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COMMITTEE MEMBERS
- M. Birmingham, (Chair)
- Dr Sam Christian, Asst.
- Frances Delsol,
- Raglan Riviere
- Dr Ralph St. Luce,
- Petronella John,

AmeriCares Emergency Response Site Visit to the Commonwealth of Dominica, June 16 through June 18, 2004

Project Manager Lisa Frantzen and International Associate Michael Chang

Overview

On Sunday, February 27^th, a fire destroyed the warehouse section of the Central Medical Store (CMS) at the Princess Margaret Hospital (PMH) in Roseau, Dominica.  The fire caused an estimated EC$4 million (USD$1.5 million) in damage.  All antibiotics, injectables, anesthetic drugs and medical supplies in the warehouse were destroyed. AmeriCares responded to this emergency by sending a 20’ container of medicines, medical supplies, and hygiene products.

Trip Objectives

• Receive feedback on the donation of medicines and supplies made by AmeriCares and visit the hospitals and clinics to which they were distributed.

• Meet Dr. Clayton Shillingford, President and Chair of the Dominican Academy of Arts and Science (DAAS).  Through Dr. Shillingford, AmeriCares was able to open communications with appropriate authorities in Dominica.  With his help we were able to ship directly to the CMS in Roseau.  Dr. Shillingford resides in Wilmington, DE but was in Dominica for our visit.

• Meet Mr. Hilary St. Claire, Supply Manager, and Mr. Errol Thomas, Chief Pharmacist, of CMS.  Mr. St. Claire has been our main contact in Dominica as CMS was the consignee of the shipment and responsible for the distribution of the donation.

• Visit CMS warehouse to observe how they are coping with damages done by the fire and storing the supplies that have since been procured. 

• Meet with Ms. Marvlyn Birmingham, Hospital Administrator at PMH, who will accompany us on our site visits and arrange a meeting with the Minister of Health and Social Security, Hon. John Fabien, and various local NGOs.

Background

The Commonwealth of Dominica gained its independence from Great Britain in 1978 and is a country located in the Eastern Caribbean.  Some 3,000 Carib Indians, still living on Dominica, are the only pre-Columbian population remaining in the eastern Caribbean.

Slightly more than four times the size of Washington, DC, Dominica’s total land area is 754 sq km.  It is the largest of the Windward Islands, located between the French dependent territories of Martinique and Guadeloupe, and its topography is the most mountainous in the Commonwealth Caribbean.

The Dominican economy depends on agriculture, primarily bananas, and remains highly vulnerable to climatic conditions and international economic developments. Production of bananas dropped sharply in 2003, a major reason for the 1% decline in GDP. In the World Bank’s 2004 list of economies, Dominica is considered to be a severly indebted country.

With a landmass that is of volcanic origin, the island has lush forests and an abundance of rivers, which is why eco-tourism is also one of the countries leading industries.  However, because of its predominantly primary health care system the country does not have the capacity to support the full range of medical needs.  The country believes that tourism would directly increase if its heath care system could treat patients in critical conditions.

Healthcare Overview

Total population: 72,000

GDP per capita (Intl $, 2003): 5,500

Life expectancy at birth m/f (years): 71.0/76.0

Healthy life expectancy at birth m/f (years, 2002): 61.9/65.6

Child mortality m/f (per 1000): 12/13

Adult mortality m/f (per 1000): 210/118

Total health expenditure per capita (Intl $, 2002): 310

Total health expenditure as % of GDP (2002): 6.4

Source: The world health report 2005 http://www.who.int/countries/dma/en/

There are 10 provinces in Dominica that are divided up into 7 health districts.  Each health District is responsible for delivering primary care to its constituents through Type I and Type III clinics.   There are 52 healthcare clinics in the country; 43 Type I and 6 Type III.

• A Type I health care clinic serves a community of approximately 500.  Some clinics, such as Salybia in the Carib Territory, can serve a population of 3,000 people in a five-mile radius. Type I clinics are staffed by a primary care nurse who is always on call and a medical resident that is based in the district’s Type III clinic.  Services delivered include:  child and reproductive health, nutrition, health education, medical care, community action, and emergency services.

• A Type III clinic is at the center of the district’s healthcare system and functions as the administrative headquarter.  Services that are provided at a Type III clinic include:  family and reproductive health, community and educational programs which are provided on a one-on-one basis, through posters and displays in waiting rooms, during home visits, and health fairs. Each Type III clinic is equipped with a dental unit, one to two beds for delivery of babies and provides a comprehensive range of services and health education.

• In the cities of Portsmouth, located on the island’s Caribbean coast, and Marigot, located on the island’s Atlantic coast, the health centers act as both Type III clinics and 28 bed inpatient hospitals.

• Roseau is the only health district that does not have a Type III clinic but is home to the country’s only major hospital and deliverer of secondary care, the Princess Margaret Hospital.

