Management of Intracapsular Neck of Femur Fractures

     Management of Intracapsular Neck of Femur Fractures

                                            Dr KS Dhillon

Anatomy of the proximal femur

The proximal femur consists of the head, neck, lesser trochanter and the greater trochanter. The head is approximately two-thirds of a sphere and its surface is articular except for fovea capitis femoris where ligament of head is attached. The greater trochanter is large prominence which projects upward from shaft on lateral aspect of junction of neck and the shaft of the femur and the lesser trochanter is protuberance on posteromedial side. The  intertrochanteric crest, extends between two trochanters on the posterior aspect and on the anterior aspect a wide, rough intertrochanteric line stretches from greater to lesser trochanter.

The neck extents from the head to the intertrochanteric region and it forms an angle of 125 degrees with the femoral shaft. The angle can vary between 120 to 135 degrees. The angle is less in adults, females and in short people. When the angle is more then 135 degrees, it is referred to as coxa valga and when less then 120 degrees it is referred to as coxa vara.

The head is anteverted between 5-15 degrees and when the anteversion is less then 15 degrees it is referred as increased femoral anteversion. When the the anteversion is less then 5 degrees, the condition is termed femoral retroversion.

The neck shaft angle is 140 degrees and the anteversion is 40 degrees at birth, both of which decreases as we become adults.

The blood supply to the head comes from three blood vessels. The foveal artery which is a branch of the obturator artery supplies the foveal region. The profunda femoris gives out two branches, the medial and lateral femoral circumflex. The ascending branch of the lateral femoral circumflex anteriorly and medial femoral circumflex posteriorly form an extracapsular arterial ring. This ring gives rise to ascending cervical arteries which form a subsynovial intracapsular arterial ring at the base of the head.

Classification of Intracapsular neck fractures 

Depending on the location, the fracture can be subcapital, transcervical or basicervical. Gardens classification is commonly used of intracapsular neck fractures [1].

Type                     Description                                  Undisplaced/Displaced
 I               Valgus impacted incomplete fracture                Nondisplaced
                 Lateral cortex fractured, medial intact 
II               Complete fracture                                              Nondisplaced
III              Complete fracture with partial displacement      Displaced
IV              Complete fracture with complete displacement  Displaced

Table I. Garden's classification

The Pauwel classification divides the fractures three groups based on the inclination of the fracture line relative to the horizontal. In Type I the inclination is less than 30°; in Type II, 30° to 50°; and in Type III it is greater than 50°. As the angle of inclination increases, the transition of forces from being compressive to shearing occurs [2]. The AO classification for intracapsular fractures is too complicated and its use is not recommended [3].

The  reliability of the Garden classification is poor with interobserver Kappa values of between 0.03 and 0.56 [4-7]. Despite the poor reliability of the Garden’s classification it is still the most commonly used classification.

The interobserver reliability of the Pauwels classification is also poor with overall kappa values around 0.31[8].

In order to improve reliability of the Garden classification, some have recommended simplifying the classification by having only 2 groups i.e displaced versus nondisplaced fractures [9,10]. Better Kappa values of between 0.67 and 0.77 have been reported with this simplified classification [9,11].

Treatment of intra-articular femoral neck fractures

Globally with the increasing mean age of the population, the incidence of hip fractures is bound to increase in years to come. These fractures are a common source of morbidity and mortality.

Management of these fractures depends on several factors such as preinjury ambulatory status, age of patient, cognitive function, and comorbidities as well as on fracture factors, such as age of the fracture, displacement of the fracture and the degree of osteoporosis.

The treatment options available include nonoperative and operative treatment for these fractures. Operative options include, percutaneous fixation, closed reduction with internal fixation, open reduction with internal fixation and arthroplasty. With several treatment options available, what then is the best treatment option?

Nondisplaced femoral neck fracture

The premorbid condition of the patient is important in determining whether to treat nondisplaced femoral neck fractures conservatively or surgically. Patients who are elderly and at high risk of anesthesia and surgery-related complications are ideally treated conservatively. Elderly patients who are nonambulatory and those who are severly demented can be treated conservatively. Surgical fixation for nondisplaced will prevent displacement of undisplaced fractures and allow for early mobilization of thr patient.

Nondisplaced fractures can be treated by percutaneous pinning or screw fixation. Zu et al [12] in 2017 carried out a systematic review of the treatment of undisplaced femoral neck fractures in the elderly. Their review included 29 studies involving 5071 patients. One thousand one hundred twenty patients were treated conservatively and 3951 had surgical treatment. The union rates were 68.8% in patients treated conservatively and 92.6% in patients treated surgically. The incidence of avascular necrosis was 10.3% in patients treated conservatively and 7.7% in those treated surgically. Fixation failure rate was low at 3.3%.

Surgical treatment is the treatment of choice for undisplaced fractures of the femoral neck in younger patients (less then 65 years). Conservative treatment is reserved for patients whose surgical risks outweigh any benefits from the surgery. Union rates are higher with operative treatment [13-15].

Oñativia et al [16] carried out a systematic review to study the outcome of treatment of undisplaced femoral neck fractures with screw fixation in the elderly (more then 60 years) patients. Three studies reported mortality rates of 18.8%; 22%, and 19% at one year follow up. One study reported mortality rate of  42% at 5 years. The overall reoperation rate ranged from 8%-19%, with conversion to hip arthroplasty in 8% and16% of the patients.

The authors concluded that internal fixation with cannulated screws for undisplaced fractures of the femoral neck in the elderly is a valuable option despite the substantial reoperation and mortality rates.

Displaced femoral neck fractures

Treatment options for displaced femoral neck fractures include closed reduction and internal fixation, open reduction and internal fixation, hemiarthroplasty and total hip replacement.

Parker and Stockton [17] carried out a Cochrane database systematic  review to determine which implant is superior for the internal fixation of intracapsular proximal femoral fractures. The review included 28 randomized or quasi randomized trials of 5,547 patients with femoral neck fractures who were treated with 19 different pin and/or screw constructs. They found that no one implant was superior to another when it came to outcomes such as fracture healing, AVN, infection, pain scores, reoperation rate, use of walking aids, periprosthetic fracture, or mortality. The sliding hip screw took longer to insert and was associated with an increased blood loss as compared to other modes of fixation.

Parker and Blundell [18] carried out a meta-analysis of 25 randomized controlled clinical trials (RCTs) involving 4,925 patients with intracapsular femoral neck fractures who were treated with various implants. They also found that no one implant was superior to another with regards to nonunion and fracture displacement rates. There was limited evidence of superiority of screw fixation over smooth pins. There was no advantage in using a side
plate for fixation.

Internal Fixation Versus Hemiarthroplasty

Masson et al [19] carried out Cochrane Database systematic review to compare internal fixation with hemiarthroplasty for treatment of displaced femoral neck fractures. The review included 13 trials involving 2091 patients. They found that with internal fixation the duration of surgery was shorter, operative blood loss was less, less blood transfusion were needed and the infection rates were lower when compared to hemiarthroplasty surgery. Arthroplasty on the other hand had a lower re-operation rate as compared to fixation (8% vs 31%). There was no difference in the length of hospital stay, mortality, degree of residual pain and postoperative mobility.

Parker et al [20] carried out a prospective randomised study to compare the outcome of internal fixation as compared to hemiarthroplasty in patients over the age of 70 years with displaced fracture of the femoral neck. The study included 455 patients. They found no differences in the outcomes for
pain, mobility, or mortality at 3-year follow-up. The revision rate was 5% for the hemiarthroplasty group and 40% in the internal fixation group.

Rödén et al [21] carried out RCT of 100 patients with displaced femoral neck fracture who were treated either with screw fixation or a bipolar prosthesis. The patients were more then 70 years old and were ambulatory before the injury. The duration of surgery was shorter and the blood loss was less in the internal fixation group. The revision rates were very high (34 of 53 patients) in the internal fixation group. Seven out of 47 patients with hemiarthroplasty had a postoperative dislocation. The mortality rates were similar at  2- or 5-year follow-up.

Rogmark et al [22]  carried out an RCT comparing internal fixation with hemiarthroplasty. At 2-year follow-up, those patients who hemiarthroplasty had improved walking and stair climbing ability, and less pain as compared to those who had internal fixation.

Lu-Yao et al [23] carried out a meta-analysis of 106 reports on the treatment of displaced fractures of the femoral neck. They found that within the first 2 years of follow up, 33% of patients who had internal fixation of a displaced fracture of the femoral neck, developed a non-union and 16% developed avascular necrosis. The reoperation rates were 20% to 30% in patients who had internal fixation as compared to 6% to 18% after hemiarthroplasty. They found that the mortality rate at thirty days was higher in patients who had a hemiarthroplasty as compared to patients who had internal fixation. The difference, however, was not significant (p = 0.22) and the difference did not persist beyond three months. The mortality rates at 2 months were lower in patients who had an anterior operative approach for the arthroplasty as compared to a posterior approach.

