In recent times there has been a spate of pictures and videos of patients (some even with private parts exposed) being circulated in the social media, especially Facebook.
Some may have originated from medical staff and some from members of the public.
Whatever the source, people need to know that these acts are a serious violation of patient privacy and should never take place.

We have been informed of a recent set of guidelines from the Ministry of Health on the use of social media in healthcare provision. You can view a copy of it here

These guidelines are timely as there is never been a more urgent need to protect patient privacy and confidentiality. In the age of the social media, pictures and videos can circulate like wildfire and it is of utmost importance that these pictures and videos should never be taken and shared inappropriately in the first place.

Here are some excerpts from the guidelines:

6.1 Features of a good social media platform that can be approved and used for group consultation:
a. Shall have a moderator
b. Platform shall allow the moderator to invite/remove the member of the group
c. Member profile can be easily identified and traced
d. Membership numbers can be controlled and limited
e. The content of conversation is not accessible to public

6.2 Currently, the following social media platforms are prohibited:
a. Facebook
b. Twitter
c. Instagram
d. Blog
e. Youtube

6.3 The list of prohibited social media platforms will be reviewed periodically.

7. Prohibition
7.1 Social media platforms shall not be used for consultation between

a. HCPs with their patients;

….

7.2 All personal information or images from any consultation shall not be used for the purpose of health education to individuals or members of the public.
7.3 Social media platforms shall not be used for referral of cases, as such referrals

Doctors please note that Facebook is now a prohibited platform and should not be used for group consultation. We still see this happening in some Facebook groups for doctors. You should know that nothing is secret even in so called “closed” or private groups since it’s so easy to share out in Facebook including taking screenshots and we often see fake or hacked accounts on Facebook so it is difficult to control people browsing any group on Facebook. You should also not use Facebook messenger to seek consultation from other doctors and certainly not use Facebook messenger or any of the prohibited social media to give medical advice (to other doctors or patients).
Some secure messaging platforms are popular amongst doctors e.g. Telegram and Whatsapp (both of which now have strong encryption) which are more “controlled” in the sense that group members are identifiable but the danger is that any information in the group can easily be shared out if it gets in the wrong hands. These social media messaging platforms are still “public” since in the broad sense they are are being used by not only doctors but other members of the public. So doctors, please beware.

For doctors, you should use strict doctors only platforms where details of discussions are not accessible by the public. For Malaysian doctors, you can consider using Dobbs Forums or the new upcoming Docquity platform which is a secure platform for doctors available to members of the Malaysian Medical Association but will be open to members of other verified doctors only networks (including Dobbs). Docquity is currently in beta and open for use by invitation only. The app is freely downloadable but the account cannot be claimed and used unless you are a registered Malaysian doctor and an MMA member.

For doctor – patient consultation you should NOT use Facebook or any other messaging platform which does not have the ability to strictly identify the patient (face to face consultation), and is not strongly encrypted. You should only consider a HIPAA compliant
Telemedicine platform such as RingMD which is a simple to use app based platform by which patients can connect to doctors of their choice for online consultation. Malaysia does not have a HIPAA and only a general PDPA, but HIPAA being so strict, it would be a superior benchmark if you are concerned about patient privacy.

(image credit : The Star)

By Dato’ Dr. Lee Yan San
(Consultant Physician & Medical advisor to Penang Diabetic Society)

Diabetes Mellitus is becoming more common and is a major cause of severe medical complications and early death. Fortunately, although diabetes cannot be cured, it can be controlled and those who are well controlled can enjoy good living and even normal life span.
Here are some facts which may help to improve diabetic care in Malaysia.

Regular follow up by your doctor is essential to avoid any chronic diabetic complications. I have noticed that many of those who do not have regular follow up by doctors or self treated with poor control are now under treatment for chronic complications of diabetes. Pharmacists are qualified only to explain how the drugs work and its side effects but are not qualified to advice on treatment, and should leave this to the doctors.
Since Type2 diabetes is now much more common and is responsible for many chronic complications due to poor control which can be avoided, I shall stress on Type2 diabetes in this article.

