SC. Sci. Med. Vol. 35, No. 10, pp. 1215-1223,1992 Printed in Great Britain. All rights reserved

0277-9536192 $5.00+ 0.00 Copyright 0 1992Pergamon Press Ltd

CONTEMPORARY HEALTH CARE AND THE COLONIAL AND NEO-COLONIAL EXPERIENCE: THE CASE OF THE DOMINICAN REPUBLIC Department of Anthropology,

LINDA M. WHITEFORD University of South Florida, Tampa, FL 33620, U.S.A.

Abstract-This article traces the development of health care policies in the Dominican Republic from their colonial and neocolonial roots to contemporary times. The Dominican case exemplifies the unique historical processes by which its health policies were created and maintained, and simultaneously, reflects the political and historical forces that shape the Caribbean as a whole. Key words-health

care, history, Dominican Republic, Caribbean

INTRODUCTION

The Dominican Republic shares with other Caribbean islands a common history of conquest, slavery, colonialism, distance from the European colonial powers, and proximity to the neo-colonial power of the U.S. This article recounts some of that history and applies a critical medical anthropology perspective to understanding the development of public health care in the Dominican Republic. The fundamental question asked is: how could a nation with the Dominican Republic’s richness of human resources, history of international health funding, a primary health care system once referred to as having “the best physical resources for primary health care” in the Caribbean, today have a public health system without sufficient medicine, nurses, bedding, rural clinics, functional equipment or supervision? In short, a public health system unable to capitalize on its resources and in organizational disarray. CONTEMPORARYDOMINICAN

HEALTH

CARE

To understand how this situation came to be, we will look at the public health system as it is now and trace the roots of its malaise in its historical context. Towards that end, we will describe the current Dominican public health care system, review the major contributions to its development made by the U.S. occupation forces between 19161922, and explain the antecedent historical conditions that set the Dominican stage for the awkward acceptance of the North American bio-medical model of health care. Cultural, historical, political, religious and economic forces central to the heritage of the Dominican Republic are exemplified even now in the values and policies of the Dominican public health system. Its highly centralized organization, patronage-based staffing policy, and urban, curative focus reflect the histories and traditions that combine to produce its unique Spanish-Caribbean character.

The data analyzed for this article were gathered over a period of 4 yr of intermittent fieldwork in the Dominican Republic. The data are based on firstperson interviews with health policy makers in the government including the Minister of Health, public health physicians, nurses and auxiliary nurse’s aids, and clients of the Dominican public health system. I was fortunate to have the co-operation of Dominican social scientists and physicians who provided me with access to information and facilitated a period of observation at one of the largest maternity hospitals in the capital of Santo Domingo. During the fieldwork we interviewed 100 postpartum women, conducted focus groups with women before they were discharged from the hospital, reviewed client records, and examined and recorded all available birth data for that period. Dominican public health care is composed of three separate and overlapping health delivery systems. The Secretaria de Estado de Salud Publica Y Asistencia Social (SESPAS) provides public health care and social assistance to the general Dominican population, serving 5 million people in 450 clinics; the Instituto Dominicano de Sequros Sociales (IDSS) offers social security coverage to 320,000 individuals and their dependents in 160 clinics; the third system, the Instituto de Seguridad Social de las Fuerzas Armadas (ISSFAPOL), provides coverage to members of the armed forces [l]. SESPAS, the largest delivery system and unit most critical to the provision of general health services, estimates that it provides care to 80% of the population [2]. However, recent reports suggest that SESPAS’ actual coverage extends to fewer than 40% of the country’s population [3]. While the government attempts to provide adequate health care to the entire population, structural and economic constraints severely restrict its ability to do so. As a result of those limitations SESPAS heavily concentrates its facilities in urban areas, focuses on curative care, is

