A year on after the first Covid-19 case was detected in Malaysia, it is clear that the Ministry of Health (MOH) is struggling to come up with a comprehensive solution. This means that the rakyat will continue to suffer until the implementation of an effective vaccination programme.
Have we learned lessons from countries that are succeeding or failed to control the pandemic?
For one whole year, the rakyat have endured what was asked of them. Whole sectors have bore the brunt of the pandemic and swallowed the proffered solutions.
Yet we are constantly dismayed to read and hear about how our politicians and leaders have failed to deliver their share of what is needed, i.e. stable leadership in this time of crisis. Instead of rallying together to fight the virus, they are back to business as usual, fighting one another and in the process, dividing the rakyat for their own personal expediency.
At the outset, a year ago, we had already stated that the MOH cannot fight this war alone. On many occasions, we have urged the MOH to mobilise private general practitioners (GPs) in this war. The GPs as the unacknowledged frontliners must be engaged and involved in a nationwide, meaningful and comprehensive private-public partnership effort to help stem the tide.
Where Are The Sources Of Infection?
Exactly where the sources of infection are must be openly identified and addressed.
The strategy of MCO lockdowns based on geographical basis will clearly not work for the present situation. Continuing with this will surely destroy the national economy.
The present active sources of infection must be analysed and segregated based on important socio-demographical parameters. We are informed that they were mainly foreign workers in construction and manufacturing sectors.
If this is the case, mitigation measures must be focused there with due diligence, care and compassion. Employers in this sector must be brought in as active collaborators and assisted in stemming such clusters.
What are the measures being taken to address the transmission between other undocumented immigrants and foreign workers who are living within the general community?
Clearly, such workers are likely to infect others as they are directly in contact with others on a daily basis.
Until this is addressed and managed appropriately, breaking the chain of community transmission by just locking up foreign workers cannot be the answer.
The present trend of increasing daily infections is alarming. It has been projected to hit 8,000 new cases per day by April.
This would mean that the pool of infectious cases in the community would have reached tens, and perhaps hundred of thousands, many of whom are still undetected and actively spreading the disease.
The CAC Is Not A Silver Bullet
For one whole year, mitigation measures to reduce active infections were mainly mandatory quarantines and admission to designated hospitals for positive cases. It is costly and not effective when there is significant community transmission.
This has resulted in a system that is inflexible and therefore unable to cope with the escalation in infections. This means that the Covid Assessment Centre (CAC) will be overwhelmed even at the beginning of its operations. The proposed CAC process is cumbersome and dependent on existing MOH personnel, who are already strained to their limits.
Furthermore, the CAC approach is not the way to manage patients and their families. The nearest GP must be involved to provide quality care and clinical monitoring. This will also assist in the detection of patients at risk of developing complications. GPs can also help in the screening and testing of contacts.
Why this was not clearly embedded into the CAC work process? This is further evidence of the lack of commitment in any meaningful private-public partnership.
A Call For A Private-Public Partnership
Once a positive case is confirmed in a household, it is very likely that the other members of the same household have been exposed, and could be infected as well.
Many of the present recommendations on what families should or should not do are akin to closing the barn door after the horses have bolted. What is needed are sensible precautions and household-based self-quarantine to prevent the spread of the disease to others.
A year ago, the Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM) submitted to the MOH a detailed proposal for a private-public partnership programme to be implemented nationwide using nationwide GPs and primary care doctors.
At the time, hydroxychloroquine was the preferred method for Covid treatment. Today, other medications have emerged as possible treatment modalities.
This proposed programme called for early diagnosis and early treatment of prima facie cases of Covid-19 at the GP or primary care level, i.e. at the community level where the main sources of infectious cases exist. It is aimed at reducing these sources to below critical massm whereby it will no longer be a danger to public health. It was aimed at supplementing the existing public health measures of testing and quarantine.
In the proposal, it was highlighted that the 7,000 or more GPs located around the country, are a valuable resource that should be actively mobilised, equipped with Personal Protective Equipment (PPE), the medications and the mandate to treat patients in the community.
The MOH should provide GPs with current recommended therapeutic options for Category One and Two patients. In the event where mass testing is not feasible, the proposal called for GPs to treat patients with prima facie evidence of the disease (presumptive diagnosis) based on accepted clinical criteria. This would leverage upon the strategic capabilities of the GPs.
Each GP treating up to 20 patients daily will be able to provide treatment for thousands of early cases of Covid-19. In a short time, they would have the capacity to reach millions of patients in a community-based setting.
The aim is to treat large numbers of early patients in the shortest time possible to bring infections to below the critical mass in order to break the chain of transmission. It is not unreasonable to envisage that it will also reduce the progress of the disease in the community, and hopefully, the number of hospital admissions.
As with regard to costs, it is clear that treatment of a presumptive case in the community setting is more cost-effective compared to treatments within hospital settings.
Addressing The Stigma Of Covid-19
To be infected with Covid-19 is not an offence. It should not carry any social or moral stigma.
The threat of compulsory lockdowns and enforced quarantines will denigrate the image of Covid-19 patients. It will drive patients and those who might be asymptomatic to go into hiding, which then makes accurate reporting and contact tracing even more difficult.
The MOH needs to rethink its strategy so as to encourage people to come forward voluntarily to be tested. It is time to encourage full voluntary community participation.
This strategy, together with a efficiently executed vaccination programme, will hopefully break the present chain of transmission.
Dr Steven Chow is the President of the Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM).
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