The following is a reply to one of the participants of my
WhatsApp group why he disagreed with me
that the Chinese prefer to seek treatment in private hospital than in
government hospitals because he believes doctors in government hospitals are
incompetent, whereas my thinking was the Chinese are richer, and can afford to
pay and avoid unbearable long queues and appointments in government hospitals.
Here’s my reply to him which maybe a bit too lengthy to
reply through WhatsApp using a smart phone. I then chose using this blog of
mine.
Dear Mr. HM Cheaw,
I thank you for your reasons why Chinese prefer to seek
treatment in private hospitals instead of going to government hospitals.
Your reason that government doctors are not competent, and
mine initial reason that Chinese are richer than other races may not
necessarily be true.
You gave an example of a few cases of your bad experience in
a government hospital. This may not be the view of the entire Chinese
population of some 6 - 7 million out of
a total population of 28.3 million people in Malaysia.
We can only get the true reason from a large scale
randomized study through an opinion poll involving a very large segment of the
Chinese population in Malaysia.
This can be done through questionnaire so that it can
represent some 6 to 8 million or more Chinese in this country. The study should
involve family members, the patients themselves and non-patients, standardized
and randomized by age groups and gender.
My reason the Chinese are richer and can afford private
treatment was just as presumptive as yours in that government doctors are
inefficient, unprofessional and negligent.
This is just an assumption because of a single bad experience your friend
who underwent an eye operation in a
government hospital (I believe), until he had to be rushed to a private
hospital for an emergency operation.
Your other reason was another friend of yours in Kuala Kangsar who died due to low white
blood count and fever when treated in
the government hospital for 3 months, and yet they were unable to find the cause of his leucopenia (low WBC
count).
You said he died because the government doctor punctured his
lungs while taking his blood. It is not clear to me why the doctor need to take
his blood from his lungs when he could easily draw blood through a
veno-puncture from the inner bent of his arm? Maybe the doctor wanted to drain
away fluid from his chest cavity?
Your third bad experience was your son and many other
patients you also mentioned
You claimed your son had low platelet count and that IMR was
unable to detect the type of virus that cause the persistent fever. Again this
is presumption. Let me explain.
First, I really do not know how to explain in detail all
these “mysteries” surrounding your dissatisfaction and the reasons why your friend died in a government hospital because you said the doctors there could not identify the disease or the problem.
Since I was using Whatsapp which is supposed
to be for only videos, short stories and messages only, I thought it is easier for me to discuss some of the possible reasons here for the benefit of a wider spectrum of readers
But I shall try to explain some possible reasons as briefly
as possible.
Leucopenia:
Secondly, there are many reasons to explain your friend’s leucopenia (low white blood count). Some of the causes include aplastic anemia, nutritional deficiencies, excessive destruction of blood cells by the spleen (hypersplenism), SLE (Systemic Lupus Erythematosus or lupus, an autoimmune disorder), leukemia (blood cancer), and possibly AIDS and HIV besides in rare cases, Kostmann's syndrome (low neutrophil count), or other myelodysplastic syndromes in Malaysia. But I am not sure as I need to see evidence-based data and records.
But having low blood count could also be anemia caused by cancer where his bone marrow was destroyed by cytotoxic drugs (chemotherapy) or by radiation. Which is which I have no idea?
All these can easily be differentiated by any competent doctor in any hospital using differential diagnosis based on history taking, clinical examination supported by haematological, serological and immunological and biochemistry. All that is required is a doctor with good clinical acumen and good sense.
It is very unlikely that his months of hospitalization with
all these investigations, and seen by so many specialists, they were unable to
home in the cause. Naturally he will suffer from persistent fever because of
his leucopenia.
Immunology:
His immunological system producing antibodies, and various immunoglobulins (IgA, IgE, IgD, Ig M…etc ) would be battling hard to take over to fight an infection. The fever itself is protective by producing heat against bacterial and pathogenic invasion.
That was why as long as his WBC count was low, he would continue to have persistent fever as you said. This is just simple good clinical sense.
On your other compliant that other patients (or was it your
son), having low platelet count or thrombocytopenia as it is medically called, and
that the Institute for Medical Research (IMR)
was unable to identify the virus or the cause.
First of all, let me
explain that a low platelet count need not necessarily mean a viral infection.
It is just one possibility.
There are
many aetiologies or causes as to why some have low platelet count
In Malaysia the most common cause (working on the epidemiological
assumption on the incidence of tropical diseases) dengue would be one of the
suspect.
Dengue or Viral: A Possibility:
In dengue you will find a drop in thrombocyte (platelet) count. I do not have the statistics off hand to specifically correlate the incidence of dengue fever with thrombocyte count at the moment as I am busy typing this letter to you at the moment. But I can do a literature search. But this takes time, and I have no patience for this as I am only writing a simple reply to you, not conducting medical research that requires literature search in a medical library.
But there are other causes too, not just dengue. Some of
them include leukemia especially chronic lymphocytic leukemia and cancers that
can invade the bone marrow. Some maybe viral
infections such as chickenpox,
parvovirus, hepatitis C, Epstein-Barr, and HIV.
Some thrombocytopenia can also be caused by an auto-immune disorders such as SLE (lupus),
some are drug-induced, especially certain antibiotics, and drugs to manage
cardiovascular and psycho-motor seizures.
