But he didn’t. There was another thread running through Bill Lo-man’s life, and it could be seen even while he was still in college. He spent his weekends drinking. In college he experienced three- and four-day episodes of “depression”—probably alcohol-related—when he would see the world as a “very sorry place.” The college psychiatrist saw the hard-drinking Loman as “undependable, careless, self-centered and evasive.” In the military, too, Loman recalled, “I spent most of my spare time drinking and chasing women.”
In law school, Loman dared to drink only on weekends—he already recognized that he could not have even one drink without going on a binge. By the age of thirty he had established a pattern of drinking heavily from lunch on Friday through Sunday evening. He was abstinent during the week, but he took frequent sick days, especially on Monday when he was recovering from weekend hangovers.
Intimacy, Career Consolidation, and Generativity were not in Bill Loman’s future. He became emotionally involved with only one woman, in his twenties. At thirty he proposed to her, but she turned him down. Pressed, he admitted that her reluctance to marry him might have been due to his binge drinking. They remained closely involved for the next twenty-five years, both living with their mothers on the weekends. When he was fifty-three, her “dominating” mother died, and she married someone else. Loman continued to live with his mother until she died. He was discontented throughout his legal career, feeling undercommitted and undercompensated.
I interviewed Bill Loman when he was fifty-nine. He was insecure and unable to make eye contact. Instead of enjoying the interview as most Study members did, he acted like an unhappy adolescent being grilled. “I don’t think I’d have joined the Study if I knew it was going to last so long,” he grumbled.
Loman manifested a pervasive melancholy. When he was fifty, his brother, another Study man who did grow up to be a superstar, sadly revealed that Bill had stopped making new friends. Despite his high income, he took no vacations, involved himself in no civic activities, and had no exciting relationships with the opposite sex. There had never been anyone in whom he had confided. Asked who he turned to in unhappiness, Loman replied, “I turn to me.”
At age sixty-five when asked, “What is your most satisfying activity?” Loman answered, “None.” Unlike many unhappy Study men and women who could rely on strong religious affiliations even when socially isolated, Loman went to church just once a year—on Christmas, with his mother. He had been raised in a church school. But alcohol abuse interferes with spiritual solace as well as the more mundane kinds.
After our interview, Loman’s alcoholism continued to progress. By sixty-five, despite reasonable health, the once-sociable Bill no longer attended any of his clubs. He could not learn new things. Unlike most of his Harvard cohort, he never even began to master the computer. The personal losses that accrue in life had never been replaced; among his friends and relatives there was no longer a single person with whom he could say he had an intimate relationship. Not surprisingly, he saw the present as the unhappiest period of his life. The happiest time, he said, had been the war years. It was hard not to be disconcerted by that. The Battle of the Bulge is not everyone’s idea of a day at the beach.
Loman’s alcoholism never affected his liver, but it destroyed his life. At thirty, both he and the girl he loved were already worrying about his drinking. At age forty, after three DWI’s with damage to others, his mother, his brother, and the police were worrying too. At age fifty-three he sought his first detoxification. But at sixty he was still going on binges where he’d drink a quart of whiskey a day for five days. The only thing that stopped him was that he always eventually became too ill to drink anymore. He had his first seizure due to alcohol withdrawal at sixty-five.
After that Loman made repeated unsuccessful efforts to go on the wagon until he died from an alcohol-related fall at seventy-four. Seventy percent of his Study mates were still alive. He did not begin his life among the Loveless, but he ended it that way.
My readers will have noted, I am certain, the—unconscious—shift in focus, and even in detail, between these two versions of Lowell/Lo-man’s life. As I’ve said before, biography is more vivid than statistics, but it is much more vulnerable to vicissitudes in the writer’s intent than numbers are. The fact is that both Lowell and Loman had a problem drinking score (PDS) of 11—in the top 10 percent of both the College and Inner City samples. For many years I struggled to make sense out of conflicting views of alcoholism, both of which had fierce partisans: was it a disease or a career path? For most of his life, Lowell/Loman’s lab tests and physical exams were clean. For most of his life his mates drank as much as he did. His career, in its own way, prospered. I can see now that he was the perfect example of why it’s so hard to say what alcoholism “really is.” It wasn’t until his last years that the evidence of what alcohol had done to him physically and psychologically really began to show. Another reason for lifetime studies. Alcoholism is a crafty foe, and even under the intense scrutiny of the Grant Study, in the case of Lowell/Loman it managed to keep itself hidden for a very long time.
We can all consider for ourselves whether in my first effort to tell this story I was in my own kind of denial, missing the disease that is alcoholism, or whether in my second I was bending the facts, forcing a heavy habitual drinker into the mold of an alcoholic. But however we explain it, both Lowell and Loman suffered from something that was indeed cunning, baffling, and powerful. It was also ultimately fatal.