Some Salient Points on Diabetes
Young Diabetics are usually Type 1 and those who started having Diabetes at an older age (especially after 40 years of age or so) are usually due to Type2.
Management of Type 1 diabetes and Type 2 are completely different. There is urgency to
treat Type 1 diabetes which requires urgent Insulin treatment to avoid having acute complications
like ketoacidosis leading to death if untreated. It is important to be certain that the patient do not
have Type 1 diabetes as they do not response to oral medications and require Insulin treatment.
Type 2 diabetes:
Type 2 diabetes is a slow onset metabolic disorder characterised by defect in insulin action (such as insulin resistance) and abnormality in insulin secretion. It develops very insidiously over months and even years until clinical symptoms make patient aware of it. To avoid finding out that your have Type 2 diabetes before complication arises, you should have a post prandial (after food) blood sugar taken routinely. For Type 2 diabetes, it is helpful to have post prandial blood sugar taken as in many early cases fasting blood sugar can be normal in spite of you having Type 2 diabetes.
Type 2 diabetes are often diagnosed during routine examinations.
In established Type 2 diabetes, the basal liver glucose output is increased. In fact, some researchers even believe that the liver may be the prime defect in Type 2 diabetes and are looking into this possibility!
Pancreatic -cell failure:
Unlike Type 1 diabetes where there is complete destruction of the pancreas, Type 2 diabetes still have some pancreatic (-cell) function. The main abnormality is impaired glucose-induced insulin secretion.
Insulin is normally secreted by the pancreatic -cell in two phases in response to as little as 90mg% of glucose in the blood in a normal person. The first fast phase which releases a larger amount of insulin is from granules containing already made insulin in response to the level of glucose in the blood.. This is followed by the slower second phase of newly synthesised insulin.
The main abnormlity in Type 2 diabetes is the absence of the first phase. In such patients, the pancreas cannot response to a heavy glucose load but is able to cope with small even intake of carbohydrate. This is a very important fact for good control. Patients must be advised to take small frequents meals and spread out their food intake to achieve good control.
However, in the late stages of Type 2 diabetes there is exhaustion of -cell reserves and thus very little insulin is secreted. At this stage, patient will need insulin treatment.
Insulin Resistance:
Insulin resistance is presently considered one of the more important factor in Type 2 diabetes especially in the obese. Insulin resistance leads to reduce ability of insulin to promote glucose uptake in muscle and fat cells thus patients will need more insulin. Insulin resistance ultimately also suppresses liver glucose production after meals. Exercise will reduce insulin resistant.
Presentation of Type 2 Diabetes:
Blood glucose is so easy to do and should be done at the slightest suspicion to avoid missing Type 2 diabetics in the elderly.
Many diabetics present with infection especially skin infection and PTB infection. New cases of Tuberculosis infection must always be screened for diabetes.
Management of Type 2 Diabetes
Type 2 diabetes has a very insidious onset and may be prevented by proper diet, exercise and weight management. Both genetic factor and environment are important in the development of Type 2 diabetes. Two large trials have recently shown that it is possible to interrupt progression to diabetes by rigorous correction of diet and exercise in susceptible individuals.
The United Kingdom Prospective Diabetes Study (UKPDS), the largest and longest study of patients with type 2 diabetes, conclusively demonstrated that improved blood glucose control in these patients reduces the risk of developing retinopathy and nephropathy and possibly reduces neuropathy (nerve damage).
UKPDS also showed that aggressive control of blood pressure in diabetics, significantly reduced strokes, diabetes-related deaths, heart failure, micro-vascular complications, and visual loss.

Criteria for good control
During the earlier days, we do not have Glycocylated Haemoglobin (HbA1c) test to help us in our management. (For every percentage point decrease in HbA1c (e.g., 9 to 8%) there is a 35% reduction in the risk of micro-vascular complications.) We therefore have only to rely on blood sugar levels.
As for blood sugar level, from my experience and logically, I feel that for Type2 diabetes, we need to rely more on Post Prandial Blood sugar readings rather than only fasting blood sugar for better control.. It stands to reason that it is no use having good fasting level but the rest of the day, blood sugar levels are way above11 mmol/l mainly from uncontrolled diet. (I have in fact received a number of referrals from ophthalmologists whose patients have poor diabetic control with various eye complications. Many of them in fact do have regular diabetic follow up by doctors before but have just rely on fasting blood glucose alone as an indicator of good control but when I did their random blood sugar after meals, the level was astonishing high; some even over 20 mmol/l! No wonder they are having such complications of diabetes. This is because in such patients the abnormality is mainly caused by defective insulin secretion in the pancreas in response to sugar in addition to insulin resistant. During fasting, when there is no food intake, the pancreas is able to cope since the pancreas is still able to secret some insulin at a time.)

It is better to give the lay person a target for control and I usually tell them that they should try to have the blood sugar level in the 5-8mmol/l range at all time. I am usually not too worried about the Fasting blood sugar being a little above the target level occasionally if non of the 2 hour post-prandial blood sugar goes above 8. Nowadays with the availability of HbA1c, I also try to aim at HbA1c below 7 and if possible below 6.5 as recently recommended which will also reduce risk of coronary and stroke but it is often more difficult in the more elderly patients whom I am very concerned of hypoglycaemic attacks which may further damage their already poor mental function.
I encourage diabetics to buy a glucometer and do their own monitoring. Most of the tests should be two hours after each meal. They can also do tests on waking before taking breakfast, 2 hours after each meal and just before going to bed. Unfortunately, most patients do not want to do their own monitoring. I usually ask such patients to come and see me randomly 2 hour either after breakfast or after lunch. On the appointment day, they are advised to stick to their usual daily routine and activities including taking their normal usual meals so that the reading will reflect their everyday situation as much as possible. I try to keep their 2hr post prandial blood sugar range between 5-8 mmol/l. None of the readings must go above 8 mmol/l. From all the reasearchs, you can avoid complications if blood sugar is leass than 10mmol/l. Recently, it was discovered than if blood sugar at all time is less than 8mmol/l, you can also avoid getting heart attacks and stroke.

Recently, researchers have agreed that it may be better to focus on lowering the after-meal blood sugar instead of just the fasting blood sugar to bring down HbAlc values thus better control.
A study using 25,000 subjects over a period of 7 years also showed that increase mortality risk was much more closely associated with 2hr pp than fasting blood sugar in Type 2 diabetes.
The main factor for poor control in my opinion is not just medication but doctors not spending enough time explaining to patients patiently what diabetes are all about and how to control their diet and encourage exercise. Patient’s understanding of the underlying pathology and problem will made them more likely to follow the doctor’s advice and thus have better control. They will understand why we stress so much on diet and exercise. Constant reminders of the proper diet and adequate exercise are very important.

Diet, Exercise & Weight Reduction
Diet and exercise should form the main stay in managing Type 2 diabetes. Patient should be encouraged to be active and involved in regular exercises. They should avoid any weight gain through inactivity. In some recent studies (Chinese & Finnish studies) as much as 58% can be prevented from getting Type 2 diabetes with diet and exercise. They were found to have increased -cell mass in the pancreas.
If patient is obese, the first line of treatment should be concentrated on loosing weight. Weight reduction can usually be achieved by increased activity and reduced calorie intake. Weight reduction itself often is enough to control the Type 2 diabetes as obesity causes insulin resistant.

