Outcome of Treatment of Traumatic Thoracolumbar Spine Fractures

        Outcome of Treatment of Traumatic Thoracolumbar Spine Fractures

 

                                                       Dr. KS Dhillon

Introduction

Fractures of the thoracolumbar spine are relatively common and represent about 65% of all traumatic spinal fractures. Thoracolumbar fractures are more common in men, and the peak incidence is seen between the ages of 20 and 40 years.

Fifty percent of thoracolumbar fractures are unstable fractures. These injuries can produce permanent disability resulting in significant social and economic burden on society. Neurological injury can be present in about 20% to 36% of the patients with thoracolumbar fractures. Neurological deficit can result in severe physical disability. It is usually not possible to predict neurological recovery in patients with traumatic spinal cord injuries because recovery depends on several preoperative prognostic factors.

The outcome of treatment of thoracolumbar fractures without neurological deficit is generally good on long term follow up. Despite technological advances in the treatment of spinal fractures, outcomes of surgery, however, remains unpredictable.

Classification of thoracolumbar fractures

There are several classification systems for thoracolumbar fractures of which the most commonly used one is that by Denis.The Denis classification divides the spine into three columns, the anterior, middle and posterior column. The anterior column consists of the two anterior third of the vertebral body and discs and the anterior longitudinal ligament, the middle column consist of the posterior third of the vertebral body and disc as well as the posterior vertebral body wall and the posterior longitudinal ligament and the posterior column consists of the pedicles, laminae, facet joints and the posterior ligamentous complex (PCL) [1]. This classification is only moderately reliable in determining clinical degree of stability. Instability is said to be present if two or more columns are disrupted.

The Denis classification has been criticized for being too simplistic that it fails to identify ligamentous injuries which can lead to occult, progressive instability.

The Spine Trauma Study Group have introduced a new classification system called the thoracolumbar injury classification and severity score (TLICS). This classification system is based on injury morphology, posterior ligamentous complex integrity and the neurologic status of the patient [2].
The injury morphology can be identified from the imaging studies. There are 3 types of injuries, compression injuries (which can produce a compression fracture or a burst fracture), translational/rotational injuries, and lastly the distraction injuries. The compression fracture is allotted 1 point, a burst fracture 2 points, translational and rotational injuries 3 points and distraction injuries 4 points (table 1).

TLICS scoring

Parameter                                              Points
Morphology
Compression fracture                                1           
Burst fracture                                            2
Translational/rotational                             3
Distraction                                                 4

Neurologic involvement
Intact                                                         0
Nerve root                                                 2
Cord, conus medullaris
Incomplete                                                3
Complete                                                  2
Cauda equina                                           3

Posterior ligamentous complex
Intact                                                         0
Injury suspected/indeterminate                  2
Injured                                                        3

Table 1. TLICS scoring system [2]

There are five categories of neurologic injury, namely intact neurologic status, nerve root injury, complete spinal cord injury, incomplete spinal cord injury, and cauda equina syndrome. Patients with intact neurologic status are alloted zero points, nerve root injury or complete spinal cord injury are allotted two points and patients with an incomplete spinal cord injury or cauda equina syndrome are allotted three points. In the last group higher points are allotted because surgical decompression in these patients can be very useful.

For the posterior ligamentous complex there are 3 categories. The first where the PCL is intact (0 points), second where injury is suspected (2 points and the third where the PCL is disrupted (3 points). A palpable interspinous gap and interspinous widening on x rays would be present when the PCL is completely disrupted.

The allotted points in the three categories are added up to get the total score which will help in decision making as to whether or not surgery should be carried out to treat the injury. Patients with 3 or less points are treated nonoperatively and patients with 5 points or more are treated operatively. Patients with a total score of 4 belong to an indistinct group, where either nonoperative or operative treatment can be considered (Table 2).

