Doctors: We must choose who lives
Government doctors are "playing God" daily, having to decide which critically ill children will get a chance to live.
Restricted by a severe bed shortage in intensive care units for children, paediatricians at the Charlotte Maxeke Academic Hospital, in Johannesburg, send at least one severely ill child who needs specialised care to a general ward every day.
"Children die because there are not enough ICU beds," said Professor Vic Davies, head of the paediatric intensive care and neonatal unit at Charlotte Maxeke.
"You have no idea [what a personal] battle it is to constantly refuse admission."
Paediatricians, child health experts and government officials said that a similar situation existed at many other state hospitals.
Davies said the ICU at Charlotte Maxeke had only 14 beds for both children and babies.
"Fourteen beds are grossly inadequate for [the] demands placed on the hospital, which could do with another 28 beds."
He said doctors had to decide who was admitted into ICU.
"We are playing God all the time.''
The deciding factor in who gets an ICU bed at the hospital is whether the patient needs a ventilator, he said.
Patients who could breathe on their own, despite being critically ill, would be sent to a general ward, because the hospital does not have a high-care unit for children.
One or two children, or infants, are turned away daily from the intensive care units at the hospital.
"More beds are needed but, no matter how loud we shout, we are not getting them," Davies said.
Department of Health spokesman Fidel Hadebe admitted to a national shortage of paediatric ICU beds.
"This can be attributed to human resources and, of course, infrastructure in general. You know that as a country we are still faced with huge problems [in] human resources, including [a shortage of] specialists."
Paediatricians say South African children are at a serious disadvantage because 80% of ICUs are dedicated to adults.
Professor Andrew Argent, medical director of paediatric intensive care at Red Cross Children's Hospital, in Cape Town, said these concerns were highlighted in the National Audit of Critical Care Resources, published in 2007.
According to the audit, only about 4% of all ICU units in South Africa are dedicated to children other than infants.
Argent said the Red Cross Children's Hospital had 20 beds for children needing intensive care and Tygerberg Hospital had only 12.
Argent said that the occupancy rate was nearly always 100%.
He said the reasons for the shortage of ICU beds for children were complex, with many people arguing that money should be spent on getting basic primary healthcare in order before spending money on specialised healthcare units for a "few children".
South Africa has one of the highest mortality rates in the world for children under the age of five.
Last year, it was reported that 75000 children under the age of five die in the country every year and that, of these, 23000 die in the first four weeks of life.
Professor Keith Bolton, a paediatrician at Rahima Moosa Mother and Child Hospital, in Johannesburg, said the shortage of ICU beds was largely due to a lack of nurses.
"In South Africa, the nursing profession has become so [diminished] in status that huge numbers of women and men who would be suitable avoid the profession," said Bolton.
On top of this, many of the nurses working in South African ICUs are not specialised in intensive care nursing.
Davies said figures from the critical care audit showed that only 26.5% of nurses working in ICUs were trained in intensive care, with 49.2% working as registered nurses and 21.4% as semi-professional nurses.
Nursing union Denosa's spokesman, Asanda Fongqo, said: "The severe shortage of nurses is one of the big challenges in health. The government must prioritise it and improve conditions in hospitals to retain nurses, who go overseas, and attract school- leavers to the profession."
The SA Medical Association's Dr Phophi Ramathuba said the country was also not producing the specialists it needed.
"In reality it takes time to produce a specialist and we don't retain them."
To become a paediatrician takes 14 years and then another two or three years to specialise in intensive care.
Dr Miles Bartlett - who saved burn victim Isabella "Pippie" Kruger's life - and Argent believe the solution to the problem lies in public-private partnerships.
"What you really need are big [paediatric intensive care] units dedicated to children. The data show that the more children specialists and nurses see, the [higher] their rate of survival." said Argent.
"There are not enough [private child patients] for many hospitals to have a paediatric ICU."
Private patients would benefit from specialist skills developed by government paediatric ICUs run as public-private partnerships, he said.
Bartlett said: "There is nothing better than returning a child to its family."
He said South Africa "is way behind the rest of the world" in treating children in their own ICUs.
University of Free State paediatric and child health department head Professor André Venter said: "It is really disheartening when you can't admit a child or a baby."
"We really have to manage our beds as best we can to benefit as many babies as we can."
The number of young babies and children turned away at Universitas Academic Hospital, in Bloemfontein, "varies enormously but could reach 10 to 20 a month", he said.