Fracture of the neck are common in the elderly and hence most of these studies were carried out in elderly patients. There is a paucity of literature on the outcome of treatment in the younger population.Though the outcome in patients with hip arthroplasty appear to be better then internal fixation in most of the studies, the goal of treatment in the younger population would be preservation of the hip by internal fixation of the fracture and dealing with complications as they arise.

Cemented or Cementless Hemiarthroplasty

The earlier hemiarthroplasty prosthesis known as the Austin Moore prosthesis were uncemented prosthesis. Then came the Thomson prosthesis which were cemented. These are still in use today. The outcome with cemented prosthesis is better then non-cemented prosthesis.

Parker et al [24] carried out a Cochrane systematic review to assess the outcome of cemented and uncemented hip arthroplasties for the treatment of femoral neck fractures. They found that there is good evidence which shows that cementing the prosthesis in place reduces postoperative pain and leads to better mobility.

Emery et al [25] carried out RCT of 53 hemiarthroplasties. Twenty seven patients had a cemented hemiarthroplasty, and 26 patients had a cementless hemiarthroplasty. At 17 month follow up they found no statistically significant difference between the groups as far as  postoperative complications such as surgical time, estimated blood loss, or mortality, were concerned. Patients with cementless stems, however,  experienced a much higher level of hip pain and were more dependent on walking aids.

Lo et al [26] also found less thigh pain in patients with cemented stem and their Harris Hip Score was higher then those with uncemented stems. There was no significant difference in complication and mortality rates.

Foster et al [27] found that 7% of the patients with cementless prosthesis had periprosthetic fracture while none of the patients cemented hemiarthroplasty had periprosthetic fracture. This study involved 244 patients, Austin Moore prosthesis were used in 70 patients and cemented Thompson prosthesis was used in 174 patients.

There is overwhelming evidence in the literature to support the use of a cemented prosthesis in the treatment of displaced femoral neck fractures in the elderly.

Unipolar or Bipolar Hemiarthroplasty

The bipolar prosthesis was introduced to reduce acetabular wear and revisions after a hemiarthroplasty by having prosthesis to prosthesis interface in a bipolar prosthesis. Many studies have tried to document superior results with a bipolar prosthesis.

A Cochrane systematic review by Parker et al [24], involving 7 trials with 857 participants and 863 fractures of the neck of the femur, comparing  unipolar hemiarthroplasty with bipolar  hemiarthroplasty showed no significant differences between the two types of implants.

There is level II evidence in the SIGN database which compares unipolar with bipolar prostheses. One of the studies by Eiskjaer et al [28] showed that there was radiological evidence that majority of motion in bipolar prosthesis occurred at the outer articulation (acetabulum-prosthesis interface). There was little or no motion at the motion at the bipolar interface. Hence the bipolar prosthesis are no different from unipolar prosthesis. The SIGN recommendations state that bipolar hemiarthroplasty should not be used in preference to unipolar hemiarthroplasty since there is limited evidence of clinical benefit of bipolar prosthesis.

Kanto et al [29] carried out a prospective, randomized controlled trial of 175 displaced intracapsular femoral neck fractures in patients over 65 years. Eighty eight had patients were treated with unipolar and 87 with bipolar prosthesis. They found no difference in revision rates between the two groups at 8 years follow up.

Ng and Lee [30] carried out a study involving 193 patients who had displaced femoral neck fractures. One hundred and eighteen of the patients were treated with unipolar prosthesis and 75 were treated with a bipolar prosthesis. At an average follow up of 4 years there was no difference between the two groups with regard to hip pain, functional hip scores, rates of acetabular erosion, component migration, revision surgery and complications rates. The authors concluded that the use of more expensive bipolar prosthesis in elderly patients is not justified.

Calder et al [31] performed a randomised prospective trial to compare a unipolar prosthesis with a bipolar prosthesis in the treatment of hip fractures in patients over the age of 80 years. At 2 years follow up they found no statistical difference between the rate of complications in the two groups. The degree of return to the preinjury state was significantly greater (p = 0.04) in patients with unipolar prosthesis. The cost of a unipolar prosthesis, according to the authors, is one quarter that of a bipolar.  The authors concluded that there can be no justification for the use of an expensive bipolar prosthesis in patients over 80 years of age.

The above studies provided level I evidence in support of unipolar prosthesis. There are several studies which favour the use of bipolar prosthesis and these include studies by Eiskjaer and Ostgård [32] (level II evidence), Yamagata et al [33] (level III evidence) and Haidukewych et al [34] (level IV evidence).

Internal Fixation or Total Hip Arthroplasty (THA)

There are several studies which provide level I and II evidence that THA
leads to better outcomes than internal fixation in patients with displaced femoral neck fractures. The function scores are higher and revision surgery rates are lower in patients treated with THA, as compared to those treated with internal fixation [35-42]. This can be an option in patients who are elderly, healthy and cognitively intact.

Complications of fracture neck femur

High mortality rates in patients with femoral neck are seen in the elderly population and not in the younger population. The young patients, however, suffer great morbidity due to high rates of osteonecrosis and non-unions.

Femoral head osteonecrosis 

The overall incidence of AVN of the femoral head in patients with femoral neck fractures has been reported to be as high as 25%. In young patients the average incidence AVN after femoral neck fractures is about 45% [43].

Several factors influence the development of osteonecrosis including age at the time of injury (AVN is less in older patients) the degree of displacement, posterior comminution, fracture line verticality and the quality of fracture reduction [44]. Most cases of AVN present within 2 years but it can manifest anytime between 6 months and 6 years [43].

Patients usually complain of groin, gluteal, or proximal thigh and or ipsilateral knee pain.The pain is usually deep seated, throbbing in nature and weight-bearing activities aggravate the pain. The pain can also be present at night.

In the early stages an MRI is the most useful imaging tool and in the later stages, x rays can demonstrate the presence of AVN. The Ficat and Arlet classification is commonly used for classifying the stages of AVN. They use a combination of plain x rays, MRI, and clinical features to stage avascular necrosis of the femoral head.

Ficat and Arlet Classification [45]

Stage 0

• Plain x rays: normal
• MRI: normal
• Clinical symptoms: nil

Stage I

• Plain x rays: normal or minor osteopenia
• MRI: edema
• Bone scan: increased uptake
• Clinical symptoms: pain usually in the groin

Stage II

• Plain x rays: mixed osteopenia and/or sclerosis and/or subchondral cysts, without subchondral lucency 
• MRI: geographic defect
• Bone scan: increased uptake
• Clinical symptoms: pain and stiffness

Stage III

• Plain x rays: crescent sign with/without cortical collapse
• MRI: same as plain radiograph
• Clinical symptoms: pain and stiffness hip with pain radiating to knee and limp
• Stage IV
• Plain x rays: end-stage with evidence of secondary osteoarthritis 
• MRI: same as plain radiograph
• Clinical symptoms: pain and limp

Haidukewych et al [46]  reported an overall AVN rate of 23% in 82 patients aged between 15 and 50 years, with 83 femoral neck fractures. Sixty five percent of the patients with AVN required total hip arthroplasty. Twenty nine percent of the patients with AVN did not have significant symptoms and did not require additional surgery. Jain et al [47] in a retrospective review of 38 patients with subcapital fractures of the femoral neck treated with internal fixation reported that the occurrence of AVN did not significantly affect patient functioning at the 2.5-year follow-up. Overall the rate of femoral head retention at 6 years is about 82% which would mean that about 18% of patients younger than age 50 years would require a total hip replacement [43].

Management of osteonecrosis of the femoral head

The definitive treatment of symptomatic AVN is total hip arthroplasty. However in young active patients this is not a suitable option. Several joint preservation options are available such as core decompression, bone grafting and femoral osteotomy.

Core decompression

Core decompression has been used in the treatment of idiopathic AVN. The procedure involves drilling a 10mm channel from the lateral femoral cortex to the center of the necrosis area to improve venous flow and improve perfusion of the femoral head. Its efficacy in post traumatic AVN has not been tested. This technique can only be used for Ficat grades I and II for pain relief. It however cannot prevent progression of the lesion [48]. Buckley et al [49] achieved a 90% success rate with core decompression combined with curettage of the necrotic area and insertion of autograft, in the treatment of atraumatic AVN. This technique will be more useful than core decompression alone in the treatment of traumatic AVN.

Bone grafting

Vascularised and non vascularised bone grafting has been used in the treatment of AVN. Various methods of bone grafting have also been used. Bone grafting is usually recommended in patients who have less than 2 mm of subchondral bone depression and when the femoral head involvement is less than 30% and also in patients when core decompression has failed [50].
Both vascularised and non vascularised fibular grafts have been used to treat non traumatic AVN.

