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How volunteering affects health and well-being. By Tyler J. VanderWeele Ph.D. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. In his now-classic book, Bowling Alone, Robert Putnam observed that healthy communities are marked by a high degree of “social trust,” a general sense that their members are not simply pursuing their own narrow good, but are willing to look out for one another as well. Putnam also noted that people in communities with strong social trust tend to volunteer their time at relatively high rates, both directly benefiting those they serve, and also indirectly encouraging such generosity in others. Volunteering and other expressions of social trust clearly promote the common good, in the sense of “the sum of those conditions of social life which allow social groups and their individual members relatively thorough and ready access to their own fulfillment” (Paul VI, Gaudium et Spes §26). Volunteering benefits the community being served, and also can help bring about social trust, which of course, in turn, can benefit the volunteers themselves. However, it also turns out that volunteering benefits the volunteers in yet further ways than one might expect. In this month’s issue of the American Journal of Preventive Medicine, several of us at the Human Flourishing Program at Harvard have published a thorough empirical investigation of this question, exploring the role of volunteering in the subsequent health and well-being of adult volunteers. The results are striking. Our Study and What We Found In our research, we used data on about 13,000 older adults in the Health and Retirement Study, with 8 years of data on each participant. We examined, for example, how volunteering in 2010 was related to subsequent health and well-being in 2014, controlling for those same health and well-being outcomes in 2006, along with a vast range of social, demographic, and behavioral characteristics. During the study period, participants who volunteered at least two hours per week (compared with not at all) subsequently had higher levels of happiness, optimism, and purpose in life, and more contact with friends; they also had lower levels of depressive symptoms, hopelessness, and loneliness, fewer perceived physical discomforts and disabilities, and more physical activity. They were also notably less likely to die in the four years of follow-up — about 40% less so! This final result is, in fact, similar to, and helps to yet further confirm, an earlier meta-analysis (combining results over many studies) of the potential effects of volunteering on mortality. This is not to say that there was evidence for effects on all outcomes examined. There was no evidence, for instance, that volunteering prevents hypertension or lung disease, and little evidence that it increases life satisfaction. However, as described above, there was evidence for an effect on many of the outcomes we looked at. Is It Causal? One might, however, wonder whether the associations are simply because those who are healthier are more able to volunteer. As with all of our empirical effect assessment research, we did a number of things to help address this possibility of “reverse causation” and to try to distinguish between association and causation. (Feel free to skip this section if you are uninterested in the methodological details!) First, volunteering was measured four years prior to the health and well-being outcomes that we evaluated. This rigorous longitudinal design helps establish the temporal ordering of the relationships, and in this way is superior to most prior studies on this topic, which often use cross-sectional data (where everything is measured at the same time). Second, we also controlled for the participants’ prior levels of health and psychological well-being, to try to rule out that it was just positive health or psychological states that were leading to greater volunteering. Third, we additionally controlled for numerous other social, demographic, and behavioral characteristics at the beginning of the study to try to rule out that these might explain the relationship. Fourth, we controlled for even earlier prior levels of volunteering, so that associations would effectively reflect changes in volunteering practices. Finally, for each outcome examined, we reported an E-value measure, that assesses how robust or sensitive results are to potential unmeasured variables, and thereby helps evaluate the evidence for causality. All of these things help establish that the associations do, at least partially, reflect causal effects, and for some of the outcomes, such as mortality risk and increasing contact with friends, the results seemed particularly robust. Although it is difficult to definitively establish causality with this sort of observational data, one can provide evidence; and here the evidence for the effects of volunteering on some of the health and well-being outcomes is quite strong. Questions of Character Of course, most people typically do not volunteer simply to improve their own health and well-being. Rather, they hope to make some small contribution to the lives of others, to the community — to the common good. It might thus seem somewhat surprising then that there appear to be effects on one’s own health and well-being also. How are we to understand this? While this extends beyond the data we have, one possibility is that volunteering itself — the long-term sustained attempt to systematically help others and help one’s community — may in turn help shape one’s character and one’s orientation towards the good. This itself may go on to contribute to a number of health and well-being outcomes. In fact, in a future research post, we will discuss some current ongoing research on how certain aspects of character (such as our item in our flourishing index measure on “I always act to promote good in all circumstances, even in difficult and challenging situations”) are strongly associated with numerous health and well-being outcomes over time. Another possibility for the effects of volunteering on well-being is that volunteering often involves sustained engagement with a community both of volunteers and of those served, and may thereby provide opportunities to build strong loving relationships. Love is not just seeking to do good to others; it is also seeking to come to know them and to be with them. By creating sustained communities, volunteering might thus also provide opportunities for the formation of good and loving relationships. Regardless of what the explanations might be, the evidence for important effects of volunteering seems sufficiently strong that, a few years ago, Dr. Stephen Post published an article recommending a “prescription” of volunteering for two hours a week. He acknowledges that for some already deeply engaged in “helping professions” in their life and work, this may not be necessary. And there is, of course, also the danger of volunteering simply for the sake of one’s own benefit, and not for that of the other, or volunteering for the purposes of “resume-padding.” We do not at present really know to what extent such self-centered forms of volunteering contribute to one’s well-being, or whether even they might go some way in positively shaping one’s character. However, for many, engaging in volunteering can be a powerful way to contribute to the good of others, to the community, to the common good, and to the good of the person volunteering as well. Volunteering Amidst COVID-19 There are of course challenges as to what can be done, and the extent of volunteering possible, within the context of the present COVID-19 pandemic. A few months ago, however, The Washington Post published a piece with several helpful suggestions, titled, “How you can help during the coronavirus outbreak: Several nonprofit organizations could use your time and money to make sure vulnerable populations are cared for during the pandemic.” There are also a number of volunteer search engines that match the interests of potential volunteers with opportunities in the local area. One engine, for example, uses zip codes; another connects potential volunteers with relevant international non-governmental organizations based on interests. The effects on communities and society can be profound. A report from the Bank of England (see esp. Figures 9 and 10) suggested that the economic value of volunteering in the UK alone may exceed 40 or 50 billion pounds. Some corporations are also beginning to recognize the value that volunteering can provide to their communities and employees. One of the Human Flourishing Program’s donors in fact offers paid time off to his company’s employees, allowing them to serve in activities of their choosing. Others could do likewise. Society as a whole, and each of us individually, will more fully thrive if we are continually seeking the good of others. Volunteering is one such way to contribute to the common good. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. References Kim, E.S., Whillans, A.V., Lee, M.T., Chen, Y. and VanderWeele, T.J. (2020). Volunteering and subsequent health and well-being in older adults: an outcome-wide longitudinal approach. American Journal of Preventive Medicine, 59:176-186.

