By the time the British transferred power to a local elite in 1957, nearly two centuries of colonial exploitation had left Malaya in a sorry state. Unsurprisingly, the newly-independent Malaysia[1] of the 1960s had a life expectancy that far trailed her former colonial master Great Britain. A baby born in Malaysia in 1960 would be expected to live 59.48 years, according to World Bank data[2] . In contrast, the UK’s life expectancy that same year was 71.13 years.

Malaysia’s development in the ensuing decades, however, has closed the gap. Today, a baby born amid the gleaming skyscrapers of Malaysia is expected to live 72.7 years—22% longer than two generations before, according to the latest data from the Department of Statistics Malaysia (DOSM)[3] . In the UK, the life expectancy for a baby boy at birth is 79.5 years.[4] But this success story is far from uniform: people living in some parts of Malaysia live far longer than their fellow citizens in other parts of the country.

According to 2017 DOSM figures, males in the northeastern state of Terengganu are expected to only live up to 68.8, while those in neighbouring Kelantan have a life expectancy of 69.2. This is an average 8% lower than national figures—a disparity which may not immediately strike one as remarkable. But to look at it another way, the life expectancy for Terengganu males today matches the national figure in 1986. In other words, life expectancy for males in the east coast states are lagging an entire generation behind.

Uneven development is not new, of course. During the colonial period, Malaya’s development was very unequal. The states on the west side of the Malayan peninsula (including Kedah, Perak, Selangor, Negri Sembilan, and Johor, along with the Straits Settlements of Penang and Malacca), which contained the vast majority of ports, tin mines, and rubber plantations, had better infrastructure, better facilities, and greater development. By contrast, the states on the east side (Kelantan and Terengganu) were far less developed. By 1909, one could travel via the West Coast railway from Johor Bahru to Penang, uninterrupted. The first stretch of the East Coast line from Gemas to Tumpat did not open till 1910, and the railway has, to this day, never reached Terengganu. Likewise, Federal Route 1 and its successor North-South Highway run through Western states.

But what’s surprising about this unequal lifespan is that it doesn’t come from the country’s colonial legacy. It was created in independent Malaysia, long after the colonial period was over. In the early 1990s, life expectancy for males on the east coast states was comparable to the national figure at about 69 years. In 1991, life expectancy in Kelantan and Terengganu were 69 and 69.3 respectively, while the corresponding national figure was 69.2.

But while other states progressed, these two east coast states remained in the 60s range, even falling throughout the 1990s before recovering in the early 2000s. A look at life expectancy overall (see graph 2) shows a massive divergence between the national level and the states of Kelantan and Terengganu starting from the early 1990s.

Most curiously, this phenomenon only afflicts men in Kelantan and Terengganu. When it comes to life expectancy, women in the two states march almost in lockstep with their national sisters.

Perhaps the strangest thing: we don’t know why.

Diet: The orthodox explanation

Diet has long been blamed for poor health among east coast residents. The cuisine of the east coast, stereotypically, has a higher sugar content compared with the rest of Malaysia.

The Malaysian Diabetes Association’s Kelantan branch secretary Ab Aziz Al-Safi Ismail once told Utusan Malaysia that the local diet causes high rates of the disease in the state, with 95.3% of loss of limbs there attributed to diabetes.

“The answer to why Kelantan has a high rate of diabetics is very easy: because they love sweet foods, and this has been going on for generations,” he said.[5]

To illustrate his point, he said, the Kelantanese are the only ones who add sugar when they eat the flatbread breakfast staple of roti canai and curry.

But the numbers don’t match.

According to the National Health and Morbidity Survey 2015 (see graph 3), the east coast states have middling prevalence of diabetes and obesity.

A high-sugar diet may affect life in Kelantan and Terengganu, but it is not an explaining factor for lower life expectancy.

Income: A Class Explanation

One measure frequently used to understand divergence in life expectancy is income, where household income and life expectancy are compared to look for possible correlation. Plotting this for Malaysian states, however, does not show a clear picture.



