Our 'Boleh'land Health System

May 16, 07 1:42pm

Once upon a time, I vowed as a naive medical student to serve fellow Malaysians with my utmost sincerity. Despite much disappointment with the mediocrity of our local university, I was determined to repay the rakyat for the subsidy they provided me with. It has finally dawned on me that it is practically impossible to provide optimum healthcare in a pathetic healthcare system like Malaysia’s. Indeed, ours is a system that is flawed at its very roots, and top. Instead of putting in concrete efforts to overcome simple problems with simple solutions, the Ministry of Health (MOH) has instead chosen to busy itself with efforts of vanity and exhibitionism. Penning a rosy Piagam Pelanggan and a lofty misi dan visi (mission and vision) for every single sub-department will not translate into better services. Putting our healthcare personnel through time-wasting, brain-washing Kursus Induksi (induction courses), Biro Tatanegara (BTN) and Penilaian Tahap Kecemerlangan (PTK) programmes will not produce more skillful and knowledgeable staff. Holding weekly perhimpunan pagi hospital (morning assemblies) and singing patriotic songs will not miraculously make anyone serve their fellow Malaysians with greater commitment and efficiency. Forcing our doctors to don bacterial-laden white coats and equally lethal neck ties is the perfect example of style without substance. Seeking and attaining MS ISO accreditation is far from reflective of the quality of services our patients are receiving. These fanciful so-called recognitions have instead added unnecessary red tape and rigidity to a clumsy, obese system already burdened and bloated with excessive bureaucracy and paperwork. The MOH’s misplaced obsession with ISO recognition and protocol is holding everybody back – doctors, nurses, lab technicians, radiographers and everyone else trying to fulfill their duties in a system that frustrates. While healthcare in much of the rest of the modern world is cruising ahead, Malaysia’s is so very wedged in the medieval ages, with no signs of any prospective improvements under a greedy government more concerned about serving the interests of its cronies in the money-loaded field of medicine. Arrested in medieval ages The typical government hospital has no computer networking system to store and track patients’ records and investigation results. When a patient is readmitted, there is no inkling what was done in the previous admission. Crucial investigation results are rarely returned to the respective patients’ notes. Almost everything is traced by phone in an age when people across the globe are downloading music, movies and any form of data at the click of a mouse. Doctors and nurses are kept crazily busy tracing investigations taken weeks and months ago, instead of seeing and attending to patients like they were trained for. Elsewhere in the medical laboratory, lab technicians are answering relentless phone calls from their clinical colleagues stationed throughout the hospital instead of performing chemical tests and analyzing specimens like they were trained for. Sending specimens and collecting results are all done by foot, resulting in senseless delays in a field that requires a constant sense of exigency. At a time and age where information transfer has never been much easier, our doctors, nurses and hospital attendants are still scurrying about like messenger pigeons chasing after scraps of paper that could be anywhere in a hospital of 600 beds. Consequently, a simple two-minute test like a full blood count can be delayed up to hours. Receiving its results can take an eternity. Not uncommonly, some important investigations can never be successfully traced which in bulk, translates to wasted millions as tests are repeated merely because the first ones were nowhere to be found. All that is needed to address this crippling deficiency is a cheap, simple networking system any computer-savvy secondary school kid is capable of setting up. Time is golden they say, and this is particularly true in cancer, where the difference between a week and a month may mean the difference between survival, morbidity and death. The histopathology services in our government system squirm along at a sluggish pace. It is totally not uncommon for one to wait months for a tissue diagnosis of a suspected malignancy, by the time which the cancer would probably have metastasized. Occasionally and not surprisingly, diagnostic reports disappear altogether, leaving the patient without a final diagnosis. Frustrated with this gaping weakness of our healthcare system, most doctors choose instead to convince patients to perform their tests in private laboratories and hospitals - at a costly sum, needless to say. The patients’ loss is the cronies’ gain, as friends of Barisan Nasional (BN) in healthcare businesses stroll gleefully on their way to the bank. Medical wards or refugees camps? Fifty years of merdeka and liberation from colonialists yet our medical wards are still very much like overrun, pre-war, post-disaster refugee camps. Sixty patients with a spectrum of ailments are packed like solid popiah into a single ward no larger than a badminton court. The immunocompromised HIV patient lies beside the old man with active tuberculosis who is coughing towards the immunosuppressed cancer patient on chemotherapy opposite his bed. There is hardly any observation of barrier nursing or isolation. It is far from surprising that our ill patients are succumbing to multiple infections. There is zero room for privacy in the typical general ward. Screens are scarce and often impossible in an overcrowded ward. Clinical procedures are performed in full view of other patients and relatives, putting the patient through untold embarrassment and loss of confidentiality. Unless the health minister desires to undergo a digital rectal examination with a strong, curious audience of 60, there is no reason why our mothers and fathers should be put through such ordeals. The general appearance of our wards is a shame. Rusty beds with broken wheels, faulty drip