Phua Kai Lit, PhD


Chapter One (Population and Health)


. Later marriages and smaller families

. More spending per child

. Working women and childcare issues

. More divorces

. Rural to urban migration and growth of cities

. More Malaysians living and working overseas: Brain Drain

. Illegal immigration

. Better health

. Ageing of the population

. Change in disease patterns to more chronic diseases

. Challenge of paying for healthcare for the aged

. More demand for services for the aged


The number of people living in Malaysia today is probably around 20 million. This number includes an estimated 1 million foreigners (those with legal immigration status as well as those who are in the country illegally). The National Census of 2000 should give a clearer picture of Malaysian demographics and population changes since the last census in 1991. Population growth has slowed down in Malaysia as the people begin to marry at older ages, have children later in their marriages and also have fewer children per family. People marry later and postpone having children because they spend more years in school nowadays and also because they wish to spend more time on building up their careers. This is especially true of women who are highly educated.


A few generations ago, it was common for women to get married in their teens and to start bearing children very soon after marriage. Few women were given the chance to acquire higher education. Today, women are more likely to study beyond secondary school and to work outside the home upon completion of their studies. Hence, women tend to marry later and to start having babies later.


People have fewer children (especially Malaysians of Chinese ancestry) because of changing social norms and values as well as pragmatic reasons such as the difficulties of balancing a career outside the home with the domestic duties of being a good wife and being a good mother to the children. Working women have to deal with this “Double Burden of Women” and the “Supermom Syndrome”, i.e., being an exemplary worker in the eyes of the boss as well as a devoted and loving mother in the eyes of the children. As women become better and better educated and they begin to rise higher and higher in the working world, their work responsibilities would increase and their working hours would also get longer and longer. It is easier on a career woman if she has only one or two kids rather than a large number of kids. Gone are the days when Malaysian Chinese women married in their teens, became housewives and had five, six, seven or more children: the number of kids is likely to be three or fewer nowadays. Working women who have their mothers living with them are the luckier ones since the latter can help to shoulder some of the burden of looking after the kids in the family. Working women who have a live-in mother-in-law can also benefit in similar ways. However, these women may experience even more difficulties if they do not get along with their mothers-in-law! Tensed relations with their live-in mothers-in-law would increase the level of stress in their lives. It is common nowadays for middle class and upper class Malaysians to hire maids from foreign countries such as Indonesia and the Philippines to do the housework and take care of the children. A maid relieves some of the pressure on the working mother. Nevertheless, this is not an ideal solution since the maid is left alone with the children while the mother is working at the office – the children may be neglected by the maid or worse. When both parents are at work outside the home, the children are essentially left unsupervised even if there happens to be a maid in the house. There is essentially nobody to discipline the kids and to make sure that they stay out of trouble if they are teenagers.


Another reason why people are having fewer children is because as people migrate from the countryside and the small towns to live and work in the big towns and cities, it becomes more and more expensive to bring up their children. In the countryside, children can help with padi farming, weeding, looking after the cows, buffaloes, goats, ducks and chickens and so on, i.e., they are economically productive and can contribute to the financial well-being of the family. But in the cities, children are less likely to be able to contribute economically to the family. They spend a lot of time in school and on school-related activities. Besides this, they are unlikely to be working unless their parents are running a family business and need assistance from the children. Therefore, it makes sense for city people to have fewer children while investing more in each of them. Thus, middle class Malaysian parents nowadays spend sizable amounts of money on their children for extra tuition classes, music lessons, martial arts courses and so on.


Malaysian society has changed a lot over the past few decades. Nowadays, cohabitation (young, unmarried couples living together) is found in big cities such as Kuala Lumpur and its surrounding suburbs. This was practically unheard of in the 1960s and 1970s. Divorce rates are rising in Malaysia. Malays have traditionally had relatively high divorce rates while divorce was very rare among the Chinese and the Indians because of social pressures against this. However, with rising educational levels among non-Malay women and their growing financial independence because of paid work outside the home, they are finding the option of dissolving unsatisfactory marriages more viable. Hence the rising divorce rates among non-Malays. However, divorcees continue to be stigmatized in Malaysia and divorced women are especially disadvantaged – it is difficult for them to get married again for various reasons. Divorced women who are middle aged and who have kids are truly handicapped in terms of finding another partner and remarrying in the “marriage market”. This is because the vast majority of men around their age would already be married. Malaysian social prejudices also prevent them from marrying men who are more than five years younger (this, however, does not apply to divorced men since men can marry much younger women). Unless they are willing to marry a man who is a widower or a divorcee, they will have much difficulty in finding a second husband. 


