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French Guiana |
 |
The Pan American Health Organization Promoting Health in the Americas |
GENERAL SITUATION AND TRENDS
Socioeconomic, Political, and Demographic Overview
The French Departments of French Guiana have been part of France since 1946. Even though it is located in the Region of the Americas, it is given special protection and granted structural funds from Europe devoted to assist developing European regions.
French Guiana occupies 90,000 km2 on the northeast coast of South America, bordered by Suriname on the west and Brazil on the east and south. Dense equatorial forest covers 90% of the territory. The main modes of access to the interior are waterways, and most communities are accessible only by motorboat. A few isolated communities have authorized landing strips.
The population of the Department remained stable during the 1960 and 1980 decades. Considerable migration to France occurred during this period, mainly as a consequence of lack of work, followed by a vigorous, although declining birth rate. Since the mid-1980s, and coinciding with declining employment rates in France, adults and retirees have returned to the Department.
The 1990 census showed an average annual population growth of 5.8% in French Guiana for the 1982–1990 period. This growth continues, and in 1996 the population density was 2 inhabitants per km2. Population estimates in 1996 were 151,780 inhabitants, the population in French Guiana is younger, with 36% under 15. In 1994, life expectancy was 78.2 years for women and 71.2 years for men.
In 1994, the fertility rate was 110.5 births per 1,000 women of childbearing age. Between 1982 and 1992 it increased by 4% among mothers 10–14 years old, and by 14% among mothers 15–19 years old. The birth rate was 29.2 resident births per 1,000 in 1995, the mortality rate was 3.9 deaths per 1,000 inhabitants, and the infant mortality rate (average for 1991–1993) was 15.3 per 1,000 live births.
Immigration from neighboring developing countries accounts for part of the growing population. In French Guiana, a third of the population is foreign.
Since 1986 fiscal incentives have set forward the public works, construction and hotel industries. Unemployment rates in French Guiana were 22% in 1986, 24.1% in 1993, 23% in 1995, and 22.4% in 1996.
Registered unemployed and underemployed persons account for half of the active population of this French Department; in the French Guiana the proportion is 44%. On the basis of the 1990 census, a survey conducted by the National Institute of Statistics and Economic Studies (INSEE) defined the high-risk population as households occupying makeshift accommodation without water in or near their dwellings and those with an unemployed head of family. An estimated 30% were considered to be high risk in French Guiana. Table 1 presents socioeconomic indicators for this French Department.
Table 1
Socioeconomic Indicators of French Guiana, 1982 and 1990
|
|
French Guiana |
|
| 1982 |
1990 |
|
| Households with running drinking water |
69,1% |
84,4% |
| Households with electricity |
80,4% |
87,8% |
| Households with sewage disposal (a) |
34,3% |
44,3% |
| Proportion of overpopulated dwellings (b) |
24,6% |
24,0% |
| Average number of persons/household |
3,3 |
3,4 |
| Urban population |
… |
64,3% |
| Literacy rate |
72,0% |
… |
(a) These figure do not include dwellings equipped with individual septic tanks.
(b) Dwellings having fewer rooms than the number of occupants.
Source: National Institute of Statistics and Economic Studies (INEEE), 1982 and 1990 reports.
Morbidity and Mortality Profile
Among the specific health problems affecting French Guiana is a high prevalence of sexually transmitted viral infections and an endemic level of dengue with epidemic outbreaks. Among noncommunicable diseases, there is a high prevalence of sickle cell anemia and a high frequency of diabetes, hypertension, and their complications (particularly chronic kidney failure). With the exception of cervical and prostate cancers there is a low incidence of malignant tumors. Traffic accidents contribute enormously to years of potential life lost (YPLL).
In 1995 there were 5,383 deaths in Martinique, Guadeloupe and French Guiana. The most recent information on death causes is for 1993, since mortality reports are prepared by the National Institute of Health and Medical Research in Paris, independently from mortality data extracted by INEEE from birth, marriage and death registries.
