Caste in Hinduism: A 300-year Old Myth

Caste in Hinduism: A 300-year Old Myth.
Part IV of VII: ‘Jati’ and Caste Systems outside Hinduism

I admit that up to now, I have touched very little on the term ‘jati’ itself purely because it is difficult to explain due to the fact that in a number of translations of Hindu Scriptures, the term ‘caste’ had replaced ‘varna’ and ‘jati’ without distinguishing the both. Whilst ‘varna’ is considered to be ‘caste’ or ‘social order’, ‘jati’ has always been considered to be the ‘sub-castes’ or even ‘true caste’. However, in actuality, ‘jati’ which depended on birth truly represented an individual’s heritage, in a similar manner as ethnicity. Distinction between individuals within a particular ‘varna’ was made based on the specific occupations of each individual; forming guild-like division amongst a particular ‘varna’. For example due to the wide range of nature and abilities of the Vaisyas, they held various occupations such as farmers, merchants, and blacksmiths. Therefore the intra-group variation that existed further stratified each individual into smaller guilds within the Vaisya group and an individual would be recognized by the community he occupies by his pedigree.

Identifying one as a ‘son of a farmer’ or a ‘son of a blacksmith’ would offer a picture to represent the environment that particular individual was/is exposed to or even describes an individual’s social status. It marks the ancestry and the heritage of an individual, and is not intended for discrimination purposes. Unfortunately, the wide intra-group variation that exists within the ‘varna’ extended beyond occupation and nature into socio-economic inequalities. The nature of each particular occupation and also its monetary returns not only fluctuate but also vary hugely, creating socio-economic barriers between ‘jatis’.

Some occupations which are ‘clean’, requiring higher levels of training/technical ability/skill and yields greater monetary returns are more favourable and command greater respect within the society as opposed to occupations that are ‘dirty’, requires less skill/training and yields lower monetary returns. This consequently led to prejudices and stereotypes attached to each ‘jati’ or guild, and eventually ‘in-group favourability bias’ exists and a particular ‘jati’ is viewed either positively or negatively. Combined with a lack of social mobility, this eventually became a fixed and rigid system that is perceived by many (and wrongly so) as the ‘caste system’ in Hinduism.

One may argue that there is no need to acquaint an individual by his background or his heritage, but instead allow his or her qualities and natures speak for themselves. I cannot agree any less. The key to understand the role of ‘jati’ within Hinduism, is that Hinduism merely accounts for the existence of ‘jati’ in human society and explains how human relations are/can be affected by ‘jati’, but Hinduism itself does not in way condemn an individual to the occupation that his/her parents possessed. Hinduism does not require a person to be identified by his/her ‘jati’ nor allows discrimination towards any particular ‘jati’.

The caste based discrimination that has so often been attached with Hinduism, is nothing more that an unfortunate consequence of inequality of men in the evolution of human society where the rich and powerful discriminate the poor and weak using whatever weapon or front to support their case; as in with Hinduism – the religion itself was wrongly exploited and misinterpreted to the benefits of certain particular groups to remain both rich and powerful, thus respected in society.

I believe I have sufficiently discussed ‘varna’ and ‘jati’ from the perspectives of Hinduism and sociology to elicit that Hinduism does not advocate the caste system. As demonstrated, the caste system can be explained from a purely sociological model not exclusive to Hinduism; the result of natural evolution (or lack of evolution) of human society.

As it would be fair to comment that not many other cultures, religious and secular societies observe this evolutionary pattern in human society, the logical question that follows is why is the hereditary, discriminatory ‘caste’ system so strongly prevalent and embedded in certain Hindu societies if Hinduism is opposed to it?

Unfortunately, there are similar ‘caste’ systems existing in non-Hindu societies as well for example amongst Indian Muslims, Indian Christians and outside India, Pakistan, Bangladesh and Sri Lanka, there is evidence of ‘caste’ systems in practice in certain African tribes and even in Japan, Korea and Yemen.

However to illustrate my point, I will only further expand on the case of Indian Muslims, because in many aspects Islam is considered to be the antithesis of Hinduism yet in India many Muslims retained a ‘castes’ systems characteristics to Hinduism [17]. Whilst some may argue that this could possibly be explained as a residual effect or remnants following the conversion of Hindu followers into Islam, I believe that this argument is weak and will not hold considering Islam is opposed to the hierarchy of ‘caste’* as it is explained by Hinduism, and was amongst the chief reasons cited by Muslims to encourage this conversion of faith of Hindu devotees into Islam.

*the usage of the word ‘caste’ in Hinduism does not imply that I am in agreement of it, but instead am offering an explanation from the perspective of Islam regarding the concept for ‘jati’ and ‘varna’

However, the reality of the situation is exemplified by the ‘Report on the Census of India, 1901’:

Report of the Census of India, 1901
According to Mr. Gait the Bengal Muhammadans "recognize two main social divisions, (1) Ashrāf or Sharīf and (2) Ajlāf, which in Bengali has been corrupted to Ātrāp. The first, which means 'noble' or 'persons of high extrac- tion,' includes all undoubted descendants of foreigners and converts from the higher castes of Hindus. All other Muhammadans, including the functional groups to be presently mentioned and all converts of lower rank, are collectively known by the contemptuous term Ajlāf, 'wretches' or 'mean people;' they are also called Kamīna or Itar, 'base' or Razīl, a corruption of Rizāl, 'worthless.'

This category includes the various classes of converts who are known as Nao Muslim in Bihar and Nasya in North Bengal, but who in East Bengal, where their numbers are greatest, have usually succeeded in establishing their claim to be called Shekh. It also includes various functional groups such as that of the Jolāhā or weaver, Dhuniā or cotton-carder, Kulu or oil-presser, Kunjra or vegetable-seller, Hajjām or barber, Darzi or tailor, and the like.

Like the higher Hindu castes, the Ashrāf consider it degrading to accept menial service or to handle the plough. The traditional occupation of the Saiads is the priesthood, while the Moghals and Pathāns correspond to the Kshatriyas of the Hindu règime.

In some places a third class, called Arzāl or 'lowest of all,' is added. It consists of the very lowest castes, such as the Halālkhor, Lālbegi, Abdāl, and Bediya, with whom no other Muhammadan would associate, and who are for- bidden to enter the mosque or to use the public burial ground." [17]

The similarities between the ‘Muhammadans’ or Muslims and Hindus in India is undeniable. The various functional groups correspond nicely with the ‘jatis’ of Hindu societies, and similarly these Muslims societies have an almost similar structure of social order: Saiads traditionally being priests corresponding to Brahmins, and Moghals and Pathans corresponding to Kshatriyas.

Here I deem it necessary to clarify (albeit repeatedly) that the ‘caste’ system is not advocated by either religion, although it does not necessarily mean it is detached from it. There are elements in Hinduism that potentially has been misinterpreted with regards to the complex relationship between ‘varna’ and ‘jati’; and subsequently has resulted in the confusion that Hinduism supports ‘caste’ based discrimination.

Similarly, Islam societies, which is (supposedly) free from slavery and caste where everyone is treated as equal [17] also suffer from the inevitable consequences of socioeconomic inequalities between various functional groups and likewise experience ‘caste’ based discrimination; parallel to an observation by Dr BR Ambedkar (an socio-politic reformist and a political leader who was amongst the chief architect of the Indian Constitution) that, “caste amongst ‘Musalmans’ (Muslims) has remained.” [18].

