Data updated for 2001

MARTINIQUE

GENERAL SITUATION AND TRENDS

Socioeconomic, Political, and Demographic Overview

The French Department of Martinique 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.

Martinique is the northernmost of the Windward Islands; Dominica is its closest neighbor on the north, and Saint Lucia is its neighbor to the south. The island covers an area of 1,130 km2 and is mountainous, with Mont Pelée, a dormant volcano rising to 1,400 m, its most prominent physical feature. The administrative and commercial capital is Fort-de-France.

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 1.1% in Martinique, for the 1982–1990 period. This growth continues, and in 1996 the population density was 353 inhabitants per km2. Population estimates in 1996 were 383,340 inhabitants, the population under 15 years representing 24.0%. In 1994, life expectancy was 82.4 years for women and 79.5 for men.

Immigration from neighboring developing countries accounts for part of the growing population.

Since 1986 fiscal incentives have set forward the public works, construction and hotel industries. Unemployment rates in Martinique were 31% in 1986, 25%in 1993, 26.1%, in 1995, and 27.2%; in 1996.

Registered unemployed and underemployed persons account for half of the active population of this French Department. 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 22% were considered to be high risk in 18% in Martinique. Table 1 presents socioeconomic indicators for this French Department.

Table 1

Socioeconomic Indicators of Martinique, 1982 and 1990

^(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 Martinique 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 fourth most frequent death cause for both sexes in Martinique; accounting for 6% to 7% of YPLL. 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 third in Martinique.

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 second place in YPLL. The malignant tumors rank first as a cause of death among women in terms of YPLL. Among men, cancers rank second as a cause of death (18% of YPLL).

SPECIFIC HEALTH PROBLEMS

Analysis by population group

Health of Children

The infant mortality rate in Martinique was halved in 10 years to 5.8 deaths per 1,000 live births in 1995. Perinatal mortality stood at 11.4 per 1,000 total births in 1996. The premature birth rate was 8% in 1996. The proportion of newborns under 2,500 g was 9.4% and those under 1,500 g was 1.3%. In 1995, 699 infants (12% of all births) were hospitalized in the neonatal wards, of whom 2.6% died during the neonatal period. The main causes of death were extreme prematurity and infections.

An average of 60 deaths per year occurred among children between the ages of 1 and 4 (2.8% of all deaths) in the 1987–1990 period. The deaths were attributed to external trauma, ill-defined illnesses, diseases of the nervous system, diseases of the respiratory system, and tumors.

A 1997 survey on immunization coverage in 1-year-olds showed 83% coverage with BCG, 97% with three DTP and polio doses, and 78% with hepatitis B vaccine, which was introduced into the immunization program in 1994.

School attendance is obligatory beginning at 6 years of age. However, one-fourth of 2-year-olds attend school, and nearly all children attend from age 3 onward.

On average, there were 35 recorded deaths each year for the 1987–1990 period among 5–14-year-olds (1.6% of all deaths). More than half were due to external trauma, and tumors. Hospital admissions for this age group were for three main causes: respiratory diseases (24%), diseases of the digestive system (18%), and trauma and poisoning (9%). There was an increase of allergic diseases, including asthma. Some 400 to 500 cases of chickenpox are reported each year, principally among elementary school-age children.

Health of Adolescents and Adults

There is almost 100% school enrollment among 15–19-year-olds, and 42% for the 20–24-year age group. Unemployment was highest among 20–24-year-olds, with 52% in 1996.

In the 1987–1990 period an average of 45 deaths occurred each year among 15–24-year-olds, with a male-to-female ratio of 3:1. Road accidents and other violent forms of death predominate among men (69% of deaths in this age group); tumors account for 8% of deaths. Among women in this age group, the external causes of trauma, primarily suicides, predominate (46% of deaths).

Deaths before age 65 account for 29% of all deaths, with a higher prevalence among men (35%) than women (21%). External causes of trauma (accidents, suicide, and violence), tumors, diseases of the circulatory system, and alcohol-related disease account for 75% of these deaths. The preponderance of tumors and disorders of the circulatory system is higher among women than men, while the converse is true for trauma and alcoholism. Nearly half of these deaths appear to be avoidable. In men, they could be avoided by altering high-risk behaviors, while more effective coverage by the health care system would lower the rate for women.

