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This week, we head to Costa Rica, the final destination on our maternal health “world tour,” where we explore the country’s unique community-based model of care. We’ll travel into the mountains with a community health worker to check up on a pregnant woman, and then head to the western coast, where we meet a doctor providing care to a small fishing village. Along the way, we’ll learn how the country’s healthcare reforms helped to expand access to rural areas and overcome high rates of child and maternal mortality.Learn more about Costa Rica’s healthcare model here:

• https://www.commonwealthfund.org/publications/case-study/2021/mar/community-oriented-primary-care-lessons-costa-rica
• https://www.ariadnelabs.org/wp-content/uploads/2017/12/CostaRica-Report-12-19-2017.pdf
• https://www.newyorker.com/magazine/2021/08/30/costa-ricans-live-longer-than-we-do-whats-the-secret

Uncared For is presented by the Commonwealth Fund, a nonprofit foundation making grants to promote an equitable, high-performing health care system. Learn more at CommonwealthFund.org.

SuChin Pak is our host. Muna Danish is our supervising producer. Giulia Hjort is our producer and Rachel Lightner is our producer and audio engineer. Isaura Aceves is our associate producer. Mix help from Kristin Mueller. Music is by Andrea Kristinsdottir. Jackie Danziger is our VP of Narrative Content. Our story consultant is Kaya Henderson. Fact-checking by Naomi Barr. Executive producers are Jessica Cordova Kramer and Stephanie Wittels Wachs.

Follow SuChin on Twitter and Instagram at @suchinpak. Stay up to date with us on Twitter, Facebook and Instagram at @LemonadaMedia.

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To follow along with a transcript, go to www.lemonadamedia.com/show/ shortly after the air date.

Transcript

SPEAKERS

Oscar, Alex, Madeline, SuChin Pak

Alex  00:07

So look over there on that mountain. There’s the community of Palmira. in that community. There’s about 300 people that live up there.

SuChin Pak  00:20

That’s Alex, a community health worker in Costa Rica. He’s telling us about Palmira, a community that’s part of his home visit route in the mountains of Limon, a region known for banana harvesting and coffee production. The other voice you’re hearing is our translator, Dr. Madeline Pesic.

Alex  00:40

Most of the communities we visit about once a week, but we have one very small community that we only visit once a month and that’s where we’re going right now. I know there’s a pregnant woman there and we can go meet her.

SuChin Pak  00:56

Alex is taking us on one of the many medical home visits he makes every day. Typically, he’s zipping down dirt roads on his motorcycle, with endless rows of towering banana trees on either side of him.

Alex  01:11

This community all works on the banana Farms, really the only source of employment that there is around here.

SuChin Pak  01:18

Today, Alex is riding with us in our noisy van as we pass motorcycles, bicycles, carts, that are all hauling the same thing.

Alex  01:30

One person can transport about 25 bananas at once. With all the bananas strapped to their back.

SuChin Pak  01:39

Alex suggests we overshoot our destination by a few minutes for a quick scenic detour. We pull over at a small opening in the brush that leads to a rocky trail.

Alex  01:59

This is the small path that we would take to get to the indigenous community of Palmira.

SuChin Pak  02:06

The banana trees have turned into gigantic willows that lead to a wide riverbed.

Alex  02:14

This is the river. That man over there you see is one of the elderly members of the indigenous community.

SuChin Pak  02:22

Alex points to a man across the river carrying a big bag of bananas on his back.

Alex  02:28

from ticket to his house. From here, it’s about a 30 minute walk from where we are now.

SuChin Pak  02:33

Alex tells us there’s a local health care team visiting patients in that man’s village right now.

Alex  02:43

So in order to get to this population, we have to cross the river and then climb up the mountain. This is what they’re doing right now is the first time they’ve been able to visit the community in about a month and a half. Because the river has been so high that they haven’t been able to get anybody in or out.

SuChin Pak  03:03

As a community health worker, Alex is used to these types of challenges when he’s providing care to rural communities. So what makes someone climb a mountain to provide health care? Madeline sees it like this.

Alex  03:19

Your health care system is a reflection of your country’s values and what people are going to agree to. So Costa Rica’s health care system is based on the principle of solidarity and universality and equity.

SuChin Pak  03:36

The Costa Rican healthcare system is built on the belief that health is a human right. And this means that their primary care system or that first point of contact in health care is often much better than ours here at home.

