Paper #1: Contributors to Burdens of Disease – Costa Rica
Spread across a total landmass of 51,000 square kilometers, the citizens of Costa Rica
(affectionately referred to as “Ticos”) have a lot to be happy about. Among the 7 countries
composing Central America, only Costa Rica and its southeastern neighbor Panama are
classified as upper-middle income economies (gross national income per capita of $4,036 to
$12,475 USD)i, and both are actually on the upper edge of that grouping.ii,iii Residents benefit
from socialized medicine, as “health has constitutional status and is considered a basic human
right.”iv Further, with “25% of the country under some category of protected area management”v
– a relatively high percentage compared with other nations – Ticos can take solace in knowing
that their coastlines and mountains, rainforests and volcanoes will be looked after for future
generations.
However, having progressed through the various stages of Omran’s epidemiologic
transition, Costa Rica now finds itself contending with the delayed degenerative diseases of stage
4vi – a frustrating “reward” for making headway against infectious diseases over the last century.
Cardiovascular disease and cancer are the two leading causes of mortality (32.5% and 20.7%,
respectively [2002 figures]vii), though non-communicable diseases (NCDs) seem to garner
insufficient attention and financial resources from politicians and policy-makers. Hidden
amongst most English-print data, the remaining 3 top causes of death – violent death (accidents,
suicides, and homicides), infections, and perinatal death (accounting for 13.1%, 5.4%, and 2.5%
of deaths) – are most clearly enumerated in the Costa Rican Ministry of Health’s own reports. viii
Despite living in 1 of the world’s 22 older democracies, Ticos have become increasingly
disenfranchised, and “the last decade has seen increasing expressions of social discontent with
protests against privatization and the two-party system.”ix (To be sure, voter abstention was
34.8% in 2006.x) Watching medical tourists and more wealthy nationals receive prompt care in
private hospitals, many Costa Ricans are likely frustrated by longer waits for healthcare services.
It is common to wait upwards of 10 months to receive a non-emergent CT scan, for instance.
Nonetheless, Costa Rican health demographics are better than regional and global averages, with
a current life expectancy at birth of 77 years of age for men and 81 for women,xi an under age 5
mortality rate of 10 per 1000 live births, and a maternal mortality ratio of 40 per 100,000 live
births.xii Ninety-seven percent of pregnant women participate in 4 or more antenatal visits, and
95% of births are attended by “skilled health personnel.”xiii The death rate is estimated to be
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4.38 per 1000 population, or about 20,900 people [2012 estimates].xiv Though the absolute
number of deaths has increased over the years, so has the population size (despite a decreasing
fertility rate).
To achieve this level of health, Costa Rica spends 5.7% of its gross domestic product
(GDP), or $234 USD per capita [2002 figures].xv Eighty-two-point-seven percent of health
sector expenditures go to the Caja Costariccense de Seguro Social (CCSS), or the Costa Rica
Social Security Fund [2004 figures]xvi – which “delivers care in the event of disease and
maternity” – and 7.7% goes towards medications.xvii By comparison, the United States spends
17.6% of its GDP or $8086 per capita, the majority of health spending [30.5%] is in hospital
care, and 10.1% goes towards prescription drugs [2009 figures].xviii
Approximately 1 in 5 Costa Ricans lives below the national poverty line,xix a figure that
sounds daunting but is nonetheless among the lowest in all of Latin America.xx Extreme poverty
tends to be worse in rural areas, but urban slums such as La Carpio on the outskirts of the capital
city of San José pose other unique challenges. This particular settlement, which is positioned
next to a landfill, is inhabited primarily by undocumented Nicaraguan immigrantsxxi. (It is worth
noting that Nicaraguan nationals, both living in Costa Rica legally or otherwise, comprise 76%
of all foreigners in the country, and 5.9% of the country’s population.xxii) With lower-quality
domiciles and sanitation services, unable to access the free national healthcare system, and often
forced to take unstable jobs as farm laborers, these immigrants are particularly subject to
environmental health concerns. For example, Costa Rica is among the highest in per capita use
of pesticides (2kg/person/year).xxiii It is unclear if these occupational exposures contribute to the
country’s high cancer rates.
