A H1N1 PANDEMIC ; UPDATES

It does appear that the pandemic declared by WHO and faithfully followed by the MOH, is a non-event. The problem started in Jan-April in Mexico, and we had our beginnings in May 2009. July-Sept were hot months and I remember the numerous meeting and dinner consults to try and formulate strategies. There was the " panic camp " that all was going sour and thousands or millions are going to die. There was the " cool down-it is not so bad camp " that said that we have a problem, but there is no cause for alarm or panic. Just ride it out like our seasonal "flu". Of course, those of us in the " cool-down camp " always wondered if those in the " panic camp" have ulterior motives ( the conspiracy theory ), ranging from USA, WHO and local MOH. Alas, there is no prove of this.
I am only happy to report that since the last posting in Nov 2009 till now, the situation is quiet. Locally, there a still sporadic cases reported in medical centers and GP clinics but nothing in alarming proportions. The MOH rightly asked us to be vigilant ( always good to be vigilant ), but sometimes strong statements about an impending second wave are made. Even the DG has stopped given out number of cases for the last month.
It is important to note that so far, even in the west where winter in upon them and school has opened for winter in late October, we have not seen a second wave. Not in the northern hemispheric countries. Of course in the southern hemispheric countries it is hot summer now and A H1N1 is by and large forgotten.
Looks like there is not second wave, not so far anyway. With globalisation and air transport across continents, whatever happens in one continent, will soon appear in the other continents. Remember, it took 1-2 months for the USA / Mexico swine flu to reach us in the beginning of the year.
Well, that is good news. I suppose we should boost up our suivellence system and be on the guard, not only against A H1N1, but also other forms of infectious disease. In fact, true to our earlier statements, dengue fever has probably killed more Malaysians through the years, then A H1N1. Dengue was a Malaysian health problem since I was in medical school, some 30 years ago, and it is still a problem. Looks like there is just no political will to eradicate dengue, and also not much money to be made on the side. Without discovery of vaccines or new treatment for dengue fever, either against the mosquitoe or the virus, no one seem very interested, although patients continue to die. Our preventive campaigns have met with severe resistance, given that part of the problem may be the government itself and also the wealthy, mighty construction firms that allow large pools of stagnant water in their compounds, and who are " untouchables".

THE LATEST TRANSATLANTIC CARDIAC BATTLE ; THE ISSUE OF hs-CRP

The Dec 21st online edition of Lancet carried an interesting long term prospective meta-analysis of 54 clinical trial, across 18 countries, involving 160,000 patients, on whether hs-CRP ( a C-reactive protein found in the blood ), affects outcomes in patients with Coronary Artery Disease ( CAD ). This study, with the acronymn of ERFC ( Emerging Risk Factor Collaboration ), was led by the group at Cambridge and published in the Lancet. Basically what they found, after going through prospective records of the 160,000 patients was that there was no co-relation between hs-CRP levels and incidence of heart attacks, angina, strokes in patients with CAD. This finding was of course in sharp contrast to the work of Dr Paul Ridker at Bringham and Women's at Boston, Mass.. Dr Ridker is the hs-CRP guru and lead investigator of the Jupiter trial on the role of rosuvastatin in the prevention and management of patients with coronary artery disease. He represents the US and new thinking. The inflammation theorist.
There are many us, myself included who thought that the old coronary risk factors would go towards suporting the basic, degenerative theory of coronary artery disease ( the old British School ), has limitations and that clincal events are in some way related to inflammation.hs-CRP measurement in the serum, is a measure of the degree of inflammation present, especially in patients with diabetes. We also know that the measurement of hs-CRP is technically difficult and unless the technicians are well trained, can be full of errors. It is not a simple test, even with kits. We have found widely differing readings from different labs and even from the same lab at different times. I suppose being a high selective and highly sensitive test have this inherent challenge. Maybe that is why the data from both sides of the big pond, is different.
I wonder what this new set of data will do to rosuvastatin, the money spinner for astra-zeneca. Rosuvastatin has been marketed as an agent that will reduce inflammation, reduce CVS events and regress plaques. It also reduces hs-CRP and the theory is that because of its efficacy in reducing hs-CRP, it is so good for management of CAD. Now that selling point may have to be re-considered.
Interesting. But as always, we must remember that this is a prospective, meta-analysis of 54 clinical trial, and not a head to head, interventional study. So that data, and conclusion must be taken in that light. It is cheaper and the Cambridge boys have given us a useful hint that all is not so simple. Something as complex as coronary artery disease cannot be so simple to understand and even to treat.

