Category Archives: Health Care

Controlling preventing arboviral circulation

Dear Editor,

Last week the Daily Herald reported that two cases of chikungunya virus CHIKV were laboratory confirmed on St. Martin. The article stated that CHIKV is in the Pacific Islands, Asia and India, but until now not in the Caribbean islands. While it is true that these are the first laboratory confirmed cases of CHIKV in the Caribbean, it is highly probable that the virus has been circulating in the Caribbean for some time. Not documenting the virus sooner probably results from a failure to invest in public health research and infrastructure.

CHIKV is similar to dengue virus DENV in that it is a viral disease transmitted by mosquitoes. Like DENV, CHIKV is what is called an ARBO virus. ARBO viruses are transmitted to humans through the bite of blood sucking vectors such as mosquitoes and other biting flies or ticks. There are over 400 types of ARBO viruses (although all are not a threat to humans). While every year each country is supposed to report prevalence, incidence, morbidity and mortality data to the Pan American Health Organisation (PAHO), the difficulty surrounding ARBO viral diagnosis causes many potential problems when data is compiled in each respective country.

According to the World Health Organisation (WHO) there is a great deal of variability in the clinical illness associated with ARBO viral infections, and it is not appropriate to adopt a detailed definition of what constitutes a definite diagnosis. Laboratory confirmation is emphasised. Additionally, many clinical signs can result in differential diagnoses as it is difficult to distinguish many ARBO viral infections clinically from each other and a wide spectrum of other bacterial and parasitic infections.

There are also no single, simple diagnostic criteria available. In a laboratory, ARBO viruses are diagnosed by isolation of the virus, by serology or by molecular diagnostic methods. However, tests requiring the identification of the virus or the viral genome are expensive and require specialised laboratories. While, there are some commercial kits available for diagnosis many concerns surround their validity resulting from inadequate sensitivity and specificity. Simply stated, often times, the results of these tests result in missed diagnosis.

In 2000, the 42nd Directing Council of PAHO adopted resolution CD42.R14 urging countries to participate in the regional exercise to measure performance with respect to 11 defined Essential Public Health Functions (EPHF). This exercise would allow countries to carry out interventions to develop their capacity and improve public health practice. In the sub-region of the English-speaking Caribbean and Antilles, countries exhibited low-intermediate performances in nearly all of the essential public health functions with only one function, reducing the impact of emergencies and disasters in health perform adequately (EPHF 11). The lowest performance was exhibited in the areas of public health research and quality assurance (EPHF 9, EPHF 10).

Despite the growing threat from emerging/re-emerging ARBO viruses, 14 years after the PAHO resolution, very few laboratories in the region have capabilities for diagnosing highly infectious diseases such as viral haemorrhagic fever, severe acute respiratory syndrome, etc. Countries often ship specimens to other regions for confirmation resulting in delayed responses to outbreaks. Laboratory-based surveillance would play a significant role in timely outbreak response and the regular analysis of laboratory data would allow for the prediction of circulating disease characteristics for citizens and the region.

In the Caribbean region the control and prevention of HIV/AIDS (reproductive health) is a priority area for infectious disease funding. HIV/AIDS is an important concern as the Caribbean region is the second most affected region in the world in terms of HIV prevalence rates. Based on 2009 data, about 1.0 per cent of the adult population (240,000 people) is living with the disease.

However, due to the nature of how ARBO viral diseases are spread (a bug bite), it is critical that an investment be made in public health infrastructure and research so that evidenced based ARBO viral control and prevention can become priority areas.

This effort must not be left to single islands but rather one of the entire Caribbean community. It is my suspicion that many ARBO viruses have been circulating and continue to actively circulate in the Caribbean. It is now time to come together as a Caribbean community and work towards prevention and control. This can be accomplished through investments in public health research laboratory capacity, improvements in communication networks and increased data sharing.

Dr. Teresa E. Leslie

President and Founder

Eastern Caribbean Public Health Foundation, St. Eustatius.

Declaration of the rights of the child

Today the results of the UNICEF childrens’ survey will be presented in Leiden.

Samenvatting Kind op BES LOWRES

It is concluded that the situation of the children on the BES islands do not meet with the standards as defined in the Declaration of the rights of the child.

Here you can read what this declaration enhances.

