LINK: http://www.malaysiakini.com/columns/113415
2 Malaysia in health services
Sim Kwang Yang
Sep 5, 09
11:47am
As we approach September 16, the date on which Sarawak achieved independence through by joing Malaysia 46 years ago, my thought turns to the progress made in developing my home state.
The Malaysiakini report on the failed Flying Doctor Service is particularly illuminating, in highlighting the problems of public health care for the rural dwellers of Sarawak – and Sabah as well.
Readers of Malaysiakini are probably urban dwellers for whom medical facilities are taken for granted, along with clean water, sanitation, good roads, and all the amenities that are available aplenty in large cities and towns
If you get sick, there is always the neighbourhood GP’s clinic; a jab and some pills will take care of the usual minor-ailments.
If you are really sick, there are always the public or private general hospitals with all the latest sophisticated medial equipment and the professional expertise at your disposal, as long as you can pay the bills.
But imagine this: what do you do when you get sick if you are a citizen living in a remote village in the deep interior of Sarawak?
Well, you try to consult the old folk or the local village healer, look for traditional medicines like some herbs and roots, and try to sleep off your ailment.
If you are afflicted with some serious conditions like cancer or a difficult child birth, you just lie down and wait to die.
In my travels throughout Sarawak a long time ago, I have seen many rural Sarawakians just lying down and waiting to die. Why?
In the upper reaches of the great rivers in Sarawak, transportation facilities are really primitive.
The only semblance of medical facilities are the rural clinics run by a dresser or a nurse, and access to them may mean hours of walking on foot and travelling in a small boat up and down those infamous rapids.
And the medical personnel and the facilities are usually not sufficient to handle really serious cases at all.
Dubious deals and deaths
Let’s take the upper or middle Baram regions for instance.
In the vast mountainous terrain of that area, the only way to send the patients with a serious medical condition is to fly them down to the Miri General Hospital in a helicopter.
That is why my blood boiled when I read about the failure of the contractor who had not fulfilled their contract agreement to provide a helicopter service.
How many rural patients have died because of their dubious deals?
The other alternative is for the rural patients to take a boat ride down the treacherous water of the Baram for many hours.
The Penans and the Orang Ulu who live in the upper reaches of the river do not always have the kind of cash to pay for the fare.
Let’s say our rural patients finally get to the Miri GH one way or another.
Their problems have just begun. The hospital may not want to admit them as in-patient because many rural Sarawakians do not have identity cards.
When the Sarawak rural mother gives birth, she may not have the strength or money to travel to the nearest National Registration Department which is always half a universe away.
Even if rural patients are admitted without identification papers, they may still be denied the assistance rendered by the Social Welfare Department on the grounds that they are not bona fide citizens!
The public hospitals in Sarawak are always over-crowded and under-staffed.
The medical personnel there are almost always overworked and stressed out. The odd ones will take it out on the patients who had come a long way from home to seek treatment.
It is also a custom in Sarawak for relatives or family members of the rural patients to accompany them to the hospital in the big city.
They will take turns to be with the patients in the hospital 24/7, to help with simple tasks like bringing a glass of water or passing the bed pan, and even to call the doctor if there is a sudden turn for the worse in the condition of the patients.
Half-way houses for patients’ families
Where are they going to live in the duration of the patient’s protracted treatment in the hospital?
You cannot expect them to check into the Holiday Inn because they would have neither cash nor credit cards, as you and I have!
The obvious solution is for the government or some charitable organisations to build a kind of halfway house for these stranded rural people with minimal facilities for cooking and sleeping.
So far, I have heard of only one project in Miri where some kind-hearted citizens have rented a house to help the Penans caught in that kind of predicament.
Let’s say the patients do not die, but recover from the treatment and is discharged.
Will the hospital authorities waive their payment as a matter of policy, and even give them money for the fare home as is done by the NHS (National Heath Services) in the UK?
Or will the petty officer at the pharmacy humiliate them about their inability to pay for the medicines to take home for follow-up treatment?
The best way of providing health care is to take medical service to the rural people.
For quite a few years in recent past, this is what a group of selfless dedicated government doctors and nurses have done.
They do not take leave all through the years, so that with the accumulated leave, they can take a long trip into the Baram interior.
They raise funds on their own to finance expenses needed for their trips and to buy medicines.
They make a few trips a year deep into the jungle to bring modern medicine to the Penan settlements and the Orang Ulu villagers.
Very often, they are the first medical team that has ever been welcome in those remote human settlements.
A doctor who had frequently gone on these trips related one story to me.
