SYLLABUS

PM 599: ONE HEALTH: Intersections between Global and Planetary Health and Health Equity– Perspectives from

May 19-June 1, 2018 (14 days)

COURSE DESCRIPTION During this course, participants are immersed in activities and experiences that facilitate the internalization of concepts such as environmental health, global health and sustainable development, surrounded by the complexity of correlations between each other. This process of conceptual integration is mediated through problem-based learning, critical discussion exercises and a variable set of community interactions. Broad social and environmental scenarios and challenges such as migration, atmospheric pollution, water sanitation and hygiene, climate change, agro-industrial development, biodiversity loss, among others, and their respective extension to health and development will be the framework to generate efforts that identify strategies to address these issues. Each unit in this program brings unique case examples from Costa Rica to facilitate the experiential learning process. Option to stay an additional 4 weeks in Costa Rica to complete a practicum is available.

COURSE DIRECTORS Mellissa Withers, PhD, MHS Associate Professor, USC Institute for Global Health Keck School of Medicine of USC [email protected]

Shubha Kumar, PhD, MPH Assistant Professor, USC Institute for Global Health Keck School of Medicine of USC [email protected]

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Carlos Alberto Faerron Guzmán, M.D., M.Sc. Director, Interamerican Center for Global Health [email protected]

LEARNING OBJECTIVES By the end of this course, students will be able to: ● Appraise the complex relationships between health, development, politics, the environment, and the socio-cultural context. ● Analyze anthropogenic variations that are linked to emerging threats to the health of vulnerable populations. ● Analyze the current existing correlations between economic growth, consumption patterns, energy production and health of vulnerable populations. ● Distinguish the similarities and differences in health systems, with a focus between Costa Rica and the U.S.A. ● Outline health needs and inequities among communities in southern Costa Rica. ● Recognize the diverse set of actors and stakeholders related to a variety of global health and planetary health issues. ● Correlate the changing demographic, nutritional, and epidemiological profile of LMIC and its relationship with health and health systems. ● Assess opportunities and challenges for professional practice in the field of global health practice.

CONTENT OVERVIEW U Topic Case Study/Field Visit (see NI below for description) T 1 1 Human Rights and Health The Inter-American Court of ● Beyond health access Human Rights/ The Costa Rican ● The importance of civil society and Humanitarian Foundation advocacy 2 Understanding health systems in context: The The EBAIS/Hospital system in Costa Rican Social Security Fund Costa Rica ● Achieving universal health care: challenges and opportunities ● Comparative aspects of health systems Moving towards promotion of health 3 Global health architecture: perspectives from the Rio Sereno Costa Rica and border between Costa Rica and Panama Border Health Post ● Leveraging cross-sectoral partnerships to tackle complex challenges 2

● Trans-border health challenges ● Migration and health 4 Systems thinking approach to the determinants of Boruca Indigenous Community health ● Structural violence and indigenous communities ● Sexual and reproductive health issues in southern Costa Rica 5 Determinants of health focus: culture and health La Casona Indigenous Community ● Intercultural approaches to healthcare delivery ● Challenges in intercultural contexts 6 Dealing with the triple-burden: globalization and Community and Ministry the epidemiological, nutritional, and demographic of Health regional offices. transitions ● Ecosystem transformations and the impact on health ● Shifting diets, chronic diseases, and oral health 7 Climate Change and Health Playa Blanca and Rincón de ● Changing livelihoods ● The importance of mangroves 8 The importance of leadership in health UPEACE ● PERMA workshop

SITE DESCRIPTIONS

Inter-American Court of Human Rights The Inter-American Court of Human Rights is a judicial organ of the Organization of American States (OAS) based in San José, Costa Rica. The purpose is to apply and interpret the American Convention on Human Rights and other human rights treaties to which the so-called Inter- American system for the protection of human rights is subject. It deals with a broad range of human rights issues, and many times related to health, such as equal access to sexual and reproductive rights throughout the nations of the American continent.

The Costa Rican Humanitarian Foundation The Costa Rican Humanitarian Foundation (FHCR) is a non-profit organization committed to the development of creative solutions to a great variety of social problems in Costa Rica. The FHCR provides opportunities to exchange friendships, assets, services, and financial resources for critical needs among different cultures, socioeconomic classes, and language groups.

