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Health care for the Bahamas


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Health care for the Bahamas A health care philosophy for the Bahamas
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Medical Association of the Bahamas
Medical Association of the Bahamas
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Public Health -- Bahamas   ( lcsh )
Medicine -- Bahamas   ( lcsh )
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This document contains some of the views of the Medical Profession in The Bahamas regarding the organization of health care for The Bahamas.
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Medical Association of the Bahamas

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The College of The Bahamas Hilda Bowen Library
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CONTENTSPAGECONTRIBUTORS'.'IVPREFACE 1 PREAMBLE 3 OBJECTIVES 4COMMUNITYPARTICIPATION 5 THE ROLE 0F GOVER NM ENT 6BAHAMIANISATION8 THE HEALTH FIELD CONCEPT 9MEDICALSERVICES 10 The Bahamas Present Health Status The Health Team(i)The Roleofthe Physician 13(ii)The Roleofthe Nurse 14(iii)The Roleofthe Auxiliary 15 Mental Health 16 Primary Care 19 Specialist Care 20 Child Health21Family Planning and Maternal Health 23 Careofthe Elderly 25 DENTAL HEALTH...............................................26 PUBLIC&ENVIRONMENTAL HEALTH 28 HEALTHEDUCATION 29 THEFAMILYISLANDS31COSTANDFINANCING 33 PROPOSALS 35 PRIORITIES 37SUMMARY-ANOVERVIEW 38 REFERENCES 40




..ACKNOWLEDGEMENTSThis document contains someofthe viewsofthe Medical Profession in The Bahamas regarding the organizationofhealth careforThe Bahamas.Itwas several years ago under the presidencyofDr.JohnLunnthatthe needforsuch a document was identified. When Dr. Lunn handed the presidency overtoDr.AndrewEsfakis, this became the main focusofhis tenure in office. A committee was appointed under the dynamite leadershipofDr. David SandstowhomtheMABisindebted for the time spent in co-ordinating, and editing this document.Weare also gratefultoDr. Granville Bainwhomade copying facilities available, Dr.AndrewEsfakiswhospent much time and money, Dr. George Sher manwhohas underwritten the costofthe printingofthe final document and Mrs. Eileen Atherton and Miss Patricia Smithforsecretarial assistance. BERNARDJ.NOTTAGE Presidentiii


..THEQUALITYOFLIFEIn many industrialised countries, theattainmentofhealth has provedsomewhatofan illusion.Manyacute diseasesofmajor public healthimportancehave certainly disappeared, onlytobe replaced by chronic debilitating physical andmental diseases. Longevity hasnotbroughtthe bliss and blessingsmanythoughtitwoulddo. Long lifewithoutimprovementinthe qualityoflifeisone of!tietragic se quelsoftechnological development in many countries.Itistherefore cleartomethatvirtually every society needs a redefinitionofits health goals today.H.MAHLER,WHOChron 30:259 1976, Director-General,WorldHealth Organization.iv


...DR. MARCUS BETHELDR.STEPHEN CASHDR.RUDOLPH DORSETT DR. ANDREW ESFAKISDR.PERRYGOMEZDR.BRIAN HUMBLESTONEDR.RONALD KNOWLESDR.JOHN LUNNDR.BERNARD NOTTAGEDR.PATRICK ROBERTSDR.VIVIAN RUSSELL DR. DAVID SANDSCONTRmUTORSM.D.,Diplomate, American Board Internal Medicine Private PracticeMB.BS.,Family Physician B.Sc.,M.D.,Senior Registrar, Department of Medicine, Princess Margaret Hospital (PMH)M.D.,Past President, Medical AssociationofThe Bahamas (MAB) General PractitionerM.B.,B.S., Sec.,M.A.B.Diplomate American Board Internal Medicine Private PracticeMB.,BS.,D.P.M.,Consultant Psychiatrist, Sandilands Hospital and PMH. MB. BS., Diplomate, American Board Internal Medicine Diplomate, American Board Nephrology Private Practice M.B., M.R.C.P. (Edinburgh) Consultant, Department of Medicine, PMH.M.B.,Ch.B., M.R.C.O.G., Consultant, Department of Obstetrics&Gynaecology, President,M.A.B.M.B.,B.S., B.Sc., M.R.C.P., Registrar, DepartmentofPaediatrics, PMH., D.D.S., B.S., Senior Dental Officer PMH.MB.,Ch.B., Diplomate, American BoardofPaediatrics Private Practice v


PREFACEThe purposeofthisworkingpaperistoattempttounfoldanewperspectiveofhealth careforBahamians, and toattempttodefine the general directionwebelievefuturehealth care programmes should follow. The paperisnotintendedtobe exhaustive. Nodoubt,many will quarrelwiththeamountofemphasis ondifferentaspects, andnoteveryone will agreewithall the ideas expressed.Itshould be no otherway,becauseitis only through honest disagreement, and warm debatethatthebroader issuesofhealth care can be clarified and further progress achieved. In this paper, some practical, theoretical and phil9sophical issueswillbe discussed.Nodoubtother issues will arisefromthese,butaslongasthe ultimate goaliskept in mind,whichistoprovide health caretoall thosewhoneed it, these difficulties can be overcome.TheCommitteePlansforhealth care programmesmustbe generatedwithina particular country.The team preparing thedocumentisnotcomposedofworldexperts,buthas the unique advantageofknowingthe local scene.WhichHealthProgramme?Whenwe lookathealth problems on aworldscale, weseegreeHdiversitywhichresultsfromsuch factors as geography, climate, education, custom, politics and health services. Health care programmes are so diversethatweshould hesitatetogeneralize or move too quicklytouniversal solutions. There has been little studyofthe effectsofdifferentmodelsofmedical care delivery on the processofsocia-economic development, the latter being the over riding objectiveofthe governmentsofmost developing countries. There have been remarkablyfewstudiesofthe cost-effectiveness of health programmes, and the general tendency in many developing countries has beentoadoptthe Western modelofhealth care, makingonlyslight adaptationswhichdonotalter its basic structure. The general picture in the WesternWorldtoday isofan incredibly expensive health industry, cateringnotforthepromotionofhealth,butfor the unlimited ap plicationofdisease technology to an afflueFlt sectionofsociety. Medicine in in dustrialized countriesisconcentratedonpersonal health care, andisfirmlybasedonthe individual doctor-patient relationship, i.e., individual care by a highly trained physician. The technological pitchoftherapeutics is so highthatside-effects and complications have become a major causeofill-health.Weneedtolookatdifferentmodelsofhealth care, and choose the aspectsofeachthatbest suit TheBahamas.TheThirdWorldSceneA root causeofinadequate health care in non-industrialised countriesisthattheir patternsofmedical care and educationofhealth personnel are copied closelyfromWestern industralised countries.1


There has been great reluctancetodeviate from these patterns, even thoughtheyare often seriously irrelevantforthe non-industrialcountryandasisnowbecoming increasingly clear, are oftennotwell suitedforthe more developed coun tries wheretheyoriginated.Muchofthe relevant technology can be reducedtoa seriesofroutine patternswhichcanbelearned, carriedout,and promoted by aux iliary personnel. To provide the basic health needstothe whole population is a challengetoall those concernedwithhealth care.D.C.SANDS, Chairman.2


PREAMBLEThe traditional conceptthatthedoctoris availabletoa patient onlywhenapproached is no longer relevanttothe problems facing The Bahamas. As workers in the health field, itisour moraldutyto ensurethatmedical care is made availabletothe entire population, and that we promote the conceptofhealth,notasanabsenceofdisease,butasa stateofcomplete physical, mental and social well being, as enshrined in the ConstitutionoftheWorldHealth Organization. More canbedonetoimprove the healthofthe Community by full employment, improvementofhousing, appropriate education, developmentofrecreational facilities, strengtheningofthe family, and the developmentofcommunityand societal goalsforall citizens, thanbytraditional individual curative and preventive medicine. Obviously, favourable social, political and economic factors are important. The Medical AssociationofThe Bahamas confines itself in this presentationtothe broad conceptofmedical services requiredtopromote and maintain good physical and mental health,withthe realization that a sick or ailing person cannot, and does not, enjoy a productive lifeofsatisfaction, no matterhowfavourable the social, political and economic factors maybe.DisparitiesinHealth ProvisionAneffective health care systemmustmeet the needsthatpeopleseeasim mediate and urgent relieve hurt, ease suffering and save lives. Large numbersofpeople have limited accesstohealth care, and the carethatothers receive doesnotanswer the problems they have. The burning question that challenges providersofhealth careishow to minimise the differences in levelsofhealth so evident inourcountry.Anysystemthatallowstwostandardsofhealth care is repugnant and should be abolished. One groupofpatients may receive good care becausetheyhave theirownphysicianswhoprovidecontinuityofcare. The best care shouldnotgoonlytothosewhocan afford it. Wherecostisanobstacletogoodhealth, a National Health Insurance Plan in needed. .DecentralizationBeyond a certain size, all systems become inefficient. Decentralizationisnowaccepted by International Health Care Plannersasthe best methodofproviding large scale health care. The geographyofThe Bahamas lends itself beautifullytothis concept. Each island or designated health area should be given the facilitiestoprovide the majorityofhealth services locally. Eachunitmustbegiven the knowhowand power to make on-the-spot decisions regarding local problemswithina Na tional Health Policy.Health PotentialWithits ideal natural environment, relativelylowpopulation density and lackofthe typiCAl so-called tropical disease, e.g., malaria, severe malnutrition, etc.,withits most prevalent diseases being preventable, The Bahamas,withinits present resources, could be a modelforhealth caretothe worldifithad a well-organized health plan. The Utopiaofperfect health and happiness doesnotexist,butwecan strive to live in harmonywithGod, our environment, our fellow-men a nd ourselves.3