Adopted by UN General Assembly Resolution 1386 (XIV) of 10 December 1959
   WHEREAS the peoples of the United Nations have, in the Charter, reaffirmed their faith in fundamental human rights and in the dignity and worth of the human person, and have determined to promote social progress and better standards of life in larger freedom,
   WHEREAS the United Nations has, in the Universal Declaration of Human Rights, proclaimed that everyone is entitled to all the rights and freedoms set forth therein, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status,
   WHEREAS the child, by reason of his physical and mental immaturity, needs special safeguards and care, including appropriate legal protection, before as well as after birth,
   WHEREAS the need for such special safeguards has been stated in the Geneva Declaration of the Rights of the Child of 1924, and recognized in the Universal Declaration of Human Rights and in the statutes of specialized agencies and international organizations concerned with the welfare of children,
   WHEREAS mankind owes to the child the best it has to give,
   Now, therefore,  Proclaims
THIS DECLARATION OF THE RIGHTS OF THE CHILD to the end that he may have a happy childhood and enjoy for his own good and for the good of society the rights and freedoms herein set forth, and calls upon parents, upon men and women as individuals, and upon voluntary organizations, local authorities and national Governments to recognize these rights and strive for their observance by legislative and other measures progressively taken in accordance with the following principles:
1   The child shall enjoy all the rights set forth in this Declaration. Every child, without any exception whatsoever, shall be entitled to these rights, without distinction or discrimination on account of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status, whether of himself or of his family.
2   The child shall enjoy special protection, and shall be given opportunities and facilities, by law and by other means, to enable him to develop physically, mentally, morally, spiritually and socially in a healthy and normal manner and in conditions of freedom and dignity. In the enactment of laws for this purpose, the best interests of the child shall be the paramount consideration.
3   The child shall be entitled from his birth to a name and a nationality.
4   The child shall enjoy the benefits of social security. He shall be entitled to grow and develop in health; to this end, special care and protection shall be provided both to him and to his mother, including adequate pre-natal and post-natal care. The child shall have the right to adequate nutrition, housing, recreation and medical services.
5   The child who is physically, mentally or socially handicapped shall be given the special treatment, education and care required by his particular condition.
6   The child, for the full and harmonious development of his personality, needs love and understanding. He shall, wherever possible, grow up in the care and under the responsibility of his parents, and, in any case, in an atmosphere of affection and of moral and material security; a child of tender years shall not, save in exceptional circumstances, be separated from his mother. Society and the public authorities shall have the duty to extend particular care to children without a family and to those without adequate means of support. Payment of State and other assistance towards the maintenance of children of large families is desirable.
7   The child is entitled to receive education, which shall be free and compulsory, at least in the elementary stages. He shall be given an education which will promote his general culture and enable him, on a basis of equal opportunity, to develop his abilities, his individual judgement, and his sense of moral and social responsibility, and to become a useful member of society.
The best interests of the child shall be the guiding principle of those responsible for his education and guidance; that responsibility lies in the first place with his parents.
The child shall have full opportunity for play and recreation, which should be directed to the same purposes as education; society and the public authorities shall endeavour to promote the enjoyment of this right.
8   The child shall in all circumstances be among the first to receive protection and relief.
9   The child shall be protected against all forms of neglect, cruelty and exploitation. He shall not be the subject of traffic, in any form.
The child shall not be admitted to employment before an appropriate minimum age; he shall in no case be caused or permitted to engage in any occupation or employment which would prejudice his health or education, or interfere with his physical, mental or moral development.
10   The child shall be protected from practices which may foster racial, religious and any other form of discrimination. He shall be brought up in a spirit of understanding, tolerance, friendship among peoples, peace and universal brotherhood, and in full consciousness that his energy and talents should be devoted to the service of his fellow men.


When I see Statia’s public swimmingpool I always start to dream. Most of the time you see it there, invitingly dark fresh turquois, with the sandstone hot path surrounding it. Pueblo kind of building, cold and fresh inside where the lockers are. Only needs a veranda, a roof outside. It doesn’t work with the few parasols they have there, it needs a structural roofing.

And then I dream of all the swimminglessons that can take place there, year round. All of the school children can swim once a week and get their swimmingdiploma’s. A swimming culture could start, with games and competitions and active participations and organizations of regional and international competitions.

By the way, my guess is 60% of the grown ups can’t swim and with the healthrisks of diabetes getting adult people to come swim and get their diploma’s can be a great opportunity for fun and activities for young and old on the island.


