Is the Malaysian Public Healthcare System in Disarray … Are we Safe?

Malaysia’s public health nightmare may already have begun and could explode at any time. The signs are there.

By Reuben Sher

It is with deep concern that Malaysians are now witnessing the unfolding meningitis outbreak in Malacca which has affected JPJ trainees located at their Academy in Tiang Dua, Malacca. Thus far, 434 staff and trainees have been affected with several hospitalized. One trainee has apparently succumbed to the illness. Bacterial meningitis if left untreated can be lethal just as any other communicable disease. 

In mid-April, MRSM students from their campuses from Beseri, Perlis; Pengkalan Hulu and Taiping, Perak had a recreational meet but a week later all three of their hostels were similarly quarantined for an “influenza” outbreak. News of the outbreak was blacked out by the Ministry of Health and Education. Parents were not in the know until a week later. Students were apparently quarantined in a sick bay at their hostels with a doctor coming in to visit them. Students badly hit by pneumonia were moved to hospital while one student at Taiping apparently ended up in Intensive Care with no news as to whether he made it. Students had fever, rigors, cough and wheezing. After being told they just had influenza, students were then allowed to return to classes. 

In March of this year, the Ministry of Health issued an alert for cases of typhoid fever in Selangor after an apparent outbreak that started from Sg Chongkak (near Kajang/Cheras), a popular weekend getaway with city folks. In April of this year, a cholera outbreak in Kajang and Klang resulted in 50 people being hospitalized. Both outbreaks were apparently the result of unhygienic food handlers and water contaminated by cholera and typhoid bacteria.

 

Although the public needs to be educated to avoid unhygienic food handlers, in urban areas, the major problem apparently is lack of enforcement by health authorities. There have been recurrent reports of health inspectors being on the take from busy but unhygienic restaurants which may explain why these restaurants, despite the swarm of flies, keep operating. Some of these stalls, many employing illegal immigrants as helpers,  right beside garbage dumps, open toilets and longkangs in PJ, Brickfields, Old Klang Road, Gombak, Setapak, Kajang, Puchong, Balakong, Seri Kembangan and presumably many other parts of the country are a real danger to the public especially children. 

Despite all the publicity regarding the swine flu which caused our Ministry of Health officials to run around to emergency conferences and scurrying to buy expensive thermal scans to be located at entry points, officials appear to have failed to comprehend the continuing lethal danger that the Aedes mosquito poses to the Malaysian population. Although dengue apparently has shown a decline over the last three weeks, 15,031 cases were recorded until April 4 with 38 deaths, compared with 9,889 cases and 22 deaths over the same period last year. This week alone another 5 died of the disease. The exact incidence of chikunkunya, a disease hitherto not prevalent in Malaysia, remains unknown as a result of underreporting. 

The re-emergence of Malaysia’s old enemy, malaria, appears to have returned with a vengeance. The rapid-spreading malaria strain in Sarawak ’s Bario highlands region, which recently has reported an increase in malaria cases, is a source of great concern with anyone associated with public healthcare because the malaria strain spreads very fast and multiplies rapidly within 24 hours instead of the usual 48 or 72 hours. More then 100 malaria cases have been reported in the highlands alone.

Tuberculosis, a disease which saw a steep decline in Malaysia up till the 80’s has increased in Malaysia in part because of the spread of HIV. TB incidence increased from 60.3 cases per 100,000 people in 2004 to 61.2 cases per 100,000 people in 2005. The annual incidence of TB has not shown much decline, with the number hovering between 60 and 70 per 100,000 population. For all forms of TB, the incidence in 1985 was 68.2 per 100,000. Last year it was at 63.1 involving 17,506 cases. The influx of a huge migrant population, especially in Sabah has negated the many preventive measures this country had taken during the 1960’s to counter the disease.

