Costa Ricans Live Longer Than Us. What’s the Secret?
In the United States and elsewhere, public health and medical care are largely separate enterprises. Costa Rica shows the benefits of integrating the two—it spends less than we do on health care and gets better results.Photographs by Fred Ramos for The New Yorker
We’ve starved our public-health sector. The Costa Rica model demonstrates what happens when you put it first.
by Atul Gawande
The cemetery in Atenas, Costa Rica, a small town in the mountains that line the country’s lush Central Valley, contains hundreds of flat white crypt markers laid out in neat rows like mah-jongg tiles, extending in every direction. On a clear afternoon in April, Álvaro Salas Chaves, who was born in Atenas in 1950, guided me through the graves.
“As a child, I witnessed every day two, three, four funerals for kids,” he said. “The cemetery was divided into two. One side for adults, and the other side for children, because the number of deaths was so high.”
Salas grew up in a small, red-roofed farmhouse just down the road. “I was a peasant boy,” he said. He slept on a straw mattress, with a wood stove in the kitchen, and no plumbing. Still, his family was among the better-off in Atenas, then a community of nine thousand people. His parents had a patch of land where they grew coffee, plantains, mangoes, and oranges, and they had three milk cows. His father also had a store on the main road through town, where he sold various staples and local produce. Situated halfway between the capital, San José, and the Pacific port city of Puntarenas, Atenas was a stop for oxcarts travelling to the coast, and the store did good business.
On the cemetery road, however, there was another kind of traffic. When someone died, a long procession of family members and neighbors trailed the coffin, passing in front of Salas’s home. The images of the mourners are still with him.
“At that time, Costa Rica was the most sad country, because the infant-mortality rate was very high,” he said. In 1950, around ten per cent of children died before their first birthday, most often from diarrheal illnesses, respiratory infections, and birth complications. Many youths and young adults died as well. The country’s average life expectancy was fifty-five years, thirteen years shorter than that in the United States at the time.
Life expectancy tends to track national income closely. Costa Rica has emerged as an exception. Searching a newer section of the cemetery that afternoon, I found only one grave for a child. Across all age cohorts, the country’s increase in health has far outpaced its increase in wealth. Although Costa Rica’s per-capita income is a sixth that of the United States—and its per-capita health-care costs are a fraction of ours—life expectancy there is approaching eighty-one years. In the United States, life expectancy peaked at just under seventy-nine years, in 2014, and has declined since.
People who have studied Costa Rica, including colleagues of mine at the research and innovation center Ariadne Labs, have identified what seems to be a key factor in its success: the country has made public health—measures to improve the health of the population as a whole—central to the delivery of medical care. Even in countries with robust universal health care, public health is usually an add-on; the vast majority of spending goes to treat the ailments of individuals. In Costa Rica, though, public health has been a priority for decades.
The covid-19 pandemic has revealed the impoverished state of public health even in affluent countries—and the cost of our neglect. Costa Rica shows what an alternative looks like. I travelled with Álvaro Salas to his home town because he had witnessed the results of his country’s expanding commitment to public health, and also because he had helped build the systems that delivered on that commitment. He understood what the country has achieved and how it was done.
When Salas was growing up, Atenas was a village of farmers and laborers. Cars were rare, and so were telephones. A radio was a luxury. In the country at large, barely half the population had running water or proper sanitation facilities, which led to high rates of polio, parasites, and diarrheal illness. Many children did not have enough to eat, and, between malnutrition and recurrent illnesses, their growth was often stunted. Like other societies where many die young, people had big families—seven or eight children was the average. Many children left school early, and only a quarter of girls completed primary education. Salas said that most children in Atenas started elementary school, but each year more and more were pulled out to do farmwork.
Important progress was achieved in the nineteen-fifties and sixties in Costa Rica, with the kind of basic public-health efforts made in many developing countries. Salas was in kindergarten, he thinks, when his family was able to pipe running water to their home from the nearby city center. A national latrine campaign provided people with outhouses made of cement. National power generation brought electrical wiring. “The most happy person was my mother!” he said.
