The year 2022 saw Malaysia recovering from the devastation of the Covid-19 pandemic in 2021, with floods and the Batang Kali landslide providing unfortunate finales to the year.
Lives were lost in the landslide and floods, with thousands also made homeless by the latter.
Covid-19 was Malaysia’s worst public health disaster to date.
The cumulative number of confirmed reported cases exceeded five million with 36,713 reported Covid-19 deaths last Dec 4 (2022).
Malaysia’s global ranking in the cumulative number of confirmed cases rose from 89th position on Nov 18, 2020, to 27th position at the end of 2022.
The deaths per million of the Malaysian population became the highest in Asean on Aug 31, 2021, and has stayed in the pole position since then.
Covid-19 overtook heart disease as the number one cause of deaths in 2021.
Maternal deaths also doubled from 117 in 2020 to 300 in 2021.
The maternal mortality ratio (MMR), which is the number of maternal deaths divided by the number of live births in the same year, increased by 2.75 times from 24.8 per 100,000 live births in 2020, to 68.2 per 100,000 live births in 2021.
The last occasion Malaysia had such a high MMR was about four decades ago in the mid-1980s.
The 2021 MMR was an indictment of the Malaysian healthcare system – it failed many pregnant women.
The lack of response from the Government, particularly the health authorities, is worrying.
Twin- and tripledemics
Continuing mutations of the SARS-CoV-2 virus will carry on impacting countries and people globally.
There has been a resurgence of influenza in many countries since late last year.
In some countries, respiratory syncytial virus (RSV) infections in children have surged.
Together with Covid-19 in the background, this has led to fears among medical experts that the collision of influenza, RSV and Covid-19 could lead to a potential “tripledemic”.
While there is no scientific definition of this term, there are already reports that hospitals in many countries have been overwhelmed.
While the three viruses are present and circulating now, the number of affected patients are not peaking at the same time.
Will the “tripledemic” or “twindemic” (Covid-19 and influenza), occur in Malaysia?
Only the cavalier would discount this likelihood.
What will be its impact on the healthcare system, which teetered on the verge of collapse in 2021?
The China effect
China has dismantled many of its strict zero Covid-19 policies in the last couple of months.
It has ceased mass lockdown of entire cities, restrictions on travel within and between regions, and allowed those infected with Covid-19 to isolate at home instead of in centralised facilities.
Because of its earlier policies, a significant proportion of China’s population has no immunity to Covid-19, whether from infection or through vaccination.
What will be impact of the SARS-CoV-2 Omicron viral variant in China?
Will Omicron behave like it did globally, i.e. more transmissible, but less severe than older variants?
Or will it behave differently in China?
What is certain is that with more infections, newer variants may emerge, and China will spend 2023 catching up with the rest of the world in terms of infections.
One scientific model, using 2022 data from Hong Kong and Shanghai, predicts that there will be about a million Covid-19 deaths in China in the next few months.
Another scientific model predicts that the Covid-19 death toll in China will be about half a million by April (2023) and 1.6 million by the end of the year (2023) if the country continues on its current path.
Will there be an impact of the increase in China’s Covid-19 cases on Malaysia, and if so, how?
Knowledge of Long Covid – a condition with myriad clinical features – is incomplete.
A review of 194 studies involving 735,006 participants published in The Lancet journal last Dec 1 (2022), reported that “45% of Covid-19 survivors, regardless of hospitalisation status, were experiencing a range of unresolved symptoms at four months”.
If that is extrapolated to Malaysia, it would involve about 2.25 million reported cases, with higher actual numbers because of under-reporting.
Could long Covid be the next public health disaster in Malaysia?
This year (2023) could be the year the world, except for China, figures out how to finally live with Covid-19.
Any prediction that Covid-19 will end in 2023 is not only premature, but naive, as the only thing predictable about Covid 19 is its unpredictability.
Other conditions of concern
The incidence of non-communicable diseases (NCD) will continue to rise, with increasing undiagnosed and uncontrolled numbers, because of the lack of coordinated control measures.
