We confirmed the effect of public health interventions (including water and sewer systems) on mortality but failed to find that medical care supply had any large impact in the pre-antibiotic era.
We turned to Massachusetts with its early, more complete data to examine whether medical care supply explains different mortality trends across large metropolitan areas, other urban areas, and rural areas. In 13 large US cities, filtering the water reduced mortality, but having more medical care supply did not.
We asked whether the growth in medical care explained some of the life-expectancy gains realised over this time period using data from big US cities and all cities and towns in Massachusetts (Catillon et al. Reduced mortality from infectious diseases, mostly benefiting younger population groups, was concurrent with large-scale public health improvements, especially clean water and sanitation. Public health improvements explained the bulk of life-expectancy gains over this period (Cutler and Miller 2005, Alsan and Goldin 2018). Medical spending started to accelerate, reaching robust growth of +1% above GDP by 1910 (Lough 1935, Getzen 2017). The start of medical care growth (1880-1935)ĭuring the period 1880-1935, scientific advances led to the regulation of the medical profession, the specialisation of doctors, and the rise of ancillary occupations. Then, at the end of this period, medical science paved the way for the development of public health interventions that bestowed prestige and authority to the medical profession, even before therapeutic care was able to treat individual illnesses effectively (Starr 1977).
Health expenditures remained limited to about 2% of GDP, growing by only about 0.2% annually, even as income was rising (Catillon et al. Sick people were safer at home than in the hospital. Infectious disease was the main cause of death. While understanding of disease, physiology, and anatomy improved during the 18th and 19th centuries, progress in medical knowledge did not rapidly translate into medical interventions helpful to patients (McKeown 1955). Source: Hacker, based on Fogel and Haines Little medical care, short lives (1800-1880)įrom 1800 until about 1880, medical care was small and stagnant, and health improved little. Average life expectancy in the US was 43 years in 1800 and 46 in 1880 (Hacker 2010). 2018) to provide a long-term look at health and health care in the US, we found both similarities to past studies and major differences.įigure 2 Life expectancy at birth in the US, 1800-2016 When we traced the development of medical care and the extension of longevity in the US from 1800 onward (Catillon et al. Demographer Samuel Preston attributed longer life to advances in public health, such as clean water and sanitation (Preston 1996).Ī closer look, however, reveals a more complex situation. Nobel prize-winning economist Robert Fogel further argued that long-term changes in life expectancy were primarily due to increased productivity, especially in agriculture (Fogel 2004). Instead, he argued that the decline in mortality was explained by environmental change (McKeown 1955) and that even during the 20th century, medical measures played a minor role compared to improved nutrition and better hygiene (McKeown 1975). Reviewing the evolution of medical knowledge and organisations in England in the 18th century – including surgery, midwifery, medicines, hospitals, dispensaries, and preventive therapies – Thomas McKeown concluded that medical care did not contribute to the reduction in mortality in the late 18th and 19th centuries. □ indicates actual data on medical spending as a share of GDP. x indicates extrapolation from Census employment data. Notes: Data sources are described in the text.
To what extent is the rise of medical care the source of improved health?įigure 1 Medical spending as a share of GDP, 1800-2016 Life expectancy of an average baby born in 1900 was three decades less than in 2015 (Figure 2). It was only in the last century that medical care’s share of total employment increased tenfold (Figure 1). Medical care was not always an economic behemoth.