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dangerously under-funded, marked by inadequate or inoperable medical equipment and high physician absenteeism [2, 41. While Dominican health statistics are underreported (estimates suggest that they are underreported by as much as 4&60%), reported rates of maternal and child mortality are high and increasing [4, p. 331. Child mortality is estimated between 70 and 100 per 1000 live births [4, p. 221, an increase over the last decade. Maternal mortality, often cited as the most under-reported of all health statistics, is double (or by some estimates quadruple) what it was in 1978 14, p. 221. In a country with a sufficient number of physicians, a population of committed medical professionals, international health program funding, and extensive exposure to Western medical models, how can we explain the development and maintenance of such an ineffective system? The answer lies, in part, with a history of multiple colonizations and military occupations, an island geography uneasily shared by two nations, and a cultural combination of Spanish authoritarian patriarchy with African cultures. Dominican health policy still reflects its colonial and neo-colonial legacies as they are translated into organizational structure. The delivery system is authoritarian, vertical, with great power invested in the executive office (often overriding any other branch of the government). “The president’s powers derive from his supreme authority over national administration, the armed forces, and all public affairs. The president is also the chief beneficiary of the trend. . . toward centralized decision-making and increased executive dominance” [2,4]. The history of centralized authority in the Dominican Republic and its public institutions can be traced to the strong executive powers centered in the Spanish colonial government and the Roman Catholic Church in the 15th century. Those executivist powers were reproduced in the colonies through the offices of the Crown and the Church-the King, and his Viceroys and Governors; and the Pope, his Bishops and Priests. In the Dominican public health system, as in other health systems, decisions are made in the central Health Ministry. Hospital Directors do not make the decisions about whom they may hire or fire, nor do they choose what mix of staffing is needed; those decisions are made by people in the Ministry of Health. Program decisions occur in the Ministry located in the national capital. Managers of regional and sectoral units of the health care system are excluded from control over their own budgets, services, and personnel. These decisions are referred to the central Ministry, causing delays in decisionmaking, loss of regional participation, and frequently patronage-based allocation of resources. Lack of training and supervision of people in lower level positions at SESPAS further erodes the ability to de-centralize decision-making, resulting in the loss of program flexibility. The Ministry of Health,

burdened by swollen numbers of personnel and dwindling resources, is limited by its own administrative policies. It is unable to delegate authority to its local, regional and district administers and so is unable to capitalize on individual initiative or to reward productive and innovative service. While decision-making is overly centralized, SESPAS’ organizational structure inhibits coordination between service delivery programs, resulting in a proliferation of similar services embedded in various discrete, vertical programs. Programs that fulfil similar functions such as family planning and maternal health are placed in administratively autonomous units. Lack of coordination between programs and lack of clarity of purpose causes confusion among clients and reduces referrals among providers. Babies who could be safely born at local clinics are instead born in large regional hospitals; seriously ill neonates who should be referred to regional hospitals are instead treated at local clinics. The complex Dominican history of multiple colonial and neocolonial sovereigns and the imposition of multiple health care systems make the Dominican system appear to be bricolage-made of fragmented parts. Private health care exists alongside the three, independent and loosely coordinated, government health systems. In addition to the parallel national government systems, international agencies and private voluntary organizations splice and graft their programs onto the already maze-like public health delivery system. Health care systems reflect the dominant cultural values of the society which they are a part. In the Dominican Republic, as in many other countries, socio-economic class differences influence access to health programs. Distribution of Dominican health resources mirrors Dominican class and power relations. It is not considered unusual that the government’s development policies sometimes benefit chiefly the wealthy. The same applies to other social and economic programs. Some programs, such as recent efforts at family planning, are specifically designed to keep the Americans busy and to keep the foreign-assistance funds flowing, at the same time providing more sinecure positions for the president to hand out and ensuring that the program is not so successful that it antagonizes an important power like the Church [5, p. 5961. Historically the Dominican Republic has experienced a sequence of multiple, externally-imposed governments, each with its own set of political, legal and administrative policies and personnel. Now, as in the past, each new national administration fills newly available bureaucratic positions with its own supporters. While that in itself is not unusual, the extent of the resultant change is. The replacement of personnel extends from the level of ministers to community health aides as the occupants of those positions change to reflect changes in the presidential office. When Balaguer resumed the Presidency in 1986, he

Contemporary health care immediately replaced the 5000 community health workers who worked for SESPAS with members of his own political party, thereby disrupting the system and losing workers with community health experience and tra.ining. Because there is no civil service tradition in the Dominican Republic there is little carry-over of policies, plans, programs, or personnel from one presidential election to the next [6,7]. As a consequence, long-term plans are disrupted, programs discontinued, policies revoked and continuity lost.

NEOCOLONIAL,

COLONIAL

U.S. intervention

HISTORY AND HEALTH CARE

1916-1924

Without a doubt the single most influential factor affecting the development of contemporary health care in the Dominican Republic is the U.S. intervention of 1916. The initial impetus for the U.S. action occurred almost 20 yr before in 1899 when President Theodore Roosevelt seized Dominican assets and placed the Republic in receivership status [8,9]. By 1905 the U.S. feared that the Dominican government would be unable to repay a series of international loans, thereby destabilizing the area. In an attempt to avoid that, the U.S. convinced the Dominican Republic to give them 55% of the revenues generated by the Dominican government for dispersal as loan repayments. This 1905 agreement, however, angered many Dominicans who took their protests to the streets of the capital. Following several years of political turmoil, the U.S. sent troops to quell the unrest. For 8 yr (from 1916 until 1924), the U.S. military occupied the Dominican Republic. During that time, new and lasting changes to the public health system began [6]. Few actions of the U.S. military government were more significant than its planned reform and development programs in the areas of education, public health and sanitation, public works, and the creation of a national guard. “These four were important because each package of reforms represented a consciously planned major commitment of the military government’s human and material resources” [lo, p. 331. The contemporary Dominican health delivery system, while reflecting national cultural values, was created as part of that 1918 package of U.S. reforms. P. E. Garrison, the U.S. Navy surgeon named as chief sanitary officer, noted the Dominican laws and regulations affecting health and sanitation and observed: “the existing laws and regulations for Public Health organization and work in Santo Domingo are so incomplete and in many cases so ambiguous and contradictory that it is considered impracticable to conduct an efficient service under their provisions” [lo, p. 411. In response to what he perceived as a loosely organized system of care, Garrison set about to create a North American model of centralization

