Some Costa Rica expats are satisfied with Caja (public) care; others opt to supplement or replace it with private care, paid out of pocket or through national or international health insurance.

One whole-hearted and one half-hearted fan of the Caja (Costa Rica’s national healthcare)

San Ramon-based expat Stephen Duplantier, 65, is a Caja fan. “We are very happy with it,” he said recently. “It’s US$18/month (a discounted rate through Association of Residents of Costa Rica–the ARCR). We go to local EBAIS (a neighborhood clinic), where there’s an excellent doctor and excellent nurses, plus all pharmaceuticals are free. Recent surgeries, diagnostic tests, ER use, pharmacy, etc.–all are totally free and high quality, and the waiting time is equal to our experience in the States.”

I agree that the Caja can be great for routine care, but when I found I needed surgery, I moved from the public to the private realm. I’d been part of the Caja system, paying around $60/month at the age of 41 and happily using their neighborhood clinics for routine care, tests, and medications. But when it became clear that I would need a major procedure, I defected to private care, opting to pay out of pocket (I’d let my U.S. insurance lapse). I was happy with the care at private Clínica Bíblica, though the final price for my stay, while quite low in comparison to U.S. prices, was still more than twice what I’d been quoted in a formal estimate.

Two that had bad experiences at public Costa Rica hospitals

Others are not so happy with the Caja.

After a motorcycle accident in Costa Rica, Matt Hogan sampled both public and private hospitals. Photo: David W. Smith

Take Matt Hogan, 35, co-founder of Finca Bella Vista, a sustainable treehouse community near the Osa Peninsula. In late 2009 he had a motorcycle accident, and was taken to the newly opened public hospital in Ciudad Cortéz. “All the newspapers had been boasting about the brand-new, state-of-the-art facilities and medical equipment, 300 clean new beds, and the rest,” says Matt. What the newspaper accounts failed to mention, according to Matt, was that all those new beds were serviced by only a few doctors who showed up only once in a while.

Matt says he suffered serious neglect and misdiagnosis (they told him he was fine). Feeling anything but fine, he had himself driven by ambulance to San José and checked himself into private Clínica Bíblica. There he was found to have one collapsed lung and the other in mid-collapse, as well as severe internal bleeding in his chest cavity. The doctors at Bíblica said that if Matt had waited another day to seek proper care he most likely would have suffocated.

Matt was very happy with the care he received at Bíblica, adding with a smile that “all the nurses were very attractive young Ticas.”

Alex Murray after being released from a 20-day hospital stay.

In another example, Alaska native Alex Murray, 72 at the time of a fire that burned over 20 percent of his body, endured an extended hospital stay that also allowed him to compare private and public care in Costa Rica.

“While expat friends with residency have had important procedures successfully performed at slight cost in the public system,” he says. “I recommend avoiding it in life-threatening situations if at all possible.”

Alex was burning garden trash at his home in the Lake Arenal region when he spilled some gas, causing the fire to flare up and burn him over much of his body. Alex spent the next 20 days in two hospitals in the capital city of San José, first at the public Hospital San Juan de Dios, and then at private Clínica Bíblica.

“Of course,” he admits, “it’s a foregone conclusion that such a comparison is unfair to the underfunded public hospital, but the devil’s in the personal details.”

Alex was first picked up by a Red Cross ambulance and taken to a clinic in nearby Tilarán. Then he was moved to the public hospital in Liberia (about an hour north), where the doctors decided to send him to the burn unit at San Juan de Dios (a public hospital) in the capital city of San José, 4 hours away.

“Arriving in San José,” says Alex, “we should have directed the driver immediately to Bíblica or Clinica Católica [two private hospitals], but, ignorant of the quality of the public hospital and anxious to get treatment, we let the driver take us to the teeming mystery that is San Juan.”

