In 1900, life expectancy in the U.S. was 47 years for men and women combined. By 2025, the figure had risen by about 32 years. Many U.S. citizens attribute this increase to the development of modern medicine and widespread availability of antibiotics. However, while antibiotics have indeed contributed, they are overshadowed by changes that most of us take for granted and simply do not think about.
Treatment of public water supplies, mainly through filtration and chlorination starting in the early 1900s, played a major role in boosting U.S. life expectancy from 1900 to 2025. These measures largely eliminated waterborne diseases like typhoid fever and diarrhea. Such interventions accounted for about half of the total mortality decline in major cities between 1900 and 1940, including three-quarters of infant mortality reductions and nearly two-thirds of child mortality reductions.
By controlling infectious diseases via clean water and sanitation, public health advances contributed to 25 of the 32 years gained in U.S. life expectancy during the 20th century. Overlapping these contributions were several other important factors: vaccinations for influenza, pneumonia, smallpox, diphtheria, whooping cough, tetanus, polio, measles, mumps, and rubella drove major mortality drops, contributing to U.S. life expectancy gains of over 25 years since 1900. These days, one almost never hears of these diseases in the developed world, except in U.S. states where anti-vaxxer zealots have been able to challenge mandatory school vaccinations. Other contributors included improved motor-vehicle safety (mandatory use of air bags and seat belts), safer tools in workplaces, safer and healthier foods (particularly for mothers and their babies), family planning, effective birth control, access to abortion, lower teen pregnancy rates, and recognition of tobacco and alcohol use as health hazards.
However, fixing health problems after they occur is both very expensive and not nearly as effective as preventing these problems in the first place. Medical interventions like antimicrobial treatment and chronic disease therapies accounted for only five years of the 32-year growth in overall life expectancy. Development and implementation of these therapies also contributed major components to the presently almost prohibitive cost of health care in America.
An ounce of prevention is worth a pound of cure
As the author has written elsewhere, Americans are our own worst enemies when it comes to health care. Diet, physical inactivity, and obesity are among the top lifestyle factors that contribute to adult mortality in the U.S., often linked to heart disease, stroke, and diabetes. Poor diet quality, particularly high sodium intake, excessive processed meats and sugars, and low consumption of fruits, vegetables, nuts, and whole grains, accounts for roughly 45 percent of cardiometabolic deaths. Inadequate physical activity contributes to about 8 to 10 percent of premature deaths in adults over 40, with higher impacts among older citizens.
Another factor driving U.S. health care costs is medical education, varying significantly by school type and residency status. Recent estimates indicate medical school costs from about $162,000 in public universities to $265,000 or more in private universities. This does not include the cost of four years of pre-medical education, plus up to three years of reduced wages in hospital internship and fellowship training. Nearly one in three clinicians entering practice now owes more than $250,000 in educational debt.
We should not wonder why so many clinicians are graduating these days as physician assistants or nurse practitioners rather than as MDs. Educational costs in these programs are significantly lower, and employment opportunity is high.
Cost versus benefit in medical education
When American health care cost is so high and the system delivers such mixed results, it may be time to ask what we are doing wrong. Answers to this question are not simple. The problem itself is systemic and subtle.
One of the answers in this issue may be that we have mistaken the value of undergraduate education for clinicians. Arguably, the primary purpose of undergraduate education for clinicians is not to prepare them for more effective general practice. It is instead to make them more competitive as applicants for the limited number of seats available in medical school programs. Clinicians who need advanced scientific training to support fundamental research do not get it from undergraduate programs. They must continue to university graduate schools. Many clinicians in research will rarely see or treat patients.
It seems to the author that doctors, hospitals, and patients need a major rethinking of their educational programs. There will always be too much to learn, and much of what doctors learn may be obsolete within a few years after graduation. But America suffers from a shortage of doctors and nurses. To address this shortage, we need to consider radical restructuring of medical education.
Present clinical education is a marathon: four years of pre-medical training, three years of medical school, one to two years of internship, and two years of fellowship. The author believes that we need to combine these programs into a single standardized six-year education and fellowship program. The last two years should offer clinical rotations between at least three specialties. The criteria of board-certifying organizations will also need to be changed.
Modern medicine was not the primary driver in increases in life expectancy during the last 125 years. Nor will it be a primary driver in improved quality of life in the 21st century if we continue ignoring the need for changes in our lifestyle habits and requiring clinicians to repeatedly jump through hoops that benefit patients only very indirectly.
As Rita Mae Brown wrote in her novel Sudden Death, “Insanity is doing the same thing over and over again but expecting different results.”
Richard A. Lawhern is a nationally recognized health care educator and patient advocate who has spent nearly three decades researching pain management and addiction policy. His extensive body of work, including over 300 published papers and interviews, reflects a deep critique of U.S. health care agencies and their approaches to chronic pain treatment. Now retired from formal academic and hospital affiliations, Richard continues to engage with professional and public audiences through platforms such as LinkedIn, Facebook, and his contributions to KevinMD. His advocacy extends to online communities like Protect People in Pain, where he works to elevate the voices of patients navigating restrictive opioid policies. Among his many publications is a guideline on opioid use for chronic non-cancer pain, reflecting his commitment to evidence-based reform in pain medicine.
