 I'm really, really delighted to welcome you to our spring celebration, Open House for the MPH students. Today we had about 10 incoming students into the program. We're expecting between 20 and 25 students to join us in the fall. But I hope by now they're already impressed that those who came to visit have made up their mind to join us in the fall. We have a snippet of what we do every Monday, which is to have a seminar series. We have guest speakers from all over the country, sometimes from all over the world, and every other week we need to discuss what they taught us in the previous week. I think it's a wonderful feature of the MPH program. And many times these are sponsored by faculty members who are doing research in the topic area, or have gone out to actually interact with the speaker in their own country. And today's speaker is really, really my pleasure to meet him for the first time after we've had several months of email correspondence. And the interaction began last summer, I think with one of our professors, Dr. Susan Abig, taking students to his institute in Costa Rica. Some of those students are here today. And today is also the National Public Health Week that we're kicking off a series of events that the Public Health Association is putting together for this week. So it is really my distinct pleasure to introduce Director Bernardo Aguiar Gonzales, who directs the Foundation Neuropropica in Costa Rica. I don't speak Spanish. I started talking a little bit this morning about the role of foreign language in global health. And as it turns out, he knew all about my postman, J.O. Boone. And it's one of those cultural things that you can never shake, and that if you have the excitement to travel around the world to pick up certain cultural and language issues that will always be of use to you. But he's going to talk to us today about a topic that is very critical as the world changes population growth. Conservation issues become more important, and social and ethnic and economic disparities continue to be at the forefront of what we mean by healthcare. So in this particular case, he will discuss linking social and ecological determinants to public health, case studies of disparities in conservation and development in Costa Rica. Please join me in welcoming Bernardo to the public. Thank you very much for inviting me. Thank you very much for actually proposing to have this activity and to let me give you a little bit of my views, my perspective, and what we gather from our own experience and research back in Costa Rica while we're having lunch. I mean, that is quite a challenge. I have to deal not only with keeping your attention up, but also beating the alkaline tide that is coming in. You know, if you finish your sandwich while I'm talking. So I really, really thank both Susana and Deli for the effort of having me here and allowing me to share some of this with you. It has been a pleasure to actually be in contact with University of California Irvine students for the last three years since I started having a relationship with students that would come from the Public Health Program and now with the Public Health Program. So today, as Deli was saying, I'm going to be addressing this particular topic and it would be a way also of raising some interest in the things that I think you can come and do in Costa Rica. Here I'm not going to get as far into the slides that I have. I have some slides of Dr. Vick in the field while she is fighting the mod that are quite interesting. But today I'm going to, you know, with you I'm going to get to the point where I actually lay out the questions that may be of interest to graduate students and faculty alike. First of all, I would like to ask a license from you and it is if I may be so bold as to remove my jacket. You're okay? So first, just a little introduction about my organization. If you have ever heard of the National Park System of Costa Rica being one of the most prestigious things that our country has achieved, Pundasino Tropica, the organization that I direct, was created around the same time as the park system was created and it was created by three of the founding fathers of the National Park System, three biologists whose names would not mean much to you if I told them, but believe me that they were three of the founding fathers of the National Park System, okay? So we've been around for about 25 years and we came up with the idea of working on sustainable development around 1985. Around 1985 we would, you know, come to the field and start saying, well, we're working with sustainable development and they would ask us, well, what is that? So we'd be in trouble. So we would call the United States universities like this one and we would call the European universities and we would ask them, hey, can you send us, you know, some definitions and experiences with sustainable development, please? And they would reply to us, you know, actually, whatever you learn, why don't you send it to us? Because we are in the same dilemma right now, okay? And may I remind you that the Brahman report came out around the late ages, not in the Middle Ages. So we were pretty much learning from mistakes. Our idea, our initial idea was to promote the fair and intelligent use of natural resources through innovative initiatives that promote human development. So we are in the business of apples and oranges. You can find more information on our website. I have a few cards here too. So if you're interested in, you know, more detail about our programs and so forth, I welcome you to go there. Anyway, my favorite metaphor as to sort of illustrate what we do is to use this little Venn diagram. Some of you have already seen this because you've been in my course. You've seen this Venn diagram that people have, you know, beaten down so many times to say, well, you know, it's an interaction between the economy, the social and the