Med. J. Malaysia Vol. 40 No. 3 September 1985

CHILD HEALTH IN MALAYSIA: 1870-1985

PAUL C. Y. CHEN

THE EARLY DEVELOPMENT OF CHILDHEALTH SERVICES (1870-1940)

During the 19th century, hospitals of the EastIndia Company were established in the StraitsSettlements but they catered largely to thegarrisons and officials. Thus child health as arecognised public health activity was, to all intentsand purposes, non-existent during this period.

During the early 20th century, Malaya underthe British rule was divided into three separateregions namely the Straits Settlements, theFederated Malay States and the Non-FederatedMalaya States.

The Federated Malay States

In the early part of the 20th century, theinfant mortal ity in the Malay states was painfullyhigh. This was reported to be mainly due to"improper feeding, neglect of sick children andignorance on the part of the mothers whilemalaria, dysentery, diarrhoea, pneumonia andpulmonary tuberculosis were the main causesof the great number of deaths"."

Paul C.Y. Chen, MD, MPH, MSc, FFCMProfessor, Department of Social& Preventive MedicineFaculty of MedicineUniversity of Malaya

59100 Kuala Lumpur, Malaysia

165

The total number of births registered in 1920in the Federated Malay States was 36,566, whiledeaths of children under a year of age was 6,920giving an infant mortality rate of 194 per 1,000live births. Convulsions, the cause assigned to3,460 deaths for that year, was actually not adisease but a symptom. Most of the deaths wereprobably caused by gastro-intestinal troubles

reportedly the result of bad feeding or weredue to malaria, broncho-pneumonia, tetanus andother infectious diseases.

The death rate for 1922 was the lowestcompared to those since 1910. This might beattributed to the establishment of infant welfarecentres at Talpinq, Ipoh and Kuala Lumpur. InKuala Pilah, the Women's Hospital was also usedas an infant welfare centre as reflected by thenumber of children brought to the outpatientdepartment; 2,375 under three years of age and1,952 between th ree and ten years of age. AnInfantile Advisory Board was also set up for thepurpose of advising as to the methods whichshould be employed to' promote the welfare ofinfants and to reduce the infant mortality ratein the Federated Malay States.

The Midwives Enactment, 1922, was gazettedin February 1923.2 The objectives of thisenactment were to secure better training ofmidwives and regulation of their practices. It alsoaimed to eliminate prejudices from the Malaymidwives (bidans) against western midwifery and

fear of hospital from the less educated Malays. The

high mortality rate due to tetanus among infantsin the first year of life further gives an indicationof the necessity for the education and supervisionof bidans and certificated midwives.

In 1922, schools inspection was added to theduties of a Health Officer in the FederatedMalay States. An effective way of improvinghealth care is through the teaching of personalhygiene to school children. There was also aseries of examinations performed on the eyesightof school children of different nationalities in1923. The vision of Malay children in thevernacular school was found to be excellent,whereas in the Engl ish speaking schools, errorsof refraction were relatively comrnon.P

The principal diseases causing mortal ltv inthe 1920s were malaria, dysentery (F ig. 1) anddiarrhoea, pulmonary tuberculosis and beri-beri.In 1924, the number of deaths attributed to fevers(most of them probably malarial) was 14,283or 42.53% of the total. Dysentery and diarrhoeaaccounted for 5.84%, pulmonary tuberculosis5.70%, pneumonia 5.02% and convulsions 10.77%.In' view of the great number of deaths caused bymalaria, the Malaria Advisory Board, whichwas a central committee, was formed for thepurpose of collecting information to enablethem to advise generally as to the methods whichshould be adopted for the control of malaria.

TABLE IINFANT MORTALITY RATE IN THE

FEDERATED MALAY STATES, 1921-30

Year Infant Mortality Rate

1921 1831922 1771923 1801924 1811925 1771927 2031928 1821929 1781930 163

N.B. The records for the state of Pahang for 1926were lost in the floods and the rate for the yearin question is therefore omitted.Source: Federated Malay States, 1931.

