Calling for RCI to learn from the Covid-19 pandemic

The MMR increased to a level unseen since the 1980s last year, indicating a decrease in the quality of healthcare for women. — Photos: Filepic

Covid-19 was Malaysia’s worst public health disaster, with the healthcare system on the verge of collapse on certain occasions.

The cumulative number of confirmed reported cases exceeded five million on Dec 4 (2022).

Malaysia’s global ranking for the cumulative number of confirmed cases rose from 89th position on Nov 18, 2020, to 27th on Dec 12 (2022).

The reported number of Covid-19 deaths in Malaysia was 36,713 on Dec 4 (2022).

The deaths per million population became the highest in Asean on Aug 31, 2021, and has stayed in the pole position since then.

On Dec 12 (2022), it exceeded that of Indonesia by 1.86 times, the Philippines by 1.93 times, Brunei by 2.16 times, Thailand by 2.33 times, Asia by 3.37 times, and the global average by 1.3 times.

According to the Statistics on Causes of Death, Malaysia, 2022, report released by the Statistics Department on Oct 27 (2022), Covid-19 overtook heart disease as the number one cause of deaths in 2021 (19.8% vs 13.7%).

Maternal deaths 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 an MMR was about four decades ago in the mid-1980s.

Maternal mortality is a vital measure of human and social development.

It is particularly revealing of women’s overall status, their access to healthcare, and the responsiveness of the healthcare system to their needs.

MMR not only identifies the risks associated with pregnancy and childbirth, but also with women’s health, and indirectly, their economic and social status.

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, to this report is worrying.

Ongoing impact

A confluence of several errors were the ingredients for the perfect Covid-19 storm Malaysia experienced from June to September 2021, with 23,539 deaths during this period.

These included:

• Insufficient testing and contact-tracing
• Insensitivity to the human resource issues of healthcare professionals
• Inadequate interactions with the private, university and non- governmental sectors
• No concerted attempt to address the non-communicable diseases that worsen Covid-19 infections
• Inadequate addressing of the squalid living conditions of migrant workers
• Some inconsistent and confusing standard operating procedures
• Non-compliance with SOPs by politicians
• Asynchronous, and even contradictory, risk communication
• Insufficient use of digital technology, and
• Insufficient genomic testing, with Malaysia’s genomic sequencing lower than other less developed Asean countries.

At the heart of these errors were political instability and poor leadership.

Covid-19 impacted many aspects of daily living, particularly health and healthcare.

For example, the Dewan Rakyat was informed on Sept 14, 2021, by the Health Ministry that its backlog of surgeries was estimated to be as high as 200,000.

It took more than a year to clear this backlog.

The long-term impact of the delays on illness/disability and death have yet to be quantified.

Reports of patients waiting in the red zone of an emergency department for days before admission were worrying, to say the least.

Global experiences from previous emergencies indicate that indirect illness/disability and death will probably exceed that of Covid-19 itself when the numbers are finally totalled up.

The two positive measures of Covid-19 were the vaccination coverage and the Greater Klang Valley Special Task Force, which brought the dire situation then under some control in about 10 weeks with aggressive coordinated public health and clinical measures.

There was political rhetoric about efforts to strengthen the national healthcare system, which has experienced underinvestment and been overworked for decades.

The rhetoric was reflected in a paltry increase in the previous Government’s allocation for the Health Ministry budget for 2023.

It took over a year to clear the backlog of surgeries caused by the Covid-19 pandemic.

More to come

There have been several epidemics and outbreaks in the first two decades of the 21st century globally.

Old diseases returned and new ones joined them.

The former included plague and poliomyelitis.

The latter included SARS (severe acute respiratory syndrome) in 2003, H1N1 influenza in 2009, MERS (Middle East respiratory syndrome) in 2012-2013, Ebola in 2014, Zika in 2015 and Covid-19 in 2020 to date.

These diseases have spread faster and further with wider impact.

Outbreaks that previously would have been localised can now become global very rapidly.

This was exemplified with Covid-19, which has killed more than 6.65 million people globally.

Although it is impossible to predict the nature of the disease(s) to come, its source or when it will start, the World Health Organization (WHO) has stated that “with a high degree of certainty, that when it comes, there will be (a) an initial delay in recognising it; (b) a serious impact on travel and trade; (c) a public reaction that includes anxiety, or even panic and confusion, and (d) this will be aided and abetted by media coverage”.

Many scientists and doctors have warned of future pandemics.

This was stated succinctly in the Richard Dimbleby lecture on Dec 5, 2021, by Dr Sarah Gilbert, professor of Vaccinology at Oxford University and inventor of the AstraZeneca Covid-19 vaccine.

She said: “This will not be the last time a virus threatens our lives and our livelihoods.

“The truth is, the next one could be worse.

“It could be more contagious, or more lethal, or both.

“We cannot allow a situation where we have gone through all we have gone through, and then find that the enormous economic losses we have sustained mean that there is still no funding for pandemic preparedness...

“Just as we invest in armed forces and intelligence and diplomacy to defend against wars, we must invest in people, research, manufacturing and institutions to defend against pandemics.”

Royal Commission of Inquiry

The primary lesson from Covid-19 was the massive impact of inequality and structural disadvantage on its course and outcome.

The chasms in Malaysia’s public healthcare system were laid bare by Covid-19.

Chronic underinvestment extracted, and is still extracting, a heavy price from the rakyat.

The nation’s roadmap cannot end with vaccination and “living with Covid-19”.

The impact of Covid-19 on related health and healthcare issues like long Covid, health inequity, healthcare workforce resilience, mental health, healthcare delivery reorientation, better ventilation in building design, etc, have to be addressed.

As such, there is a strong case for the establishment of a Royal Commission of Inquiry (RCI) to inquire into and report on the preparations and response to the Covid-19 pandemic, as well as to make recommendations on the strategies and solutions to strengthen the healthcare system so that it can be better prepared for the next public health emergency.

The RCI would have to determine what Covid-19 management measures worked and what did not.

The objective is to learn from the errors made and recommend solutions.

In meeting its objectives, the RCI would have consider any disparities evident in the impact of Covid-19 on different categories of people, the public health response and the response of the healthcare sector.

They would also have to listen to and consider carefully the experiences of bereaved families and others who have suffered consequential hardship or loss, as well as have reasonable regard to international comparisons.

Such a Commission should be chaired by a senior retired judge.

Its membership should include stakeholders like civil society and professionals.

To ensure public trust and to obviate politicisation, no current or retired politicians should be appointed to the RCI.

The RCI is not only an urgent imperative, but also critical for planning for the next outbreak or epidemic.

To postpone the RCI to a later date would deprive Malaysia the opportunity to put in place measures for the next public health emergency.

Towards this end, a timeframe, e.g. six to nine months, has to be put in place for the RCI to submit its report to the nation and Parliament.

We need to be willing to face unpalatable truths and change our mindset from being reactive to proactive.

Waiting for the next public health disaster to occur before further action is taken will be already be too late for many.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email [e-mail]. 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.