stands held in place by cheap plaster, blinking fluorescent lamps, and noisy mini-wall fans are the norm of the day and make good for a scene in Dark Water. Our febrile elderly patients become dehydrated, and literally fry in the seething heat that epitomizes the current state of our hospitals. Septic patients with high fever, chills and rigors waste away in crammy, stuffy, noisy general wards, while the crooks they elected as representatives recuperate from a simple ankle sprain in spacious, air-conditioned single bedded rooms, oblivious to the sufferings of the simple-minded folk who put them in power in the very first place. As BN-putras plunder the nation even as one is reading this article, ill and sick Malaysians are wasting away in shoddy wards so deficient in so many aspects. ECG machines so crucial in diagnosing acute cardiac events are sometimes shared between two wards of 80 patients. In times of emergencies, doctors and nurses run helter skelter hunting for elusive ECGs, pulse oximetries, ventilatory bags, oxygen tanks, arterial blood gas machines and heck, even blood pressure sets. Not uncommonly, life-saving intubation sets are incomplete or faulty and cardiac monitors are so ancient that the readings cannot possibly be taken seriously. Our patients wait months to undergo CT scans, ultrasounds and MRIs. Ineveitably, some patients meet their Maker way before their appointment date. In one large state in East Malaysia, there are merely two CT scans to serve two million people, one of which is low-grade and substandard. With the rise in vascular diseases, most government hospitals still do not offer CT angiography. In an oil-rich nation, is this beyond our means? In our existing miserable state, doctors, nurses and attendants do not even have working counters of their own and are instead wrestling for limited space to do the ridiculous paperwork bestowed upon them, in stark contrast to the posh, cooling office that the minister sits in. Pitiable corrective measures Some hospitals, in a vain attempt to deal with the overcrowded wards, transfer “stable” patients to so-called extension wards which are commonly separated from the main hospital. Not infrequently, these supposedly stable patients deteriorate and require urgent intervention – elusive help which would not arrive as there is usually no resident doctor on-call in these peripheral units located far away from the main hospital building. Many needless deaths occur due to delayed help in these “recovery units” and “extension wards”. Our clinics are not any better, if not worse. With the massive wealth of Tanah Melayu, it is beyond belief that most of our wards and clinics are not equipped with a computer and printer. Referral letters are hand-written, resulting in unquantifiable confusion, communication errors and disastrous consequences. Specimen tubes have to be labeled manually instead of cheap and convenient printed stickers. Up to five patients undergo consultations simultaneously in a room no bigger than a Proton Perdana. Malaysia Boleh? Government ambulance services are reasonably renowned by now – for the wrong reasons. While the public may decry the unnecessary deaths of Mohd Yusry and Yusnita Abas due to alleged ambulance delay, much more nonsense does not reach public knowledge. Poorly equipped to begin with, most of our ambulances serve as nothing more than a modified human transporter, with no inbuilt oxygenation, no ready supply of emergency drugs, no intubation sets, no communication services save for the driver’s handphone. Patients’ running out of oxygen supply during an ambulance ride is a daily occurence. Essentially, our ambulances serve only to transport an ill patient from one place to another in the shortest time possible. Whatever happens along the way is solely left to God, and beyond the control of any medical personnel, who has few tools to work with. The sad state of our ambulance services is seen beyond emergencies. In many rural districts, ambulances serve as perhaps the only form of transport for poor patients to travel to a general hospital. Our ambulances fail miserably even in this undemanding task. Recovering patients end up stranded for weeks awaiting ambulances from the district hospitals to send them home to their anxious families. Ward beds are occupied unnecessarily. Some patients waited so long that by the time an ambulance is actually available, they developed severe hospital-acquired infections due to an unnecessarily prolonged stay in the ward. Here in Malaysia, the field of emergency medicine is one that lacks a sense of urgency. Uncannily however, such lackadaisical attitude is cleverly hidden during by-elections. Unsupportive support services Our sad state stretches far beyond the clinical scenario. Our hospital support services are equally, if not more pathetic. Faulty elevators lie in ruins, unrepaired for months, causing delay in almost everything and to everyone. The elderly lady with severe osteoarthritis is forced to walk up seven flights of stairs to visit her ailing husband. Is this humane? Far from it. Urgent phone calls lose their very adjective as doctors wait 10 minutes for calls to be answered and a further 10 minutes as operators flip through prehistoric, dog-eared antique phone books instead of an ultra-convenient computerized directory. What could have been achieved in minutes and seconds takes hours and days instead. Replacing a burnt bulb takes a mere four minutes but getting the personnel to actually do so may take up to four months. So much for privatisation of hospital support services. Improvements to our healthcare do not require fanciful slogans so characteristic of the Badawi administration. We do not need more time-wasting, money-consuming kursus (courses) or more standard operating procedures (SOP) that make everything so rigid and methodical. As it is, everything is already moving at snail’s pace. With that statement, I am of course guilty of insulting the snail. We need wisdom and sincerity if we are to improve our healthcare. Both unfortunately, are not synonymous with the BN regime.

