Press Statement from the Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM) 25.1.2021, Kuala Lumpur

 

How to lose the war on COVID 


A year on after the first case in Malaysia and endless fire-fighting measures, it is clear that the Ministry of Health (MoH) is struggling for a comprehensive solution. This means that the rakyat and foreign workers will continue to suffer until perhaps the implementation of an effective vaccine programme.  

Have we gleaned the pearls from countries that are succeeding and that have failed? For one whole year, the rakyat have faithfully delivered what was asked of them. They have taken the toll, the pain and suffering of the hardship of the pandemic and its purported solutions. Yet, we are constantly dismayed and disgusted to read and hear about how our career politicians and leaders have failed to deliver their share of what is needed, i.e. stable leadership in this time of crisis.  

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 the private General Practitioners (GPs) in this war.  

The GPs, the unacknowledged frontliners, must be engaged and involved in a nationwide, meaningful and comprehensive private-public-partnership effort to help stem the tide.  

Who and where is the pool of infection?  

At present, exactly where the pool of infection is must be openly identified and addressed. The strategy of wholesale MCO-lockdowns based on geographical basis will clearly not work for the present disease landscape. Continuing with this will surely kill the economy and not the virus! The present active pool of infection must be analysed and segregated based on important socio-demographical parameters. We are informed that they were mainly the foreign workers in construction and manufacturing sectors in which case the mitigation measures must be aimed there and exercise with due diligence, care and compassion. However, it will also be pertinent to ask, what are the measures being taken to address the transmission between other undocumented immigrants, foreign workers who are living within the general community. Clearly, they are also likely to be the ones passing the infection in the community as they are directly in contact with you and me in activities of daily living; be it in supermarkets, restaurants, public transport facilities, etc. Until this is addressed and micromanaged, breaking the chain of community transmission by just locking up foreign workers in the other two major sectors or the population cannot be the answer. 

The present exponential  increase in daily infection is indeed very alarming. It is projected to hit 8000 new cases per day by mid- April, 2021. This would mean that the pool of infectious cases in the community would have now reached hundred of thousands, many of which will remain undetected and continue community spread.  

The COVID Assessment Center (CAC) is not the silver bullet. For one whole year, there have been no active treatment measures to reduce this reservoir of active infection other than by quarantine,  rest at home and admission to designated hospitals if tested positive. This modus operandi has resulted in an inflexible system that is unable to cope with the present escalation in numbers. We can envisage that the proposed CAC will be easily overwhelmed the moment it starts.

The work flow of the CAC process is cumbersome and too dependent on existing MOH manpower which is already overstretched. Furthermore, the CAC approach is not the only or the best way to manage patients and their families at home. The family doctor or the GP nearest to the home must be involved to give the personalised quality of care and clinical monitoring to detect the patients at risk of complications. GPs can also help in screening and testing of contacts. Why this was not clearly embedded into the CAC work process module is a testimony to the lack of seriousness in the call for meaningful PPP. Engage the GPs now It should be acknowledged that once you confirm a positive case in a household, it is very likely that the entire household would have already being exposed and perhaps infected. Many of the fine-tuned ideas of what families should or should not do is like closing the barn door after the horses have bolted. What families need to do is exercise sensible precaution and maintain household-based self quarantine so as not to spread the disease to others.  

A year ago, the FPMPAM had submitted to the MoH, a detailed proposal for a Private-Public Partnership programme to be implemented nationwide using existing nation-wide GPs and primary care doctors. At that time hydroxychloroquine was the rising star for COVID treatment. Today, other medications have emerged as possible treatment modalities. The proposed PPP programme called for “early diagnosis and early treatment of prima facie cases of COVID 19 at the GP/primary care level “ i.e. at the community level where the main pool of infectious cases lurks. It is aimed at reducing the size of this pool to below critical mass whereby it will no longer be a public health danger. It is aimed at supplementing the existing public health measures of testing and quarantine. In the proposal, the following points were highlighted:

  • The 7000 or more GPs, well-located around the country are the very resource that should be actively mobilised and equipped with the PPEs, the medications and the mandate to treat patients in the community. This was the other battle ground in Ground Zero that needs to be opened up.

  • The enormous GPs strategic capability in this protracted war should have been brought into force. Each GP seeing and treating up to 20 patients daily will be able, in a short while, 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 MoH should provide GPs with whatever currently recommended therapeutic options for Category 1 and 2 patients.

  • In the event mass testing is not feasible, the proposal calls for GPs to treat patients with prima facie evidence of the disease (presumptive diagnosis) based on accepted clinical criteria.

  • The aim is to treat large number of early patients in a short time to bring the infectious pool to below the critical mass in order to break the chain of transmission.

  • It is not unreasonable to envisage that it will also modulate the progress of the disease and decrease progress to severe disease and hopefully the number of hospital admissions.

  • As with regard to cost, it is clear that treatment of a presumptive case in the community setting will be way below what it will cost in the hospital setting. 


Addressing the Stigma of COVID To be inflicted with COVID is not a crime . Neither should it be looked upon as a social taboo. At this juncture, you will probably not know who infected you. It is just unfortunate and sometimes tragic. The present media narrative with threat of compulsory lockdowns, quarantine, isolation from loved ones, barbed wire with armed personnel carrying submachine gun casts a very negative image of the disease and its sufferers. It drives patients and those who may have asymptomatic disease to go into hiding which then makes accurate reporting and contact tracing even more difficult. 

The MoH needs to relook at its public media strategy to encourage people to come forward voluntarily. It is about time for the narrative to encourage full voluntary community participation. This strategy together with an efficiently executed vaccination programme will break the chain of transmission.  


 

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