H1N1 Flu: Onwards to Mitigation Phase...

Cumulative A(H1N1) flu cases topped 671 on 11 July 2009: 485 imported and 186 local transmissions. Thus far we've been lucky, there has been no deaths reported in Malaysia. Most of our patients have recovered completely, as detailed by the D-G of Health in NST: Influenza A (H1N1): Nearly all patients fully recovered.

Yet worldwide, the positively-tested H1N1 cases have exceeded 100,000. The WHO reports that some 105,304 cases (an increase of 1,374 cases overnight) with 463 deaths from 143 countries, have now been identified. Although not universally known, the fatality rate has maintained at a remarkably consistent 0.44% or 1 in 227, hardly changed from a month ago.

In the United Kingdom worries are now surfacing as more deaths (up to 14 as of 10 July 2009) from this supposedly benign form of flu have been reported. With 9700 reported cases now in the UK, some 335 people are still hospitalised with some 43 being in critical care. Thus, there are people who fall seriously ill, especially when they also have underlying health problems. With the fall or autumn approaching, there is fear that worse is yet to come.

At the G8 meeting in Italy, US president Barack Obama urged that Americans ramp up preparedness against the A(H1N1) influenza, warning that the virus could return with a vengeance in the fall, that "the potential for a significant outbreak in the fall is looming." He added that "we want to make sure that we are not promoting panic, but we are promting vigilance and preparedness" (AFP, July 10, 2009).

Specific vaccination would be the way to go, but the vaccine only recently developed, is yet to be fully tested for efficacy, but most health authorities believe that this would be the most effective and safe way to combat this community spread of the virus.

In a CrossTalk interview with the NST "Don't sensationalise H1N1 stories", I continue to maintain that we should remain at full vigilance and preparedness, and that what we have been doing thus far, is not alarmist but necessary under the current state of infection of the A(H1N1).

As we progress from containment to mitigation phase, we must urge every citizen to remain calm but responsible so that they can help prevent even greater local spread of the infection. Personal hygiene and even voluntary social distancing is still the prudent approach even if these are inconvenient or costly from a personal or even national perspective.

But we must observe our civic responsibilities and duty if we are to face this pandemic together and come out of this with as little scathing consequences as possible. Unfortunately, the full extent of this influenza outbreak is unlikely to abate anytime soon, with most authorities believing that it would be at least a year or two before this infection makes any meaningful decline to levels of normalcy...

Sunday Star 12 July 2009, highlights a comprehensive and balanced review by Dr Milton Lum (What is an appropriate response?) on the H1N1 pandemic and the difficulties involved in making the appropriate response to this virus in Malaysia.

Clearly no one will have the correct response and there will be detractors that we are either doing too much, or not enough. The uncertainties associated with this pandemic unfortunately have not abated, and might never be known until this pandemic blows over in the next few years... then, and only then will we be enlightened, in hindsight!

What then would the final human toll be? How would Malaysians have fared, and will there be recriminations of having done too little too late, to stem the more unwelcome outcomes? Or, would we then be accused to having alarmingly propagated another Y2K-like non-event?

I think most of us would have preferred that perhaps, we had been judiciously overcautious and that we had mitigated more deaths than would have had taken place otherwise. We'd preferred the inconvenience, the stringent preparedness, until the true benignity or malevolence of this H1N1 pandemic had blown over, even if these measures had cost us a little more, in terms of resources, personal space, and even hard-pressed financial outlay!

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Have Doctors Been Complicit in Driving Healthcare Cost?

“Doctors have been complicit in driving up health care costs. They need to become part of the solution.” ~ Editorial: Doctors & the Cost of Care, New York Times, 13 June, 2009

“The greatest threat to America’s fiscal health is not Social Security. It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.” ~ President Barack Obama, in a March 2009 speech at the White House.

“Medicine has become a pig trough here. We took a wrong turn when doctors stopped being doctors and became businessmen.” ~ Dr Lester Dyke, Cardiac Surgeon, McAllen, Texas


Healthcare Cost has Escalated
Last night, while I was having dinner with some friends, I was once again reminded that perhaps health care cost in Malaysia has escalated beyond the pale of inflation or affordability.

