By Ooi Kee Beng in Penang Monthly, April 2022
ON MARCH 12, 2022, Tan Sri Dato’ Seri Dr. Noor Hisham bin Abdullah, Director-General of Health for Malaysia, was awarded the inaugural Dr. Wu Lien-Teh Award for Leadership in Public Health by The Dr. Wu Lien-Teh Society in recognition of his leadership of the healthcare sector during the Covid-19 pandemic, and for revolutionising a new approach for affordable drug development to eliminate Hepatitis C. At the event held at Penang Institute, he delivered a public lecture titled “Steeling Up Against the Omicron Storm – Is Malaysia Prepared?” as the 6th edition of the Dr. Wu Lien-Teh Public Lecture, regularly co-organised by Penang Institute and The Dr. Wu Lien-Teh Society.
Penang Monthly met up with him before the lecture for a short chat.
Ooi Kee Beng: Welcome to Penang Institute, Tan Sri Dato’ Seri Dr. Noor Hisham, and congratulations on the well-deserved award. How surprised were you at suddenly becoming a celebrity, and even a global celebrity?
Noor Hisham: Well, it’s not about me; it’s not about the Director-General; it’s not about the position. I was appointed Director-General on November 14, 2012, and the confirmation was on March 1, 2013. So, over the years I have been doing my job. But maybe the optics were different. In early 2020, there was no government in place; we had to take over and make the decisions. I had to step forward for two weeks as there was no government then. We had to address a lot of issues, deciding on what was certain and what was unpredictable.
There was a lot of fear among the public, you know; so we had to decide on how we were to address the fear and the anxiety. To calm the public, we had to base our information on science, on facts and on data. It’s just like me talking to a patient. If the patient has cancer, how do I break the news to them? And that’s not the end of it. How do we now move forward to overcome the cancer? Instead of one patient, you have to address the nation.
This is why I think this pandemic Covid-19 has given us an opportunity to get people together, using the whole-government-and-whole-society approach. We are facing a health crisis, a pandemic, for the first time in many people’s lives.
Then there were the economic issues. When you lock down, the impact on businesses is enormous, of course. There was the political crisis as well. We were facing three crises in one go. So how do we handle this? It was important for us to calm the public, and to take things one day at a time. Using what we learn about the behaviour of the virus, we adapt slowly. Using the same knowledge about the behaviour of the virus, we look at the situation and continue to understand Covid-19, and we adapt our measures, step by step to it.
OKB: And all this was happening at a time when there was no reassurance globally either. Nobody knew much about the virus.
NH: So, we had to be very conservative at that point in time. There were mainly two approaches. One was the herd immunity approach. This is a very risky way: You allow the infection to spread, and hopefully, the community builds up sufficient natural immunity. But the risk is that the vulnerable population dying from the fatality can get very high. This is what was practised in Sweden, and in the U.K. initially. But when the death rate exponentially increased, they had to stop it, and the King of Sweden had to apologise to the public. They had thought that only the older age groups were vulnerable, but it turned out that younger age groups were also affected, and this overwhelmed the healthcare facilities.
We have the experience of handling SARS and MERS-CoV, and we always use the prevention-and-control method, which simply means we try to avoid getting infected. So, our initial strategy was the use of public health and social measures, and advising the public to stay home. We were not certain how the virus spread. So we suggested wearing of the mask in public, physical distancing, frequent hand-washing, and avoidance of crowded places and of poorly ventilated, confined spaces. All this was basically external protection. People had no antibodies against this virus, and there was no vaccine yet. That’s why our strategy initially was totally different.