Vaccination campaigns against polio, diphtheria, and rubella reached Salas and his classmates when he was in elementary school, as did a child-nutrition program that the government rolled out across the country, with aid from the Kennedy Administration. “We had this lunch—hot food,” he recalled. “I still have the flavor in my mouth. It was very nice to have a plate of soup with rice.” His family, with its cows and its store, was never nutritionally deprived—Salas grew to six feet—but his friends were often hungry. And so school attendance jumped. “The mothers and the families saw that it was a good idea now to send the kids to school, because they were fed,” he said.
Along the way, the Ministry of Health provided an official in every community with resources and staff devoted to preventing infectious-disease outbreaks, malnutrition, toxic hazards, sanitary problems, and the like. These local public-health units, geared toward community-wide concerns, worked in parallel with a health-care system built to address individual needs. Still, both remained rudimentary in Atenas. The nearest hospital was sixteen miles away, in the city of Alajuela, and understaffed. “At that time, it was far, because the road was impossible,” Salas said.
So when did Costa Rica’s results diverge from others’? That started in the early nineteen-seventies: the country adopted a national health plan, which broadened the health-care coverage provided by its social-security system, and a rural health program, which brought the kind of medical services that the cities had to the rest of the country. Atenas finally got a primary-care clinic. “With two or three doctors,” Salas recalled. “With five nurses. With social workers. For everything.” In 1973, the social-security administration was charged with upgrading the hospital system, including in Alajuela and other rural regions. In this early period, the country spent more of its G.D.P. on the health of its people than did other countries of similar income levels—and, indeed, more than some richer ones. But what set Costa Rica apart wasn’t simply the amount it spent on health care. It was how the money was spent: targeting the most readily preventable kinds of death and disability.
Álvaro Salas brought his work at community clinics to bear on national policy.
That may sound like common sense. But medical systems seldom focus on any overarching outcome for the communities they serve. We doctors are reactive. We wait to see who arrives at our office and try to help out with their “chief complaint.” We move on to the next person’s chief complaint: What seems to be the problem? We don’t ask what our town’s most important health needs are, let alone make a concerted effort to tackle them. If we were oriented toward public health, we would have been in touch with all our patients, if not everyone in the communities we serve, to schedule appointments for vaccination against the coronavirus, the No. 3 killer in the past year. We would have coördinated with public-health officials to prevent cardiovascular disease, the No. 1 killer, by jointly taking aim at high blood pressure and cholesterol, smoking, and dietary salt intake. We would have made a priority of preventing disease, rather than just treating it. But we haven’t.
In the nineteen-seventies, Costa Rica identified maternal and child mortality as its biggest source of lost years of life. The public-health units directed pregnant women to prenatal care and delivery in hospitals, where officials made sure that personnel were prepared to prevent and manage the most frequent dangers, such as maternal hemorrhage, newborn respiratory failure, and sepsis. Nutrition programs helped reduce food shortages and underweight births; sanitation and vaccination campaigns reduced infectious diseases, from cholera to diphtheria; and a network of primary-care clinics delivered better treatment for children who did fall sick. Clinics also provided better access to contraception; by 1990, the average family size had dropped to just over three children.
The strategy demonstrated rapid and dramatic results. In 1970, seven per cent of children died before their first birthday. By 1980, only two per cent did. In the course of the decade, maternal deaths fell by eighty per cent. The nation’s over-all life expectancy became the longest in Latin America, and kept growing. By 1985, Costa Rica’s life expectancy matched that of the United States. Demographers and economists took notice. The country was the best performer among a handful of countries that seemed to defy the rule that health requires wealth.
