In Costa Rica: integrating public health and primary care
In Part Two of our Costa Rica series, Dr. Tara Kiran takes you inside an EBAIS (Equipos Básicos de Atención Integral de Salud) clinic on the Nicoya Peninsula in Costa Rica to see what it actually looks like to deliver primary care beyond clinic walls. Costa Rica organizes primary care around geography. Each clinic is accountable for a defined population — and community health workers play a central role in making sure no one is missed. They visit households, provide education on prevention and chronic condition management, deliver vaccines, identify risks early, and act as a bridge between public health and clinical care. It isn’t a perfect system. But it is an ambitious one. And it offers a powerful contrast to Canada’s often fragmented approach to primary care and public health — reminding us that building a system where everyone has care is not just a matter of funding, but of design.
Further reading:
Listen to Part 1 of our series on Costa Rica with Dr. Madeline Pesec
Take a look at the research article that first introduced me to Madeline (co-authored by Dr. Atul Gawande)
Explore this brief Commonwealth Fund case study on the Costa Rican primary care system or dive deeper into this more detailed case study from Ariadne Labs
Read the article “Costa Ricans Live Longer Than We Do. What’s the Secret?” in the New Yorker magazine by Dr. Atul Gawande
Read the BBC article Tara mentioned about how Nicoya Peninsula is home to a large number of centenarians
Learn more about rising violence in Costa Rica related to femicide and gang violence
MAINPRO CREDITS: Family doctors can claim Mainpro Credits by completing a linking learning exercise.
More about Primary Focus:
Subscribe to our Substack newsletter
Have an idea for an episode? Email primary.focus@unityhealth.to
-
In Costa Rica: integrating public health and primary care
Primary Focus Podcast
Introduction
Dr. Tara Kiran (00:13) Welcome to Primary Focus. I'm your host, Dr. Tara Kiran. I'm a family doctor and a researcher, and I created this podcast to launch a conversation we really need to have about how we can deliver primary care to more people across our country. Today: Part Two of our series on Costa Rica.
If you missed Part One, I suggest you go back and enjoy the really dynamic conversation I had with Boston-based physician and researcher Dr. Madeline Pesec. She laid out important background and context for this on-the-ground look at Costa Rica's primary care system — one that's been built over decades and one that consistently achieves more than its resources would predict.
She's also the person who introduced me to a local physician leader who became my volunteer guide on my trip to Costa Rica. Here's Madeline telling me more about Luis.
Dr. Tara Kiran Tell me a little bit about him, because you know him. I met him in Costa Rica, and he was such a gracious host. He drove several hours with his team to meet me, and then we drove for another hour to go to the EBAIS, and then we spent some time there. So tell me a little more about Luis.
Dr. Madeline Pesec Luis — I think I just showed up in his office. He made time and space for me and we talked for two or three hours in the middle of his workday. I'm sure he had a hundred other things to get done. But alongside being a lead of the region, he is incredibly focused on how to leverage data to do the right thing, and to do it consistently. He serves a health region that historically was quite underserved, and has worked to substantially improve their health metrics and health outcomes. And I believe he is working on or has just finished his PhD — again in this pursuit of knowledge, using evidence to grow and do better for his people and his region.
This is someone who — hopefully you'll hear some audio from him — you can just feel it. There's lots of audio for him, because also one of my weaknesses: I don't speak Spanish. So he was the translator for me the whole time.
I hope listeners can feel the love. One of my role models was Dr. Paul Farmer, and he used to end every consult note he would write in the hospital with: "With love, Infectious Disease." And it just struck me that what you see, and what you felt, and what listeners will hopefully hear is that love — love for patients, love for the work, for his country, and for this incremental improvement: every day, do it better than we did the day before and use every tool in our belt to marry this very quantitative, rational analysis with love.
Driving to the Clinic
Dr. Tara Kiran (03:08) Luis and his colleagues picked me up right from my yoga retreat centre in a large black SUV. We drove through small villages and countryside along a very potholed road to get to the clinic Luis wanted to show me.
[In the car, Luis navigating:]
Luis Carlos Vargas Martínez Turn left on [uncertain: Calle Boca]. Each area has so many [uncertain: byes — road diversions?]. Yes. So they — área salud — no, no, no, no.
