By CHIN MUI YOON, Photos by ART CHEN and courtesy of the COAC, Sunday April 15, 2007.
Winner of MDGs Media Awards 2007, Print Category, First Prize.
Despite years of progressive healthcare programmes, why are diseases and poverty continuing to plague our indigenous people and preventing Malaysia from completely achieving our Millennium Development Goals?
MEDICAL student Amy Lee, 25, recalls prenatal classes, a monitored diet and regular medical check-ups throughout her pregnancy.
(Photo: Medical officer Dr Navin Francis attending to TB patient Zarina Atam, 40, who is accompanied by her husband and four children at the Gombak Hospital.)
Most expectant mothers experience similar care and attention during those crucial nine months – but what if you’re living in the middle of a jungle?
“I’m shaken by what I’ve seen during my three-month stint at the Orang Asli Hospital in Gombak (in Selangor),” Lee says. “Many patients, including expectant mothers, have never experienced even the basic healthcare the rest of us take for granted throughout our lives, like proper nutrition, vitamins, clean water and medical attention.
“The children have blondish hair due to nutritional deficiencies. Their swollen abdomens speak of worm infestation. Many have lice in their hair and they are covered head to toe with fungal infections.”
Malaysia proudly highlights our success in attaining the UN Millennium Development Goals (MDG), a set of nine targets launched in 2001 that signatory nations have agreed to fulfil by 2015. The MDG goals cover poverty eradication, education, gender equality, environment and global partnerships. (Photo: Dr Colin Nicholas.)
We have dramatically succeeded in reducing child mortality rates by two-thirds and improved maternal health to the level of developed countries. The successes are credited to Malaysia’s general health service development and secular (non-health) factors such as reducing poverty from 49.4% in 1970 to 5.1% in 2002.
From seven health clinics in 1957 to over 4,000 today, and an increase from 66 hospitals to 125 nationwide, Malaysia certainly has a healthy outlook, especially with a RM7bil budget for the Health Ministry alone, equivalent to 3.6% of the GDP.
(Photo:The orang asli traditionally prefer to remain in their villages where trained midwives and traditional healers cater to their health needs.)
When it comes to the orang asli, however, it isn’t such a rosy picture of health. They are the only ethnic group in Malaysia under the purview of a dedicated department, the Orang Asli Affairs Department (JHEOA or Jabatan Hal Ehwal Orang Asli), which is empowered through the Aboriginal Peoples Act 1954 (revised 1974). Despite this, they have the highest number of cases of infectious diseases that were supposedly eradicated years ago.
Their number has grown from some 54,000 in 1969 to nearly 150,000 today, representing 0.6% of the national population.
“Yet the orang asli had 51.5% of malaria cases recorded in Peninsular Malaysia in 2001,” says Dr Colin Nicholas, coordinator of the NGO Centre for Orang Asli Concerns (COAC).
He adds that in 2003, this figure increased to 53.6%.
From 1998 to 2002 the incidence of leprosy among the orang asli increased three-fold (from nine cases to 27) while the national incidence fell 25% (from 236 cases to 179).
A doctor previously posted at the Gombak hospital recalls a recent visit via helicopter to a riverside village in Sungai Lipis, Pahang.
“The children were naked and many had greenish mucus running down their chins. Most were covered with fungal infections. Some young ones were eating soil, possibly because of a medical condition called Pica, which results in iron or zinc deficiencies that can trigger unusual cravings.
“But they also had worm infestations which deny the children what little nutrition they can get from their food. They vomited worms when we attended to them. Little wonder they are susceptible to even the common cold that our immune system easily shakes off!”
While the orang asli welcomed the medical team, some who needed hospitalisation were reluctant to be flown out because they feared being alone out of their forest sanctuary.
Would health education have prevented Juli Lasam, 44, from becoming a leprosy victim that has left him with weakened hands and stumps for toes? He is now struggling to provide for his children who are attending the nearby schools.
