Sunday, June 28, 2009

Bank Crisis Through The Ages

According to "Bank Crisis Through The Ages" on National Public Radio's Weekend Edition on Sunday, June 28, 2009, "Each financial crisis in American history has brought sweeping changes and pledges that bank failures will be averted in the future. Planet Money's Chana Joffe-Walt and Alex Blumberg take a tour of financial regulation through the ages."

Click the link above to listen to the story (6 min 39 sec).

Should pharmaceutical companies advertise prescription drugs?

Why do pharmaceutical companies advertise prescription drugs on television? Consumers are legally unable to buy them without being prescribed by a doctor. Should drugs be marketed directly to consumers? When people are ill, they visit doctors to seek treatment. Doctors are trained to assess medical conditions and they are in the best position to recommend treatment. Doctors need to be informed about the potential benefits and side effects of all treatment options? Do patients need to be given a sales pitch to encourage them to seek treatment? Is there a better way to inform the public?

Critics claim the reason why pharmaceutical companies advertise their drugs is because it does indeed increase their sales. They have powerful lobbies that convinced the Food and Drug Administration (FDA) in 1997 to relax regulations that prohibited advertising for these controlled substances. So now many patients go to doctors asking for specific drugs they have seen in advertisements. They do not seek the doctor's informed opinion of the best course of treatment. And many doctors provide these drugs to patients even when they are not the preferred way to treat a condition. They realize patients may go to a different doctor if their requests are not satisfied.

Do drug companies and lobbyists for other groups have too much influence on the U.S. health care system?

Other criticisms of the pharmaceutical industry were discussed in the July 15, 2004 edition of The New York Review of Books. or "The Truth About Drug Companies."

See also "Beyond Advertising: The Pharmaceutical Industry's Hidden Marketing Tactics."

See also "Drug Advertising Skyrockets."

Saturday, June 27, 2009

California's Fiscal Crisis: The Legacy of Proposition 13

In his June 27, 2009 TIME magazine article California's Fiscal Crisis: The Legacy of Proposition 13, Kevin O'Leary argues California's current fiscal crisis is directly attributable to the June 6, 1978 passage of the "People's Initiative to Limit Property Taxation," better known as Proposition 13, which was a ballot initiative to amend California´s state constitution:
The financial crisis in California grew worse this week as State Controller John Chiang warned that if legislators and Governor Arnold Schwarzenegger fail to come up with a budget-balancing package, he would begin paying California's bills with IOUs on July 2. The last time the state did this was during the Great Depression.

What has brought California to such a perilous state? How did its government become so wildly dysfunctional? One obvious cause is the deep recession that has caused tax revenues to plunge for all states. But California's woes have a set of deeper reasons: direct democracy run amok, timid governors, partisan gridlock and a flawed constitution all contribute to budget chaos and people in pain. And at the root of California's misery lies Proposition 13, the antitax measure that ignited the Reagan Revolution and the conservative era. In Washington, the Reagan-Bush era is over. But in California, the conservative legacy lives on. (Read TIME's report: Can the U.S. Afford to Let California Fail?)

Before Prop 13, in the 1950s and '60s, California was a liberal showcase. Governors Earl Warren and Pat Brown responded to the population growth of the postwar boom with a massive program of public infrastructure — the nation's finest public college system, the freeway system and the state aqueduct that carries water from the well-watered north to the parched south. When Ronald Reagan was governor he actually raised taxes. Then Proposition 13 shot the tires out of Pat Brown's liberal state. Liberal legislative leaders such as Willie Brown and John Burton jerry-rigged repairs and kept the damaged vehicle running for 30 years. Now Republican Arnold Schwarzenegger says there is no choice but to complete the demolition by slashing essential services. (TIME's Joel Stein weighs in on California's state of insanity)

Proposition 13 was the brainchild of the late Howard Jarvis. The antitax crusader was a policy genius not unlike Franklin D. Roosevelt. Both shared an affinity for designing deep structural change that, once embedded in the political system, is nearly impossible to alter without a massive change of heart by voters. Social Security is the lasting legacy of the New Deal era because F.D.R. understood that workers who contribute payroll-tax deductions from their paychecks would not want politicians tinkering with their retirement dollars. Conservatives have mounted assaults on Social Security through the years but to no avail.