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and organization for Dominican health care. While some of the laws and regulations issued by Garrison’s office focused on the control of addictive drugs and infectious disease-problems that also plagued his troops-i.e. control of narcotic drugs, the establishment of effective quarantines, and regulation of prostitution, other mandates dealt with the entire legal structure governing Dominican public health and sanitation programs. The primary thrust of this effort was to convert the decentralized Dominican health and sanitation system to a centralized system controlled by the chief sanitary officer residing in Santo Domingo. In August of 1918, Executive Order No. 196 restructured the Dominican health system, removing local power and authority and placing the controls in the hands of the chief sanitary officer in Santo Domingo [ 10, p. 421. By the next year Executive Order No. 338, the Ley de Sunidud (Health Law), provided a unified code governing all aspects of health and sanitation [lo, p. 421. The Ley de Sunidud tried to create an entire health system by decree. “The tiy de Sanidud reflected both the health and sanitation needs of the republic and the preoccupations of military officials. . . it established an intricate nationwide system under the centralized authority of a new cabinet-level office, the Ministry of Sanitation and Beneficence. In the health field the law specifically regulated the practice of medicine, pharmacy and related professions, established standards for hospitals and other medical institutions, and created a national laboratory” [lo, p. 421. Simultaneously, it focused on the control and prevention of communicable diseases such as smallpox and syphilis through a program of compulsory vaccination, a prohibition of prostitution, and regularizing quarantine functions. It also decreed control over the preparation and sale of drugs, the removal of garbage and disposal of human wastes, and the creation of a potable water supply. Last, but certainly not least, the Ley de Sunidud created its own enforcement system. However, to accomplish those ends the U.S. military government had to pump a massive infusion of foreign money and foreign nationals into the Dominican health care system. In 1917 there were 95 doctors and licentiates of medicine in the entire country [lo, pp. 42431. In 1916, the national and municipal governments together were able to raise only $30,000 to provide for health care costs. By 1920, the U.S. military government and local Dominican govemments were able to increase the amount they provided for public health and sanitation to $657,000 [lo, pp. 43441. To its credit, the military government provided the nation with an increased number of hospital beds, improved technology, and desperately needed medicine and physicians. The long-term consequences of the U.S. changes to the Dominican health care system, however, were less uniformly positive. The sys-

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tern established by the military government excluded folk practitioners by its focus on a bio-medical model and banned the practice of folk medicine, making it a crime punishable by a year in jail [lo, p. 461. However, the most serious consequences of the changes did not become visible until after the withdrawal of the U.S. troops in 1924. When the military government left the island, they took with them not only their financial support, but also their medical and support personnel and their equipment. During the 8 yr of the occupation, Dominicans were not placed in high-level administrative positions in the military government, nor were they trained to administer projects. As a consequence, when the U.S. forces withdrew taking with them the U.S. administrators and physicians, they left the Dominican public health system bereft of the money and the expertise necessary to make it function. They left the physical infrastructure and the legal superstructure that remain today, but without the trained human resources it required. They left a centralized, expensive, technology and physician-dependent urban, curative health care system in an impoverished rural nation. The U.S. occupation also brought the Dominican Republic into the international health arena when the country signed the International Convention to fight epidemics of cholera, bubonic plague, and yellow fever [l 1, 121. This agreement stemmed in part from the need to protect the occupation forces from the ravages of tropical diseases such as dysentery, cholera, and yellow fever. The occupation also provided major structural and infrastructural changes in the Dominican public health system when the U.S. Marines cleared roads, dug sewers, built hospitals and organized health care to fit their North American model [6, 131. New public health laws were created, similar to those already existing in the U.S. governing the practice of medicine, the importation and control of foreign drugs, and a system of inspections of hospitals, health homes, houses of beneficence, asylums, hospices, slaughterhouses and cemeteries was imposed [12]. Physicians were required to report all cases of infectious diseases such as dysentery, cholera, pertussis, dengue, diphtheria, measles, typhus, grippe, septicemia and smallpox [12]. Health care was consolidated under the control of physicians and administrators located in the few large urban centers. While many of the changes made by the military government were unquestionably major improvements in the provision of health care, in other ways the North American model was an inappropriate choice. Previous to the U.S. occupation Dominicans had depended on folk medicine and indigenous healers. Both were excluded from, and their legitimacy challenged by, the North American model. Traditionally midwives had been significant providers of health care to both women and children; within 50 yr of the occupation they were no longer practicing within the formal system. At the time of the occupation, most

