My First Costa Rican Patients

I ride down the hill to the hospital with 2 Costa Rican medical students. I am to be working this morning with one of the 3 primary care doctors that operate out of the San Vito hospital. Within 2 minutes I am reminded of why I did NOT choose to work in primary care. We see a well-appearing woman who is 1 week post-partum (after having given birth). Any issues? Any bleeding? Baby doing OK? A quick exam and we close her chart and turn our focus to the baby. Problems feeding? Gaining weight?  Any fever? All is well so the talk moves to discussing family planning and birth control options. Prescriptions for folic acid are given and the patient and her baby are on their way.

The other patients are similarly unexciting to me. Diabetes. Checking your sugars? Watching your diet? Bloodwork OK? Hypertension. Eating low salt? EKG normal? taking your meds? Swelling of you feet? I am aching for someone with an acute issue: pulmonary edema, a stroke, an overdose, a traumatic injury.

Unfortunately I have no exciting pictures here except for the buildings that comprise the hospital. There are no HIPAA laws in Costa Rica so it is totally OK for me to photograph whomever I want in the clinic. (Seriously I confirmed this with multiple hospital administrators.) For those unfamiliar with this legislation HIPAA is what guarantees that your health information remains private, and is the reason hospitals and doctors in the US can't share your info without your permission. It's also the reason why if you come into an ER in say New York City in a coma after a car accident I have no way to check what medications you are allergic to and I might give one that induces an anaphylactic reaction. Anyways... my American medical education has deeply rooted the principle of patient privacy into my being and I just can't bring myself to whip out the camera and take pictures of patients as they visit their doctor.

The San Vito Hospital. It is composed of 3 main buildings linked together. This one contains the primary care clinics and also the other outpatient offices used by the internist (internal medicine trained physician) and other subspecialists such as a cardiologist. There is 1 internal medicine trained physician at the hospital. The other subspecialists reside in neighboring cities and come to San Vito a few times a month for clinic.

This is the Radiology Building. There is 1 radiologist in San Vito and when he's on vacation you have to read your own films. Earlier this month they got an ultrasound machine. The radiologist performs the scans himself. In the US this is done by a technician and the radiologist simply interprets the images. Likewise the physicians here do their own EKG's.

Further down the street is the Urgencias (Urgent Care) section of the hospital. This is actually setup rather similar to the US with an entrance for patients to walk in as well as a driveway where ambulances can pull up.

The Roads

I already mentioned that raw materials for concrete are tough to come by in this part of the world. They must be shipped in from the capital city San Jose which makes pavement a very expensive luxury. Aside from the main road the rest were simply gravel or just plain dirt. Having a 4x4 with good ground clearance is almost a necessity here. Combine this with frequent flash flooding and steep mountainous terrain and you have a recipe for disaster. Surprisingly, however, traffic accidents were rather uncommon.

Mud road. This was on a NOT-rainy day

Bus vs. Tanker on blind turn.

Luckily no one was hurt in this collision

Typical vehicle

Better leave plenty of time to get to work... in case you get caught behind this guy

Typical parking lot

Street with sidewalk near San Vito hospital

A House Without Walls

Dr Ortiz's house is nothing short of amazing. It is located on a hilltop about 2 miles from the downtown (el centro) part of San Vito. It is at approximately 4,000 feet elevation making it more chilly than tropical. The house is set back almost 1/4 mile from the main road. He has a farm with pigs and chickens on the property. There is a small stream running through as well. The house itself is very large with multiple rooms to accommodate up to 20 guests (at least that was the most who stayed while I was there).  It has a sort of hostel feel to it. All manner of guests pass through: students doing international relief work, UN workers taking a break from their jobs in other Latin American countries, bigshot government officials from San Jose (the capital of Costa Rica) passing through town for a mix of business and getting away from the city, Costa Rican medical students, Costa Rican college students, European social workers doing projects here... the list goes on and on.

Is it a leaf? Not it's an insect

Oh yeah and except for the bedrooms there are no walls. The house literally blends in with the jungle. In fact many of the homes here have a similar construction. Why not when the temperature is basically perfect every single day of the year? And even though it rains every day from April to November it is rarely windy so the overhanging roof keeps all the water out just fine. Plus there was Internet access via cell phone 3G USB sticks. And I don't know if it's because they use GSM technology or what but the speed and reception was definitely better than I am used to in New York City.

Are there bugs? Yes of course but at this elevation there are no mosquitoes (and hence no malaria) and really they are only an issue at night. Are there animals? Yes. Just 1/2 mile from here is a wildlife reserve that charges top dollar for tourists to bird and animal watch. Apparently a few years ago there was a problem with a band of monkeys that would come and steal food from the kitchen, but they haven't been around in a while. Also Dr Ortiz has a pack of 7 dogs of various breeds, ages and sizes so I imagine they scare away most jungle critters. Staying in the house was sort of like a mix between camping and being in a luxury hotel. There was the occassional spider on the wall or ceiling when you woke up in the morning and you had to shake out your clothes before putting them on to clear out any scorpions that might have snuck in overnight. But overall it was a really cool vibe.

Bunk room at night time

Bunk room in the day

Dinner Table

Yup that's right, a hot tub in the jungle

Kitchen and breakfast bar

Indoor/outdoor bathroom

Hey it's better than camping

Rear of the house with ktichen

Rear entrance

Housing Project

Today on the way into town Dr Ortiz takes us through a housing project. You  have to prove financial need to qualify for government housing. Otherwise a 2.5 acre piece of land here without a house on it costs about $50,000. Pretty good by US standards, but the average schoolteacher here makes around $500/month and a physician starts out at $3,000/month. That being said rent is very cheap costing something like $200/month for a 2 bedroom home, usually with a spectacular view. Then again you are living in a town with 3 restaurants, 2 grocery stores, and where the nearest movie theatre is a 3 hour drive away. Like many of the roads in Costa Rica, the one winding through the neighborhood is a disaster. Raw materials for concrete must be shipped in all the way from San Jose which makes it very expensive to make a paved road. This particular neighborhood has a school. And of course it has a Casa de Salud (more on this later)

So anyways that $50,000 is tough to come by in a town with minimal industry except coffee production. Once the land is gifted out and the concrete foundation poured, electricity wired, and plumbing plumbed the raw materials for the house are dropped off and the neighbors all pitch in to build the home. Just like the Amish. And cheaper than hiring a construction crew, of course.



