Reflection Four by Emily Bippus

   The ATAP workers undergo a 6-month training in order to provide services in their communities. Similar to the United States, nurses must attend nursing school and complete the requirements in order to tend to patients. Doctors in Costa Rica study for seven years to receive their medical degree. After they complete their M.D., they study for an additional four to five years to become a specialist in a particular field, such as pediatrics, cardiology, geriatrics, etc.
The amount of training is comparable to the United States, though ATAP workers do not have a direct equivalent. Nurses Aides are the most similar and receive a few months of training as well. Registered Nurses typically have a bachelor’s degrees, however programs such as the Shadyside nursing program in Pittsburgh require two years but those graduates can work as an RN only in the UPMC system. Costa Rican doctors study slightly less time to become an M.D., but there are integrated B.S./M.D. programs that allow students to acquire the degree in a shorter span as well. Because there are no regulations as to the numbers of students who enroll in doctors and nurses programs in Costa Rica, there are many medical professions who have the training but remain unemployed.
Global humanitarian influence seemed limited, although international loans are a source of funding. The largest common influence of the facilities that we visited was the presence of Roman Catholic figures, despite being a public facility. There’s also an emphasis on family, a Costa Rican and Catholic tradition. In the homes, ATAPs ask questions about every family member and focus on the family unit as a whole as well as the individual.
Today we were in the home of an older woman in Tilarán with the ATAPs, Marcela and Sidney. During their questioning, one of the woman’s sons called and she began to cry. The ATAPs revealed that she was lonely and missed her children. They finished the visit and part of her “treatment” was that the ATAPs would contact her children to ask that they call and visit more often.
Clinicians in Costa Rica receive very similar trainings to those in the United States, but the differences lie in the Costa Rican wholesome approach to health care.

Reflection Five by Megan Struck and Photos From The Past Few Days

Reflection 5 by Megan Stuck

After being in Costa Rica for a week at this point, I have learned that the health care is paid for by people paying taxes for the social security, businesses funding private clinics, and patients paying out of pocket for services. Overall the nation spends roughly 9.9% of the GDP on health care. They run on a primary national health insurance system mostly, but some of the wealthier citizens can afford to go to private hospitals and they have to pay out of pocket. Everyone is entitled to healthcare in Costa Rica because it is seen as a basic human right to be able to live a healthy life no matter what the person’s socioeconomic background is. Due to this concept, the government will provide health care to anyone who needs it regardless of their ability to pay, which includes refugees. Obviously this is a good thing for the refugees, however is reduces the resources available for citizens and it makes their wait times longer than they already are.

Today we spent the day hiking through a cloud forest and doing a canopy tour on bridges above the trees. This was very interesting because we got to learn a lot about the different indigenous species of animals and plants. After this we went to visit our last clinic of the trip. This was probably my favorite clinic visit because they did a very good job of explaining the system and showing us a presentation along with pictures on how their clinic operates. After this we went to a hummingbird gallery and we saw different species of hummingbirds as well as one of the most deadly vipers in the country. Then the rest of our day was spent on meals and exploring the local community.

Reflections Two and Three by Katie Smith

Cultural Visit to Coffee Plantation

  Cultural Visit to Poas Volcano



Reflection Two

Prompt: Discuss how population structure, dependency ratios, birth and death rates, infant mortality rate, age, sex, race/ethnicity, in-migration, out-migration, and net migration influence health and health services in Costa Rica.


Below is a graph depicting the population structure of Costa Rica in 2016 taken from the Central Intelligence Agency (CIA) World Factbook (2016).

Costa Rica has a population of approximately 4,800,000. As you can see, the ratio of males to females is tilted slightly in favor of there being more males at all ages except for seniors ages 65+. This population structure is common for most developed countries. The dependency ratio is a measure that shows the number of ‘dependents’ (citizens ages 0-14 and 65+) to the total ‘independent’ population (ages 15-64). The assumption is that dependents do not work and therefore rely on the independents to care for them; dependents do not contribute to economic growth of a country whereas those ages 15-64 are assumed to be of working age and therefore, contribute to the economy. Costa Rica has a dependency ratio of 45.4% (CIA, 2016). For purposes of comparison, the U.S. has a dependency ratio of 51%. Generally, a lower dependency ratio is ideal. The population pyramid below provides evidence that the vast majority of dependents in Costa Rica are those 0-14 which is preferable because in the future, there will continue to be a large enough working population to support the aging population. You can see, however, that there is a bulge of increased population ages 15-30 which may pose a problem when this age group reaches retirement age if fertility levels remain constant or decrease.

