Thursday, March 19, 2020

Malaysia - Convid and Undocumented Migrants? No arrest, detention and waiver of medical fees and passport requirements?

In Malaysia, one group of residents in this country that the government has not dealt with are the UNDOCUMENTED MIGRANTS and there are many in Malaysia, some say maybe about 5 million. Most of them come from our neighboring countries like Indonesia, Thailand and Philippines - as travel in and out of Malaysia avoiding officials ports of entry is not that difficult.

The Department of Statistics Malaysia estimates that there are 3.2 million non-citizens in 2019. Non-citizens is a broad term that encompasses migrants (both legal and illegal, with another study estimating a total of between 3.9 and 5.5 million people in Malaysia), refugees (estimated 180,000 people) and stateless people (at least 12,000 in Peninsular Malaysia and unknown numbers in Sabah, comprising Bajau Laut, nomadic tribes, street children and children of migrant workers, and unwed foreigners with local partners).

The government needs to rethink its healthcare policies towards undocumented migrant workers as the current policy drives them underground and made contact tracing and quarantine difficult for management of outbreaks, said epidemiologist Dr Chan Chee Khoon.

Now, being 'undocumented', they are considered 'illegal' and are always worried of being arrested, detained and deported by the police, immigration department, etc..

Being undocumented, they also will not have access to the Malaysian health care facilities - primarily due to fear of arrest, detention, prosecution, 'whipping' if convicted, etc...

During this Convid pandemic, the Malaysian restrictions in place may have little effect if they do not deal with 'undocumented migrants' in the country.

...most specifically the large pools of undocumented migrant workers (easily a million in the Klang Valley) who have strong incentives to avoid contact with government agencies, making contact tracing more difficult in an outbreak situation....Nonetheless, most fatalities and severely ill cases that might occur among undocumented migrants presumably would come to attention at some point, but this would be much delayed, which greatly complicates efforts at containment and mitigation, not to mention treatment.


PROPOSED ACTIONS

Immediate moratorium on all enforcement against UNDOCUMENTED migrant workers (no arrest, detention, prosecution, deportation). Hospitals and government facilities will not 'inform on undocumented migrants' - safe to come for testing and treatment...) - in this way, Malaysia will be able to deal with ALL in Malaysia, and no more have a significant class, who may be infected and too afraid to seek treatment - hence, possibly infecting others. No need for the production of PASSPORTS or Identity cards...as most do not even have this.

FEES at hospitals and government health facilities waived during this period. Now the fees charged for non-Malaysian citizens is quite high. We do not want people who may be showing symptoms or are sick to stay away because they simply cannot afford to pay. Now, while Malaysian need to pay a registration fee of RM1, non-citizens have to pay RM50 just to see a doctor at the clinics or hospitals. To see a Specialist, it cost even more. While we tackle Convid, maybe the government can waive fees for non-Malaysians, or just require them to pay the token RM1 to see a doctor. [No need to have documents for registration too].

Many of these Undocumented migrant workers earn daily/monthly incomes through work. But since, the Convid restrictions until end of the month, has basically stopped most work - hence no income. Government should also consider what to do with the daily livelihood cost of these undocumented migrants. Prolonged deprivation of work or means of earning income may result in desperation and other negative things happenings. Note that increased police presence also makes it more difficult to return to their countries, maybe through the same way they came in. 

Considering the numbers, and the fact they live in Malaysia amongst all of us, IGNORING them will not help Malaysia deal with Covid, would it?

Remember that identification of these undocumented migrants is very difficult as they look very much like Malaysians

How many UNDOCUMENTED MIGRANT victims of Convid-19 in Malaysia now? None?



Covid-19 and contact averse undocumented migrants
Letters

Saturday, 14 Mar 2020 

EPIDEMIOLOGISTS attempt to model quantitatively the course of an infectious outbreak by plotting the number of cases over time in a curve-fitting exercise whose shape reflects parameter values like the reproductive number (average number of secondary infections produced by a typical existing infection) and incubation period (duration between exposure to an infectious organism and the emergence of noticeable symptoms).

Such exercises have been undertaken by researchers at the University of Hong Kong, Imperial College (London) and National University of Singapore, among others.

It was on the basis of such fitted epidemic curves that Dr Bruce Aylward, team leader for the WHO-China Joint Mission on Coronavirus (Feb 16 to Feb 24,2020) assessed that the Chinese government may have averted hundreds of thousands of additional infected cases through their extraordinarily robust containment efforts in Wuhan, Hubei, and other cities and provinces.