Plakseychuk et al [51] compared the outcome of vascularized and nonvascularized fibular grafts for Ficat stages I to III AVN. At 7 years follow-up, the authors reported an 80% femoral head survival for stage I and II hips in the vascularized fibula group compared with 30% in the nonvascularized group. The results for stage III hips were poor in both  groups.

Rotational Osteotomy

The anterior-superior part of the femoral head is typically involved in  advanced osteonecrosis (stages III and IV). In such patients a rotational proximal femoral osteotomy can be carried out to shift the collapsed portion away from the weight bearing zone of the femoral head. This operation can only be carried out when at least 66% of the femoral head cartilage is intact [52]. Sugioka et al [53] have reported excellent results with rotational osteotomies of the proximal femur in patients with stage III and IV.  They reported a 73% success rate in stage III and a 70% success rate in stage IV disease at 3-year to 6-year follow-up. Gallinaro and Masse [54] obtained satisfactory outcome in 62.5% of their patients with stage II and stage III disease with a flexion osteotomy of the proximal femur.

Mont et al [54] were able to obtain good or excellent results in 76% of their patients who had osteotomies for stage II and stage III disease. Twenty four percent of their patients had a fair or poor result.

Total Hip Arthroplasty

The last option for the treatment of AVN is a total hip replacement. The earlier reports of total hip arthroplasty (THA) in patients with AVN showed poor survivorship and outcomes [56-60]. More recent reports, however, suggests that the survivorship or outcomes of THA for AVN are improving [61-64]. With better outcome of THA in patients with AVN, more patients are now offered a THA instead of joint salvage procedure.

Non-union

The incidence of non-union after femoral neck fractures varies between 10% to 33% [65]. The degree of initial fracture displacement, the quality of reduction and increasing age of the patient correlates with a higher risk of a non-union[66-69].

The patient typically presents with pain in the groin. X rays will show the presence of nonunion. When any doubt exists then a CT scan will help confirm the diagnosis.
The options available for treatment of a nonunion include, fixation with new implant, valgus osteotomy, prosthetic replacement and arthrodesis. In  young patients, salvage of the femoral head with preservation of the hip joint is desirable. This can be achieved by a valgus osteotomy or bone grafting [70].

A valgus osteotomy converts a vertical fracture line into a horizontal fracture line thereby converting the shearing forces parallel to the nonunion to compressive forces which promote healing.
Marti et al [71] published a large series of 50 patients with femoral neck nonunion who were treated with a Pauwel abduction osteotomy. The average age of the patients was 53 years and the average follow-up was  7.1 years. Forty-three of the 50 femoral neck nonunions healed (86% union rate). The seven femoral neck nonunions which did not heal were treated with prosthetic replacement. Other authors have reported union rates of between 85% to 100% [72].

Bone grafting is rarely used for treatment of femoral neck nonunions. Bone grafting is usually carried out when there is considerable loss of bone stock and in non-unions with well-aligned fractures where the shear angles are low [44].

Conclusion

Nearly half of the hip fractures involve the femoral neck and these fractures are seen in the elderly who sustain these fractures from simple falls. Femoral neck fractures are rare in young adults. Displaced femoral neck fractures in the elderly patients are treated with a hemiarthroplasty or a hip replacement. Non-displaced and valgus impacted femoral neck fractures are treated with internal fixation. Nonelderly patients are not suitable for hip arthroplasty and they are treated by hip preservation surgical procedures such as close or open reduction with internal fixation of the fracture.
Non surgical treatment is reserved for patients who are not fit to undergo a surgical procedure.
The outcome of surgical fixation of nondisplaced fracture is good but the treatment of displaced fractures is fraught with major complications such as nonunions and or AVN. Nonunions of femoral neck fractures can be treated with valgus osteotomy with very high success rate. Treatment of AVN can be a problem in young active patients. The treatment options for AVN are not so reliable and often a total hip arthroplasty is required which has a limited lifespan and is not suitable for young patients.

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Value of Magnetic Resonance Imaging for the lumbar spine and the knee

     Value of Magnetic Resonance Imaging for the lumbar spine and the knee

                                           Dr KS Dhillon

What is magnetic resonance imaging (MRI)?

MRI is a non-invasive imaging technology which produces three dimensional detailed anatomical images of the soft tissues as well as the bone. It is used to detect disease for diagnosis, and for monitoring of treatment. Sophisticated technology is used to obtain these images.
 
Our body tissues are made of water which contains protons. MRI uses powerful magnets which produce a strong magnetic field. This magnetic field forces the protons to align with this field.
A low-energy radiofrequency current is then pulsed through the patient which stimulates the protons to spin out of equilibrium, straining against the pull of the magnetic field. When the radiofrequency field is turned off, the protons realign with the magnetic field, the energy released is picked up the MRI sensors. The time taken by the protons to realign, the energy released and changes in the environment and the chemical nature of the molecules are recorded by the computer and images are generated. Patients are advised to remain very still while they are in the MRI machine, so that the images do not become blurred.

Intravenous contrast containing Gadolinium is sometimes given to the patient before or during the MRI to increase the speed of realignment of protons with the magnetic field. The faster realignment results in brighter MRI images.

Unlike X-rays and CT scans there is ionizing radiation with MRI.

Uses of MRI

MRI scans are useful for imaging soft tissues. Imaging of bone is best done with X rays and CT scans. MRI scans are useful for detecting infections and tumours in bones. MRI scans are usually used for scanning the brain, spinal cord and nerves, joints, muscles, ligaments, and tendons.

Risks associated with MRI scanning

MRI machines do not produce ionizing radiation but they create a very powerful magnetic field which extends beyond the machine. This magnetic field can exert very powerful forces iron, steel, and other magnetizable objects. Prior to an MRI scan the patient should notify the doctor if he/she has any form of metallic implant in or on the body.

The following should be taken into consideration when an MRI scan is to be done:

• Implants---People with the following implants, especially those containing iron, should not enter the MRI machine: prosthetic implants, plates and screws, staples, artificial heart valves, implanted cardioverter, insulin pumps, cochlear implants, deep brain stimulators, vagus nerve stimulators, pacemakers, loop recorders, and capsules from capsule endoscopy. 
• Claustrophobia—Narrow tunnel machine can produce claustrophobia in some people especially when the scan times are long. Such patients may need sedation or and anesthesia for the procedure.
• Pregnancy—MRI scanning is not advisable in the first trimester of pregnancy when the fetus’s organs are forming and the use of contrast is strictly prohibited in this stage of pregnancy.
• Contrast agents—Nephrogenic systemic fibrosis can develop in patients with severe renal failure on dialysis, if contrast is used. 
• Noise—In some MRI machines the sound intensity can reach up to 120 decibels and hence special ear protection may be needed.
• Nerve Stimulation—A rapid switch of fields in the MRI can produce twitching sensation which can be very uncomfortable.

Accuracy and reliability of MRI scans

In orthopaedic surgery MRI scans are frequently done for evaluation of the spine and joints of the upper and lower limb. An MRI is a very sensitive imaging tool but unfortunately it is not very specific. Abnormalities are common on  MRI scans but often many of the abnormalities are of no consequence. It is very rare for an M.R.I. to be reported as ‘normal study’.

Furthermore radiologists who analyze these scans are not error-proof. Varying error rates in MRI reporting have been published.

MRI scans in spinal disorders

Lumbar disc nomenclature for interpretation of MRI scans of the spine has been standardised on the recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology [1].

A normal lumbar disc is composed of a central nucleus pulposus and peripheral annulus fibrosus and is wholly contained within the boundaries of the disc space.

Degenerative changes in the discs are subdivided into the following subcategories, annular fissure, degeneration, and herniation.

Annular fissures are separations of annular fibres from their vertebral attachment or separation of annular fibers. The fissures can be concentric where the separation of annular fibers is parallel to the peripheral contour of the disc or radial where separation is vertical, horizontal or oblique. The use of the term tear should be avoided because a tear denotes injury. Fissures are due to degeneration and not injury.

Degeneration of the disc would include narrowing of the disc space, disc desiccation, diffuse bulging of the annulus beyond the disc space, fibrosis, fissuring, intradiscal gas, mucinous degeneration of the annulus, osteophytes, inflammatory changes, and end plate sclerosis. [1].

Herniation of the disc is defined as displacement of disc material beyond the limits of the intervertebral disc space.

Disc bulges are not disc herniation. In disc bulges the disc tissue extends beyond the edges of the ring apophyses, throughout the circumference of the disc (symmetric bulge), or 25% of the circumference (asymmetric bulge).

Depending on the shape of displaced disc material, the herniated disc is classified as protrusion or extrusion.