Management as per TLICS score

Management                            Points
Nonoperative                             0–3
Nonoperative or operative           4
Operative                                    ≥5

Table 2. Management as per TLICS score [2]

Outcome of treatment of thoracolumbar fractures

Abudou et al [3] carried out a Cochrane systematic review of literature upto September 2012 to compare the outcomes of surgical with non-surgical treatment of patients with thoracolumbar burst fractures who had no neurological deficit. They were only able to find two suitable studies which reported the outcome in 79 patients who were followed up for two years or more. Both studies were judged to have unclear risk of selection bias and a high risk of performance and detection biases because of lack of blinding.

They found that there is insufficient evidence in literature  to conclude ‘whether surgical or non-surgical treatment yields superior pain and functional outcomes for people with thoracolumbar burst fractures without neurological deficit’ [3]. Surgery can be associated with early complications and need for repeat surgery. Surgical treatment is more costly than  non-surgical treatment.

Gnanenthiran et al [4] carried out a meta-analysis to compare pain (VAS) and function (Roland Morris Disability Questionnaire) in patients who had thoracolumbar burst fracture with no neurologic deficit and were treated surgically or non-surgically. Secondary outcomes measured included ‘return to work, radiographic progression of kyphosis, radiographic progression of spinal canal stenosis, complications, cost, and length of hospitalization’[4]. They found that there was no differences in pain, RMDQ score, kyphosis, and return to work rates between the two groups. There was better radiographic correction in the surgical group but surgical treatment was associated with higher complication rate and higher cost of treatment.

The authors concluded that there was insufficient evidence in literature to support the superiority of surgical treatment over non-surgical treatment in the treatment of patients with thoracolumbar burst fractures with no neurologic deficit.

Bakhsheshian et al [5] did a systematic review of literature over a 20 years period to assess the outcome of nonoperative management of traumatic thoracolumbar burst fractures. There wear 45 studies which met their inclusion criteria. Of these 45 studies,16 studies investigated techniques of conservative treatment, 20 studies compared surgical to non-surgical management, and 9 papers investigated the prognosis of non-surgical treatment.

They found 9 high-level studies (Levels I–II) which investigated the non-surgical management of burst thoracolumbar fractures.They found that the outcome of treatment in neurologically intact patients was the same irrespective of the technique used for conservative treatment. No one technique was found to be superior to another.

There was a high level of evidence which demonstrated that the functional outcomes with non-surgical management when compared with surgical management was the same in patients who had no neurological deficit. There was high level evidence to show that neurological deficit is not an absolute contraindication for conservative treatment.

Scheer et al [6] carried out a systematic review of literature, including publications over a 20 years period, to assess the outcome of surgical treatment of thoracolumbar burst fractures. Twenty three level 1 and level 2 studies met their inclusion criteria.

They found that there was high level evidence for short or long-segment posterior pedicle instrumentation of the spine without fusion. Long-segment pedicle fIxation provided better correction as compared to short segment fixation.  The Low Back Outcome Scores (LBOS) however were similar. Long constructs provided more rigidity but it reduced patient mobility which affected patients quality of life.

Spinal fusion is not necessary in addition to spinal instrumentation. Fusion does not improve clinical or radiological outcome after posterior instrumentation. Fusion can, however, increase the operative time and risk of infection. Open approaches to spine surgery can be associated with higher morbidity. High level evidence shows that the thoracolumbar muscle attachments are best preserved and percutaneous as well as paraspinal approaches are useful for the treatment of thoracolumbar burst fractures.
There is level 2 evidence to show that the radiographic, clinical, and functional outcomes are similar irrespective of whether an anterior, posterior, or combined approach is used for instrumentation. The complication rates are higher with the anterior and combined approaches  as compared to the posterior approach. The cost of treatment was higher with the anterior approach as compared to the posterior approach.

Moller et al [7] studied the outcome of nonoperatively treated burst fractures of the thoracic and lumbar spine in adults at an average follow up of 27 years (range 23 to 41 years). Their study included 16 men with an average age of 31 years and 11 women with an average age of 40 years.
There were 4 Denis type A burst fractures, 18 Denis type B, 1 Denis type C, and 4 Denis type E fractures. Seven patients had neurological deficits.

