Cultural Visit to Coffee Plantation
Cultural Visit to Poas Volcano
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 www.infogr.am.com 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