Based on YPLL, infectious and parasitic diseases are the second most frequent death cause for both sexes in French Guiana. The most frequent causes of death in the perinatal period are anoxia and other respiratory diseases.
Injury and poisoning (particularly road traffic accidents) are the primary cause of death among men, contributing to over one-third of YPLL among the male population. Among women, these two causes rank first in French Guiana.
While cardiovascular disorders are the largest contributor to mortality, their importance should be viewed in light of the late age at which death occurs. These disorders occupy third place in YPLL in French Guiana. The malignant tumors rank fourth as a cause of death among women in terms of YPLL. Among men, cancers rank fifth as a cause of death (4% of YPLL).
SPECIFIC HEALTH PROBLEMS
Analysis by population group
Health of children and adolescents
The perinatal mortality rate in French Guiana has remained at around 30 per 1,000 live births for the past 10 years. In 1995, neonatal infections, congenital malformations, and toxemia of pregnancy were the main causes of death during the perinatal period. The infant mortality rate was reduced three-fold in 20 years, falling from 50 per 1,000 in the 1970s, to an average of 15 per 1,000 in recent years. The three main causes of hospitalization in the 1992–1993 period were premature births and low birthweight (48%), infectious diseases (17%), and acute respiratory infections (6%).
The Departmental Maternal and Infant Protection Unit has a system for permanent recording of information for the perinatal period in all public and private maternity clinics, and in the departmental health centers. It consists of records of pregnancy results and fact sheets on the causes of perinatal deaths, as recommended by WHO.
The ratio of stillbirths to newborns weighing 500 g and 1,000 g was 22.6 per 1,000 and 16.7 per 1,000, respectively, in 1995. Early neonatal mortality was 9.8 per 1,000 for births at 500 g and 8.6 per 1,000 for those at 1,000 g. The premature birth rate has been stable at 12% since 1993. The proportion of newborns with a birthweight of less than 2,500 g is 11%.
In 1995, 67.3% of women sought fewer than the seven consultations provided by law during pregnancy, 53.3% sought fewer than six consultations, and 19.7% sought three consultations or fewer. The situation among minors is alarming: 79% sought fewer than seven prenatal consultations.
Between 1981 and 1983 deaths among 1–4-year-olds were due mainly to external causes and trauma, 67 per 100,000 population and diseases of the central nervous system showed a mortality rate of 40. In the 1988–1990 period the leading causes were infectious diseases with a mortality rate of 37, external causes and trauma 30 and respiratory diseases 18. The main causes of hospitalization in this age group are infectious diseases (18%), cranial trauma (13%), and chronic illnesses of the upper respiratory tract (11%).
Among children in the 5–14-year age group, the three main causes of death in the 1988–1990 period were: external causes and trauma, 12 per 100,000, infectious diseases with a mortality rate of 6, and circulatory diseases with a mortality rate of 4. The main reasons for hospitalization for children between the ages of 5 and 9 were broken limbs (14%), cranial trauma (12%), and appendicitis (12%). Among 10–14-year-olds appendicitis was the main cause (18%), followed by broken limbs (14%), and normal delivery (12%).
Early pregnancies, drug abuse, and AIDS and other STDs appeared to be the main health problems among adolescents. In the past decade, approximately 8% of mothers have been under age 18. In 1992, one-third of this group showed signs of pathology during pregnancy. Of the AIDS-affected population, 11.3% are under 20 years old.
Health of Adults
Between 1988 and 1990 the main causes of death among women in the 15–34-year age group were suicide (20%), road traffic accidents (10%), and AIDS (10%); for women ages 35–64 the main causes were malignant tumors (30%) and cerebrovascular diseases (16%). Among men ages 15–34 the main causes were traffic accidents (20%), AIDS (10%), suicide (8%), and homicide (6.3%); for men 35–64 years old malignant tumors predominated (11%), followed by AIDS (10%), cerebrovascular diseases (9%), and road traffic accidents (9%).