OBJECTIVESThe primary aimofthisdocumentistoarticulate the views of the Health Pro fessions on the provisionofhealth careforresidentsofThe Bahamas.Itis intendedthatthis paperbepresented to Governmentfordiscussion, thereby creating a means whereby the local profession can influence Government's policy on health care provision.Todate,forhistorical and traditional reasons, there have beennomeaningful discussions between Government and the local Health' Professionsonaspectsofhealth care provision. In addition, Government has never publicly articulated a full comprehensive statementofits health care goals. There has beennoeasily iden tifiable policy. Sinceitis acceptedthatGovernmentisultimately responsibleforguarding the good healthofall its citizens, and since equally, the Health Professions bear thebruntofthe responsibilityforimplementationofpolicy and deliveryofhealth care,itisobviousthatonly a limited success canbeachieved unless there is co-operation between thesetwobodies. Thus, asimportantasall else, in the compilationofthis document,isthe desire on the partofthe Health Professionstodemonstratetothe Government and the citizensofourBahamas,thatthe local Health Professions are concernedabouttheprovisionofhealth care; that they understand the needs and the problems;thattheyhave applied themselvestothese, and they present herein their ideas astothe solu tions,withinthe limitsofour resources.4


COMMUNITYPARTICIPATIONThe last decade has seen thegrowthofamovementtowardsparticipation bycommunitieswhichorganize theireffortsinsupportofhealth programmes.Communityorganization will bethedecisivefactorin exploiting the potentialofthe people, channeling their concern in the directionofgenuine social service ac tivitiestoimprove the environment. Theeffectswill beoftheutmostimportancein thestrugyletoa ttain substantiallybetterhealth, and thuspromotethesteadydevelopmentphysical, social and cultural of man. In countries where there has been realmotivationtoincrec:se the well-beingofthecommunity,the population has responded beyond expectations.Itisimportanttolistentothe people, andtogive them a voice in decisions and a role inthework,including the financing. Acommunityisorganizedintogroupswhosecompositiondepends on the typeofproblem and the actiontobe takenforits solution. Eachgroupis assigned specific responsibilities. Collaborationofthesegroupswiththe national and local health authorities will makeitpossibletoexpand the aims and assure thecontinuityand completionofeach programme.TheFamily Islands ideallyofferthenecessary conditionsforthepromotionofcomprehensive development programmes, including agricu Itural and livestock production,housing, schools, health services, local roads, and othercomponentsthatcontributetothe improvementofliving conditions.5


THEROLEOFGOVERNMENTItisa basic premisethathealth care shouldbeprovidedforallwhoneedit.Itistherefore someone'sdutytoprovide a systemofhealth care.Thatsomeone is clear ly Government or a Governmental Agency. Since Governmentbydefinitionrepresents all the people, the health care systemmustbe universally availabletoall the people, wherever they are in The Bahamas. Such a system,forevery citizenofThe Bahamas, will involve the recognitionofmany diseases, and willuncovermanyproblemswitha socialand/orenvironmental facet, andmusttherefore benotonly universal,butalso comprehensive.Itmustaimtoensurethatno-one failstogetthe necessary care(withinthe limitsofavailable resources). nomatterhowrare or unusual his health problem is. Healthmustbe high on the scaleofsocial and economic prioritiesofany Government, because the healthofa nation is basictothegrowthandproductivityofits economy, and alsoofcourse,outofhuman compassionand political necessity. Good health is,afterall, a primary sourceofsocial andeconomicdevelopment. Locally, Government's agencyforhealth care and delivery istheMinistryofHealth. The systemofMinisterial administration has serious organizational, finan cial,productivityand access problems. Innovations are therefore needed urgently in the systemofdelivery. The MinistryofHealth should, and must, take the leadership role inthedevelopment of the systemforadequate health care delivery. Its personnel should include personswiththe administrative and technical expertisetoadvise Governmenton the establishmentofobjectives, the formulation of policiestoachieve those objectives, and the evaluationoftheresultsofthepolicy implementation. Implementationofpolicy should be carriedoutthroughquasi-Government bodies establishedunderthe indirect responsibility of the Minister of Health (e.g., a Hospital Corporationtorun all aspectsofHospitalCare). TheMinistryofHealth should alsopromoteinteraction between private and public mechanisms in ordertoexpand the capacityofthe available health resources.Itshouldpromotecontinuous planningatGovernmental and private levels,toensurethatinstitutional arrangementsforquality service are rational, andthatthecostofhealth careisbearable and properly providedforin a developingeconomy.Itmustbe rememberedthatmonies spentonhealth care,whetherbyindividuals, by Insurance Companies,orfromthe Public Treasury, are all partofthecountry'snational asset, andmustthereforebeusedbothefficiently and effectively. Fundingofthehealth care systemisanotherareaofinvolvementforGovern ment. AlternativesforGovernmentasthe providerofperSQnal health care rangefromthealmosttotal National Health Service conceptofsocialised medicineofthe6


British model,toa totally private enterprise system, supported by reputable In surance Agencies. Becauseofthe existencein any populationofa percentageofindigents, Government must take responsibilityforthe personal health careofat least some of its citizens the poor and the aged are extant examples.Asa resultofthe British experience,itisnowrecognizedthatin our economic system,noGovernment should, or can, undertaketofinance everything. No coun try, evenifpreparedtopay the taxes, can supply everything. The American ex perience has shown, however,thatunbridled medical enterprise does restrict accessofmany citizenstoadequate care becauseofcost. A balance must thereforebestruck between Government fundingofpersonal health servicesforindigents and other special groups suchasthe aged, and private funding through Insurance and allied agencies. Government must be prepared, however,tofund adequately health education, disease prevention programmes and the environmental aspectsofhealth problems.7


BAHAMIANISATIONThe Medical Profession supports the Government's policyofBahamianisation, and advocates its applicationtothe administration and practiceofmedicineatall levels. Bahamianisation,asviewed by us, includes"theembracingofa philosophyofwhatitmeanstobeBahamian; acommitmenttochange the society until the en tire societyisgeared towards serving itsowncitizenry enabling Bahamianstobe the real beneficiariEls". Presently, less than 20%ofdoctors practicing medicine in The Bahamas are Bahamians.Anincreasing numberofBahamians are studying or practicing medicine abroad.Itwill take some years before The Bahamas can be relatively self sufficient in doctors, evenifthatisdesirable. This canbeachieved soonerwithanactive educational programmeforundergraduates, and a motivational schemefordoctorstotake post-graduate specialized training. Since medical education is long and expensive, thereisanurgent needforthe institutionofmedical scholarships. Adequate post-graduate expenditure can onlybeachievedifGovernment and the Profession set guidelines,give direction, and positively motivate medical professionalstoenter those areasofmedicine in which the need is greatest.ButBahamianisation must mean more than simply the provisionofBahamian doctors. It must mean also lookingatour peculiar health programmes anofinding innovativelocalsolutions. Itisunrealistictoexpect provisionofall the North American/European facilities. Their value is questionable in a developing societys_uchasourown.Wemust be prepared then,toreview the system whichwecurrently have, and create one uniquely suitedtoThe Bahamas.8'


THE HEALTH FIELD CONCEPTAMODELHealth status is the resultofinteractions amongatleastfourmajor factors human biology, the environment, lifestyle, and medical practice. While the Medical AssociationofThe Bahamas hasasits immediate areaofactivitymedical practice,itrecognizes the needforseeking harmonywithother forcesforoptimal outcome. Thus, the thrustofthis paper will centre around only oneofthese factors medical practice and its organization.HumanBiology The human body is a complicated organism, and any disturbance in in heritance, maturation, ageingorfunctioningofthe many organ systems, can result in ill-health.Itis indeed amazingthatthe majorityofus are born healthy and remain so formostofour lives.TheEnvironmentThe"environment"means everything externaltothe human body.Toa large extent, it determines our disease pattern. Of special importance are our food, clothing and housing -atpresent largely inappropriateforthe Bahamian environ ment. Our'local climateisoneofthe best in the world.WhenColumbus arrived, the nativesworea loin cloth only, seemedtobeingood health, and were living in harmonywiththeir environment.Withitslowpopulation density, healthy natural environment, lackofepidemic disease and relatively high income, The Bahamas couldbea modelforhealth care,ifwewere brave enoughtodirect our resources and energytothosewhoneeditmostata costthatisnotprohibitive. Our social environment isasimportantasthe physical one. Pressures in society determine our life-style,whichmay inturnaffectourhealth adversely,forexample bottle feedingofinfants, smoking and drinking excessively. Life-StyleHealthandBehaviour,Manydiseases, such as gastroenteritis, pneumonia, alcoholism, are relatedtothewaypeople live their customs, the presence of poverty and lack of education. Mortal disease in many countries todayismore preventablebythe individual thanitiscurable by the physician. Human diseaseisa productofhuman behaviour, individualaswellasfamily orcommunity.This is clearlybroughtoutin the evidence linking smokingwithlung cancer, obesity and lack of exercisewithcardiovascular diseases; frequent pregnan9


cies with infant malnutrition; new attides towards sex with the spreadofvenereal diseases, and alcoholismwithcirrhosisofthe liver. The needforhealth care on a family basis is apparent, and muchofthe modern medical care failstoachieve its objective because the doctors donotlook beyond the individual and thus failtoseethe family. One essential attributeofa doctor is his abilitytoseethrough symptomsofillnesstoits prevention in the future through changing the patternsofin dividual and family behaviour. Big business, through advertising, has been very successful in convincing peo pletochange their behaviour,forexample, eating patterns, smoking and drinking habits. The challengetohealth workers and Government istoencourage peopletochange their behaviourorlife-stylefortheir own good health. Our countryhasall the elementstomould a characteristic wayoflife based on genuine national aspirations,butnot on imitation.10


