QCOSTARICA – January and February will be critical months for medical services in Costa Rica, with an increased risk of collapse in hospital services for patients than ever before during this health crisis.
Experts in infectology, epidemiology, and demography predict that the number of infections, hospitalizations and deaths from covid-19 will rebound in these first weeks of 2021 after the relaxation in the practice of basic measures; among them, maintaining social bubbles, respecting physical distancing and using masks well.
Many people – at least one in four, according to an opinion study by the University of Costa Rica (UCR), published in December – recognized that they would break their social bubble and share with others to celebrate Christmas and the end of the year.
Just a peek on the streets in these last days of 2020 to notice the return of vehicular congestion and the tumult of people in the main commercial avenues and centers of the country.
“The mobility of people has increased, especially since July. The maximums of relative mobility were registered in December, which will imply, I believe, a greater number of infections by the end of 2020, and the beginning of 2021. It is highly probable, yes, a collapse of the health service delivery system.
“The staff of the Caja (CCSS) is not infinite. And other than that they are not robots. They are people who need rest. They are people who are exhausted and overwhelmed because they are constantly exposed to risk.
“We find many factors that come together at this time to make us project less positive scenarios for the beginning of 2021 because we are going to see, at least in the first two months of the year, the effects of the very probable increase in cases due this year-end,” says epidemiologist Juan José Romero, director of the Master’s in Public Health at the Universidad Nacional (UNA).
The increase in the mobility of people runs parallel to the increase in the number of cases of SARS-CoV2, the coronavirus responsible for covid-19.
It has also been demonstrated, with studies of the State of the Nation Program, that less mobility associated with the sanitary vehicle restriction contributes to slowing down the spread of the virus throughout the territory.
“I call it‘ surfing the wave ’(measures to contain pandemic): learning to surf it to get to shore safely is part of what this should look like.” Dr. María Luisa Ávila, former Minister of Health and pediatric infectologist
Economist, health worker and demographer Luis Rosero Bixby agrees with Romero. According to the specialist, “what can be expected is a significant rebound in the pandemic.”
“Since mid-November, the situation of the pandemic in Costa Rica is very strange and unexpected: there was no increase in the R rate that should have resulted from Black Friday, the long weekend of November 30, and the payment of the Aguinaldo (Christmas bonus).
“Something strange is happening among us. Hopefully, it is not artifice or bias of a lower degree of case detection. And I hope this unexpected phenomenon is repeated and there is no increase with the Christmas and New Year’s Eve parties. However, objectively, what we can expect is a significant rebound in the pandemic,” Rosero noted.
In his analysis of 2020, the demographer clarifies that, although the number of cases did not increase in recent weeks, deaths and hospitalizations did increase.
“In part, it is associated with an increase in the proportion of cases that are seniors (personas adultas mayores – PAM). We have gone from 6% that are PAM until August, to 10%. Therefore, they are people with more complications. Of course, this increase may be an artifice that we are detecting fewer cases of covid-19 among young people,” he warned.
2020 closed with 169,321 accumulated cases since March, 2, with 185 deaths and 590 hospitalized, 239 of them in an Intensive Care Unit (ICU), according to the report of the Ministry of Health with data as of December 31.
Social ‘Burn out’, the trigger
Fed up is one of the words that could best define what many people are experiencing ten months after Costa Rica declared a national emergency and that among its consequences is the relaxation of measures: that people are so tired to respect the basic protocol to go out or get home after being exposed to a higher risk scenario such as public transport.
Pediatric infectologist and former Minister of Health, Dr. María Luisa Ávila Agüero, recognizes the existence of this social ‘burn out’ (burnout syndrome). People, she says, are undoubtedly affected by the confinement.
This confinement and limitations to move with the freedom that was previously had, Avila says, bring with them mental health problems (anxiety, depression).
“These are variables that are producing great depletion. The potential risk of this wear and tear is to relax the measures that have been recommended. In the beginning, we thought it was six months, but we are already on our way to the year.
“This is a double-edged sword. They are measures in which the risk-benefit must be weighed. The vehicle restriction has worked to contain the dispersion, to save time, and to gradually modulate the appearance of new cases. I call it ‘surfing the wave’: learning to surf it to get to shore safely is part of how this should look,” said the former minister of health.
Avila recommends only leaving home when necessary, and if you must go to places where exposure to risk is greater, comply with discipline with physical distancing, correct hand washing, and the use of a mask.
The so-called social determinants of health have come to the fore with the pandemic, which has been confirmed as a phenomenon beyond health. For this reason, it has been called a syndemic.
For Avila, those determinants of health, such as employment or education, have suffered a huge impact as a result of the covid-19.
“There has been great damage, but still there are deniers, who believe that the virus does not exist, that the mask does not work at all and they believe that this is a government plot. This, unfortunately, in an era where communication is so fast, it reaches a lot of people,” said the good doctor.
For Juan José Romero, this pandemic exposed many of the social deficiencies and inequities, which came together and be the breeding ground for this virus to produce greater damage than extreme poverty could have caused (almost 113,000 households are in that condition in Costa Rica; more than 435,000 people) and unemployment.
In addition, discovered was the existence of people not covered by the health system.
From July 2019 to July 2020, the number of extremely poor increased by 1.8 percentage points, that is, 96,697 more people according to data from the National Institute of Statistics and Censuses (INEC).
Unemployment, meanwhile, reached a historic figure last year: 24% in the second quarter of 2020, which implied an increase of 12.1 percentage points compared to the same period in 2019, when it stood at 11.9%.
“People are fused by everything that covid-19 means, both because of fear, mistrust, excessive precaution not to become infected or infect others, but also because of the effects it has had on individual and family economies.
“This is going to have an effect in the medium and long term. This whole scenario is a substrate for people to tend to have greater laxity with protocols and violate distancing. We try to expand bubbles, and we create work and friendship bubbles (…),” adds Romero.
Luis Rosero Bixby predicts an increase in economic and social inequalities.
“It seems that economically those who have lost the most are the lower-income groups and the informal sector of the economy. And a serious social gap is growing: that of education. This gap is above all qualitative.
“Children from the lowest social strata are receiving an education of much lower quality than groups with good access to the Internet, computers, and with the support of their parents or guardians in virtual education,” says the demographer.
On the other hand, specialists see hope in vaccination, although they warn that due to the global availability of vaccines this will be a slow process and that it will require complex logistics to complete successfully.
The first vaccines (Pfizer/Biontech) arrived in Costa Rica on December 23, and the first vaccines applied on December 24, and it is expected to reach 3 million people in the course of this year.