78.5%, malaria 18.6%, beri-beri 8.2% andtuberculosis of respiratory system 3.2%.

The Non-Federated Malay States

There was no combined official reports on childhealth for the Non-Federated Malay States. Dataare separately available for each state. During

th is period,in Johore, infant welfare centres wereset up to improve the care of infants and youngchildren. A lot of time was spent training midwivesin antenatal care, general health principles andinfant feeding. Convulsions was also the chiefcause of deaths for infants under one year of age.Table II shows the principal causes of deaths ofchildren and infants in Johore in the year 1935.

TABLE 11PRINCIPAL CAUSES OF DEATHS

OF CHILDREN & INFANTS, JOHORE 1935

Overall, there was a steady reduction in theloss of lives in the very young as shown in Table I.Deaths among infants under one year of age in1930 formed one quarter of the total deaths at allages, whilst deaths of infants and young childrenup to five years of age accounted for almost 40%of the total.

In the 1930s, the principal causes of deaths forchildren under ten were malaria, diphtheria,tetanus, tuberculosis of the respiratory system,

beri-beri and convulsions. 99.75% of those whodied of convulsions were children under 10 years.This was followed by diphtheria, in which 93.5%of deaths were children under 10 years, tetanus

166

Causes of death

ConvulsionsFever unspecifiedPremature birthMarasmusPneumoniaDiarrhoea and enteritisMalariaBronchitisTetanus neonatorum

Source: Johore, 1936.

Total number of deaths

1,4741,027

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Vaccination was made compulsory in Johorefor all infants and other persons at other agesunder certain circumstances by virtue of theVaccination Enactment, 1930. There werefive public vaccinators who travelled around thevillages and rural areas, working to a pre-arrangeditinerary. In addition, vaccinations were performedat hospitals, health offices, clinics and by travellingdispensaries.

Inspection of schools were made. Quite anumber of school children were found to besuffering from dental caries. Government dentalclinics were subsequently set up for schoolchildren in government hospitals in Johore Bahru,Muar, Batu Pahat and Segamat. Majority ofschools in Johore Bahru also supplied toothbrushes to the pupils at wholesale prices.Instructions and demonstrations on the propermethod of brushing the teeth were carried outby the government dentist at the clinic duringattendance for treatment.

Medical Officers-in-charge of the maternityand welfare centre. Due to this reason, nowork could be carried out in a systematicmanner. Thus, during this period, there wasno definite scheme of preventive health workamong women and children in Kedah.

The principal causes of infant deaths in Kedahfor the years 1935 and 1936 reported in order of

frequency, is shown in Table IV. Most of thechildren suffered from intestinal parasites andat least 80% of all outpatients suffered fromworms. The majority of the diseases for whichtreatment were sought could have been preventedand a campaign of education in personal hygienewas urgently undertaken in Kedah. Mothers wereadvised to reduce artificial feeding and this ledto a reduction in the incidence of gastro-enteritiswith a corresponding drop in the death rate ofchildren under four weeks of age.

Child Health During the Period 1941-1956

In Kedah, deaths and illnesses in early lifestood out most prominently. 45% of the deathsin the state apparently took place in the 0-20age group, while over 25% occurred during thefirst 12 months of life. The infant mortality ratein Kedah in the 1930's is shown in Table Ill.

In Table Ill, the data indicates that the infantmortality rate remained high over the six yearsfrom 1932 to 1937. Reference to the mortalityfigures at different age periods showed that nearly50% of infant deaths occurred during the firstmonth of life. One of the problems faced inKedah was the frequent changes of the female

Source: Kedah, 1937.