A total-lives-saved approach could help guide pandemic decision-making. By Tyler J. VanderWeele Ph.D. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. The COVID-19 pandemic has presented cities, countries, and the world, with a series of difficult trade-offs: Should they prevent more infection or reduce unemployment? Limit contagion to lessen mortality or cease social isolation? Re-open schools, and if so, under what conditions, and at what cost to the worsening of a second wave of the pandemic? These are difficult decisions. They arguably involve incommensurable goods: life, health, social connection, knowledge/education, and the economy. Moreover, the trade-offs between these goods are likely to differ in different regions. Calculus of Lives in COVID-19 Decisions A JAMA article just published by the Human Flourishing Program at Harvard proposes an approach to navigating these decisions that takes well-being into account while prioritizing life itself. It can feel harsh, unreasonable, or even immoral to value economic consequences or personal happiness against the number of lives lost. Our approach avoids doing so. Instead, it acknowledges and makes use of the fact that many other aspects of well-being contribute to the preservation of life. For example, meta-analyses (combining evidence across numerous rigorous longitudinal studies) estimate that unemployment increases mortality risk by 1.63-fold; social isolation increases mortality risk by 1.29-fold; and depression increases mortality risk by 1.34-fold. Many of the things that matter most to us in reality also affect survival and longevity. That fact may prove useful in constructing arguments concerning COVID-19 pandemic policies that may sometimes be persuasive to numerous parties potentially holding different priorities and values. The idea would be to attempt to estimate the total lives saved or lost, due to all causes of death, from different lock-down, social distancing, workplace, school re-opening, and other policies. Such a “total lives-saved” approach would include not only lives saved or lost due to infection, but also lives saved or lost due to the consequences of unemployment, social isolation, depression, and other factors. While there are methodological challenges to this approach, evaluating total lives saved has significant advantages. Such an approach takes well-being seriously, yet also acknowledges that life itself is the highest good at stake in these decisions. Other Approaches May Be Helpful for Some Purposes but Not Others Other approaches that incorporate well-being have been used in the past to make difficult decisions when life is at stake. One of the most widely used approaches within the medical decision-making literature makes use of a metric called “quality-adjusted life years” (QALYs). QALYs are calculated using the years of life remaining but weighting each year with a quality-of-life score (on a 0 to 1 scale), often determined by an individual’s ability to carry out daily activities and their freedom from pain and mental disturbance. A related metric, well-being years (WELLBYs), instead uses a more general evaluation of life satisfaction for its weighting of each year of life, and it has recently been proposed to help make decisions as to when to end lock-down in the United Kingdom. Those of us at the Human Flourishing Program at Harvard certainly think happiness and life satisfaction are important, but we also think that human flourishing extends beyond this and includes meaning and purpose, health, character, and social relationships We have proposed a 10-item measure to help assess these various domains of flourishing. Such a measure could likewise be alternatively used in weighting, to provide a broader picture of flourishing. The resulting metric, obtained by weighting each year of life by the flourishing measure, might be referred to as “flourishing years” (FLRYs). However, when life itself is at stake, these measures are inadequate. The use of QALYs (or WELLBYs or FLRYs) in such decisions then effectively presupposes a trade-off between life and well-being, and it is not at all clear that this is reasonable. Important criticisms have thus been leveled against the use of QALYs on several accounts. The use of QALYs has been criticized for not properly handling the question of death, and improperly handling the value of life. The use of QALYs in decision-making has also been criticized because it effectively down-weights the lives of the poor, suffering, disabled, and vulnerable since their “quality of life” tends to be lower. These are important criticisms. Moreover, these very same criticisms would apply also to the use of WELLBYs or FLRYs if employed in decisions in which life itself is at stake. Total Lives Saved Approach and Its Challenges The advantage of the total lives-saved approach is that it avoids a number of these moral difficulties. It treats all lives as being of equal worth. It still takes into account well-being, but it does so through its effects on life itself. However, as noted above, the effects of well-being on mortality are considerable. There are methodological challenges that accompany this total lives-saved approach. While we have decades of data on the effects of unemployment, depression, and social isolation on mortality, we have much less data on the effects of different pandemic policies on these economic, social, psychological outcomes. However, in the past few months, with different cities and countries making different pandemic decisions, there is now a wealth of new data that might be used to formally evaluate the effects of these policy decisions. Such evaluation could also include the effects of different policies on other aspects of life such as lower use of preventive medical services, delayed cancer treatment, and less participation in religious communities and other communities, each of which also has effects on mortality. The total lives-saved approach is moreover conservative in its deference to infection-related mortality because it does not directly take into account social and other goods, viewed as distinct ends. However, the conservative nature of this approach may also be an asset. If there comes a point at which the number of lives lost from economic, social, and psychological consequences of different policy decisions outweighs the number of lives lost from infection, then it should be clear that it is time for policy-makers to take these into account. Well-being is important for its own sake. It is also important in its consequences for mortality. It is important in constructing arguments and evaluating policies related to the difficulties we now face. It is important in thinking through trade-offs in the present COVID-19 calculus of lives. A total lives-saved approach can provide a means of accounting for well-being that prioritizes human life. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. References VanderWeele, T.J. (2020). Challenges estimating total lives lost in COVID-19 decisions: consideration of mortality related to unemployment, social isolation, and depression. JAMA, in press. doi:10.1001/jama.2020.12187.

New research shows the importance of civic engagement for human flourishing. Guest author: Dominic Burbidge (University of Oxford; Canterbury Institute; Templeton World Charity Foundation) Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. This research note highlights the Templeton World Charity Foundation’s Citizenship in a Networked Age project at the University of Oxford. The project explores human flourishing and civic engagement in relation to changes in technology and social networks. The Human Flourishing Program was to host a spring symposium at Harvard on this theme, in collaboration with the University of Oxford and the Templeton World Charity Foundation, but it unfortunately had to be cancelled due to Covid-19. In lieu of the conference, we link to podcasts from the symposium’s panelists and an executive summary of the report. With the threat of a second virus wave looming and preparations afoot for new ways of living-at-distance, it is clear that the habits we forge in the upcoming weeks and months will help shape a new normal. Will we ever get back the same depth of relationships we had before the pandemic struck? We are relying more and more on digital technologies and online relationships in order to maintain human solidarity during the crisis. Is such increased reliance on digital technologies just a blip, or is the coronavirus instead accelerating a process that has been underway for some time? We need to think critically about what these changes mean for what society is and is for. In a recent Public Discourse article, “Pandemics and the Agency of Citizens,” R. J. Snell writes that our efforts to combat coronavirus are being countered by a more general trend toward moral individualism, through which we have come dangerously close to jettisoning our commitment to a common civic project. Ironically, this comes at a time when we most need to realize our duty as citizens to seek a common good. As Snell remarks, “Rather than understand the individual within thick networks of relationships and duties, this error views us as unencumbered—as denuded of the actual human relationships and obligations that give us meaning and purpose.” The Citizenship in a Networked Age Project For the past two years, the Citizenship in a Networked Age project at the University of Oxford has been helping to identify civic ideals that are applicable to our changing networks of relationships and duties. A great deal of research and innovation has gone into developing new digital technologies that increase the efficiency of our communications, but there is correspondingly little research into how we are being affected by these innovations as a moral community. Digital technologies help us communicate and carry out tasks together despite being remote. That is an asset at times like these. But the danger is that they also increase the remoteness of our moral decision-making by encouraging instant reaction in place of thick relationships. To tackle this danger head-on, researchers at the project set the following two goals: first, to identify what is distinct about human moral decision-making; and second, to offer suggestions as to how this special human capacity can be harnessed for reimagining society’s “moral whole”—the common good binding us together as a purposeful, meaningful community. Citizenship, fundamentally, is about civic engagement—the “partnering-up” of individuals to form a robust society. More than a legal nicety, citizenship is a key way in which we show our social nature. It is the way our individual freedom of association translates into the coordinated action that makes society more than the sum of its parts. Importantly, it involves a special type of moral reasoning that takes the perspective of one’s wider community into account and asks about the common good. The project’s report argues that humans have a special capacity for moral reasoning and that it is our limitations as compared to artificial intelligence that reveal this most clearly. As much as transhumanists claim otherwise, we are all going to die. And yet, despite this, we seek deep, everlasting goods—things like happiness, love, belonging, meaning, forgiveness, and doing the right thing. These are moral goods in that we pursue them not because they make us materially better off but because their depth completes us. As we obtain them, we seek to spread them, both to other parts of our lives and to the lives of others. Our limitations in realizing our desires give rise to a need to work out for ourselves what is most meaningful and worthwhile. This personal struggle is the basis of our moral reasoning. But can our particular capacity for moral reasoning be used to reimagine society’s common good? Here we hit against a serious problem. Most social science on human networks and social connectivity assumes without debate the normative/empirical distinction, and therefore has reduced space for talking about whether our changing patterns of social relationships promote or hinder flourishing. The focus is on describing what networks look like, not analyzing whether they work towards a common good. Recommendations To fill the gap, we need robust discussion of “civic virtues”—the habits and practices that both bind us together as a supportive community and direct us towards the common good. The Oxford report makes 7 recommendations to reclaim lost ground: Identify and protect human uniqueness for moral decision-making. Nurture the complementary skills of humans and machines for collective decision-making. Engage in consensus-building about civic ideals for a networked age. Teach listening as a civic virtue. Maintain distance between thought and speech. Promote the value of privacy for personal moral development. Revalue democracy in terms of the ability to bring about social unity and trust. Foremost among these recommendations is the need to promote the civic virtue of listening well. This practice has received precious little analysis in the social sciences and yet much of our togetherness depends on it. Current technological advances often fragment our attention span, making the giving of undivided attention to others a precious resource. Understanding good listening as a civic virtue is an important first step in healing our polarization and accelerating the sharing of truthful information. At the heart of all this is the need to look not just at how individuals flourish but how groups, corporations, and society as a whole flourish through each person’s free pursuit of the common good. We need our discussion of virtues and moral reasoning to enter into dialogue with society-wide analysis of the overall purpose of community. Only then will we grasp the “moral whole” of our togetherness. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team.

