|The Nutrition and Health Transition of Democratic Costa Rica (INFDC, 1995, 228 p.)|
|Appendix 3 - Health conditions in Costa Rica 1994|
In 1987 Costa Rica had 2,790,600 inhabitants. Based on official projections, the 1992 population was estimated at 3,099,063, with an age structure as follows: 0-4 years of age, 12.8%; 5-14 years, 23.1%; 15-64 years, 59.8%; 65 years or older, 4.3%. The population density increased from 50 inhabitants per km² in 1984 to 60.7 in 1992. The Central region is home to 65% of the population, with a density of 230.1 inhabitants per km²; in other regions of the country the population density ranges from 19 to 40 inhabitants per km². The population is 47% urban and 53% rural. Between 1960 and 1990 the urban population grew at an average annual rate of 3.9%.
The growth of the Central region has been largely the result of internal migration, although international migration has also played a part, particularly during the period 1975 to 1985, when three regions of the country registered net immigration (Central, Huetar Norte, Huetar Atlica). There continue to be two main currents of migration: from small cities and rural areas to the country's principal urban centers, and from economically depressed rural areas where employment opportunities are limited and most of the land is owned by a few individuals to other rural areas in which development is taking place and the demand for workers is greater.
In 1989, 40,800 refugees were living in the country. By July 1993, the number had fallen to 31,875. In addition, there are an estimated 250,000 undocumented aliens.
The natural population growth rate for the period 1991-1992 was 2.26%. The total fertility rate decreased from 3.5 children per woman between 1980 and 1985 to 3.26 between 1985 and 1990. In 1991 the birth rate was 26.3 per 1,000 population, and life expectancy at birth for the period 1990-1995 was estimated at 75.2 years.
Birth and death records suffer from late registration of mortality, which is estimated at 2.8% for general mortality and 3% for infant mortality. No medical death certificate is issued for 24% of deaths in general, whereas only 2.8% of infant deaths lack medical certification.
The general mortality rate recorded in 1991 was 3.8 per 1,000 population and there were a total of 11,792 deaths. The infant mortality rate in 1991 was 13.9 per 1,000 live births. Deaths attributed to signs, symptoms, and ill-defined conditions made up 1.7% of the total.
In 1991 four major groups of causes accounted for 70% of all deaths: 29.4% were due to diseases of the circulatory system, 20% to malignant neoplasms, 10.5% to external causes, and 10.2% to diseases of the respiratory system, with rates of 11.2, 7.6, 4.0, and 3.9 per 10,000 population, respectively. Infectious and parasitic diseases, which in 1970 ranked as the leading cause of death and accounted for 20.5% of all deaths (a mortality rate of 13.6 per 10,000 population), in 1991 ranked 10th and were responsible for 2.8% of all deaths (a rate of 1.1 per 10,000 population).
Among the general population in 1991 acute myocardial infarction was the leading cause of death, accounting for 9.6% of all deaths. The mortality rate from this cause increased from 2.6 per 10,000 population in 1970 to 3.7 in 1991. In second place was malignant neoplasm of the stomach, which caused 5% of all deaths. The mortality rate from this cause, 2.0 per 10,000 population, has changed very little since 1970. The third leading cause of death was other forms of chronic ischemic heart disease, at a rate of 1.6. Chronic airway obstruction ranked fourth, at a rate of 1.2, and acute cerebrovascular disease and diabetes mellitus ranked fifth and sixth, respectively, at rates of 1.2 and 1.0 per 10,000 population.
Analysis by Population Group
Perinatal and Child Health
The decline in infant mortality between 1970 and 1980 (from 61.5 to 19.1 per 1,000 live births) slowed between 1980 and 1985, when the rate was 17.6 per 1,000. In 1991 the rate recorded was 13.9 per 1,000 live births. The neonatal mortality rate fell from 25.2 per 1,000 live births in 1970 to 11.2 in 1980 and 8.6 in 1991. Similarly, the postneonatal mortality rate decreased from 36.3 per 1,000 live births in 1970 to 7.9 in 1980 and 5.2 in 1991. The perinatal mortality rate, which in 1975 was 23.7 per 1,000 live births, declined to 12.1 per 1,000 in 1991. The highest infant mortality rate registered in any of the country's counties in 1991 was 31.4 per 1,000 live births, and the lowest was 2.7 per 1,000.
Children under 1 year of age accounted for 9.5% of all deaths in 1991. The leading causes of death in this age group changed between 1970 and 1991. Intestinal infectious diseases moved from first to seventh place, the rate declining from 16.7 to 0.4 per 1,000 live births. In 1991 conditions originating in the perinatal period, congenital anomalies, and diseases of the respiratory system were the three leading causes of death in this age group, with rates of 6.1, 3.9, and 1.5 per 1,000 live births, respectively.
In 1990 the leading causes for outpatient medical visits among children under 1 year, in descending order, were bronchitis (10%), well-child visits (8%), acute respiratory infections (6%), acute tonsillitis (6%), and infections of the skin end subcutaneous tissue (5.5%). In 1990, date on hospital discharges from institutions of the Costa Rican Social Security Institute (CCSS) show that the leading causes of hospitalization in this age group were conditions originating in the perinatal period (39.3% - a proportion equal to 3.5% of all discharges), intestinal infectious diseases (12.5%), pneumonia (7%), and congenital anomalies (6.5%).
