance. Of course the health system could benefit from better use of IT. The Rand Corporation has estimated that the widespread use of electronic medical records would eventually yield annual savings of $81 billion, while also improving care and reducing preventable deaths, and the White House estimates that creating and spreading the technology would cost just $50 billion. But in what other industry would an investment with such a massive annual return not be funded by the industry itself? (And while $50 billion may sound like a big investment, it’s only about 2 percent of the health-care industry’s annual revenues.)

Technology is effective only when it’s properly applied. Since most physicians and health-care companies haven’t adopted electronic medical records on their own, what makes us think they will appropriately use all this new IT? Most of the benefits of the technology (record portability, a reduction in costly and dangerous clinical errors) would likely accrue to patients, not providers. In a consumer-facing industry, this alone would drive companies to make the investments to stay competitive. But of course, we patients aren’t the real customers; government funding of electronic records wouldn’t change that.

I hope that whatever reform is finally enacted this fall works—preventing people from slipping through the cracks, raising the quality standard of the health-care industry, and delivering all this at acceptable cost. But looking at the big picture, I fear it won’t. So I think we should at least begin to debate and think about larger reforms, and a different direction—if not for this round of reform, then for the next one. Politics is, of course, the art of the possible. If our health-care crisis does not abate, the possibilities for reform may expand beyond their current, tight limits.

A Way Forward

The most important single step we can take toward truly reforming our system is to move away from comprehensive health insurance as the single model for financing care. And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system. I believe if the government took on the goal of better supporting consumers—by bringing greater transparency and competition to the health-care industry, and by directly subsidizing those who can’t afford care—we’d find that consumers could buy much more of their care directly than we might initially think, and that over time we’d see better care and better service, at lower cost, as a result.

A more consumer-centered health-care system would not rely on a single form of financing for health-care purchases; it would make use of different sorts of financing for different elements of care—with routine care funded largely out of our incomes; major, predictable expenses (including much end-of-life care) funded by savings and credit; and massive, unpredictable expenses funded by insurance.

For years, a number of reformers have advocated a more “consumer-driven” care system—a term coined by the Harvard Business School professor Regina Herzlinger, who has written extensively on the subject. Many different steps could move us toward such a system. Here’s one approach that—although it may sound radical—makes sense to me.

First, we should replace our current web of employer- and government-based insurance with a single program of catastrophic insurance open to all Americans—indeed, all Americans should be required to buy it—with fixed premiums based solely on age. This program would be best run as a single national pool, without underwriting for specific risk factors, and would ultimately replace Medicare, Medicaid, and private insurance. All Americans would be insured against catastrophic illness, throughout their lives.

Proposals for true catastrophic insurance usually founder on the definition of catastrophe. So much of the amount we now spend is dedicated to problems that are considered catastrophic, the argument goes, that a separate catastrophic system is pointless. A typical catastrophic insurance policy today might cover any expenses above, say, $2,000. That threshold is far too low; ultimately, a threshold of $50,000 or more would be better. (Chronic conditions with expected annual costs above some lower threshold would also be covered.) We might consider other mechanisms to keep total costs down: the plan could be required to pay out no more in any year than its available premiums, for instance, with premium increases limited to the general rate of inflation. But the real key would be to restrict the coverage to true catastrophes—if this approach is to work, only a minority of us should ever be beneficiaries.

How would we pay for most of our health care? The same way we pay for everything else—out of our income and savings. Medicare itself is, in a sense, a form of forced savings, as is commercial insurance. In place of these programs and the premiums we now contribute to them, and along with catastrophic insurance, the government should create a new form of health savings account—a vehicle that has existed, though in imperfect form, since 2003. Every American should be required to maintain an HSA, and contribute a minimum percentage of post-tax income, subject to a floor and a cap in total dollar contributions. The income percentage required should rise over a working life, as wages and wealth typically do.

All noncatastrophic care should eventually be funded out of HSAs. But account-holders should be allowed to withdraw money for any purpose, without penalty, once the funds exceed a ceiling established for each age, and at death any remaining money should be disbursed through inheritance. Our current methods of health-care funding create a “use it or lose it” imperative. This new approach would ensure that families put aside funds for future expenses, but would not force them to spend the funds only on health care.

What about care that falls through the cracks—major expenses (an appendectomy, sports injury, or birth) that might exceed the current balance of someone’s HSA but are not catastrophic? These should be funded the same way we pay for most expensive purchases that confer long-term benefits: with credit. Americans should be able to borrow against their future contributions to their HSA to cover major health needs; the government could lend directly, or provide guidelines for private lending. Catastrophic coverage should apply with no deductible for young people, but as people age and save, they should pay a steadily increasing deductible from their HSA, unless the HSA has been exhausted. As a result, much end-of-life care would be paid through savings.

Anyone with whom I discuss this approach has the same question: How am I supposed to be able to afford health care in this system? Well, what if I gave you $1.77 million? Recall, that’s how much an insured 22-year-old at my company could expect to pay—and to have paid on his and his family’s behalf—over his lifetime, assuming health-care costs are tamed. Sure, most of that money doesn’t pass through your hands now. It’s hidden in company payments for premiums, or in Medicare taxes and premiums. But think about it: If you had access to those funds over your lifetime, wouldn’t you be able to afford your own care? And wouldn’t you consume health care differently if you and your family didn’t have to spend that money only on care?

For lower-income Americans who can’t fund all of their catastrophic premiums or minimum HSA contributions, the government should fill the gap—in some cases, providing all the funding. You don’t think we spend an absurd amount of money on health care? If we abolished Medicaid, we could spend the same money to make a roughly $3,000 HSA contribution and a $2,000 catastrophic-premium payment for 60 million Americans every year. That’s a $12,000 annual HSA plus catastrophic coverage for a low-income family of four. Do we really believe most of them wouldn’t be better off?

Some experts worry that requiring people to pay directly for routine care would cause some to put off regular checkups. So here’s a solution: the government could provide vouchers to all Americans for a free checkup every two years. If everyone participated, the annual cost would be about $30 billion—a small fraction of the government’s current spending on care.

Today, insurance covers almost all health-care expenditures. The few consumers who pay from their pockets are simply an afterthought for most providers. Imagine how things might change if more people were buying their health care the way they buy anything else. I’m certain that all the obfuscation over prices would vanish pretty quickly, and that we’d see an end to unreadable bills. And that physicians, who spend an enormous amount of time on insurance-related paperwork, would have more time for patients.

In fact, as a result of our fraying insurance system, you can already see some nascent features of a consumer-centered system. Since 2006, Wal-Mart has offered $4 prescriptions for a month’s supply of common generic medications. It has also been slowly rolling out retail clinics for routine care such as physicals, blood work, and treatment for common ailments like strep throat. Prices for each service are easily obtained; most are in the neighborhood of $50 to $80. Likewise, “concierge care,” or the “boutique” style of medical practice—in which physicians provide unlimited services and fast appointments in return for a fixed monthly or annual fee—is beginning to spread from the rich to the middle class. Qliance Medical Group, for instance, now operates clinics serving some 3,000 patients in the Seattle and Tacoma, Washington, areas, charging $49 to $79 a month for unlimited primary care, defined expansively.

It’s worth pausing over this last example. Many experts believe that the U.S. would get better health outcomes at lower cost if payment to providers were structured around the management of health or whole episodes of care, instead of through piecemeal fees. Medicare and private insurers have, to various degrees, moved toward (or at least experimented with) these sorts of payments, and are continuing to do so—but slowly, haltingly, and in the face of much obstruction by providers. But aren’t we likely to see just these sorts of payment mechanisms develop organically in a consumer-centered health-care system? For simplicity and predictability, many people will prefer to pay a fixed monthly or annual fee for primary or chronic care, and providers will move to serve that demand.

Likewise, what patient, when considering getting an artificial hip, would want to deal with a confusion of multiple bills from physicians, facilities, and physical therapists? Aren’t providers likely to organize themselves to provide a single price to the consumer for care and rehabilitation? And won’t that, in itself, put pressure on providers to work together as efficiently as possible, and to minimize the medical errors that would eat into their joint fee? I suspect we would see a rapid decline in the predominance of the fee-for-service model, making way for real innovation and choice in service plans and funding. And the payment system would not be set by fiat; it would remain responsive to treatment breakthroughs and changes in consumer demand.

Many consumers would be able to make many decisions, unaided, in such a system. But we’d also probably see the rise of health-care agents—paid by, and responsible to, the consumer—to help choose providers and to act as advocates during long and complex care episodes.

How else might the system change? Technological innovation—which is now almost completely insensitive to costs, and which often takes the form of slightly improved treatments for much higher prices—would begin to concern itself with value, not just quality. Many innovations might drive prices down, not up. Convenient, lower-cost specialty centers might proliferate. The need for unpaid indigent care would go away—everyone, recall, would have both catastrophic insurance and an HSA, funded entirely by the government when necessary—and with it much of the rationale for protecting hospitals against competition.

Of course, none of this would happen overnight. And the government has an essential role to play in arming consumers with good information. Congress should require maximum transparency on services, prices, and results (and some elements of the Obama administration’s reform plan would move the industry in this direction). We should establish a more comprehensive system of quality inspection of all providers, and publish all the findings. Safety and efficacy must remain the cornerstone of government licensing, but regulatory bias should favor competition and prevent incumbents from using red tape to forestall competition.