There should be at least one positive news report for every three negative ones. By Tyler J. VanderWeele Ph.D. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. With the present tumult, upheaval, and violence in the United States, this may not seem like the right time to send out this message, but we do firmly believe at the Human Flourishing Program at Harvard that focusing the mind on what is good, and the ensuing actions that promote good, is deeply needed to address what is wrong with the world and to promote global well-being. We recently published an article entitled, “A Public Health Approach to Negative News Media: The 3-to-1 Solution.” This article proposes that news media outlets commit to reporting at least one piece of positive news on good actions that make the world better for every three pieces of negative news. The article proposes, moreover, that viewers should only connect with news media that make a commitment to doing so. The article points to substantial evidence that suggests viewing or witnessing a positive or altruistic event makes it more likely that a person will undertake a subsequent altruistic action. Conversely, viewing a negative event perpetuates negative actions. While the effect for any individual instance of media exposure is small, this effect is dramatically multiplied by the vast number of people viewing media and the contagion that follows. We suggest that public health implications could thus be massive. Compounding this problem further, news media tend to have more viewers when they report on negative events because people are frightened. Since news outlets have an incentive to increase viewership, this has created a situation where most news is negative. We believe this comes with a severe cost to individuals and to society. Within our present context of COVID-19, and the yet further unrest surrounding the death of George Floyd, this may seem like an odd time to release this message. Our paper was in fact submitted last fall. It was scheduled for release in March, right around the time it became evident that COVID-19 was going to have a major impact throughout the entire world. We therefore requested that the journal postpone its release, which they were willing to do. Undoubtedly, what took place ought not to have occurred. Justice is demanded. Reforms are very much needed. The anger and indignation is clearly understandable. But what should the response then be? Is the ensuing looting, destruction, and further violence by some the best way forward? Is this another example of how one atrocious act can lead to many others, and which may be further amplified by media? Terrence Floyd, George Floyd’s brother, while undoubtedly suffering severely from the loss of his brother, nevertheless, commented this week concerning his brother and the violence: “He was about peace, he was about unity … the ripping up, the damaging your hometown: It’s not the way he would want ... That's not what my brother was about.” Negative news reporting is necessary. It is necessary to bring awareness to society’s ills and problems and to create the motivation and will to have them addressed. And our article acknowledges this. But we also need examples of actions that are positive, that build and show love and forgiveness, and that do so even in the midst of violence. In the words of Terrence Floyd, we need to “do something positive or make a change another way.” Thus, in addition to covering the protests, media outlets could also present examples of efforts to improve schools in disadvantaged neighborhoods, of volunteering within communities, and of contexts in which race relations are working well; and, along with advocating for much-needed police reforms, media could additionally advocate for community support of police, many of whom are truly trying to do their jobs well. This is not a setting aside of justice. Justice can be pursued without perpetuating further violence towards others. Seeking justice is compatible with love, and the seeking of the ultimate good of the other. In the words of Martin Luther King Jr., “What is needed is a realization that power without love is reckless and abusive… Power at its best is love implementing the demands of justice, and justice at its best is love correcting everything that stands against love.” We each need to be a part of the process that King describes: seeking to promote actions that are good and implementing the demands of justice in love. And for this, we need the assistance of one another, and we also need the assistance of the media, in its traditional forms and in social media. In order to encourage a shift in the media landscape, we argue that people should turn their attention to media outlets that help promote this seeking of the good and abandon those media venues that do not. Negative media reporting is necessary, but it also needs to be balanced in reporting that promotes the seeking of the good of others. This need for a change of focus is true even in our present circumstances. It is true amidst the atrocities that have recently occurred. It is true amidst the havoc that has been created by COVID-19 wherein repeated media exposure leads to increased anxiety, heightened stress, and adverse effects on health. It is true during the present upheaval with its contagion of violence and hatred. We need the reporting of what is good. We also need justice. We need love for one another and the seeking of the ultimate good of the other. And we need the media to assist in that task. Our proposal is simple. It is a call for news outlets to, at a minimum, report one positive story for every three negative stories. It is also a call for viewers to do their part by giving their attention to media venues that do so. This will facilitate the seeking of what is good and actions that promote love and goodness in the lives of others. This realignment is not to the neglect of justice, but rather always with the aim of bringing about peace, as Terrence believed his brother, George Floyd, would have wanted. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. References VanderWeele, T.J. and Brooks, A.C. (2020). A public health approach to negative news media: the 3-to-1 solution. American Journal of Health Promotion, in press. doi:10.1177/0890117120914227.

Helping others, building relationships, and finding happiness in hard times. By Tyler J. VanderWeele Ph.D. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. The emergence and rapid spread of coronavirus (COVID-19) have been threatening the world’s order, stability, and well-being. Many cities and countries are now under lockdown; many people have been infected, and many have died. The world’s economies are threatened. To what extent is it possible to flourish amidst this pandemic? There will inevitably be painful losses of health, of lives, of livelihoods, and of much that we hold dear. While we must do what we can to prevent or mitigate these, we must also accept that there will, despite our best efforts, still be terrible losses. We must prepare for these. However, we can also look for other ways to flourish, even during this time of uncertainty, difficulty, and loss. Doing so will better help us—on a personal and societal level—to overcome this crisis. Our framework for flourishing at the Human Flourishing Program at Harvard acknowledges that health-related and economic aspects of life (concerning which there will be losses) are central and important. Yet there are other important dimensions to flourishing as well: meaning and purpose, character and virtue, close social relationships, and happiness. We can still pursue these in various ways, even during these very difficult times. Helping Others In one of our recent research posts, we described how research indicates that volunteering, the helping of others, is an especially powerful pathway to enhancing meaning and purpose. Regular group volunteering activities may be more challenging during this time when large group gatherings are being discouraged. However, there are still numerous opportunities to help those around you. A neighbor in my townhouse association recently volunteered to pick up groceries for others, so that the elderly residents, for whom the virus seems particularly deadly, would not be exposed. You can find similar ways to help those around you, increasing your sense of purpose and meaning while shaping your habits towards kindness, helpfulness, and generosity. Further reflection upon right action and generosity towards others likewise calls into question the practice of hoarding food and resources for oneself, potentially resulting in systemic distributional failures. Instead, we should acquire only what is reasonably needed for ourselves and our family. This will ensure shelves are not empty. Considering others in this way is not easy. It requires us to embody principles of love and generosity towards others. Acting in this way helps us develop the virtues that are important for both our own flourishing and that of our communities. Strengthening Relationships During these challenging times, you can also seek to flourish by strengthening your relationships and friendships. This too is not entirely straightforward while “social distancing” policies are being put in place. However, if you live with family or friends, this can be a good time to invest—in a child, or a spouse, or a housemate—in ways that may not have been possible before, or which could not previously take place due to lack of time. You can also use the extra time confined at home to call a friend or a relative who you may have been out of touch with for a while. Call up a parent, or a grandparent. While some of the best public advice is for those over age 70 to self-isolate, this does not have to mean losing touch. Call regularly; use technologies and video calls that allow you to see each other’s face; offer to deliver groceries or other necessities if nearby, while still avoiding unnecessary contact. Start making it a habit to connect. Furthermore, you can use the time that is available to reflect more generally on your relationships. Are there any friendships that could be strengthened at a distance? Are there any relationships that are in need of reconciliation or forgiveness? Patterns of bitterness and resentment can hinder one’s relationships and undermine one’s own well-being. There are helpful resources that can be used to work through the process of forgiveness. This may be a good time to do so. All of these things might enhance close relationships. Finding Happiness There are also practices that can contribute to happiness, which for many seems particularly elusive at present. For example, there is considerable evidence that writing down (or sharing with others) three things for which you are grateful, three times a week, can considerably improve life satisfaction and alleviate depressive symptoms. You might consider doing this on the phone with friends or elderly relatives who may otherwise be isolated. Regularly practicing acts of kindness towards others likewise has been shown, even in randomized trials, to improve happiness. We have recently published a brief guide to evidence-based activities to improve various aspects of flourishing. Many of these, the evidence suggests, contribute to happiness and life satisfaction. While various institutional pathways to flourishing—such as family, education, work, and religious community—are likewise under threat, there is much that can still be done. Schools and universities have found creative ways to carry out teaching online. Parents are making efforts to teach their young children at home. Workplaces have found ways to work remotely. While many churches, synagogues, and mosques have now suspended their services, this can provide an opportunity for increased personal devotions and prayer or new practices of family religious rituals. Facing Suffering and Hardships While there are things that can be done to enhance various aspects of flourishing in one’s life, the actions above will not get us out of the crisis, nor prevent the losses associated with it. Six months from now, many of us may have lost a loved one. Many will have lost their jobs and a good deal of their savings. At this point, it is already clear that many of us will confront significant and painful losses in this crisis. For many of us, suffering will be inevitable. Suffering is not necessarily the opposite of flourishing. Suffering entails the experience of the loss of something good. It is painful. A holistic approach to flourishing requires a way to deal with and to confront the suffering that we will inevitably experience. While our research on suffering at the Human Flourishing Program at Harvard is still in its infancy, we have begun collecting data on suffering from over 1,200 factory workers in Sri Lanka and from over 5,000 international flight attendants. Our goal is to better understand how suffering relates to and affects flourishing over time. While there is, unsurprisingly, a negative correlation between the flourishing measures and the suffering measures in the data, that correlation, in fact, turns out to be relatively weak. It is possible, at least to some extent, to flourish amidst suffering. In the midst of suffering, we can still find ways to respond that promote at least some aspects of flourishing. We can respond to suffering by trying to understand the situation and by acknowledging the loss; by turning to others in our communities for support and comfort; by re-evaluating our values, desires, and purposes; by trying to find new meaning and opportunities for growth amidst suffering; by eventually trying to adjust to the circumstances, regain the good that was lost, or find new ways forward. The theological traditions we draw upon in some of our own work suggest that suffering can be viewed as an opportunity for growth, a sacrifice of the good that was lost for a greater orientation towards the transcendent and divine. However, all of these responses must acknowledge the reality of the suffering itself, the loss of something good or someone loved. The suffering that the present pandemic has brought about, and will bring about, is very real. While we can still try to flourish amidst loss and pain, we must accept that there will be suffering. Reflecting on Life Our confrontation with suffering, and even death, provides an important opportunity for reflection. What is it that we value most? What relationships might be in need of forgiveness or reconciliation? How is it that we are to understand our lives and our own mortality? These are not easy questions. For these, we must turn away from the data. We must turn towards our interior life, to those around us who are wise, to our rich theological and philosophical traditions, to try, as best as possible, to discern what it is that matters most. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. References VanderWeele, T.J. (2017). On the promotion of human flourishing. Proceedings of the National Academy of Sciences of the United States of America, 31:8148-8156. VanderWeele, T.J. (2019). Suffering and response: directions in empirical research. Social Science and Medicine, 224:58-66.