MEDICALSERVICESPRESENTHEALTHSTATUSThe present organizationofmedical services consistsofa dual systemofGovernment and Private Practice. The Princess Margaret Hospital providesInPatient andOutPatient servicesforNew Providence and accommodationforthe useofprivate practitioners. The private practitioners are mainly generalists, although afewofthese have speciality qualifications. Fewofthe private general practitioners do total family care. The hospital's primary care department has no established continuity,asitis staffed mainly by transient non-Bahamians. Primary careiseither donebythe Out Patient Departmentofthe hospital, orinthe officeofa private practitioner. Patients frequently alternate between private practitioners and the Out Patient Department, depending on their economic status, andnotinfrequentlyflytothe United Statesformedical carewithoutreference when they become fed upwiththe local system. The system is even more primitive in the Family Islands, whereprimary careisdeliveredbya District Medical Officerorcommunity nurse, often overtoolarge anareawithpoor communications, althoughfewofthe wealthier territories have had private practitioners for some years. There isnoorganized peripheral primary care systeminmost partsofThe Bahamas. Taole 1 showsthatinfant mortality, and maternal mortality are higher than ex pected, given the general levelofdevelopmentofNew Providence, where 50%ofthe population live. Recordsofpatients discharged from the Princess Margaret Hospitalaswellasthose attending clinics, reveal a high incidenceofpreventable disease syphillis, gonococcal infection, amoebiasis, tetanus, measles, tuberculosis, infectious hepatitis, typhoid fever, gastroenteritis, malnutrition, anaemia, pneumonia, etc.Withrespect to the reports on the causesofmorbidity and mortality (Table21.itissignificantthata large bulkofthe hospital services dealwith(a)communicable, parasitic and infectious diseases, (b) pregnancy, childbirth and pre-natal and peri natal complications and (c), physical and mental impairments caused by accidents, poisoning and violence. This indicatesthatan'important partofhospital resources is being used in solv ing problemsthatcould be solved by preventive medical action and improvementofthe environment. Table 3 and 4 reveal that The Bahamas has a generous supplyofdoctors.Mostare concentrated inNewProvidence, givingita population/doctor ratioof773, a figure thatiscomparabletothe most industrial nationsofthe Western World. Table 5 showshowThe Bahamas compares internationally. The infant mortalityrateisa good indicationofthe overall health status. Sweden,withgenerous11


..health resources,asindicated by the GNP, has the lowest infant mortality rate in the world. The Bahamas cannot hope, and its resources willnotallow it,toattainsuchalevel withinthenear futuJe. (However, we compare poorlywithJamaica, whose health resources are much less than ours). Most Third World countries, like The Bahamas, have optedfora large hospital,asopposed to regional health centres. This patternofdeveloping a health service has been likened to Pharoah's engineers startingtobuild the pyramidsfromthe top. Our central hospital doesnotsatisfy local demandsforhealth care, and is cer tainlynota referral centre. The system allows large sumstobe spent on treatment,butfundstobuy vaccines are difficult to obtain. Againwemust make a choice -a large central hospital, or many small health centresforthe community.Whathappens to the patient attending the Out Patient Departmentatthe Princess Margaret Hospital?Hemust face a long wait, a quick evaluation, a bottleofmedicine, perhaps some wordsofadvice, and the slow walk backtothesClmehome environment. Oncehehasrecovered from this minor illness,whatwill be different in his overall health status?Ishenow better prepared to take personal measures necessarytoprevent the same disease recurring? Whenheisnext ill, will heknowhow to betterusethe health facilities?Ifa health facilityisusedforthe purposeforwhichitwas designed, then duplication and inefficiencyisminimal. The public and health workers must be educatedinhowbest to use the healthfacilities available. The national expenditure on health does not necessarily reflectwhatis obtainedinreturn. For example, theU.S.A.iscurrently spending three times as'muchper head on healthasEuropean countries, but there are18countrieswitha lowerinfantmortality; nor do her citizens surviveaslongasthoseofmany other countries. The Bahamasisina similar situation. Until thereisa comprehensive organized health system, serving the majorityofthe people, and especially thoseatthe greatest risk, the health system will remain inefficient, wasteful, a sourceoffrustra tiontothe health workers, and willnotmakeanoptimal contributiontothe develop mentofthe country.HEALTHSTATUSSUMMARY1)Statistics are incomplete andinadequate.2)Thereisa poor distributionofhealth personnelwithover-concentration in New Providence.3)The proportionofmoney allocated to health is generous.4)The Health Statusisbelow the potential.5)The potentialisgood, based on per-capita income,doctor/patientratio, and the prevalenceofpreventable diseases.6)The Bahamas compares unfavourablywithother countries in the Caribbean with less resources, using the gross national productasa reference.7)The Government isnotgetting its money's worthintermsofreduced morbidity and mortality. This suggeststhathealth resources couldbeadministered more efficiently. 12


(THEROLE OF THEPHYSICIANTheage-oldconceptthatthe medicalmanshould carefora patientonlywhenapproachedisno longer relevanttothe problemsfacingThe Bahamas today. There arefourmajor rolesthatadoctorhastoplay. First, hemustbe competentin the fieldofclinical medicine, sothathe can treat his patient. Itmustbe remembered, however,thatalmostallthemajor diseases threatening life and reducingefficiencyand energy, can be diagnosed and treated by the useofbasic clinical skills and instruments, and simple medicines. Absenceofadvanced diagnostic andtreatmentfacilities is a challengetothedoctor'sskill. Secondly, thedoctorshould be equallycompetentin diagnosing the illsofthecommunitybyusing appropriate epidemiological tools, and he should be abletoprescribe the remediesin,termsofenvironmental control, immunization, and health education. Everydoctormustfeel a senseofresponsibility towards thecommunityhe serves. Thirdly, he shouldplayaleadership role in thecontextofcommunityhealth,workingas a team leaderwithnurses, sanitarians, health auxiliaries, ad ministrators, and others. Lastly,he should be a health educator, teaching his patients andthecommunityaboutthepreventative andpromotiveaspectsofindividual andcommunityhealth. The roleofthe physician is largely shaped by the setting inwhichhe works.Thephysicianworkingasa member of a teamatthe Princess Margaret Hospital has a verydifferentroletothatofthe physicianworkingalone in a Family Island. Oneofthemostpowerfuldeterminantsofthescopeofany health service istheattitudeofthe professional personneltowardsdelegating responsibilitiestopersonswithlesser training. Physiciansmustdelegatemoreresponsibilitytoauxiliaries, and free themselvestobe leadersofhealth teams. The physician's education should prepare himtoseehealthasatotalsystem.13


THE ROLEOFTHE NURSEBecauseofthepeculiartopographyofThe Bahamas,theNurse assumes a ma- jorrole inthedeliveryofHealth Caretothepeopleofthese islands.Itis therefore desirablethatnurses assume and maintain a degreeofprofessionalismcommensuratewiththe roletheyhavetoplay.TheSchoolofNursingTheSchoolofNursing should maintain its high standard guaranteeing itsinter national recognition.TheBachelorate Programme should be encouraged inasmanythatare desirousofthis, especially those Nurses interested'inbecomingNurse Prac titioners. Nursing educationmustbe designedwithinthecontextofourlocal needs and resources.TheNurseintheReferralCentres-IP.M.H.andTheRand)All categoriesofNurses, Administrative, Specialist Nursesofall types, GeneralDutynurses and Nurse Aids,willcometogethertocareforacutely ill patients and patients requiring specialist care. Specialist Trained Nurses,e.g.,ICU, Dialysis,Accident&Emergency, Burns, Psychiatric,etc.,willbe practising in the areasoftheir expertise. GeneralDutyRegistered Nurses become specialist in theirownrightthrough"onthejob"training and thereforerotationofnurses should be minimized. In the Referral Centres privatedutynursing should be minimized and one systemofnurs ing employed, sothata more cohesive nursingunitisoperated. Nursesmustcon tinuetoexercise Administrative and Managerialfunctionin referral centres and as such should be qualifiedtodoso. Specialty Clinics in Referral Centresoughttoincludeifpossible a Nurse Practi tioner an therebyallowforbetteroperationofthese clines, i.e., sothattheytrulybecome specialist clinics.NurseintheFamilyIslands&PeripheralItisrecognisedthatpresently Nurses in the Family Islands andtoa lesserextentinNewProvidence,functionatthelevelofthenowpopular term Nurse Practitioner, i.e., Nurses involved in Primary Care, making assessments and initiating therapy.Ifthis highly desirable practise by nurses istocontinue then these present nurses need encouragement andfurthertraining so astoperf,orm even better. Initial train ingforNurse Practitionersmustbe available at the Referral Centres and a systemofcontinuingeducationmustalsobeprovic:Jd. Nurse Practitionerstogetherwithphysicians and para-medical personnel in peripheral clinicsthroughoutNewProvidence,willbecentral figures if decentralised Health Care istobe successful. There areothercategoriesofnursesthatcould be mentioned,butthereisa consistent theme the nurse iscontinuouslyconcernedwiththecomfortand well beingofpeople.Tobring this concerntobear effectively on health problems, re quire flexibilityandinitiative infunctioningasa memberofa health team.14


THE ROLE OF THEAUXILIARYThisconceptcallsforpersonswithless education and less skill than profes sionals, doing partoftheworkofprofessionals. Scarcity itself makes the suggestion:use auxiliariestoextend the effectivenessofprofessional and paramedical per sonnel. The ideaofusing auxiliary and paramedical personnelisuniversally accepted,butoftenwithoutfull appreciationofwhatis involved if the systemistobeef fective. Auxiliaries cannotbepassive workers, standing near the professionals, awaiting instructions.Theymuststand between professionals and situations, actingasfilters, sothatonlythe problemsthatneed the skill and knowledgeofpro fessionalsgetthrough. The systemwillnotworkifthe professionals havetomakethefirst decision on most problems. Notethattheauxiliary personnel will be evaluating and solving problems and not,assomewouldsuggest, merely mechanically carryingoutassigned tasks.Whencarefully selected and adequately trained, auxiliaries can be effective substitutesforfully qualified professional personnel.Anytaskwhichhastoberepeatedmanytimes, eventhoughitiscomparatively intricate, should betaughttoauxiliaries.MoreDoctorsorMoreAuxiliaries? The Out Patient Department atthePrincess Margaret Hospital begsforthe useofauxiliaries. Adoctorseeing60patients a daycannotprovjdegoodcare.Hecould provide excellent careifheworkedwitha teamofauxiliarieswhotreatedtheminorproblems and referredthemore complicated casestohim. The choicemustbe made moredoctorsor more auxiliaries.15