TABLE IVPRINCIPAL CAUSES OF INFANT DEATHS

IN KEDAH. 1935 AND 1936

313220

522

483010

222

Approximate % of total infant deaths1935 1936

Premature birthConvulsionsFever unspecifiedPneumoniaDiagnosed malariaBowel disease

Diseases

During the Japanese Occupation, statistics werehard to obtain. However, it would not be difficultto imagine the child health standards consideringthe abominable situation of the adults during thetime. The records available were sufficient to showa steady rise in the number of registered deathsand in 1944, this was 50% above the pre-war level.Although no large scale epidemics of the moreserious infectious diseases had been reportedduring this period, there was no doubt that malariadid become very much more prevalent. Under­nourishment was almost nationwide, although

120141148148145138

Infant mortality rate(per 1000 live births)

TABLE IIIINFANT MORTALITY RATE IN KEDAH

Year

193219331934193519361937

168

frank nutritional diseases were less prevalent thanmight have been expected."

The total number of births registered for theyear 1946 was 183,960 while that of infant deathswas 16,877 giving a crude death rate of 92 per1,000. From 1947 onwards, there was a declinein the infant mortality rate. Such was in partdue to improved nutrition of mothers leadingto a reduction of infant beri-beri in breastfedbabies. This was quite obvious among the Malavsin Malacca who had a high rate of death frominfant beri-beri. Their infant mortality rate fellfrom 257 in 1940 to 113 in 1949. Other note­worthy factors causing the decline included theincrease in breast feeding (because of shortageof condensed milk) and the reduction in theincidence of malaria.

Major causes of deaths during this period wereattributed to infection, lack of care during andafter child birth and poor nutrition. The mainconcern of the Federation was with the preventionof major infectious diseases such as malaria,the reduction of pulmonary tuberculosis, theeradication of yaws as well as the treatment ofleprosy and mental disorders.

Diphtheria occurred sporadically and annualfigures suggest that it had been on the increasesince 1947. The high mortality emphasizes theimportance of immunization against diphtheria.Immunization campaigns were carried out butthe level of protection achieved was generallylow. Only 38% of the total number of infantswere immunized in 1955. There were 141,188immunizations recorded in the Federation ofMalaya in 1956.

The year 1951 will always be a landmark in thehistory of tuberculosis control in the Federationof Malaya, since it saw the commencement of theBCG campaign, which was well received by thepublic and was carried out in schools, infantwelfare centres and maternity wards. Thiscampaign increased in momentum during thelatter part of the year. Out of 249,181 personswho were tested with tuberculin, 133,355 werevacinated with BCG.5

169

Poliomyelitis represented yet another diseaseof low endemicity affecting chiefly members ofthe younger age group. There were 199 cases(nationwide) with 21 deaths reported in 1951.Morbidity was highest in Selangor with 49 casesand nine deaths. However, the number of casesand deaths for Malaya as a whole dropped to 37and four in 1955.

Yaws in Malaya was a disease of the ruralpopulace particularly among the Malay children.The disease had become more widespread afterthe War. In 1940, it was a disease which wasdisappearing from all areas but the most remote.But after World War 11, it was distressingly obviousamong Malay children in every rural area. Insome of the kampongs in the East Coast, almostevery child was affected.

In 1949, the number of cases of yaws through­out the Federation was 61,377 of which almost50% were children under 10 years of age. A causeof increase was the complete absence of treatmentduring the war period. After the war, continuoustreatment by arsenic injections lowered thenumber of yaws patients. After a surveyconducted by WHO, anti-yaws campaigns werelaunched in Kelantan and Trengganu in April1954. Within Cl few years, yaws was beingeffectively eliminated from most areas byinjections of suitable doses of penicillin to everysufferer and carrier.

In view of malnutrition among children, thefeeding of school children were carried out on anextensive scale by the education authorities.In 1946, 120,000 children benefited from thisfeeding scheme. Full cream and humanised milkwere also supplied to young children at the infantwelfare centres. A comparison of recordedincidences of beri-beri over a number of yearshelps to provide some insight into the state ofnutrition of the people in Malaya (Fig. 2). Theoccurrence of beri-beri in the Malay Peninsula hadan ultimate relationship with the consumptionof a diet of which polished rice forms the staple. 5

In the area of dental health of school children,dental nurses were trained in 1949 to administer

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appropriate treatment due to a shortage ofqualified dental surgeons. These dental nursesspecialised in the field of preventive dentistryand their focus of training was on the detectionof early cavities and infected fissures in the teethof children. This was aimed at curbing dentaldecay which was quite common among schoolchildren.