Fortunately, overall, the environmental burden of disease (as from air and water pollution
and arthropod disease vectors) is relatively small, making up 16% of the total burden and leading
to 3200 deaths annually and 20 disability-adjusted life years (DALYs).xxiv In fact, Costa Rica is
among the strongest performers by environmental performance index (EPI) – a measure that
considers both environmental health (effects on human health and the environmental burden of
disease) and ecosystem vitality – ranking higher than countries like France, the United States,
and all of its Spanish-speaking neighbors.xxv See figure 2.
Communicable diseases cause only about 7% of proportional mortality,xxvi a number that
is about half of what it was 4 years ago.xxvii (It is important to point out, however, that while
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both these figures come from the WHO, it is unclear if the same methods were used to make the
2010 and 2008 estimates. Similarly, there may be “double-dipping” by including insect vectors
in both environmental and communicable diseases.) Vaccination rates are 99.9% for MMR and
94% for DTP [2000 figures], in part due to the Expanded Program on Immunizations.xxviii The
prevalence of tuberculosis is relatively low at 18 per 100,000 population, and prevalence of HIV
is 3 per 1000 adults aged 15-49, which is also lower than regional and global averages.xxix As
suggested above, mosquitos, sand flies, and reduvid bugs are important disease vectors,
spreading such diseases as malaria, dengue, and Chagas disease. Dengue reemerged in Costa
Rica in 1993, and there has been a sustained increase in cases of malaria since 2003.xxx, xxxi
The proportion of deaths due to non-communicable diseases has increased considerably
over the last few years: 81%, up from 62%.xxxii, xxxiii All NCDs combined have an agestandardized death rate of 431 per 100,000 men and 333.3 per 100,000 women.xxxiv Presently,
cardiovascular disease (CVD) accounts for 30% of total NCD mortalityxxxv (ie. 24.3% of allcause mortality), but it has been far and away the most significant cause of death since at least
the 1970s.xxxvi Cardiovascular disease and diabetes combined account for about half of the agestandardized death rate for both men and women (ie, 181 and 127 per 100,000 population,
respectively).xxxvii The age-standardized death rate for all cancers is 120 per 100,000 men and 93
per 100,000 women.xxxviii Non-lung cancers cause only 1.5 DALYs per 1000 capita, a rate
actually moderately-low compared to other countries.xxxix Some of the other important causes of
morbidity and mortality, such as asthma, neuropsychiatric disorders, musculoskeletal diseases,
and road traffic injuries, are difficult to compare to one another directly, as the number of
DALYs is not proportional to Costa Rica’s comparative global ranking for that disease group.
(For example, road traffic injuries – an important contributor to the “injuries” burden – have a
higher DALY rate [2.0 DALYs per 1000 capita] than non-lung cancers, but compared to other
countries, Costa Rica is “doing worse” with cancers than transit injuries. Framed in this way,
Costa Rica is most notably on the higher end of the DALY spectrum for asthma and
neuropsychiatric disorders, compared to other countries. Interestingly, this perspective actually
makes cardiovascular disease and non-lung cancers appear less daunting than they are.) See
figure 3.
Just slightly over half of Ticos fall into the 20 to 59 year-old demographic. The leading
causes of death for the 20 to 44 year-old subset are “external causes” (often poorly defined but
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meant to include accidents and violence), followed by tumors in men and CVD in women.