MENTAL HEALTH CAREFORBAHAMIANSA plan for mental health care should takeintoaccount socio-cultural mores, prevailing economic conditions, pre-existing medical care models and religious philosophies in the community. Mental healthispartoftotal health; thus physical and mental health are inextricably inter-dependent, a fact which many health pro fessionals overlook; they often feel that the fieldofphysical and psychiatric medicine are separate. The interactionofthese factors, plus the patient's genetic makeup, will deter mine the symptom-complexhepresentstothe health professional -inother words, his awarenessofdisease, even when affected by the same illnessasanother person, will vary accordingtohis experience and life situation. These latter dif ferences will determinehowheviews the ideaofgetting well, orinsome instances, totally abandons it. Below are some examplesofdifferences in approachtohealth care in Bahamians.1)A Business Executivewitha drinking problem declines treatmentinthe Alcoholic Unit at Sandilands, for fearofthe social stigma. His illness worsens, and he may die eventuallyofcirrhosis through lackoftreatment.2)A wealthy Bay Street merchantwhohas no faithinthe Bahamian health care system, makes numerous expensive health tripstoMiami and New York.Hemay get better, and feel he has received valueformoney. However,hedoesnotrealize thathecould receive equally good medical treatment within The Bahamas,atless cost.3)A housewife, anxious about her husband's infidelity and decreasing interest in the family, suffers attacksofabdominal pain. The doctor tells her after tests, thathecan find nothing wrongwithher. Sheknowsthere is something wrong; then follows a seriesofvisitstodifferent doctors whose treatments donotworkimmediately. The patient's anxiety increases. She becomes progressively more depressed and deluded about "beingfixed",believes her foodispoisoned, and gets admittedtoSandi lands Hospitalfortreatment. She emerges intwotothree weeks, feeling better, but may havetomeet the same problem when she returns home.Ifthe domestic scene does not change after intervention by a Psychiatric Social Worker, then the patient may lapse into the same condition after several months. From these examples, several points should be noted:1)Every effort shouldbemadetopromote confidence in local health professionals.Ifdoctors are competent and practice sound ethical medicine, then other health workers will follow by example.2)Patients shouldbeencouragedtoattend one General Practitioner only. The "lihoppingaround"inwhich many Bahamians tend to indulge in the medical market, only leadstoincreased anxietywithinthemselves, and a frustrated bodyofdoctorswhoare unabletotreat their patients satisfactorily. Patients should be discouraged from referring themselvestoSpecialists.16


3)Withincreased public confidence in our health delivery system, there willbeless societal anxiety, therefore less disease, andfewerpeople trekkingtothe U.S.A.orHaititocure their ailments. Mental Health Educationthroughthe school system and the mediaisnecessarytoalleviate someofthese anxieties.PRESENTPROBLEMSCOMINGUNDERTHEPOilTFOLIOOFPSYCHIATRY1)Alcoholism2)Drug Habituation3)Major PsychosesofSchizophrenia and Manic-Depressive Disorder4)Personality Disorders and DelinquencyinAdolescence5)Mental Retardation6)Chronic Brain Damaged Patients, and Demented PatientsPRESENT SERVICEThis is centeredatSandilands Rehabilitation Centre,with240 psychiatric beds. Included in Sandilands HospitalisanAlcoholicUnit(24 beds), and an AdmissionUnit(22 beds). The remaining beds areforintermediate and long-stay patients.NexttoSandilands Hospital istheChild Guidance Centre, a facilityfordiagnosis andOutPatient psychotherapy inyoungpeople under17yearsofage.OutPatient referralsfromother disciplines are seenatPsychiatric Clinics in theNewWingofthePrincessMargaretHospital.Althoughweprovide a psychiatric servicewhichcompares favourablywithalmostany in the Caribbean area, there is stillroomforimprovement. Sandi lands Hospital still carries a stigma inthemindsofsome people, despite numerousattemptson the partofMinistryofHealth Personnel and The Bahamas Mental Health Associationthroughthe media,toallay public anxiety.ThePsychiatricServices'Five-YearDevelopmentPlanReferenceHEA/SRS/17,putforwardon12thApril1976,suggested:1)AnAdolescentUnitatSdndilands Rehabilitation Centre and anewAlcoholicUnit.2) Theformationofa50bed Department of Psychiatry at Princess Margaret Hospital, comprising: 30 General Psychiatric Beds10Children's Beds10Special Beds 'forAddictionCases. Thisformatparallels psychiatric facilities in modern hospitalsthroughouttheworld.ManyBahamianswouldagreetotreatmentfora psychiatric problematthe Princess Margaret Hospital, whereastheywoulddecline treatment at Sandilands Hospital. Progressively more peoplewouldrealizethatitisnotnecessarytobe"crazy"toreceive psychiatrictreatmentatthePrincess Margaret Hospital. In time, more peoplewouldpresentfortreatmentearlier in their illness,witha resultant decrease in severepsychoticreactions.17


Alcoholism remains a major health hazard in The Bahamas. Therapeutically, we areonlytouching the very tipofthe iceberg. There are probably more than 8,000 alcoholics in the country. Thefollowingfigures illustrate the ratiooffirst admission alcoholicstore admitted alcoholics, to total admissionsforany reason,inanyoneyearatSan dilands Hospital:197455/238/8131976111/295/950Few alcoholic patients come in voluntarily. They are usually psychotic, and when they regain their judgement after afewdays' detoxification, often agree to admissiontothe Alcoholic Unit,butforthewrongreasons: (usually socio-economic ones).Manyofthese patients have descended the social scale, andwhenthey leave hospital, they returntotheirownalcoholic sub-cu Iture. Alcoholicswhoarenotdeteriorated are usually fearfulofSandilands Hospital, and decline treatment there. A Detoxification Unit is neededatPrincess Margaret Hospital where the alcoholic may spend his firstfewdays, and thenifhe wishestohavefurthertreatment,betransferredtoanAlcoholicUnitatPrincess Margaret Hospital. The effectivenessofthe present systemfortreating alcoholics islow,because thosewhoare treated,atpresent carry theworstprognosis.3)Expansionofstaffingofthe Child Guidance Centretoinclude a Consultant Psychiatrist.4),The creationofa special agency to dealwithproblemsofalcoholism. This has recently been effectedbytheformationofThe Bahamas CouncilonAlcoholism, which has been largely responsibleforthe setting upofthe I:lalf-Way HouseforAlcoholics -"RosettaHouse".5)ExpansionofOccupational Therapy Facilities. There is a need in this areaforproviding equipmentforIndustrial and Agricultural skills.6)Assessmentofpsychiatric needsinthe Family Islands. Thereisnodoubtthat severalofthe larger Islandswouldbehelpedbya visiting psychiatrist and Social Worker. Currently,manydischarged patientsfromSen dilands Hospital have to come periodicallytoNassauforcheckups. This isbothcostly and time-consumingforthem.7)a. AHalf-WayHouseforAlcoholics. This has already been accomplished. b. A Half-Way Houseforpsychiatric patients. Thetreatmentofyoung delinquents and adolescentswithbehavioural pro blems needs special consideration. They usually continue their antisocial behaviourifthey are returnedtothe same environment which engendered their disorder. Rather than spend repeated periods in the Mental Hospital,itwouldbe betteriftheycould be rehabilitatedbyhaving an extended periodofonetotwoyears in an educa tionalcommunitymodelled along the linesoftheTwinValleys School in Ontario, Canada.Thelatter is an independent,non-profitmaking organizationwith150pupils,whoare referredfromvarious agencies, such as Psychiatric Hospitals, the Courts, the Church and Social Welfare.Theycomealmostwithoutexceptionfromdisturbed families, and have usually failedtorespondtothe Agencies previously handling them. TheCommunityis an educational one, and functions along the linesofhelping the young peopletobe self-sufficient.18


PRIMARYCAREPrimary care maybedefinedasmedical attentionoradvice giventoanyonewitha need.Sucha service is renderedbypersonalcontactorcommunicationwithany personwhomaybeacknowledged and designatedascompetenttogive suchattentionoradvice, in anyaccidentorillness.Itfollowsthatprimary careconstitutesan initial servicethatcanberenderedbyadoctor,a paramedic, nurse,ornurse practitioner. This initial care may be adequate,orcontinuous, ormaybe a preliminarybutnecessary serviceforpatientsthatsubsequently require Specialistand/or hospital care. For theCommonwealthofTheBahamas, such a system demandsthattelephoneorwireless communication between all Family Islands andNewPro videncebefunctionalatall times. A phone callfromany Family Islandtoa Specialist in FreeportorNewProvidenceoftenmayeliminatethenecessityofexpensive emergency flights. InNewProvidence alone, aMay1977 surveybythis body,oftwenty-sixGeneral Practitioners (i.e. no Specialists canvassed) revealedthatthese doctors, providing Primary Care services,asdefined above,tookcareofno less than 3,100 patients perworkingweek in THEIR OFFICES. Assumingonlysixworkdays perworkingweek,itmeansthatover 500 patient visits perworkingday were madetothese doctors.Andassumingonly300workingdays per year,itmeansthatwell over 150,000 patients' visitsweremadetothisgroup,as comparedtothefigureofjustover 100,000 seenatthe OutpatientsDepartmentofthe Princess Margaret Hospitalforthe year 1976.Thusprivate physiciansasagroupprovide a greaterproportionoftheprimary care service. The remainderisprovidedatthe hospital.Theprimary care service should ideally be provided near the patient's home. These areimportantfactstoconsider when formu lating a comprehensive health plan. Private practice therefore providesmanyadvantagestothepatient, physician and Government, andistobe encouraged wherever possible. Theconceptofthe public patient should be abolished. Peoplewanttobe treatedasprivate individuals, andnotasdiseased persons in anovercrowdedOut Patient Department. A com prehensive National Health Planwhereall patients are treatedasprivate patients wOl,ld provide manyofthese advantages.19


SPECIALIST CAREAll patients should have ready accesstoSpecialist care where the need arises, and the facility and personnel exist.Atall times, Specialist consultation should be available inthebasic fieldsofIn ternal Medicine, Surgery, Obstetrics&Gynaecology, Anaesthesiology, Paediatrics, Radiology and Psychiatry.Whenour resources allow,itis desirablethatthere be more comprehensive Specialist care available -forexample the fieldsofEar, Nose and Throat Surgery, Dermatology and Neurology, etc. Thereoughttoexist adequate meanswherebypatients in the Family Islands(anbe transportedtoa referral centre (Princess Margaret Hospital)forSpecialist care, especially on an emergency basis. Regular visitsbySpecialiststotheFamily Islandswouldgreatly reducetheneedfortransfertoNassau. In many cases, a telephone callforadvice maybeallthatisneededtoprevent unnecessary transfer. For the Specialisttobe effective, theremustexist certain facilities and materials. These,werecognizeofcourse, depp-ndtoa significant extentontheinancial resources available. Purchasing and installationofsuch materiaJsforusebythe Specialist should be done in consultationwiththe Specialistorthe Depart ment involved. In the deliveryofSpecialist care, services should be equally availabletothepublic and private patient.20


