A question that frequently comes up in healthcare debates is "would you rather be alive now or alive with the medical technology of 1970".

You'd be giving up genetic testing, numerous advances in wound care, a number of advanced antibiotics, leaps in transplant technology, and a whole slew of joint-replacement innovations. Plus cancer treatments, and of course, AIDS therapies. Massive impacts, right?

And if today is better than 1970, 1970 was better than 1950, and 1950 better than 1920, and....

Right?

Not so fast.

New York City have been tracking mortality rates since 1800, and there's a chart I love to pass around in these discussions, with the charming cocktail-party friendly title of "The Conquest of Pestilence in New York City ... as shown by the death rate as recorded in the official records of the Department of Health and Mental Hygiene".

The 20th century has seen a host of medical advances: antibiotics, vaccines, transplants, tailored drugs, implants. High-cost, yes, but huge impacts.

No, not really.

https://1.bp.blogspot.com/-uTWEATUzgxk/TXQoTibILtI/AAAAAAAAA...

The turning point in the chart -- where the increase in mortality as New York as it grew from a town of 60,515 (1800) to a city of 813,669 (1860), was the formation of the Department of Public Health itself, in 1866. Peak mortality hit 50/1,000 in the 1830s, 180s, and 1860s, with a sustained average above 35/1,000, and marked volatility as the city was rocked by epidemics. By the 1890s, it had fallen to 20, and 1920, about 12. The pre-WWII low was actually in 1939-40, at just over 10, and mortality rose through the early 1970s. There has been a further decline, to about 7.5, since 1990.

Analysis elsewhere suggests that this is almost wholly attributable to increased longevity among minority populations -- nonwhites generally, black women, and especially black men. My suspicion (though I've not researched in depth) is that this is largely attributable to increased access to medical care, either through improved socioeconomic status and access to the commercial healthcare market, or through public health programmes. There is little if any evidence that the gains come from medical technology itself.

This is a topic that's been much studied. Robert J. Gordon's epic assessment of US economic progress, The Rise and Fall of American Growth (2016) looks hard at medical advances, particularly since 1970, and finds them largely absent. Victor Fuchs, healthcare economist (heavily cited by Gordon) has found published similar results for the past few decades.

A personal anecdote is a close friend who'd died of an obscure cancer in the early 1990s. The (brutal) treatments they'd undergone were essentially unchanged since the early 1970s, or even 1960s, as I read the literature, and have changed little in the ensuing nearly three decades. Given that one of the questions and agonies we faced at the time was "what if some miracle cure emerges, or we weren't doing enough", this failure-to-advance is in some ways a bit of validation: we really try to do everything we could, and applied the best available knowledge, and no, even now, the outcome is virtually unchanged: four out of five patients with that diagnosis die within five years, often less.

(Other friends have survived their, mostly other, cancer diagnoses. And of the cancer-friends we'd made, some are still alive, others have died, in cases of complications from treatment, including blood- and tissue-donation related infections such as hepatitis. Life is not fair.)

Real healthcare improvement, as with so many other quality-of-life improvements, comes not from heroic measures, but by assuring adequate access. And the market is a terrible mechanism for assuring such adequacy.