Among 45 to 64 year-olds, however, there is some reshuffling, with external causes and CVD
being the leading causes of death in men, and tumors and CVD being the leading causes in
women.xl The mortality rate for this latter subset is almost five times greater than its younger
counterpart, at 50 per 10,000 population [2002 figures].xli Adults aged 65 years and older
comprise 7.5% of the country’s total population. Likely due to the Latin American cultural focus
on extended family, only 1% live in nursing homes. Like other age groups, 90% have social
security coverage, but unlike them, 64% lack retirement pensions and 28% still live in poverty.xlii
These individuals may be financially less well-off to contend with the costs of the chronic
conditions that follow them into older age: cancer in men and other chronic conditions like
diabetes in women.xliii
The 4578 deaths [1999 figures]xliv from CVD particularly affect senior citizens – a
finding in-line with the epidemiologic transition. Forty-seven percent of deaths from circulatory
diseases are due to ischemic coronary disease (which affects men disproportionately), and 19%
are by cerebrovascular disease (which affects women disproportionately).xlv These proportions
alone suggest hypercholesterolemia is a more important player than hypertension, and to be sure,
elevated cholesterol affects 37.1% of men and 43.6% of women and elevated blood pressure is
noted in 31.6% of men and 22.5% of women over age 24 [2008 figures]xlvi. Twenty-point-nine
percent of men and 28.3% of women over age 19 are obese, and 59.4% of men and 57.2% of
women are overweight.xlvii See figure 4. (Of note, a 2002 survey of schoolchildren aged 7 to 15
found 12.7% were overweight and 7.9% were obese.xlviii) Forty-one-point-two percent of the
population fails to get the recommended 30 minutes of daily exercise 5 times a week. Compared
to regional averages, though, Costa Ricans are more likely to have hypertension but less likely to
be obese. A social shift away from traditional diets of rice, beans, and fruit and to processed
convenience foods and an underutilization of pharmacotherapy may be 2 contributors to these
major risk factors. As with other Latin American countries, dining in a fast-food restaurant is
often seen as a sign of higher socioeconomic status.
The only reported risk factor to explain Costa Rica’s high cancer burden is tobacco use:
24% of men and 8% of women over age 14 smoke, which is less than the regional average, but
this does not detail the absolute amount of tobacco products or velocity at which they are used.
Screening for some cancers is available at CCSS clinics, but the turn-around time is so long,
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testing may be futile. For example, only one laboratory in all of Costa Rica reviews Pap smears,
resulting in a 6 month delay between obtaining the sample and receiving the results, a period that
pushes the chronologic limits of the American Congress of Obstetricians and Gynecologists
(ACOG) screening algorithm.xlix Nonetheless, “each year 7,500 new cancer cases are diagnosed,
resulting in more than 3,500 deaths. The country’s tumor registry, which has been in place since
1980, shows that incidence rates have increased by approximately 40% since the early 1990s,
although the mortality rate has not changed significantly in recent years.”l Thus, diagnosis may
be improving, but interventions are not. See figure 5.
“Other NCDs” account for 15% of deaths overallli, but the details are hard to tease out.
This garbage-bin of a category includes chronic respiratory diseases and diabetes, which warrant
their own by-lines. Asthma costs Ticos 2.3 DALYs per 1000 capita, a high figure compared to
other countries,lii and all chronic respiratory diseases together cause an age-standardized death
rate of 33.5 per 100,000 men and 22 per 100,000 women.liii Diabetes has a mortality rate of 19.3
per 100,000 population.liv One study showed that in the metropolitan San José area, 7.9% had
diabetes, but only a small percentage (1.9%) of those affected was unaware of the diagnosis.lv
“Unintentional” injuries (homicides, suicides, and accidents) as a class make up 13% of
all-cause mortality.lvi These are not included in estimates of NCD but nonetheless also feature a
heterogeneous list of causes of morbidity and mortality, result in 2.8 DALYs per 1000 capita,
with senior citizens being most affected.lvii, lviii Not surprisingly, traffic accidents tend to affect
men more, with one-quarter of deaths in the drivers, one-quarter in pedestrians, and, ostensibly,
one-half in the vehicle’s passengers.lix Women are victims of a different form of violence: “58%
of women [of all ages] suffered at least one incident of physical or sexual violence, or both, most
often at the hands of the men in their lives.”lx
The Concerted Health Agenda does list a focus on social violence as one of its 10 health
sector commitments (as well as foci on treatment of NCDs and their risk factors and promotion
of healthy lifestyles), but “this leadership role has been weakened due to limitations of the
Ministry of Health, such as insufficient resources and institutional capacity, although efforts to
correct these problems are under way and the situation is gradually improving.”lxi The
responsibility for reform of healthcare service delivery and financing has been shifted from the
Ministry of Health to the CCSS,lxii a move that pessimistically could be perceived as shifting a
burden, or, more optimistically, as giving the reigns to the individuals at the front lines.