As mentioned earlier, Malaysian couples are having fewer children. This

reduction in the birth rate has given rise to the problem of ageing of the population, i.e., because fewer children are being born, the percent of old people in the Malaysian population rises steadily over time. The present number of elderly people in Malaysia is about 5% of the total population. However, if present trends continue, this may rise to over 20% in the future, i.e., one in every five Malaysians in the future will be an elderly person. What is likely to happen as the Malaysian population ages? As the population ages, we can expect the demand for services used heavily by the elderly to increase. These would include dental and health services (including demand for pharmaceutical products), leisure services such as tourism, nursing homes and related social welfare services and so on. Thus, these sectors of the economy are likely to boom in the near future. Because of population ageing, Malaysia would also need larger numbers of doctors and nurses who specialize in treating the elderly, nursing home aides, home health workers and so on.


Malaysia is also getting more urbanized, i.e., more and more people are moving from the countryside to live and work in the big towns and cities. Indeed, it is likely that much of the residents of major Malaysian towns and cities such as Kuala Lumpur, Penang, Johor Baru and Ipoh were born elsewhere and moved to these big towns because of better educational and work opportunities. Thus, industrial development in the Klang Valley, the Bayan Lepas area of Penang Island and around Johor Baru has been accompanied by migration and population increase. Thus, we witness the phenomenon of “emptying out” of the cities during major festivals such as Hari Raya Aidil Fitri and the Chinese New Year. Much of the residents of the major towns and cities are on their way home to celebrate the festivities with their relatives in smaller towns elsewhere or in the rural areas. We mentioned in-migration and population increase earlier. In the case of Johor Baru, the availability of higher-paying jobs in nearby Singapore has also been an important factor in its population increase. Malaysians who live in Johor Baru can commute daily to work in Singapore. Indeed, during each weekday morning, the number of Malaysians traveling into Singapore to work is considerable and number in the hundreds of thousands.


The shift in population from the countryside and small towns to the more economically dynamic big towns and cities such as Kuala Lumpur, Penang and Johor Baru has, however, given rise to problems such as overcrowding, constant traffic jams, inflation in the price of essential goods such as housing, greater strain on services such as electricity, water supply, sanitation and rubbish collection and so on. It has also contributed to the problem of “urban sprawl”, i.e., the cities keep expanding outward and the suburbs keep growing and growing. It becomes more and more difficult to identify where one city ends and where the next begins. This is especially evident when one drives from Kuala Lumpur to Port Klang via Petaling Jaya, Subang Jaya, Shah Alam and Klang. The surrounding countryside disappears and there seems to be no end to the “concrete jungle” as greenery disappears to be replaced by more and more concrete. 


As for other aspects of migration, people who migrate to the cities but who are poorly-educated or unskilled are likely to end up with low-paying jobs and to live in poor quality or squatter housing. Migrants who are highly educated or highly skilled tend to secure better-paying jobs but are likely to end up in a housing market where the price of housing seems to go up year after year. House prices in the Klang Valley and in Johor Baru are among the highest in Malaysia. Thus, some of the gains from holding higher-paying city jobs are cancelled by the higher prices in the major towns and cities. Besides this, it is also likely that migrants would find living and working in the city to be more stressful than life in the countryside and small towns. Thus, after their retirement, these migrants are likely to return to their kampungs and small towns in Kelantan, Terengganu, Pahang, Kedah and so on.


As mentioned earlier, Malaysians are moving from the countryside to the towns and cities. However, some are going beyond these – they are migrating overseas to Singapore, Australia, New Zealand, Britain and North  America. There have also been reports of Malaysians migrating to work illegally in Taiwan and Japan. Some overseas Malaysians are students who decided to stay behind after completion of their higher education in countries like Australia and the United States. Others are those who decided to work overseas because of higher pay or because overseas earnings seem high when converted into Malaysian ringgit. Whatever their reasons may be, if the number of highly-educated and highly-skilled Malaysians working overseas is high, this would result in a significant “brain drain” problem for the country, i.e., some of our best brains would have drained out and their potential contributions to Malaysian society and to the Malaysian economy are lost. However, the bright side of the picture is that overseas Malaysians do contribute to the Malaysian economy indirectly by remitting money home. They can also contribute when and if they finally return home to work after acquiring new skills and mastering the latest technology while working overseas.


The polar opposite of emigration of Malaysians to foreign countries is, of course, immigration of foreigners into Malaysia. Foreign workers in Malaysia can be classified by skill level and by legal status. They can be skilled or unskilled and legal or illegal. These two categories can also overlap, i.e., there can be skilled, legal foreign workers as well as skilled, illegal foreign workers (such as those who enter Malaysia on a social visit pass but who engage in consultancy or professional work while in the country). There can also be unskilled, legal and unskilled, illegal workers.

The controversy over immigrant workers deals more with those who are unskilled (especially those who are unskilled as well as of illegal status). The Malaysian Trades Union Congress (MTUC) opposes continued entry of unskilled foreign workers into this country because of the downward pressure exerted on wage levels by large numbers of foreigners who are willing to work for lower wages than Malaysian citizens. Employers, on the other hand, support the continued influx of foreign workers since they can lower their labour costs by employing these lower-priced foreigners. Another argument from the employers is that without foreigners, “undesirable” jobs would go unfilled since Malaysians shun them and that even the survival of some industries would be threatened, e.g., labour-intensive sectors such as oil palm plantations. It should also not be forgotten that unskilled immigrant labour includes domestic workers from Indonesia and the Philippines. Their presence in Malaysia allows local women to work outside the home in full-time jobs. Whatever the case may be, the continued influx of unskilled, illegal foreign workers (such as those from Sumatra into Peninsular Malaysia and those from Kalimantan and Mindanao into East Malaysia) is perceived as a major problem by many Malaysians.


