It is difficult to sum up, or even rank, 2 1/2 centuries’ worth of medical accomplishments in the U.S. While some might think of cutting-edge, snazzy technological achievements, James Gutierrez, MD, starts somewhere far less glamorous: clean water, working sewers and enough food to go around.
As the U.S. approaches its 250th anniversary, Becker’s spoke with Dr. Gutierrez, enterprise chief of primary care at Cleveland Clinic, about what drove the country’s longevity gains — and where he thinks the next 250 years of medicine will deliver the most for patients.
His answer is a useful directive for health system leaders weighing where to invest: the flashiest science is not always what moves the needle on how long, and well, Americans live.
The past 250 years
When the Declaration of Independence was signed in 1776, the average life expectancy was roughly 35 to 40 years. By 2024, it had reached a record 79 years: 81.4 for women and 76.5 for men, according to CDC data.
Of course, that does not mean most North American colonists died in middle age. It reflects how many never made it out of childhood. In colonial America, an estimated 10% to 30% of children did not survive their first year, and the survivors still faced countless diseases and other hazards of 17th and 18th century life.
“We think about the Founding Fathers as these older men with gray hair or white powdered wigs, some of them lived into fairly late age,” Dr. Gutierrez said. “George Washington died in his late 60s, [Thomas] Jefferson and [Benjamin] Franklin lived into their 80s, and John Adams hit 90, but they were really exceptions.”
Smallpox, tuberculosis, pneumonia, measles, malaria, typhoid and other diarrheal infections were major killers, and childbirth itself was dangerous enough that many women died delivering.
After surviving what Dr. Gutierrez described as the “gauntlet” of infancy and childhood, Americans still experienced poor nutrition, high contagion rates due to urban crowding, and poor sewage systems. (Do not Google what America looked like pre-sewage systems right before a meal.)
What changed the math, Dr. Gutierrez said, was not medicine as most people picture it. It was public health. As the 1800s progressed, better sewage systems and safer water supplies cut waterborne infections such as typhoid. A maturing agricultural system delivered more consistent nutrition. Less urban crowding slowed contagion. And the first smallpox vaccine, introduced around the turn of the 19th century, began to blunt one of the era’s deadliest diseases.
“Those things really made a difference, much more than advances in what we’d consider medicine,” Dr. Gutierrez said.
The 20th century introduced many tools clinicians recognize today. Vaccines for influenza, polio, measles, mumps and rubella arrived through the early and middle decades, followed later by pneumonia and HPV vaccines. Penicillin reached wide use around World War II, and antibiotics that followed drove down deaths from infection.
The result was a fundamental shift. With sanitation, safe food and water, vaccines and antibiotics in place, chronic diseases — such as heart disease, diabetes, cancer, stroke and smoking-driven lung disease — replaced infection as the leading threat to American lives.
Medicine responded with screening for breast, colon, prostate and cervical cancers, and with effective treatment for high blood pressure, high cholesterol and diabetes that sharply cut deaths from heart attacks and strokes.
The next 250 years
Medicine is now entering what Dr. Gutierrez calls the era of genetic and targeted therapy, or treatments that can address disease at a molecular level, “really like clicking a switch,” including cancer therapies built from a patient’s own immune system.
Paired with AI’s ability to process the genome and model how thousands of potential drugs might behave in a given individual, he expects a steady run of breakthroughs against diseases with a genetic or molecular basis.
But he is careful about what that will and will not do for the population. The gains he considers most consequential still lie in “the more basic blocking and tackling,” including access to care and screenings and treatment for common conditions such as hypertension and diabetes, which remain top causes of death in the U.S.
“By focusing on those more basic interventions, we still have the most opportunity to truly impact a greater number of individuals in this country,” he said.
There is also a question of what “longer” could and should mean. Dr. Gutierrez frames the goal as extending the healthy lifespan.
“What people want isn’t just more years. They want more healthy years,” he said. “They want more years to be independent, to be mobile, to be cognitively intact, to enjoy the things and the people that they care about the most.”
For health system leaders, that distinction carries a cost. Science suggests a finite ceiling on the human lifespan, Dr. Gutierrez said, but continued advances will keep pushing overall longevity higher, and the newest therapies are not cheap.
Some gene, cell and molecular treatments, for example, run into the millions of dollars per personalized dose.
“The capacity of the health system, as well as the amount we’re going to have to be willing to spend as a society, those are going to be decisions we’re going to be continuing to have to struggle with as time goes on,” he said.
Cleveland Clinic’s role
Cleveland Clinic has operated since 1921, beginning as a multi-specialty group practice. It has since grown to include 27 hospitals, including 20 in Ohio, five in Florida, one in London and one in Abu Dhabi, United Arab Emirates. The system also provides healthcare through about 300 sites of care.
Several of the advances Dr. Gutierrez described trace back to its labs and operating rooms. Researchers there discovered serotonin in 1948, work that would later shape widely used treatments for anxiety and depression, and isolated angiotensin, laying the foundation for the ACE inhibitors and angiotensin receptor blockers that remain among the most common blood pressure drugs today.
Coronary angiography was developed there in 1958, followed by coronary artery bypass surgery in 1967. More recently, the system helped pioneer brain mapping used to pinpoint epileptic seizures and, in 2021, developed an investigational vaccine to prevent triple-negative breast cancer.
Among the possibilities Dr. Gutierrez finds most exciting is the breast cancer vaccine work, which has continued after its lead researcher, immunologist Vincent Tuohy, PhD, died in 2023. The vaccine candidate raises the prospect that one of the deadliest cancers in women could someday be prevented or treated with a vaccine.
“As I’ve gotten older, I’ve gotten more of a sense of history and appreciation of the organization,” said Dr. Gutierrez, who is celebrating his 30th anniversary with Cleveland Clinic in August. “I certainly feel like I’ve been fortunate to be part of this organization for a long time.”
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