of the Dominican population lived in the rural countryside with only a small percentage of the population residing in either of its two primary cities. The U.S. health care model located health centers in the places with the highest concentration of people, leaving the rural areas unattended and without access. In short, the U.S. model functioned very well in the provision of urban physical resources and in the conceptual organization of health care, but the long-term consequences of the exclusion of traditional practitioners, dependence on highly-skilled, technologically trained specialists, its urban focus and centralized control set the stage for the current problems that beset contemporary Dominican public health. What conditions so predisposed the Dominican government to accept this North American model of public health? How can we explain why the impact of the intervention was so powerful as to determine the Dominican public health system for the subsequent 80 yr? How were conditions different in the Dominican Republic from other developing countries whose health systems evolved from both colonial patterns and indigenous systems? Unlike Jamaica whose British colonial roots are clearly visible in its contemporary health system, Dominican health care does not predominantly reflect its Spanish colonial roots. To comprehend the causes of the fragmented nature of contemporary Dominican health care, we must first understand the antecedent political and cultural conditions that set the stage for Dominicans to accept this hierarchical, centralized, authoritarian model. The antecedent conditions begin in the 16th century with the Spanish colonization of Santo Domingo and so it is there that we will begin. Colonial history

In the 16th century Spain and Portugal agreed to divide the New World between themselves, thus indelibly transforming indigenous cultures throughout the Caribbean. Spain’s drive to discover, conquer and control the New World created the colony of Santo Domingo when Columbus landed on its north shore in 1492. 500 yr later Santo Domingo is no longer a Spanish colony, but even as an independent nation the monopolistic health care policies that direct the Dominican health system reflect the legacy of that early Spanish colonial rule. The early colonial history of public health in the Dominican Republic was one of monopolization and centralization of control. Central to that experience were institutional controls designed by the Spanish metropole to manage its new colony. Spain’s influence was not limited to its effect on health care, but also its influence on all of Dominican culture. Contemporary Dominican life still reflects the residual effects of Spanish colonial rule in the political and cultural patterns of gender, family, and class relations, and in the institutionalization of power. Santo Domingo, as the island of Hispaniola was originally called, was Spain’s first colony in the New

Contemporary

World. Colonized by Spain in the 15th century, and annexed, occupied or colonized by France, Haiti and the U.S., the Dominican Republic evolved a complex pattern of political ambivalence, seeking independence when a protectorate, and a protector when free. As part of Spain’s ‘grand social experiment’ the colonizing of the New World, the Spanish Crown built cities, towns, hospitals, universities, and roads. It peopled its new world with peninsular Spaniards, and later with Africans. The Church sent clergy to convert, and the Crown sent settlers to conquer the indigenous Tainos and Arawaks. A complex and expansive body of laws dictated relations between the metropole and the colony, between the colonists and the Indians, and among colonial relations with the Church and the Crown [9]. The Spanish cultural experiment in creating a new social order included consideration of the physical and intellectual, as well as moral and religious wellbeing of the colony. The first hospital in the Americas was begun in 1502 when the Spanish Crown and the island’s governor built San Nicolas de Bari in Santo Domingo. Shortly thereafter, in 1510, the first leprosarium was built; in 1532 the colony graduated its first physician, and in 1538 the University of Santo Domingo became the first university in the New World when Pope Paul III signed a Papal Bull decreeing its creation [l 11. The Spanish Crown and the Roman Catholic Church controlled the political, economic, religious, social and medical institutions of the colony. “God had reserved for the Spanish monarchs, not only all the treasures of the New World, but a still greater treasure of inestimable value, in the infinite number of souls destined to be brought over into the bosom of the Christian Church” Columbus wrote in his log notes [14]. These treasures were for Spain alone, and the Crown created an absolute monopolization of New World resources, both human and fiscal. The metropolitan government held a monopoly on political decisions; the metropolitan institutions had a monopoly on trade agreements; and metropolitan nationals had the monopoly on social and economic privileges associated with colonial governmental positions and social status [14]. For a short time, Santo Domingo was Spain’s premier colony. She was Spain’s treasure of the New World. Before Mexico and Peru dazzled Spain with their riches, Santo Domingo was the center of the Spanish colonial empire, the farthest Spanish outpost, the gateway to New Worlds, the Grand Colonial Experiment. As such it was the focus of the Iberian force to conquer the unknown world and to increase the riches of its Church and Crown. The Church

