The health care sector is facing a shortage of skilled personnel (for instance, there are only 30 active nurses and 18 pharmacists between St. Kitts and Nevis, or one pharmacist for 2,222 people), as well as a perception problem. Many Kittitians and Nevisians choose to get urgent medical attention and even routine, primary health care abroad, and others have no choice. For instance, the absence of hemodialysis treatment at the Joseph N. France Hospital leaves many patients with ESRD (end-stage renal disease), or chronic or permanent kidney failure, who require that specific dialysis treatment with no other avenue but to go elsewhere for care. People who live in rural areas often have to travel to town for certain treatment because the quality of care has yet to be standardized among health centres.