At follow-up, 21 patients reported no or minimal back pain or disability with an Oswestry mean score of 4 (range 0-16). Six patients, three of who were classified Frankel D at baseline reported moderate or severe disability with an Oswestry mean score of 39 (range, 26-54). Of the 27 patients, 6 were classified as Frankel D, and 21 were classified as Frankel E. They found that the local kyphosis had increased by a mean of 3 degrees. The disc height adjacent to the fractured vertebra remained unchanged at follow up.

They concluded that the long term outcome, of nonoperative treatment of  burst fractures of the thoracolumbar spine in adults with minor or no neurological deficit, is predominantly favorable and that there appears to be no increase in risk for disc height reduction in the adjacent discs on long term follow up.

Moller et al [8] studied the long term outcome of treatment of thoracolumbar vertebral fractures in late adolescence. Eighteen boys and 5 girls with thoracolumbar fractures were followed up after 27 to 47 years with  subjective, objective and radiological evaluation. Fourteen patients had a one-column compression fracture, one had a Denis type A, six a Denis type B, one a Denis type D and one patient had a Chance fracture. At baseline  one had a partial paresis of one leg and another one developed a transient paraparesis during the first week. All the patients were treated non-surgically. At the last follow-up, 18 patients had no complaints, 5 had occasional back pain. Twenty were classified as Frankel E and 3 were classified as Frankel D. The radiographic vertebral height of the fractured vertebra remained unchanged during the study period.

They concluded that patients in late adolescence who are treated conservatively for thoracolumbar fractures with minor or no neurological deficit have a favourable long-term outcome.

The post traumatic kyphosis in the fractured region following thoracolumbar fractures in children below 13 years at the time of injury can decrease with time. Karlsson et al [9] did a study involving 12 boys and 12 girls, aged 7-16 years who sustained thoracolumbar fractures which were treated conservatively. The follow up period was between 27 to 47 years.  They found that in 8 individuals (33%), all aged 13 or less at the time of the fracture, there was a decrease of post traumatic kyphosis at the last follow up. This would mean that remodelling of the vertebrae is possible in young children. No increase in degeneration of the adjacent disc was observed in this study.

Outcome of treatment in patients with neurological deficit

Literature on the long term outcome of treatment of patients with thoracolumbar fractures associated with neurological deficit is sparse.

Dobran et al [10] carried out a retrospective analysis of 69 patients who were treated operatively for traumatic spinal cord injury. The patients had posterior stabilization of the spine performed within 24 hours of the the trauma. Surgery was indicated in patients with neurological deficit, severe spinal deformity with canal encroachment of more than 50%, vertebral body wedging of more than 60%, kyphosis of more than 25° and when there was spinal instability.

At one year follow up, 72.4% of the patients with neurological deficit show an improvement in neurological function and no patients deteriorated after the surgery.

The neurological improvement rates were 88.46% in patients with lumbar injuries, 45.45% in thoracic injuries and 66.6% in patients with thoracolumbar injuries.

In patients with thoracolumbar spinal cord injuries, 72.4% of the patients neurologically improved one or more ASIA (American Spinal Injury Association) level after the surgery compared to the neurological status on admission.

Marré et al [11] carried out a retrospective review of 51 patients who had thoracic fractures and were treated by surgery. Of the 51 patients who had surgery, 6 had incomplete neurological deficit and 22 had a complete lesion on admission.

Three of the four patients who were ASIA B at presentation improved one ASIA grade at one year follow up. Two patients with ASIA D made full recovery. Five of the 6 patients (83.3%) who had an incomplete cord injury demonstrated neurological recovery during their follow-up.

The study showed that in none of the patients with ASIA A there was improvement in their neurological status. There was no deterioration of neurological status in any of the patients.
Verlaan et al [12] carried out a systematic review of the literature, to evaluate surgical treatment of traumatic thoracic and lumbar spine fractures. They found a 132 full-text papers from 1970 until 2001. The majority of the papers were retrospective case-series. The total number of patients in these papers was 5,748 patients. There were five surgical techniques that were used for treatment of these patients. This included  posterior short-segment, posterior long-segment, anterior and combined anterior with posterior (AP) techniques.