O yes, and that building you see there in the background is supposed to be fixed up for groups of overseas children to accomodate them when they are here with their sportsteams.


Statia, Saba look at direct patients’ flight to Bonaire

By Suzanne Koelega for DH picture Koos Sneek and Carlyle Tearr at the Ocan gathering by Annemieke Jansen  THE HAGUE–As St. Maarten seems to have little enthusiasm for upgrading St. Maarten Medical Center (SMMC) to provide St. Eustatius and Saba with specialist health care, the islands have taken it upon themselves to explore options for a direct flight to Bonaire so patients can be treated at Mariadal Hospital in Kralendijk.

Statia Commissioner Koos Sneek announced on Wednesday evening that the islands, together with the Dutch Ministry of Public Health, Wellbeing and Sports VWS, are looking for a direct flight from St. Eustatius to Bonaire so they can transport 20-24 patients from St. Eustatius and Saba to the hospital in Bonaire.

The level of specialist care at SMMC is not what it should be, also because cooperation with Amsterdam hospitals VU Medical Centre and AMC didn’t work out. “A number of specialists that were working there under the agreement with the VU and AMC have left disappointed,” said Sneek at a dialogue gathering with people from the islands in The Hague, organised by the Consultative Body for Dutch Caribbean persons in The Netherlands OCaN.

“It is our wish and also that of The Hague to concentrate more on St. Maarten, whereby The Netherlands is willing to assist the SMMC and to support moves to increase specialist care, as this would reduce the need for referrals to Colombia and Guadeloupe,” he said.

However, he added, “Up to now there seems to be little enthusiasm on the part of St. Maarten.” He noted that the care currently offered at Mariadal Hospital was better, because Dutch specialists work there and the range of specialist care has expanded.

Investment in upgrading SMMC has not materialised. This investment is important for St. Eustatius and Saba for the referral of their patients for specialist care. “Our people want to stay closer to home for medical care, even though health care in Colombia is top of the line,” said Sneek.

According to Sneek, investment in SMMC would benefit the people of St. Maarten as well as the people from St. Eustatius and Saba. The medical referrals, some 24 persons on a daily basis, contribute to St. Maarten’s economy. Patients use Windward Islands Airways International Winair, busses, taxis and rental cars, they eat in restaurants and if necessary they spend the night in a hotel.

“It is clear that good relations are beneficial both for St. Maarten and for our islands,” said Sneek.

In the event of a medical emergency St. Eustatius and Saba have an emergency helicopter on standby. This helicopter has been stationed in St. Eustatius since last year. “As SMMC is the first destination for our medical emergencies, some improvement in the relations between our islands is desirable, not only where it comes to SMMC, but also regarding services at Princess Juliana International Airport, which leave a lot to be desired.”

The Commissioner reported that the Bonaire, St. Eustatius and Saba delegations had had a “very good meeting” with Dutch Minister of Public Health, Wellbeing and Sports Edith Schippers on Wednesday. “It was better than we and she had expected.”

Parties discussed ways to reduce the cost of sending patients abroad to hospitals in Guadeloupe and Colombia, which amounted to US $85 million in 2012. “World-class, quality healthcare is provided there, but at a very high cost,” said Sneek.

Because of the increased cost of health care on the islands and the need to slash the health care budget in The Netherlands, Minister Schippers announced late December last year that she would take dental work and physical therapy out of the health care package on the islands.

The islands presented a counterproposal on Wednesday. “We too see that money is wasted, but we think there are other ways to save cost without taking dental care and physical therapy out of the package. With our proposal The Netherlands saves money and we keep the package, which is a win-win situation for everyone,” said Sneek.

No politics please

The relatively negative reaction of Members of the First and Second Chambers of the Dutch Parliament to a request by the visiting St. Maarten  parliamentary delegation to support St. Maarten seeking a soft loan for the expansion and upgrading of the local hospital (see Thursday paper) was a bit too quick and easy. For one thing, St. Maarten Medical Center (SMMC) is also very important for people of the nearby Caribbean Netherlands islands St. Eustatius and Saba. Particularly when it regards an emergency where time is of the essence, having to take these patients elsewhere conceivably could mean the difference between life and death. The political establishment in The Hague would do well to recognise that reality a bit more.