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Boruca Indigenous territory The ancestors of the modern Boruca constituted a group that governed the greater part of the peninsula of Osa. Known for their crafts, especially fabrics, and their unique masks painted in balsa wood. In Boruca we visit the educational Kan Tan farm. This site seeks the human and community development of Boruca and its visitors. It is based on fundamental principles of indigenous traditions, seeking to promote “development to establish human bonds and strengthen brotherhood among peoples”. In addition, a commitment is made to local indigenous families, indigenous children and youth. The activities here are varied according to the objectives and the permanence of groups and they range from the guided walks, to spiritual retreats, in addition to experiencing how the Boruca people live.

Rio Sereno Border Post Located on the southern border of Costa Rica, we find the migratory passage of Rio Sereno. A local predominate site for agricultural activities (, banana, cattle) and commerce. At Rio Sereno, we will find, but a few government buildings, a grocery store, and a couple of other small stores. Nevertheless, Rio Sereno presents the same social conditions of vulnerability of other migratory passages. Here, during the time of the coffee harvest in Costa Rica, we have the migration of around 15,000 Ngobes. It is in this place, where a series of health interventions are delivered. Interventions that address issues such as validation of human rights and labor rights, interculturality, sexual and reproductive health, prevention and promotion of communicable diseases, and vaccination and screening campaigns.

La Casona In the southern region of Costa Rica, province of , in the canton of Coto Brus, we find the Ngobe-Bugle indigenous territory of La Casona. With an area of 7900 hectares and an Indigenous resident population of more than 1600 inhabitants, the Ngobes are an indigenous group who have preserved to a high degree their culture, traditions, history, legends, arts and other ancient customs. The territory is made up of eleven smaller communities. However, La Casona is the place with the largest settlement. It is here that complex socio-cultural realities develop and it is easy to see how inequities determine health conditions. It is in this precise place that we address basic issues of global health such as interculturality, the relevance of “Asesores Culturales” (cultural advisors) as a means of contextualizing community realities, traditional medicine, midwives and validation of rights in the areas of gender, adolescence, and maternity.

La Cuesta - African Palm Oil and Pineapple fields One of the poorest municipalities in Costa Rica per Human Development Index, Corredores is a bordering canton to Panamá. Development policies have focused on facilitating the entrance of large corporations for the harvest of African Palm Oil and Pineapple. Large fractions of the land here are now dedicated to these crops. Environmental consequences have led to ecosystems transformations that are altering in a direct manner the burden of disease in the region. Vector 4 disease are changing in transmission patterns as well as a transition of nutritional intake of the surrounding populations. There have been reports of major contamination of the water sources in the communities near the plantations. For these visits, we rely on the collaboration from local activists as well as from members of the local Ministry of Health office.

Rincon de Osa and Playa Blanca Two small fishing communities facing the Golfo Dulce, they have been immensely affected by unsustainable fishing activities and drastic changes in sea level, coral reef bleaching, and mangrove destruction. They are home to a set of projects that connect environmental and human health issues.

TEACHING AND LEARNING STRATEGIES ● Field visits and on site key stakeholder interviews to observe and document key elements of global health. ● In-class discussion of readings, and workshops to stimulate alternative ideas, and approaches. ● Case study analysis and presentation on critical issues on global health to exemplify global health in context.

Participants will be engaged dynamically on a day-to-day basis, with approximately one-half in- class lectures and participatory activities (in the morning) and one-half of their day spend in the field (in the afternoon). This allows the necessary integration to enable participants to build competencies that allow them to more comprehensively understand and effectively work in complex and challenging global health contexts.

COSTS

Student Lodging, Meals, and Transportation

Most all of the expenses are included in the total program price of approx. $1,000 per person plus tuition. Participants of this program will stay in facilities such as research stations and hotels depending on program location. All locations will count with the educational facilities required for a world class experience, including Wi-Fi, lecturing rooms, dorms, among other services and amenities. Room and most meals are facilitated by CISG and included throughout the program. Dietary requirements and restrictions can be accommodated. Private daily bus is included, as well as the domestic flight to return to San Jose. Two full-day tours are also included (to Doka Coffee Farm/La Paz Waterfall Garden, and to Corcovado National Park.)