A new era for the study of wellbeing. By Tyler J. VanderWeele Ph.D. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. The Global Flourishing Study is a longitudinal research study being carried out in collaboration between scholars at the Human Flourishing Program at Harvard and Baylor’s Institute for Studies of Religion, and in partnership with Gallup and the Center for Open Science. The study will involve data collection for approximately 240,000 participants, from 22 geographically and culturally diverse countries, with nationally representative samples within each country, and with annual data collection on the same panel of individuals, with a rich set of survey items, for five waves of data. The panel will include individuals from Argentina, Australia, Brazil, Egypt, Germany, India, Indonesia, Israel, Japan, Kenya, Mexico, Nigeria, the Philippines, Poland, Russia, Turkey, South Africa, Spain, Tanzania, Ukraine, the United Kingdom, and the United States. These countries were selected in consultation with Gallup to maximize coverage of the world’s population, to ensure geographic, cultural, and religious diversity, and in consideration of existing data collection infrastructure and feasibility. This $43.4 million initiative is being supported by a consortium of funders including the John Templeton Foundation, the Templeton Religion Trust, the Templeton World Charity Foundation, the Fetzer Institute, the Paul Foster Family Foundation, the Wellbeing for Planet Earth Foundation, the Well Being Trust, and the David & Carol Myers Foundation. The study has the potential to transform and dramatically expand our understanding of human flourishing. The Contribution of the Study Prior research on flourishing has been severely limited by several factors. Much prior research on the factors that shape flourishing has relied upon cross-sectional samples, with all of the data collected at the same time. Reliance on cross-sectional data makes it difficult to provide evidence concerning causation. Much of the research on wellbeing has also been restricted to samples in the United States and Europe. The Global Flourishing Study will seek to address the present gaps in our research knowledge by using longitudinal data and more methodologically rigorous approaches and outcome-wide designs to examine how changes in various social, demographic, economic, political, psychological, religious, and character-related variables affect subsequent wellbeing and by employing a global probability-based panel study that includes people of diverse geographical, cultural, and religious backgrounds. The GFS will expand knowledge on the extent to which, and in what ways, many of the world’s largest nations are, or are not, flourishing, and why. Its longitudinal design will supply evidence concerning the causes of flourishing, while the large panel size and global scope, and nationally representative sampling will give insights from around the world. The study thus has the capacity to fundamentally advance our understanding of the societal determinants of human flourishing and to deeply enrich our knowledge concerning how this might vary by cultural context, and what might be universal. The Survey Items The design of the GFS has benefited from extensive feedback from a globally diverse group of scholars. Preparation for the study began in 2018 with a core set of demographic, religious, and wellbeing questions. Scholars from diverse disciplines were then asked to help select the best items for numerous important constructs related to the potential constituents and causes of wellbeing. The entire set of questions was sent out to scholars around the world for feedback and refinement, and to help address potential translational and cross-cultural issues. Open feedback was then solicited over a period of several months, with over 130 scholars and respondents contributing comments and suggestions. Based on this feedback, a revised survey was developed and then further refined in collaboration with Gallup following translational, cognitive testing, and piloting work. A full report on the survey development process from Gallup is available and the final set of questions that will be used in the Global Flourishing Study can be found in Appendix 2 of that report (p. 43-52). Some of the questions will be asked only at empanelment, and others will be asked every year. The study will include our own flourishing index assessment with 12 questions across 6 domains of human flourishing including happiness and life satisfaction, physical and mental health, meaning and purpose, character and virtue, close social relationships, and financial and material stability. But the wellbeing questions are not restricted to these twelve. Numerous other wellbeing items are also included, along with questions on demographic and economic characteristics, religion and spirituality, health, behaviors, character, childhood experience and upbringing, personality, community and social support, and political and national context. The first wave of data is anticipated to be available fall 2023. Open Data Access The Global Flourishing Study will be an open-access data resource that will be available to researchers, journalists, policymakers, and educators around the world. The data itself will be hosted by the Center for Open Science. Starting with the second wave of data collection, access to the data will be available to anyone without restriction one year following the data collection for each wave. Anyone can also access the data immediately upon release for specific analysis purposes by submitting a pre-registration of the proposed research to the Center for Open Science. Such pre-registration helps improve the credibility of analyses and helps avoid arbitrary data-fishing, especially in the early stages of the use of the data. The data will, however, ultimately be made fully open-access, without any restrictions on use, one year following each wave of subsequent data collection. We hope that by making the Global Flourishing Study data an open-access resource we will empower research on wellbeing all over the globe. The Future of Flourishing The Global Flourishing Study has the potential to powerfully advance our understanding of the distribution and determinants of flourishing. The data collection by Gallup will include countries in all six inhabited continents, representing nearly half of the world’s population, and will include five years of annual data collection. Its potential is extraordinary… but the study need not even be restricted to its present state. There is potential to add more countries and more waves of data. The project’s directors Byron Johnson at Baylor and Tyler J. VanderWeele at Harvard would be happy to speak to anyone who might be interested in funding additional countries, or additional waves. More information and commentary on the Global Flourishing Study can be found in our joint press release, in our joint press conference, and in the Questionnaire Development Report from Gallup. We are very grateful to all of the scholars, participants, and funders who have contributed so much to make this possible and we very much hope that the study will profoundly advance our understanding of how individuals and societies can flourish and that it will thereby contribute to people’s lives and advance the promotion of human flourishing. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. References Crabtree, S., English, C., Johnson, B.R., Ritter, Z., and VanderWeele, T.J. (2021). Global Flourishing Study: Questionnaire Development Report. Washington DC: Gallup Inc. VanderWeele, T.J. (2017). On the promotion of human flourishing. Proceedings of the National Academy of Sciences, USA, 114, 8148–8156.