Moving from the system we’ve got now to the one I’ve outlined would be complicated, and would take a long time. Most of us have been paying into an insurance system for years, expecting that our future health-care bills would be paid; we haven’t been saving separately for these expenses. It would take a full generation to completely migrate from relying on Medicare to saving for late-life care; from Medicaid for the disadvantaged to catastrophic insurance and subsidized savings accounts. Such a transition would require the slow reduction of Medicare taxes, premiums, and benefit levels for those not yet eligible, and a corresponding slow ramp-up in HSAs. And the national catastrophic plan would need to start with much broader coverage and higher premiums than the ultimate goal, in order to fund the care needed today by our aging population. Nonetheless, the benefits of a consumer-centered approach—lower costs for better service—should have early and large dividends for all of us throughout the period of transition. The earlier we start, the less a transition will ultimately cost.

Many experts oppose the whole concept of a greater role for consumers in our health-care system. They worry that patients lack the necessary knowledge to be good consumers, that unscrupulous providers will take advantage of them, that they will overspend on low-benefit treatments and under-spend on high-benefit preventive care, and that such waste will leave some patients unable to afford highly beneficial care.

They are right, of course. Whatever replaces our current system will be flawed; that’s the nature of health care and, indeed, of all human institutions. Our current system features all of these problems already—as does the one the Obama reforms would create. Because health care is so complex and because each individual has a unique health profile, no system can be perfect.

I believe my proposed approach passes two meaningful tests. It will do a better job than our current system of controlling prices, allocating resources, expanding access, and safeguarding quality. And it will do a better job than a more government-driven approach of harnessing medicine’s dynamism to develop and spread the new knowledge, technologies, and techniques that improve the quality of life. We won’t be perfect consumers, but we’re more likely than large bureaucracies to encourage better medicine over time.

All of the health-care interest groups—hospitals, insurance companies, professional groups, pharmaceuticals, device manufacturers, even advocates for the poor—have a major stake in the current system. Overturning it would favor only the 300 million of us who use the system and—whether we realize it or not—pay for it. Until we start asking the type of questions my father’s death inspired me to ask, until we demand the same price and quality accountability in health care that we demand in everything else, each new health-care reform will cost us more and serve us less.

$636,687.75

Ten days after my father’s death, the hospital sent my mother a copy of the bill for his five-week stay: $636,687.75. He was charged $11,590 per night for his ICU room; $7,407 per night for a semiprivate room before he was moved to the ICU; $145,432 for drugs; $41,696 for respiratory services. Even the most casual effort to compare these prices to marginal costs or to the costs of off-the-shelf components demonstrates the absurdity of these numbers, but why should my mother care? Her share of the bill was only $992; the balance, undoubtedly at some huge discount, was paid by Medicare.

Wasn’t this an extraordinary benefit, a windfall return on American citizenship? Or at least some small relief for a distraught widow?

Not really. You can feel grateful for the protection currently offered by Medicare (or by private insurance) only if you don’t realize how much you truly spend to fund this system over your lifetime, and if you believe you’re getting good care in return.

Would our health-care system be so outrageously expensive if each American family directly spent even half of that $1.77 million that it will contribute to health insurance and Medicare over a lifetime, instead of entrusting care to massive government and private intermediaries? Like its predecessors, the Obama administration treats additional government funding as a solution to unaffordable health care, rather than its cause. The current reform will likely expand our government’s already massive role in health-care decision-making—all just to continue the illusion that someone else is paying for our care.

But let’s forget about money for a moment. Aren’t we also likely to get worse care in any system where providers are more accountable to insurance companies and government agencies than to us?

Before we further remove ourselves as direct consumers of health care—with all of our beneficial influence on quality, service, and price—let me ask you to consider one more question. Imagine my father’s hospital had to present the bill for his “care” not to a government bureaucracy, but to my grieving mother. Do you really believe that the hospital—forced to face the victim of its poor-quality service, forced to collect the bill from the real customer—wouldn’t have figured out how to make its doctors wash their hands?

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A Very Dangerous Game

Posted by steveneidman on June 16, 2009

Bullying’s Hidden Danger

by Tim Murphy

If you hear Jodee Blanco’s painful coming-of-age story and it reminds you of the Stephen King classic in which a teenage girl tortured by her peers finally wreaks revenge upon them, Blanco will beat you to the punch. “If you saw Carrie, then you’ll know what I went through,” she says.

“I was singled out from fifth-grade through the end of high school,” says the husky-voiced Blanco, 45, who grew up outside of Chicago, and is the author of Please Stop Laughing at Me, a memoir of being bullied. “I was very vocal, very verbal, and very artsy.”

For that, she says, she suffered a litany of miseries: Some popular girls invited themselves over to her place for a sleepover, and when she finally fell asleep, doused her with ketchup, mustard, and makeup. Because she volunteered with kids with Down Syndrome and defended them against other kids’ taunts, her shoes were thrown in the toilet with a note that said, “Everyone hates you, retard lover—go to another school.” The abuse continued right through senior year in high school, she says, when a guy whom she thought was a friend (when they were alone, at any rate) wrote in her yearbook: “Fuck you, bitch, everybody hates you and always will.”

By her junior year in high school, she couldn’t take it anymore. In front of her mother and grandfather in the kitchen, she says, she pulled a butcher knife, threatened to kill everyone in her school, then cut her own face before her family wrested the knife away from her and took her to the emergency room. A barrage of psychiatric evaluations and medications followed. “Everybody had an answer,” she says, “but back then, nobody understood bullying. They just didn’t get it.”

Since then, a growing body of research has linked being bullied to such later disorders as emotional trouble, depression, and post-traumatic stress disorder, which Blanco says she currently experiences due to being bullied. But now, a new study from Britain suggests that bullying may have even more dire psychiatric effects. Researchers from the University of Warwick in Coventry, England, followed nearly 6,500 children from before birth until age 13. They found that those who were bullied by peers between the ages of 8 and 10 were twice as likely to show signs of psychosis—such as visual and auditory hallucinations, delusions, and disordered thinking—by adolescence. Those who’d been severely or chronically bullied were more than four times as likely.

Dieter Wolke, one of the researchers, says the study is the first to follow the effects of bullying going forward in real-time, rather than relying on the childhood memories of mentally ill adults. The study is also remarkable, he says, because it found a strong correlation between bullying and psychotic symptoms, even when it took into account a family predisposition toward schizophrenia or bipolar disorder, in which such symptoms often emerge. “All current theories focus very much on predicting neurological or genetic factors in predicting psychosis,” he says, “but this may actually show how potent social factors can be.”

The findings come as no surprise to Blanco, who now tours schools nationwide to present her seminar, It’s Not Just Joking Around, an autobiographical reenactment of her years being bullied. “My message to kids is just that,” she says. “That it’s not just joking around. You damage each other for life.”

To be clear, Wolke and his colleagues are not saying that bullying alone can cause schizophrenia. They theorize, however, that it may bring out the disease’s symptoms early in young people who are genetically predisposed to it. They also theorize that the psychotic symptoms may be the effects of the brain “rewiring” itself when a person is put under chronic, heavy stress. They will be following the study’s young people into adulthood, which may continue to yield more clues.

Also striking about the study, according to Wolke, is that it found no difference between direct bullying—physical and/or verbal abuse—and more subtle bullying, such as social exclusion or ostracization. Both forms, if severe and sustained, were linked to psychotic symptoms. That, too, doesn’t surprise Blanco. “Bullying isn’t just the mean things you do,” she says. “It’s all the nice things you never do. That can do more damage.”

The study adds to the growing evidence that bullying-prevention programs are needed in schools and communities, says Wolke. The programs that show the most success so far, he says, are “whole school” programs that address the issue on many levels—calling schoolwide conferences, having students do role-playing exercises and fill out questionnaires, and training teachers to better spot and intervene in bullying episodes. Peer-counseling programs, which pair children with older peers to serve as their protectors, have also shown some success, Wolke says.

An array of programs have emerged in recent years in the U.S., driven partly by new national networks of parents, teachers, and bullying survivors, such as the group Bully Police. Blanco argues that the most effective programs are ones like hers, where adult survivors of bullying tell young people how it damaged them later in life. “It’s not about just hanging up a poster in the hallway that says, ‘Don’t Be a Bully,’” she says. Parents whose kids are bullied and ostracized should look even just “one town away,” she says, to find their children an alternate after-school activity or social group that they can derive hope from, she says.

Years later, she says, the bullying she experienced still takes its toll on her, even though her life’s work is now stopping the same thing from happening to other children. “When I went to high schools to do appearances, I would think it was 1980 again and would stand in the hallway, shaking. I’d take out my checkbook and look at the dates remind myself it was now, not then.” And she’s found another coping mechanism: She’s since reached out to, and befriended, many of the people she said bullied her the worst back in childhood. They say they had no idea they were doing such damage, she says. “When things got really bad” with her post-traumatic stress disorder, she says, “I would call one of them and say, ‘Tell me you don’t hate me. Tell me you’re not going to hurt me anymore.’”