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STUDENT ASSESSMENT Students will be evaluated on the basis of their participation, collaboration and contribution to cohort learning. Immersive and experiential learning requires active participation from the student in the course. Attendance is obligatory throughout the program. In addition to attendance, students are expected to actively engage throughout the course and complete the required readings ahead of the corresponding unit. Appropriate evidence of participation and collaboration will be agreed between students and faculty before the commencement of the course. Students are responsible for compiling and presenting evidence of their participation and collaboration as a requirement for successful completion of this course. Students will demonstrate their knowledge acquisition from both their didactic learning and their experiential learning activities through the following:

Pre-trip Preparation 15% Complete assigned background readings, online training in community-based research and ethics, attend 3 pre-trip meetings

Reflective Journal 25% See instructions for more details.

In the Field 15% Active engagement & participation in all lectures & field visits is required.

Reading Reports 25% Individual paper answering three main questions that came from the assigned course readings and lectures. Due within 2 weeks after return from the trip.

Group Project 20% Working in teams, students will select a public health topic relevant to Costa Rica to research prior to & during trip. Groups will make a final oral presentation in Costa Rica. See instructions for more details.

ASSIGNMENT INSTRUCTIONS Reflective Journal (25% of course grade) Participating in international global health experiences can be transformative and life changing. This is especially true in a setting such as the ones that we will be immersed in, in which students experience a resource-limited environment, meet new people and observe new cultures. Students will submit a reflective journal based on the material covered and experiences in this class, including skills developed and the international experience in itself. This should be about 10-12 pages, double-spaced, with 11- or 12-point font and ½-inch to 1-inch margins. Students should begin the journal prior to trip departure to reflect on their assumptions and expectations for the trip in about one page. They should also write a list of 5 questions relating to the course topics that they hope to answer on the trip. Then, during the trip, students should write at least 12 daily thoughtful and well-crafted entries into the journal, which should include key takeaway

6 messages or lessons from the daily course activities (lectures, materials). Each daily entry should be at least one-half page. Then, after the end of the trip, students should write a final commentary/reflection of 2-3 pages. Due by June 15, 2018.

The following elements should be incorporated into the reflective journal: 1. Expectations and goals for this course, including why this appealed to you and the skills you hope to develop on this trip. 2. Description of reactions and feelings that emerged throughout the course- before, during, and after the experience. 3. Reflection of how the student’s own values, beliefs, and assumptions influenced perceptions of the Costa Rica experience. 4. Description of how the course will influence your future understanding, attitudes, and practices with regards to global health. 5. Overview of the knowledge and skills that were learned or advanced (thinking about the core competencies for the MPH degree)

Group Presentation (20% of course grade) Students will work with group members to conduct a literature review on your group’s topic before we leave for Costa Rica. A literature search should include at least 7 articles published within in the last 10 years. It is likely that 7 articles on your topic specifically from Costa Rica specifically so students can also search for some from other Latin American countries, as well as for reports published by UNICEF, the WHO, World Bank, etc. The objective is to develop an understanding of the country and the various communities that will be visited. Groups will continue to build on this exercise throughout the trip. The report should include historical, geographical, social, cultural and public health information regarding Costa Rica relating to the selected health topic. For example, if the topic is nutrition in schools, articles about similar nutritional interventions in school settings in can be included. Groups will make a 20-minute presentation at the end of the trip using up to 25 slides. The powerpoint presentations should be engaging and informative. ALL group members should actively participate. .

COURSE MODULE DESCRIPTIONS: Pre-trip Readings: • United Nations Universal Declaration of Human Rights. Available at: http://www.un.org/en/documents/udhr/

• Ouma, BDO, and Dimaras, H. (2013) Views from the global south: exploring how student volunteers from the global north can achieve sustainable impact in global health. Globalization and Health, 9:32.