CHILD HEALTH"Theworld is yours,aswellasours,butin the last analysis,itis yours. You young people fullofvigour and vitality, are in the bloomoflife, likethesunateight or nine in the morning. Our hope is placed in you the world belongstoyou."Thefutureofthe country depends on its children, andthegreatest contributionthatweasdoctors canmaketo tha tfutureistopromote the physica Ia nd emotional healthofchildren,toprevent disease, treatiteffectively, and alleviate handicaps. The Paediatrician hasanenormous responsibility,notmerelyfortreating the sick child and restoring himtohealth,butalsoforprevention and counselling,forcol laboratingwithObstetricians in the preventionofnoxious factorsofpregnancywhichmany damage the foetus;forguiding parentsonthe physical, intellectual and emotional managementoftheir children, sothattheir children are happy and healthy and achieve their best; andforcollaboratingwithothers concernedwithchild health public health services, family doctors, nurses and teachers. Eventothe casual observer,itis apparentthatchild care in The Bahamasissporadic, limited in scope, inadequately integrated, and of limited efficacy. Consider these facts:1)The Bahamas has a young population 60%areless than 24 yearsofage.2)Womenofchild-bearing age and children under15years (the groups exposedtomaternal and child health risks), comprise 63% in the Caribbean.3)The proportion of deathsofchildren under 5 years,withrespecttothe total numberofdeaths, is 20%, whereas in theU.S.A.and Canada, the proportion is5%.The facts described above are explainedtoa large extentbythe weakness in the administrative infrastructureofmaternal and child care service; inappropriate and I;mited useofprofessional and auxiliary personnel; their uneven distribution, the difficulties in communication, transportation and equipment, and the lackofeffec tivecommunityparticipationinrelated programmes. The causesofchild mortalityforthe most part canbereduced. The main causes are gastroenteritis, communicable diseases, respiratory illnesses, accidents, and poisoning.Althoughinadequately documented, malnutritionisundoubtedly animportantbasicorrelatedofinfant mortality. A most urgent problem in child care in The Bahamas todayisthe acute shor tage of hospital beds. However, the answer, isnotto build more hospital space,buttoprevent disease through immunization, and providing health care in the com munity. A more immediate reliefofhospital overcrowding couldbeachieved through a half-way house, where childrenwhodonotneed hospital care could stay until col lected by their parents.21


PROPOSALSMAJORAXIOMSOFCHILD CARE1)Child careisimmensely worthwhile. The maxim is widely heldthatthe bestwayto improve a nation's health in the long termistocareforyoung children andwomenofchild-bearing age.2)Wemust aim foramaximum retumintermsofreduction of mortality and morbidity, and thismustbe obtainedwithinthe resources available.3)Donotseparate mother and child.Upto the ageoffive years, the child is heavily dependent on mother, and effective health care must doasmuchaspossibletoenhance her competence and skill. Mother and child neednotbe separated, even when the childishospitalizedorthe mother works. large in stitutions could provide nursery facilitiesforits employeesattheworkplace.4)Health services needtobe near the child's home.5)Senior child health personnel must be deeply involved in health care at the com munity level.6)Prevention is better than cure, and the potentialforpreventionofdiseases in children through the promotionofgood health health education, health supervision, public health and immunization, is tremendous.ItisProposed:1)Thatthe servicesformaternal and child health be combined and co-ordinated sothatthe high risk group receives effective health services. These should be directed towards the familyasaunitofthe community.2)Thatthe intolerable overcrowding in the Children's Departmentofthe Princess Margaret Hospital be corrected very soon. This is best done by directing resources at preventable and easily treated diseases in the community.3)That the emphasis on immunization be continued with special attentiontomeaslesandrubellavaccination,whichisatpresent sadly lacking.4)Thatweaimtoreduce the morbidity and mortalityfromthemostcommon causes first gastroenteritis, communicable diseases, respiratory diseases and accidents.5)That the health careforchildren be incorporated into a National Youth Develop ment Plan. Such a plan should promote, during childhood and early youth, recreational activities and opportunitiesforeducation and vocational orienta tion.6)That special emphasis be placed on the careofbothmother and child during pregnancy, labour and after birth, and also on the careofthe newborn and children through the various stagesofchildhood, particularly the first yearoflife.7)That.as many functionsaspossible be delegatedtonurses and auxiliarieswithadequate training and supervision.8)Thata half-way housebeestablishedtoease the severe overcrowding in the Chilqren's Ward.9)That the healthofchildren be promoted through welfare services. Of special noteisthe need to: -a)Maintain a strict adoption policy. b) Seekoutand prevent conditionsthatleadtochild abuse. c) Update legislation regarding the rightsofchildren and the responsibilitiesoftheir guardians.22


FAMILYPLANNING(ANDMATERNALHEALTH)The social, economic and health benefitsoffamily planningforparents and children, famiiies, and the societyasa whole, are well known and fully accepted. In this regard, family planningatthe outset should be distinguished from family limita tionorpopulation control. Family Planning here means adequate spacing between the birthsofsuccessive children,aswellaslimitingofadditionstothe family and family size. Adequate spacing allows the familytoadjusttothe additionofthenewmember, and provides the time neededforthe mother to recover and regain her nor mal health status before another pregnancy.InThe Bahamas, several factors dictatethata serious and sustained effort be madetoeducate the populacewithrespecttofamily planning. These include the alarming increase in unwanted pregnancies in mothersofall age and social groups, but particularly in unmarried teenagers: the continued negative attitudetocontraception and sterilization, particularly among males; the continuanceoflackoffull useofmaternal health services, and the small but undesirable numberofpregnancy-related maternal deaths especially in young mothersoflarge families. The factthatin larger population areas the utility resources, e.g. water, are insufficienttoadequately service the increasing popula tion, isanadded factor. Thereisthereforeanurgent needfora positive, planned policy statementfromGovernment on Family Planning. This policy should be formulatedonthe basisofconfirmed, adequately researched individual and societal needs.Itshould be done onlyconsultationwithinterested bodies, particularly with the people in need, and most likelytobe affected, andMedical Profession. No policy can or will be accepted unlessitis needed; the peoplewhoneeditrecognize the need, and the provisionsforimplementationofthatpolicy are adequate, relevant, and casted within the limitsofavailable resources financial and personnel. Inboththese regards, the useofacceptable private funding, and voluntary personnel should be actively pursued and utilized. The needs areasfollows:1)Family Planning services mustbemade generally availabletothe whole populationatlowcost. This may take several forms, ranging from local/regional Family Planning advice centres, to centres associatedwithex isting maternal and child health care centres,toFamily Planning Clinics. In these clinics, adviceisgiven, and in addition, contraceptivemethods are readily Iyavailable.2)Aneducational programme must be instituted immediately, stressing the importanceoffamily planningtothe healthofmothers and children, and the familyasa whole. This may take the form of newspaper advertisements and ar ticles, radio and television programmes, and public lectures by membersofthe health care team. There is a particular needfora sex and family life education programmeforthe schools, andanextramural programmeforadults. These should be taught by personswithtraining in the teachingofsex and family life education. Full use should be madeofall varietiesofaudio-visual aids.23


3)Positive consideration must be giventothe provisionofinformation tomalesand young people the latter probably through youth guidance centres.Withyoung persons, the aim should betopostpone the birthofthe first child.4)All contraceptive methods should be available. Consideration should be giventothe provisionoffree contraception universally. Where thisisnotpossible permanently, e.g.withsingle methods (suchasoral contraception or condomsasopposedtomultiple duration methods suchasthe I.U.C.D., the long acting injectable hormoneorthe diaphragm), consideration may be giventoproviding free intial coursesofsay three months, followed by a subsidised provisionofcontraceptives at cost.Itmustbenotedthatclinical experience showsthatthere is a high disconti nuance rate among contraceptive users. A programmeforfamily planning will only succeedifany deterrent to continued use is recognized and avoided. The implementationofa Family Planning Policy can only be organized afterthatpolicy is formulated and its aims are fully understood. The Medical Professionisreadytotake the lead in the implementationofany such Policy designedtoalleviate this complex problem.24


CARE OF THE ELDERLYItshould be the responsibilityofboth the profession and the Governmenttoen sure that our elderly citizens are providedwithadequate health care. This requires proper planning and a genuine involvementinorder to avoid the crisis medical en counter which,formany elderly people, is far too frequent, andtoavoid invoking in our elderly, the feelingthatthey are a bother to either the physician or to the State. Proper planningisnecessary,notonlytomake maximum useofavailable resources,butalso because the numberofelderly citizens is boundtoincrease as a natural spin-offofthe general improvement in living standards. Thisisanarea in which good Preventive MedicineISextremely important, and much could be donebythe Public Health NurseorHealth Visitor in checking the home environment, and in encouraging both the elderly patient and the patient's "relativestoassist them in attending the various clinics. Very often, elderly persons are broughttothe Out Patient Departmentortoa physician's office because the relativeswantthem"admitted".Often, thereisno organic disease and no needforadmissiontoa hospital facility. Frequently, therealreasonsforwanting elderly patients admitted may vary from"lackofspace"inthe home, "crankiness" on the partofsome elderly person, to lackofdesireorinterest by the youngerfamily memberstoassistinthe careofelderly persons. The hospital,asan acute care facility, is no placeforsuch an admission.Evennow,much needed and relatively expensive bed space in our hospitalisoccupied by such persons. Ob viously, thereisa needtoincrease the Geriatric facility. The lackofspacetoprovide special Geriatric care could only worsen in the foreseeable future. Preventive careinthis respect couldbefacilitated by:1)The establishment of regional clinics.2)Increased public education or public awarenessofavailable services, suchasdental clinics, treatment for hypertension and related cardiovascular diseases and rehabilitative therapy, e.g. physical therapy after strokes. A genuine commitment to the goalofproviding our elderly citizenswithbetter health care, requires a restructuringofsome facetsofthe health care delivery system,witha greater emphasis on Preventive Medicine, increased Geriatric facilitiestoprovideforthe specific needsofthe elderly population, and at the same time, avoid unnecessary burden on the hospital facilities. Also needed are new and different sourcesoffinancing. Lodges, Trade Unions, Churches etc., mightplayavery important role in this respect. Immediate trainingofinterested young nurses and doctors in the special fieldofgeriatrics.Weshould stress, however, that proper careofthe elderly is most often best achievedinthe home environment. The family contact is there, and this avoids the impersonal care which may creep into institutional medicine. Very often, however, thisisnot feasible, either becauseofspace, economics, lackoffamily motivation,oreven lackofa family. The resultisthattoomanyofour elderly citizens spend their last days in miserable surroundings in hunger, andwithouteven basic care. These recommendations,ifimplemented, wouIdalleviate someofthese problems.25