Health of older adults
Between 1988 and 1990, the most frequent causes of death among those 65 and over were cerebrovascular diseases, (19% in men, 23% in women), respiratory diseases (7%), infectious diseases (7%), and malignant tumors of the digestive system (7%). The most common chronic illnesses in this age group are severe hypertension, 19% in men and 36% in women, diabetes, (15% in both sexes), and tumors, 15% in men and 9% in women.
Analysis by type of Disease
Communicable Diseases
Vector-borne diseases. The incidence of malaria in French Guiana is high: 5,892 biologically confirmed cases were registered in 1995. The three types most frequently encountered were Plasmodium falciparum, P. vivax, and P. malariae. The two areas of malaria transmission in French Guiana are the two large border rivers (Maroni and Oyapock) where transmission is permanent, and the coastal zone, with sporadic and limited transmission. Since the malaria-infected areas are very distinct, it is difficult to define the global evolutionary trend.
Beginning in 1994, there was an outbreak of the disease in the Upper Maroni (Maripasoula) region. Migratory movements, mainly from Brazil and Suriname, connected with gold mining along the rivers have contributed to this rise in malaria transmission.
In 1992, a study revealed a 68% in vivo failure rate of chloroquine malaria treatment (62% in vitro), with 24% resistance to quinine. These findings were confirmed by in vitro chemosensitivity conducted at the Pasteur Institute (1993–1996), which also indicated resistance to halofantrine.
The dengue vector in French Guiana is Aedes aegypti and the 1, 2, and 4 virus types circulate in an endemic-epidemic mode. An epidemic wave caused by the dengue-2 serotype was observed from July 1991 to October 1992. During that period 40 cases of dengue hemorrhagic fever were registered, including six deaths. In December 1995, this serotype reappeared mainly in Cayenne. There has been a new outbreak of the disease since the last quarter of 1996 with distribution of dengue-1 in Kourou and dengue-2 in Cayenne.
Cholera and other communicable intestinal diseases. Together with malaria, diarrhea is the principal reason for consultation and observation in the departmental health centers. Typhoid breaks out in small epidemics, mainly in the communities in the Maroni region.
The first case of cholera was reported in French Guiana in 1991. Between December 1991 and November 1994, 22 cases of cholera were reported, 55% of which originated in rural areas. No case of cholera has been reported in French Guiana since November 1994.
Acquired Immunodeficiency Syndrome. Since the beginning of the epidemic, 588 cases of AIDS have been reported in French Guiana. Women account for 38.4% of all cases; 30–39-year-olds are the most affected age group (38.8%), followed by the 40–49-year age group (17.7%), and the 20–29-year age group (15.6%). Transmission in 79.2% of cases is heterosexual. While mother-to-fetus transmission is a striking aspect, representing 58 cases (9.9% of all cases), transmission in a drug-abuse context is very low (2%). Of the cases reported, 57.8% died as of 31 December 1996.
"Tritherapy" or multi-drug treatment of AIDS began in August 1996, and patients have access to viral-load measurement. In 1997 French Guiana embarked on a "strategic programming" process to address this high-priority disease.
Tuberculosis and Leprosy. In 1995, 69 cases of tuberculosis were registered. The predominance of the disease among males in 1994 (male-to-female ratio of 2.2:1) appears to have tapered off (male-to-female ratio of 1.16:1 in 1995). Two-thirds of tuberculosis cases are found among immigrants from Brazil, Haiti, and Suriname. The tuberculosis/HIV co-infection rate was 19% in 1995. Poverty and marginality, which have been exacerbated since 1993 in French Guiana, are factors that probably encourage transmission of tuberculosis.
In French Guiana, 15 to 20 new cases of leprosy are detected each year. The paucibacillary forms predominate (nearly 80%). Since 1986, the incidence of leprosy has dropped by half and ranges from 0.08 to 0.15 per 1,000. Prevalence has shown a steady decrease, from 3.2 per 1,000 in 1985 to 1.1 per 1,000 in 1995.