The current birth rate in Costa Rica is 15.7 births/1,000 population (global ranking: #122). The current death rate is 4.6 deaths/1,000 population (global ranking: #201). The infant mortality rate is 8.3 deaths/100,000 live births (global ranking: #151) The sex ratio is 1.05 males/females and the median age is 30.9 years. 83.6% of the population is white or mestizo, 6.7% is mulato, 2.4% is indigenous, 1.1% is of black or African descent, and the remaining are categorized as “other”.

Costa Rica is a popular choice for regional immigration because it bolsters job opportunities and impressive social programs due to the government’s investment in social spending; almost 20% of their GDP goes to such programs such as education, universal healthcare, and public sanitation efforts. About 9% of the population is foreign-born, and of those, about ¾ came from Nicaragua. To quantify this, the net migration rate for Costa Rica is 0.8 migrants/1,000 population. (CIA, 2016).

All these demographic factors play a visible role in determining health and health services in Costa Rica. This concludes the background research for response #2. See journal for reflection on Day #2 in Costa Rica and for further analysis of how these factors influence the both individual and population health in Costa Rica.

Today we visited Heredia Hospital in Costa Rica. We received a full tour of the hospital and surrounding grounds. I was struck by the drastic difference between this hospital and the one we visited yesterday in San Jose. Today‘s hospital was a regional hospital (level II primary care as compared the the national hospital yesterday) and served a population of approximately 500,000 citizens. On average, 600 beds are designated to the ER and filled daily, and 800-1000 beds are allocated for external consults (non-emergencies).
 Since this hospital was on a lower level than yesterday‘s, I expected the infrastructure to be similar if not worse. However, Heredia was much more modern. In fact, the hospital was built just six years ago. The building itself cost 105 million dollars which is shockingly inexpensive considering the high-tech medical equipment and quality facilities housed in the hospital. Every room was exceptionally clean, the patients were able to enjoy much greater privacy, and the interior design closely mimicked that which one would expect from a typical hospital in the US. I learned that the level of hospital is not indicative of its design or infrastructure. Ideally, because the health care system is run by the government, all hospitals and clinics should receive equal funding and resources to continuously improve facilities. However, many providers acknowledged that politics do play an unfair advantage at times. They stated that often, clinics and hospitals which are located in areas with greater political power receive more funding from politicians who are looking to please constituents. Therefore, these facilities are often much nicer than those in more rural, underserved areas.
Something else that stood out to me during the visit today was that this hospital also had very long lines where patients were waiting to receive their medication from the pharmacy. Since I witnessed this same scenario in San Jose at La Hospital de Caulderon Guardia I wondered if long wait times were a problem for the Costa Rican health care system. The providers answered that yes it is, and often times patients will utilize their public insurance for the visit to the doctor but then purchase their medication or other needed services from a private source to avoid the wait. I have heard this is very popular in many countries where the health care is run publically. It would be interesting to learn if the government is taking any steps to reduce wait times. I plan on asking about this in the coming days.

Visit to Heredia Hospital

Visit to Clinica De Abargandes

Reflection # 3

Prompt: Let’s investigate country-specific data on morbidity and mortality in Costa Rica. What are the main causes of death for different age groups? What are the most prevalent diseases?   What are the policies regarding known health risks such as tobacco, drugs, alcohol, sexual behaviors, guns, violence, automobile accidents and so on?


Below is an infographic taken from created with Centers for Disease Control and Prevention (CDC) data that illustrates the top causes of death in Costa Rica. As you can see, coronary heart disease is most fatal disease with a 16% mortality rate. Next is stroke at 7%, and third is lung disease at 5%. Grouping all the types of cancers together shows that over 20% of deaths in Costa Rica are attributable to cancer. Hypertension and diabetes are prevalent as well, and some deaths are due to non-disease factors such as road injuries (4%) and interpersonal violence (2%) (GBD Compare, 2010). Costa Rica has an adult obesity rate of 24% which is significantly lower than America’s 35.7% adult obesity rate. However, this is still an increase number and contributes to the fact that over 83% of total deaths in Costa Rica can be attributed to preventable, non-communicable diseases. [See pie chart below]. However, chronic disease primarily affects the older population; the probability of dying from NCD in Costa Rica for those ages 30-70 is only 12%. (WHO, 2016).

The two major risk factors for adults are tobacco smoking and alcohol consumption. It is estimated that 24% of males and 8% of females are current tobacco smokers. Measuring alcohol consumption in liters of pure alcohol, men consume 7.5 annually whereas woman consume 3.2 annually. The Ministry of Health does have an operational policy and strategy plan to reduce tobacco use, however, no such plan is in place to reduce alcohol use.