Of course for diseases such as Hepatitis B, C and HIV, it is anyone’s guess what the actual statistics are in Malaysia as widespread screening is hampered by costs, manpower and ethics. But judging from the rampant reports of drug abuse and liver related illnesses in hospitals, it could be significant. The question is, are we doing enough and are the strategies adopted by the government the correct ones. Perhaps not.

During Malaysia’s early years, a great proportion of the health budget was poured into public health. Curative care in the form of hospitals took a back seat and was left mainly to private hospitals. Indeed, almost all the early Director-Generals of Health in this country were from Public Health.

When clinicians from hospitals started being appointed as Director Generals, much of the money meant for public healthcare has been channeled to hospitals. There was a race to build high tech, costly hospitals that could match Western ones. This strategy would ultimately prove to be a losing game as hospitals, although an integral part of healthcare, swallow humongous amounts of money compared to the tiny proportion that is required to prevent illnesses in the first place.

Moreover, the MOH has been stuck and looks like they will be marooned for a long time to come as they continue to dither as to whether public hospitals should be turned over to independent managers, trusts or corporatised entities to ensure that Malaysian hospitals continue to be viable in correlation with the infrastructure and equipment costs tax payers have invested in.

Reports suggest that expensive equipment and even more expensive hospitals remain underutilized and in some cases not utilized at all. The wastage, especially in terms of the maintenance and non-upgradeability of much of these equipment may not be recoverable. Taking this hospital path has its benefits, but you must be able to keep up in terms of technology, skills, training and manpower.

But you can never substitute nor replace public health care with purely hospital-based medicine. That would be a fatal error, especially in Malaysia with our porous borders, large immigrant population and now our outstretched rural health care services. In fact, instead of focusing on more stringent regulations and enactments to ascertain that many of these communicable diseases are kept in check, regulations pertaining to hospitals and clinics have taken precedence.

There is talk about pathology bills, more medical Acts, even medical equipment enactments. The wisdom of enacting Western style regulations and using scarce resources meant for public health to monitor and enforce these enactments on a society that clearly has yet to understand what these laws mean, is one of the leading causes of displeasure of the masses against the current government.  Malaysia is like a little child, trying to run when it hasn’t quite learnt how to crawl yet. Does priority in clinic licensing out in Bario take precedence when folks there can’t even get a doctor to serve them permanently?

There is little coordination between social, local council and health authorities to prevent overcrowding. Homes or flats meant for three are shared by 10 people. Blocked or stagnant drains, abandoned buildings with large pools of Aedes infested waters, unhygienic stalls and eateries, overcrowded schools, virtually no garbage disposal at apartment complexes nor maintenance have become the battleground for pointing fingers between authorities. Children play on narrow corridors 10 floors high and stay in cubicles, 8 to a flat meant for 4.

Can we indeed even trust the water that flows out of our taps? Not so. No one in Malaysia would even dream of drinking water right off a tap before boiling it or filtering it. In fact, the Minister of Health would be the first to come out with a statement that it is not his problem although unclean water is the first source of food-related communicable illnesses.

Immigrants walk this nation’s borders with wanton ease. We have Acts and Regulations to convict and jail a doctor if a clinic is unlicensed as in the Basmullah case, but a stall owner who puts a hundred people in hospital because his workers are not vaccinated for typhoid gets away with a punitive fine. A hostel warden who cramps 12 students into a tiny dorm endangering them to TB or influenza gets away with a lecture while a doctor who misses a sodomized patient gets hounded like a dog.

And of course we have immigration officers who let in thousands of disease-bearing Filipinos and Indonesians at the border get off scot-free while the Director-General is busy assembling a panel of doctors colluding as to how to fabricate post-mortem medical reports.

Malaysia’s public health nightmare may already have begun and could explode at any time. The signs are there. The Government would do well to bring in a Public Healthcare expert as the next DG fast. And that too, one who would spend more time focusing on trying to protect the Malaysian population from being obliterated by communicable and lifestyle disease epidemics instead of trying to make a quick buck manufacturing vaccines or fabricating post-mortem reports on the side.