In the spring of 1996, Tom and I volunteered to help Gretchen Daily and Paul Ehrlich with their butterfly field work in Costa Rica for a week. We flew to San José, Costa Rica, rented a car, and drove about 6 hours south from San José to the Wilson Botanical Gardens Organization for Tropical Studies (OTS) Station near the little town of San Vito. Occasionally, we needed to go into the town of San Vito in order to buy supplies (mostly bananas for the butterflies and beer for us), and we would pass by the hospital in San Vito on the way. As we planned to return for a week the following year in January, 1997, I wrote to the director of the OTS station at the Wilson Gardens, the biologist Dr. Luis Diego Gomez, telling him I was returning and asking him if there were any specific needs of the hospital with which I could help (medications, supplies, etc.). He wrote back that they needed "everything". Apparently, their emergency supplies had been depleted in the hurricane in July '96, and they were especially in need of suture material, and emergency medications such as syringe-ready dopamine, and anything else I could bring down.
The San Vito Hospital is part of the Costa Rican national health care
system run by Caja Costarricense de Seguridad Social (CCSS). It serves the
county of Coto Brus with a population of 50,000 of which about 1000 are
native Guaymi Indians. In addition, and as a result of the International
Agreement for Border Zones, it occasionally serves Panamanian persons from
nearby towns of Unión and Sereno.
All Costa Ricans, employed or not, have free access to the services of this and any other hospital. Employed citizens contribute 9% of their salaries to the CCSS system. Employers contribute 19% of the salaries paid to their workers. However, in a rural, agricultural area like San Vito, collection of these taxes amounts to 200 million colones ($1 equals 220 colones as of Jan. 97), that means a deficit of 600 million for this hospital with an annual budget of 800 million colones.
The hospital director is Dr. Maria Arias Valle, and Chief of Emergencies and Inpatient services is Dr. Pablo Ortiz R.
During the month before I left, I made a number of contacts with people in order to obtain supplies. I discovered an organization called "Recovery" which collects discarded but still good supplies from hospitals in the area and arranges for them to be donated overseas, e.g. to Bosnia, South America, etc. The representative told me they might be able to get some supplies to me to take to Central America. One evening, while a music rehearsal was going on in our living room, he called me back to say he had some supplies for me. Unfortunately, I did not want to interrupt the rehearsal, so I let the answering machine pick up. It was very suspicious-sounding for the guests to hear him ask for me and say he was "Doug", and he had my "drugs and supplies ready", and to meet him at some storage locker off Highway #101. I did go out there and rummaged through a trailer full of medical items, and was free to take whatever I wanted. I selected a large box of assorted suture material (estimated at $6.38 per package, several hundred packages, all still sterile and not outdated), a case of sterilized and unopened biopsy forceps, cervical collars, bandage protectors, and several boxes of medication samples including antihypertensives, thyroid medication, medicine for Parkinson's disease, asthma inhalers, and others. In addition, I contacted a number of local pharmaceutical company representatives and obtained several cases of antibiotics, narcotics, and pediatric Tylenol.
Gretchen Daily helped with carrying down two large boxes of the equipment the week before I left, then Tom and I took down the drugs. I warned Gretchen that maybe some of the supplies might not be useful in this remote location, and she thought otherwise. She pictured the biopsy forceps being used somehow creatively at the local gas station, and was sure that nothing would go unused. I received a letter from the San Vito Hospital director stating who I was and that I was bringing these supplies to them (I wasn't sure how unusual it would be to be caught bringing drugs into Central America). We packed the drugs into a huge army-sized duffel bag, and ended up sailing through customs with no questions asked.
After we had spent several days at the Botanical Gardens with Gretchen, Paul, and their colleague George, Luis invited Dr. Pablo Ortiz from the hospital to join us for lunch at the Garden, and there I learned some things about him and the hospital itself. Pablo has been the director of the emergency department and of inpatient services there for about 9 years. Before that, he told me he had done part or all of his residency in Boston (a great setting for emergency training). Prior to that he told me he had done his medical training in the Ukraine. He spoke English fluently, and had a great sense of humor. He invited me to spend the morning with him at the hospital the following day. We gave him the medical supplies, and the next day when I visited, I saw that they had sorted through the stash, separating out portions of it for the indian reservation and outlying clinics, etc. As they do not have the equipment to perform many procedures, they were planning to ship off the boxes of biopsy forceps to the main hospital in San Isidro, and exchange this equipment for other supplies they needed.
