Poverty, Sickness, And Death: Why Sabah’s Covid-19 Patients Are Ill

A doctor from Tawau Hospital says that the number of Covid-19 patients who require supplemental oxygen is increasing.

KUALA LUMPUR, Oct 20 — Covid-19 patients in Sabah are sicker because of poverty, poor access to health facilities in the large rural state, and fear of arrest among undocumented migrants when seeking treatment, health experts said.

An anonymous medical officer from Tawau Hospital told CodeBlue that Covid-19 patients requiring supplemental oxygen are increasing in Sabah, which means more coronavirus patients are getting severely sick as they require additional support for breathing.

Covid-19 patients from Semporna Hospital are referred to Tawau Hospital for further management. The Tawau medical officer said Covid-19 patients coming from Semporna Hospital are in the worst condition when they arrive, most of the time intubated (tube inserted into the throat and connected to a ventilator to support one’s breathing).

“If their condition worsens, despite the intubation, patients mostly succumb to death,” the medical officer said.

The doctor also pointed out that Covid-19 patients who require supplemental oxygen are increasing.

“Intensive care unit (ICU) was once full and unable to receive intubated patients from Semporna. Semporna had to divert the patients to Lahad Datu.”

The Ministry of Health (MOH) previously reported that 43 per cent of Covid-19 patients from Sabah were more ill, requiring hospitalisation, which is more than triple the 12 per cent rate of Malaysia’s overall Covid-19 cases in April.

A total of 47 people in Sabah have died from Covid-19 in 12 consecutive days from October 8 to October 19. Only two coronavirus-related deaths in Malaysia in that period were reported outside the state – both in Selangor.

Stage One coronavirus patients test positive with Covid-19 but do not have symptoms, while stage two are patients who show mild symptoms. These patients are admitted to low-risk quarantine and treatment centres in Sabah. According to Health director-general Dr Noor Hisham Abdullah on October 17, bed occupancy of 5,414 beds across Covid-19 hospitals and quarantine centres in Sabah was 35 per cent, which amounts to 1,895 Covid-19 patients.

Covid-19 patients categorised stage three to five are admitted to hospitals. Patients who are in the third stage suffer from pneumonia, but they are relatively stable, not requiring supplemental oxygen. Stage four patients suffer from pneumonia and require supplemental oxygen, while stage five patients are on ventilator support.

Dr Noor Hisham also said the occupancy of ICU beds for both Covid-19 and non-Covid-19 patients in Sabah was 72 per cent of 122 beds as of October 17, while 32 per cent of 180 ventilators are being used across Sabah among Covid-19 and non Covid-19 patients.

Both Undocumented Migrants And Malaysians Seek Late Treatment

An anaesthesiologist attending to a Covid-19 patient. Picture from the Malaysian Society of Anaesthesiology.

The medical officer from Tawau also highlighted that Sabah has many undocumented migrants who only seek treatment at the later stages because of the cost of treatment. Although Malaysia’s public health care system is heavily subsidised for Malaysian citizens, foreigners must pay certain rates.

“Most of the patients came late to the hospital because they have no document. They can’t pay the hospital bills,” the medical officer said.

A study in 2019 found that the Malaysian health care system is inaccessible for migrant workers. Major causes include affordability and financial constraints, and the need for legal documents like valid passports and work permits.

Besides undocumented migrants, the medical officer said that even Malaysians with identification cards present themselves to hospitals very late because of transportation issues. Sabah is the second largest state in Malaysia at 73,620 sq km; Kinabatangan district is as big as Pahang.

“Some of them live on some island that needs a boat to go to hospital — the waiting time for the boat plus the journey time on the boat,” the doctor said.

The doctor also said that even if the government were to increase Covid-19 screening, it would be difficult to track some of the houses of Sabahans.

The Bajau Laut community, for example, uses canoes as their homes. So, even if health officers have enough manpower to conduct mass testing, the logistics or finding homes of these undocumented migrants will be difficult.

Immunity For Undocumented Migrants

Public health medicine specialist and associate professor of epidemiology at Universiti Malaya, Dr Nirmala Bhoo Pathy. Picture from Dr Nirmala Bhoo Pathy.

Dr Nirmala Bhoo Pathy, a public health medicine specialist from University Malaya, also said that Sabah has a large proportion of undocoumented migrants who would be fearful to come forward.

“These people may continue holding on and go on with life until they become really sick before seeking help,” Dr Nirmala said.

“It is open knowledge that our undocumented migrants were detained during the second wave of the pandemic in March, and this scares away the rest, who fear being arrested.”

Dr Nirmala said that since Covid-19 is a public health emergency, immunity should be given to undocumented migrants as no residents should be left behind, in order to get the situation under control. However, she said that this is beyond the power of the people in the health system.

