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For much of the 20th century, medical progress seemed limitless.

Antibiotics revolutionized the care of infections. Vaccines turned deadly childhood diseases into distant memories. Americans lived longer, healthier lives than their parents.

Yet today, some of the in public health are unraveling.

Even as the world struggles to control a mysterious new viral illness known as COVID-19, U.S. health officials are refighting battles they thought they had won, such as , and protecting young people from . These hard-fought victories are at risk as parents avoid vaccinating children, obesity rates climb, and vaping spreads like wildfire among teens.

Things looked promising for American health in 2014, when life expectancy hit 78.9 years. Then, life expectancy declined for three straight years 鈥� the longest sustained drop since the Spanish flu of 1918, which killed about and 50 million people worldwide, said Dr. Steven Woolf, a professor of family medicine and population health at Virginia Commonwealth University.

Although life expectancy , it hasn鈥檛 yet regained the lost ground, according to the Centers for Disease Control and Prevention.

鈥淭hese trends show we鈥檙e going backwards,鈥� said Dr. Sadiya Khan, an assistant professor of cardiology and epidemiology at Northwestern University Feinberg School of Medicine.

While the reasons for the backsliding are complex, many public health problems could have been avoided, experts say, through stronger action by federal regulators and more attention to prevention.

鈥淲e鈥檝e had an overwhelming investment in doctors and medicine,鈥� said Dr. Sandro Galea, dean of the Boston University School of Public Health. 鈥淲e need to invest in prevention 鈥� , , and

The country has split into , often , but with vastly different life expectancies. Americans in the are 鈥� hoping to live to 100 and beyond 鈥� while residents of the are dying from preventable causes decades earlier, which pulls down life expectancy overall.

鈥� resistant to even the strongest antibiotics 鈥� threaten to turn back the clock on the treatment of infectious diseases. Resistance occurs when bacteria and fungi evolve in ways that let them survive and flourish, in spite of treatment with the best available drugs. Each year, resistant organisms cause more than 2.8 million infections and kill more than 35,000 people in the U.S.

With deadly new types of bacteria and fungi ever emerging, Dr. Robert Redfield, the CDC director, said the world has entered a Half of all , for example, are resistant to at least one type of antibiotic, and the CDC warns that 鈥渓ittle now stands between us and untreatable gonorrhea.鈥�

That news comes as the CDC also reports of combined cases of gonorrhea, syphilis and chlamydia, which were once so easily treated that they seemed like minor threats compared with HIV.

The United States has seen a resurgence of , a , which increases the risk of miscarriage, permanent disabilities and infant death. Although women and babies can be protected with early prenatal care, 1,306 newborns were born with congenital syphilis in 2018 and 94 of them died, according to the CDC.

Those numbers illustrate the 鈥渇ailure of American public health,鈥� said Dr. Cornelius 鈥淣eil鈥� Clancy, a spokesperson for the Infectious Diseases Society of America. 鈥淚t should be a global embarrassment.鈥�

The proliferation of resistant microbes has been , by doctors who write as well as farmers who give the drugs to , said Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University Medical Center in Nashville, Tennessee.

Although new medications are urgently needed, drug companies are because of the financial risk, said Clancy, noting that two developers of antibiotics recently The federal government needs to do more to make sure patients have access to effective treatments, he said. 鈥淭he antibiotic market is on life support,鈥� Clancy said. 鈥淭hat shows the real perversion in how the health care system is set up.鈥�

A Slow Decline

A closer look at the data shows that American health was beginning to suffer 30 years ago. slowed as manufacturing jobs moved overseas and factory towns deteriorated, Woolf said.

By the 1990s, life expectancy in the United States was falling behind that of other developed countries.

The , which began in the 1980s, is taking a toll on Americans in midlife, leading to diabetes and other chronic illnesses that deprive them of decades of life. Although novel drugs for cancer and other serious diseases give some patients additional months or even years, Khan said, 鈥渢he gains we鈥檙e making at the tail end of life cannot make up for what鈥檚 happening in midlife.鈥�

Progress against overall heart disease has stalled since 2010. Deaths from 鈥� which can be caused by high blood pressure and blocked arteries around the heart 鈥� are Deaths from high blood pressure, which can lead to kidney failure, also have

鈥淚t鈥檚 not that we don鈥檛 have good blood pressure drugs,鈥� Khan said. 鈥淏ut those drugs don鈥檛 do any good if people don鈥檛 have access to them.鈥�

Addicting A New Generation

While the United States never declared victory over alcohol or drug addiction, the country has made enormous progress against tobacco. Just a few years ago, anti-smoking activists were optimistic enough to talk about the

Today, vaping has largely replaced smoking among teens, said Matthew Myers, president of the Campaign for Tobacco-Free Kids. Although cigarette use among high school students fell from to today, studies show used electronic cigarettes in the previous month.

say they鈥檝e taken 鈥渧igorous enforcement actions aimed at ensuring e-cigarettes and other tobacco products aren鈥檛 being marketed or sold to kids.鈥� But Myers said FDA officials were slow to recognize the threat to children.