5
Regardless, the CCSS infrastructure, with its 893 field-based Equipo Básico de Atención Integral
en Salud (EBAIS), or Basic Comprehensive Health Care Teams, only covers about 75% of the
population (ie, 4000 citizens per team),lxiii clearly showing the need for involvement of other
public and private parties.
According to the WHO, at present, Costa Rica has a national health reporting system that
records NCD cause-specific mortality, morbidity, and risk factors, but does not have funding for
NCD treatment and control, let alone prevention and health promotion. Further, it lacks “an
integrated or topic-specific policy” for CVD, diabetes, chronic respiratory diseases, and tobacco
use. (This is particularly disheartening given that the problem of CVD is not new.) Costa Rica
does, however, have policies on cancer, obesity, and physical inactivity.lxiv See figure 6. Thus,
governmental priorities should be on critical evaluation of risk factors and applying those to
health promotion efforts. CVD and diabetes, which are often found together in metabolic
syndrome, should receive increased attention, as their contribution to mortality continues to
increase. Morbidity and mortality rates will not improve without further focus on NCDs.
It is easy to give criticisms as an outsider. Consequently, it is also important to
acknowledge financial and time constraints that further flesh out Costa Rica’s picture of health
and to highlight its successes. With the resources available, the country still ranks in the “high”
quartile of the United Nation’s Human Development Index (HDI) – 69 out of 187 countries in
2011 – with the most noticeable improvement in the education index between 1980 and 2000.lxv
(The methods used to rank nations changed within the last decade, so it is incorrect to look at
2005’s ranking of 47 and assume there has been a sudden, drastic drop in the HDI’s measure of
“a long and healthy life, access to knowledge and a decent standard of living.”lxvi) See figure 7.
This paper has sought to provide an interesting overview of both Costa Rica’s current
state of health and to explore the various areas of health, including environmental health,
communicable disease, and NCDs. CVD and cancer together account for more than half of
Ticos’ mortality, with violent death rounding out the top 3 major contributors to mortality.
These and other disease processes with long-term sequelae (such as chronic respiratory disease)
also contribute to disability, but data on lost productivity and other financial strains is lacking
from available English-language resources. Health care providers in CCSS and EBAIS are
helpful resources in collecting further information, and further stratification of disease burdens
by socioeconomic status may help best target needed interventions.
6
Figure 1: Proportional all-cause mortality in Costa Rica, all ages.lxvii
Figure 2: “The plot shows (from left to right) how well a country is doing overall compared to
how much they are improving over time (bottom to top).”lxviii
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Figure 3: Proportional mortality due to non-communicable diseases (% of total deaths, all ages)
in Costa Rica.lxix
Figure 4: Selected adult risk factors for CVD in Costa Rica.lxx
8
Breast cancer
Cervical cancer
Stomach cancer
Notes
"Most concentrated in urban areas of country's central valley."
"Its distribution is rural and in the coastal regions of the country."
"Costa Rica figures among the ten countries of the world with the highest
stomach cancer incidence [no data given] and mortality rates… The eastern
portions of the central valley and southern Costa Rica have the most cases."
Figure 5: Age-adjusted incidence and mortality rates for various types of cancer in Costa Rica,
1990 and 2000.lxxi (Original graphs based on reference.)
Figure 6: Costa Rica’s capacity to address and respond to NCDs.lxxii
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Figure 7: Trends in Costa Rica’s HDI component indices 1980-2011.lxxiii
Bibliography – principle resources
Costa Rica: Health Profile; WHO, May 2012
http://www.who.int/gho/countries/cri.pdf
Country Profile of Environmental Burden of Disease: Costa Rica; WHO, 2009
http://www.who.int/quantifying_ehimpacts/national/countryprofile/costarica.pdf
Country Statistics: Costa Rica; PAHO, 2012
http://new.paho.org/hq/index.php?option=com_content&view=article&id=3222&Itemid=2408
“Health in the Americas, 2007, volume II – countries;” WHO, 2007
http://www.amro.who.int/hia/archivosvol2/paisesing/Costa%20Rica%20English.pdf
“Health Situation Analysis and Trends Summary;” PAHO, no date (2000?)