“A 22-year-old man had a suspected case of leprosy. But he ran off to hide inside the jungle. He was finally persuaded to come out for treatment after a while. I was shocked at his appearance; he looked like a man of 50. His blood was so diluted it was like Ribena. His haemoglobin count was 3.2 instead of the normal 12,” said the doctor, who declined to be named.
Even if they are not fearful of modern treatment, ignorance can take its toll.
Juli Lasam, 44, says he wished he had known how to recognise the symptoms of leprosy earlier.
“It might have saved me the pain I go through now every day,” he says, pointing to the stumps on both feet that are all he has left of his toes.
Juli first discovered white patches on his arms and legs in 1995. He bathed regularly as piped water is supplied to his village of Ulu Tamu in Batangkali, Selangor, but the discolouration would not disappear. He had no idea that the patches were classic symptoms of leprosy.
By the time Juli realised he was losing sensation in his toes and fingers, it was too late. Medical staff who regularly visited his village immediately sought treatment for Lasam and he was hospitalised for four months. Today he struggles to provide for his 12 children by tapping rubber for RM10 a day.
The cases of TB or leprosy are worrying in view of these forgotten diseases returning in deadly, drug-resistant new strains. More forests are being de-gazetted for development, which increases the risk of these contagious diseases spreading.
These communicable diseases are supposed to have been eradicated years ago. Yet 1.6 million people are infected annually worldwide with TB making it the deadliest infectious disease on the planet after AIDS, according to the World Health Organisation (WHO).
The high rate of infected orang asli is not surprising to Dr Nicholas.
“TB is a classic indicator of malnutrition; it simply indicates that the orang asli are not getting sufficient nutrition,” he says.
A Universiti Kebangsaan Malaysia study on the nutritional status of women and children in rural populations reported that over 30% of orang asli women were malnourished compared to less than 15% of Felda settlement women, who had a higher risk of developing complications related to obesity and diabetes. The study also noted the high prevalence of goitre among the orang asli community, especially among women, reflecting an iodine deficiency and malnutrition.
Another doctor previously posted at the orang asli hospital in Gombak says the orang asli catch even common illnesses and diseases easily due to their weakened immune systems, which stems from poor diets.
A mobile rural healthcare service conducting post natal checks.
“In some cases, we had to even discourage the mothers from breastfeeding because they were malnourished. We had to supplement them with formula milk,” he says.
Their diet doesn’t even have sufficient iodine salt intake that most of us take for granted. They also live in small, cramped huts without good air circulation. The close contact makes it easy for communicable diseases to spread.”
Melvin Spigelman, of the New York-based TB Alliance that is developing new drugs in fighting the disease, says in a report, “People who have compromised immune systems are much more vulnerable. TB has never ceased to plague the developing world. It is a quintessential disease of the poor.”
So it should not be surprising that the orang asli’s TB infection rate is so high – they are the poorest group in Malaysia, with 76.9% living below the poverty line (an income of below RM500 a month) compared to the national rate of 6.5%.
Dr Nicholas adds that there is still strong discrimination against and condescension towards the orang asli.
He notes that there have been many recorded cases where the orang asli were blamed for the ailments they came down with or were accused of being the cause of disease outbreaks in other communities. (See ‘The blame game’ on page 5.)
“There is a strong underlying assumption in state policies that orang asli backwardness is a result of their way of life and remote location,” says Dr Nicholas. “But that’s not true, they do not live in the middle of the jungle. Most live on the fringes of forests with nearby kampungs barely half a mile away; few live far from health facilities.”
He points out that, ironically, their health was better 30 years ago.
“Some of the practices employed defeat the purpose of rural healthcare for orang asli. We need to bring healthcare to them, not isolate them in hospitals and ask them to wait one month for treatment. And only one third of the patients at the orang asli hospital are orang asli, the rest are from the local community.”
Dr Nicholas says healthcare is dependent on the individuals posted at the various hospitals and clinics. There have been claims that orang asli were discriminated against by being treated last even though they had arrived first.
However, the hospital’s medical officer, Dr Navin Francis, takes a different view:
“Many children have poor hygiene even in the basic things like clean fingers. Some kids have already lost their teeth at 10 years old. We are doing all we can. We are reaching out to them by air, land and boat. Hygiene to some orang asli is considered a luxury not a necessity. They just live in a different world.”