Alex  03:50

The United States is really Patchwork, it’s up to you to go find a primary care doctor if that’s something that’s important to you. Our health care system is not a system as we all lived and experienced.

SuChin Pak  04:06

So far in this series, we flipped to the Germans and the Dutch to learn about how midwives and postpartum maternity aides could really revolutionize our maternal care here at home. But we need to take this a step further, because we can’t separate maternal health needs from the day to day function of primary care. They’re so deeply intertwined. But in the US, we’re roughly one in 10 Americans don’t have a go to doctor of any kind. Primary Care is often an afterthought, in part thanks to decades of underinvestment and a low number of providers. This is understandably frustrating. It makes people wonder; How can we live a happy healthy life when we’re at the whim of a failing system? So today, we’re leaving Europe and heading to Costa Rica, where we’ll see an example of community focused primary care in action. Soon, we’ll talk to pregnant people, community health workers and experts about how the story behind this Latin American countries success could inspire our own approach to care.

Alex  05:11

Primary Care is at the heart of every well-functioning healthcare system.

SuChin Pak  05:30

This is UNCARED FOR. I’m your host, SuChin Pak.

SuChin Pak  05:40

Madeline, thank you so much for getting back on the mic with us.

Madeline  05:46

Guys, just give me one second, my washing machine has decided to restart, which is inconvenient. Okay. It’s gonna happen. Throw some pillows over the tour. See if that helps.

SuChin Pak  05:58

That’s Dr. Madeline Pesic again, our team’s resident medical expert and translator turned soundproofing assistant.

Madeline  06:05

All right, I am back and we are hopefully quiet in the background now.

SuChin Pak  06:12

Madeline is an internal medicine and pediatrics resident at Brigham and Women’s Hospital in Boston. She’s also a research fellow at […] labs, a global health […]

Madeline  06:24

So my research into Costa Rica initially came out of a little bit of curiosity to say, gosh, this country has incredible health outcomes, how are they doing it? What makes their health care system produce better results, United States life expectancy and Costa Rica’s longer than in the United States? What are they doing right? And what can we learn from that? And what we came down to was that they have an incredibly strong primary health care system.

SuChin Pak  06:52

We hear this word primary care a lot, and I hear it in my personal life all the time. I have a vague notion of what it is. But can you really pinpoint what does primary care mean? And then why it’s so important.

Madeline  07:10

When it comes down to it primary care is your first contact, it’s your first point of entry into the healthcare system. Primary care is really comprehensive. It covers every organ system; primary cares job is to coordinate between medical professionals. If you have a lung doctor, and a heart doctor, and an ear doctor and a kidney doctor, they all need to talk to each other and understand you as a whole. That primary care doctor is going to provide that coordination. And the primary care doctor is also going to provide continuity over time.

SuChin Pak  07:44

I have a PCP and I see them maybe once a year for my annual checkup. But Madeline says they should be playing a much bigger role in our care, because they’re actually the ones shaping our health outcomes.

Madeline  07:57

A good primary care doctor in a strong primary health care system is working with you day after day, year after year to solidify healthy habits to quickly identify early warning signs of disease and really focuses on health promotion.

SuChin Pak  08:15

So then I guess the natural question then is how are we in the US doing in terms of primary care.

Madeline  08:23

So the United States, we don’t have a coordinated health care system, doctors don’t often talk to one another. And the quality of care that you get really depends on where you live, what health insurance you have, and what services you have access to. And then there’s a lot of people that don’t have a primary care doctor, and so that systems not working for them.

SuChin Pak  08:45

But in Costa Rica, the primary care system works hard for its people by prioritizing access and equity.

Madeline  08:55

So Costa Rica’s healthcare system as a whole is really fundamentally different than the United States system. And I say that because their system is primarily a central government run health care system, with an option to get medical care from the private sector, if citizens want to, but everybody has to buy health insurance through the government at the bare minimum, and then every Costa Rican has access to that health care system.

Oscar  09:27

In Costa Rica, health is considered a right.

SuChin Pak  09:32

That’s Dr. Oscar Vegas. He works for the […] or the Costa Rican Social Security fund, the organization that manages the populations health care. After a major public health reform in the 90s, the government made the […] responsible for primary health care with the principles of universality and solidarity.