In addition, everyone should know that SMMC was practically bankrupt not too long ago and it’s only through the joint efforts of the board, management and personnel – as well as leniency among creditors, including government – that the medical institution was saved from fi nancial ruin. To now not take the next step required to guarantee its long term viability – also according to former director Dr. George Scot – could well render all those efforts practically meaningless.

It’s understandable to a certain extent that there is some concern about proposed medical tourism projects on the island and their possible consequences for SMMC, but that must be separated from the real need to improve the latter facility for patients of all three Windward Islands. In any case, if private clinics targeting well-off visitors in need of care are to be established, watertight arrangements can be made regarding the quantity and type of care they offer to residents, also with the local medical insurers, so that SMMC does not suffer adverse effects. Of course, all that has happened and been said in the past week may not have increased the willingness to cooperate with one another, yet such is exactly what would serve the citizens of the Dutch Kingdom best in this case. The health of the population is nothing to play politics with.

About Medical Care at IPOK The Hague

The Parliamentary delegations agreed to urge their governments to facilitate organising a health care conference in Aruba later this year to discuss this and other health care-related issues on the local and Kingdom levels. Governments, hospitals, health care insurance providers and patient organisations would be invited.

Member of the Second Chamber Pierre Heijnen of the Labour Party PvdA remarked that it was essential to prepare well for this conference. “The success of a conference depends on a solid preparation. You have to be able to take concrete decisions,” he said. The delegations agreed to assign a quartermaster for the conference.

The St. Maarten delegation has asked The Netherlands for support to realise a soft loan of NAf. 30 million to expand and upgrade St. Maarten Medical Center (SMMC) during a meeting of the Inter-Parliamentary Consultation of the Kingdom IPOK on Wednesday.

 Member of the First Chamber of the Dutch Parliament Marijke Linthorst of the Labour Party PvdA said it was important to maintain the lucrative services of health care at the hospital. One of the ways to make SMMC profitable is through medical tourism, she said.According to Linthorst, it was “unacceptable” that government should support a hospital that loses money while private clinics make money by offering lucrative medical services. “What is your government doing to make sure that the lucrative medical treatments flow back into the hospital?” she asked. “It is not right to ask The Netherlands for help with a loan while your government doesn’t do what it should,” she said.

Richardson responded that St. Maarten wasn’t asking for money, but merely for support by the Dutch to negotiate a low interest loan. He said that the St. Maarten Government was looking into the aspect of private clinics, but added that the SMMC project was urgent and the clock was ticking.


Wednesday, 06 March 2013 22:58



Source is Daily Herald, article is here:

Questions for Statia and Edith Schippers

DH Tuesday, 26 February 2013 20:46

Dear Editor,

Serious questions should now be asked about the way the health insurance and hospital system is run on the islands of the Caribbean Netherlands. The Dutch Minister of Public Health Edith Schippers has been asked to trim the health insurance package for the islands. It is absolutely time she looked at the costs or more precisely, at the way the treatment system is administered by some of her civil servants.

In the Netherlands, each citizen is required to pay for health insurance. Failure to do so results in fines. No dough, no show! However, on Statia a residence card is all that is needed to get free medical treatment; this philosophy is excellent but expensive. It almost mirrors the national insurance facilities in the United Kingdom (UK) and Canada.

What about the off-island medical treatment in Colombia and Guadeloupe? Whereas I cannot speak for the linguistic mess of the latter, I can add my personal experience of the former.

Medical facilities in Medellin are excellent and internationally recognised for the high quality treatment they provide. Patients that fly out to Medellin are treated by the very best doctors and surgeons as well as afforded almost VIP clinical status as regards nursing facilities and accommodation. Cleanliness is observed in military fashion 24 hours a day. Furthermore, the ratio of medical staff to patients is four to one.

So, why should the minister fix that which is not broken? But, there is something broken. The service provided by the island administration that runs this off-island medical tourism needs vast improvement. For example (and a bit like Columbus before), patients sometimes arrive at hospital not knowing where to go or who will greet and treat them. Their disease and symptoms have not been communicated by the insurance company. The first question the Colombian doctor asks the patient is often, “What is the matter with you?” A waste!

Worse still, MRI scans and x-rays are often not sent by the insurance department or given to the patient to accompany him or her. Such expensive diagnosis tests are, therefore, repeated in Medellin and add to the length of the patient’s stay in the country; moreover, those MRI scans were acquired by patients travelling to St. Maarten beforehand. Travel and overnight stays on St. Maarten for something that will not be used is once again a complete waste of public money.