In 2008, Costa Rica joined the WHO Framework Convention on Tobacco Control which places standardized regulations on tobacco. In Costa Rica nearly all public smoking and promotion/advertisement of tobacco is banned. The minimum age to buy tobacco is 18. On tobacco products, 50% of the label must be covered with health warnings (either text or visual). The MOH uses all fines collected from tobacco violations to fund their anti-smoking campaign. They are hopeful to reduce the rate of tobacco use further as it still accounts for nearly 8% of adult deaths and is a hazard to children with 9% reporting tobacco use (The Tobacco Atlas, 2013).

Costa Rica has different regulations surrounding alcohol consumption than the U.S. has. In Costa Rica, the minimum legal drinking age is 16. At 16 it is legal to consume beer and wine and 18 is the legal age for liquor consumption. Public drinking is illegal in Costa Rica. Drinking and driving is not illegal in Costa Rica, however, while you may drink alcohol while driving you may not be intoxicated while driving.

Costa Rica has strict drug laws. The Costa Rican law states that the “cultivation, production, transport, and trafficking of all drugs, including cannabis, are merged in to a single category and are qualified as criminal offenses punishable to 8 to 12 years of imprisonment” (The Costa Rican News, 2014). However, these strict laws fail to prevent drug trade/violence. Costa Rica’s geography, specifically it’s thinly-patrolled borders and waters, paired with a insufficient security force make the country a major transport and storage location for illegal drug trafficking. From 2014 to 2015 there was a 20% rise in homicide rate alone. The government in Costa Rica is focused on eliminating drug trafficking by allocating more spending on enforcement and focusing on counter-narcotics programs. Improvements in the counter-narcotics programs can be attributed to the help provided by the U.S. government in training, equipment, and infrastructure projects.

According to the U.S. embassy, crime is on the rise in Costa Rica. The majority of criminal action is caused by small groups or individuals and while most is non-violent (theft, robbery), violent acts are increasing. In the U.S. Department of State Crime and Safety report for Costa Rica, the crime rating is listed as high. Theft is the main crime affecting travelers, however, the rising homicide rate is a concern for citizens. Sex tourism is also prevalent, and organized crime groups (gangs) are a threat.

On a more positive note, the terrorism rate is low and Costa Rica has a stable democracy with no civil unrest. Police response is available through 911 when needed, however, limited resources often means that delay occurs. The Fuerza Publica is the uniformed policy agency, the Organismno de Investigacion is in charge of investigating all crimes for prosecution, and the Margracion controls all aspects of immigration with assistance from the Ministry of Governorship and Police (U.S. Department of State, 2016).

Today we started our day by visiting Clinca de Abangares in Los Juntas. I was surprised that the clinic appeared to be even more modern than the first hospital in San Jose as well. I’m learning that the level of the clinic is not correlated with the infrastructure, rather, it is the age of the facility that determines the level of quality and hig-ttech equipment provided within the facility.
Unfortunately, this clinic was undergoing renovations so we were unable to tour the facility. We also did not have a chance to split up into groups to follow all three ATAP workers because one was ill and the other was not working. Instead, we followed just one and split into groups of three. While it was not ideal, I am grateful that we each at least had a chance to accompany the ATAP worker on one house visit. The visit I witnessed was the ATAP worker meeting with a young woman who was about 25 years of age. She had just recently moved in with her husband so this was her first visit with the ATAP worker in this community. The ATAP worker completed a surgery which recorded her personal demographics, her health history and risk factors, her living conditions, and her vaccination records. No vaccines were administered as she was up to date with all medications, however, the ATAP worker did provide her with medication for parasites as a preventive measure since her living conditions put her at risk. The ATAP worker also counseled her on the important of diet, exercise, sanitation, and self-examinations for breast cancer.
The ATAP worker works about 8 hours a day, typically visiting about 5-8 houses per day. He/she is assigned to a geographical region of about 3,000 patients and must visit each house annually, sometimes more than once if needed. The ATAP workers also go into schools and local businesses to provide primary medical care. They then record the health data they collect on their visits into a central registry which the public health workers use to determine the health priorities for that specific community. In order to accomplish these tasks, ATAP workers receive a six-month training as a basic  primary medical techbician. However, most said that the majority of their learning comes from on-the-job experience. While the ATAP worker is not as educated as doctors or nurses, they are sill well-respected in the medical community because they play a vital role in prevention which is a core principle of the health care system in Costa Ricas. They also develop a personal relationship with the community members they serve through the repeated house visits they conduct. It was certainly interesting to see the patients being so welcoming and trusting with the workers, especially when they stop by unannounced. I could not help but think that this same relationship would just not be possible back home in the US where everyone operates on a rushed, very busy schedule centered around work away from the home. This is just one of the many interesting comparisons I have made from my time in Costa Rica.

Cultural visit to Playa Blanca

Not Just Numbers

Students on the 2017 program in front of the Calderon Guardia Hospital in San Jose, Costa Rica with Dr. Chaves.