The suspension of religious services and its alternatives. By Tyler J. VanderWeele Ph.D. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. This present pandemic has restricted our capacity to meet and be with others. Social distancing makes social relationships, and social connection, much more difficult. Indeed, it restricts communal gatherings. There is a large research literature that positively connects community, social relationships, and social gatherings to important health and well-being outcomes. Much of our own work at the Human Flourishing Program at Harvard has considered the potential effects of participating in a religious community on health and well-being. Our research, along with that of others, has provided evidence that religious service attendance has substantial protective effects on longevity, depression, suicide, psychological well-being and health behaviors, and, most recently, on preventing “deaths of despair." There is thus evidence that religious community contributes substantially to human flourishing. However, the present COVID-19 pandemic has resulted in the suspension of religious services in many places throughout the world. This has generally been necessary to prevent the spread of the infection. Love of Neighbor and the Suspension of Religious Services Some of those who participate in religious communities have argued that the spiritual good that comes out of religious services is in fact more important than the risk to physical health and that religious services ought to therefore proceed regardless of the risks. The problem with this argument is that coronavirus (COVID-19) is not just a disease but an infectious disease. Attending religious services, with their close person-to-person contact and their extended time of meeting, puts not only one’s own physical health at risk, but also that of one’s community, nation, and world. With this in view, an important theological principle in such cases is arguably love of neighbor: not putting one’s neighbor (and especially the elderly and vulnerable) at excessive risk by one’s actions. In most Christian understandings of this principle, love of God and love of neighbor are not to be pitted against one another. Rather the former entails the latter. We’ve recently developed these ideas further in a paper just published in Journal of Religion and Health to argue that, even from the perspective of the values and ends that religious communities and churches hold, the right course of action, when the epidemic is at its peak, has indeed been the suspension of religious services. In some places, the peak is now indeed past and some restrictions have been relaxed. Yet, it is the principle of love of neighbor that arguably ought to guide decisions and actions. Navigating the Suspension When meetings are suspended, this of course leaves open the difficult question of how religious people may cope with the loss of important spiritual resources that religious services provide and which, as our research has shown, contribute considerably to health and well-being. There is a real loss here. However, many religious communities have found ways to at least partially offset these losses. Many have moved to virtual services and webcasting. Others have established online discussion groups or studies of Scripture. Many others have encouraged increased personal and family devotion, prayer, and ritual. Some have even established “drive-through” prayer and confession. Each of these contributes, though none is likely to be a fully adequate replacement to the in-person meetings and community. To what extent do these alternatives truly provide a substitute? It is of course difficult to assess the effects on spiritual well-being of online versus in-person service. Moreover, we also do not yet know enough about the mechanisms by which religious services seem to exert such powerful effects on health. Some of the effects are inevitably social, but some are almost certainly also related to the specific content: a common purpose, vision, hope, and encouragement to love. It is likely the coming together of the social, and the distinctively religious values, that allows these communities to contribute so much to health and well-being. It is thus not entirely clear the extent to which the health, well-being, and spiritual benefits of such services will extend to these new forms of practice that have recently developed. Probably some will; and some will not. When the present pandemic has passed, it will be important to re-establish face-to-face meetings and services, rather than relying entirely on technological alternatives. Religious communities will also need to reflect on preparations for being able to meet again while navigating the social distancing measures that may still be in place. However, in many places, the virtual alternatives may, at least for some time, continue to be helpful partial substitutes. Indeed, a recent survey from Gallup has indicated that within the United States, because of the availability of these online alternatives, levels of weekly religious service attendance (of some form) at present is not in fact very different than it was a year ago, down from 32% to just 31%. Clearly, there is a strong interest in preserving some form of the religious life of these communities, even when face-to-face meetings are not possible. Promoting Love of Neighbor Very likely one of the means by which churches and religious communities improve health and well-being is by trying to live out the command to love one’s neighbor and seek the good of others. There have inevitably been failures, even abuse, in this regard within churches, and these failures need to be acknowledged and addressed, but ultimately it is that principle of love of neighbor that is to guide the interactions of the community members. This principle of love is more challenging at the present time with the social distancing measures in place. However, as we have discussed in a previous post, there are numerous possibilities to carry this out as well, including connecting with family and friends via phone or video-conferencing; helping out neighbors in need with practicalities and grocery deliveries; donating to charities that are seeking to provide help and relief; volunteering one’s time to medical practices providing care; seeking to restore relationships that may be broken and in need of forgiveness; investing more deeply in a spouse, child or housemate. All of these things can still be done at the present time. Assessing Love and the Promotion of Flourishing Much of our work at the Human Flourishing Program at Harvard has been devoted to the rigorous empirical analysis of pathways to well-being other than the consumption of material goods. Financial and material stability and safety are unquestionably an essential cornerstone for health and well-being. The present pandemic has made this clear in countless ways. However, people also care about more than physical and financial health. Our program is thus also trying to understand what gives rise to a sense of meaning and purpose, what brings true happiness, and what helps shape character, improve relationships, and contribute to spiritual well-being. These other aspects of flourishing are critical if we are to empower the flourishing of individuals and of societies. Based on the research that we and others have conducted, we are sufficiently convinced that love itself is a very important pathway to flourishing that we have recently decided to invest considerable effort in the years ahead on the difficult, indeed perhaps well-nigh impossible, task of trying to develop approaches to its quantitative assessment. While such quantitative assessment may seem far-fetched, the seeds of this idea were planted decades ago, even within public health and medicine. In 1955, Philip Solomon published a piece in the New England Journal of Medicine, entitled simply, “Love: A Clinical Definition.” He argued for the relevance of the concept of love within medicine. In 2000, Jeff Levin published a paper on the “epidemiology of love,” laying out what might be possible if the concept were better studied and employed within epidemiology and public health. Yet more recently, just last year, a relatively new health-care start-up, Devoted Health, declared its primary principle of market differentiation to be… love. Surely, the concept indeed deserves a more prominent role in our attempts to promote health and well-being, and it deserves more rigorous empirical study as well. Prior attempts at scale development for the construct of love have been made. But these have arguably been inadequate in their conceptual coverage of the construct. Our own past research has examined the importance of various aspects of love, including forgiveness and parental love, in shaping health and well-being. We hope to develop a more comprehensive assessment of love: one that considers both the giving and receiving of love and uses classifications and distinctions that have appeared repeatedly in much theological and philosophical literature. For example, we want to include both what one might call “contributory love”—seeking to contribute good for the beloved, and “unitive love”—seeking to be present with or united to the beloved. We also want to consider the various aspects of love across different types of interpersonal relationships, including parent-child, spouse, friend, God, neighbor, stranger, and even enemy. We anticipate this undertaking occupying several years of our research. As with our prior work on the measurement of meaning, we would first intend to compile a list of all previously proposed items for assessment and then categorize them according to distinctions from the philosophical and theological literature, employ those items that were most conceptually adequate, and supplement them with newly developed assessment items to help fill the remaining conceptual space. Further work would then be needed to evaluate the psychometric properties of the proposed measures. Though difficult, we think that this undertaking will ultimately prove worthwhile. It will help us better understand how the giving and receiving of love contributes to the health and well-being of individuals and communities. It will help us see how love shapes health, meaning, happiness, and relationships, as well as other aspects of character and spiritual life. We will be able to connect this to our other measurement assessment work on suffering, on spiritual well-being, on communities, on meaning, and on flourishing. It will help us understand how love can be encouraged and how it might contribute to a vast range of physical, psychological, social and spiritual ends. Understanding this will be important in general, and perhaps especially so during such difficult times as we now face. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. References VanderWeele, T.J. (2020). Love of neighbor during a pandemic: navigating the competing goods of religious gatherings and physical health. Journal of Religion and Health, in press. doi: 10.1007/s10943-020-01031-6.

