Enhancing Human Capital Through Health

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.]

  1. #1 by cu on Tuesday, 18 November 2008 - 7:31 am

    Do you know that:

    The Malaysian government suspended Parliament and the executive branch governed on its own through the National Operations Council until 1971. The NOC proposed amendments to the Sedition Act that made illegal the questioning of, among others, Article 153. These amendments were passed by Parliament as law when it reconvened in 1971.

    Article 153 – Bumiputra privilege quota.

  2. #2 by Godfather on Tuesday, 18 November 2008 - 8:10 am

    The old Mamakthir singlehandedly killed meritocracy in this country, and in fact many in UMNO basically termed emigrants “good riddance to bad rubbish” when they went overseas to study in top universities, never to return.

    Bakri, do you think the “new” UMNO leadership understands the risks of brain drain ? Nah, they would rather corral a herd of obedient cattle than worry about some smart alecs of different races clamouring for fairness, transparency and accountability.

    The motto of UMNO is “Steal for Today, Tomorrow’s Another Day”.

  3. #3 by Jimm on Tuesday, 18 November 2008 - 9:32 am

    what are health when umno only interested in ill-wealth from day one….

  4. #4 by All For The Road on Tuesday, 18 November 2008 - 10:10 am

    Freedom of the press and freedom to express oneself in Malaysia! What freedom? Everything is gagged and muzzled right from the press and print media to the ordinary individual! Owners of these newspapers and publications of whatever have to renew their licences and permits annually to the Home Ministry. One false step and they will have it.

    Remember, some months ago, two newspapers viz. Sin Chew Daily News and The Sun and the weekly organ of PKR were served show-cause letters by the Home Ministry for reasons seemed dubious. What have these print media done to deserve such a warning?

    Freedom of expression? Recent events and gatherings to express and show certain displeasures and dissatisfactions were being
    confronted and dispersed with high-handed and tough police actions much to the horror and dismay of the general public. There is simply no voice of dissent and opinion which are not tolerated by the authorities with the assistance of ‘the-men-in-blue’ uniforms to act against such legitimate and peaceful grouses!

  5. #5 by Loh on Tuesday, 18 November 2008 - 10:42 am

    Sorry, off topic

    ///exclusive ‘Just because we are women and we don’t have that thing between the legs so we are not good,’ says Rafiah Salim over her contract’s non-renewal///–Malaysiakini

    The government insisted that selection was based on meritocracy. There are other examples of meritocracy selection such as those equating matriculasi with HSC in university admission. The government has perfected the art on how to justify their decision. I am happy that Rafiah Salim has chosen a graphic means to describe the issue.

    It used to be a choice between races, and now it is between genders; and all those are on top of other consideration like cronyism and corruption. Wonders never cease in wonderful bolehland

  6. #6 by monsterball on Tuesday, 18 November 2008 - 10:51 am

    This is like teaching Std 5 students….how to have a better life….brain washing all of them…away from the cause and effects of our unhappy living conditions..caused by UMNO..and BN.
    Just focus…change of government and that..your votes are most powerful..then all will know what to do for their children and families.
    Don’t be a smart selfish voter.
    Be a smart Malaysian voter….thinking for country and it’s people. Once you do that…your family interests are included automatically.
    Don’t be fooled with twisted facts…expertly done by the biggest devil of our country…Mahathir.
    That old man..sadly….loves to divide and rule…accused others on corruptions….play race and religion politics…to keep saying that’s the right way….so that ….he can bluff himself…having done… nothing wrong…in his 22 years ..as the worst PM …we ever had.
    He is fighting his own guilty conscience…..all the time!!
    He is a sicko!!

  7. #7 by k1980 on Tuesday, 18 November 2008 - 12:21 pm

    Enhancing Human Capital Through Health? You must be joking. Human Capital can be much better enhanced through the dismissal of the umno administration!

  8. #8 by Godfather on Tuesday, 18 November 2008 - 1:38 pm

    The only “capital” that UMNO can understand is the money that flows into their pockets. “Intellectual capital” and “human capital” are alien terms to the den of thieves.

  9. #9 by raven77 on Tuesday, 18 November 2008 - 4:27 pm

    Health …is a low priority in this country…where life is cheap..Gordon Brown in the UK will talk about health in his election agenda and so must Obama or McCain……in fact anyone in the developed world risks loosing an election if healthcare is omitted….but in this country the weakest administrators and most ill qualified politicians and civil service run healthcare on a health budget already completely looted by the UMNO government……In Malaysia..if you fall sick…you are dead in no time.

  10. #10 by rubini on Wednesday, 19 November 2008 - 1:47 am

    This is country is run based on stupidity, 22 years of corrupt & rotting administration. Only intelligent individuals like your goodself promotes health, education & freedom.

  11. #11 by delon85 on Wednesday, 19 November 2008 - 4:27 am

    Why am I not surprised that there are Kelab UMNO everywhere? What purposes does these clubs serve overseas?

  12. #12 by k1980 on Wednesday, 19 November 2008 - 8:23 am

    The sole and only purpose of having Kelab UMNO overseas is to ensure that those voters overseas will have no choice but to vote for umno/bn during the GE.

  13. #13 by Loh on Wednesday, 19 November 2008 - 1:29 pm

    Sorry, off-topic

    ///1. The teaching of science and maths in English has actually driven all students overall to excel and improve in the English language.

    2. After all, it was Dr Mahathir Mohamad who made the initial switch. And I am sure that the wise Tun would have soul-searched every aspect of the decision.

    3. He chose to be bold to bring about the changes knowing then it was important to switch in order for the younger generations to remain competitive in a globalised technology-driven world.

    4. So the policy has been proven right. Why change it and handicap our youngsters’ future?

    5.One has to look at the oak tree and not the acorn.

    By P. Sivakumar. The writer is president, Malaysian Indian Business Association. http://www.malaysiakini.com/letters/93309 ///

    Para.1. Yes but at what cost? At the cost now expended would not the students have better command of the English language if they were given more hours in English language rather than the system now adopted? It was the order from TDM without proper technical investigation. In life as in business, there should be cost benefit analysis before a good decision is arrived at. To claim that it works because it produces some results is the usual technique to fool the uninitiated.

    People in the teaching profession have concluded that improving of the standard of English language among the students can be better achieved by increasing the number of teaching hours in the subjects itself without having to compromise the teaching of mathematics and science, at the primary level. The students can easily learn to switch to the teaching of science, mathematics, and other subjects in English at the secondary level. That has been proven since the 1950s when the students from Penang Chung Ling High School were able to gain direct admission to universities in USA, and the students were known to excel.

    Para.2. In the 1970s in China, Chairman Hua of China decreed that whatever Mao said was right. Mao was a great leader of the world, but not all that he proposed was correct. But at least the Chinese in China believe that Mao has the interest of the country at heart. His decisions were not swayed by personal gains.

    When it was not the universal truth, the writer’s claim of TDM’s wisdom makes one get goose bumps, and more so in attributing him to have soul-searched before making decision. Is the writer feeling proud of the Indian lineage when his idol has declared himself to have 100% Malay blood running in the veins?

    Para3. The person who was the first to change and destroy the education system of the country only wanted to sow seeds of discontent so that people can assign blame to his successor, PM AAB. If he ever cared for the well beings of the nation, he should have reverted back to the education system that he found it when he was the Education Minister. He should have brought back the English medium schools which existed until May 13.

    Para.4. On what basis can the policy be said to have been proven right; by making wild claim?

    Para.5. It used to be the forest and the trees. Now it is more focused!

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