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Studying Health Care in Costa Rica
By Fred Gifford, PhD
This past summer marked the first offering of a new MSU Study Abroad program
enabling students to study another country’s health care system: “Ethics
and History of Development and Health Care in Costa Rica.” Seventeen
students, mostly from Michigan State, spent six weeks studying questions
concerning health and Costa Rica – the health care system, the society
of Costa Rica more generally, and the social determinants of health –
while also having opportunities to live with a Spanish-speaking Costa Rican
family and to visit the rainforest.
Administered by the Department of Philosophy, the Costa Rica program
is a descendent of the long-standing program, “Medical Ethics and
History of Health Care in London,” which is administered by MSU’s
Interdisciplinary Programs in Health and Humanities (IPHH). Interestingly,
there are similarities between these health care systems. Like the United
Kingdom, Costa Rica is a country with many fewer resources than the U.S.,
and yet which manages to provide good quality health care for almost all
its citizens and to generate impressive health outcome statistics through
a large government program. Indeed, those in Costa Rica’s health
care system over the years have paid attention to and tried to learn from
health care reform in the U.K. (and elsewhere). There are certainly large
differences of culture, politics and environment, and this goes even deeper
than the smaller number of Indian restaurants and the larger number of
palm trees and active volcanoes! The program welcomes both undergraduate
and graduate students, and both students and practitioners in the health
care professions. Those going into the health field can gain a lot from
this course – they can examine a health care system that is very
different from our own, learning the perspectives of practitioners, policy
makers and academics in this small and proud country. They can get an
international perspective on health and health policy, due, for instance,
to the role of the World Health Organization and the Pan-American Health
Organization. They can expand their cultural horizons, learn about Costa
Rican life, culture, history, economy and politics, and see how those
matters of culture play a role in health and health care. At the same
time, they can work on their Spanish (invaluable for those intending to
work in health care in the U.S.)! The classes are held in English, but
to navigate and enjoy the country (including one’s home life) requires
knowledge of Spanish. Further, this coming summer there will be 60 hours
(4 credits) of Spanish language instruction. This is in addition to four
credits of philosophy and three of history.
The home base of the program is San Jose, Costa Rica’s capital
and largest city, located in the temperate Central Valley. Students divide
their time between classroom and trips to museums and health care settings
and other locations. They visit a variety of national hospitals in San
Jose, as well as a regional hospital and some EBAISs (primary care centers),
both urban and rural. Presentations are given by a variety of local speakers,
health care professionals, as well as professionals concerned with health
care policy and professors at the University of Costa Rica.
Students explore such questions as: How did Costa Rica’s health
care system come to be, and how does it operate within the present political
and social milieu? What deficiencies does it have, and what challenges
does it face as the government is no longer able to provide the amount
of resources for the system that it did in the past? What ethical issues
emerge in such a health care system, in the attempt to provide health
care effectively, efficiently and fairly, with limited resources? How
are these similar to and how are they different from those that arise
in a country like the U.S.? How can these challenges be met, and how can
these ethical issues be addressed?
Doing this requires placing questions concerning the health care system
and the analysis of ethical issues in Costa Rica in the context of the
country as a whole, its culture, its history and political and economic
system, its natural environment and its status as a developing nation.
This is, of course, a multi-faceted, interdisciplinary endeavor. Topics
addressed range from public health to rainforest preservation to alternative
medicine and medicinal plants to international debt to doctor-patient
relationships to the role of government in health care, to poverty, health
care access, human rights and the social determinants of health.
Costa Rica is an especially interesting place to examine health care.
It is a developing nation that has in many ways been successful in providing
health care and other services. Life expectancy and infant mortality statistics
are roughly the same as in the developed nations of Europe and the United
States. The WHO’s World Health Report for 2000, ranking members states’
health systems in terms of overall performance, gave Costa Rica a ranking
of 36th. (The United States ranked 37th.) Substantial governmental effort
is put into the health of the people. Indeed, the public system of health
care, the Caja Costarricense de Seguro Social (the “Caja”) is
the largest segment of the government. Begun in 1940, the Caja today provides
high quality health care for almost all Costa Rica’s citizens. There
has been a lot of emphasis on public health, as well as on extending health
care to the rural areas. Over 800 small, local community clinics, called
EBAIS’s, provide primary care, including vaccinations, health education,
and yearly home visits. But there is still significant (and indeed increasing)
poverty, and Costa Rica struggles to meet the health care needs of its
people with quite limited resources – especially since the economic
crisis of the early 1980’s and the subsequent “structural adjustment”
requirements attached to further international loans.