Oscar  09:54

We divided the whole country in the sectors we call them health sectors or territories, small territories, each one is taken care of by the […]

SuChin Pak  10:05

A […] is a local primary health care team that all citizens are assigned to based on their geographic location.

Oscar  10:14

We’ll say in Costa Rica, that there’s a football court. There’s a church, there’s a school, and there’s no […]. So these are the pillars of the community.

SuChin Pak  10:28

Each […] team cares for about 4000 people and works to promote access and continuity of care.

Madeline  10:36

Every single Costa Rican is assigned to one of these primary care teams, and every single one of these primary care teams has a community health worker assigned to it.

Oscar  10:47

That community agent goes house by house every day, vaccinating people finding out what people are in risk, implementing basic interventions.

Madeline  11:01

This is someone who is out there visiting patients in their homes, in their communities and bringing health promotion to them.

SuChin Pak  11:14

Like Alex Mora, the community health worker we met earlier. Is there a role in the US that it’s similar to that like, what could we even compare that to here in the US?

Madeline  11:27

There’s nothing like it in the United States. So we were fortunate enough to meet Alex and he has been working with the same community, the same land, the same people for the past 27 years.

SuChin Pak  11:46

Alex is a big guy. He’s over six feet tall with broad shoulders that fill out the white […] he has on. Alex is what’s known as an […], or a primary care health care worker who makes home visits to people in nearby communities. […] have been called the champions of the Costa Rican healthcare system. And they take a lot of pride in their work.

Alex  12:12

I love working as a […] because you really get to know your population that you’re working with. I know where all of the elderly people live, I know where all the pregnant women live.

SuChin Pak  12:22

Again, that’s Madeline translating for us.

Madeline  12:25

I know where the diabetics are hypertensive, where all these higher risk patients live. And really, my job is to go out into the community and do education, which is what I love.

SuChin Pak  12:35

Alex has a special connection to the remote mountain region of Limone.

Alex  12:41

I was born on a Banana Farm in a community called […] that was owned by a banana company called standard free company. I remember sometimes some indigenous folks came to our house. They were friends with my dad, and they slept in our house with us. And I think it was really from that point on that I developed a strong connection to indigenous communities and a desire to work with them.

SuChin Pak  13:12

We were able to see Alex’s work in action shadowing him on a home visit to Palestina, a banana farming village bordering the mountains. We’re here to visit a woman named Fabiola who’s five months pregnant with her second child. From the van we see a small but sprawling house on a hill. Recycled lumber provides a stable framework but the walls are mostly open. Chickens and dogs roam the yard, navigating piles of kids toys and scrap metal.

Alex  13:48

Let’s make sure that we get audio of the dog barking because that was hands out to him. Most of all these home visits are all the dogs if we go.

SuChin Pak  13:54

We’re greeted by Fabiola wearing shorts flip flops, and a gray Levi’s t shirt stretched across her pregnant belly. She invites Alex inside. To the right there’s a bedroom and then the next room over there’s a TV playing kids cartoons. To the left. A long wooden table is covered with household knickknacks. Faviola sits down and Alex takes her blood pressure measures her blood sugar levels and sees how she’s doing overall. She had been really nauseous lately; she says but luckily she’s been able to keep food down. Alex gives her some advice about proper nutrition and takes notes on his tablet. In that tablet is Faviolas entire patient history collected and what is called the feature familiar or for Amelie file. But the tablet Alex is using doesn’t just record medical records on it, he’s able to make a full profile of people’s homes and living conditions.

Madeline  15:15

So I’ll describe the quality of the floor. Is it a dirt floor? Or is it a concrete floor, I’ll describe the walls that they have running water. I’ll see if the House has electricity, what other types of electronic devices they might have in the house. And I’ll also ask them about any preexisting health conditions that anyone in the house has. For women especially, it’s really important to record the number of births and pregnancies that they’ve had, and also to record the date of their last pap smear.

SuChin Pak  15:44

This information is also digitized and added to their electronic medical record, so it’s easy to access for everyone on fabulous care team. Alex says it can help her providers consider her social determinants of health too. So they can see the ways that her living and working conditions might impact her health.

Madeline  16:46

then we can link this information about the house we can link them to other social agencies that can help provide the family with more support services. Wow.

