It has been a surreal start to the second decade of this new millennia, to say the least. What began as a distant murmur of a threat has now reached many shores, taking with it scores of lives including our brave colleagues in the medical fraternity.
Right now, the most famous man in Malaysia is an endocrine surgeon who in 2018 was awarded the Fellowship Ad Hominem of The Royal College of Surgeons of Edinburgh (RCSEd). As to why this is so, he has been addressing the nation for the last two weeks on a daily basis – telling all of the tally of cases daily, giving condolences to families of patients who succumbed to the pandemic, reassuring the people to stay home and keep the fight, explaining in detail the setbacks and the plan forward. In short, he projects hope to the anxious well, and commands respect from the troops on the battlefront – urging them forward and standing ground against an unprecedented threat of the modern times.
Malaysia entered the Coronavirus conflict in late January with a few imported cases, which later exploded with the infamous Tabligh cluster in March. This became one of the largest contact tracing exercise ever conducted in Malaysia, with help from the police in the manhunt of virus reservoirs. This became the first test for the emerging victor of the well-publicized power struggle for control of the country. Luckily the Prime Minister pulled through, declaring a nationwide Movement Control Order, an unprecedented move since the last racial riots in 1969. A few more additional clusters appeared soon after, forcing a more draconian measure to further restrict movement in areas of high transmission rates, effectively the largest military enforced curfews during peace times. This doctrine has the one mission – to flatten the epidemic curve.
Semantics aside, there are lessons to be learned and shared from how Malaysia has fared so far in handling the Coronavirus scourge – from the perspective of surgeons.
Harnessing the natural leadership of surgeons
Surgeons sometimes end up helming as the chief in charge of a given hospital, perhaps for the charismatic leadership often portrayed or for the tenacity and intensity showed in the pursuit of uncompromising quality. As an example, the teaching hospital affiliated to the Faculty of Medicine, UKM – the Chancellor Tuanku Muhriz Hospital (HCTM), is headed by a Vascular Surgeon, also a Fellow of this prestigious college. Can a surgeon handle the rigours and challenges of preparing a hospital to face the COVID-19 crisis?
Regardless of the technical background, experience or lack thereof – in an unprecedented crisis like this, the leadership must be strong, consistent and responsive.
Surgeons are not epidemiologists, but the approach to mitigating this pandemic share familiar concepts. Resources are scarce as a result of a surge in demand. Some form of effective infection-preventing workflow to keep infection away from the healthcare worker needs to be implemented. Adequate containment of the disease requires the distancing of healthy at risk individuals away from the infected victim. Terms such as triage, asepsis technique, adequate margins, and tissue clearance consecutively have useful analogous meanings as surgeons in management positions make important decisions to safeguard the lives of hospital staff whilst delivering essential frontline services.
Break the chain of infection; Preserve the continuum of screen, test and treat
Malaysia’s primary strategy remain unchanged – contain and treat, while it is still in the late containment phase. To prevent an overwhelming surge of patients admitted to hospitals, it is imperative to minimise false positive cases to the lowest possible number. For this, the choice to use RT-PCR prevails until proven otherwise. However, much criticism has been placed on the Malaysian Ministry of Health’s strategy to only use RT-PCR diagnostics in the management of COVID-19 cases. This decision somewhat hampers population wide testing for the infection, as the RT-PCR is labour intensive and time consuming. As surgeons, we are reminded of the Foecal Occult Blood Test fallacy, and controversies in the screening of Prostate and Breast Cancers. Point-of-Care Testing (POCT) is touted to be the ultimate solution, but many of the new kits remain technically inadequate. Even with RT-PCR, this test itself has its own nuances – differing reagents, workflows and sampling methods produce significant deviations.
Engineering system resilience under times of strain
This global pandemic undoubtedly shocks the system to its core, rendering business unusual as the prevailing scenario. The ability to collate and divide the forces into new service streams quickly and effectively is paramount to transform existing workforce structures to meet with the new demands of dealing with the coronavirus phenomenon, both technically and the care burden tsunami
The power of networks to bridge gaps
No one single hospital plays a so called central role – each is only a part of the healthcare system and the larger global network. When one goes down temporarily another takes up the slack until the last one standing. In Malaysia, the public hospitals of the Ministry of Health take up the primary front – both for the care and testing needs of COVID-19 cases. As the situation changes, through ministerial leads, other facilities from the Ministry of Higher Education (MOHE) and Ministry of Science, Technology and Innovation (MOSTI) were roped in into the cause willingly.
Perhaps the most important thing to note from the Malaysian COVID-19 experience is that despite having what is essentially a hanged government just days before the Movement Control Order being implemented, the public health services remained intact and fully ready to combat this disease at a national level. The integrity of the national health system remained strong and committed regardless political turmoil. It was not the power of the parliament that contributed to this, but rather the professionalism and the commitment to uphold the highest standards of care by Malaysian healthcare professionals, both in the public and private sector. Let it be known that our solidarity, and of others in the healthcare sector matters in this global fight. Encourage partnerships and collaboration, wherever you are and in whatever you do for the sake of the battles ahead. We will not be spared of failures and desperation, but we shall persevere to protect what we hold dear.
Professor Hanafiah Harunarashid, Director Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia (UKM), International Surgical Advisor, RCSEd.