MORE CANCER RISKS WITH MSCT SCANS. LATEST STUDIES.

I have always been very concerned about the uncontrolled, proliferation of MSCT scan machines in the country in general and the Klang Valley in particular. Two recent clinical papers in the 14th Dec 2009 Archives of Internal Medicine, highlights the cancer risks with widespread use of the MSCT scans.I will use the titles directly and they will be self explannatory. The first paper by Drs Smith-Bindman R, Lipson J, Marcus R, et al. entitled "Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer." Arch Intern Med 2009; 169:2078-2086. The second is by Dr Berrington de González A, Mahesh M, Kim KP, et al. entitled " Projected cancer risks from computed tomographic scans performed in the United States in 2007. " Arch Intern Med 2009; 169:2071-2077. As you can see, in 2007 across the US, about 57million scans were performed, and now we have a 2 year follow-up. The research shows that 29,000 cancers occurred in the patients who were scanned. There were cancers of various types and affected particularly the young females. For some reasons, females were more prone. They also discovered that the same institution doing scans had different doses, even for the same kind of scans. Looks like there is almost no standard dose.
I suppose what I am trying to say is that scans done must be for a good reason. The benefit from the information must outweigh the cancer risk from the scans. Routine scans cannot fit into this category and there the risk outweighs the benefit. There are risk from the scans. They are not innocent. When we first started to alert the public, many cardiologist were upset with us ( even till now ). But they have taken heed ( grudgingly, I suppose ). I understand that nowadays, there is more explanation regarding cancer radiation risk. To be fair, the current generation of scans, especially the latest 256 slice MSCT has much less radiation and can scan the whole heart in one heart beat, thereby reducing radiation. Of course, it is more expensive.
The other issue with widespread use of the MSCT is that, many innocuous small nodules are picked up incidentally, resulting in many unnecessary surgical biopsies and additional procedures, thereby increasing cost and risk. Not to mention the many sleepless nights for the subject, once he is told that he has a ?" lung nodule ".
Basically, I would like to emphasize that whatever tests we order, the benefit from the information derived from the test must far outweigh the risk of the test. Else, the test should not be done and something less risky should be prefered.

IS ANYONE IN THE GOVERNMENT CONCERNED ABOUT THE STANDARD OF MEDICAL CARE IN MALAYSIA?

This piece was written for the STAR. Lets see if they will publish, and when.

Recently, there have been much concerned expressed in the mass media about the many medical schools and the concern about the quality of healthcare in our country. It is very worrying when politicians use medical schools as an incentive for votes, oblivious to the effects that too many medical school will have on the healthcare standards in the country. A politician goes on an overseas trip and duely announces the setting up of a medical school. Is this wise?

It is important to note that there are already, at the last count, 22 medical schools up and running in Malaysia, a country of 27 million people. Each year, about 4 thousand medical graduate enter the job market. Because medical school is very much a theoretical course, these 4,000 new medical graduates need to undergo “housemanship “. When I graduated, we were on “ houseman “ night duty, every other night, so we get to clerk and take care ( first hand ) many, many patients. Now, with 4 thousand medical graduates entering the job market, there are not enough patients in government hospitals for all these new medical graduates to get houseman post for training. I hear that houseman nowadays go on call like once a week and they have to share patient with their fellow houseman in the wards. Because of this ( too many housemen ), the housemen are found to be inadequately trained. They have not been adequately exposed to enough patients, so the ministry of Health has decided that housemenship should now be two years. That means that the government hospitals now have 8 thousand housemen, trying to train. Obviously, this will mean that double the number will only get half the already inadequate exposure. Resulting in very poorly trained housemen and eventually medical officers. We hear of medical officers who are unable to make diagnosis, or deal with emergencies, or do simple procedures like central line insertions.

So also nursing training and paramedical training. It is so commercialised that you pay your tuition fees and get a certificate at the end. Supervision and training materials and trainers are limited, so the trainees just memorize facts, sit for an exam and hopefully pass. It is so commercialise that graduates cannot perform when they are out in the real world.

So we now have poorly trained medical officers, houseman, nurses, paramedics.