They had encountered a Penan man in one village with a thorn from a rattan vine lodged deep in his thigh. It had been there for three weeks.
Thorn in the flesh removed…weeks later
Actually, he had gone to the health clinic at Lio Matoh, 3 hours boat ride and 2 hours hitch ride away.
The medical officer there removed half the thorn and said he could do no more.
So the man returned to his village, waiting for the infection to worsen, and perhaps to die, until our volunteer medical team arrived.
A young doctor from Kuching removed the offensive thorn with the under a torch light using a pair of primitive pincers.
I bet you this grateful Penan man will remember that young Chinese doctor for the rest life.
Their main problem is funding. They try to raise funds from charitable organisations like the Lion’s Club, as well as private companies.
The best solution is for them to set up a charitable trust fund that can begin to receive donations from overseas.
But for that, they will need a million ringgit to start with. So you guys with many millions to spare do remember these good doctors in your will.
As we are still located in this ambiguous period between two independence day celebrations, my thought goes out to this group of enlightened doctors and nurses.
They have sacrificed their time and talent, taken the long and torturous journey to bringing modern medicine to the homes of those Malaysians long forgotten by the nation 46 years after their independence from British rule.
You will not hear much about these good Samaritans, because they are publicity shy.
But they embody for me the best spirit of Merdeka. They have shown us all that charity indeed begins at home.
Unfortunately, this is the only voluntary effort I know of that does its best to relieve the physical suffering of Sarawak’s rural dwellers.
Those who receive help from them are indeed fortunate, but there are numerous people in the deep interior who continue to suffer neglect by the government.
For them, Merdeka has made no difference in their inability to gain access to public health care.
This just goes to show that the lives of rural people are cheaper than those in the towns and cities.
This is the 2Malaysia we have.
The first Malaysia belongs to those in the cities and towns whose life is precious, and the second Malaysia exists among those whose life is cheap and expendable, in the deep interior of Sarawak and Sabah.
46年前的9月16日，砂拉越通过加入马来西亚取得独立。马来西亚日跫音渐进，我的思绪转移到我故乡在这些年来所取得的进展。