The proportion of children with low birthweight (under 2,500 g) has remained at around 6.7% since 1988.
Breast-feeding increased between 1975, when 85.3% of infants were breast-fed from birth, and 1990, when 93.9% were breast-fed. The proportion of children exclusively breast-fed for 3 months increased from 16.7% to 47.9% between 1975 and 1990, while the proportion exclusively breast-fed for 6 months increased from 11.2% to 21.7%.
The mortality rate among children age 1-4 years decreased from 51.1 per 10,000 in 1970 to 10.1 in 1980 and 6.5 in 1991. In the latter year, 1.8% of all deaths occurred in this age group. Between 1970 and 1991 infectious and parasitic diseases dropped from first to fourth place among the leading causes of death in this age group, with the rate falling from 25.9 per 10,000 in 1970 to 0.9 in 1991. Congenital anomalies ranked as the leading cause of death in 1991, followed, in descending order, by external causes and diseases of the respiratory system. The five leading causes of doctor visits were acute tonsillitis, bronchitis, nasopharyngitis and sinusitis, anemia, and asthma. In 1990 this age group accounted for 5% of all hospital discharges, with intestinal infections being the most frequent cause of hospitalization (18.2%), followed by bronchial asthma, pneumonia, and other respiratory infections, and by congenital anomalies.
Based on the indicator weight-for-height, in 1991 the reported prevalence of mild malnutrition among children under 6 years of age, was 17.9%, that of moderate malnutrition was 2.4%, and that of severe malnutrition was 0.1%. The prevalence of overweight was 2% among children under 1 year, 1.7% among children ages 1 to 2, and 1.7% among those ages 3 to 5 years.
The age group 5 to 9 years accounted for 0.8% of total mortality in 1991. External causes were the leading cause of death, followed by malignant neoplasms, diseases of the nervous system and sensory organs, infectious and parasitic diseases, and endocrine and metabolic diseases and immunity disorders. The causes for outpatient medical visits in this age group were similar to those for the group ages 1 to 4 years. Hospital discharges in this group made up 3.4% of all discharges. The leading causes of hospitalization were acute respiratory infections and bronchial asthma (14.4%), appendicitis (6.6%), congenital anomalies (5.2%), and intestinal infections (5%).
Adolescent and Adult Health
In 1991 young people ages 10 to 19 made up 20.4% of the population and those ages 20 to 24 constituted 9.4%; thus, almost one-third of the national population was between 10 and 24 years of age. According to 1984 census data, 15.9% of the economically active population was composed of young people ages 15 to 19 years. The 1989 household survey showed that 24% of the adolescent population was employed.
In 1991, deaths in the age group 10 to 14 years accounted for 0.8% of total mortality, deaths in the group 15 to 19 for 1.2%, and deaths in the group 20 to 24 for 1.7%. The leading cause of death among persons 10 to 14 years of age was external causes, with a rate of 1.4 per 10,000 population; accidental drowning and submersion and transport accidents were the predominant external causes. The second leading cause of death was diseases of the nervous system and sensory organs, with a rate of 0.62 per 10,000 population, the principal ones being, in descending order, infantile cerebral palsy, other brain disorders, and epilepsy. Malignant neoplasms ranked third, with a rate of 0.22 per 10,000 population.
Mortality in the group ages 15 to 24 accounted for 2.9% of total mortality. Two-thirds of the deaths in this group were of males, and the leading cause was external causes, mainly transport accidents of all types.
In regard to morbidity, 10.5% of all doctor visits at CCSS institutions (close to 6 million) and 11 % of all hospital discharges in 1987 involved persons ages 10 to 19 years. The leading reasons for consultations were prenatal care (6%), acute tonsillitis (4.9%), and pharyngitis-nasopharyngitis (4.7%). Among males, the most common reasons were infections of the skin and subcutaneous tissue (13.2%); sinusitis, laryngopharyngitis, and acute tonsillitis (10.1%); and "other" parasitic diseases (5%). Among females they were nasopharyngitis and sinusitis (8.9%); prenatal care (6.7%); and infections of the skin and subcutaneous tissue (6%).
The leading causes associated with hospital discharge in the group 10 to 19 years of age in 1990 were direct obstetric causes (27%), normal delivery (21.2%), and appendicitis (4.5%) for females, and appendicitis (10%), wounds and injury to blood vessels (7.9%), and intracranial and internal injuries (6.4%) for males.
In 1991, 16.2% of all live births (81,110) were to mothers under 20 years of age. Complications of pregnancy, childbirth, and the puerperium accounted for 71.3% of hospital discharges among the female adolescent population.
Mortality among the population aged 15 to 49 accounted for 16.2% of total mortality in 1991 (1,922 deaths). The leading cause was the group of external causes, which accounted for 36% of the deaths, or a rate of 4.3 per 10,000 population (down from the rate of 6.3 reported in 1980). Malignant neoplasms ranked second, causing 19.2% of the deaths, with a rate of 2.3. In third place were diseases of the circulatory system, which accounted for 14.3% (a rate of 1.7 per 10,000 population). Of the total number of deaths, 65% were of males, among whom violent causes, including both accidents and suicide, predominated.