Therefore we can conclude that this ‘caste’ system is not exclusive to Hinduism (or Muslims), and likewise ‘caste’ discrimination cannot be solely attributed to Hindu communities and can almost wholly be explained from a sociological point of view as I have discussed above.

(A complete list of references will be published at the end of the final part (Part VII) of this article)

Caste in Hinduism: A 300-year Old Myth

Caste in Hinduism: A 300-year Old Myth.
Part III of VII: Applying a Sociological Model and Determining ‘Varna’

More importantly, none of the discussions in Part I and II provide an adequate explanation as to how an individual is placed within the society; as a Brahmin, Kshatriya, Vaisya or a Sudra. What makes one a Brahmin or a Sudra; birth, occupation or nature?

The current and common misconception amongst many Hindu and non-Hindus alike regarding social order, is that caste, ‘jati’ or ‘varna’ is determined by birth; a hereditary system where a child takes after the status of his/her parents (often being the father). There is both truth and fiction in this claim.

In many ancient civilisations (and to a certain extent, present day societies) there was a lack of social mobility amongst individuals. Taking for example the feudal system in Europe during the medieval times where at the time of the decline of the Roman Empire, churches were amongst the only institutions that had managed to remain intact and served as central political and cultural institutions due to the high literacy levels amongst bishops and other religious figures. Consequently they become significantly influential in forming governments and other political institution, which eventually paved the way for feudalism.

Central governments were either under direct control by churches, or if otherwise still had maintained close ties with religious figures, delegated authority to local Lords in areas which the central government had less power. The local Lords in return (having sworn allegiances with the central government) supported themselves by authority of military organization, law and order and taxation; and through a commendation ceremony would elect a vassal to whom the Lord would provide a fief. And finally at the bottom of the social order lay the serfs who would serve the vassal by providing labour and service.

Thus the sequential social order as it stood during the medieval times which placed the Bishops at the top of the order followed by Dukes and Local Lords who were granted territorial authority, followed by vassals and finally the serfs. Under this stratification, not only a social order was put in place, but it was characterized by a lack of social mobility from one group to another.

A child born to serf is likely to learn to the trades of his parents, and therefore is equipped with the skills to become a serf. Likewise a child born to a Lord is likely to become familiar with the trades of his parents, and therefore will be better equipped with the knowledge and abilities to become a Lord himself. This by no means condemns any individual to a certain social group, but simply states the likelihood of a child to learn the trades of his parents and likewise occupy the position his parents did within the same social order. These conditions that prevailed in ancient civilisations prevented much social mobility and therefore individuals were often confined to within the social group they were born into – not hugely dissimilar to the ‘hereditary caste system’.

Karl Marx often explained feudalism from almost a purely capitalist economic model, but his astute observations remains valid in explaining that the structure of these societies was inevitable at the times they existed:

Wage Labour and Capital
The relations of production in their totality constitute what is called the social relations, society, and, moreover, a society at a definite stage of historical development, a society with peculiar, distinctive characteristics. Ancient society, feudal society, bourgeois (or capitalist) society, are such totalities of relations of production, each of which denotes a particular stage of development in the history of mankind [14].

The Poverty of Philosophy
The hand-mill gives you society with the feudal lord; the steam-mill society with the industrial capitalist [15].

Similarly human society in India and amongst Hindus could not possibly escape the birth of inequality amongst men and the lack of social mobility. Thereby a person’s place in the society became almost pre-determined by birth itself, taking after his/her parents. However I am quick to alert readers that social order is Hinduism is not determined by birth, and therefore ‘hereditary caste system’ is not a concept advocated by Hinduism. I drew an analogy (perhaps imperfect) between the social mobility in India and medieval Europe to simply illustrate the point that the lack of social mobility in ancient human civilisations was an unfortunate but unavoidable occurrence in the evolution of human society, simply due to inevitable inequality amongst men in any given society. A son of a Sudra is ‘likely’ to be raised in the nature of a Sudra and trained in the trades of a Sudra. Likewise a son of a Brahmin is ‘likely’ to be raised in the nature of a Brahmin and trained in the knowledge and abilities of a Brahmin.

Nevertheless, birth and upbringing alone does not determine the nature, qualities and abilities of an individual. Whilst the lack of social mobility in ancient civilisations predicts the likelihood of a child to follow onto the footsteps of his parents, by no means is his future predetermined or even absolute. This is clearly illustrated by an excerpt from the Mahabharata; a conversation between King Nahusha (in the form of a celestial serpent) and Prince Yudhishthira (the eldest son of King Pandu):

Mahabharata, Book III: Varna Parva, Chapter CLXXIX
The serpent said, 'O Yudhishthira, say--Who is a Brahmana and what should be known? By thy speech I infer thee to be highly intelligent.'

"Yudhishthira said, 'O foremost of serpents, he, it is asserted by the wise, in whom are seen truth, charity, forgiveness, good conduct, benevolence, observance of the rites of his order and mercy is a Brahmana. And, O serpent, that which should be known is even the supreme Brahma, in which is neither happiness nor misery--and attaining which beings are not affected with misery; what is thy opinion?'

"The serpent said, 'O Yudhishthira, truth, charity, forgiveness, benevolence, benignity, kindness and the Veda which worketh the benefit of the four orders, which is the authority in matters of religion and which is true, are seen even in the Sudra. As regards the object to be known and which thou allegest is without both happiness and misery, I do not see any such that is devoid of these.'

"Yudhishthira said, Those characteristics that are present in a Sudra, do not exist in a Brahmana; nor do those that are in a Brahmana exist in a Sudra. And a Sudra is not a Sudra by birth alone--nor a Brahmana is Brahmana by birth alone. He, it is said by the wise, in whom are seen those virtues is a Brahmana. And people term him a Sudra in whom those qualities do not exist, even though he be a Brahmana by birth. And again, as for thy assertion that the object to be known (as asserted by me) doth not exist, because nothing exists that is devoid of both (happiness and misery), such indeed is the opinion, O serpent, that nothing exists that is without (them) both. But as in cold, heat doth not exist, nor in heat, cold, so there cannot exist an object in which both (happiness and misery) cannot exist?"

"The serpent said, 'O king, if thou recognise him as a Brahmana by characteristics, then, O long-lived one, the distinction of caste* becometh futile as long as conduct doth not come into play.'

"Yudhishthira said, 'In human society, O mighty and highly intelligent serpent, it is difficult to ascertain one's caste*, because of promiscuous intercourse among the four orders. This is my opinion. Men belonging to all orders (promiscuously) beget offspring upon women of all the orders. And of men, speech, sexual intercourse, birth and death are common. And to this the Rishis have borne testimony by using as the beginning of a sacrifice such expressions as--of what caste* so ever we may be, we celebrate the sacrifice. Therefore, those that are wise have asserted that character is the chief essential requisite… [16]

*I am unable to ascertain the original Sanskrit word that ‘caste’ has replaced in the translation above, therefore I advice readers to be aware that the word ‘caste’ here itself is used to describe one of the four groups of men as explained by the Rig Veda.

The excerpt above explicitly states that that ‘varna’ is not pre-determined, by birth, and as has been repeatedly mentioned is determined by nature or character that an individual has been attributed with to perform his duty. As further demonstrated by the following excerpts from the Bhagavad Gita; Lord Krishna explaining to Prince Arjuna, his duties as a Kshatriya and the character he needs to possess to fulfil his duties:

Bhagavad Gita, Chapter II
O son of Prithâ! it is not worthy of you. Cast off this base weakness of heart, and arise, O terror of (your) foes!...