environment, right? Any of you have seen this? Yes? No? Maybe? Yes, of course. Well, for us, the important part is not so much the dimensions that are included there, but the fact that you, in order to be really effective as of sustainability, you need to build it based on the little pieces, okay? And those little pieces are the context, the specific context that you're working with. So be it a bioregion, be it a community. It is about going down to the lowest level of detail in order to understand what really is happening in those contexts rather than trying to find universal solutions. So in our case, we have chosen to actually go down to that level and try to focus on the environmental conflicts, okay? The environmental conflicts that actually prevent us from attaining sustainability. And we feel that those conflicts come a lot from the unfair distribution of the costs and benefits of sustainable development and conservation. So that's our specific focus. We try to address that through three programs, community empowerment, sustainable productive solutions and global environmental citizenship. I will be speaking a little more about the global environmental citizenship idea this afternoon in the student's meeting. But basically, we are taking the Agenda 21 concept of global environmental citizenship and somehow articulating it and relating it with our own programs. Okay, just a geography check. Everybody knows where Costa Rica is, right? It's Costa Rica, not Puerto Rico. Okay, so, right there. That one. Not the one a little further east. Now, this country had the crazy idea in the middle of the 90s to actually do something that is very daring. How many of you know what percentage of Costa Rica's land is in protected areas? That's part of the marking page that everybody gives you when you're going to Costa Rica or even if you call a travel agency. 87. No! 75 percent? No! 50. Ah! No. It's 25 percent of its territory that is in protected areas, okay? But since about 1996, we made a decision to actually divide the whole country into a network of conservation areas, okay? So how many do we have here? One, two, three, four, five, six, seven, eight, nine, ten, 11. 11 conservation areas. Now, in these conservation areas, Costa Rica has set itself for the challenge to manage resources by our region, okay? So it is a mandate of our environmental policy that all of these regions are going to integrate the whole grid of landscapes into sustainable management units that involve not only the protected areas, okay, but also involve the areas where humans are living, including buffer zones, non-buffer zones, I mean, whatever is in there must be managed in a way that harmonizes the goals of development and conservation in the nation. Now, that, you know, is a really ambitious project that actually includes 100 percent of the country. So the clarification of how much is in protected areas and how much is our project of conservation is important, okay? 25 percent is our protected area system, but we want to actually manage in a bioregional way 100 percent of the country. So that has been one of the parts that establishes our reputation as a green republic or a green nation. So for that, we have a few more things. 95.9 percent literacy rate, not bad for a country that was graduated recently from being a developing nation by the U.S. aid standards of GMP. That was about 10 years ago. Costa Ricans have a constitutional right to a healthy and clean environment. This is something that many countries in the world, including the United States, cannot brag about. We can. How effective is that? We'll talk about that, but we do have a constitutional mandate that allows us to go to the constitutional court and sewer developer, because they are infringing upon our constitutional right to a healthy and clean environment. Just like in the United States, you tried to do when you were negotiating NEPA, which failed. So Article 1 of NEPA was renegotiated, reshaped, and it ended up being a watered-down focus on environmental impact statements, rather than a national environmental protection act. So many countries in the world would want to have that. Well, we got that in the mid-90s. We have a biodiversity law that actually establishes that all resources from biodiversity are public, or are public property. What does this mean? Well, it means that you cannot just go into a Costa Rica rainforest and put a patent on this. Okay? So the benefits of that biodiversity are to be managed and remain for the common of the people that live in Costa Rica are its citizens. No army. I'm sure you have heard this. It was outlawed in 1948. So it's unconstitutional to have an army in Costa Rica. People who have double citizenship between Costa Rica and the US are in big trouble, okay? Because that poses a whole dilemma. Can you actually refuse to participate in the army based on, you know, being a double national with a country that actually forbids to have an army? Kind of a Quakers dilemma. Anyway, those are some of the things that we like to talk about when we talk about Costa Rica as it is enlightened and socially and environmentally enlightened countries. Now, health care-wise, 79 years is our life expectancy. Not too bad. Here we are. Teeny battery. So that's not too bad. And in fact, we're well known around the world for, you know, in fact that about 150,000 tourists come per year for medical tourism in Costa Rica. Lots of plastic surgery. Other kinds of things that are more affordable. Lots of dental work, too, and so forth. Our mortality rate under five is also quite high. I mean, quite low. I'm sorry, quite high in terms of ranking. 