In 1991 persons aged 50 years and over accounted for 71 % (8,136) of all deaths. Over three-quarters of these deaths (77.7%) were due to four groups of causes. The leading cause, accounting for 36% of all deaths in this group, was diseases of the circulatory system, with a rate of 83.2 per 10,000, and of these diseases acute myocardial infarction was the most important (29%). The second leading cause, with a rate of 51.0 per 10,000, was malignant neoplasms, which accounted for 23% of the deaths; malignant neoplasm of the stomach was the predominant cause in this group. Diseases of the respiratory system, with a rate of 25.7 per 10,000, ranked third, accounting for 11.7% of the deaths; chronic obstructive pulmonary disease and bronchopneumonia predominated in this group. In fourth place were external causes, which accounted for 5% of all the deaths in this age group and had a rate of 11.3 per 10,000.
Persons 20 to 59 years of age made 51.3% of all outpatient visits to CCSS institutions. Of these visits, 70% involved persons ages 20 to 44 and 71% were visits made by women of childbearing age. According to a survey carried out in 1987, the primary causes for outpatient visits in this age group were diseases of the skin and subcutaneous tissue (88%), upper and lower back problems (6.7%), and gastroduodenitis (5%) among males, and hypertensive disease (6.2%), prenatal care (6.1%), and neurotic disorders (4.1%) among females. Hospital discharge records for 1990 indicate that the 20 to 59 year age group accounted for 58.7% of all discharges from CCSS institutions; of these discharges, 76% were women aged 20 to 44 years. Direct obstetric causes were the leading cause of hospitalization among females (34.4%), followed by normal delivery (19.8%), and abortion (5%). Among the male population, the leading causes were psychoses and neurotic disorders (5.8%), osteomuscular diseases (5.3%), and intracranial and internal injury (5.1%).
Health of Women
In 1991 females made up an estimated 49% of the total population; 24% were under 10 years of age, 21.2% were 10 to 19 years, 38.4% were 20 to 44 years, 9.8% were 45 to 59 years, and 6.9% were 60 years of age or older.
Regarding leading causes of death in the female population, cardiovascular diseases account for 30.6% of all female deaths, malignant neoplasms for 20.2%, diseases of the respiratory system for 12.1 %, and external causes for 5.6%. The most frequent sites of malignant neoplasms are the stomach, uterine cervix, and breast. The contributions of these three types of cancer to total female deaths are 19.4%, 11.3%, and 9.4%, respectively, and the corresponding mortality rates are 13.8,8.1, and 6.7 per 100,000 females. As with males, the leading external cause among females was transport accidents, which accounted for 30.9%, followed by accidental falls, especially among elderly women.
Females made 63.4% of the outpatient visits to CCSS establishments, with women ages 20 to 44 years accounting for 58%. The most frequent reasons for seeking medical care among females ages 20 to 59 years were pregnancy related causes, hypertensive disease (6.2%), neurotic disorders (4.1 %), and upper and lower back problems (3.7%). Females accounted for 69% of all hospital discharges in 1990; of those discharges, 68% were of women ages 20 to 59 years. Direct obstetric causes, normal delivery, and abortion together accounted for 59% of the discharges among women in this age group, and other diseases of the female genital organs accounted for 3.8%. Diabetes mellitus, disorders of the eye, ischemic heart disease, respiratory diseases, and hypertensive disease together were responsible for 30% of hospitalizations in women age 60 years and over.
In 1991 a total of 89,221 pregnancies (80% low-risk and 20% high-risk) and 81,110 live births were recorded. Of these births, 16.2% were to women under the age of 20 years, 73% were to women 20 to 35 years, and 10.7% were to women over 35 years. Overall, 38% of the total number of births were to single mothers, with considerably higher proportions in the provinces of Guanacaste, Puntarenas, and Lim60.7%, 53%, and 60%, respectively); 65% of all live births among adolescent women were to single mothers.
In 1991, 96% of all births took place in hospitals, and 95% were attended by a physician or an obstetric nurse; 20% of all births were by cesarean section. Only 55% of the women giving birth in hospitals had received prenatal care. In 1990 the number of prenatal visits per birth averaged 2.4. Maternal mortality declined from 7.0 (41 deaths) to 3.5 (28 deaths) per 10,000 live births between 1975 and 1990. The leading causes of maternal death were hemorrhage, infections, and toxemia of pregnancy.
Rape, incest, sexual abuse, and other types of physical aggression are important problems for women. According to information for 1993, every day 60 complaints of domestic violence are lodged with the Office of the Public Defender for Women and the Program for Abused Women. This number is undoubtedly an underestimate of the problem, since most cases of abuse are not reported. A study carried out in 1993 found that an estimated 77.8% of women had been victims of some type of violent conduct by their male partners. According to the Office of Women's Affairs, the majority of the 14 rapes reported on average every day, involve adolescents ages 11 to 16 years, and 90% of the pregnancies occurring among girls under 14 years are the result of sexual abuse, generally committed by a close relative.