The two most' prevalent diseases among therural children during this period were diarrhoeaand dysentery. However, there was a steadyimprovement in the overall health conditionof children throughout the Federation. Severecases of malnutrition became less common andthe general standard of nutrition of the averagechild showed improvement.

CHILD HEALTH IN THEPOST INDEPENDENCE PERIOD:DEVELOPING A BASICINFRASTRUCTURE

With increasing self-government in the 1950'sand independence in 1957, the prime task beforethe government was the need to focus itsdevelopment efforts on the long neglected ruralareas where the people were trapped in a cycleof poverty and ill-health. In the social andeconomic plans of the government, priority wasgiven to the channell ing and coordination of all,resources towards efforts to raise' the standardof living of the rural people in terms of housing,roads, bridges, land for development, watersupplies, processing and marketing of ruralproduce, schools, playing fields, electricity,telecommunications and health services." Thusthe development of health services in rural areascame to be one component of total developmentwhich included such vast projects as the MudaIrrigation Scheme covering 260,000 acres ofrice land and land development schemes covering866,058 acres of land providing improvedprospects for about 68,088 families.s

The basic rural health plan involved the settingup of one rural health unit for every 50,000 ofthe rural population, the unit being made up of

171

one main health centre, four health sub-centresand 20 midwife stations, each midwife coveringa population of 2,000 (Fig. 3). By the end of1970, a total of 44 main health centres, 180 healthsub-centres and 943 midwife stations had beenestablished in the rural areas (Table V), togetherwith 209 mobile dispensaries operating in areasnot vet covered by this scheme.

Further improvement was made in theprovision of preventive and curative services inrural areas with the conversion of the three-tier tothe two-tier system of health care delivery whichbegan in 1974. By this change, the health sub­centres were upgraded to health centres to serve15,000 - 20,000 rural population while midwifeclinics were upgraded to kelinik desa with twoluturewet desa (community nurses) to serve4,000 population.f Maternal and child healthformed the chief functional component of theservices offered by each rural health unit, theother fu nctions being the control ofcommunicable disease, environmental sanitation,medical care, dental care, laboratory services,health education of the public, and records andreporting of statistics. The maternal and childhealth component included antenatal care of

TABLE VPROGRESS IN THE BUILDING PROGRAMME

OF THE RURAL HEALTH SERVICE

Type of clinicDevelopment Plan Main Sub- Midwife

centre centre station

First Five-Year Plan 8 8 26(1956-1960)

Second Five-Year Plan 31 114 617(1961-1965)

Third Five-Year Plan 5 58 300(1966-1970)

Fourth Five-Year Plan 29 66 339*(1971-1975)

Fifth Five-Year Plan 4 6 183(1976-1980)

Total (1956-1980) 77 252 1,465**

* 51 Midwives centres converted to Klinik Desa.** Includes 551 Klinik Desa.

- FLOW OF SERVICES AND PATIENTS

RURAL {I - MAIN CENTRE

HEALTH 2 - SUB-CENTRE

UNIT: 3 - MIDWIFE STATION

HOSPITAL: 4

Fig. 3 A rural health unit designed for a population of 50,000 and composed of a main health centre, four health sub­centres, and 20 midwife stations.

home and at clinics, home delivery of normalcases, after-care of mother and child, homevisiting, family planning, child health clinicsfor infants and toddlers, school health services,and the nutrition programme. The threecategories of staff who were responsible fordirect patient-care were the staff health nurses(Division I Nurse-midwife), the assistant healthnurse (Division 11 Nurse-midwife), and thetrained midwife (Division 11 Midwife), the trainedmidwife being responsible for only the first threeof the seven components listed.