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The REAL Key to Happiness

Posted by steveneidman on June 9, 2009

What Makes Us Happy?

by Joshua Wolf Shenk

Case No. 218

How’s this for the good life? You’re rich, and you made the dough yourself. You’re well into your 80s, and have spent hardly a day in the hospital. Your wife had a cancer scare, but she’s recovered and by your side, just as she’s been for more than 60 years. Asked to rate the marriage on a#FF0000 scale of 1 to 9, where 1 is perfectly miserable and 9 is perfectly happy, you circle the highest number. You’ve got two good kids, grandkids too. A survey asks you: “If you had your life to live over again, what problem, if any, would you have sought help for and to whom would you have gone?” “Probably I am fooling myself,” you write, “but I don’t think I would want to change anything.” If only we could take what you’ve done, reduce it to a set of rules, and apply it systematically.

Right?

Case No. 47

You literally fell down drunk and died. Not quite what the study had in mind.

Last fall, I spent about a month in the file room of the Harvard Study of Adult Development, hoping to learn the secrets of the good life. The project is one of the longest-running—and probably the most exhaustive—longitudinal studies of mental and physical well-being in history. Begun in 1937 as a study of healthy, well-adjusted Harvard sophomores (all male), it has followed its subjects for more than 70 years.

From their days of bull sessions in Cambridge to their active duty in World War II, through marriages and divorces, professional advancement and collapse—and now well into retirement—the men have submitted to regular medical exams, taken psychological tests, returned questionnaires, and sat for interviews. The files holding the data are as thick as unabridged dictionaries. They sit in a wall of locked cabinets in an office suite behind Fenway Park in Boston, in a plain room with beige carpeting and fluorescent lights that is littered with the detritus of many decades of social-scientific inquiry: a pile of enormous spreadsheet data books; a 1970s-era typewriter; a Macintosh PowerBook, circa 1993. All that’s missing are the IBM punch cards used to analyze the data in the early days.

For 42 years, the psychiatrist George Vaillant has been the chief curator of these lives, the chief investigator of their experiences, and the chief analyst of their lessons. His own life has been so woven into the study—and the study has become such a creature of his mind—that neither can be understood without the other. As Vaillant nears retirement (he’s now 74), and the study survivors approach death—the roughly half still living are in their late 80s—it’s a good time to examine both, and to do so, I was granted unprecedented access to case files ordinarily restricted to researchers.

As a young man, Vaillant fell in love with the longitudinal method of research, which tracks relatively small samples over long periods of time (as in Michael Apted’s Seven Up!documentaries). In 1961, as a psychiatric resident at the Massachusetts Mental Health Center, Vaillant found himself intrigued by two patients with manic depression who had 25 years earlier been diagnosed as incurable schizophrenics. Vaillant asked around for other cases of remitted schizophrenia and pulled their charts. “These records hadn’t been assembled to do research,” Vaillant told me recently, “but it was contemporary, real-time information, with none of the errors you get from memory or the distortions you get when you narrate history from the vantage of the present.” In 1967, after similar work following up on heroin addicts, he discovered the Harvard Study, and his jaw dropped. “To be able to study lives in such depth, over so many decades,” he said, “it was like looking through the Mount Palomar telescope,” then the most powerful in the world. Soon after he began to work with the material, he found himself talking about the project to his psychoanalyst. Showing him the key that opened the study cabinets, Vaillant said, “I have the key to Fort Knox.”

Such bravado had defined the study from the start. Arlie Bock—a brusque, no-nonsense physician who grew up in Iowa and took over the health services at Harvard University in the 1930s—conceived the project with his patron, the department-store magnate W. T. Grant. Writing in September 1938, Bock declared that medical research paid too much attention to sick people; that dividing the body up into symptoms and diseases—and viewing it through the lenses of a hundred micro-specialties—could never shed light on the urgent question of how, on the whole, to live well. His study would draw on undergraduates who could “paddle their own canoe,” Bock said, and it would “attempt to analyze the forces that have produced normal young men.” He defined normal as “that combination of sentiments and physiological factors which in toto is commonly interpreted as successful living.”

Bock assembled a team that spanned medicine, physiology, anthropology, psychiatry, psychology, and social work, and was advised by such luminaries as the psychiatrist Adolf Meyer and the psychologist Henry Murray. Combing through health data, academic records, and recommendations from the Harvard dean, they chose 268 students—mostly from the classes of 1942, ’43, and ’44—and measured them from every conceivable angle and with every available scientific tool.

Exhaustive medical exams noted everything from major organ function, to the measure of lactic acid after five minutes on a treadmill, to the size of the “lip seam” and the hanging length of the scrotum. Using a new test called the electroencephalograph, the study measured the electrical activity in the brain, and sought to deduce character from the squiggles. During a home visit, a social worker took not only a boy’s history—when he stopped wetting his bed, how he learned about sex—but also extensive medical and social histories on his parents and extended family. The boys interpreted Rorschach inkblots, submitted handwriting samples for analysis, and talked extensively with psychiatrists. They stripped naked so that every dimension of their bodies could be measured for “anthropometric” analysis, a kind of whole-body phrenology based on the premise that stock character types could be seen from body proportions.

Inveighing against medicine’s tendency to think small and specialized, Bock made big promises. He told the Harvard Crimson in 1942 that his study of successful men was pitched at easing “the disharmony of the world at large.” One early Grant Study document compared its prospects to the accomplishments of Socrates, Galileo, and Pasteur. But in fact the study staff remained bound by their respective disciplines and by the kinds of narrow topics that yield academic journal papers. Titles from the study’s early years included “Resting-Pulse and Blood-Pressure Values in Relation to Physical Fitness in Young Men”; “Instruction Time in Certain Multiple Choice Tests”; and “Notes on Usage of Male Personal Names.” Perhaps the height of the study’s usefulness in its early days was to lend its methods to the military, for officer selection in World War II.

Most longitudinal studies die on the vine because funders expect results quickly. W. T. Grant was no exception. He held on for about a decade—allowing the staff to keep sending detailed annual questionnaires to the men, hold regular case conferences, and publish a flurry of papers and several books—before he stopped sending checks. By the late 1940s, the Rockefeller Foundation took an interest, funding a research anthropologist named Margaret Lantis, who visited every man she could track down (which was all but a few). But by the mid-1950s, the study was on life support. The staff, including Clark Heath, who had managed the study for Bock, scattered, and the project fell into the care of a lone Harvard Health Services psychologist, Charles McArthur. He kept it limping along—surveys dwindled to once every two years—in part by asking questions about smoking habits and cigarette-brand preferences, a nod to a new study patron, Philip Morris. One survey asked, “If you never smoked, why didn’t you?”

It was a far cry from Galileo.

But as Vaillant points out, longitudinal studies, like wines, improve with age. And as the Grant Study men entered middle age—they spent their 40s in the 1960s—many achieved dramatic success. Four members of the sample ran for the U.S. Senate. One served in a presidential Cabinet, and one was president. There was a best-selling novelist (not, Vaillant has revealed, Norman Mailer, Harvard class of ’43). But hidden amid the shimmering successes were darker hues. As early as 1948, 20 members of the group displayed severe psychiatric difficulties. By age 50, almost a third of the men had at one time or another met Vaillant’s criteria for mental illness. Underneath the tweed jackets of these Harvard elites beat troubled hearts. Arlie Bock didn’t get it. “They were normal when I picked them,” he told Vaillant in the 1960s. “It must have been the psychiatrists who screwed them up.”

Case No. 141

What happened to you?

You grew up in a kind of fairy tale, in a big-city brownstone with 11 rooms and three baths. Your father practiced medicine and made a mint. When you were a college sophomore, you described him as thoughtful, funny, and patient. “Once in awhile his children get his goat,” you wrote, “but he never gets sore without a cause.” Your mother painted and served on prominent boards. You called her “artistic” and civic-minded.

As a child, you played all the sports, were good to your two sisters, and loved church. You and some other boys from Sunday school—it met at your house—used to study the families in your neighborhood, choosing one every year to present with Christmas baskets. When the garbageman’s wife found out you had polio, she cried. But you recovered fully, that was your way. “I could discover no problems of importance,” the study’s social worker concluded after seeing your family. “The atmosphere of the home is one of happiness and harmony.”

At Harvard, you continued to shine. “Perhaps more than any other boy who has been in the Grant Study,” the staff noted about you, “the following participant exemplifies the qualities of a superior personality: stability, intelligence, good judgment, health, high purpose, and ideals.” Basically, they were in a swoon. They described you as especially likely to achieve “both external and internal satisfactions.” And you seemed well on your way. After a stint in the Air Force—“the whole thing was like a game,” you said—you studied for work in a helping profession. “Our lives are like the talents in the parable of the three stewards,” you wrote. “It is something that has been given to us for the time being and we have the opportunity and privilege of doing our best with this precious gift.”

And then what happened? You married, and took a posting overseas. You started smoking and drinking. In 1951—you were 31—you wrote, “I think the most important element that has emerged in my own psychic picture is a fuller realization of my own hostilities. In early years I used to pride myself on not having any. This was probably because they were too deeply buried and I unwilling and afraid to face them.” By your mid-30s, you had basically dropped out of sight. You stopped returning questionnaires. “Please, please … let us hear from you,” Dr. Vaillant wrote you in 1967. You wrote to say you’d come see him in Cambridge, and that you’d return the last survey, but the next thing the study heard of you, you had died of a sudden disease.

