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The decade of the 1970s

During this period, the evolution of the health situation in Costa Rica took on special characteristics. The health improvements were much greater than would have been predicted based on previous trends and the growth of the national economy. Mortality declined among all age groups, but the decline was particularly strong among children. As a result, the process of the epidemiological transition accelerated. There was a spectacular absolute and proportional decline in mortality associated with infections and parasites and a proportional increase in diseases of adults and the elderly. Cardiovascular diseases and cancer became the two leading causes of death, followed by accidental and violent deaths.

The Indicators That Were More Affected

In contrast with the previous period, infant morality declined more than overall mortality, and neonatal mortality became the largest component of infant mortality. The proportion of mortality, among people aged 50 years or older increased substantially, and life expectancy at birth increased to 73 years by 1975-1980. The incidence of preventable communicable diseases decreased dramatically, and there have been no reports of polio in the country since 1974 or diphtheria since 1977. With these achievements, most of the goals proposed in the initiative "Health for All by the Year 2000" were achieved 20 years before the deadline. The behavior of the main health indicators during this period is analyzed in the following sections.

Overall Mortality

Overall mortality declined from 6.6 to 4.1/1,000. In addition to the reduction in mortality rates, the principal causes of mortality also changed. While infectious and parasitic diseases moved from second to eighth place, cardiovascular diseases and cancer became the first and second causes of death, respectively. Prematurity and some diseases of early infancy moved up to fourth place, and birth anomalies occupied fifth place. Among the first five specific causes of death, mortality due to diarrhea moved from second to seventh place and pneumonia and bronchopneumonia from fourth to fifth place.

Infant Mortality

Infant mortality declined during the decade from 61.5 to 19.1/1,000 live births. The rate of decline was 7.7% per year in the first half of the decade and 9.9% in the second half, a spectacular decline when compared with the 1.1% decline during the previous decade.

A comparison of the infant mortality trends between 1930 and 1980 in Costa Rica with those observed in developed nations (an average of Denmark, Norway, Holland, Sweden, France, England and Wales, and the United States) shows that by 1930 the more advanced nations had already reached the rate of 63/1,000 that was found in Costa Rica in 1970 (Figure 1). The decrease from this rate to 18 per 1,000 in the developed countries required more than three decades, this same reduction took place in Costa Rica in less than 10 years. This illustrates the enormous speed at which the infant mortality rate declined in Costa Rica as a result of the policies and programs adopted in 1972.

This reduction had a much greater effect on postneonatal mortality, which declined during the decade from 36.3 to 7.9/1,000 live births (an annual decline of 7.8%). By contrast, neonatal mortality declined from 25.2 to 11.2/1,000 (an annual decline of 5.6%), as shown in Figure 2.

Taking into account that these indicators represent national averages and that there are wide variations among counties with respect to quality of life, it is important to study the infant mortality patterns at the county level, where this information is available using triennial rates, to avoid biasing the results due to the low number of births and deaths in a small population. Table 1 presents the 1972-1988 patterns. This table as well as Figure 3 shows that during this period there was a decrease in infant mortality in counties throughout the country, which is a reflection of the efforts that made to achieve a greater equity in the provision of health services.

During 1972-1974, the national average infant mortality rate was 44/1,000, with a range of 20 to 69.9/1,000 in 85% of the counties. Ten percent of the counties that had a lower quality of life had an infant mortality rate of 70/1,000. Between 1975 and 1977, the national average was 32.8/1,000 and the spread of the range narrowed. The range in 85% of the counties was 10 to 49.9/1,000, and only 6.4% of them had a rate of 50/1,000 or more. Finally, between 1980 and 1982, the national average was 19.5/1,000, with 96.4% of the counties falling between 10 and 29.9/1,000 and only 2.4/1,000 with 30/1,000 or more.

In this decade, birth anomalies, immaturity and certain diseases of early infancy became the leading causes of death among this age group. Among the main specific causes of death, gastroenteritis and colitis moved from first to fifth place, representing a reduction from 16.7 to 1.4/1,000.

Mortality Among Children One to Four Years Old

Child mortality among one- to four-year-olds declined rapidly from 5.1 to 1.0/1,000 between 1970 and 1980. The annual rate of reduction increased from 4.7% during the last five years of the previous decade to 11.8% during the first half of the 1970s. Among one- to four-year-old children, accidents and violence became the leading causes of death, accounting for 20% of deaths in this age group compared to 5.5% before this period.

TABLE 1. Infant Mortality Rates in the Counties of Costa Rica

Source: Anuarios y tabulaciones de la Dirección General de Estadística y Censos y del Departmento de Estadístuca de la Unidad Sectorial de Planificación del Ministerio de Salud.

