50th Malaysia-Singapore Congress Of Medicine And 3rd Amm-ams-hkam Tripartite Congress

  1. It gives me great pleasure to be here on this great occasion of the Golden Jubilee of the foremost medical institution in Malaysia. The establishment of this important national institution in the immediate post-Independence era helped to signify our ability to stand alone in the highest professions. It continues to play an unparalleled role in fostering the abilities of the various elements of the medical community in the country to carry out their noble duty of preventing avoidable diseases and healing those already sick. The Medical Academy will continue to play a hugely important role in the nation as it moves forward into its next half century, preparing and guiding the medical profession to meet existing and emerging challenges.
  2. Remarkable medical and scientific advances have been made in the past 50 years since the establishment of the Academy, to the very great benefit of us all. Life expectancy is rising across the world, and infant mortality is falling. But as we move forward into the next 50 years, those of you in the medical field will continue to face enormous challenges. These challenges even sometimes seem to be increasing. They come from both infectious or communicable diseases, and from non-communicable or chronic diseases. Global rates of these latter diseases, from cancer to heart disease, continue to rise. This causes incalculable costs and suffering for society and for individuals. At the same time, we have infectious diseases that defy our best efforts to defeat them. Deaths from dengue continue, even though malaria was more or less brought under control over a decade back. Other more globalized infectious diseases such as the Zika and Ebola viruses create further challenges for the medical profession, and present considerable potential risks for our society.
  3. In responding to these challenges effectively, it will be necessary to deploy all the many resources we have at our disposal. As well as medical and scientific activities and functions, these include public education, which plays an enormously important role in combatting both communicable and non-communicable diseases. Developing effective public education campaigns in turn rests on good understanding of the social and socio-economic dimensions of these diseases. This includes the so-called ‘lifestyle’ factors that contribute to chronic diseases, and the social and cultural factors that drive the spread of epidemics, a key one now being the unprecedented global movement of people. This has already led the Zika virus, for example, to spread to nearly every single country within Latin and Central America from its initial epicenter in Brazil. The same processes of globalization and modernization are also contributing to rising rates of chronic disease. This is through both the changes in diet, behaviour and stress patterns, and the increased exposure to environmental stressors associated with industrialization and urbanization. These complex social and socio-economic dimensions deepen further the already difficult challenges of responding effectively. At the same time, however, they do provide us with important clues for developing more effective policy responses. A holistic approach that encompasses social and medical aspects is thus crucial to addressing the enormous medical challenges that we still face.