Noncommunicable Diseases and Other Health-Related Problems
Nutritional and Metabolic Disorders. Protein-energy malnutrition mainly affects the black population of the Maroni region, particularly in babies being weaned. There are 15 to 20 hospitalizations per year for severe infant malnutrition (kwashiorkor, marasmus, and mixed forms) at the Saint Laurent Hospital in Maroni. Infant protein-energy malnutrition in the black population is linked to a number of factors, mainly reduced interest in breast-feeding and belief systems regarding infant feeding.
Malignant tumors. Cancers are the leading cause of death in the 35–64-year age group. In men, cancer mainly affects the digestive system, the prostate, and the respiratory system. In women, the most frequent are tumors of the digestive system (37%) and cancer of the uterus (20%).
Mental and behavioral disorders. French Guiana has conducted few studies on its inhabitants suffering from mental disorders. Hospital data, however, indicate a general increase in activity in recent years, especially in child and juvenile psychiatry. The data reveal a high percentage of forcibly hospitalized patients (30.6% in 1993, while the national average was 21%); a lack of suitable structures for stabilized illnesses or handicaps, resulting in hospitalizations not justified in terms of psychiatry; and the onerous burden of health coverage for drug addicts. In 1993, drug addicts accounted for 22.6% of hospitalizations and 73% of forcible hospitalizations. Fifty percent of hospitalized drug addicts have an associated severe psychiatric disorder.
According to a recent study on drug addicts treated at the care establishments, 7% used crack cocaine, 59% are between the ages of 20 and 34, and 66% are out of work (compared with 14% of addicts with stable jobs).
There is a dearth of information on alcohol-related morbidity, but 3% of all deaths appeared to be alcohol-related.
RESPONSE OF THE HEALTH SYSTEM
National Health Plans and Policies
The State Department of Health is part of France's Ministry of Labor and Social Affairs. Other participants in health activities are the Ministry of the Interior (drug abuse programs), the Environment, Agriculture (food safety) and National Education (school health).
A 1992 law provides that all persons residing in France and in French Departments have the right to financial assistance for medical treatment costs in case of need. Access to medical attention for the poor is organized by the Department in which they live. The Department pays either the entire cost or the "ticket moderateur," which is a portion ranging from 0% to 65% depending on the nature of the illness, the care provided, or the type of medication. The costs of care to the homeless are paid by the State.
Health insurance is provided by the social security system, a State-sponsored mechanism financed with compulsory contributions from salaries. The patient pays the total cost of treatment directly to the health provider and is later reimbursed by a health insurance agency. Reimbursement amounts are negotiated by healthcare providers and the social security system. A growing proportion of the population voluntarily takes out additional insurance to finance non-reimbursable portions. A system of direct payment by insurers relieves the patient from having to advance the cost, particularly for hospital and drug costs. In these cases, the health insurance system pays directly to the healthcare provider and the patient contributes the "ticket moderateur".
Organization of the Health Sector
Institutional Organization
The State has responsibility for general public health, including community-wide disease prevention, sanitation surveillance, border health control, and the control of major diseases and drug and alcohol addiction. The State oversees training of health personnel, helps define their conditions of work, monitors observance of quality-control regulations and health safety in treatment centers, and regulates pharmaceutical products. Moreover, it supervises the adequacy of treatment and preventive arrangements and regulates the volume of treatment provided. The central Government oversees the functioning of public hospitals, appoints their directors, establishes their budgets, and organizes their staff recruitment. Finally, the State supervises social welfare, its financing, the rules for population coverage, and financial responsibility for treatment.
A prefect manages the State decentralized services corresponding to each of the Ministries involved, particularly those relating to health issues. At the local level, other prefects manage a Health and Social Affairs Office and the Interregional Social Security Office, common to the three departments and with a central seat in Martinique.
Under the 1983 decentralization law, certain State medical and social responsibilities were transferred to the Presidents of the General Councils in each Department. These include: maternal and child welfare, immunization, tuberculosis control, sexually transmitted diseases (excluding AIDS), cancer, leprosy, child social welfare, and part of the assistance to the elderly and to disabled adults. The mayors may have certain responsibilities for sanitation and immunization, and chair the boards of directors of public health establishments.