They assessed the neurological, radiologic, and functional outcome and complications in this group of patients. They found that partial neurological deficits had a potential to resolve irrespective of the type of surgical treatment provided. Surprisingly, none of the five techniques used was able to maintain the corrected kyphosis angle. The functional outcome after surgery appears to be better than what is usually assumed by most people. They found that complications after surgery were uncommon.

Conclusion

Treatment of traumatic thoracolumbar burst fractures remains a challenge. There appears to be no consensus as to what is the best techniques for operative and nonoperative treatment of these fractures. The main aim of treatment is to mobilize the patient early and to obtain a stable spine with maximum mobility  as well as to obtain the best possible neurological outcome. In patients who have no neurological deficit the optimal treatment is nonsurgical. There is high level of evidence to show that the outcome of conservative treatment in patients with no neurology is the same as those with surgical treatment without the complications associated with surgery. The cost of nonsurgical treatment is also lower then surgical treatment.

The evidence in support of the optimal treatment for patients with neurological deficit, however, remains unclear. When clinical and radiological assessment shows that the patient requires surgery, there is no consensus on the technique to be used for spinal stabilization. There, however, is some evidence in literature to show that short- or long-segment pedicle instrumentation without fusion is preferable. The percutaneous and paraspinal approaches have been found to be less invasive.
The long term outcome of conservative treatment of burst fractures of the thoracolumbar spine in adolescents and adult with no or minor neurological deficit is generally favourable.

There are several surgical techniques available for the treatment of unstable spine fractures. Studies show that there is no one technique which is superior to another. The anterior and combined approaches were associated with more complications. Partial neurological deficits after spinal injuries have a potential to resolve but ASIA A type of complete paralysis usually has no potential for recovery.

References

1. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817–831. 
2. Vaccaro AR, Zeiller SC, Hulbert RJ, Anderson PA, Harris M, Hedlund R, et al. The thoracolumbar injury severity score: a proposed treatment algorithm. J Spinal Disord Tech. 2005;18:209–15.
3. Abudou M, Chen X, Kong X, Wu T. Surgical versus non-surgical treatment for thoracolumbar burst fractures without neurological deficit.Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD005079. DOI: 10.1002/14651858.CD005079.pub3.
4. Gnanenthiran SR, Adie S, Harris IA. Nonoperative versus operative treatment for thoracolumbar burst fractures without neurologic deficit: a meta-analysis. Clin Orthop Relat Res. 2011;470(2):567–577. doi:10.1007/s11999-011-2157-7.
5. Bakhsheshian J et al. Evidence-based management of traumatic thoracolumbar burst fractures: a systematic review of nonoperative management. Neurosurg Focus . 2014; Volume 37 (1): 1-8.
6. Scheer JK, Bakhsheshian J, Fakurnejad S et al. Evidence-Based Medicine of Traumatic Thoracolumbar Burst Fractures:A Systematic Review of Operative Management across 20 Years. Global Spine J 2015;5:73.
7. Moller A, Hasserius R, Redlund-Johnell I, Ohlin A, Karlsson MK. Nonoperatively treated burst fractures of the thoracic and lumbar spine in adults: a 23- to 41-year follow-up. Spine J. 2007 Nov-Dec;7(6):701-7. 
8. Moller A, Hasserius R, Besjakov J, Ohlin A, and Karlsson M. Vertebral fractures in late adolescence: a 27 to 47-year follow-up. Eur Spine J. 2006 Aug; 15(8): 1247–1254.
9. Karlsson MK, Moller A, Hasserius R, Besjakov J, Karlsson C, Ohlin A. A modeling capacity of vertebral fractures exists during growth: an up-to-47-year follow-up. Spine (Phila Pa 1976). 2003 Sep 15;28(18):2087-92. 
10. Dobran M, Iacoangeli M, Di Somma LG M, Rienzo AD, Colasanti R, Niccolò Nocchi, Alvaro L, Moriconi E, Nasi D, Scerrati M. Neurological outcome in a series of 58 patients operated for traumatic thoracolumbar spinal cord injuries. Surg Neurol Int 28-Aug-2014;5.
11. Marré B, Ballesteros V, Martínez C, et al. Thoracic spine fractures: injury profile and outcomes of a surgically treated cohort. Eur Spine J. 2011;20(9):1427–1433. doi:10.1007/s00586-011-1698-5.
12. Verlaan JJ, Diekerhof CH, Buskens E, van der Tweel I, Verbout AJ, Dhert WJ, Oner FC.  Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine (Phila Pa 1976). 2004 Apr 1;29(7):803-14.