Compliance is important, and the public must understand why it is being done. The lockdown that we suggested was a short one. It was for two weeks, and we then had to extend it to four weeks. We started on March 18, 2020. By April, we were almost flattening the curve. By July, we managed to have three days with zero cases. But then, how long can you stay at home? I think when compliance got poor, that was when the infections started spreading. We were looking at the possibility of increasing testing, to detect and break the chain of infection. So we had an increase in terms of RTK antigen testing. In January 2020, our testing capacity was about 1,000 a day. Now with the RTK antigen, I think we can reach up to 250,000 a day. So we had the means to test; we also needed vaccination coverage. Negotiations were ongoing during that period of time, while a lot of clinical trials were being done.
In December 2020, the U.K. and the U.S. started vaccinating their population. We started vaccinating our population in February. We had three stages of vaccination: First, priority was given to healthcare workers and those who were vulnerable; second, we vaccinated the adult population, and then we moved to adolescents and now children. So, all this was based on science and data.
So that’s how we changed our approach, from prevention and control to herd immunity; and now we practise both. Apart from testing and vaccination, as well as public health measures, we also carried out trials with Ivermectin and such. Looking at some trials, we thought they were not being done correctly. So we did our own clinical trials. And sure enough, these showed that there was no difference when using Ivermectin at an advanced stage. We are still doing a trial on Ivermectin and looking at prophylactic use to see whether it works or not. We now have a new antiviral, Paxlovid, which shows about 89 to 90% effectiveness in stopping the progression from early stage to advanced stage. And we also have Molnupiravir.
OKB: You now have quite a good toolbox.
NH: Yes. A good toolbox is now available. So, why wait? We can now open up.
The vaccination coverage now is 99% for adults, 91% for adolescents. About 66% have received a booster shot. Among children between five and 11, about 31% have had a single dose. So we now think we are able to take a herd immunity approach. Our strategy now is to open up all sectors – economic, social and so on – but still encourage public compliance. I think we can strike that balance.
Hope for the Best, Prepare for the Worst
OKB: So, is the worst over?
NH: We hope so. But whatever we say, we must prepare for the worst, and then hope for the best. Now with the existing virus, Omicron, we know it is less severe than Delta. Nonetheless, it is still dangerous for the vulnerable population, for those unvaccinated, the elderly, and those with comorbidities or non-communicable diseases. We think that now there will be a move towards a pandemic of the unvaccinated. That will come. For all of us who have been vaccinated, if you get infected, you will have mild or even no symptoms. We have seen this with Omicron: 99.5% are in Categories 1 and 2, with mild symptoms. Only probably 0.5% are in Categories 3, 4 and 5. And those, we can also treat.
Compared to July or August last year, although cases are high now, there has been a decoupling effect; admissions are still very low, our capacity and mobile system are still able to handle it. At 40% utilisation, our ICUs are still able to manage. We continue to treat non-Covid cases in hospitals, unlike last year when we had to cancel all the elective cases. In fact, we have no need yet to send such cases to private hospitals. Having that capacity, we have the room to monitor things closely.
But there will be a caveat. If we should see a new and virulent variant appear, then we have no choice but to go back to Square One. But right now, the dominant variant is Omicron, not only in Malaysia but all over the world. And if that remains the situation, I think we can live with the virus, and hopefully, with herd immunity among the vaccinated and among the 3 million who have recovered, we can control the disease and move forward.
OKB: From what we know about this virus, or viruses in general, we can’t really predict if the next variant will be worse for us, can we?
NH: What we know is that the virus will continue to mutate. We hope for the best, but whatever the case, our system must stay robust enough. If there is anything we can learn from this pandemic it is that: First, we have to work as a team; second, we must continue to adopt digital tools to monitor and to manage high patient load. We should monitor them using virtual tools, and consultation and monitoring can be done at home, for example.
Initially, we had a simple MySejahtera, then MySJ Trace and then Gerak Malaysia. The last was used by the police to control cross-border travel. MySJ Trace is basically Bluetooth-based. We decided that we could not have three systems; it would confuse the public. So, we stuck to MySejahtera, which now has the MySJ Trace function within it to make you aware that you have been in close contact with an infected person, and that you should do self-testing.