94% of birds are attended by skilled personnel. Malaria mortality is also very, very low. Right? Social indicators, okay? And this is the result of historical conditions that brought the country to have a very progressive environmental revolution if I can use that term in the mid-90s and also a very, very strong welfare state after the 1940s. Now... Yes? Does the constitutional right to health include free access to health care? No, the constitutional right I was talking about was healthy and... Yeah. We do have... We do have the establishment of an obligation in the same article of the state of procuring the best standard of living to the people of Costa Rica. And our socialized medicine system is a constitutional socialized medicine system. So that creates a right to health. Okay, but it's not the same as a right to health as an article itself. It's a word rather than directly stated in an article. Yes? Nikoya Peninsula, right there. It's one of the Blue Zones, one of Butner's Blue Zones. One of those places in the world that are being studied because people live over 100 years consistently there. Yeah. And you know that Loma Linda here in California is one of those, too. Apparently Okinawa in Japan. And there's a whole bunch of conditions that are being studied. I know that Suzanne, I see like her eyes. Eat nuts! Whole grain, culture is isolated. Family no smoking, plant-based diet. You know. And legumes and social engagement and constant modern physical activity and all those good things that supposedly make you live longer. They've gone and studied the fact that we have one of those Blue Zones. Alright. Then Butner has gone there and made reports about all business come out in the press. So, then why do I want to have this talk? Right? I mean who's familiar with this Holy Grail? So, it's just a pleasure. Can we call it a draw? Maybe, I mean, am I a Black Knight? Let's look at it a little bit beyond the surface. Costa Rica has indeed a very remarkable socialized medicine system. It's regionalized to the point that communities have little basic units of attention called device. Those plus regional clinics work to have a whole network that then ends up in regional hospitals. I mean, this type of infrastructure works. I mean, it does exist. Now, if you go to Wikipedia the source of 80% of the knowledge that all students manage nowadays you will realize that most of the citations in the section that says Health Costa Rica the newest of them are from 2002. 2002-ish, more or less. Okay? When it comes to health reporting if I'm not mistaken to be up to date is kind of important, right? I mean, if your indicators are not up to date there's a sign of something that's kind of not too good. Well, this report from 2009 by the Metro American Health Initiative does illustrate to us that indicators, management and administration of data and use and dissemination of health information are efficient according to a self-assessment of Costa Rican health authorities. Okay? So, we have a problem. Houston. This reason studied too by Morega Salas Melby who is one of those HPE economists that appear every once in a while. I count myself on them. Has studied the self-perceived state of health in Costa Rica. He's found statistical evidence to say that there is a significant difference in the regions of the country. So, it is not the same if I'm in the central urban areas than I am in a faraway area. Now, there are international studies that usually say, well, but you know, those people that don't live close to pollution in urban areas usually tend to be healthier. Well, that is not the case in Costa Rica. We don't really have evidence, statistical evidence according to this study that that is the case. In fact, people that live in urban areas are feeling that they are healthier than people that are living in some remote areas. This other study by the same scholar tells us that there is a coincidence between the areas of lower increase in public health expenditures and the areas of lower social development in this. You can see in the graph that the darker areas in the upper one are the ones that have the higher levels of social development. And in the lower graph you can see actually the areas where the highest percentage of increase in public expenditures in public health are. Now, some areas like down here along the Caribbean coast and some parts of the north coincide with the areas of lowest social development index. What is happening? We have a problem in terms of the investment that we are making in public health for some special reason why the fact is that it is coinciding with the areas of less social development. This is the disaggregated human development index of Costa Rica. 2005 is the newest information I can give. The darker areas are the areas of lower human development. The lighter areas are the ones that have higher human development. The indicators just as the human development index of the United Nations are life expectancy education and material well-being. The largest differences in the case of Costa Rica are determined by material well-being which is mostly influenced by income. Now this is the most urban area of the country. In fact about half of the population live in this valley in the central valley. Those that have experienced the courses down in Costa Rica may tell you that you are usually in the central valley wanting to run into one of the more sort of protected area in diverse areas of the country. Now do notice that in terms of income you also have a poll here this is mostly because of big infrastructure and tourism development. So the same here this is tourism development too tourism development and tourism development to make areas of higher income than the rest of the country. This is the index of human poverty. Here, dark against that highest poverty rates lighter is the lower poverty rates. Notice that some of the area here that was in higher income also is higher in poverty. This is because a lot of the income that is coming to those tourist areas is actually foreign investment. So it's generated there it brings higher levels of income for the area like a GDP but it doesn't trickle down to the population. So a