Jarvis created a similarly impregnable institution. When he rode the wave of anger over skyrocketing property-tax assessments to pass Proposition 13 in 1978, he included a two-thirds vote requirement for the passage of any new taxes in California — an insurmountable obstacle built on populist allergy to any kind of new levy. Beholden to a tax-averse electorate, the state's liberals and moderates have attempted to live with Proposition 13 while continuing to provide the state services Californians expect — freeways, higher education, locking up felons, assisting needy families and, very importantly, essential funding to local government and school districts that vanished after the antitax measure passed.

Now, however, that balancing act no longer seems possible. In the state's current fiscal crisis, California's public schools stand to lose $5.3 billion on top of $7.4 billion in cuts last year. Superintendents and school boards foresee teacher layoffs, increased class sizes, the loss of computer labs and libraries and, in some districts, insolvency. Superintendent Ramon Cortines says the Los Angeles Unified School District will lay off more than 2,500 teachers.

"If not for the county [welfare program], lots of people would be out on the streets and I'd be one of them with my two kids," says Cinnamon McDaniel. Petite and well dressed, McDaniel is hardly the Reagan-stereotype welfare mom of yore. The 26-year-old African American mother of two was employed until a year ago when her doctor ordered her to stop working because of complications with her second pregnancy. A high school graduate and a preschool teacher's aide for six years, she is working toward a nursing degree. Following a divorce, she now receives a welfare check for $623 as well as food stamps and the state's health coverage for low-income families. "Last year I was able to work and pay my own bills. I'd like to see if Gov. Schwarzenegger could cut it on $600 a month."

South of Los Angeles at California State University, Fullerton, Nicole Muth, 22, has just finished her junior year with straight A's. Muth grew up in Modesto with "lots of love but no money." Raised by her aunt and uncle, she receives a Cal Grant of $4,500 a year. "It definitely helps," says Muth, who credits the grant with allowing her to focus on her studies. As part of his proposed budget cuts, however, Schwarzenegger says Cal Grants should be phased out and that money promised to the incoming college class eliminated. "I appreciate the grant very much and I'm concerned about students coming after me not having the opportunities I've had," says Muth. "I'm really sad to see our state in this economic crisis. It's bewildering." Muth is not alone.

The governor has addressed the need for shrinking the state, saying, "We have to go and make certain cuts in health care. We have to make certain cuts in education, in higher education, in all these various different programs, in prisons, law enforcement and so on." But Anthony Wright, executive director of Health Access California, a nonprofit advocacy group, says, "These are no longer cuts. These are amputations, and the question is, Which limb are we cutting off today?"

What Makes Us Happy?

The article "What Makes Us Happy?" in the June 2009 edition of The Atlantic provides some answers:
What Makes Us Happy? by Joshua Wolf Shenk

Is there a formula—some mix of love, work, and psychological adaptation—for a good life? For 72 years, researchers at Harvard have been examining this question, following 268 men who entered college in the late 1930s through war, career, marriage and divorce, parenthood and grandparenthood, and old age. Here, for the first time, a journalist gains access to the archive of one of the most comprehensive longitudinal studies in history. Its contents, as much literature as science, offer profound insight into the human condition—and into the brilliant, complex mind of the study’s longtime director, George Vaillant.

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.


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 named Martin 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.”

Examining the Scientific Consensus on Climate Change

According to the survey "Examining the Scientific Consensus on Climate Change" published in January 2009:

"It seems that the debate on the authenticity of global warming and the role played by human activity is largely nonexistent among those who understand the nuances and scientific basis of long-term climate processes."

Of the 3,146 survey respondents, 96.2% of the climatologists engaged in research believe that average global temperatures have increased in the last 200 years and 97.4% of them believe that human activity is a major cause of global warming.

Including all scientists who participated in the survey (most of whom are not climatologists), 90% agree global temperatures have increased compared to levels before 1800, and 80% consider human activity a primary cause.

Citation: Doran, P. T., and M. Kendall Zimmerman (2009), Examining the Scientific Consensus on Climate Change, Eos Trans. AGU, 90(3), doi:10.1029/2009EO030002.

Climate Change: Increasing Skepticism?

