Paper #2: Health Determinants Policy Brief
Executive Summary
Sponsored by the Costa Rican Ministry of Health and directed toward the office of Johnny Araya
Monge, the mayor of the capital city of San José, this policy brief sets the scene for
cardiovascular disease (CVD) as the largest disease burden facing Costa Ricans today. It then
goes on to review potential target groups for intervention and the cost-effectiveness of some of
these strategies. Ultimately, it proposes reinvestment in existing regional polideportivos (sports
complexes) as a means to improve health outcomes, slowly but surely, for all residents,
regardless of socioeconomic status, educational level, or citizenship.
Statement of problem
How can the Costa Rican Ministry of Health best curtail the rising burden of non-communicable
diseases (NCD) within its political boundaries?
Background
Non-communicable disease, the umbrella term for non-infectious and non-contagious illness, is
truly an epidemic of global proportions. The World Health Organization (WHO) reports that
NCDs are the leading cause of mortality in the world, accounting for greater than 60% of all
deaths. To be fair, this broad category includes many heterogeneous illnesses, including
inherited genetic disorders and the equally vague subcategory of environmental diseases. The
“environment” in this case includes more than just the outdoors, but any external factor that
affects human health. Thus, pollution, nutrition, and so-called “lifestyle choices” are included
here. These factors play into diseases of poverty – such as contaminated water, poor sanitation,
and malnutrition – on one end of the economic spectrum, and diseases of affluence – asthma,
diabetes mellitus type 2, and heart disease, for example – on the other. As societies amass
wealth and move along the industrialization continuum, their members are increasingly at risk
from these disease burdens.
In Costa Rica, the figures are striking. Cardiovascular disease (CVD) alone accounts for slightly
less than 25% of all deaths, yet there is no integrated policy or action plan, sponsored at the
government level, aimed to combat this rising tide. Further, CVD costs the population 1.6
disability-adjusted life years (DALYs) per 1000 capita and strains the national healthcare system
as both native-born and foreign residents seek care for this chronic condition. This burden did
not come without warning. Since 1980, Costa Ricans’ average body mass index (BMIs) has
steadily risen from approximately 23.5 to 27 kg/m2, with women overtaking men in the mid1990s. (Normal BMI is between 18.5 and 25; overweight, between 25 and 30; and obese, 30 and
above.) To be sure, over 59% of adult men (age 19 and above) and over 57% of adult women in
Costa Rica are overweight, and nearly 21% of adult men and over 28% of adult women are
obese. The cause of this rise is multifactorial, including genetic predisposition, changing diet,
and physical inactivity. For instance, over 41% of the population does not get the recommended
30 minutes of exercise 5 times a week. Sadly, even schoolchildren (age 7-15) are affected by the
obesity epidemic, as one study showed nearly 13% are overweight and nearly 8% are obese.
Even though Costa Rica has slightly lower rates of obesity than the regional average, things do
not look promising for Costa Rica’s youth.
Interventions by Group
The fattening cream rises to the top, and CVD is the most important NCD in Costa Rica today.
From this problem, 3 distinct groups emerge: adults with CVD, adults with risk factors for but
without the diagnosis of CVD, and youth at risk. (Given that some risk factors for CVD such as
age, gender, and heredity cannot be changed, it can be argued that anyone who does not already
have CVD is at risk for the outcome.) Consequently, there are 5 general options for intervention:
1) Do nothing. Called inaction by critics and surveillance or “watchful waiting” by proponents,
this is always an option. However, continuing along the current path, in which no governmentallevel policies exist for contending with CVD (and those addressing physical inactivity and
unhealthy diet seem to be inadequate), will likely only allow the numbers of Costa Ricans
affected by CVD to swell. Given the sequelae of lost productivity and income, strained
healthcare resources, and individual quality of life, clearly this is not recommended.
2) Target adults with CVD. Focusing on those are already affected by the illness avoids
“wasting” resources on those who don’t (yet) need them. Patients are also potentially more
receptive of outreach efforts in general, as diagnosis alone, irrespective of any symptoms or
secondary outcomes, may be enough to motivate change. Examples of interventions would
include “heart-healthy” exercise classes, peer support groups to encourage other forms of
lifestyle modification, or special informational sessions with physicians reviewing
pharmacotherapeutic options. Dedicating all energies to this group, however, represents a
Sisyphean task, as it “misses the boat” on curtailing the epidemic and only chases its tail.
3) Reach out to adults without CVD. Rather than slowing disease progression through
secondary prevention as above, primary prevention attempts to keep it from occurring in the first
place. Though moving further “upstream” is usually more effective with regard to health
outcomes, getting “buy in” from members of this group can be difficult. Examples of
interventions might include regular cholesterol and diabetes screening tests at primary care
clinics, regulations on food nutritional labels, and public health awareness campaigns warning of
the dangers of an unhealthy lifestyle. (The latter can be particularly powerful when playing
towards weaknesses or fears, such as impotence due to vascular disease in men.) Alone, this
approach may be too unfocused, or, separately, wait too long to encourage healthy diet and
exercise – habits that are often formed in childhood. Which brings us to our next point…
4) Focus on impressionable youth. Overweight and obese schoolchildren are more likely to
become overweight and obese adults. Consequently, sponsoring nutrition and physical education
classes in the compulsory secondary education domain provides students with tools they can
carry for years to come. (Another approach might be to sponsor a poster contest about healthy
lifestyles, which would generate buzz among the children and potentially avoid hiring an ad
agency to create public health campaigns later.) The oft-asked question, “what did you learn in
school today?” opens the door to youth bringing the message home. Additionally, children’s
well-intentioned nagging or questioning upon seeing their parents doing less-healthy things
gently reinforces the Ministry of Health’s message at a more personal (and less easily ignored)
level.