Health of the Elderly
In 1991 persons 60 years of age and over made up 6.4% of the population, up from 5.5% in 1980. Of all the deaths that year, 62% were persons in this age group, and most (74%) of those deaths were due to three causes: diseases of the circulatory system, which accounted for 39% (a rate of 143.6 per 10,000 population); malignant neoplasms, which accounted for 22% (81.2 per 10,000 population); and diseases of the respiratory system, which accounted for 13% (46.3 per 10,000 population).
This age group accounted for 14.1 % of the outpatient visits to CCSS institutions and 12.5% of the discharges from CCSS hospitals. Among females 60 years and over, the three leading causes of outpatient visits were hypertensive disease (18.4%), diabetes mellitus (8.1 %), and arthropathies and related disorders (5.8%). Among males in the age group, these causes for outpatient visitis accounted for 15.4%, 5.9%, and 5.1 %, respectively. Neurotic disorders were the fourth leading cause for outpatient visits among women (3.6%) and the seventh leading cause among men (2.8%). The three principal causes associated with hospital discharge in 1990 for both sexes were ischemic heart disease (7.2%), diseases of the eye, ear, and mastoid process (5.9%), and diabetes mellitus (5.8%). Ischemic heart disease ranked first among men (8.4%) and third among women (6%), while diabetes mellitus was the leading cause among women (7.5%) and ranked seventh among men (4%). Diseases of the eye, ear, and mastoid process ranked second among women (6.4%) and third among men (5.5%). Diseases of the male genital organs were the second leading cause associated with hospital discharge among elderly men (7.4%).
A study of morbidity carried out in the county of Coronado in 1986 and 1987 found the most prevalent chronic diseases to be osteomuscular and joint diseases (49.1 %), followed by arterial hypertension (38.4%), diabetes mellitus (13.9%), cerebrovascular accident (6.7%), and malignant neoplasms (4.5%).
The work force in 1990 totaled 1,017,151 persons - 38% of the total population. Only 573,321 employed persons (56%) had insurance coverage for work-related accidents and diseases, although by law all workers must be covered. That same year there was an average of 10,357 occupational accidents per month, or 345 per day.
According to a report by the National Insurance Institute (INS), the four leading types of work-related accidents in 1990 were accidental falls (21.6%); accidents caused by submersion, suffocation, and foreign bodies (5.3%); accidental poisoning by solid or liquid substances (4.7%); and transport accidents (2.7%).
Diseases and Health Impairments
In 1975 a total of 304 cases of malaria were reported, for a rate of 1.5 per 10,000 population. Between 1980 and 1985 the number of cases rose from 368 to 722, while the rate increased from 1.6 to 2.7 per 10,000 population. In 1990 the number of reported cases totaled 1,142 (a rate of 3.8 per 10,000), and in 1991, 3,247 cases (a rate of 10.5). Seventy-four percent of the cases occurred in the Huetar Atlica region (province of Lim In 1992 there were 6,951 cases (22.5 per 10,000 population). Of that total, 1,173 (16.9%) occurred in foreigners and 5,210 were detected in the (province of Lim which experienced considerable immigration in connection with the growth of the banana industry in the area. In addition, ecological changes in the province as a result of banana-growing - deforestation and flooding of large areas - created favorable conditions for proliferation of the vector.
The last six eases of diphtheria in the country were reported in 1975. No cases of poliomyelitis have been reported since 1973. Tetanus cases decreased from 46 in 1975 to just 2 in 1992 (rates of 2 and 0.1 per 100,000, respectively, in those years). A total of 1,165 cases of whooping cough were reported in 1975 (a rate of 5.9 per 10,000) and 29 in 1992 (a rate of 0.1 per 10,000). Costa Rica continued to experience cyclical outbreaks of measles, and an epidemic in 1979-1980 resulted in 7,883 cases and 42 deaths, for a case-fatality rate of 5.3 per 1,000. An outbreak in 1986-1987 was responsible for 8,457 cases and 16 deaths, making the case-fatality rate 1.9 per 1,000. During the period 1988-1990 there were only 467 cases and no deaths. However, in 1991-1992 another epidemic produced 8,701 cases and a case-fatality rate of 6 per 1,000 (54 deaths); 60% of those deaths were of persons under 1 or over 19 years of age.
Cholera and Other Intestinal Infectious Diseases
The first case of cholera in the country was detected in 1992, and as of April 1993 a total of 16 cases had been reported, 9 of which were imported. Mortality from diarrheal diseases has decreased among both children and adults. In 1970 these diseases were the leading cause of death, accounting for 10.5% of all deaths, with a mortality rate of 7.0 per 10,000. By 1991 they had dropped to 22nd place and accounted for only 0.9% of deaths, with a rate of 0.4 per 10,000. As a cause of infant death, diarrheal diseases moved from first place in 1970, when they accounted for 27% of all infant deaths (rate of 16.7 per 1,000 live births), to seventh place in 1991, when they accounted for 3% of all infant deaths (rate of 0.4 per 1,000 live births).
