by M. Bakri Musa

Two well-recognized factors to enhancing the quality of human capital are health and education. When citizens are healthy and well educated, their capacity to be productive and contributing members of society is greatly enhanced. The converse, when they are unhealthy and poorly educated, they are a burden upon society.

To the pair I would add a third: freedom. To get the best out of people, we must grant them space to enable them to develop their talent and pursue their passion. Then we should grant them the freedom to express themselves and their creations.

Great and inspiring works in the arts and sciences are the creations of those who are passionate in what they do. Such passions come only when people are given the freedom to pursue their dreams and aspirations. Such endeavors are rarely undertaken purely in the pursuit of honor or wealth but for their own intrinsic pleasures and rewards.

Honors and material rewards may well follow, and we should not minimize their importance. They help inspire and motivate the rest – the talented and otherwise – who need the extra nudge.

As for freedom, there may be exceptions to my statement but they are more apparent than real. Ananta Pramoedya Toer produced his greatest literary works while imprisoned under the most trying physical conditions on Pulau Buru. The authorities may have imprisoned him physically, but as he contemptuously asserted in his autobiography, they could not imprison his will and thought, though not for lack of trying.

In this session, my fellow panelist Dr. Azly Rahman will discuss education, his expertise, and I, health. We will not be discussing the third factor: freedom.

There is an important link between health and education, especially in the young, as succinctly stated by President Clinton’s Surgeon-General Jocelyn Elder, “You cannot educate a child who is not healthy, and you cannot keep a child healthy who is not educated.”

Citizens’ Health and the Economy

Citizens’ good health is good for the economy. The WHO Commission on Macroeconomics and Health chaired by Jeffrey Sachs, currently the holder of the Ungku Aziz Chair in Economics at University of Malaya, reaffirms the powerful link between health, poverty reduction, and economic growth. The report challenges the traditional argument that the health of citizens will automatically improve with economic growth. Indeed the opposite is true; improved health is a critical requirement for economic development in poor countries.

A NBER report claims that a one-year improvement in a country’s life expectancy (an index of health) contributes to a four percent increase in economic output, and that good health of the citizens has a greater impact on the economy than work experience or years of schooling.

Anecdotally consider that had P. Ramlee had heart angioplasty back in 1973, imagine how many more beautiful songs and wonderful movies he would have made. Another, quantify the economic value of Mahathir’s contributions since he had his successful heart surgery in 1989.

Considerations of good health and its impact on economic development aside, I would like to demolish a few myths relating health, which should be the concern of everyone, and medicine, my vocation. The realities are these. First, there is minimal if any relationship between the two. Civil engineers contribute more toward citizens’ good health than medical doctors. This is true here in Buffalo as in Bombay. Indeed the problem over there is precisely that Indian engineers are more concerned with writing software codes for American companies than trying to build reliable sewer systems or garbage collection in their city.

Before they built a freeway near my California town, I spent many a night and weekend in the operating suite dealing with severe accident cases. Thankfully, those cases are much fewer today. The cost of the new freeway has now more than repaid itself through the lives saved and limbs preserved, not to mention property damages spared.

The second is that there is little correlation between the amount of resources expended on healthcare and good health. America spends twice as much on a per capita basis on healthcare as compared to Canada or Germany, but we are not twice as healthy as they are.

Third, the assertion by the WHO Commission that investments in healthcare pay economic dividends is true only up to a point. America spends nearly 15 percent of its GDP on healthcare, and fast rising, threatening the economy. The concern here is with reining in the escalating costs.

Last, increasingly the destroyers of good health today are caused less by diseases due to pathogens and more the consequences of lifestyles: smoking, alcohol, diet, and lack of exercise. This is true in the developed as well as developing world. Even with diseases like AIDS where there is a clear biologic etiology, the most effective interventions lie not with expensive new therapies rather with changes in lifestyles. This is even truer with other modern scourges including drug addiction. Consequently the remedies to the major threats on health and lives today lay for the most part outside the purview of medicine.

The other startling revelation is that often the most effective interventions affecting our health and thus productivity are also the cheapest. The economic historian David Landes writes that the one medical device that has the greatest impact on worker productivity is the eyeglass, followed by the equally simple and cheap body soap.

Following that would be investments in civil engineering projects like reliable piped potable water, effective garbage collection, and a functioning sewer system. Even providing electricity contributes to good health, as it would reduce food poisoning as foods could now be safely stored in refrigerators instead of becoming rancid quickly in a hot climate. Even if these services were to be highly subsidized, they would still create considerable savings by eliminating such preventable diseases as cholera, dysentery, and hepatitis.