5) Have your (fat-free) cake and eat it, too. Focusing on schoolchildren allows the beneficial
side-effect of spill-over to their parents. Consider, then, the links and commonalities between
the focus groups to best design interventions that could reach and benefit everyone. This
idealistic-sounding goal potentially allows for improved health outcomes in affected adults and
reduces the number of young people and adults who later receive the diagnosis.
Interventions by Cost
In selecting an option, it is important to compare the cost of the intervention against that of the
status quo. As the burden of CVD – and NCDs in general – continues to rise, inaction will likely
be the most costly option, both financially and in other ways mentioned above. Thus, any
investment, though daunting at first, has the potential to result in overall lower costs.
Unfortunately, only a handful of countries – Canada, China, South Africa, the United Kingdom,
and the United States – have publicly reported what they spend on treating CVD. Regardless,
these figures don’t necessarily reflect the burden directly, as a country may spend a lot with little
benefit, or, conversely, not be spending enough to make an impact. The WHO Commission on
Macroeconomics and Health suggests that interventions should be less than three times a
country’s GNI per capita to be cost-effective. Shockingly, this works out to be about $10,000
per quality-adjusted life year (QALY) for the wealthier countries in Latin America. Multidrug
regimens for primary prevention in high-risk individuals are proposed to cost between $750 and
1220 per DALY averted, and interventions for secondary prevention are estimated to be between
$310 and 72,000 by this same measure, with coronary artery bypass surgery accounting for the
high upper margin. Dietary interventions (eg, reduced salt content in manufactured foods) would
be expected to cost between $1320 and 4000, and tobacco reduction efforts should cost between
$3 and 3000 per DALY averted, with a 33% increase in the cost of cigarettes accounting for the
low lower margin. Surprisingly, physical fitness initiatives, which are often less expensive and
would slow the progression of CVD risk factors, have not been analyzed in this way, perhaps due
to the delay between investment and outcome measures. One Canadian study (Lowensteyn et
al), however, reported that unsupervised exercise was highly cost-effective for both genders,
across all age groups, and for individuals with and without CVD, even with a 30% compliance
rate. The incremental cost-effectiveness ratio here was $12,000 per year of life saved (YOLS),
which is not directly comparable to the “per DALY averted” measure.
Policy Proposal
One lynchpin that joins the nation is a love of athletics. During important soccer matches, be
them intracity or international, people will crowd around small televisions in tienda storefronts
or listen covertly to the radio while stuck at their deskjob. How can we capitalize on this
passion, using it as motivation to get Costa Ricans exercising more and eating better?
Refocused attention on regional polideportivos, or sports complexes, is a novel proposal. With
each of Costa Rica’s 81 cantons (counties) having at least one such arena, a legal requirement,
the majority of residents have reasonable access to athletic fields and equipment. Some
programs, such as swimming lessons, have the potential to improve other health statistics like
death from drowning as well. Even if club patrons are not inspired to improve their diet (as is
often the case when an individual starts an exercise regimen), their efforts will still burn off
excess calories and work towards better cardiovascular health.
To start, San José’s canton of the same name will feature longer hours of operation; this requires
only a few more hours of electricity to keep the lights on and man-power to keep the grounds
adequately supervised by security guards. Based on positive response from club patrons, this
action can be scaled to other polideportivos in the city and around the nation. Foreign
corporations like Kaiser Permanente have made similar investments in neighborhood playing
fields in their home countries, and though the actual figures are not publicly available, it still
goes to show that the local government may not necessarily have to shoulder the entire cost.
Further, to keep facilities properly maintained, a modest fee is charged for the more expensive
club components – namely, use of the swimming pool and sporting equipment – so more affluent
residents can help cover the cost as well, without the poorer ones being denied access to safe
playing fields.
Many children dream of becoming the next Edison Arantes do Nascimento (better known as
“Pelé”) or Cristiano Ronaldo, and it is certainly in our country’s best interests to help the next
star develop and be discovered. A low-cost advertising campaign featuring the Costa Rican
soccer team will “get the word out” about the extended club hours via billboards and television
ads, emphasizing the importance of physical activity but without dwelling on the negative effects
of CVD. A 20-25% increase in polideportivo use over the span of 1 year will be considered a
success; other health metrics will lag behind this, but should nonetheless be monitored as the
program develops.
Summary Statement
Cutting across the health determinants of nutrition, exercise, and gender, this less-traditional
policy proposal of extending sports complex hours to combat morbidity and mortality from CVD
allows flexibility to serve individual community needs whilst catering to all residents, regardless
of whether they are enrolled in school or have a job, pay Social Security, or even possess Costa
Rican citizenship.