http://www.paho.org/English/DD/AIS/cp_188.htm
NCD Country Profiles: Costa Rica; WHO, 2011
http://www.who.int/nmh/countries/cri_en.pdf
“Situación de Salud;” Ministerio de Salud - Costa Rica, 2002
http://new.paho.org/cor/index.php?option=com_docman&task=doc_download&gid=197&Itemid
=222
10
Bibliography – other resources
CARMEN Country Profiles: Costa Rica; Pan American Health Organization (regional office of
WHO), no date (2006?)
http://www.paho.org/English/AD/DPC/NC/carmen-costa-rica.pdf
Costa Rica 5th in Global Environmental Performance Index
http://www.insidecostarica.com/dailynews/2012/march/02/costarica12030207.htm
“Country and Lending Groups;” World Bank, no date (accessed 2012)
http://data.worldbank.org/about/country-classifications/country-and-lending-groups
EPI (Environmental Performance Index) – 2012 rankings; Yale University, 2012
http://epi.yale.edu/epi2012/rankings
http://epi.yale.edu/dataexplorer/countryprofiles?iso=CRI
Gersh, BJ, et al. “The epidemic of cardiovascular disease in the developing world: global
implications.” European Heart Journal: 31(6), 2010. 642-8.
http://eurheartj.oxfordjournals.org.proxy.lib.duke.edu/content/31/6/642.long
“Health Expenditures: U.S.;” CDC, 2012
http://www.cdc.gov/nchs/fastats/hexpense.htm
Health Situation in the Americas: Basic Indicators; PAHO, 2012
http://ais.paho.org/chi/brochures/2012/BI_2012_ENG.pdf
“Human Development Report 2011: Costa Rica;” UNDP, 2011
http://hdrstats.undp.org/en/countries/profiles/cri.html
http://hdrstats.undp.org/images/explanations/CRI.pdf
Li, Ming Jiu. “Teaching Caselettes: La Carpio, Costa Rica – Friendship.” The Kenan Institute
for Ethics at Duke University, no date (posted 2010, accessed 2012)
http://www.duke.edu/web/kenanethics/CaseStudies/LaCarpioFriendship.pdf
“New Cervical Cancer Screening Recommendations from the U.S. Preventive Services Task
Force and the American Cancer Society/American Society for Colposcopy and Cervical
Pathology/American Society for Clinical Pathology;” ACOG, 2012
http://www.acog.org/About_ACOG/Announcements/New_Cervical_Cancer_Screening_Recom
mendations
“Poverty in Costa Rica;” original source: CEPAL (La Comisión Económica para América
Latina), 2012
http://www.costaricalaw.com/Demographics-and-Population/poverty-in-costa-rica.html
“The World Factbook;” CIA, 2012
https://www.cia.gov/library/publications/the-world-factbook/fields/2066.html
11
“Country and Lending Groups;” World Bank, no date (accessed 2012)
“Human Development Report 2011: Costa Rica;” UNDP, 2011
iii
Costa Rica: Health Profile; WHO, May 2012
iv
“Health in the Americas, 2007, volume II – countries;” WHO, 2007
v
Ibid.
vi
Gersh et al. “The epidemic of cardiovascular disease in the developing world: global implications.” European
Heart Journal: 31(6), 2010. 642-8.
vii
“Situación de Salud;” Ministerio de Salud - Costa Rica, 2002
viii
Ibid.
ix
“Health Situation Analysis and Trends Summary;” PAHO, no date (2000?)
x
“Health in the Americas, 2007, volume II – countries;” WHO, 2007
xi
Ibid.
xii
Costa Rica: Health Profile; WHO, May 2012
xiii
Ibid.
xiv
“The World Factbook;” CIA, 2012
xv
“Health Situation Analysis and Trends Summary;” PAHO, no date (2000?)
xvi
“Health in the Americas, 2007, volume II – countries;” WHO, 2007
xvii
Ibid.