OKB: I suppose some version of MySejahtera will become the basic and even permanent tool for public healthcare management…
NH: It is a new and effective tool. Over the years, we have handled many epidemics, like SARS and MERS-CoV. We did not have digital tools. Now we do, and we will enhance it. MySejahtera can manage vaccination appointments; a lot of things can be done with it. In fact, with the information and geo-location that we have on non-communicable diseases (NCDs), we can take a more targeted approach now. There are endless possibilities using technology to enhance public healthcare.
OKB: So, in Malaysia, healthcare could be the major driver for Malaysian e-governance, you think?
NH: There is a transformation in healthcare through digital means. It can be very efficient. As you may know, we are able to monitor as many as 600,000 patients at home, using MySejahtera.
I wrote a paper a while ago, on the Uberisation of healthcare; on the process of bringing health services to individual homes. We started this 10 years ago, providing pharmacy services; the patient does not need to come to the hospital to collect the medications, instead we send them home to him or her.
So it’s about bringing health services to the community. In psychiatric treatment, we now have Mentari clinics. Such interventions as were done in hospital can now happen in Mentari clinics. In Jalan Ipoh, we converted a four-storey shop lot into an operation centre, and we are able to do 30 operations a day – cataracts, etc. This has been going on for 10 years. And the results show that these clinics function better than any hospital, public or private; you get quality in terms of low complications, and you get high efficiency.
Clearing the Backlog
OKB: Sounds like you have a good chance to make the most of the crises.
NH: That’s just it. Every crisis has its opportunities. So now the opportunities are in terms of healthcare transformation, and in health-seeking behaviour, looking at mental health services, and also especially non-Covid cases now. Having had to shut down elective care because of Covid, we now have a bad backlog. How do we clear this backlog?
Again, we work with the public, pro bono. For example, just the other day we focused on treating renal stones – we have a unique way of removing the stone using keyhole surgery. We got surgeons from the public and private sectors in Damansara and had a four-day carnival, basically just to clear cases; like gotong-royong, if you like. We opened up all the theatres, four or five of them running concurrently. We managed to clear 62 cases. Recently in Tawau, we did the same thing – mass cataract operations were needed because there was a backlog there. Within four to five days, we managed to clear about 200 cases. Again, we brought in specialists from the public and private sectors, and we brought in equipment from the public sector, with some companies sponsoring. And then we cleared all the cases.
With digital means, with coordination and engagement, all this has become possible. Importantly, we now have social media. We can keep the public informed. We update information every day. We can engage with people, explaining the issues and challenges and managing expectations. That way, we win public trust. We calm the public down so they know what to do and what not to do. So that’s important, the using of social media.
OKB: And always maintaining your reputation as scientists and service personnel…
NH: Yes, no politics at all, just back to basic scientific facts and data.
OKB: Can you say something about your relationship with politicians during the long crisis?
NH: We need the politicians to engage with the public, and we need to provide them with the right information. So I think they have a role to play. The politician is closer to the community, and can disseminate the right information to the community. It’s important to win public trust, for example, in encouraging people to be vaccinated.
And we must be coordinated. For example, if we want to lock down one area, then we need to provide facilities and food, et cetera. So other agencies have to come in to help us, and to provide security as well. So we need the whole-government-and-whole-society approach to solve such big problems.
OKB: Malaysians have been suffering along with the rest of the world these last two years. What are your views on the types of suffering people have been going through? Covid-19 must have left a string of psychological traumas along the way.
NH: Yes. The public must now adapt to the new situation, the new norm, as we call it. They must first understand the issues and challenges so that they know what to expect. There has definitely been a strong impact on mental health – staying for long periods at home, not socialising, and on top of that, the economic slowdown and challenges.
But you know, we cannot look at this only from the health perspective. We need to involve all sectors – NGOs or other ministries – to address the issues. But it must not take too long. Once we can tackle health issues enough in order to open up, then we can focus on mental health issues. So now, I think the key is to increase the vaccination rate; once the vaccination coverage is good, there’s nothing to stop us opening up.