《当今大马》的报道点出了失败的飞行医生服务（Flying Doctor Service），也凸显了砂拉越和沙巴两州乡区人民的公共卫生问题。
《当今大马》读者大概都是城市居民。大城市和市镇地区的设施完备，医院诊所、清洁食水、卫生设备、完善公路等等一应俱全，也许居民都会认为这些基本设施都是理所当然的。如果阁下生病了，邻里就有一家家庭诊所。打一支针，吃些药丸，一般小病，迎刃而解。如果阁下真的生大病，在附近就可找到拥有最先进医疗设施的公立或私立医院，以及随时为您服务的专业医疗团队，只要阁下付得起医药费就行了。
原住民得病只有等死
但是，试想像一下：如果你是住在砂拉越内陆偏僻乡村的公民，生病了应该怎么办呢？好吧，你试着跟长辈或当地乡村医者请教，讨了一些传统药物如草药和树根，吃了倒头就睡，看看会不会睡醒病除。如果阁下惨遭癌症、难产等严重症状缠身，就只能躺下等待离开人间。
我在很久以前游走砂拉越时，就看到很多乡区砂拉越人躺下等待撒手尘寰。为什么？在砂拉越很多大河的上游流域，交通设施其实都还未开发。唯一勉强足以成为医疗设施的，就是由医疗助理（注一）或护士经营的乡区诊所。要想见见他们，阁下必须亲自走路，跋山涉水好几个小时，坐着小船乘着忽高忽低越过无情的急流。这些医护人员和设施，通常都对大病束手无策。
我们就以峇南（Baram）上游或中游地区为例子。在那浩浩无际的山丘地区，动用直升机把病人送到美里中央医院是唯一的方法。这就是为什么当我读到承包商没有履行合约以提供直升机服务时，我会气得七孔冒烟的原因。多少病人因为他们的含糊交易而丧命？
乡区病人的另一个选择，就是花上很多个小时乘船越过惊险的峇南河。住在河流上游流域的本南人（Penan）和乌鲁人（Ulu），通常都付不起船费。
没身份证难进政府医院
举个例子，就假设我们的乡区病人，终于以其中一个方式抵达美里中央医院了。他们的问题才刚开始—— 医院并不愿意收容他们为住院病人，因为很多乡区砂拉越人没有身份证。当一个住在砂拉越乡区的妈妈生了小孩之后，她也许没有力气或车马费走访最靠近的国家注册局——那注册局通常都坐落在山长水远的地方。即使他们没有证件也被允许住院，社会福利局还可能会拒绝援助他们——理由是他们并非真正的公民！
砂拉越的公共医院时常“客满为患”，医疗团队人手不足。那里的医护人员通常都是超时工作，心理压力极大。有些脾气古怪的医护人员，就会把那些远道而来求医的病人当出气筒。
陪伴亲朋戚友到大城市的医院去看病，是砂拉越人的生活习惯。他们都会轮流在医院守候24小时，帮亲人斟茶递水，或准备床上便盆，甚至是当病情急转直下时召唤医生。
康复之后却无力偿还医药费
在这段漫长的求医过程，他们又应该在哪里留宿呢？阁下当然不可以期望他们入住假日大饭店（Holiday Inn），因为他们身无分文，不像我们“披金带卡”。很明显的解决方法就是：政府或福利团体搭建一种中途客栈的房子，房子里有基本设施，让那些陷入困境的村民可以在那里烹饪、睡觉。到目前为止，我曾听说过美里一些善心人合租一间房子，帮助那些面临同样困难的本南人。
再举个例子，如果病人没有病死，反而在接受治疗之后康复了，然后又出院了。院方会否执行不收费的政策，抑或甚至如同英国的国民健保服务般，资助他们回家的费用？抑或药房里的小气官员会否对他们不客气，开腔羞辱他们没钱买药？
义务医生进入山地行医
提供健保服务的最佳方法，就是为乡区居民带来医疗服务。最近这些年来，这就是一批无私的政府医生和护士所致力献身的工作。他们这些年来都没有动用年假，当年假累积够了，他们就可以长途跋涉到峇南内陆地区。他们自掏腰包资助远行和药物的费用，在一年内好几次走访本南区、乌鲁村，为他们带来先进的医疗服务。他们常常都成为第一次走访这些偏僻地区的医疗团队。
其中一位常参与这计划的医生跟我分享一个故事。他们曾在某个乡村见到一个本南男子。有一根藤刺刺在他的大腿上已经三个星期了。
藤刺足以要一个人的命
其实他曾到过廖玛多 （Lio Matoh ）的诊所。他乘了三小时的船，搭了两小时的顺风车才抵达那里。医生给他拔掉了一半的藤刺，然后说他无能为力了。该本南男子也只能无奈地回家，等待伤口恶化，或许准备等死，直到我们的医疗团队抵步为止。一位来自古晋的年轻医生，凭着简单的钳子和手电筒就把那恼人的藤刺给拔掉了。我敢说这个心存感激的本南男子，一辈子都会记得那位年轻华裔医生。
这群医生面临的主要问题是资金。他们尝试向慈善团体如狮子会募款，或者寻求私人公司协助。最好的解决方法就是：设立一个可接受海外捐助的慈善基金。但是这基金也必须要有一百万令吉来启动，因此诸位若有数百万令吉的闲钱，写遗嘱时，就请不要忘记这些好医生。
东马内陆居民“独立”了吗？
正当我们还在两个独立庆祝日的模糊期间，我就想起这批开明的医生和护士。他们牺牲了时间和才华，长途跋涉为这些脱离英国殖民统治后，又被国家遗忘长达46年的大马人提供先进医疗服务。
这批像撒马利亚人（注二）的医护人员，阁下是很少会听到他们的消息的，因为他们害怕曝光。但他们向我体现了最佳的默迪卡精神，也向我们展示：其实慈善始于家园。很可惜地，就减轻砂拉越乡区居民的痛楚来说，这就是我所知的唯一一个志愿行动。
能够接受他们援助的居民其实都很幸运，但是还有很多住在内陆的人们因为政府忽视而继续受苦。对他们而言，他们没能力享用公共医疗设施的事实，独立其实并没有改变一些什么。
这显示乡区人民的生命，比城市居民的生命还要贱。这就是我们所拥有的两个马来西亚。第一个马来西亚属于城市和市镇居民，他们的生命珍贵得很；第二个马来西亚，就存在于沙巴和砂拉越内陆地区，那些居民的生命都很廉价，而且随时可被牺牲。
注解：
（一） 作者沈观仰表示，医疗助理（dresser）是砂拉越的一个特殊职位。医疗助理不是医生，而是一个曾受过一些医疗训练的初级看护。 “Dresser”一词大概源自英文的敷伤口（dressing the wound)。
（二） 撒马利亚人（Samaritans）：（英国）撒马利亚慈善咨询中心（为想自杀的人和其他不幸者提供咨询的组织，主要通过电话提供咨询服务）（新牛津英汉双解大词典，第1881页。）