Dr. Tara Kiran The clinic we're heading to is on the Nicoya Peninsula — an 80-mile-long peninsula on Costa Rica's Pacific coast, just south of the border with Nicaragua. It's home to many pristine, isolated beach towns, wildlife refuges, and yoga retreats. It's also a part of Costa Rica that's made headlines for its high proportion of centenarian residents — according to one BBC article, three and a half times the global average.
Here's Luis.
Luis Carlos Vargas Martínez Nicoya is the health area. This [uncertain: EBAIS] — Nosara — is one of the EBAIS within the health area. Exactly. There are — a hundred and five health areas. Exactly. Seven regions, I think. Exactly. That's great. I was reading.
Dr. Tara Kiran As we talked about in our last episode, Costa Rica is broken up into seven health regions, and from there into about 105 health areas. Health areas are responsible for disease prevention, community health education, home care, and primary care delivery for between 30,000 and 110,000 residents. Each health area's size is dependent on both the geographical needs of the population and the regional capacity. Each health area has on average about ten EBAIS teams.
Now, I want to tell you what EBAIS stands for, but I'm a little worried I might pronounce it wrong. So here's Dr. Madeline Pesec instead.
Dr. Madeline Pesec The EBAIS teams stand for the Equipo Básico de Atención Integral de Salud. And what that translates to in English is the basic healthcare teams for the holistic provision of health.
Dr. Tara Kiran Like we talked about in our last episode with Madeline, EBAIS are integrated primary healthcare clinics with team members who serve the local population. Residents are assigned to the local clinic based on where they live. On average, a single EBAIS clinic serves about 4,000 people.
Arriving at the EBAIS Clinic
Luis Carlos Vargas Martínez (05:35) Right there — there are two EBAIS. There are two EBAIS. Exactly. For around seven thousand, five hundred [people]. Okay. Here, they start work at seven AM [and run] to ten PM. The EBAIS is open seven AM to ten PM. Exactly. Yes. And you said there are two of them. Yeah, exactly. Side by side. Side by side.
Dr. Tara Kiran Who exactly works at these EBAIS clinics?
Luis Carlos Vargas Martínez One doctor. One nurse auxiliary. One pharmacist.
Dr. Tara Kiran Luis says that in addition to the doctor and the nurse, there's also a pharmacy technician and a medical clerk — someone who creates the doctor's daily agenda, but who also analyzes the clinic's data and pulls together chronic condition registries.
And one more important role.
Luis Carlos Vargas Martínez And one ATAP.
Dr. Tara Kiran And that's like a — a healthcare worker, exactly. From what Madeline told us in our last episode, these ATAPs — or Asistentes Técnicos de Atención Primaria — are primary healthcare technical assistants. They go out to residents in the community.
Dr. Tara Kiran I'm very interested in the role of the ATAP, the community health worker — and how they work together with the doctor and nurse. It's a unique role. It's not one that we have in Canada. Let's go.
Luis Carlos Vargas Martínez Let's go.
Dr. Tara Kiran During my visit, I speak to a doctor at the clinic about how their role is different from the doctor's role in a lot of other health systems, like the one here in Canada. While at the clinic I also spoke to a nurse, the receptionist, and — because the pharmacy is integrated within the clinic — the pharmacy technician. You're not going to hear those interviews, but I'll weave my insights from those conversations into the tour of the clinic.
Canada is a much richer country than Costa Rica. When you adjust for cost of living, Canada has about twice the economic resources per person compared to Costa Rica. And that makes Costa Rica's primary care system all the more impressive. Because where Canada has the money, we lack the system. In Costa Rica, they've got the system, but they don't have the monetary resources we have.
Inside the Clinic
Dr. Tara Kiran (07:57) These are not the bright, white, institutional-looking clinics you're used to. The buildings here are made from exposed concrete; the infrastructure is crumbling in spots, and most of them are painted what Madeline called "institutional caja blue" — the signature colour of the Social Security Administration, known as the Caja.
The clinic I'm visiting today has that caja blue bordering the building, but I should mention that the exterior walls are actually kind of a pale mustard yellow. Here's Luis giving me a very quick tour.
Luis Carlos Vargas Martínez Right now we'll have the pharmacy over here.
Dr. Tara Kiran Inside, the clinic waiting room is very busy, but also clean and organized. The clinic walls are mostly ivory in colour, but there's also lots of caja blue. It's mid-November, so there are little Christmas decorations everywhere on display. And in one room there's even a Finding Nemo mural painted on the windows.