Diabetics should avoid taking sugar completely. Fine starch should be avoided as it is easily digestible and turn into sugar thus lead to peaking of blood sugar. It is best for diabetics to take starch containing a lot of fibres such as whole meal bread and unpolished rice. Patients should take a high fibre diet with large amounts of vegetables. They should avoid heavy meals and space out their intake into small frequent meals.

Oral Hypoglycaemic agents
We shall need to use oral hypoglycaemic agents if diet, exercise and loosing weight is not sufficient to control the diabetes.

Treatment with Insulin
Insulin treatment is required for Type 1 diabetes. For Type 2 diabetes, it may be necessary if diet and oral hypoglycaemic agents are not sufficient for good control. Many types of Insulin are now available and your doctor will choose one that will be most appropriate to your life style.

Monitoring
Monitoring is important and you should have a home monitoring gadget to make sure that
your diabetes are well control over 24 hours.. There are five times you can monitor your blood sugar which is fasting, 2 hours after breakfast, lunch and dinner and before going to bed. Do not just do fasting blood sugar but alternate the time to make certain your diabetes is well control 24 hours and not just in the morning when you wake up. Doing post-prandial blood sugar will also help you control your diet.

Telemedicine is something quite new to Malaysians in general, and for both patients as well as doctors. But in this modern era of fast broadband and mobiles, imagine if you could consult with your doctor wherever you are, perhaps from the convenience of your home. You might prefer this rather than having to beat traffic jams, finding a parking spot in busy hospitals or clinics and having to put up with long waits at the doctor’s office.
Telemedicine would also be particularly useful for homebound patients, if you are unable to travel to the clinic/hospital or if perhaps you might be overseas and urgently need to speak with your doctor.
Some might be hesitant using this technology but modern Telemedicine allows you to consult with your doctor Face to Face, just like you would with a real visit to your doctor. While the doctor cannot examine you, real time face to face consultation is the next best thing and careful history can elucidate a lot of information and visual cues also play an important part in the clinical assessment. For doctors, this is far better than taking phone calls from patients which is inadvisable since there is no proper identification of the caller and no record of the consultation. In the same light, consultation via text and email are also not advisable.

What are the options Malaysian patients and doctors have today? We have come across three Telemedicine platforms that are available right now, two of them are already functional and the third still in beta but looks promising.

RingMD is a regional startup (it began in Singapore but is now available to Malaysians) which brings Telemedicine to you via Web and also iOS and Android Apps. Video consultations are encrypted end to end, patients can securely text their doctors and doctors can make clinical notes and also prescribe medication.
Sign up is free. There is no subscription and patients only pay per consultation. Patient setup an appointment for Teleconsultation with the doctor of their choice and there are reminders via email and SMS when the appointment time is due. A “Ring Now” feature for specific doctors is coming. While doctors can prescribe, patients have to fill out the prescription themselves at their local pharmacy. Texting between patients and doctors allow sending attachments like PDFs.

U2Doc is a Malaysian Telemdicine venture which works in the same way but requires a compatible browser (currently only Chrome and Firefox, and for mobile browser only Android but not iOS). There are no native apps for mobiles or tablets.
Patients also set appointments for Teleconsultation. We find that the interface is rather complex and patients may have difficulties navigating the site.
Like RingMD, sign up is free. There is no subscription and patients only pay per consultation. Doctors however are expected to purchase “airtime” in order to use the system and this may not prove popular in the long run with doctors.

Teleme is a new Malaysian startup which offers web based Teleconsultation. There are currently no mobile app options for Teleme. We however find the design neater than U2Doc and it is easier to use. It is still in beta though so do expect some early bugs and quirks but the platform is now accepting signups from patients and doctors. One nice feature about Teleme is that they have a tie up with pharmacies and prescribed medicines can be delivered to your doorstep if you wish.
Like the others, signup is free, there is no subscription – patients only pay per consultation. The system allows doctors to provide patients with a code for free trials.

Legal issues
While Malaysia has a Telemedicine Act (1997), this Act has yet to be enforced. Practitioners nonetheless are advised to take a Telemedicine consent from patients so that patients understand the nature and limitations of this platform. If there are still any misgivings, with proper consent, a Face to Face Teleconsultation is far and away better than doctors engaging in phone consultations!
For doctors, the best practice is still to engage in Teleconsultation with existing patients whom they have already seen in their clinics.

Conclusions
Telemedicine is at the cutting edge of modern medical practice. It allows doctors to extend their service and availability to their patients beyond the physical office. For non-ambulatory patients it could be a boon for a doctor to virtually make a home visit and it could make a big difference to things like diabetic and blood pressure control for home bound patients.
Will it take off in Malaysia? I think in time it will. Once patients and doctors see the benefits, Telemedicine is a no-brainer

Further reading:
What Are the Benefits and Advantages of Telemedicine?

Malaysian doctors may also join the discussion the Telehealth section of the Dobbs Forums.

Recently we came across an informative doctor blog (not many well maintained these days due to people indulging in Facebook but it goes to show how useful blog posts can be!): Random Indulgence. We’ve Blogrolled this in our collection of Malaysian Doctor Blogs. If you have a blog which you wish to include, please let us know.

Anyway, the blog in question has useful posts on how to apply for housemanship in Malaysia, which I think will be of interest to medical students and fresh medical graduates. Here are the links:

How To Apply (for) Housemanship In Malaysia Part (1) – MMC KKM

How To Apply (for) Housemanship In Malaysia Part (2) – SPA INTERVIEW

How To Apply (for) Housemanship In Malaysia Part (3) – EHOUSEMAN PTM

Well done for documenting the process!