Meritocracy -- A Myth or A Paradox?

                 Meritocracy -- A Myth or A Paradox?

                                          Dr. KS Dhillon

Introduction

Meritocracy is a term which was first introduced by Michael Young in his 1958 dystopian satirical book ‘The Rise of the Meritocracy’ [1]. Young introduced the formula that “IQ + effort = merit”. The Merriam-Webster dictionary defines meritocracy as ‘a system in which the talented are chosen and moved ahead on the basis of their achievement’ [2].

There is a widespread belief that rewards in life such as university admissions, jobs, money, and power should be skill and effort based. This belief has made meritocracy a leading social ideal.
Many who believe in meritocracy are of the opinion that hereditary aristocracy based on birth should be cast aside to create a level playing field. Merit is the product of talent (IQ) plus determined effort (effort).  Hence many believe that merit rather than luck determines success or failure. There are others who believe that this assumption is demonstrably false because talent and the capacity for determined effort depend to a large extent on one’s genetic endowments and upbringing. To have the required genetic endowments and upbringing is, most of the time, a matter of chance [3].

There are two sides to the issue of meritocracy, the objective, and subjective side. The objective side looks at whether social positions in society are distributed according to academic achievement since academic achievement is considered as an indicator of individual merit. The subjective side looks at whether people are convinced that the diplomas obtained by education are acquired through merit and that later in life the best-educated individuals get the best social positions.

Does meritocracy exist? Is it a myth? 

This is a very important question considering that there is a shift to meritocratic employment strategies across the world. Many people believe that the world is meritocratic and they also believe that the world should be run meritocratically. A 2009 British Social Attitudes survey in the UK found that 84 percent of respondents were of the opinion that hard work is essential and very important if one has to get ahead in life [4]. Similarly, a survey by the Brookings Institute (USA) in 2016 found that 69 percent of Americans believed that people are rewarded for intelligence and skill.

The respondents in both UK and USA believed that factors, such as luck and having a wealthy background were less important. Similar thoughts are apparently popular around the world [3].
Many around the world believe that rewards in life such as university admissions, jobs, money, and power should be based on skill and effort rather than lottery of birth or hereditary aristocracy.
Intellectuals such as McManus, for example, believe that Britain is a meritocracy, with its social class related strongly to intelligence [5]. He also believes that intellectual ability is a major predictor of school examination results and hence entrance to universities.

Saunders [6] on the other hand believed that upward social mobility is due to one's ability rather than on formal qualifications alone. Brighter people he believes, tend to perform better in exams as well as in the labour market. He believed that one can work one's way out of a position in low social class if one is able and motivated enough.

Though the infrastructure for this upward mobility exits, there is not much such upward mobility from the working class to the middle class. The reason why the middle-class individuals can get their children into the same social class in society is because their children are equally motivated as them and the children of working class lack the ability and motivation to advance in society. Saunders beliefs offer ‘a social-Darwinian justification to social class inequalities and relative class mobility, whereby the ‘fittest’ and ablest get a better share of the resources available in a social system’ [7]. His understanding of meritocracy hence is compatible with a market-driven, competitive society.
Though there are different definitions of merit and irrespective of how one defines merit, the impact of merit on upward social mobility remains limited.

Though educational qualifications are important, they are not sufficient to help a person in securing access to a better social position in society [7].   This so-called ‘meritocratic failure’ is often attributed to the role the family plays in a given individuals life. Studies show that ‘parents income and cultural status’ is closely related to an individual's elite private school education and elite university education [7]. This type of education rather than merit help individuals land the highest paying jobs and high social positions in society.

