There was nothing magical about the care I saw that day. Herrera wasn’t a saint. But he may have been something better than that: he was the point of contact between a national system and a great many individual lives, seeing to every small detail required for the broader demands of community health.
Salas and I returned to the central clinic, where we met with the medical director of the Atenas Health Area, Carolina Amador. She is in her late forties, with long auburn hair and a quiet, observant air, and she oversees all seven EBAIS teams. Like Salas, she had wanted to be a doctor since she was in high school. And she, too, took the opportunity offered to Costa Rican medical graduates to spend a year working in an isolated community. It was around the time the EBAIS system was being launched, and she spent that year helping to provide primary care for an island fishing village, where basic supplies had to be delivered by boat. “I did Pap smears with a flashlight,” she recalled, sitting in her office behind a large wooden desk.
Amador has overseen the Atenas Health Area for seventeen years. She says that the hardest part of her job involves human resources. “People want the director to be their parent, their adviser, their friend, and someone who can get them anything they want,” she said. “I am their psychologist, too. Everyone is motivated differently.”
When Salas was growing up in Atenas, the nearest hospital was sixteen miles away, and understaffed. Now the area’s roughly thirty thousand residents are served by seven fully equipped EBAIS teams.
She wants all the members of her teams to understand that their priority is “the relationship with the community, not just between the physician and patient.” This, she said, is the foundation of the EBAIS system. There are critical services that have to reach everyone in the community at every stage of life, she explained. Children have regular pediatric visits, starting from the first days of life. Pregnant women have their prenatal and postnatal checks. All adults have tests and follow-up visits to prevent and treat everything from iron deficiency to H.I.V. It’s all free. If people don’t show up for their appointments, she makes sure their team finds out why and figures out what can be done.
Amador described a group program that her staff created for people who have poorly controlled diabetes. They meet on Mondays for two hours in a twelve-week course covering topics from cooking proper meals to administering their insulin. They learn far more than they would in sporadic office visits, and they become a group of peers who know and encourage one another. Amador and her colleagues have documented substantial reductions in blood-sugar levels. That led them to create other groups, including a Zoom forum that was begun as adolescent depression rose during the pandemic—the forum drew ninety teen-agers—and a nutrition program for bus drivers, who have been found to have a high rate of obesity.
Salas was grinning. Everything he had created with his clinic in El Roble, everything he’d tried to build into the EBAIS system almost three decades ago, had come fully to life in his home town. A generation of professionals like Amador and Herrera had embraced his belief that individual health and public health are inseparable.
Integrating the two has effects that aren’t so visible to patients. I spent the next morning with Mario Quesada, the primary-care physician for an EBAIS team serving the mountainside neighborhoods of Altos de Naranjo and San Isidro. Each week, he spends three days seeing patients at a clinic halfway up the mountain, and two days at a site on top of the mountain. I visited the one halfway up. It looked much like any other house on the street, which seemed to be the standard design for such clinics. Quesada, who is forty-one, wore a pin-striped, short-sleeved shirt and a microphone headset; during the pandemic, half his appointments have been virtual.
By eight o’clock that morning, he’d already seen three patients—he’d diagnosed a benign rash, a goiter, and an ear infection. The first visit I observed was a telehealth appointment in which he advised a woman with migraines about a change in medication, typing up his notes as they spoke. These were routine visits, and would have been recognizable to primary-care doctors all over the world.
Yet a couple of the visits I observed made apparent the subtle strengths of the EBAIS approach. One involved, as Quesada put it, “un caso difícil ”—an incontinent sixty-five-year-old woman with schizophrenia. The woman, who lives with her daughter, also has a psychiatrist and a social worker. That day, she needed her prescriptions refilled. But Quesada also saw a note in her ficha familiar about family circ*mstances which led him to ask her about her supply of diapers. The EBAIS provides up to forty a month, which was enough until her bowel troubles worsened recently. Quesada suspected that her daughter might not be able to afford more, and learned that the woman was indeed short. He did a quick check of the records and found that another family had returned a box of diapers after an elder died. She could have the box, he said. It was a small thing. But a lack of such basic supplies could mean the breakdown of skin from sitting too long in stool, and lead to infection and wound-care problems. Quesada’s simple reallocation of resources was possible only because he had a bigger picture of the community he serves.
In another telehealth visit, a woman with diabetes and severe hypertension complained that she had been waiting more than a year to get follow-up blood tests. When Quesada consulted her records online, he saw that he had ordered the tests months earlier, but the woman hadn’t shown up for any of them. He told her where to go for her lab tests and filled out the lab orders that she’d need. He could have told her to pick up the order slips, but she’d failed to do that before, too. So Quesada looked through the upcoming appointment list and noticed that a neighbor of hers would be at the clinic soon. He told the woman he’d send her lab orders with the neighbor.