While the Church served as an agency of conquest it also provided the infrastructure for training colonists in its universities and provided health care in its hospitals. As the Church became a large and

health care

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wealthy landowner, it challenged the Crown for political dominance. In response, the Crown consolidated its control over the colony by increasing and legalizing its authority over the Church. Papal Bulls in 1501 and 1508 gave Ferdinand of Spain the power to appoint clergy to the colonies, control revenues secured in the colonies, and under the cover of Patronato Real (Royal Patronage), the right to veto Papal Bulls [15]. Many religious people came to the New World from Spain to seek their material fortunes as well as to gather souls. The Church provided medical practitioners and facilitated the institutionalization of health care on the island. The first autopsy recorded in the New World was conducted in 1539 to answer a priest’s question whether he should bless one soul or two in the death of a pair of Siamese twins. Some clergy devoted themselves to helping others and became opponents of the often brutal and inhumane treatment of the Indians. Antonio de Montesinos, a member of the first Dominican Mission in Santo Domingo, opposed the Spanish treatment of the Indians as early as 1511 [6]. In response to the powerful and vociferous Dominican missionaries, King Ferdinand II of Aragon created the earliest and most humane of the Spanish codes designed to order life in the colonies. The codes known as the Laws of Burgos (Ley de Burgos) were established in 1512 to limit the harsh conditions the colonists imposed on the Indians [9]. They were the first laws designed to protect native peoples and represented an unusual acknowledgement of the common humanity of all peoples. The codes were also designed to reduce the intolerably high mortality rate among the indigenous population and the destruction of the existing labor force. The Crown recognized the colony’s need to maintain its labor force and tried to limit the large landowners, both Church and Iberian settlers, in their treatment of the Indians. Even in their protection of the Indians, however, the Crown did not forget that the colonies existed for the greater glory of Spain. As Queen Isabella wrote to the Governor of Santo Domingo: “The Indians [shall] live in community with the Christians of the island and go among them, by which means they will help each other to cultivate, settle, and reap the fruits of the island, and extract the gold which may be there, and bring profit to my kingdom and subjects” [9, p. 231. Appalled at the treatment Indians received, some priests attempted to protect the indigenous people. The most outspoken advocate for the Indians was Fray Bartolome de las Casas [13]. While de las Casas argued powerfully on behalf of the Indians, he realized that the encomienda system of forced labor was critical to Spain’s economic plan for the colony and that opposition to changes in the system would be useless. Instead he sought relief for the Indians in protected settlements. He successfully argued that the Indians should be allowed to live as family units

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under the protection of a priest in settlements of three or four hundred. When a virulent smallpox epidemic ravaged the island in 1519 the plan for the Indians’ protection proved fatal (131. Poor health due to overwork and a lack of natural immunity to smallpox made the Indians susceptible to the disease and the combination resulted in the destruction of entire communities. The smallpox epidemic further exacerbated the fear of contagion and authorities sealed off the port to prevent its spread, resulting in the first official quarantine in the New World [16]. But the quarantine was too late; the epidemic ravaged the island, hastening the destruction of the native Taino and Arawak populations and increasing the demand for imported laborers. The Crown

In 1492 Columbus was made the first Viceroy (Vice-King) of the West Indies; his executive powers were extended by the Spanish Crown to encompass all the lands he might discover. The Crown’s authority was hierarchical and absolutist, with power centrally controlled by the monarchy and distributed through its deputies in the colonies. As the Crown sought to control its political rival the Church, it also sought to subordinate its own deputies and settlers. Geographic distance between the metropole and the colony, however, limited the Crown’s ability to achieve complete control on the island, a struggle exacerbated by the conquistadors, missionaries and settlers who were drawn to the New World. The settlers were offered private ownership by the Crown. Early exploration and conquest were allowed to be undertaken as private enterprise under license from the Crown [15]. The encomiendu system of forced labor was also introduced by the Crown as a method of rewarding peninsular families who assisted the Iberian government in her colonies. It was perhaps inevitable, then, that conflict should erupt over control of land, people and profits between the absolutist and monopolistic monarchy, and the independent and entrepreneurial settlers. In an attempt to maintain hegemony in the power struggles amongst Church, Crown and colonists, the Crown created central administrative hierarchies to regulate all economic matters such as trade (Cusus de Contratacion), as well as non-economic matters (Consejo de Zndius). These central administration hierarchies existed to facilitate efficient extraction of resources from the colonies and their deliverance to the Crown. The economic base of the colony was organized to provide for the needs of the mother country; colonial export production for the metropole was strictly dictated by the Crown. The Crown encouraged the production of particular items and discouraged the production of other goods that might compete with products produced in the mother country [IS]. For the Spaniards, the early contact period provided an opportunity to establish adminis-