Even the standard of medical specialist in this country have been subjected to “ political standards “. There are many specialist out there who cannot interprete common Xrays and ECGs.

Of course the off quoted reason is that there are not enough doctors in the country. But this is simply not true. There is a severe mal-distribution of doctors. All doctors, upon completing their training, they all gravitate to work in public hospitals in the urban centres, or set up centers in the urban centers, resulting in urban centres having a doctor-patient ratio is about 1:390. Whereas in the areas, less doctors volunteer to go, and also some states in Malaysia have local rules which bar doctors from practicing, unless they are given exemptions. Therefore, it is true that in some rural areas, the doctor patient ratio could be 1: 4,000 ( partly by design ). It would be good if we can have a doctor patient ratio of 1: 1,000 – 2,000 like some developed countries, and evenly distributed. Towards this end, we actually suggested to the ministry of Health, many years ago, to issue doctors with a certificate of need, so that they can save in areas of need, to even out the mal-distribution of doctors.

We are very concern and wish to ask the governments and politicians not to commercialise and politicize medical schools. Doctors must be adequately trained to care for patients. It is a noble profession and we wish that the politicians will allow it to remain so. Please stop the mass production of doctors and improve medical care for the rakyat.

HEALTHY LIFESTYLE, PREVENT DIABETES

Arguably, the most outstanding article with commercial health value this week must be the article published in the Dec 14th issue of Archives of Internal Medicine, by Dr Mark Woodward et al, entitled "Coffee, Decaffineinated coffee and tea consumption in relation to incident of type 2 diabetes mellitus ". There is obvious commercial value and also important human health value. Diabetes is a very deadly, chronic disease, that can take much healthcare dollar. What is more important is that it can be prevented if we learn to take care of ourselves. Simple chnages in lifestyle can prevent this very "expensive " disease.
Dr Woodward and colleagues from 3 continents, went into the internet search engines, and look for all the prospective studies that linked diabetes with tea and coffee consumption. ( nowadays, it is too expensive to conduct large scale, interventional studies, so registries and prospective studies are cheaper to conduct and also the internet search is also cheap and affordable, with some value ). Their team ( fellows from Australia, Europe and Dr Woodward from Mount Sinai School of Medicine, New York ), found 18 prospective studies from 1966-2009 that fitted their criteria. It involve 475,922 participants. They just look for the association between the participants' drinking habits of coffee and tea and the incidence of T2 Diabetes. They found that there was a relationship. They found that if you drink 3-4 cups of coffee ( whether caf or decaf ) or tea, there was a 20% reduction in the incidence of T2 diabetes. In fact, their graph showed that for every cup of coffee or tea additional per day, there was a 7% reduction of T2DM. That is great information, if it is proven to be true.
What we do not know is why? Why did drinking tea or coffee reduce the incidence of T2DM. Is it because of anti-oxidants, magnesium, other yet unknown chemicals present in coffee and tea, or is it because of the lower amount of sugar in these drinks when compared to the more popular "teh tarik ", coca-cola and carbonated drinks? Knowing the exact reasons will obviously have evn more commercial value.
Lastly, I must mention that this is a prospective registry type data, which is essentially pattern forming. It is not exactly an interventional studies, comparing those who drink from those who do not, which tend to be more accurate. Here Dr Woodward and colleagues tried to indentify those who follow from one life-style and see their incidence of the disease that you are studying. It is a horizontal study, not a vertical, more interventional study overtime. We do need some vertical interventional study, to be more certain. But it also cost more, and so is unlikely to be done. Horizontal prospective studies are noce and gives an association, but it cannot be confirmatory.
For me, I take it that drinking coffee or tea is good for my health and live it at that. I will also exercise regularly and keep my weight at BMI 24 and waistline of 34 inches. I wish to avoid T2 diabetes mellitus as best as I can.

