![]() ![]() ![]() “The mothers and the families saw that it was a good idea now to send the kids to school, because they were fed,” he said.Īlong the way, the Ministry of Health provided an official in every community with resources and staff devoted to preventing infectious-disease outbreaks, malnutrition, toxic hazards, sanitary problems, and the like. It was very nice to have a plate of soup with rice.” His family, with its cows and its store, was never nutritionally deprived-Salas grew to six feet-but his friends were often hungry. “We had this lunch-hot food,” he recalled. Vaccination campaigns against polio, diphtheria, and rubella reached Salas and his classmates when he was in elementary school, as did a child-nutrition program that the government rolled out across the country, with aid from the Kennedy Administration. “The most happy person was my mother!” he said. National power generation brought electrical wiring. A national latrine campaign provided people with outhouses made of cement. Salas was in kindergarten, he thinks, when his family was able to pipe running water to their home from the nearby city center. Important progress was achieved in the nineteen-fifties and sixties in Costa Rica, with the kind of basic public-health efforts made in many developing countries. Salas said that most children in Atenas started elementary school, but each year more and more were pulled out to do farmwork. Many children left school early, and only a quarter of girls completed primary education. ![]() Like other societies where many die young, people had big families-seven or eight children was the average. Many children did not have enough to eat, and, between malnutrition and recurrent illnesses, their growth was often stunted. In the country at large, barely half the population had running water or proper sanitation facilities, which led to high rates of polio, parasites, and diarrheal illness. When Salas was growing up, Atenas was a village of farmers and laborers. He understood what the country has achieved and how it was done. I travelled with Álvaro Salas to his home town because he had witnessed the results of his country’s expanding commitment to public health, and also because he had helped build the systems that delivered on that commitment. Costa Rica shows what an alternative looks like. The COVID-19 pandemic has revealed the impoverished state of public health even in affluent countries-and the cost of our neglect. In Costa Rica, though, public health has been a priority for decades. 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. People who have studied Costa Rica, including colleagues of mine at the research and innovation center Ariadne Labs, have identified what seems to be a key factor in its success: the country has made public health-measures to improve the health of the population as a whole-central to the delivery of medical care. The country’s average life expectancy was fifty-five years, thirteen years shorter than that in the United States at the time. Many youths and young adults died as well. In 1950, around ten per cent of children died before their first birthday, most often from diarrheal illnesses, respiratory infections, and birth complications. “At that time, Costa Rica was the most sad country, because the infant-mortality rate was very high,” he said. The images of the mourners are still with him. When someone died, a long procession of family members and neighbors trailed the coffin, passing in front of Salas’s home. On the cemetery road, however, there was another kind of traffic. Situated halfway between the capital, San José, and the Pacific port city of Puntarenas, Atenas was a stop for oxcarts travelling to the coast, and the store did good business. ![]() His father also had a store on the main road through town, where he sold various staples and local produce. His parents had a patch of land where they grew coffee, plantains, mangoes, and oranges, and they had three milk cows. Still, his family was among the better-off in Atenas, then a community of nine thousand people. He slept on a straw mattress, with a woodstove in the kitchen, and no plumbing. Salas grew up in a small, red-roofed farmhouse just down the road. ![]()
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