In a disc protrusion the disc material protrudes beyond the normal confines of the intervertebral disc, over a segment less than 25% of the circumference of the disc. The width of the base of the protrusion is wider than the largest diameter of the disc material which projects beyond the normal disc margins. The protrusion, however, must not extend above or below the relevant vertebral endplates.

Disc extrusion is present when the distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base of the disc material. Extrusion is also present when there is no continuity between the disc material beyond the disc space and that within the disc space, and this also referred to as sequestration of the disc.

Herniation of disc into the vertebral body through the endplate is referred to as intravertebral herniation or Schmorl node.

Lumbar MRI diagnostic error rates

Herzog et al [2] carried out a prospective observational study to compare the interpretive findings reported for one patient scanned at 10 different MRI centers over a period of 3 weeks. A 63-year-old woman with a history of low back pain and right L5 radicular symptoms had an MRI of the lumbar spine at 10 different centre within the span of 3 weeks. Two reference MRI examinations were performed at one of the authors' institutions.

They found marked variability in the reporting of interpretive findings and a high prevalence rate of interpretive errors in radiologists' reports.

They found that the overall agreement on interpretive findings was poor. The  average true-positive rate (sensitivity) was 56.4%±11.7 and the miss rate was high at 43.6%±11.7. Effect of spinal pathology on nerve roots was described in only 5 out of the 10 examination reports [2].

The authors concluded that the centre at which the MRI examination was done and the radiologist who interprets the scans, can have a direct impact on radiological diagnosis, subsequent treatment, and clinical outcome.

Harm from overuse of lumbar MRI scans

Wnuk et al [3] carried out a study to determine the proportion of MRI examinations of the lumbar spine which had a detectable impact on the care of the patient (actional outcome). This study had a retrospective cohort of 5,365 outpatient MRI examinations. Actionable outcomes studied included, MRI findings that led to an intervention such as surgery; a new diagnosis such as cancer, infection, or a fracture; when the scanning was for a follow up of known lumbar pathology. Potential harm was identified when the MRI was done for suspicion of cancer or infection but the examination resulted in no positive diagnosis.

They found that the proportion of actionable MRI scans was only 13%. In  36 suspected cases of cancer or infection, the false positives was 81%. In  59% of suspicious examinations further scans were ordered of which 86%  were false positives [3].

The authors concluded that the proportion of lumbar spine MRI examinations that were useful in patient management was small. The false-positive rates were also high and the proportion of false positives which led to further investigation was high too [3].

Low back pain and MRI findings

Besides infections, inflammation, tumours and fracture/dislocation of the spine, the etiology of low back pain remains unknown despite advances in spine imaging and the advent of MRI scanning. Normal morphological changes in the disc which occurs with aging can be present on MRI scanning without any symptoms.

The precise cause of back pain can only be determined in less than 50% of patients with back pain [4]. There is also no relationship between the severity of the lesion seen in imaging and the back pain [5-7].

Clear morphological changes in the aging disc can be seen on MRI scans of the spine in patients who have no back pain [8-11].  On the other hand it is also not uncommon to see patients with severe back pain whose MRI examination shows minimal disc changes [12].

Anterior segment of the lumbar spine

The intervertebral disc is composed of two components, the nucleus pulposus and annulus fibrosus. Fifty percent of the central volume of the disc is composed of the nucleus pulposus which is composed of a loose network of collagen fibres in a proteoglycan matrix which contains some chondrocytes. The nucleus pulposus has a high intensity on T2-weighted  MRI images. After the age of 30 years, dehydration of the disc with fibrous transformation occurs which presents as low intensity linear image in the center of the disc [13].

The annulus fibrosus surrounds the nucleus pulposus on all sides. It is made up of a network of dense elastic collagen fibers which has a low intensity on MRI images. The most peripheral fibers of the annulus fibrosus are known as Sharpey's fibers and they anchor the annulus to the edges of the vertebral endplates. The vertebral endplates are covered by hyaline cartilage which allows the exchange of several metabolites, such as water, glucose and oxygen, with the disc.

Disc degeneration can result from genetic predisposition, ageing, microtrauma and nutritional factors [14]. Disc degeneration usually does not produce symptoms.

There are 4 MRI signs of disc degeneration which may occur together or separately. This includes loss of intensity with T2-weighting, a reduction in disc height, high intensity on posterior aspect of the disc, disc herniation, and endplate changes [12].

T2-weighted low intensity and decreased disc height 

T2-weighted low intensity and decreased disc height is very common in
 asymptomatic individuals. The prevalence is related to the age and between the ages of 20 to 80 years the prevalence rate is between 36% and 85% [15,16]. The changes are most common at the lower two lumbar regions. Mild disc degenerative changes are present in 26% to 100% of the population studied and moderate to severe changes are seen in 35% to 72% of the population studied [10, 11, 17].

High intensity on posterior aspect of the disc,

Desiccation of the disc with age leads to fissuring. Fissuring allows the nucleus pulposus material to leak into these fissures at the posterior aspect of the disc. This nuclear material shows up as high intensity on T2-weighted images. This fissures also allow the disc material to herniate beyond the disc margin and this occurs most frequently at L4-L5 and L5-S1, occasionally at L2-L3 and rarely at L1-L2 [11,18].

The prevalence of posterior high intensity in asymptomatic individuals varies between 12% and 56% [10,18], and it increases with age [10]. In   Stadnik et al’s study involving 36 asymptomatic volunteers, in those who were less then 30 years of age, 11% had a zone of T2-weighted high intensity and in those who were 61 years and above, 100% of the individuals had high intensity zone [10].

Bulging disc and disc herniation herniation

A bulging disc is said to be present when 50% of the circumference of disc tissue extends beyond the edges of the intervertebral ring apophyses. A focal disc protrusion is present when less than 25% of the disc circumference protrudes and a broad-based herniation is present when between 25 and 50% of the disc circumference protrudes beyond the intervertebral ring apophyses. A disc extrusion exists when the greatest  diameter of the fragment beyond the disc space is greater than the distance between the edges of its base.  A  sequestration is present when the disc fragment has lost attachment with the disc and the fragment is in the spinal canal proximal or distal to the disc space [12].
The incidence of global disc bulging, which is usually associated with a decrease in disc height, is about 15 to 81% in asymptomatic individuals [10,19].

Eighty percent of the disc herniations are posterolateral, 10% median, 10%  foraminal or extraforaminal. Anterior disc herniations are rare [12].

Protrusion disc herniations are common in asymptomatic individuals with a prevalence of between 20% to 63% [8,9,10,17,19]. Extrusion disc herniations are rare in asymptomatic subjects with a prevalence of between 0 and 24% [8,9,10, 16,17]. Sequestration disc herniation are not found in asymptomatic individuals [12].

The prevalence of schmorl's nodes is between 19 to 24% in asymptomatic subjects [9].

Vertebral endplate changes

Modic et al [20] carried out an MRI study in 474 patients with low back pain, and they described endplate signal changes in disc degeneration which were divided into three grades:

• Modic type 1 changes with an edematous appearance, hypointense on T1 images and hyperintense on T2 images, with enhancement following gadolinium injection.
• Modic type 2 changes with fatty changes, hyperintense on T1 images and isointense or slightly increased signal intensity on T2 images. 
• Modic type 3 changes with fibrous/osteosclerotic changes, hypointense on both T1 and T2-weighted images.

The etiology and physiopathology of Modic 1 endplate changes remain unknown. The changes may be due microtrauma and biochemical changes due to subchondral strains in the endplates. Modic 1 changes are also seen in patients with discitis/osteomyelitis with low virulence pathogens [21]. Modic type I changes are seen more frequently in patients with low back pain (46%) compared to asymptomatic general population (6%) [22].

Posterior segment of the lumbar spine

The posterior part of the lumbar spine consists of pedicles on either sides behind the vertebral body from which arise the transverse process on either side, superior and inferior articular processes with facets, laminae and the spinous process. The borders of the spinal canal are formed by the posterior part of the vertebrae anteriorly, the pedicles on the sides and the laminae posteriorly.The inferior vertebral notch above and the superior vertebral notch below form the intervertebral foramen through which the nerve root exits the spinal canal. The inferior articular facet of the vertebra above and the superior articular facet of the vertebra below form the posterior facet joint.

The posterior facet joint is a synovial joint which is covered by a capsule. The capsule is strongly innervated by the medial rami of the posterior branches of the spinal nerves.  These rami also have muscular sensory collaterals. The facet joints are inferiorly, posteriorly and laterally oblique. The joints transmit load and stabilize the spinal segment during flexion, extension and rotational movements [12].

Degeneration of the facet joints occurs with age. The decrease in disc height leads to subluxation of these joints which can lead to degeneration of the facet joints. An MRI of the spine can show loss of articular cartilage, subchondral sclerosis, osteophyte formation and intra-articular effusion.
Facet joint arthritis occurs most often at L4-L5. CT scan abnormalities of the facet joints can be seen in 64% to 67% of asymptomatic individuals. Facet arthritis is very common after the age of 45 to 50 years [23-28].

