Newer Subspecialties: Adding Value To The Health White Paper? – Dr Lokman Mohd Noh

Clinical immunology is an established subspecialty practice in many other countries. Straying from accepted global practice would put us at a disadvantage when it comes to treating immune mediated diseases.

The Health White Paper for Malaysia has been long awaited. Among its goals are the reform of the health care system and an equitable, credible, and sustainable health care system focusing on critical and long-standing issues. (Kertas Putih document, Bab 2, p 11)

Primary And Secondary Health care

Primary health care refers to essential health care based on practical, scientifically sound, and socially acceptable methods with technology made universally accessible to the community.  

Secondary health care includes specialised treatment for patients who have been referred for specific care, often provided by the hospital.

The realm of primary health care has received sufficient attention with extensive discussion in the media, but secondary health care has not been given the attention.

The perpetual issue of constraints within the public health service requires scrutiny and a reorientation, so that patients with severe conditions can seek general and specialist /subspecialist treatment.

The continuity from primary care to secondary care is crucial in ensuring that patients receive adequate patient care within the appropriate setting.

The Newer Subspecialties 

The time is ripe to explore and assess the relevance of the newer disciplines of medicine, i.e. subspecialties. These include clinical immunology, immunopathology, and clinical pharmacology. 

Clinical immunology started to be established in Malaysia in the late 1970s but was left fallow when local clinical immunologists left the country. However, it made a comeback at the Pediatric Institute, Hospital Kuala Lumpur in 1986. 

Since then, five new clinicians trained in clinical immunology have returned from abroad, providing consultations in immune mediated diseases in local public and private hospitals. However, clinical immunology and immunopathology have the ignominy of non-recognition by the National Specialist Registry (NSR) under the Ministry of Health (MOH).

Clinical Immunology Vs Clinical Genetics

Clinical genetics, which is an example of translational medicine, is recognised by the NSR. While the genes identify what is amiss in clinical genetics, clinical immunology explains how abnormal genes cause disease in patients.

The NSR has adopted clinical genetics as a subspecialty, but not clinical immunology, although they work in synergy. The delay in recognising clinical immunology is a step backward.

Clinical immunology underpins most of the immune-mediated diseases, specifically primary immunodeficiencies, inborn errors of immunity, allergies, and autoimmune diseases. It also includes the study of the immunity of infectious disease that can spur vaccine discovery.

Developing Talents For Research

The Health White Paper also emphasises the preparation of human capital for the training, nurturing, and licensing of the health workforce. There must be an emphasis on professional development and in-service training.

To benefit from newer technology and research advances, talents should be identified and developed within an appropriate ecosystem. Merely emphasising fundamental research is short-sighted. The obsession with clinical research is self-defeating.

Optimising Practice Through Strong Research Capacity

Besides clinical care, clinical immunology is relevant in empowering local data through research especially when it comes to infectious diseases.

Unlike Singapore, Hong Kong, and Italy, which optimised their vaccination schedule by reducing the number of doses of mRNA vaccine for those infected via natural means, thereby reducing adverse events, Malaysia could not do so.

Malaysia could not do so when its clinical immunologists are unrecognised and were not invited to sit on any national committee until late in the pandemic. 

Research Collaboration Between Research Organisations

Another downside of research practice in Malaysia is the lack of desire in sharing research results between organisations, including the MOH and universities. We should emulate the transatlantic collaborations between pharmaceutical giants Pfizer and Biontech, which has succeeded in fast-tracking the discovery of the mRNA vaccine.

We Need Quality And Quantity 

We need more talents and more research projects in various aspects to yield cutting-edge discoveries, which is the practice of many top universities worldwide.

While local scientists with proven track records can obtain sizeable research grants, a similar stimulus should also be accorded to returning talents in clinical immunology.

Denying them would waste their acquired skills, leading to a brain drain.

Role Of Local Clinical Immunologists 

The present role of the clinical immunologist is not merely to treat patients, but also to nurture local talents and attract overseas talents.

It is reassuring that local clinical immunologists have been called to train specialists for new subspecialties, namely pediatric infectious diseases and immunology.

However, the NSR’s continuing rejection of the clinical immunology subspecialty puts us at odds with the spirit of the Health White Paper. This is happening against a backdrop of increasing cases and high mortality rates for congenital immunodeficiency and primary immune deficiency.

The essential functions of clinical immunology cannot be disputed: 

  • Affords high-end care to patients with immune mediated diseases.
  • Democratisation of subspecialist care at regional hospitals.
  • Added stimulus for innovation in research in infectious diseases.
  • Provides an outlet for talents to be trained locally, thus limiting the medical brain drain.
  • Enhancing medical tourism for patients with immune mediated diseases.

Clinical immunology is an established subspecialty practice in many other countries. Straying from accepted global practice would put us at a disadvantage when it comes to treating immune mediated diseases.

Let us add value to the Heath White Paper by evaluating and recognising newer medical disciplines. including clinical immunology.  

Dr Lokman Mohd Noh is a consultant paediatrician and a member of TIGERS (Translational Immunology Group for Education Research and Society).

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.

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