Thursday, October 30, 2008

This Just In - Brrrrr!

The news from Costa Rica today is "Cold Spell for the next 2 Days"

Just what is "cold" anyway? For folks in San José, cold = a high of 22 degrees Celsius (71.6 F)

Consider that "normal" highs for late October (the rainiest and coldest month) are 26-28 C (79 - 82.5 F).

I remember our homestay hostess in Sámara saying that San José was coooold - she showed us a sheepskin jacket she had just for SJ trips. This was told to us in February, in the middle of a 90+ F day...

Wednesday, October 29, 2008

Another Reason to Love Costa Rica

Do we *really* need another reason to love Costa Rica?

Well, why not? We have so many *big* reasons, how 'bout a smallish one :-D

Costa Rica does not change their clocks twice a year to accommodate daylight savings time! Of course, it makes sense not to, as the country lies just 10 degrees North of the equator. Sunrise and sunset pretty much happen at the same time year-round. Why mess with perfection?

I've always detested one thing about spring in the states - losing that hour of sleep when we change the clocks. Now there's a new reason to be wary. A new study reports that heart-attack risks go way up for the three business days following the spring "sleep deprivation." It is more pronounced for women, and for people under 65.

Pura Vida!

Saturday, October 18, 2008

Serious About Soccer...

There can be no doubt about it - Costa Rica is serious about their soccer! When it comes up against political corruption, soccer gets the action.

Earlier this year, Costa Rica broke with Taiwan, and officially supported China instead. China has been using its financial muscle to pull other counties to its side in its fight to stop Taiwan from being recognized as a separate country - China still claims Taiwan as part of its republic. Costa Rica succumbed after decades of supporting Taiwan. There was a lot of under the table action going on - money going this way and that.

Specifically, China bought bonds that were used to replace the soccer stadium in San Jose. This is the Saprissas' home stadium, and this is the team that most often represents Costa Rica in international tournaments. So, a lot is at stake. The old stadium was torn down in May, and construction on the new stadium was to begin in November.

Earlier this month, the scandal hit the fan - the public found out about the table. Politicians were embarrassed, and a suit went to the constitutional court to stop the construction. The court ordered a stop while they reviewed the suit. This is when soccer fans said "whoa! wait a minute! We went from an old stadium to a hole in the ground! We need our soccer!" (ok, technically, they said "futbol") There were marches. There were news articles. There were phone calls...

Then the constitutional court broke a record (well, maybe - I don't really know if they did, but this was *fast*). What usually takes 3 months, took less than 2 weeks. The court voted *unanimously* to continue construction!

Costa Rican soccer wins the day!

Tuesday, October 7, 2008

Hot Water? Only in the Shower...

A lot of people are surprised when they come to Costa Rica and find that the only hot water is in the shower. This can require some mental adjustments, especially if you are used to washing clothes and dishes in hot water. Most people's first thought is "gross!" how do you get anything clean!?

For me, washing clothes in cold water is nothing new - we did it this way my entire life. It saves energy, and doesn't make much difference in the cleanliness.

Dishwashing was an entirely different story though. It took me a while to get over that icky feeling of washing dirty dishes in cold water. True, the soap in Costa Rica is specially formulated for cold water, and the dishes *look* clean, but what about germs? Could 4 million Costa Ricans be wrong? Well, guess what I just found - a study :D.

The FDA recommends washing dishes in 110 degree F soapy water, rinsing, then soaking in sanitizer. Ohio State University researchers added bacteria to dishes with dried-on food, and found that these dishes washed in soapy room-temperature water, rinsed, and then weakly sanitized with ammonium-based chemicals achieved FDA-acceptable results.

However, dishes that were especially difficult to get clean were forks, because food stuck to the tines. Also, milk-coated glasses hung onto the bacteria more than any other food.

Recommendations from the study were to
1) spend extra cleaning time on forks
2) wash dishes right away before food dries - this saves washing time and gets rid of problematic places where bacteria might be able to survive washing and drying

My added recommendation is to rinse and/or soak dishes if you can't wash right away - this keeps the food from drying on the dishes.

Of course, some people go whole hog and get a hot-water heater connected to a dishwasher...

Sunday, October 5, 2008

Comparing Medical Care for Pain and End-Of-Life

I just saw a report that graded the United States on how we are doing taking care of people when we are seriously ill and dying. There is a whole specialty in medicine for this, called Palliative Care. It focuses on relief of the pain and other symptoms of serious illness.

We are not doing too well. The entire United States earned a "C" and several states completely failed! This got me thinking - how is this graded? and how does it compare to other countries, specifically to Costa Rica?