… Therefore you ought not to grieve for any being. Having regard to your own duty also, you ought not to falter, for there is nothing better for a Kshatriya than a righteous battle. Happy those Kshatriyas, O son of Prithâ! who can find such a battle (to fight)--come of itself--an open door to heaven! But if you will not fight this righteous battle, then you will have abandoned your own duty and your fame, and you will incur sin. All beings, too, will tell of your everlasting infamy; and to one who has been honoured, infamy is (a) greater (evil) than death. (Warriors who are) masters of great cars will think that you abstained from the battle through fear, and having been highly thought of by them, you will fall down to littleness…

… Killed, you will obtain heaven; victorious, you will enjoy the earth. Therefore arise, O son of Kuntî! resolved to (engage in) battle [11].

(A complete list of references will be published at the end of the final part (Part VII) of this article)

Caste in Hinduism: A 300-year Old Myth

Caste in Hinduism: A 300-year Old Myth.
Part II of VII: Inequality amongst Men

Inequality amongst men is not a concept that is unique or exclusive to Hinduism, and regardless of how we wish and attempt to abolish these inequalities, they exist nevertheless. Jean-Jacques Rousseau described that inequality amongst men is present from the moment an individual is born, “natural [inequality]…is established by nature and consists of differences in age, health, strength of body and qualities of the mind or soul [12].” These social stratifications that exists in Hindu Holy Scriptures are not intended to discriminate or create social division, or even to create inequality. Instead, they exist to demonstrate and explain that inequality amongst men is inevitable, from the moment one is born. Each individual possesses features, characteristics and abilities that vary in nature and strength that is unique to him or her self; and one should use these skills that they possess to perform their duties within the society for a number of reasons (two reasons of which I will explain); firstly to fulfil their purpose of life by performing their duties and not defecting from their responsibilities to themselves, their families, to society and God, and secondly fulfilling their roles within the society which in turn enables society to function smoothly.

Revisiting the original verse from the Rig Veda itself (as quoted in Part I) describing the origin of the various ‘varnas’ from the ‘Purusa’ explained that the world was formed by the various body parts of the ‘Purusa’ and consists of the society that inhabits the world, as described by each ‘varna’ group; instilling a social order in society. However, this by no means condemns any particular group to being less important than another. I agree that Hindu scriptures have consistently attributed positive characteristics to Brahmin and Kshatriyas, and less positive characteristics to describe Vaisyas and Sudras. But as social theory dictates, social order is often determined by the nature of each group: an individual who possesses greater knowledge abilities will inevitably be promoted to the top of the social order, whereas an individual who is lacking in knowledge and ability is rooted to the bottom. Hinduism does not force, impose or advocate the creation of this social order, but accounts for its existence. It does not preach idealism, but explains the realism of human society.

For a society to exist and function in an organized and civilized manner, social order is a necessity. All layers of the society are crucial to its functioning. A whole body can only function at its fullest potential if all its organs function accordingly; a society can only function if the various social groups perform its duties accordingly. The various body parts of the ‘Purusa’ that make up the various ‘varnas’ are each in itself vital organs of which the world is built from; and for it to function as it was meant to, it requires each organ or body part to perform its duty as it was designed for. The failure of any one organ (group) to function as intended, can only lead to an imperfect body (world/society).

Does this effectively mean that Hinduism advocates inequality amongst men? No; instead Hinduism stands for the exact opposite of that and in fact preaches equality amongst all men. Nevertheless how is it possible that Hinduism, which acknowledges inequality amongst men, preach equality instead?

Bhagavad Gita, Chapter IX
I am alike to all beings; to me none is hateful, none dear. But those who worship me with devotion (dwell) in me, and I too in them.

Even if a very ill-conducted man worships me, not worshipping any one else, he must certainly be deemed to be good, for he has well resolved. He soon becomes devout of heart, and obtains lasting tranquillity.

(You may) affirm, O son of Kuntî! that my devotee is never ruined. For, O son of Prithâ! even those who are of sinful birth , women, Vaisyas; and Sûdras likewise, resorting to me, attain the supreme goal.

What then (need be said of) holy Brâhmanas and royal saints who are (my) devotees? Coming to this transient unhappy world, worship me [11].

Inequality and equality amongst men in Hinduism are two concepts that are co-dependant yet antagonize each other; a paradox that explains the complexity of human society. Man and woman are not equal in build, emotions and abilities, as a priest and a king are not equal in knowledge, character, qualities and abilities, as with a king and a labourer. These inequalities exist as a consequence of nature and nurture of each individual, which eventually leads to their role and place within the order of society, as further demonstrated by another selected excerpt from the Bhagavad Gita:

Bhagavad Gita, Chapter IV
According to the aptitudes resulting from the dispositions of Nature (Gunas) and from works, the social order of fourfold division has been created by Me. Though I am their originator, know Me to be not an agent but the Spirit unchanging [13].

The key to understanding this complex relationship between inequality and equality is to appreciate that each individual regardless of caste, gender, ability, ‘karma/dharma’ has his/her role to play in this world to maintain its order, and therefore is required to perform his/her duty as prescribed by God; and by doing so are perceived equally in attaining the supreme goal. The various body parts of the ‘Purusa’; the ‘mouth’, ‘arms’, ‘thighs’ and ‘feet’, all of which have different physical characteristics, abilities and functions, yet are equally as important in forming a perfect ‘body’.

(A complete list of references will be published at the end of the final part (Part VII) of this article)

Caste in Hinduism: A 300-year Old Myth

Caste in Hinduism: A 300-year Old Myth

Part I of VII: An Introduction to the Origin of Caste and ‘varna’

Caste is sociologically defined as an endogamous and hereditary social group limited to persons of the same rank, occupation, economic position, etc., and having customs distinguishing it from other such groups. As such, many may already be familiar with the ‘caste system’ that is attached to Hinduism: in a way that the Hindu society is traditionally divided into social divisions by which a particular caste has its own privileges and limitations; a rigid hereditary system that is transferred from one generation to the next. These definitions of caste are widely accepted, and Hinduism have constantly been at the receiving end of the brunt imposed by human rights activists, sociologists, and both political and religious leaders from all quarters, for the ‘caste based discrimination’ that is allegedly advocated by Hinduism.

However, are these allegations actually true? During my research for this article, I discovered many shocking truths and myths about ‘caste’ in Hinduism; a concept taken for granted and condemned by many in line with the definitions that I have provided above. Here I wish to unearth some of the facts and myths on ‘caste’ and Hinduism that many have previously been unaware of, from theological, sociological and historical perspectives. The purpose of my article is to display my findings, facts, expert opinions and arguments on this hugely disputed controversy in attempt to prove to you that ‘caste’ in Hinduism is nothing more than a 300 year old myth originating from flawed Western interpretations of concepts within Hinduism.

The word ‘caste’ itself is a Latin/Roman derivative of castus/casto/chaste [1,2] from the 15^th century; defined as ‘a race of men, pure, or lineage’. Its application to Hindu social groups only picked up in India in the 17^th century [2] and has since replaced the word ‘jati’ and ‘varna’ in existing literature and text almost synonymously, yet by large inaccurately.