In a June 26, 2009 editorial in The Wall Street Journal, Kimberley A. Strassel claims the number of skeptics is increasing:
Steve Fielding recently asked the Obama administration to reassure him on the science of man-made global warming. When the administration proved unhelpful, Mr. Fielding decided to vote against climate-change legislation.

If you haven't heard of this politician, it's because he's a member of the Australian Senate. As the U.S. House of Representatives prepares to pass a climate-change bill, the Australian Parliament is preparing to kill its own country's carbon-emissions scheme. Why? A growing number of Australian politicians, scientists and citizens once again doubt the science of human-caused global warming.

Among the many reasons President Barack Obama and the Democratic majority are so intent on quickly jamming a cap-and-trade system through Congress is because the global warming tide is again shifting. It turns out Al Gore and the United Nations (with an assist from the media), did a little too vociferous a job smearing anyone who disagreed with them as "deniers." The backlash has brought the scientific debate roaring back to life in Australia, Europe, Japan and even, if less reported, the U.S.

In April, the Polish Academy of Sciences published a document challenging man-made global warming. In the Czech Republic, where President Vaclav Klaus remains a leading skeptic, today only 11% of the population believes humans play a role. In France, President Nicolas Sarkozy wants to tap Claude Allegre to lead the country's new ministry of industry and innovation. Twenty years ago Mr. Allegre was among the first to trill about man-made global warming, but the geochemist has since recanted. New Zealand last year elected a new government, which immediately suspended the country's weeks-old cap-and-trade program.

The number of skeptics, far from shrinking, is swelling. Oklahoma Sen. Jim Inhofe now counts more than 700 scientists who disagree with the U.N. -- 13 times the number who authored the U.N.'s 2007 climate summary for policymakers. Joanne Simpson, the world's first woman to receive a Ph.D. in meteorology, expressed relief upon her retirement last year that she was finally free to speak "frankly" of her nonbelief. Dr. Kiminori Itoh, a Japanese environmental physical chemist who contributed to a U.N. climate report, dubs man-made warming "the worst scientific scandal in history." Norway's Ivar Giaever, Nobel Prize winner for physics, decries it as the "new religion." A group of 54 noted physicists, led by Princeton's Will Happer, is demanding the American Physical Society revise its position that the science is settled. (Both Nature and Science magazines have refused to run the physicists' open letter.)

The collapse of the "consensus" has been driven by reality. The inconvenient truth is that the earth's temperatures have flat-lined since 2001, despite growing concentrations of C02. Peer-reviewed research has debunked doomsday scenarios about the polar ice caps, hurricanes, malaria, extinctions, rising oceans. A global financial crisis has politicians taking a harder look at the science that would require them to hamstring their economies to rein in carbon.

Credit for Australia's own era of renewed enlightenment goes to Dr. Ian Plimer, a well-known Australian geologist. Earlier this year he published "Heaven and Earth," a damning critique of the "evidence" underpinning man-made global warming. The book is already in its fifth printing. So compelling is it that Paul Sheehan, a noted Australian columnist -- and ardent global warming believer -- in April humbly pronounced it "an evidence-based attack on conformity and orthodoxy, including my own, and a reminder to respect informed dissent and beware of ideology subverting evidence." Australian polls have shown a sharp uptick in public skepticism; the press is back to questioning scientific dogma; blogs are having a field day.

The rise in skepticism also came as Prime Minister Kevin Rudd, elected like Mr. Obama on promises to combat global warming, was attempting his own emissions-reduction scheme. His administration was forced to delay the implementation of the program until at least 2011, just to get the legislation through Australia's House. The Senate was not so easily swayed.

Mr. Fielding, a crucial vote on the bill, was so alarmed by the renewed science debate that he made a fact-finding trip to the U.S., attending the Heartland Institute's annual conference for climate skeptics. He also visited with Joseph Aldy, Mr. Obama's special assistant on energy and the environment, where he challenged the Obama team to address his doubts. They apparently didn't.

This week Mr. Fielding issued a statement: He would not be voting for the bill. He would not risk job losses on "unconvincing green science." The bill is set to founder as the Australian parliament breaks for the winter.

Republicans in the U.S. have, in recent years, turned ever more to the cost arguments against climate legislation. That's made sense in light of the economic crisis. If Speaker Nancy Pelosi fails to push through her bill, it will be because rural and Blue Dog Democrats fret about the economic ramifications. Yet if the rest of the world is any indication, now might be the time for U.S. politicians to re-engage on the science. One thing for sure: They won't be alone.