Interspinous bursitis (Baastrup disease)

Baastrup disease, also known as “kissing spine” syndrome is a relatively common lumbar spinal which is characterized by low back pain arising from the close approximation of adjacent posterior spinous processes and resultant degenerative changes, most often seen at L4-L5. Adjoining spinous processes hypertrophy and friction between the two leads to formation of synovial neoarticulation. The back pain is relieved with spinal flexion and increases with spinal extension. An MRI will show an increased interspinous signal on T2-weighted images and decreased signal on T1-weighted images. Though fairly common this condition is often underdiagnosed and missed.

Kwong et al [28] reviewed the abdominopelvic CT scans of 1008 patients and they found evidence of Baastrup disease in 413 patients (41.0%). In individuals 80 years and above the prevalence was 81%.

Lumbar Spondylolysis

A stress fracture of the isthmus is called spondylolysis and it may be unilateral or bilateral. It is usually caused by repeated microtrauma and rarely it may be caused by acute trauma. When it is bilateral, it may lead to spondylolisthesis. Most often spondylolysis is seen at L5 (85 to 90%) [12].
According to Hollenberg et al [29], based on MRI findings, spondylolysis can be divided into 4 grades:

• Grade 1 where there is isthmic edema with or without edema of the pedicle or adjacent joint. There is no cortical abnormality.
• Grade 2 where there is isthmic edema with incomplete fracture of the isthmus.
• Grade 3 where there is isthmic edema with complete fracture of the isthmus.
• Grade 4 where there is complete fracture of the isthmus without edema.

The prevalence of isthmic fracture with or without spondylolisthesis is about 7% to 8.5% in asymptomatic patients and it increases with sporting activities [30-32].

Degenerative lumbar spondylolisthesis

Degenerative sagittalization of the articular facets leads to the displacement of the superior vertebral body over the inferior vertebral body and this is referred to as spondylolisthesis. This displacement is usually anterior(anterolisthesis) with some degree of rotation [12]. Sometimes the displacement can be posterior (reterolisthesis).The Meyerding classification describes four grades of listhesis [33].

• grade I: 0-25%
• grade II: 26-50% 
• grade III: 51-75% 
• grade IV: 76-100%  
• grade V (spondyloptosis): >100%

Spondylolisthesis mostly occurs at L4 and is more common in females. Individuals who are overweight and have hyperlordosis are more prone to develop spondylolisthesis.

Value of MRI signs

There is a high prevalence of abnormal findings on MRI scanning of the lumbar spine in asymptomatic individuals. This raises the question of the value of MRI scanning in patients with back pain. Only Modic type 1 changes and extensive zygapophyseal edematous changes appear to  have some correlation with low back pain. Large disc herniation and sequestrated disc have correlation with root symptoms but not back pain.

MRI scans of the knee

MRI scanning for detecting ACL and meniscal injuries

Miller [34] carried out a prospective study comparing the accuracy of the clinical diagnosis of meniscus tear with magnetic resonance imaging. It was a prospective, single-blind study of 57 consecutive knees with initial clinical diagnosis of a torn meniscus who underwent arthroscopy. They found that the overall accuracy for the clinical diagnosis of meniscal tear was 80.7% and the accuracy for MRI was lower at 73.7%. Inappropriate treatment would have resulted in 35.1% of the patients if MRI findings were used to determine surgical treatment. Hence clinical diagnosis is more reliable then MRI scanning for detecting meniscal tears. 

Rose et al [35] carried out a study to compare the accuracy of clinical examination and magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament (ACL) tears. It was a prospective and retrospective study involving 154 patients who were clinically diagnosed to have a meniscal or ACL tear and underwent arthroscopy. One hundred patients had clinical examination followed by MRI, and 54 had clinical examination alone. In patient who had clinical examination and MRI, the accuracy of MRI was 98% for ACL tears,75% for medial meniscal tears, 69% for lateral meniscal tears. The accuracy of clinical examination for complete ACL tears was 99%, 82% for medial meniscal tears, 76% for lateral meniscal tears. The accuracy of clinical examination for the 54 patients who underwent clinical examination without MRI was not significantly different from the accuracy of clinical examination in the other 100 patients. The MRI contributed to treatment in only 16 of 100 cases. The authors concluded that MRI is useful only in exceptional case and its routine use is not recommended for patients with suspected ACL and meniscal injuries. They described MRI as an expensive and unnecessary diagnostic test in patients with suspected meniscal and ACL tears.

Rayan et al [36] carried out a prospective study to compare and correlate clinical, MRI, and arthroscopic findings in patients with suspected meniscal  and ACL tears. The study involved 131 patients with suspected meniscal or ACL tears. They found that clinical examination had better sensitivity (0.86 vs. 0.76), specificity (0.73 vs. 0.52), predictive values, and diagnostic accuracy when compared to MRI scans in diagnosis for medial meniscal tears. There was only marginal difference in the diagnosis of lateral meniscal and anterior cruciate ligament injuries. The authors concluded that when clinical examination is carefully performed it can provide an equal or better diagnosis of meniscal and ACL tears when compared to MRI scans.

Kocabey et al [37] carried out a prospective longitudinal study to compare the accuracy of clinical examination as compared to MRI  in diagnosis of meniscal and ACL pathology. The study included 50 consecutive patients who had clinical examination, MRI of the knee and arthroscopy. The authors found no statistical difference between clinical examination and MRI in the diagnosis of medial or lateral meniscal tears or ACL tears ( P >.05). The accuracy of the clinical examination and MRI evaluation was the same. The authors concluded that a well-trained surgeon can rely on clinical examination for diagnosing meniscal and ACL tears and that routine  MRI scan of the knee is not recommended.

Mohan et al [38] conducted a retrospective study of 150 patients  to assess the  diagnostic accuracy of clinical examination. They found that the accuracy for diagnosis of medial meniscus tears was 88% and for lateral meniscal tears the accuracy was 92%. They concluded that the clinical diagnosis of meniscal tears is as reliable as the MRI scan.

Felli et al [38] carried out a prospective study to compare the accuracy of clinical examination to that of MRI for the diagnosis of meniscal tears and chronic anterior cruciate ligament tears. They found that there was no difference between clinical and MRI evaluations in the diagnosis of medial meniscus and anterior cruciate ligament injuries. A trained radiologist was able to obtain better sensitivity, specificity and accuracy in the diagnosis of lateral meniscus tears.

Phelan et al [40] carried out a systematic review and meta-analysis to determine the diagnostic accuracy of MRI in the diagnosis of ACL, medial meniscus and lateral meniscus tears. They found that the overall sensitivity and specificity of MRI for ACL tears was 87 % and 93 % respectively, for  medial meniscal tears the sensitivity and specificity was 89% and 88% respectively and for lateral meniscus the sensitivity and specificity was 78% and 95 % respectively. Magnetic field strength did not affect the accuracy of the diagnosis. They found that most of the studies had a high or unclear risk of bias.

Conclusion

The prevalence of abnormal findings on MRI scanning of the lumbar spine in asymptomatic individuals is high which is why there are questions about the value of MRI scanning in patients with back pain. Only Modic type 1 changes and extensive zygapophyseal edematous changes appear to  have some correlation with low back pain.

There is not much value of MRI scanning for diagnosis of ACL and
meniscal tears in the knee. In fact clinical examination is equal to or more superior then MRI in the diagnosis of ACL and meniscal tears.

In orthopaedic clinical practice the spine and the knee are the two parts of the human body that are most commonly subjected to MRI scanning. The judicious use of MRI scanning can result in tremendous monetary saving and lowering the healthcare expenditure.

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Racism in Malaysia--A myth or reality

                  Racism in Malaysia--A myth or reality

                                         Dr KS Dhillon

What is racism?

The Oxford dictionary defines racism as ‘prejudice, discrimination, or antagonism directed against someone of a different race based on the belief that one's own race is superior’ [1].

The Cambridge dictionary defines racism as ‘the belief that people's qualities are influenced by their race and that the members of other races are not as good as the members of your own, or the resulting unfair treatment of members of other races’ [2].

The International Convention on the Elimination of All Forms of Racial Discrimination (ICERD) has a comprehensive definition of racism. The ICERD defines racial discrimination as: “Any distinction, exclusion, restriction or preference based on race, color, descent, or national or ethnic origin which has the purpose or effect of nullifying or impairing the recognition, enjoyment or exercise, on an equal footing, of human rights and fundamental freedoms in the political, economic, social, cultural or any other field of public life”[3].

The Plural Society of Malaysia

The population of Malaysia in the first quarter stands at 32.66 million [4].
The Malays form 50.1% of the population, the Chinese 22.6%, indigenous Bumiputra groups other than the Malays 11.8%, Indians 6.7% and other groups account for 0.7%. Non-citizens account for 8.2% of Malaysia's resident population.