Religious community associated with fewer deaths from suicide, drug, and alcohol. By Tyler J. VanderWeele Ph.D. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. Deaths of Despair Anne Case and Angus Deaton coined the term “deaths of despair” for deaths related to suicide, drug use, and alcohol poisoning in their influential 2015 paper. They argued that such deaths often share a context of hopelessness and indifference toward living. Deaths of despair have increased dramatically over the past couple of decades, and especially so for white men and women without a college degree. Recent trends have in fact been so severe that they led to reduced life expectancies in the United States for three consecutive years, in 2015, 2016, and 2017. This is the longest consecutive decline since World War I. Our recent paper at the Human Flourishing Program at Harvard, just published this month in JAMA Psychiatry, which also ran a podcast, explores the potential protective power of religious community in preventing such deaths of despair. Our Study Our study examined 66,492 women from the Nurses’ Health Study II and 43,141 men from the Health Professionals Follow-Up Study, following them for roughly two decades. We examined whether attending religious services was associated with a lower likelihood of death due to suicide, drug overdose, or alcohol in the roughly 20 years that followed. We controlled for numerous other characteristics including age, race, geographic region, income, health status, health behaviors, smoking, mental health, other forms of social support, and numerous other variables as well. What We Found The women in the Nurses’ Health Study II were followed from 2001, when religious service attendance was assessed, all the way through 2017. Compared to those who never attended religious services, participants who attended at least once a week were 68 percent less likely to die by suicide, drug overdose or alcohol, during the 16 years that followed. This was true even after controlling for a potentially wide range of confounding factors. For the men in the Health Professionals Follow-Up Study, followed from 1988 through 2014, those attending weekly, compared to not at all, were 33 percent less likely to die by suicide, drug overdose or alcohol, during the 26 years that they were followed. Our paper considered a wide range of sensitivity analyses to see if the results varied much based on different ways of analyzing and looking at the data and the results were quite consistent. These reductions in deaths are substantial. The reductions are of such a magnitude that they were covered in the headlines of the Harvard Gazette. Associations of this magnitude are worth considering further. Economic and Social Contexts The observed increase in deaths of despair over time is clearly worrying. Reflection is needed to address this problem. Authors Case and Deaton have argued that one cause is declining job opportunities for the working class, which leads to financial difficulties, frustrated expectations, and hopelessness. These problems are then amplified by declining social and family support structures, and declining marriage rates to which the economic difficulties undoubtedly also contribute. Struggles like these have moreover, and unfortunately, coincided with the increased availability and use of opioids which have in turn also contributed to an increase in these deaths of despair. The economic hardship and job-related difficulties are certainly an important context within which despair can arise. However, despair is not restricted to the working class or to economic struggles. Despair can arise any time seemingly insurmountable problems come up. One such context is clinician burnout. The increasing stresses placed on physicians, nurses, and other health-care professionals have led to increasing burn-out and decreasing job satisfaction. Studies have reported higher suicide rates among clinicians than the general public, perhaps especially for women. The increasing demands placed on healthcare workers during the pandemic of coronavirus (COVID-19) will likely yet further increase these stresses as potential causes of despair. We thus need to consider important resources for confronting despair and for preventing deaths from despair, both in these contexts and in others. Religious community may be one such resource. Religion and Confronting Despair Our study was not able to examine the mechanisms by which religious services seemed to prevent these deaths of despair. We will try to examine this in subsequent work. However, a number of mechanisms do seem plausible. Social relationships formed within a religious community may help provide support and encouragement when individuals face problems and are confronted with despair. Religious communities may also foster a sense of greater purpose that helps during times of struggle. Religious teachings on the value and inherent worth and dignity of each and every life, and teachings that suicide is therefore wrong, likewise likely contribute. Teachings on the responsibility one has for the care of one’s body may prevent riskier behaviors concerning excessive alcohol and the use of drugs. A belief or hope that God is present, or will provide a better future may also counter a sense of despair. Religious teachings may also help make better sense of suffering and assist people in finding meaning within suffering. Suffering itself, while inevitably difficult, may provide opportunities for growth in character, causing one to turn to transcendent sources of faith and hope and meaning, and may lead to re-evaluating one’s purposes and values. Such new meanings may likewise help prevent severe struggles with despair, and thereby also prevent deaths of despair. Religious communities may very well contribute in all of these ways, as an antidote to despair. While our study specifically concerned the role of religious community, other forms of communal participation are valuable as well and may be associated with lower suicide. However, that religious communities offer not only social support but also purpose, hope, and meaning within suffering may in part be why both we, and others, have found religious community more strongly beneficial for preventing suicide and mortality than other forms of social support. Social support and other forms of community life do matter. However, for those with religious commitments, communal forms of religious participation may be especially helpful. Moving Forward With the world in a state of crisis of the coronavirus pandemic, issues of despair may well be on the rise. Suicide rates in the United States have been rising for some time. We do need to approach these problems from a variety of perspectives including those concerning economic contexts, potential therapeutic approaches, and addressing the conditions that give to despair. However, we should also look at resources that help us confront despair directly. Religious community is one such resource. The data from our study provides strong evidence that this is so for health professionals. Further work could examine whether similar associations are also at play in difficult economic contexts currently confronted by the working class. Unfortunately, however, the present pandemic, itself the source of despair for many, has generally necessitated the suspension of communal religious gatherings. In a future posting, we will explore how individuals and communities might navigate these challenges when one of the most important means of confronting despair is seemingly inaccessible. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. References Chen, Y., Koh, H.K., Kawachi, I., Botticelli, M., and VanderWeele, T.J. Religious service attendance and deaths related to drugs, alcohol, and suicide among US health care professionals. JAMA Psychiatry, in press. DOI:10.1001/jamapsychiatry.2020.0175.

Why we need to study health and not just disease and risk. By Tyler J. VanderWeele Ph.D. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. About 20 years ago, psychologist Martin Seligman in his 1998 Presidential Address at the American Psychology Association called for more emphasis on what he referred to as “positive psychology,” conceived of as the science of human strengths. Seligman argued that “although psychology has come to understand quite a bit about how people survive and endure under conditions of adversity, we know very little about how normal people flourish under more benign conditions,” and he proposed ways to build an infrastructure around this “new science and profession of positive psychology.” While work on positive aspects of psychology had undoubtedly been taking place for decades previously, this empowering of the positive psychology movement had powerful effects on the way we think about promoting mental health today, and on the discipline of psychology as a whole. But what about physical health, and what about other disciplines? Today we ask you to consider with us whether a similar perspective change is needed in epidemiology and public health policy. Positive Epidemiology? Several of us at the Human Flourishing Program, along with our collaborators at Harvard’s Lee Kum Sheung Center for Health and Happiness, just published a commentary entitled Positive Epidemiology? This article is intended to explore this issue of whether epidemiology—the branch of science that deals with the distribution and determinants of disease and health—might itself benefit from a re-balancing of priorities, similar to what has happened in psychology. We believe that it would. This is not to deny that epidemiologists or public health officials have indeed sometimes studied the positive aspects of health—sometimes referred to as “health assets”—but, as was the case with psychology, the emphasis has been on reducing the negative elements of health. The focus has been on diseases and their related risk factors. Epidemiologists tend to ask questions about what causes disease, how diseases spread, and other related issues. This perspective has tended to predominate, rather than the study of health and health assets. We propose that a shifting of the balance is desirable. What Is Public Health Missing? You may have seen us argue elsewhere that various pathways to flourishing, such as family, religious community, education, and work all contribute substantially to population-level health and well-being. While education and employment do receive some attention in the epidemiologic literature, family and religious community receive much less. By neglecting these pathways, we are limiting our understanding of what is shaping health at a population level concerning outcomes ranging from longevity to depression and suicide. Everyone cares about physical health. But people also care about being happy, having a sense of meaning, trying to be a good person, and having good relationships and community. In neglecting these positive aspects of health and well-being, and by focusing predominantly on disease and risk factors, public health officials and researchers neglect the full range of things that people care about in life. Furthermore, in our commentary, you will see evidence that these other positive aspects of life also, in fact, shape health and even longevity. But these health assets are also sought for their own sake. Moreover, sometimes there are trade-offs between physical health and these other ends. There can be trade-offs, for example, in medical decision-making. And there may be trade-offs in varying associations with specific “exposures.” Ignoring these trade-offs in our epidemiologic studies and in their interpretation leads to myopic conclusions. One study published a few years ago reported an association between divorce/separation and reduced body mass index. This may indeed be the case. But without also examining outcomes such as happiness, mental health, meaning, relationships, and divorce’s effects on children, the study does not give an adequate picture of the full effects on health and well-being, even though there may not be anything wrong with the study scientifically. A move toward positive epidemiology and an examination of other positive outcomes could help correct this short-sightedness. The Way Forward We are certainly not arguing for an abandonment of the more traditional focus of epidemiology on topics such as cardiovascular disease, cancer, and infectious disease. These are critical topics in supporting population health. Recent concerns about coronavirus, and in fact any actual experience of disease, make very clear that considerable weight ought to be given to these topics, as indeed has been the case in the past. However, we do think more research and resources ought to be devoted to “positive” aspects of health as well. One way to help facilitate that shift is the inclusion of measures of positive well-being outcomes in our epidemiologic cohort studies. Our own brief flourishing measure, consisting of a total of just 12 short questions, across 6 domains of life, was intended as one straightforward way to facilitate this enhancement. We have also been trying to develop unique data resources specifically oriented to the study of positive outcomes. Epidemiology has a powerful set of methodological tools to uncover causal pathways, and these same tools could be employed to attempt to understand the determinants of not only physical health but also happiness, meaning, character, and close relationships as well. Open Questions What are the open questions? If we are to move forward toward a more positive epidemiology, one important set of questions concerns resource allocation. Even if a convincing case can be made to invest substantially more in the study of positive health and well-being and positive health assets, how far should the balance really shift? Another difficult set of questions concerns disciplinary boundaries. Are these topics truly an appropriate object of study for epidemiology? Should they not be left to the “positive” psychologists? While this might seem a reasonable position on the face of it, the fact that we know that various positive psychological and social factors can shape physical health would arguably be reasonable grounds that their study is important for epidemiology. We hope to contribute to interdisciplinary dialogue on these important topics at the Human Flourishing Program. A final set of difficult questions concerns what we really mean by “positive?” Is employment “positive,” or is it simply to be understood as the absence of unemployment? Is “positive” simply the absence of the “negative?” And, if so, might our traditional emphases concerning disease and risk factors for disease, in fact, be sufficient? These are difficult conceptual questions. At the Human Flourishing Program, we do believe that the distinction is important and real. We tend to think of “positive” as that pertaining to some good that is sought as its own end; that which is “negative” is then that which pertains to the loss of some good that is sought as its own end. Happiness, health, meaning, virtue, and relationships are all sought as their own end. Trying to delimit the precise boundaries of what is meant by “positive epidemiology” would undoubtedly require further conceptual work. It would require more reflection, as a community, on goods and on those final ends we are seeking. But that reflection may, in and of itself, also prove valuable. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. References VanderWeele, T.J., Chen. Y., Long, K.N., Kim, E.S., Trudel-Fitzgerald, C., Kubzansky, L.D. (2020). Positive epidemiology? Epidemiology, 31:189-193.