In 1990 intestinal infectious diseases accounted for 3% of all discharges from CCSS hospitals. According to Ministry of Health records on notifiable diseases, in 1991 a total of 68,887 cases of diarrheal disease were reported, yielding a rate of 2,231 per 100,000 population.
The incidence rate of hepatitis (all types) has declined steadily, from 95.0 per 100,000 population in 1985 to 85.1 in 1990 and 39.7 in 1991. Nevertheless, outbreaks of hepatitis A continue to occur in small communities in which fecal contamination of water has been confirmed.
Chronic Communicable Diseases
Fifty cases of tuberculosis (all forms) were reported in 1990, (a rate of 1.6 per 100,000 population), and 201 in 1991 (6.5 per 100,000). By comparison, in 1980 and 1985 the rates had been 20.5 and 13.9 per 100,000 population, respectively.
The number of cases of leprosy has declined. In 1980 there were 47 reported cases and the rate was 2.1 per 100,000 population, while the rates in 1985 and 1991 fell to 1.1 and 0.5 per 100,000 population, respectively.
In 1991 respiratory diseases were the fourth leading cause of death overall, accounting for 10% of total mortality, with a rate of 3.9 per 10,000 population. Among the population ages 50 years and over, these diseases were the third leading cause of death, with a rate of 25.7 per 10,000 population. The most important of these diseases in 1991 were chronic obstructive pulmonary disease and bronchopneumonia. Mortality from respiratory diseases has decreased substantially, especially among children under 1 year of age. In that group bronchopneumonia ranked fourth as a cause of death in 1991 (rate of 0.6 per 1,000 live births), whereas in 1970 it had ranked second (rate of 6.9 per 1,000 live births).
A national survey of outpatient visits found that in 1987 acute respiratory infections and other respiratory diseases were the leading causes of outpatient visits to CCSS institutions, accounting for 17.8%, and in 1989 they were the diagnosis associated with 7.6% of all hospital discharges among children under 10 years of age. Bronchitis is second only to acute tonsillitis as a reason for outpatient visits among children ages 1 to 4 years.
AIDS and Other Sexually Transmitted Diseases
As of December 1992, 433 cases of AIDS had been reported: 57.5% in homosexuals, 15.2% in bisexuals, and 8.5% in heterosexuals. Of all the reported cases, 86.8% occurred in persons 20 to 49 years of age, and 7% (32 cases) were in females. Seven cases resulting from perinatal transmission have been reported since 1988.
The rates of gonorrhea reported by the Ministry of Health were 380.8 and 313.6 per 100,000 population in 1980 and 1985, respectively. In 1990 and 1992 the rates were 141.8 and 107.6 per 100,000 population.
Nutritional and Metabolic Diseases and Deficiencies
In 1975, 53% of children under 6 years of age showed some degree of malnutrition: 40.9% mild, 11.2% moderate, and 1.1 % severe. Among the same age group in 1982, the proportion was around 44%: 38% mild, 5% moderate, and 0.3% severe. In 1990, 21% of the children under 6 years that were covered by the Ministry of Health's primary health care program showed malnutrition: 18.2% mild, 2.6% moderate, and 0.17% severe.
Other assessments made on the basis of height-for-age among 7-year-olds, indicated that the proportion exhibiting growth retardation had decreased from 20.4% in 1979 to 9.2% in 1989. The children who are malnourished belong to families whose principal source of income is agriculture, and children living in rural areas are the most severely affected.
A nutrition survey in 1982 found that 10% of children under 6 years of age were obese. In 1990, 3.2% of the population in this age group covered by the primary health care program was found to be overweight. Among adults a study using data from 1982 showed the prevalence of obesity to be 31.5% overall, with a higher proportion in urban areas (38.5%) than in rural areas (28.2%). Obesity was more frequent among women (40%) than men (22%), and increased markedly with age among persons of both sexes. In the population under 35 years of age the prevalence was 32% among females and 14% among males, while in the population over 35 it was 51% among females and 30% among males. Another study indicated that the prevalence of obesity was 14.4% and 33.3% among rural males and females, respectively, and 20.7% and 39.2% among urban males and females.
The prevalence of diabetes mellitus in persons age 15 and over was 4.2%; however, in persons age 60 and over a study conducted in 1986-1987 found the frequency to be 13.9% overall, 15.8% among women, and 11.5% among men. Diabetes accounted for 2.3% of outpatient visits by women to CCSS establishments and 1.6% of visits by men. Among patients over the age of 44, the proportion of visits due to this disease increased to 5% for both sexes, and for those over 59 years of age, it increased to 8.2% for women and 6% for men. The death rate from diabetes in 1985 was 0.7 per 10,000 population, but it climbed to 1.0 per 10,000 in 1991, and diabetes ranked 16th among all defined causes of death.
Diseases of the circulatory system are the leading cause of death in Costa Rica. Since 1975 the death rate from this cause has fluctuated between 10.3 and 11.2 per 10,000 population. In 1991 cardiovascular diseases were responsible for 29% of all deaths. The leading causes within the group of circulatory diseases were acute myocardial infarction, atherosclerosis, ischemic heart disease, and cerebrovascular disease.