Write to

Like many editorials, this one wants the reader to jump to a conclusion. The author says the number of skeptics has increased, with the inference that they are large in number. Yet she never mentions how many scientists believe in global warming. A survey published in January 2009 concludes that for every 260 climatologists who are skeptical of climate change, there are 9,740 convinced of its existence. Admittedly that is not 100%, but 97.4% is close.

Friday, June 26, 2009

Should regulations of markets be simplified?

In his June 26, 2009 TIME magazine article, "Dumbing Down Regulation," Justin Fox argues for simplified regulation of markets:
If only our financial regulations were dumber! It's not a cry you hear often. But phrased a little differently, it may be the most cogent criticism of the convoluted regulatory approach of recent decades--and one that applies to most of the Obama Administration's financial-reform proposals.

The argument goes like this: the biggest flaw in current financial regulation is not that there is too little of it or too much, but that it relies on regulators knowing best. We regulate because financial systems are fragile, prone to booms and busts that can have harmful effects on the real economy. But regulators aren't immune to the boom-bust cycle. They have an understandable habit of easing up when times are good and cracking down when they're not. In doing so, they often amplify the ups and downs of markets rather than modulate them. (Watch TIME's video of Peter Schiff trash-talking the markets.)

You can spin this into a case for reduced regulation--regulators are likely to mess up, so why bother? But it can also point toward an approach based not so much on discretion as on rules, the simpler the better. I first encountered this argument last fall in the work of left-leaning blogger Matthew Yglesias--he advocated "crude measures" like the old ban on interstate banking. Lately, though, I've been hearing similar suggestions from those of a conservative, University of Chicago bent. "When you give a lot of discretion to regulators, they don't use the tools that are given to them," Chicago economist Gary Becker said at a conference this spring. His prescription: rules, not leeway.

The antidiscretion case has been made for years with regard to Federal Reserve monetary policy. Becker's Chicago teacher Milton Friedman thought that instead of tweaking interest rates, the Fed should just automatically increase the money supply 3% to 4% a year. Measuring the money supply in an era of financial innovation has turned out to be awfully hard, so in recent years believers in an automated Fed have turned to an equation concocted by Stanford economist John Taylor that takes in inflation, current economic growth and long-term-trend growth and churns out a suggested Fed interest-rate target. Taylor and some other conservatives have said that if the Fed had followed his rule in the early 2000s, all would be well today. There's no way of knowing if this is true, but it's hard to see how it could have led to a worse outcome than the monetary course chosen by the smarties at the Fed.

As for other forms of financial regulation, many conservatives long thought that few, if any, were needed, but the crisis has changed some minds. Alan Greenspan's famous October admission that his antiregulation ideology had failed was a landmark on this front. Federal judge and Chicago Law School professor Richard Posner's new book, A Failure of Capitalism, is another. In it, Posner fingers financial deregulation as a major cause of the crisis. He's less clear about what we ought to do now, although one of his suggestions very much fits the crude-measure standard: we should consider raising income taxes on high earners "in order to reduce their appetite for risk-taking."

Capital requirements are an area in which many observers think dumbing down is in order. Regulators spent decades fine-tuning their risk-weighted capital rules, in some cases using the supposedly sophisticated risk models developed by banks themselves. The result was ratios of debt to capital that topped 35 to 1 at some investment banks. Oops! A simpler, cruder standard (say, 10 to 1) surely would have worked better.

Then there's the 1933 Glass-Steagall Act, which separated commercial banking from other financial endeavors. By the time Congress repealed the law in 1999, it seemed utterly out of step with the times, but now many economists are wondering if there is something to the idea of separating risky financial activities from essential ones. Or we could tax financial transactions, a policy suggested as far back as 1929 by Virginia Senator Carter Glass (he of the Glass-Steagall Act) and now identified most closely with the late Yale economist James Tobin. In the 1970s, Tobin proposed a tax on currency trades to throw "sand in the wheels" of international finance and damp speculation.

Larry Summers, now the top economic adviser in the Obama White House, was a proponent of such taxes in the 1980s and early 1990s. There's no hint of them in the Administration's 88-page white paper on financial regulation. There is talk of higher capital requirements, tougher consumer-protection standards and new rules for derivatives. But taken as a whole, the document sketches a regulatory approach that still relies heavily on judgment and smarts. Maybe it's time for some dumbing down.