Auto Immune Disorders:
But I think autoimmune disorders such as immune thrombocytopenia (idiopathic thrombocytopenic purpura or ITP) besides dengue, and certain viral infections may also cause a low platelet count due to excessive destruction of blood components by the spleen. But I am not too sure as a study is also needed to confirm, else we work only on assumptions.
But heavy and severe bacterial infections can lower the
platelet count and cause an elevation of WBC. A low platelet count may also
signal exposure to toxic chemicals such
as benzene that can destroy the bone marrow.
Nutritional:
But we do not know the real cause when you merely mentioned “low blood platelet” But there are also caused by nutritional deficiencies in vitamin B-12, folic acid, and iron although this may be less likely if they are nutritionally adequate fed Chinese, and living in Malaysia, unless they drink too much alcohol.
Aplastic anemia is another consideration we need to look into. In medicine there are so many possibilities. That’s how we conduct medical research. We cannot follow text-book knowledge especially some old editions.
But I think we can suspect dengue, because as I have explained earlier, this is the most common communicable disease affecting tropical countries like Malaysia. Moreover you said your son recovered uneventfully which in most cases this is very typical with dengue or if it was caused by some kind of virus especially on the bone marrow.
All other causes such as aplastic anemia or ITP are almost
irreversible and intractable. This is clinical logic we can infer merely from
what you said in your 2 -3 words for the medical history.
Serological and Molecular Assays:
But if you think it was a viral infection which even
At the IMR as far as I know during my last visit there during the IMR Open Day last year (2018), they now use polymerase chain reaction (PCR) method instead of the older ELISA. Molecular sequencing of viral RNA and DNA genomes is the latest procedure a research institute like IMR would use to identify a specific strain of virus.
However, there is one difficulty. If a specific virus such
as rhinoviruses (cold viruses) mutates as they always do - very fast, this
changes their DNA genomic profile. This is just a simple example.
Genomic Data Base:
When they do, then scientists at IMR would not have the database
of all known viruses to compare. If that is a new genomic signature, then how
do you expect them to identify something that is not there in their database? So
you cannot blame them. It would be something new to them - in fact a discovery.
Traditional Culture Diagnostic:
Even if it was bacterial and not viral infection that causes
the thrombocytopenia they still can identify the bacteria or the cause using
convention culture methods such as using MacConkey agar, eosin methylene blue,
blood agar, mannitol salt agar…etc. and observing colour changes or gas formation.
These are the traditional assays which I remember learning
during my student days in bacteriology and microbiology practical classes.
But for very difficult to identify and new bacteria or any
pathogens, IMR will switch to the much more advanced and sophisticated molecular
assays such as PCR. This is not a problem for them. The Head of the
Bacteriology Division at IMR told me they
have the capability of using molecular assays when I visited them during their Open Day in October last year.
So if you think it was either bacterial or a viral infection
such as dengue that caused your son low blood count, then it could be a new
strain not in the genomic database. This is what I feel. But there may be other
possibilities which I cannot think of at this moment.
Being Scientifically Unbias:
I am not trying to defend government hospitals over private hospitals or their doctors. But I am sure the government hospital or hospitals where you have the bad experience is not that incompetent as that. I am sure they have their specialists and expertise to look into all these possibilities I have briefly explained above. It is a matter of having a very good clinical acumen supported by lab investigations for which the IMR has all those sophistication as it is the National Diagnostic Laboratory.
I hope you would not be discouraged using government
hospitals based on assumptions that the doctors there are not competent.
Of course my former colleague Dr. Rita Gregory here in this chat
group recently sent us an article something like a law suit against the Kuala
Lumpur Hospital (KLH) and the doctors there who attended to a very senior physician, in fact a former head of medical department at KLH whom Dr Rita
knows. Dr. Rita was a Consultant Haematologist at IMR. Her opinion is very
The private hospital diagnosed it as septic arthritis, but when she was referred to KLH, the doctors
there insisted it was OA (osteoarthritis).
A Case of Misdiagnosis:
It was already diagnosed as infective arthritis in a private hospital, but she was referred to KLH, the incompetency of the doctors there reverse that diagnosis and treated her as a case of OA. She died because of that. Now there is a law suit against the doctors and KLH since KLH is such a major hospital, and biggest one in the country too.
The clinical presentation and features of sepsis of the
joints is different from those of OA that any doctor can almost instantly differentiate
between the two. But we will not go into that.
Study Needed:
In conclusion, it is not safe to assume. Neither should I assume that all Chinese are rich to afford going only to private hospitals, and Malays and Indians less so, thus they mainly go to government hospital s and other government health clinics. This is just guesswork.
A study using questionnaire for an opinion poll is needed to
know why various races chose various hospitals.
My Personal Choice:
I am a Chinese, and I chose to go only to a government hospital because I am not rich, and I cannot afford to be warded in a private hospital for 5 months like I did for a venous stasis last year. It would have cost me at least Ringgit one million, whereas I got it completely free-of-charge in a one-room with bath attached in a first class ward. It was as simple as that!
I hope I have enlightened you, Mr. HM Cheaw!
Lim ju boo
(A former medical researcher at IMR)