Source: Department of Statistics Malaysia

Kelantan, which has the second lowest life expectancy, has the lowest median household income. However, Terengganu, which performs the worst in life expectancy, has a mid-range median income. This means that, at RM4,694 a month, Terengganu’s median household income surpasses states with better life expectancy.

Here’s what Kelantan and Terengganu have in common—they have the highest concentration of poor households in Peninsular Malaysia, according to two separate academic studies which used different measures.[6]

A 2016 study[7] mapping concentration of poor households in the peninsular found the “prominent poverty hot spots” to be Northern Kelantan and Northern and Middle Terengganu. The researchers from Universiti Teknologi Malaysia, University of South Florida, and University for Development Studies, Ghana, looked at districts in all states and measured the number of households who earn below the poverty line. They found that the northern parts of Kelantan and Terengganu have the highest concentration of “extreme poverty” where household earn RM520 or less a month.

“The heads of poor households in these rural areas are simply not making enough money,” they said.

So is poverty killing east coast men? Such a suggestion may seem jarring in a country like Malaysia, which has a robust welfare system and where universal access to healthcare is guaranteed. All Malaysians can access walk-in GP services for as little as RM1 (USD0.24), and these services act as referral points for more specialised care in public hospitals at almost 100% subsidy.

But access doesn’t only mean low financial barriers.

Universiti Malaya (UM) academic Dr Noran Hairi is a co-author of a study published last year[8], which found that poorer Malaysians are dying younger. And like the 2016 mapping study, the UM researchers found most of those dying younger were concentrated in Terengganu and Kelantan.

Instead of measuring income, Dr Noran and her team used a deprivation index which measured things like a household’s type of dwelling, whether they had access to infrastructure like water and electricity, availability of transport and even if they own a television set.

The index was then compared to infant, child and adult mortality rates in Peninsular Malaysia. What they found was people in regions with higher concentration of deprived districts were dying younger.

Dr Noran said the deprivation index helped capture determinants which are beyond the residents’ control—like infrastructure and government policy.

“What we are looking at are issues. A simple example is the Titanic. When we map out the death rates (from the sinking of the Titanic), we see that it follows a social status.

“Not as many of the ‘haves’ die as the ‘have-nots’. We try to explain why there are more survivors from a certain social class. Firstly because there were not enough lifeboats so women and children were prioritised but even then there were more from higher classes who survived.

“So we look at the situation of the ship. The passengers in the first and second class cabins had easier access to the lifeboats. So it is mainly about the policies and conditions, and not what the individual could have done,” she said.

In 21st century Malaysia, the UM researchers found that higher mortality rates in poorer districts reflected an environment where there were less opportunities for better quality of life.

They observed that Malaysia’s development has been driven by industrialisation, which was concentrated on the peninsular west coast.

In 1960, agriculture made up 37% of the economy and produced 66.2% of jobs. In 2015, it made up only 7% of the economy and 12.7% of jobs.

East coast states, like Kelantan and Terengganu, relied heavily on agriculture and fisheries and the national shift away from this has left an impact on health outcomes there.

“All districts regardless of average wealth of its population have groups of people who are disadvantaged and therefore susceptible to poorer health outcomes. However, if the district itself is wealthy, it will have better infrastructure, healthcare and social services which are able to alleviate the burden of disease across its population,” they said.

Dr Noran said Malaysia’s public healthcare is “among the best in the world” with the vast majority living within 5km of a health clinic.

But the researchers found respondents in the deprived districts were more inclined to use alternative healing methods, leaving medical treatment to a later stage of illness, thus impacting treatment and mortality outcomes.

A recent study by Raja Perempuan Zainab II Hospital in Kelantan[9] found that more than half of cancer patients in the states trust alternative treatments including visiting bomoh (shamans). 54% cited fear as a factor behind not consulting doctors. To mitigate this, the hospital holds awareness roadshows, which include bringing diagnostic and prevention services like mammograms into communities.