• World Health Organization. Country Report: Costa Rica. (2015) Available at: http://www.who.int/gho/countries/cri.pdf?ua=1

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• World Health Organization. Noncommunicable Disease Report: Costa Rica. (2015) Available at: http://www.who.int/nmh/countries/cri_en.pdf?ua=1

• World Health Organization. Country Cooperation Strategy Report: Costa Rica. (2016) Available at: http://apps.who.int/iris/bitstream/10665/250646/1/ccsbrief_cri_en.pdf?ua=1

UNIT 1: Human Rights and Health

Through the interaction with NGOs working at the forefront of human rights and health advocacy, this unit will further the participants´ understanding to the interrelationships between human rights frameworks and health as a human right. Throughout the activities we will explore and broaden the different definitions of health in international agreements, and how the use of the human rights framework could be of use for health policy advocacy, good governance, and a transformative strategy for health systems. Readings: • World Health Organization. (2002) 25 [Twenty five] questions and answers on health and human rights. Available at: http://www.who.int/hhr/information/25%20Questions%20and%20Answers%20on%20He alth%20and%20Human%20Rights.pdf • Sen, A. (2008) Why and How is Health a human right? The Lancet, 13: 372. • Farmer, P. (1999) Pathologies of power: rethinking health and human rights. American Journal of Public Health, 89(10): 1486-1496. • Marmot, M. (2008) Closing the gap in a generation: health equity through action on the social determinants of health, The Lancet, 372: 1661-1669. • UN High Commissioner for Human Rights. Factsheet on the right to health. No. 31. (2008) Available at: http://www.ohchr.org/Documents/Publications/Factsheet31.pdf • Gruskin, S, Mills, EJ, and Tarantola, D. (2007) History, principles, and practice of health and human rights. The Lancet, 370:449-455.

UNIT 2: Understanding health systems in context: The Costa Rican Social Security Fund This unit examines health care systems and provides a better understanding of how health systems operate. The activities will cover a brief recap of the historical development of health care systems as well as the current models for financing and organizing health systems. We will further explore the role of promotion of health, prevention of disease and other non-medical factors in population health outcomes. A specific focus will be placed on the historical and

8 contextual factors that led the Costa Rican health systems to be considered one of the most efficient in the world.

Readings:

● Murray, CJL, and Frenk, J. (2000) A framework for assessing the performance of health systems. Bulletin of the World Health Organization 78(6): 717-731.

● Chapter 1. Why do health systems matter? In WHO (2000). The World Health Report 2000. Health Systems: Improving Performance. Geneva: World Health Organisation. http://www.who.int/whr/2000/en/whr00_ch1_en.pdf

● World Health Organization (2007) Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes. WHO’s Framework for Action. Available at: http://apps.who.int/iris/bitstream/10665/43918/1/9789241596077_eng.pdf

● WHO. (2008) Introduction and overview in The World Health Report 2008. Primary Health Care – Now more than ever. WHO. Geneva, Available at: http://www.who.int/whr/2008/whr08_en.pdf ,

● Frenk, J. (2009) Reinventing primary health care: the need for systems integration. The Lancet, 11;374(9684):170-3.

UNIT 3: Global health architecture and governance: perspectives from the ground Developing countries, more than others, face challenges that transcend their borders, and there is growing recognition that globalization impacts health outcomes and health determinants. Health- related decisions within a country are being affected increasingly more by the global political, economic, social decisions taken at other latitudes, compromising their national strategies. Specific attention will be drawn to complex bi-national challenges between Costa Rica and Panamá, specifically around highly mobile populations across both borders and extra continental migrants travelling to the US and beyond. A look at local successful cross-sectoral partnerships will provide a framework for future collaborative work for the participant. Readings:

● Ng N, and Ruger JP (2011). Global Health Governance at a Crossroads. Global Health Governance, 3(2).

● Fidler, D. (2007). Architecture Amidst Anarchy: Global Health's Quest for Governance (2007). Articles by Maurer Faculty. Paper 329.

● Maximizing Positive Synergies Academic Consortium. (2009). Interactions between Global Health Initiatives and health systems: evidence from countries. World Health Organization; Geneva.

● Frenk J, and Moon, S. (2013). Governance Challenges in Global Health. The New England Journal of Medicine, 368:10.

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UNIT 4: Systems thinking approach to the determinants of health Current understanding of the determinants of health can sometimes be reductionist and over- simplistic. These views hardly reflect the complex non-linear reality and interplay of the different determinants over population´s health. By visiting an indigenous community historically affected by structural violence (the Borucas), students will be able to understand the social/biological/ecological causal factors that negatively impact health more fully than is usually taught within a classroom setting. The immersive approach allows an introduction to the complexity of health and human rights, and the close correlation with economic development, politics, the environment, human rights, and the socio-cultural context. Readings:

● Jayasinghe, S. (2011) Conceptualising population health: from mechanistic thinking to complexity science. Emerging themes in epidemiology, 8(1):2.