lot of the communities that live there have actually a middle high level of poverty. Now in the rest it basically replicates the same central tendency that we have in Costa Rica with poor areas in the south Pacific and away from that central urban area. This is a promotional image for equal tourism in Costa Rica. What can you say about that social landscape? Is it familiar to you? Have you seen it, any place close by? I was thinking about this yesterday when you took me to Coronado del Mar. This is the Central Pacific. Actually this is Marriott Los Reinos. And this is one of those everything included packages places where you can actually go to the airport somebody in an air-condition that comes and picks you up takes you down to the resort, you go in there you know, you play golf eat well you can use a beach that has white sand that doesn't exist in this area of the country. But it's nice. So they brought it from another side of the country. You can go and have a wonderful condo and view of the terrorist landscape which was completely changed back there was a little forest we moved there and go down to the marina take your yacht for a ride and then you can go back get on the bus with the AC go back to the airport and leave. And you've had an equal touristic experience in Costa Rica. Now I'm not I mean, this is something that is being criticized by the Crest Center in the University of Stanford. There is a little bit of a tug of war right now between the idea of what does apply the ecotourism meaning in Costa Rica. I like to say, well, are we between green topia and green washing in terms of this particular case. Someone asked me is ecotourism a solution for conservation? And you're like, okay, well, let's talk about what you define by ecotourism, okay? Because there's different models of ecotourism. Now in the case of this type of investment it does coincide with some locations where, you know, some of the most popular national parks part of the influence area of this little resort is this wonderful little spot here in yellow, which is usually said to be one of the favorite places to visit by UCI students when they do our summer course. That's Manuela Antonio. Manuela Antonio National Park. Manuela Antonio National Park and Poaz National Park two of the most visited national parks in the country those are in yellow here and then the Zubal came. Then you have other areas that have very visited national parks as is the case up there in the north in Santa Rosa National Park and the others that are in orange also have quite a bit of visitors. The rest of them are ones that don't have a real emphasis. Now is conservation is the mixture of conservation and development really making a contribution to sustainability in Costa Rica is the type of investment that is being attracted by our natural attractions really, you know, benefiting all the areas of the country alike. What are the consequences of this in terms of public health? It really, I feel really concerned by the coincidence that I see between the levels of social development indexes which if they are white you know, I was telling you they are low and the density of protected areas. Look at this check this out, this south part of Costa Rica in the highlands here here okay up here let's add one more layer lots of external immigration is coming to Costa Rica because of the higher level of cross domestic product higher level of jobs are logical right? Well, that means also that there is immigration from neighboring nations in the case of Costa Rica we have three larger donor countries the first one being Nicaragua the second one being Colombia and the third one being Peru okay? now they go to the areas where the standard of living or work is higher the main exception to that is Nicaraguan workers which come a lot for agricultural work like, you know, Latin Americans come here to the US but the fact is that, you know, they are seeking to find work in those areas of higher urban concentration sound familiar? have you heard of a country that actually has a similar immigration issues? okay mere coincidence now, in term migration from rural areas is mostly focused on housing and work options so housing may not be a stimulus for people that live in the urban areas I mean, actually, Costa Rica is going through a process of suburbanization like the one that you have in states you know, like this one, right? I mean, people start with the leap rock developments and you start seeing people go farther and farther away because that's where houses are cheaper okay? but in terms of work people do tend to migrate from those areas where there's more protected areas so is that sustainable? what does that do to the social landscape of a country? does Costa Rica want to have a protected area system which actually induces people to get out of there? and then in case you didn't know 5% of the Costa Rican population lives now in the United States we used to be portrayed as this non-migrant country well, the fact is that we have 5% of our population here only here and everybody says, well, but Costa Ricans are so educated it's a real pleasure to have them there I mean, Costa Ricans come to the US and they all integrate because they're so well educated and so forth but I can tell you the 250,000 Costa Ricans that live in the United States only about 70,000 are documented coincidentally near coincidences most of them come from this area of the country and most of them live you know this in Patterson, New Jersey and in LA because cultural networks are already established there you start going to where the cultural networks are right? so that's what we have the Costa Rican population so this brings us to a situation of great contradictions in the country and there are a series of examples where you actually see very clearly the bad distribution of the cost and benefits of conservation and development one of them is this one lots of