The dengue spike in 2022 will continue to take its toll in 2023.
This will impact on long Covid and NCDs, and their complications; and also strain service delivery in the underinvested, overworked and crowded public healthcare system.
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The spill-on effect from backlogged surgeries due to the movement control order, together with undiagnosed (and thus, untreated) NCDs, will inevitably lead to premature and excess illness/disability and death.
Unfortunately, such data are unavailable in the public domain.
Public trust and health policies
Healthcare will be increasingly provided by non-health sectors with technological tools, e.g. online purchases of drugs and medical devices.
The Health Ministry’s budgetary allocations cannot assure improved patient safety and quality care unless wastages, inefficiencies and the role of middlemen are reduced markedly, and there is an open and just culture within the ministry.
As long as health policies are formulated without genuine consultation with stakeholders, success will be limited or absent.
Public trust will continue to wane for reasons that include:
- Poor risk communication
- Poor or non-compliance to standard operating procedures
- Failure of authorities to engage meaningfully with the private sector, universities and civil society
- Misuse and abuse of social media
- Lack of transparency, and
- Poorly considered health and healthcare measures.
At a tipping point, the pressure for change will be unstoppable and the government of the day will have to oblige.
Increasing healthcare expenditure
Healthcare expenditure and medical inflation will continue to rise because of our ageing population, NCDs, long Covid, other infectious diseases, new technologies, increasing patient demands, and unrestrained middlemen in healthcare.
Increasing out-of-pocket expenditures in the private and public sectors will lead to more families facing financial ruin if they or their relatives get catastrophic diseases, e.g. cancer, heart attack, stroke and Covid-19, or are made redundant.
More private general practitioner (GP) clinics, and even hospitals, will close, because of financial unsustainability, healthcare staff burnout and stringent implementation of regulatory requirements.
Medical unemployment and disgruntlement will continue with the issue of contract doctors yet to be adequately addressed.
The best and brightest will seek employment abroad as Malaysia is one of the few countries that trains doctors at public expense for other countries.
The Health Ministry’s response to the public disclosure by Universiti Malaya’s previous Faculty of Medicine dean that about 30 of its best and brightest are lost to Singapore annually, was, to say the least, pathetic.
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With such attitudes, how can there be solutions to junior doctors’ plight?
There will be mergers, acquisitions and closures of some private medical schools because of financial unsustainability and reducing demand.
The minimal involvement of GPs in the management of NCDs in public sector patients will impact negatively on population health and the risks of Covid-19, other infectious diseases and NCDs themselves.
New technologies, e.g. portable and individual diagnostics, smart drug delivery mechanisms, genome sequencing, machine learning, artificial intelligence etc, will increasingly impact on healthcare.
Messenger ribonucleic acid (mRNA) technology ameliorated the Covid-19 pandemic significantly by preventing 12.2 million deaths in developed countries between Dec 8, 2020, to Dec 31, 2021.
Its potential for vaccine development for other diseases is being increasingly exploited.
Issues of patient confidentiality, security and safety, as well as the successes and failures of the new technologies, will be problematic.
New technologies are just tools.
Discrimination and careful evaluation are critical for humane healthcare and not technological exuberance.
So, will healthcare improve in 2023?
Covid-19 and the floods exposed numerous examples of irresponsibility, unaccountability and incompetence that were underpinned by arrogance and poor insight.
The 15th General Election led to a new government with the major coalitions having health and healthcare in their manifestos.
Will there be substantial changes in health and healthcare management?
Or will 2023 be a year of reckoning for the healthcare system?
Healthcare is avoidable by staying healthy.
A healthy diet, maintaining an appropriate weight, regular exercise, sufficient rest, safe sexual practices, avoiding tobacco smoking, moderate alcohol consumption and keeping vaccinations current are necessary.
This requires effort, smart lifestyle choices and the occasional medical check-up.
Long Covid and other health risks can be minimised by being responsible individually and getting vaccinated.
Wishing all readers good health in 2023.
Take care and stay safe.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email [email protected]. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.