For the past few weeks, I’ve been rotating through pediatrics. In the emergency room, I met a little boy I’ll call Ian.

Ian was wary of everyone who came close to him, especially anyone holding a stethoscope or thermometer. Sometimes all it took was the way you raised your hand, or a glance toward his neck, for him to retreat behind invisible walls. He was only about a year and a half, but he had already learned caution.

About a week or two later, something changed. Ian had been transferred to the ward. When I walked in, before I even reached his cot, he smiled. I had become familiar. Safe. His cheeks were fuller, his eyes clearer, and even his mother admitted he was doing much better.

Then there was Jay (also not his real name). Jay was bubbly from the start. He barely spoke or moved much initially, but he smiled a lot. By the time he was discharged, I had become “Aunty,” and his mother was exhausted from chasing him all over the ward.

But this piece isn’t really about Ian or Jay, except that it is.

It’s about the conversations that kept repeating themselves over those weeks. The kind that linger long after ward rounds end.

The silent patients

I saw children being brought in far too late, when little could be done. I saw parents refusing an intervention because “someone” had said not to. I imagined Jay needing a procedure, only for his parents to refuse out of fear, misinformation, or deeply held beliefs. Or Ian requiring further investigations after a difficult diagnostic process, only for his parents to decide the tests were unnecessary. After all, he already looked better.

What struck me the most? Almost always, these children had no say.

No say in coming to the hospital.
No say in staying.
No say in whether treatment was started, or abandoned.

Sometimes the reason was ignorance. Sometimes it was lack of funds. Sometimes sheer stubbornness, only broken by fear when things became unbearable. And often, this was not their first contact with the health system.

Systemic barriers to care

What I was witnessing wasn’t isolated. Studies from various parts of West Africa consistently show that many children present late to hospitals, even with severe illness. Caregivers frequently cite cost, poor recognition of danger signs, self-medication, and prior care in non-hospital settings as reasons for delay. What conversations on the ward revealed to me is that these barriers don’t automatically disappear once a child is admitted. They continue to shape how caregivers receive, and sometimes resist, medical interventions.

And this raises an uncomfortable question: If parental beliefs or limitations are actively harming a child, where do we step in to protect that child?

This is where child welfare and social services are meant to come in.

The gap between policy and practice

In my attempt to understand this better, I learned that (at least on paper) such systems exist. In Ghana, for example, there is a formal Child and Family Welfare Policy published in 2017. It was developed collaboratively by the government and UNICEF, and emphasizes coordination between health services, social welfare officers, and the legal system to protect vulnerable children.

It sounds reassuring. Even noble. But once we move from policy to practice, uncomfortable questions quickly surface.

If a child is taken in as a ward of the state to allow necessary medical care, can the system truly sustain that care? Are there enough social workers to follow cases beyond discharge? What happens if parents remain adamant and actively disrupt treatment? Are there provisions for temporary placement? And in cases requiring prolonged care, such as childhood cancer, who funds repeated chemotherapy sessions, transportation, accommodation, and lost income for caregivers?

Even global organizations acknowledge that child protection and social welfare systems in many low-resource settings are fragmented and under-resourced, especially at community and district levels where these decisions actually unfold. So when the system cannot carry the full weight of intervention, what happens next?

Often, the first response is persuasion. We educate. We counsel. We reason. We hope.

Sometimes it works. Other times it doesn’t. And when it doesn’t, many cases are quietly left to chance, not because no one cares, but because there is only so much the system can absorb.

The ethical dilemma

This is where my discomfort lies.

Is the child welfare system, in practice, doing more harm than good? Does its mere existence create an illusion of safety, making us believe solutions are available when they are not? Is it meant to be a deterrent, a legal threat that forces difficult decisions? Or is it sometimes a figurehead, offering moral reassurance without the infrastructure to back it up?

These questions feel particularly heavy in under-resourced settings like much of West Africa, where poverty, cultural beliefs, and fragile systems intersect daily at the bedside.

I don’t have clear answers.

What I do know is this: Children like Ian and Jay depend entirely on the adults around them, and when those adults hesitate, disagree, or simply cannot afford to act, the systems designed to protect children are tested in their most uncomfortable form.

Perhaps for now, all we can do is show up one child, one family, one conversation at a time. But beyond the consulting room, we also need to step into the spaces where these decisions are shaped: policy rooms, funding discussions, community education, and advocacy platforms.

Because if children cannot advocate for themselves, and our systems cannot fully step in either, then the question remains unavoidable: What exactly do we owe them?

Maureen Oluwaseun Adeboye is a medical student in Ghana.