Hospital San Juan de Dios in Costa Rica

Three days at a Public Hospital: San Juan de Dios

“In our three days there,” says Alex, “no doctor ever consulted us, though one led a group of students into my room each day. The nurses, male and female, sometimes seemed like the proverbial five or six workmen who stand around a pothole gabbing while one guy fills the hole. For the most part, they were not dedicated, not attentive, not very competent, and not sympathetic. They seemed the dregs of the nursing schools. A friendly nurse assigned to draw blood samples spent three days drilling mostly dry holes all over my landscape, partly due to my extremely low blood pressure. One rough middle-aged nurse told me that I was not much hurt nor in pain. I finally had to yell at her, “Don’t touch me. Don’t touch me.” She desisted, smiling to herself, it seemed.

“A night crew came on and half-heartedly started to bathe me and change my dressings. Three stood on one side of the bed and made little come-hither motions with their fingers. Two stood on the other side and made little shooing gestures. Finally, they decided to help me turn.

“They would not let my wife sleep in one of the three extra beds crowded into my room. Instead she spent her nights trying to sleep in a plastic chair. In the not-very-clean bathroom, she found bloody bandages in a corner.”

Clínica Bíblica in Costa Rica

Seventeen Days at a Private Hospital: Clínica Bíblica

Alex and his wife decided that they needed to move him to a private facility. “When I was admitted to Clínica Bíblica,” he says, “I recognized immediately that here was a competent staff. The emergency room nurse quickly found a vein and soon had a set of color-coded vials filled with my blood. All staff were purposeful and attentive.

“The next evening I began to rave and tried to tear off my bandages and leave the hospital. A doctor soon arrived and said my actions were due to a lack of oxygen to the brain. I was then moved to intensive care where a coma was induced and I was intubated, remaining thus for five days, not a reassuring sight for my four daughters who arrived from points around the globe.

“I doubt that these measures would have been taken at San Juan de Dios. Three doctors tended me at Bíblica, one a burn doctor, one a plastic surgeon who moved skin from my thigh to my hip, and one a staff doctor. They each came by almost every day to talk with us. The nursing staff was a no-nonsense but friendly and attentive group, evidently the better graduates of the nursing schools. Midway through my stay, physical therapists began visiting daily to exercise my wasted muscles. When I left, I had lost 14 pounds and could walk only a few steps unassisted, but I was recovering.

“And throughout my stay, my wife was permitted to sleep on a narrow built-in bed or cot in each room. “

For more information on health care in Costa Rica, see Living Abroad in Costa Rica by Erin Van Rheenen, or visit www.livingabroadincostarica.com.

He asked doctors and public-health experts what they thought of how expats fare in China, where, according to World Bank estimates, 750,000 people die prematurely each year just from air pollution. “Alarming upsurges in birth defects and cancer rates are reported even in the state-controlled press,” notes Fallow, in his “How I Survived China” in the November issue of The Atlantic.

The air quality is so bad, writes Fallow, that he and his wife joked with friends that now was the time to take up smoking, since their lungs would never know the difference.

A foreign-trained doctor in Beijing told Fallow, “Just using your eyes, you know this can’t be good for anybody.”  Fallow continues,

Another way to know this is via a clandestine air-quality station that the U.S. Embassy has built in Beijing. The Chinese government does not report, and may not even measure, what other countries consider the most dangerous form of air pollution: PM2.5, the smallest particulate matter, tiny enough to work its way deep into the alveoli. Instead, Chinese reports cover only the grosser PM10 particulates, which are less dangerous but more unsightly, because they make the air dark and turn your handkerchief black if you blow your nose. (Spitting on the street: routine in China. Blowing your nose into a handkerchief: something no cultured person would do.) These unauthorized PM2.5 readings, sent out on a Twitter stream (BeijingAir), show the pollution in Beijing routinely to be in the “Very Unhealthy” or “Hazardous” range, not seen in U.S. cities in decades.

Other doctors and fellow expats told him, “you get over it” (bouncing back once they return to more healthy settings), and that he should “worry about something else.” A Chinese doctor told Fallow, “I tell my patients, the most important ‘medical’ step you can take is to put on a seat belt in a car, wear a helmet on a bike, and run for your life in crosswalks.”

But Fallows ends on a high note, quoting a Western-trained doctor pointing out that China “is an exciting place. It’s a historic time. People seem to feel alive.”

