Imputabilidad del empleador por responsabilidad contractual objetiva y subjetiva

A great act of medical creation lies at the heart of Costa Rica's modern polity. - Steven Palmer (2003:207)

Before, the middle class had a dependable, secure system. Now, they are taxed but they don’t receive services.

- Costa Rican plastic surgeon (2006)

There is a hospital around the corner from where I am staying and looks like it should be torn down… Clínica Bíblica [private hospital] is as modern as it gets.

- U.S. cosmetic surgery patient (2008) Prelude: betting on breasts

In conversation with Costa Rican plastic surgeons, I often asked which aesthetic procedures were most popular among their patients, and whether there was variation between North Americans and Costa Ricans. There is not much difference, they said. Women from the U.S. generally want larger breast implants, but overall the desire for specific types of body modification has more to do with age than where a person comes from, they said. Older women (and, increasingly, men) want to reduce the visual effects of aging through lifts (eyelids, face, arms, stomach, breasts) and facial peels, whereas adults of all ages are drawn to the weight loss shortcut offered by liposuction. Young women, meanwhile, are desperate for larger breasts, they told me, and most breast

implant patients are from Costa Rica. (Breast augmentations are among the least expensive invasive aesthetic procedures, so North Americans do not have a strong financial incentive to travel to Costa Rica for implants unless they are part of a more extensive operation, such as a full body lift combined with implants).20

According to the American Society of Plastic Surgeons, almost 350,000 breast augmentation procedures were performed in the U.S. in 2007, a 64% increase since 2000 (2008). Statistics for cosmetic breast surgeries in Costa Rica are not available. However, based on conversations with doctors, patients, and acquaintances, I suggest that breast augmentation surgery is even more popular in Costa Rica than in the U.S. Silicon gel breast implants are routinely inserted in girls as young as 15, and the operation is a popular high school graduation gift from parents to daughters.21 Augmentations are even performed in state-sponsored hospitals as training exercises or favors for colleagues and acquaintances, in addition to breast lifts and post-mastectomy breast reconstructions. The ceaseless media attention on cosmetic surgery in Costa Rica, moreover, often focuses on breast implants, including graphic, sexualized images of surgically feminized bodies. The authors of a Costa Rican beauty magazine article titled “Invasion of Large Breasts,” for example, write about breast implants as ubiquitous and as an almost obligatory “choice” for Costa Rican women:

20 _{This insistence on cultural homogeneity between Costa Rica and the U.S. occludes} differences in perceptions of beauty, but it also points to the mobility of plastic surgery’s objects and techniques, and the assumptions about health, normalcy and well-being in which its practices are moored.

21 _{The U.S. Food and Drug Administration banned the use of silicone breast implants in} 1992 and re-approved them in November 2006 (United States FDA 2007) The ban helped enhance the attractiveness of Costa Rica to U.S. women seeking the more “natural” look of silicone implants, which were never banned in Costa Rica.

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Voluptuous breasts seem to be in style. If we don’t see them on TV, they are in magazines, advertisements, bars, and in general, in the street… Large breasts are being democratized. More and more models, actors, and mere mortals decide to magnify their sensuality… after all, who doesn’t want to feel beautiful?

(De Lemos et al. 2006).22

Breasts are even used to sell increasingly popular American-style fast food. A 2006 Costa Rican television commercial for Burger King, for example, featured a nurse with large, semi-exposed breasts who takes a crying child from its mother as she lies in a hospital bed. The baby immediately becomes quiet, while a deep male voice announces that “even babies like them bigger.” The scene shifts to a close-up of hamburgers and French fries. As an expression (and stimulation) of the interplay of desires for

participation in new forms of consumption, the advertisement speaks to a new economic and cultural order in Costa Rica. To examine more closely the particular hold that this form of consumerism has on Costa Rican bodies and subjects, I present a story set in today’s cosmopolitan San José. The protagonist is a woman who sought to heal and beautify her body through cosmetic surgery, and whose self-care practices can be situated in Costa Rica’s changing conceptions of health and medical citizenship.