Pablo spent the next several hours showing me around the hospital, introducing me to colleagues, and occasionally getting interrupted to go back to the emergency room to deal with a patient. The emergency room consists of a couple of rooms with one bed each, as well as a few medical instrument trays, lights and that was about it. One room had one of the older stand-up EKG machines that performs only rhythms strips. Pablo informed me that was their only EKG machine, and unfortunately, it had been broken for some time and is essentially useless. They have no intravenous infusion pumps, thus any medicine which needs to be given by continuous infusion is not available.
One of the patients we saw was a 9-year-old boy with a large, ulcerating skin lesion on his forehead. (This was not really an emergency...there are actually very few dermatologic emergencies, but, as in the US, the emergency room handles everything....more on that later). It was quickly diagnosed as the cutaneous form of Leishmaniasis, a hemoflagellate transmitted by sandflies. The little boy hopped up onto the exam table, and held perfectly still and gritted his teeth while Pablo injected the lesion with several ccs of medication. I was amazed that the little guy didn't whimper or put up any kind of fuss.
Pablo then showed me around the rest of the hospital. Even though the indigenous Indian population accounts for a small percentage of their overall population, they seemed to represent a larger (maybe 30%) percent of the hospitalized patients. The pediatric ward had 7 or 8 beds/cribs in it, and several were occupied by Indian children. Pablo explained that a number of them have tuberculosis or complications thereof. It is extremely prevalent in the Indian population, and very difficult to eradicate, as it takes a year of therapy with several different medications. As most of the Indians live more than 3 hours by foot from the hospital, and have no electricity or running water, compliance with even the simplest medication regimens and follow-up is nearly impossible.
Another prevalent condition apparently is asthma. There is one room in the hospital with lounge chairs (pretty beat-up) and nebulizers, and I saw several people in there at once receiving breathing treatments. They are not sure why the prevalence of asthma seems particularly high there, perhaps because of the variety of grasses and/or pesticides coming into use. At that point I was glad to see that all of the asthma medications I brought down would probably be put to good use.
A large percentage of the hospital space is dedicated to maternity. They have one room with several beds for women in labor (there were two of them at the time I was there), one room for deliveries with two gurneys, and another room for post-partum women. Pablo stated there are 3 to 4 births everyday. As they do not have the equipment to perform C-sections or give blood, any woman requiring such a procedure is transferred to a larger hospital either in Golfito or San Isidro (hours away). Pablo said with only two birthing tables, and two births a day, sometimes things get pretty crowded.
One of the things that amazed me is that with this high birth rate and the number of children, there is only one pediatrician for the entire county hospital. Pablo said as of a few years ago, there wasn't even one, and the government sent a different pediatrician down every month...usually somebody who had just finished training. He said that the reason they had such a hard time keeping anybody there is because of the poor school system there. As soon as the doctor had a family of his own and his children reached school-age, he would move his family back to the capital city, San José, so his kids could get a better education. They were finally able to recruit somebody there who has been there for the last year. I met him that day; he is young, looks just out of training. Pablo took me to the pediatric clinic area where, at 11:00am there were 5 or 6 patients waiting to see him, and he was in the middle of examining a child. He later broke free to speak with us.
As my specialty within neurology is epilepsy, I was wondering what medications they had available there for treating seizures. I was pleasantly surprised to learn that the medications available (Dilantin, Tegretol, Depakote, Phenobarbital) there are the standard ones in use in the US, though the newer antiepileptic drugs (Lamictal, Neurontin) don't appear to be in use there yet. Obviously, with no EEG machines, the diagnosis of epilepsy is a clinical one, which in the overwhelming majority of cases, is perfectly reasonable. I also asked about the treatment of status epilepticus (an emergency condition of continuous seizure activity). The docs there were certainly aware of the latest treatments (e.g. Versed drips, etc.), however, they did not have the drugs available or equipment needed to administer it. Actually, I was very impressed to find out their level of knowledge of various treatments was what would be called standard of care here in the US, it was just that the drugs and equipment were simply not to be had. Any patient who had a respiratory arrest, e.g. from medications administered or because of a primary pulmonary process, would have to be "bagged", i.e. ventilated by hand by the doctor as he/she was transported, several hours away, to another hospital that had ventilators.
There were separate rooms in the hospital for a female and male ward. The rooms were not that large, and each had 6 or 7 beds and essentially no privacy, not even a curtain around the bed. The one bathroom was shared.
There was a separate, "isolation room" of similar size in the hospital. This was a room created several years ago for an anticipated cholera outbreak which, as yet, has not happened in Costa Rica, but did in nearby countries. This "isolation room" has no door, and as far as I could tell, looked just like the other "wards", but had a separate bathroom.
One smaller room housed some broken chairs and a couple of cribs. Curiously, all of the beds, gurneys and cribs looked old and worn, and had labels on them stating something like: Property of Plantation Hospital, Florida. Pablo explained that when this hospital in Florida went out of business, they managed to obtain some of the furniture and supplies they were tossing out.