Sadly in many societies equality of opportunities and education do not exist for meritocracy to work. Even if more opportunities were provided to working-class children through education, the structural and cultural inequalities will remain, preventing upward social mobility for these class of individuals [7].

Many believe that meritocracy, as defined by most people, is a myth. More people apparently advance in life due to unquantifiable and unpredictable random factors, such as relatives, friends, chance meetings, etc, rather than from the knowledge, IQ and the qualification that they possess [8]. Discrimination exists in most societies where privileged groups, privileged races and social elites such as the middle class, the whites, males and heterosexuals, progress upwards much more easily and faster than other groups or individuals [8].

Connections with people in high positions in government and private sector can ensure career progression and advancement in social status more than qualifications or intelligence can. Rich parents can buy entrance into elite schools and universities as well as secure jobs in elite professions, for their children, regardless of their innate intelligence [8].

The existence of meritocracy, therefore, appears to be a myth, although it is widely held that merit rather than luck ultimately determines success or failure. Some would go to the extent of saying merit itself is largely the result of luck. Genetic endowments and upbring provides the talent and grit needed for success in life. In essence, the concept of meritocracy, therefore, is something that can to a large extent be inherited and not earned over generations. Some have described meritocracy as a long-standing delusion of which we hear everyday and everywhere [9].

Notwithstanding the myth of meritocracy, meritocracy has been described as a paradox by others.

The Paradox of Meritocracy

Castilla and Benard [10] coined the phrase “paradox of meritocracy”. In an ideal meritocratic system every individual irrespective of their race, gender and class should have an equal opportunity to progress and advance in the society based on their individual merit and effort [10]. Many researchers believe that the system does work on the basis of merit [11,12,13].

Some believe that meritocracy has become the culture in most advanced capitalist countries and this culture provides fair and legitimate distribution of rewards in most organizations [14,15,16].
Despite the belief of many that the meritocracy system does exist and does work in most organizations, there are others who believe that inequalities exist at the workplace in organizations which have adopted merit-based programs [17].

Castilla and Benard [10] developed and tested a ‘theoretical argument that when an organizational culture promotes meritocracy (compared with when it does not), managers in that organization may ironically show greater bias in favor of men over equally performing women in translating employee performance evaluations into rewards and other key career outcomes’.

They conducted three experiments involving 445 participants who had managerial skills. They were asked to make recommendations for promotion, bonus, and job termination based on several employee profiles. They manipulated the gender of the employees who were being evaluated and they also manipulated the companies whose core values emphasized meritocracy in evaluations and compensation with that which did not. Their findings were consistent across all three studies. They found that in organizations which were labeled as meritocratic, the managerial individuals preferred male employees over equally qualified female employees. The males were given a larger monetary reward as compared to equally qualified female employees in meritocratic organization. In non-meritocratic organizations, no such discrimination was found.

The reason for this paradox is not clear but there are a couple of mechanisms which make it possible. One is the role of moral credentials. When an individual has established his moral credentials as a non-prejudiced person he is more prone to express prejudiced attitudes [18]. In organizations where there is a strong belief that the organization is meritocratic, the managers who also endorse this belief, tend to do moral credentialing which make bias more likely when dealing with their employees. The culture in these organizations convinces the managers to believe that they are unbiased since the are a meritocratic organization. This then prevents them from having insight into their own prejudices. When the managers start to believe that they are unbiased and fair, than they become convinced that their motivations will not be questioned and their actions will not be interpreted as prejudiced. In such situations, they feel less constrained by social norms and they allow their decisions to be influenced by stereotypes which leads to discrimination in the organization [10].

The other mechanism is the sense of personal objectivity. Uhlmann and Cohen [19] believe that personal objectivity dictates the extent to which an individual acts on his/her beliefs. This will also include stereotypical beliefs. Their work showed that when people feel objective, they become
more confident that their beliefs are correct and they are more likely to act on their beliefs. Hence, when people hold negative stereotypes about women at the workplace, they are likely to express these stereotypes in employment decisions.