The blogger is a member of the Dobbs forums, Malaysia’s pioneer and largest online network of doctors on web, Facebook and now app powered too (on Docquity). We have over 14,000 doctors combined on all networks, so if you are a Malaysian doctor, do sign up and join Dobbs which is completely FREE! Instructions are at http://dobbs.my

We are seeing quite a trend these days for people to take to the social media to criticize all manner of things, including healthcare, doctors, nurses and medical staff.
Some of these criticisms may be the result of poor communication or poor understanding on the part of patients or relatives leading to unwarranted criticisms which in some cases even amount to slander.
How should doctors react? Should doctors sue?

Here are some useful tips from KevinMD which I think all doctors should consider. In essence:
1) Do listen to the criticism as the patient is trying to vent in the most convenient means at hand these days
2) Do not engage in online debates with the patient. Take it offline and engage privately with disgruntled patients.
3) Do not sue as it risks the “Streisand effect” and at the end of the day, the lawyers are the winners.

Physicians: How to Manage Online Criticism

This 2:23 video shares how patients have more avenues than ever to express opinions online about their doctor, making it inevitable that a doctor will face criticism on the web. Kevin Pho, MD, of KevinMD.com, social media’s leading physician voice, shares three tips for how doctors should respond: 1.

Some time ago, there was a blog post criticizing a local obstetrician for proceeding with a caesarian section but the author of the blog post did not really understand the whole picture. Instead of taking action against her or even suing her, the hospital administration engaged the blogger privately and the blog post was taken down and replaced with an apology. That’s probably the best way to handle things but it requires a sympathetic administration and one willing to assist the doctor and do the right thing.

I think we need to be careful before we shoot off those social media posts criticising our healthcare staff. Do you really know the whole story? Why not talk and discuss with the doctor or hospital administration instead?

This post was inspired by discussions in the DOBBS forums. DOBBS, or Doctors Only Bulletin Board System, is the pioneer initiative to connect Malaysian doctors online. Today there are well over 12,000 doctors in all our platforms comprising Web forums, Social Media (Dobbs Facebook is the biggest Malaysian doctors group with over 11,600 members) and the new Docquity app based platform.
For more information on how to join the DOBBS network, see http://dobbs.my

The recent diphtheria death of a child, those with serious illness/admissions and the need for active health surveillance of many others is of grave concern. It appears we are reversing all our health gains in our country. The majority of our population have little memory of the horrific nature of diseases that we have prevented using vaccines. Those of us who have worked in the health system for many decades have experienced the devastating effects of diphtheria, pertussis (whooping cough), tetanus, polio, measles, Hib meningitis, etc. I remember going through two diphtheria epidemics in different parts of the country where we lost many children. Children coming to us choking due to the membrane that diphtheria causes in the throat and our futile struggle to salvage them. And for those that seemed to survive, some die suddenly from the complication of myocarditis (inflammation of the nerves of the heart). It was heart breaking for parents and those of us caring for the children.

Medical professionals recognise that vaccines have side effects but most of them are mild. However the health benefits of vaccines to the community are enormous. No health initiative has changed the lives of children as much as vaccines. Vaccines protect not just the child vaccinated but also all the children and susceptible adults (such as the very young, sick and the elderly) in the community by herd immunity.

In this day and age, to deny a child a vaccine for a basic preventable disease like diphtheria is unthinkable. Equally unacceptable are individuals who advocate that children not receive vaccines. Many of these advocates are dubious individuals, with titles of uncertain reliability, who claim to be experts, advising against vaccines. Where are they now that this child has died of diphtheria (with more deaths possibly to come)? Will they stand up and take responsibility for these easily preventable deaths?

It time to act against those who offer false and slanderous information on vaccines and make them responsible for the preventable illness and deaths of children in the country.

I sympathise with parents who want what is best for their children and are worried about vaccine side effects. But it is important to read and trust facts/science not claims or opinions that are posted on social media. For the sake of your child and all Malaysian children, I hope parents will support the use of vaccines.

Thank you.

Dato’ Dr Amar-Singh HSS
Senior Consultant Paediatrician
Head Paediatric Department, Hospital RPB Ipoh, Pera

Imagine
(a Malaysia Without Vaccines, I wonder if you can?)

Imagine there’s no vaccines
It’s easy if you try
No protection for our children
Above us only infections
Imagine all the children
Living in disease… Aha-ah…

Imagine there’s no measles jabs
It isn’t hard to do
Nothing to protect us, we can only die
And no diphtheria protection, too
Imagine all the children
Living in disease… You…

You may say I’m a dreamer wanting immunisation
But I’m not the only one
I hope someday you’ll join us
And all children will be protected as one

Imagine no diseases
I wonder if you can
No need for death or disability
Vaccines for all mankind
Imagine all the children
Living life to the full…. You…

You may say I’m a dreamer wanting immunisation
But I’m not the only one
I hope someday you’ll join us
And all children will be protected as one

With special thanks and the utmost respects to John Lennon for the beautiful original version.

Dedicated to the hundreds of thousands of Malaysian children who did not die or get disabled because vaccines protected them and the community.

Thank you.