• There is no tertiary care provided and therefore patients with cases that cannot be treated in country are airlifted to neighboring Guadeloupe or Martinique. 

• Major diseases in the country are diabetes and hypertension.  Deaths from cancer are second to those of cardiovascular disease.

• There is one optometrist in the country, based at PMH, who visits every health district every other month.

• Ross Medical School, an affiliated U.S University, is located in Portsmouth but does not contribute much to the countries health care system.

• There is one nursing school on the island yet still there is a severe shortage of nurses and healthcare professionals.  Many that attend this school end up leaving the country for the US, the UK, or other developed countries where the pay is better.  

AmeriCares History

In the past, AmeriCares has supported 5 MOP missions to Dominica with medical supplies valued at $29,000.  This is the first time AmeriCares has sent a sea container to the Commonwealth nation.    

Site Visit Overview

June 16^th

Met with Ms. Marvlyn Birmingham, Hospital Administrator at the Princess Margaret Hospital and Dr Clayton Shillingford, President and Chair of the Dominica Academy of Arts and Sciences.

• Dr. Shillingford put AmeriCares in contact with the Ministry of Health, the Princess Margaret Hospital and the Central Medical Store in order to make this emergency response possible.

• Ms. Birmingham was responsible for arranging our agenda.  Since we arrived late in the workday, this meeting was primarily to lay out appointments and site visits for the next two days.

Ms. Birmingham provided a lot of insight into the Dominican Health System and how medicines are purchased for the hospitals and clinics.

• Dominica is a member of the Organization of Eastern Caribbean States (OECS) and the Pharmaceutical Procurement Service (PPS).  The OECS is a nine member group comprised of the following countries; Antigua and Barbuda, Commonwealth of Dominica, Grenada, Montserrat, St Kitts and Nevis, St. Lucia and St Vincent and the Grenadines. Anguilla and the British Virgin Islands are associate members of the OECS.

• Within the OECS, the PPS is the agency that submits pharmaceutical purchase orders on behalf of participating countries to contracted suppliers. 

• Orders are placed through PPS on a quarterly basis and although PPS is ordering in bulk and prices are lower for OECS members, Ms. Birmingham said that it is often difficult for Dominica to pay for the supplies.

Ms. Birmingham also showed us a proposal that she is working on with a delegation from George Washington University Medical Center. 

• A delegation of administrators, doctors, and professors from George Washington University conducted a site visit and assessment of the Dominican healthcare system from January 26 to January 30, 2005.

 

• The recommendations and priority of needs made by the delegation and agreed upon by Ms. Birmingham for further program development are:
• Developing an ICU and Telemetry Center at the Princess Margaret Hospital
• Creating a Community Health Program in Dominica and in D.C. that address metabolic disorders, hypertension, diabetes and obesity; and HIV/AIDS.
• Developing an Exchange program between the Princess Margaret Hospital and GWUMC for nurses, physicians, and medical and public health students.

June 17^th

We started out the day by meeting the Minister of Health and Social Security Hon. John Fabian.  The Minister was recently elected to office in March and has set the following objectives for his term.

·        To promote health from a more holistic viewpoint: lifestyle changes and health education.

·        Would like High Commissioners and overseas Embassies to be more active and involved with international NGOs.

·        Engage people of the Diaspora to provide health and medical training in Dominica.

The Minister made it very clear that drug donations are welcomed and help to supplement what is procured from PPS.  Many times the country has to go outside of PPS to purchase pharmaceuticals and supplies.  Medical Donations will not interfere or disrupt the current system.

After meeting with the Minister we went and visited the Central Medical Store where we met Mr. Hilary St. Claire and Mr. Errol Thomas Chief Pharmacists.  CMS was the consignee and distributor of the AmeriCares donation. 

The following information is from the meeting:

• Ringers Lactate, Heparin, and IV irrigation solutions were the only products not useful in the shipment.  CMS had to destroy 10 – 15 cases of these irrigation solutions; they are not used in Dominica.

• Distribution report was not possible because the sea container had to be emptied in one day and returned to the shipping company.  District clinics went to the Central Medical Store on the day the container was cleared to receive the medicines, supplies, and hygiene products. 

• Since medicines donated by AmeriCares were not of the exact dosages in their normal inventory, CMS instructed the district doctors, pharmacists, and nurses to use them like they would sample medicines.

Medical supplies and hygiene products were very useful and are always welcomed. 

We were able to see the damage done by the fire in the Warehouse.  It was first believed that the fire was caused by an electrical problem but after further investigation the reason for the fire has been determined unknown. 

• The warehouse is attached to the Central Medical Store offices, which were fortunately unaffected by the fire.  The current space that CMS is using for storing all medicines was previously only used for tablets and powders. 

• At the time of the fire district clinics had just received medicines and were restocked for the next four months.  The Central Medical Store places an order through the Ministry of Health and Social Security to the PPS in St. Lucia.