It's here that we meet Dr. Rosales.
Dr. José Javier Rosales [in Spanish] My name is José Javier Rosales. I'm originally from Santa Cruz. I finished my studies in San José in 2022. I spent some time working in emergency rooms in Santa Cruz before I came to the clinic.
Dr. Tara Kiran Today he's wearing dark blue scrubs — I'd guess he's in his late twenties or early thirties. He talked to us while sitting at his desk, next to a green curtain he can pull across to add privacy to the exam room. He says he has around 3,500 patients.
Luis Carlos Vargas Martínez (09:53) [translating] What he said is probably a little more — there are people we've uncounted, people we're not a hundred percent sure about. So it's about 3,500, but it could be more. We said ten — [uncertain: the clinic covers around 3,500 to maybe more].
Dr. Tara Kiran As you heard, this clinic serves about 3,500 patients. The clinic has two doctors and between them they staff the clinic from about seven AM to ten PM, six days a week.
Dr. Tara Kiran And do you switch? Sometimes do you do afternoon?
Dr. Rosales (via Luis translating) No, I'm always on the morning.
Dr. Tara Kiran Dr. Rosales says their schedules are fixed — they don't really rotate who's on daytime and who covers the evening. When I spoke to him, he had just started working at the clinic a few months before.
Dr. Tara Kiran Is it hard to find a doctor who will work four PM to ten PM Monday to Friday and three PM to ten PM on Saturday?
Luis Carlos Vargas Martínez It's really hard.
Dr. Tara Kiran [Luis translating an exchange with Dr. Rosales:] They don't have transport for the patient. So if they get sick, the doctor has to transport with them?
Luis Carlos Vargas Martínez [translating] They would, if any patient is in a critical condition — you have to go with the patient to the hospital and then back here to work.
Dr. Tara Kiran Wow. And they drive themselves or —
Luis Carlos Vargas Martínez They have a driver, but they have to go with the driver. There's no ambulance.
Dr. Tara Kiran Whereas when you're the daytime doctor, that doesn't happen. It sounds like it's only the nighttime doctor who does that. Exactly.
Now in Canada, this is not how it works. We take turns covering evening shifts. But here, if you're on evenings, it seems you're on evenings every night.
[A small aside:]
In our podcast episodes about Costa Rica, we're talking about the public system, which is there for everyone in Costa Rica. There is, though, a parallel private system that's supplemental and could provide more personalized and faster access to physicians and tests. It's used, for example, by people with a higher income who can pay privately, or for people who have employer-provided health insurance.
Dr. Tara Kiran I asked Dr. Rosales why he chose to work in the public clinic over one of the private clinics we drove by on the way here.
Luis Carlos Vargas Martínez (translating) He said we have a lot of advantages working in the public system — month by month, your salary, you have social security, you have any kind of benefits. Which you wouldn't have if you didn't work in the public system. So most doctors prefer to work in the public system.
Dr. Tara Kiran Now, Dr. Rosales refers to himself as a general physician. General physicians have done a medical degree and a short internship, and then they can start work in hospitals or EBAIS clinics. You could go further and become a family medicine specialist, but that's another four years of supervised, work-based training — much like a residency here in Canada. There are, though, very few family medicine specialists in Costa Rica. They largely act as clinical and system leaders within each health area. Most of the doctors in the EBAIS are general doctors.
Now, Dr. Rosales says he sees about 32 patients a day. Most of those patients are coming in to see him because of a chronic condition — like high blood pressure, diabetes, or asthma. But he reserves about six slots for urgent issues: people with fever or diarrhea, or children who are sick. He says, though, that even though they're supposed to be open for acute issues, those slots often fill up with patients who have chronic conditions.
Luis Carlos Vargas Martínez (translating, re: scheduling) He says often his colleague who makes the schedule will tell him: "Doctor, we're full, there's no space." And then he needs to squeeze them in on top of his full schedule. Or if it's an emergency, he needs to treat it that way.
Dr. Tara Kiran Can I see your agenda? Is that okay?
[Dr. Rosales shows his schedule.]
He has maybe one spot open this afternoon, but tomorrow there are only five patients booked. He says the slots always end up filling up.