*

On a warm afternoon in April, 2006, I arrive at a tall, modernist building facing San José’s largest park, La Sabana. Occupying a former airfield, the park’s sparse stands of trees and open, grassy areas are worn from human activity, and bear little resemblance to the images of lush, pristine nature deployed to draw tourists to Costa Rica. La Sabana is, however, surrounded on nearly all sides by affluence, and is comfortably removed from downtown San José’s frenetic tangle of traffic and commerce. The building I am

visiting is home to several foreign-owned businesses, and is one of the city’s many architectural monuments to the ever-extending reach of foreign capital into Costa Rica. Its neighbors include a tennis club, upscale restaurants, two plastic surgery clinics, and several large government buildings. Traci, a 30-year-old woman who underwent breast augmentation surgery last year, waits for me as I exit the elevator on an upper floor. She works at a “sportsbook,” whose call center jobs have become a common feature of Costa Rica’s trasnationalizing employment landscape. This particular sportsbook has an online casino, where people around the world (including many U.S. residents of Costa Rica) play poker and other virtual card games (their wins and losses are decidedly not virtual), and it also accepts wagers on sporting events. The company is based in the U.S., but has evaded anti-gambling laws by moving its offices offshore to Costa Rica, where laws are less restrictive.

Traci ushers me through a large room with banks of computers and several employees talking on the phone. They primarily take calls from people in the U.S. who want to place bets, so English fluency is a job requirement. Call center wages are typically US$5 an hour, she says, which is higher than Costa Rica’s average income but barely enough to be comfortably middle class in San José, where the cost of living is much higher than in rural areas.23 Traci started working here ten years ago, taking phone wagers on horse races, and now she earns US$800 per week as the president’s assistant. We enter his office, a large room strewn with Asian rugs and expensive chairs, the walls lined with dark wood paneling and framed photographs of American baseball players and

23 _{In 2004, the average household income in Costa Rica was approximately US$8,600} (State of the Nation Program 2005).

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racehorses. Traci’s desk is in the corner, and I wonder if she serves as another kind of trophy in this masculinized hyperspace of neoliberal success and mobility.

Traci tells me that she was born in the U.S. to Costa Rican parents. She lived there for several years as a child and again as an adult, but ultimately returned to Costa Rica to be closer to her family. She misses the U.S. “Costa Rica is pretty,” she says, “but it’s too Third World.” Traci seems to reside in a space that is culturally, economically, and medically outside of this third-worldness. She tells me she would go to a Caja hospital for a serious health problem, but prefers to pay for private medical consultations. Throughout our conversation, Traci switches easily between English and Spanish, her verbal fluidity matching her ease with different cultural registers. She explains that the enthusiasm for breast implants in Costa Rica is “almost like an epidemic.” Just at this sportsbook alone, she says, three other girls besides herself have recently purchased “new breasts” at local cosmetic surgery clinics. Years ago, cosmetic surgery was accessible only to the wealthy, she tells me, whereas now more people can afford it. And nearly everyone wants it, since Costa Ricans are strongly influenced by local and U.S. television shows promoting and sensationalizing biomedical techniques of body reshaping. I cannot help but think of the popular Colombian soap opera from the late 1990s, Ugly Betty, whose main character finds professional and romantic success only after undergoing a complete makeover in her appearance and social status: “In Betty, ‘beauty’ could be acquired by accommodating Western, ‘white’ middle-class patriarchal norms of femininity” (Rivero 2003:72).

