Chapter 6: People: Our Most Precious Asset (Cont’d)
Keeping Malaysians Healthy
The third element to a productive populace would be health. It is widely assumed that Westerners are healthy because of their superior medical care. Wrong! Yes, they have superb hospitals and doctors, but that is not the primary reason. In fact there is very little correlation between expenditures on healthcare and the outcome.
With economic development Westerners could afford better nutrition, clothing, and housing; these contribute greatly to good health. Civil engineering marvels as water and sewer treatment, and public health measures like immunizations and stringent food hygiene contribute more to good health than hospitals and doctors. Even the availability of electricity improves health through better food refrigeration. Better engineering and modern financing like long-term mortgages make homes affordable. In Northern Canada, pneumonia in the young was reduced dramatically not through the availability of antibiotics or pediatricians but through better-designed homes with vestibules to the front door and double-paned windows to reduce the cold draft. Even the simple invention of soap contributed greatly to enhancing personal health.
The major factors contributing to morbidity and mortality in the developed world are lifestyles: smoking, alcohol, overeating, and lack of exercise. Physicians and modern medicine cannot do much to resolve those problems except to repair the inflicted damages. In the developing world, the leading causes of death and disability are trauma (from wars and accidents), infectious diseases (AIDS and malaria stand out), and under- and malnutrition. Modern medicine has only a minor role in preventing and alleviating such scourges.
Central sewers and water treatment plants are expensive but there are cheaper substitutes suitable for rural areas. The UN has designed a simple latrine that could be sold with subsidy if need be. The resultant improvement in health and thus productivity (fewer flies and worms, reduced enteric diseases) would more than recoup the investments. Similarly, the government could build in each village a deep well and a simple filtering system, as in Bangladesh.
Paul O’Neill related his moment of epiphany while visiting Uganda as US Treasury Secretary. He was distressed to see so many children suffering from diarrhea because of contaminated water. It was wrenching. He quickly inquired on how much it would cost to build a deep well and lay the pipes. Only a few hundred dollars! He then asked how many such villages there were and quickly calculated the total costs. To his amazement, it was only a few million dollars. Imagine the improvement in the well being of the nation for that modest investment.
The Ugandan official then gently reminded O’Neill that only a few years earlier an American-funded study estimated that it would cost $2 billion to supply the country with potable water. Stunned by the bloated estimate, O’Neill asked to see the plans. Sure enough, the facility was designed to the specifications of Cleveland, Ohio, not for a poor country. Thus it included expensive and unnecessary environmental impact studies as well as high-cost maintenance.28 Sometimes by thinking small and cheap, one can achieve much more, or even great things. Many foreign aids programs funded by such august bodies as the World Bank suffer from such massive leakages as well as through corruption.29
Malaria, which still plagues the Third World, used to be common in the California delta. By building levees, malaria is now no longer a threat. The intended purpose was not to control malaria but to reclaim fertile farmland and control floods, but the effect was to direct the water into swift channels where the mosquitoes could not breed. The economic benefits doubled: more fertile farmland and a healthier population.
Another example would be improved highway engineering like divided freeways, medians, cloverleaf intersections, and clear signs that help reduce accidents. Malaysian highways may rank with those of the West, but only superficially. I have never seen a police patrol car even during peak times, and because of that, the road is filled with dangerously overloaded trucks and buses rushing at frightening speed. There are no highway safety checks; heavy vehicles with worn tires and unsafe brakes have free rein. The tragic part is that the lives maimed and destroyed on these highways are those previously healthy and productive.
Even new diseases like the bird flu and Nipah virus meningitis are best tackled through better engineering and public health measures. Saskatchewan, Canada, produces more hogs than Malaysia. As they are raised under stringent hygienic conditions with better control of the waste, the animals are healthier and pose less of a health hazard to themselves and their handlers, and ultimately the public. There is also considerably less pollution. The Negri Sembilan coast is polluted because of hog farming along the Linggi River; this was also where the Nipah virus outbreak occurred a few years ago.
Avian flu is another major threat. Comparing a poultry farm in China with that in California would readily demonstrate why the disease started there and not in California.