‘Jati’ coming from the root word ‘jat’ by definition is ‘birth’, comprises of the various ‘sub-castes’ of ‘varna’ (a Sanskrit word derived from ‘vrn’ meaning ‘colour, cover or veil’. Simply put, in western interpretation of Hindu texts, ‘varna’ is considered to be the ‘caste system’ or ‘social class’, consisting of various ‘jatis’ which makeup the individual castes or sub-castes within this system. Whilst this is not hugely inaccurate, it hardly explains the complex relationship of ‘jati’ and ‘varna’ in the context of Hinduism.

‘Jati’ and ‘varna’ themselves, are concepts within Hinduism, which simply cannot be replaced by singular Western words, especially with a word like ‘caste’ which is not only inaccurate but etymologically carries an entire different meaning from the Sanskrit words that it has replaced in interpretations of Hindu texts. These concepts are hugely difficult to explain in it selves, simply due to the metaphorical and poetic nature of which Hinduism literature is construed upon and also the vast amount of literature, rendering its texts open to various interpretations.

One of the most obvious examples of such difficulties in interpreting Hindu texts is explaining what ‘varna’ truly stands for. In the Rig Veda (which is the oldest and considered to be one of the most important Hindu scriptures, consisting of 1028 hymns), the word ‘varna’ appears a number of times, yet it represents a broad and vague description of colour and cover. To be more exact, of the 22 times that ‘varna’ was mentioned in the Rig Veda, on 17 occasions it referred to the lustre of specific gods, twice to describe the colour of the sky, twice to describe the lustre of the Dasas/Dasyus and once more ambiguously to satisfy the ‘varna’ of a married couple by consummating their marriage by trying for a child [3].

However before that, interpreting the Rig Veda requires one to be aware of the historical significance of the Aryans vs. Dasas/Dasyus, a subject thoroughly discussed the in the Holy Scriptures. It explains in very simplistic terms how the Aryans battled the Dasas/Dasyus (described as brahma-dvisah; people who were opposed to devotion/prayers, although they were broadly accepted as worshippers of Lord Shiva), and upon victory, the Aryans bestowed the land with prosperity:

Rig Veda 5.14.4
Agni born shone out slaying the Dasyus, the darkness by the light, he found the Cows, the Waters, Swar [4,5]

Aurobindo in The Secret of the Veda explains that, in the struggle between light and darkness; truth and falsehood, divine and undivine is described [5], and Agni by defeating the Dasyus, allowed the creation of a heavenly world.

Whilst, the Aryan Invasion Theory vs. Indigenous Aryan Theory still remains an unresolved controversial discussion, in general, Aryans have consistently been associated with lighter, brighter colours as opposed to the Dasa/Dasyus who have been ascribed with darkness in numerous Hindu texts. However, although it is generally accepted that the Aryans had a fairer skin complexion compared to the Dasyus, nowhere does any of the Hindu texts explicitly state or even imply that references to colours associated to each group was applied to the skin colour of either group.

In fact, the ‘varna’ of these distinct groups merely attributes symbolic colours to a certain cosmological quality (guna)/energy/aura associated with each particular group; white corresponds to clarity (sattya), red to energy (rajas) and black to darkness (tamas), and this in turn as described by Koenraad Elst is projected into the social spectrum to represent the qualities of the various classes in society: Brahmins are white, Kshatriyas are red, Sudras are black and Vaisyas who have mixed qualities are represented as yellow [3].

Hans Hock, an expert linguist commenting of Hindu literature states that the racial interpretation of the Indian texts “must be considered dubious” and “early Sanskrit literature offers no conclusive evidence of pre-occupation with skin colour”; whilst the world or Aryans is often described with words such as “light, white, broad and wide” and the Dasus/Dasyus were described with words such as “darkness or fog”, in most instances racial interpretation can safely be ruled out [6].

And this is demonstrated by how even epic characters such as Lord Krishna were often portrayed with skin colour of ‘blackish’ or ‘dark-blue’. In Mahabhrata, Draupadi, the daughter of King Drupada and also the wife of the Pandava brothers was considered beautiful for her ‘dark’ skin, and in fact was named Brahmanas by Krishna due to her radiant dusky skin. In Chapter 37 of the Mahabhrata, Arjuna was described as a ‘dark mass of clouds’ next to the beautiful complexion of the daughter of King Matsya. On the other hand, Shiva (considered by invasion theorists to be worshipped by Dasus/Dasyus) have been described as ‘gour varna’ (white colour) and even fair-skinned [6,7], yet strangely He is most commonly depicted as dark-skinned, or a tan of blue. As a matter of fact, even Veda Vyasa, (the one who compiled the Vedas) who wrote the Mahabhrata was also known as Krishna Dvaipayana; of which the term Krishna (not to be confused with Lord Krishna) was in reference to his dark-skin.

But concept of ‘jati’ and ‘varna’ in Hinduism is not as simple as being ‘gour’ (white) or ‘shyama’ (black), nor is as simple as being a ‘brahmin’ or a ‘shudra’. Having established that skin colour is irrelevant in determining ‘varna’, I attempt to correct other widespread misconceptions regarding ‘jati’ and ‘varna’, which I hypothesize as having originated from fundamentally flawed Western interpretations of Hindu scriptures and ideologies, leading to what many people around the world, Hindu and non-Hindu alike, understand (and wrongly so) about caste and social order within the religion.

Rig Veda 10.90.11-14
When they divided Purusa how many portions did they make?
What do they call his mouth, his arms? What do they call his thighs and feet?

The Brahman was his mouth, of both his arms was the Rajanya made.
His thighs became the Vaisya, from his feet the Sudra was produced.

The Moon was gendered from his mind, and from his eye the Sun had birth;
Indra and Agni from his mouth were born, and Vayu from his breath.

Forth from his navel came mid-air the sky was fashioned from his head
Earth from his feet, and from his car the regions. Thus they formed the worlds [4].

It is widely accepted that Hinduism divides the human society into their respective ‘varnas’ based on their origin from ‘Purusha’: Brahmans (Brahmins), Rajanyas (Kshatriyas), Vaishysas and Sudra. This verse from the Purusa Sukta (Hymn 90, Book 10) from the Rig Veda explains the creation of the world by God from ‘Purusha’, which by definition is the primeval man, considered to be the soul of the universe, which is created out of his body. Yet, I am quick to remind you that there was not a single occurrence of the term ‘varna’ in the entire Purusha Sukta, let alone in reference to any of the fore-mentioned groups above, which I thought was odd considering this very verse has been repeatedly been quoted as the origin of the ‘varna’ system.

Nevertheless the ‘varna’ system (as it is most commonly understood) can be loosely described as the following:

1. Brahmana/Brahmin

This scholarly community consists of learned individuals of the Holy Scriptures and possess high levels of knowledge regarding the Vedas and the religion. A Brahmana/Brahmin is sometimes considered closest to God, due to his inner knowledge and understanding of the religion and is able to perform priestly duties. Their duties also involve teaching of the Vedas as protectors of the religion.

2. Rajanyas/Kshatriyas

The Kshatriyas consists of the ruling and administrative class, ranging from kings and princes to warriors and leaders, and from generals to foot-soldiers. Etymologically the word ‘raj’ meant to rule and ‘kshatriyah’ originating from ‘ksatram’ meant ‘rule’ or power [8]. They are considered protectors of ‘dharma’ (duty and justice) and land, and are meant to uphold law and honour.