Non-communicable diseases

  1. Globalized epidemics present perhaps the most frightening public health risk, with their potential to generate catastrophic levels of death and suffering. But it is non-communicable chronic diseases that remain the world’s biggest killers, accounting for an estimated 60% of deaths worldwide. Half of these deaths are due to cardiovascular disease, which is still the number one cause of death globally. Lower- and middle-income countries are disproportionately affected, as rising incomes and urbanization result in lifestyle and diet changes. These, in turn, contribute to higher rates of obesity, Type 2 diabetes and heart disease. Many developing countries still lack the sophisticated medical facilities and infrastructure needed to treat these problems effectively however. Here in Malaysia we are lucky to have world-class medical infrastructure and very strong capacities in cardiovascular surgery. But the complex and expensive treatment required is beyond the reach of many Malaysians. As most of you here already know very well, heart disease accounts for around 25% of deaths in Malaysia.
  2. This high level reflects in part our ever-increasing rates of obesity and Type 2 diabetes, two problems so closely associated that they are increasingly referred to as ‘diabesity’. Only 4.4% of the adult population was classed as obese in the 1990s, but the rate is now 18%, with another 27% overweight.[1] This means that nearly 50% of adult Malaysians are putting their health at risk in this way. Prevalence of type 2 diabetes has increased even more sharply, from 11.6% of the adult population a decade ago, to 17.5% today. Increasing rates of obesity and diabetes in children are, of course, particularly worrying. One study found that 13.9% of 10-year olds here are obese. This compares to youth rates of 16.9% in the United States, which are themselves among the highest in the world.[2] Various studies show that overweight and obese children have a high chance of remaining so as adults, with all the potential health problems that this entails. With the exception of cancer, this area represents perhaps the major public health challenge of our times.
  3. The treatment of heart disease has improved considerably, especially for those who can afford it. Our health service has made great strides in the past decades in expanding public access to cardiovascular treatment. This includes the provision of university hospitals for treatment and training of specialists, among other measures. But prevention clearly remains a major challenge, as shown by the ever-increasing rates of these diseases. Many prevention strategies that have been adopted, here and elsewhere, appear to have had only limited success. Government efforts here to curb smoking for example, a key risk factor for heart disease, have had little impact, with one estimate putting the number of male adult smokers at a startling 46.5.[3] This is unlike in some Western countries where smoking is one of the few risk factors for heart disease that has fallen somewhat. Bans on smoking in public areas have contributed to this, along with increasingly targeted public education on the risks of smoking.
  4. Diet is clearly another key aspect of prevention, but policies on diet have also had limited impact. This may be due in part to an over-emphasis in the past on limiting the intake of fats and particularly saturated fats. Understanding of the causal links between saturated fats, cholesterol and heart disease has been shifting recently, as evidence suggests that these have been over-stated. The growing questioning of this association comes from both investigative journalists, published in credible and well-received popular science books,[4] and from medical researchers. A number of meta-analyses have been published in recent years, by respected scientists and in leading journals. These generally concur with the conclusions of one which states, ‘there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of coronary heart disease and cardiovascular disease”.[5]
  5. This past emphasis on fat is being replaced by a focus on the role of sugar and so-called ‘ultra-processed’ food products. These manufactured products have little or no actual nutritional value, and consist mainly of sugar and refined carbohydrates. Consumption of these products has doubled in the United States and Canada in the past decade, as well as in countries such as Brazil and elsewhere. This growing attention to the dangers of ultra-processed food products should resonate strongly here in Malaysia, where consumption of these ubiquitous junk foods is also clearly far higher than in the past.
  6. There is a growing recognition of the role of sugar, or what one leading specialist in pediatric obesity calls ‘deadly poison’.[6] This is reflected in the inclusion for the first time in the United States dietary guidelines for 2015-2020 of a recommended limit for sugar consumption.[7] At 10% of daily calories, or around 50 grams a day, this amount would still be considered excessive by many heart specialists. Some countries have introduced taxes on canned soda as part of efforts to reduce sugar consumption, including Denmark and Mexico. While it is too early to judge the success of such approaches, they reflect this broader shift towards tackling sugar rather than fat as the main dietary culprit in ‘diabesity’ and heart disease.
  7. Malaysia has also introduced many policies aimed at addressing these diseases, including many aimed specifically at childhood obesity. One recent study lists 19 different regulations and programmes that have been introduced here in the past decade or so. These encompass diet, exercise and education and include Guidelines on the Marketing of Food and Drink to Children, The Active and Productive Community Programme, ‘One Child One Sport’, among many others.[8] These strategies may have had some positive impact in relation to childhood obesity, growth rates of which appear to have leveled out somewhat in recent years.[9] But they have as yet been unable to outweigh the seemingly inexorable forces of the ‘nutritional transition’ that is driving obesity in Malaysia and elsewhere. This term refers to the evolution of diet and lifestyle associated with economic growth and the increased incomes and modernization that they bring.
  8. It is important to understand the nature of this transition better in order to craft effective policies, including public information campaigns. Here in Malaysia, as we know, the evidence on these aspects shows a greater vulnerability to obesity among women and among those whose family members are also affected. Some evidence suggests that lower, and lower middle-income groups, have a higher susceptibility to becoming overweight and obese. Greater vulnerability is also associated with fewer years of education. Although Malaysian families can increasingly afford to consume ultra-processed foods, at the same time they may not fully understand the nutritional implications for themselves and their children. This is borne out by one study which found that nearly a third of parents of pre-schoolers here have poor understanding of nutrition.[10]
  9. This kind of more detailed social profiling of the different factors that increase vulnerability to ‘diabesity’ can help inform the development of more targeted policies in response. This approach has already been adopted here to some extent. The focus of policy efforts at the community level and on education targeted at parents and schools is particularly welcome, and we need to build on this further.