Malignant neoplasms are the second leading cause of death. Since 1975 they have accounted for 20% of total mortality. The cancer death rate rose from 6.6 per 10,000 population in 1970 to 7.6 in 1991, and was higher among persons older than 45 years of age. Among males, the most common sites of malignancy were the stomach, with rates of 26.1 per 100,000 males in 1975 and 24.8 in 1991; prostate, with rates of 4.9 per 100,000 males in 1975 and 9.0 in 1991; trachea, bronchus, and lung, with rates of 6.4 per 100,000 population in 1975 and 7.8 in 1991; and liver and bile ducts, with a rate of 4.4 per 100,000 population (in 1975 this type of cancer ranked 14th among causes of death, with a rate of 1.4 per 100,000).
Among females, stomach cancer was the most common type, with a rate of 13.4 per 100,000 females in 1975 and 13.8 in 1991. The second most common type was cancer of the uterine cervix, which in 1975 was the third leading cause of death among women. The mortality rate from this cancer increased from 5.5 per 100,000 women in 1975 to 8.1 in 1991. Third was breast cancer, which moved from second place among the leading causes of female death in 1975, with a rate of 5.7 per 100,000 women, to third place in 1991, with a rate of 6.7. The fourth most common site of malignancy was the pancreas, with a rate of 4.3 per 100,000 women.
In 1990 malignant neoplasms accounted for 3.6% of all CCSS hospital discharges.
Accidents and Violence
The group of causes comprising accidents, injuries, and poisoning is the third leading cause of death among the 17 major cause groups and was responsible for 4.4 deaths per 10,000 population in 1990. Deaths from transport accidents in 1990 made up 32% of total mortality from external causes. The most affected age groups were those 45 years and over, 35 to 39, and 20 to 34, among whom the rates were 30.3, 20.3, and 19.1 per 100,000 population, respectively. More males than females died in each of these age groups. Among all types of transport accidents, the leading cause of death was motor vehicle collisions with pedestrians.
In 1990 mortality from suicide accounted for 12% of total mortality from external causes. The 60-and-over age group was the most affected, with a rate of 9.8 per 100,000, followed by the 20 to 44 age group, with a rate of 9.2 per 100,000. Mortality from homicide constituted 10% of total mortality from external causes in 1990. Of the homicides investigated by the Judicial Investigation Agency in 1990, 18% were the result of conflicts between individuals, 16.5% resulted from fights, and 15.8% stemmed from robbery or assault.
Injuries, fractures, poisoning, and other external causes accounted for 6.4% of all CCSS hospital discharges in 1990.
Alcoholism, Smoking, and Drug Dependence
The prevalence of smoking among the population age 18 years and over is 22.3%. The prevalence is higher among males (33.8%) than females (11.2%) in all age groups. Male smokers also smoke more cigarettes per day. Fifty-four percent of males and 84.7% of females have never smoked, and 12.2% of males and 4.1% of females are ax-smokers. In 1984 the prevalence of smoking in the adolescent population was estimated at 12.7% (17.0% among males and 9.6% among females). Among those under the age of 15 the prevalence was 9.6% and among those aged 15 to 20 it was 14.9%.
The prevalence of alcohol consumption is 57% (10% of those who drink are excessive drinkers and 5% are alcoholics). The problem is greater among men than women. Drinking begins at very early ages: 10% of drinkers started drinking by 12 years of aye, 26% by 15, and 46% by 18. Of the excessive drinkers and alcoholics, 80% and 59%, respectively, are between 15 and 34 years of age. In 1992 an increase in alcohol consumption among women was noted, with a 27% rise in moderate drinking and an 11.1 % increase in excessive drinking in relation to 1980 levels.
In regard to the use of psychotropic drugs, 37 million doses of benzodiazopines were prescribed in 1990. It is estimated that 7.6% of persons aged 12 and over regularly take hypnotics, 6.9% take tranquilizers, and 5.1% take stimulants. In addition, 1.6% of this population uses marijuana and 0.5% uses cocaine.
Mental and Behavioral Disorders
In 1987 mental and behavioral disorders accounted for 6.3% of all outpatient visits to CCSS institutions; neurotic disorders were the leading cause for both sexes (3.2% among females and 2% in males), especially for those over the age of 20. In the population ages 20 to 59 years, neurotic disorders were the third leading reason for outpatient visits among women (4.1%) and the fifth among men (3.5%). In the group age 60 and over, these disorders were the fourth leading cause among women (3.6%) and the seventh among men (9.8%). In 1990 psychoses, neurotic disorders, drug abuse, and other mental disorders accounted for 3% of hospital discharges. Such disorders were the sixth leading cause of hospitalization (1.9%) in the group ages 20 to 44, the fourth (4.2%) in the group ages 45 to 50, and the 12th (2.6%) in the group age 60 and over.
In 1991 the DMF (decayed, missing, filled teeth) index among children under 12 years of age was 8.4, which is a reduction from the figure of 9.1 reported in 1984. The problem is most severe in the provinces of LimGuanacaste, and Puntarenas. Periodontal disease becomes more common at advanced ages.