3. Vaisyas

Vaisyas, or the peasantry appears as the basis of the state on which the priesthood and military caste rest [9]. It comprises of merchants, artisans, entrepreneurs, farmers and commoners. Derived from the root ‘vish’ meaning ‘to live’, vaisyas have been been attributed with a ‘yellow guna’ denoting their wide range of mixed abilities. In Buddhism, it almost analogous to the term ‘gahapati’ in the Pali texts [9], referring to the household; a particular strata of society meant to represent the reality within society.

4. Sudras

Actions consisting of service are the duty of the Sudras, born of their own nature [10] of which its ‘guna’ has been described as black*. This service providing community contributes not only labour to the society, but offers obeisances to higher sections of the society. Their duty is mainly to serve and provide service to the Brahmins, Kshatriyas and the Vaisyas.

*as described earlier, this is a projection by Koenraad Elst from the ‘varna’ of the ‘guna’ of each group into the social spectrum, and the description of Sudras possessing a black ‘guna’ representing darkness is not to be taken as discriminatory, but purely as a description of their nature, qualities and duties (which will be explained in greater detail).

There are numerous religious scriptures that attempt to describe and teach the very ‘varna’ system that was described above, one of which is The Bhagavad Gita: a dialogue between Lord Krishna and Prince Arjuna on the eve of the battle of Kurukshetra demonstrates how Lord Krishna guides Prince Arjuna into performing his duties as a Kshatriya, at a difficult time for the Prince who is beset by conflicting emotions and thoughts. This select verse from the final chapter of this particular Holy Scripture describes the nature of each group and the concomitant duties alongside the qualities that individuals of each group possess:

Bhagavad Gita, Chapter XVIII
The duties of Brâhmanas, Kshatriyas, and Vaisyas, and of Sûdras, too, O terror of your foes! are distinguished according to the qualities born of nature.

Tranquillity, restraint of the senses, penance, purity, forgiveness, straightforwardness, also knowledge, experience, and belief (in a future world), this is the natural duty of Brâhmanas.

Valour, glory, Courage, dexterity, not slinking away from battle, gifts, exercise of lordly power, this is the natural duty of Kshatriyas.

Agriculture, tending cattle, trade, (this) is the natural duty of Vaisyas, And the natural duty of Sûdras, too, consists in service.

(Every) man intent on his own respective duties obtains perfection. Listen, now, how one intent on one's own duty obtains perfection. Worshipping, by (the performance of) his own duty, him from whom all things proceed, and by whom all this is permeated, a man obtains perfection. One's duty, though defective, is better than another's duty well performed. Performing the duty prescribed by nature, one does not incur sin [11].

(A complete list of references will be published at the end of the final part (Part VII) of this article)

An overview of Malaysia’s healthcare system. A miracle or a disaster?

An overview of Malaysia’s healthcare system. A miracle or a disaster?

Part III of III – The Professionals and a Conclusion
Having discussed patients’ attitudes and the balancing act between the public and private healthcare sector, I imagine the next obvious discussion lies in the attitude and professionalism of the healthcare workers themselves. Before I go on, I wish to share my experience to readers, as an insider to the system:

“A young man, was admitted into the Intensive Care Unit (ICU) for a fatal overdose of paraquat (a type of herbicide); an obvious suicide attempt. With the patient critically ill, the family waited nervously outside the ward. The Medical Officer (MO) briefed the freshly graduated House Officer (HO) of what the priorities are in regards of treating the patient, before she left him to deal with this tremendous but seemly impossible task of treating this patient. Shortly afterwards, the patient arrests, and the HO attempts to resuscitate him, and calls for help from the available medical staff in the ward. In that instance, the nurses and an attendant immediately came to support the HO. Meanwhile, the patient’s family, who realised the sudden urgency in the medical staff, sensed that something was going horribly wrong, tried to force their way into the ward. The nurses and attendant, restrained them from entering the ward, and told them that they were only getting in the way of the medical team. So the nervous family, were forced to wait outside, and their only comprehension of the scenario, was the little they could see through the tiny window that connects the ward to the outside.

In ICU, the HO is tiring from performing the cardiac massage whilst the other nurses who crowd the ICU are discouraging the HO in what they believe is a futile attempt. I was in utter disbelief when a nurse muttered these exact words,

“Cukup la doktor, dia sudah mati! (That’s enough doctor, he’s already dead).”

I understand that given the scenario, the survival of a patient who had consumed a fatal dose of paraquat is practically zilch. But nowhere along my medical training have I encountered calling a living man, dead, and staff discouraging the efforts of another staff to attempt to save him, regardless of the odds.

The HO ignoring these comments persevered but eventually exhausted, requests for a nurse to take over. She reluctantly takes over, but with minimal regard and effort for the technique required for the cardiac massage, she ultimately renders the procedure useless. The HO pushes her aside to continue with the cardiac massage, whilst the attendant (who is also trained for the procedure) comments, that he would feel obliged to help only if he were paid to do so. The HO, losing the battle of resuscitating the patient, recognises the need for an urgent inotropic drug administration asks the nurse to titre the required dose. But at that moment, the HO realises, all the nurses had left, save one who was a student nurse and inexperienced and even she had to call for the other more senior nurses to help prepare the required drug.

Finally, the patient dies. The HO walks over to the family to break the news. They cried in disbelief as they hear the difficult and shocking news, but they were well within earshot when the MO yells in background from across the ward, calling for the HO hurry up with his ‘time wasting’ and carry on to complete his wards rounds because she could not be bothered to wait any longer.”

This actual event took place in a district government hospital in Malaysia during my attachment as a pre-medical student. In my brief time there, there were uncountable accounts of unprofessional behaviour ranging across all levels of medical staff. Doctor-patient relationship goes no further than the extent of providing a drug to cure the disease. Nurses constantly complain of having to deal with both the patients’ and doctors’ attitudes, yet demonstrate little ability in completing their chores at an acceptable standard. These problems that I have highlighted are merely the tip of the iceberg of hugely unprofessional behaviour amongst medical staff in public healthcare service. Having experienced the public healthcare sector from varying perspectives, I have enough reason to believe that anyone would be discouraged from seeking healthcare services from the public healthcare services, if one could afford the more professional private healthcare service.

And if readers realised, I have yet to even discuss the competency of the medical staff in delivering a healthcare service that consumers require and demand. We have reason to believe that medical malpractice and negligence in government hospitals happens, which is indicated by the number of legal suits that have been filed, many of which reputedly have been settled out of courts. With the furore surrounding the de-recognization of Crimea Medical State University and other medical schools from Ukraine, the Malaysia Medical Association (MMA) stated that it places the highest importance in standards of doctors which are allowed to practice in Malaysia, a claim that is used to support their move. However, there have been numerous rebuttals from various groups demanding that Malaysia Medical Association (MMA) reveal and standardize the criteria which are used to ‘recognize’ medical degrees issued from all universities, yet it fell on deaf ears. The inconsistency that MMA portrays is worrying, with medical graduates pouring into the country from various institutions worldwide. How are we to know if they really are qualified to practice in Malaysia? The MMA solution to the question is a separate qualifying examination, which medical students from non-recognized universities need to pass. I personally wonder how many of our local graduates would actually pass these examinations.

