August 26, 2021

Gawande: What Costa Rica can teach America about living longer

Daily Briefing

    Writing for the New Yorker, Atul Gawande explains how Costa Rica bolstered its average life expectancy from 55 in the 1950s to nearly 81 today—above the United States' average life expectancy—by unifying two approaches to health that are largely kept separate in America: public health and medical care.

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    Costa Rica's first moves towards progress

    In 1950, about 10% of children in Costa Rica died before their first birthday, and many children and young adults died as well, Gawande writes.

    However, through the 1950s and 1960s, the country made "[i]mportant progress" with the sort of "basic public-health efforts made in many developing countries," Gawande writes, including making running water and electricity more accessible; implementing a national latrine campaign; vaccinating against polio, diphtheria, and rubella; and funding a child-nutrition program.

    But the country didn't surge ahead of other nations' public health initiatives until the 1970s, Gawande writes, when Costa Rica implemented a national health plan, expanding the health coverage offered through its social security system, and adopted a rural health program. Not only were Costa Rica's investments more significant than other nations' as a share of its GDP, Gawande writes, but it also targeted that spending on "the most readily preventable kinds of death and disability."

    For instance, Costa Rica in the 1970s identified maternal and child mortality "as its biggest source of lost years of life," Gawande writes, so the country established public health units to help pregnant women receive prenatal and delivery care. In addition, officials ensured health care providers at hospitals were prepared to manage the most common dangers associated with childbirth, including maternal hemorrhage, newborn respiratory failure, and sepsis.

    By 1980, the percentage of children who died before their first birthday had dropped from 7% in 1970 to 2%, and maternal deaths dropped by 80%, Gawande writes. Overall, life expectancy reached parity with the United States by 1985.

    How Álvaro Salas Chaves helped Costa Rica continue its efforts

    To capture the trajectory of Costa Rica's public health success story, Gawande highlights in particular the personal efforts of Álvaro Salas Chaves, who has worked as a doctor and health official in Costa Rica.

    In 1977, following a medical internship, Salas began working in the Nicoya Peninsula as part of a year of social service, funded by the Costa Rican government, where he was in charge of developing a new mobile public health unit. These units didn't just treat patients, Gawande writes, but conducted surveys and diagnosed entire communities.

    During his work, Salas discovered many women in the area had severe anemia, the water was contaminated with parasites, and there were high rates of respiratory infection outbreaks, Gawande writes. In response, Salas's team distributed iron tablets and vitamins, as well as other medications, such as antiparasitics and antibiotics. They also organized clean drinking water sites and helped fight outbreaks of infectious diseases, such as malaria.

    Salas' initiatives were a success, so, when Salas was later hired at a hospital in Puntarenas, he proposed to the hospital director that a new house be turned into a neighborhood clinic—and just months later, asked for another clinic. The director agreed both times.

    "Because the results were very good," Salas said. "They had less people coming to the hospital—less lines, less waiting lists."

    By 1990, Salas was appointed to lead policy development at CCSS, the nation's health care agency, Gawande writes. That's where Salas developed a plan to bring public and individual health together. The plan had three main parts:

    1. The public health services from the nation's Ministry of Health would merge with CCSS' system of hospitals and clinics, allowing public health officials to set objectives for the whole health care system;
    2. CCSS would integrate data about household conditions and needs with the medical record system, utilizing the data to inform national priorities, set objectives, and track progress; and
    3. Every Costa Rican would be provided with a local primary health care team, called an Equipo Básico de Atención Integral en Salud (ebais). This team would include a physician, nurse, and a trained community health care worker known as an Asistente Técnico en Atención Primaria (atap).

    According to Gawande, these ataps—who combine "the skills of a medical worker and a public health aide"—each make a certain number of annual visits to local households, based on the health needs of each family.

    Specifically, the ataps make three annual visits to what are categorized as "Priority 1 homes," in which an elderly person or an individual with a severe disability, uncontrolled chronic disease, or high-risk condition lives alone; two annual visits to "Priority 2 homes," where individuals with more moderate risk live; and at least one annual visit to "Priority 3 homes," which include everyone else.

    By 1998, when Salas left his post at CCSS, the country had enough ebais teams to reach about half its population, Gawande writes—and by 2006, almost the entire population of Costa Rica had an ebais. In fact, Gawande writes, during the Covid-19 pandemic, ebais teams have been in charge of distributing Covid-19 vaccines.

    Could the US do something similar?

    Since the ebais teams were developed, deaths from communicable diseases in Costa Rica have dropped by  94%, and progress has been made against non-communicable diseases as well, Gawande writes. All the while, Costa Rica has surpassed the United States' average life expectancy while spending less than the world average on health care as a percentage of income.

    Costa Rica's model "suggests that directing [health care expenditures] wisely—in ways attentive to the greatest opportunities for impact—can be transformative when it comes to the less connected and the less advantaged," Gawande writes.

    To contextualize these benefits, Gawande cites a study from Stanford University that found people from families with a medically trained relative were 10% more likely to live past the age of 80. Younger relatives, meanwhile, were more likely to be vaccinated, less likely to have a drug or alcohol addiction, and less likely to be admitted to the hospital. Older relatives had lower chronic disease rates.

    While Gawande acknowledges that a public health program can't put a doctor in your family, Costa Rica's model "shows that we can provide something close: a primary care team whom individuals know personally and can call upon in the course of their lives."

    And it's also a model that the United States has—at rare times—demonstrated it can emulate, Gawande adds, such as through the nation's effort to vaccinate Americans against hepatitis B.

    In the 1990s, the U.S. government sought to provide hepatitis B vaccinations to all hospital workers. As part of the initiative, hospital personnel got in touch with each employee at least once a year to offer them preventive care for free, Gawande writes. By 1995, two-thirds of hospital workers had gotten vaccinated, and infections among the workers dropped 98%.

    Of course, Gawande writes the United States hasn't implemented a similarly comprehensive approach to the population at large—in fact, while Costa Rica vaccinates nearly 90% of infants against hepatitis B at birth, the United States vaccinates just two-thirds. But Gawande writes that Costa Rica provides a potential roadmap for how America.

    "It is possible to change the picture," Salas said. "It is possible to call upon a group of people … who think and can see 20 years, 30 years ahead. It is possible to raise an idea and see it supported by a younger generation to become real." (Gawande, New Yorker, 8/23)

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