Malaysian healthcare had a tumultuous 2023

According to local data, ecigarette use among teenagers has increased in the past four years. — Filepic

The World Health Organization (WHO) declared the end of the Covid-19 pandemic on May 5, 2023.

Although there was a downward trend in the reported number of Covid-19 cases and deaths since late 2022 in Malaysia, the country had the highest number of reported deaths per capita from Covid-19 in Asean.

Globally, health systems recovered from Covid-19 in 2023.

Deferred treatments and surgeries during the pandemic exacted a toll from those affected.

Although healthcare professionals stated that it was no different in Malaysia, no published data was available.

This year marked another tumultuous one in Malaysian healthcare.

Some key issues are discussed below.

Nicotine addiction

Nicotine from tobacco smoke releases dopamine in the same regions of the brain as other addictive drugs like opioids and cocaine.

It causes mood changes that make the smoker feel good temporarily.

Inhaled tobacco smoke delivers nicotine to the brain within 20 seconds, which makes it very addictive.

With tobacco cessation, nicotine levels in the brain decreases triggering processes that cause cycles of cravings and urges that maintains addiction.

Long-term brain changes from continued nicotine exposure leads to nicotine dependence.

Nicotine addiction is one of the easiest addictions to develop, can develop quickly and one of the most difficult to be rid of.

Attempts at smoking cessation cause withdrawal symptoms which are relieved with renewed tobacco use.

The author Mark Twain stated aptly “Giving up smoking is the easiest thing in the world. I know because I’ve done it thousands of times.”

Habitual use of tobacco and tobacco products remain a significant contributor to global health problems.

We spend billions annually treating smoking-related illnesses such as lung cancer. — 123rf.com

This is related to the easy availability of tobacco and nicotine products, increasing affordability and marketing strategies that increasingly use social media to reach the public.

The most recent data on smoking prevalence in Malaysia was 21.3% i.e. four in 10 males aged 15 and above smoke.

Ecigarettes with nicotine (vaping) was developed to help smokers quit tobacco smoking.

Like opioids used in pain relief, ecigarettes have been misused and abused.

Ecigarette use in Malaysians aged 13-17 years increased from 9.8% in 2017 to 14.9% in 2022.

The most significant event in 2023 was nicotine delisting from the Poisons List on April 1, which was a monumental bungle by the then Health Minister.

The bungle opened the floodgates to advertising, promotion and sales of nicotine products; entry of tobacco companies to the vaping market; and most importantly, legalised sales to everyone including minors below 18 years.

Entrepreneurs responded to the nicotine delisting by holding the DKECE International E-cigarettes Exhibitions Vape Show on May 13, 2023, with active participation of young people.

The then Health Minister stated in court filings that she had the right to ignore the Poisons Board recommendation not to delist nicotine.

This was the first occasion in my senior doctor's memory when a Health Minister ignored professional advice.

Non-governmental organisations committed to reducing the morbidity and mortality of nicotine addiction sued the then Health Minister – another first.

That this was embarrassing would be putting it mildly.

Control of Smoking Products for Public Health Bill 2023

The above Bill was passed by both Houses of Parliament last month with the proposed generational ban on smoking and vaping excluded.

In the fractious debate in the Dewan Rakyat, the tobacco industry’s interference in public health policy was highlighted.

It is pertinent to note that Malaysia’s score in the Global Tobacco Industry Interference Index of the Global Centre for Good Governance in Tobacco Control was 75 in 2023 compared to 66 in 2021 – a higher score was indicative of a higher level of industry interference.

This is the ninth worst score among the 10-member Asean countries.

The Bill omitted “smoking devices”.

Parliament was informed that safety standards of these devices would be regulated by the Domestic Trade and Cost of Living Ministry, and manufacturing by the Ministry of Investment, Trade and Industry, which poses a conundrum.

Will inter-ministerial coordination be robust enough for effective prevention and control of nicotine addiction?

In the Bill, there was reduction of the fines and removal of custodial penalty from that in the Control of Tobacco Product Regulations 2004 (under Food Act 1983).

Malaysia reportedly spends an estimated RM16 billion annually treating smoking-related illnesses e.g. cardiovascular disease and lung cancer.

The revenue from cigarettes and vapes is reported to be an estimated RM1.2 billion.

The Health Ministry’s vision envisages Malaysia will be a tobacco free nation by 2040 i.e. smoking prevalence of less than 5%.

Will the Control of Smoking Products for Public Health Bill 2023 be fit for purpose?

This depends on the regulations promulgated and its enforcement as well as coordination with other ministries.

Only time will tell.

Junior doctors

These young doctors comprise the backbone of the medical workforce in public healthcare facilities and transfers have been the norm in the public sector for decades.

During the Covid-19 pandemic, junior doctors encountered challenging personal and professional conditions like long working hours in personal protective equipment (PPE); trying to protect themselves and their families from potential illness; adapting to new ways of working; training opportunities replaced by service provision and examination postponements; and some even lost their lives.

Yet the sacrifices of the junior doctors during the pandemic were forgotten.

During the Covid-19 pandemic, junior doctors encountered challenging personal and professional conditions such as long working hours. — Filepic

The transfer exercises in 2023 were chaotic due to factors that included poor coordination and communication between Putrajaya and healthcare facilities; ignorance of healthcare facilities needs and requests; and an insensitivity to the needs of the junior doctors.

Furthermore, contract doctors were directed by the Health Ministry to resign when appointed to permanent posts.

This process reportedly prevented reimbursement for work transfers and affected salary grades and promotion.

Reports of bullying, burnout and non-transparent criteria for specialist training also added to junior doctors’ woes.

Was this approach in consonance with the government’s Madani framework?

Health White Paper (HWP)

When the HWP was adopted by Parliament in June 2023, notwithstanding its shortcomings, many were hopeful of changes.

After all, all parties in the government had made promises on healthcare in their election manifestos.

Since then, there have been no announcements, particularly on the governance mechanisms for the implementation and monitoring organisations in the HWP.

Steps to address the HWP’s shortcomings have yet to be initiated; instead, the HWP hype has been replaced by a whimper.

Covid-19 highlighted the times when the Malaysian health system verged on collapse.

If the government has not learnt from this near-miss and starts implementing the HWP, there may not be another chance when the next outbreak comes along.

Is there political will and leadership to act on the HWP?

Summary

Nicotine delisting from the Poisons List was the primary event that was deleterious to Malaysians’ health.

Unlike Covid-19’s acute effects, the effects of nicotine delisting would not be obvious immediately but in the medium to long-term.

This bungle was mitigated somewhat by the Control of Smoking Products for Public Health Bill and the HWP which offered hope but no action, to date.

In short, 2023 was another annus horribilis for Malaysian healthcare.

What will 2024 bring?

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.