The right for a healthcare service that meets the patients’ needs is a basic right that all citizens of Malaysia deserve. Anything short of that can only be perceived as an infringement of such a basic right. The earlier parts of my text discussed the growing trend of consumerism behaviour amongst healthcare users worldwide, but more prevalent in the developed country, a trend that is not currently widely observed in Malaysia, which could offer an explanation of the passivity of healthcare users in Malaysia with regards to the service that is being offered. This is a product of the paternalistic doctor-patient relationship, the elevation of the status of the doctor to somewhat mimicking a demigod: a doctor cannot do harm! Unfortunately, this is not true, and patients in Malaysia need to understand this, fast. We can preach about the unprofessional behaviour of the healthcare workers to limitless ends, but unless the patients adopt a new mentality, the arena of medical practice in Malaysia may never change.

Patients need to be more willing to assume a greater share of responsibility in their healthcare; be more willing to learn about the conditions which they suffer from and understand the implications of each treatment options. They need to discard their passive role and be more active with regards to the management of their own health, not merely absorbing the doctors paternalistic views, but instead challenging them to deliver the best of what the healthcare service has to offer. But this evolution will take time, and as for yet, it is impractical to introduce modern aspects of communication in medicine, such as informed consent and shared decision making, as patients are nowhere ready to take responsibility for their own health, and doctors likewise are nowhere ready to relinquish the authority and supremacy that they have been privileged to, all these years.

There are numerous areas in within the healthcare system that I have yet to discuss, such as healthcare delivery within the private sector, measuring patient satisfaction rates, and even expenses within the healthcare system. Also, I have not even approached the issue from the perspective of the medical staff, the limitations they face within the service, obstacles posed by guidelines, protocols and other red tape, inadequate facilities, poor opportunities for training, massive patient loads, horrendous working hours, and the list can go on. Other limitations in my text stemmed from the difficulty in accessing crucial statistics, such as exact figures of patients within each sector, breakdown of expenditure of the Ministry of Health, previous budget allocations, mortality rates, waiting times for patients in out-patients, waiting lists for medical/surgical procedures/investigations and others. Figures from the government allocations into the national budget and the 9MP, are in itself not useful unless we have figures from previous years to compare to and observe trends.

However, despite the numerous problems in the healthcare system that Malaysia faces, all is not lost. On the whole, as Ramesh and Holliday have said, Malaysia is truly a healthcare miracle, a miracle which has been made possible by the government who have created a system that is accessible by the multiple strata of the Malaysian society. For all the complaints, facts and statistics still prove that Malaysia possesses one of the leading healthcare systems in the Southeast Asia region, and a system that is the envy of many other developing countries. Furthermore, we can take some comfort in the recent efforts by the government with plans in place to show that things are definitely moving forward towards providing a better healthcare system for all. It may not be perfect, but it is definitely improving. However, the first step towards improvement lies in the ability to acknowledge the shortcomings within the system, such as some of the ones that I have discussed above. I self admittedly understand that huge chunks of my text have been critical of various parties, purely because I believe that there is much room for improvement.

As to the answer to the question that I put forward, ‘Is Malaysia’s healthcare system a miracle or a disaster?”…I believe that it is a miracle. It is an achievement that no one could have predicted with the numerous inadequacies and flaws at various levels. The existing system in far from being perfect, but it is undoubtedly a miracle that the healthcare system has succeeding in raising the overall standard of health (measured in terms of the variable mentioned above) of the mass population in Malaysia; a performance that deludes the circumstances under which the healthcare system operates on. However, as one who is within the medical profession, I too can appreciate and sympathize with the numerous problems that healthcare providers face: the lack of resources, support and protection. It is simply that, as patient, I would never give another the power to do harm, onto me.

An overview of Malaysia’s healthcare system. A miracle or a disaster?

An overview of Malaysia’s healthcare system. A miracle or a disaster?

Part II of III – Healthcare Economics and How it Affects Us

Statistics from the World Bank and the Harvard Team in 1999 revealed that in 1996, the total expenditure in healthcare services (public and private sector) amounted to only 2.9% of the Malaysia’s GDP of which 1.4% was in the public sector and 1.5% was spent in the private sector. At first glance these statistics may appear to demonstrate that the decentralisation of healthcare services was successful, but upon closer investigation it clearly shows that it the proportion of expenditure is hugely disproportionate relative to the population size these distinct sectors service.

Pharmabiz (an online news service) in a report in 2004 estimated that the private sector in Malaysia only accounted for 20% of the countries hospital beds, yet it employed almost 54% of the doctors in Malaysia. Marzolf (1996), also observed a similar trend in the mid-1990’s, estimated that 75% of beds in the country were provided by government services, yet it only employed 45% of all doctors in the country.

Therefore, self-admittedly by taking a large leap of faith, I assume that it is fair to conclude that almost an equal share of Malaysia’s GDP (if not more spent in the private sector) was spent on approximately 20-25% of all patients in Malaysia, who sought services from private healthcare providers and on 75-80% of all patients in Malaysia, who sought services from the public sector. Clearly no one can deny the huge disparity that exists between private and public healthcare services. It is no surprise that services provided by the private sector in most fields are almost unanimously superior compared to service provided by the public sector. But, surely the huge disparity in quality, standards, workforce and expertise portrays the government’s insensitivity towards the masses and their inept ability to exert control over maintaining the balance between healthcare provisions supplied by the public sector vs. the private sector.

However is it fair to expect taxpayers and consumers of the public healthcare service to accept substandard care from the public services?

In March 2006, the Ministry of Health started a pilot project in Selayang and Putrajaya government hospitals, where these centres will remain open after normal working hours to provide private specialist care for full-paying patients. This project was designed to last for 6 months with the aims to reduce waiting lists for specialist care, with the hope that patients who can afford this option will choose to pay and avoid the long queues. At the end of the 6 months, it will be decided that if deemed successful this project would be expanded to other government hospitals as well. This ‘full-paying patient’ scheme have received mixed responses from various parties. The Coalition Against Health Care Privatisation (GMPKK) which is made up of various NGO’s, political parties and trade unions is amongst the key opposition of this project. Their arguments revolve around the fact that only 30% of specialists in Malaysia are employed by the public healthcare sector and have to deal with about 70% of the patient load in Malaysia. With these specialists burdened with a massive patient load, these extra hours for cash incentives will only over-work them and may affect the quality of care than the non-paying patients will receive. Also, patients may be threatened, pressured or even manipulated into paying for their treatment for ‘better’ care by specialists.

Prior to the introduction of the project, Deputy Health Minister Datuk Dr Abdul Latiff Ahmad said it was introduced to prevent government hospital facilities from being abused by people in higher income groups:

“For example, a patient who can well afford it, only has to pay RM3,000 for surgery as has been set now in government hospitals whereas he is capable of paying up to RM15,000...This will affect the chances of lower income groups from obtaining similar surgery or treatment.”

What I fail to understand is that the public healthcare sector which is funded by the government should cater for all income groups indiscriminately; simply because all income groups are taxed accordingly. Although the government has insisted that this project is only a pilot project, to determine its feasibility, it demonstrates the governments’ inability to continue its funding of its patients requiring specialist care and also insensitivity towards tax payers. This full-paying patient scheme can only be perceived as a system that imposes a ‘double-tax’ on patients who seek quality care from the public healthcare system. However, the project should have ended in September 2006, but what does the verdict say on the feasibility of the ‘full-paying patient scheme’?