Dr. Vaillant tracked down your therapist. You seemed unable to grow up, the therapist said. You had an affair with a girl he considered psychotic. You looked steadily more disheveled. You had come to see your father as overpowering and distant, your mother as overbearing. She made you feel like a black sheep in your illustrious family. Your parents had split up, it turns out.

In your last days, you “could not settle down,” a friend told Dr. Vaillant. You “just sort of wandered,” sometimes offering ad hoc therapy groups, often sitting in peace protests. You broke out spontaneously into Greek and Latin poetry. You lived on a houseboat. You smoked dope. But you still had a beautiful sense of humor. “One of the most perplexing and charming people I have ever met in my life,” your friend said. Your obituary made you sound like a hell of a man—a war hero, a peace activist, a baseball fan.

In all Vaillant’s literature—and, by agreement, in this essay, too—the Grant Study men remain anonymous. (Even the numbers on the case studies have been changed.) A handful have publicly identified themselves—including Ben Bradlee, the longtime editor of The Washington Post, who opened his memoir, A Good Life, with his first trip to the study office. John F. Kennedy was a Grant Study man, too, though his files were long ago withdrawn from the study office and sealed until 2040. Ironically, it was the notation of that seal in the archive that allowed me to confirm JFK’s involvement, which has not been recognized publicly before now.

Of course, Kennedy—the heir to ruthless, ambitious privilege; the philanderer of “Camelot”; the paragon of casual wit and physical vigor who, backstage, suffered from debilitating illness—is no one’s idea of “normal.” And that’s the point. The study began in the spirit of laying lives out on a microscope slide. But it turned out that the lives were too big, too weird, too full of subtleties and contradictions to fit any easy conception of “successful living.” Arlie Bock had gone looking for binary conclusions—yeses and nos, dos and don’ts. But the enduring lessons would be paradoxical, not only on the substance of the men’s lives (the most inspiring triumphs were often studies in hardship) but also with respect to method: if it was to come to life, this cleaver-sharp science project would need the rounding influence of storytelling.

In George Vaillant, the Grant Study found its storyteller, and in the Grant Study, Vaillant found a set of data, and a series of texts, suited to his peculiar gifts. A tall man, with a gravelly voice, steel-gray hair, and eyes that can radiate great joy and deep sadness, Vaillant blends the regal bearing of his old-money ancestors, the emotional directness of his psychiatric colleagues, and a genial absentmindedness. (A colleague recalls one day in the 1980s when Vaillant came to the office in his slippers.)

As with many of the men he came to study, Vaillant’s gifts and talents were shaped by his needs and pains. Born in 1934, Vaillant grew up in what he described to me as “blessed circumstances”—living “during the Great Depression with a nurse, a maid, and a cook, but without anybody having so much money that you stared in dismay at the newspapers” as stock prices sagged. And his parents had a storybook romance. They met in Mexico City, where she was the daughter of a prominent expatriate American banker and he was a hotshot archaeologist working on pre-Columbian Aztec digs. When George was 2, he says, his father “gave up being Indiana Jones and became a suit,” first as a curator at the American Museum of Natural History in New York City and then as the director of the University Museum at the University of Pennsylvania in Philadelphia. He was an accomplished man who, his son says, showed little trace of doubt or depression. But one Sunday afternoon in 1945, at home in Devon, Pennsylvania, George Clapp Vaillant, then 44, went out into the yard after a nap. His wife found him by the pool, a revolver next to him and a fatal wound through the mouth. His elder son and namesake, the last to see his father alive, was 10 years old.

Immediately, a curtain of silence fell around the tragedy. “In WASP fashion,” Vaillant says, “it was handled with ‘Let’s get this put away as quickly as possible.’” His mother, Suzannah Beck Vaillant, picked up the children and took them to Arizona. “We never saw our house again,” says Henry Vaillant, George’s younger brother. “We never attended the memorial service. It was just kind of a complete cutoff.”

A few years later, their father’s 25th-reunion book, hardbound in red cloth, arrived in the mail from Harvard College. George spent days with it, spellbound by the photographs and words that showed college students morphing, over the course of a few paragraphs, into 47-year-olds. The seed of interest in longitudinal research had been planted; it germinated decades later in Vaillant’s psychiatric residency and then in the ultimate vein of data he discovered at Harvard. It was 1967, and the Grant Study men were beginning to return for their 25th college reunions. Vaillant was 33. He would spend the rest of his career—and expects to spend the rest of his life—following these men.

The range of his training and the complexity of his own character proved to be crucial to his research. After Harvard College (where he wrote for the Lampoon, the humor magazine, and studied history and literature), Harvard Medical School, and a residency at the Massachusetts Mental Health Center, Vaillant studied at the Boston Psychoanalytic Institute, which he calls a “temple” to Freud’s ideas. He learned the orthodoxy, which included a literary approach to human lives, bringing theory to bear through deep reading of individual cases. But he also had training in the rigors of data-driven experimental science, including a two-year fellowship at a Skinnerian laboratory, where he studied neurotransmitter levels in pigeons and monkeys. There he learned to use the behaviorist B. F. Skinner’s “cumulative behavioral recorder,” which collapses behaviors across minutes, hours, or days onto a chart to be inspected in a single sitting.

The undertones of psychoanalysis are tragic; Freud dismissed the very idea of “normality” as “an ideal fiction” and famously remarked that he hoped to transform “hysterical misery into common unhappiness.” The spirit of modern social science, by contrast, draws on a brash optimism that the secrets to life can be laid bare. Vaillant is an optimist marinated in tragedy, not just in his life experience, but in his taste. Above his desk hangs a letter from a group of his medical residents to their successors, advising them to prepare for Vaillant’s “obscure literary references” by reading Tennessee Williams’s The Glass Menagerie, Arthur Miller’s Death of a Salesman, and Henrik Ibsen’s A Doll’s House. Vaillant loves Dostoyevsky and Tolstoy, too, and the cartoons of the dark humorist Charles Addams, like the one where several Christmas carolers sing merrily at the Addams family doorstep, while Morticia, Lurch, and Gomez stand on the roof, ready to tip a vat of hot oil on their heads. When his children were small, Vaillant would read them a poem about a tribe of happy-go-lucky bears, who lived in a kind of Eden until a tribe of mangier, smarter bears came along and enslaved them. “I would weep at this story,” remembers his daughter Anne Vaillant. “Dad thought it was funny, and I think somehow it was helpful to him that I had such feelings about it. There was this sort of, ‘This is the way life is.’”

Yet, even as he takes pleasure in poking holes in an innocent idealism, Vaillant says his hopeful temperament is best summed up by the story of a father who on Christmas Eve puts into one son’s stocking a fine gold watch, and into another son’s, a pile of horse manure. The next morning, the first boy comes to his father and says glumly, “Dad, I just don’t know what I’ll do with this watch. It’s so fragile. It could break.” The other boy runs to him and says, “Daddy! Daddy! Santa left me a pony, if only I can just find it!”

The story gets to the heart of Vaillant’s angle on the Grant Study. His central question is not how much or how little trouble these men met, but rather precisely how—and to what effect—they responded to that trouble. His main interpretive lens has been the psychoanalytic metaphor of “adaptations,” or unconscious responses to pain, conflict, or uncertainty. Formalized by Anna Freud on the basis of her father’s work, adaptations (also called “defense mechanisms”) are unconscious thoughts and behaviors that you could say either shape or distort—depending on whether you approve or disapprove—a person’s reality.

Vaillant explains defenses as the mental equivalent of a basic biological process. When we cut ourselves, for example, our blood clots—a swift and involuntary response that maintains homeostasis. Similarly, when we encounter a challenge large or small—a mother’s death or a broken shoelace—our defenses float us through the emotional swamp. And just as clotting can save us from bleeding to death—or plug a coronary artery and lead to a heart attack—defenses can spell our redemption or ruin. Vaillant’s taxonomy ranks defenses from worst to best, in four categories.

At the bottom of the pile are the unhealthiest, or “psychotic,” adaptations—like paranoia, hallucination, or megalomania—which, while they can serve to make reality tolerable for the person employing them, seem crazy to anyone else. One level up are the “immature” adaptations, which include acting out, passive aggression, hypochondria, projection, and fantasy. These aren’t as isolating as psychotic adaptations, but they impede intimacy. “Neurotic” defenses are common in “normal” people. These include intellectualization (mutating the primal stuff of life into objects of formal thought); dissociation (intense, often brief, removal from one’s feelings); and repression, which, Vaillant says, can involve “seemingly inexplicable naïveté, memory lapse, or failure to acknowledge input from a selected sense organ.” The healthiest, or “mature,” adaptations include altruism, humor, anticipation (looking ahead and planning for future discomfort), suppression (a conscious decision to postpone attention to an impulse or conflict, to be addressed in good time), and sublimation (finding outlets for feelings, like putting aggression into sport, or lust into courtship).