trative and extractive techniques to be reapplied later in Mexico and Peru [17]. For the colony, it laid out a blueprint for its future social and economic relations. Santo Domingo flourished as Spain’s premier colony for only 50 yr. Then the discovery of the Mexican and Peruvian riches offered more for Spain’s attention, and Santo Domingo became a way-station instead of a center. Spanish interest in the island waned and the major Hispanic colonies became no more than “fuelling stations and bastions for the treasure fleets” [17, p. 241. By the middle of the 16th century the colony’s history was one of neglect and encroachment. Between 1560 and 1586 its coasts were attacked by English and French buccaneers and the coastal towns and cities were sacked. In 1586 Sir Francis Drake spent 3 months systematically looting the city of Santo Domingo after having burned its perimeters. Attacked from the water by the British, neglected by its Spanish sovereign, the colony found its western border occupied by the French. Soon after the western portion of Hispaniola became a French colony leaving the island divided between European metropoles, isolated from them both and from each other. The colonial health system of Sunto Domingo

As part of its ‘Grand Social Experiment’, Spain produced a series of innovative public health laws recreating the European nosological systems in the New World and transposing the Hippocratic humoral tradition onto island beliefs. Early in the 16th century laws were passed to provide health care for slaves working on sugar plantations [18]. Physicians were to be established in every settlement [16]; hospitals were to be built for the poor and for victims of contagious disease [18], and the significance of quarantines was officially recognized. Philip II ordered every Spanish ship to carry a doctor, a surgeon and a pharmacist [ 111.During the 17th and 18th centuries, laws were decreed ordering the training and licensing of midwives and doctors [ 161, the creation of sanitary commissions, the appointments of public health officers, and the regulation of the medical profession

[161. Laws decreed in Spain, however, were not always followed in the colony. The enormous geographic and conceptual distance between Spain and her New World colony resulted in limited freedom for the colony. As long as the freedom did not extend to interference with the Crown’s purse, public health laws could be ignored. This became particularly true as Spanish support of the colony gave way to Spanish indifference. “The keystone of Caribbean ‘development’ in past centuries was. labor. . . without labor the Caribbean islands would have been deserts in spite of European arms, European capital and technical knowledge, and European ambitions. . . . For most of the islands during most of their post-Columbian history, labor had to be impressed, coerced, dragged,

Contemporary health care and driven to work-and most of the time, to simplify the problem of discipline, labor was enslaved” [17, p. 451. The encomienda system, dependent on forced labor and often directed by a cruel hand, found itself with a rapidly diminishing supply of laborers. As a result, Spain began to import Africans to Santo Domingo, probably no later than 1505 [17]. With this new population came health problems previously unknown to the European practitioners and new public health laws were developed. ‘The terrible green monster’, sugar cane, came to Santo Domingo with Christopher Columbus and was paired with African slaves by his son, Diego [14]. Within 50 yr of the colony’s Spanish discovery, Santo Domingo was successfully exporting sugar for European markets [17]. Sugar cane production, however, was impossible without a vast labor supply but by the early part of the 16th century the island was already depleted of its local labor force. Both the settlers and the Crown were acutely aware of the necessity of maintaining the supply of labor. Initially the Crown responded to this need by ordering each plantation to provide a physician for its workers; however, few encomenderos complied [12]. Health problems continued and almost a century later in 1784 the Crown decreed the Carolina Black Code to protect pregnant slaves from overwork and from ‘soliman’ (a common folk medicine based on arsenic) poisoning. The Carolina Black Code had 37 chapters of detailed health instructions and prohibitions on the use of pregnant slaves: they were to be provided adequate nutrition, protected from strenuous labor during pregnancy, and their infants were to be sheltered during the perinatal period [12]. The colony was a long way from Spain, however, and it is impossible to know how often the Carolina Black Code was adhered to. Distance was not the only factor limiting colonial compliance. Relations between the Crown and colonial landowners were often turbulent; the Crown granted ownership to the colonists, but required them to pay large sums of money to the Crown. The Crown protected the settlers to offset the power of the Church, while the Church provided limited health care to the native peoples and slaves in an attempt to counterbalance the forces of the Crown and its settlers. Royal Edicts directing the settlers how to treat pregnant slaves arose not only from a concern with the health of the slaves, but also from a need to restore or maintain the productive capacity of individuals at levels required by the exigencies of the crops. The tropical conditions of the Caribbean were considered unsalubrious by the peninsular Spaniards. Within 10 yr of the founding of the colony Nicolas de Ovando, the Governor of the colony, built the first hospital in the New World. The hospital was built partially out of Ovando’s own money, the rest of the support came from the citizens of the colony and the Queen [18]. This early hospital reflects the twin colonial powers; Ovando represented the Crown as