Birth anomalies moved from the eleventh to the fourth leading cause of death as the mortality rate from birth anomalies increased from 0.4 to 1.1/10,000. Among the main specific causes of death, gastroenteritis and colitis moved from first to fifth place, representing a reduction from 11.9 to 0.74/10,000.

Mortality Among Children Under Five

Between 1970 and 1980, the percentage of overall mortality due to mortality among children under five declined from 41 % to 17% at the same time that its rate declined 32.5% during the first half and 37.7% during the second half of the decade. Figure 4 shows the steepness of the slope when compared with the trends in the previous decades.

Infectious and Parasitic Diseases

The decline in deaths attributed to infectious and parasitic diseases was so dramatic that it represented a 92% reduction (from 13.6 to 1. 5/10,000). The proportion of total deaths explained by these diseases declined from 20.5% to only 3%. Among the infectious and parasitic diseases that were particularly important at the beginning of the decade were septicemia, tetanus, tuberculosis, ascaris, and diarrheal diseases. The latter declined from 7.0 to 0.5/10,000 and moved from second to seventh place in the ranking of causes of death. The proportion of total deaths explained by these diseases declined from 10.5% to 1.2%.

The improvements in record-keeping of diseases that by law had to be reported by the end of the 1960s, in addition to the implementation of an epidemiological surveillance system at the beginning of the 1970s, allow an assessment of the notable reduction that took place in the vaccine-preventable diseases. The rate of measles declined from 262.5 to 44.5/100,000 between 1970 and 1980. During the same period, the rate of pertussis (whooping cough) declined from 74.4 to 39.3/100,000 and the rate of tetanus from 4.9 to 0.1/100,000. The rate of tuberculosis also declined from 28.6 to 19.6/100,000. Polio and diphtheria were eliminated by immunization during this period. Morbidity that could be prevented through improvements in basic sanitation also declined substantially. The rates of typhoid went from 3.6 to 0.2/100,000, paratyphoid from 0.5 to 0.2/100,000, salmonellosis from 13.4 to 0.9/100,000, and shigellosis from 18.4 to 0.2/100,000.

Mortality-Among Children 5 to 14 Years Old

Mortality rates among 5- to 14-year-old children also declined substantially from 9.0/10,000 in 1970 to 4.6/10,000 in 1980. The annual rate of reduction in mortality in this group increased from 0.4% in the previous five years to 7.5% during the first half of this decade.

During this period, the rate of diarrheal diseases declined from 7 to 0.1/1,000 and moved from second to twelfth place in the ranking of causes of death, and measles showed a similar pattern. By contrast, malignant tumors moved from fifth to second place and birch anomalies from seventeenth to fifth place. Accidents and violence remained the leading causes of death, increasing from 1.6 to 2.0/10,000 and also causing a larger proportion of deaths (from 16.9% to 42.5%).

Mortality Among the Population 15 to 49 Years Old

Mortality rates among the 15- to 49-year-old population also decreased, although to a lesser extent than infant and child mortality, from 20/10,000 in 1970 to 15.1/10,000 in 1980. For this age group, accidents and violence were the main causes, but chronic degenerative diseases were also a major cause of death. Ischemic heart disease moved from fourth to second place as a cause of death, and cerebrovascular disease moved from fifth co third. Mortality from suicide and self-inflicted injuries moved from twelfth to sixth place.

Mortality Among the Population 50 or More Years Old

Although mortality among chose aged 50 years and older declined from 28.7/1,000 in 1970 to 22.6/1,000 in 1980, the proportion of deaths in the total population attributed to this age group increased from 41.8% to 61.4%. The causes of death in this age group were similar to those of the 15- to 49-year-old group, with a predominance of chronic degenerative diseases. Pneumonia and bronchopneumonia moved from fourth to sixth place, and their rate declined from 2.0 to 0.9/1,000.

Nutritional Status Patterns

Nutritional surveys conducted in the country between 1966 and 1975 showed a small decline in the proportion of malnourished children younger than six years. The proportion declined from 57.4% to 53.2%, and (using the Gómez classification)¹ the proportion of children with degrees II and III malnutrition declined from 13.7% to 12.3%. However, a survey conducted only three years later (i.e., in 1978) showed reduced rates of 45% for malnourished children and 8.7% for children with degrees II and III malnutrition. Four years later, in 1982, a new survey recorded a rate of overall malnutrition of 34.2% and a rate of 3.6% for children with degrees II and III malnutrition. This survey also showed that 88.7% of the children younger than six years had an adequate weight for height.

¹ Degree 175-90%, degree II 60-75%, degree III < 60% of normal weight for age.

