COVID-19 in Costa Rica: Navigating the Virus
By Luis G Solis
Costa Rica is a republic located in Central America with a population of 5 million. It is the oldest democracy in Latin America. Ruled by Spain until 1821, Costa Rica developed as a nation keen on public education and health, which got an investment fillip after it abolished the armed forces as a permanent institution.
In 1942, amid World War II, tiny Costa Rica in Central America experienced a transcendental transformation that would have a lasting impact on the country’s development ever since. Under the leadership of the President, a medical doctor imbued of Catholic social doctrine; supported by the Roman Catholic Archbishop of San José; and, with the enthusiastic endorsement of the Secretary-General of the Communist Party, the National Assembly enacted one of the most progressive Social Security regimes in Latin America. Incorporated into the Constitution and perfectioned through time, this regime provides the public, universal access to prime medical services, manages the mandatory pension system, and in doing so, has become the country’s cornerstone of political and social stability.
Nearly eight decades later, it also explains why Costa Rica, a highly indebted, middle-income country was able to navigate the initial impact of the COVID-19 pandemic successfully, becoming a ‘model case’, universally praised by the WHO, most multilateral health outfits and the international media. Indeed, in a world capsizing by the terrific impacts of the pandemic and surrounded by countries devastated by a combined lack of timely and adequate health decisions regarding the crisis, Costa Rica shone as a hopeful, albeit exceptional example to follow.
Why was this possible? Furthermore, why did Costa Rica become increasingly incapable of withstanding the pandemic once the Government decided to lift the containment measures and opened the economy?
Health: Public policy and institutions matter
The first and foremost reason why Costa Rica has been able to handle the pandemic is because of its strong, scientifically and professionally savvy, well-financed public healthcare system. This is no small accomplishment. Nor can it be improvised overnight. As mentioned before, Costa Rica has seen the Social Security Institute (CCSS in its Spanish acronym) thrive through the decades and become the most important institution of its Welfare State. An institution that works permanently and with the highest medical standards towards the health needs of its population. One that, thanks to its financial structure based in a tripartite contribution of the State, employers and workers, offers universal coverage to all, including those who are unable to pay because they are either indigents, unemployed or impoverished migrants.
Costa Ricans enjoy a very sophisticated framework of health policies handled by the Ministry of Health as rector and distributed throughout the country by the CCSS. From primary care to open-heart surgeries and liver transplants, from vaccination programs strictly enforced by regulations under the care of communal clinics to nation-wide mental health, nutrition and sex education campaigns, the CCSS is capable, on a permanent basis, of administering and operationalizing the services it routinely provides with the support and endorsement of the public.
Other than the ‘structural’ and conceptual bases upon which the health system has been built, which are responsible for its legitimacy within the body politic of the Costa Rican State, the existence of the CCSS has given the country notable health indicators that rival those of Scandinavia and surpass those of the US and many European Union members. This means that the population was better prepared to withstand the impact of the pandemic, was used to believing in the health provisions and protocols requested by doctors, act accordingly and receive up-to-date and reliable information from the system. Many times, this information was the result of significant institutional research as well.
The CCSS, which is autonomous from the Executive branch, has also been capable of counting on its own financial resources (and with the support of the State when necessary) to buy the equipment it requires to provide first-class medical services in increasingly modern clinics and general hospitals. True, the pandemic caught the CCSS off-guard regarding the inventory of sanitary materiel during the first weeks of the crisis. Yet, the deficits were covered fast enough and mostly did not hurt the overall handling of the pandemic because the contagion indices and death rates never surpassed 2% and 0.18% respectively for more than 80 days. This would become a crucial issue as the situation gradually deteriorated after the month of June (2020).
Economic opening and worsening health conditions
Costa Rica was no exception to the bitter debate between the advocates of aperture, and those insisting on the need to delay it until the downward trends of the pandemic could be certified. Throughout the world, this debate went on for weeks, particularly as all the economies took a plunge, and national and international trade, tourism, finance, and business indicators collapsed. In the United States, the Trump Administration stand to force the re-opening of the economy, which in fact, required the loosening of the strict controls imposed upon social behaviour for many weeks, became a ‘model’ that many business and political leaders promoted in other countries. Parents were also eager to see their children resume classes, and the public, in general, especially younger people, wanted to go back to unrestrained socialization practices. Despite the warnings of the experts that kept cautioning about the dangers that an abrupt end of the sanitary measures could produce, anxious citizens stormed the streets, beaches, bars, and other recreational spaces. The exemplary behaviour of the previous months was soon lost, and small but extremely vocal groups of fanatics began to undermine the restrictions, accusing those who favoured or advocated those of being ‘unpatriotic’. The insane fights over face masks as symbols of ideological wars is a good proof of this.
