Even in countries with robust universal health care, public health is usually an add-on; the vast majority of spending goes to treat the ailments of individuals. In Costa Rica, though, public health has been a priority for decades.

The COVID-19 pandemic has revealed the impoverished state of public health even in affluent countries—and the cost of our neglect. Costa Rica shows what an alternative looks like.

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medical systems seldom focus on any overarching outcome for the communities they serve. We doctors are reactive. We wait to see who arrives at our office and try to help out with their “chief complaint.” We move on to the next person’s chief complaint: What seems to be the problem? We don’t ask what our town’s most important health needs are, let alone make a concerted effort to tackle them. If we were oriented toward public health, we would have been in touch with all our patients, if not everyone in the communities we serve, to schedule appointments for vaccination against the coronavirus, the No. 3 killer in the past year. We would have coördinated with public-health officials to prevent cardiovascular disease, the No. 1 killer, by jointly taking aim at high blood pressure and cholesterol, smoking, and dietary salt intake. We would have made a priority of preventing disease, rather than just treating it. But we haven’t.

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Each ATAP is responsible for visiting all the people assigned to his or her team, which for Herrera represented about fourteen hundred households. The homes are grouped into three categories. Priority 1 homes have an elderly person living alone or an individual with a severe disability, an uncontrolled chronic disease, or a high-risk condition; they average three preventive visits a year. Priority 2 homes have occupants with more moderate risk and get two visits a year. The rest are Priority 3 homes and get one visit a year.

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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.

Read more in the New Yorker.