Residents of the French Departments enjoy unrestricted access to a wide range of primary and secondary medical services in France. In 1991, the University Hospitals and Regional Cancer Control Centers in France provided 61,000 hospital days to 4,500 patients from the French Departments, which represent an estimated 15% of hospital operation in French Guiana. More than 25% of those days were for treatment of cancer patients, followed by patients suffering from cardiovascular disorders and genitourinary diseases. The social security system reimburses hospital expenses, but pays airfares for only a small proportion of patients requiring medical treatment not available in the Departments.
Public and private hospitals provide full hospitalization, ambulatory treatment, and outpatient consultations. Inpatient care is divided into short-term treatment (acute conditions), follow-up (convalescence, readaptation, and functional rehabilitation), and long-term care (designed essentially for the elderly). Private practitioners provide most ambulatory or home care, although patients may also avail themselves of outpatient services at hospitals or treatment centers.
The public and private sectors differ in some regards. Teaching and research are part of the specific missions of the public hospitals. They are obliged to accept all patients and employ only salaried staff. Physicians in private hospitals charge fees.
Since 1985, public establishments have been financed primarily through a grant made by the State on an annual basis and paid by the health insurance scheme. Private establishments are funded through lump-sum payments and daily rates fixed by the regional health insurance offices. Their funding is thus proportionate to their activity, which is not the case for public hospitals.
Organization of Health Regulation Activities
Environmental protection: These are the responsibility of the State in each Department. Water for human consumption and use (including sea water and swimming pools) and treatment of wastewater are periodically inspected.
Food safety: The Departmental Bureau of Health and Social Affairs and the Veterinary Department (Ministry of Agriculture) conduct food poisoning surveys. The Departmental Bureau of Competency, Consumption and Fraud Elimination (Ministry of Internal Revenue) performs quality control of comestible goods and food preservation.
Health Technology: Health equipments are nationally supervised; all equipments can be installed at health facilities only after clearance from national authorities, on the basis of a sanitary map which shows the relation of bed capacity and major medical equipments to the number of inhabitants.
Organization of Services for care of the Population
Health promotion: The Center for Health Education of France develops campaigns on a variety of health and hygiene topics that are delivered by the Departments. In addition, the National System of Medical Insurance conducts screening and prevention campaigns (for example, for cervical and breast cancer). The Departmental Bureau of Health and Social Affairs has the capacity to conduct campaigns using education materials sensitive to the local conditions.
Water Supply, Sewerage Systems, and Solid Waste Disposal. The drinking water made available to 85% of the population, which is concentrated on the coast, is generally of high quality. The communities in the interior have water of mediocre, if not extremely poor quality; their treatment centers are either inadequate or have facility maintenance problems. The most serious problems affecting water quality are bacteriological parameters, the presence of aluminum, by-products of chlorination, and the occasional presence of mercury.
Sewage facilities for domestic wastewater are not very effective in French Guiana. It is estimated that only 30% of the wastewater produced is treated. French Guiana has no organized treatment or recycling facility for domestic wastes. Landfills are the only means of waste disposal, and there are only two controlled landfills, both located in the urban area of Cayenne. In addition there are some 20 crude communal landfills and more than 100 random dumping grounds. Most of the landfills are installed without prior impact studies, often on unsuitable sites.
Disease Prevention and Control Programs: Residents of the Departments have access to regular examinations during their school years and in the workplace. Also, maternal and child welfare services are available to pregnant women and young children. The Departmental Bureau of Health and Social Affairs is responsible for reporting notifiable communicable diseases.
Control of Vector-Borne Diseases. Malaria control is the province of the Departmental Disinfection Bureau and comprises vector control by spraying homes (walls), impregnating mosquito nets with long-lasting insecticides, attacking the parasite pool with active detection techniques, and treatment of parasite vectors. The surveillance system is based on compulsory notification of cases of local and imported malaria and on active and passive detection. The Disinfection Bureau and Pasteur Institute of French Guiana also conduct entomological surveillance. The Pasteur Institute is responsible for entomological studies on malaria vectors and their sensitivity to antibiotic products.