SuChin Pak  17:04

Back at Faviola’s house and Palestina. Alex answers her questions and wraps up her checkup. As we’re leaving we catch a glimpse of her four year old son hanging out in the backyard. Do you want to show them your chickens? Faviola asks. The boy nods shyly and leads us to a row of animal coops in the backyard. While her son shows us his baby chicks, Faviola chats with Alex one on one.

Alex  17:47

So even at our home visit today, after I went to go do the regular prenatal visit, that woman pulled me aside and said, You know, I also have this really bad toothache. So I’ll be able to get her linked up with the orthodontics here and get her an appointment to get her tooth taken care of as soon as possible.

SuChin Pak  18:07

When we get back to the clinic, Alex calls an orthodontist and makes an appointment for Fabula. So she can bypass the traditional referral process. By bringing prenatal care directly to her, he was able to address all of fabulous health concerns, not just the ones related to her pregnancy, and this is something she likely would not have had if Alex hadn’t come to her home.

Alex  18:36

is something that I always tell my coworkers that technically we are primary healthcare, technical assistance. But the moment we go to someone’s house, they might need a doctor, they might need a social worker, they might need a psychologist, and we adapt to fill whatever role the person might need.

SuChin Pak  18:59

I have to admit, I’m not sure what it would even feel like to have your health care provider care about you as a person, not just a patient. Just like the midwives we followed in Germany and the postpartum aids we shadowed in the Netherlands. Alex’s role as an […] is all about building relationships, and trust.

Alex  19:27

So for me, I always try and go above and beyond what is technically required of me from my job description. And that helps the community to really see me as the link to the medical system.

SuChin Pak  19:41

That link is so necessary, especially here in the US, where so many people have to travel long distances for care. And while there’s already a significant primary care shortage, rural areas are hit the hardest. Having a link to the system like Alex who comes to you, well, that would be a game changer. After the break, we’ll learn how the Costa Rican primary care system got to where it is today. Before the break, we learned about the importance of primary care in Costa Rican health care, what’s at the heart of their model, and how […] like Alex Mora help function so well. But it wasn’t always this way.

Madeline  20:34

Before the reform, their primary health care system looked pretty similar to the one we have in the United States.

SuChin Pak  20:43

That’s Dr. Madeline Pesic again.

Madeline  20:46

It was piecemeal, it was patchwork, two different governmental organizations were both providing primary care services. And there wasn’t like a unified vision of what primary care should be throughout the whole country.

SuChin Pak  21:00

But that changed in the 90s, when the country realized that their piecemeal health system wasn’t doing everything it could for the Costa Rican people. A measles outbreak brought the underlying issues too ahead. And when the demand for care skyrocketed, the system hit a breaking point. And that’s what really kick started the government’s plan for reform. They knew they needed one unified health care system to meet their populations every need. So they transferred primary care and public health prevention to just one agency in charge of it all. The CA, or the Social Security Administration that we mentioned earlier.

Madeline  21:42

vaccinations, health promotion, all those classic public health functions got subsumed under the Social Security Administration.

SuChin Pak  21:52

Why did they want to put all these health care systems under one roof? Well, because they were finding a disconnect in care. Here’s Dr. Oscar Villegas again.

Oscar  22:03

before they reform, if a person was pregnant, or if there was a small child and just needed vaccinations, you have to go to the Minister of Health. But if they found out that the child had a high risk of something or disease or anything, then they would refer it to the Social Security. So there was not a big communication or continue to services between the different establishments. And now, because of the integration, you only go to one place your device. So that’s the main door for the whole system.

SuChin Pak  22:37

This main door or the […] primary care teams, which you heard about earlier, came about because of a very real health care need. Back in the 50s, barely half of the country’s population had running water or proper sanitation facilities. And this contributed to widespread infectious diseases like malaria, and high rates of mortality, including maternal and infant mortality. Nearly 10% of babies die before their first birthday. And these shocking stats push the Costa Rican government into action. One important step came in the 70s, when the Ministry of Health created pilot programs for community health workers.

Oscar  23:22

I said part of the intervention, they trained local workers, and they will knock on everybody’s door and say, well, I’m so and so. And I well know you come in, do you want some coffee, it was easy for them to engage with the community and do the interventions in order to control malaria.