Dato’ Dr Amar-Singh HSS
Senior Consultant Paediatrician
Head Paediatric Department, Hospital RPB Ipoh, Perak

The Health Minister recently announced

PUTRAJAYA: The Health Ministry is seriously considering a national health insurance scheme which is run and supported by the government, the minister, Dr S Subramaniam, said yesterday.
He said the scheme would be voluntary and an alternative to private health care.
“There will be no private player (insurance company) and no profit motive. The government health insurance scheme will evolve according to time,” he told reporters.
“It is too early for me to give details such as the structure the scheme and so on. I am just throwing it out as a concept and let the relevant party discuss it.”
The move to introduce the government healthcare insurance scheme did not mean that the government plans to stop the current public healthcare delivery system.
“The government is still responsible to the public in providing the public healthcare system that everyone is utilising now. The public healthcare delivery will still continue and will not change.”
However, about half of Malaysians currently turn to private clinics and private hospitals for medical attention.
Subramaniam said the ministry had been studying the government healthcare insurance scheme concept for the past few months and analysing the challenges involved in implementing such a scheme.
“Once we are confident, we will offer it to the public,” he further said.
The ministry came up with the idea of introducing the government health insurance scheme as it was aware that one of the challenges for Malaysians was paying for healthcare services.
“Such a situation can get people into financial catastrophe. The government healthcare insurance scheme may just be the answer.”

Do you think the Government should be running a competing Health insurance scheme alongside the other Health insurance options available to the public?
I seriously doubt this is a good idea. Talk is easy but implementation will be very difficult.
Who is going to run this? Where will the funding come from? As they say, the devil is in the details.

Our take is that instead of running a parallel health insurance scheme the Government should instead regulate the existing Health insurance industry. Authorities should stick to doing what they do best – regulate.

1) Make Health insurance affordable by making sure premiums are reasonable
2) Make sure that insurance claims are not obstructed or delayed but instead paid up on time
3) Make sure that people with pre-existing illnesses and all ages (including the elderly) are not denied insurance cover
4) Come up with a website which helps people make comparisons and choices on available health insurance schemes (something like the US Affordable Healthcare website)

We blogged quite a bit on Health Insurance Reforms so instead of sounding like a broken record, please read our previous posts.

The recent judicial decision in East Malaysia seems to have escaped the attention of some media outlets. Another rapist married his child victim and was allowed to get away with the sexual abuse in court. The Borneo Post (http://www.theborneopost.com/2016/07/28/statutory-rape-case-accused-discharged-as-he-married-victim/) carried the distressing account of a 28 year old man who clearly took advantage of a 14 year old child and was freed by court. The report states the judge’s decision was “Since the complainant and the victim of the subject matter of this case wish to withdraw the complaint against the accused on the ground that she is now married to him, there is no necessity to proceed further with this case. “Therefore the accused is discharged not amounting to acquittal.”

It’s amazing that, despite the outcry from many on previous such instances, our legal system continues to favour the rapist and not the victim. This decision by our legal system, in ruling in support of a rapist and sex abuser needs to be reviewed. Or systems must not continue to fail children.

Under the Penal Code this girl is under 16 years of age and it is obviously statutory rape; which means there is no defence. The judge would be required by law to rule in the favour of the victim and punish this rapist. If withdrawal of a police report makes this difficult the Child Act could be used. Under the Child Act this person is under 18 and sexually abused. The Child Act is a mandatory reporting system, which means that withdrawing the police report is meaningless. The Welfare, Health and Police are mandated by law to take action. And the judge can rule in the favour of the victim against the perpetrator.

I wonder also who it is that allowed this marriage to take place and solemnised it? That authority also needs to be investigated by the Welfare Department for aiding and abetting sexual abuse.

I hope the Welfare Department will act immediately to rescue this child under the Child Act. She requires urgent and sustained emotional and psychological support and counselling. Her parents are also obviously not supporting her rights and needs.

Often the legal profession suggest that the rest of us are poor at understanding the law. But we know justice and injustice when we see it. We have witnessed a number of rulings that concern us. From adults who put fingers in the vagina of children being let off, to the continual abuse of children by marrying them to adults. The child in this situation will now have to live with her rapist.

The legal system must regain some sense of decorum and earn back the respect of the public.
We look to the legal system to protect children not harm them.

Thank you.

Dato’ Dr Amar-Singh HSS
Senior Consultant Paediatrician
Head Paediatric Department, Hospital RPB Ipoh, Perak

We have updated our Doctors’ Blog roll with the addition of Dr. Nilesh Anand’s Blog on Advice & Experiments At The Intersection of Medicine, Life and Entrepreneurship

Are you a Malaysian medical doctor who maintains a blog? If you want us to list it for you, feel free to contact us

I hope the title has encouraged you to read this article. It is not meant to be pessimistic but a realistic look at our current situation. The opinions expressed here are personal and do not reflect those of the organisation I work with.

As we stand today as a nation, with our poor health behaviours, the Zika epidemic that is coming (if not already here) will hit us hard. The following realities or facts are the reason for my statement:
1. The Zika virus is spread mainly by infected Aedes mosquitoes and also by sexual transmission. Our nation is rich with Aedes mosquitoes.
2. The virus is new to us, we are not immune to it, there is no definitive drug to treat it and any vaccine will take a few years to be developed and tested.
3. Most importantly we have failed as a nation in our fight against Dengue, and the same mosquito vectors carry Zika.

Dengue may kill, but if you recover you become well again.
Zika will maim and cause significant disability, especially to unborn children. And as we are still not immune to it, large numbers have the potential to be infected. Imagine all our children that may become disabled as a result of this virus. The numbers from countries struggling with the Zika virus are frightening, even to me as a medical consultant. Current evidence suggests that between 15-20% of infected pregnant mothers will have a baby with brain damage, especially in early pregnancy.

We may want to believe that we can prevent Zika from reaching Malaysia but that is a myth. The symptoms of Zika virus disease are very common (fever, rash, headache, red eyes, etc) and many people infected with Zika will have mild symptoms or no symptoms.

The best way to prevent Zika is to prevent mosquito bites. This means getting rid of Aedes mosquitoes. The public will demand that the Ministry of Health (MOH) take action on this, like they have for Dengue. But Zika, like Dengue will not be controlled by the MOH alone, but only with the involvement of the people of this country, every person.