From 1960 onwards momentum began to pickup in the development of maternal and childhealth services and by the end of 1980 consi-

172

derable progress had been made. In 1970, insome states, particularly the more ru ral stateswith higher proportions of Malays, the percentageof births attended by trained midwives, nurses anddoctors was as low as 36%, while in states thatwere more urbanised and with lower proportionsof Malays, the percentage was as high as 88%.This has been in part due to the fact that in manyrural Malay communities there has beencompetition between the modern trained midwifeand the bidan kampung (traditional Malay birthattendant). However, in 1983, there was a vastimprovement in these rural states (Fig. 4) wherethe percentage of deliveries by trained healthpersonnel is qu ite high.

Perlis86.6

Penang78.3 75.4

Kelantan~~====\

78.6"'I'~-

Pahang

Negeri Sembilan

Per cent of registered birthsattended by trained health personnel

in 1983

Singapore

~ 60 - 69%

~ 70 -79%

D 80 - 89%

o miles 60

*Including F.T. (78.4%) & Selangor (63.6%)

Fig. 4 Per cent of registered births attended by trained health personnel according to geographical location in PeninsularMalaysia 1983.

THE PRESENT STATE OFCHILD HEALTH

The child population in Malaysia increased by11% from 4;7, million in 1970 to 5.2 million

173

in 1980. However, the proportion of childrendeclined from 45% in 1970 to 39% in 1980following the drop in fertility as a result of theincreasing awareness by the population of theimportance of family planning. Infants and

Following the achievement of Independence

in 1957, the control of tu berculosis was given

priority. The National Tuberculosis Centre andthe National Tuberculosis Campaign wereinaugurated in 1961. To protect susceptibles,persons up to 20 years of age were given BCG

vaccination, with emphasis on newborns, infants,and primary school entrants. By 1970, 65.7%of the population 0-19 years had been covered.In 1976/77, a coverage of 82.6% was recorded

and this is higher than the target of 75%. Up toDecember 1983, a total of over 8 million hadbeen vaccinated. Revaccination of primary schoolleavers and secondary school children startedin 1975 and by December 1983, a total of 1.7

Fig.5 Infant mortality rate 1920 - 1982.

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children below the age of four constitutedabout 34% of the child population in 1980with the remaining 66% being made up ofchildren aged 5-14 years.

In view of the importance of comprehensivehealth care in child development, maternal andchild health centres have been widely extended

by the government throughout the country. Bythe end of 1982, 1,595 midwife clinics andru raj cl inics, 341 health centres and 29 mobilehealth teams were established in the rural areasto provide better health care to mothers andchildren. Consequently, attendance at thematernal and child health centres increased from2.6 million in 1970 to 4.1 million in 1982.The health status of the mothers and their

children improved as measured by the steady

fall in the country's nee-natal mortality rate,infant mortality rate and maternal rate as shownin Table IV.

Infant Mortality

Fig. 5 shows the infant mortality rate from1920 till 1982. The decline in the infant mortalityrate indicates an improvement in the generalhealth of children. The decrease in the infantmortal ity rate can be attributed to compulsoryimmunization against certain diseases such asdiphteria and tuberculosis, improved standardsof living, increased availability of better medicalfacil ities and the better state of nutrition.

Tuberculosis

Before independence in 1957, tuberculosiswas a major public health problem in thecountry. More than one-quarter of the hospital

beds were occupied by tuberculosis patients andalmost one-tenth of the total health budgetwas spent on tuberculosis. The prevalence ofinfection among the child population wasalarmingly high. Random tuberculin surveys

revealed that about 25% were infected by the

age of five years, as many as 50% by the age of10, and almost 75% by the age of 15.

174

220

200

180

160

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80

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o1920 1940

Year

1960 1980

600

500

400'"g; 300Ctl

U

200

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63 65 67 69 71

Year

73 75 77 79 81 83

Source: Prathap and Lirn (1984).