Three factors worsened the situation in Costa Rica. Firstly, the public’s disregard of the national reality once the control measures were lifted. Significant numbers of people misinterpreted the Government’s ‘flexibility’ as an announcement of the end of the pandemic. While the health authorities never ceased to appeal to common sense, providing daily data about the increasing numbers of the sick; the public simply did not care. This new attitude was bad enough, but in becoming the ‘new normal’ amidst other very troubling factors that appeared simultaneously, it reconstituted a favourable environment for the virus’ propagation.
Secondly, thousands of Nicaraguans come into Costa Rica as seasonal labour in agricultural and cattle venues. Working under less than favourable conditions, underpaid, underfed, and living in unhealthy, crowded spaces, these Nicaraguan nationals soon became another source of contagion. The Nicaraguan Government has refused even to acknowledge the pandemic, and therefore, has taken no precautionary measures to control it. Neither has it implemented emergency protocols nor provided updated, reliable information regarding the health situation in the country. The lack of sufficient controls on the part of the Costa Rican authorities added to the reluctance of agricultural businesses to improve the conditions of their ‘imported’ working force, produce alarming contagion curves both in the northern part of Costa Rica (adjacent to Nicaragua), as well as farther south, where many sick people sought medical attention.
Other Nicaraguan migrants fleeing the dire health, economic and political conditions in their home country, also enter Costa Rica illegally by the thousands. This population, which generally lives in the surroundings of the bigger cities of the Central Plateau (where the capital, San Jose, is located), is also prone to contagion due to their harsh living conditions. While there is no medical evidence that the Nicaraguan population is to be blamed for the significant increase in COVID-19 cases in the country, it is always easy to signal them as being responsible for it. Luckily, xenophobic expressions have been mild so far and have not gone out of control. Yet this is a threat that cannot be overruled as the numbers of seriously ill and dead persons increase.
Lastly, the pandemic arrived in Costa Rica at a time when the economy was already faltering. Suffering from endemic indebtedness (over 60% of the GDP), a high fiscal deficit (more than 9%), a significant population of poor and extremely poor citizens (over 21%), and facing an unemployment rate of over 12% in 2019, the country was struggling to overcome decades of less than optimum economic performance. The pandemic further worsened these indicators. It also destroyed many productive ecosystems, particularly the two upon which the country’s economic well-being depended: highly sophisticated medical devises (over 54% of all exports), and tourism (3 million visitors a year; the single largest service sector in the country). Hence, in Costa Rica as in the rest of the World, COVID-19 became not only a health but also a socioeconomic pandemic.
Within this context, it was very difficult for the Government of President Carlos Alvarado to keep the economy closed. Neither could it withstand easily the intense pressures from the public (eager to go back to work or even to start finding jobs) and the powerful private sector chambers. He also had to face growing animosity from the political opposition, eager to undermine his popularity after emerging victorious from the first stage of the pandemic, and with an eye on the next national elections in February 2022.
Thus, loosening restrictions, worsened by the factors mentioned before, inevitably produced a spike in new contagions and deaths. According to the Johns Hopkins University site, in less than 45 days, the death toll in Costa Rica increased from 6 (total in the first 80 days of the pandemic) to 40 (one a day) since the end of June 2020. Still one of the best cases in Latin America, and not having endured the collapse of the health system, Costa Rica is, nevertheless undergoing a severe phase of COVID-19 resurgence. Only Uruguay stands today as the ultimate successful model in the Americas.
The existence of a strong public healthcare system has been crucial in ensuring Costa Rica’s mostly successful handling of the COVID-19 pandemic. In the absence of it, the results would have probably resembled those of the rest of the Central American countries, including Panama. It is clear then, that enjoying such a system is important yet not sufficient to ensure a country’s capability to quench a massive crisis such as the one posed by the current pandemic.
It is still impossible to predict what the ultimate outcome of this pandemic will be. Yet, at least for Costa Rica, it will unlikely mean the kind of catastrophe that it has produced in the US, Mexico, Brazil, Nicaragua, and Ecuador. Having a well-grounded, social security system that is universal, financed by a tripartite, solidarity mechanism and accessible to the inhabitants regardless of their economic condition and national origin, makes the difference. The doctor-President, the priest and the communist lawyer were right, 80 years ago.
AUTHOR
Luis G Solis, Former President of Costa Rica (2014-2018); Interim Director, The Kimberly Green Latin American and Caribbean Centre, Florida International University
Disclaimer: The views and opinions expressed in this article are those of the author/s and do not necessarily reflect the official policy or position of Azim Premji University or Foundation.