How supportive employment programs can help some of the most disadvantaged. By Tyler J. VanderWeele Ph.D. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. Many people have a love-hate relationship with work. It can provide an income, but it can also be tedious. It might give a sense of meaning and purpose, but can sometimes be all-consuming and lead to burnout. The workplace can provide a source of social relationships, but it can interfere with time with friends and family. These sets of trade-offs may lead one to wonder what the net contribution of work on flourishing truly is? Our prior review and survey of the evidence found that, on the whole, the effects of work on well-being are profoundly positive. Work as a Pathway to Flourishing On average, work tends to increase one’s satisfaction with life, contribute to mental and possibly even physical health, give a sense of meaning and purpose, allow for character growth, provide an opportunity for social relationships, and of course provide an income as well. This assessment of the effect of work on flourishing is applicable on average, and may not apply for each and every individual. For some, exposure to a hazardous work environment, or excessive working hours, may indeed decrease their flourishing. But on average – averaging all positive and negative experiences – the effects of work on flourishing do seem to be positive. How Far Does it Extend? We might wonder, however, how far these benefits extend. Maybe it is the case that work is good for those who are already well-off, but that for those who are struggling, or who are lower in the socio-economic spectrum, perhaps work ends up being oppressive. One of the recent papers from the Human Flourishing Program at Harvard, published earlier this year, attempted to provide analyses to help answer certain aspects of this question. We used meta-analysis techniques, that combined the results across many studies, to specifically evaluate the effects of supportive employment programs in providing work for those with mental health challenges. Supportive Employment Supportive employment is an approach to help those with some identified disability to find competitive employment. Traditionally, the disability was severe mental illness, but the approach has been expanded in recent years to cover a range of mental and physical conditions such as spinal cord injuries in veterans as well as affective disorders. Important to the approach, individuals are supported in their efforts to find competitive employment right from the beginning and do not have to wait until they have finished some treatment program or training program. Treatment and/or training may be offered, but this takes place concurrently with the employment assistance or employment itself. This is a move beyond previous programs that often had a stepwise implementation wherein “patients” would receive clinical care and perhaps elementary vocational training prior to seeking employment. They would then often receive a time-limited job placement, developed by the rehabilitation agency, where participants would work in preparation for a competitive job. Supportive employment approaches build on the idea that employment itself contributes to well-being and that mental health issues can be addressed concurrently with an employment search. Participants are thus offered help in support of actual competitive positions that they may hope to retain for a longer period of time. What We Found Our study sought to evaluate all of the evidence from rigorous randomized trials of such supportive employment interventions and assess their effects on a wide range of outcomes. We found that those who received supportive employment interventions were 63% more likely to find competitive employment during the study, and they were 79% more likely to still be employed at the end of the study. Those receiving supportive employment intervention were employed on average for a considerably longer period of time and received considerably more income from their employment (about half a standard deviation greater on both of these outcomes). What about quality of life? These effects were more heterogeneous: it seemed that the interventions improved quality of life in some settings, and perhaps did not have much effect on the quality of life in other settings. Importantly, however, these supportive employment interventions did not magically “fix” all problems. There was little evidence, for example, that the supportive employment interventions improved the mental health of the participants. Employment is certainly not a panacea to fix all problems. Numerous approaches to improve flourishing, including work, but extending beyond work and employment, are certainly needed. And this study in particular indicated that while the supportive employment interventions improved employment and income, and sometimes quality of life, further help from mental health professionals would generally be needed in order to address the often severe mental health issues of those that enrolled in these studies. On the whole, however, these supportive employment interventions clearly improved several aspects of well-being. Implications? The research has potentially important policy implications. The fact that these supportive employment interventions can be used to help those even with fairly severe disability provides an important tool to help some of the most disadvantaged in society. It is a tool that may be preferable to or could supplement more traditional welfare programs. While providing individuals in need with welfare payments can indeed help meet their material needs, the flourishing of a person requires more than that. Flourishing includes also having a sense of purpose, having good relationships, opportunities to develop, and satisfaction with life. Work and employment can be one means to help achieve these other aspects of flourishing. By helping those in need find employment, they are equipped not only with income, but with potentially meaningful work that contributes to society, and can help them flourish in various other ways as well. Work is certainly not the only pathway to flourishing, but it is often an important one. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. References Frederick, D.E. and VanderWeele, T.J. (2019). Supported employment: meta-analysis and review of randomized controlled trials of individual placement and support. PLoS One, 14(2):e0212208.