SuChin Pak  23:45

These were people like Alex Mora, who we followed earlier on a home visit that were trained in public health work.

Oscar  23:53

And so they would go to every corner of the of the country, by boat by walking by horse by bicycle any means, the goal was to cover everyone.

SuChin Pak  24:06

By boat, by horse, by bicycle. These new health programs are founded on accessibility in the most literal sense. And that principle of health as a human right continues to be essential to this day. But it wasn’t just the community health workers who contributed to better health care in Costa Rica, the Ministry of Health started opening up health clinics throughout the country, and most people were accessing care like never before. Plus, the government had started investing in sanitation campaigns to fight infectious diseases. And an economic boom resulted in more funding for infrastructure, like better roads, which were really lacking in more rural regions.

Oscar  24:49

I have photographs where people had to go on top of Margarita, have an oxcart, and they will have to travel for hours in order to have a delivery and things changed dramatically when resources were oriented towards infrastructure and towards water and towards health services and all that it transformed the country.

SuChin Pak  25:11

By 1980, the malaria outbreak was under control, the infant mortality rate had dropped to about 2%. And maternal deaths had fallen drastically by 80%. It turned out that treating the whole person combining disease prevention and treatment really worked. And that’s when the Ministry of Health saw an opportunity.

Oscar  25:35

What do we do with all these train people? And so they had the brilliant of the of changing them to […]

SuChin Pak  25:44

[…] or the community health worker role that’s now standard across all […] teams. Costa Rica’s reforms in the 1990s came about due to a breaking point, a measles outbreak that expose the cracks in their system. And that makes me think of the Covid 19 pandemic, which revealed just how broken our healthcare system is here at home. But a crisis can also mean an opportunity for change. Yes, the pandemic was unexpected, but we failed at keeping our country’s mortality rate down. At over 1 million COVID related deaths, the US was hit harder than any other country. Those losses are irreplaceable. If we had a stronger and more integrated public health infrastructure, our response might have looked very different. And you can see how in Costa Rica, a community and public health oriented system has led to better health outcomes overall. One example of their success was in a small fishing village called Target lists on the country’s western coast.

Madeline  26:55

So target list is a small community outside of a very heavily touristed area, kind of a surfing beach town, called jaco. And initially, the health clinic was only in jaco, and residents from Tarcoles and the surrounding area had to drive 45 minutes to 15 minutes into the major city to be seen.

SuChin Pak  27:19

Back in the 90s. The small community and Tarcolesdid not have its own clinic. Instead, they had a primary care team that visited twice a week taking appointments out of an old school building. But by 2002, the Tarcoles population had grown.

Madeline  27:36

The Tarcoles is community decided that they wanted to have a clinic in their city.

SuChin Pak  27:41

The community was now large enough to qualify for a permanent clinic with an […] team totally dedicated to them. So the community banded together and requested just that.

Madeline  27:55

But the social security administration didn’t have the money to buy a building in that moment. So the tacos community decided that they would build it themselves and then they would be able to rent it out to the Social Security Administration. So the Tarcoles community came together, decided that this was important to them and made it happen.

SuChin Pak  28:19

Over the next 9 years, the group successfully raised money to purchase land and construct a new clinic in 2010. The building built by the community for the community was complete. Five years later, the HCA has established a fully staffed permanent clinic just for target lists, and the impact was significant. After opening the clinic deaths from chronic non-communicable diseases fell. And across the country, the opening of primary care clinics led to a steady decrease of overall mortality rates. But this sort of progress doesn’t happen just like that.

Oscar  29:00

This is not an easy process. This requires time. It requires a lot of effort, and especially continuity of actions in order to achieve the goal.

SuChin Pak  29:13

After the break, we traveled to Tarcoles to see firsthand whether time has worked in its favor. What you’re hearing is Madeline and the rest of our team and our bumpy yet trusty van that had gotten us through wild and rainy drive through a mountain range the night before. There we were back at it again with no rain to speak of, nearing the end of our two hour journey from San Jose to the popular surfing town of jaco. But we’re not here to surf or buy chocolate fruity monkey poop souvenirs from one of the dozen or so gift shops in the main strip. We’re here to see how the Tarcoles […] is doing seven years after it first open.

SuChin Pak  30:31

The person we were here to see was Dr. Solano, is the general physician on staff at the target list of is where he’s been working for the past four years. He says he’s in charge of 9000 people right now, most of whom are employed in the fishing industry and qualify as low income.