As of now, the percentage of GDP spent by Malaysia on healthcare services still stands well below the 5% of GDP recommendation by WHO. Mafauzy M. in an editorial in January 2000 stated that Malaysia’s expenditure in public healthcare services in 1994 was about 2% of the GDP, compared to the US who spent 14% of their GDP and the G-7 who spent between 5-8% of their GDP. Meanwhile Phamabiz projections estimate that Malaysia’s healthcare expenditure may eventually reach 6% of GDP only by the year 2020

N.B I am obliged to inform readers that the statistics from Mafauzy M.’s editorial and Phamabiz did not cite their sources and therefore I caution readers that the inclusion of these statistics in my text is purely to triangulate the various sources in hope to gain a differing perspectives of our healthcare system.

Although these projections seems reasonable, we must understand that in this space of 15 years there will be tremendous changes within the healthcare needs of the Malaysian population, mainly due to changes in the population demographics as a higher proportion of our population will be older, evolution of diseases and medical advances, just to name a few. Furthermore, by consistently spending less than recommended, we can almost be certain that the Malaysian healthcare system will soon fall much further behind other developed countries (who is consistently spending a higher percentage of their GDP) and over this space of 15 years, I can only foresee this gap multiplying itself. By year 2020, which has been earmarked as the time to announce Malaysia as a developed country, I predict our healthcare system to be nowhere closer to one worthy of a developed country.

According to the Human Development Report in 2006 prepared by the United Nations Development Programme (UNDP), Malaysia was ranked 61/177 based on the Human Development Index which takes into account factors involving life expectancy, literacy and standard of living. The report revealed that in 2003 Malaysia also spent 3.8% of the GDP for healthcare services of which 2.2% was allocated to public health expenditure which ranked Malaysia at 124/175 based on percentage of GDP on public health expenditure. Private health expenditure amounted to 1.6% of GDP which ranked Malaysia at 123/175. Therefore I found it surprising that Malaysia ranked 75/175 in terms of total health expenditure (public and private sectors) per capita amounting to US$374 (adjusted for purchasing power parity).

N.B. Health expenditure per capita was adjusted for purchasing power parity (PPP) in US$ to allow a more valid comparison between countries and does not represent the absolute amount of expenditure per capita in RM.

However, there are signs of improvement in recent times. Although during the 1990-2004 period there were only 70 physicians per 100,000 population in Malaysia; ranking Malaysia at 101/175 in the UNDP 2006 Report, trends show that the ratio has improved greatly compared to those released by the World Bank, 1999 that show there were only 14 physicians per 100, 000 people in 1960 and 44 physicians per 100, 000 people in 1995; more than a 60% increase presently, in ratio of physicians to per 100, 000 people since 1995. Another crucial statistic that strengthens the claims of signs of an improving healthcare delivery is the population’s life expectancy since birth. The World Bank, 1999 showed that life expectancy in Malaysia since birth at 1962 and 1997 stood at 55.8 years and 71.6 years respectively. The UNDP 2006 Reports measured Malaysia’s life expectancy since birth at a hugely improved 73.4 years, ranking Malaysia at 58/175!

Ramesh and Holliday, 2001 in their article titled, ‘Healthcare Miracle: East and Southeast Asia’ applauded Malaysia (amongst Hong Kong and Singapore) for having achieved a remarkable health care status are a modest cost. The paper argued that the financing of the healthcare system is not the key factor for the performance, but rather concentrating the provisions on in-patient care, an expensive component but of considerable efficiency. Whereas on the whole, there was less importance placed on out-patient care; a feature common to the three healthcare system discussed. However, the paper was exact in recognizing its limitations and acknowledging that the improved markers of health status in Malaysia are not solely attributed to the contributions of the healthcare delivery system. On a separate note, I also believe it is worthy of mention that the paper also recognize and warn that with increasing efforts to privatisation, it will increase inflation and the cost of healthcare to the society as a whole, as discussed above earlier. In summary, Ramesh and Holliday marvelled at the manner how Malaysia continued to demonstrate improved health status markers despite contributing well below the 5% of GDP recommended by WHO.

The governments’ stand and approach to the future of the healthcare system in Malaysia also shows greater intent towards improving the healthcare system than previously. Mafauzy M. claims that the government allocates approximately 5% of the national budget to the Ministry of Health amounting to approximately RM2.6 billion, which I presume was true at the time her editorial was published. However, the Federal Government Budget in 2006 through the Operating expenditure Estimates by the Treasury Department of the Ministry of Finance, revealed that approximately RM7.4 billion was allocated to the Ministry of Health, which amounts to almost 7.3% of the entire budget. Of which, RM1.3 billion is allocated purely for development expenditure amongst which RM85 million to complete construction of hospitals in Alor Setar and Cameron Highlands, RM 229 million for building and upgrading clinics nationwide, and RM 131 million for upgrading hospital laboratories and equipment.

Also the Ninth Malaysia Plan 2006-2010 (Rancangan Malaysia Ke-sembilan) states that the Ministry of Health will continue to be the leading agency and main provider of health services and together with other healthcare service provides and NGO’s will receive an allocated 5.4% of the budget amounting to almost RM10.2 billion, of which RM3.3 billion will go into public health care, RM5.4 billion into patient care services, which includes building new hospitals and renovation and RM1.4 billion into other healthcare services, which includes training of staff. The 9MP also outlines a broad plan to cover areas of weakness within the existing system such as greater efforts into development, primary and secondary prevention, and improving the efficiency of the delivery. Also it shows greater sensitivity towards a more equal distribution of healthcare services and with aims to improve healthcare services delivery to rural areas.

However, before we marvel at statistics that have led to Ramesh and Holliday lauding Malaysia as ‘Southeast Asia’s Healthcare Miracle’, we must be aware that the healthcare system in Malaysia, as previously mentioned, focuses mainly on in-patient care, or tertiary care. Therefore by implication, it means areas of medicine such as primary care, primary and secondary prevention which often utilises out-patient services are less pronounced and less successful in terms of implementation. These areas of medicine usually involves long term management dealing with numerous chronic medical conditions, as opposed to the in-patient setting which can only deal with acute conditions.

Therefore, patients who suffer from conditions that are more often prevented or controlled via careful long-term monitoring which is not plausible within the in-patient setting, often are left to manage their own conditions, until an acute event which requires hospitalisation occurs. This often leads to a drastic disruption to the patients’ life, and can also lead to a poorer quality of life following recovery after the acute episode of the disease. Furthermore, cost-benefit analysis of numerous conditions have demonstrated that long-term management of chronic conditions with primary and secondary prevention methods are often more cost-efficient than treating the acute complications of these diseases within the in-patient setting. By failing to control these chronic diseases, numerous hospital beds are unnecessarily occupied and unavailable to other patients who might need them. The management of such acute-on-chronic conditions are mostly otherwise preventable, and avoids unnecessary incurred costs of treating them within in-patients.