In contrast to Anna Freud, who located the origins of defenses in the sexual conflicts of a child, Vaillant sees adaptations as arising organically from the pain of experience and playing out through the whole lifespan. Take his comparison of two Grant Study men, whom he named “David Goodhart” and “Carlton Tarrytown” in his first book on the study, Adaptation to Life, published in 1977. Both men grew up fearful and lonely. Goodhart was raised in a blue-collar family, had a bigoted, alcoholic father, and a mother he described as “very nervous, irritable, anxious, and a worrier.” Tarrytown was richer, and was raised in a wealthy suburb, but he also had an alcoholic father, and his mother was so depressed that he feared she would commit suicide. Goodhart went on to become a national leader on civil-rights issues—a master, Vaillant argued, of the “mature” defenses of sublimation and altruism. By his late 40s, staff researchers using independent ratings put Goodhart in the top fifth of the Grant Study in psychological adjustment. Tarrytown, meanwhile, was in the bottom fifth. A doctor who left a regular practice to work for the state, a three-time divorcé who anesthetized his pain with alcohol and sedatives, Tarrytown was, Vaillant said, a user of dissociation and projection—“neurotic” and “immature” defenses, respectively. After a relapse into drug abuse, Tarrytown killed himself at 53. Goodhart lived to 70. Though Vaillant says that the “dashing major” of midlife became a stolid and portly brigadier general, Goodhart’s obituaries still celebrated a hero of civil rights.

Most psychology preoccupies itself with mapping the heavens of health in sharp contrast to the underworld of illness. “Social anxiety disorder” is distinguished from shyness. Depression is defined as errors in cognition. Vaillant’s work, in contrast, creates a refreshing conversation about health and illness as weather patterns in a common space. “Much of what is labeled mental illness,” Vaillant writes, “simply reflects our ‘unwise’ deployment of defense mechanisms. If we use defenses well, we are deemed mentally healthy, conscientious, funny, creative, and altruistic. If we use them badly, the psychiatrist diagnoses us ill, our neighbors label us unpleasant, and society brands us immoral.”

This perspective is shaped by a long-term view. Whereas clinicians focus on treating a problem at any given time, Vaillant is more like a biographer, looking to make sense of a whole life—or, to take an even broader view, like an anthropologist or naturalist looking to capture an era. The good news, he argues, is that diseases—and people, too—have a “natural history.” After all, many of the “psychotic” adaptations are common in toddlers, and the “immature” adaptations are essential in later childhood, and they often fade with maturity. As adolescents, the Grant Study men were twice as likely to use immature defenses as mature ones, but in middle life they were four times as likely to use mature defenses—and the progress continued into old age. When they were between 50 and 75, Vaillant found, altruism and humor grew more prevalent, while all the immature defenses grew more rare.

This means that a glimpse of any one moment in a life can be deeply misleading. A man at 20 who appears the model of altruism may turn out to be a kind of emotional prodigy—or he may be ducking the kind of engagement with reality that his peers are both moving toward and defending against. And, on the other extreme, a man at 20 who appears impossibly wounded may turn out to be gestating toward maturity.

Such was the case, Vaillant argues, with “Dr. Godfrey Minot Camille,” a poetic and troubled young man who spent so much time at the Harvard infirmary complaining of vague symptoms that a college physician declared, “This boy is becoming a regular psychoneurotic.” He’d grown up in a frigid environment—he ate his meals alone until age 6—and spoke of his desolation with heartbreaking clarity. A member of the study staff advised him: “When you come to the end of your rope, tie a knot and hold on.” He replied: “But the knot was tied so long ago, and I have been hanging on tight for such a long time.” After graduating from medical school, he attempted suicide.

With the help of psychotherapy and with the passage of time, his hypochondria eased and he began to show “displacement,” the strategy of shifting preoccupations from a painful source to more neutral ground. When his sister died, he sent her autopsy report to the Grant Study office, with a cool note saying that he expected it would be “an item of news.” He reported another family death this way: “I received an inheritance from my mother.”

For Camille, such detached neutrality seemed to herald progress. At 35, he spent 14 months in a hospital for an infection and had what he described as a spiritual awakening. “Someone with a capital ‘S’ cared about me,” he wrote. Afterward, he bloomed as a psychiatrist, channeling his own needs into service. He said he liked the “distant closeness” of psychotherapy—and liked getting paid for it. As a child, he had fantasized about being a minister or physician. “Finally, at age forty, wish became behavior,” Vaillant wrote.

In his 2002 book, Aging Well, Vaillant returned to this man’s story, this time calling him “Ted Merton” to emphasize his spiritual development. (The men in Vaillant’s books always have florid pseudonyms—Horace Lamb, Frederick Lion, Bill Loman, etc.) In several vignettes in the book, Vaillant presents Merton as an exemplar of how mature adaptations are a real-life alchemy, a way of turning the dross of emotional crises, pain, and deprivation into the gold of human connection, accomplishment, and creativity. “Such mechanisms are analogous to the involuntary grace by which an oyster, coping with an irritating grain of sand, creates a pearl,” he writes. “Humans, too, when confronted with irritants, engage in unconscious but often creative behavior.”

But “creative” doesn’t equate to ease. At ages 55 and 60, Merton had severe depressions. In the first instance he was hospitalized. The second instance coincided with his second divorce, and “he lost not only his wife, his savings, and his job, but even his network of professional colleagues.” Going forth into the breach of life can deepen meaning, but also deepen wounds.

Case No. 158

An attractive, amiable boy from a working-class background, you struck the study staff as happy, stable, and sociable. “My general impression is that this boy will be normal and well-adjusted—rather dynamic and positive,” the psychiatrist reported.

After college, you got an advanced degree and began to climb the rungs in your profession. You married a terrific girl, and you two played piano together for fun. You eventually had five kids. Asked about your work in education, you said, “What I am doing is not work; it is fun. I know what real work is like.” Asked at age 25 whether you had “any personal problems or emotional conflicts (including sexual),” you answered, “No … As Plato or some of your psychiatrists might say, I am at present just ‘riding the wave.’” You come across in your files as smart, sensible, and hard-working. “This man has always kept a pleasant face turned toward the world,” Dr. Heath noted after a visit from you in 1949. From your questionnaire that year, he got “a hint … that everything has not been satisfactory” at your job. But you had no complaints. After interviewing you at your 25th reunion, Dr. Vaillant described you as a “solid guy.”

Two years later, at 49, you were running a major institution. The strain showed immediately. Asked for a brief job description, you wrote: “RESPONSIBLE (BLAMED) FOR EVERYTHING.” You added, “No matter what I do … I am wrong … We are just ducks in a shooting gallery. Any duck will do.” On top of your job troubles, your mother had a stroke, and your wife developed cancer. Three years after you started the job, you resigned before you could be fired. You were 52, and you never worked again. (You kept afloat with income from stock in a company you’d done work for, and a pension.)

Seven years later, Dr. Vaillant spoke with you: “He continued to obsess … about his resignation,” he wrote. Four years later, you returned to the subject “in an obsessional way.” Four years later still: “It seemed as if all time had stopped” for you when you resigned. “At times I wondered if there was anybody home,” Dr. Vaillant wrote. Your first wife had died, and you treated your second wife “like a familiar old shoe,” he said.

But you called yourself happy. When you were 74, the questionnaire asked: “Have you ever felt so down in the dumps that nothing could cheer you up?” and gave the options “All of the time, some of the time, none of the time.” You circled “None of the time.” “Have you felt calm and peaceful?” You circled “All of the time.” Two years later, the study asked: “Many people hope to become wiser as they grow older. Would you give an example of a bit of wisdom you acquired and how you came by it?” You wrote that, after having polio and diphtheria in childhood, “I never gave up hope that I could compete again. Never expect you will fail. Don’t cry, if you do.”

What allows people to work, and love, as they grow old? By the time the Grant Study men had entered retirement, Vaillant, who had then been following them for a quarter century, had identified seven major factors that predict healthy aging, both physically and psychologically.

Employing mature adaptations was one. The others were education, stable marriage, not smoking, not abusing alcohol, some exercise, and healthy weight. Of the 106 Harvard men who had five or six of these factors in their favor at age 50, half ended up at 80 as what Vaillant called “happy-well” and only 7.5 percent as “sad-sick.” Meanwhile, of the men who had three or fewer of the health factors at age 50, none ended up “happy-well” at 80. Even if they had been in adequate physical shape at 50, the men who had three or fewer protective factors were three times as likely to be dead at 80 as those with four or more factors.

What factors don’t matter? Vaillant identified some surprises. Cholesterol levels at age 50 have nothing to do with health in old age. While social ease correlates highly with good psychosocial adjustment in college and early adulthood, its significance diminishes over time. The predictive importance of childhood temperament also diminishes over time: shy, anxious kids tend to do poorly in young adulthood, but by age 70, are just as likely as the outgoing kids to be “happy-well.” Vaillant sums up: “If you follow lives long enough, the risk factors for healthy life adjustment change. There is an age to watch your cholesterol and an age to ignore it.”

The study has yielded some additional subtle surprises. Regular exercise in college predicted late-life mental health better than it did physical health. And depression turned out to be a major drain on physical health: of the men who were diagnosed with depression by age 50, more than 70 percent had died or were chronically ill by 63. More broadly, pessimists seemed to suffer physically in comparison with optimists, perhaps because they’re less likely to connect with others or care for themselves.

More than 80 percent of the Grant Study men served in World War II, a fact that allowed Vaillant to study the effect of combat. The men who survived heavy fighting developed more chronic physical illnesses and died sooner than those who saw little or no combat, he found. And “severity of trauma is the best predictor of who is likely to develop PTSD.” (This may sound obvious, but it countered the claim that post-traumatic stress disorder was just the manifestation of preexisting troubles.) He also found that personality traits assigned by the psychiatrists in the initial interviews largely predicted who would become Democrats (descriptions included “sensitive,” “cultural,” and “introspective”) and Republicans (“pragmatic” and “organized”).