DENTAL HEALTHIn a developingcountrysuch as The Bahamas, thequalityofhealth care demands consistentattentionin orderforanyprogresstobe made inthismostvital areaofthenational life. Thewholeideaofnation building dependstoa very large extent onthehealthofthosewhoare called upontohelp build the nation. Thati!1eludes practically everyone.Whilemuchistobe desired in termsoftheoverall healthofthenation,muchmore is desired in termsofthe Dental Health Care. Perhaps nootherareaofhealth care has been more neglected thanthatofDental care, despite thefactthatdental diseases are perhapsthemostprevalentofdiseases in theworldtoday, especiallyinthe"civilized"westernworld.Dental disease_constitutea majorthreattothe well beingofanycommunity.The seriousnessofthese diseasesisnottheirthreattolife,butthefactthattheycan disfiguretheface, cause severe painaswell asaffectnutrition and other vital processesofthe body. Because healthy teeth also enhance personal appearances,thelossofteeth,aswellastheunhealthy appearanceofteeth very often contributetoa person's mental attitudetowardsself andhowoneappearstoothers. Thetreatmentofmostdental problems,unfortunately,happenstobe rather expensive. Only thosewhocanaffordthehighestqualitytreatmentare presently receiving it. This can be one reasonforneglect onthepartofthegeneral population.Anotherimportantfactortobe considered inthedeliveryofproper dental careisthe lackofsufficientdentalmanpower.Whilethis isnota very acute problem here in Nassauorperhaps in Freeport, itisa serious problem intheFamily Islands. In ordertodealwiththese problems effectively, a systematic planofstrategy based on the preventionofdental diseasemustbe implemented.Withthisinmind,the Bahama Islands Dental Association has electedtoimplementtheideas receivedfromthe lastworkshop on Dental HealthStrategyheld in St. Lucia onMay21-29ofthis yearwithmodificationstosuitourlocal environment.Amongthe areastobe given specialattentionare:1.Dental Caries2.Periodontal Disease 3. Malocclusion and Dentofacial deformities4.Cleft Lip and Cleft Palate5.Oral Cancer 6. Lesionsofthe Oral Cavity other than cancer 7. OralAspectofSystematic Diseases The problemsofdental caries and periodontal disease aretoppriorityasthese arethemostcommon.Thegeneral planfordealingwiththese specified areas con sistsof:A. A National Dental Education Programmethroughthe useofthe available news media. S. A training programmeforschool teachers andcommunitynurses in routine preventive dental health care.C.Thetraining and useofdental auxiliary personneltoreduce themanpowershortage. D. A complete revisionofthe DentalActtoreflect a positivemovein the directionofusing dental auxiliaries in a preventive dental care programme. These are the main areasthatwill require immediateattentionofGovernment,26


todiscuss in detailwithrepresentativesofthe Dental Profession,whoare lookingforwardto making a definite and positivecontributiontoHealth Care in the Bahama Islands.27


PUBLIC&ENVIRONMENTAL HEALTHPublic health may be definedas"Astateofphysical and social well-beingasitappliestofamilies, groups, sub-cultures, communities and the entire population". Itisuniversalinscope andassuch, the public health affecting one segmentofthe population, necessarily affects the systemasa whole. The Bahamasasa countryofnumerous and widely scattered islands, has special public health problems and special public health advantages. The special public health problems include thedifficultyofboth central and peripheral com munication and supervision.The special advantages include the natural barriersfor.the spread and limitationofcommunicable diseases. .TourismAsa tourist resort, The Bahamasisatanincreased riskofimported infectious diseases.StrictPublic Health measures should be maintained in termsofthe control and surveillanceofits portsofentry.withparticular referencetoThe Bahamasasan island nation.EducationFundamentaltoany sound Public Health System is a sound systemofPublic Health Education.Itissuggestedthatoneofthe best meansofinstituting or promoting satisfactory Public Health Educationisby meansofthe School Health Programme.Anadequate Immunization Programme is essentialtocontrol and minimize the incidenceofthe common infectious diseaseofchildhood, and also adulthood. Good environmental sanitationisoftheutmostimportance, especially since the vast majorityofthe children admittedtohospital are there becauseoftotally preventable diseases.AnimalsThe healthofthe publicisinfluenced by the health statusofthe animals in the community. Whether usedforfood orforpets, they can be a sourceofdisease. For a health care programmetobe complete,itmust make provisionforsecuring the healthofthe animals in the community.SporTthsMd'IA...h'I d.I eeIcassoclatlon recognises te Important ro e sportsanrecreatlona activities play in the promotionofgood health. Sports activityforcitizensofallages should be encouraged. The establishmentofplaying grounds should be expedited and school sporting facilities shouldbeopenedtothe publicoutofschool hours and during school vacations.Environmental HealthWhathas occurred in the industrial society should serveasa warningtothe non-industrial countries.Ineffect, the exploitationofnatural resources, in dustrialization, and unplanned urbanization, have led to air, water, and soil pollution which has affected the favourable equilibrium between man and his environment. The Bahamas has been relatively freeofpollution. However, continued vigilanceisnecessary in protecting the marine ecology, especiallywiththe in troductionofoil tankers in our waters. The efficient collection and disposalofwaste, provisionofpotable water supply, and adequate sewerage systems are basic ingredientsforbetter health throughout the Commonwealth. In a tourist economy like outs,itismandatory that we minimise diseases spread by water and food. To achieve this end strict surveillanceofpersons workingwithorhandling food, must be maintained whether they be in hotels, restaurants, schools, or side-walk stalls.28


HEALTH EDUCATIONRelevanceandRealityMostofour health personnel are trainedinmore industrial nationsofthe WesternWorld,whichhave exported philosophiesofmedical carethathave focus ed on high qualityc':)reofindividual patients. These philosophies havenotprovided the answersforhealth careofthe great majoritywhodonothave accesstothis ex cellenceofindividual care. Inmostnon-industrial countries, these philosophies have failed miserably becausetheconstraints under which healthmustbe delivered have been ignored. Constraints suchaslimited resources, illiteracy etc. demand different technology, different attitudes and adifferentethic.Muchofthe relevant technology canbereducedtoa seriesofroutine patternswhichcan be learnt, carried out, and promotedbyauxiliary personnel. Educational programmes should be relevanttothe jobstobedone andthejobs should be shaped realistically in termsofthe preparationofthosewhowilldothem.ThePhysicianThe Government should encourage the pursuance of medical training by Baha mians. Medical Scholarships bothfortheundergraduate and postgraduate studies should be provided. It sl10uld encourage Bahamian medical graduatestoattainthemedical skillswhichare currently lacking by offering special assistance to interested physicians. Assistance shouldnotonly be financial,butthrough appropriate Governmental agencies, physicians should be placed in reputable institutionsofgraduate medical training. Having attained these special skills, the physicians shouldbeencouragedtotakeuppositions where the majorityofpeople couldgetmaximum benefit. The actual needforphysicians, both at a primary care and speciality level, should be reviewed regularly. This could be best done by a Medical Education Com mittee. This Committee couldbejointly appointed by the Association and the MinistryofHealth. It should beanongoing Committee, should meet regularly, and should report annually on the needformedical personnel.Inorderforpatientstobenefitfromthe most recent medical developments,itismandatorythatphysicians subject themselvestosometypeofongoing medical education programme. This couldbeorganizedbythe Education Committee.OtherHealthPersonnelInthe area of nursing, a similar committee should determine and continuously review the needfornurses. Nurses should be encouragedtoacquire special skills and be placed where maximum benefitwouldbe obtainedfromtheir training. Incen tives shouldbeprovidedthatwouldencourage nursestowanttobetter their medical knowledge and update themselves in the various nursing techniques.29


The Government, should encourage the pursuanceoftrainingbyBahamiansinthe areasofri:lboratory technology, radiologic technology, pharmacy, and other paramedical fields (e.g. E.C.G., E.E.G.; and inhalation therapy).PublicEducationThe Medical AssociationofThe Bahamaswouldliketoemphasizethattheeducationofpatients is an integral partoftheir care. Personnel should be availabletoteach patientsabouttheir diseases, and the variousformsoftreatmentwhichthey receive. The benefitsthatwouldaccruefrominsistence on a programmeofpatienteducation are obvious. In the chronic illnessofdiabetes mellitus,forexample, the various complicationswouldbe lessened. There would be less suffering, and the costofhealth care deliverytothe patientwouldbe minimized. Education program mes in the areasofmaternal and child healthwouldsimilarly be very rewarding. The Medical AssociationofTheBahamas should seek accesstoall media th0 newspapers, radio, television, movie houses, plays, institutions,workplaces and schools.Whenthe preferenceofthe public differs seriouslyfromwhatis desirable in termsofhealth needs, there is the possibilityofeducating the publictowantthatwhichitneeds. Human resources are the basic elementforthe structure andfunctionofa health system. Education and training mustbeplanned according to the.more importanthealth problems, and to the feasible methodsfortheir solution. A crucial issueisthe educationofhealth personnel. The entire sequenceofevents requiredtoimprove health care recognition of the needforchange, design and implementationofnewsystems,and their further evaluation and modification means,inessence, education.HealthInstitutionsHospitals and health institutions are traditionally teaching centres. The Medical Associationwouldliketosee the standardofhealth care raised sothatourhealth institutions could become teaching centresformedical students and any other allied health studentsfromthe UniversityoftheWestIndies. Such a learning atmospherewouldhave advantagesforteachers, students and patients.30