Once the hospital patient finally departs for Colombia, he will discover that his daily allowance of US$25 will not go far. But, what is far is the distant location of the hotel booked by the insurance department for the overnight stay in Curaçao. A single taxi ride from Curaçao airport to downtown hotel will cost $25 in each direction. This is unacceptable and the misery is made even more evident by the departure tax that the patient has to fork out from his or her purse. This amounts to $60 for all the flights in one direction.

The patient is, therefore, obliged to pay $110 each to get to Medellin. Breakfast at stop-over hotel is not included and if daily allowances are not paid on time as is often the case, hardship results.

Nevertheless, hotels in Medellin are very comfortable but once again, many miles from the hospital. This adds to the cost since a return taxi ride amounts to approximately $30 in rush hour. For the patient and companion, this is not such a problem because one free return taxi ride is provided per day. But, this does not change the fact that the health insurance has to pick up the long distance taxi bill.

The big sting in the tail is the return flight. Once the Colombian doctor has given the “okay” to return to the respective BES Island, it can take another eight days before the patient can leave. This is because the insurance department on Statia is too slow and inefficient.

My experience of this costly delay is not uncommon. Having informed the Statia insurance department that the patient was okay for travel by the doctor at 14:00 of a Thursday, four working days were required to produce the travel booking and that travel booking was for a flight a full week later on Friday of the following week!

One of the reasons for this delay is that only low cost flights are booked (whilst slightly more expensive alternative flights and routes are available). The whole travel side is a disaster and costs the Dutch Ministry of Health many extra days of hotel accommodation and daily allowances through this false economy. More significantly, it also robs the island development of absent personnel who contribute to the economy or running of the island and robs families of loved ones.

Some patients and companions are stranded in Colombia for many months without a logical programme of treatment that allows them to return home when and where necessary. It is a scandal!

I know it is hard on these islands for civil servants to perceive citizens as customers – even though the public pays for their salaries. However, in this case, an immediate and complete review of the system and its workings is required. A quality improvement process is clearly overdue.

By my own calculations, the budget for off-island medical treatment could be reduced by 25 per cent. In reading this letter, the Health Minister, therefore, needs to shake up her own people as well as the budget that provides such lousy services. But, will Edith Schippers take note?

A concerned citizen

Health commissioners met with Health ministry representatives

(DH 16 feb 13) ST. EUSTATIUS–Saba Commissioner of Health Bruce Zagers and his counterpart of St. Eustatius Koos Sneek held a joint meeting Monday with two representatives of the Dutch Ministry of Health, Welfare and Sport. Also in attendance were Island Secretaries Menno van der Velde of Saba and Jan Helmond of Statia. The Commissioners had initiated the joint meeting due to recent developments in healthcare and capitalized on the opportunity to address issues that continue to present problems for the procedural quality of healthcare and insurance services, they said in a joint statement on Friday.

Longstanding issues centring on medical travel were discussed. Both Commissioners explained that payment of daily travel allowances continues to be a problem. Too often patients travelling abroad for medical treatment do not receive their allowance on time and even have to wait months before payment occurs. This is inexcusable and puts an added financial burden on patients, particularly those on low or fixed income, the commissioners stated.

Medical chaperoning was also brought to the table, as it is becoming increasingly more difficult and costly for patients to find proper travel companions. The Commissioners believe this is an issue deserving of more attention and viable solutions.

For the last two years, Guadeloupe has served as a medical destination for patients from Saba and Statia. The Commissioners requested that taking Guadeloupe off the list be considered, mainly because of cultural and language differences. Most patients are not pleased with the experiences on the French island and the Commissioners therefore believe that the money spent in Guadeloupe for medical treatment is best invested in medical facilities within the Dutch Caribbean.

The ongoing negotiations between National Helicopter Company, which provides Saba and Statia with medical evacuations, and the fuel supplier are of growing concern. Concrete agreements must be reached between the companies, or both Commissioners agree this would put medical evacuations in a precarious situation and patients at risk. The Commissioners also brought forward the matter of dentists and technicians not being paid on time by insurers. This is not good business practice and is a trend the Commissioners don’t want to see continued. The islands depend on proper and continued treatment and care by medical specialists. If specialists are not guaranteed punctual payment for their work, the patients are the ones who will suffer, was Zagers’ and Sneek’s opinion.