The 166-bed hospital was built in 1957 and is under the JHEOA. Some nine medical officers are posted there with four or five on duty at any one time.
The deputy director-general of JHEOA’s health and medical division, Dr Sai’ah Abdullah, says this is a sufficient number although previously posted doctors have said they had their hands full juggling duties at the wards and the outpatient clinic that caters to the local community. The staff, including nurses and pharmacists, is seconded from the Health Ministry, she says.
Inevitably, the orang asli’s health and well-being are linked to their way of life.
Dr Nicholas contends that their malnourishment is due to the disruption and depletion of their resource base caused by logging and deforestation.
The tussle between state land and tanah rezab, or the orang asli’s ancestral lands, has long been reported in the news. The latest case involves a group of orang asli opposing a national botanical garden project near their settlement in Bidor, Perak, which they say encroaches on their ancestral land.
Many orang asli are trapped in a cycle of poverty.
The orang asli traditionally live very simply, and this is sometimes erroneously perceived as being lazy.
Health officials say education is key to improving the lives and health of the orang asli. Unfortunately, as Dr Nicholas points out, the majority of the children don’t go to school simply because their parents can’t afford it.
He also questions the lack of recruitment of orang asli paramedics since the 1990s. In the early years of the hospital, the medical officers conducted training for the shamans in the villages, who are still held in high regard, especially in the interior.
“We need to complement traditional healthcare practices with modern ones,” he says. “People go to the shamans first. Some shamans look at symptoms and immediately know the person is down with malaria and refer him to the nearest clinic. The shaman would say that the kuman, or bacteria, is too small for him to ‘catch’.”
Dr Sai’ah agrees that traditional healers and midwives are still well regarded in the orang asli villages and says the Health Ministry still conducts training for them twice a year in four different locations.
“They (the shamans) are taught modern healthcare practices and how to identify diseases.”
She adds that the challenge of administering modern healthcare to the orang asli is in building rapport between the people and the medical staff.
“Sometimes we even stay a week at a settlement. There are times when we have to coax some of the orang asli to undergo medical treatment.
“We have a RM9mil budget from the JHEOA and the Ministry responds to requests for aid very quickly. I’d say that the orang asli are getting a lot of attention, sometimes even more so than the general population! We are looking after them from the womb to the tomb.”
That is a view Dr Nicholas cannot agree with: “Ministers always think the situation is fine on the ground and that the orang asli are being taken care of because their staff report so. If that is true, how do you explain the majority of orang asli living below the poverty line?
“The issue is to get rid of the prejudice we have towards the orang asli or we’ll never improve the situation. All the attention has been guided by that prejudice and not reality.”
The sad facts
THE orang asli, numbering 149,500, is the poorest group in the country. Some 77% of orang asli households are categorised to be living below the poverty level.
From 1998 to 2002 the incidence of leprosy among the orang asli increased three-fold (from nine cases to 27) while the national incidence fell 25% (from 236 cases to 179).
This dreaded disease afflicts half a million people annually worldwide leaving victims permanently scarred and often horribly disfigured. The disease eats at the skin, mucous membranes and nerves. In the past, leprosy patients were isolated in leper colonies such as Sungai Buloh, Selangor, and Pulau Jerejak, Penang.
Accordingly, orang asli life expectancy at birth is estimated at 52 years for females and 54 years for males, which is significantly lower than that for the national population, 75 years for females and 69 years for males.
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The article speaks of Malaysia’s success in reducing child mortality rates and improving maternal health to the level of developed nations. It looks closely at indigenous groups within Malaysia, particularly the Orang Asli, who have a high level of infectious diseases. Fear of modern treatment, ignorance of health problems, lack of sufficient nutrition and lack of education are examined within the article.
Chin Mui Yoon, Star Publications, Malaysia, April 2007
Judges’ Comments: "fresh, well written and the MDG element is distinct." "It is solid, thorough, well-written and widely relevant."
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