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4. Evolution of an epidemiological profile

Stages of a process
The first four decades of the century
The period between 1940 and 1970
The decade of the 1970s
The decade of the 1980s
The last decade of the century
Final comments

Dr. Lenin Sáenz


Health has been a highly valued asset in the culture of Costa Rica, and throughout the twentieth century the government has paid an ever-increasing amount of attention to improving the health of the country. Government intervention in health was particularly successful during the 1970s, when health policies and strategies focused primarily on the protection of chose human groups that were more vulnerable and unprotected. During thee period, resources were used to solve the most vulnerable problems with the available technology. The outcomes of these actions were a substantial improvement of the public health and an accelerated process of epidemiological transition, under which the pathologies that characterize underdevelopment gave way to the diseases prevalent in industrialized nations in the absence of an equivalent economic growth. Under these conditions, mortality among youth declined substantially and shifted to older subgroups. This was accompanied by a decline in infectious diseases and an increase in chronic diseases, such as cardiovascular disease and cancer, and in accidental and violent deaths. These latter currently constitute about 60% of all deaths. In addition, the annual population growth rate, which in the 1960s was the second highest in the world at 4%, declined substantially to 2.5%. The fertility rate also declined and reached 119/1,000 coward the end of the 1980s. As a consequence of these changes, the population aged and the age structure was modified accordingly. Whereas the proportion of the population under 15 years of age declined from 45.7% at the beginning of the 1970s to 36.5% by the end of the 1980s, the proportion aged 50 years and older increased from 10% to 12% during the same period.

In order to have a better understanding of this transition and its acceleration during that decade, it is important to review the antecedents and the outstanding aspects of thee evolution. Although it would have been ideal to have morbidity data to make such an analysis, this is not possible, because the data for medical visits and hospital discharges are not easily obtained for the entire period and might not be sufficiently reliable. Even though the epidemiological surveillance systems that have been in place during the last two decades continuously provide information on those diseases that have to be reported routinely, similar information is not available for a considerable number of ocher diseases. For these reasons most of the statistics presented in this chapter are based on mortality estimates obtained from annual reports and internal documents from the Ministry of Health and from annual reports and other documents from the General Directorate of Census and Statistics. Even though during the first decades of this century there were problems with underreporting and the use of a different disease nomenclature that complicates their interpretation, birch and death records have been improving constantly; during the last four decades, their quality and coverage have been satisfactory, and they have been particularly reliable during the last three decades. An estimated 1% of births are recorded with a delay, 5% of deaths are not recorded or are recorded with a delay, and 71% of deaths are documented with a medical certificate. During the last 15 years, the proportion of reports with an improper definition of cause of death has declined substantially.

Since the beginning of this century, general and infant mortality estimates have allowed the evolution of these health phenomena to be documented and general conclusions to be reached regarding the possible impact of health policies and strategies. Throughout most of this century, infant mortality, which is one of the most sensitive indicators, has represented a very significant proportion of the total deaths.

Stages of a process

In order to facilitate the analysis of the events that have taken place in the area of health during this century, the author considers that it is convenient to divide them into several stages based on specific characteristics involving the behavior of health indicators as well as the socioeconomic situation and the response of the country institutions to what at the time were considered the most important health problems:

• In an initial stage, which covers the first four decades of this century, mortality rates were high and fluctuating, with a clear predominance of infectious and parasitic diseases among children under five years of age. The predominant health activities involved the creation and institutionalization of entities whose mission was to solve specific problems.

• A clear mortality decline can be observed between 1940 and 1970 at the same time that infectious and parasitic diseases continued to be prevalent. During this stage, health actions were based on the treatment approach.

• During the 1970s, a dramatic decline in mortality and morbidity due to infections and parasites can be observed in all age groups. During this stage, a cohesive see of policies and health strategies guided the activities following a broad preventive approach.

• During the 1980s, the country experienced the worst socioeconomic crisis, and the government reduced the resources allocated to the health sector. Whereas during the first half of the 1980s the rate of decline in mortality decreased, during the second half of the past decade a greater improvement in health indicators was observed coinciding with a resolution of the crisis, a modest increase in resource allocation and continuing decentralization of the health sector.

• The last decade of this century will be the final stage. The trends observed during the last decade allow for the prediction of the probable evolution of the health status and principal causes of death in all age groups and geographic regions, assuming that new factors do not cause a deviation from past trends.