Crandall and Eshleman [20]  coined the term “justification-suppression model” (JSM) of prejudice. According to Crandall and Eshleman their JSM shows that there are several ‘social, cultural, cognitive, and developmental factors’ which create a variety of prejudices in people, including, ‘racial, ethnic, religious, sexual, patriotic, and so on’.  These  factors create so called "genuine" prejudices. These genuine prejudices are negative reactions which cannot be seen but are powerful and have strong motivational forces. Other forces such as social norms, personal  standards, beliefs and values can suppress these prejudices. Suppressed prejudices can be expressed when liberated by beliefs, ideologies and attributions. Justification processes facilitates the expression of these prejudice, and ‘justification allows expression of prejudice without guilt or shame’. This leads to discrimination at the workplace [20].

Without doubt managers in a meritocratic organization believe that their decisions are impartial and they apply stereotypes in their employment decisions. The prejudices maybe racial, ethnic, religious, sexual or others. This paradox of meritocracy is real and exits in most so called meritocratic organizations.

Meritocracy in Malaysia

‘We hold these truths to be self–evident, that all men are created equal, that they are endowed by their Creator with certain inalienable rights,
that among these are life, liberty and the pursuit of happiness’.
                                                                    - Thomas Jefferson

But in Malaysia, all are not created equal. Article 153 of the Constitution of Malaysia grants the Yang di-Pertuan Agong (The King) responsibility for safeguarding the special position of the malays and the bumiputras. The bumiputras are granted special rights in the form of reserved slots in local universities, colleges and other public education institutions. They also have special land reservations and places are set aside for the bumiputras especially the malays in the civil and military services. The constitution also provides for special privileges for the bumiputras in terms of scholarship and business permits. The article 153 led to the implementation of affirmative action policies which benefit only the bumiputras. This has created a racialist distinction between malaysians of different ethnic background. It is rather difficult to balance meritocracy with affirmative action.

After the May 1969 riots National Operations Council (NOC) was set up to rule the country until 1971. The NOC proposed that the Sedition Act be amended to make questioning of Article 153 illegal. Parliament passed the  amendments as law when it reconvened in 1971. In line with the Article 153, first the National Economic Policy (NEP) and later the National Development Policy (NDP) was introduced to assist the malays and the bumiputras.

 In 2003, the then prime minister Mahathir began to remind the malays to  abandon their "crutches," and he implemented a policy of "meritocracy". Some branded this “meritocracy” as a sham because it divided students into two streams prior to university admission. The bumiputras went colleges or universities where they did a matriculation course and the non-malays had to do the Sijil Tinggi Pelajaran Malaysia (STPM) examination which was considered to be much more difficult and competitive examination as compared to the matriculation examination.

The idea of implementing total meritocracy in Malaysia does and will continue to face strong resistance and objections from some sections of the Malaysian society. The main opposition to the full implementation of meritocracy is from politicians who want to maintain unity among the malays so that UMNO can maintain their dominant position to have control over the government and administration of the country [21].

Conclusion

The word meritocracy was first coined by Michael Young in 1958. It is supposed to be a system where talented people move upward in society based on their achievement. Though many around the world believe that rewards in life such as university admissions, jobs, money and power should be based on skill and effort rather than lottery of birth or hereditary aristocracy. The reality is that the impact of merit on upward social mobility remains limited.

More people advance in life due to random factors, such as relatives, friends, chance meetings etc, rather than from the knowledge, IQ and the qualification that they posses. Therefore many believe that meritocracy as defined by most people is a myth.

There is discrimination in most societies where privileged groups, privileged races and social elites progress upwards much more easily and faster than other groups or individual.

Some have described meritocracy as a paradox because in meritocratic organization there is more discrimination then in non-meritocratic organizations.

In Malaysia all are ‘not equal’ and this inequality is guaranteed by our constitution. Our government’s affirmative policies to raise the economic standard of the bumiputras are contradictory the concept of meritocracy. The main opposition to the implementation of meritocracy in Malaysia comes from politicians who want to remain in power and control the government and administration of the country. Meritocracy is unlikely to be implemented in malaysia in the near or distant future.