Again and again, Vaillant has returned to his major preoccupations. One is alcoholism, which he found is probably the horse, and not the cart, of pathology. “People often say, ‘That poor man. His wife left him and he’s taken to drink,’” Vaillant says. “But when you look closely, you see that he’s begun to drink, and that has helped drive his wife away.” The horrors of drink so preoccupied Vaillant that he devoted a stand-alone study to it: The Natural History of Alcoholism.

Vaillant’s other main interest is the power of relationships. “It is social aptitude,” he writes, “not intellectual brilliance or parental social class, that leads to successful aging.” Warm connections are necessary—and if not found in a mother or father, they can come from siblings, uncles, friends, mentors. The men’s relationships at age 47, he found, predicted late-life adjustment better than any other variable, except defenses. Good sibling relationships seem especially powerful: 93 percent of the men who were thriving at age 65 had been close to a brother or sister when younger. In an interview in the March 2008 newsletter to the Grant Study subjects, Vaillant was asked, “What have you learned from the Grant Study men?” Vaillant’s response: “That the only thing that really matters in life are your relationships to other people.”

The authority of these findings stems in large part from the rarity of the source. Few longitudinal studies survive in good health for whole lifetimes, because funding runs dry and the participants drift away. Vaillant managed, drawing on federal grants and private gifts, to finance surveys every two years, physicals every five years, and interviews every 15 years. The original study social worker, Lewise Gregory Davies, helped him goad the subjects to stay in touch, but it wasn’t a hard sell. The Grant Study men saw themselves as part of an elite club.

Vaillant also dramatically expanded his scope by taking over a defunct study of juvenile delinquents in inner-city Boston, run by the criminologists Sheldon and Eleanor Glueck. Launched in 1939, the study had a control group of nondelinquent boys who grew up in similar circumstances—children of poor, mostly foreign-born parents, about half of whom lived in a home without a tub or a shower. In the 1970s, Vaillant and his staff tracked down most of these nondelinquent boys—it took years—so that today the Harvard Study of Adult Development consists of two cohorts, the “Grant men” and the “Glueck men.” Vaillant also arranged to interview a group of women from the legendary Stanford Terman study, which in the 1920s began to follow a group of high-IQ kids in California.

In contrast to the Grant data, the Glueck study data suggested that industriousness in childhood—as indicated by such things as whether the boys had part-time jobs, took on chores, or joined school clubs or sports teams—predicted adult mental health better than any other factor, including family cohesion and warm maternal relationships. “What we do,” Vaillant concluded, “affects how we feel just as much as how we feel affects what we do.”

Interestingly, while the Glueck men were 50 percent more likely to become dependent on alcohol than the Harvard men, the ones who did were more than twice as likely to eventually get sober. “The difference has nothing to do with treatment, intelligence, self-care, or having something to lose,” Vaillant told Harvard magazine. “It does have to do with hitting bottom. Someone sleeping under the elevated-train tracks can at some point recognize that he’s an alcoholic, but the guy getting stewed every night at a private club may not.”

But Vaillant has largely played down the distinctions among the samples. For example, while he allows that, in mortality rates, the inner-city men at age 68 to 70 resembled the Terman and Harvard cohorts at 78 to 80, he says that most of the difference can be explained by less education, more obesity, and greater abuse of alcohol and cigarettes. “When these four variables were controlled,” he writes, “their much lower parental social class, IQ, and current income were not important.” But of course those are awfully significant variables to “control.” Vaillant points out that at age 70, the inner-city men who graduated from college were just as healthy as the Harvard men. But only 29 Glueck men did finish college—about 6 percent of the sample.

Having survived so many eras, the Grant Study is a palimpsest of the modern history of medicine and psychology, each respective era’s methods and preoccupations inscribed atop the preceding ones. In the 1930s, Arlie Bock’s work was influenced by the movement called “constitutional medicine,” which started as a holistic reaction to the minimalism engendered by Pasteur and germ theory. Charles McArthur, who picked up the study in the mid-1950s, was principally interested in matching people to suitable careers through psychological testing—perfect for the Man in the Gray Flannel Suit era. Vaillant’s use of statistical technique to justify psychoanalytic claims reflected the mode of late-1960s academic psychiatry, and his work caught on in the 1970s as part of a trend emphasizing adult development. Gail Sheehy’s 1976 best seller, Passages, drew on the Grant Study, as well as on the research of Daniel Levinson, who went on to publish The Seasons of a Man’s Life. (Sheehy was sued for alleged plagiarism by another academic, Roger Gould, who later published his own take on adult development in Transformations; Gould’s case was settled out of court.)

As Freud was displaced by biological psychiatry and cognitive psychology—and the massive data sets and double-blind trials that became the industry standard—Vaillant’s work risked obsolescence. But in the late 1990s, a tide called “positive psychology” came in, and lifted his boat. Driven by a savvy, brilliant psychologist at the University of Pennsylvania namedMartin Seligman, the movement to create a scientific study of the good life has spread wildly through academia and popular culture (dozens of books, a cover story in Time, attention from Oprah, etc.).

Vaillant became a kind of godfather to the field, and a champion of its message that psychology can improve ordinary lives, not just treat disease. But in many ways, his role in the movement is as provocateur. Last October, I watched him give a lecture to Seligman’s graduate students on the power of positive emotions—awe, love, compassion, gratitude, forgiveness, joy, hope, and trust (or faith). “The happiness books say, ‘Try happiness. You’ll like it a lot more than misery’—which is perfectly true,” he told them. But why, he asked, do people tell psychologists they’d cross the street to avoid someone who had given them a compliment the previous day?

In fact, Vaillant went on, positive emotions make us more vulnerable than negative ones. One reason is that they’re future-oriented. Fear and sadness have immediate payoffs—protecting us from attack or attracting resources at times of distress. Gratitude and joy, over time, will yield better health and deeper connections—but in the short term actually put us at risk. That’s because, while negative emotions tend to be insulating, positive emotions expose us to the common elements of rejection and heartbreak.

To illustrate his point, he told a story about one of his “prize” Grant Study men, a doctor and well-loved husband. “On his 70th birthday,” Vaillant said, “when he retired from the faculty of medicine, his wife got hold of his patient list and secretly wrote to many of his longest-running patients, ‘Would you write a letter of appreciation?’ And back came 100 single-spaced, desperately loving letters—often with pictures attached. And she put them in a lovely presentation box covered with Thai silk, and gave it to him.” Eight years later, Vaillant interviewed the man, who proudly pulled the box down from his shelf. “George, I don’t know what you’re going to make of this,” the man said, as he began to cry, “but I’ve never read it.” “It’s very hard,” Vaillant said, “for most of us to tolerate being loved.”

Vaillant brings a healthy dose of subtlety to a field that sometimes seems to glide past it. The bookstore shelves are lined with titles that have an almost messianic tone, as in Happier: Learn the Secrets to Daily Joy and Lasting Fulfillment. But what does it mean, really, to be happier? For 30 years, Denmark has topped international happiness surveys. But Danes are hardly a sanguine bunch. Ask an American how it’s going, and you will usually hear “Really good.” Ask a Dane, and you will hear “Det kunne være værre (It could be worse).” “Danes have consistently low (and indubitably realistic) expectations for the year to come,” a team of Danish scholars concluded. “Year after year they are pleasantly surprised to find that not everything is getting more rotten in the state of Denmark.”

Of course, happiness scientists have come up with all kinds of straightforward, and actionable, findings: that money does little to make us happier once our basic needs are met; that marriage and faith lead to happiness (or it could be that happy people are more likely to be married and spiritual); that temperamental “set points” for happiness—a predisposition to stay at a certain level of happiness—account for a large, but not overwhelming, percentage of our well-being. (Fifty percent, says Sonja Lyubomirsky in The How of Happiness. Circumstances account for 10 percent, and the other 40 percent is within our control.) But why do countries with the highest self-reports of subjective well-being also yield the most suicides? How is it that children are often found to be a source of “negative affect” (sadness, anger)—yet people identify children as their greatest source of pleasure?

The questions are unresolved, in large part because of method. The psychologist Ed Diener, at the University of Illinois, has helped lay the empirical foundation for positive psychology, drawing most recently on data from the Gallup World Poll, which interviewed a representative sample of 360,000 people from 145 countries. “You can say a lot of general things from these data that you could never say before,” Diener says. “But many of them are relatively shallow. People who go to church report more joy. But if you ask why, we don’t know. George has these small samples—and they’re Harvard men, my goodness, not so generalizable. Yet he has deep data, and he brings so many things together at once.”

Seligman describes Diener as the “engineer” of positive psychology, “trying to do better, more replicable, more transparent science.” Vaillant and his work, though, remind Seligman of the roots of psychology—the study of the soul. “To practice scientific psychology is to have as few premises as you can, to account for as much of the soul as you can get away with,” Seligman says. “Everyone in positive psychology who seeks to explain the mysteries of the psyche wants deeper stuff. George is the poet of this movement. He makes us aware that we’re yearning for deeper stuff.”