Some people were skeptical. Costa Rica had endured numerous economic crises before 1970; perhaps the subsequent decade of economic stability had made the difference. Or maybe it was the country’s large investment in education, which had lifted the proportion of girls who completed primary education from a quarter in 1960 to two-thirds in 1980. A careful statistical analysis indicated that such factors did contribute to child survival—but that eighty per cent of the gains were tied to improvements in health services. The municipalities with the best public-health coverage had the largest declines in infant mortality.
A big question remained, though: Could Costa Rica sustain its progress? Public-health strategies might be able to address mortality in childhood and young adulthood, but many people believe that adding years from middle age onward is a wholly different endeavor. Countries at this stage tend to switch approaches, deëmphasizing public health and primary care and giving priority to hospitals and advanced specialties.
Costa Rica did not change course, however. It kept going even farther down the one it was on. And that’s where Álvaro Salas comes in.
“I became very active in politics,” he recalled. “But I hated the people who speak and speak and do nothing. So I decided to organize groups of premedical students to visit poor communities in the country and to bring students from the third year or fourth year in the school of medicine to treat them.” Salas turned out to have a Pied Piper charm and a talent for getting things done, even as a freshman. The medical school’s dean, he learned, had close connections at the Ministry of Health. He met with the dean, and came away with both medical-faculty support and ministry supplies for his venture.
In his travels, Salas discovered that many of Costa Rica’s villages were even poorer than Atenas. “They had tuberculosis, they had leprosy, they had everything,” he said. He continued his volunteer work through college and medical school. And, as the country adopted its national health plan and spent more on public health, he could see not only what a difference such actions made but how much remained to be done. “My goals got bigger,” he said.
Salas was put in charge of setting up a new mobile public-health unit, one of many deployed in the government’s rural health program. When you work at a hospital, patients come to you. In a public-health unit, you have to go to them. Salas and his team made visits to villages along the sea. In addition to treating patients, they conducted household surveys, and pieced together diagnoses of whole communities. He found high rates of severe anemia among women, water contaminated with parasites, and outbreaks of respiratory infections. Owing to the new reforms, Salas could now do something about what he observed. Members of his team distributed iron tablets and vitamins and basic medicines such as antiparasitics and antibiotics. They helped organize sites for clean drinking water. They fought malaria and outbreaks of other infectious diseases. And, in the data they collected and the people they encountered, Salas could see the benefits.
At year’s end, he was hired at a hospital in Puntarenas. But, after his experience in Nicoya, he did not think the way most clinicians do. “At that time in Costa Rica, it was very common to see people with blankets outside the hospital, pillows, waiting for a bed,” he told me. Elsewhere, people were living in squatter settlements and slums without roads, electricity, or sanitation. “For me, it was very clear that hospitals have a role, but we have to work at the community level first.” The government was building a housing development for around a thousand residents in a barrio called El Roble. Salas proposed to the hospital director that one of the new houses be turned into a neighborhood clinic—to save people from having to go to the hospital.
Salas’s voluble exuberance was again persuasive. The director gave him a staff of two, and the housing authority gave him a house. The clinic was small, with a waiting room in front and an examining room in back. Just as in Nicoya, he and his team went door to door, creating a record for every family.
“Didn’t people find that strange?” I asked.
“I had a very nice uniform,” Salas said, laughing. “Green surgery scrubs.”
He was a bear of a man, with a walrus mustache, a desk-drawer chin, and a head of dark, wavy hair; his ebullience was tempered with an air of kindness. No one in El Roble turned him away. “We knew everything,” he said. “Who is pregnant, who has a child, who has a malnutrition problem.”
Salas became a neighborhood doctor and a public-health officer rolled into one. In addition to drawing blood for basic lab tests, he and his team collected stool samples to look for parasites. Because they also tested for blood in the stool, Salas detected one patient’s colon cancer early enough that it could be treated before it spread.
A few months after opening the clinic, Salas asked the hospital to let him open another. The director again said yes. “Because the results were very good,” Salas said. “They had less people coming to the hospital—less lines, less waiting lists.” He set up a physician and more nurses in another Puntarenas barrio, a poorer one. “Again, the results were very good.”