The mainstays of these containment efforts were:

> Isolation and treatment of virus positive cases;

> Contact tracing and quarantine of close contacts who were untested or who tested negative; and

> Massive social distancing in various forms, all carried out in unavoidably disruptive ways but which nonetheless allowed for the basic living essentials and needed care, by and large, to be delivered.

Malaysia, however, has specific demographic characteristics that are not easily modelled upon such simulations of epidemic dynamics, most specifically the large pools of undocumented migrant workers (easily a million in the Klang Valley) who have strong incentives to avoid contact with government agencies, making contact tracing more difficult in an outbreak situation.

Nonetheless, most fatalities and severely ill cases that might occur among undocumented migrants presumably would come to attention at some point, but this would be much delayed, which greatly complicates efforts at containment and mitigation, not to mention treatment.

Citizens’ Health Initiative (CHI) knows that our Health Ministry is aware of these potential spillover scenarios through previous discussions with Dr Chong Chee Kheong (formerly director of disease control and currently deputy director-general for public health) as well as via recent communications with senior officers of the WHO and UNU-International Institute for Global Health in Kuala Lumpur.

What is less clear though is the proactive measures and contingency plans the Health Ministry may have for coping with such scenarios.

Are there, for example, initiatives to engage more closely with those channels of healthcare access that undocumented migrants resort to when in need of care, like voluntary clinics such as those run by Tzu Chi Foundation, Pertiwi Soup Kitchen, Teddy Mobile Clinic and Global Doctors Hospital Mont Kiara (assuming they also cater to unsuccessful asylum applicants and undocumented migrant workers in addition to refugees)?

These laudable endeavours operate as de facto “safe(r) spaces” which could supplement the Health Ministry’s efforts in outreach and communication with marginalised communities, especially those that need some assurance of sanctuary when accessing needed care.

Beyond that, civil society organisations, migrant networks and communities, UN agencies and indeed embassies of the labour-sending countries could assess the information and health communication needs of the respective migrant communities, and translate and disseminate useful, actionable information for individual as well as community coping responses.

How might we know if the Covid-19 outbreak in Malaysia has spilled over into the undocumented migrant population?

At the moment, the Health Ministry is relying on its existing sentinel surveillance for influenza-like illnesses (ILI) and Sari (severe acute respiratory infections) to also detect sporadic cases of SARS-CoV-2 positives as a red flag for community viral transmission with no traceable contact history. This could be how infected undocumented migrants might directly or indirectly come to attention.

Somewhat reassuringly, the sentinel surveillance so far has not detected any sporadic cases. The reported first case of a presumed sporadic case has now turned out to have a contact history traceable to a known infected case, as reported in “Sporadic no more: Source of Covid-19 infection traced to religious event” (The Star, March 12; online at https://bit.ly/2wTY46a).

We should treat this as a wake-up call for the urgency of an “all of government” effort led by Prime Minister Tan Sri Muhyiddin Yassin to respond proactively to an escalating emergency.

We should not need the ijtimak tabligh incident at the Seri Petaling Mosque – “Covid-19: Health Minister urges those at mosque gathering to come in for screening” (The Star, March 12; online at https://bit.ly/2vRsSVj) – to drive home the urgency for proactive measures by a health minister or director-general who might have felt constrained in proposing bans on large religious gatherings and sporting events, school and university closures when necessary, and policy changes pertaining to immigration and home affairs, income maintenance/employment security, and etc.

The PM needs to step up and take charge with the overarching authority of his office.

CHAN CHEE KHOON
ScD (Epidemiology)

Citizens’ Health Initiative CHI is an informal grouping of individuals seeking to promote citizen involvement in healthcare reforms and health policy in Malaysia.  - Star, 14/3/2020

Proposing a Non-Citizens Health Act for Malaysia


THE recent polio case in Sabah highlights the people our health system has left behind. Therefore, we propose a Non-Citizens Health Act for Malaysia to achieve universal health coverage, which is both our Health Minister’s stated aim and a World Health Organisation commitment.