When Vaillant told me he was going to speak to Seligman’s class, he said his message would be from William Blake: “Joy and woe are woven fine.” Earlier in his career, he would use such occasions to demonstrate, with stories and data, the bright side of pain—how adaptations can allow us to turn dross into gold. Now he articulates the dark side of pleasure and connection—or, at least, the way that our most profound yearnings can arise from our most basic fears.

Case No. 218, continued

On first glance, you are the study’s exemplar. In Dr. Vaillant’s “decathlon” of mental health—10 measures, taken at various points between ages 18 and 80, including personality stability at ages 21 and 29, and social supports at 70—you have ranked in the top 10 of the Grant Study men the entire way through, one of only three men to have done so.

What’s your secret? Is it your steely resolve? After a major accident in college, you returned to campus in a back brace, but you looked healthy. You had a kind of emotional steel, too. When you were 13, your mother ran off with your father’s best friend. And though your parents reunited two years later, a pall of disquiet hung over your three-room apartment when the social worker came for her visit. But you said your parents’ divorce was “just like in the movies,” and that you someday “would like to have some marital difficulties” of your own.

After the war—during which you worked on a major weapons system—and graduate school, you married, and your bond with your wife only deepened over time. Indeed, while your mother remains a haunting presence in your surveys—eventually diagnosed with manic depression, she was often hospitalized and received many courses of shock therapy—the warmth of your relationship with your wife and kids, and fond memories of your maternal grandfather, seemed to sustain you.

Yet your file shows a quiet, but persistent, questioning about a path not taken. As a sophomore in college, you emphasized how much money you wanted to make, but also wondered whether you’d be better off in medicine. After the war, you said you were “too tense & high strung” and had less interest in money than before. At 33, you said, “If I had to do it all over again I am positive I would have gone into medicine—but it’s a little late.” At 44, you sold your business and talked about teaching high school. You regretted that (according to a study staff member’s notes) you’d “made no real contribution to humanity.” At 74, you said again that if you could do it over again, you would go into medicine. In fact, you said, your father had urged you to do it, to avoid the Army. “That annoyed me,” you said, and so you went another way.

There is something unreachable in your file. “Probably I am fooling myself,” you wrote in 1987, at age 63, “but I don’t think I would want to change anything.” How can we know if you’re fooling yourself? How can even you know? According to Dr. Vaillant’s model of adaptations, the very way we deal with reality is by distorting it—and we do this unconsciously. When we start pulling at this thread, an awfully big spool of thoughts and questions begins to unravel onto the floor.

You never seemed to pull the thread. When the study asked you to indicate “some of the fundamental beliefs, concepts, philosophy of life or articles of faith which help carry you along or tide you over rough spots,” you wrote: “Hard to answer since I am really not too introspective. However, I have an overriding sense (or philosophy) that it’s all a big nothing—or ‘chasing after wind’ as it says in Ecclesiastes & therefore, at least up to the present, nothing has caused me too much grief.”

Case No. 47, continued

You are the study’s antihero, its jester, its subversive philosopher. From the first pages of your file, you practically explode with personality. In the social worker’s office, you laughed uproariously, slapping your arm against your chair. He “seems to be thoroughly delighted with the family idiosyncrasies,” Lewise Gregory, the original staff social worker, wrote. “He has a delightful, spontaneous sense of humor … [a] bubbling, effervescent quality.” “My family considers it a great joke that I am a ‘normal boy,’” you wrote. “‘Good God!’”

You ducked the war, as a conscientious objector. “I’ve answered a great many questions,” you wrote in your 1946 survey. “Now I’d like to ask you people a couple of questions. By what standards of reason are you calling people ‘adjusted’ these days? Happy? Contented? Hopeful? If people have adjusted to a society that seems hell-bent on destroying itself in the next couple of decades, just what does that prove about the people?”

You got married young, and did odd jobs—including a stint as a guinea pig in a hospital study on shipwreck survival. You said that you were fascinated by the “nuts” on the psychiatric ward, and you wondered whether you could escape the “WASP cocoon.” You worked in public relations and had three kids.

You said you wanted to be a writer, but that looked like a distant dream. You started drinking. In college, you had said you were the life of the party without alcohol. By 1948, you were drinking sherry. In 1951, you reported that you regularly took a few drinks. By 1964, you wrote, “Really tie one on about twice a week,” and you continued, “Well, I eat too much, smoke too much, drink too much liquor and coffee, get too little exercise, and I’ve got to do something about all these things. “On the other hand,” you wrote, “I’ve never been more productive, and I’m a little wary of rocking the boat right now by going on a clean living kick … I’m about as adjusted and effective as the average Fine Upstanding Neurotic can hope to be.”

After a divorce, and a move across the country, and a second marriage—you left her for a mistress who later left you—you came out of the closet. And you began to publish and write full-time. The Grant Study got some of your best work. When a questionnaire asked what ideas carried you through rough spots, you wrote, “It’s important to care and to try, even tho the effects of one’s caring and trying may be absurd, futile, or so woven into the future as to be indetectable.” Asked what effect the Grant Study had on you, you wrote, “Just one more little token that I am God’s Elect. And I really don’t need any such tokens, thank you.”

In the early 1970s, Dr. Vaillant came to see you in your small apartment, with an old couch, an old-fashioned typewriter, a sink full of dishes, and a Harvard-insignia chair in the corner. Ever the conscientious objector, you asked for his definition of “normality.” You said you loved The Sorrow and the Pity and that, in the movie, the sort of men the Grant Study prized fought on the side of the Nazis, “whereas the kooks and the homosexuals were all in the resistance.” You told Dr. Vaillant he should read Joseph Heller on the unrelieved tragedy of conventionally successful businessmen.

Your “mental status was paradoxical,” Dr. Vaillant wrote in his notes. You were clearly depressed, he observed, and yet full of joy and vitality. “He could have been a resistance leader,” Dr. Vaillant wrote. “He really did seem free about himself.” Intrigued, and puzzled, he sent you a portion of his manuscript-in-progress, wanting your thoughts. “The data’s fantastic,” you replied. “The methodology you are using is highly sophisticated. But the end judgments, the final assessments, seem simplistic.

“I mean, I can imagine some poor bastard who’s fulfilled all your criteria for successful adaptation to life, … upon retirement to some aged enclave near Tampa just staring out over the ocean waiting for the next attack of chest pain, and wondering what he’s missed all his life What’s the difference between a guy who at his final conscious moments before death has a nostalgic grin on his face as if to say, ‘Boy, I sure squeezed that lemon’ and the other man who fights for every last breath in an effort to turn back time to some nagging unfinished business?”

You went on to a very productive career, and became an important figure in the gay-rights movement. You softened toward your parents and children, and made peace with your ex-wife. You took long walks. And you kept drinking. After a day in your “collar,” you said, you let the dog loose.

“If you had your life to live over again,” the study asked you in 1981, “what problem, if any, would you have sought help for and to whom would you have gone?” “I’ve come to believe that ‘help’ is for the most part useless and destructive,” you answered. “Can you imagine Arlie Bock—God bless his soul—trying to help me work out my problems? … Or Clark Heath? The poor old boys would have headed for the hills! The ‘helping professions’ are in general camp-followers of the dominant culture, just like the clergy, and the psychiatrists. (I except Freud and Vaillant.)”

Around this time, Dr. Vaillant wrote about you: “The debate continues in my mind, whether he is going to be the exception and be able to break all the rules of mental health and alcoholism or whether the Greek fates will destroy him. Only time will tell.” Dr. Vaillant urged you to go to AA. You died at age 64, when you fell down the stairs of your apartment building. The autopsy found high levels of alcohol in your blood.

In Adaptation to Life, where you appeared as “Alan Poe,” Vaillant had admired your altruism and sublimation, and your eloquence, but worried you were “stalked by death, suicide and skid row.” You had written in retort, “Of course, the prognosis of death is a pretty sure bet … Hell, I could be dead by the time you get this letter. But if I am, let it be published … that—especially in the last five years—‘I sure squeezed that lemon!’”

Can the good life be accounted for with a set of rules? Can we even say who has a “good life” in any broad way? At times, Vaillant wears his lab coat and lays out his findings matter-of-factly. (“As a means of uncovering truth,” he wrote in Adaptation to Life, “the experimental method is superior to intuition.”) More often, he speaks from a literary and philosophical perspective. (In the same chapter, he wrote of the men, “Their lives were too human for science, too beautiful for numbers, too sad for diagnosis and too immortal for bound journals.) In one of my early conversations with him, he described the study files as hundreds of Brothers Karamazovs. Later, after taking a stab at answering several Big Questions I had asked him—Do people change? What does the study teach us about the good life?—he said to me, “Why don’t you tell me when you have time to come up to Boston and read one of these Russian novels?”

Indeed, the lives themselves—dramatic, pathetic, inspiring, exhausting—resonate on a frequency that no data set could tune to. The physical material—wispy sheets from carbon copies; ink from fountain pens—has a texture. You can hear the men’s voices, not only in their answers, but in their silences, as they stride through time both personal (masturbation reports give way to reports on children; career plans give way to retirement plans) and historical (did they vote for Dewey or Truman?; “What do you think about today’s student protesters, drug users, hippies, etc.?”). Secrets come out. One man did not acknowledge to himself until he reached his late 70s that he was gay. With this level of intimacy and depth, the lives do become worthy of Tolstoy or Dostoyevsky.