A close friend whose brother was suddenly taken ill with haemorrhagic fever was admitted into a Klang Valley hospital, where he developed complications one after another. He bled into the gut, and also into the brain, went into shock which also led to kidney failure. He was transfused profusely, had intensive critical care, required haemodialysis, and was consulted by at least 4 specialists including an internist, a nephrologist, a gastroenterologist and a neurosurgeon. Sadly, after 9 days of deteriorating multi-organ function, he died. And the bill exceeded an unexpected RM45,000.

That was the crux of the complaint—why was the bill so high, and was there any overcharging, and if not, were our doctors' billings too excessive, if not too exorbitant?

There was a suggestion that perhaps under such complex illness requiring multiple physician input and management, there could perhaps be more coordination, and perhaps an attenuated billing system of professional fees. The aggrieved family lamented that almost all the doctors charged the maximum complex fee for each visit, although, most of these visits appear cursory and lasted just a few minutes per time. The gentleman noted that some of the physicians did not simply consult with this one patient, but attended to a few others in the ICU at the same visit, so why had he charged so much?

To add fuel to the fire, when he complained to one of the hospital directors, he was told that nearly all the doctors had begun charging the highest rates ever since the new regulations came into being—putting squarely the blame on the Ministry of Health for including the fee schedule in the Private Healthcare Facilities and Services Regulations, in 2006. He further added that when the physicians first started practice at that hospital, they were all driving Protons, but now all have upgraded to expensive imported models!

Such fatuous unthinking comments can only contribute to unhappiness and feelings of possible overcharging in the minds of grieving relatives. These also underline the unspoken or misspoken envy that many hospital administrators harbour against many of our professional doctors, whom they perceive as perhaps earning too much!

This recent anecdote demonstrates the complex nature of the healthcare cost conundrum, not just in the USA, but closer home, in our own backyard as well.

Modern Medical Care is NOT Free Lunch
One sad fact which is misunderstood, is that healthcare is or should be readily affordable to everyone, including the least endowed. There is that public expectation that while life-saving care should be universally available, it should never be too costly, because this can potentially cause severe hardship to, or even bankrupt the victims of such unforeseen medical disasters.

But it is precisely these forms of catastrophic illnesses which are frightfully expensive; particularly when many high-tech measures have been engaged to try reverse or even to ameliorate deteriorating bodily functions.

Intensive care therapies with multiple organ support measures, including close monitoring and mechanical ventilation support, are very costly. Actual costs of using mechanical ventilation, oxygen therapy and supporting medications and close scrupulous monitoring, can easily rake up to RM3000 - RM5000 per day (excluding physician fees)!

Unfortunately again, this has not been made known to the public at large, because either some third party payer had been reimbursing thus far, or that many continue to assume that these therapies would be charged at rates equal to those at public hospitals.

Here is the conundrum: our public hospital charges are massively subsidised through our tax dollars! These are not free lunches, and cannot be transposed so easily into private settings, where every penny has to be counted and balanced!

Here too lies the failure of our government to address and expose the real cost of healthcare. We have been cross-subsidising healthcare costs for so long and offering our citizens' healthcare cost at such ludicrously low rates, that they have grown accustomed to these unrealistic levels.

Of the 12.9 billion ringgit government spending on health care, the public had paid only a miserly 2%, according to Health Minister Dato' Sri Liow. Thus, the public healthcare sector is 98% subsidised by our tax dollars!

Unfortunately too, our health insurance (private prepaid plans) take up is still notoriously low, with less than 15% (11.9 to 14.4%) of the private health care expenses being paid for by such means. Most private health care expenditure (73-75%) is still paid out of pocket!

Yet, most citizen and consumer groups are still clamouring for the continuity of such practices, believing that our poorer segments of society must never lose out to every 'reasonable' medical care whenever they need these. Just what is defined as 'reasonable' medical care remains to be agreed upon! Laudable as these social affirmative aspirations may be, they are seriously flawed, when we have an unapologetic proclivity to an undisguised market-driven economic model.

Until and unless this economic model changes, there is little hope for some semblance of balance in health care considerations. Hence, the reality bites are such that some form of rationing and queuing must accompany every possible healthcare system where we have finite resources, but infinite needs!