The Role of the ATAP
Dr. Tara Kiran (14:28) The care Dr. Rosales is offering at the clinic is largely for people with chronic conditions and acute issues. That's similar to much of the work doctors in Canada do. But here in Costa Rica, there is a big difference. The first point of contact is actually the community health worker — the ATAP. In this clinic, Dr. Rosales says that while he sees patients when they need him, he doesn't really know them. He's not from this community, and all the ongoing relationships built with patients — those are built with the ATAP.
Dr. Rosales meets with the ATAP only once a month, unless there's a specific case they need to discuss.
Dr. Tara Kiran How does a patient know when to see you versus the nurse versus the ATAP?
Luis Carlos Vargas Martínez (translating) He said it's really important to understand the ATAP. The ATAP has the medical information — very important information from the patient. So the ATAP knows all of the people.
Dr. Tara Kiran Yes, exactly. And he or she tells them when to come to see the doctor?
Luis Carlos Vargas Martínez Yeah, exactly.
Dr. Tara Kiran In general, most of the pre-booked patients for Dr. Rosales have actually been referred by the ATAP — because they have a chronic condition, or, for example, they're pregnant. The ATAP play a unique and critical role in Costa Rica's primary care system: one that's integrated with public health and that serves the entire population.
Coming up, we'll meet the ATAP team Dr. Rosales works with.
Meeting the ATAPs
Dr. Tara Kiran (17:17) In this clinic, there are three ATAPs who go out into the community. Luis says they mostly travel by scooter or motorcycle, and then on foot.
This role, for me, is what makes this system so unique — not just that the community health workers go out to the patient, but also that it's done with a population-based approach.
Luis Carlos Vargas Martínez These are the different areas that the ATAPs cover within Nosara: Los Ángeles, [uncertain: Gran Norte], [uncertain: Gaza —] —
Dr. Tara Kiran In the clinic, there's actually a wall covered in maps of the Nosara area this EBAIS covers. Next to it is a large whiteboard with a list of vaccines and the stock count of each in the clinic.
Because the ATAPs work outside of the clinic most of the time, I was just hoping to catch one of them at this visit.
Luis Carlos Vargas Martínez Wow — three?
Dr. Tara Kiran My lucky day.
Luis Carlos Vargas Martínez Yes, I see.
Dr. Tara Kiran Luis said they're all here today because they're working on a census — a study to get more accurate numbers on the real population that lives in the area. The ATAPs say that during COVID, when they stopped doing home visits, more people moved into the region, and as a result they don't have clear numbers anymore.
And so Luis and I got to sit down with Angelina, [uncertain: Kahner], and Eric to talk about their work in their community — again with Luis playing translator.
These ATAPs have a daily goal for how many houses they need to visit. Though Angelina says it's sometimes hard because the family might not be home or might turn them away.
Dr. Tara Kiran I would love to know what you do on a typical day — what you did yesterday or what you're going to do today.
Luis Carlos Vargas Martínez (translating) In this EBAIS, the ATAPs are each responsible for visiting about 1,500 patients multiple times a year. Their work is assigned based on the colour-coded maps I mentioned. They each have a digital tablet with their agenda and access to the integrated medical record for each family that they see. At the end of each day, they make an agenda for the next day with a goal for how many homes they'll visit tomorrow.
Dr. Tara Kiran (19:37) But he said normally he has time to attend eight [homes].
But the agenda is about fifty. And so — does the computer prioritize it, or does it give you a list and you pick which ones?
Luis Carlos Vargas Martínez (translating) By order. Each home has a number. And so the agenda is made according to those numbers — so that the homes are close together.
Dr. Tara Kiran Okay. And can you see the last visit date there too? Does that factor in — like, do you go to the ones you haven't been to in a long time?
Luis Carlos Vargas Martínez (translating) He said it's possible.
Dr. Tara Kiran Based on this system, homes are rated as a level one, two, or three risk. No matter the risk level, ATAPs are expected to visit every home at least once a year. But if a home is rated risk level one, they're visited three times a year; level two gets two visits; and level three, the goal is one visit per year.
In the home, the ATAP can administer vaccines, take blood pressures, check blood sugars where necessary. Luis says they also look for women who are, as he puts it, "pregnant without control" — meaning they've not yet been checked by a doctor during their pregnancy. The ATAP might also do checkups on children in the home.