Since the Second Consensus Conference on Malaria (Cayenne, October 1995), recommendations for treating malaria in French Guiana exclude chloroquine as a first medication and concentrate on the use of quinine in association with doxycycline, halofantrine, or mefloquine.
The Pasteur Institute is the National Reference Center for surveillance of dengue and yellow fever and is responsible for identifying viral strains. The current surveillance system is based on the positive seroreactions requested by doctors. The Disinfection Bureau’s vector control relies on different activities such as: control of larval deposits by periodic visits to homes; visits and treatment of close contacts of positive seroreaction cases; and larva control and imagocide among the close contacts of seropositive patients. Imagocide activities are stepped up when there is a resurgence of dengue cases. Health education campaigns are organized through the media, the national education department, and associations to encourage public participation in the elimination of larval deposits.
Given its geographical situation and the risks of infection with yellow fever virus, immunization in French Guiana is compulsory from the age of 12 months, with a booster shot every 10 years. All of the Department’s health centers have been equipped to perform this immunization since 1995. Compulsory vaccination is performed free of charge in the health and prevention centers. Besides the compulsory vaccinations (BCG, DTP, polio, and yellow fever), the General Council covers measles, mumps, and rubella immunization, and provides immunization against hepatitis B for groups with high risk of infection.
Mental Health Plans. The regional psychiatry plan, decreed in 1996, defines goals for the next five years. Priorities were the creation of new sector divisions (three for adult psychiatry, and one for child-youth psychiatry); extension of access to care, particularly for the inhabitants of isolated communities; and measures to cover psychiatric emergencies and dangerous patients.
Organization and Operation of Personal Health Care Services
The coastal area of French Guiana has three urban centers—Cayenne, Kourou, and Saint Laurent du Maroni—home to nearly 80% of the population. The coast enjoys developed health facilities (three hospitals and three private clinics), a network of private doctors, and prevention facilities administered by the General Council. The population of the interior is distributed mainly along the two border rivers and in the outback. In the remote rural areas where there are no private doctors or hospitals, there is a network of public health clinics administered by the General Council. Access to treatment, including medicines, is entirely free in these facilities.
There are two public hospitals, one is in Cayenne (with 526 beds, 80 of which are devoted to psychiatric patients), the other is in Saint Laurent du Maroni (104 beds). There is a nonprofit private clinic in Kourou (65 beds), and three non-profit clinics in Cayenne (with 81, 45, and 36 beds). There are no cardiac surgery, neurosurgery, or serious burn facilities in French Guiana, making medical evacuation to the Antilles or France a necessity. There are 9 medical health centers and, in the remote areas, 17 satellite health centers staffed by health workers. The health centers provide nursing care and medical consultations and maintain beds for patients needing observation. The territory has been divided into 12 health zones, which more or less follow the administrative borders. Doctors usually travel in canoes along difficult routes (up to six hours in a canoe within a single health zone). Health teams may transfer a patient to the coastal hospitals. Canoe, airplane, helicopter, or ambulance are the modes of evacuation, depending on the center’s location and the degree of urgency. Evacuations are done for consultations or specialist examinations, planned hospitalization, and medical emergencies.
Since 1993, the social security service has shared in the operation costs of the departmental health centers, prorated on the estimated percentage of insured persons residing in a community.
Service networks: A system of municipal hospitals is available to provide intoxication and hepatitis C therapy, which strengthens the coordination among hospital doctors and private practitioners. There are also HIV infection information and healthcare centers.
Diagnostic ancillary services and blood transfusion units: Blood transfusion units operate nationally under the French Blood Agency. Regionally, a physician monitors proper blood-transfusion practices.
There are 3 private and 2 public biomedical labs in French Guiana; and 25 private and 8 public in Martinique. The prefect may authorize the operation of private laboratories taking into account local conditions, personnel qualifications and available equipments. The public labs are part of the hospitals.
Specialized services: Psychiatric services in France are organized by geographical areas. Each adult psychiatry service covers an area of about 70,000 inhabitants; for each three of these services there is a child psychiatry service.
