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Life expectancy: Atul Gawande explores the differences that make Costa Rica’s higher than ours

Costa Rica checks in with a life expectancy of 80.94 years, almost two years higher than the U.S. figure.

A woman checks her cell phone in front of the San Rafael Hospital in Alajuela, Costa Rica.
A woman checks her cell phone in front of the San Rafael Hospital in Alajuela, Costa Rica.
REUTERS/Juan Carlos Ulate

Despite being the most powerful and richest (or among the richest, depending on how you measure) nation on earth, and despite spending by a HUGE margin the most per capita on health care, U.S. average life expectancy, which checks in at 79.11 years, ranks 46th in the world, according to “Worldometer.”

I’m sure someone could quibble with the methodology behind any such rankings, but no amount of such quibbling could eliminate the VERY large disparity between where we rank on health spending and where we rank on health outcomes. This has always struck me as a huge outrage, easily known by anyone who chooses to know it.

In the current issue of the New Yorker, Atul Gawande, an American surgeon, health researcher and journalist, takes as his starting point the comparison between U.S. life expectancy and that of Costa Rica, a small Central American nation which, although the most prosperous in its region, has a much, much lower average income than ours, but which checks in with a life expectancy of 80.94 years, almost two years higher than the U.S. figure.

It wasn’t always thus. Gawande’s exploration of how Costa Rica raised its life expectancy stretches back to the 1950s, when Costa Rica’s life expectancy was 55 years, trailing the U.S. figure by far. Since then, Costa Rica’s figure has risen steadily, while the U.S. life expectancy has actually been declining recently (and starting declining before COVID was an explanatory factor).

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Gawande’s long, smart piece is headlined “Costa Ricans Live Longer Than Us. What’s the Secret?” The answer, can  be accessed via this link. But in case you don’t go there, his answer to “What’s the Secret?” is summarized in the sub-headline: “We’ve starved our public-health sector; The Costa Rica model demonstrates what happens when you put it first.”

I should hasten to add that U.S. health care spending – more than $10,000 per capita – is, by a wide margin, the highest of any nation. But that figure is spread very unevenly across the economic classes with an obvious concentration around the wealthy. That’s why the key to the Gawande quote in the paragraph above refers to “public-sector” health care spending statistics.

Long story short, and I’ve already belabored it, is that as a nation, we spend more than anyone on health care, but the spending is concentrated on more affluent Americans, leaving huge swaths of our population un- or under-served.

And the difference between private and public-sector health spending is not all, maybe even not mainly, about Costa Rica spending more so poor people can see a doctor when they are sick. It’s about things like preventive health, vaccinations, etc., and other things that have an impact on health like clean water and free-lunch programs in grade schools, but, of course, it also includes widespread access for poor people to doctors and nurses and medicine.

Here are a couple of paragraphs that summarize more specifically what spending, not necessarily for medicine or doctor visits but for things that make people healthier, looks like:

In the nineteen-seventies, Costa Rica identified maternal and child mortality as its biggest source of lost years of life. The public-health units directed pregnant women to prenatal care and delivery in hospitals, where officials made sure that personnel were prepared to prevent and manage the most frequent dangers, such as maternal hemorrhage, newborn respiratory failure, and sepsis.

Nutrition programs helped reduce food shortages and underweight births; sanitation and vaccination campaigns reduced infectious diseases, from cholera to diphtheria; and a network of primary-care clinics delivered better treatment for children who did fall sick. Clinics also provided better access to contraception; by 1990, the average family size had dropped to just over three children.

The strategy demonstrated rapid and dramatic results. In 1970, seven per cent of children died before their first birthday. By 1980, only two per cent did. In the course of the decade, maternal deaths fell by eighty per cent. The nation’s over-all life expectancy became the longest in Latin America, and kept growing. By 1985, Costa Rica’s life expectancy matched that of the United States.

Since then, as mentioned above, Costa Rican life expectancy has surpassed ours.

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P.S If you subscribe to the print version of the New Yorker, Gawande’s piece will be in the Aug. 30 issue, which hasn’t arrived in your mailbox yet. But  the article is online and can  be read now, as I said above, via this link.