Fig. 6 Annually registered cases of childhood tuberculosis (0-12 years) bacteriologically positive and negative, PeninsularMalaysia 1963-1983.

million of this population group had beenrevaccinated .9

There has been progressive decline in thenumber of tu berculosis, bacteriologicallyconfirmed and unconfirmed cases (Fig. 6).Analysis of the annual cohorts of bacteriologicallypositive and negative cases in the 0-19 yearage group registered since 1973 indicated thatthe incidence had been two to three times loweramong the vaccinated population compared tothe unvaccinated population.

Diphtheria

There was a general increase in the notification

of diphtheria in 1958. However, there was noepidemic outbreak and the cases reported weresporadic in nature. Immunization against diphtheriawas offered in all government hospitals includingmaternal and child health clinics. Total numberof children immunized in the Federation ofMalaya in 1958 was 126,061. Despite the factthat diphtheria could by this time be preventedand eradicated, it continued to be reported inunduly large numbers. The reason for this can beattributed to the public apathy inspite ofimproved health education. Only a smallpercentage of the child population was being

175

immunized effectively. Most of the children,after having received the first injection were notbrought back for the second or third injection,thus making the immunization less effective.

In 1957, 214 children between 1-4 years ofage died of this disease. However, a great deal ofimprovement has occu rred since those early daysand by 1981, no deaths were being recorded fromdiphtheria (Fig. 7), which today is no longer adisease of any major importance.

CONCLUSION

Generally, the post independence period haswitnessed a marked improvement in the level ofcare and protection for children in Malaysia.The government's programmes towards betternutrition, health care, education and welfarefor children, are aimed at enhancing their well­being and ensuring their proper physical and

mental development in order to enable them toplay their rightful role in the socio-economicdevelopment of the country. The task ofimproving the quality of life of the children,however, cannot be shouldered by the govern­ment alone. The public through voluntaryorganizations, professional bodies, and other

social institutions should also assist in providing

1960 1964 1968 1972 1976 1980

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ACKNOWLEDGEMENTS

I wish to thank Miss Teong Seow Kin for hervaluable contribution and assistance, Miss Malinda

Hue for typing the manuscripts, and Mr RajaIsaiah Rasiah for some of the artwork.

REFERENCES

Federated Malay States. Medical Report for the year1920. Kuala Lumpur: FMS Govt. Press, 1921.

2 Federated Malay States. The Midwives Enactment,1922. In The Enectrnents passed during the year1922 and Rules thereunder, together with Rules,etc, under Enactments passed prior to 1922. KualaLumpur: FMS Govt. Press, 1923.

3 Federated Malay States. Annual Medical Report forthe year ending 31st December 1923. Kuala Lumpur:FMS Govt. Press, 1924.

4 Malayan Union. Report of the Medical Departmentfor the year 1946. Kuala Lumpur: Govt. Printers,

1948.

Fig. 7 Medically Certified & Inspected Deaths of Childrenaged 1-14 years from Diphtheria, Malaysia,1957 - 1981.

amenities and services. Together with governmentefforts, an active and committed involvement ofthe public would ensure the realization of the fullpotential of Malaysian children in the future.

176

5 Federation of Malaya. Report of the MedicalDepartment for the year 1951. Kuala Lumpur: Govt.Pri nters, 1953.

6 Fraser and Stanton. Beri-beri and vitamin S, in theInstitute for Medical Research 1900-1950. Kuala

Lumpur: Institute for Medical Research, 1949.

7 Chen P C Y. The medical auxiliary in rural Malaysia.Lancet 1973; 1:983-985.

8 Malaysia. Fourth Malaysia Plan 1981-1985. Kuala

Lumpur: National Printing Department, 1981.

9 Prathap G, Um L. Epidemiology and control oftuberculosis in Malaysia. J. Malaysian Soc Hlth 1984;4:1-9.