The 1992–1993 hospital morbidity survey showed that for women between the ages of 15 and 64 more than one-third of the hospital stays were related to maternity. This was followed by genitourinary diseases (11%) and digestive ailments (9%). Among men of the same ages, 21% of hospital admissions followed trauma or poisoning, whereas 14% were due to diseases of the circulatory system. Diseases for which social security covers hospitalization for patients between age 15 and 34 include mental disorders (37%), diabetes (9%), sickle cell anemia (8%), and cardiac failure (8%). Diabetes, severe hypertension, and mental disorders are the main conditions requiring hospitalization in the 35–64-year age group.

Health of older adults

In 1996, 15% of Martinique’s population was 60 or over. The main causes of death for those age 60 and older are cerebrovascular diseases, prostate cancer, and cardiac failure in men, and cerebrovascular diseases, cardiac failure, and diabetes in women. Cancer, hypertension, and diabetes are the most commonly observed pathologies. Hospital admissions increase sharply with age, and adults over age 65 represent 23% of all short-term hospital stays.

The elderly population is still well integrated into the family in Martinique. In the 75–85-year age group, 37 % still live at home. The population aged 75 and over live in urban and peripheral urban areas, 28% of them in the capital.

Efforts to reduce unhealthy housing have provided this population group with improved basic sanitation conditions. Only 16% of those age 60 and over have no indoor toilets, and 6% have no source of potable water. Two-thirds own their own homes and 2% live in institutions or as boarders with families.

Reproductive Health

The number of women of childbearing age was estimated at 104,200 in 1996 (52% of the female population). The fertility rate was 1.8 children per woman in 1994, compared with 2.1 in 1990. The birth rate in 1995 was 14.4 per 1,000. Deliveries by girls under age 15 are unusual (1 delivery in 1,000). Deliveries by girls under age 18 account for some 2% of births.

Contraception is accessible to all women either through the private medical system, the Maternal and Child Welfare Service, or family-planning centers. During 1996, the Martiniquan Association for Family Information and Guidance, a private family-planning center, was consulted by 11,312 women, 95% of whom were seeking contraceptives. The pill is prescribed for 78% of women; IUDs are used by 18% of women.

Seven prenatal visits for pregnant women are fully covered by the health care system. The proportion of women rarely or poorly monitored (under four visits) ranges between 7% and 8.5%. In 1996, virtually all births took place in either a hospital or clinic, and 0.3% at home. The public hospitals attend to 68% of deliveries, while 32% take place in private clinics. The cesarean-section rate is 14% in the public sector and 16% in the private. The proportion of multiple pregnancies is stable, at 1.3% in 1996. The maternal mortality rate was 54 deaths per 100,000 births for the 1987–1993 period.

Abortions, which have been legal up to the 10th week of pregnancy since 1982, approximate 2,000 a year. In 1994, 23 abortions per 100 conceptions were recorded. A study of the 1992 statistical records shows that most abortions occur among women between 20 and 30 years of age, with minors representing 5%. These women are most often single (72%) and 62% are students or gainfully employed. Two-thirds had had previous pregnancies and one-fifth had undergone a prior abortion. Abortion is not officially practiced in the private sector, but it does occur owing to the long waiting lists in the public sector. An estimated 20% of abortion requests are not granted.

Health of the Family

The 1990 population census showed that household size in Martinique had decreased sharply, with 14% of households with 6 people or more compared with 30% in the 1974 census. In addition, various generations cohabit less often than in the past. In 1990, nearly 4 out of 5 households had a very simple structure: people living alone (21%), adults alone with children (16%), and couples with children (32%) or without children (10%). Also, 39% of children were in single-parent homes. This situation is linked to tradition (women bring up their children alone) and to a more recent development (the breakup of couples). Moreover, 77% of children under age 7 come from homes where both parents (or the single parent) practice a profession.

Health of the Handicapped

The disability prevalence rate among children age 10–19 years is 12.6 per 1,000. The most frequently observed impairments are intellectual (36%) and other psychological deficiencies (21%). There are approximately 100 children acutely affected and suffering from multiple handicaps. Over half of these children have been placed in specialized institutions or receive institutional monitoring. The number of disabled adults (over age 20) is estimated at 15,000. Over 5,000 receive a disabled adult allowance. Fewer than 3% live in specialized institutions.