• The warehouse was badly damaged and will have to be razed.  There are plans to build a new warehouse on the same site with help from outside funding. 

After visiting CMS, Ms. Birmingham took us to the Type III clinic in the St Joseph’s health district.

·        Patients that visit the clinic do not have to pay for its services nor for the medicines they receive.

·        When we visited the clinic the Doctor of the St. Joseph’s District was meeting with all of the district’s nurses. Most of the healthcare professionals in the country are female nurses.  All of the professionals delivering health care that we meet were females except for the Pharmacist at the Portsmouth Hospital.

At the University of the West Indies, Ms. Birmingham informed us that 75% of the premed students are female.  This speaks to a larger social issue throughout the Caribbean.

 

·        The St. Josephs Clinic deals mostly in deliveries and check up exams.  They have two general exam rooms that also serve as a room for deliveries.  The clinic also has a room for dentistry; the dentist visits every Tuesday from Roseau. 

·        The Pharmacists at the clinic were appreciative of the medicines received and said that the Captopril 12.5mg was more appropriate for their patients with high blood pressure then the Captopril 25mg that they usually receive from the Central Medical Stores.  She was also very pleased with the Amoxil, Biesdorf cream, Fluconazole and Cipro that she received.

Portsmouth Type III Clinic and Hospital

• The Portsmouth Type III Clinic and Hospital is the center of the Portsmouth healthcare district.  The building is split into two sections, the clinic and the hospital.

• The clinic section focuses on maternity and child health and delivers such services as pre and postnatal care, family planning, and vaccinations.  They make it a point to see all pregnant mothers in their district and will make home visits if they hear of a case that has not yet visited the clinic.   

• The 28 beds in the hospital are spilt between three different wards, male, female and child.  The hospital has a Causality and Emergency room and a room for surgery.  Any major emergency or surgery is either referred to the Princess Margaret Hospital in Roseau, about 1 hour and 15 minuets south, or to Martinique or Guadeloupe. 
• There is a dermatologist that visits every week on Friday and an optometrist that visits every other month. 

 

Site Visit Conclusions

·        After visiting with the St Joseph and Portsmouth Type III clinics we are very confident that AmeriCares donations were well received and very useful.

 

CMS and the district clinics were also thankful for the medical supplies AmeriCares sent.  Supplies such as syringes, gloves, gowns, and hygiene products are always in high demand. 

·        When first speaking with Mr. St. Claire and Mr. Thomas, it was uncertain whether the donation was useful to the Dominican clinics.

 

After conducting the site visits and talking to the pharmacists to St. Joseph and Portsmouth clinics, we found that not only were the medicines extremely helpful but that in some cases the dosages that AmeriCares sent were more appropriate for the patients then what CMS purchases from the PPS.

·        Overall the AmeriCares emergency response was successful in that all but 10-15 cases of irrigation solutions were widely accepted and put to immediate use. 

June 18^th

• Met with representatives from Life Goes On, an affiliate of Life Line International an international NGO based in the U.K., and the Dominican Red Cross.

• Both organizations are involved in HIV/AIDS training in the country, as there is a large social stigma associated with the disease.  Being a small country with a small population, there are problems getting people tested for the disease, as they are not confident that their results will be kept confidential. 

• Life Goes On is currently educating and training 50 nurses, healthcare providers, and community workers in a 3 day a week 3 month course on HIV/AIDS. Their hope is for these 50 to then conduct similar educational courses in the areas they serve.

• Life Goes On is also in the process of raising money to build the first hospice in the country.   The hospice would accept all people living with terminal illnesses but would specialize in those living with HIV/AIDS.

•  The Dominican Association of the Red Cross is conducting a HIV/AIDS educational program for youth between the ages of 12-25, whose curriculum and programming is overseen by the Caribbean Red Cross.  Other training programs being run by the Dominican Red Cross are in disaster management and first aid.

Conclusion

The overall emergency response and site visit to Dominica was a success.  From the Minister of Health, to hospital administrators, to local pharmacists, AmeriCares made great connections in all of levels of the Dominican health care system.

If AmeriCares is looking for a country that can accept 4 to 6 40’ containers a year, Dominica is not a good candidate.  However, with a primary health care system and a severe lack of medical professionals the health care needs of the country are extremely high.  All of the people we met said that drug donations certainly have a place in the health care system and can make a difference in treating patients and with institutional budgets.

AmeriCares might consider future donations to Dominica when we are overstocked with a certain product and our current partners have reached their limit.  CMS was able to accept medicines with 6-8 month dating and had expressed interest in accepting certain medicines, such as antibiotics, that are not on their pharmaceutical list.

With CMS as the consignee, shipments clear customs quickly and can be labeled their full value.  Working under the Ministry of Health, CMS does not have to pay custom taxes on imported goods.   If AmeriCares were to consider Dominica for an on-going partnership, 2 to 4 20’ containers a year would be an appropriate volume.