IS IT THE HEALTHCARE SERVICES, DG OR PM AT BREAKING POINT?

Dr Musa Mohd Nordin
12 January 2021
musamn@gmail.com

Sometimes one wonders who is at the breaking point?

Is it really the healthcare services?
Or is it the leader of the healthcare services who is short of ideas to stem the rises in the COVID-19 numbers?
Or is it the leader of the nation who is struggling to keep the governing coalition together?

We have now experienced two MCOs. The MCO 1.0 to tackle the second wave was successful. The second, a CMCO, was a total failure because the trajectory of the pandemic curve failed to plateau and instead reported highest numbers ever experienced.

Yesterday’s announcement was in reality MCO 3.0 and not MCO 2.0. One often relates to increasing numbers post acronym as a progression, an advancement as in IR4.0.

Unfortunately MCO 3.0 connotes the contrary. It reflects the third failure of government and the MoH to tame the raging coronavirus. To the former it is not too far fetched to suggest that it is in reality a PMCO aka Political MCO. Whilst to the latter it is really a classical display of Einstein’s words of wisdom “Insanity is doing the same thing over and over again and expecting different results”.

It is rather disappointing that the government did not have the courtesy to consult 46 of our esteemed medical colleagues, who signed the Open Letter to the PM, to pick their brains as to show how best to move forward.

OK! The rhetorics aside let us roll up our sleeves, huddle together and get down to the business of saving our beloved nation.

Since the government has now plunged the nation into MCO 3.0, it is now responsible for protecting the S bit of the holistic program of mitigating the COVID-19 pandemic, FTTIS, Find-Test-Trace-Isolate-SUPPORT.

That is to SUPPORT the rakyat and nation throughout the period of the MCO 3.0

To SUPPORT the more than 1 million individuals who are rendered jobless
To SUPPORT the feeding and wellbeing of families whose breadwinner have failed to now put food on the table and the provision of basic essentials.
To SUPPORT the vulnerable and marginalized communities
To SUPPORT the SMEs and other industries who face the looming threat of bankruptcy
To SUPPORT the vulnerable persons and women who are prone to mental breakdowns, suicidal tendencies and the increasing incidence of domestic violence
To SUPPORT the front-liners who have been on call the past 12 months and are now burnt-out.
To SUPPORT the national economy which is bleeding billions of ringgit daily and yet failing to secure FDIs.

All the ministries and government agencies must get their act together as part of the whole-of-government approach to address all the abovementioned social determinants of health which would significantly impact the current healthcare landscape.

They must immediately, like yesterday really, roll-out strategies to create employment opportunities, address food security, housing, social services and education, among others, which would contribute towards a value-based healthcare services.

The MoH needs to prove Einstein wrong by now thinking out of the box and to re-strategize its COVID-19 framework of action. It must fully utilize MCO 3.0 as a breather, a circuit breaker, to crush the incidence of the coronavirus, not only flatten but to plunge the pandemic curve.

It can achieve this by:

Immediately ramping the FTTIS strategy.
Outline and operationalize its exit strategy out of this pandemic.
Put in place a sustainable long-term plan so as not to be trapped in a vicious cycle of MCOs.

Until and unless the MoH transforms its modus operandi in dealing with the spiraling cases of COVID-19, it will fail to flatten let alone plunge the epidemic curve. The MoH must change its old ways and immediately institute the following evidence based and best pandemic management practices.

a. TESTING must be ramped to below 5% WHO seropositive rate, better still less than 3%
Testing is a central pillar of clinical and public health response to the COVID-19 emergency. All testing modalities have a specific role but the one- size-fits-all approach by the MOH by mandating PCR in virtually all testing circumstances is a failure.

For surveillance purposes the MoH must shift from PCR to RTK-Ag testing. Just see the effectiveness of the RTK-Ag work-flow versus that of PCR.

Surveillance TESTING with RTK-Ag:
Day 1-Test. Day 1-RESULTS informed to patients. Day 2-Call case and ISOLATE. Day 2-Start TRACING

Surveillance TESTING with PCR:
Day 1-TEST. Day 3 -RESULTS. Day 5-Call case, Day 7-8 ISOLATE/Pick up for admission.

b. Testing via contact TRACING versus triaged, mass screening
Contact tracing is very slow because it is manually done and will only outreach testing to a few people eg household. It is thus very REACTIVE in nature, an anti-thesis to sound pandemic management.
Triaged mass screening is PROACTIVE since the hot spots are identified by Artificial Intelligence and larger numbers can be tested.
It will also pick up the asymptomatic and pre-symptomatic cases which make up 50-60% of the cases who would otherwise be unknowingly spreading the disease in the community.

