|The Nutrition and Health Transition of Democratic Costa Rica (International Nutrition Foundation for Developing Countries - INFDC, 1995, 228 pages)|
|4. Evolution of an epidemiological profile|
Evolution of the Situation
The pace of progress that occurred during the 1970s was interrupted during the 1980s, when the country was hit by the most severe economic crisis in its history. The mortality declines slowed down considerably in most age groups, eventually stagnating at the levels reached during the first five years and slightly improving during the second half of the decade. Since this pattern coincided with the crisis and its consequences, it is worthwhile dividing this period into halves to make a better assessment of the relationship between the health indicators and the national economy.
Even though overall mortality continued to decline, it declined at a slower rate than in the second half of the previous decade, and it reached 3.8/1,000 by 1989.
The distribution of causes of death remained basically the same. Cardiovascular diseases and cancerous tumors remained as the two leading causes of death. The proportion of deaths attributed to these conditions increased, and the proportion attributed to pneumonia and bronchopneumonia decreased.
Life expectancy at birch increased gradually and eventually reached 75 years in 1985-1990 compared with 76 in the United States in 1989-1991 (UNICEF, 1991, 1994).
The enormous average annual reduction in infant mortality observed during the second half of the previous decade decreased dramatically during the first half of the 1980s, from 9.9% to 1.6%, but increased again during the second half of this decade to 5.2%. Infant mortality declined from 19.1 to 13.9/1,000 during this decade. This deceleration had a greater effect on neonatal mortality, which was 11.2/1,000 throughout the first half of the decade and reached 8.8/1,000 by the end of the decade. Postneonatal mortality declined to 5.0/1,000 by the end of the decade, as shown in Figure 2.
The distribution of causes of infant death remained basically the same. Prematurity, certain diseases of early infancy, and birch anomalies remained the leading causes of death. Diarrheal diseases moved in the ranking from fourth to fifth place.
Mortality Among Children One to Four Years Old
Mortality among one- to four-year-old children declined from 10.1 to 7.4/10,000 during the first half and to 7.2/10,000 during the second half of the decade. In contrast to infant mortality, the rate of improvement declined in the second half of the decade.
Birth anomalies became a more important cause of death, reaching second place by the end of the decade, with a rate of 1.4/10,000. Violence and accidents remained the leading causes of death, and the proportion of deaths attributed to them increased from 19.8% to 23.6%.
Mortality Among Children Under Five
Child mortality declined from 17% in 1980 to 16% in 1985 and 12% in 1989. The average annual rate of reduction was only 1.2% during the first half, but it was 4.7% during the second half of the decade.
Infectious and Parasitic Diseases
The prevalence of infectious and parasitic diseases continued to decline from 1.7 to 0.9/10,000, and their impact on overall mortality declined. Diseases that were particularly important causes of death in the 1970s, such as diarrhea, tetanus, septicemia, and tuberculosis, continued to decline, although at a much slower pace.
Morbidity resulting from immunopreventable diseases continued to decline throughout the decade. In 1990, measles reached 2.7/100,000, pertussis 2.5/100,000, tuberculosis 1.7/100,000, and tetanus remained at 0.1/100,000. There were no polio or diphtheria cases reported during this decade. Meanwhile, morbidity that could be prevented by basic sanitation followed a more erratic pattern. Typhoid showed a moderate increase during the first half until it reached 0.6/100,000 in 1986, but declined to 0.3/100,000 in 1990. Paratyphoid remained at 0.2/100,000 during the first half, but no cases were recorded during the following four years. Salmonellosis remained at 3.4/100,000 during the first half but later declined until it reached 0.9/100,000 in 1990. Shigellosis followed an increasing trend and reached 2.4/100,000 in 1986 and 6.4/100,000 in 1990.
Mortality Among Children 5 to 14 Years Old
Mortality changes among 5- to 14-year-old children during this decade contrasted with chose in the previous decade. During the first half of the decade, the average annual rate of decrease in mortality accelerated from 3.6% to 7%. Mortality in this age group reached a rate of 3/10,000 and remained almost constant during the second half of the decade, as shown in Figure 5.
Two important changes in the structure of the causes of mortality were the absence of deaths attributed to measles in 1988 and 1989 and the reduction in the diarrheal disease rate, which shifted from third to ninth place. By contrast, congenital disorders moved from seventeenth to fourth place. Although the rates of accidents and malignant tumors decreased, the proportion of deaths attributed to them increased.
Mortality Among the Population 15 to 49 Years Old
Mortality among the 15- to 49-year-old population steadily declined throughout the decade. The decline was faster during the first five years, when mortality reached 12.2/1,000, than during the second five years, when it reached 11.8/1,000.
Along with accidents, which, as in the previous decade, were the leading cause of death, chronic degenerative diseases became strongly predominant during this decade. Ischemic heart disease remained in second place; cerebrovascular diseases were displaced from third to fourth place by stomach cancer. Meanwhile, suicides and self-inflicted injuries moved up to fifth place in the ranking as coral mortality declined.
Mortality Among the Population 50 or More Years Old
The mortality rate among the population 50 and older ranged only between 22.6 and 22.3/1,000, although the proportion of deaths represented by this age group increased from 61.4% to 70. 1%. The main causes of death were chronic degenerative diseases, particularly cardiovascular disease and cancers, which occurred at increased rates, while pneumonia and bronchopneumonia became less important as causes of death.
Factors That Affected the Situation
Some have cried to explain the deceleration in improvements in health indicators by the difficulty of increasing even more the vase improvements in health that had already been achieved. This explanation, however, might not be valid, since some industrialized countries have achieved even better health outcomes and the health indicators. Therefore, it is important to look for another explanation.
The model of economic development of the Central American countries stagnated during the 1970s. The favorable economic trends deteriorated due to the serious repercussions of the economic crisis not only on the economy but also on the social and political structures. Within this context, at the beginning of the 1980s, Costa Rica suffered the full impact of the economic crisis. The steady growth of the GNP deteriorated dramatically between 1980 and 1982. Real production declined 9.1 %; the national currency was devalued; prices increased 179.5%; overt unemployment reached 9.4%; real wages declined 40%; the proportion of poor families increased 53% in both urban and rural areas; the cost of essential foods increased more than income, and in 1982 they cost more than the average wage. Foreign debt, which was 114.5% of the GNP in 1982, exceeded the country's resources to pay for it, and the interest payments on this debt represented more than 50% of the value of exports of goods and services.
To restore economic stability, the government increased taxes and limited the expansion of public expenditures. This caused a net reduction in constant colones in health investments, which declined from 7.6% of the GNP in 1980 to 5.7% in 1983.
The significant decline in the rate of improvement in health indicators coincided with the negative influence of the social and economic deterioration. Furthermore, the reduction in per capita health expenditures forced the government to reduce its efforts to improve the health situation in the country. This reduction in investment, together with the drop in per capita national income, coincided with a slowdown in the pace at which infant and child morality was improving. Nevertheless, this slowdown in health improvement was not as severe as would be expected based on the socioeconomic crisis. Figure 6 shows how the drop in income per capita coincided with an interruption in the rate of decline in infant mortality.
Mortality patterns among subjects 5 to 14 years of age were unexpected, because there was an acceleration in the pace of improvement during the first half of the decade, when the economic crisis was most severe, and a deceleration in these improvements during the second half, when the crisis was becoming less severe. A possible explanation for these findings is that there were two cohorts that reached the 5- to 14-year-old group between 1980 and 1985 and benefited during the previous decade from programs that reduced their risks of morbidity and mortality. A cohort thee suffered the impact of the crisis during the previous five years reached this age group in 1985.