“That made sense when I heard it,” writes Fallow. “In China I had felt terrible, but alive…and that makes me say that foreigners who want to go should not be deterred.”

Photo: atlasnetwork.org

Some stem cell scientists in the U.S. say these treatments offer false hope to patients desperate enough to take a chance on techniques that have not been scientifically proven.

Costa Rican doctors like Dr. Fabio Solano, who directs the stem cell institute at San Jose’s CIMA Hospital, disagree. Solano says they’re providing medical tourists with groundbreaking (and affordable) treatments. Dr. Solano estimates that his team has treated as many as 400 patients with procedures that involve stem cells.

Costa Rica is known for its high-quality medical care.  More and more medical tourists come here for surgery and other treatments that they can’t afford back home.

And despite the naysayers, success stories about stem cell treatments in Costa Rica abound, from 8-year-old Kenneth Kelley receiving stem cell treatment for autism to Trish Stressman seeking treatment for her chest-down paralysis, to Jennifer Blankenship, who received treatment for her multiple sclerosis (MS).

But many doctors urge caution. Dr. Jack Kessler, an expert in stem cell research at Northwestern University’s Feinberg School of Medicine in Chicago, warns, “The lay press is unfortunately replete with many overstatements and misconceptions about what can be accomplished in the short term by stem cell biology,”

FDA says don’t go abroad for treatment, but are they tarring all non-U.S. facilities with the same brush?

CNN reports that the International Society of Stem Cell Researchers and the FDA discourage Americans from traveling overseas for stem cell therapy. Clinics are operating worldwide–in China, Russia, Mexico, and Costa Rica, among other places.

I fear ISSCR and the FDA may be tarring too many countries, hospitals, and procedures with the same brush. I have personal experience of Costa Rican (private) hospitals and can attest to their quality. As for providing treatments not allowed in the U.S., I’m not an expert, but have read a bit about the lengthy (and sometimes arbitrary) review process that new drugs and procedures must go through in the U.S.

There’s also the issue of stem cell research and treatment being a political hot potato in the U.S., which has probably set medical advances back years, if not decades. It wasn’t until March of this year that President Obama issued an executive order that lifted Bush-era restrictions on federal funding for stem cell research.

Stem cell research is also a political issue in Catholic Costa Rica, where researchers are not allowed to work with human embryos (even in vitro fertilization is against the law). Doctors and researchers in Costa Rica have supposedly done an end run around that prohibition by working with “adult” stem cells (derived from tissue including body fat and umbilical blood or tissue).

About stem cell treatment

Wikipedia defines stem cell treatments as “a type of cell therapy that introduce new cells into damaged tissue in order to treat a disease or injury. Many medical researchers believe that stem cell treatments have the potential to change the face of human disease and alleviate suffering. The ability of stem cells to self-renew and give rise to subsequent generations that can differentiate offers a large potential to culture tissues that can replace diseased and damaged tissues in the body, without the risk of rejection and side effects.”

The focus on Costa Rica’s medical system doesn’t surprise me. I lived there, and ended up having major surgery in the capital city of San Jose. No hospital stay is fun, but I received very competent care, and the bill didn’t push me to the brink of bankruptcy (the biggest cause of bankruptcy in the U.S. is said to be unpaid medical bills.)

In the Medical Tourism Conference video, we see Bob (his last name is not provided) from Orlando, Florida, as he flies to San Jose, Costa Rica, to have a double knee replacement at Clinica Biblica, one of the top rated facilities in a country. Bob consults with English-speaking doctors, jokes that this is the first time the doctor was waiting for him, and sings the praises of Costa Rican medical care. He even fits in a visit to the rainforest aerial tram at Braulio Carillo National Park.

The video says Bob’s double knee surgery would have cost $100,000 in the U.S., and that it cost him about $20,000 in Costa Rica.

The video has that marketing vibe, where you wonder if they’re telling you the full story. But it happens to be true that Costa Rica’s not a bad place to go for medical care. No system is perfect, but I’ve had surgery (lucky me!) in both the U.S. and Costa Rica, and felt I received good care in both cases. And the cost difference is staggering.

