We are in a public health and health-care crisis that began long before Covid-19. Much of this deterioration is the unfortunate consequence of the uncoupling of our increasingly expensive for-profit medical care system from public health, in a process that began nearly a century ago. The pandemic was a reckoning that made our institutional failings impossible to ignore, and our shocking excess death rate is only one metric of the cost of that neglect. Costa Rica, however, a Central American nation of five million with a per capita income that is one-sixth of that of the United States, is a living laboratory of what can be accomplished when public health comes first, instead of dead last.
Despite their relative poverty, Costa Ricans live longer than their wealthier counterparts elsewhere, with a life expectancy that now approaches eighty-one years. Men who survive to age sixty have the longest life expectancy of any people in the world, surpassing even the long-lived Japanese. How did they do it? The key seems to be in the nation’s familiar catchphrase: pura vida, or the pure life. Costa Rica is a centuries-old democracy with universal health care, no standing army, and the highest literacy rate in Central America, and it has been relatively insulated from the corruption, narco-terrorism, and civil wars that have plagued neighbors like Panama, Nicaragua, and Guatemala.
Researchers believe that their leisurely pace of life, network of family and friends, regular exercise, and purposeful lives seem to be their recipe for longevity. But the cornerstone of Costa Rica’s blueprint for a long life is that individual health and public health are inextricably linked. As a nation, they consistently employ the basic tools of public health to keep residents healthy. They ensure that all their citizens are vaccinated, that they live in sanitary environments with clean running water, and that they have ready access to proper nutrition and health care through more than a thousand community-based clinics, even in remote rural regions in the mountains that can only be accessed by horseback.
This was not always the case. In 1950, one in ten Costa Rican infants died before their first birthdays, succumbing to the diarrheal illnesses, respiratory infections, and birth complications that the U.S. had brought under control decades before. Many children and adolescents didn’t survive into adulthood. Life expectancy hovered around fifty-five years, which was about thirteen years shorter than here in America. In about half the homes, there was no running water or adequate sanitation, resulting in high rates of polio, parasites, and diarrheal diseases. Malnutrition was rampant, and children went hungry and their growth was often stunted.
All that began to change in the 1950s and ’60s, when fundamental public health efforts began to transform the society. Water was piped into homes, national power generation electrified the country, and the government provided outhouses made of cement and embarked on vaccination campaigns against polio, diphtheria, and rubella. Each community had a public health staff that was dedicated to guarding against disease outbreaks and combating malnutrition and other hazards. These teams worked in tandem with the healthcare system, which was still in its nascent stages. The truly revolutionary reforms began in the 1970s, when the nation adopted a national health plan and set up clinics in rural areas that provided the same medical care as in the cities. But instead of treating patients on a scattershot, individual basis the way we do here, Costa Rica used its scant health-care dollars to identify the diseases that were killing most residents and then implemented strategies to prevent them. Maternal and child mortality were the first targets. Pregnant women were given prenatal care, and rural residents were transported to cities weeks before their due date to ensure a safe delivery in hospitals. Nutrition programs helped reduce malnutrition, sanitation and vaccination campaigns effectively lowered the incidence of cholera and diphtheria, and a nationwide network of clinics provided better treatments when kids did get sick. The results were astonishing: By 1980, infant mortality had dropped to 2 percent.
In the four decades since, Costa Rica has continued on this path, integrating public health services with their network of hospitals and clinics, and allowing public health officials to set the national health-care agenda—not Big Pharma, not health-care executives beholden to their shareholders, and not the lawmakers who rely on what my friend and public policy expert David W. Johnson calls the “healthcare-industrial complex” to bankroll their election campaigns. By 2006, nearly the entire country enjoyed universal primary care, and the lack of access to care that plagues many Americans is a foreign concept to Costa Ricans; at birth, they are assigned a local primary care health team that includes a doctor, a nurse, and a community health worker, who will follow them throughout their lives.
There are now more than a thousand neighborhood teams that visit each household at least once a year, and the outreach workers are well versed in the health status of all the residents and deliver care that emphasizes prevention and public health. The system is not perfect— because of the nation’s limited budgets, there can be months-long waits for advanced imaging and procedures, and specialists are in short supply. But the wide health-care disparities that are endemic in the U.S. are virtually nonexistent in Costa Rica, where such things as differences in infant mortality based on a family’s income or where they live have been erased.
We can do better.