INTERVENTIONAL CARDIOVASCULAR FORUM 2009, AWANA GENTINGS, 11th-13th Dec 2009 FOLLOWUP REPORT

Well, the weekend is over. This year, we tried for the first time, a three half day meeting. Friday being a working day in most states ( except Selangor ), saw poor attendance. By saturday, we were back to what it was previously, in terms of attendance. In terms of clinical material and case presentations and discussions, it was very good and informative. The Thais came well prepared and on Thursday, so that they presented many caes on Friday morning. Interesting ones, from which we all learn alot. Looks like we are not yet ready to close clinic to come. Looks like it has to be a strictly weekend meeting, for the moment at least.
Awana Gentings was easy to get to. It took me about 65 mins from Subang, driving at a leisurely pace. On Thursday afternoon, the traffic was good. The resort itself could do with some refurbrishing and maintainence work. I nearly could not get into my room on saturday as the door lock was jammed. Also the cook tried to serve me curry mee, picking up the mee and ingredients with his bare hands. I declined the mee and reported to the manager, that I did not know what the cook last did, before touching the mee. The children who came along had fun, as there was much to do. Conference facilities for a meeting of 50-60 people were adequate.
The attendance on Friday was 40 odd made up of about 20+ Malaysians, anout 10 Thais, and about 10 sponsors representative. Saturday was about 50+ and Sunday about 30+. We saw about 30 cine cases. Although we did not planned it, we saw many cases of thrombus ( blood clots ) in arteries, and how each interventionist dealt with it. The foreign speakers also showed some of their cases. There was of course, free and unbridled discussion in a spirit of learning. No one tried to " Lord " it over the others. There were two cardiac surgeons in the audience to keep over enthusiatic interventionist in check. To remind us that in some situations, cardiac surgery may be the better option. I think that that is important. The younger members felt ( they all shared with me ) that they learned alot from the discussions of the cases. The lectures were good, and well prepared. The lecture on the use of Plavix, with Losec was particularly informative. We all learned that it was still controversial. Maybe we should use Plavix + aspirin with a H2 antagonist as a prefered initial strategy. The data on plavix PPI interaction was still rather controversial. It depends on which camp you came from.
The gala night was great. Not many people attended. Looks like the sponsors had taken many away privately. Those who were there ( about 6 tables ) had a good time, eating, laughing, joking and having good wine. This year, one delegate donated 4 bottles of good wine. Those that I bought for the evening were of average quality only. Suffice to say that we finished all the wine. The Thais are quite good wine drinkers. We all had a jolly goodtime.
Well, we spend well within the budget. When I looked over the master bill for Awana on Sunday afternoon, we were very healthy ( budget-wise ). I have yet to see the overall bill. I expect it to be well within our means. The sponsors' response so far ( of course when I ask them, it is a bias response ) was good. They were pleased. I shall be speaking to some of the big bosses to see what kind of feedback they will give me.
As for next year ( everyone is asking ), there were many suggetsions for improvement. Some wanted it earlier, some suggested that we go overseas. The Thais suggested that we should reciprocate and hold it in Thailand next year. I replied that we will consider and budget is an important factor ( as always ). As for the academic content, I suppose the cine review sessions will definitely remain and may be enhanced. Maybe it should be abit more structured.
Overall, I think that we fulfilled our objective of helping to further raise the standard of interventional cardiology, in Malaysia, and maybe Thailand too. It was a good weekend of learning.

INTERVENTIONAL CARDIOVASCULAR FORUM 2009, AWANA GENTINGS, 11th-13th Dec 2009

In an attempt to get the Malaysian Cardiovascular Interventional community together, we have been organising the " Interventional Cardiovascular Forum " annually for the last 5 years. This years meeting is the fifth. There are many of us, who being senior, felt that by meeting together and discussing our tough cases, we can share experience and so shorten the learning curve for interventionist in the country, thereby improving patient care. The industry could see the aim and their support through the many years have been unwaivering. For this I thank them. We also appreciate them by being very transparent in our accounts, working with one of them as a secretariat, so that they know how the money is being used. In the early part of 2009, we saw that an economic recession is coming, so we decided that we need to cut down cost and meeting at a more affordable venue. Previously, we used to meet in 5 star hotels in Langkawi.
Little did we realise that interventional cardiologist are a rather pampered lot ( how did I not know that ). They would rather holiday oversease or only in 5 star hotels. One large group feels that they know all, and so there is no need to meet to discuss work. They felt that once they have done 10 angioplasties, they are experts for all time, and earning money, holidaying overseas is more important. Another large group of seniors are either uncomfortable sharing with their juniors or felt that there is no need to breed competition. The last group just do not wish to take time off. They just want to work, hang around waiting for work and just keep to their own work shell. This is the state of Interventional Cardiology in Malaysia. The apathy and " I am OK, please leave me alone mentality " is so prevalent. Even amongst us professionals. Mind you, this whole weekend is all sponsored, so that the interventionist do not have to pay ( maybe that is the problem. ? cheap things no good mentality ).
Nonetheless, before I sound so gloomy, about 50 of us ( target is 60 ) will gather tomorrow morning at the " Jelatek Room " at Awana and start our lectures and discussion on our cases. There will be exhibitor's table and displays. There will be three foreigners in our faculty, and about 13 sponsors. If previous experience is anything to go by, there will be interesting cases, some with good results, some disasters, some new way of doing things. Things to learn, I am sure. There will be update lectures from experts, both locals and overseas. This weekend should be a learning experience. In the evening, we meet informally over dinner to renew acquaintances. We felt that friendship was important as a community so that we can continue to share with each other and consult each other formally or informally for the better care of our patients.
I hope that all goes well, and we all learn from each other, and improve our patient care.

