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she and her brother were removed from their home by the city’s child protection bureau, separated from each other, and placed in foster care. Ever since, she had been ricocheting through the system, staying for a week or a month or a year in each foster or group home until, inevitably, tensions escalated over food or homework or TV, and she ran away or her caregivers gave up. Then it was on to another placement. In the previous six years, she had cycled through nine different homes.
    When I met Monisha, in the fall of 2010, she had just turned eighteen, and three days earlier, she had been emancipated from the foster-care system in which she had spent almost half her life. Her most painful experience, she told me, was the day she was placed in foster care. Without any warning, she was pulled out of class by a social worker she had never met and driven to a strange new home. It was months before she was able to have any contact with her father. “I remember the first day like it was yesterday,” she told me. “Every detail. I still have dreams about it. I feel like I’m going to be damaged forever.”
    As we sat in the therapy room at the clinic, I asked Monisha to describe for me what that damage felt like. She is unusually articulate about her emotional state—when she feels sad or depressed, she writes poems—and she enumerated her symptoms with precision. She had insomnia and nightmares, she said, and at times her body inexplicably ached. Her hands sometimes trembled uncontrollably. Her hair had recently started falling out, and she was wearing a pale green headscarf to cover up a thin patch. More than anything, she felt anxious: anxious about school, anxious about her young daughter, anxious about earthquakes. “I think about the weirdest things,” she said. “I think about the world ending. If a plane flies over me, I think they’re going to drop a bomb. I think about my dad dying. If I lose him, I don’t know what I’m going to do.” She was even anxious about her anxiety. “When I get scared, I start shaking,” she said. “My heart starts beating. I start sweating. You know how people say ‘I was scared to death’? I get scared that that’s really going to happen to me one day.”
    The firehouse metaphor might help us understand what was happening with Monisha Sullivan. When she was a child, her fire alarm went off constantly, at top volume: My mom and stepmom are punching each other; I’m never going to see my dad again; no one’s home to make me dinner; my foster family isn’t going to take care of me. Every time the alarm went off, her stress-response system sent out all the trucks, sirens blaring. The firefighters smashed in some windows and soaked some carpets, and by the time Monisha turned eighteen, her biggest problem wasn’t the threats that she faced from the world around her. It was the damage the firefighters had done.
    When McEwen first proposed the notion of allostatic load, in the 1990s, he didn’t conceive of it as an actual numerical index. But recently, he and other researchers, led by Teresa Seeman,a gerontologist at UCLA, have been trying to “operationalize” allostatic load, to produce a single number for each individual that would express the damage that a lifetime of stress management had imposed. Doctors use comparable biological-risk indicators all the time today, most notably blood pressure measurements. Those numbers are obviously useful as predictors of certain medical conditions (which is why your doctor takes your blood pressure every time you visit his or her office, no matter what ailment you might be there for). The problem is, blood pressure readings alone are not precise measures of future health risks. A more accurate allostatic-load index would include not just blood pressure and heart rate but other stress-sensitive measures: levels of cholesterol and high-sensitivity C-reactive protein (a leading marker for cardiovascular disease); readings of cortisol