The Elephant Was Never Pink. It Was Always White

The Truth Behind the Hospital Fusion Debate in Aruba

A patient in San Nicolas wakes up with pain. Nothing dramatic. But enough to worry.

They go to a nearby provider. Tests are done. Reassurance is given.

Later, they are referred onward. A new doctor. A new intake. And then comes a sentence many Arubans quietly recognize:"We'll need to repeat the diagnostics."

Not because the first test was wrong. But because the system does not fully recognize itself.

That moment — small, practical, frustrating — is where this entire debate lives.

Not in LinkedIn posts. Not in metaphors of elephants or donkeys. But in the lived experience of people moving through a system that is not fully aligned.

This is not about definitions

In Aruba, we often speak as if the question is simple: Do we have one hospital, or two?

Legally, that question does not exist.

There is no codified definition of what a "hospital" is — not in the Landsverordening AZV, not in the Landsverordening kwaliteit in de gezondheidszorg, not in the Burgerlijk Wetboek.

What we call a "hospital" is not a legal category. It is a role within a system.

And that means we are not debating facts. We are debating design choices.

What follows is not speculation

What follows is not speculation. I have spent years studying this system from the inside — as a legal scholar, as a patient advocate, and as the author of "E Derechonan di Pashent." I have written a doctoral dissertation (Utrecht University) of nearly five hundred pages on healthcare quality in Aruba. I have read the contracts others prefer not to discuss.

I have listened to the patients others prefer not to hear. And I have learned that:

in healthcare, the most dangerous person in the room is not the one with the loudest voice — it is the one who understands both the law and the lived experience behind it.

The system was designed to limit what it now criticizes

There is a point in this debate that has remained carefully implicit. It is time to make it explicit.

When the government of Aruba granted property rights to Stichting Onroerend Goed Aruba (SOGA) for the land on which the Horacio Oduber Hospital sits, and contracted SOGA to construct and manage the hospital buildings, SOGA secured something remarkable in return: a penalty clause prohibiting the government from permitting another hospital on the island for the duration of the contract. Violation triggers a multi-million dollar damages claim against the Aruban state.

Let that sink in.

A private foundation, contracted to build and manage a government-subsidized hospital, obtained the legal right to prevent Aruba from ever developing a second hospital — under threat of financial penalty to the government itself.

This is not a neutral policy environment. This is a structurally engineered constraint on healthcare development, dressed as a sustainability clause.

And now — against that backdrop — the CEO of that same hospital tells us that ImSan is not a real hospital because it never developed full hospital capacity.

The logical problem is not subtle.

You cannot spend years operating a contractual barrier to another institution's growth, and then present the result of that constraint as evidence of that institution's inherent incompleteness. That is not analysis. That is circular reasoning in the service of a predetermined conclusion.

In legal terms, this arrangement raises serious questions — about competition, about the limits of private contractual power over public health infrastructure, and about the good faith obligations of all parties involved.

The premise that "Aruba does not have two hospitals" is presented as fact. But it is a fact that was, in significant part, legally manufactured.

Fragmentation is an easy word. Reality is harder.

We are told that the problem is fragmentation. That care is divided. That resources are duplicated.

But where is the data?

And what do patients actually experience?

They experience repetition. They experience delay. They experience uncertainty.

Not necessarily because there are too many providers — but because coordination is not structurally guaranteed.

That is a different problem.

Because the opposite of fragmentation is not merger. The opposite of fragmentation is coordination. And coordination does not require one institution absorbing another.

Plurality is not the problem — uncoordinated plurality is

In well-designed healthcare systems, multiple providers are not a flaw. They are a design choice.

They create incentives to maintain quality. They give patients real choice. They prevent dependency on a single institution.

But only if the system enforces coordination.

Without coordination, plurality feels inefficient. With coordination, plurality becomes resilient.

Resilience is not theoretical

In 2019, a ransomware attack disrupted the Horacio Oduber Hospital. Care did not stop — but it was strained.

Now imagine a fully integrated system: one structure, one dependency, one failure point. No fallback. No parallel capacity.This is what system design calls a single point of failure.

COVID-19 showed the same principle. Demand surges unpredictably.

And in Aruba we are talking about a population of over 100,000 residents, and more than 1.4 million annual visitors.

This is not a system where redundancy is a luxury. It is a system where redundancy is protection.

So the real design question is: how do we reduce waste without eliminating safety margins?

Because efficiency without redundancy is not strength. It is fragility.

Access is not a logistical detail — it is a right

For someone in San Nicolas, access is not theoretical. It is distance. It is time. It is whether they go — or wait. And sometimes, whether they go at all.

Healthcare systems must be designed around that reality. Not as an afterthought — but as a principle grounded in law, like our own constitution: Article V.23 of the Staatsregeling Aruba, and human rights, like Article 12 of the International Covenant on Economic, Social and Cultural Rights.

These instruments of law guarantee the right to healthcare — and that right requires multiple access points, not fewer. Two hospitals does not mean inefficiency by default. In many cases, they are equity in practice.

Pink elephants, donkeys — or the patient at the center?

What people are actually reacting to

The public response to this debate about the fusion of hospitals in Aruba, has been intense. But it is not random, and it is not irrational.

