Welcome! Hope you don’t mind the company - I’ve invited a couple of Lord of the Rings Elves to share with us warm slices of Mom’s apple pie. Crispy crumble topping, heaps of sugary thick-cut apples, fresh out of my oven. Yum! I’m serving it up with a dollop of history and a shake of statistics.
Last week, we played “Truth or Fiction” with headlines like, “eat a low fat diet to extend life” versus “make sure you get at least a pint of olive oil in your diet every week.” So, if you follow my advice, I’m predicting you’ll live a healthier and longer life. By the end of this week, I want you to see if you consider immortality unarguably good. I’ve just asked the elves and they don’t think so. Really?
First things first - switching from Just You to You and the Other 8 billion Yous.
The science of body counts, the basis for how we think about living and dying on a population level, began with a water pump. One of my heroes, Dr. John Snow, a London physician, noticed in the 1850’s that deaths clustered in neighborhoods. Armed with nothing but a map and a notebook, he realized that among London victims, addresses bunched around Broad Street where all the nearby folk got their water. Although his contemporaries thought all disease was spread by air vapors, the Victorian authorities tested his crazy theory and screwed off the pump handle. And voila – people stopped dying.
But the story gets even better. London was drowning in its own filth. In the hottest months of 1858, called the “Great Stink”, the sewage-filled Thames got so putrid and smelly that Parliament, housed along its banks, had to soak its curtains in chloride of lime to keep its members from fainting. They responded by funding the first city-wide sewer system and the first mandatory, national program for counting deaths - the British Births and Deaths Registration Act of 1836.
Our stats today about death follow that almost 200-year-old blueprint. As a medical intern, I remember traipsing down to a dim room in the basement to fill-out death certificates – not my favorite job. I hated it because I had to write in a single cause of death even when multiple factors contributed and sometimes had to shade the truth when families asked me to avoid labeling the cause as suicide, drugs, or AIDS. But. in general, our stats are pretty accurate
We all want to live longer. What happens then?
First, the good news: We live a whole lot longer than our ancestors and it’s mostly because we’ve wiped out infectious diseases like plague and smallpox and yellow fever and dysentery. It’s one of humanity's greatest achievements. Today instead of dying young from sudden infections, we die old from chronic, manageable diseases. Get your arms around this:
In 1900 America:
Over 30% of infants died before their first birthday
Average life expectancy was just 48 years
Infectious diseases were the leading killers
Today's #1 and #2 killers - heart disease and cancer - ranked only fourth and eighth in the 1900's death threat list.
Today’s America:
Infant mortality has plummeted to 0.28% (2.8 per 1,000 births)
Life expectancy has reached 79 years
Chronic diseases are now what deep sixes us.
For 10,000 years, life expectancy barely budged. Then came sanitation, vaccination, and antibiotics. Yes – vaccination. Smallpox, for instance, a virus that once swept through and wiped-out young and old in entire cities was eradicated by a vaccine. In the past decade, when parents stopped vaccinating their children, in response to the only paper (since proven to be falsified for personal gain) to ever implicate childhood vaccinations in autism, epidemics swept through their communities, killing and maiming hundreds of innocents.
Antibiotics, like penicillin first marketed during WWII, changed everything. But don’t get complacent. One of the biggest threats to humanity today is that bugs are outrunning us in their ability to overcome the benefits of these miracle drugs through resistance.
Covid was a shocking wake-up call that at any moment, a new pandemic might emerge and take a terrible toll. The nay-sayers who don’t believe that vaccines reduced deaths from Covid are just plain wrong. A 2024 publication in BMC Infectious Diseases showed that in 25 Randomized Clinical Trials of 22 vaccines, almost all reduced the risk of symptomatic Covid by over 90% with no more adverse events than in the non-vaccinated group. Post-vaccination, the chances of dying from Covid plummets.