George Vaillant has not been just the principal reader of these novels. To a large extent, he is the author. He framed most of the questions; he conducted most of the interviews, which exist, not in recordings or transcripts, but only in his notes and interpretations. To explain the study, I needed to understand him, and how the themes from his life circled back to inform his work (and vice versa).

Strenuous defenses, I came to see, are no mere academic theme for Vaillant, who has molded his life story like so much clay. Consider the story of his father’s suicide and his own delight in going through the 25th-reunion book as a 13-year-old. When I asked Vaillant if the experience of paging through the book had been tinged with sadness, he said, “It was fascinating,” and went on to describe his awe and wonder at longitudinal studies. If he were observing his own case, Vaillant himself would probably call this “reaction formation”—responding to anxiety (pain at grasping a father’s violent departure) with an opposite tendency (joy at watching men, quite like him, develop through time).

But Vaillant’s sister, Joanna Settle, described their father’s death as the “North Star” essential for navigating her brother’s story. Henry Vaillant, George’s brother, agreed. “Since that time,” he said, “it was as if George wanted to do two things. He wanted to surpass our father, and he also wanted to find out who our father was.”

Considering the Harvard study through the lens of Vaillant’s adaptations, one wonders whether he looked to do both at once. Henry Vaillant says that their father was depressed and drinking heavily at the time of his suicide; afterward, he says, his mother propagated the “heroic myth” that their father—who had worked for the U.S. Embassy in wartime Peru and, at the time of his death, was set to join the Office of War Information—was a war casualty, undone by the pressure. Does this help explain George Vaillant’s deep interest in alcoholism, and in the psychological impact of combat?

“I sometimes wondered if another motivation for the study of these lives,” says Henry Vaillant, was “to learn how to live his own life right. As if by interviewing all these very successful people, he would get the knack. And of course in many ways, he has the knack.”

Indeed, Vaillant’s work is widely read and cited; he travels the world speaking to adoring audiences (“the leisure of the theoried class,” he calls it); his colleagues and students marvel at his capacity for empathy and connection. “George sees the best in people,” Martin Seligman says, “and he brings out the best in people.”

I saw this firsthand in Vaillant’s work with H’Sien Hayward, a second-year doctoral student in psychology at Harvard with a penetrating analytical mind and a big heart. Hayward has been paraplegic and bound to a wheelchair since a car accident at 16. She studies “post-traumatic growth,” the surprising beneficial changes that many people experience after pain or injury. She approached Vaillant on a lark—she never thought someone so famous would have time to advise her. She was shocked, she told me, to see that he insisted on talking about her ideas—and about the pains and hopes that gave rise to them. “The only way to keep it is to give it away,” he told her, articulating and enacting the essence of altruism.

The experience, Hayward said, was “transformative.” Frustrated by academic politics when she came to work with him, she told me, “I felt like a little bird with a broken wing, and he lifted me back up and mended me and made me fall back in love with behavioral science—using science to understand humans and all of their complexity.” Hayward came to consider Vaillant as “the embodiment of healthy aging—mentally, emotionally, and everything. He’s the person we’d all hope to end up to be.”

But Vaillant’s closest friends and family tell a very different story, of a man plagued by distance and strife in his relationships. “George is someone who holds things in,” says the psychiatrist James Barrett Jr., his oldest friend. “I don’t think he has many confidants. I would call George someone who has a problem with intimacy.”

Nowhere has Vaillant been more powerful and articulate than in describing the importance of intimacy and love. And nowhere has he struggled more deeply in his life. He had four children with his first wife, whom he divorced in 1970 after 15 years of marriage. He quickly got married again, to a young woman he had met while speaking in Australia. She came to the United States to help raise Vaillant’s children, including an autistic son. She and Vaillant also had a child of their own. During this time, his daughter Anne says, “he was jet-setting around the world and she was holding down the roof at home.”

But in the early 1990s, Vaillant left his second wife for a colleague at the study. After five tumultuous years, he and his third wife split, and he returned (“with his tail between his legs,” his brother says) to his second wife.

This protracted drama stirred up resentments on all sides—in the women involved, for obvious reasons, but among Vaillant’s children, too. “There was a civil war in the family,” Anne Vaillant says, “and everyone suffered.” And although she says there has been some “détente,” four of Vaillant’s five children have gone long periods without speaking to him. Vaillant himself describes his family as akin to King Lear’s, and himself as “a disconnected, narcissistic father.” It struck me that the kingdom has more than an ordinary share of woes.

Vaillant’s own work provides an uncanny description of his strengths and struggles. “On the bright side,” he has written, “reaction formation allows us to care for someone else when we wish to be cared for ourselves.” But in intimate relationships, he continued, the defense “rarely leads to happiness for either party.”

Yet Vaillant seems largely unaware of the way his defenses apply to his own case—even though he is aware of being unaware; he regularly told me that he would not be a good source of information about his own life, because of distortion. The Harvard data illustrate this phenomenon well. In 1946, for example, 34 percent of the Grant Study men who had served in World War II reported having come under enemy fire, and 25 percent said they had killed an enemy. In 1988, the first number climbed to 40 percent—and the second fell to about 14 percent. “As is well known,” Vaillant concluded, “with the passage of years, old wars become more adventurous and less dangerous.”

Distortions can clearly serve a protective function. In a test involving a set of pictures, older people tend to remember fewer distressing images (like snakes) and more pleasant ones (like Ferris wheels) than younger people. By giving a profound shape to aging, this tendency can make for a softer, rounder old age, but also a deluded one. One brilliant woman from the Stanford Terman study had been pre-med in college; when she was 30, a vocational survey identified medicine as the field most suitable for her. But her ambitions were squashed by gender bias and the Great Depression, and she ended up a housewife. How, the study staff asked her at age 78, had she managed the gap between her potential and her achievement? “I never knew I had any potential,” she answered. Had she ever thought of being a doctor? Never, she said.

At age 50, one Grant Study man declared, “God is dead and man is very much alive and has a wonderful future.” He had stopped going to church, he said, when he arrived at Harvard. But as a sophomore, he had reported going to mass four times a week. When Vaillant sent this—and several similar vignettes—to the man for his approval to publish them, the man wrote back, “George, you must have sent these to the wrong person.” Vaillant writes, “He could not believe that his college persona could have ever been him. Maturation makes liars of us all.”

When we discussed his marriages, Vaillant asked me to report simply that he had been married to his present wife for 40 years, which struck me not as a calculated deception but as a deeply worn habit of thought. Indeed, a few years ago, Anne told me, her father was looking over pictures of her wedding, and came across a picture of his third wife. He stood there puzzled for a time, and then finally asked Anne: “Who is that woman?” “I began to worry that he’d begun to have Alzheimer’s,” Anne says. “But I actually don’t think it’s an organic thing. I think it’s self-protection.” This is what Vaillant calls “repression,” and he’s been using it for a long time. “When I was younger, he would forget everything,” Anne says. “It was almost like he had his brain erased.”

Vaillant has passed along day-to-day management of the study to his colleague Robert Waldinger, a researcher and a psychoanalyst. As has always been necessary, Waldinger has kept this 72-year-old ship in the water by paying homage to the dominant model of health. Today, that means taking MRIs of the Grant and Glueck men, collecting DNA swabs—and asking for volunteers to donate their brains to the study. (Meanwhile, recent efficacy studies have restored some luster to psychoanalytic ideas, so the project still encompasses a range of approaches.)

Though Vaillant spends half the year in Australia, his wife’s native land, he is still deeply involved in the study, retains his title as co-director, and operates out of the study’s office when he’s in Boston. He also works the phones to keep track of the men’s lives—and their deaths. “I’m trying to reach [name deleted],” I overheard him say one day on the phone from the study’s office. He spoke loudly; I gathered the call was overseas. “Oh. I see,” he said after a pause. “Do you know of what cause?”

Recently, I asked Vaillant what happened when the men died. “I just got an e-mail this morning from one of the men’s sons,” he said, “that his father died this January. He would have been 89.” I asked him how it felt. He paused, and then said, “The answer to your question is not a pretty one—which is that when someone dies, I finally know what happened to them. And they go in a tidy place in the computer, and they are properly stuffed, and I’ve done my duty by them. Every now and then, there’s a sense of grief, and the sense of losing someone, but it’s usually pretty clinical. I’m usually callous with regard to death, from my father dying suddenly and unexpectedly.” He added, “I’m not a model of adult development.”

Vaillant’s confession reminded me of a poignant lesson from his work—that seeing a defense is easier than changing it. Only with patience and tenderness might a person surrender his barbed armor for a softer shield. Perhaps in this, I thought, lies the key to the good life—not rules to follow, nor problems to avoid, but an engaged humility, an earnest acceptance of life’s pains and promises. In his efforts to manifest this spirit, George Vaillant is, if not a model, then certainly a practiced guide. For all his love of science and its conclusions, he returns to stories and their questions. When I asked him if there was a death that had affected him, he mentioned Case No. 47—“Alan Poe”—an inspiring, tragic man, who left many lessons and many mysteries, who earnestly sought to “squeeze that lemon.”

Joshua Wolf Shenk, the director of the Rose O’Neill Literary House at Washington College, is the author ofLincoln’s Melancholy: How Depression Challenged a President and Fueled His Greatness. He can be reached at jw@shenk.net.

 

 

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