Will Overstimulating Economy Bring Inflation?

The National Public Radio (NPR) story "Will Overstimulating Economy Bring Inflation?" considers the relationship between overall spending and inflation:
Morning Edition, June 26, 2009 · While the United States worries about a repeat of the Great Depression, Germans have another crisis in mind: the hyperinflation that hit them more than 80 years ago. And inflation may be on German Chancellor Angela Merkel's mind when she meets with President Obama in Washington on Friday.

Just after World War I, Germany underwent what is now the textbook case of hyperinflation. Germany had debts to pay and it had gotten into the bad habit of basically printing money. At the peak of the crisis, German currency included a 50-million-mark note.

In When Money Dies: The Nightmare of the Weimar Collapse, Adam Fergusson wrote:

"In October 1923 it was noted by the British Embassy in Berlin that the number of marks to the pound equaled the number of yards from the Earth to the sun.

"Dr. Schacht, Germany's National Currency Commissioner, explained that at the end of the Great War one could in theory have bought 500,000,000,000 eggs for the same price as that for which, five years later, only a single egg could be procured."
Some people worry the United States might be heading for inflation soon. The amount of money in an economy is determined by its central bank, which is supposed to be independent of politics.

In the current crisis, the Federal Reserve and other central banks around the world have been taking unprecedented, historic steps to make credit available — to basically push money into the economy.

The head of Germany's central bank has warned that this could lead to inflation.

Merkel earlier this month said, "We must return to an independent central bank policy, and to a policy of reason. Otherwise, in 10 years' time, we'll be in exactly the same situation."

Merkel worried the central banks might be bowing to political pressure, losing their independence.

Josef Joffe, editor of the German newspaper Die Zeit, says concern about inflation is in the German DNA. He worries there's just too much money in the economy.

"[U.S. Treasury Secretary] Tim Geithner and [Fed Chairman Ben] Bernanke and the president and [National Economic Council Director] Larry Summers think they can soak it up again when the time comes," Joffe says. "But meanwhile, they are pumping unprecedented liquidity into the American global system. And I just can only say, 'Good luck, Mr. President, in soaking up that excess liquidity.' And I think that's what Mrs. Merkel reacted to. If the Germans believe in one god, it's the independence of the central bank."

So are we at risk of catching a nasty case of inflation down the road? I took our U.S. economy in for a kind of doctor's office visit to a place that gives this advice out to countries all the time — the International Monetary Fund.

"What we have been telling ... not this country, but all our members, is that there is a need in the short run for macroeconomic policies to support economic activity. But there is a need for every central bank, for every government to have a strategy, to start thinking now about how to exit when the moment comes," says Carlo Cottarelli, the IMF's director of fiscal affairs.

There could be difficulties, he says.

Raising interest rates and pulling money back out of the economy is often unpopular. It's been said the role of a central bank is to "pull away the punch bowl, just as the party gets going." That time is arguably still in the future. As we all know, it's still a pretty lousy party.

Thursday, June 25, 2009

World Health Organization (WHO) Assessment of the World's Health Systems

[For just the list of rankings, see "Listing by Rank" or "Alphabetical Listing."]

According to a 2000 World Health Organization (WHO) report "World Health Organization Assesses the World's Health Systems":
The World Health Organization has carried out the first ever analysis of the world's health systems. Using five performance indicators to measure health systems in 191 member states, it finds that France provides the best overall health care followed among major countries by Italy, Spain, Oman, Austria and Japan.

The findings are published today, 21 June, in The World Health Report 2000 – Health systems: Improving performance*.

*Copies of the Report can be ordered from

The U.S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance, the report finds. The United Kingdom, which spends just six percent of GDP on health services, ranks 18 th . Several small countries – San Marino, Andorra, Malta and Singapore are rated close behind second- placed Italy.

WHO Director-General Dr Gro Harlem Brundtland says: "The main message from this report is that the health and well- being of people around the world depend critically on the performance of the health systems that serve them. Yet there is wide variation in performance, even among countries with similar levels of income and health expenditure. It is essential for decision- makers to understand the underlying reasons so that system performance, and hence the health of populations, can be improved."

