Atul Gawande writes for the New Yorker on Costa Rica’s secret to longevity–government investment in public health. Gawande reports on the value of the Costa Rican health care model, which weaves together public health and primary health care.
Seventy years ago, in 1950, the average life expectancy in Costa Rica was 55 and the average life expectancy in the US was 68. But, now Costa Ricans live longer than Americans. Of note, national income in Costa Rica is far lower than the US, which normally would mean lower life expectancy. And, its per-capita income is one sixth the per-capita income in the US.
Now, Costa Rica spends a small portion of what the US spends on health care, and its average life expectancy is 81. In comparison, average life expectancy in the US is about 79. The secret, says Gawande, is Costa Rica’s investment in public health–focusing on making the entire population healthier.
Over the last several decades, Costa Rica invested in running water, electricity, vaccines, child nutrition. Every community had a health minister with resources to stop or prevent infectious disease, sanitary issues, poor nutrition, toxic hazards. Then, in the early 1970’s, Costa Rica offered universal primary care coverage and access to care in both metropolitan and rural communities.
Unlike the US, Costa Rica targeted preventable death and disability. Gawande argues that the US is reactive in its approach to health care, treating patients who seek treatment and focusing exclusively on them and not their communities. If we were focused on preventing disease, we would be stopping cardiovascular disease, which is the number one killer. Our focus would be on reducing high blood pressure and high cholesterol.
Costa Rica first targeted infant mortality and reduced rates to two percent over a decade. Then, it created a mobile public-health unit, so doctors could visit people at their homes and in their communities. They could assess and address the biggest health issues.
Costa Rica then merged their public health and health care systems, which most countries keep separate. And, they assigned every resident to a primary care team. Among other things, each year, the team would visit the 4,000-5,000 people in their community, in their homes to assess their health needs.
Costa Rica back then did not have comprehensive universal coverage but it had universal primary care in 1,000 communities. And, it had individuals with both medical and public health skills visiting the 1,400 or so homes in their communities. The priority visits happen three times a year to homes of isolated older adults or people with disabilities and other high-risk individuals. Second up are people with moderate health risks who get two visits a year. Everyone else gets a single visit.
The community health approach allows the health care workers to reallocate supplies among people in the community where appropriate or to have a neighbor help out another neighbor to get needed care. In the US, public health officials have no relationship with health care workers or people in the community. They can detect local issues, but they do not have the means to address many of them. For example, they might know the community needs COVID testing and vaccines, but they have no relationship with the doctors who provide these services.
As a result of Costa Rica’s community health efforts, few people die of communicable diseases any longer. And, many fewer people die of non-communicable disease. Life expectancy has increased for people between 15 and 60, with a 8.7 percent mortality rate. In the US the mortality rate for that age group is 11.2 percent.
Moreover, in the US, inequities in life expectancy among the wealthiest and least wealthy are profound. People in the top 1 percent of income live between 10 and 15 years longer than people in the bottom 1 percent of income. Inequities are also geographically-driven for poorer people. Low-income people live longer in New York City than in Los Vegas or Omaha City.
A study out of Stanford University found that people live longer when there’s a medical professional in their family. And, the closer their ties to that family member, the longer they are likely to live. While we can’t assure that every family has a blood tie to a health care professional, bringing a primary-care team to the family is a good alternative.
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