As they work, they're filling out a family health record form on their tablet in the integrated electronic medical record. You might remember that in my interview with Madeline in Part One, she recalled seeing a piece of paper on the outside of people's homes where ATAPs logged their visits. This is now done digitally. And as mentioned, the ATAP might refer someone in the family — with a chronic condition or a pregnancy — to Dr. Rosales or the night-shift doctor back at the clinic.
What ATAPs Do Beyond Clinical Care
Dr. Tara Kiran (21:55) When they visit a home, the ATAPs also do health education — staying healthy, and supporting people in the home who have chronic conditions. They might also offer education on topics like violence against women or substance use, if those are relevant. All three of the ATAPs I spoke to say that violence and drugs are more and more a part of their work.
Dr. Tara Kiran What is one of the most challenging parts of your job?
Luis Carlos Vargas Martínez (translating) He said: violence. Violence and drugs. It's really violent because of drugs. So frequently it's at night.
Angelina (via Luis) [uncertain: Los principales retos que tienen es visitar ese sector —] They have to go to a specific place or region that has a higher level of violence.
Dr. Tara Kiran Violence is escalating in Costa Rica. In December 2025, Costa Rica's ombudsman sounded the alarm on a deepening crisis of violence against women, with femicides hitting a peak not seen in over a decade. And like Angelina, [uncertain: Kahner], and Eric say, there's also been a big increase in violent crime driven by gang warfare over drug trafficking. Though this gang violence seems to mostly affect big cities, the ATAPs at this clinic say it's happening in their communities too. You can imagine how escalating violence might make community health workers more reticent to knock on doors.
Luis Carlos Vargas Martínez (translating) He says there is some weight to letting people know you're an ATAP. The residents have a lot of respect for the work that ATAPs do.
The Joy of the Work
Dr. Tara Kiran What is one part of your job that you really love?
[Luis translates as the ATAPs share stories about their favourite patients.]
Luis Carlos Vargas Martínez (24:14) (translating Eric's story) He said: "I'm really grateful to try to invite people in — people without any kind of control." He described an experience about two older adults — he said seventy-eight years old — who had never come to the clinic. They had a really large fungal infection on their [uncertain: arm] — and he invited them to come and receive medical attention. So when they left, they bought [uncertain: a thank-you gift]. She came close to Christmas, to say thank you.
Dr. Tara Kiran Angelina says she loves taking care of older adults. She says they often tell her that no one comes to visit them — so they're excited to see the ATAP, because the ATAP listens to them and offers some companionship.
Luis Carlos Vargas Martínez (translating Angelina) She said that she really loves her older adult patients. It's really sad for her when they pass away.
Dr. Tara Kiran (25:25) These ATAPs say their job is not just about illness — it's about the relationships they make with the people.
Closing Reflections: Costa Rica
Dr. Tara Kiran (25:50) Today is my last day here in Costa Rica. It's a small country, but it is a country that had vision and ambition. So even though Costa Rica is a country with fewer resources, I think there's a lot that we can learn.
They share the value that every person in the country should have access to primary care. And so they have a system here that is not just about delivering medical care in a clinic — it really integrates primary care together with public health, health promotion, and disease prevention in a way that's very community-grounded. With primary care at the centre of what they do, they're able to achieve outcomes including lower infant mortality and longer life expectancy. There's a lot we can learn here about a population-based approach to primary care and integration of primary care into community.
It's what the people we spoke to through Our Care wanted to see. We just need to set the ambition — just like Costa Rica.
Lessons for Canada
Dr. Tara Kiran (27:01) Okay, let's talk about Canada. Here in Canada, there are actually some communities where we have people who do work similar to the community health workers in Costa Rica. We'll hear more about them in upcoming episodes. Sometimes they're called community health workers, but sometimes also community ambassadors or cross-cultural health brokers. They play a really important role, especially in high-priority areas.
But an important difference is that in Costa Rica, they take a population-based approach. The ATAPs know everyone in the community. In fact, it's their job to know who is living in the community and what their situation is like. Much of the time, people in the community don't need to go out and seek a doctor's advice — the ATAP comes to them, and refers them to the doctor when that's needed.
To me, this gets at another really important issue: the integration of public health and primary care in Costa Rica. This goes back to decisions made decades ago that there should be just one government agency responsible for both primary care and public health. That means they can move in a unified, wellness-oriented direction. When they invest in keeping people well, the same agency reaps the rewards of lower healthcare costs down the road.
