00:10Hi, welcome back to Consider This, I'm Melissa Idris. Public health experts often say that
00:16infectious disease control is only as strong as the most vulnerable populations access to care
00:22and this includes migrant workers which make up a significant part of our workforce. Now
00:29can we as a country effectively control tuberculosis if segments of the population face barriers to
00:36accessing health care? Joining me on the show now is Dr. Tarani Loganathan who is an Associate Professor
00:42with UM's Department of Social and Preventive Medicine. She's also an Atlantic Fellow for Health
00:48Equity in Southeast Asia and has written and spoken extensively on access to health care for
00:54migrant workers in Malaysia. Dr. Tarani, it's good to have you back on the show. Thank you so much for
00:58joining me. Let's talk about why TB is often associated with social and economic vulnerability
01:07and I'm curious to know for TB, which groups might you consider vulnerable populations to this disease?
01:17Thank you for having me Melissa. TB is called a disease of poverty and it thrives in social and
01:24economic vulnerabilities, you know, the populations that are vulnerable are basically low-income
01:31populations. This is because poor living conditions, you know, having very crowded living conditions,
01:39overcrowding, poor ventilation, also malnourished. So malnutrition is a risk factor because they have less
01:48resistance to infections. The lack of healthcare access, lack of access to healthcare is a determinant
01:56because you know, you will be detected later, you may not be able to complete treatment and also people who
02:04are
02:04living in high-risk environments. So that is like incarcerated in prisons, detention centers, or yeah, those kind of settings.
02:13So those places, infections just spread while. So migrant workers are at risk, but also poor people generally.
02:24If I just may ask you about migrant workers specifically, data from the health ministry shows that about 80%
02:34of the tuberculosis
02:35cases in Malaysia actually involve Malaysians. And yet I still see this perception in public discourse that it's migrant workers
02:44that are driving the spread of TB.
02:46I'm just wondering if you have any thoughts about that. Why there is such a gap between the data and
02:53the public narrative?
02:56Yeah, so stigma is a terrible thing. You have to remember in Malaysia, the migrant workers are healthy workers.
03:06They come into the country healthy to work. To come into Malaysia, they have to go to pre-departure medical
03:13screening.
03:14And then in Malaysia, almost immediately, they have to do a medical checkup on them for MEMA.
03:20And annually, every year, they have to pass this medical checkup.
03:24You know, so they are healthy in Malaysia. They have to be healthy to work.
03:30But of course, the conditions that they work in would get them at higher risk of infection.
03:38But it is not any different from anybody else in Malaysia.
03:44So let's talk a little bit about some of the conditions that migrant workers face, the barriers that they face
03:52when accessing healthcare.
03:54For TB, what makes, what barriers for TB detection and treatment, what makes it more difficult for migrant workers to
04:02access those services?
04:05Okay, specifically for TB. So, you know, I just mentioned the mandatory annual examination they have to do for MEMA.
04:14So basically, if they are suspected of TB infection, not even confirmed suspected with maybe some changes on chest x
04:24-ray, it might or might not be TB.
04:26They fail their medical examination and will be deported, have to go back. No word permit and would have to
04:33go back.
04:33So this is a major stigma. So every migrant worker would know if they come forward and they are diagnosed
04:42or suspected of TB,
04:44that they cannot work in Malaysia. So even if they are symptomatic, they would be reluctant, very reluctant to be
04:51diagnosed with TB.
04:54So this is a major barrier.
04:57So that's the kind of immigration consequences that may affect, I guess, willingness to step up and seek treatment or
05:07diagnosis.
05:08Talk to me about the cost involved, because how much of a deterrent is cost?
05:13Because non-citizens actually face higher healthcare fees, don't they?
05:18Yeah, you're very right. But TB is one of those infectious diseases in Malaysia that is actually free at MOH
05:29government clinics.
05:31But just to put an issue, I mean, to introduce this to you, TB medication is free.
05:41OK, but the investigations that go into diagnosing the TB is not.
05:48So if you are not diagnosed with TB yet and you have to go through chest x-rays,
05:54putem tests, blood tests, whatever, to establish that diagnosis, you will be charged for those.
06:00So that could be prohibitive. The same thing happened during COVID-19.
06:05Yeah. So the investigations are not free, especially if you do not have a diagnosis.
06:12Thank you for bringing up COVID-19. What lessons did we learn from that, particularly in the diagnosis?
06:20When you are making the comparison to COVID, I assume that the tests for COVID,
06:26the cost for that was borne by the migrant worker themselves?
06:30Yeah, I mean, especially in the initial days when we were asking people to come forward to be screened.