The first four decades of the century

During the first four decades of this century, the health situation was characterized by high mortality rates among infants and the population as a whole and by an erratic behavior of these indicators. The overall mortality rate declined only from 24.0 to 17.1/1,000, an average annual rate of reduction of 0.7%. Mortality rates fluctuated widely, particularly during the first three decades, reaching as high as 28.7/1,000 in 1920 (Sáenz, 1990). It is noticeable thee the increase in mortality that took place between 1900 and 1920 (4.7/1,000) is higher than the total mortality rate recorded in the country during 1980 (4.1/1,000).

Infant mortality followed a similar pattern, characterized by an increase during the initial decades that reached 248 infant deaths per 1,000 live births in 1920. The reduction in infant mortality during this stage was only 0.8% per year. Traditionally, malnutrition and unsanitary environments have been associated with high mortality rates among children under five years old. During this stage, under-five child mortality was very high, and instead of declining, it increased from 47% to 52%. By contrast, the mortality among people aged 50 years or older was very low, because only 23% of the population reached this age. Nevertheless, life expectancy at birch increased from 35.1 years in 1910 to 46.9 years in 1940.

Mortality caused by infectious and parasitic diseases represented the main health problem, and these conditions accounted for 65% of all deaths in 1920. The behavior of this parameter was very erratic, and its rate fluctuated between 186.1 and 81.3/10,000, with an annual rate of reduction of only 0.6% between 1910 and 1940. Intestinal parasites, malaria, tuberculosis, and respiratory infections accounted for a large proportion of deaths during this period.

The national economy, which was very vulnerable at this stage, experienced a series of crises thee led to the fall of the liberal economic system and the economic impoverishment of the country, which affected the low-income groups more severely. The emerging middle class was unable to fulfill its expectations of improvements, many small-land workers lost their land, and the people who received a steady income either lost their jobs or experienced a net reduction in their salaries (Rosero, 1984). The educational level was very low, with an illiteracy rate of 54.8% at the beginning of this period that declined to 26.7% by the end.

Most health-related welfare activities were undertaken by the private sector and charity organizations. The government levied a "welfare tax" thee was used to finance existing hospitals that were run by organizations formed by community leaders; these organizations in face acted with a great deal of autonomy. In addition, several counties in the country had health centers thee provided poor people with medical care and preventive services for the control of epidemics.

Preventive health policy was oriented coward legislation and the creation of organizations for the resolution of specific problems. This process culminated in 1927 with the creation of the Ministry of Public Health and Social Protection.

The period between 1940 and 1970

Mortality decreased substantially between 1940 and 1970 (down from 17.1 to 6.6/1,000, during these 30 years, representing an average annual reduction rate of 2.1 %) than infant mortality (down from 132.4 to 61.5/1,000, representing an average annual reduction rate of 1.8%). The under-five mortality remained high but nevertheless decreased from 51.8% to 40.9%, while mortality among people aged 50 years and older increased from 22.9% to 41.6%. Life expectancy at birch increased from 46.9 years at the beginning of the period to 68.1 between 1965 and 1970.

Mortality caused by infections and parasites began to decline. Infectious and parasitic diseases accounted for 47.6% of coral deaths in 1940 and 20.5% in 1970. The prevalence of these diseases declined from 81.31 10,000 in 1940 to 13.6/10,000 in 1970, representing an annual reduction rate of 2.8%. Malaria declined so much thee by the end of this stage it was considered to be practically eradicated.

By contrast, motor vehicle accidents became an important cause of death. During this period, particularly during the 1950s, the economy grew in a sustained and substantial fashion and a new style of development was adopted. The government expanded its field of action and adopted policies that allowed it to provide a large number of jobs and to allocate a substantial amount of resources for the provision of public services. Illiteracy declined from 26.7% to 11.2%.

The enormous technological advances that took place throughout the world provided useful insecticides for the fight against several pathogen carriers, new vaccines for the prevention of some diseases and effective drugs for treating diseases, as well as new and better equipment for diagnosis and treatment. This period represents the beginning and rapid development of the era of antibiotics.

The government of Costa Rica defined a group of social policies. Among them, chose that led to the creation and expansion of the Social Security Institute deserve special mention. Health coverage was expanded with the construction of new hospitals and the replacement of the old hospitals that were incapable of satisfying the demand. A large variety of government, private, and volunteer health organizations remained, which were not adequately coordinated even though they received some funding from the government (Sáenz, 1983).

Even though the health policies were still based on the curative approach, as indicated by the face that 80% of the budget was allocated to hospital care, legislation was created to protect public health, new specialized entities were created for preventive health, and new organizations were created at the local level.

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