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.”
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 circumstances 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.
“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.
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.
The conclusion, therefore, is that Costa Rica offers a healthy lifestyle that promotes longevity. Costa Rica's public health system, known as the Caja, is a strong contributing factor. Medical services begin before birth, with excellent prenatal care, and continue throughout a Costa Rican's life.Why does Costa Rica have such a high life expectancy? ›
Comparisons with the United States and Sweden show that the Costa Rican advantage comes mostly from reduced incidence of cardiovascular diseases, coupled with a low prevalence of obesity, as the only available explanatory risk factor.Do Costa Ricans live longer than Americans? ›
Costa Rica has higher life expectancy than the United States even though its per capita income and its health expenditure are small fractions of those in the United States (1).Why are Costa Ricans so healthy? ›
Costa Ricans have access to free education and a guaranteed state pension. It is the only country in Central America where 100 percent of the population has access to electricity and a source of drinking water. It is also one of the few countries in the region that offers universal health coverage.Why is Costa Rica happier than the US? ›
Researchers have identified Costa Rica's primary sources of happiness as renewable resources—strong social bonds, a clean environment, and investment in education.What race are most Costa Ricans? ›
The majority of the Costa Rican Population comes from Europe since it was a Spanish colony for a long time. 83.6% of the Ticos are white or mestizo, 6.7% mulattoes, 2.4% Native American and 1.1% black or Afro-Caribbean. This makes Costa Rica one of the most ethnically homogeneous countries in Central America.What is the biggest problem in Costa Rica? ›
Poverty. The poverty level is one in four in Costa Rica.What is the number one cause of death in Costa Rica? ›
For a stay longer than 90 days a residence permit must be established. 2.Other nationals might not require an entry visa to Costa Rica. To verify all entry requirements according to your nationality please see the following link nationalities. 3.What races live longer? ›
Racial gaps in life expectancy have long been recognized. The same CDC data show that nationally, Hispanic Americans have the longest life expectancy, followed by white and then Black Americans.
- Monaco. As the second-smallest country in the world, Monaco has the longest life expectancy on Earth at 89.4 years, according to the World Factbook. ...
- Japan. ...
- Singapore. ...
- San Marino. ...
Except in exclusive hotels and gated communities that are constructed with advanced plumbing, flushing toilet paper in Costa Rica is a no-no. The simple reason for the request is that Costa Rica's small and antiquated septic systems can't accommodate discarded toilet paper without clogging.What are Costa Ricans proud of? ›
Costa Ricans are proud of their values. They believe in education and healthcare and make it freely available to its people. They are proud of their long-standing history as a democracy. In fact, they are the oldest and most stable democracy in the region.What are Costa Ricans known for? ›
Nowadays, thanks to the rich volcanic soil, Costa Rica is well-known for its gourmet coffee beans with the famous Tarrazú considered among the finest beans in the world. Along with bananas, coffee might just be the most famous Costa Rican export.Why is poverty so high in Costa Rica? ›
And without a doubt, income inequality is one of the main causes of poverty in Costa Rica. Urban Costa Ricans are largely outpacing rural Costa Ricans when it comes to income. The top 20 percent of earners make an average of $4,650 per month, while the bottom twenty percent make only $360.Why do US citizens retire in Costa Rica? ›
Retiring in a foreign country like Costa Rica offers Americans an opportunity for the good life at a cheaper price. Rents, food and healthcare are much cheaper than in the U.S. This helps you stretch your savings much further once you're relying on your fixed monthly income in retirement.What is the happiest country in the world? ›
- Finland. Finland ranks as the world's happiest country based on the 2021 report, with a score of 7.842 out of a total possible score of 10. ...
- Denmark. ...
- Iceland. ...
- Netherlands. ...
- Norway. ...
- Sweden. ...
- Honorable Mention: Bhutan.
As of 2019 most Costa Ricans are primarily of Spanish ancestry with minorities of Nicaraguan, Italian, Portuguese, German, French, British, Irish, Jamaican, Greek, mixed or other Latin American ancestries.What are female Costa Ricans called? ›
Costa Rican men are called Ticos and women are called Ticas. How many people live in Costa Rica? The population of Costa Rica is just over 5 million but it is always growing! More people have come to paradise in the past two decades than ever before.