An erroneous paper on religion and generosity is finally retracted. By Tyler J. VanderWeele Ph.D. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. In 2015, a paper by Jean Decety and co-authors reported that children who were brought up religiously were less generous. The paper received a great deal of attention, and was covered by over 80 media outlets including The Economist, the Boston Globe, the Los Angeles Times, and Scientific American. As it turned out, however, the paper by Decety was wrong. Another scholar, Azim Shariff, a leading expert on religion and pro-social behavior, was surprised by the results, as his own research and meta-analysis (combining evidence across studies from many authors) indicated that religious participation, in most settings, increased generosity. Shariff requested the data to try to understand more clearly what might explain the discrepancy. Questioning the Reports To Decety’s credit, he released the data. And upon re-analysis, Shariff discovered that the results were due to a coding error. The data had been collected across numerous countries, e.g. United States, Canada, Turkey, etc. and the country information had been coded as “1, 2, 3…” Although Decety’s paper had reported that they had controlled for country, they had accidentally not controlled for each country, but just treated it as a single continuous variable so that, for example “Canada” (coded as 2) was twice the “United States” (coded as 1). Regardless of what one might think about the relative merits and rankings of countries, this is obviously not the right way to analyze data. When it was correctly analyzed, using separate indicators for each country, Decety’s “findings” disappeared. Shariff’s re-analysis and correction was published in the same journal, Current Biology, in 2016. The media, however, did not follow along. While it covered extensively the initial incorrect results, only four media outlets picked up the correction. In fact, Decety’s paper has continued to be cited in media articles on religion. Just last month two such articles appeared (one on Buzzworthy and one on TruthTheory) citing Decety’s paper that religious children were less generous. The paper’s influence seems to continue even after it has been shown to be wrong. Last month, however, the journal, Current Biology, at last formally retracted the paper. If one looks for the paper on the journal’s website, it gives notice of the retraction by the authors. Correction mechanisms in science can sometimes work slowly, but they did, in the end, seem to be effective here. More work still needs to be done as to how this might translate into corrections in media reporting as well: The two articles above were both published after the formal retraction of the paper. Religious Upbringing and Flourishing in Young Adulthood Our own research on the topic at the Human Flourishing Program at Harvard, published last year in a paper in the American Journal of Epidemiology, has likewise suggested results more in line with Shariff’s meta-analysis. Moreover, rather than looking at whether religious children are more or less generous as children, we examined how a religious upbringing shaped children over time from adolescence into young adulthood. We found that during childhood and adolescence, those who attended religious services regularly were subsequently 29 percent more likely to have high levels of volunteering than those who did not. Those who attended services regularly were also 87 percent more likely to subsequently have high levels of forgiveness; and those who prayed and meditated regularly were 47 percent more likely to have a high sense of mission. Again, the effects of a religious upbringing seemed to contribute to a greater generosity toward others many years later during young adulthood. Our study also indicated that those who were raised religiously were also protected from what are sometimes called the “big three” dangers of adolescence: depression, drug use, and risky behaviors. They were also more likely to have higher levels of happiness in young adulthood. In addition to the primary research paper, we also published a more accessible summary of the study and results for a general reader with the Institute for Family Studies, and earlier this year we published an op-ed in USA Today exploring what our results might mean for parents. The Christian Medical and Dental Association ran a recent podcast on the research. Implications for Families? The implications for families and parents arguably need to be more nuanced. While health and generosity are very important to people, decisions about religion are usually not made only on those grounds. Rather, religious beliefs and commitments are shaped by values, systems of meaning, experiences, relationships, evidence, and truth claims about the divine. These are the types of considerations many parents use in making decisions about religious commitments with regard to their family. While the evidence from our study and others may make the benefits of religious practice clear, recent sexual abuse scandals have left many parents wondering whether they should pull children out of religious communities. Certainly, these instances of abuse need to be addressed and justice served, and those who covered up the abuse cases need to be held accountable. However, what our research indicates is that, on average, the effects of religious community are profoundly positive. These are averages across all positive and all negative experiences; they do not in any way excuse the incidents of harm by religious leaders or institutions, but they do make clear the substantial benefits of religious practice overall. Ceasing those practices could, on average, likely lead to worse health and well-being outcomes. It would, on average at least, lead to more harm than good. The sexual abuse scandals need to be addressed, but abandoning religious practice may not be the best response. Modern life is busy, and it can take a strong commitment to participate in a community, to set time aside for prayer or meditation, and to encourage children in these practices. Our study suggests that for those who already hold these beliefs, setting such time aside in parenting, and for adolescents to engage in these practices, is worthwhile. The evidence to date does suggest that for those who already hold religious commitments, participation in religious community will increase generosity, and general well-being, in addition, of course, to religion’s primary end of approaching the divine. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. References Chen, Y. and VanderWeele, T.J. (2018). Associations of religious upbringing with subsequent health and well-being from adolescence to young adulthood: an outcome-wide analysis. American Journal of Epidemiology, 187:2355–2364.

The effects of media may be small, but they are not irrelevant. By Tyler J. VanderWeele Ph.D. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. Does it matter what we watch, or what sort of media we consume? This question has been debated in various forms. One particularly heated topic, especially in psychology, has been whether violent video games lead to greater levels of aggressive behaviors. Some studies have indicated yes; others have suggested no. The existing meta-analyses, which attempt to aggregate all of the available data and studies, are themselves divided. What is one to think? Trying to Resolve the Disputes At the Human Flourishing Program at Harvard, we aim to make use of sophisticated statistical methods to help address these sorts of controversies. In the case of the meta-analyses on video game violence, some of the problems have been an exclusive focus on just the “statistical significance” of the estimates; one meta-analysis indicates “yes, statistical significance,” and another not. The problem may be that there is not a single answer; video game violence may matter in some circumstances, but not in others. The effects may be heterogeneous. Earlier this year, we, published new metrics for assessing meta-analyses that better account for such heterogeneity. When these new approaches were applied to the question of video game violence, we were able to show that, although there are indeed some disagreements across the competing meta-analyses, there is also a lot of agreement. (See our paper published last month in Perspectives on Psychological Science for technical details). Specifically, the meta-analyses, including those that claim “statistical significance” and also those that do not, indicate, when using our metrics, that in the vast majority of circumstances, video game violence does increase aggressive behavior, but in almost all such contexts, the average effects are relatively modest. Thus, video game violence does seem to increase aggressive behavior, by at least a little. But the various meta-analyses also agree that violent video games would rarely increase the likelihood of high levels of aggressive behavior by 40 percent. Some disagreements remain, such as in how many contexts (e.g., different types of games) playing these games increases the likelihood of high levels of aggressive behavior by 20 percent–40 percent. But the data from all these studies seem to agree that there are usually at least small detrimental effects. Practical Implications So… does this matter in practice? Sometimes these video game studies are criticized for the fact that they really tell us nothing about longer-term outcomes, and this is indeed mostly true. Most of the experimental studies carried out in laboratory settings only assess very short-term effects of playing, versus not playing, a violent video game on one particular occasion. However, small effects, across millions of people, can add up. Moreover, if one is to take theories of character development seriously, then character and behaviors are shaped by the formation of habits and repeated actions across many settings. This would suggest that if violent video games are played frequently, as indeed they often are, this might have at least some effects on one’s character. The effects on an individual occasion are almost certainly small, but, over many occasions, they might be non-negligible. Mass Shootings? There has been a recent discussion as to whether violent video games might play a role in bringing about mass shootings, with many of the media reports claiming that scientific research had disproved this. Our research was even cited in a recent New York Times piece about this very question. But as indicated above, one limitation of the data is that the most rigorous studies are done in lab settings, and long-term outcomes are not measured. Although the lab data suggests that effects on average are small, small effects on average are compatible with effects that are, for particular individuals, large or determinative. It is unlikely, however, that being randomized to play a violent video game, on one specific occasion, is going to lead to a mass shooting. Thus, laboratory experiments do not really provide the right type of data to sort out how important video game violence may, or may not, be in giving rise to mass shootings. The media reports which claim that video game violence plays no role in mass shootings are not justified; but nor are the media reports that blame the shootings on video games. The truth is that we simply do not know. The right studies have not been done. Even our more nuanced analyses are compatible with video game violence playing an important role in a mass shooting, and compatible with their being entirely irrelevant. A different type of study (e.g., which assessed violent video game practices retrospectively for those who carried out mass shootings and how that compared with the general population, controlling for other variables) would be needed. Suicide Some of these considerations are also relevant to other forms of media. There has been a recent debate on whether media portraying suicide might increase the likelihood, for those viewing, of attempting suicide themselves. Once again, our new metrics can be helpful. Our research on the topic of suicide was recently published in JAMA Psychiatry and indicated that in about two-thirds of the settings (different movies, television shows, etc.), the media portrayal of suicide increased subsequent suicide rates, but that in about one in five settings, the portrayal may have even had moderate protective effects, though considerably less often than they were detrimental. Again, the effects are relatively small, but small effects across many people can add up. For example, another recent analysis in JAMA Psychiatry indicated that the release of the Netflix series 13 Reasons Why, which portrays a young girl’s suicide, resulting in excess of 103 adolescent suicides, even after controlling for prior temporal and seasonal trends. It would seem not a good idea here to say because study effects are “small,” these 103 adolescents who took their own life do not matter. A Better Way Forward for Flourishing The results of these various studies certainly do not imply we should resort to some form of extreme censorship or impose restrictions on freedom of speech. However, we do think the evidence concerning the effects of various forms of media should be made clear, and producers should at least be aware of it when making decisions. Moreover, from the consumer’s perspective, while the effects are mostly small, there are, of course, numerous ways to make use of one’s leisure time. A focus on what is good, admirable, and noble may be more conducive to flourishing than playing violent video games or watching media depictions of suicide. Receive Tyler's monthly insight and research updates from the Human Flourishing Program team. References Mathur, M. and VanderWeele, T.J. (2019). Finding common ground in meta-analysis “wars” on violent video games. Perspectives on Psychological Science, 14:705-708. VanderWeele, T.J., Mathur, M.B., and Chen, Y. Media portrayals and public health implications for suicide and other behaviors. JAMA Psychiatry, Published online May 29, 2019. doi:10.1001/jamapsychiatry.2019.0842.