Now, the bad news: U.S. life expectancy sucks despite Americans priding ourselves on having the world’s most advanced medical technology. We rank 48th in longevity, behind all of Europe and Canada, but also Costa Rica, Panama, Chile, and even Albania. To make matters worse, healthcare takes twice the bite out of our pocketbooks as compared to any other developed country.
A 2020 study comparing an American to a Brit found that given identical behavioral risk and demographic factors, the Brit lived a year longer than the American. Why? Their system is all about prevention - every citizen has a general practitioner monitoring the basics: blood pressure, blood sugar, weight, diet, exercise, and smoking. Meanwhile, less than half of Americans get regular preventive care. Residents of the UK live longer and remain healthier until the end of life. Isn’t that what we all want as we age?
In another research paper, from 2019, just 52% of Americans rated their healthcare as excellent/good, compared to 60% of UK National Health Service users.
What's the American healthcare system to do? As you know, I’m not short on opinions so here’s what I think. First, cut the fat. One-third of U.S. healthcare spending produces no value – it’s pure waste. Limiting or taxing massive profits made by our “non-profit” healthcare institutions might be a start.
Second, some central oversight might help - we're the only developed nation in the world that has a system that evolved with no rhyme or reason. There’s one exception. The Veterans Affairs system, serving nine million Veterans. On every survey and every metric, VA hospitals outperform privates. Patients are more satisfied, hospitals are cleaner, more Veterans get referred to palliative care before they die (86% as compared to less than one third in private hospitals) and Vets are more likely to have an Advance Directive (72% vs. less than 40%). So, at the end of life, ex-soldiers are more likely to have pain-free, choice-driven deaths. If that’s not enough to convince you, I’ll add that better VA care is delivered at a lower cost. That means more money for other programs like Social Security and Medicare
The Aging Challenge: A Global Paradox
Our increasing life expectancy is a two-sided coin. Global population is projected to reach 10.4 billion by 2086, with us oldsters driving the growth. More humans on the earth both heat the planet and inflame tempers. Take the looming "water wars". Drought drives about 10% of immigration now and this will get worse – much worse. Or that climate change from greenhouse gases is produced by more people needing more energy.
But today’s population explosion is not due to too many children. It’s because people live longer.
If anything, we are making too few babies. Demographers call this the problem of the "Upside-down Pyramid" - too few young supporting too many old. Birth rates are well below the 2.1 needed to replace the current population and provide stability. For example, Hong Kong’s is 0.8 births/woman, South Korea, 0.9, and China, 1.2. The U.S. rate of 1.7 is higher, but our population is still declining. Asian countries have started offering cash incentives, free education, and generous parental leave to solve the problem, with no success. If birth rates remain low, Social Security will crash (within a decade in the U.S.), businesses will collapse for want of workers, and food shortages for want of farm labor. Not pretty.
The reality no one is willing to talk about - even whisper about - is that living well past the point that life has no quality is not (at least according to my elf friends here) - such a human good. On the other hand, will I or you be the ones to reject heroic measures if we still have any possibility of a few more weeks or months?
TAKE HOMES: As a public health professional, I've wrestled with aging's paradox my whole career. Our most cherished possession – longer life - is killing our planet and threatening the welfare of our children. If there ever was a devil’s dilemma, this is it. What’s good for you and me is a mess for mankind.
I've come to believe that there is no free lunch. I think your goals should be:
Live disability-free until the end
Reduce your individual environmental footprint
Consider not only your pain and suffering if you chose extreme measures at the end of life but also the future of your children and grandchildren
Join the conversation – Don’t be shy. This stuff is pretty controversial. Let me know what you think in the comments. And don't forget to visit Fully Informed Conversations (https://www.fullyinformedconversations.org/)
Livingly yours,
Mom
(Roberta Ness, MD, MPH)
What a wonderful read!
I’m reminded of a thought I heard a number of years ago: “Dad’s life would have been perfect if he’d just lived 5 years less.”