IN-STENT RE-STENOSIS, YOU CAN HELP WITH INTENSIVE EXERCISE.

Angioplasty is now it her 32rd year ( Sept 15th, 1977 ). Through all the years, we have always battled with the problem of re-stenosis, the achilles heel of angioplasty. Back in 1993 before the publication of the STRESS and BENESTENT ( these are the two large scale clinical trial that established the role of the stent ) results, we all were sure that the stent would solve the problem of restenosis. Well, it did to a certain degree. We reduced restenosis ( plain old balloon angioplasty restenosis of 40-50 % ) from 40-50% to 15-20% with the bare-metal stents ( in particular the JnJ PS 153 ). That was not good enough and we were soon developing drug-coated stents. The RAVEL results were know at the turn of the century, in 2001, which showed that with the CYPHER ( JnJ Cordis, sirolimus eluting stent ), at one year, in a highly selective population, the restenosis was zero %. I thought that that was two good to be true. Sure enough when one studied the restenosis with the DES in an allcomers population, the DES restenosis rate is probably nearer 5-10%. The there is the problem with stent thrombosis. But that is another story for another day.
So after 32years, we have improved from a restenosis rate of 40-50% to 5-10%. To be honest, during the 32years, we have also moved the goal post. The initial POBA ( plain old balloon angioplasty ) restenosis rates were all angiographically determined ( meaning we tend to see more with the angiogram, and so tend to do more ). Nowadays, unless it is for clinical trial purposes, more and more studies are prepared to use clinical re-stenosis rates and target lesion re-vascularisation or target vessel failures. Be that as it may;
I wanted to share an important clinical study with you that comes from Norway. Dr Peter Munk and colleagues from Stavanger University Hospital, Norway, that appeared in the American Heart Journal Nov 2009. They studied the effects of intensive exercise on restenosis. They studied 80 patients, 40 in the control arm, on the usual regular follow-up following PCI with DES or BMS, and 40 patients on an intensive exercise program following PCI with DES or BMS. Intensive exercise program, included a supervised exercise program for 60 mins, with 10 mins warm up and 10 mins recovery. They exercise for 40 mins either on the bicycle ergometer, or the treadmill, achieveing a target heart rate about 80-90% maximum. This exercise is followed three times a week, and at the end of six months, the patients were re-studied. They found that the late lumen loss was 0.39mm for those in the contrlled arm and 0.10mm for those in the intensive exercise arm. There was also improvement in their Hs-CRP levels and peak oxygen uptake and flow mediated dilatation. Basically, everything was better especially the arterial lumen.
True, this is a small study but I like the study because, it does mean that patients can help to take care of themselves. Sometimes, we have patients who feel that once that have survived and paid for the procedure, everything is done, and they are OK. They then revert to their old habits, hoping that tehy will be well, and should they get restenosis, they would blame the procedure and maybe the operator for doing a bad job.
Besides that, the study also generates a few hypothesis. For example, it would appear that inflammation plays an important role in late lumen loss. And that this inflammation is not well controlled by the drug on the stent. Anyway, some of the patients in the study had bare-metal stents and so there is no drug to talk of, and yet they had benefited from intensive exercise.
Of course, it would appear that the senior citizens who may not be able to exercise, are at a disadvantage.
Whatever it is, all those of you out there who have a stent put in, you can help yourselves if you keep fit with exercise for one hour three times a week. It may help to reduce your chance of stent restenosis, and save you time, risk and money.