This year’s medical tourism gathering hopes to draw as many as 2,000 participants.  Last year’s congress (the first of its kind) drew around 850 attendees from 45 countries. Insurance companies and insurance providers came, along with representatives from hospitals, clinics, and governments around the world. Everyone wants in on this new industry, which, according to Deloitte, will have up to 23 million Americans traveling internationally for medical care by 2017, spending up to $79.5 billion dollars each year.

For more on health care in Costa Rica

Photo credit: zipline from Skytrek, Monteverde

1. No cause for panic. So far, swine flu isn’t much more threatening than regular seasonal flu. Still, more people are susceptible to swine flu and U.S. health officials are worried because it hung in so firmly here during the summer — a time of year the flu usually goes away.

2. Virus tougher on some. Swine flu is more of a threat to certain groups — children under 2, pregnant women, people with health problems like asthma, diabetes and heart disease. Teens and young adults are also more vulnerable to swine flu.

3. Wash your hands often and long. Like seasonal flu, swine flu spreads through the coughs and sneezes of people who are sick.

4. Get the kids vaccinated. These groups should be first in line for swine flu shots, especially if vaccine supplies are limited — people 6 months to 24 years old, pregnant women, health care workers.

5. Get your shots early. Millions of swine flu shots should be available by October. If you are in one of the priority groups, try to get your shot as early as possible.

6. Immunity takes awhile. Even those first in line for shots won’t have immunity until around Thanksgiving. That’s because it’s likely to take two shots, given three weeks apart, to provide protection. And it takes a week or two after the last shot for the vaccine to take full effect.

7. Vaccines are being tested. Health officials presume the swine flu vaccine is safe and effective, but they’re testing it to make sure.

8. Help! Surrounded by swine flu. If an outbreak of swine flu hits your area before you’re vaccinated, stay away from public gathering places. Keep washing those hands and keep your hands away from your eyes, nose and mouth.

9. What if you get sick? If you have other health problems or are pregnant and develop flu-like symptoms, call your doctor right away. You may be prescribed Tamiflu or Relenza. These drugs can reduce the severity of swine flu if taken right after symptoms start. If you develop breathing problems (rapid breathing for kids), pain in your chest, constant vomiting or a fever that keeps rising, go to an emergency room. Most people, though, should just stay home and rest.

10. No swine flu from barbecue. Swine flu is not spread by handling meat, whether it’s raw or cooked.

In addition, the very fact that the medical tourism option exists fosters healthy competition, allowing U.S. insurance companies (or whoever ends up being our ‘provider’) to negotiate better rates on procedures right here in the United States.

USA Today reports that “Shortly after Hartford, Conn.-based Aetna Inc. and the Maine-based grocery chain Hannaford Bros. Co. launched a program to send patients to Singapore for hip and knee replacements, some New England hospitals countered with their own deals. So far, three patients have benefited from the competitive pricing; Hannaford has sent no one overseas, even though the program pays travel and lodging costs.”

Everywhere you look, newspapers and magazines are reporting on Americans going abroad for elective procedures and saving thousands, or even tens of thousands of dollars. For example,

Elizabeth Kunz of South Carolina needed eight crowns, a filling and a root canal. Though she had insurance, the procedures would have cost around $10,000 in the U.S. Her insurance company, BlueCross BlueShield, said they’d pay for her to see a dentist in Costa Rica. She booked a trip. The work cost her $2,800.

Ben Schreiner, 63, also of South Carolina, was going to wait until he turned 65 (and qualified for Medicare) to have his hernia surgery. Without Medicare, but with his current medical insurance, he would have had to pay a $10,000 deductible. After hearing about medical tourism, he did some research, and then flew to Costa Rica for the surgery. He ended up spending $4,400, including travel expenses.

Some say that medical tourism is not yet common enough to play a role in health care reform. Paul Keckley, executive director of the Deloitte Center for Health Solutions, estimates that medical tourism spending accounted for no more 1% of the $2.36 trillion spent on health care in the United States in 2007.
But the practice is on the rise. And knowing that many Americans must go abroad to afford the medical care they need gives the push for health care reform even more urgency.