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Governor of the colony while the Church, ever vying with the Crown, provided the hospital with privileges and administrators by Papal Bulls of Popes Paulo V, Sixto V, and Clements VIII [16]. By 1512 the Crown ordered the erection of the Cathedral in Santo Domingo and commanded the Viceroy to build hospitals in every settlement in the colony. The hospitals were to be paid for by tithes usually paid directly to the Church, but in the colonies the tithes were paid directly to the Spanish monarchs. The Right of Patronage (Patronato Real) gave to the Crown the Church’s money and, in exchange, the Crown was obliged to support the Church’s role to build and maintain churches in the New World [16]. For the next 200 yr Spain continued to issue edicts specifying health care laws for Santo Domingo. “It was characteristic of Spanish ways of thought that the system of colonial government created in the second and third decades of the 16th century should be primarily judicial rather than administrative in character. Spain had carried over from the age of feudalism into the age of sovereignty the notion of jurisdiction as the essential function of authority” [19, p. 211. In 1768 the Crown commanded that a Sanitary Commission be created to oversee the retrieval of garbage, the sweeping of streets and maintenance of public places [16]. A century later, another Royal Edict required that all midwives practicing on the island be licensed and licensure be granted only after the applicant had completed a course of approved training and passed a set of qualifying exams. Spain continued to decree laws but declined to provide support requisite for their institutional organization and implementation. Previous to the Royal Edict most midwives were women; the edict prohibited women from partaking in the training or the examinations requisite for licensure, thereby limiting the practice of midwifery to men [16]. Had Santo Domingo either been more important or closer to Spain this edict might have been enforced, eliminating women midwives. The edict, however, was not enforced and most medical treatment on the island continued to be provided by women midwives and folk healers. While Spain directed the judicial and legislative life of the colony, it refused to respond to the colony’s repeated request that protomedicates be sent to the island. Protomedicates were physicians formally authorized to teach medicine and their presence in the colony would have allowed the development of an internal medical market for the benefit of the settler population. The colonists would have benefited by this development both through the provision of services and the potential profit it derived. Spain, always aware of the colonists’ potential for independence and alert to the inroads into the Spanish purse caused by colonial autonomy, sent no protomedicates to Santo Domingo [l 11. All of Spain’s public health legislation, policies and institutions in Santo Domingo were ended in 1795

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LINDA

M. WHITEFORD

when Spain signed the Treaty of Basle, giving France the entire island of Hispaniola [9]. “Spain’s first colony in the New World was Spanish no longer” [13, p. 201. France revoked the Carolina Black Code, disbanded the sanitary commissions, closed the universities, dismissed the health councils, and declared the practice of medicine free and unregulated, available to anyone who wished to practice it [16]. The loss of its “once proud and premier colony” [20, p. 5851 did not cripple Spain’s colonial empire; for Santo Domingo, however, it signalled a period of intense political turmoil and decline. In a brief period of 17 yr (1805-1822), Santo Domingo became a French colony, overthrew the French government and again became a Spanish colony, was given its independence from Spain, and immediately occupied by Haiti [13]. Haiti governed the Dominican Republic for the next 22 yr (1822-1844). The sanitary commissions, health councils and universities were closed again, having been opened only briefly during the Spanish tenure following the French period of governing. However, not all of the changes were negative. Haiti rescinded the archaic Spanish penal code and imposed the more enlightened Napoleonic Code. The most damaging Haitian order was the tax Haiti levied on the former Spanish colony. This tax was to be paid by Dominicans as Haitian compensation to French landowners for land taken from the French in the Haitian rebellion [14]. In 1844 Dominicans overthrew the Haitian forces and declared their independence, immediately seeking protection for the new Republic [14]. Fearing attacks from its western frontier with Haiti, the Dominican President negotiated with France, England and Spain to establish a protectorate for the country [6, 131. Each refused until finally Spain accepted the Dominican Republic as a protectorate and annexed its old colony. This “. . . unique reversal of the normal trend of colonial development” [13, p. 461 was a disaster for the new Republic. Spain reimposed the archaic Spanish Penal Code over the Napoleonic Code, and proceeded to consume 80% of the public revenues in the provision of sinecure jobs for Spaniards sent out from the Iberian peninsula [13]. The negative consequences of the return to Spanish control (Esparia Boba) gave the final impetus to the Dominican War of Insurrection, and in 1865 the Dominican Republic re-emerged as the Second Republic. History and geography, however, conspired to limit the Second Republic’s sovereignty. Controlled by European colonial powers throughout the 16th, 17th, 18th, and intermittently during the 19th century, in the 20th century the Dominican Republic came into the U.S. neo-colonial sphere of influence. While the immediate impetus for the structure of contemporary Dominican public health is the U.S. intervention of 1916, the health system was transformed into one uniquely Dominican by Dominican culture and history. Dominican culture reflects a Caribbean mix of Europe and Africa where the