Vector borne diseases require us either to avoid the vector (preventing mosquitoe bites is not easy) or removing the vector (preventing mosquitoe breeding which is possible). But we are a dirty nation. We like to believe it is a minority that throw rubbish and the majority are civic minded. But the reality is that many Malaysians throw rubbish anywhere they like. A visit to recreational areas will show you how trashed we are. Our cities are rubbished, drains choked and even hospital compounds littered by visitors.

We have a small window of opportunity to prevent the wide spread of Zika virus in the nation.
Every single Malaysian needs to act today to prevent Zika transmission.

We need to aggressively, proactively and consistently keep our home compounds, our neighbourhoods and our cities clean. We must empower our authorities to take action against those who do not do so and endanger the health of our children. This includes construction sites, recreational areas, public amenities, etc. Our politicians must not be allowed to interfere when compounds are issued for mosquitoes breeding at projects or development sites – governmental or private. Our city councils must really work, not claim to work. We must work as communities to change our recalcitrant neighbours.

Some will say it cannot be done but this is not true. Singapore has been able to reduce its Aedes household/premises index (percentage of facilities breeding Aedes) from 50% in the 1970s (i.e. every other house) to 0.2% in 2013.

When our children get disabled as a result of Zika, let’s not blame others but ourselves as a nation.

Zika and Dengue prevention are the responsibility of all Malaysians.
We will win this fight as a nation united or not at all.

Thank you.

Dato’ Dr Amar-Singh HSS
Senior Consultant Paediatrician

Cost of Medicine and medical care has escalated so much over the years. In the past, the medical field is partly charitable to help in healing. Only those who have no financial ambitions will go into the medical field. This includes the manufacture of medicine. Now it is becoming more commercial and the population is forced to spend so much more to receive treatment. However, making some profit is necessary and understandable but it should not become a lucrative trade.
In the past, drugs were so cheap that doctors sometimes did not even need to charge patient extra for them and just charge only their humble consultation fee. Now drugs are so expensive that some patients may not even be able to afford them. Manufacturing drugs has become a lucrative trade. Unlike in the past, now many drug firm owners are very rich, and even billionaires. Unfortunately nowadays, people are trying to make money in the drug trade since they are essential products and people need to spend on them. Prices of new drugs keep increasing instead of reducing unlike in the past where the drug price is reduced once it has been on the market for some time and has recovered the cost of research, etc in making it. Sadly, It is all so commercial now.
With regards to doctors, in the past only those who are really interested in medicine and are charitable and wanting to help heal people will take up medicine and not just to become rich but regretfully, it is certainly not the case now. In the past, admission to medical school is also very competitive and you need to have top scores in science to be selected. Students are also interviewed for their inclinations before being selected.

Dato’ Dr. Lee Yan San
(Past President, MMA and MMC Council member)

Dato’ Dr. Lee Yan San is a member of the DOBBS Doctors Network, a pioneering initiative to connect Malaysian doctors online. DOBBS stands for Doctors Only Bulletin Board System and is running on Web Forums, Social Media (Dobbs FB is the largest and most active doctors group on Facebook with over 12,000 members), and Mobile app
To find out more on how to join the DOBBS community, visit http://dobbs.my. Connect with your colleagues!

SCHOMOS is the section in the Malaysian Medical Association which supports House officers and Medical Officers.
This is the latest official guide for junior doctors which should be very useful :

Download (PDF, 1.34MB)

Here are some useful links:
Join the MMA – the official body representing Malaysian doctors. All doctors should join and be united as one.

DOBBS network – the free pioneer initiative to connect all Malaysian doctors online, running on Web forums, Facebook group (over 12,000 Malaysian doctors, making it the largest doctors and most active doctors only group), and mobile app (Docquity)

As we face the threat of the Zika virus we must recognise that we are on a ‘learning curve’ or a ‘state of evolution’ as to our understanding of this problem. What we know today may change dramatically as doctors and scientists understand this condition better. Unfortunately some individuals circulate or voice opinions which are not founded on data or evidence and can confuse us. As such it is important to keep abreast of good information (evidence based) as it becomes available. Time and good data will make uncertainties clearer and enable us to respond to this challenge more meaningfully. This article is to offer answers (where possible) to some common FAQs (frequently asked questions) and also express some of our uncertainties. I will try and provide references to answers offered so that individuals can read the data for themselves

Is Zika Transmission Happening in Malaysia?

We know that Zika was first identified in Uganda in 1947 and then spread to Asia. It was detected in an Aedes mosquito in Peninsular Malaysia in 1969. In September 2014 a tourist was found to be infected with Zika after travelling in Sabah. (Source: http://wwwnc.cdc.gov/eid/article/21/5/14-1960_article). So Zika has been around, possibly circulating in low numbers for some time. In the past 2 weeks we have seen one Malaysian visitor to Singapore get infected and another with local transmission in Sabah. Despite testing many mosquitoes and patients with symptoms the Ministry of Health has yet to identify more cases or virus spread.

Will Zika Spread in Malaysia?

We expect it will. Although the virus has been around for some time, most Malaysians are not immune to it, hence it can spread easily. In addition we have the appropriate mosquito vectors in abundance, the Aedes mosquitoes. Remember that it is a mild illness with some fever, rashes, red-eyes and joint pain. The majority are asymptomatic, i.e. may be infected but not show signs. These asymptomatic and mild cases still have the virus in the body for a few days and it can spread to others if they are bitten by Aedes mosquitoes or via sex for longer periods or to their foetus.

Why do Some Countries seem to have a Worse Outcome or Larger Epidemic?