But fear of modern medicine is far too simplistic an explanation, and plays into negative stereotypes of rural and poor households wreathed in ignorance and superstition. Access is a far more predictive, and measurable, explanatory factor.

By recording a household’s access to transportation, Dr Noran and her colleagues found that living 5km away from a public GP clinic does not mean much if a household is located in districts with poor roads and public transportation.

“It may cost a day’s income to (go to a clinic),” she said. The local healer is thus a more convenient option.

GP clinics also do not have the capacity for advanced diagnostics, referring patients to public hospitals even further away—and correspondingly, more expensive to get to and requiring time off from work.

This matched findings of a separate study[10] which found that Malaysian households with the lowest income live furthest from health facilities.

The wealthiest respondents lived an average 10.6 km from a public hospital while the distance was more than double at an average 23.6 km for the poorest respondents.

Correspondingly, those who do not seek care in hospitals tended to concentrate in Kelantan (36.2%) and Terengganu (36.5%).

Even if a patient makes it to a public hospital on the east coast, the queue to see a specialist is likely to stretch further than those on the more affluent west coast states, a report by the World Health Organisation shows[11].

[WHO defines west coast states as Johor, Negeri Sembilan, Melaka, Selangor, Perak, Penang, Kedah, Perlis and the federal territories of Kuala Lumpur and Putrajaya, while east coast states are Pahang, Kelantan and Terengganu. However, it should be noted for the purpose of our analysis that Pahang’s income levels are much higher than Kelantan and Terengganu. At RM32,244, its GDP per capita in 2016 places it at the top half of Malaysian states in terms of income. Terengganu is 10th (RM27,268) while Kelantan is last (RM12,812). This means private healthcare is more accessible to Pahang residents, as is travel to other states for medical purposes.]

Using ministry data, the 2013 WHO report shows there are fewer doctors and nurses in the east coast region, compared to the more affluent west coast region. This trend is consistent for other types of medical professionals, compared to the population.

The WHO said regional discrepancy is most marked when it comes to medical specialists in Malaysia, in both public and private service. West coast states had twice as many specialists compared to east coast states, in both public and private service.

Similar trends persists when it comes to hospital beds and the number of public health clinics for GP services in the east coast states.

Dr Halim Salleh, who retired from as associate professor at the medical faculty at University Sains Malaysia in Kelantan in 2014, said the lower numbers of health professionals in the east coast states reflects higher levels of privatisation of healthcare in the country.

In a paper published as part of United Nations journal, he noted that the number of doctors in public service outnumbered those in the private sector in 1970s. The balance tipped in the 1980s, in line with rapid neoliberal industrialisation.

He said while all medical graduates in Malaysia undergo a three-year mandatory public service, an “obviously large number” leave the service once they attain senior positions.

“To some extent, the trend of doctors’ leaving government service is to be expected: by one estimate for early 2000s, doctors in the government services were earning only about 10% of the salaries enjoyed by their private sector counterparts,” he said.

The number of specialists in the east coast states would not differ so markedly if there were opportunities for private sector growth there. However, the states’ median income indicates that private healthcare is beyond the reach of most Terengganu and Kelantan residents, making it a less viable market.

Contacted recently, he is reluctant to say if this is the reason for lower life expectancy in the two states.

He said while the link between poverty and health outcomes has been long established through various academic research, a deeper study taking into account the social, economical and political factors is needed to truly establish why men on the east coast states of Kelantan and Terengganu die younger than their cousins in the other parts of Peninsular Malaysia.

The mysterious gender gap

Further study is also needed to understand why life expectancy for females in Kelantan and Terengganu far surpass the males.

Although still at the bottom of the table, life expectancy for females in Kelantan (75.2 years) and Terengganu (74.6 years) is comparable to national figures for females in 2004 (75.5 years)—a lag less severe than their male counterparts. (Recall that life expectancy for males in Terengganu in 2017 is on par with national figures from 1986.)

