This article first appeared in Forum, The Edge Malaysia Weekly on October 4, 2021 - October 10, 2021

Until Sept 20, Covid-19 had claimed more than 23,000 lives in Malaysia. Of this number, a large proportion — 19% of all deaths, or 4,472 people — were brought in dead (BID). That is, they died from Covid-19 before receiving any treatment at a healthcare facility.

In this article, we suggest three potential causes of BIDs and three solutions to the high number of BIDs in Malaysia. We also call for immediate action to understand the actual reasons and to reduce the number of such deaths.

First, citizens do not know when to ask for medical help as health literacy remains poor in Malaysia. It is poor for diseases in general and Covid-19 in particular. For example, while our secondary school curriculum does include content on health sciences, it is very basic and students are not tested on health literacy in any public examination.

The ultra-fast pace of social media and the challenges of fake or sensationalised news compound the issue, with the average citizen not knowing whom to trust. The ever-changing science and standard operating procedures of Covid-19 further complicate the already-poor health literacy of Malaysians. All this explains why many citizens may not know when, where, who and how to ask for medical help regarding Covid-19.

Second, BIDs are disproportionately represented by marginalised communities, such as perhaps foreign workers, those living alone, or the extreme poor. For example, foreign workers are up to four times more likely to be BID compared with Malaysians. This could be because healthcare is unsubsidised and is unaffordable for this group in Malaysia.

They may also face deportation if they do not have legal papers, amid conflicting statements from the health and home ministries. Communication barriers with healthcare providers are also a likely challenge faced by marginalised communities, including the Orang Asli. Commonly available healthcare materials on Covid-19 are mostly in English or Bahasa Malaysia, which may limit their understanding. Additionally, daily wage earners may not feel incentivised to seek treatment as their wages are tied closely to their daily output. All these create situations that discourage people from asking for medical help.

Third, inadequate testing and tracing strategies prevent people from knowing they are sick with Covid-19 in the first place. Malaysia is not testing enough, and has recorded a persistently high share of positive Covid-19 tests of between 12% and 15%, when the World Health Organization recommends a rate of less than 5%.

It is also likely that our contact tracing system is slow and incomplete, although we do not have data to show how quickly we complete contact tracing and its completeness. A combination of under-testing and slow/incomplete tracing means that we will not know who is infected. As at August, 91% of all BIDs did not even know they had Covid-19. Their ignorance is a double risk; they are at higher risk of being BID and they continue to spread Covid-19 in the community.

We propose solutions for each of the three causes. However, all solutions must begin with rigorous data research on the actual causes of BIDs. As there is never a single cause, all solutions must simultaneously address multiple causes.

First, we must increase the health literacy of all residents in the country. This means providing health information to society so residents can make good health judgments and self-risk-assessment. It is important to transparently provide granular data to the public and conduct appropriate analysis so the right information is disseminated. The press as the fourth estate must be encouraged to question and the government must, in turn, provide answers.

Certain populations, such as older age groups, those with lower education levels or lower household incomes, have been identified as having relatively low health literacy. Efforts must be targeted to encourage positive health-seeking behaviours in these groups, using appropriate culture-specific language, vocabulary and media.

Obviously, it is important to deliver messages in the language the intended recipients are comfortable with. This would include providing available materials in languages such as Mandarin, Tamil, Iban or Kadazan, or for the benefit of our foreign workers, Burmese, Nepali or Hindi.

A targeted education effort requires an all-of-government approach, with the Ministry of Health cooperating with the Ministries of Education; Communications; Women, Family and Community Development; and Youth and Sports. Health information must be easily accessible and in digestible “chunks”.

Second, we must systematically remove the barriers to access healthcare for at-risk groups. Currently, Circular 10/2001 of Malaysia’s Ministry of Health obliges all healthcare providers to report undocumented foreigners to the police and immigration authorities. This decision has led to 20 years of foreigners gradually losing trust in public healthcare in Malaysia. Therefore, decoupling healthcare services from law enforcement is the first step to encouraging undocumented foreign workers to seek medical help, a move that will also protect Malaysian citizens.

Separately, we have to vaccinate foreign workers more quickly and more effectively. The World Bank estimates the number of irregular foreign workers in Malaysia at as many as four million. Non-governmental organisations (NGOs) must be empowered and enabled to carry out mobile vaccination stations, especially in industrial areas where large populations of foreign workers reside.

A good example of NGO outreach is the health clinic for Rohingya refugees organised by MERCY Malaysia. Additionally, the government should widely publicise the eligibility of foreign workers for walk-in vaccinations. These efforts can be complemented by targeted communication campaigns to other foreign workers.

We must also find ways to reduce the financial burden of treatment for at-risk groups, including Malaysian citizens. As most of them are daily wage earners, incentives such as paid leave during quarantine, testing or vaccinations are important to encourage them to seek medical attention.

In addition, we must remove the negative consequences for employees calling in sick or not reporting symptoms, such as wage cuts and firings. This will encourage testing and increase the pick-up rates for Covid-19. This is especially important because home test saliva kits are now available and we must make it easy, worthwhile and consequence-free for ordinary citizens to report positive tests.

Third, we must strengthen our testing and tracing capabilities and then communicate this information as widely and quickly as possible to communities. The ceiling price for self-test kits is a good policy, and will allow for easier access to testing by reducing financial barriers.

However, further reductions are needed as the current RM19.90 per test ceiling is steep for those from the B40 (bottom 40% income group) community, especially for multiple tests. A B40 family of five will use 6% of their average household income (RM3,152) just to get tested twice a month.

People must feel incentivised to test and report positive results, without fearing negative consequences like social stigmas. If people are not encouraged to report positive test results, they may hide their status but continue to participate in societal activities, further spreading Covid-19. Additionally, it will lead to inaccurate data on Covid-19 cases, which is harmful as it reduces the public’s ability to make informed decisions. Both will increase the difficulty of managing the pandemic and reducing the number of BIDs.

Reducing BIDs requires a multifaceted approach. Neglecting one aspect of it will lead to a knock-on effect that may derail any progress against the pandemic. BIDs at the beginning of the pandemic may be inevitable, but 20 months into the pandemic, any BID constitutes a policy failure. We can, and must, do more.

John Paul Sim is a medical undergraduate, Dr Khor Swee Kheng specialises in health policies and Dr Sean Thum is in specialist psychiatry training.

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