The most successful form of primary care in Malaysia relies heavily on private general practitioners (GP) clinics that have mushroomed throughout the country. These are easily accessible in most parts of the country by anybody at all, requiring only a quick registration process and the GP is at your service. Unfortunately, the GP service is ultimately a privately owned business that provides out-patient care for anyone willing to pay. These clinics by large, are poorly regulated with huge amounts of ongoing concealed malpractice, out-dated medical practice, unprofessional behaviour, and conflicting interest between doctor and patient. Therefore, it is shocking that these privately own GP clinics are the only form of out-patient healthcare service that ‘reliably’ provides a long-term management of chronic conditions with the concept of continuity of care, allowing the patients and doctor to forge a relationship that allows the doctor to appreciate the individual needs of the patients and cater for them in a manner that the public healthcare service is unable to do. Although, this is not necessarily guaranteed because with the increasing competition amongst private healthcare providers, there is also a huge disparity within the standards of service provided by GP clinics, and consequently a shift of patients from one GP to another for better service and value for their money. Unfortunately, this disrupts the concept of continuity of care and thereby the most valuable service provided by the GP itself.

(to be cont.: Part III of III – The Professionals and a Conclusion

An overview of Malaysia’s healthcare system. A miracle or a disaster?

An overview of Malaysia’s healthcare system. A miracle or a disaster?

Part I of III – Consumerism and a Dual Health Care System

“…First do no harm. What is implicit in this simple precept of medicine? An awesome power. The power to do harm. Who gives you this power? The patient…because he trusts you. He trusts you the way a child trusts. He trusts you to do no harm…”

~Dean Walcott; Patch Adams, the movie~

The 1998 movie, Patch Adams (based on a true story) which was set in the early 1970’s accurately captured the paternalistic relationship between a doctor and his patient. Historically, for many years, doctors and other medical staff alike have imposed their thoughts, ideas, and beliefs onto their patients in a paternalistic manner under the guise of maintaining professional distance, preventing transference and a superiority complex stemming from specialised inside medical knowledge. These elements have been deemed necessary to deliver the most appropriate and unbiased healthcare service to the patient.

But the medical profession is no longer as untouchable as it once was before. Patients in the developed countries, in the wake of consumerism are currently rejecting these traditionalistic approaches by healthcare providers.

Over the years numerous medical scandals have shook the foundations of a once unquestionable medical practice; the distribution of Creutzfeldt-Jakob disease (CJD) contaminated growth hormones in France (1985), the Apotex Drug Trial scandal in Toronto (1995) are amongst two scandals which have received wide media attention. More recently are the tragedy of Dr Shipman and the horrifying truth about the Bristol hospital scandal, the two most recent medical disasters in the UK which has contributed tremendously to the tarnished reputation of the formerly sacred profession and consequently lead to an increased medical awareness and consumerism amongst patients in the UK.

Patients worldwide are slowly but surely beginning to gain awareness of their rights as consumers with regards to healthcare services, and especially with the severely inflated costs that is being incurred by these healthcare providers. There is an increasing demand amongst patients from their healthcare providers for better overall services apart from a simple prescription to cure the disease; patients are demanding to be more informed regarding the disease itself, treatment options, and psychosocial problems stemming from the impact of the disease on the patients.

Simply put, patients now expect a healthcare service that is centred around the patient and his/her life rather than traditional practices where it revolved primarily around the disease, an idea which Dr Patch Adams brought forth and startled many at the time. It is no longer acceptable for a medical practitioner to merely provide a cure for the disease, but instead is expected to investigate the patients’ symptoms to form a definite diagnosis and offer the patient a number of treatment options in which the patient can choose by means of making an ‘informed consent’ and a ‘shared decision making process’ of the best treatment for the symptoms the patient experiences in view of the particular patients’ lifestyle, taking into account of the psychological and social impact the disease process and its treatment has on the patient, his/her lifestyle and social circle. Not to mention that all this has to be achieved in confidence between the medical practitioner and the patient with the ultimate goal of improving the patients’ quality of life or to regain as much function as prior to their morbidity.

How much of all these are actually practiced by healthcare providers in Malaysia?

It is difficult to appreciate the effectiveness of the healthcare system in Malaysia due to its complex structuring, which can be (at simplest terms) described as dominated by the public sector with increasing decentralisation to the private sector.

As a former colony of the UK, it is no surprise that Malaysia’s public sector is loosely based on the highly successful National Health Services (NHS) which forms the backbone of the public healthcare services of the UK. However, with the increasing burden of disease, patients’ expectations, patient load and financial constraints, the public healthcare system in Malaysia now faces a struggle to deliver healthcare services to the public and seeks to lighten its burden by the process of decentralisation; increasing privatization of healthcare services to mainly to reduce the patient load in the public sector. Whilst the actual intention of the government to promote the private sector is genuine to improve the delivery of healthcare services to the masses, it underestimated the waves of repercussions produced by the blossoming of private healthcare providers.

The initial push towards promoting private healthcare providers was intended to offload the burden from the public sector, in hope with increasing privatization, the standards of healthcare services delivery will improve tremendously. This indeed proved true, but at the cost of severely inflated medical costs causing many to revert back to seeking services from the public sector whose costs by large were relatively unaffected by the inflation that beset the private sector, and thereby still managing to sustain its services at minimal costs. However, the shift of patients from the private sector into the public sector proved that the governments’ actions were made redundant as the decentralization efforts failed to create the impact they had hoped for and consequently the public sector were once again beleaguered by the same problems they faced prior to the promotion of healthcare privatisation.

There is no doubt that the increasing competition within the private healthcare sector has led to a tremendous improvement in the delivery of services which ties in nicely with the patients’ consumerism. Areas which has benefited largely with this improvement in delivery are things such as, improved doctor-patient relationship, better communication, shorter waiting-lists for investigations allowing prompt diagnoses, more generous time allocation per patient, more comfortable stays at hospitals and better patient adherence to treatment, just to mention a few.

But what shadows all the benefits that I had mentioned above is the concomitant inflation that accompanied privatisation has lead to it being a highly lucrative business. Facing stiff competition, private sectors seek to hire the best medical practitioners and expertise in their respective fields to improve their own standards, and do not hesitate to offer irresistible salaries to those who they deem as valuable assets to their service [business]. Although this improves the ability of private healthcare providers to deliver better services, it regrettably forces a brain-drain of expertise from the public sector to the private sector. It does not take a genius to understand that the public sector is by no means able to compete with the private sector in terms of offering better financial wages, benefits and working environments; whilst appreciating the priority of the government: to provide a sustainable public healthcare service at an acceptable standard to the masses and attempting to keep the bill down to a minimum.

Unfortunately, as the masses revert back to the public healthcare services, many find themselves dissatisfied and wanting for better services having experienced the luxuries of the private sector. The demands of modern medicine and consumerism of patients impose a significant pressure on institutionalised healthcare services such as the public healthcare service in Malaysia to deliver. However it is vital to understand that from the governments’ standpoint, the aim of the public sector is to provide a healthcare service that is accessible to the majority population and often this is only possible by compromising the quality of individual services to cater for a larger population. Thereby this creates a disproportion between the actual needs of the patient, the demands of the patients (or perceived needs), and the delivery of the healthcare service by the public sector; rendering patients to deem the public sector as unsuccessful, ineffective and seek better services from the private sector.

Ultimately, this dual healthcare system consisting of a public sector employing efforts of decentralisation via promoting the privatisation of healthcare services has lead to a gaping inequality between the two sectors. This is characterised by the huge swing of patients, especially those belonging to the middle-class between the public sector and the private sector, having left with the difficult choice of choosing between a much higher quality of healthcare service or settling for the cheaper option.

(to be cont.: Part II of III – Healthcare Economics and How it Affects Us)