We simply cannot afford to offer every possible technologically-advanced therapy to everyone on demand! Or even on need! Someone has to pay for this, and even though most nations in the world claim to have some form of universal access to healthcare, none can ever offer every possible medical care to anyone, everyone, on demand, every time!

We simply have to understand that while we can strive toward some form of universal access to healthcare, we also have to accept that some degree of delay, queuing, even rationing based on cost-effectiveness and affordability will have to be made by some medical authority or health economist.

Our public must be made to understand that that is the social contract for cheaper or hugely subsidised healthcare—that some form of delay is inevitable and that everyone needs to be patient and trust that the system would be fair in its distribution of the healthcare largesse.

Others who choose to deviate from the common pool will invariably have to pay more, and perhaps in an unfair manner, may demand some quicker access, some queue jumping or even some more heroic therapeutic measures, which on economic grounds might not have been justifiable, without the extra infusion of cold hard cash!

Fair for some isn't fair for all. But such is the power of capital and greater funding... It does not pretend to be socialist or utopian in equitable distribution.

Modern Advances demand Greater Utilisation, hence Higher Costs
Modern advances in measures to keep patients alive or support their recovery, are often accompanied by extremely expensive techniques and medications. Sadly, the availability of these new advances have led to increased demand and utilisation, rightly or wrongly!

There has always been this tendency by health workers and doctors to use more devices, more tests, more new therapies simply because these are available. Increasingly, informed IT-savvy patients are now also demanding more that should be done, even with fringe or outside chance benefits!

Thus, inadvertently, doctors and demanding patients alike contribute toward this increased cost by utilising more resources.

Do these necessarily improve survival or save lives? Often this is difficult to calculate with certainty, although on the individual basis, most doctors would swear by their efficacy and cost-efficiencies—each life saved or improved, is nevertheless one more life salvaged—whatever the costs!

The reality is that we cannot afford this on a universal scale! So we will have to re-look into this system gone awry. We have to re-tweak the system to ensure that it does not self-destruct from institutional collapse!

With regards to the above unfortunate patient though, it is regrettable that he did not survive despite the heroic measures that were attempted to sustain him. But, were the costs justified? That is another question, which many doctors have to consider and contemplate more and more. We have to decide how much to do, to refer, to test, to treat, or to let go, on some of these difficult professional actions.

Should we now have to consider the economic angle early, even as we struggle our level best to salvage a critically-ill, even terminally-ill or futile patient, without being accused of despondent incompetence?

How much do we need to temper our increasing dependence on and utilisation of newer and newfangled devices and measures to artificially support failing bodily functions? Is the cost of terminal or futile care justifiable even if there was just that very slim glimmer of hope?

And finally, do we as physicians need to charge at our extreme limits just because these patients are difficult and complex to manage, although our actual consulting moments with our patients appear so transient, sometimes cursory, sometimes callous, to their loved ones looking in?

Do we need to educate our patients and their relatives that the medical consult is not simply that few minutes of coming by the patient, that cursory examining of their pulse, or BP, or a quick scan of the charts?

Should we inform them that deep within our buzzing minds, we are always contemplating, making algorithmic decisions and choices, interrogating test results and assimilating previously learnt knowledge, past training experiences and newer information, even as we just sidle past our bed-ridden patients and auscultate their chest, or palpate their abdomen, out of dispassionate automatism rather than unfeigned examination?

Must we indeed demand and earn our professional fee that we feel we are entitled to, rather than out of duty and compassion...? Are we guilty of contributing toward the skyrocketing healthcare costs, and shouldn't we perhaps learn to temper this relentless trend?

How much can we value our professional skills in terms of monetary equivalence—how much do we cost our services, and to which level are we willing to take this inchoate economic appraisal as an increasingly specific service commodity?

How can we temper our economic worth vis-a-vis our vaunted altruistic benevolent vocation, our professionalism in a consumerist market-driven economy? When is enough, enough?

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Subsidy Woes, more than meets the eye...

See Malaysiakini Subsidy Woes...

Economics-trained or free-market-inclined Malaysians are now speaking out loud, that we should accept the fact that subsidies are no longer tenable in today's globalised economy.