There are two administrative offices in charge of the disabled: the Departmental Commission for Special Education reviews all the employment applications of disabled persons under 20 years of age, as well as financial support applications from their families. For disabled persons 20 years of age and older, the Commission for Technical Orientation and Professional Reclassification of each department offers work placement services and assessment of financial assistance and special referral services.
Since 1984, the French prison population has received medical coverage equivalent to that of the general population.
Inputs For Health
Drugs and immunobiological products: In the Antilles and in French Guiana there are 308 pharmacies, (140 in Guadeloupe, 139 in Martinique, and 29 in French Guiana) and 7 wholesale distributors (2 in Guadeloupe, 2 in Martinique, and 3 in French Guiana). All pharmaceutical products, including vaccines, are imported from France. Usually, drugs are available by doctors’ prescription and the patient is reimbursed by a health insurance agency. A system of direct payment by insurers relieves the patient from having to advance the cost. The authorities set the price of reimbursable drugs. Generic drugs have yet to find a significant niche in the French drug market. The price for drugs in the Departments is adjusted to offset transportation costs. In the last 20 years there has been a sharp increase (approximately eightfold) in expenditures for medications by households in the French Departments.
Quality control of pharmaceutical products is based on health surveillance activities, alert systems, operation manuals, continuing education of pharmaceutic personnel (soon to be mandatory), and site inspections to pharmacies in each region. Drug advertising to the public and physicians is regulated. Health authorities conduct periodic information campaigns on drugs and their proper use.
Medical equipment: Implementation of major medical equipment requires authorization of the prefect. Some equipments are shared by the three departments. For example, a magnetic resonance imaging device in Martinique and a lithotriptor in Guadeloupe.
Human resources
Education and training: Doctors are trained in the medical schools attached to the university hospitals. A tertiary cycle of medical studies exists with a training capacity of 5 specialists and approximately 100 general practitioners per year in the Departments. This takes place through an agreement between the University of Bordeaux II and the Antilles-French Guiana Training and Research Unit, which is attached to the University of Antilles-French Guiana.
The Fort-de-France and Pointe-à-Pitre teaching hospitals serve as supervised practical training facilities for medical students. A school in Martinique, attached to the Fort-de-France university hospital, trains 14 midwives a year; a school for operating room nurses at the Lamentin Hospital in Martinique trains 10 nurses a year; and there are two schools for ambulance staff, one in Martinique and the other in Guadeloupe. There is also a school of nursing in each of the Departments, training a total of 61 nurses per year. Other health professionals are trained in France.
Continuing medical education is provided for salaried doctors in the health establishments where they are employed, and has been compulsory for private doctors since 1996. This training is managed by Regional Councils for Continuing Education and the National Council for Continuing Education.
Healthcare Personnel: As of January 1997, the ratio of private doctors in the Departments was 66 general practitioners and 40 specialists per 100,000 population. Private doctors are paid for each consultation, while other health professionals may be salaried or may practice privately and be paid for each consultation.
Health research and technology
The National Institute of Health and Medical Research has a unit in Guadeloupe devoted to emoglobinopathy. The Institute has Research Guidance Committees in each Department.
External technical and financial cooperation
To ensure access to care for the destitute, Physicians of the World, a nongovernmental organization, provides free medical consultations. Likewise, the AIDES Association, in partnership with State authorities, is involved in the fight against AIDS.
Specific projects are assisted through the Inter-ministerial Fund for the Caribbean. The Fund, which receives approximately 10 million francs (US$ 1.8 million) annually, is administered by an inter-ministerial delegation responsible to the prefect of Guadeloupe, and is designed to support bilateral cooperation projects involving at least one Department and a neighboring foreign country. One-sixth of the Fund is devoted to health. Health facilities, particularly the Fort-de-France and Pointe-à-Pitre teaching hospitals, negotiate cooperative activities with neighboring countries in the areas of training, telemedicine, and on-site visits by health practitioners to administer treatment.