Today one disease that imposes the greatest economic burden worldwide is malaria. Controlling it, together with other vector-driven diseases like dengue, rests more with civil engineering than modern medicine. South Florida has the same climate as Malaysia, yet Miami is not inundated with malaria or dengue because its lawns are cut, swamps drained, and gutters covered and unclogged. There is also regular surveillance followed by fogging operations if need be. All these are outside the purview of medicine.

Again here, simple physical measures like using insecticide-impregnated mosquito nets are very effective prophylaxis. I am surprised that in many Malaysian homes these nets are a rarity today.

The next level would be adopting generally accepted public health practices like vaccination as well as maternal and child healthcare. The greatest improvement in infant and maternal mortality rates in Malaysia came not with the building of the new medical schools but with the introduction of rural health programs manned by midwives and public health nurses pioneered by the Director-General of Health, Tan Sri Majid Ismail. His achievements are even more remarkable considering that he was not a public health professional, rather an orthopedic surgeon.

Last, where they appropriately should belong, at the bottom of the totem pole, would be fancy hospitals, expensive medical schools, and highly-paid physicians. Spectacular medical advances are by their very nature dramatic and headline-hogging, thus easily grabbing the attention of leaders. They would then want to do the same thing in their own country just to prove that the natives are just as smart. Cost considerations or deliberate weighing in the various alternatives never enter the deliberations.

Halfway Technology Versus Real Advances in Medicine

We must distinguish between genuine medical advances which are not only highly effective but also cheap from what the American pathologist Lewis Thomas called “halfway technology,” which are dramatic and highly expensive “advances” but of limited utility. The classic example is polio. The real advance there was the development of an effective vaccine. The halfway technologies were the iron lungs and the elaborate limb restoration surgeries.

Many years ago Kelantan proudly announced the setting up of a medical school. That was misplaced considering that the state was (still is) regularly plagued with outbreaks of cholera for lack of an effective community water supply and reliable sewer system. A medical school however, is sexier.

Malaysia is not alone in falling for this trap, so is the rest of the developing world. The bulk of children in India lack the basics; without running water, healthcare, and immunization. Yet it has no shortage of expensive medical schools. Those investments had zero impact on the health of ordinary Indians, especially the children. All India succeeded in doing is to provide doctors for American hospitals.

Third World leaders go for this route first as they want their children to be attending those medical schools. It is their personal, not national priority.

Lastly, medical tourism; this is more a niche of tourist industry rather than of medical care. It has more to do with bringing in the tourist dollar and only secondarily in enhancing medical care. Yet properly adopted, it could serve both.

To cater for these affluent patients especially those from the West, you must provide superior service, or at least one that meets or even exceeds prevailing international standards, and at a competitive price to compensate for the “foreign” factor.

If your target market were the affluent of the Third World, then your standards need not have to be so stringent, but then that market is small and not very lucrative. It is also transient, as eventually those countries too will upgrade their services and recapture their lost market.

Besides, the Western market is huge as modern medical care is now the “right” of not just the rich but of everyone, including those dependent on the state. .In meeting that high international standard needed to cater for this market, local healthcare providers will have to improve their services in terms of professional quality, consumer friendliness, and of course, price. These efforts in turn would spill over to benefit the local market, with those highly developed skills and expertise diffusing onto the local community.

To meet this international standard, local medical schools and teaching hospitals must be upgraded substantially. Local young specialists must acquire internationally-recognized professional qualifications. The specialist certificate issued by the local university would not impress or attract an international cliental.

On a more practical level, these professionals must not only be conversant but also comfortable with their clients. As they are for the most part from the West, our healthcare professionals must be fluent in English and at ease with Western culture. Meaning, the way we teach our doctors will have to change to emphasize English language skills.

While that would be desirable, there is one hidden potential trap. As those professionals now have internationally-recognized qualifications and skills, the world is now the market for their services, not just Malaysia. You thus risk losing your precious talent to the West, as is the current experience in most developing countries. The solution to that however is not to lower local standards, rather to make sure that conditions at home are attractive enough professionally and otherwise so they would not be tempted to look beyond our borders.

Malaysia is way ahead of India or China socially and economically. Malaysians would not tolerate having to depend on “barefoot village doctors” for their medical care. Meaning, we could still have our fancy hospitals and medical schools but at the same time we must make sure that our drains are regularly unclogged and be covered, the bulk of our citizens have access to reliable piped potable water and adequate sewer treatment systems, and that Malaysian be covered with basic public health measures as child and maternal care, including the standard immunizations. Those steps would ensure that Malaysians remain healthy and be productive members of society.

[Talk given at a forum at the University of Buffalo, on November 1, 2008, themed “Alif Ba Ta, Towards the New Malay,” organized by Kelab UMNO New York-New Jersey.]