The presence of so many ethnic groups in Malaysia has made Malaysian society a multicultural and multilingual society with a Malaysian national culture of richness and diversity.

Malays

Malays are the largest ethnic group in Malaysia. Malays are generally muslims and they practice Malay culture. By definition, generally muslims of any race who practice Malay culture are called Malys. Malay is the national language of the country. Their malay culture is influenced by Hinduism, Buddhism, and animism. Efforts of the "Islamization" Movement which grew in the 1980s and 1990s has led to elimination, from the Malay culture, of cultural elements of Hinduism, Buddhism, and animism.

Chinese Malaysians

Chinese Malaysians are the second largest ethnic group in Malaysia, accounting for 22.6% of the population. They have been in Malaysia for centuries. The peak migrative wave occurred in the Nineteenth Century. When they arrived in Malaya they were involved in railway construction and tin mining and are now. Their religion is mainly Buddhism or Taoism.

Non-Malay Bumiputera and Other Indigenous Groups

The Non-Malay Bumiputera and Other Indigenous groups comprise 11.8% of the Malaysian population. These include the Dayak, the Iban, the Biyaduhs, the Kadazan, and various aboriginal groups. Some Burmese, the Chams, Khmers, and the Malaysian Siamese have also been given Bumiputera status.

Indian Malaysians

Indian Malaysians form 6.7% of the Malaysian population. There are several subgroups Indian Malaysian including Tamils, Telugus, and Punjabis. The Tamils account for 86% of this subgroup of the Malaysian population. Tamils began arriving in the 18th and 19th Centuries during the colonial rule. Those from India were brought in as labourers to construct railways and to work in plantations.
Tamils from Ceylon (Sri Lanka) were English-educated and they worked as teachers, clerks, public servants, hospital assistants, and other white collar jobs. Punjabis were enlisted in the police force and in the Malaysian army.

Majority of the Indians were Hindus, the punjabis were mostly Sikhs and there were some muslims who migrated from South India. Some of the Indian Muslims of have intermarried with the Malay Muslims and become Bumiputras.

Other Ethnic Groups

Other Ethnic groups account for 8.8% of the Malaysian population and these include Malaysians of European or Middle Eastern ancestry, the  Nepalese, Filipinos, Burmese and Vietnamese. Descendants of British, Portuguese, and Dutch colonists are referred to as Eurasian Malaysians.

Malaysian Federal constitution [5]

There are provisions in the Federal Constitution of Malaysian which prohibits racial discrimination. This is spelt out in Article 8 (1, 2) and Article 12.

Article 8 (1 & 2) states that:
(1) All persons are equal before the law and entitled to the equal
protection of the law.
(2) Except as expressly authorized by this Constitution, there shall be no
discrimination against citizens on the ground only of religion, race,
descent or place of birth or gender in any law or in the appointment to
any office or employment under a public authority or in the
administration of any law relating to the acquisition, holding or
disposition of properly or the establishing on carrying on of any trade,
business, profession, vocation or employment.

Article 12 (1) states that:
Without prejudice to the generality of Article 8, there shall be no
discrimination against any citizen on the grounds only of religion, race,
descent or place of birth.
There are exceptions to principles of equality in the protection of the rights of Malaysian as provided for in the above two articles. The exceptions are contained in Article 153 on the Malaysian Constitution.

Article 153 (1) states that:
It shall be the responsibility of the Yang di-Pertuan Agong to safeguard
the special position of the Malays and natives of any of the States of
Sabah and Sarawak and the legitimate interests of other communities in
accordance with the provisions of this Article.
Clause 2 and 3 article 153 specifically spells out the reservation of quotas for public service positions, scholarships, educational or training privileges and business permits or licenses to safeguard the special position of the Malays and natives of any of the States of Sabah and Sarawak.
Despite these exceptions, clause 7 and 8 of Article 153 has provisions to ensure the protection of legitimate interests of other communities.

Article 153 (7):
Nothing in this Article shall operate to deprive or authorize the
deprivation of any person of any right, privilege, permit or license accrued
to or enjoyed or held by him or to authorize a refusal to renew to any
person any such permit or license or refusal to grant to the heirs,
successors or assigns of a person any permit or license when the renewal
or grant might reasonably be expected in the ordinary course of events.
Despite these constitutional guarantees racial discrimination appears to be rife in Malaysia.

Racial Discrimination in Malaysia

The Pusat Komas report on racial discrimination in Malaysia for 2017 highlighted six trends of racial discrimination [6]. These include:

• Racial and Religious Discrimination
• Racial Discrimination in Other Industries
• Groups, Agencies and Individuals that use Provocative Racial Sentiments
• Political Groups, Hate Speech and Racial Statements
• Entrenched Racism among Malaysians
• Xenophobic Behaviour 

1. Racial and Religious Discrimination

The Pusat Komas report on racial discrimination in Malaysia for 2017 showed a new trend of racial discrimination due to creeping religious extremism. This creeping religious extremism led to discriminatory actions which impeded the rights of Malaysians of other ethnic groups. Some examples of these discriminatory actions include [6]:

‘Muslim-only’ toilet at a highway. On 12 January 2017 a ‘Muslim-only’ toilet sign was purportedly installed at the rest area on the East Coast Expressway. The sign was however later removed.
Seizure of Paintbrushes made with Pig Bristles. On 8 February 2017 officials from the Domestic Trade, Cooperatives and Consumerism Ministry (KPDNKK) conducted raids on shops throughout the country and confiscated 2,003 paint brushes which were they believed were made with pig bristles. Following the incident, groups such as the Muslim Consumer Association of Malaysia (PPIM) demanded that non-food products be also have ‘halal’ label. Further investigations showed that some of the brushes confiscated were actually made with goat’s hair and not made of pig bristles.

Separate drinking cups for different religions in school. On 11 August 2017 it was reported that a primary school in Hulu Langat, Selangor, segregated drinking cups of Muslim and non-Muslim students. The  cups were labelled “Murid Islam” (Muslim students) and “Murid bukan Islam” (non-Muslim students) and were placed near a water dispenser. After a hue and cry the Selangor Education Department ordered the removal of such labels.

‘Muslims-only’ laundromat in Muar, Johor. On 24 September 2017 it was reported that a self-service laundromat in Muar had sparked controversy on social media for only allowing Muslims to use the laundromat. At the entrance, the shop’s signboard had the following  words on it– “For Muslim customers only. Muslim-friendly. Leave your shoes outside.” The laundromat owner’s initiative had the support of  the Johor Islamic Religious Affairs Committee Chairman, the Johor Mufti, as well as the President of the Malaysia Ahli Sunnah Waljamaah Organization (Aswaja). After a reprimand by the Sultan of Johore the laundromat owner removed the sign and apologised.

Muslims-only’ laundromat in Kangar, Perlis. On 29 September 2017 it was reported that there was muslim only laundromat operating in Perlis. The sign board stated that “This laundry is dedicated for Muslim use only” and that the shop practices “Islamic laundry concept”. After a rebuke from the Perlis Mufti the laundry removed the ‘Muslim-only’ sign.

2.Racial Discrimination in Business

Several instances of racial discrimination within businesses were reported in 2017. Racial insensitivity in the business industries depicted other races in a negative manner [6].

Body Shop job advertisement. On 12 January 2017 a report highlighted a job vacancy advertisement by a local franchise of The Body Shop which stated, “Wanted: Chinese only”.  The racially discriminatory job advertisement offended some people which led the  Body Shop to launched an investigation into the matter. The Body Shop then publicly apologised for the unsanctioned advertisement.

Buying /Renting houses in the property market. A report dated 9 March 2017 highlighted discrimination in the property market. The Star’s R.AGE team did some investigative work and they found that racial discrimination was prevalent in the Malaysian property market. Three R.AGE journalists of different races, called 30 property listings and they found that 50 per cent of the agents or house owners rejected them because they were of a different race. They also found that such actions of racial discrimination were so widespread in Malaysia where landlords instructed the agents to immediately reject people of certain races or nationalities. This was based on their  prejudices that people of certain races and nationalities were bad tenants.

Bata Promotion. On 17 April 2017 a report highlighted a marketing advertisement which many found to be racially provocative and insensitive. A KLCC Bata outlet placed a promotional standee among school shoes which stated “Shoes For: Indian School Children”.  Many questioned whether the promotion is only for Indian children. The Facebook user who first broke the news about this “racist” promotion did further research and to his surprise he found a good explanation for the title of the promotion. The shoes apparently were  created for school children in India in 1936. The shoes are sold all over the world and have become one of the best-selling shoes of all time.