pictures, right? this is in Spanish, I'm sorry but it's an infographic that came out in the newspaper I'm going to use it to illustrate my point I don't know if I'm going to have time to go through the four slides that I have but I'm going to try to give you the best with this this is the central valley that I was talking to you about and in this central valley half of the population of the nation lives now there's one factor and it is water water quality by all practical means you could argue that this is the most important water shed in the nation because it provides the water for about half of the country's population right? now there's a little detail there's a little dark detail about this whole much volatility that few people know and it is the fact that that whole much does not have a water treatment system ok? so everything goes to the rivers all the everyone is done eating all the duty goes straight and wrong to the rivers the problem is so bad that one of the solutions that the municipal government has is that it doesn't allow people to connect themselves to the public sewer system anymore but they need to build by law septic tanks in order to deal with the problem while they actually build a treatment tank it seems like there is right now money from the international development bank in order to fix this problem but they've been saying that the money is there for a while so we're still wondering if it's going to be true the fact is that all this sewage waste and so forth comes down the stream into the main river that goes down to this watershed ending up in the pacific ocean now this is the central pacific here and this is a national park called carada national park carada national park has wetlands that actually do an amazing job at processing all the love that they gave from upstream and this is why actually you have a bridge here that crosses the main road that goes down to the central pacific where you can see these guys that's you know everybody's taking pictures of the alligators hey love to see the alligators they're huge big fat you know big crockies and they take pictures of them and you know if you're even more of a daredevil you can go down here and you can actually take a boat tour and if you go on the boat tour you realize that you're you know amidst tons of plastic bottles tons of tires tons of you know all sorts of solid waste you actually can go to this sorry you can go down let's let her rest there you can go down to this little mangrove reserve that is here which actually provides the service of night sleeping for the macaws that are in Karara National Park and you can you know go through the mangrove and in the mangrove you can find women's stockings at this height you know or plastic bottles at this height amidst the mangrove trees you can see nice pink flamingo looking birds that are going to be you know kind of stepping on their way around the crash and so forth and if you talk to the people that actually live down here in the fishing villages they'll tell you know what every day we have to actually go with our boats further out in order to be able to fish okay textbook 101 example of environmental justice problems Costa Rica and water companies that is such a good question wells wells it's impossible to I mean they do around the coast they do have mostly groundwater is what they use as a septic tanks and water wells indeed actually if you see some of the designs you know where the septic tanks are being built for the hotels I mean don't get me wrong but this is a country that has an extremely high water table like your country you know it's a tropical country and you know that permeability to 100% is you know unlikely when you're building septic tanks made of cinder blocks so they build them made of cinder blocks there's some permeability that is happening you know sometimes you see a septic tank less than 100 feet away from the ocean so guess what's happening we're all sharing love I mean excuse me for being so it's crazy you know hey you know I'm just gonna apply I'm not gonna talk about this example because I think we're gonna consume all the time maybe yes okay so wetland conservation in that region where actually I was telling you about that is the South Pacific region where we have one of our centers and you're starting to see development that looks like this infrastructural development that river used to flow completely clear into the ocean in a marine national park you know what that does right who's familiar with dead spots erosion with with the amount of organic material that goes up there will bring you know a lot of bacteria into the ocean the bacteria will start eating the oxygen and you will have these spots not every time but sometimes actually become anoxic so what happens when a fish swims by kaboots and you start getting lots of dead fishes in the coastline well that's what this type of thing can do I don't need a PhD in engineering in order to know that there's something a little inadequate about the fact that the managing construction there especially thinking about the fact that it's the rainy season now in this area in this mangrove research ok we have the threat of that type of development that is advancing from the north we have the threat of hydroelectric dam that is being built by the government upstream these are mangroves so if you don't know this they are really affected by the change in the balance of sediments if they've been receiving a type of sediment for years then they have an established pattern of sediments and if you take away that sediment you're changing the ecosystem the mangroves are going to start dying basically and then somebody came up with the idea that you need to develop larger scale tourism in the region and you need to put an airport right there international airport and this is between the land wetland and the marine wetland so right there imagine it's 747 coming down close