The Department of Statistics Malaysia estimates that there are 3.2 million non-citizens in 2019. Non-citizens is a broad term that encompasses migrants (both legal and illegal, with another study estimating a total of between 3.9 and 5.5 million people in Malaysia), refugees (estimated 180,000 people) and stateless people (at least 12,000 in Peninsular Malaysia and unknown numbers in Sabah, comprising Bajau Laut, nomadic tribes, street children and children of migrant workers, and unwed foreigners with local partners).

Naturally, there are caveats. Calculations can differ for legitimate reasons, but it’s reasonable to believe that the official statistics undercounts the number of non-citizens. The list of categories is not exhaustive (e.g. foreign students and asylum-seekers aren’t included). Each category has different legal definitions, and the same individual might change categories over time.

These are important caveats, but they can detract from more useful discussions about solutions.

The fundamental problem is easily articulated but difficult to solve. In general terms, Malaysia doesn’t even recognise the existence or concept of refugees, stateless people and illegal immigrants. 

As a result, non-citizens have almost no health rights and cannot meaningfully access Malaysia’s health system either public or private.

Access to healthcare has many additional barriers: financial (too costly), legal (risk of arrest), physical (a nomadic lifestyle or life in remote jungle camps) or cultural (misinformation and fear).

There are two insurance schemes for legal foreign workers, the Employment Injury Scheme by Socso and the Foreign Workers Hospitalisation and Surgical Insurance Scheme (SPIKPA). However, the coverage is minimal, excludes outpatient treatment and maternal or antenatal care, and only supports legal workers.

To make matters worse, non-citizens are being charged between 24 and 100 times more than citizens to access care in public hospitals since January 2016 after the Fees Act (Medical) 1951 was amended for foreigners.

The Immigration Act requires everyone to report the presence of undocumented foreigners to the police, which creates an ethical dilemma for doctors and nurses who are simply trying to save lives.

Other than very basic care at general practitioner clinics, private care is generally unaffordable to non-citizens. Private hospitalisation is almost completely inaccessible except for ad hoc interventions by private hospitals and non-governmental organisations.

There are many reasons to extend health rights to non-citizens, especially children and pregnant women. Many are powerful moral, ethical, humanistic, religious, philosophical, international law and human rights reasons. There is also the public health case, especially if we want to prevent communicable diseases among citizens and non-citizens alike. There is even an economic case to provide health rights to migrants because healthier migrants will increase Malaysia’s prosperity.

However, we are aware of the countervailing political realities. The justice of using scarce taxpayer money for non-taxpayers is an important consideration. The government has to secure our borders, as our generosity can’t be bottomless. There could be pushback from Malaysians whose own rights are still being secured, and Malaysia could be a more attractive destination for free riders.

After carefully considering both the case for and against providing health rights to non-citizens, we believe that Malaysia must pass a Non-Citizens Health Act to provide certain health rights for non-citizens. In this case, we are proposing a realistic framework for action.

This act would prescribe basic health rights for all non-citizens, starting with vaccinations, maternal and antenatal care, child health up to the age of five and treatment for certain communicable diseases such as pulmonary tuberculosis.

Maternal health should include sensitive, non-coercive and thoughtfully delivered family planning services so that non-citizens do not misconstrue this as attempting to control their numbers.

The government can consider additional services at regular intervals of three to five years because international standards, health systems and financing capabilities would evolve over time.

These services must be provided free or nearly free, alongside effective education and decriminalising non-citizens’ attendance in public health facilities. The funds can come from a combination of existing levies on foreign workers, private insurance or taxation.

All non-citizens should be allowed (indeed, encouraged) to purchase private insurance (similar to Thailand since 2001), and this can be run by NGOs on a privately-held, non-profit basis. Allowing more non-citizens, legal or otherwise, to purchase health insurance reduces adverse selection, increases the risk-pooling effect and may even reduce the premiums over time.

The public health reason for enshrining such rights deserve elaboration. Thailand has kept its rate of tuberculosis at a constant low despite the influx of migrants from Myanmar and Indochina, which have higher rates of tuberculosis.

This is due to their dual policy of extending health rights to all migrants while simultaneously securing their borders.

If Malaysia continues to pretend that non-citizens don’t exist within our borders, we’ll see more outbreaks of polio and tuberculosis on top of the human cost of these unnecessary diseases.

There are also compelling ethical and logical reasons to enshrine these rights. Children and mothers are among the most vulnerable populations, and they deserve our care. Preventive care is cheap and cost-effective. It will not only prevent outbreaks but also emergencies when non-citizens come to hospitals with massive complications requiring heroic (and expensive) curative care.