xviii
“Health Expenditures: U.S.;” CDC, 2012
xix
Country profile of Environmental Burden of Disease: Costa Rica; WHO, 2009
xx
“Poverty in Costa Rica;” original source: CEPAL (La Comisión Económica para América Latina), 2012
xxi
Li, Ming Jiu. “Teaching Caselettes: La Carpio, Costa Rica – Friendship.” The Kenan Institute for Ethics at Duke
University, no date (posted 2010, accessed 2012)
xxii
“Health in the Americas, 2007, volume II – countries;” WHO, 2007”
xxiii
Ibid.
xxiv
Country profile of Environmental Burden of Disease: Costa Rica; WHO, 2009
xxv
EPI (Environmental Performance Index) – 2012 rankings; Yale University, 2012
xxvi
NCD Country Profiles: Costa Rica; WHO, 2011
xxvii
Costa Rica: Health Profile; WHO, May 2012
xxviii
“Health Situation Analysis and Trends Summary;” PAHO, no date (2000?)
xxix
Costa Rica: Health Profile; WHO, May 2012
xxx
Country Profile of Environmental Burden of Disease: Costa Rica; WHO, 2009
xxxi
“Situación de Salud;” Ministerio de Salud - Costa Rica, 2002
xxxii
NCD Country Profiles: Costa Rica; WHO, 2011
xxxiii
Costa Rica: Health Profile; WHO, May 2012
xxxiv
NCD Country Profiles: Costa Rica; WHO, 2011
xxxv
Ibid.
xxxvi
“Health in the Americas, 2007, volume II – countries;” WHO, 2007
xxxvii
NCD Country Profiles: Costa Rica; WHO, 2011
xxxviii
Ibid.
xxxix
Country profile of Environmental Burden of Disease: Costa Rica; WHO, 2009
xl
“Health in the Americas, 2007, volume II – countries;” WHO, 2007
xli
Ibid.
xlii
Ibid.
xliii
Ibid.
xliv
“Health Situation Analysis and Trends Summary;” PAHO, date (2000?)
xlv
Ibid.
xlvi
“Health in the Americas, 2007, volume II – countries;” WHO, 2007
xlvii
Ibid.
xlviii
Ibid.
xlix
“New Cervical Cancer Screening Recommendations from the U.S. Preventive Services Task Force and the
American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical
Pathology;” ACOG, 2012
l
“Health in the Americas, 2007, volume II – countries;” WHO, 2007
li
NCD Country Profiles: Costa Rica; WHO, 2011
i
ii
12
lii
Country profile of Environmental Burden of Disease: Costa Rica; WHO, 2009
NCD Country Profiles: Costa Rica; WHO, 2011
liv
“Health in the Americas, 2007, volume II – countries;” WHO, 2007
lv
Ibid.
lvi
NCD Country Profiles: Costa Rica; WHO, 2011
lvii
Country profile of Environmental Burden of Disease: Costa Rica; WHO, 2009
lviii
“Health Situation Analysis and Trends Summary;” PAHO, no date (2000?)
lix
“Health in the Americas, 2007, volume II – countries;” WHO, 2007
lx
Ibid.
lxi
Ibid.
lxii
Ibid.
lxiii
“Health Situation Analysis and Trends Summary;” PAHO, no date (2000?)
lxiv
NCD Country Profiles: Costa Rica; WHO, 2011
lxv
“Human Development Report 2011: Costa Rica;” UNDP, 2011
lxvi
Ibid.
lxvii
“Situación de Salud;” Ministerio de Salud - Costa Rica, 2002
lxviii
EPI (Environmental Performance Index) – 2012 rankings; Yale University, 2012
lxix
NCD Country Profiles: Costa Rica; WHO, 2011
lxx
Costa Rica: Health Profile; WHO, May 2012
lxxi
“Health in the Americas, 2007, volume II – countries;” WHO, 2007
lxxii
NCD Country Profiles: Costa Rica; WHO, 2011
lxxiii
“Human Development Report 2011: Costa Rica;” UNDP, 2011
liii
13