THE MALAYSIAN HEALTHCARE ; PHARMARCY SERVICES 2008 REVIEW

From the 30th Nov till 2nd Dec 2009, we ( the Federation of Private Medical Practitioners of Malaysia ) were invited to participate in a Pharmaceutical Services Division, Minitry of Health workshop in Port Dickson. It was held at the Corus Paradise Resort, Port Dickson. The workshop was entitled " Ensuring Fair Access to Medicines - Pharmaceutical Pricing Policies and Regulations ".
Of course, with such a title, our ears perk-up. It smelled like at attempt to regulate doctors right to use drugs of their choice, be it generic or branded, to use cheaper alternatives for the treatment of disease conditions, and even more alarming, the regulations to separate dispensing and prescribing. These are all important issues to resolve, as it will definitely affect the medical primary care landscape.
Even before we went for the workshop, we were very surprise at the choice of the venue. Why hold an important workshop away from KL and Putra Jaya, and at a run down 3-star ( at best hotel ). I suppose if you are a government servant, it makes more sense ( afterall it is jus after a long weekend ), to have a workshop in a resort town and hotel. However, if you are busy private self employed doctor or group practice, then you will wonder why. Be that as it may, we also noticed that, of the list of 46 participants, representing various Pharmaceutical divisions in Ministry of Health, EPU, and other pharmaceutical bodies, there were only two private medical associations invited, with 5 doctors listed as invited delegates to represent these private medical bodies. This was despite our protest in July 2009, at the last " Malaysian National Drug Policy mid-term review " workshop, that they must include more private doctors, as the topics discuss will impact on pprivate healthcare. Looks like they never bothered.
Anyway despite all these grouses, we went ( what choice do we have ), to say our little bit. The three of us from the FPMPAM took turns ( as we were private self employed practitioners, and we do need to earn our bread ). I learned a few facts from the lectures. I learned that we spend about RM 430M in 2000 on medicines ( 6.32% of healthcare budget ), in 2007, we spend about RM 1.3B on medicines ( about 10% of the healthcare budget ), and in 2008, we spend RM 1.5B on medicines ( about 11.7% of the healthcare budget ). This is a very reasonable number and is by no means excessive. There is little need to change or trim down, as what we are spending on medicines is the world average. Whatmore, to state that our healthcare system has produced outcomes, as measured by life expectancy, infant mortality, that is easily comparable with any other country around us, except maybe Singapore, and maybe if we compare maternal mortality, we still have room for improvement. Afterall, we only spend about 3.6% of our GDP on healthcare. A very small amount by any standards, to get the outcome that we are getting.
I also learn that in the Pharmaceutical Division procurement and drug delivery services, as we observe from Yr 2006 to Yr 2008, it took longer to get drugs out to depot centers in West Malaysia. In S'wak, over time, it took less time from 2006-2008. I could not understand that. How come with improvement in the country's transport system, it was taking longer, so that the drug depot centers, would run out of drugs., including essential ones.
All in all, there looks like a great paucity of data on healhcare and healthcare delivery, in the country. Many a time, we are just using logical thinking, following patterns from other countries, WHO advice ( experience from first world countries ) and a strong dose of " gut feeling " ( read how the people in charge feels ). Our drive to gather information and data, before making important strategic decision is still greatly lacking.
We went to the workshop with 2 important messages. Firstly, involve more private doctors in the discussions as they are one third the stakeholders in the drug policies ( namely the pharmas, the doctors and the patients ). The room was filled with pharmas and administrators and only three doctors. The second clear message is, why try and fix something which ain't broken? We are spending 3.6% of our GDP on healthcare ( a small amount by first world standards ) and getting good outcomes, and we are spending 11.7% of our healthcare budget on medicines, which is again a very reasonable amount by any standards, to get the outcomes that we are getting. We are getting value for money.
Anyway, the three of us felt, after the sessions, that whatever was being discussed, was already very much decided and awaiting implementation. Looks like the authorities, have decided that there must be generic substitution ( something we wrote on earlier ) and they will implement a separation of prescribing and dispensing, come what may, whether is good for healthcare in Malaysia or not. Whether we are spending our healthcare budget wisely or not.
But then this is Malaysia. Looks like they will do whatever they wish, and why should healthcare be any different.