The solutions to the major threats on health and lives lay for the most part outside the purview of medicine. The Works and Transport Ministries as well as the Police Force have more to contribute than the Health Ministry. I do not belittle the contributions of modern medicine. Today a patient with acute appendicitis has every expectation to be cured and out of hospital to resume his normal life in a matter of days. In the developing world, many still die of such readily treated maladies.
Many associate the miracles of modern medicine with such spectacular and expensive interventions like heart transplants. On the contrary, the true miracles are much less heralded, cheap, and taken for granted, like polio vaccines. Even relatively expensive vaccines (Hepatitis B) are still very cost effective. These proven basic public health measures should be provided to all even if they involve heavy subsidies. In reality they are not subsidies rather investments in our human capital, and a very profitable one at that. Besides, it is the right thing to do.
Many blame modern technology for the escalating costs of today’s medical care. Again this is a myth. The really true advances like polio vaccine are actually quite cheap. Expensive items like heart transplants are what Lewis Thomas called “halfway technologies.” He gave the example of polio. In the 1950s many polio victims were kept alive through expensive iron-lung machines. Similarly there were expensive and tedious operations aimed at strengthening the extremities damaged by the disease. Those were all “halfway technologies.” The real advance came with fully understanding the nature of the virus causing the disease, and with that the discovery of the vaccine. That is the real technological advance.
The distinguished economist Ungku Aziz, whose insight on rural poverty is unmatched, attributes the backwardness (mental and physical) of rural youths to their inadequate nutrition and chronic parasitic infestations. He astutely observed that even today rural Malays are shorter and smaller than their urban counterparts. Similarly today’s Asian children are taller and heavier than those of the immediate postwar period, reflecting their better nutrition. Genetics cannot explain such quick changes.
If such physical attributes could be readily improved within a generation through better nutrition and public facilities, imagine what could be done to enhance intellectual development.
Providing school meals is one effective way to improve the nutrition of rural children. America is doing this in its inner schools. To solve the high dropout rates, some economists suggest paying parents to keep their children in schools, as with the Progressa program in Latin America.30 Malaysia should do both. As for worm infestations (common among rural children and contribute to their listlessness), providing WHO-designed latrines would be far more effective than regular de-worming. I am against resorting to drugs as the first line of attack. When I was young, my parents insisted that I use wooden sandals that cost pennies. That is the cheapest, safest and most effective preventive measure; it beats regular de-worming hands (or pants!) down.
Another neglected aspect of public health is child and maternal care. Again, you do not need high-priced doctors to achieve this. Midwives, public health nurses, and dental hygienists could be trained at a fraction of the time and cost. The benefits to the citizens would be immense. Malaysia has been cited by the World Bank as a model for successfully investing in maternal health. This was the initiative of Tan Sri Majid Ismail, the Director-General of Health in the 1970s. Remarkable considering that he was an orthopedic surgeon, not a pubic health expert. Every village now has a modern-trained midwife; they are the unsung heroes of Malaysia’s remarkable improvement in maternal health. The prenatal environment is crucial in the development of the fetus, and of the baby.
Poor dental hygiene also contributes to ill health. Junk food, candies, and not brushing teeth are factors; another is the lack of water fluoridation. This can be overcome with supplements. When I was in primary school, there were regular visits by the dental nurse who would instruct us on basic dental hygiene as well as taking care of simple problems.
We lament the poor performances of rural pupils who for the most part are Malays. Implementing these simple measures would help tremendously. We cannot expect these poor rural children to perform at peak level mentally and physically when they are undernourished, chronically anemic, ravaged with worm infestations, and burdened with bad dentition.
These basic but essential healthcare items must be addressed first, even ahead of building new hospitals and medical schools. Tan Sri Majid Ismail once told me that healthcare is a bottomless pit. Unless prudently handled, it could bankrupt the nation. America is desperately trying to restrain its healthcare costs, currently consuming in excess of 15 percent of its GDP. Prudent healthcare spending means emphasizing basic public health, and providing basic medical care only for those who cannot afford it. It is not the government’s responsibility to subsidize healthcare to those who can afford it.
Healthcare policies must be part of the overall economic policy. With increased wealth, the citizens can take care of their own health, thus saving government resources. Also with economic growth, many would be lifted out of poverty. That in itself is health enhancing.
Next: Empowering Citizens