All these forms of population changes (falling birth rates and population ageing, urbanization of the Malaysian population, and immigration of foreign workers) are related to changes in Malaysian health indicators. Two commonly used health indicators are the infant mortality rate and the life expectancy rate. The infant mortality rate gives an idea of how many babies die before reaching their first birthday. The life expectancy rate gives us an idea of how long men and women are likely to live, on the average. As the standard of living in Malaysia rises (higher income and education levels, better housing with piped water and proper sanitation facilities, better access to basic healthcare services), these health indicators have steadily improved. The infant mortality rate continues to fall and the life expectancy rates for both men and women continue to increase. However, although the “diseases of poverty” (such as diseases due to malnutrition like beri-beri and diseases due to contaminated water supply and poor sanitation like cholera) are declining in importance, diseases associated with affluence and population ageing are increasing in importance. As income levels rise, the diet of the Malaysian population becomes more and more like the “Western” pattern with high levels of protein, fat, sugar and salt intake and this results in higher rates of overweight, heart and circulatory diseases, stroke, diabetes and so on. Other major killers of Malaysians include cancer, injuries such as road traffic accidents and suicides. Cancer is related to higher rates of smoking (e.g. lung cancer), population ageing, industrialisation and very likely, to changes in diet and to higher levels of environmental pollution. Certain forms of cancer are linked to increased occupational exposure to dangerous chemicals as a result of the growing number of industrial jobs in Malaysia.  The larger number of deaths and disabilities due to road traffic accidents is due to the larger number of vehicles on the road, the larger number of young drivers and to higher driving speeds on the roads. Motorcycle riders are at higher risk of being killed or maimed in road traffic accidents than motorists. Young motorists and young motorcycle riders are at especially high risk because of lack of driving experience and their greater propensity for risk-taking behaviour on the roads and highways of Malaysia. Suicides have gained in importance as a leading cause of death because of the decline in infectious diseases and because many of the diseases which affect the ageing population are chronic diseases which do not result in quick death. Thus, although rates of heart disease, stroke, diabetes etc. are rising, people who suffer from these can continue to live for many years although their “quality of life” is adversely affected. There is also growing recognition of the problem of domestic violence within families. Domestic violence victims (who tend to be female) can suffer severe injuries at the hands of family members. As the pattern of diseases change from infectious diseases to chronic diseases, Malaysia needs to deal with the emerging problem of how to organize, finance and provide healthcare and social services to greater numbers of young invalids (due mainly to road accidents) and elderly people with long term illnesses. There is a trend of rising healthcare costs and unless the Government continues to provide heavily subsidized health services to the people, this would be a problem that all Malaysians will have to face in the near future.


Malaysia also has a significant problem of drug abuse and drug addiction in relation to our population. Although drug addicts are disproportionately Malay, in late 2000, there are reports of growing abuse of a drug called “Ecstasy” by Chinese teenagers and youths. The drug abuse problem is also linked to the problem of rising cases of HIV/AIDS in the country. The virus which attacks the immune system of the human body and gives rise to AIDS can be spread through the exchange of contaminated needles used to inject drugs. Thus, drug addicts who share needles are at high risk of contracting the HIV virus. The virus can also be transmitted through sexual contact. Hence, drug addicts who engage in prostitution to earn money to pay for drugs are at higher risk of contracting the virus or can easily spread the virus if they themselves are already HIV positive. Crime rates can also increase if drug abusers resort to petty theft and to robberies in order to get money to feed their addictions.


From the public health point of view, immigrant workers from poor countries can “import” infectious diseases such as tuberculosis into Malaysia. Thus, foreign workers should be carefully screened for infectious diseases before being allowed into the country. A new development in the region (beginning in the early 1990s) is the phenomenon of cross-border pollution, i.e., the notorious “haze” originating in Indonesia (Sumatra and Kalimantan) and blowing into Malaysia, Singapore, southern Thailand and Brunei. Although Indonesian peasants who practice slash-and-burn agriculture are often accused of being the cause of the problem, there have been reports that multinational agricultural companies (e.g. Malaysian companies operating in Indonesia) are actually the main culprits. The haze is an important health hazard for children, the elderly and those who suffer from chronic respiratory and cardiovascular diseases as prolonged exposure to it is the equivalent of smoking many packs of cigarettes in a day. In Malaysia today, the health status of certain sub-groups tend to be significantly poorer than the health status of the majority, e.g., the Orang Asli, estate workers and immigrants (especially illegal immigrants). Much can be done to improve the health of these sub-groups.