A Scottish surgeon observes healthcare delivery in Sarawak's interior

Prof Watson speaks with doctors at the Sarawak General Hospital at the beginning of his visit to Malaysia. — Photos: Prof Dr Angus Watson

You might not think it, but the rural regions of northern Scotland and the interiors of Sarawak share something in common.

According to consultant colorectal surgeon Professor Dr Angus Watson, both areas face challenges in terms of getting healthcare services as they are often isolated and difficult to get to.

The 53-year-old, who is attached to the University of Aberdeen and National Health Service (NHS) Highland in Scotland, shares: “One of the challenges that we have in the NHS back home is the difficulty in recruiting and retaining surgeons and medical staff to work in remote areas.

“For example, in my health area, there are four remote hospitals that are small and probably a similar size to Kapit (in Sarawak), but we cannot recruit surgeons to go and work there.”

Similarly, in Malaysia, it is difficult to place and retain doctors, especially senior ones, in remote clinics and hospitals in the rural and interior areas.

Prof Watson had the opportunity to experience firsthand how the healthcare system operates in Sarawak last year (2019).

As the inaugural recipient of the Tuanku Muhriz Fellowship in Rural Surgery from The Royal College of Surgeons of Edinburgh (RCSEd), he spent two weeks in Malaysia last September (2019).

The fellowship – named after RCSEd honorary fellow and Yang di-Pertuan Besar of Negri Sembilan Tuanku Muhriz Tuanku Munawir – allows RCSEd members based in the United Kingdom, to apply for an annual grant to travel to Malaysia to either train in or experience rural surgery.

Prof Watson’s aim was the latter, as he wanted to get to know our rural healthcare infrastructure and examine the similar challenges Malaysia’s and Scotland’s rural healthcare systems have.

From Kuching to Kapit

His journey, coordinated by Health Ministry officials and the RCSEd office in Kuala Lumpur, began in Kuching at the Sarawak General Hospital – the main tertiary and referral hospital in the state.

He says: “My Malaysian colleagues were keen that I have a real experience and they were keen that I saw the entire pathway from the interior out to Kuching (albeit from the other way around).”

He spent a day there, visiting the hospital wards and outpatient clinics, as well as hearing presentations by local surgeons on the challenges they face in delivering healthcare to their patients.

This was followed by a flight to Sibu and a visit with a similar itinerary to its hospital – the second largest one in Sarawak and the secondary referral hospital for eight district hospitals, including Hospital Kapit, in the central region of Sarawak.

“Then we got on this amazing boat – I’ve travelled all over the world and I’ve never seen anything like that – it’s long and thin, takes about 90 people and travels really fast.

“That was in Sibu, so it was three-and-a-half-hours up the Rajang River to Kapit,” says Prof Watson.

He adds: “You get a real flavour of what Borneo is like, in terms of the distances patients would have to travel to access healthcare – and there’s no complete road from Sibu to Kapit.

“So most patients, if they’re being transferred, will come down on the express boat, and they’ve got a very well worked-out system of transferring patients from Kapit down to Sibu.”

His destination was Hospital Kapit – a non-specialist district hospital.

“That was pretty interesting because it is principally run by medical officers (MOs) – fairly new doctors, who have done a couple of years’ foundation programme (housemanship) and are in their first two, three (and) four years of training.

“And I was impressed by the attitude and the standards – they were outstanding young people; honestly, I thought they were really good.

“They take on a lot of responsibility – and probably more responsibility than you would get in some hospitals in the United Kingdom.

“They really like the placing, because from a clinical point of view, they get a lot of experience,” he says.

Prof Watson was also interested in the assistant medical officers, a position he was seeing for the first time, as well as the available equipment at the hospital.

He also visited a large Klinik Kesihatan (Health Clinic) in Kapit, manned by nine MOs and headed by a family medicine specialist.