A 1994 survey revealed that visual impairment affected an estimated 5% of the disabled population between 20 and 60 years old.

Analysis by Type of Disease

Communicable Diseases

Vector-Borne Diseases. In Martinique malaria is entirely imported and its annual incidence is low. No cases of yellow fever have been recorded. In 1995 and 1996 yellow fever immunizations were given to 3,164 and 3,951 persons, respectively, by the Departmental Hygiene Laboratory.

Dengue epidemics occur annually. The annual incidence of dengue-2 and -4 was approximately 2 cases per 10,000 inhabitants in 1993, increasing to 14 per 10,000 in 1995 owing to pronounced hurricane activity. There were 9 cases per 10,000 inhabitants in 1996. These cases were all confirmed by serology. The upsurge of cases takes place in August–September, peaking in December–January. In 1995, three cases of dengue hemorrhagic fever were recorded, with one death. In 1996, 14 cases were reported, but there were no deaths.

No cases of poliomyelitis, diphtheria, or whooping cough have been reported to the health authorities for more than 10 years. Recorded cases of measles mainly affected children with an average age of 9. In 1995, 8 laboratory-confirmed cases were reported, and 13 in 1996. The immunization coverage survey conducted by the departmental authorities in January 1997 showed it to be 90% for the Department as a whole. There have been no cases of neonatal tetanus since the end of the 1970s. However, cases of tetanus do occur among the elderly (11 per year), owing to their loss of vaccine immunity. Since 1990, the measles, mumps, and rubella triple vaccine was applied in systematic immunization campaigns. Influenza syndromes have been reported to the Departmental Bureau of Health and Social Affairs by the sentinel doctor network since 1995. In 1996, 10,064 cases were reported.

In February 1992 a decree mandated testing for HBsAg during the sixth month of pregnancy. A seroprevalence survey conducted in Martinique on a sample of 492 women who gave birth in 1993 revealed a prevalence of 0.6% for HBsAg. A second survey conducted by the Maternal and Child Welfare from August 1992 to June 1993 on 1,000 pregnant women showed a prevalence of 1.13%. Hepatitis C affects an estimated 3,000 persons in Martinique. As of March 1996, 44 patients had been admitted to the chronic hepatitis C unit.

Cholera and other infectious intestinal diseases. There have been no reported cases of cholera in Martinique.

Salmonella is the most common etiological agent of food poisoning (68.1% of sources for which a causal agent was identified). The number of cases of Salmonella typhi is steadily decreasing, confirming the disappearance of major epidemics of typhoid and paratyphoid fevers long considered to be the most important communicable disease in Martinique. An average of 14 cases are reported per month, most (30 cases) occur in the month of August.

Between August 1995 and July 1996, 14 cases of ciguatera were admitted to hospital and an additional 32 cases were reported but not admitted. The annual incidence rate is 1.2 cases per 10,000 inhabitants. With high incidence throughout the year, viral gastroenteritis epidemics are the prime cause of diarrhea in Martinique. There has been a 90% reduction in cases of hookworm and 80% in cases of threadworm in the last six years owing to a higher level of hygiene, preventive activities, and Departmental Bureau of Health and Social Affairs screening. High-risk population groups (military recruits and farm workers) are systematically screened, but because of their risk status, screening results cannot be applied to the population at large. Polyparasitism (hookworm and threadworm or Schistosoma mansoni) were detected in 5% of the cases.

Tuberculosis and Leprosy. The incidence of tuberculosis fell from 66 cases in 1982 to 33 in 1995. A retrospective study of all 178 tuberculosis cases from 1990 to 1995 shows a drop in the average age of patients, from 57.5 years of age in 1991 to 48.4 year of age in 1995, probably due to HIV co-infection. The most frequent form of the disease is pulmonary (82%). Out of 169 cases documented, 6% have suffered a relapse. Most cases (92%) are found in Martiniquans. While the number of tuberculosis sufferers infected with HIV has been falling since 1993, HIV-positive individuals are at 900 times greater risk for contracting tuberculosis. The extra-pulmonary forms of the disease are encountered particularly in HIV co-infection.