to a 70,000 acre wetland you know what what's the problem with that? birds there you go it's going to be suicide land wetlands the water mirrors attract lots of birds there they feed, they migrate they do lots of things and I don't know what kind of an environmental impact sediments are going to do but just by looking where they're putting it there may be some problems anyway this is the most significant mangrove reserve of its type in the American Pacific that's the reserve that is there and we promise so this is also the area as I was telling you that gradually sees more migration Costa Rica has been for the last months involved in a border conflict with Nicaragua Costa Rica and Nicaragua share a huge common border wetland this is the Costa rican side the Caíleg-Noreste national wetland and this is the national wildlife refuge of San Juan on the Nicaraguas both are Ramsar sites who knows what Ramsar sites are they're in protection because they are of international importance according to the international wetlands well the Nicaraguan government started building a canal to connect the river to this lagoon okay I really don't want to side on who did what right then the fact that one is pointing fingers at the other one that sovereignty is being discussed and so forth there's even google maps involvement in this conflict because everything started because google maps drew their border differently than it had been traditionally and therefore they claimed that that land was there so anyway without wanting to get into that one the fact is that it's not too big of an area that is under dispute I mean it's only about 500 acres up there but according to the Ramsar technical report the impact could be over about 50,000 acres of wetlands okay because they are changing the flow of the river and therefore they are changing the sediment conditions therefore they are changing the configuration of the whole wetland in fact some Costa Rican natural scientists are concerned about the fact that the increase in sediments here is going to break the bar that used to hold this estuary separated from the ocean and they are getting that sediment going with the current and it will in fact affect eventually the corals of national parks all the way to the south of Costa Rica okay now recently a man from the region where this is happening declared well actually this conflict has been a blessing because the health services they don't have anything in this area back to my point finally this is a protected area that is actually right next to the city of San Jose and what happened here is that they created this protected area this is part of the 25% that we were counting at the beginning okay what happened is that they created this protected area but they didn't make everything public land and that is a possibility according to some laws just as you have BLN lands in the US or you have national forests that are not old public land you can have that in Costa Rica now the only problem is that in this particular area you have two things one is that this whole corner is taken by what used to be the dump of the city of San Jose okay and the other one is that a little well actually large community of swatters established itself in what used to be a public area okay so what has been the consequence of that well according to the forestry law there cannot be constructions at a distance of less than 50 feet away from the edge of a river there's sewage pipes that come out of there okay you can see here as urban growth is actually starting to push into the protected area water pollution is really high I mean we have found their significant levels of hexadellum chromium anybody know what hexadellum chromium can do to you Erin Brockovich cancer also the levels of polyforms are off charts that's my understanding solid waste goes all the way to the river this is a protected area okay so this neighborhood is called beautiful view in the west it's all squires that do very heroic work in being able to build in these conditions so this is my question to you we feel that one of the reasons why we have this situation in the country is because programs like this one programs that actually seek to reduce the bridge between environmental health and public health are not developed in our country we don't have anything that actually does this bridging of apples and oranges in such a systematic and developed way as you all do it okay definitely students that help us bring into the need to bridge these areas of inquiry is necessary definitely we need to establish baseline studies that do the accounting of apples and oranges together don't get me wrong there are a few approaches that are actually seeking to do this in the country but it's not widespread it's not internalized by any means into the research agendas of the main research institutions of the country and over there develop intersection policies that benefit conservation while improving community quality of life and indigenous development options consistently are needed and some of the conservation efforts in Costa Rica were established with the I don't know the US model basically which is to put out a representative piece of landscape without taking into account the fact that people are actually close or nearby the Yellowstone syndrome some people actually call it the sheriff syndrome right sheriff walks into the saloon, shoots everybody and then says this town is really calm everybody buys by the law some people say that that's how some of our parks were created and if you in this sense that you know having the synergies of those who are working in ecosystem health with public health and trans disciplines as political ecology for instance would be something that would really really be key to actually be able to tackle contradictory issues like the ones that I've pointed to you and you know to definitely make Costa Rica to lean on the way of green topia