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Community Health Engagement Coordinator Helps Students Explore Health Equity in US and Costa Rica
Erika Hood (far right), Dr. Michael Householder (in sunglasses and hat), BETH 315/415 students, and local children help with beach cleanup as part of a local initiative to ban single-use plastic in one Costa Rican city. 
Some of the students from Bioethics 315/415 in front of one of the local health clinics that form the backbone of Costa Rica's healthcare system.  
A poster at the university's 2017 Research ShowCASE sparked a conversation about health equity and an academic partnership between Community Health Engagement Coordinator Erika Hood, M.Ed, and Dr. Michael Householder, Associate Director, SAGES and Assistant Dean of the CWRU College of Arts and Sciences. Ms. Hood was the lead author on the poster "Creating Greater Destinies: Lessons learned from a resident driven approach to improve health, increase opportunity, and strengthen community," which focused on the REACH initiative's work with community residents to create health equity in low-resource neighborhoods. 

Dr. Householder co-teaches The Ethics of Health in the United States and Costa Rica (BETH 315C/415C) with Dr. Suzanne Rivera, Assistant Professor of Bioethics and Vice President for Research at CWRU. The course considers the bioethics of public health by comparing the radically different healthcare systems of the United States and Costa Rice and the effect these systems have on health outcomes in these countries. Per capita health expenditures in the US in 2015 were $9,536, among the highest in the world. However, the US ranks near the bottom of industrialized countries on life expectancy and infant mortality, among other health indicators. By contrast, 2015 per capita health expenditures in Costa Rica were $929, with health outcomes that are similar to and, in some cases, better than the United States.

The course focused on infant mortality as its primary public health indicator and revolved around a 12-day study trip to Costa Rica to meet with public health professionals and providers in both rural and urban areas. Dr. Householder asked Ms. Hood to be a part of the course and the trip to provide students with a hands-on perspective of community health engagement from an American perspective. 

In some ways, the Costa Rican health care system is built from the bottom up. Health care is a constitutionally guaranteed human right, and universal health care for citizens and residents is provided through the Costa Rican Department of Social Security (CCSS or “the Caja”) and financed by employers, individuals, and the government. Services are also available through private providers. The country's service network consists of seven national/specialty hospitals, 31 major clinics and regional hospitals, and 947 primary attention units that provide the first level of care. Each of these units functions as a neighborhood clinic, serving approximately 4,000 people. (Costa Rica has a population of just under 5 million.) Each clinic is staffed by a physician, nurse technician, pharmacist, records clerk, and primary care technician and is run by a community advisory board. This local focus gives community members a direct voice in their healthcare system. 

In her work with the PRCHN's IMPACT study and REACH initiative, Ms. Hood worked directly on health disparity projects with community members who are directly affected by systemic racism and marginalization, which leads to disinvestment in their communities and poor health outcomes. Her participation in the course as a Contributing Instructor provided students with on-the-ground knowledge about community-based initiatives, how residents really feel about the issue, what priorities residents identified to address the issue, how to inform other community members, and how to engage with a community about serious issues that impact their health.  

Ms. Hood met with the students before the trip as part of a panel in which she discussed her role at the PRCHN and with REACH, as well as her work managing the 44128 One Community Infant Mortality Collaborative. She then accompanied the class to Costa Rica to provide another lens through which students could view the country's health care system. Dr. Householder states that “By sharing her experience engaging community members in public health, Erika helped students recognize the importance of looking beyond health care providers and government agencies for solutions to Cuyahoga County’s infant mortality problem.”

Ohio and Cuyahoga County in particular have among the highest infant mortality rates in the United States. In fact, Costa Rica's infant mortality rate is slightly lower overall than that of Cuyahoga County. Over the past five years, the city of Cleveland has averaged about 13 infant deaths per 1,000 live births, which is twice the national rate. While the rate of infant deaths declined slightly in 2017, Cuyahoga County still has a tremendous racial disparity in infant mortality rates. In 2016, three times as many black infants as white infants died in the county. Ms. Hood was saddened but not shocked to see evidence of similar racial disparities in infant mortality rates in Costa Rica. "it is just a reminder that no matter where you go, people of African descent are marginalized and, in turn, disparities will exist," she says. "We have a lot of work to do in order to change this narrative."



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