Out of 195 cases of leprosy followed by health institutions, in the active population, 92% were seen during 1996. Of the 458 patients under observation without treatment, 79.2% were examined in 1996.

Acquired Immunodeficiency Syndrome. The AIDS epidemic in Martinique poses a priority public health problem. As of 1 January 1997, 402 cases of AIDS had been reported; 26% in women and 74% in men. Since the onset of the epidemic, 262 people have died of AIDS. HIV seropositivity is not subject to any notification, and only known AIDS cases are reported.

There were 44 new AIDS cases reported in 1992, 43 in 1993, 49 in 1994, 38 in 1995 and 35 in 1996. The epidemic has stabilized and is probably on the decline. Heterosexual infection is 82% among women and 60% among men, or 64% for both sexes combined. This predominance is not due to under-representation of other transmission groups, but is caused by the increase in heterosexual transmission. A survey conducted in 1994 on sexual behavior in the Antilles and French Guiana revealed the significance of constant multiple partners in the French Departments. No socioprofessional class or age group has escaped the AIDS epidemic in Martinique.

Because of exceedingly strict regulation regarding blood-transfusion, the virus is no longer transmitted by that route. Improved coverage of seropositive pregnant women has reduced transmission of the virus from mother to child to approximately 10%; there are currently 14 infected children.

Martinique has a departmental AIDS control scheme. Funds allocated for AIDS control amount to 6 million francs for prevention, and 20 million francs for treatment. The treatment provided in Martinique is progressive. Tritherapy began in June 1996, and some 250 patients receive bi- or tritherapy. There are approximately 400 persons monitored for seropositivity at all stages, and the viral load of patients is now routinely measured.

Noncommunicable Diseases and Other Health-Related Problems

Nutritional and Metabolic Disorders. No diseases linked to nutritional deficiencies have been recorded for over 10 years. However, a higher socioeconomic level has brought about changes in eating behaviors, with the ensuing excess-linked diseases (obesity, diabetes, and high cholesterol). An average of 85 deaths from diabetes are recorded each year (4% of all deaths). Diabetes accounts for 22% of hospitalizations that are fully covered by the social security system.

Cardiovascular Diseases. Cardiovascular disorders are the leading cause of mortality in Martinique. An average of 740 deaths, 30% of all deaths, were recorded each year in the 1990–1992 period. The impact of cardiovascular disorders on premature deaths (i.e., deaths between the ages of 1 and 64) is the same for both sexes, representing 21% of premature deaths.

The Social Security Code provides for coverage of 30 "long-term" diseases, or those requiring protracted or expensive treatment. Cardiovascular disorders, primarily acute hypertension and cerebrovascular accidents, account for 40% of long-term admissions each year. Cardiovascular disorders also account for 8% of all short-term admissions, placing them in fourth place among reasons for hospitalization. Hypertension is estimated to occur in 20% of the general population.

Malignant tumors. Every year some 500 deaths from malignant tumors are recorded; tumors are responsible for one-quarter of deaths among men and one-fifth of deaths among women. Standardized cancer mortality rates dropped by 10% in the 1980s. All cancer cases have been recorded in Martinique since 1981. Cancer incidence in Martinique is lower than that found in other regions and countries of the world.

The prostate cancer rate among men is high and on the increase. Ear, nose, and throat cancers are particularly widespread, while the incidence of broncho-pulmonary cancers is low. Among women, the incidence of cancer of the cervix is very high and breast cancer somewhat low. The incidence of cancer of the esophagus and stomach is high for both sexes, while there are few colon and rectal cancer cases. The cancer registry shows that between 1981 and 1990 there were 153 cases of oral cancer among men and 30 among women.

Accidents and Violence. There was an annual average of 51 road accident deaths between 1991 and 1994. Mortality rates have leveled off since 1992 but the number of serious injuries is increasing. Of all road accident deaths in 1994, 34% were drivers of two-wheeled vehicles, 48% were driving cars, and 19% were pedestrians. Serious road accident victims involving two-wheeled vehicles are more common among teenagers and young adults. The under 15-year age group comprises the most victims among pedestrians.