Photo by Erin Van Rheenen: Children’s examination room, at Hospital CIMA in Escazú, Costa Rica.

More information on healthcare in Costa Rica.

Travel Alerts
U.S. State Department Travel Alerts refer to short-term conditions (like flu epidemics) that pose risks to the security of U.S. citizens (and others, of course, but the State Department concerns itself with U.S. citizens). Their web site clarifies the Travel Alert designation further:

“Natural disasters, terrorist attacks, coups, anniversaries of terrorist events, election-related demonstrations or violence, and high-profile events such as international conferences or regional sports events are examples of conditions that might generate a Travel Alert.”

The Alerts have expiration dates. For example, a Mexico alert, which centered around crime and violence (especially along the U.S.-Mexico border), expired August 20, 2009 (though alerts may be renewed at their expiration dates, as this one was).

Just because there’s a Travel Alert in place doesn’t mean you should necessarily cancel your trip. In the case of Mexico, for instance, even the Alert itself allows that

“Millions of U.S. citizens safely visit Mexico each year (including thousands who cross the land border every day for study, tourism or business),” but “violence in the country has increased recently. It is imperative that travelers understand the risks of travel to Mexico, how best to avoid dangerous situations, and whom to contact if one becomes a crime victim.”

In early 2010,  these countries were on the State Department’s Travel Alert list: India, the Philippines, Malaysia, Niger, Germany, Tanzania, and Mexico.

Travel Warnings

Travel Warnings, on the other hand, are more serious, and of special interest to those considering moving to that country. Warnings  “describe long-term, protracted conditions that make a country dangerous or unstable,” according the State Department. The Warning can also mean that the U.S. Government is hindered in helping Americans living or traveling in that country due to the closure of an embassy or consulate or because of a reduction of its staff.

The Warnings are useful in that they often give very specific information about problems and potential problems. In the case of Pakistan, for instance, we learn that

“Since 2007, several American citizens throughout Pakistan have been kidnapped for ransom or for personal reasons. Kidnappings of foreigners are particularly common in the Northwest Frontier Province (NWFP) and Baluchistan. In 2008, one Iranian and two Afghan diplomats, two Chinese engineers, and a Polish engineer were kidnapped in NWFP. In February 2009, an American UNHCR official was kidnapped in Baluchistan. Kidnappings of Pakistanis also increased dramatically across the country, usually for ransom.”

Still, a country being on the Travel Warnings list doesn’t mean that you should never in a million years consider going there. Independent travelers will use the warnings and alerts as starting points, seeking more information from a variety of sources. For example, I was planning a trip to Nepal a year ago (there have been Travel Warnings for Nepal for several years now). I read the State Department’s warning (paying close attention to which parts of the country were highlighted as problematic), sought out books and articles about the country and its politics, and spoke with people who’d been there recently. After all my research I concluded that I still wanted to go. Health problems made me cancel that trip, but I would have gone and still hope to go, Travel Warning or not.

And the director who recently made a movie about Surfing Gaza obviously didn’t let the Gaza and West Bank Travel Warning deter him.

Travel Warnings have no expiration dates—presumably the State Department monitors the situation and removes the warning when conditions improve.

As of early 2010, these countries were on the State Department’s Travel Warning list: Haiti, Pakistan, Sudan, Somalia, Mauritania, Chad, Mali, Sri Lanka, Nepal, Algeria, Colombia, Guinea, Lebanon, Cote d’Ivoire, Philippines, Democratic Republic of the Congo, Eritrea, Central African Republic, Israel, the West Bank and Gaza, Kenya, Afghanistan, Burundi, Nigeria, Haiti, Iran, Yemen, Saudi Arabia, Uzbekistan, Iraq, Georgia, and Syria.

The motivation is simple. Traveling halfway around the world for medical care has one enormous advantage, at least for U.S. citizens: you save money–often tens of thousands of dollars. And if you choose wisely, the quality can be as high as the best care you’d get in the U.S.

