In this week’s World of Genomics, we’re off to the southeast Asian country Malaysia. Home to four UNESCO World Heritage Sites and famed for its delicious culinary offerings, it’s no surprise Malaysia is a popular tourist hotspot. One of the world’s few megadiverse nations, the tropical country is home to thousands of plant and animal species. A haven for ecologists, what does Malaysia have to offer the field of genomics?
Population of Malaysia
Malaysia is split into two distinct geographical areas – Peninsular Malaysia and Eastern Malaysia. Peninsular Malaysia is situated on the Malay peninsula and borders Thailand to the North, whilst a southern causeway connects it to the island of Singapore. 400km to the east, across the Strait of Malacca, sits Eastern Malaysia, bordering Indonesia and Brunei on the island of Borneo.
Malaysia’s unique geographical landscape contributes to a complicated, yet rich, history. Eastern Malaysia, particularly the large state Sarawak, is thought to have been inhabited for over 40,000 years. In contrast, evidence of human settlement on the peninsula only dates back 6,000 years. The southeast Asian region was historically a busy crossroads, with travellers and traders crossing the Strait of Malacca in high numbers. This led to an influx of immigrants from other regions, yet due to the vast geographical rift, the two Malaysian settlements developed distinct cultures in response to outside influences.
The position of the Strait of Malacca as a prominent area for trade was eventually known worldwide, and European forces made numerous attempts to control the region. In the 16th century, Portugal was successful in capturing the Strait and the surrounding Malaysian territory. However, Portugal’s diminishing control over the region in the 17th century led to subsequent annexation by the Dutch. British occupation followed in the 19th century, with this status quo remaining until Malaysian independence in 1957.
Today, the region remains diverse. The largest ethnic group is the Bumiputera – a word that describes the indigenous and aboriginal people living on the peninsula and in the Malaysian areas of Borneo. There is also a significant number of Chinese and Indian settlers, and the region is popular with British expats.
Geographic and Population Statistics
- Land area: 330,803 km2
- Gross domestic product (GDP):
- Total: $373 billion (2021)
- Per capita: $11,109 (2021)
- Population size: 33.6 million (2021)
- Birth rate: 15 per 1000 (2020)
- Death rate: 5 per 1000 (2020)
- Infant mortality rate: 7 per 1000 (2021)
- Average life expectancy: 76 (2020)
- Male: 74 (2020)
- Female: 78 (2020)
- Ethnicity: 69.7% Bumiputera, 22.9% Chinese, 6.6% Indian and 0.8% other.
Malaysia inherited its healthcare system from the British prior to independence in 1957. Initially, hospitals and other facilities were concentrated in urban areas, but the government focused on expansion following the end of British rule. Malaysia now operates what is known as a “two-tiered” public health system. Citizens and legal residents of Malaysia are entitled to universal healthcare, provided by the government. However, a substantial private healthcare system operates in tandem. The private sector complements the state-funded system by providing facilities and treatments that may not be available in rural areas or that may have long wait times. A 2013 health care review reported that, while the public sector is responsible for the provision of over 80% of inpatient treatments, primary care in urban areas was largely obtained privately. In 2009, around a third of the nation’s 30,000 doctors were reported to be working in the private sector.
Despite the prominence of private healthcare, the state-funded system generally operates well. The system comprises what are known as health clinics and community clinics. A health clinic is typically responsible for the care of up to 20,000 individuals and provides a wide range of in- and out-patient treatments. Community clinics complement health clinics on a smaller scale, providing care to groups of around 4,000 individuals. Care is generally provided by community nurses and midwifes. Treatments provided by community clinics include family planning and home care for the elderly and disabled.
In recent years, government health expenditure has increased significantly, with around 5% of its budget being devoted to healthcare. This money comes primarily from public taxes and allows for the provision of care that is mostly free at the point of service, or in some cases requiring a small 2-3% contribution.
Typically, the leading causes of death in Malaysia are ischaemic heart disease, pneumonia and cardiovascular disease. However, in recent years COVID-19 has taken the top spot. Despite being faced with a growing and ageing population, Malaysia is a known for being a generally healthy nation. Life expectancy has increased by over a decade for both males and females since the 1970s, and infant mortality rates have decreased by over 80% in the same period.
Excluding COVID-19, non-communicable diseases contribute to the majority of deaths in Malaysia. One of the most common conditions suffered by Malaysian individuals is type 2 diabetes, with somewhere between 10-25% of adults diagnosed with the condition. The prevalence of type 2 diabetes is the cause of a major public health burden, costing the nation around $600 million a year. A recent increase in adults with the disease correlates with a rise in obesity levels. Nearly a fifth of Malaysian adults are obese, and the number is expected to double in the next decade. To combat this, a recent workshop conducted by the Academy of Medical Sciences concluded that a number of steps could be taken to decrease obesity levels in Malaysia, including stricter food regulations and encouraging physical activity in school children.
In light of the number of deaths attributed to COVID-19, and rising concerns about monkeypox, the Malaysian government developed a five-step plan in 2022 to combat infectious disease. The control of communicable diseases is not something unfamiliar in Malaysia – malaria, tuberculosis and dengue fever are endemic to the country. Whilst malaria rates have decreased in recent years, dengue fever and tuberculosis outbreaks have slowly increased in number, although fatality rates are much lower than they were even two decades ago.
