The clinician’s responsibility

In this issue’s ‘Hot Topics’ contribution, Velaphi and Rhoda review the poor outcomes of South African neonatal care. They point out that South Africa, as one of only 8 countries globally, sadly finds itself in the company of African countries such as Cameroon, Chad, Congo and Zimbabwe in having shown no improvement in neonatal outcomes over the past 20 years, despite having arguably the most advanced economy on the continent. In addition to the quoted sources of information on neonatal care, the Saving Children 2009 report on the sixth survey of child healthcare in South Africa1 shows that there also exists a trend of an increasing proportion of neonates among child hospital deaths, and specifically of deaths in the first week of life. These are presumably babies who are being admitted or re-admitted into the curative child healthcare hospital beds after discharge from obstetric and routine neonatal care. Both the Perinatal Problem Identification Programme and the Child Problem Identification Programme reports highlight numerous avoidable factors in these infant deaths. Velaphi and Rhoda rightly make the point that clinicians, comprehensively defined as all professionals working with patients, must play the major role by providing appropriate care, meaning that they must serve the patient with good clinical judgement in accordance with best practice protocol based on research evidence.

Health system administrators must provide the infrastructure and resources for clinical work, but it is a misunderstanding of their role if clinicians are to be considered just as employees in a post-filling numbers game. Clinicians should see themselves as employees, yes, but even more so as caring professionals with particular, specific skills and obligations towards their patients. This characterises the profession and makes it a calling more than a job. These are the skills and attributes that patients and their families look for and respond to in their reactions to healthcare. In their ethical responses to day-to-day challenges, clinicians cannot escape the personal responsibility for care that is so central to the Hippocratic tradition of healing sometimes, but helping always.

In their study of incorrectly diagnosed children without HIV infection referred to a large paediatric antiretroviral therapy (ART) clinic, Feucht and co-workers also allude to clinical responsibility. In the large South African ART programmes, it is inevitable that the primary care sector must shoulder an increasing responsibility for clinical decision-making with regard to diagnosis, ART initiation and onward referral. These decisions, however, require clinical training and individualisation of patient care. The risk of far-reaching consequences from unthinking generalised application of standard protocols to all patients is obvious.

For the rest, we again carry articles with a wide spectrum of topics. Balogun et al. wondered how the ubiquitous mobile telephone could be utilised for child health promotion in Nigeria. They found that more than three-quarters of mothers interviewed were willing to receive SMS reminders regarding child immunisation appointments. Where immunisation coverage is still not adequate, this is an idea worth exploring.

Oketcho and others studied epidemiological factors in diarrhoea admissions to a Tanzanian regional hospital. The known associations with seasonality, common infections and water supply were found, but there were also differing referral patterns from certain of the district hospitals, suggesting local variables possibly associated with the health professionals.

The South African Paediatric Association’s biannual congress takes place this month. Once again there will be scope for presentation of research from established academics and from registrars. We look forward to publishing some of the work.

1. Stephen CR. The very young child: Neonates (0 - 28 days). In: Stephen CR, Bamford LJ, Patrick ME, Wittenberg DF, eds. Saving Children 2009: Five Years of Data. A Sixth Survey Of Child Healthcare In South Africa. Pretoria: Tshepesa Press, MRC, CDC, 2011:102-118.

S Afr J CH 2012;6(3):66. DOI:10.7196/SAJCH.499