People travel abroad for root canals, routine dental work, face lifts, hysterectomies, joint replacement, and bypass surgery, to name just a few of the more common procedures. Some of those heading overseas are among the nearly 50 million Americans without health insurance. Some have insurance that doesn’t cover what they need or that has a deductible or co-payment so high it’s cheaper to pay out of pocket in another country. A small minority of the people going abroad for care are sent by their own insurance companies.

Recently, the nation’s largest health insurer, WellPoint, began a pilot program with Serigraph, a graphics company with operations in Wisconsin, Mexico and Asia. U.S. employees of Serigraph can opt to travel to India to have non-emergency surgery. WellPoint says the cost of care is about 80% lower in India, largely because of dramatically lower charges for labor, drugs and medical devices. WellPoint is partnering in India with Apollo Hospitals, a consortium of 47 medical facilities.

Just how much can you save?  Recent figures from the CDC: spinal fusion surgery in India costs $5,500, compared to over $60,000 in the U.S.; a heart bypass in Thailand costs $11,000, compared to as much as $130,000 in the U.S. A report last year in Business Week echoed the CDC’s figures for heart bypass operations in Thailand and the U.S., adding that in Singapore that operation would cost $18,500 and in India $10,000.

See more on Wellpoint in the Los Angeles Times.

Intense training can be a risk in travel-related DVT

In hospitals, deep vein thrombosis (DVT) may occur after surgery, especially surgery below the waist, like hip surgery. And it’s true that you should avoid surgery for at least 30 days after air travel if possible.  But the risk factors for DVT on an airplane are very different from those in a hospital, and include recent intense athletic conditioning, particularly training for endurance sports like marathons.

According to Airhealth, the most common travel-related risk factors for DVT are:

1. Athletic training, especially training for endurance sports like marathons.

2. Recent surgery or injury. If you have just run a marathon, you probably have at least minor bruising that can trigger clotting. Kick-boxing also produces such injuries.

3. Personal or family history of DVT.

4. Cancer, heart disease, diabetes. Obesity is often cited as a risk factor, but probably ranks much lower than the preceding diseases.

5. Women who are pregnant or taking estrogen as birth control or hormone replacement.

6. Age over 40 is often cited as a risk factor; sometime age over 60 is cited. Butin Airhealth’s registry, over 80% of those suffering DVT while traveling are under age 60, and the majority are under 50.

See also How to avoid blot clots while traveling.

They're squeezing more and more passengers into coach these days. Photo from blisstree.com

Take heart, obsessive travelers: according to the Centers for Disease Control (CDC), more than 63 million Americans travel abroad each year, and the great majority of them never have any major problems.

Still, we need to pay attention to the risks of travel. A study released yesterday by doctors at Harvard University found that travel is associated with a 3-fold higher risk for blood clots, called deep vein thrombosis (DVT), with the risk increasing for each 2-hour increase in travel time.

The clots, which often form in the deep veins of the legs, may occasionally break loose and head for the heart or lungs, which may lead to heart failure or stroke (which may, in turn, lead to death). Lots of “maybes” in that chain of events, but still, we need to pay attention.

Any type of travel where you sit still for long periods can be potential dangerous, but flying seems to be especially problematic. It’s harder to get up and move around on a plane, your legs are often stuffed into a woefully small space (in fact, DVT is often called “economy class syndrome.”) And the air in planes is also very dry, raising the risk of dehydration.

Scary, to be sure. But the CDC offers some simple but effective steps to minimize your risk.

While traveling

1. When sitting for long periods of time, such as when traveling for more than four hours:

• Get up and walk around every 2 to 3 hours.
• Wear loose-fitting clothes.
• Drink plenty of water, and avoid drinking anything with alcohol or caffeine in it.

2. Exercise your legs while you’re sitting by:

• Raising and lowering your heels while keeping your toes on the floor
• Raising and lowering your toes while keeping your heels on the floor
• Tightening and releasing your leg muscles

Lifestyle changes that help you avoid DVT:

• Exercise regularly
• Maintain a healthy weight
• Don’t smoke
• If you have a family history of DVT, talk to your doctor about medication (anticoagulants) to prevent or treat DVT

At Airhealth.org you can download a handy wallet card that reminds you of how to avoid DVT.