Wednesday, March 6, 2013

Costa Rica - Health Care, Tours, and Peeing on Trees

The past two days have been a blur. We started the day off yesterday morning with a talk (shown here) hosted by 
Dr. Mario Tristan, the IHCAI Foundation General-Director.

Note: if you don't want to know anything about socialized healthcare and Costa Rica's health system, skip to the photos below! 

The talk focused on how health care in Costa Rica has changed in recent years, as well as its current strengths and flaws. Basically, health care in Costa Rica is completely universal. Everyone pays a percentage of their income into "CAJA" - the big fund for national health care. Everybody pays, whether they use the public healthcare system funded by CAJA or not. Even if they opt to only use the private, pay-as-you-go health care system, they still pay into CAJA.

If you're a Tico and you go to a public hospital, everything is covered. All of your tests, hospital stays, medications, procedures, surgeries, anesthesia - COVERED. Great, right? Ideally, yes. However, the system is so backlogged that only the most urgent cases get seen in a timely manner. Also, unless it's a traumatic, life-and-death situation, you can't just "go" to one of the national hospitals. There are three levels of referrals that you have to wade through - first your regional EBAIS (Equipo Básico de Atención Integral en Salud), then your regional primary care physician's office, then on to the main hospital. You have to be seen in each location and it has to be determined that they do not have the resources to treat your ailment before you can be referred to the next level. This process takes forever.

Not only that, but once you get to one of the big hospitals at the end of the referral chain, it can take months to years to finally get the procedure you're hoping for. For example, let's say you have gallstones. They hurt. A lot. You are in constant pain. You go to your EBAIS. They send you to a doctor's office. The doctor's office schedules a consult for you in the main hospital in the central valley. When you meet with that physician, they determine that the condition is currently not fatal, as the stones are mobile, so you're not at risk of obstruction. They determine that your condition will eventually worsen to the point where you have no choice but to have your gallbladder removed. They add you to the list of people waiting to have their gallbladder removed - a waiting list 440 days long. This is not an exaggeration. They tell you that eventually your condition could become complicated due to obstruction, and that in this case your symptoms would worsen and your skin would take on a jaundiced, yellowy appearance. You can have you gallbladder out when your turn on the list comes up, or your condition becomes emergent - whichever come first. Until then, you're given some meds and told to deal with the pain.

Enter the reason for the private healthcare "business" system. Basically, these private "hospitals" popped up to supply more timely options (and thus much more expensive options) to the wealthier clientele. They say they're targeting the Costa Rican "middle class," but this middle class is rapidly disappearing into a polarized high- and low-earning class duality.

The private hospitals do the simpler procedures, but bill every single thing to the patient. Anything traumatic or more involved gets turfed to the public system. None of the privately-performed services are covered by the public healthcare system, but they may be partially covered if you've subscribed to additional, private insurance - just like here in the States.

And thus, the world of medical tourism is born. Even though these private healthcare costs are crazy high for the average Costa Rican, they're way lower than they would be in the United States and other developed countries around the world for the same procedures. An operation that might cost $12,000 - $14,000 elsewhere might only cost $3,500 in Costa Rica. So, even with the cost of a plane ticket, it makes more sense to have this operation in Costa Rica.

That's the gist of what I learned about the Costa Rican healthcare system - both the private and public sectors - over the past 36 hours. Yesterday, after learning the basics of this (which were actually fleshed out more thoroughly today), we got some coffee, talked some more, then went out for lunch at this awesome restaurant called Don't Remember The Name near IHCAI headquarters:

After lunch, we went on a tour of the city and saw all this cool stuff:

El Barrio Chino - Chinatown in San José, Costa Rica.

This guy peeing on a tree, right next to where cars park.

The brand new sports stadium, where Costa Rica is hosting the Central American Games.

Some crazy jugglers, drummers, and gawkers.
And stilt-walking-creeper-clowns advertising for Claró! 
Lots of cool buildings, like this one! It was really cloudy - though that has since cleared up.
And this one - one of the several gorgeous churches around San José.