Watsons Malaysia ‘blackface’ advertisement. On 8 June 2017 a report highlighted when certain segments of Malaysian society was offended by Watsons Malaysia Legenda Cun Raya commercial where Watson’s had used a “blackface” model in its Hari Raya commercial.  It was based on the story of “princesses and beauties” where a rich merchant falls in love with a woman after hearing her sing. The merchant was however, shocked when he found that the woman had dark skin but all became well again after she “washes off” her face. The Watson’s advertisement ended with a quote stating that, “Only at Watsons you’ll be beautiful”. There was an uproar and Watsons had to remove the advertisement and apologised for the video [6].

3. Groups, Agencies and Individuals That Use Provocative Racial Sentiments

Issuance of provocative racial statements is quite common in Malaysia. Lack of legal action against groups, agencies and individuals who issue these racially provocative statements have emboldened many more to issue such statement and thereby continue to damage the nation’s social cohesion and national unity [6].

a. Perkasa Defending Malay Rights

Perkasa (Parti Pribumi Perkasa; Mighty Native Organisation), a Malay non-governmental organisation formed by Ibrahim Ali in 2008 has continuously provoked non-Malays and non-muslims, especially Chinese and Indians through vocal, physical and violent means. Since no legal action has been taken against him, he continues to issue offensive and seditious remarks. Some of the incidence in 2017 include [6]:

i. Perkasa wants Bumi quotas for Commercial Property

On 4 May 2017 Perkasa urged the government to allocate quotas for Bumiputeras in commercial real estate. Bumiputera quotas for residential properties has been in existence for a long time. Perkasa vice president Datuk Ruhanie Ahmad urged the government to introduce affirmative action policies to increase bumiputera ownership of industrial property and offices.
He urged the government to set up a special body to purchase residential and industrial properties which have been allotted to bumiputeras which failed to sell [6].

ii. Perkasa warns Proton to continue serving Bumiputera interests

On 24 May 2017 a report highlighted Perkasa’s fear that a 49.9% stake sale of Proton to Chinese automaker Zhejiang Geely would undermine bumiputera interest and Perkasa requested the government to ensure that Proton continues to protect the bumiputera interests and safeguard the interest of Bumiputera vendors. Perkasa also wanted Proton to continue building up the capacities and skills of Bumiputera vendors and workers [6].

iii. Chinese language banners at ECRL launch infuriates Perkasa

In a report dated 9 August 2017, Perkasa secretary-general Syed Hassan Syed Ali accused the government of pawning the country’s dignity to the Chinese. This resulted from the presence of chinese language banners at the launch of the East Coast Rail Link (ECRL), a major China/Malaysia project. The presence of an emcee from China infuriated Perkasa more.
The then Culture Minister Nazri Abdul Aziz responded by labelling Perkasa as racist and that Perkasa did not represent anybody.

Syed Hassan, responded by asking Malays to pray and find new leaders with strong Malay identity who can ensure that their future interests are  protected.

Perkasa President Ibrahim Ali responded to calls stating that their NGO is racist by admitting that he is “King of Racist and is proud to be one.'' He condemned those who called Perkasa racist and he said that Perkasa is only defending the rights of the Malays as enshrined in the Federal Constitution [6].

iv. Perkasa threatens ‘war’ on government if UEC recognised

A news report dated 19 November 2017 highlighted Perkasa’s strong stand  against the recognition of the Unified Examination Certificate (UEC) for Chinese independent high schools. Perkasa said that they will “declare war” on the Federal Government if the government recognised the UEC. The UEC is recognised as a qualification for entrance into many universities overseas but it is not recognised by the government in Malaysia for entry into public universities. Perkasa has always taken a strong position against the recognition of the UEC in Malaysia for entry into public universities [6].

v. Perkasa criticizing Budget 2018 stating that it makes Bumis second-class citizens

A 19 November 2017 reported the criticism of the Budget 2018 by Perkasa. Perkasa said that the 2018 government budget has made Bumiputeras second-class citizens. Perkasa Deputy president, Ruhanie Ahmad claimed that 95 per cent of the poor people in Malaysia are Bumiputeras and also claimed that Bumiputeras made up more than 75 percent of the country’s poor general workers who were paid low salaries. He accused the government of not allocating sufficient monies in the budget to resolve the plight of the Bumiputeras.

A former senator, Akhbar Ali, on the other hand claimed that Bumiputeras made up 70 percent of the country’s entire population and hence 70 percent of the federal budget should be allocated for bumiputera interest. He also said that the Bumiputeras were treated like third-class citizens and not second-class citizens. He also believed that Bumiputeras poverty rate was eight times worse than that of the Chinese five times worse than that of the indians [6].

b. Persatuan Pengguna Islam Malaysia (PPIM) Defending Islam

Persatuan Pengguna Islam Malaysia (PPIM, Muslim Consumers Association of Malaya) has been a strong advocate for Muslim rights. The association has been a staunch critic of certain policies and has been a strong advocate for Muslim rights. Their repeated strong calls to protect Islamic rights has at times led to incidences of religious and racial discrimination. They were supportive of the government’s raid on hardware shops to seize brushes which were believed to be made from pig bristle [6].

i. PPIM calls for the labelling of animal-associated Products

A news report dated 8 February 2017 highlighted PPIM’s chief activists concerns about not labelling non-halal non-consumable objects sold to the public. In fact this followed the raid at hardware shops to seize brushes that were believed to be made from pig bristles. He wanted the government to make labelling of all animal-associated products compulsory before they are placed in the market for sale. He wanted the government to take action against businesses who knowingly sold items that contain pig parts without informing consumers.

Unfortunately, he went on to state that many Muslim consumers are not smart and that they would consume things blindly, even brushes if the pig logo was not there [6]. He however did not call for label of other animal products which are sensitive to other religious beliefs.

ii. PPIM alongside other Islamic NGOs Establishes Bertindak

A news report dated 26 April 2017 highlighted the formation of Bertindak (Badan Bertindak Melayu Islam; Malay Islam Action Body). PPIM, Perkasa and MJMM (Pertubuhan Martabat Jalinan Muhibah Malaysia) joined hands to established Bertindak. Bertindak was formed in response to Hindraf’s questioning of the government’s decision to give permanent residence to the controversial preacher, Dr. Zakir Naik.

Dr. Zakir Naik a controversial preacher from India has been banned from  countries such as India, Bangladesh, Canada and the United Kingdom for apparently inciting youngsters to carry out terror activities and also for giving hate speeches. Dr. Zakir Naik has also apparently been denigrating other religions such as Hinduism and Christianity in some of his speeches.
Bertindak was formed with the aim of calling all Muslims to go against Hindraf [6].

c. Ikatan Muslimin Malaysia (ISMA)

In 2016 Ikatan Muslimin Malaysia (Isma) president Abdullah Zaik Abd Rahman was fined palatry RM2,000 by a Sessions Court for publishing a seditious article on the NGO’s website. In the article he had labelled Chinese who had come to Malay during the colonial rule as intruders.
Notwithstanding being charged under the sedition act for statements which
erode national unity and social cohesion, ISMA has continued to issue racially discriminatory statements on the pretext of defending Islam [6].

i. ISMA claims the proposal to insert the Rukunegara as a preamble to the Federal Constitution denigrates Islam’s position

A report on 24 January 2017 highlighted ISMA objection to a proposal by groups to insert the Rukunegara as the preamble to the Federal Constitution. ISMA claimed that such a move will denigrate Islam’s position as religion of the federation. ISMA also claimed that such a move will dilute the privilege of the Malays and erode the position of the Malays [6].

ii. ISMA alongside other Muslim NGOs lodge police report against Hannah Yeoh

In September 2017 ISMA and 15 other Muslim non-government organizations (NGOs) lodged a police report against Hannah Yeoh, the Selangor State Assembly speaker, for allegedly preaching about Christianity to the people in the country. Hannah had written a book ‘Becoming Hannah’ in which she chronicled how her faith inspired her to seek political office to help secure, by the grace of God and much prayer, a better future for all Malaysians.
The muslim NGOs questioned the purpose of her book and they stated that it was an attempt by her to spread the Christianity to others. They demanded that the police investigate and take action against her [6].

iii. ISMA posting photos of a dog in a launderette

In September 2017 news reports highlighted ISMA’s condemnation of those who opposed the controversial incident of Muslim-only launderettes in Johor and in Perlis. ISMA published photos of a dog accompanying a person to a launderette and asked if it was not wrong to bring a dog or a pig into a shop patronised by Muslims? They claimed that it was precisely for this reason that Muslim-only launderettes were necessary. ISMA further went on to ask if it was not wrong to place a dog in a shopping trolley in a shopping mall? ISMA was appalled with the state of affairs in this muslim country where unbelievers can do anything and muslims cannot [6].

d. Dr. Kamarul Zaman Yusoff, UUM lecturer

In May 2017 the press highlighted a police report made by Dr. Kamarul Zaman Yusoff, a lecturer at UUM (Universiti Utara Malaysia) and the director of UUM’s Malaysian Institute for Political Studies director against Hannah Yeoh for publishing her autobiography. Kamarul Zaman Yusoff claimed that the book contained “too many stories and quotations from the Bible” which influenced him towards christianity. He also claimed that the stories can influence readers to feel admiration for the greatness of Hannah Yeoh’s. He was of the view that the book was an attempt to “coax, influence and instigate” non-Christians to convert or deepen their interest in Christian teachings [6].

