ArticleProceedings of the National Academy of Sciences of the United States of America2016
Exploring why Costa Rica outperforms the United States in life expectancy: A tale of two inequality gradients.
Article in Proceedings of the National Academy of Sciences of the United States of America, 2016. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 23 papers, 1 of them a synthesis that pooled it.
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Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
23 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Health inequalities in a middle-income country: a systematic review of the Costa Rican case.Frontiers in public health · 2024Pooled it
- Comparing the Risk of SARS-CoV-2 Immune Resistance Evolving Across Regions in the Americas with Differing Approaches to Public Health.Pathogens (Basel, Switzerland) · 2026Article
- Catching up with stagnation: cause-specific dynamics of change in life expectancy at age 65 in the United States, Canada, and Latin America, 2000-2019.The Gerontologist · 2025Observational
- Construct validity of the self-report instrument of perceived stress in the general Costa Rican population of retirement age: CRELES study.Frontiers in public health · 2025Article
- Social gradient and rural-urban disparities in cancer mortality in Costa Rica.Cancer epidemiology · 2024Article
- Inequalities in Disability-Free and Disabling Multimorbid Life Expectancy in Costa Rica, Mexico, and the United States.The journals of gerontology. Series B, Psychological sciences and social sciences · 2024Article
- COVID-19 and long-term impact on symptoms and Health-Related Quality of Life in Costa Rica: the RESPIRA cohort study.BMC infectious diseases · 2024Article
- Assessing the relationship between multimorbidity, NCD configurations, frailty phenotypes, and mortality risk in older adults.BMC geriatrics · 2024Article
- Understanding Loneliness in an Aging Population of San Vito de Coto Brus, Costa Rica.Annals of global health · 2024Article
- Medical Education in Costa Rica. From Flexner to COVID-19: Integrative Answers for Old and New Challenges.Medical science educator · 2023Article
- Frailty as a predictor of mortality: a comparative cohort study of older adults in Costa Rica and the United States.BMC public health · 2023Article
- Excess mortality from COVID 19 in Costa Rica: a registry based study using Poisson regression.Lancet regional health. Americas · 2023Article
- Micro- and Macronutrient Intake in Elderly Costa Ricans: The Costa Rican Longevity and Healthy Aging Study (CRELES).Nutrients · 2023Article
- Health inequalities in cause-specific mortality in Costa Rica: a population-based cohort study.Revista de saude publica · 2023Article
- Is life expectancy higher in countries and territories with publicly funded health care? Global analysis of health care access and the social determinants of health.Journal of global health · 2022Article
- Gender Differences in Perceived Stress and Its Relationship to Telomere Length in Costa Rican Adults.Frontiers in psychology · 2022Article
- Diet and Leukocyte Telomere Length in a Population with Extended Longevity: The Costa Rican Longevity and Healthy Aging Study (CRELES).Nutrients · 2021Article
- Associations between education and dementia in the Caribbean and the United States: An international comparison.Alzheimer's & dementia (New York, N. Y.) · 2021Article
- Redistributive effects of different pension systems when longevity varies by socioeconomic status.Journal of the economics of ageing · 2020Article
- Health policy impacts on malaria transmission in Costa Rica.Parasitology · 2020Article
Corrections and comments
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2 authors.
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Abstract
Mortality in the United States is 18% higher than in Costa Rica among adult men and 10% higher among middle-aged women, despite the several times higher income and health expenditures of the United States. This comparison simultaneously shows the potential for substantially lowering mortality in other middle-income countries and highlights the United States' poor health performance. The United States' underperformance is strongly linked to its much steeper socioeconomic (SES) gradients in health. Although the highest SES quartile in the United States has better mortality than the highest quartile in Costa Rica, US mortality in its lowest quartile is markedly worse than in Costa Rica's lowest quartile, providing powerful evidence that the US health inequality patterns are not inevitable. High SES-mortality gradients in the United States are apparent in all broad cause-of-death groups, but Costa Rica's overall mortality advantage can be explained largely by two causes of death: lung cancer and heart disease. Lung cancer mortality in the United States is four times higher among men and six times higher among women compared with Costa Rica. Mortality by heart disease is 54% and 12% higher in the United States than in Costa Rica for men and women, respectively. SES gradients for heart disease and diabetes mortality are also much steeper in the United States. These patterns may be partly explained by much steeper SES gradients in the United States compared with Costa Rica for behavioral and medical risk factors such as smoking, obesity, lack of health insurance, and uncontrolled dysglycemia and hypertension.
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