With more than using e-cigarettes, Myers said, 鈥渕ore kids are addicted to nicotine today than at any time in the past 20 years. If that trend isn鈥檛 reversed rapidly and dynamically, it threatens to undermine 40 years of progress.鈥�

Ignoring Science

Where children live has long determined their risk of infectious disease. Around the world, children in the often lack access to lifesaving vaccines.

Yet in the United States 鈥� where provides free vaccines 鈥� some of the lowest vaccination rates are in , where some parents disregard the medical evidence that vaccinating kids is safe.

Studies show that vaccination rates are drastically lower in some private schools and than in public schools.

It could be argued that vaccines have been a victim of their own success.

Before the development of a vaccine in the 1960s, measles infected an estimated a year, hospitalizing 48,000, causing brain inflammation in about 1,000 and killing 500, according to the CDC.

By 2000, , and the United States declared that year that it had .

鈥淣ow, mothers say, 鈥業 don鈥檛 see any measles. Why do we have to keep vaccinating?鈥欌�� Schaffner said. 鈥淲hen you don鈥檛 fear the disease, it becomes very hard to value the vaccine.鈥�

Last year, a measles outbreak in New York communities with low vaccination rates spread to people 鈥� the most in 25 years 鈥� and nearly cost the country its measles elimination status. 鈥淢easles is still out there,鈥� Schaffner said. 鈥淚t is our obligation to understand how fragile our victory is.鈥�

Health-Wealth Disparities

To be sure, some aspects of American health are getting better.

Cancer death rates have fallen 27% in the past 25 years, according to the The teen birth rate is at an all-time low; teen pregnancy rates have dropped by half since 1991, according to the And HIV, which was once a death sentence, can now be controlled with a . With treatment, can live into old age.

鈥淚t鈥檚 important to highlight the enormous successes,鈥� Redfield said. 鈥淲e鈥檙e on the verge of in the U.S. in

Yet the health gap has grown wider in recent years. Life expectancy in some regions of the country grew by four years from 2001 to 2014, while it shrank by two years in others, according to a .

The gap in life expectancy is strongly linked to income: The richest 1% of American men live 15 years longer than the poorest 1%; the richest women live 10 years longer than the poorest, according to the study.

鈥淲e鈥檙e not going to erase that difference by telling people to eat right and exercise,鈥� said Dr. Richard Besser, CEO of the Robert Wood Johnson Foundation and former acting director of the CDC. 鈥淧ersonal choices are part of it. But the choices people make depend on the choices they鈥檙e given. For far too many people, their choices are extremely limited.鈥�

The infant mortality rate of black babies is twice as high as that of white newborns, according to the . Babies born to well-educated, middle-class black mothers are more likely to die before their 1st birthday than babies born to poor white mothers with less than a high school education, according to a report from the .

In trying to improve American health, policymakers in recent years have focused largely on expanding access to medical care and encouraging healthy lifestyles. Today, many advocate taking a broader approach, calling for systemic change to lift families out of the that erodes

鈥淪o many of the changes in life expectancy are related to Besser said. 鈥� go hand in hand.鈥�

Several policies have been shown to improve health.

, for example, have lower rates of obesity, child abuse and neglect, youth violence and emergency department visits, according to the CDC.

And 鈥� which provide refunds to lower-income people 鈥� have been credited with keeping more families and children above the poverty line than any other federal, state or local program, according to the CDC. Among families who receive these tax credits, mothers have better mental health and babies have lower rates of infant mortality and weigh more at birth, a sign of health.

Improving a person鈥檚 environment has the potential to help them far more than writing a prescription, said John Auerbach, president and CEO of the nonprofit Trust for America鈥檚 Health.

鈥淚f we think we can treat our way out of this, we will never solve the problem,鈥� Auerbach said. 鈥淲e need to look upstream at the .鈥