patriarchal Spanish family is the ideal, but reality includes West African patterns of entrepreneurial women. Dominicans speak Spanish, trace their cultural heritage to Spain, and share its acceptance of authority and hierarchical structures. Simultaneously, Dominicans enjoy cultural traditions from Africa including distinctive culinary practices, music and medicine. While the U.S. intervention imposed a Western medical model, the cultural stage for its acceptance had already been set. Dominican experience with both Spain and the U.S. reinforced the reward system of patronage. During the occupation the U.S. imported foreign professionals to develop, administer and provide health care. Dominicans were given low-level jobs, and those only if they curried favor (by co-operating with and not obstructing) the occupation forces. Spain also imported foreign nationals to conduct the business of creating and governing the new colony. Jobs were secured by connections through family, history of work for the Crown, or becoming a member of the Church. The explicit codification of patronage could be traced to the Crown’s order of Patronato Real (royal patronage). Today the Dominican government is the nation’s single largest employer and all of those jobs, from the highest minister to the last street sweeper, are controlled by the President. These jobs, like those before, are distributed to family, loyal workers and members of the group. CONCLUSION

The Spanish colonial and the U.S. neocolonial experiences certainly shaped Dominican cultural and governmental forms. The Spanish Royal Edicts and decrees, as well as the U.S. Occupational Forces’ laws, provided the cultural and legal superstructure for the Dominican health system. Simultaneously, a less visible but still powerful factor in the development of the health system, is the country’s history of multiple sovereignties. The Dominican Republic, first as a colony and then as a Republic, had little opportunity to develop structures, policies, and delivery systems reflective of local needs or adaptive to local resources. Its opportunities were truncated by powerful forces external to the island nation. The Dominican public health system must be understood as a result of the country’s fragmented national history; as a reflection of Spanish cultural respect for authority and hierarchy; as a reflection of class and race relations codified during slavery and reified during the Haitian occupation; and as a reflection of North American admiration for biomedicine. Spain transmitted the cultural value of respect for authority by rewarding the loyal colonists among a population dependent on the Crown’s patronage. Spain also superimposed the hierarchical ordering of status and role based on relation to the ruling group, class, and race. The social order based on these variables was reinforced by each successive

Contemporary health care external political power, often excluding native Dominicans. The U.S. military government continued the precedent of exclusion. Dominicans were not trained as physicians or administrators to take over after the withdrawal of U.S. forces. Dominican professionals were not incorporated into key decision-making positions, nor were they included as consultants. The exclusion of indigenous healers, folk medicine and midwives from the Dominican public health system reflects a loss of valuable resources, denied for their lack of fit with the North American bio-medical model. Just as Spain’s legacy of enlightened protections such as the Ley de Burgos and the Carolina Black Code were mixed with legacies of conquest and slavery, Haiti likewise left a mixed legacy-a destructive occupation and an improved legal system based on the Napoleonic Code. The legacy from the U.S. contribution was also both positive and negative: the provision of roads, schools, hospitals and sewers improved Dominican life substantially. At the same time, the exclusion of traditional health care providers and the arbitrary imposition of the biomedical model helped shape the difficulties the Dominican health system is facing today. Seen as the result of those historical, political and cultural forces, we can understand both the development and maintenance of the contemporary health system. The picture that emerges is one of a system overly centralized, with parallel uncoordinated sectors, multiple vertical programs, little continuity in personnel, and little use of interrelated services. The policies directing the system emanate from an executivist central government which does not delegate responsibility to its regional centers, and is therefore unable to respond to local needs. Staffing positions are often filled not according to skill, but according to patronage. The authoritarian structure limits feedback required to adapt health programs to the needs of particular populations, thereby limiting the system’s ability to provide appropriate care. Observing the Dominican public health experience should cause us to re-evaluate previously held notions about appropriate health care models. We need to ask if health care would have been different had the Dominican Republic been allowed to develop its own indigenous system, incorporating folk healers, midwives and physicians, dependent on each for their own particular skills. The Dominican experience challenges us to re-assess the desirability of exporting health care models appropriate for the technology and personnel of the exporter, but not necessarily to those who receive it. The Dominican case also suggests that we need to evaluate not only the range of personnel and technology when considering alternative health models, but also focuses our attention on the need to analyze the culture and history of the people being served.

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Acknowledgemenrs-The

research was made possible through grants from the Research Council and the College of Social and Behavioral Sciencesof the University of South Florida. Both my Dominican and U.S. colleagues facilitated this research by their support and critical appraisals. I especially appreciate the insight gained from Frank Moya Pons, Hugo Mendoza, Carolyn Sargent, Loma Rhodes, Andrew Whiteford and Doug Uzzell. Several graduate students from the University of South Florida toiled over the manuscript in its various forms and the article benefited from the work of Diego Salazar, Donna Romeo and Steven Gouldman. REFERENCES

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