The healthiest time in human history

Taking stock of the present, to shape a healthier future.

I will start this essay by saying something controversial, something which many readers may disagree with, perhaps strongly: there has never been a better, healthier time to be alive than right now. I say this is controversial because we are in the business of improving health. This starts with recognizing the many ways health needs improvement. If we do not spend significant parts of our days deepening our understanding of how health is undermined by forces like racism, inequality, climate change, and hate, we are, in a sense, not doing our job. Doing our job also means communicating to the wider world how these forces harm health. This work of communication means emphasizing where we are falling short on health and, perhaps at times, strategically deemphasizing where we are actually doing well.

This is understandable. The more we learn about health, the more our data reflect a country, and world, characterized by deep health inequities. Globally, we see persistent inequities in life expectancy, shaped by a range of factors, including economic inequality. We also see health inequities in the US, shaped by factors like race, class, and LGBTQ status. The presence of these inequities urges us to center them in our conversations, to ensure they are core to our thinking about health.

Given our awareness of these inequities, it is indeed understandable that we may sometimes think we have made no progress on health. But is this thinking always right? I would suggest it is not. It is important to acknowledge progress—first, to remind ourselves that progress is indeed possible, which helps us avoid despair in the face of ongoing suffering and tragedy. Second, we should be acknowledging progress because we aspire to a pursuit of health that is fact-based, grounded in truth. And the truth is that this is, arguably, the healthiest time in human history, even as it is also a time when we see much that is wrong and needs to be addressed. This paradox was well captured by Max Roser, who said, “The world is awful. The world is much better. The world can be much better.” This is indeed a paradox, perhaps a contradiction. But, as I have written previously, creating a healthier world means being comfortable with paradox and contradiction. In our pursuit of this world, it is important to know what has been achieved—and why—and what has not yet been achieved—and why not.

So let us start with what we have achieved. We have made enormous progress through improvements in social conditions, through fundamental changes in the world around us—such as cleaner air and water, and, yes, medical interventions. Life expectancy has increased enormously over the past 150 years. Even between 2000 and 2019, there was a 6-year global life expectancy increase. In the early 20th century, life expectancy in the United States was around 48 years, today it sits at about 79 years. This progress—even as it remains characterized by inequities—reflects a history of global health getting steadily, and sometimes exponentially, better due to progress in a range of areas.

In the 1800s, diseases like cholera and typhoid fever were rampant due to poor sanitation, with cholera outbreaks killing tens of thousands in Europe. Improvements in sanitation did much to reduce mortality from such diseases, as in the case of Ignaz Semmelweis’s efforts to introduce handwashing to hospital settings.

The introduction of antibiotics, such as penicillin, dramatically reduced mortality from bacterial infections; for example, deaths from syphilis dropped by over 90%.

Smallpox was declared eradicated in 1980, thanks to a global vaccination campaign, saving an estimated 5 million lives annually that would have been lost to the disease.

Polio cases have decreased by over 99% since 1988, with only 175 reported cases in 2019, compared to 350,000 in 1988.

More recently, the rapid development and distribution of COVID-19 vaccines demonstrated the power of modern medical science coupled with public-private partnerships and political will.

Public health has also had success through information campaigns aimed at supporting healthier behaviors. These include smoking cessation campaigns, HIV/AIDS awareness, and vaccination programs, all of which have saved countless lives. Many lives have also been saved through efforts over the years to create a safer context for driving through the shaping of better roads, seatbelt laws, and road safety education campaigns. Such efforts further reflect how creating healthier populations means creating contexts where health can thrive even when persons sometimes making decisions misaligned with improving health.

Core to this is the creation of policy frameworks that shape such contexts at the national and global level. Nationally, universal healthcare systems in countries like Canada help to ensure that, when disease does emerge, no one’s health is left behind. In the US, national health policy is shaped by key institutions like the CDC, which help to operationalize health policy so that it can do the most good. At the global level, international organizations like the WHO play crucial roles in health promotion and disease prevention. Such work is particularly important when we face a global threat, like COVID, which does not respect national boundaries and requires a coordinated global response. Health institutions, working in concert with good health policy, are key to preventing such crises and addressing them when they do emerge. They are not perfect, and their work is far from complete, as seen in the lingering presence of health inequities. But they have made much progress and continue to do so.     

Taken together, these achievements have helped usher in a better, healthier world. They emerged during different historical moments, reflecting a range of social, economic, and political forces, and a range of motivations on the part of health reformers. However, all of these achievements speak of a consistent commitment to creating the conditions that generate health. They came about because individuals and communities dedicated themselves to creating not just better treatments for disease but a better, healthier world in which disease was less likely to emerge.

Yet for all our steps towards such a world, there is still much we have not achieved. Centrally, there remain, as I have mentioned, enormous, persistent health inequalities: socioeconomic, racial, and geographical disparities in health. In the US alone, Black people are likelier to sicken and die than White people, people with less money are sicker and live shorter lives than people with more. We see similar inequities globally, as structural forces create a world of health haves and have-nots. As we deal with these inequities, we also face emerging health threats which present changes for us all. They include antibiotic resistance, climate change, and the risks posed by novel infectious diseases. Complicating our efforts to address these challenges are the rise of new media, the disruptive influence of new technologies, and the spread of misinformation. The world may indeed be better than it has ever been, but it is also quickly evolving. With this evolution comes much that is good, but also much that is challenging. It is up to us to also evolve in our engagement with the world and our pursuit of health.

What will it take to address the challenges we face, build on the progress we have made, eliminate inequities, and achieve what we need to achieve in our pursuit of health? Certainly, it will take actions—concrete steps towards creating the policies and shoring up the institutions that support a healthier world. But the actions we take begin with the ideas we embrace, the philosophy that guides our efforts. Getting health right means thinking about health the right way. Building a healthier world requires us to first think deeply about the meaning of health and well-being in modern society and then about how our actions can best align with these first-principles considerations. It is our thoughts that must guide our conversations that then guide our actions.

It is easy to skip these steps. Indeed, we often do. This makes it all the more important that we are intentional about taking time to truly think through what we do and why we do it. The focus of these essays over the last year and a half has been to help us do just that. In the past, my writing has focused on what we need to talk about when we talk about health, with special focus on addressing the inequities that create health gaps. Here, I have tried to focus on what we need to think about when we think about health—the philosophy that can help guide our efforts in pursuit of a healthier world. We have indeed made progress in creating this world. But it can sometimes feel like we have done so in spite of ourselves. We rode waves of technological progress, improvements in sanitation, economic prosperity for many (but by no means for all) and a general sense that we should be working towards a healthier world. And this ushered in progress. But throughout all this, we did not have a unifying philosophy of health, a grounding in a common understanding of what we were doing and why that cut across the many sectors and activities that matter for health.

We now find ourselves at an inflection point. It is a healthier time to be alive than ever before, but there is still much to do. Doing it will take the focus that comes with doing the philosophical legwork that supports a fully optimized pursuit of health. The lessons of COVID, the political shocks of this moment, the disruptive influence of new technologies—these all suggest that now is a time for taking stock, for evaluating the thinking that is behind our doing. As I have engaged with this thinking in these essays, I have also had the privilege of speaking with many in the health community—readers, colleagues, and friends in science and academia. These conversations have enriched my thoughts and helped make these reflections better, sharper.  The task now is to sharpen our thinking on a new philosophy of health, one that is grounded in our best values, pragmatic and supple enough to navigate the complex present, and committed to a radical vision of a healthier world for all.

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Also this week

Thoughts with Michael Stein on good judgement and building trust within both the scientific enterprise and the public.