Why did you want breast implant surgery?, I ask Traci. “I needed it, I wanted it, I could do it,” she says, succinctly condensing the interplay of desire with its naturalization

as need, and fulfillment via medical commodification. “My body disgusted me,” she goes on, “and I felt like a little boy.” She was not searching for perfection, she insists, “I just wanted to be in proportion.” She conducted Internet research to find out about risks and benefits, interviewed several surgeons, and negotiated implant size with them (the surgeons she rejected were more paternalistic, and did not want her to participate in the decision about how many cubic centimeters of silicone gel would be inserted in her body). Her now ex-husband, whom she describes as a “hippie” from the U.S., tried to talk her out of the operation, but she finally decided to go ahead with it anyway. She explains her rationale further:

I’m not looking for attention; I did it more for me. I felt confident with my body, but why not make it better? At the beach, I get a lot more male attention now. People ask me if they’re mine, and I say, ‘yes, they’re mine—I paid for them!’ She paid $3,100 for her new breasts, to be exact (in addition to two days of regret, which she tells me passed soon enough). Just as she weaves effortlessly between

colloquial English and Spanish, Traci’s narrative (like those of most cosmetic surgery consumers I spoke with) veers between two, almost contradictory, logics. The first frames cosmetic surgery as part of a simple quest for normalcy; her body was outside of an acceptable range of gendered proportion, and plastic surgery offered a treatment to restore it to its proper shape and femininity. The second logic positions cosmetic surgery as a technique of self-betterment via consumption—a means through which Traci could make herself the person she had long imagined she could be.

As our conversation winds down and I am preparing to leave, Traci asks if I’ve ever considered getting implants myself. It is a trick question, meant kindly. I consider my feeling of repulsion at the thought of a surgeon cutting my body and shoving heavy bags of plastic gel into my flesh (I have seen this procedure performed in the operating

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room, and “shove” is the most accurate term I can find to describe the vigorous activity of coaxing an implant through a much smaller incision). I cannot say this to Traci, however, since it might imply that her motives were based on weakness or vanity. Even the surgically disinclined understand the tacit agreement among women to approve of any efforts at self-improvement. If I say yes, on the other hand, I reproduce the cultural

imperative of relentless work on the self, affirm the symbolic capital of conventional femininity, and contribute to the further naturalization of a widening arsenal of biomedical techniques for self-enhancement. I realize, not for the first time, that I am always interpellated, uneasily, by cosmetic surgery’s discourse.

Figure 1. “We Care More about the Size of Your Smile than the Size of Your Bust.” Advertisement for cosmetic surgery in Perfil magazine. February 2006.

Introduction

I began this chapter with the story of a Costa Rican consumer of cosmetic surgery for two reasons: the first is to highlight surgical enhancement as a set of practices through which subjects are produced as agents of their own well-being. This regime has enfolded

both North Americans and Costa Ricans in its sticky embrace, while informing broader transformations in the contours of Costa Rica as a nation and a surgical destination. In the process of being surgically transformed, in other words, local and foreign bodies become condensed materializations of the economic and social re-fashioning of Costa Rica itself. My second goal is to point to the tensions and contradictions in Costa Rica’s recent embrace of new forms of consumption via privatization and transnationalization, since the dominant national narrative persists in locating citizenship, and the production of healthy citizens, in the dominance of large state institutions and industries. What does it mean that Traci does not feel a strong affinity for this narrative? And how do other Costa Ricans navigate the shifting terrain of medical participation?

In this chapter, I address these questions by outlining the historical development of Costa Rican biomedicine, and considering the recent expansion of private medical services catering to tourists, foreign residents, and elite Costa Ricans. First, I discuss how biomedicine developed as a project of Costa Rica’s model of social democracy, and a cornerstone of a national project that associates access to state-sponsored social services with development and modernization. I then turn to the ascendance of neoliberalism, through which ruling elites have promoted deregulation, privatization, and foreign investment. I consider the consequences of these changes, and the tensions between this new regime and continued public sector dominance in the provision of health care.24 I conclude with a discussion of medical tourism’s transformation from an informal cottage industry to a key branch of Costa Rica’s fervent private sector expansion, and the

24 _{The public sector is also active in banking, insurance, telecommunications, and} electricity.

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connections between medical consumers’ North-South migration and a less welcomed cross-border flow from Nicaragua.