Dr Christopher Murray, Director of WHO's Global Programme on Evidence for Health Policy. says: "Although significant progress has been achieved in past decades, virtually all countries are under- utilizing the resources that are available to them. This leads to large numbers of preventable deaths and disabilities; unnecessary suffering, injustice, inequality and denial of an individual's basic rights to health."

The impact of failures in health systems is most severe on the poor everywhere, who are driven deeper into poverty by lack of financial protection against ill- health, the report says.

"The poor are treated with less respect, given less choice of service providers and offered lower- quality amenities," says Dr Brundtland. "In trying to buy health from their own pockets, they pay and become poorer."

The World Health Report says the main failings of many health systems are:

-Many health ministries focus on the public sector and often disregard the frequently much larger private sector health care.
-In many countries, some if not most physicians work simultaneously for the public sector and in private practice. This means the public sector ends up subsidizing unofficial private practice.
-Many governments fail to prevent a "black market" in health, where widespread corruption, bribery, "moonlighting" and other illegal practices flourish. The black markets, which themselves are caused by malfunctioning health systems, and low income of health workers, further undermine those systems.
-Many health ministries fail to enforce regulations that they themselves have created or are supposed to implement in the public interest.

Dr Julio Frenk, Executive Director for Evidence and Information for Policy at WHO, says: "By providing a comparative guide to what works and what doesn't work, we can help countries to learn from each other and thereby improve the performance of their health systems."

Dr Philip Musgrove, editor-in-chief of the report, says: "The WHO study finds that it isn't just how much you invest in total, or where you put facilities geographically, that matters. It's the balance among inputs that counts – for example, you have to have the right number of nurses per doctor."

Most of the lowest placed countries are in sub-Saharan Africa where life expectancies are low. HIV and AIDS are major causes of ill-health. Because of the AIDS epidemic, healthy life expectancy for babies born in 2000 in many of these nations has dropped to 40 years or less.

One key recommendation from the report is for countries to extend health insurance to as large a percentage of the population as possible. WHO says that it is better to make "pre-payments" on health care as much as possible, whether in the form of insurance, taxes or social security.

While private health expenses in industrial countries now average only some 25 percent because of universal health coverage (except in the United States, where it is 56%), in India, families typically pay 80 percent of their health care costs as "out-of- pocket" expenses when they receive health care.

"It is especially beneficial to make sure that as large a percentage as possible of the poorest people in each country can get insurance," says Dr Frenk. "Insurance protects people against the catastrophic effects of poor health. What we are seeing is that in many countries, the poor pay a higher percentage of their income on health care than the rich."

"In many countries without a health insurance safety net, many families have to pay more than 100 percent of their income for health care when hit with sudden emergencies. In other words, illness forces them into debt."

In designing the framework for health system performance, WHO broke new methodological ground, employing a technique not previously used for health systems. It compares each country's system to what the experts estimate to be the upper limit of what can be done with the level of resources available in that country. It also measures what each country's system has accomplished in comparison with those of other countries.

WHO's assessment system was based on five indicators: overall level of population health; health inequalities (or disparities) within the population; overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts); distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system); and the distribution of the health system's financial burden within the population (who pays the costs).

"We have created a new tool to help us measure performance," says Dr Murray. "As we develop it further and strengthen the raw data used for these measures in the years to come, we believe this will be an increasingly useful tool for governments in improving their own health systems."

Other findings in the annual WHO report include:

-In Europe, health systems in Mediterranean countries such as France, Italy and Spain are rated higher than others in the continent. Norway is the highest Scandinavian nation, at 11th .
-Colombia, Chile, Costa Rica and Cuba are rated highest among the Latin American nations – 22nd, 33rd, 36th and 39th in the world, respectively.
-Singapore is ranked 6th , the only Asian country apart from Japan in the top 10 countries.
-In the Pacific, Australia ranks 32 nd overall, while New Zealand is 41st .
-In the Middle East and North Africa, many countries rank highly: Oman is in 8 th place overall, Saudi Arabia is ranked 26th , United Arab Emirates 27th and Morocco, 29th.

In 1970, Oman's health care system was not performing well. The child mortality rate was high. But major government investments have proved to be successful in improving system performance. "Oman's success shows that tremendous strides can be accomplished in a relatively short period of time," says Dr Murray.

