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.

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.

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.