UN calls for mass circumcision of men to tackle Aids epidemics

· Trials find procedure reduces infection by 60%
· Programmes expected to focus on African nations


The United Nations yesterday urged all countries with devastating Aids epidemics to launch mass male circumcision programmes following evidence that the surgical procedure can protect against HIV infection.

The World Health Organisation and UNAids, the joint UN programme on HIV/Aids, made the official recommendations after a meeting of experts in Montreux, Switzerland, to consider the evidence from three trials in Africa, which were stopped early when it became clear that men who had been circumcised were up to 60% less likely to get HIV than those who had not.

Experts accept circumcision is a sensitive issue, tied in to social and religious traditions. During sectarian fighting in India, Muslims and Hindus at one time would tell friend from foe by pulling down their trousers - all Muslims were circumcised.

But research suggests men and women in Africa would accept male circumcision if it lowered the risk of Aids, and WHO experts yesterday held out the prospect of cultural change over a decade or more. Catherine Hankins, associate director of the WHO, said that within about a decade in the 1980s and 1990s, South Korea went from no circumcision of boys to circumcising 90%, influenced by the example of the US.

WHO and UNAids recommend that all heterosexual men should be offered circumcision in countries with severe Aids epidemics. "We are talking largely or most importantly about countries of sub-Saharan Africa and to a lesser extent eastern Africa," said Kevin de Cock, director of the Aids department at the WHO. But he said it was for countries to decide whether and how to implement the guidance. He expected discussions would now take place on the implications in countries in Europe and the US. However, there is no evidence yet that circumcision offers any protection to men who have sex with men.

Circumcision could bring many benefits in the long term - it is estimated that universal male circumcision in sub-Saharan Africa, where HIV/Aids is most prevalent, could prevent 5.7 million new infections and 3 million deaths over 20 years.

But the WHO's experts yesterday tempered enthusiasm with considerable caution. Circumcision, they say, must not be seen as a magic bullet. It is only partially protective, and they fear some men may assume they can sleep around with impunity and no longer need to practise safe sex techniques, such as wearing a condom.

"We haven't had news like this in an extremely long time," said Dr Hankins. "It is an exciting development, but it is partial protection for men. Circumcised men can still become infected and can still transmit the virus to their partners."

The logistics of rolling out circumcision are formidable for impoverished countries burdened with Aids and already struggling to test, counsel and treat all who arrive at their clinics. The WHO is recommending they first focus on adult males, even though the procedure is easier in babies, because it is most urgent to reduce infections in the sexually active age group.

It emphasises the importance of sensitivity, counselling and a lack of coercion when offering circumcision and that those who perform it are trained and perform the procedure in a hygienic setting. The WHO also wants donor governments to help fund programmes.

Dr de Cock said the meeting of experts that decided on the guidance disagreed on little, although "there are people who are very concerned that male circumcision has such heavy social and cultural connotations that they would want more data from the world of social science before making any recommendations".

Some spoke in terms of "symbolism and assault on the body's integrity", he said. But set against that was the weight of the disaster that Aids represented in Africa. "The thing to me that comes closest to the Aids epidemic for its assault on African culture is slavery," said Dr de Cock.

At a glance: Circumcision

Circumcision is almost as old as mankind. The first evidence of the ritual removal of all or part of the foreskin as a rite of puberty comes from aboriginal tribes around or before 10,000 BC, followed by communities in north-eastern Africa and the Arab peninsula some 4,000 years later.

The Jewish tradition of male circumcision dates back to the book of Genesis, part of the Torah, which told of God's command to Abraham that he should circumcise himself and his sons. Circumcision was considered a sign of the Covenant.

Jesus was circumcised, but St Paul ruled that converts to Christianity did not need to undergo the operation. In 570, Muhammad was born "already circumcised" which is said to have given rise to universal circumcision among Muslim men.

As the centuries moved on, arguments raged over circumcision. The foreskin was identified as the most sensitive part of the penis by the Italian anatomist Jacopo Berengario da Carpi in the 15th century. In the 1800s removal of the foreskin became widespread in Britain and the US to prevent boys masturbating. About a quarter to a third of the world's males are circumcised, most of them Muslim or American.

Sarah Boseley, health editor
Thursday March 29, 2007
The Guardian