Well, the grading website ( references the Journal of Palliative Medicine, which is only available by subscription, so I can't judge the methodology. But the summary of the methodology looks extremely tailored - it excludes small hospitals, facilities for psychiatric treatment, chronic care, rehabilitation, ENT, pediatrics, and federally controlled facilities. What's left? (Setting aside the nature of studies, even ones you could drive a truck through. Maybe that's too harsh? it is a professional journal, after all.) I looked at the results and looked for what I could compare. I came away with the fact that it is difficult enough to find consistency from state to state. There are no numbers or factors I could see that I could use to compare to another country.

So, I looked for a world report (, and found one from Help the Hospices and the National Hospice and Palliative Care Organization (NHPCO) from 2006.

This study looks like it is done every year. It categorizes countries around the world by their approach to palliative care.
The four groups are:
1) no known hospice-palliative care activity
2) capacity building activity (but no service yet)
3) countries with localized provision of hospice-palliative care, and
4) countries where hospice and palliative care activities are approaching integration with the wider health system. (defined further at the bottom of this post)

Both the USA and Costa Rica are in Group 4, and so are at the highest level defined. Now, if the USA is not doing too well, but it is at the highest level, it is clear that the world as a whole has a long row to hoe.

Here is a brief history of palliative care for each country:

In the USA, the Connecticut Hospice provided the first home care service for the dying in 1974. The forerunner of the National Hospice and Palliative care organization (NHPCO) was founded in 1978. Reimbursement for hospice patients through the Medicare program was enacted in 1983, and by 2005, NHPCO estimated that 1.2 million patients were being cared for nationwide within hospice programs. To find a report for a specific state:

Costa Rica is a small country with an established health system committed to providing good quality care at a reasonable price to every citizen. With a government-sponsored network of 29 hospitals and more than 250 clinics throughout the country, the Caja Costarricense de Seguro Social (CCSS) has primary responsibility for providing low cost health services to its 4 million inhabitants. The Clinic for Pain and Palliative Care was established in the Calderón Guardia Hospital in the early 1990s and later became recognized as the National Center for Pain Control and Palliative Care (1999). A national pain control and palliative care policy was adopted in 2001.

The report compares several factors in evaluating the level of the country - Human Development Index, Crude Death Rates, Gross Domestic Product, and Ratio of services to population.

The human development index (HDI) gives a multiple measure of a country’s development, based on: longevity, knowledge, and standard of living. There is a strong association between palliative care and human development, as 83% of Group 4 countries have a high index (1-57), and another 14% with a medium index (58-145).
HDI rank / index:
Costa Rica = 47
USA = 10

2006 Crude Death Rates (CDR) are the total number of deaths per thousand persons which occur in the same year. These ranged from 3.7 to 13.4 among Group 4 countries. The correlation between CDR and palliative care is difficult to state, since the ranges for the groups overlap, and CDR is under-reported. However, the study states that the countries with the lowest CDR in Group 4 are distinctly lower than those in the other groups.
Costa Rica = 3.8
USA = 8.4

Gross domestic product (GDP) per capita is indicative of a country’s wealth; it is the market value of the total final output of goods and services produced in a country over a specific period. There appears to be no relationship between a country’s wealth (GDP per capita) and palliative care development, since high and low income countries are represented in each of the four groups of countries.

The comparison of the ratio of palliative care services to population, and rank in the Americas, shows little difference between the two, especially given the wide range around the world.
Costa Rica (ranked 5th) = 26 services => 166 per 1000
USA (ranked 4th) = 4000 services => 75 per 1000

Studies are interesting in that they try to level the playing field and give an objective look at an issue. These usually involve numbers and statistics. However, the cultural effect, especially on the field of medicine, is stripped. To balance this, think of the differences between a visit to your doctor in the states and to your doctor in Costa Rica. The Costa Rican doctor is trained (culturally and medically) to put you at ease. If you are in pain, you get the pain taken care of, *then* deal with fixing things. Caring for the patient as a person, and showing that you care is a natural part of the Costa Rican medical profession. It seems to me then that palliative care is regarded as just another normal part of medical training. It would seem a little strange to have a specialty just for this. But in the USA culture, where doctors are pushed towards spending less time with patients, and tackling illnesses as an entity separate from the patient, this specialty makes sense. It addresses the built-in lack in treating the patient as a whole in the states.

--- Some more details ---
World Health Organization interviewed Dr. Isaias G. Salas-Herrera, chief of the National Pain and Palliative Care Center, in San Jose, and his assistant Dr. Rigoberto Monestel. They discuss Costa Rica's national policy for pain control and palliative care.
The national health policy is here (in Spanish)
Note that you can enter this URL in Google's translation tool to read it in English:

Group 4 activities are defined further as:

(breakdown of "Capacity Building" as in Group 2)
• Presence of sensitized personnel
• Expressions of interest with key organizations (eg APCA, HAU, IAHPC, Hospice Information)
• Links established (international) with service providers
• Conference participation
• Visits to hospice-palliative care organizations
• Education and training (visiting teams)
• External training courses undertaken
• Preparation of a strategy for service development
• Lobbying: policymakers/ health ministries