Reflection 1 – Serena Carlson

We can begin to compare the U.S. and Costa Rica by looking at a few indicators; GDP and HDI within healthcare metrics. The U.S. spends roughly 17% of it’s GDP on healthcare, while Costa Rica only spends 9%. Per capita spending for the U.S falls around $9,400 per person and $1400 for Costa Rica. These are vast differences that mean real dollars and funds diverted.

Another metric to measure between countries is the HDI (Human Development Index). This metric evaluates and measures the quantity of life, overall well-being, and one’s standard of living. Basically, one’s quality of life. There are 188 countries that use this index and the U.S. measures at 8 and Costa Rica measures at 69. Other factors that influence this measurement are: life expectancy at birth, and years of education. Norway comes in at number 1 in this index.

Clearly it appears we have a higher HDI, or a higher standard of life, but do we have a better quality of life or standard of care? There are other factors to consider and measure. Infant mortality rates in the U.S. is 6.1 live births for every 1,000. Costa Rica measures at 8.7 for 1,00 births. Life expectancy for the U.S comes in at 78.8 years and in Costa Rica it comes in at 79.3. Costa Rica has overall longer life expectancy rates than the U.S. Additionally, the U.S. spends the most per patient worldwide and comes in at number 48 overall in outcomes worldwide. This indicates throwing money at a problem doesn’t solve it or provide better outcomes.

These are just numbers and are easy to get lost in translation. Each one of these number listed above equates to a human life. Today I visited The Calderon Guardia Hospital in San Jose, Costa Rica. It was an eye-opening experience. We met with Dr. Eli Chaves who specialized in Geriatrics. He spent 2.5 hours with me and other students. He gave us a detailed explanation of Costa Rica’s universal healthcare system. He also provided us with a tour and detailed explanations on quality and standard of care at his hospital.

On our visit, several things stood out to me of what we can takeaway from Costa Rica: preventive care visits, maternity and post-natal care. In Costa Rica it is common place for elderly patients to have 4 physical checkups: to check in with the patient, monitor their chronic conditions such as dementia, coronary issues and mobility. In the U.S. elderly patients receive one annual visit. Medicare only pays for one each year. Prior to the ACA preventive visits were not covered. Costa Rica sees a patient every 3 months for follow up and to coordinate care. In the U.S. it’s once a year unless an issue arises. Clearly, Costa Rica is aiming for true preventive care. Their model is proactive versus the U.S’s model which seems to be reactive. Dr. Chaves also explained how visits are made to the elderly patient’s homes for follow up if they are not able to make it in to the hospital. We do not have currently have such supports in place.

The maternity and post-natal services in Costa Rica are very different than what we have in the U.S. We spoke with Dr. Barrientos, who specialized in Pediatrics and then went on to gain another specialty in Neonatal medicine delivers healthcare to mothers and babies. Dr. Barrientos cares for the most weak and youngest infants in San Jose. She gave us a comprehensive overview of how her nation delivers healthcare to its women and infants. First off, Costa Rica only has 10% of its births via caesarian. The U.S has about 38%. That means 1 in 10 babies in Costa Rica is delivered via caesarian and in the U.S., almost 4 out of 10. That’s a 30% higher frequency in the U.S., not something to ignore.

While in the hospital I observed how Costa Rica practices maternal and fetal medicine. Two takeaways were infant care and breast milk support. In Costs Rica, the baby stays with mother at all times and shares the same bed to create bonding for both mother and baby. We never see this in the U.S. I never witnessed a brand new baby sharing the same bed with their mother while being moved throughout the hospital. The baby and mother do not have separate beds, they share one. The mother and child are immediately supported in the hospital. Prior to discharge, each mother is sent home with a packet filled with support and services needed foe the infant’s first year of life.

The other large takeaway was breastfeeding. Breastfeeding is highly promoted and only in exceptions formula was provided. A huge progression in what Costa Rica practices is their breast milk bank. This bank keeps breast milk on hand for premature babies, for babies needing extra care or for mothers who have trouble lactating. The hospital asks all mothers to pump extra breast milk and it is sent to the milk bank at a neighboring hospital in San Ramon, Costa Rica.

After the first day it is amazing to see how a poorer nation is striving to provide excellent healthcare to its citizens. The downfall of the U.S. is its outlook on how it views healthcare as an interchangeable commodity and privilege. Costa Rica views healthcare as a right and its mission is to provide equal access to all citizens. The U.S. can learn from Costa Rica and how It delivers healthcare to its citizens.


The author of today’s blog, Serena Carlson. Serena is a junior and a HPA major.

They symbol of the health care system in Costa Rica is a mother and child.