As of 2012 most Costa Ricans are of primarily Spanish or Spanish/Mixed ancestry with minorities of German, Italian, French, Dutch, British, Swedish and Greek ancestry. Whites, Castizo and Mestizo together comprise 83% of the population.Why is Costa Rica so wealthy? ›
Known for its beaches, mountain ranges, volcanoes and varied wildlife, Costa Rica's rich biodiversity makes it a popular destination for eco-tourists. Traditionally a producer of agricultural goods such as coffee and bananas, its economy has diversified and tourism now ranks as the country's number one earner.How much does a small house cost in Costa Rica? ›
|United States v/s Costa Rica||United States Average ($)||Costa Rica Average ($)|
|Housing (comparable 3 bedroom, 2 bath)||$1000-3000||$500-1200|
|Gasoline (per gallon of regular)||$3.00||$5.00|
|ADSL Internet monthly (1024/512 kb/sec)||$34.95||$28.25|
|Home Phone Service (basic monthly fee)||$29.95||$7.00|
- Leave valuables unattended.
- Go to the beach at night.
- Buy drugs.
- Swim in front of a surf break.
- Take a dip in the river.
- Think you can get a base tan.
- Skip out on mosquito repellent.
Costa Rica's homicide rate in 2021 was 11.5 per 100,000.Who is responsible for the most deaths in the world? ›
But both Hitler and Stalin were outdone by Mao Zedong. From 1958 to 1962, his Great Leap Forward policy led to the deaths of up to 45 million people – easily making it the biggest episode of mass murder ever recorded. Opinions to start the day, in your inbox. Sign up.What is the safest place to live in Costa Rica? ›
There are many safe cities in Costa Rica to call home. Several of the safest towns include Tamarindo, Atenas, Escazu, San Mateo, Puerto Viejo, Dota, Heredia and Dominical.What is the penalty for overstaying in Costa Rica? ›
Foreigners staying longer than allowed in Costa Rica and having their immigration document (DIMEX) expired at the time of departure must pay 100 dollars for every month expired.How much do you need to live comfortably in Costa Rica per month? ›
Cost of Living in Costa Rica: $1,100 to $4,000.
|Rent (Western-style 1-bedroom)||$450|
|Utilities (including fast wifi)||$140|
Costa Rica's 90-Day (Maximum) Tourist Visa
For citizens of many countries, including the United States, Canada, and many European countries, the tourist visa can be for up to 90 days. After 90 days, you will need to leave the country and reenter to get a new visa stamp with a new end date.
Abstract. Using gene frequency data for 62 protein loci and 23 blood group loci, we studied the genetic relationship of the three major races of man, Caucasoid, Negroid, and Mongoloid. Genetic distance data indicate that Caucasoid and Mongoloid are somewhat closer to each other than to Negroid.What race has the shortest life span? ›
Life expectancy for Black people was only 71.8 years compared to 77.6 years for White people and 78.8 years for Hispanic people. Life expectancy was even lower for Black males at only 68 years. Data were not available for other racial/ethnic groups.What nationality has the shortest lifespan? ›
- Lesotho (54.366 years)
- Nigeria (54.808 years)
- Sierra Leone (54.81 years)
- Somalia (57.5 years)
- Ivory Coast (57.844 years)
- South Sudan (57.948 years)
- Guinea Bissau (58.444 years)
- Equatorial Guinea (58.878 years)
A Mediterranean diet remains one of the gold standards for living longer and more healthfully. This pattern is characterized by a high intake of fruits and vegetables; whole grains; pulses; healthful fats from nuts, olive oil, and avocado; and herbs and spices. It includes seafood a few times a week.Why do Italians live so long? ›
As the renowned medical journal Lancet points out, eating habits play a key role when it comes to Italians and longevity. A large part of the population can easily bring fresh and healthy food to the table, regardless of social status and income. This is what makes the difference.
In fact, the Melis family has been named the longest-living family in the world by Guinness World Records. The nine siblings - six girls and three boys - have a combined age of 818 years.Where do the healthiest people live? ›
According to Blue Zones, the people living in Okinawa are fortunate enough to have extremely low rates of cancer, heart disease, and dementia compared to Americans. Their longevity can also be attributed to strong social ties, as well as a deep sense of purpose.
- Sardinia, Italy. On the island of Sardinia, you find the world's longest-lived men. ...
- Okinawa, Japan. These islands are home to the longest-lived women in the world. ...
- Nicoya, Costa Rica. ...
- Loma Linda, California. ...
- Ikaria, Greece.
- Finland — 70.9.
- Canada — 69.8.