We are uncertain about this but definitely testing for cases increases the numbers we will detect. One scientific opinion, from Imperial College London, based on two preliminary studies suggests that a previous dengue infection may amplify Zika infection. (Source: https://www.sciencedaily.com/releases/2016/06/160623112309.htm). This may account for the rapid spread in South American countries like Brazil as well as in Singapore (and possibly us in the near future).

Does Zika Cause Brain Damage (Microcephaly) in Unborn Babies?

Zika on its own is not very worrying. What has focused our attention on it is the brain damage (microcephaly) in unborn babies that has been linked to it in some countries, especially Brazil. But some have argued that Zika is not the cause of the damage but environmental toxins and pesticides are. They argue that the rates of microcephaly are low in some countries and that there is a ‘cover up’. The World Health Organisation (WHO) and others have tried to evaluate all rumours and offer an evidence based response. (Source: Dispelling rumours around Zika and complications http://www.who.int/emergencies/zika-virus/articles/rumours/en/, http://www.iflscience.com/health-and-medicine/report-claims-pesticides-are-blame-rise-microcephaly/). But perhaps the best evaluation of the risk is a good publication in the New England Journal of Medicine that looked at all the evidence and concluded that “a causal relationship exists between prenatal Zika virus infection and microcephaly and other serious brain anomalies”. (Source: Zika Virus and Birth Defects — Reviewing the Evidence for Causality http://www.nejm.org/doi/full/10.1056/NEJMsr1604338#t=article).

An important piece of evidence is that, in a number of documented Zika infections in pregnancy, where the babies have died (in the womb or after birth), the brain tissue has documented Zika virus. In addition babies born with brain damage related to Zika have been found in a number of countries including the USA. (Source: http://www.paho.org/hq/index.php?option=com_content&id=11599&Itemid=41691, http://www.nbcnewyork.com/news/local/Zika-Baby-Microcephaly-New-York-City-Hospital-Birth–387941232.html). Another important observation is that in a small number of twins where the mother was infected with Zika, only one developed microcephaly. This refutes the possibility of an environmental toxin as both babies would be damaged in the womb. As some of these twins were dizygotic (meaning that they develop from two different eggs) it suggests that genetic factors are possibly important in whether an unborn baby develops brain damage.

The general public must realise that there are many causes for microcephaly in newborn babies including genetic/chromosomal defects, other congenital infections (e.g. rubella, toxoplasmosis, cytomegalovirus), toxins (alcohol, some drugs or toxic chemicals), blood supply interruption to the brain in the womb, etc. So infection with Zika in pregnancy may not always be the cause of the damage seen.

Is there more than One Type of Zika Virus?

There are two Zika strains (or lineages), an African and Asian Strain. The strains currently circulating in the Western Hemisphere (and Singapore) are more closely related to the Asian lineage than to the African lineage. We are uncertain if there is a difference in the behaviour of the strains in affecting the unborn child. (Source: http://nar.oxfordjournals.org/content/early/2016/08/31/nar.gkw765.full, https://www.sciencedaily.com/releases/2016/09/160901125057.htm,http://www.who.int/mediacentre/news/releases/2016/zika-cabo-verde/en/).

Should I have an Abortion if I am Infected with Zika and Pregnant?

It is important to realise that the reason babies have a small head (microcephaly) with Zika infection is because the brain has become damaged and is not growing so well i.e. a smaller brain with damage to brain cells. The degree of damage is only now being described and is variable. (Source: http://pubs.rsna.org/doi/full/10.1148/radiol.2016161584, http://www.wsj.com/articles/brain-damage-in-zika-babies-is-far-worse-than-doctors-expected-1461859591). From experience with other congenital viral infections, the more severe ones may die early. Some will live with severe disabilities others with relatively mild developmental problems.

Abortion is not strictly illegal in Malaysia. An exception clause has been added to Section 312 of the Penal Code that states “a medical practitioner registered under the Medical Act 1971 who terminates the pregnancy of a woman … if such medical practitioner is of the opinion, formed in good faith, that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or injury to the mental or physical health of the pregnant woman, greater than if the pregnancy were terminated.” Note that the clause includes the mental health of the mother as well. The Ministry of Health has clear guidelines when a termination of pregnancy can be done. (Source: http://www.moh.gov.my/images/gallery/Garispanduan/Guideline%20On%20TOP%20for%20Hospitals%20in%20MOH.pdf).

The decision to have an abortion must be a careful one and should follow MOH guidelines. It requires first to have a confirmed diagnosis of Zika in pregnancy. Testing can be done in a number of government hospitals and private laboratories, see the attached list. Secondly an Obstetrician experienced in detailed foetal ultrasound should evaluate if the unborn child has brain damage. Finally the parents should make an informed decision with their doctor in view of the available information. It is important to note that terminations of pregnancy after 22 weeks of gestation (~6 months pregnant) are difficult.

The Royal College of Obstetricians and Gynaecologists in the UK have stated “When a significant brain abnormality or microcephaly is confirmed, the option of termination of pregnancy should be discussed with the woman, regardless of gestation.” (Source: https://www.rcog.org.uk/en/news/qas-related-to-zika-virus-and-pregnancy/#q20).

What about Sexual Transmission of Zika?

Zika is an unusual Flavivirus in that it can spread by means other than mosquitoes. It is now recognised that the virus is transmitted sexually and can remain in the semen for up to 6 months and the vagina for some time (maximal duration uncertain). This means that Zika can spread not just by mosquitoes but also by sexual contact and blood transfusions. Remember that 80% of people infected with Zika may not be aware they are infected. Of more concern is a recent study in mice where the virus replicated in the vagina and damaged foetal mice brains. (Source: http://www.cell.com/cell/fulltext/S0092-8674(16)31053-4). This is early research but it may suggest that sexual infections may be potentially more harmful to the foetus.