References

1. Michael Young. The Rise of the Meritocracy, 1870-2033: An Essay on Education and Equality. London: Thames and Hudson, 1958.
2. Merriam-Webster dictionary at https://www.merriam-webster.com/dictionary/meritocracy. Accessed on 9/3/19.
3. Mark C. A belief in meritocracy is not only false: it’s bad for you. At https://aeon.co/ideas/a-belief-in-meritocracy-is-not-only-false-its-bad-for-you , accessed on 13/3/19.
4. National Centre for Social Research. (2011). British Social Attitudes Survey, 2009. [data collection]. UK Data Service. SN: 6695, http://doi.org/10.5255/UKDA-SN-6695-1.
5. McManus IC.Social class data are problematic to interpret, BMJ e-letter, 27 Jun 2004 at http://bmj.com/cgi/eletters/328/7455/1545#64772. 
6. Saunders. Social mobility in Britain: An empirical evaluation of two      competing theories.Sociology 1997;31, no. 2: 261–88.
7. Themelis S. Meritocracy through education and social mobility in post-war Britain: A critical examination. British Journal of Sociology of Education. 2008; 29:5, 427-438.
8. Morrell P. Britain is not a meritocracy…response to ‘The standardised admission ratio for measuring widening participation in medical schools: analysis of UK medical school admissions by ethnicity, socioeconomic status, and sex’ at https://www.bmj.com/rapid-response/2011/10/30/britain-not-meritocracy%E2%80%A6 accessed on 20/3/19.
9. Reay D. Review of Jo Littler, Against Meritocracy: Culture, Power, and Myths of Mobility at https://www.theoryculturesociety.org/review-jo-littler-meritocracy-culture-power-myths-mobility/ accessed on 21/3/19.
10. Castilla EJ., and Benard S. “The Paradox of Meritocracy in Organizations.” Administrative Science Quarterly 55 (2010): 543-576. © 2010 by Johnson Graduate School, Cornell University.
11. Kluegel, J. R., and E. R. Smith 1986 Beliefs about Inequality:  American’s Views of What Is and What Ought to Be. New York: de Gruyter.
12. Ladd, E. C. 1994 The American Ideology. Storrs, T: Roper Center for Public Opinion Research.
13. Ladd, E. C., and K. H. Bowman. 1998 Attitudes toward Economic Inequality. Washington, DC: EI Press.
14. Scully MA. 1997 “Meritocracy.” In P. H. Werhane and R. E. Freeman (eds.), Blackwell Encyclopedic Dictionary of Business Ethics: 413–414. Oxford: Blackwell.
15. Scully MA. 2000 “Manage your own employability: Meritocracy and the legitimation of inequality in internal labor markets.” In C. R. Leana and D. Rousseau (eds.), Relational Wealth: The Advantages of Stability in a Changing Economy: 199–214. New York: Oxford University Press.
16. McNamee SJ and Miller RK. 2004 The Meritocracy Myth. Lanham, MD: Rowman and Littlefield.
17. Castilla EJ. 2008 “Gender, race, and meritocracy in organizational careers.” American Journal of Sociology,113: 1479–1526.
18. Monin, B., and D. T. Miller 2001 “Moral credentials and the expression of prejudice.” Journal of Personality and Social Psychology, 81: 5–16.
19. Uhlmann, E. L., and G. L. Cohen. 2007 “I think it, therefore it’s true”: Effects of self perceived objectivity on hiring discrimination.” Organizational Behavior and Human Decision Processes, 104: 207–223.
20. Crandall, C. S., and A. Eshleman. 2003 “A justification-suppression model of the expression and experience of prejudice”. Psychological Bulletin, 129: 414–446.
21. Hamzah Bin Ali. The Politics of Meritocracy in Malaysia at https://apps.dtic.mil/dtic/tr/fulltext/u2/a420243.pdf accessed on 2/4/19.