Senior Defence Minister Ismail Sabri Yaakob said last May that illegal immigrants will still be arrested because they are violating the law, despite medical professionals and human rights groups criticising the act of arresting undocumented migrants as it only drives them underground instead of coming forward to be screened.

Former Malaysian Medical Association (MMA) president Dr Milton Lum also agreed that in a public health emergency, going after undocumented migrant workers is not wise as it will drive them underground.

“This leads to the hampering of detection, diagnosis, treatment, contact tracing and isolation all of which facilitates spread of Covid-19,” Dr Lum said.

Low Socioeconomic Groups Have Higher Prevalence Of Infectious Disease

Alpha Specialist Centre consultant obstetrician & gynaecologist Dr Milton Lum asks a question at the Malaysian Healthcare Conference 2019 in Kuala Lumpur on March 7, 2019. Picture from fb.com/ksinsti.

Besides that, Dr Lum said that many people in the lower socio-economic groups suffer more from infectious and non-communicable diseases, compared to those who are better off.

“Published reports from the United States and the United Kingdom document higher incidence of Covid-19 cases and deaths among the poorer segments of society,” Dr Lum said.

Sabah has been ranked as Malaysia’s poorest state with a poverty rate of 19.5 per cent, involving 99,869 households, based on the 2019 Poverty Line Income (PGK) calculation methodology.

According to the former MMA president, Sabah’s health system is not as developed as Peninsular Malaysia for various reasons like geography, infrastructure, underfunding, and limited human resources.

Through social media posts by doctors, it was seen that a small district hospital like Semporna Hospital had to rely on donations for a balloon concept tent to isolate their patients. When the tent started leaking, the frontliners themselves were pumping air into the tent every 30 minutes.

At another district hospital in Beluran, frontliners and volunteers were seen building isolation rooms themselves, instead of outsourcing the project, to save cost.

Furthermore, Dr Lum said that Sabah has close proximity and porous borders with Philippines and Indonesia, both which have the highest number of Covid-19 cases in ASEAN, i.e more than 350,000 cases each as of October 19.

On October 10, New Straits Times reported that six undocumented migrants from the Philippines and Indonesia had fled quarantine from the Tawau Temporary Detention Centre.

Uncertain If Malnutrition Causes More Severe Covid-19 Disease

Dr Tan Poh Tin (far right), a consultant paediatrician and public health specialist based in Kuching. Picture from Dr Tan Poh Tin.

A cross-sectional study among children between six and 59 months done in Tenom, Sabah, found that based on the Composite Index Anthropometric Failure (CIAF) by the World Health Organization (WHO) child growth standards 2006, a total of 42.3 per cent were underweight, 34.7 per cent had stunted growth, and 10 per cent had wasting.

The 2020 global nutrition report in the context of Covid-19 found that undernourished people have weaker immune systems, hence may be at a greater risk of contracting the coronavirus.

Public health-trained paediatrician Dr Tan Poh Tin told CodeBlue that at this point of time, it is too early to say if malnutrition has caused Sabah Covid-19 patients to be more ill.

“At the moment, personally I don’t think it’s fair to Sabahans and Sabah doctors and also MOH to speculate,” Dr Tan said.

However, Dr Tan said a Covid-19 patient’s weight, height, age, sex, ethnic group, and nutrition status should be recorded upon hospital admission, so that a retrospective review can be done to identify the contributing factor, which then can be used as a prevention measure or to help other countries.

Mixed Messages To The Public

A police roadblock at Rawang-Kuala Lumpur on October 14, 2020, during the Conditional Movement Control Order. Picture by the Malaysian Armed Forces.

Dr Tan also highlighted that the public is getting mixed messages from people who should know better and are in the public eye. Political leaders and lawmakers across the aisle have often been pictured flouting Covid-19 guidelines by not wearing face masks or not socially distancing.

She said it is not that health education is not working, but that highly qualified and educated people in certain positions, who should know more about the virus, are portraying a different thing with their behaviour.

“It’s the contamination of information by people who know better but giving a different message with their behaviour,” Dr Tan said.

“At the end of the day, the information is getting very difficult now because of so many conflicting inputs, so I wouldn’t say MOH has not done enough. It’s a mixed messaging, and the examples of the people who wander around.”

WHO director-general Tedros Adhanom Ghebreyesus has slammed world leaders for mixed messages on Covid-19. He said that leaders in countries like the United States, Brazil, and India, which are facing large outbreaks, have rejected or played down advice and recommendations made by scientific experts to take tougher actions.

The Guardian questioned how one can be expected to follow government guidelines when even politicians are seen shaking hands, violating government guidelines. Political strategist Dominic Cummings had travelled hundreds of miles north while experiencing Covid-19 symptoms.

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