I know this because patients tell me directly.

They go to a private lab or clinic for diagnostics — sometimes an MRI they paid for out of pocket, because they cannot wait and they are not ready to travel abroad. They arrive at the Horacio Oduber Hospital with results in hand. And they are told: we cannot accept these. Do it again here.

No clear protocol is cited. No clinical justification is offered. What patients hear from staff, when they hear anything at all, is that tests performed outside HOH cannot be trusted. What patients understand — correctly — is that outside providers are not seen as partners. They are seen as competition to be neutralized.

However, in a publicly funded system, paid entirely by AZV, where there is no open market and no private competition in the classical sense, this logic is not only clinically unjustifiable. It is a misuse of institutional power at the patient's expense.

Then there is the question of culture.

ImSan's connection to Baptist International health systems and its JCI Gold Accreditation brought something that cannot be measured in square meters or equipment lists: a service culture.

The late Dr. Rajnherc understood something fundamental — that Arubans value warmth, hospitality, and being seen as a person, not a case number. That is not sentimentality. That is patient experience, and patient experience is a clinical variable.

HOH, by contrast, is described by patients — consistently, repeatedly, across years — as cold. Amsterdam cold. Staff are treated as expendable. Employees pay for their own coffee while executive offices resemble penthouses. The emergency room, notoriously, asks patients to wait four to six hours, correctly identifies that most cases are not acute emergencies, and then does nothing — no referral to a GP, no guidance, no next step. Because it is not in the job description. Because the system is designed for show, not for service.

And then there are the moments where the gap between institutions becomes dangerous.

A patient transferred from ImSan to the HOH emergency room arrived without being immediately attended to. She was not their patient. In the transfer, her clothes were left behind at ImSan. An elderly woman, modest, covered only by a thin piece of fabric, waiting in an emergency room where nobody felt responsible for her.

That is not a communication failure. That is what happens when two institutions operate without a shared protocol, without a shared record, without a shared sense of responsibility for the human being moving between them.

Lack of (optimal) communication between healthcare providers is the number one documented cause of medical error. This is not my opinion. It is the finding of every major patient safety body in the world.

So when people say they prefer ImSan — when they say it is cleaner, warmer, faster, more human — they are not being nostalgic. They are making a rational assessment based on lived experience.

And when they resist the idea of HOH absorbing ImSan, they are not resisting coordination. They are protecting the one part of the system that still makes them feel safe enough to walk through the door.

This debate has already moved beyond policy

Some voices express this in terms of identity, culture, and even historical power dynamics. At times, those expressions are sharp or exaggerated.

But they signal something real: the system is no longer experienced as neutral.

When healthcare debates become about belonging, identity, and control, it means the system is no longer felt as ours. That cannot be dismissed. But it must be translated back into what it actually requires: structural clarity, fair governance, enforceable coordination, and visible accountability.

A system is not only structure — it is relationship

A former physician described a moment from decades ago: an elderly man in San Nicolas, seriously ill, refused to go to the hospital. Not because care was unavailable. But because he did not want to go there. He did not feel at home there.

That story matters.

Because it reveals something systems often ignore: a healthcare system is not only judged by what it can do, but by whether people feel safe enough to enter it.

Over time, our system did not just change structurally. It changed relationally.

And when that relationship weakens, people hesitate. People distrust. People resist centralization. That is not irrational. It is a signal.

What should happen now

Before any structural fusion of hospitals in Aruba is discussed, three things must be made explicit.

First, full transparency on the contractual and financial frameworks — including the SOGA arrangement — that have shaped what our system looks like today. The public has a right to understand the conditions under which their healthcare was designed.

Second, public data on diagnostics, referrals, redundancy rates, wait times, and patient outcomes — across both institutions. Not assumptions. Not LinkedIn posts. Data.

Third, a concrete coordination model — a shared electronic patient record, common protocols, clear referral pathways — implemented and evaluated without merger. If coordination cannot be achieved within the current structure, that failure must be demonstrated transparently. Not assumed. Not used as retroactive justification for absorption.

Only then can structural change be considered with legitimacy.

I want to be clear about what I am not saying. I am not saying the system is fine. It is not fine. I am not saying ImSan is beyond criticism. No institution is. And I am not saying that deeper integration will never be necessary.

What I am saying is this: you do not redesign a system you have not yet honestly described.

You do not absorb an institution whose limitations you helped engineer.

And you do not build trust by bypassing the people — the patients, the staff, the parliament — whose lives this decision will shape.

Aruba is small enough that every bad system decision is felt by everyone. And strong enough that if we design this honestly, we can build something that actually works.

That is the conversation worth having. Not pink elephants. Not donkeys. But humans caring for each other, in healthcare and beyond.

Jayburtt Dijkhoff, PhD Expert in Health Law, Healthcare Quality and Social Reflection

Author of E Derechonan di Pashent (The Rights of the Patient)

If you have ever been in a situation where they tried to make you invisible — unanswered emails, ignored letters, no response — you were not without power. You were without the tools to use it.

Yabinan di Poder 1: Own Your Position — coming soon. Follow the conversation.