Medical visionaries and nation building

Our song is solemn and vibrant Nuestro canto es solemne y vibrante it is the hymn of a better world, es el himno de un mundo major where everyone finds refuge donde todos encuentran amparo in the law that protects them . en la ley que les da protección. We are strong modern soldiers Somos fuertes soldados modernos of a beautiful national project, de una hermosa función nacional, that protects the children of the nation que protege a los hijos del pueblo offering Social Security, ofreciendo el Seguro Social,

For a large and beautiful homeland Por la Patria más grande y Hermosa with the faith that we put in God con la fe que ponemos en Dios, Social Security is a magnificent el Seguro Social es grandioso guarantee of a better world garantía de un mundo major.

- Costa Rica’s Social Security Hymn,

first performed in 1964 (Caja Costarricense de Seguro Social 2008a)

Costa Rica is the exception in Central America, we are told by historians, tourists, and Costa Ricans themselves. Sometimes referred to as the “Switzerland of Central America,” Costa Rica is locally and internationally imagined as an oasis of democracy, egalitarianism, and prosperity in a region torn by war, dictatorships, and extreme

inequalities in wealth. Costa Rican exceptionalism also contains a myth of racial purity— a “white legend” in which Costa Ricans are assumed to be of “pure,” European descent (Edelman 1999). Historians have reproduced this narrative, tracing Costa Rica’s

exceptional status to Spanish colonial rule, the territory’s remoteness from colonial administrative centers, its small population, scarce (and geographically marginal)

indigenous groups, and its relatively less exploitive labor relations (Perez-Brignoli 1997; Skidmore and Smith 1997; Woodward 1985).

Recent scholars of Latin America, however, have generated compelling critiques of Costa Rican exceptionalism, emphasizing its erasure of a long history of social and economic inequalities and racialized oppression, particularly towards indigenous peoples, agricultural laborers and Costa Ricans of African descent (Harpelle 2002; Paige 1997; Putnam 2002). Nonetheless, exceptionalism continues to inform and animate prevailing understandings of Costa Rican national identity and nationhood. Deployed to attract tourists and foreign investors (Rivers-Moore 2007), the myth of Costa Rica as exception omits not only past complexities, but has recently run up against less-than-exceptional features of the nation’s contemporary social, political and economic landscape. These include increasing air and water pollution, deforestation, poverty, popular disenchantment with the government and ruling elites, and large migrations of impoverished laborers from other Latin American countries. Nicaraguan migrants, in particular, are popularly perceived as a threat to Costa Rican exceptionalism, prompting “a public discourse centering on the defense of the racial purity of Costa Rica” (Molina-Jiménez 2005:106).

Costa Rican national identity is also bound up with state institutions, and their presence in the everyday lives of the nation’s citizens. The largest state institution, the Costa Rican Social Security Fund (CCSS), administers the national health program, and its genealogy can be traced to the colonial and post-colonial formation of medical institutions and professions. In the 19th century, many physicians were members of the nascent government and the coffee producing elite, so medicine and politics have long been intertwined projects. In addition, according to medical historian Steven Palmer, a

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longstanding accommodation among heterogeneous medical practitioners (including popular and indigenous healers) was gradually replaced by biomedical hegemony in the late 19th century—a process that was connected to the construction of the state:

The dramatic advances in surgery and the revolution in bacteriology that reshaped the scientific identity of medical doctors throughout the world during this period gave the Costa Rican profession a central symbolic role in the liberal polity… The rise of this vanguard and the professionalization of medicine was integral to the building of a modern Costa Rican state apparatus (Palmer 2003:67).

Although medical service provision was not dominated by the state until the 20th century, the roots of its social mandate include an 1871 addition to the Costa Rican constitution. The clause described the state’s obligation to provide a fair distribution of wealth and a social security system for workers (Cruz 1991). This project was invigorated by way of a “medical populism” that spread through Latin America in the early 20th century (Palmer 2003:219). The state’s control over the social, economic, and bodily