Information in the WHO report also rates countries according to the different components of the performance index.

Responsiveness: The nations with the most responsive health systems are the United States, Switzerland, Luxembourg, Denmark, Germany, Japan, Canada, Norway, Netherlands and Sweden. The reason these are all advanced industrial nations is that a number of the elements of responsiveness depend strongly on the availability of resources. In addition, many of these countries were the first to begin addressing the responsiveness of their health systems to people's needs.

Fairness of financial contribution: When WHO measured the fairness of financial contribution to health systems, countries lined up differently. The measurement is based on the fraction of a household's capacity to spend (income minus food expenditure) that goes on health care (including tax payments, social insurance, private insurance and out of pocket payments). Colombia was the top-rated country in this category, followed by Luxembourg, Belgium, Djibouti, Denmark, Ireland, Germany, Norway, Japan and Finland.

Colombia achieved top rank because someone with a low income might pay the equivalent of one dollar per year for health care, while a high- income individual pays 7.6 dollars.

Countries judged to have the least fair financing of health systems include Sierra Leone, Myanmar, Brazil, China, Viet Nam, Nepal, Russian Federation, Peru and Cambodia.

Brazil, a middle-income nation, ranks low in this table because its people make high out-of-pocket payments for health care. This means a substantial number of households pay a large fraction of their income (after paying for food) on health care. The same explanation applies to the fairness of financing Peru's health system. The reason why the Russian Federation ranks low is most likely related to the impact of the economic crisis in the 1990s. This has severely reduced government spending on health and led to increased out-of-pocket payment.

In North America, Canada rates as the country with the fairest mechanism for health system finance – ranked at 17-19, while the United States is at 54-55. Cuba is the highest among Latin American and Caribbean nations at 23-25.

The report indicates – clearly – the attributes of a good health system in relation to the elements of the performance measure, given below.

Overall Level of Health: A good health system, above all, contributes to good health. To assess overall population health and thus to judge how well the objective of good health is being achieved, WHO has chosen to use the measure of disability- adjusted life expectancy (DALE). This has the advantage of being directly comparable to life expectancy and is readily compared across populations. The report provides estimates for all countries of disability- adjusted life expectancy. DALE is estimated to equal or exceed 70 years in 24 countries, and 60 years in over half the Member States of WHO. At the other extreme are 32 countries where disability- adjusted life expectancy is estimated to be less than 40 years. Many of these are countries characterised by major epidemics of HIV/ AIDS, among other causes.

Distribution of Health in the Populations: It is not sufficient to protect or improve the average health of the population, if - at the same time - inequality worsens or remains high because the gain accrues disproportionately to those already enjoying better health. The health system also has the responsibility to try to reduce inequalities by prioritizing actions to improve the health of the worse-off, wherever these inequalities are caused by conditions amenable to intervention. The objective of good health is really twofold: the best attainable average level – goodness – and the smallest feasible differences among individuals and groups – fairness. A gain in either one of these, with no change in the other, constitutes an improvement.

Responsiveness: Responsiveness includes two major components. These are (a) respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health); and (b) client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider).

Distribution of Financing: There are good and bad ways to raise the resources for a health system, but they are more or less good primarily as they affect how fairly the financial burden is shared. Fair financing, as the name suggests, is only concerned with distribution. It is not related to the total resource bill, nor to how the funds are used. The objectives of the health system do not include any particular level of total spending, either absolutely or relative to income. This is because, at all levels of spending there are other possible uses for the resources devoted to health. The level of funding to allocate to the health system is a social choice – with no correct answer. Nonetheless, the report suggests that countries spending less than around 60 dollars per person per year on health find that their populations are unable to access health services from an adequately performing health system.

In order to reflect these attributes, health systems have to carry out certain functions. They build human resources through investment and training, they deliver services, they finance all these activities. They act as the overall stewards of the resources and powers entrusted to them. In focusing on these few universal functions of health systems, the report provides evidence to assist policy- makers as they make choices to improve health system performance.

The World Health Report 2000 consists of a message from the WHO's Director-General, an overview, six chapters and statistical annexes. The chapter headings are "Why do health systems matter?", "How well do health systems perform?", Health services: well chosen, well organized?", "What resources are needed?", "Who pays for health systems?", and "How is the public interest protected?"