Risks in the Physical Environment
Costa Rica has experienced increases in the accumulation of solid wastes, air pollution (caused mainly by motor vehicles), and contamination of water by chemical substances.
In 1990, according to the Costa Rican Institute of Water and Sewerage Systems (ICAA), 92.8% of the population countrywide was being supplied with water; nevertheless, in many communities the quality of the water is not optimum for human consumption. The ICAA reported that national coverage for collection and sanitary disposal of wastewater was 39%. Solid waste collection reaches only 46% of the population, and it is estimated that only 30% of the total amount collected is disposed of properly. The San Josetropolitan area has one sanitary landfill, which is not satisfactorily managed.
Risks in the Work Environment
The number of pesticide poisonings in Costa Rica increased from 193 cases in 1987 (6.9 per 100,000 population) to 293 cases in 1990 (9.7 per 100,000). Information from the Ministry of Health indicates that 64% of the banana plantations studied did not have suitable systems for managing agrochemicals and 82% lacked adequate procedures for handling contaminated liquid wastes.
Natural Disasters and Industrial Accidents
Hurricane Joan, which skirted the Atlantic coast on 23 October 1988, caused serious flooding and cut off communication with several communities. The storm caused 21 deaths and left more than 7,500 persons homeless, in addition to destroying road systems. The most serious consequence of hurricane Joan was the economic damage it caused through destruction of crops and livestock in the affected areas.
An earthquake occurred on 22 December 1990, affecting primarily the province of Alajuela. Although many homes and buildings in the area were damaged, only one person died. Another earthquake occurred on 16 February 1991 in the Central Valley, destroying approximately 35 homes and causing moderate damage to 15 and slight damage to 66. The earthquake of 22 April 1991 in the province of Limas one of the strongest ever to have occurred in Costa Rica. It caused tremendous infrastructure damage to the port of Limnd to road systems in the Caribbean region. Some damage was also reported in the provinces of San Josnd Cartago. Forty-eight people died and 561 were injured as a result of this earthquake, and another 6,841 sustained earthquake-related damages. A total of 2,894 homes were destroyed and 4,427 were damaged.
Contamination of Food
The most common type of foodborne disease is poisoning by Staphylococcus aureus, followed by shigellosis and salmonellosis. The reported incidence of staphylococcal food poisoning was 7.7 per 100,000 population in 1987 and 18.2 in 1990. The incidence of shigellosis was 1.6 per 100,000 in 1987 and 6.4 in 1990, and that of salmonellosis was 1.8 per 100,000 in 1987 and 3.4 in 1990.
A study conducted over the period 1985 to 1988 demonstrated the presence of aflatoxins in white corn; more than 50% of the samples analyzed showed levels ³20 parts per million.
Together, the CCSS and the Ministry of Health employ close to 90% of the human resources in the health sector. In 1991 the CCSS had 25,599 health employees, (approximately 75% of the resources of the sector), and the Ministry had 5,718, for a total of 31,317 (10.3 per 10,000 population). Of these workers, 2,759 were physicians (9 per 10,000 population), 339 were dentists (1.1 per 10,000 population), 397 were microbiologists (1.29 per 10,000 population), 221 were pharmacists (0.72 per 10,000 population), and 1,630 were professional nurses (5.28 per 10,000).
In 1990 the ICAA had 3,100 employees, and the INS had 58 workers engaged directly in health-related activities (2.5% of its total staff).
The human resources in all areas, in terms of rates per 10,000 population, increased between 1970 and 1987. Approximately 49% of the health sector work force carries out activities related to personal health care and environmental protection. The rest perform administrative or general service duties. Although two-thirds of the work force is concentrated in the Central region - where the central offices, the principal medical centers, and a large proportion of the population are located - only one-tenth of these persons are engaged in central-level administrative activities.
The three cooperatives in existence in 1993 - which provided services under contract to the CCSS and the Ministry of Health - had a total work force of about 350.
Training for health personnel is provided by several public and private institutions, which are either part of a university or linked to one, especially the University of Costa Rica. Each institution in the sector has responsibility for the continuing education and training of its personnel. The CCSS, in particular, provides such training through the Center for Strategic Development and information on Health and Social Security.
The country has never had coordinated programs and policies with regard to human resources development, which has led to imbalances between the quantity, type, and distribution of available resources, on the one hand, and the health needs of the population and the programs carried out to address them, on the other.
In 1989 there were 3,179 students enrolled in university programs in the health sciences: 70.6% at the University of Costa Rica, 9.2% at other public institutions, and 20.2% at private universities. The University of Costa Rica established a graduate degree program in public health in 1989.
During 1990 public spending on health represented 7.8% of the GDP. Spending remained at around this level throughout the period 1988-1992. The revenues of health sector institutions in 1990 amounted to US$ 378.98 million, while spending by these institutions totaled US$ 385.78 million; spending by the Ministry of Health and the CCSS accounted for 87% of the US$ 6.80 million deficit.