CONCLUSION
Prospective study has consistently shown alcoholism to be the cause, not the result, of dependent, sociopathic, neurotic, or aggressive personality disorders. Alcoholism is the cause, not the result, of unhappy marriages. Alcoholism is the cause of many deaths, too, and not only through liver cirrhosis and motor vehicle accidents—suicides, homicides, cancers, heart disease, and depressed immune systems can all be chalked up to this serial killer. The critical factors predicting recovery from alcohol dependence, besides its severity, appear to be finding a (preferably) nonpharmacological substitute for alcohol, compulsory supervision (with immediate negative consequences for relapse), new loving relationships, and involvement in inspirational programs.
Prolonged follow-up reveals two fundamental paradoxes in predicting the life course of alcoholism. Socially disadvantaged men, men with strong family histories of alcoholism, and men with early onset of severe alcohol dependence were more likely than other men to become stably abstinent. In contrast, alcohol abusers with excellent social supports, high education, good health habits, and late onset of minimal alcohol abuse—epitomized by the College sample—were more likely to remain chronic alcohol abusers. If their alcohol-related problems were truly minimal, they also had an excellent chance of returning to lifelong social (controlled) drinking. In short, it appears to be the most and the least severe alcoholics who enjoy the best chance of long-term remission.
10
SURPRISING FINDINGS
There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.
—WILLIAM SHAKESPEARE
AS I’VE TRIED TO CONVEY throughout this book, longitudinal studies are constructions of intrinsic contradiction and paradox. They require investment in massive information collection before there’s any way to know for certain whether the information being compiled is the kind that can answer the questions the Study is posing. Much of this vast accumulation will almost assuredly never answer any questions at all. Yet in the huge heaps of data, little glints may sometimes be perceived. Some will turn out to be fool’s gold. But some, suddenly—with a different cast of light or a sudden shift in context or a new analytical technology—identify themselves as twenty-four karat. There are unexpected, unexplainable, curious, and just plain odd findings in every large longitudinal study, and these are the very ones that beg for review every so often, just in case.
Here are some of the tantalizing glints from the Harvard Study of Adult Developme
nt. In time they may, as my final lesson from Chapter 2 suggests, help to elucidate one or two of life’s enduring mysteries.
I. WHY DO THE RICH LIVE LONGER THAN THE POOR?
The last fifty years of epidemiology are making it ever clearer that the human lifespan is finite; after a point, the greatest riches in the world can’t help you live longer. Nonetheless, the poor die sooner. In the United States it is socioeconomic status (income, education, occupation, access to health care) that is thought to account for this disparity, not the malnutrition and infection that shorten lifespans in third world countries.
Some people blame society for discriminatory access to health care and for toxic neighborhoods, poor nutrition, poor schools, and high unemployment; some blame the victim for dropping out of school, delinquency, bad habits, and poor self-care. While there is danger that the current emphasis on individual health promotion can be used in the service of victim-blaming, I’ve shown in Chapter 7 that the role of health-related behaviors cannot be carelessly dismissed out of political correctness.1
Nevertheless, as Marcia Angell, former editor-in-chief of the New England Journal of Medicine, has pointed out, “Despite the importance of socioeconomic status to health, no one quite knows how it operates. It is, perhaps, the most mysterious of the determinants of health.”2
Nowhere is the Harvard Study of Adult Development as powerful as when it addresses this mysterious relationship between health and social class. The College and Inner City groups were matched for several important confounders: gender, race, geography, absence of delinquency, and a 1920–1930 birth cohort. But the two samples were clearly dichotomized by social class and intelligence (at least according to standard IQ tests), since the Inner City men were matched to a low-scoring group of delinquent youths. As Figure 10.1 illustrates, the Inner City cohort has been becoming disabled ten years earlier on average than the College sample, and dying ten years sooner; the estimated average longevity of the Inner City men is seventy years, of the College men, seventy-nine years.
The morbidity of the two samples is similar with regard to illnesses that are independent of self-care: that is, cancer (excluding lung), arthritis, heart disease, and brain disease. But there was twice as much lung cancer, emphysema, and cirrhosis, and three times as much Type II diabetes, among the Inner City men as in the College sample. The Inner City men were also more than three times as likely to be overweight. All these differences, however, disappeared for Inner City men who graduated from college.
Figure 10.1 Death after fifty for College men, Inner City men, and Inner City college graduates.
The average Inner City man was much less educated than the Harvard graduates, and he also led a far less healthy lifestyle. But the more education an Inner City man obtained, the more likely he was to stop smoking, avoid obesity, and be circumspect in his use of alcohol. The estimated average age of death for the Grant Study men who did not go to graduate school and the college-educated Inner City men was identical—seventy-nine years, if the World War II deaths are excluded.
So we have to ask: Does education really predict healthy aging independent of social class and intelligence? The college-educated Inner City men were neither more intelligent nor more privileged socially than their peers who did not attend college, so those two factors do not explain the nine-year difference in their estimated lifespans. The college-educated Inner City men had carefully tested IQs that were on average 30 points lower than their Harvard counterparts’, and they attended lesser colleges. They were a full inch shorter, suggesting inferior childhood nutrition, and none of them had the upper-middle- or upper-class advantages typical of two-thirds of the Harvard men. In middle age, only half as many of the Inner City men as College men had made it into the ranks of the upper class, and they made only half as much money. Thus, neither intelligence nor status nor wealth can account for the disappearance of the nine-year shortfall in lifespan once an Inner City man had graduated from college. Parity of education alone was enough to produce parity in physical health.