Madeline  30:56

We usually see people from 7am to 4pm every day. So we see about four patients per hour, which means that we have 15 minutes to see each patient.

SuChin Pak  31:05

But not all of those patients are local to Tarcoles. Once a week, Dr. Solana travels up to 20 kilometers to visit more rural secluded communities that aren’t able to make the trek down to Tarcoles. While this setup is a decent band aid solution for now, it’s exhausting for Dr. Solano. And it’s a reminder of what Tarcoles used to be a town lacking in health equity and accessibility. But Dr. Solana is not the only one feeling stretched thin.

Madeline  31:40

Unfortunately, sometimes the gynecologists are overwhelmed and there’s just not capacity to see everyone. And so if the weight is very long, I will end up managing the entirety of the pregnancy myself even if it is high risk. The biggest challenge is for high risk pregnancies, the time to wait to see a specialist. And so often these high risk pregnancies are being managed only at the primary care level, because they aren’t able to get in to see a gynecologist quickly enough. And so in this region in this clinic, that’s the biggest challenge that they face.

SuChin Pak  32:19

These staff shortages and long wait times can be especially dangerous if someone is labeled as a high risk pregnancy. And the solution isn’t an easy one.

Madeline  32:32

It’s really challenging. As the population grows, we haven’t been able to get approval for additional […] here. It’s just a lot of people to be seen by one physician. So there has to be a way to make […] more quickly, as the population continues to grow so that we can keep up with increased demand.

SuChin Pak  32:55

After hearing what Dr. Solano had to say about the health of his community, it became pretty obvious that Tarcoles which had once been upheld, as a success story was now struggling.

Madeline  33:08

The doctor that was there was telling us that it’s pretty overwhelming all of the things that he has to juggle right now. And you can’t provide the type of comprehensive care that this model relies on. If those numbers get too big, or if the doctor gets pulled away to do visiting clinics and other areas too many days of the week.

SuChin Pak  33:29

Seven years ago, when Madeline first visited, she remembers the Tarcoles clinic being a great example of the Costa Rican health care system. But fast forward to today, and the clinic is experiencing growing pains without the right kind of support. And this isn’t uncommon. Oftentimes, change can counter intuitively lead to a sense of complacency. But for a system to function long term. It needs more of the same resources that helped it function successfully in the first place.

Madeline  34:02

What we’re seeing right now is a healthcare system that is stretched financially, hypothetically, is a model in Costa Rica. Is it sustainable financially, yes, right now, is Costa Rica struggling with how to finance this model and how to finance our whole healthcare system? Absolutely.

SuChin Pak  34:22

It makes sense. Their system was totally overhauled. And committing to change means finding a way to fund it. I mean, in this country, we certainly know a thing or two about financial gridlock. But complicated politics doesn’t mean change isn’t possible.

Madeline  34:39

Has Costa Rica encountered bumps in the road with making that glorious mental model a reality? Absolutely. And it’s not, you know, a perfectly well-oiled machine quite yet. But when it works, it really works.

Oscar  34:57

The problem is that there still many communities that are having problems having not good results.

SuChin Pak  35:05

Oscar again.

Oscar  35:07

And so we could focus on that and said, Well, what do we need in order to improve and one of the answers was more resources. We need more attempts; we need more advice. We need more health areas, we need more equipment, more infrastructure.

SuChin Pak  35:24

In January, the […] approved the creation of more than 300 health care teams over the next five years. And while this is great progress, more attention needs to be paid to communities like Tarcoles. The thing is addressing the needs of everyone in the country takes money and buy in from a government that some say has started D prioritizing primary care to focus on specialists like cardiologist and neurologists.

Madeline  35:51

The biomedical model has so much allure, it’s shiny, it’s new, it’s scientific, you’ve got medications, you’ve got lab tests, it seems sexier than boots on the ground, community promotion. But slowly over time, the biomedical of lower has started to make the preventive work a little bit less emphasized.

Oscar  36:18

Hospitals, a look at the primary care as a basic care or inferior care, we need to be in the position where primary care can be recognized at the same level of care as the rest of the system.

SuChin Pak  36:34

And that’s important, because primary care covers so much more than disease prevention and health screenings. It’s the first touch point for most pregnant people.

