Costa Rica is a country in Central America between Nicaragua and Panama. Central America is a harsh place, right? Refugees seeking asylum from Central America have created a border crisis in our own country with thousands fleeing horrible conditions and coming into the United States daily. Here is a shocking fact. Citizens of Costa Rica live longer than we do! Can that possibly be true?
It is true! Not only that, but the maternal mortality rate in Costa Rica for 2020 was estimated at 22.0 deaths per 100 000 live births, a reduction of 42.9% from the estimated value for 2000. Their healthcare system is more effective than ours. Costa Rica! The maternal mortality rate in the United States for 2021 was 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020 and 20.1 in 2019. A woman in Costa Rica is more likely to survive delivery than an American woman. Their stats are improving and ours are getting worse. There are huge racial disparities in our maternal mortality rates. White maternal mortality in 2021 was 26.6 per 100,000 while black maternal mortality was 69.9 per 100,000. A black woman in America is three times as likely to die in childbirth as a Costa Rican woman.
Here is a brief summary from the Advisory Board on the healthcare miracle in Costa Rica: “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.” That is the key-addressing the fundamentals at the community level. Friday I wrote about Michael Fine and the organization he founded—Primary Care for All Americans. Micheal was Director of Public Health for the state of Rhode Island. My bet is on him. He has this figured out and he will make a difference!
These advances didn’t just happen. They were the result of deliberate healthcare reform that began 50 years ago. Costa Rica expanded healthcare coverage and focused on a rural health program. They focused their efforts on “the most readily preventable kinds of death and disability.
For example, leaders in Costa Rica looked at their data and identified maternal and child mortality “as the biggest source of lost years of life.” Then they established public health units to make certain pregnant women receive prenatal care and assistance with delivery. In hospitals, they focused on the common causes of death associated with pregnancy— maternal hemorrhage, sepsis, and newborn breathing problems. Within ten years, death before age one dropped from 7% to 2%. Maternal deaths dropped by 80%. By 1985, Costa Ricans lived as long as Americans.
A single doctor, Alvaro Salas Chaves, accelerated the trajectory of health reform in Costa Rica. In 1977, he developed a new mobile public health unit. They didn’t just treat individuals, they analyzed community data, and addressed community needs. He was highly successful.
He moved on to work at a hospital in Puntarenas. The Costa Rican health system was dominated by hospital care at the time. He asked the hospital administrator to help him start a neighborhood clinic. That clinic was so successful, he came back just months later and asked for another one. Very quickly there was less demand for hospital services, fewer lines, and shorter waiting lists. The health system in Costa Rica is no longer dominated by hospitals. Costa Rica reduces the need for hospital beds by keeping people healthier.
Over the next decade or so, the Salas innovations were so successful that he was appointed to lead policy at the nation’s health care agency. There he developed a plan to bring public and individual health together. There were three main parts to this plan.
- The public health services would merge with the system of hospitals and clinics, enabling public health leaders to set the goals of the entire health system.
- They integrated data about the household setting with the medical record system. They used the data to set priorities, objective, and track progress.
- They made certain that every Costa Rican would have access to a local primary care health team that included a doctor, nurse, and a community health worker. The health workers made visits to homes annually at least and more often as required.
I mentioned Dr. Atul Gawande and his wonderful article earlier. He said, “our system is designed for the great breakthrough, not the great follow through.” Here is a great example. Hepatitis B is a blood borne form of hepatitis. It is a terrible disease. It may lead to liver failure and a need for a liver transplant or liver cancer. It is one of the top 5 causes of death in Americans aged 45 to 65. There are 4 millon Americans infected with hepatitis B or C. There is a vaccine for hepatitis B but that vaccine was not developed in Costa Rica. It was not proven to work in Costa Rica. The vaccine is extremely effective.
One of the most dangerous occupations in terms of hepatitis B infection is healthcare worker. Gawande’s own aunt was a nurse who slowly died of liver failure because of hepatitis B. That was before a hepatitis B vaccine was available. Now we have one. In the 1990’s, there was a national campaign to vaccinate all healthcare workers. Hepatitis B infections dropped by a remarkable 98% as a result. Here’s the rub. Mothers with hepatitis can transmit it to their children during childbirth. Ninety percent of Costa Rican infants receive hepatitis B vaccine. Only 2/3 of American infants receive it. Our hepatitis disease rates have barely budged. Only 25% of American adults have been vaccinated. Viral hepatitis infection rates are much higher among immigrant Asians and Africans, the poor, and IV drug user. These are the people who have the most trouble getting medical advice and treatment.
We now have the capability to eliminate hepatitis B and hepatitis C but I am not optimistic that will happen in the US. As Dr Gawande says, we are the best at developing the next new offensive scheme in football, but we don’t tend to the fundamentals— blocking tackling, and execution. That is why we are losing the game and other countries—even Costa Rica—have better health at lower cost. We have many great tools now to improve health. The greatest gains will come from bringing those tools together in best practice protocols and making certain that every appropriate patient gets every appropriate treatment. I call that lunch pail or hard hat medicine.
These efforts in Costa Rica based on science, data, and evidence have been highly successful. Costa Ricans live longer than Americans while spending less on health care as a percentage of gross domestic product. They spend about 7% of GDP on healthcare. We spend 18%. Their population is about 5 million which is about the size of South Carolina. Community owned primary care teams can provide world-class healthcare in rural areas. Costa Rica has done that. Will you?
Thousands of people are fleeing Central America every day. They are not running away from Costa Rica. Why not? Costa Rica is the most stable democracy in Latin America. It has a good economy, good healthcare, and good education. It gets 99% of its energy from renewable sources and has reversed deforestation. The people are solving these problems themselves. We could learn a thing or two from Costa Rica.
The opportunity exists today in the United States to exceed the longevity achieved in Costa Rica. Advanced primary care teams can consistently produce optimal medical therapy (OMT). Even in patients with type 2 diabetes and chronic kidney disease who are very high risk, OMT prolongs healthy life by eight years when compared with usual care. Patients on OMT have one fourth as many heart attacks, one fifth as many strokes, and one sixth as many progress to dialysis. Hospitalizations for heart failure are reduced by 70%. Patients who have had a heart attack on OMT are ten times a as likely to be alive in five years compared with patients in usual care and they cost $21,900 per patient per year less. We have been working for three years develop the infrastructure to support organizations in producing OMT for these chronic illnesses consistently. We have replicated these results with a worksite clinic in Louisiana. Patients seen in the clinic cost half as much, were hospitalized one fifth as often, and in the ER one third as often compared to patients seen in the broader community. We can do this! Let’s get started.
