SANTO DOMINGO, Dominican Republic -- Rosa Elba Santana struggles to comprehend what went tragically wrong for her infant twins at the Robert Reid Cabral Children's Hospital, one of the few places for someone with a sick kid and not much money in the Dominican capital.
Rosanna and Isaac died, according to their death certificates, from a bacteriological infection. But the clinical explanation only raises more questions for Santana, who took the month-old twins to the state-run hospital because the girl had stomach pains and the boy seemed to have trouble breathing.
"I took them to be checked, not because it was serious," the 20-year-old mother said in a sparsely furnished home with a dirt floor where she is living with her toddler son, mother and a sister. "Instead of getting better, they got worse."
Her twins were among 11 babies who died at Robert Reid Cabral over three days in early October, a cluster of deaths that shocked Dominicans and brought what some say is long-overdue attention to one of the country's most important medical institutions. It also raises questions about overall quality of health care for the poor in the Dominican Republic.
Following the deaths, President Danilo Medina appointed a commission to investigate. It found significant shortcomings at the hospital, leading to the firings of the nation's health minister, the hospital director and others, even as officials have defended the overall care at the 300-bed facility.
The commission, led by the attorney general, determined in a preliminary investigation that infections contracted in the hospital were responsible for the deaths of four of the 11 children, including Santana's twins. Four other deaths stemmed from "deficiencies in the quality" of medical care, including a failure that lasted several hours in the system that supplies oxygen to the hospital's respirators. In only one of the deaths did the patient receive adequate treatment, their report found.
The ousted director, Rosa Nieves Paulino, who was deputy director for seven years before moving to the top job when Medina took office in 2012, sought to defend her tenure by noting that the hospital's mortality rate declined in recent years. Even so, the death rate is three times the national average for public hospitals and there were at least two other clusters of deaths there since June.
"The children who come to the hospital are very sick. And, of those who died, some of them had been here less than 24 hours," she said.
There could be other factors behind the mortality rate, including the fact the hospital treats children who are poorer and sicker than the overall population. There isn't enough data to determine if the number of deaths is "alarming," said the new director, Jose Miguel Ferreras.
"We can't say three or four deaths per day is a high figure without a deeper analysis," Ferreras said.
Still, officials and doctors concede the hospital is understaffed, underfunded and overfilled. Santana recalls there were four other babies crowded onto the same bed as her twins when she took them there to be checked out. Ferreras, however, said that only occurs in the emergency room, not after patients have been admitted.
The Dominican Republic has pockets of extreme wealth but it still largely is a poor country of 10 million. UNICEF says widespread malnutrition is primarily responsible for the country's infant mortality rate of 27 per 1,000 births. The average for all of Latin America and the Caribbean is 16 per 1,000, according to the Pan American Health Organization.
Robert Reid Cabral opened in 1956 and is named for a Dominican pediatrician and brother of a former president, but is popularly known as "El Angelita" for its original name honoring Angelita Trujillo, daughter of a former dictator. Because it accepts payments from social security and is willing to treat the very poor at no cost, it draws patients from throughout the country, including many who, like Santana, live in slums on the outskirts of the capital.
"They told me this was the place to take your children, where they have the specialists," she said.
Sitting on her tattered couch, Santana, who is single and has no job, tries to make sense of the death certificates, which describe how her son died while doctors tried to perform a blood transfusion to treat sepsis that had overwhelmed his body. Her daughter died under similar circumstances the next day. Prosecutors interviewed her for the commission's investigation but she hasn't heard back from them. She doesn't know whether she will receive any compensation for her loss.
Some parents of other children who died invited her to take part in a protest at the hospital but she declined. "I will never go back to El Angelita," she said. "I'm afraid to go there."
Doctors and nurses who work at Robert Reid Cabral say the main problem at the government-funded hospital is a lack of resources. They have an annual budget of just $1.7 million and admit about 13,000 patients a year.
Last year, the government eliminated the minimum fee for patients lacking health insurance or social security coverage and "there was an avalanche in the demand for service," which strained the hospital even more, said Dr. Martiza Lopez, the head of a committee of doctors that has pushed to increase the budget.
Doctors and nurses at the hospital, like counterparts in other parts of the country, repeatedly have gone on strike over their dismal wages and working conditions. Doctors who are specialists earn about $1,000 a month, and many must take side jobs to get by. Some, like Dr. Radhames Ovalles, accuse of the government of trying to win political points by expanding access to health care without paying for it.
"The government should stop its rhetoric and begin to take care of the poorest," he said.
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