Dead
children - the true state of our child health services
COMMENT
| In Malaysia, there is a tendency to shoot the messenger that brings bad news,
especially in government. For those who have a long memory, you will remember
the times when health staff in the civil service had attempted to speak up but
often have been victimised instead.
I
am encouraged to write this because of recent comments by our health minister
under our new Pakatan Harapan government who has asked us to speak up and share
the truth. He has encouraged dissenting voices and constructive criticism. In addition,
our finance minister has encouraged submissions for the upcoming budget in
October. I hope that these suggestions would be considered for funding of
urgent critical needs for children in our public health service.
This
article is to describe the reality, the truth of what is happening in the child
health services in Malaysia. I've worked for more than 35 years in the civil
service, most of the time as a paediatrician with children. I want to make a
clear distinction that this article only deals with services in hospitals in
the Ministry of Health (MOH). There are dire and important unmet needs for our
child health services in the public health sector but I am not dealing with
them in this article. Here I would like to outline the struggles faced by
paediatricians and staff working in paediatric departments all over the country
on a daily basis.
Reality One: Critical shortage of Nicu & Picu beds
The
first reality and fact is that we are desperately short of intensive care and
high dependency beds for children all over the country. Every day most
paediatric departments will be scrambling to try and find a bed for an ill baby
or child. Our neonatal intensive care units (Nicus) that care for premature and
ill babies and our paediatric intensive care units (Picus) that look after
older, seriously unwell children are grossly inadequate all over the country to
meet basic needs. Most of our existing Nicus and Picus are cramped, small and
in dire need of expansion.
The
sad reality is that we have to make painful and heart-wrenching decisions every
day; some children, especially tiny premature babies, that could be salvaged
and saved are not offered care because we just don't have the beds. In
addition, we waste a lot of resources, time and energy to transport children
all over the country; from one state to another just because there is bed
shortage; often dislocating parents and families and causing more hardship.
Despite
many submissions over many decades to the MOH for expansion and growth of
intensive care for children, inadequate resources have been allocated for the
development of these services. We have faced a lot of anguish from parents and
colleagues because at times we are just not able to offer the services that
could very easily rescue children. All of us try very hard, but for years the
growth and development of our Nicus and Picus have been grossly retarded.
Reality Two: Critical shortage of equipment in existing
Nicu & Picu beds
The
second painful reality is that there is a critical shortage of vital intensive
care equipment in our Nicus and Picus. Much of the equipment is old, some do
not function very well and fail often. Some of the equipment is already beyond
economic repair (BER), but we are forced to continue using them as we have a
severe shortage. Imagine using incubators where the wall of the incubator is
really blurred and it's hard to see the baby inside. Some departments are
forced to share intensive care monitors between ill babies (two babies using a
single monitor) and this is of serious concern as mistakes can easily be made.
Many of our older generation ventilators are more damaging than helpful to
premature lungs. Every year the allocation that each paediatric department
obtains for equipment is barely enough to purchase a few items, let alone get
replacements.
Reality Three: Extreme shortage of nurses
The
inconvenient truth is that we are very short of nurses in our Nicus and Picus.
Many of our Nicus and Picus operate with one nurse looking after three
intensive care babies/children at night. The recommended norm is one to one
(actually 1.5 nurses to one child is a better ratio so that we can deal with
emergencies). Surprisingly our adult ICUs can be allocated one nurse to one
adult but not for children. In the daytime, we can manage with one nurse
looking after two ill children but at night it is a crisis.
A
simple analysis of deaths in children who died in our ICUs will show that the
rate of death is much higher at night. In addition, there is an enormous strain
on our nursing staff both physically and emotionally. Managing three intensive
care children at one time, night after night takes a toll on you. A recent
study we conducted showed that one in five nurses in our NICUs are coping
poorly and depressed over the death of infants in their care. All of us are
affected by the deaths of babies and children, especially those that we know
could have been saved if the resources were adequate.
The response
If
anyone tells you that things are not as bad as I am describing here, then they
are not speaking the truth; things are worse than what I am describing here.
If
anyone says we have not spoken up in the system, then they are not speaking the
truth. Many attempts have been made to bring this to the attention of our
government. Although MOH is aware of it, no one seems to be able to change the
situation on the ground or get more funding to save the lives of children.
What
is always surprising to many of us as paediatricians, is that the adult
intensive care units in our country have better bed strength, better equipment
and better staffing. Somehow we seem to invest in adults more than we invest in
children who are far more fragile and in need. I am not here to knock our adult
services but to appeal that we do something for children. This chronic neglect
of our Nicus and Picus cannot continue; many lives have been lost and more will
be if things remain unchanged. Our national under-five mortality rate has
flat-lined for more than 15 years.
I
often ask myself as to whether we want to hear the truth. We often "sugar
coat" the reality. When VIPs and government ministers visit hospitals
there is often a frantic "clean-up and touch-up" (wasted money) with
a good front presented to suggest “no major problems”. I call these “potted
plant visits” – putting out our nice plants for the VIP to view. Governments
always want to hide or neglect the truth, which is the very antithesis of
governing.
Do
we want to continue believing "Everything is OK” and that “We will
manage”? I have heard this much of my life, that “MOH will manage with the
limited funds allocated”. No, we are not managing well and it is getting worse.
We
have fallen so far behind countries like Taiwan and S Korea in our healthcare
services. They were, in the past, lagging behind us and looked up to us as an
example. But now we admire the services they have been able to develop and have
invested in.
So
I appeal to our finance minister, come this October budget, please don’t
allocate money to build new buildings. Or buy highways. Or invest in flying
cars. Or buy tanks and plane. Or continue with mega-projects, etc.
Put
the budget where it counts – saving the lives of babies and children.
And
make sure the allocation goes to the babies and children who are in our Nicus
and Picus. Otherwise, it will be diluted by the enormous needs of our starved
and underfunded MOH and never reach the children.
If
we do not start funding paediatric services adequately and grow them, we will
have to accept the reality that we do not care enough for the children of our
nation.
The writer is a senior consultant paediatrician.
The views expressed here are those of the
author/contributor and do not necessarily represent the views of Malaysiakini.
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