● Subramanian SV, and Kawachi I. (2004) Income Inequality and Health: What Have We Learned So Far? Epidemiologic Reviews, 26: 78-91.

● Krieger, N. (2003) Genders, sexes, and health: what are the connections—and why does it matter? International Journal of Epidemiology, 32(4): 652-657.

● Lipscomb, HJ, Loomis, D., McDonald, MA., Argue, RA., and Wing, S. (2006) A conceptual model of work and health disparities in the United States. International Journal of Health Services, 36(1): 25-50.

● Adler, NE, and Newman, K. (2002) Socioeconomic disparities in health: pathways and policies. Health Affairs, 21(2): 60-76.

UNIT 5: Determinants of health focus: culture and health There is a need to visualize global health as an intercultural process that requires respectful approaches, tolerance, validation, ethics, horizontality, and contextualization. The prior involves considering the biological, cultural and social diversity of human beings and their influence in the process of health/disease. This unit analyzes the definition of culture/multiculturalism, identifies intercultural health needs, and works on limitations and opportunities of global intercultural health. The engagement with La Casona indigenous community and the local health system helps participants reveal the practical applications of the intercultural approach to health beyond this community. Readings:

● Napier, A.D., Ancarno, C., Butler, B., Calabrese, J., Chater, A., Chatterjee, H., Guesnet, F., Horne, R., Jacyna, S., Jadhav, S. and Macdonald, A. (2014) Culture and health. The Lancet, 384(9954):1607-1639.

● Spector, RE. (2002) Cultural diversity in health and illness. Journal of Transcultural Nursing, 13(3):197-199.

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● Thomas, SB, Fine, MJ, and Ibrahim, SA. (2004) Health disparities: the importance of culture and health communication. American Journal of Public Health, 94(12): 2050.

● Miner, H. (1956) Body ritual among the Nacirema. American Anthropologist, 58(3):503- 507.

● Tercedor-Sánchez, M., & López-Rodríguez, C. I. (2012). Access to health in an intercultural setting: the role of corpora and images in grasping term variation. Linguistica Antverpiensia, New Series–Themes in Translation Studies, (11):247-268. Available at: https://lans.ua.ac.be/index.php/LANS-TTS/article/view/306/196

● UNICEF. (2014). Sistematización buenas prácticas Ngobes desarrolladas para la promoción de estilos de vida saludables y la atención de la salud materna infantil en la población indígena Ngöbe. New York; UNICEF. Available at: http://www.aecid.es/Centro- Documentacion/Documentos/Publicaciones%20coeditadas%20por%20AECID/Sistemati zaci%C3%B3n%20buenas%20pr%C3%A1cticas%20Ngobe.pdf

UNIT 6: Dealing with the triple-burden: globalization and the epidemiological and demographic transition The significant ongoing change of population dynamics must be analyzed with particular attention to the increasing socioeconomic disparities amongst vulnerable populations. This unit will emphasize aspects of Costa Rican population dynamics, such as changing age-structures of populations and changing epidemiological profiles – that impact health systems. It will further examine the interlinkages between environmental health, human health and the societal aspects on which these two depend on. Case example will focus on local agricultural activities and their impact on environment and consequently health, as well as the developmental challenges in of an impoverished community in the southern lowlands of Costa Rica. Readings:

● Huynen, MM., Martens, P. and Hilderink, HB. (2005) The health impacts of globalisation: a conceptual framework. Globalization and health, 1(1):14.

● McMichael, AJ. (2013) Globalization, Climate Change, and Human Health. New England Journal of Medicine, 368(14): 1335–43.

● Ostfeld, RS. (2017) Biodiversity loss and the ecology of infectious disease. The Lancet Planetary Health, 1.1: e2-e3.

● Whitmee, Sarah, et al. (2015) Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health. The Lancet, 386.10007: 1973-2028

● Sheiham, A, and Watt, RG. (2000) The common risk factor approach: a rational basis for promoting oral health. Community dentistry and oral epidemiology, 28(6):399-406.