c. FIND: Upgrading Contact Tracing from manual to digital mode.
Only 4% of Contact Tracing is achieved utilizing MySejahtera, The rest is undertaken manually using hardcopy forms, from registration to result.
This unnecessarily uses up a large amount of manpower. It is a very slow, laborious process and risk losing the close contacts.
SeLangkah automated Contact Tracing leverages on data science and machine learning. This use of digitalization is very fast, reduces manpower and minimizes error.
The other added value is its capability to FIND the potential hot spots as part of the holistic program of FTTIS.
This attached heat map illustrates the predicted versus validated attempts at forecasting sites for mass testing.
The forecast hotspots positive rates were 5%, 12.5% and 20.5%.
The forecast positive rates for the cold spots were 0%, 1.9% and 2%
This validates the accuracy of our digital TRACING of cases and FINDING of hot spots for mass screening to bust COVID-19 clusters and sporadic cases.

d. DATA SHARING
For the first time we are hearing detailed specifics of our healthcare capacity since the epidemic began. And surprisingly or not, it did not come from the MoH but from the PM himself.
It simply illustrates how secretive the MoH is and its refusal to share national COVID-19 statistics with major stakeholders.
COVID-19 trackers, nay the rakyat is totally flabbergasted because we are deprived of our daily data. Instead the researchers in Oxford and John Hopkins are more entitled and deserving of our daily COVID-19 statistics than us.
And what is even more amusing is that they and our guys in SeLangkah do more of the thinking and analysis underscoring the statistics than the MoH which only regurgitates the numbers like the scoreboard in the EPL.
The Singapore MoH has been uploading daily on its website a whole array of statistics related to the pandemic. In fact, there is also an interactive website of the data to enable stake-holders and news portals to compile, share, examine and feedback.

e. HEALTHCARE CAPACITY
Since the protection of the healthcare capacity is the raison d’etre of the MCO3.0, then I think it is reasonable to request for daily statistics of the utilization aka Bed Occupancy Rate (BOR) of the general beds, the ICU beds and the ventilators.
More pertinent data would include the following KPI:

a. A newly diagnosed Stage 3 case should be admitted to a COVID-19 hospital within 2 hours
b. A Stage 4 case should have access to an ICU bed within 1 hour
c. A Stage 5 case requiring respiratory support should have ventilator access stat aka immediately
d. A deteriorating Stage 2 case should be transferred to a COVID-19 hospital within 1 hour of SOS phone call
e. Asymptomatic, mild and stable Stage 1 and 2 cases presently nursed in COVID-19 hospitals should be sent for Home Isolation with clear SOP, like since yesterday.

f. ENHANCE PUBLIC HEALTH INITIATIVES
The government and MOH should support initiatives that enhance public health measures in industries, prisons, detention centres which are the epicentres of COVID-19 outbreaks and the health education of high risk populations eg migrant workers, refugees.

One such initiative is POIS (Preventing and early detection of Outbreaks at Ignition Sites) which is a tripartite government, private sector and NGO partnership which emphasizes early detection testing regime, enhances public health measures and health education of industry and migrant workers.
The POIS Initiative developed in consultation with industry and the WHO, truly embraces and operationalizes a whole-of-government and whole-of-society approach.

It is most demoralizing and financially destructive from the industry perspective when they volunteer testing of their staff and when the relevant agency learns of the positive cases, the factory is immediately ordered to be closed and fined.

The nation needs to shift from its “fire-fighting” and punitive (stick approach) mode of combating the pandemic towards a more preventative and sustainable program of empowering all its stakeholders, fostering a win-win partnership and getting a buy in from industries and citizens (carrot approach).
Awareness and understanding reinforced through strategic risk communications would encourage all stakeholders down to the rakyat to do the right thing and to do things right.

NGOs like IMARET, MRA, MERCY and Tzu Chi etc are doing a great job of engagement with the local community and especially with the marginalized communities who represent a disproportionate large proportion of COVID-19 cases due to their less than satisfactory living conditions eg migrants, refugees
All of these would remain futile if our leaders do not lead by example and walk the talk.

If the minister who preaches daily on TV about the nation’s pandemic situation is “cakap tak serupa bikin” and the head of the MOH practices double standards and allows exceptions to suit the whims and fancies of the politicians, then the nation will continually remain at the mercy of the coronavirus and doomed to a vicious cycle of MCOs.