So why are women in Kelantan and Terengganu living much longer than the men despite facing the same conditions of income, healthcare and infrastructure? One theory might be childbirth. Kelantan and Terengganu have the second and third highest crude birth rate in the country, behind Putrajaya.

As crude birth rate is the rate of birth by population, the federal territory Putrajaya ranks high due to its miniscule population of 90,000 people. Kelantan and Terengganu have 1.718 million and 1.125 million people respectively.

High birth rates and the fact that 99% of Malaysian births are attended by a skilled health professional indicates that women in these states are more likely to access healthcare, regardless of their circumstances. That postpartum care in rural areas includes up to eight home visits also indicates that a greater proportion of women access healthcare.

Politics: not an explanation

Politics is an important factor when it comes to Kelantan and Terengganu. Kelantan has been governed by Islamist party PAS since 1990, while Terengganu was under PAS rule for two terms, in the 1970s and the early 2000s, and once again following the 2018 general election.

Both are oil producing states but oil royalties from the federal government—or the lack of it—has been used as evidence of marginalisation along political lines.

When the PAS wrested power from Barisan Nasional (BN) in Terengganu in 1999, the 5% oil royalty paid to the state was replaced with wang ehsan, a discretionary contribution to the state channeled through federal agencies and not directly to state coffers.[12] This was reversed on request of the state government took over Terengganu in 2004.

Kelantan, however, is still embroiled in a long court battle over the matter. It says the federal government wrongfully denied the state the royalties, using technicalities over the distance of the oil wells and the Kelantan coast.

One way to check if a state’s population have indeed been punished for voting against the former ruling coalition is to look at healthcare spending per capita. According to the Malaysian Federal Constitution, all spending on public health comes from the federal coffers. As such, healthcare expenditure per capita figures could show if there has been elements of deprivation on political lines. A look at the latest figures released by the Department of Statistics, however, suggests otherwise.

While Terengganu and Kelantan have among the lowest healthcare spending per capita, the reason is unlikely as simply as mere political calculation. Selangor and Penang—both states held by the then-opposition coalition from 2008 until the recent election—are in the top half in the list of healthcare spending per capita. Conversely, the BN’s stronghold states Johor and Sabah are among the bottom four.

We need more data

But as Dr Noran and her team established, multiple factors determine deprivation. In this case, it could include spending on industrial infrastructure, public transportation and education, for example. A more robust measure would take into account total federal spending for each state.

Partisan politics means that federal ministers have often times touted how much the federal government has spent on “opposition states” like Kelantan, but getting into the details is a little more complicated.

Public policy researcher Tricia Yeoh said state allocations are difficult to quantify as the Treasury’s budget documents only provides spending per ministry, and ministries do not conventionally provide tabulations of its spending per state.

Of course, it would have been possible for the office in charge to extract the values of grants allocated to each state to facilitate detailed analysis, she wrote in her column in the magazine Penang Monthly[13], but with the right to information not enshrined in Malaysia, public access to such data remains a challenge.

Such figures, however, are more readily available in healthcare, where measures are frequently reported to international bodies like the WHO and the United Nations.

These statistics have helped academics like Dr Noran to continue their research into health and socioeconomic determinants in Malaysia as the nation progresses into a developed nation.

Following their study on deprivation and life expectancy, the team looked at obesity rates across the nation over the years. This time, the team matched it to income levels.

They found that while obesity rates are still relatively higher among the rich, there is evidence of a shift towards higher concentrations among the lower income.

In fact, the latest National Health and Morbidity Survey shows that prevalence of obesity among the lower income groups almost paces the higher income groups. This means that lifestyle illnesses are now affecting the lower-income to a higher degree, Dr Noran said.

Coupled with challenges of healthcare provision in the lower income east coast states, and without direct intervention to boost mortality figures in these states, the story of life expectancy disparity in Malaysia may remain fairly grim.