● Schrecker, T., Labonté, R. and De Vogli, R. (2008) Globalisation and health: the need for a global vision. The Lancet, 372(9650): 1670-1676. 11

UNIT 7: Climate Change and Health Health impacts of climate change can seem disconnected to our everyday reality. Climate change will impact hardest vulnerable populations in the tropical regions of the world. The projected and ongoing consequences of climate change will be explored, using Costa Rica as a case example, more specifically, the fragile and highly biodiverse region of the Osa Peninsula. Discussion will also focus on the roles of future public health professionals in mitigating and creating resilience in the battle against climate change.

Readings: ● Frumkin, H, Hess, J, Luber, G, Malilay, J, and McGeehin, M. (2008). Climate change: The public health response. American Journal of Public Health, 98(3): 435-445. ● McMichael, AJ. (2013) Globalization, Climate Change, and Human Health. New England Journal of Medicine, 368 (14): 1335–43. ● MacPherson, CC. (2012) Climate Change Matters. Journal of Medical Ethics, 40(4): 288-290. ● Levy, BS, and Patz, JA. (2015) Climate Change, Human Rights, and Social Justice. Annals of Global Health, 80(3): 310-322.

● Reidpath, DD, Gruskin, S, and Allotey, P. (2015) Is the right to health compatible with sustainability? J Glob Health, 5(1):010301.

UNIT 8: The importance of leadership in health

This seminar focuses on a human paradigm of leadership – the ability to connect with people you work with, to see how things look from their perspective, to engage and motivate them appealing to their strengths and passions. We’ll look at the PERMA framework of positive psychology presented by Dr. Martin Seligman to explain the elements that influence human well-being, and use this to think through how to lead to represent the best in yourself and those around you

Readings:

· Achor, Shawn (2012). Positive Intelligence. Harvard Business Review.

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OUTLINE OF PROGRAM SCHEDULE:

Saturday, Day 1:

• Arrive at SJO. • Overnight in SJO at 3- or 4-star hotel in double rooms

Sunday, Day 2:

• Program Overview • Full-day tour to Doka Coffee Estate and La Paz Waterfall Gardens with lunch • Overnight again in SJO

Monday, Day 3:

• UNIT 1: Human Rights and Health • Field visit to the Costa Rican Humanitarian Foundation • Field visit to the Inter-American Court of Human Rights • Overnight again in SJO

Tuesday, Day 4:

• UNIT 2: Understanding health systems in context: The Costa Rican Social Security Fund • Field visit to Caja Costarricense de Seguro Social Hospital/Clinic • Travel to by private bus (approx. 5 hours) • Overnight in San Vito at OTS facilities (2-3 people per room with shared social spaces and bathrooms)

Wednesday, Day 5:

• UNIT 3: Global health architecture: perspectives from the ground • Field visit to Rio Sereno Border • Overnight again in San Vito

Thursday, Day 6: • UNIT 4: Systems thinking approach to the determinants of health • Field visit to Boruca Indigenous Community • Overnight again in San Vito

Friday, Day 7:

• UNIT 5: Determinants of health focus: culture and health • Field visit to Casona • Overnight again in San Vito

Saturday, Day 8:

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• UNIT 6: Dealing with the triple-burden: globalization and the epidemiological, nutritional, and demographic transitions • Visit to La Cuesta • Overnight in Osa Peninsula in double rooms in a hotel with swimming pool.

Sunday, Day 9: • Rest day in Osa Peninsula • OPTIONAL: Cocoa Tour • Overnight again in Osa Peninsula

Monday, Day 10: • UNIT 7: Climate Change and Health • Visit to Playa Blanca and vicinities • Overnight in Osa Peninsula

Tuesday, Day 11:

• UNIT 8: The importance of leadership in health • Group Presentations • Full-day workshop on leadership • Overnight again in Osa Peninsula

Wednesday, Day 12:

• Free day (full day hike to Corcovado National Park) • Overnight again in Osa Peninsula

Thursday, Day 13:

• Short flight to San José • Time to work in groups • Farewell dinner • Overnight in SJO

Friday, Day 14:

• Departure to the US or option to stay and travel on their own

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