One recurring theme emerges: Market prices should dictate 'real prices' of goods and services as if the entire world is on par with each other, and the playing field is level the world over.

Thomas Friedman's The World is Flat dictum appears to influence everyman's idea of where the world is now and especially where it should be heading: "that globalization has leveled the competitive playing fields between industrial and emerging market countries."

But not everyone agrees that this perspective accurately reflects the situation on the ground. In the real world, perhaps some 80-90% of the world's people remain outside the reach and access of globalised markets and benefits (Why the World isn't Flat)

Professor Pankaj Ghemawat argues in Foreign Policy, Mar/Apr 2007, that more than 90% of all business worldwide are local affairs, where regional, investment and niche factors continue to dominate and exert great economic impacts.

But the 'reality bites' so forcefully enunciated by new-age economists are less sanguine and less certain for its unequal and asymmetric effects on the widely divergent and disparate economies around the world - invariably worse for poorer, less developed nations.

It is true that whenever governments try to apply 'unrealistic' protectionist methods to cushion local economies, (by price controls or artificial suppression on certain goods and services), these may in the longer term be harder to equilibrate when markets are forcefully pried open due to shocks such as the current oil price crunch. (It's worthwhile reminding ourselves that in 1990s, a barrel of oil was selling at US$10-20; in 2006 US$70; and today June 2008 we're at US$135 per barrel! See BBC's Why the oil price keep rising)

Supply chain mechanisms so long entrenched in our modern economic structure, have also undervalued many commodities such as grains (rice, corn or wheat), greens, fruits, etc.

Thus far, the brawn of being a farmer and/or grower has had unequal, artificially constrained but lesser benefits when compared with the downstream supplier, processor and/or distributor.

Then we have market speculators who disproportionately live off the paper or electronic gambles of artificial prices and guessworks, who profit at 'unreal' excesses, at the drop of a phone call, an email, an sms, or a wave of the hand!

Such inequitable distribution of economic benefits have led to great distortions and disparity of wealth. While most people welcome the much-touted 'trickle-down' effects, this mechanism tends to find its equilibrium at snail's pace. Completely free-market forces work by uplifting the lowest strata of society in staggeringly slow steps, whilst creating a smaller but hugely enriched upper class, a new bourgeoisie through near-instantaneous windfalls.

In Malaysia, to be fair, we have less of such a chasm of wealth disparity, although pockets of shameful indigence and poverty can be found in marginalised segments in inner city slums, suburban TOLs, hardcore rural communities, and some itinerant indigenous peoples.

More a problem would be that huge middle-to-low-income segments which embody a probable three-quarters of our population - these people are neither here nor there... Needless to say, these people will be hardest hit, when their bread-and-butter issues are put at serious jeopardy.

Because of our aggressive stance at luring Foreign Direct Investments (FDIs) with low-wages and tax-exempt pioneer statuses, many of our workers are paid artificially-suppressed salaries - hence their income has remained low. (For years, The Economist's Big Mac Index frequently attest to the fact that Malaysians are paying relatively cheaply for a similar priced Big Mac elsewhere.) To cushion this, we have introduced subsidies which are needed to price-control a basket of commodities, so that these remain affordable to the low earning power of the general populace!

Now we are told to buck up and face up to the facts - no more subsidies! We are expected to sustain our lifestyle with the relatively low wages that had for so long been thrust upon us, in the name of competitiveness for foreign funds and investments. Our workers have been denied minimum wage negotiations, and many industries are deprived of the bargaining power of trade unions!

On top of this, our Ringgit (Malaysian currency) has been protected from finding its true value, and we lag behind many regional currencies - our money is quite small! And we do this because, we wish for our exported goods to remain competitive...

Thus, our purchasing power has been severely curtailed when one wanders into the real globalised world out there - we have to pay so much more in real terms for goods outside this country. This is extremely onerous when one is a lowly-paid Malaysian worker.

So it is extremely unfair to now ask of Malaysians to tighten our belts and be more prudent! I don't believe the rakyat has been profligate or spendthrift, most of us just don't earn enough!

