Dying Healthy: Public Health Priorities for Fixed Population Life Expectancies

A longer life has long been one of the central goals of investments in public health and medicine. Population longevity is frequently used to measure the success of a country's health care system, and life expectancy in many countries increased by more than 30 years in the past century. The 21st century began with new medications and procedures to fight disease, and we are now at the dawn of a genomic revolution that has promised even more remarkable opportunities to cure disease and extend life. However, recent data suggest that the human lifespan probably has an unalterable biological limit of approximately 115 years and that virtually all humans will die before age 90 years (1). Advances in medical treatmentespecially for cancerare thus increasingly unlikely to provide substantial gains in healthy human longevity, and whatever increase in population lifespan was due to medical advances in the second half of the 20th century is unlikely to be replicated. As such, it is time to stop putting almost all of our resources into the search for life-extending therapies. Instead, we should shift our focus and investments toward identifying strategies that improve quality of life overall and compress illness at the end of life (2). Three arguments support this conclusion. First, the increase in life expectancy over the past century was mostly caused by social, economic, and political advances that created conditions for healthier populations, especially newborns and infants. Advances in medical care contributed less to overall lifespan than did advances in hygiene, food safety, and clean water; decreases in infectious diseases; and improvements in living standards (3). Second, the life expectancy gain of the 20th century was disproportionately recorded in the first half of the century. Life expectancy in the United States increased from 47 years to 68 years between 1900 and 1950 for a 21-year gain (42%) but only from 68 years to 77 years between 1950 and 2000 for a 9-year gain (13%). The latest available data show that life expectancy did not change in 2013 or 2014 and decreased in 2015 and 2016. Even biological optimists who are bullish on increasing longevity in many parts of the world agree that the life expectancy in the United States is unlikely to increase in the next 30 years (4, 5). Finally, evidence suggests that even persons of advanced age who benefit most from new medical interventionstypically the wealthy and well insuredwill gain relatively few healthy years of life from medical care. We have entered an era of radically diminishing returns on our medical investments. Data for 71 cancer drugs consecutively approved between 2001 and 2012 suggest that their overall contribution to patient survival was 2.1 months (6). The gains attributable to personalized cancer medicine thus far have been similarly minimal (7). Absent a realistic assessment showing that new medical technologies can radically increase a healthy human lifespan, we suggest that our investment priorities should shift away from medical research and even end-of-life medical care toward the same social, cultural, and political factors that successfully prolonged life in the last century. A societal shift in resource allocation for health will take time, but we believe that we should begin the conversation now to get us there. National health research priorities should be set on the basis of population health and well-being rather than a search for new medical treatments for individual persons. Public investments in education, transportation, housing, and antidiscrimination initiatives would directly affect the quality of life of everyone in the community. They would directly contribute to preventing chronic diseases, such as diabetes, and do more to improve the population's quality of life than additional medical research aimed at treating individual persons with specific diseases. The argument is not that we should eliminate funding for medical research to try to prevent or even cure diseases, but that public funding should privilege research on improving and sustaining quality of life instead of focusing on increasing length of life. Doing so would mean that conditions that affect decades of a person's life (such as arthritis, autism, macular degeneration, and dementia) and their prevention would have priority over end-of-life illnesses, such as end-stage cardiac disease and many types of cancer. Recognizing that we have reached our species' age limit or are at least close to doing so also calls for an embrace of new approaches to ease the collective burden of death and dying. Although medicine is slowly accepting palliative care, that approach in isolation tangles with death only as a byproduct of medical failure. Recognition of the inevitability of death within a relatively predictable timescale suggests a fuller reckoning with end-of-life care as a concern for population health (not just medical care for individual patients) that is worthy of scholarship and action (8). Preserving quality of life through the lifespan is fundamentally a public health goal. Nearly 40 years ago, James Fries suggested that we focus our efforts on postponing chronic illness to the shortest period possible (2). Most persons in the United States would agree that this is a reasonable public health (and medical) goal, but achieving it has been elusive and unfortunately will remain so without proper attention paid to it by a shift in focus of biomedicine, such as what we propose here. We are not the first to suggest that we have reached diminishing returns in high-technology medicine. Calls to redirect our resources to quality of life have been ignored in the past and will be resisted now (9, 10). We suggest that an unstinting focus on the inevitability of death can perhaps paradoxically be healthy and help better focus our minds on how we should invest our resources toward creating healthier populations and living well for our largely biologically determined, limited lifespan. Healthy aging could lead to dying healthy by compressing illness at the end of life to little or nothing, which is a most worthy human goal.