Madeline  36:45

I see maternal care, in the same way that I see heart disease or diabetes, in that this is something that’s going to happen to a huge segment of our population. And certainly some folks are going to need specialized care. But in the beginning of your pregnancy, you need someone who knows you who knows your social context, who knows where you live, who knows how long it takes you to walk to your clinic, who understands you as a person.

SuChin Pak  37:19

So primary care physicians that know your entire medical history, health areas created based on geographic need community health workers that go door to door, what examples can the US realistically and that’s the key word realistically borrow from the Costa Rican healthcare system?

Madeline  37:41

You know, I’ve been reflecting on this question for five years. And it’s definitely not a copy paste situation. You know, we can’t take everything that’s good about the Costa Rican healthcare system and implement it in the United States. I don’t even know if we could do it in one city, we have to build our own system that’s going to work for people, and that’s going to be acceptable to them. So for example, Costa Ricans are assigned based on the zip code they live in to the clinic they get to go to, probably wouldn’t go over so well here. But I think that the concept of multidisciplinary teams, the concepts of community health workers, that are from the community that they’re serving, that we can absolutely do a better job of focusing on.

SuChin Pak  38:28

This is something our country is actively working on. Almost every state is either integrating community health workers in some capacity, or has already done so. And these efforts are making a difference. For example, in Mississippi, when community health workers were integrated into cardiovascular disease prevention programs, they successfully improved health outcomes and reduced health disparities and cost effective ways. And earlier this year, the Biden administration set aside millions to fund more community public health workers throughout the country. But one of our country’s major health care pain points is rural America, which is home to 14% of our population. Like we mentioned earlier, areas like these tend to have less access to health care, and more and more rural hospitals have been closing in recent years. That’s where more equitable coordinated primary care should really come into play. Rural access, it’s also something that Alex Mora, the community health worker we met earlier, basically wakes up and goes to bed thinking about every single day, he can’t help it.

Alex 39:49

So one of my dreams for this health area is that all of the indigenous communities would be able to access medical care through a footbridge that would help them to get across the river. When we’re in the wintertime, the level of the river increases and people just can’t get out. But extremely expensive to do. It’s just a dream right now.

SuChin Pak  40:25

Alex has a lot of dreams for his community, but dreams need political will to become a reality. And Costa Rica showed that will when they overhauled their entire system to focus on two often overlooked aspects, public health and primary care. Both remained largely an afterthought in the US something that COVID pandemic showed us very clearly. So are we going to change our system or stick with the status quo, healthcare spending continues to rise, and employers are paying more than ever to cover health care. In a country where over half the population is covered through their employer, something will need to change. Remember, in the US, we pay so much more on health care than similar countries and still have worse health outcomes. Why? Like Madeline said earlier.

Madeline  41:20

Your health care system is a reflection of your country’s values.

SuChin Pak  41:25

Costa Rica system shows how a country can respond to the needs of its citizens through a community minded approach to health. And that’s in stark contrast to our system, which seems to be holding tight to our principles of individualism. It’s about your insurance plan, your zip code, your employer, your income bracket, not that everyone deserves affordable health care as a human being.

SuChin Pak  41:50

While we can expect to transform our system right away, thinking of health care as a fundamental right, feels like a good place to start. In our last and final episode of the series, we’re packing our bags and flying back to the US where we’ll meet the people working to integrate culturally Centered Care here at home.

CREDITS  42:37

UNCARED FOR is a production of Lemonada Media. I’m your host SuChin Pak. Muna Danish is our supervising producer. Giulia Hjort is our producer. And Rachel Lightner is our producer and audio engineer. Isaura Aceves is our associate producer. Mix help from Kristin Mueller. Music is by Andí Kristinsdóttir, Jackie Danziger is our VP of narrative content. A story consultant is Kaya Henderson. Fact checking by Naomi Barr. Executive Producers are Jessica Cordova Kramer and Stephanie Wittels Wachs. This season of Uncared For is created in partnership with the Commonwealth Fund. There’s more UNCARED FOR with Lemonada Premium subscribers get exclusive access to bonus content, like interviews with health experts, midwives and doulas. Subscribe now in Apple podcasts, follow UNCARED FOR wherever you get your podcasts or listen ad free on Amazon music with your Prime membership.