That level of familiarity—the fact that he understood the community around his patient and how it could help—was astounding to me, even as the limitations seemed apparent.
Herrera administered a flu vaccine at a resident’s home. Since the development of the EBAIS system, deaths from communicable diseases have fallen by ninety-four per cent.
“She’s not going to get her tests done, is she?” I said.
“It’s fifty-fifty,” he said. “One can only do so much. I do my work. They must do theirs.”
In my discussions with clinicians and patients, the weaknesses in the system were not hard to find. With Costa Rica’s constrained resources, there was not enough staffing, especially for specialists. When it came to secondary care, months-long waits for advanced imaging and for procedures were common. People who could afford to do so carried additional insurance for private health care or paid cash to supplement the care that they received from the government. But the EBAIS system remains immensely popular, and politically untouchable. It has advantages that patients can feel, even if they don’t see all the inner workings.
Near the end of my conversation with Carolina Amador, she explained her approach to the pandemic, and she called up a graph on her computer that showed up-to-the-moment rates of COVID cases and deaths by age, sex, and neighborhood. In Angeles, for instance, three per cent of the population had been infected; in Santa Eulalia, nine per cent had been. It was the kind of report I’d seen in the hands of local public-health officials in the United States. They generated these reports, but they hadn’t been given the tools or the authority to act on them directly. Because these officials remain outside the American health-care system, they had to beg providers to respond with adequate testing and vaccination. When that proved insufficient, they were forced to launch their own operations, such as drive-through testing sites and stadium vaccination clinics—and they had to do so from scratch, in a mad rush. The operations were all too delayed and temporary. Here, Amador could see the places with the greatest need and deploy doctors, nurses, and community-health workers to do testing and vaccination. Amid COVID, Costa Rica had demonstrated yet again how primary-care leaders could make health happen.
The results are enviable. Since the development of the EBAIS system, deaths from communicable diseases have fallen by ninety-four per cent, and decisive progress has been made against non-communicable diseases as well. It’s not just that Costa Rica has surpassed America’s life expectancy while spending less on health care as a percentage of income; it actually spends less than the world average. The biggest gain these days is in the middle years of life. For people between fifteen and sixty years of age, the mortality rate in Costa Rica is 8.7 per cent, versus 11.2 per cent in the U.S.—a thirty-per-cent difference. But older people do better, too: in Costa Rica, the average sixty-year-old survives another 24.2 years, compared with 23.6 years in the U.S.
The concern with the U.S. health system has never been about what it is capable of achieving at its best. It is about the large disparities we tolerate. Higher income, in particular, is associated with much longer life. In a 2016 study, the Harvard economist Raj Chetty and his research team found that the difference in life expectancy between forty-year-olds in the top one per cent of American income distribution and in the bottom one per cent is fifteen years for men and ten years for women.
But the team also found that where people live in America can make a big difference in how their income affects their longevity. Forty-year-olds who are in the lowest quarter of income distribution—making up to about thirty-five thousand dollars a year—live four years longer in New York City than in Las Vegas, Indianapolis, or Oklahoma City. For the top one per cent, place matters far less.
In a way, it’s a hopeful finding: if being working class shortens your life less in some places than in others, then evidently it’s possible to spread around some of the advantages that come with higher income. Chetty’s work didn’t say how, but it contained some clues. The geographic differences in mortality for people at lower socioeconomic levels were primarily due to increased disease rather than to increased injury. So healthier behaviors—reflected in local rates of obesity, smoking, and exercise—made a big difference for low earners, as did the quality of local hospital care. Chetty also found that low-income individuals tended to live longest, and have healthier behaviors, in cities with highly educated populations and high incomes. The local level of inequality, or the rates at which people were unemployed or uninsured, didn’t appear to matter much. What did seem to help was a higher level of local government expenditures.
As an ATAP, Herrera brought COVID vaccines to certain patients who were unable to travel to their local clinics. Because every resident is enrolled with an EBAIS, everyone was contacted individually about a vaccination appointment.
The Costa Rica model suggests that directing those 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. In an ingenious study, a group of Stanford economists compared families that include a doctor or a nurse with those that do not. The study focussed on Sweden, where, for many years, medical schools used a lottery to select among equally qualified applicants, providing the researchers with a set of otherwise matched families. The study found that people with a medically trained relative were ten per cent more likely to live beyond the age of eighty. Younger relatives were more likely to be vaccinated, were less likely to have drug or alcohol addiction, and had fewer hospital admissions. Older relatives had a lower rate of chronic illnesses such as heart disease. The study even found a “dose response” pattern: the closer that relatives lived to the family health professional, and the closer on the family tree, the larger the benefit. Relationships with people who can supply beneficial knowledge, authority, norms, and encouragement appear to make a major difference in mortality.