In 1966, the prevalence of endemic goiter and retinol deficiency was 18% and 32%, respectively. During the 1970s, these two nutritional disorders were controlled to a point that they were no longer considered a public health problem.

Factors That Might Have Been Responsible for the Success

The economies of the Central American countries have grown at a steady pace since the 1950s. The prosperity of the export sector facilitated the mutual free trade of regional produces, which in turn favored an incense process of industrialization. The importance of the foreign trade sector grew during the following two decades. This sector began to change its structure by including among its exports a series of nontraditional produces and by expanding the imports of intermediary produces as well as capital goods. The gross national produce (GNP) increased substantially, and a middle class emerged, in association with progressive urbanization, the increasing importance of secondary economic activities and the increased diversification of the productive sector. However, the new economic and social classes simply replaced the previous ones through a process of change and modernization thee did not threaten the existing economic structure (Sáenz, 1988).

During the 1970s, the situation in Costa Rica was similar to that in the rest of Central America. The GNP showed a substantial increment from US $ 656 to US $ 892, and government health expenditures increased from 5.1% to 7.6% of the GNP. However, the health improvements in Costa Rica during that decade were so impressive and so different from chose found in ocher Central American nations that economic factors alone cannot account for the dramatic improvement in health status.

Based on a model developed by the United Nations to study fecundity determinants, it is possible to establish, for different economic, social, and demographic indicators, the correspondence of the value of each indicator with a theoretical index of development that ranges from 0 to 100. Using this model with seven economic and three social indicators, Rosero (1985) estimated the proportion of infant mortality that could be attributed to each indicator in Costa Rica between 1950 and 1980. When comparing the expected with the observed rates, it is possible to observe a trend of improvement for both the observed infant mortality and the two sees of expected indicators. This trend, however, changes sharply in 1970 because the improvements in infant mortality accelerate precipitously while the two sees of indicators continue to follow the past trend.

In view of the discrepancy between the patterns of health and the social and economic indicators in Costa Rica when compared with ocher countries in the region, it becomes important to assess the role of government in these positive health outcomes. This issue is summarized in the following discussion.

Health policy and a National Health Plan were developed at the beginning of the decade based on the concept of "narrowing the social differences" proposed in the National Development Plan. The outcomes of the National Health Plan were:

• Substantial changes in legislation and the structure of health services;

• Coverage in services provided by the Social Security Institute increased from 39% to 78% and included new economic groups and geographic areas;

• Large increments in coverage for services provided by the Ministry of Health that included new programs for the dispersed rural and disadvantaged urban populations. With the new coverage it was possible to reach 60% of the rural population, including 95% of the dispersed rural, and 40% of the urban population. The activities included health education and disease prevention through immunizations and sanitation;

• Development of extensive food supplementation programs for preschool and school-aged children and of food fortification programs for the prevention of specific nutritional deficiencies; and

• Financing of new programs and more investment of resources to broaden nutritional programs based on a new law for social development and family assistance that served as an instrument for the distribution of the nation's wealth by facilitating the participation of the socioeconomically deprived.

The large improvements in health observed during this decade, which were unexpected based on previous trends, coincided with the implementation of primary health care strategies, with emphasis on prevention and health education (Sáenz, 1985a), and the investment of increased resources thee targeted the most vulnerable subgroups.

At the beginning of this decade, the coverage of health services was very poor, and nutritional deficiencies and immunopreventable and sanitation-preventable diseases were very common. The response to these problems was a large increase in food and nutrition programs and a substantial increase in the coverage of health services. This was particularly true among the dispersed rural and the disadvantaged urban populations, where immunization coverage reached 80% and access to water supplies in the rural areas increased from 56% to 68% (the percentage of households with water within the household increased from 39% to 64%). Throughout this time, universal access to water in urban areas was sustained, and the percentage of households with adequate facilities for fecal disposal increased from 60% to 96% in urban areas and from 41% to 88% in rural areas (Sáenz, 1985b).

Once the response to the problems is understood, it is easier to understand the rapid decline in mortality, particularly among children under five years old: more than a 94% reduction in morbidity associated with immunopreventable diseases and with typhoid, paratyphoid, salmonellosis, and amoebic dysentery. In addition, it is possible to assert with confidence that, the health situation of a country can be improved much more than expected from the level of national economic growth by taking appropriate actions. In the case of Costa Rica, the government response, including the see of actions that culminated in the Health Policy and the National Plan, allowed for vase health improvements that went far beyond expectations based on the economic situation of the country. The case of Costa Rica in this period is a very good example of what can be achieved when there is political will to prioritize the protection of chose human beings who are more vulnerable and to base efforts on targeting the most important health problems with the available resources.

The decade of the 1980s

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.

Overall Mortality

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).

Infant Mortality

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.

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