That the U.S has the highest rates of chronic diseases in the world, a foundational idea in the recent MAHA report, is, in many ways, a privilege: for, in the 21st century, our children do not die of infection.
Why do I say “privilege?” Because a century ago, this was not the case. In fact, in 1900, infections — pneumonia, tuberculosis, and diarrheal illness — were the top three killers in the United States, and forty percent of these deaths occurred in children younger than five years old. That was a time when the average life expectancy was just 45 years old, an age many of us would now consider to be mid-life.
By the end of the 20th century, heart disease, stroke, and cancer accounted for over fifty percent of all deaths in the United States, while the percentage of deaths from infection plummeted to under five percent — even accounting for the lives lost in the influenza and HIV pandemics in the intervening century. But if you zoom in, you may notice something intriguing: while the death rate from infection plummeted, the mortality rate for chronic diseases actually remained flat. We can more or less interpret this to mean that we die of chronic diseases because infections aren’t killing us first.
That we live long enough is, perhaps, one of the great success stories of governmental, scientific, and technological progress. It is a story that includes the adoption of sanitation practices, improvement in living conditions, the discovery of antibiotics, widespread vaccination, and concerted efforts by public health departments across the country to track and treat infection. It represents a transition away from an era of high childhood mortality rates to an era of higher quality childhood and longer lives.
But something strange has now happened now: Despite the millions of lives saved and the demonstrable improvements in life span and quality of life, despite the expertise and recommendations of physicians and scientists — or indeed, perhaps because of this — the focus of the current administration, and much of the public, has shifted away from prevention and treatment of infectious diseases, as if these problems over and done with, or as if solving them are mutually exclusive.
Some detractors say that in an age of antibiotics, infectious diseases can easily be treated, and we should focus our resources elsewhere. While this is certainly true, many vaccines prevent viral infections, which cannot be treated with antibiotics, and inappropriate prescribing of antibiotics will only serve to fuel superbugs that can survive antibiotics. Other critics, perhaps your neighbor or a former classmate, claim that vaccines are not needed because we don’t see illnesses like measles circulate anymore. This is, of course, a logical fallacy: we don’t see vaccine-preventable illnesses — or we didn’t, until the recent outbreak in Texas — precisely because vaccines are so powerful at preventing these illnesses! Measles was eradicated because of vaccines, not because vaccines are not needed.
This shift has resulted from misinformation, misunderstanding, and erosion of trust in medical and scientific expertise, none of which solves the problem of chronic disease, nor does it make us healthier.
Solving chronic disease starts with the food we eat and with exercise. But it also starts with good preventative health, the kind you can get with a really good primary care doctor or pediatrician — prevention so good, it never seems necessary. The proposed efforts to control chronic disease in the MAHA report do not contain an actionable assessment of the challenges we face. For example, primary care doctors are hard to come by, because the insurance-industrial complex disincentivizes and devalues preventative medicine, leading to a cascade of short appointment times, long wait times, and disappointed and frustrated patients and doctors alike. Cases of cancer in young people are on the rise, but our funding agencies have been castrated, and the administration is shutting down the war on cancer. The United States has the highest health care costs in the world. There remains significant work to be done — and to make America healthier will require multidisciplinary efforts from families, scientists, doctors, policy makers, and even insurance companies.
Solving the problem of chronic diseases is well worth our efforts, and these efforts should not be at the cost of the tremendous progress in extending duration and quality of life we have already made. A school-aged child in California recently died of a rare complication of measles nearly a decade after contracting the virus as an infant. Efforts to improve our overall health must occur in tandem with the continued efforts to eradicate infectious disease: The lives of our children depend on it.
Ultimately, the best medicine for infections is the same as the best medicine for chronic diseases, and it comes down to a deeply American maxim, coined by Benjamin Franklin himself forty years before America’s independence: an ounce of prevention is worth a pound of cure.