Genomic Medicine Capabilities
Newborn screening has been carried out in Malaysia since the 1980s. However, this covers a very limited range of diseases and additional testing is not offered through the public health system. A 2016 study recommended that genetic testing for inborn errors of metabolism, a common ailment in the Malaysian population, be introduced as standard, although this hasn’t yet been implemented. Furthermore, a 2020 study revealed around 20-25% of the population had never heard of genetic testing or were opposed to its use. Despite these shortcomings, many private companies offer a plethora of genetic tests for all ages, including SNP microarrays and whole exome sequencing.
There is also a shortage of genetic counsellors and clinical geneticists in the nation. As of 2021, only 14 clinical geneticists were working in Malaysia, and only nine genetic counsellors. To combat these low numbers, a genetic counselling course was set up at the Universiti Kebangsaan Malaysia, and Malaysian genetic counsellors are being encouraged to return to work in their native country.
In contrast, precision medicine is an up and coming field in Malaysia. In 2019, a platform for tumour profiling was developed, which could pinpoint specific biomarkers to predict the effectiveness of certain treatments. The country also has an active genomics research sphere, with many scientists pursuing gene editing in the context of medical genetics. However, there are no ethics guidelines governing this practice in the country, and many are pushing for more regulation surrounding biotechnology and gene editing.
Asma Ismail: Asma Ismail is a prominent molecular biologist responsible for developing a diagnostic test for typhoid. She currently holds the title of Vice Chancellor of the Universiti Sains Malaysia, and was previously the president of the Academy of Sciences of Malaysia and Director-General of Higher Education. She was the first woman to have held any of these positions.
Serena Nik-Zainal: Serena Nik-Zainal is a British-Malaysian clinician who focuses on genomics in human disease, particularly in cancer. Her work has focused on whole genome sequencing of tumours and the identification of mutational signatures in various diseases. Her work has earned her various accolades including the Crick Lecture by the Royal Society.
Kavita Subramaniam: Kavita Subramaniam is a Malaysian biologist who currently works at King’s College London. She studies a genetic skin condition and is currently working on engineering a gene therapy approach for treatment.
Izzat Suffian: Currently conducting research at the International Islamic University Malaysia, Izzat Suffian is involved in the design of drug delivery systems. A prominent researcher in the nanoparticle field, he has earned the prestigious Wellcome Image Award twice.
Malaysian Genomics Resource Centre: The Malaysian Genomics Resource Centre provides genetic testing and analysis for various health conditions. Their goal is to provide accessible, sustainable healthcare to the Malaysian population.
Genetics and Regenerative Medicine Research Centre: The centre is part of the Universiti Putra Malaysia. Founded in 2012, researchers at the centre focus on stem cell research, tissue engineering and the immune system, among other topics. The aim of research at the centre is to improve patient outcomes, with a bench-to-bedside approach.
Centre for Bioinformatics Research, Universiti of Kebangsaan Malaysia: The Centre for Bioinformatics Research is part of the University’s Institute for Systems Biology, established in 2005. Alongside bioinformatics research, the centre is responsible for providing training and workshops to promote the field of bioinformatics in Malaysia.
Malaysian Node of the Human Variome Project (MyHVP): MyHVP is the 18th branch of the Human Variome Project (HVP). The HVP aims to gather information on genetic variation that contributes to human disease, whilst MyHVP aims to collect this data for use in a Malaysian specific context.
GenomeAsia 100K Project: The GenomeAsia 100K Project was set up to combat the lack of diversity in genomics research. The data collected includes whole genomes from over 1,700 individuals across Asia, 156 of whom hail from Malaysia.
Malay Genome Project: Whilst the Malay population is not entirely confined to Malaysia, the majority of Malay individuals reside in the country. The Malay Genome Project is led out of Singapore and focuses on collecting genetic data to improve the health of Malay individuals.
Future Genomic Landscape:
With an active research landscape and growing awareness of the benefits of genomic medicine, the future of genomics in Malaysia looks promising. Despite the aforementioned opposition to genetic testing from some individuals, the government has increased expenditure in the field with the hopes of not only implementing more effective screening, but also raising awareness. With the majority of the nation agreeing that testing should be utilised, especially for newborn screening, there should be little pushback.
In October 2022, the National Institutes of Health entered into an agreement with Malaysian Genomics in order to promote genomics and pharmaceutical research. This was with a view to improve healthcare in the country. There are also calls for the implementation of more robust electronic health records in Malaysia. This, alongside the nation’s strong biotech industry and emphasis on precision medicine research, should see the country integrating more genetic medicine into its healthcare system in the not-too-distant future.
Brittanica. Malaysia. Available at: https://www.britannica.com/place/Malaysia
World Bank. Indicators. Available at: https://data.worldbank.org/indicator
Wikipedia. Malaysia. Available at: https://en.wikipedia.org/wiki/Malaysia
World Health Organisation. 2013. Malaysia Health System Review. Available at: https://apps.who.int/iris/bitstream/handle/10665/206911/9789290615842_eng.pdf
Kalidasan, V., and Das, K. 2021. Is Malaysia Ready for Human Gene Editing: A Regulatory, Biosafety and Biosecurtiy Perspective. Frontiers in Biotechnology and Bioengineering. Available at: https://doi.org/10.3389/fbioe.2021.649203
Academy of Medical Sciences. Addressing the Global Health Challenge of Obesity in Malaysia. 2017. Available at: https://acmedsci.ac.uk/file-download/18861164