The breakdown of health spending by the various sector institutions was as follows: Ministry of Health, 10.8%; CCSS, 72%; IAFA, 0.5%; INCIENSA, 0.3%; ICAA, 8.1%; and INS, 8.3%. Most (69%) of the revenues of the health sector come from employer-employee contributions to the social security system and workers' insurance plan, 7% from funds allocated under the national budges, 8.7% from fees charged for goods and cervices, 4.7% from the Fund for Social Development and Family Allowances, and 11.6% from the proceeds of lotteries and other sources.
Hospital services account for 34% of total spending (54% of CCSS spending), CCSS outpatient services for 27%, and Ministry of Health programs for 10%. Services provided by other sector institutions account for the remainder.
According to a survey carried out in 1987 and 1988 by the Department of Statistics and Censuses, private spending on health amounted to US$ 77.20 million in 1988, which is equal to 23% of the amount spent by the Ministry of Health and the CCSS that year.
In 1992 the Ministry of Health had 61 health centers and 379 health posts. In addition, it provided services jointly with the CCSS in 60 establishments (1 regional hospital, 4 peripheral hospitals, and 55 clinics), making a total of 500 health centers and posts wholly or partially under Ministry responsibility. The resources of the Ministry of Health also include 64 school dental clinics, 24 mobile medical unite, 59 mobile dental units, 462 health education and nutrition centers (CEN), 62 health education and nutrition centers and school cafeterias (CENCE), and 44 comprehensive child health and nutrition centers (CINAI).
The CCSS operates 29 hospitals (9 national, 7 regional, and 13 peripheral) and 141 outpatient clinics, 2 of which are administered by health cooperatives. In addition, it provides outpatient services at 2 health centers and 2 health posts of the Ministry of Health (joint health centers). CCSS resources also include 21 community health posts or clinics, which operate out of their own facilities or out of facilities owned by the community or by a health cooperative.
According to data from 1989, the Ministry of Health had 40 beds in rural health centers, 50 at the INCIENSA, and 127 at the IAFA. In 1991 the CCSS had 6,382 beds (20.6 per 10,000 population); 66.4% were in the national hospitals, 18.6% were in the 7 regional hospitals, and 15.0% were in the 13 peripheral hospitals. Of the total number of beds available, 27% (5.5 per 10,000) are designated for chronically ill patients and the rest for acutely ill patients. There are 742 pediatric beds, 47% of which are at the National Children's Hospital.
In 1991 there were 289,316 hospital discharges. The bed occupancy rate was 78.2%, the average hospital stay was 6.1 days, and the bed turnover rate was 45.4. As for outpatient services, productivity was 3.8 medical consultations per contracted hour (1,573,309 hours), 2.4 dental consultations per contracted hour (267,414 hours), and 2.1 consultations per contracted hour for other professionals (101,665 hours). The number of both hospital discharges and outpatient services remained more or less constant during the period 1989-1990.
The Ministry of Health/CCSS network of services in 1992 included 119 clinical and 16 specialized laboratories, 175 pharmacies, 45 diagnostic imaging facilities (3 with CAT scan equipment), and 27 blood banks associated with the laboratories of the hospital network and with the National Blood Bank, which is operated jointly with the Red Cross.
In the public sector, infrastructure for the production of drugs and biologicals is limited. Only the CCSS has any facilities, and they consist of one small laboratory that makes pharmaceutical products, one that produces parenteral solutions, and another that makes chemical reagents.
The INS operates one temporary shelter and health center, one central clinic that provides outpatient services, and 16 small dispensaries located strategically throughout the country. It contracts out the bulk of the services it offers to CCSS and to private clinics and physicians.
In 1991 the ICAA operated 118 water systems. It has five regional offices and several local agencies.
The private health care sector is not extensive. As of early 1992 it included only four small private clinics with a total of 155 hospital beds; 352 pharmacies; 195 clinical laboratories; and 25 diagnostic imaging facilities (one with CAT scan equipment). The sector also includes a large number of private physicians and dentists and a small number of rehabilitation clinics and dental, pathology, and cytology laboratories distributed throughout the country. However, no records or reliable data are available on the size of this private network.
The country has 26 private laboratories or companies engaged in the manufacture of pharmaceutical products; 20 are domestically owned and six are run by multinational firms. Two of the latter are located in trade areas and process products for export.
PAHO. 1994. Health conditions in the Americas, Volume II. PAHO, Washington, DC, 140-152.
The Nutrition and Health Transition of Democratic Costa Rica
The remarkable improvement in health and nutrition statistics in Costa Rica from those of a developing country to a rate characteristic of industrialized countries in a single decade in the 1970s is without precedent. This book, written mainly by Costa Rican health officials intimately involved in this health revolution, explores what was accomplished, how it was done, and why it was done. It describes the astonishingly wide range of social initiatives taken by the governments of the 1970s. It is intended as a reference text for students of public health and social medicine and as a stimulus to persons everywhere responsible for health and policy planning. It is a uniquely and authoritative and readable summary of a successful health and demographic transition by a poor developing country in advance of and contributing to its economic development.
International Nutrition Foundation for Developing Countries
Charles Street Station, P.O. Box 500
Boston, MA 02114-0500 USA
Telephone (617) 227-8747
Fax (617) 227-9405
Telex 650 3978146 MCI UW