The houses are all of the same construction: a concrete slab with wood or concrete frame, synthetic paneling and a tin roof. All single story. Most have cars parked outside. A few have some vegetables or flowers growing nearby. ALL of them have potable drinking water provided by the government free of charge. Likewise electricity with the corresponding network of poles and cables overhead. In fact the percent of Costa Ricans who have potable water and electricity is something like 98%. That's pretty amazing when you consider that the terrain here is rainforest/jungle with mountains and frequent flash floods.

Local gradeschool

This lot with this view is for sale for just $48,000

Day 3 - Banana Plantation Visit

Today my host Dr Ortiz is taking several of us on a tour of a banana plantation. I guess the goal is to show us what the lives of some of the workers is and to imagine what sort of healthcare needs they might have. To get to the banana plantation we pass through some crazy mountain roads. We pass the summit in the clouds shivering and then end up in tropical climate at the Panama border. Interestingly the borders are all open. So in the picture below the left side is Panama (where alcohol and most consumer goods are really cheap) and the right side is Costa Rica (where cigarettes are cheaper due to fewer taxes).

We straddle the border for some time and then come across plantation after plantation. There are 2 types: palm trees for palm oil and bananas. These plantations used to be owned privately but a few years back the government took them over and now they are each collectively owned by the workers who farm the land. They are called cooperatives. Sounds like a great idea but apparently these people are extremely poor. Each co-op has a planned town with buildings arranged around (you guessed it) a soccer field. All the workers live there. There is a school every couple of co-ops. 

The banana factory is approx the size of  2 large roadside gas stations from the US. Here´s a rundown of the trip the fruit takes. First it is covered by blue plastic bags so bugs and birds don´t eat it all while it is ripening on the tree. While still green, the bananas are harvested in a large bunch in the fields and then carried by 2 or more workers to a trolley system where they are hung on a track. After approx 15 bunches are gathered like this, they are chained together and a worker hauls them back to the factory via a cable hitched to his belt. This is basically like the guy who collects the shopping carts at the grocery store parking lot but it´s all 15 ft up in the air on a suspended track. Also interesting is that the bananas trees have been bred to be low enough to the ground that a ladder is not needed to harvest the fruit. Smart. And the plants continually produce fruit non-stop all year round.

On arrival the large bunch of approximately 80 bananas is chopped up into the more familiar bunches of 5-10 and put into a water tank. From there it passes through a series of workers whose job it is to pull out the rejects from the assembly line. For example if a banana is too big, too long, or too stocky it will be put in the reject conveyer belt. I guess this makes sense as I have never seen an oddly shaped banana in the store in the US. But where do these rejects go? Simple. They are loaded on a truck and sold in Central American markets. The rest are further cleansed and then boxed up and loaded onto a tractor trailer. The factory foreman says they process at most 2 truckloads of bananas per day.

This is an örganic fair trade¨plant so only a mild chemical is sprayed onto the bunches during the process. Also rather comical is that there are multiple sets of brand name stickers at the plant. depending on what day and what truck they are loading a banana either gets stamped as Dole, Del Monte or Oke. So literally there is no difference in the fruits between those brands. Oh and box of approx 100 bananas fetches ~$7 for the cooperative. The rest of the markup in price must be going to the company shipping them from this field, across mountain roads, onto a boat, and across the Atlantic or Pacific, onto a truck and into a supermarket in Europe or the US.

Day 2

Up early and on the bus. Literally the distance from my hip joint to my knee joint is greater than the distance between the seats of the bus. The Ticos (that´s what local Costa Ricans call themsleves) are generally kind and try to keep the seat next to me free. Still I have no problem sleeping most of the way.

The bus stops at several other bus ¨stations¨ which appear to be semi-official buildings where buses come and go from. Makes sense as most the towns are very small, probably no more than a few thousand people. However the bus also seems to convert to ¨regular city bus mode¨picking people up at random locations, then a fare is negotiated with the driver and they exit the bus a few miles later, often at unmarked locations. Weird. I guess there are probably so few buses that pass through why not use the main bus as a local one too? This phenomenon continues as we get into the more remote and hillier regions. Here people seem to emerge literally out of the jungle from the sides of the road to be picked up and then dropped off at equally uninhabited locations where they walk off the road and disappear back into the jungle.

Soon we start arriving in more defined towns. There are no signs anywhere announcing which town we are in so I keep asking the other passengers. They seem amused and slightly annoyed by my ignorance. Or maybe its just my beginner Spanish. At one such town almost the entire bus clears out. I ask if this is San Vito. ¨No¨I am told. Then as we continue down the road I finally see a sign, stating San Vito airport. Actually it´s just an approx 1/4 mile strip of concrete on a relatively flat surface to serve as a runway. At the next stop I ask if we are in San Vito. ¨No, we already passed San Vito¨. Oh well. I exit the bus and then catch another random bus heading the other direction.

Finally back in town I look around for someone who might be a doctor. Finding no such person I go to a pay phone and call him. He will be there in 5 minutes. 15 minutes later a new SUT pulls up and a woman gets out and waves to me. I get in and we head up the road higher into the mountains.