We should move towards opening up, but we also do not want to open up and then close and then open up and then close again.
OKB: You need to maintain public trust in you, of course.
NH: Yes, we must not lose public confidence. Now, with vaccination and with public health measures, we can quickly move forward.
OKB: Should governments at the state and federal levels, in your opinion, invest in a national programme for the future?
NH: Yes. Obviously, I think we need the federal government and state governments to coordinate in terms of information, and also because we are not only dealing with health issues here. It’s about daily life issues, economic, social, religious, education, et cetera.
OKB: We’re talking about social habits and public behaviour here, right?
NH: Yes, public behaviour changes are important now. We have to move towards health-seeking behaviour. For example, a simple thing is cleanliness. How can we increase the cleanliness of our population? We always talk about public toilets in our country and compare them to those in the West. We should do something about it.
I think we have to cultivate a mind-set for cleanliness, frequent hand-washing. If you are out and are not able to exercise physical distancing and you get infected, at least you have the vaccine or neutralising antibodies. So this is why we need both external and internal protection; external means taking public health measures, and internal protection is vaccination. But apart from prevention, we also need to have treatment available; if you are in a high-risk group, we can use antivirals on you. These are the strategies in place. With these, the country is ready to open.
OKB: Over the last two years, you would have seen your health apparatus, you know, the distribution of medicine and information, tighten up greatly.
NH: The technologies had been available, but there was no push for us to use them. Now, we are very familiar with videoconferencing, for example. So we need to use that to enhance our healthcare services. Once we have the habit of using these technologies, we can make full use of the digital healthcare system in place; we can bring the system to the home and to the community. It’s a win-win situation for us all to embrace these technologies.
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OKB: That would be one of the most positive things to have happened during Covid-19.
NH: And it can help us prepare for the next pandemic as well.
OKB: And the people’s digital literacy is now much better.
NH: I think this is one interesting step forward. In China, they don’t use currency anymore; everything is digital now. All this is going to transform the way we do business; the way we conduct meetings, et cetera. So we want technology to push us towards health-seeking behaviour. It’s more efficient, has a higher impact, keeps costs reasonable, and brings good outcome.
OKB: Let me ask you one last question: How difficult was the process of deciding on April 1 as the day for Malaysia to open up?
NH: Earlier, there was a suggestion for us to open up on March 1. Where the vaccination campaign is concerned, we are about two or three months behind the U.K. and Europe, and we saw that they were having an Omicron surge. Looking at the data, our Omicron surge would just be beginning in March. So, we anticipated that probably only by the end of March will we see a descent in cases.
At the moment [March 12, 2022], we are now reaching a plateau, and I do think the cases will go down by the end of March. We had thought March 1 was too early, so we asked for a delay. Secondly, we want to see if there’s a decoupling effect or not. We don’t want it to be a mere short-term change, and suffer a rise in hospital admissions.
We noted a spike up of 33,000 cases, but admissions remained manageable. On August 26, 2021, we had a spike up to 24,600 cases and the hospitals were pretty congested, and there were at the same time 100 or 200 people waiting in the emergency department for admission.
So, this time, we do see a true decoupling effect and that gives us the confidence to move forward. We also look at the infections coming from overseas, and these are much less than local transmissions. Local transmissions make up most of the transmissions; so, given all that, I think we are able to open up.
OKB: Thank you so much, Tan Sri Noor Hisham for taking the time to speak to Penang Monthly. Good luck to you, and to all of us in the months ahead. We all hope for the best.
 Noor Hisham Abdullah: “The uberisation of healthcare in Malaysia”, 9 March 2019, in The Edge: https://www.theedgemarkets.com/article/uberisation-healthcare-malaysia#.YixlD_QWF2U.whatsapp.