“That was great, just to see how well it was organised – the pharmacy, the consultations happening, the privacy that (patients) were offered – and the range of health benefits that were available.”

The Health Ministry boat that transported Prof Watson and the local healthcare team from Kapit to Mujong and to the longhouses where the team ran the monthly mobile health clinics.The Health Ministry boat that transported Prof Watson and the local healthcare team from Kapit to Mujong and to the longhouses where the team ran the monthly mobile health clinics.

Further into the interior

The next day, Prof Watson was taken further into the interior on a Health Ministry boat making its monthly healthcare visits to upriver villages.

Their first stop was Klinik Kesihatan Nanga Mujong, located about two hours’ boat ride from Kapit and staffed by two assistant medical officers and three nurses.

“I got an understanding of, again, how difficult it is (to transport patients), because the water in the Rajang was low and the boat had some difficult in going upriver because of the depth of the river,” he says.

He was impressed by the set-up of the clinic, which included a labour room, a breastfeeding room and an incubator.

The assistant medical officers also gave him a presentation of the work they did, the longhouses they served, and the patients they had transported to Hospital Kapit and how they did it.

Over the next couple of days, Prof Watson followed the ministry team to visit and run clinics at a handful of longhouses along the river, using the village of Mujong as their base.

“When we went to the longhouses, the Iban (residents) were just so welcoming and they really looking forward to the visit,” he shares.

He was interested to observe how the patients keep their own medical records and the longevity of some of the longhouse residents, one of whom was over a century old.

“Seeing that healthcare delivery, in the communal area of the longhouse, outside of their front doors, was fantastic,” he says.

The only snag was that the river was too low for them to travel upriver to longhouses near the border with Indonesia, as per the original plan.

Instead, they executed their back-up plan of visiting longhouses downriver in Ibau.

After that, Prof Watson retraced his path back to hazy Kuala Lumpur for engagement meetings with various healthcare leaders like the Health director-general, the Malaysian Armed Forces Health Service Division director and Mercy Malaysia president.

Some of the longhouse residents welcomed Prof Watson and the Health Ministry team with tuak, langkau and grilled wild boar.Some of the longhouse residents welcomed Prof Watson and the Health Ministry team with tuak, langkau and grilled wild boar.

An enjoyable experience

This was not Prof Watson’s first time in Malaysia. However, his previous visit provided quite a different experience.

“Before I did medicine, I was in the (British) army, I was in the Gurkha regiment (what is now known as the Royal Gurkha Rifles).

“My first experience in Malaysia was three months of jungle warfare (training) in Johor.

“It was fantastic to be able to come back 30-plus years later to Malaysia,” he says.

This time around, he was determined to explore our famous food.

“I think I’ve put on quite a bit of weight, because I fell into the Malaysian tradition of having a meeting and eating food.

“And I was determined to have a different Malaysian breakfast each morning,” he shares with a laugh.

His favourite? Roti canai goreng – a variant of roti canai that is a particular product of Kapit.

He also particularly enjoyed the after-hours spent with the clinic staff he stayed with in the clinic quarters.

“There was a lot of fun to be had – it felt like a real family. When we all ate together in the evening, there was a real feeling of camaraderie.

“And I honestly don’t believe that was for my benefit – that’s how they conduct themselves,” he says.

Overall, Prof Watson was impressed with his experience of how healthcare is delivered in the Sarawak interior.

“I guess what I wasn’t prepared for was how well-organised healthcare infrastructure is in the interior, and that was so impressive – I can’t overstate how impressed I was with the organisation.

“And I’m not just saying this, but I think the Health Ministry should be congratulated for doing that.

“If you think about it, how do you tie in a healthcare system with the Petronas Twin Towers in KL with quite a lot of money to a tribes person in the middle of the jungle whose only way to get out is on a boat?

“How do you create a healthcare system that fits?

“But it seems that that has been successfully done.

“Yes, it has challenges and things, but I think that’s pretty remarkable.”

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