Well-trained medical sociologists will scoff at this assertion. Do not the Whitehall Studies by Sir Michael Marmot in England appear to show that social class is one of the leading causes, if not the leading cause, of premature death in England? Did not the health of Whitehall civil servants improve with every step in their pay grade?3 Yes. But Marmot’s early Whitehall studies did not control for education or alcoholism. Our study of the Inner City men showed that education is very significantly associated with income and job promotion, and alcoholism is very significantly deleterious to both.4 That is, with every step in pay grade, the chances rose of a man being nonalcoholic and better educated. It is likely that it is these factors, not the job or the pay grade, that facilitate better health. This is yet another instance where the choices we make appear to influence how long we will live.
Most social science studies, including Marmot’s own early ones, control only for self-reported alcohol consumption, which, as I have been at pains to point out, correlates very poorly with objective alcohol abuse. In our samples, however, the difference in health outcomes among occupational levels diminished sharply once we controlled for alcohol abuse, which tends to depress occupational level. Alcoholism is bad for career advancement as well as for health.
The question then becomes: If education so powerfully affects self-care (as well as the more obvious job status), what affects whether or not people stay in school? In general, pursuit of education is most successful in coherent communities that invest heavily in their families and their school systems in an atmosphere of gender and racial tolerance. People with no hope for the future don’t pursue education effectively. Providing that hope is the responsibility of the community, not the individual.
That said, however, the pursuit of education also reflects individual personality traits of perseverance and planfulness—traits that Friedman and Martin have shown to be important to longevity.5 An important postscript to these findings is a recent paper by David Baber and colleagues, who find that it is not only increased education per se that reduces mortality; of equal importance was what Baber et al. called health reading fluency—the capacity to read prescription bottles, understand preventive services, and so on.6
II. IS PTSD DUE TO COMBAT OR TO PERSONALITY DISORDER?
The frequency of posttraumatic stress disorder (PTSD) among returning Vietnam veterans has led many to wonder whether the principal causal factor is not severe combat stress after all, but pre-existing personality disorder. To address this question, the Grant Study took advantage of the fact that most of its members were World War II veterans. Not only had they all been extensively studied before the war, but they were all extensively debriefed after the war on their combat experiences, their physical symptoms during combat, and their persisting stress-related symptoms. John Monks, an internist particularly interested in combat experience, carried out these debriefings.7 Forty years later, sociologist Glen Elder and I asked all the surviving College veterans (excluding the early Study dropouts) to fill out questionnaires regarding persisting symptoms of posttraumatic stress. (PTSD had not yet been “invented” in 1946, but its principal symptoms had been anticipated by the prescient Monks.) One hundred and seven men returned questionnaires. These men had also completed the NEO, which, as I’ve described in Chapter 4, is an extensive and popular multiple-choice scale that includes a scale for the trait Neuroticism.8 We were particularly interested to learn if the men who developed symptoms of posttraumatic stress had already looked vulnerable before the war, or if combat really was the primary factor in symptom development. (Please note here, however, that since the Study men had been protected to some degree by education and rank from the circumstances in which frank PTSD develops, we were studying symptoms of posttraumatic stress, not the disorder per se.)
First, the men who experienced the most intense combat did not appear to have been more vulnerable by nature; in fact, they manifested superior psychosocial health in adolescence an
d also at age sixty-five. Second, it was only the men with high combat exposure who continued to report symptoms compatible with PTSD after forty years. Third, we found that symptoms of posttraumatic stress both in 1946 and in 1988 were predicted independently by two factors: combat exposure and number of physiological symptoms during combat stress (but not during civilian stress). As I’ve already noted, severe combat exposure also predicted early death. It was noteworthy that the symptoms of posttraumatic stress reported in 1946 were not correlated with evidence of subsequent major depressive disorder, alcohol abuse, or poor psychosocial adjustment. Only combat exposure made a significant statistical contribution to posttraumatic stress symptoms, and that contribution was very significant. And while the NEO trait Neuroticism was associated with bleak childhood, psychiatrist utilization, poor psychosocial outcome at age forty-seven, and physiological symptoms during civilian stress, it was not associated with PTSD.9
Sixteen men who endured severe combat reported no posttraumatic stress symptoms in 1946, and in 1988 still could not recall ever having had such symptoms. When we compared these sixteen resilient men to the eighteen with high combat exposure who did experience symptoms, their Neuroticism scores were the same. However, their defensive styles were not. The high combat veterans who manifested less mature defenses as young adults had very significantly more symptoms than those with more mature defenses (Chapter 8). Equally important, seven (39 percent) of the men with high combat experience and less mature defenses were dead by age sixty-five, while no man with mature defenses was. In the Grant Study, high combat exposure per se was not associated with a higher incidence of postwar alcoholism, but as I’ve said, the Grant Study men also did not develop full-blown PTSD.
Triumphs of Experience: The Men of the Harvard Grant Study Page 32