The crowds are everywhere - though it's not like you'd think. CARS have the right-of-way, and will hit pedestrians that get in the way. They seriously won't stop. Look out. Also, taxis MUST have yellow triangles like this painted on the side, otherwise they're illegal. The illegal ones are more likely to rob / gouge you on prices. No fun, that.
After the city tour, we hit up the National Gold Museum and learned about the beginnings of Costa Rica. Dr. Daniel Naranjo led the tour (he's an awesome guy), and explained the reasoning behind the tour by saying, "We took you to the museum so you could see how our country started and maybe understand a little bit more about how we came to the way things are today." It was a great idea, and I was fascinated by all of the amazingly detailed golden artifacts that were produced in a day/age with no modern technology:

My ticket, yo.

It always hits me hard at exhibits like this how horrible the conquest of the Americas was.
It's definitely something that should never be forgotten, and exhibits like this are key for that.

This is a map depicting where all of the original tribes of Costa Rica lived.
Today, there are only a few of these original tribes left.
Gold artifacts - hair brooches and ornamental pieces.

Gold artifacts 2.

Gold artifacts 3: Awesome Frogs.

My personal favorite gold guy was this dragon-lizard.

Here's a panorama of the whole gold exhibit room. Very cool.
After the gold museum, we headed downtown to an indoor market. As evidence of how I suck sometimes, I didn't take any pictures of the market, but here's a random picture of a spice display:

Costa Rican Spices. Better than normal spices back home?
I'll never know.
I bought four different kinds of freshly-roasted coffee from a shop on the street outside the market, and can't WAIT to see what it tastes like once I get back home. I also picked up a little treat for Wife, who loves surprises but hates waiting for them! She's finding out about this via my blog post, for the record...

After the market, we headed across town and back to our host families for a quick dinner, then hit the town for a few more hours to go out dancing. It was a crazy fun night that left everyone exhausted and sore from all the moving and shaking - something that made it a bit more difficult to get up for today - a day full of shadowing and touring of various hospitals.

We started the day off by going to a nearby hospital and shadowing in the emergency department. Fortunately for the people but UNfortunately for us, things were really really slow, so I was only able to shadow during the visit of one patient. Amazingly enough, I was able to follow everything that was discussed, both between the doctor and the patient, and between the various doctors during consultations! The patient presented with some vaginal bleeding issues early in her pregnancy. I was asked to hold the light while the physician examined the cervix using a speculum, and it was determined that the source of the bleeding was indeed the uterus and not an internal vaginal lesion. However, it was so early in the pregnancy that it could not yet be determined via ultrasound or fetal heart monitoring whether the baby was alive or not, so a 48-hour β-hCG (human chorionic gonadotropin hormone) test would be required. Basically, throughout the first 8 months of pregnancy the plasma levels of hCG double every 24-48 hours, as long as the baby continues to live. Doctors can measure this level twice (48 hours apart) and non-invasively determine the baby's status. It was an interesting shadowing, and very emotionally charged, as it involved a lot of anxiety and fear on the part of the mother, and skillful counseling on the part of the lead physician.

After the shadowing experience, we talked about our experiences for an hour, then grabbed some Subway and set off to shadow three different hospitals. I wasn't able to take as many photos today, as it's generally frowned-upon to take photos while in the hospitals, but I did manage to get these:

View from the parking lot of the national women's hotel.

We were personally welcomed by the chiefs of each hospital that we visited - the
National Women's and Children's Hospitals, and one of the various private hospitals.
Here, the chief of the Children's Hospital personally greeted our group.
Non-standard Self-Portrait!
Here are a couple of my classmates who had no clue I was taking a picture
as they discussed the pros and cons to public and private healthcare.
And here's the group!

After touring through all three hospitals, each of which was very impressive in terms of quality and cleanliness of facilities, we took a bus back to IHCAI Headquarters to have a quick wrap-up session of the day. From there, we headed back to the host family houses for some dinner. Since then, I've been relaxing, watching some Big Bang Theory, and writing this blog post. WHEW. I'm beat, and I don't think my feet have EVER been this sore. Including band camp that year that I marched the second-lowest bass drum. I was a younger man then, with younger feet... Mad props to all you older people out there that manage to stay active. I can only imagine how the soreness intensity will increase with age!

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