by Irene Davall
Jill was four months pregnant when she and Alex arrived in The Bahamas for a winter vacation. The Islands, a mere 50 miles off Florida’s east coast, provide an almost picture-perfect vacation milieu: Radiant sun, sparkling water, glistening beaches, an incredible choice of activities. The first few days couldn’t have been better, but Friday, after lunch, Jill doubled over with sharp abdominal pains. The frightened couple rushed to find a doctor. A kindly cab driver steered them to Doctors’ Hospital, a private facility in Nassau, the capital city.
Emergency Room personnel summoned an obstetrician who prodded and poked and recommended an overnight stay for tests. “Before you check in,” he said, “the hospital requires a $2,000 deposit. Don’t worry, we accept all major credit cards.”
Tests revealed a small ovarian cyst but no malignancy. Twenty-four hours later the pain had subsided and Alex and Jill returned to their seaside apartment.
Later, Jill said she had nothing but praise for both hospital and doctor, but admitted the demand for a $2,000 deposit and a $980 bill for her overnight stay were a shock. “We are Canadians. Had that emergency happened in Canada, the cost to us would have been free because Medicare covers the majority of medical services and is paid for by income and other taxes.”
But Alex and Jill were lucky. Bahamian health care is a two-tier system and the cab driver had steered them to the top tier where patients with money receive immediate hospital admission, early surgery and therapy. Had the cab taken them to the nearby Princess Margaret, the largest public hospital in The Bahamas, Jill might have waited hours to see a doctor or find an empty bed.
The enormous obstacles impeding good health care for 250,000 Bahamians have not been overcome by an annual expenditure of $90 million. The population spreads over 29 islands; at least a third live in homes without electricity or running water, and 10 doctors and 1.5 dentists strain to care for each 10,000 people. “Doctors cannot deliver adequate care when they attend more than 40 patients a day,” says one official. “Under such conditions health education, maintenance and preventive care are largely ignored.”
Bahamians, like people the world over, are addicted to unhealthy life styles: Indiscriminate eating, lack of exercise, cigarettes and excessive alcohol consumption. Twenty percent have high blood pressure and elevated cholesterol levels. Alcohol and drug-related problems represent more than one-third of all admissions to the only psychiatric facility in the country.
As long as a decade ago, the country’s health system was severely overtaxed; now, with rampant drug abuse and AIDS, the system seems stretched to capacity. The ratio of AIDS infection is said to equal that of New York and San Francisco, and is not only killing men but impacting on mothers and babies. Concerned people shake their heads as they say, “We have lost a whole generation of our children to drugs.”
The Ministry of Health has now singled out women and children for priority care, that care delivered through a network of 119 hospitals, clinics and health centers. There is at least one such center on every inhabited island. Nearly 6,000 babies are born annually; one-fourth to unmarried mothers and 28 percent to teenagers. Young women who eat poorly and smoke or drink during pregnancy often bear sick babies, contributing heavily to a high infant mortality rate. Six years ago that rate was 36 per 1,000 births. “An aberration” says one official. 1985-86 coincided with the cocaine epidemic and AIDS infection; still 1988 saw infant mortality fall to 21.4, a sizeable reduction. But, add perinatal and neonatal deaths, and the rate jumps to 53 per 1,000 births, a tragedy since improved prenatal care and prevention of accidents in the home could reduce the rate quickly and cheaply.
Bahamas Planned Parenthood Association (BPP)
Six years ago the Association opened its doors; today it owns a building in Nassau which houses a national headquarters and free-standing clinic. At the invitation of Patricia Francis, the Executive Director, I visited the BPP one February afternoon. Colorful posters decorated a large, bright, cheerful reception area: Today’s Woman Plans for Tomorrow; Don’t Blame Us For Teenage Pregnancy — Tell Us How To Avoid It; Sex Education Teaches Us About Our Values, Our Bodies, Our Future.
Posted near the check-in counter, a list of services and fee scales reminds patients that services are free only to proven hardship cases. The clinic services over 10,000 clients annually; 5-6,000 are repeat visits.
The annual budget of $259,500 does not stretch to staffing government clinics but the Association sells contraceptives to the Health Ministry and offers counseling on family planning to clinic personnel. Ambitious future plans include sub clinics throughout the Islands, information and education programs for schools, civic organizations and corporate employers.
Abortion Abortion is as ambiguous as it was in the States before Roe v. Wade. A young, single mother said “I don’t think it is legal but I really don’t know. If I wanted an abortion I would fly to Miami where it’s legal and not very expensive.” A male newspaper reporter said “I don’t know, but I think it is illegal. I don’t know any woman who has had one.”