Infectious or communicable diseases

  1. Infectious diseases present a very different but equally urgent set of threats and challenges. It was once thought that these communicable diseases had been more or less beaten, with the advent of antibiotics and vaccines. But this has turned out to be far from true. As one specialist put it, ‘their amazing ability to adapt, evolve and spread to new places’ makes infectious microbes ‘a formidable adversary for scientists and doctors’.[11] These abilities are particularly dangerous in a highly globalized world characterized by massive and unprecedented flows of people, animals, fruits and vegetables, and all kinds of other products. Despite all the regulations and preventative measures that have been put into place, the very scale of these movements, combined with the adaptive and opportunistic nature of viruses, bacteria and microbes, greatly deepens the potential for an epidemic to emerge and spread.
  2. When this happens, as seen currently with the Zika virus and the Middle East Respiratory Syndrome or MERS, responses become like a race or a fight against the further spread of the disease. In the case of the recent outbreak of the Ebola virus in West Africa, this battle at one point became extremely urgent. Ebola is particularly dangerous as it is transmitted easily from person to person and has a high fatality rate if untreated. During the second half of 2014, this virus was spreading exponentially in the crowded urban slums of Freetown and Monrovia, with the potential to reach catastrophic levels. Although it did not thankfully spread to this part of the world, at that time there was a growing number of cases in Europe and the United States. This was despite stringent travel restrictions and quarantine measures. Only through concerted international and local efforts was this major threat averted, although over 11,000 deaths still occurred over a two year period.
  3. The global scope of such threats, and the considerable variation in national capabilities to respond, means that response strategies must now be mounted at regional and global levels. The complex medical and scientific investigations that are necessary to understand and contain such infectious disease epidemics are beyond the capacity of many poorer developing countries. This was certainly the case for the West African countries at the epicenter of the Ebola epidemic, which struggled even to provide basic care for the large numbers affected by the disease. International organizations were criticized for not responding more effectively in the early stages of the outbreak – before it reached crisis proportions. But they did eventually provide the inputs of funds, expertise, equipment and personnel on the scale needed for both treatment and containment. The United States Center for Disease Control and Prevention, Medicins sans Frontieres, and the World Health Organization to a lesser extent, all played leading roles.
  4. Local responses were also crucial to stemming the spread of the epidemic however, particularly through the development and delivery of an effective public information campaign. This was based on an in-depth understanding of the socio-cultural factors that were contributing to the exponential spread of the disease in over-crowded urban areas.[12] One key factor was the widespread distrust of officials which led some to keep affected family members at home. Simple and clear treatment and prevention messages were disseminated in affected communities by familiar community members who also offered reassurance at this time of high levels of stress and fear. This approach helped to change behavior in the ways required to contain the spread of the virus, and in this way complemented the international emergency medical response.

Ladies and Gentleman

  1. These experiences during the Ebola crisis have underscored the importance both of understanding the social aspects of highly dangerous epidemics of infectious diseases, and of the central role played by public health education in addressing them. These are also both key elements of the response to communicable diseases. Whether designed to address the prevention and treatment of obesity, diabetes and heart disease, or to halt the spread of infectious diseases, successful public health information campaigns must be grounded in accurate and detailed social analysis. The method of delivery is then a further key element in their success. Effective social responses in this way complement the equally crucial medical and scientific aspects.
  2. Through a combination of research across all relevant fields, international scientific and medical collaboration, and learning from the policy experiences of other countries, we can develop more effective ways to address the major medical challenges that we continue to face here in Malaysia. We have spent the past 50 years building a modern medical establishment of which we can be immensely proud. This has provided a strong foundation for our medical profession across all its various areas of specialization. Now as we move forward to meet the challenges of the next 50 years, we must become even better prepared through our joint efforts and continued commitment to the noble goals of our medical profession.


  1. Jan Mohd. et al., (2014) ‘Prevalence and Determinants of Overweight, Obesity and Type 2 Diabetes in Adults in Malaysia,’ Asia Pacific Journal of Public Health 27 (2)
  2. Sabramani et al. (2015) ‘Managing Obesity in Malaysian Schools : Are we doing the right strategies ?’ Malaysian Journal of Public Health Medicine, Vol 15 (2)
  3. Malaysia Third National Morbidity survey 2006
  4. Nina Teicholz, ‘The Big Fat Surprise’ Simon and Schuster (2014)
  5. Quote from Kraus (2010), other meta-analyses include Chowdhury et al. 2014 (72 studies), de Souza et al. 2015, Harcombe 2015 (192 studies) 
  6. Robert Lustig, Professor of Pediatric Obesity at Berkeley, California and author of “Fat Chance : The Hidden Truth about Sugar, Obesity and Disease’ (2013) Harper Collins Publishers
  7. https://health.gov/dietaryguidelines/2015/guidelines
  8. Sabramani et al. (2015)
  9. ibid.
  10. ibid.
  11. Alexandra Levitt (2013) ‘Deadly Outbreaks’, Skyhorse Publishing, New York
  12. International Crisis Group (2014), ‘The politics behind the Ebola crisis’
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