In 1993 there were 2,722 work accidents. Eight deaths occurred (six involving travel), and 112 accidents had late effects.

An average of 40 suicides per year were recorded in the 1987–1990 period (1.9% of deaths). The suicide rates are higher among men over 65. The suicide mortality rate increased among men, but dropped slightly among women since the 1982–1984 period. There was an annual average of seven homicides in the 1987–1990 period.

Substance Abuse. During 1990–1992, an average of 131 alcohol-related deaths were recorded each year, accounting for 6% of all deaths. Alcohol-related deaths account for 9.2% of all male deaths compared with 2.2% of all female deaths. The 45–64-year age group is the most affected.

During the 1990–1993 period, an annual average of 147 deaths attributable to tobacco were recorded (7% of all deaths).

Marijuana has long been the most widely consumed illicit drug in Martinique. Crack cocaine entered the scene in the early 1980s and is currently widely used, alone or in conjunction with marijuana. In November 1995, the health and social services treated 198 drug addicts. Illegal drug activity doubled between 1992 and 1995.

Mental disorders are a major public health problem. Psychiatric treatment of adults in Martinique is concentrated in a single hospital. A study of diagnoses of hospitalized patients reveals a considerable proportion of schizophrenia and other psychoses. There are 470 beds for psychiatric hospitalization.

The child and juvenile psychiatry units provide a network of community services in Martinique. A day clinic with 15 places for autistic and similarly affected children under 11 years of age has been in operation since 1993.

A survey of children aged 6–10 years shows that 30 % suffer from tooth decay. This is most often encountered in families living in a vulnerable social situation. There is no fluorine in the water in Martinique and supplementation by fluoridated salt or fluorine pills is necessary.

Sickle cell anemia is the most common genetic disease in the Antilles. The detection coverage rate in Martinique is 99%. Two studies have shown that 10% of the population bore some sickle cell trait, 0.17% of the subjects being SS and 0.24 % SC. One union in 65 poses a risk, and 15 to 20 children will be born annually with a phenotype that triggers a major sickle cell syndrome. In addition, 600 children (i.e., nearly 10%) will be born with the sickle cell trait.

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 3% of hospital operation in Martinique, respectively. 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.

Health Services and Resources

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 for consumption is subject to intensive controls and is of high quality. Some 23 parameters are regularly checked and warning procedures are in place in the event that contaminants exceed certain levels. The pesticides used in agriculture must conform to national standards. Pesticides have not been found in the drinking water supply. Industrial medicine covers poisoning prevention; in the last 10 years cases of poisoning have fallen by 90%, standing at present at five cases per year.

Organization of public services regarding health and environmental issues involves six State units, as well as local communities. Special groups are encouraged to study specific environmental problems.

Atmospheric pollution in Martinique is limited to that caused by automobile emissions in urban centers and along major highways. Burning of sugar cane fields or rum production produce very low levels of pollution, and there is virtually no industrial air pollution. New cars are required to be equipped with catalytic exhaust systems. An increasing number of automobiles use unleaded gas (approximately 30%). 

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. 

Organization and Operation of Personal Health Care Services 

The regional health organization plan in Martinique includes an "emergency" and "resuscitation" section. It comprises three public hospitals (including one teaching hospital), and three private clinics.

The public sector offers 1,831 beds for short-term hospitalization, 114 beds for follow-up and functional rehabilitation, and 101 beds for medium-term care. The private sector provides 100 beds for short-term care, 39 for follow-up and functional rehabilitation, and 61 for medium-term care. Specialties are provided in all categories and offer a full range of treatment.

Ambulatory care provided includes home dialysis, alcohol and cancer control centers, and a multiple-addiction center. Emergency medical care is given special attention in the regional health organization plan. The current organization has established a hotline center ("Center 15") accessed through a single toll-free emergency telephone number. This center provides appropriate care, from physician care to helicopter transportation and specialized medical care. Emergency calls made to "Center 15" are serviced by an emergency unit at Fort-de-France Teaching Hospital and three emergency units at public hospitals

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 25 private and 8 public biomedical labs 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 Martinique there are 139 pharmacies and 2 wholesale distributors. 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.

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.