06:37So come to the clinic and get screened. So migrant workers would come and then they would realize that they
06:43have to pay for it.
06:44It was not free. It was different when MOH would come to your neighborhood and ask you to.
06:50I mean, that means they are requesting the test. They suspect you of the disease and that would be free.
06:55But if you're walking in, you might be symptomatic, but if you're walking in, you have to pay for it.
07:00So this is a loophole there. So I think, Melissa, there is a difference between COVID-19 and TB.
07:09I mean, they are both infectious diseases. They both spread by respiratory diseases, but they are quite different.
07:15So COVID-19, you know, it's an acute infection and so on. TB is something that doesn't spread so easily.
07:28Right. You mentioned a little bit about the, I guess, the job consequences of when migrant workers come out to
07:38seek treatment, to seek diagnosis.
07:40I do wonder what role employers play in this, in facilitating or even in discouraging workers from seeking medical care,
07:50medical treatment.
07:51So, Melissa, this is a bit of a difficult question here because, I mean, you can imagine it's a similar
08:01quandary that you put the employers in because they, of course, they want, they want their workforce to be healthy.
08:08So work continues. But if you have a TB diagnosis in your, in your factory or in your, in your
08:18employee, basically, there will be disruption.
08:24Because MOH, TB is a preventable disease and it's a notifiable disease under the Prevention and Control of Infectious Disease
08:33Act, Act 342.
08:36So basically, the public health authorities would have to come in, they have to screen everybody, they have to make
08:42sure everything, you know, no one has TB.
08:45You know, so it's like similar to COVID. Yeah. So it's those things. So work disruption is a problem.
08:54Right. Because of the, I guess, the public health elements of this, I do wonder what you would like, given
09:01your extensive background in this, Dr. Terani, is there anything you would like to see improved in the way we,
09:09Malaysia approaches migrants' health and infectious disease control?
09:14And I'm speaking more broadly here beyond even TB.
09:19Yeah. So I would say, I mean, first of all, when, about TB and infectious disease, I mean, we, we
09:26need to separate it from immigration.
09:29Hmm. It is a public health issue. It is a health issue. It needs to be treated. And if you
09:37do not detect and treat properly, so TB, basically, you need to treat for six months.
09:47You know, so, and it, a treatment disruption, discontinuation would cause other problems that's not good for public health either.
09:55Because it's, we get things called multi-drug resistant TB, which is really hard to handle.
10:03Okay. So that's the reason why public health, the doctors involved are very concerned about TB. So, six months of
10:13treatment. So I would say, we do not want immigration action. We want everyone who is diagnosed with TB to,
10:20to be initiated on TB treatment.
10:24So, you can't be saying that this is a foreigner. So they need to be sent home because deportation does
10:32not happen overnight. They will still be in our detention camps or wherever. And that, that place would also get
10:42TB.
10:43You know, so treatment has to be completed, has to be initiated and completed. I would say it's better if
10:50they stay in Malaysia and they get treated properly. If they do send them off back to their country, they
10:58need to make sure that the treatment process is not interrupted. So that's continuity of care. This is just humanitarian.
11:04So it's just like, I am referring a case back to Indonesia. I have to call back the doctor in
11:11Indonesia and make sure they have the medical history and they know that this is a patient that needs. So
11:16the treatment is not disrupted. I mean, this is medical practice and humanitarian care. We cannot, TB is not good
11:23for any country. Yeah.
11:26Anything beyond TB as well. Health care and immigration does not mix very well. We've, we've got many examples of
11:37this, uh, regarding, uh, health care costs. So we have, um, Melissa, you rightly pointed out that the cost for
11:47the treatment is very expensive in clinical siatan and, um, migrant workers have, uh, insurance.
11:56Which does not cover, uh, outpatient care. It only covers, uh, inpatient care. So hospitalization. So, um, this is a
12:06prohibitive thing. So, uh, they, they may not come in unless it's really necessary. And, um, you know, I mean,
12:15uh, that, that could have consequences to all of us, to that, to their health and to all of us
12:19as well.
12:19So, um, um, well, if we are not going to revise the, the fees, we should make sure insurance covers
12:26everything, right? Yeah.
12:28Yeah. Dr. Therini, thank you so much for being on the show with me today. Dr. Therini Logan-Avon from
12:34UM's Department of Social and Preventive Medicine.
12:38Wrapping up this episode of Consider This, I'm Melissa Idris, signing off for the evening. Thank you so much for
12:43watching and good night.
12:44Thank you so much for watching.
12:47Thank you so much for watching.
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