FAMILV ISLANDSIntroduction'Primary health caretoFamily Islands isatinadequate. Our geography and scattered population requiresthatspecial methodsofhealth care delivery be in stituted. Health care mustbetakentothe people.Itisenvisaged that a General Practitioner in a Family Island could cover 2,500 to 4,000 patients, dependingonthe number and qualityofphysician assistants, or the area to be covered, and the stateofcommunications (roads, telephones).Itiscer tainly hoped that local personnel willberecruited, and this includes doctors, direct lyfromthe commu nity in which they are to serve.J'Doctors can be encouragedtoworkin the Family Islandsifcertain incentives are offered. Financial advantages could include higher salaries than their colleagues in Nassau, good housing and educational opportunitiesfortheir children would help. The rightofprivate practice wouldbeattractive to some doctors. More important, is a satisfying and useful professional life. Thedoctormust be convincedthatthe loweringofmortality rates from common diseases is regardedwithequal importanceasthe highest clinical expertise. The Family Island isanideal situationforthe physiciantolead a health teamofauxiliaries!offeringanintegrated curative and preventive service which could sur pass the largely curative service'Offered through his colleaguesinNassau. The'Family Islands, where half the population live, are not receiving their shareofthe national health resources. A'specific sum should be allocated to these islands 'in proportion to their needs.Toensurethatthe funds are used efficiently withinanorganized health plan,itmay be wisetoappoint a special health Co-Ordinatorforthe Family Islands.A.RegionalHealthCentresItisproposed that a limited numberofRegional Health Care Centres be established in selected Family Islands determinedbypopulation size and geographyofthe region.Eachcentre istobe continually staffed by medical andparamedical personnel and each centre appropriately equippedforOut Patient care and minor surgery. Special attentionatall timestoproper maintenanceofeach centre andto adequate medical supplies (drugs, instruments, etc.) The Regional Health 'Centres would function in the general frameworkofthe proposed comprehensive health care schemeforThe Bahamas. Thetwomajor hospitals (Princess Margaret Hospital and Rand Memorial Hospital) would be usedasR.eferralCentresforintensive medical care and major surgery, and other diagnostic and treatment procedures beyond the capabilityofthe regional health centre, andatthe discretionofthe resident physician.PhysiciansPhysicians usedtostaff eachcentrE!should be trainedasprimary care physi.31


cians. These physicians should be given the opportunitytoregularly upgrade their professional standards through Government funded study leave. Wages and benefits must reflectnotonly the experienceofthe physician,butalso considerationofthe relative cultural deprivation and necessityforschoolingofdependentsinareas other than where the physicianisresident. A rotational schemeforphysicians among the Family Island Health Centresisproposed. This servestoacquaint physicianswithother islands and their special problems and guard against complacency and boredom.NursesNurses should be specially trained and equippedtofunction in areasasnurse practitioners, capableofmedically screening patie.nts and trafficking the samefromisolated settlementstoregional health centresfordefinitive diagnosisortherapy. Also, they should be abletoprovide basic medical care and midwifery. They wouldberesponsibletoand under the guidanceofthe Regional Health Centres, and wouldbeusedtoprovide ambulatory medical caretoisolated com munitieswithinthe sphereofeach regional centre. Healthisintimately relatedtodevelopment. The thrustoffuture industrial development should beinthe Family Islands, particularly in viewofthe over crowding and shortageofwater in New Providence. Developmentinthe Family Islands willbethe best incentiveforhealth workerstolive there. .PatientsThe health servicesforpeople in the family islands are less than thoseforthe people livinginNassau. This disparity is unacceptable.Anyhealth programme must aimatproviding good healthtothe residentsofall islands. However, there will stillbethe needtotransfer patientstoNassau. For such pa tients, a major problem at present is the lackofaccommodationinNassauforpa tients and relatives seeking health carenotavailable in their home island.32


COSTANDFINANCINGAllocationofResourcesWiththe increasing life expectancy, decreaseininfantmortality, and the in creasing birth rate, the present facilitieswhichare generally regardedtobe inade quate, are expectedtobeplaced under greater stress. These facilities are in dire. needofmodernization and additional hospitalbeds.are neededtoprovide the recommended averageoffouracute hospital beds per thousandofpopulation. The problemsofmodernization, andofobtaining the goalofbestormaximum useofresources and manpower which presently faceboththe profession and Govern ment, are seenasbeing aggravatedbythe present overly rigid, overly centralized direction and makingofpolicy which characterized the MinistryofHealth. The Government, as spokesmanforthe people,hasevery righttomake policy and decide in which direction the developmentofHealth Careforits citizens should go. Surely, however, these decisions ultimately should be takeninclose consultationwiththe profession, both private and public, since the hospitals and proposed Regional Clinics shouldbeas self-sufficient as possible, and to a greater extent, be abletofinance theirownoperations. Itistherefore desirablethatGovernment should appoint an autonomous groupwithfull responsibility for overseeing the daytoday running of the hospital. Such a group should include representatives frombothGovernment and from outstanding personsinthe professional and business fields. This approach would encouragethatthese facilitiesberunasbusiness venturesorinvestments (which they are), andensure maximum return on outlay, while at the same time, carryingouttheir responsibilities.FinancingHealthInsuranceThe Bahamian should be abletoobtain excellent medical care in hisowncoun try. In addition, the qualityofmedical care offered inourhospitals should neverbethe sourceoffrustrationormisgivings.Withour present overly-paternalistic Health System, someofthese problems seemtobe built in. Thereisnodoubtthat a finan ciallystable institution,withadequate bed space, pleasant surroundings, good nurs ing and physician care,wouldbe a sourceofpridetoour citizens. People wouldnotresent payingforgood care in clean and pleasant surroun dings.Tothis end, and alongwiththe conceptthatboth hospitals and Health Cen tres should beasfinancially self-sufficientaspossible, the Association strongly recommends the institution of mandatory Health Insurance. This insurance should coverbothsickness and hospitalization, and couldbecarriedoutbybothGovernmentand the private sector. Alternatively, National Insurance might be expandedtoembrace the increased insurance coverage. Specifically, we recommend:1)Mandatory Health Insurance (private sector and Government or expanded National Insurance Scheme.21EstablishmentofRegional Health Centres complete unitsinthemselves able33..


toprovideforthe family's basic medical needs financial self-sufficiency of such unitsisdesirable whenever feasible.3)Thatthe Medical AssociationofThe Bahamas itselflookintothe possibilityofestablishingand/or staffing such centres.4)Wherever possible, health care in such centres should be providedbyBahamian physicians and nurses. Such regional units shouldnotonlybephysically attractive,butalso really complete small clinics. Underlying all of these suggestions are the basic principlesofadequate in suranceforeveryone, feeforservices, andthateach unit should make a significant financial contribution towards itsownoperation. Lastly, andofconsiderable im portance, such changes should pgovide some incentiveforyoung Bahamian physi cianstoreturn home.TheIndigentIndigent individuals, or thosenotcoveredbyinsurance, should have their care underwritten by Government. Government's outlay in this respect wouldbecon siderably less than the present scheme. The public outlayforthepresent system is boundtogrowand become more burdensome year by year.Italmost encourages separate standards in health care; oneforthe rich and anotherforthepoor. This is farfromsatisfactory, eitherforthe bulkofits consumers or the majorityofthosewhoare called upontodeliver this care. Whichever Health Care plan is adopted, the burdenofcost will fall on the public, directly or indirectly.34


PROPOSALSItis proposed that:1)Community participationinhealth care be actively encouraged.2)The Government adopt and implement a comprehensive health programme, and that the Medical Association and other health bodies be consulted when formulatin!;! such a programme.3)The Government continue its generous allocationofresourcestohealth care, realizing thatitisaninvestmentforthe development of the nation.4)Bahamians be given the opportunity,inkeepingwiththe policyofBahamianization,tofind local solutionstoour health problems.5)The hospitals be disestablished, and administered by independent boards.6)The health facilitiesbedecentralized,withthe aimofproviding health careasneartothe patient's home as possible.7)The physician expand his role soastobeabletodiagnose and treatnotonlytheillsofhis patient,butthe illsofthe community.8)Doctors keep abreast with modern developmentinmedicine, and translate themtofitour local situation.9)The Medical Association take an active partincommunity health beyond the limiteddoctor/patientrelationship. 10l Good dental health be promoted, and that the need for fluoridation be re-evaluated. 11) The roleofnurses be expandedtoassume more responsibility in the diagnosis and treatment of patients.12)The Auxiliary personnel be trained in specific areastoallowforinitialcontactwitha patient under supervision.13)The health resourcesbedirectedatthe"family"asa health UnitInthe community,withspecial emphasis on Maternal/Child Health Care the groupatgreatest risk: 14) A half-way house be establishedforchildrenwhodonotneed the acute care servicesofthe hospitaI.15)All effortstobe madetocareforthe elderly.16)Mental Health services be incorporatedasfaraspossibleintothe general health services,inorder to remove the stigmaofmental disease.35


17)A Family Planning Programmeforthe nation be initiatedasa matterofurgency.18)A system of health care be provided where every patient can have hisownphysician andbetreatedasan individual.19)Ample potable waterbeprovidedtothewholepopulation. 20) A sewerage system and other sanitary meansofexcreta disposalbeestablished in each islandofthe Commonwealth. 21)Ourenvironment be protectedfromthe hazardsofpollution. 22) Health educationbegiven its rightful priority in the health care programme; health educators be given the meanstoeffectively reach thecommunityand convince the public to alter its life styleforthe betterment of itsownhealth. 23) A concertedefforttobe madetokeep the costofhealth care and drugstoa minimum. 24) The Family Islandsbegiven appropriate shareofthe health resources, andthata special supervisorfor Family Islandsbeappointed.25)Incentives be offeredtoencourage Bahamian health personnel toworkintheFamily Islands. 26) A National Health Insurance programme be intiatedtobe run either by Government or private insurance companies. 27) The health resources be directed to the priorities among health problems, takingintoconsiderationcommunityconcern, prevalence, seriousness, and the susceptabilitytomanagement. 28) Particular attentionbepaidtopreventive health care. 29) International health expertise besoughtand used where appropriate.30)A mechanismbesetupforthe recordingand retrievalofinformation in ordertoevaluate the health programme.36