- Thailand — 68.2.
- Slovenia — 67.8.
- United Kingdom — 67.2.
- Germany — 65.5.
- South Korea — 65.4.
- Sweden — 64.9.
Feminine Hygienic Products
Shannon says: Pads are found abundantly in most grocery stores and pharmacies. Tampons are also found, but more sparsely. There are only one or two brands, usually sold in quantities of ten.
Topics such as pre-marital sex, abortion, and gay marriage are generally avoided. Costa Ricans are very polite, so be sure not to put your feet on furniture; always say please and thank you, and try not raise your voice in anger, at least in public.
Can you drink the water in Costa Rica? The short answer is yes. You can drink the tap water in Costa Rica safely in most every part of the country. In some rural areas, including the Caribbean and in non-touristy places, you may want to stick with bottled water.Are Costa Ricans nice people? ›
Costa Ricans tend to be proud, friendly, and diverse people who enjoy sharing their culture and social activities with newcomers. Costa Rica is the place of pura vida (pure life), a contagious attitude of living life to the fullest.What 3 things is Costa Rica known for? ›
Costa Rica is famous for its incredible natural wonders, rich biodiversity, aromatic coffee, and progressive government. It is home to some of the most beautiful rainforests, beaches, and mountains in the world.Why is Costa Rica so special? ›
According to Culture Trip, Costa Rica is home to 27 national parks and five percent of the world's biodiversity. But it's not all just jungles. It's also cloud forests, swamps, coral reefs, dry forests, and rainforests.What do Costa Ricans believe? ›
According to recent data, 76.3% of Costa Ricans identify as Catholic. An additional 13.7% are Evangelical Christians, 1.3% are Jehovah's Witness, and 0.7% are Protestant Christian. The remaining 8% either have no religion (3.2%) or are of other faiths (4.8%), including Mormonism, Judaism and Islam.What do Costa Rican call themselves? ›
Costa Ricans are usually called ticos by themselves as well as by people of other Spanish-speaking countries. “Tico” and “tica” (male and female) are colloquial terms that Costa Ricans gave themselves, due to their linguistic tendency to add the diminutive “tico” to the end of words.Do Costa Ricans live longer? ›
On average, life expectancy is slightly greater for Costa Ricans (79.8 years) than for U.S. citizens (78.6 years). In addition, Costa Rica ranks 29th in terms of longevity in the world. In Costa Rica, women live longer than men.Why do Hispanics live longer? ›
Despite having higher rates of poverty, harsher jobs, less education and health services than non-Hispanic white, they tend to live longer and are more resistant to disease. Several theories have been hypostasized as to why this happens, including dietary factors, social support, and a slower biological clock.Why do the Spanish live so long? ›
Environmental factors -- such as high levels of sunshine and a pleasant climate in most regions -- plus the Mediterranean diet, an emphasis on physical activity, strong social relationships, and a robust public health system seem to lie behind the longevity of Spaniards.
|#||Country||Males Life Expectancy|
Why? Latinos' slower aging may result from their Native American ancestry, the study's main author, Steve Horvath of the David Geffen School of Medicine at UCLA, told the L.A. Times. The process cannot be explained by Latinos' diet, education, obesity or socioeconomic status, factors for which the researchers adjusted.Why do Puerto Ricans live so long? ›
Experts attribute the "Hispanic paradox" to a number of factors. The Latino population tends to be younger, compared to other demographic groups. Hispanics also have lower smoking rates, better diet and better general health - at least in the first few years after immigrating into the US.How are Mexicans so healthy? ›
Immigrants reported that traditional Mexican health practices can often prevent or resolve problems before they require medical attention. Such practices promoted keeping calm, staying active and maintaining a positive attitude, to consuming traditional foods and herbal remedies.Why are the Spanish so healthy? ›
People in Spain eat a Mediterranean diet rich in omega-3, fats, and protein, which has been linked to a lower risk of dementia, heart disease, and cancer, placing Spain among the top five countries in terms of life expectancy.How do Spanish people stay thin? ›
They avoid big meals.
They eat small portions of a dish to avoid eating more than required. Also, instead of eating a single heavy meal, they eat several small meals throughout the day which keeps them energetic while also resulting in them eating only what they want.
Hispanics can expect to live to 78.8 years, while whites can expect to live 77.6 years. Some of the Hispanic lifespan advantage is attributed to social behaviors, such as having strong community and multi-generational households.