Questions and concerns were also raised about the recently announced changes in healthcare, which are expected to take effect as of July 1. Both commissioners questioned whether these changes made by Minister of Health Edith Schippers had been influenced by a draft report on the quality of care on Bonaire, Statia and Saba. Considering that this report has not been read by them and is still on the drawing board, the minister’s decision was deemed “premature and haphazard.” Budget issues were also discussed. Whereas the so-called Havermans’ Report was used as the basis for estimating the cost of healthcare in the islands, a local committee of experts arrived at a much higher assessment, which led the Commissioners to the conclusion that clearly the wrong starting point had been used.

The commissioners finally emphasized to the Dutch representatives that based on the Healthcare Law BES (“Wet Gezondheidszorg BES”), healthcare on the islands is expected to improve over time and eventually be on the same level as in The Netherlands. They both accused the Ministry of Health of making legal and procedural decisions that are in great conflict with this law and therefore undermining its fundamental aim. “The Commissioners can only conclude that the Ministry of Health is less focused on having an improved healthcare system for the islands and only interested in making financial cuts to the budget without considering their consequences,” Commissioners Zagers and Sneek said in concluding their statement.

Second Chamber demands clarity on island’s health care insurance

THE HAGUE–The Second Chamber of the Dutch Government shares the concerns of the First Chamber where it comes to health care in the Caribbean Netherlands and the decision of Dutch Minister of Public Health, Wellbeing and Sports Edith Schippers to trim the health insurance package on the islands per July 1, 2013.

Parties in the Second Chamber used the opportunity to submit written questions and express their concerns to Minister Schippers. The contributions of the parties represented in the Second Chamber’s Permanent Committee for Public Health, Wellbeing and Sports were sent to the Minister on Thursday.

Member of Parliament (MP) Pierre Heijnen of the Labour Party PvdA said that for the PvdA this issue was not yet over as his party had some problems with the Minister’s decision and the way  this decision had been taken without prior  consultation of the islands. “I have the same concerns as the Senate,” he said. He announced that there would be a debate with the Minister in the near future.

Not only the PvdA but also the Democratic D66 Party and the Christian Union (CU) want clarity on the exact reasons for the steep increase in health care cost of 20 million euros in 2012 and are asking the Minister to look at alternatives to manage the cost of health care.

MP Wassila Hachchi and her colleagues of D66 Pia Dijkstra and Vera Bergkamp were critical of the decision of Minister Schippers to level the health care insurance package in the Dutch public entities Bonaire, St. Eustatius and Saba as much as possible with the package in The Netherlands. “The Minister unfairly makes a comparison with the European  Netherlands.

 Hachchi (D’66) “The minister unfairly makes a comparison with the European Netherlands.”

There are clear differences in the social economic situation between the Caribbean Netherlands and the European part of The Netherlands. The average income on the islands is much lower and there is no level playing field where it comes to the (social) allowances regime,” the MPs of D66 stated.

D66 urged the Minister to get in contact with the health insurance providers to look at offering additional insurance for the people of the Caribbean Netherlands. Additional health insurance is possible  in The Netherlands, but not on the islands. The CU also urged the Minister to make it possible for people in the Caribbean Netherlands to take additional health care insurance. The Democrats were further irked by the fact that the Minister only announced the decision to curb the health care insurance package for the Caribbean Netherlands on December 21, 2012, 10 days before the measures would go into effect.

“We find it a shame that the initial implementation date of January 1, 2013, was only moved up by six months after the commotion on the islands.” According to D66, the communication was poor and communication errors such as these should be prevented in the future.

The CU voiced its concern about the elimination of physical therapy from the health care insurance in the Caribbean Netherlands. The fact that the people on the islands do not have the possibility to take additional insurance has consequences for physical therapy care. MP Ari Slob of the CU asked whether people of the islands could still make use of physical therapy care after July 1, 2013. “Is there a risk that physical therapy will completely disappear from the Caribbean Netherlands? Surely that cannot be the intention.” Slob said he understood that the Minister had to carefully look at the increasing health care cost on the islands. He asked for answers to the same questions that the First Chamber has already posed to the Minister about the increase in cost. These questions have to do with the changed euro-to-US Dollar exchange rate, the initial budget calculation which was too low, the efforts to bring health care to a higher level, the insular and small situation of the islands and the cost of medical referrals abroad.