That's not the same here in Canada. Our primary care system and public health system are separate. They may refer to each other and try to collaborate — but ultimately, what happens in public health affects a different budget than the pot of money used to fund primary care. For example, in Ontario, public health units are run by the city, while healthcare delivery is a provincial obligation. Public health focuses on vaccines and specific health promotion activities like breastfeeding, child development, parenting, and preventing harm for people who use drugs. But these are often delivered in a silo from what's happening in primary care.
Our information systems aren't connected, and we don't really know what one another does. Let's say a patient of mine gets a vaccine at a public health clinic — I don't get a notification, and it's not added to the patient's electronic medical record. That leaves it up to the patient to tell me the next time they see me that they've received that vaccine. Public health units don't even have a list of the doctors working in their region — something that became a big issue in the pandemic when they were trying to communicate important updates. If doctors had signed up for their newsletter, they'd get those communications. If not, there was no reliable way to reach the doctors practicing in the area.
Those are just two examples of how our communication systems don't work with each other and how we're really operating in silos when it comes to primary care and public health in Canada.
Ultimately, I go back to that 2017 paper in Health Affairs where Madeline Pesec and Asaf Bitton talk about the four pillars of the Costa Rican primary care system: integrating public health and primary care; geographic impanelment — covering the entire population in a community; strong interprofessional teams; and robust data feedback loops to track outcomes and ensure the system is meeting its goals.
Of course, the Costa Rican system isn't perfect. From both Dr. Madeline Pesec and the people I spoke to in Costa Rica, I heard a lot about how the system has been slowly eroding due to underfunding — a challenge common around the world. But even under strain, Costa Rica achieves better outcomes — lower infant mortality, longer life expectancy — than their spending would predict. In fact, according to data from the OECD, Costa Rica's life expectancy at birth is higher than the United States and on par with countries like Germany and the UK.
For me, the lesson for us is clear. We have the resources. We just need to find the ambition to design a system that puts primary and community care at the centre and ensures every single person is cared for, no matter where they live.
Acknowledgements
Dr. Tara Kiran (31:21) I'd really like to thank a lot of people for their help with this episode. A big thank you to Dr. Madeline Pesec for all her help bringing this two-part series to life, and for introducing me to Luis Carlos Vargas Martínez, who served an incredible double duty as guide and translator. I very literally could not have made this episode without him. Also, a big thank you to Luis's colleagues, Dr. [uncertain: Eddie Apoy] and [uncertain: Juliana Monje Agüero], who joined us on the car ride and clinic tour and offered their expertise along the way. And to everyone in this EBAIS clinic who let me interview them, including Dr. Rosales, Angelina, [uncertain: Kahner], and Eric.
Credits and Closing
Primary Focus was created by Dr. Tara Kiran and is made possible by funding from the MAP Centre for Urban Health Solutions, the St. Michael's Foundation, and the Max Bell Foundation. Maryam Danesh is our research assistant. Seema Marwaha and Emily Holton are our creative advisors. Our producer is Avery Moore Kloss.
If you'd like to read more content from Dr. Kiran about Canada's primary care system, join the Substack newsletter at primaryfocus.substack.com, or visit primaryfocus.ca. For more information on the Our Care standard and the public's vision for a better primary care system, visit ourcare.ca.
Family doctors in Canada who are listening to this episode can claim Mainpro+ credits by completing a Linking Learning exercise. See the show notes for more information.
And finally, if you're enjoying this podcast, please share it in your networks. It's only through enlarging the conversation about primary care in this country that we'll ever really affect system change. If you have ideas for topics or places to visit and feature, please do reach out at primaryfocus@unityhealth.to.
The information shared in this podcast is for educational and informational purposes only. It is not intended as medical advice and should not be used as a substitute for professional medical care, diagnosis, or treatment. Always consult with a qualified healthcare professional before making any medical decisions or changes to your health routine. Views expressed in this podcast are those of the speakers and do not necessarily reflect the views of any organizations the speakers may be affiliated with.
Side effects of listening to this podcast may include: a strong impulse to help fix the primary care crisis in Canada; a feeling of anger over how many Canadians do not have access to primary care; increased feelings of empathy toward primary care professionals who are just trying to make it work; and intermittent visions of hope that we can find a better way.