Conclusion

Our analysis shows that while ethnicity or even diet are frequently blamed for poor quality of life indicators in states like Kelantan and Terengganu, access to healthcare is a better predictor of life expectancy. Overall, it appears federal policies have lead to the underdevelopment of these states, with correspondingly adverse health outcomes.

A change in federal government may bring some positive changes for Kelantan and Terengganu. Weeks following the election, the PAS-led state governments announced that the new Pakatan Harapan government will channel oil royalties directly to the state government’s coffers—a move which could help the state roll out measures to attract investments for economic development.

Having lost almost every seat it contested in Kelantan and Terengganu, Pakatan Harapan has also vowed to boost its showings in these states in the next general election. This could mean channeling federal funds into these states to boost development and support the livelihoods of its residents, convincing voters there it could better govern than PAS.

The focus to court voters through better economic outcomes could be the turning point for life expectancy in Malaysia. But whether it will retain momentum to catch up with the nation would require long-term federal investment and commitment beyond the next general election.

References

[1] Malaysia was formed in 1963 by a merger of the Federation of Malaya with the British colonial territories of Singapore, North Borneo (renamed Sabah), and Sarawak. Singapore left Malaysia in 1965.

[2] https://data.worldbank.org/indicator/SP.DYN.LE00.IN?end=2016&locations=MY&start=1960&view=chart

[3] Department of Statistics Malaysia: https://www.dosm.gov.my/v1/index.php?r=column/pdfPrev&id=dkdvKzZ0K1NiemEwNlJteDBSUGorQT09, accessed 18 July 2018.

[4] UK Office of National statistics: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/lifeexpectancyatbirthandatage65bylocalareasinenglandandwales/2015-11-04#national-life-expectancy-at-birth , accessed 13 June 2018.

[5] Utusan Malaysia, “Ramai hidap kencing manis di Kelantan”, 8 February 2006, http://ww1.utusan.com.my/utusan/info.asp?y=2006&dt=0208&pub=Utusan_Malaysia&sec=Dalam_Negeri&pg=dn_08.htm , accessed 18 July 2018.

[6] Jeevitha Mariappun, Noran N. Hairi, and Chiu-Wan Ng. “Are the Poor Dying Younger in Malaysia? An Examination of the Socioeconomic Gradient in Mortality.” Ed. Andrew R. Dalby. PLoS ONE11.6 (2016): e0158685. PMC. Web. 18 July 2018.

Rafee Majid, Abdul Razak Jaffar, Noordini Che Man, Mehdrad Vaziri and Mohamed Sulemana, Mapping Poverty Hot Spots in Peninsular Malaysia using Spatial Autocorrelation Analysis, Universiti Teknologi Malaysia, Johor Bahru, Malaysia, 12-14 August 2015 , Accessible online: http://eprints.utm.my/id/eprint/61717/2/MohammadRafeeMajid2015_MappingPovertyHotSpotsinPeninsularMalaysia.pdf , accessed 18 July 2018.

[7] Ibid.

[8] Mariappun, Hairi, and Ng, “Are the Poor Dying Younger in Malaysia?”

[9] The New Straits Times, “Worrying: Cancer patients trust bomoh more,” 15 March 2018, https://www.nst.com.my/news/exclusive/2018/03/345302/worrying-cancer-patients-trust-bomoh-more

[10] Khoo Boo Teik ed. Policy Regimes and the Political Economy of Poverty Reduction in Malaysia, Palgrave McMillan, 2012.

[11] World Health Organization: http://www.moh.gov.my/penerbitan/Laporan/WPR%20Country%20Profile.pdf , accessed 18 July 2018.

[12] Utusan Malaysia “Terengganu minta Kerajaan Pusat kembalikan royalti minyak”, 21 April 2008, http://ww1.utusan.com.my/utusan/info.asp?y=2008&dt=0421&pub=Utusan_Malaysia&sec=Muka_Hadapan&pg=mh_02.htm