A private system of health care for those who can pay for it has grown
up along side the Caja, and many people who can afford to do so go instead
(or in addition) to these health care services to avoid what are sometimes
long waits. As might be expected, the interaction between the public and
private systems of health care generates a number of complicated policy
and ethical questions. (Some of these arise from the fact that many physicians
are employed by both systems.) The emergence of many new private medical
schools raises a number of dilemmas as well, both with respect to regulation
of quality and with respect to the crowding of teaching hospitals with
medical students.
The private sector draws a certain amount of “health tourism,”
where the lower cost of high quality cosmetic surgery in Costa Rica induces
many to travel from other countries, including the U.S., to Costa Rica
for such elective treatment.
The public medical system is equally a modern scientific one, but there
are also especially interesting issues to study concerning traditional
medicine and the health beliefs of the people. For instance, the rule
has been that traditional healing is not to be covered by the government
health system, but there have recently been movements in the direction
of having such care “within the Caja.”
The Caja provides high tech and expensive treatments, such as transplantation
and (by law) full coverage of drugs for persons with AIDS, despite its
huge cost. Indeed, the latter is taken advantage of by individuals who
come from other countries and find a way to qualify to get this treatment.
This results in pressures elsewhere in the system, so the country is facing
grave challenges and is being forced to rethink how it is going to provide
and pay for health care, and what modifications there may need to be in
the system that has worked pretty well for decades.
A central challenge to the system arises from the huge numbers of Nicaraguan
immigrants into Costa Rica. The Nicaraguans do make a contribution to
the economy, taking many jobs that Costarricenses tend not to want to
take, but their numbers also put a tremendous strain on the social resources,
especially health resources. These facts pose ethical and policy dilemmas
concerning the provision of medical care to illegal immigrants and their
families, as well as the question of whether Costa Rica should be compensated
with resources from richer counties for this care that they provide.
The environment plays a role in this course in a number of ways. First,
there is the connection to public health. On the one hand, Costa Rica
has emphasized public health. It has had for some decades an impressive
public system of water and sewage, providing potable water to the vast
majority of people. On the other hand, the pressures of urban expansion
and the agricultural use of chemical pesticides pose significant threats
to public health.
Second, the natural environment is a crucial resource for a developing
tropical nation like Costa Rica. One of the most striking features of
Costa Rica – certainly one of the strongest tourist draws –
is the country’s enormous degree of biodiversity and natural beauty
(i.e., rainforests, cloud forests, mountains, beaches, active volcanoes).
For instance, Costa Rica covers only 0.03 % of the Earth’s surface,
roughly the size of West Virginia, yet it contains 5% of all of the Earth’s
life forms. On the other hand, it lost almost half of its forest cover
between 1950 and 1990, during which time it had the highest deforestation
rate of Central America. Then again, Costa Rica has put together an extraordinary
system of national parks and other protected areas, so that the 25% of
the country which remains forested is now pretty well protected, and has
been a world leader in its attempts at conservation. Tourism (including
eco-tourism) has been in recent years Costa Rica’s most important
industry; many are hopeful that this will allow the convergence of the
goals of economic self-interest and environmental protection.
Another connection between environmental issues and health concerns
the rich resource that the rainforest provides in terms of potential medicines.
Students in the program visit INBio (Instituto Nacional de Biodiversidad),
a research and education institute that has been involved in cataloguing
those resources for over a decade, and which has also — quite controversially
– worked with corporations such as Merck & Co. to discover and
exploit those resources.
Students also explore a number of questions about the environment, such
as: What policy and ethical issues emerge concerning the management and
preservation of the natural environment? What is important about preserving
the environment? How is this to be balanced with the short-term economic
well-being of individual human beings? How does the “health”
of the ecosystem relate to the health of the people? Whose responsibility
is it to do something about it? Is eco-tourism going to succeed as a way
to provide for sustainable economic stability?
This coming summer, “Ethics and History of Development and Health
Care in Costa Rica” will span eight weeks, from June 3 to July 26,
2002. For more information, please feel free to contact Fred Gifford via
email (gifford@msu.edu) or call Michigan
State University’s Office of Study Abroad at (517) 353-8920. The
deadline for receiving applications is March 1, 2002.
Fred
Gifford
Department of Philosophy
Michigan State University
Editor's
Note:
The
Costa Rica course, "Ethics and History of Development and Health
Care," is further described (including cost and application procedures)
on-line at http://studyabroad.msu.edu/programs/costaethics.html.
Information on the London course, "Ethics and History of Development
and Health Care," can be found at http://iphh.msu.edu.
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