Standard practice on the ground is to provide emergency life-saving measures for foreigners, although this is not explicitly mandated, allowed or prohibited by the government. In this silence, doctors and nurses will do what they deem necessary for the patient’s benefit. Therefore, the law must protect healthcare professionals from punitive action if non-citizens fail to settle hospital bills.

This act must also remove the requirement for health professionals to inform the Immigration Department if they are treating undocumented migrants to avoid a professional conflict of interest.

The Malaysian government must also implement durable legal solutions for all categories of non-citizens in the country. In addition, the national registration pathways must be strengthened so that every child born in the interior parts of Malaysia will receive the MyKad, which determines their legal rights as citizens, including health and education.

We urge the government to debate and then pass a Non-Citizens Health Act, and assert our soft power by demonstrating a humane, practical and politically feasible solution to the world.

DR KHOR SWEE KHENG
DR JOHN TEO
PROFESSOR PANG YONG KEK (President, Malaysian Thoracic Society)
PROFESSOR TANG SWEE FONG (Secretary, Malaysian Paediatrics Association)
FEDERATION OF REPRODUCTIVE HEALTH ASSOCIATIONS, MALAYSIA HEIDY QUAH (President, Refuge for the Refugees)
JAMES BAWI THANG BIK (President, Alliance of Chin Refugees)
ALL WOMEN’S ACTION SOCIETY
DATUK DR AMAR SINGH-HSS
DR SUBATRA JAYARAJ
DATUK DR RAVINDRAN JEGASOTHY
DR TIMOTHY CHENG
Source: Star, 11/1/2020

‘Rethink healthcare for migrant workers’

Nation


Tuesday, 03 Mar 2020

By LOH FOON FONG





Chan Chee Khoon



KUALA LUMPUR: The government needs to rethink its healthcare policies towards undocumented migrant workers as the current policy drives them underground and made contact tracing and quarantine difficult for management of outbreaks, said epidemiologist Dr Chan Chee Khoon.

He said Malaysia could not ignore its large pool of undocumented migrant workers as long as contact tracing (those who have come in close contact with those who have been tested positive with Covid-19) and quarantine remained as tools for managing the outbreak.

“The Health Ministry and Home Ministry need to rethink their policies towards undocumented migrant workers, which currently drive them underground rather than encourage them to come forth to seek treatment when afflicted with infectious and other ailments.

“It would be extremely difficult to carry out contact tracing when undocumented migrant workers have strong incentives to avoid contact with government agencies, ” he said.

Dr Chan was asked whether Malaysia should change its strategy of handling Covid-19 following reports saying that the Covid-19 was different from the SARS and has more similarities with H1N1 and spread as quickly as influenza but not as deadly as SARS.


On Saturday, Universiti Malaya academician Emeritus Prof Datuk Dr Lam Sai Kit said the government could refer to the National Influenza Pandemic Preparedness Plan it developed in 2006 should the Covid-19 outbreak turn pandemic.

But Dr Chan said that when countries moved towards Red Alert (out-of-control epidemic spread), contact tracing and quarantine may be less useful.

“At that point, the emphasis may shift to include tracing recovered cases, and even infected individuals who shrugged it off with mild symptoms or even without symptoms, and who never came to attention.

“An antibody test to identify those who have been infected and subsequently recovered would be very useful to allow for collection of plasma from them.

“China has been attempting to use the plasma to treat the severely ill cases, ” he said.

Based on China’s statistics, there would be four times more cases of recovered persons than of severely ill persons, which is a potential huge pool of plasma to harvest, he said.

“So, the challenge is keeping track of these cases and having the capacity to produce safe and efficacious plasma in the required volumes, ” said Dr Chan.

He said that this would be useful while awaiting vaccines and more effective treatment modalities to be introduced, on top of stepped-up measures at social distancing.

Asked if the same would be done if the outbreak reached pandemic level (out-of-control community spread in many countries), Dr Chan said countries would have to deploy multiple measures or reallocate resources to include social distancing and mandatory self-quarantines when targeted contact tracing and institutional quarantines no longer suffice.

Individual measures to reduce infection risk such as frequent, proper handwashing, informed risk avoidance behaviours and institutional responses which are not unduly alarmist should be undertaken. - Star, 3/3/2020
 

 



 

  

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