The newspaper morgue has no clippings on abortion, but at the library I hit pay dirt. Although some articles were several years old, they doubtless describe today’s situation precisely.
“Abortion is slowly becoming an accepted household word,” wrote Dorothy Panza in 1976. “The new trend among young unwed mothers to sit and decide whether or not to have the child is indicative of liberation of Bahamian female attitudes …Although there are no actual statistics because the act is not legal, it has been estimated that more than 30 percent of all pregnancies end in abortion in Nassau…If abortion should become legalized here, the question of increased promiscuity, population control and women’s liberation will be some of the major ones facing our society.”
An article dated 1981 claimed one in every five pregnancies on New Providence (home of half the Islands’ people) ends in therapeutic abortion and the rate of abortion in 1980 tripled the number of those recorded in 1976. Abortions account for almost 25 percent of all gyn procedures and over 12 percent of all surgical procedures. These are perhaps the first and second most common surgical procedures done in Princess Margaret Hospital.
Patricia Francis at BPP said “It is illegal, but that is not the complete answer. No abortions are performed in family planning clinics and women do not raise the question in those clinics. When a woman asks, we give her options: Go to a government clinic or to a private physician. Some doctors do abortions, others do not. The Bahamas prides itself on being a Christian nation; sex outside marriage is considered bad. I don’t expect to see legalized abortion in my lifetime.”
Double Trouble Drug abuse and AIDS are the double trouble clogging good health delivery. The Islands are transshipment points between South American producers and North American consumers. As one would expect, drugs which “fall off the ships” in considerable quantities are sold and consumed on the Islands. The exact amount is unknown, but 60 to 80 new cases of cocaine abuse are treated every 90 days.
Because of opportunistic infections, multiple hospital admissions and long treatment periods, the AIDS epidemic has had a devastating affect on health delivery. “Overall, the average number of admissions for AIDS has been three per week, but hospitalizations of two to three weeks are not unusual and one patient stayed three months.”
In general, males are AIDS-infected almost twice as commonly as females, but most infected women are childbearing age and engaged in high risk behaviors: Intravenous drug use, unprotected intercourse with IV drug-using men, prostitution, or prostitution for drugs without practicing safe sex.
Susan began using drugs at 12 and became sexually active at 13. At 15 she asked the clinic for treatment. Because of the perceived association between drugs and promiscuity, the doctors screened her for AIDS, found her HIV positive and dubbed her “double trouble.” Susan could only give first names of her sexual contacts and didn’t know their addresses. Her mother, a single parent, has three other children who abuse drugs.
Janet, a 25-year-old woman, had two children by her first boyfriend. After they broke up she had one child by a second man. The baby died shortly after its birth in 1983. Janet got pregnant by a third partner and had another baby who was admitted to the hospital at eight months for “failure to thrive” and several episodes of gastroenteritis. In 1985 this child was found to be HIV positive and died.
“We have a third generation of AIDS victims as infected mothers pass the disease on to their babies,” declared a member of the Task Force on AIDS. The Task Force, established four years ago, believes it is making some headway against the epidemic as the population gets more information.
What of the future? Newspaper headlines often call financing the greatest health care problem in the country, but The Ministry lists some impressive achievements as indicators of their progress:
• 94 new nurses graduated in one year;
• Nurses are taking advanced training in midwifery both locally and abroad.
Those who believe early education is the best, perhaps the only, solution are delighted with new Family Life Education Classes mandated in all grades since September 1990. Blessed by the Anglican Bishop, the courses are endorsed by most churches. Taught by nurses and homeroom teachers, the classes teach students about health issues, drugs, life skills and family planning. With over 60,000 students enrolled in more than 200 schools, these classes should have considerable impact in a year or two.
Another hopeful indicator is the number of women enrolled in colleges. “Over the years women allowed themselves to be used sexually with near-disastrous results, but now attitudes are changing mainly due to better education,” says Patricia Francis of BPP. More women than men are studying at the college level. Females now outnumber males in classes in business, English and law.
Two decades ago Betty Friedan commented that young women “… only need a little more experience to understand that the gut issues of this revolution involve employment and education and new social institutions.” Who can doubt women’s liberation will work near miracles in The Bahamian Islands, one of the more beautiful places on earth?
For the past 24 years, Irene Davall has spent three weeks of each winter at a yoga retreat in The Bahamas.