Then, we also have these ridiculously expensive prices of cars and road taxes. Whatever the arguments for discouraging outflow of local funds for foreign goods, we are simply paying too exorbitant a price.

For most Malaysians, owning a car is a necessity and not a luxury! Imagine that many cars are now hire-purchased upwards to 9 years! Imagine the interests one has to cough up, the loss of discretionary spending power for more productive purposes rather than just servicing unending loans. Painfully count the numbers - of wasted funds, which are a form of individual tax, the benefits of which elude us.

Of course, one can also argue for greater utilisation of local public transport, but these have always been the most inconsistent and arguably the worst managed public service! One spends hours in erratic, uncomfortable, crammed spaces, which once again makes the task of getting to and from work all the more wasteful in terms of loss of time, energy and productivity!

Our houses are also high-priced with relatively few people actually owning their own homes - some housing loans now stretch into 30 years and beyond, with some lenders introducing loan carry-forwards to the next generation! How sick and cynical to imagine that we pass on our debts into the new generation!

So how can the average rakyat cope especially now with further inevitable increases in costs for almost everything else on top of fuel, gas, food, etc? The authorities must find alternative measures to soften the blow of its most painful and inconsiderate fuel price hike in Malaysian history. It must take cognizance of all these real-life facts and how it is impacting the common people, and not argue Keynesian economic niceties for a beleaguered populace!

One must read the arrogant and insensitive editorial in yesterday's NST to understand the warped psyche of our MSM and its cloistered masters: "... after decades of mollycoddling with some of the world's highest fuel subsidies and lowest pump prices, the spoilt Malaysian consumer had no way to anticipate what it would feel like actually to have the candy snatched from the cradle... Enough of such mewling. This country has for too long carried too great a burden in its paternalistic protection of consumers, encouraging profligate consumption in blase indifference to real costs -- and can hardly be said to have received any lasting appreciation for that in return, witness the present administration's continuing travails in the wake of its mauling in the general election... this is the shock of recognition that runs the circle round: the anaesthesia of artificially low fuel and power prices had made a fools' paradise of life in this country. Now here's the wake-up call."

Such paternalistic scolding and the crass reference to vengeance against a populace which had not appreciated and thus rejected the previous administration at the last election, is truly uncalled for and shameful! It's no wonder that more and more Malaysians believe that the authorities and the mainstream media (MSM) have loss their bearings and are totally out of touch with the rakyat. Will they never learn?

But perhaps, there's more than meets the eye. I have heard quiet musings that our country coffers may be drying up. That despite our healthy trade surpluses month on month, we might be facing a credit crunch soon. Some business and economist friends have calculated that despite all the pump-priming from Petronas Ringgit diversions, we are now running out of bail-out money.

By refusing IMF and World Bank intervention and dictates during the 1997-8 financial crisis, the then government had pushed for and relied on internal funding on several mega-projects to sustain the appearance of a healthier than actual economy. It is believed that tens of billions of ringgit have been pumped into the Putrajaya and KLIA projects - now the chicken has come home to roost.

Some remembered that several Malaysian Sovereign Wealth Bonds have been sold at very attractive interest rates, and may now be at the verge of maturing - so, the reality of having to come true on our promises is near, unless we forfeit our goodwill and solvency! Perhaps these are the real reasons why we cannot sustain the subsidies, we are simply running on empty.

How is it we have not utilised our Petro-dollars or ringgit for better more prudent iron-clad funds for the future is a question that has to be addressed. Dr M Bakri Musa has lamented the fact that we have not had a Malaysian Petroleum Heritage Fund, to help safeguard our future and that of our next generations.

During the Agong's Birthday address, Baginda Yang Di Pertuan Agong Tuanku Mizan said "I was concerned when informed that by 2011, the nation's petroleum imports would be much higher than its exports. I am of the opinion that it would be an injustice if we were to completely extract and enjoy the benefits without leaving anything at all for future generations." Tuanku Mizan further noted that the nation's petroleum resources should be managed efficiently so that the nation's wealth could be inherited and enjoyed by future generations. We all echo His Majesty's wise call and heart-felt concern.

Malaysians can expect no less than a true and transparent accounting of the state of our nation's coffers - our future may hinge on this precarious crisis.