Pablo showed me this room and described some plans he has for turning it into a hospice. Often, patients from the region are cared for at home when they are in the terminal phase of their illness, but many times this becomes overwhelming for the families. He wanted to create a hospice room for dying patients to be cared for when they can no longer be cared for at home. They still need beds for the patients, and he wanted to create it so that family members could stay with the patient as well.
Later in the morning, Pablo again had to go back to the emergency room, and he left me in the doctor's "lounge" with one of his colleagues. There isn't really a doctor's lounge, but there is an on-call room which doubles as one. In it there is a bunk bed, a sink, and a plastic chair. There is a TV, and telephone. On the bulletin board was the call schedule. It looked like any other on-call room I'd been in! I chatted with one of the other doctors during this time. This was exclusively in Spanish, but having spent 1/3 of my residency training working in the county hospital in San José, California, my medical Spanish wasn't too bad. This doctor was in his late forties, and was very enthusiastic about meeting me. About 8 years ago, he had apparently had a neurologic condition called a Wallenberg Syndrome which he proceeded to describe to me in detail, and excitedly told me about his complete recovery. He is an internist in San Vito, and I asked him how long he had been there. He replied, 10 years. I then asked him where he was before that, and he said Romania!
I was surprised at the Eastern bloc/Soviet connection of these doctors, and asked about it. Apparently up until a few years ago, these countries offered scholarships/medical training all throughout the third world, and this doctor estimated that as many as 10% of practicing doctors in Costa Rica were trained in some Eastern European or Russian medical school.
Apparently, the US offered no such deals. Surely, this was done in exchange for something (bananas? other goods or raw supplies?), but I didn't expect that. The capital city of San José, Costa Rica, has the big medical school where most of the medical training takes place now. As part of their service, the trainees are frequently required to spend some number of months in outlying areas, such as San Vito.
At one point, 5 or 6 years ago, Pablo had set up a program for medical students from Stanford University Medical School to come down to spend one month learning rural primary care. The first two students came, and he said it did not work out. The students were women, and they apparently reported back to them that they had a bad experience with the men there (getting hassled, etc.) and did not find that acceptable. This is not something I found to be problematic while I have been there, although usually I have been in the company of other men while in Costa Rica. I know that Gretchen often goes jogging alone in the street in San Vito when she is working there, and I haven't heard her say she has been hassled. In any case, it seemed sad to me that this one experience soured Stanford on this particular rotation for students. In the meantime, the hospital at San Vito has developed a relationship with the Harvard pediatric residency program, and they send one of their senior pediatric residents down for one month rotations in their final year. That is surely a very worthwhile experience for the resident, and probably a boost for the hospital as well.
The hospital has a small laboratory for blood counts and serum chemistry studies. There is also an X-ray room where basic radiographic studies (chest, abdomen, limbs) can be performed. Anybody needing more sophisticated studies travels about 3 hours to San Isidro or else to the capital city, San José, about 6 hours away. Many of the emergency cases are the same types of emergencies we see here; however, with the advent of motorcycle use down there, accident victims are on the rise. There is also a fair number of machete wounds which need suturing. Pablo said that, as in America, many poor people use the emergency room for their general medical care. He said there are some, (as in America) who abuse this to the extent of coming there for food and soap.
Regarding infectious diseases there, TB is prevalent among the Indian population, especially the children. Pablo also said that giardia (intestinal parasite) and ascaris (intestinal worm) are also prevalent.
They have also recently discovered an as-yet undescribed gastrointestinal parasite which somehow affects the blood vessels in this region; they call it some type of "angistrongylus", and appear to be able to diagnose it by blood test, but there is no known treatment for it yet.
Pablo is greatly loved and respected by the entire community. He had just stopped smoking, and frequently took small breaks from his work in the hospital to run across the street (dirt road) to one of the little cafes to drink a cup of black coffee when he felt the cigarette urge. I followed him over there on one of his breaks, and as soon as he sat down, two little boys, about 6 years old, came running up to him. One had hurt his finger the day before, and it was quite swollen and red. It was clear that Pablo's work never ends...I was so impressed with how dedicated he is.
It was helpful for me to actually see the hospital, meet the doctors, and see the equipment they had (or didn't have). I do plan to return next year, and will spend the next few months trying to arrange for more supplies to be delivered. It was actually true, they did need literally everything. There are not enough gurneys,beds or cribs, there are no trays for the beds, they need wheelchairs, crutches, IV infusion pumps, at least one working EKG machine, and of course, basic medicines. I'll see what I can arrange. If anyone reading this is interested in helping, do let me know.
Back to the general Costa Rica story.