Can we control Zika in Malaysia if it Spreads?

A tough question and most countries doubt they can. But there has been remarkable success in Cuba with army deployment to support public health efforts. (Source: http://wiat.com/2016/09/04/cuba-reports-remarkable-success-in-containing-zika-virus/). But there is concern with the impact of such a volume of insecticide use. Reports from Florida show concern with the death of other insects, especially millions of bees. One recent study showed that some female Aedes aegypti mosquitoes can pass the Zika virus to their eggs/offspring. This highlights the importance of not just killing the adult mosquitoes but also the eggs. (Source: http://m.ajtmh.org/content/early/2016/08/23/ajtmh.16-0448.full.pdf). We however can definitely reduce the intensity of any Zika epidemic if the general public make a serious effort to reduce Aedes breeding sites. The impact on Dengue would also be significant.

Will a Vaccine Save Us?

Vaccinating against Zika is an important strategy and one early clinical trial testing the first vaccine against Zika has just started. Some are advocating for a Dengue and Zika virus combination vaccine in view of concerns (see link above on ‘dengue infection may amplify Zika infection’). (Source: http://labiotech.eu/zika-dengue-virus-vaccines/). However vaccine development takes time and lots of research and it is unlikely we will see a viable product in the next 2-3 years.

When will we see the Impact of a Zika Virus Epidemic?

Assuming that Zika damages a certain percentage of unborn children, then the full impact of the Zika virus epidemic will be seen 1-2 years later (and beyond); when larger numbers of microcephalic babies are born. That is when families and the health services will face the challenges of supporting all these disabled children. Note also that there is some preliminary data from experiments infecting adult mice brains with Zika that showed damage to some brain cells (Source: http://www.cell.com/cell-stem-cell/fulltext/S1934-5909(16)30252-1). What this means for the developing brains of young children is still uncertain.

I hope this discussion has been useful to summarise some of the concerns and current evidence. There are more questions than answers at this stage. The public should be proactive to read good data as it comes out so as to make informed decisions for their health.

Dato’ Dr Amar-Singh HSS
Senior Consultant Paediatrician

Testing for Zika – local laboratories

Dear Specialists

Please read and consider signing this petition to the MMC

What is at stake is your annual APC!

“Preamble:

Due to the Amendments to the Medical Act,
All Doctors in Malaysia to continue practicing must have valid Indemnity Insurance as well as comply to adequate CME via CME points collection.
In addition, Specialist Doctors have to renew their National Specialist Register enrolment every 5 years by applying to the Academy of Medicine, the body entrusted to set specialist standards.
The Malaysian Medical Association has a well tested CME Point collection system that is in place for all doctors that enable them to renew their Annual Practising Certificate with the Malaysian Medical Council.
The Malaysian Medical Council has the Legal Mandate to decide on the eligibility of Doctors` Practising Rights in Malaysia.
We therefore request that:

1) The determination of such rights MUST ONLY come from MMC and not any other organisations for Specialists Doctors.
2) There MUST BE A VERIFIABLE SYSTEM for Specialist Doctors to renew their APC and NSR without duplication.
Specialist Doctors must have a choice of myCPD, MMA CPD App , AMM Web based system OR any other methods approved by MMC for CME points collection & submission
3) The collection of CME points and the validity as well as recognition of CME points must only come from MMC and WHAT is recognised by MMC should also be recognised by all other organisations to ensure UNIFORMITY and FAIRNESS.
ALL cateogories of CME Activity from A1 to A9 recognised by MMC Must be Recognised by All other Parties.

For All Specialists and Specialists in Training,
Please sign if you support this petition.”

This is a video which will walk you through the basic usage of the MMA CPD App

Please also see the FAQ on the MMA CPD App

This is a short video which demonstrates how CPD Providers registered with the MMA can use the MMA Scanner app to quickly mark attendance and assign CPD points for attendees

Reminder for all Hospitals, Medical Associations and Socities: 1 July 2018 is when CPD points start counting for real. Please don’t wait until the last minute to register as a CPD provider as unless you do, your local CPD events won’t be able to get points for your attendees. As from 2017, ALL previous CPD providers registered with the MMA must re-regoster
Do so at
http://registercpdprovider.mma.org.my/

Related posts:

Register as a CPD Provider

Register as a CPD Provider II – some FAQs

Please read for important updates on CPD points for medical professionals.
CPD points are now mandated by LAW for APC renewal and will take effect when you apply in 2019 for the 2020 APC but the points accumulation starts 1 July 2018 so please beware!

Now that the dust from the 14th General Elections is settling, the new cabinet is being formed.
We shall be having a new Health Minister who hasn’t been announced yet.
Who is your choice of Health Minister?
We asked this of our doctors in the DOBBS Forum

Note that the above is just a screen shot and not the actual poll which is ongoing in our forums.

If you are a Malaysian doctor, you are most welcome to join DOBBS, the pioneer and largest Internet forum for Malaysian doctors. Membership is free, just register at https://dobbs.my/osr

An APC (Annual Practicing Certificate) is mandated by law as a prerequisite for doctors to practice.
There have been grouses from doctors, evident in our forums, about delays in receiving their APCs.
This has now been acknowledged by the the President of the MMC who also happens to be the DG of Health.

The statement however only points to “email addresses” in the MMC website if you seek more info.

If you are one of the doctors who face problems getting your APC, you may use this specific email address:

via the Dobbs Forums

DOBBS, or Doctors only Bulletin Board System is Malaysia’s pioneer and largest forum for Malaysian doctors. Membership is completely free. Just register at https://dobbs.my/osr