(breakdown of "Localized Activities" as in Group 3)
• Critical mass of activists in one or more locations
• Service established – often linked to home care
• Local awareness/ support
• Sources of funding established (though may be heavily donor dependent and relatively isolated from one another, with little impact on wider health policy)
• Morphine available
• Some training undertaken by the hospice organization

(additional activities specific to Group 4)
• Critical mass of activists countrywide
• Range of providers and service types
• Broad awareness of palliative care
• Measure of integration with mainstream service providers
• Impact on policy
• Established education centers
• Academic links
• Research undertaken
• National Association

Saturday, October 4, 2008

Rain = 1, Electricity = 0

Talk about deja vu!

Last night, we got our first rain of the season in California. Finally! I know, friends in Costa Rica are sick of rain, and there is still Rainiest-month-October to get through.

So, we're just getting ready for bed, the rain has started, and BLINK! The electricity goes out! It's out for *hours!* Where are we again? *Not* Costa Rica?!?

Lost? You're Not Alone

We all have those moments where we feel like we need to take a moment and get oriented. We get off the bus in a new town, look around, feel an urge to look at our map, compass, GPS, whatever. For most people, this is the extent of it. You get your bearings, and off you go. Maybe you circle the block once, but you get where you need to go.

If you click on the "navigation" label, you will see pretty much how my process works - it can be a lot of fun.

But there are those who simply will never be able to find their way around. They are the perennially lost. We joke about it, but a new study shows that there is a developmental brain disorder that is the root cause of this disability. Researchers have "documented the first case of a patient who, without apparent brain damage or cognitive impairment, is unable to orient within any environment."

"When moving through an environment – familiar or not – a person creates a mental representation of the environment, called a cognitive map. It is the ability to "create" and "read" these cognitive maps that enables a person to navigate by following a route without getting lost."

The inability to create these cognitive maps causes this "topographical disorientation."

There is a website specifically designed to inform people about orientation skills and to reach others who experience topographical disorientation, GettingLost

Friday, October 3, 2008

High Anxiety

High Anxiety - no, not the movie :D
Just life lately...

Perhaps it's because this is the longest we've been away from Costa Rica. Maybe life in the states is starting to overcome our "tranquilo" gained in Costa Rica. Who knows?

In our quest to return, we've had change after change after change. We first thought we *had* to be back in September. This is the month that our residency expires, and we thought we had to renew then. So, all our plans revolved around that requirement. We had to figure out how to renew my driver's license - no problem, just change my address. But we also had to solve how we were going to vote - BIG problem - leaving too early for "early voting" and no knowledge about voting from abroad. Turns out you can vote from abroad fairly easily for the federal ballot; still not sure how (or if) you can vote in state elections.

But, as the month drew near, and we started to find out more about the changing laws, we discovered that no, we in fact did not have to be there in that month. Instead, we had to *call* in that month to get an appointment for renewing our residency.

So, on to our next change. We had heard that appointments were taking one or two months from the time people called. Therefore, we expected something in November (give or take). Well, this solved the license and voting problems, but added a few others.

By this time, our passports had gotten a bit close to the expiration date, and so we sent them off to get renewed (I know, I can hear the teeth-sucking all the way from here). So we enlist the help of ARCR - great group, highly recommended. They tell us all about what we need to have ready for renewal - including (guess what) our passports! Unngggh. All we could say was that we expect them back by November. Well, so they put off getting an appointment, we get anxious because we *know* we need to call *in* September (and September is running out). But then (whew) Rick's passport comes. His new one. Not his old one - the one with all our entry/exit stamps - the one that proves we met our residency requirement. PANIC! Deep breath. Read the insert that says the old one will come separately. Wait on pins and needles. We got the old one in a couple more days. Whew! So now we ask if we could get the appointment - Rick has his passport, and mine should be coming any day now (after all, they were mailed only a couple of days apart). Well, ok - we got an appointment. BUT. It is *not* in November! It is in *February!*


Welcome back to California - medical bills!

Welcome back to California - here are your medical bills - yikes!

We had a busy week going to dentists and doctors. I will say right up front, I would not even consider going to any other dentist or doctor in the states - ours are great! However, this is a pure illustration of the differences in the cost of health care between California and Costa Rica.

Cost for a thorough teeth-cleaning, exam, and x-rays:
California = $255
Costa Rica = $90

Cost for a filling - composite:
California = $250 (plus $115 for happy gas and topical numbing, 'cause I'm a baby)
Costa Rica = $50 (as reported by Saratica)

The same week, Rick went to the Doctor for a sinus problem, and came away with three prescriptions for almost $300. We're waiting for the bill from the Doctor, but I am sure it will be over $100. The last time we saw a Doctor in Costa Rica, the office visit was $12.

And people wonder why medical tourism is taking off...