PRIORITIESWithoutstatistical datatogCJideus, choosing prioritiesisa most difficult task. Individuals will tendtofeel that theirareaofworkhas the greatest need because theyseethe problems daily.Withoutthe resourcestoserve all the needs simultaneously, a choice mustbemade from the following list.1.A National Health Programme.2.A National Health Insurance Plan. 3. DecentralizationofHealth Services.4.DisestablishmentofHospitals5.A DepartmentofHealth Statistics 6. ImprovementofMaternal and Child Health Services7.A Family Planning Programme8.Preventative Health Care Before Curative Care. The prioritiesofhealth care should beofmuutual concerntoboth Government and the Medical AssociationofThe Bahamas.37


SUMMARY-ANOVERVIEWWearewhatour genetic inheritance makes us, and our environment allows us to be. Disease reflects our failuretoadapt to the inner and outer environment. Healthisofconcerntothe individual and the community, becauseitenables each persontorealize his potential. Good health should be enjoyed equally by all membersofsociety. No nationhasasyet achieved this goal,butthis doesnotprecludeitfrom being our fun damental aim and the responsibilityofour Government. No country can affordtoprovide every citizen with every possible formofmedical technology, nor would this necessarily be goodforthe healthofthe individual andofsociety. On the contrary, quite apart from possible adverse side-effects and iatrogenic diseases,itwould tend to make people overdependent on a medical technology. In a population thatisfrequently ill, productivityislowered.Itisdesirable, therefore, to plan economic development hand in handwithhealth care. Itismore than desirable;itisessential. Health developmentisessentially a political and social process. Health technology mustbeapplied in harmony with society. Thisisnotsynonymouswiththe developmentofincreasingly sophisticated services in medical institutions.Inmany countries, the valueofthese expensive institutions canbeseriously questionedifmeasuredintermsoftheir impact on improving health statusofthe population. Other social processes (e.g. education), are in the same position, makingitim perative to join forces in common planning and co-ordinationofall the social ser vices. Such planning requires clear definitionofa social policy,ofwhich health policy formsanintegral part.Aswethink about designing new systemsofhealth care and improving existing systems, we must keepinmindthatthe system, however well designed, willnotautomatically improve health. Whether the goalistoimprove healthorreduce the birth rate, behavioural change is necessary. Thiscanseldom be accomplished in a Health Centreorhospital clinic. The Health Service must reach into communities and establish a close relationship with the people before they can hopetoinfluence their lives. Therearecertain critical connections between medical technology and the public, andifthese connections arenotfirm and effective, the benefitsofthattechnologydonotreach the public. This link between medical knowledge and the peopleisa complex chainofcon cepts, techniques, people, decisions and events. The linksinthe chain are basically:(1)Technical capability,(2)Resources men and money and materials,(3)Plann ing and organization,(4)The health delivery system. For The Bahamas, the weakest links are poor organization and an inappropriate health delivery system. The health statusofThe Bahamas is relatively good in the world picture,butitfalls shortofour great potential.Ithas taken the world a century to learnthatbetter health isnotattended by a lessening demandforhealth services. The demand never slackens, only increases.38


The awareness becomes a concern, thenanexpectation, then a demand, and the demand grows faster than the possibilitiesofresponse. Someofthe leading causesofill-health, e.g. alcoholism, arenotsubjecttothe easily packaged curesofmodern medicine. They are tiedupwiththe customs, culture and the ways in which people live their lives. The most important advances in health lie in influencing the behaviourofpeople, anditis herethatcapabilityismeagre indeed.Itissad that in The Bahamas, preventable diseases still plague pregnant mothers and early childhood contributed by diseasesthathave been showntobe largely preventable. These conditions limit life expectancy,butare also responsibleforthe poor scholastic performanceofmany school children,forlowproductivity,notto mention a pessimistic outlookonlife.Itisone thingtobe awareofthe great need,butanothertohave the full recognitionofthe deeper implicationsofthat need and a determinationtoserve. The aimofthe Medical AssociationofThe Bahamas istopointoutthatneed.Ifwe could convince the leadersinthe communitythatthereisan urgent need, thenwecan sit down and workouthowtosatisfy these needs in waysthatare appropriateforThe Bahamas. The guidelinesforchange canbestated simply -toeasethe suffering and improve the healthofall people,asmuchasresources will allow. Butweknowthe simplicityofthe statementisdeceptive. However, the dual pro blemsofservingallthe people and making useoflimited resources will affect our thinking every time.Wemustnotassume thathealth is being caredforsimply because a system for health exists. We must learn to recognize the right issues, findoutwhatthe right tools are, and put them in the right hands.Itmay require developing approachestohealth carethatare entirely new.Wemustbewillingtodoso, and relinquishthatwhich is outmoded.Wehave stated broad principles, andnotplansofaction. These must come after priorities have been decidedinconsultation with Government Agencies. Wedon'thave all the answers,butwemust first ask the right questions:Whatare theneeds?Where are the resources? In viewofthe needs and the resources,whatare the objectives?Whatprogrammes and organizational structures will be most effec tive in meeting these objectives?Howcan the effectivenessofthe system be evaluated? Itisanticipated that there will be areas where differences in policy or philosophy willbeevident. Butitis hoped thatindiscussing the paper, we will seek first those areas where we agree, initiate a planofaction, then continue the debateonthe areasofdisagreement.Weare confronted with a serious problem. Itisthe lag between the timeanideaisconceived and the timeitiseffected. We will do welltoask what are the waysinwhich that lag might be reduced.39..


..SOMEREFERENCES1)MedicalCarein Developing Countries Maurice King, 1967. 2) Health Careinthe DevelopingWorldJohnBryant, 1969.3)A New Perspectiveonthe HealthofCanadian Marc Lalonde,1974.4)Paediatric Prioritiesinthe Developing World David Morley,1973.5)The DeliveryofHealth Services in the People's RepublicofChina Peter Wilenski,1976.6)The Challenge Faced by the Medical Profession in Tropical Countries V.T.H. Guaranatne, Regional Director, World Health Organization, Delhi, India. Tropical Doctor, October1976.7)Health Services Research: A Wprking ModelB.Stanfield, NEJM, July 19th1973.8)A New ApproachtoHealth Care Delivery ServiceinThe BahamasPAHO/WHO,1972.9)Annual Reportofthe Chief Medical Officer, Ministry of Health, Bahamas,1974.10)LimitstoMedicine Ivan Illich, 1976.111Ten-Year Health Plan for the AmericasPAHO/WHODocumentary No.118,January1973.12)WorlaFebruary March,1974.13)Child Health Across Boundaries.Peds.Vol. 5q.No.2,February,1977.


TABLE 1POPULATIONANDVITALSTATISTICSTotal mid-year population Live Births Birth rate/1000 population Deaths (excluding stillbirths) Death rate/1000population Still births Still-Birth rate/1000 total births Infant deaths Infantdeath rate/1000live births Neonatal deaths (less than28days) Neonatal death rate/ 1,000 live births Deaths 1-4 years/1000 aged 1-4 (approx.) Maternal mortalityrate/1,OOOlive births Natural increase rate/1000 population Annual Report MinistryofHealth, Bahamas, 197441197,000 4,50022.99104.6N.A.N.A.12026.78619.140.916.65


TABLE 2LEADING CAUSES OFMORBIDITYANDMORTALITYJRANKMORBIDITY%MORTALITY%ORDERNo.1Child birth, complications 32.2 Diseaseofthe Circulatoryofpregnancy, and PuerSystem 26.4 perium--------No.2Diseases of the Respiratory System135Perinatal Causes 18.8-------No.3Accidents, Poising, and Violence 11.2 Neoplasms 12.8--------No.4Diseasesofthe Circulatory System 7.6 Accidents, Poisoning and Violence 12.3-------No.5I nfective and Parastic Diseases 5.6 Diseases of the Respira-torySystem 10.4-------No.6Diseaseofthe GenitoUrinary System 5.5 Diseases of the Digestive System 5.2 Annual Report MinistryofHealth, Bahamas, 197442


TABLE 3STATISTICS OF DOCTORSConsultantF.T. P.T. Sm. Registrar Registrar SHOHOMed. Officer Totalt1.Ministry----2 22.P.M.H.Co-ordinator---1 1Medical Dept. 2-3 1 4 3-13Surgical Dept.323 42 3-17Paediatrics Dept.1--235-1106S.& GYN. Dept. 2-1 4 3 3-13Anaesthet. Dept. 2--5---7Lab.31----4Radiology Dept.1------1Ace.& Emerg.D.--1 6--7O.P.D.--1 7--83. Rand Hasp.--1 4--1 64.SandilandsRe. 3--3 1-185.HealthOffices----4 4 6.FamilyIslands-----16 167.Total Govt.163103219 1425119Private N.P.-----3939Private -Fam.Islands----1717175FTFull TimePTPart Time SHO Senior House OfficerHOHouse Officer..N.P. New Providence


TABLE 4HEALTH INSTITUTIONSPrincess Margaret Hospital Mental Hospital Geriatric Hospital Rand Hospital Rassin Hospital Lyford CayBED STRENGTH424240150 5825 14Total New Providence Islands1.Population203,946 121,311 82,6352.Doctors,175 157 17 3.Population/Doct. Ratio1172m486044


TABLE 5COMPARISONOFDEMOqRAPHICANDVITAL STATISTICSStatistics Sweden Cuba Tanzania Jamaica Barbados Bahamas--Population Total (millions)8.18.7 13.8 1.8 0.25 0.2%Rural 18.6 39.5 90.0 Annual Population Increase 0.2 2.3 2.7-0.13.7%Crude Birth rate per 1,000 13.5 28.3 47.03821.9 22.9-Infant mortality (per 1,000 births)1027160to1652629.2 26.7 Population under15yr.(%)21.0 36.7 50.04040-Popu lation/ Physician650-27,935-23501172GNP/capita in U.S. Dollars $5,910-$89.004606701544SeeReferences9,16,17. GNP Gross National Product. (DataforTable 5 covers period 1971-74)..-,,,

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