4. Political Groups, Hate Speech and Racial Statements

Politicians using the racial card to maintain their power to control their constituencies and voters is not new in Malaysia. The power game has always been and still is based on race and racial issues and racial sentiments. Politicians continue to use the racial card to gain political mileage and to ensure their political survival but at the same time they condemn the usage of racial politics in their “efforts” to promote national unity and social cohesion [6]. Some of the examples include:

a. Rural and Regional Development Minister, Datuk Seri Ismail Sabri

Datuk Seri Ismail Sabri Yaakob who was the Rural and Regional Development Minister in 2017 has been portraying himself as a champion of Bumiputera rights. He said that people should not label him as a racist just because he was assisting the Bumiputeras in the country. In 2017 he continued to make racist statements in the guise of protecting the rights of the  Bumiputeras [6].
 

i. Datuk Seri Ismail Sabri making a racist statement in Sarawak

A news report in February 2017 quoted the than Rural and Regional Development Minister, Datuk Seri Ismail Sabri Yaakob urging Malaysians to keep the then government in power since only his government can safeguard the rights of Bumiputeras. He went on to stress that his government has been taking good care of the Bumiputeras by implementing policies which protected their rights and privileges without affecting the rights of other races.
Sarawak state PKR chairman Baru Bian responded by saying that Ismail Sabri’s statement was racist and his aim was to divide the community along ethnic lines and to create fear and resentment amongst other races[6].

ii. Datuk Seri Ismail Sabri reminds the Chinese community to think of Stability

On 20 August 2017, Berita Harian, a local news portal, reported a reminder by Datuk Seri Ismail Sabri to the Chinese community to think carefully about the country’s stability before making up their mind about the party to support in the next general election. He further reminded the chinese since that since majority of the chinese community is the business sector, hence they would need a strong and stable government like the one they have to ensure that their businesses could continue and flourish [6].

iii. Expansion of Mara Digital Malls

In December 2015 Datuk Seri Ismail had opened a Mara digital mall for Malays to compete against a long well established digital mall in Kuala Lumpur which was predominantly run by chinese. This was followed by development of Mara digital malls in Shah Alam, Ipoh and Kuantan. On 30 October 2017 a news portal reported that Datuk Seri Ismail had said that his ministry will establish Mara Digital Malls, which only allow Malay
and Bumiputera entrepreneurs, in two more states namely Malacca and Johor. In future his ministry will continue to explore opportunities to create at least one more Mara Digital Mall in each state. He said that his ministry’s long-term goal was to expand Mara Digital to the district level. His aim was to make sure that the Bumiputeras are left in ICT-related business [6].

b. UMNO Information Chief Annuar Musa

Not to be left behind, UMNO information chief, Annuar Musa also played the race card championing the rights of the Malays as Datuk Seri Ismail Sabri Yaakob did. Some of the provocative racist statements and events  that took place in 2017 include:

i. Annuar Musa offers RM10k reward for evidence that Kit Siang is ‘anti-Islam and racist’

On 23 March 2017 the press highlighted a call by Annuar Musa offering
RM10,000 cash reward to anyone who could find documentary evidence that “Lim Kit Siang is racist, anti-Islam and a dictator”. This was in response to DAP Parliamentary leader Lim Kit Siang’s challenge to Annuar Musa to repeat his statement that Lim Kit Siang is a racist, outside the Parliament. Subsequently, Annuar Musa distributed a book titled DAP Bahaya Kepada Melayu-Islam Di Malaysia (DAP a danger to Malays and Islam in Malaysia). In a ceremony in Shah Alam he handed out a prize of RM10,000 to a group of anonymous writers who wrote 16 essays in that book. In the ceremony, he said that UMNO defends the Chinese while the DAP brings them ruin. He also said that UMNO Malays love the chinese the most and they allow the chinese to have chinese names and allow them to practice their chinese culture. He also said that UMNO gives the Chinese political and economic protection which allows them to progress economically and become richer than the Malays.
The DAP Socialist Youth (DAPSY) chief lodged a police report against Annuar Musa for dissemination of false information but no action was taken against him by the police[6].

ii. Annuar Musa stating that racial politics stemmed after DAP’s birth

On 26 September 2017, Malaysiakini news portal highlighted Annuar Musa’s claim that the DAP created racial politics. He claimed that there were no racial politics before the DAP was born after the separation of Singapore. According to him numerous race-related issues were politicised after DAP came into existence [6].

iii. Annuar Musa stating that the Government want Chinese as equal partners

In November 2017 Annuar Musa in a forum had stated that the Chinese could not become equal partners in the country’s administration because Chinese community supported DAP who are in the opposition. He also claimed that the government wanted the Chinese to become leaders and senators but it was not possible because the Chinese community supported the opposition. He also accused the DAP for creating a rift among the Malays so that they could gain power [6].

c. Racial Politicising of Education

Politicians in Malaysia have not spared efforts to even racially politicised education so that they could garner support from their majority races.

 i. Academic accusing former Prime Minister of betraying the Malays by ‘forcing’ PPSMI in schools

In 2003, the former Prime Minister Tun Dr Mahathir Mohamad introduced the Policy of Teaching Science and Mathematics in English (PPSMI) in Malaysian schools. In March 2017 an academic, comparative literature expert, Professor Datuk Seri Dr Md Salleh Yaapar accused Tun Dr Mahathir of degrading the special position of Bahasa Melayu by introducing the PPSMI. He accused Tun Dr. Mahathir of betraying the Malay Kings and violating the Federal Constitution. He went on to say that “there exists a language apartheid phenomenon where the English language is hailed and at the same time, Bahasa Melayu is degraded and insulted” [6].

ii. Prime Minister Datuk Seri Najib Razak stating that Political power gives Malays better shot at education

In March 2017 the Prime Minister Datuk Seri Najib Razak reminded the people that the position of Malay and Bumiputera children is better because of Umno’s struggle. He told the people not to expect the opposition,which is spearheaded by the DAP, to carry out programs which will help improve the position of the Malays and Bumiputera students. Political power, he said is necessary for all these good things to happen [6].

iii. Chinese Education Prominent under Prime Minister Datuk Seri Najib Razak’s administration

In December 2017 the then Deputy Education Minister II Datuk Chong Sin Woon praised the then Prime Minister Datuk Seri Najib Razak for promoting Chinese education in the country. He said that the chinese community continued to enjoy more benefits, which involved the construction of more Chinese-medium schools under the Barisan rule.
He reminded the public that the Government has since 2012 spent nearly RM21 million for Chinese-medium primary schools and nearly RM24 million for Chinese-medium secondary schools. Chinese language he said is given prominence and is taught in national primary and secondary schools.
He said that people should not listen to the opposition who will manipulate the Chinese education to fish for votes in the coming General Election [6].

d. PAS President Hitting out at Non-Muslims Stating that They Have No Right to Reject Initiatives to Improve Islamic affairs for Muslims

On 6 April 2017 PAS President Abdul Hadi Awang tabled his controversial RUU 355 bill and at the same time he hit out at non-Muslims, saying that they do not have any right to reject initiatives to improve Islamic affairs for Muslims in the country. He also warned non-Muslims not to question Islam which is the country’s official religion [6].

e. Inclusion of Bersatu in Pakatan Harapan Aimed at Triggering ‘Malay tsunami’

Parti Pribumi Bersatu Malaysia (Bersatu) a Malay party consisting of former UMNO members and headed by Tun Mahathir was formed in 2017 and the party  joined and headed the opposition block known as Pakatan Harapan.The move was made to secure the Malay support in the next general election and win over the Malays, especially those in UMNO’s rural vote bank [6].

f. Government to study Indian Muslims’ request to be recognized as Bumiputera

The Federation of Malaysian Indian Muslim Associations (PERMIM) President Dhajudeen Hameed had requested the then Prime Minister Datuk Seri Najib Razak to recognise the Indian Muslim community as  Bumiputeras. The than Prime Minister Datuk Seri Najib Razak had in 2017 stated that the government will study the request. He he accepted that Indian Muslims are like Bumiputeras. He also accepted Dhajudeen’s suggestion to set up an Indian Muslim community centre for members where the members could reach out and discuss matters with the prime minister [6].

g. Deputy Prime Minister Accuses Tun Dr. Mahathir Mohamad of using the Malays and UMNO

On 30 July 2017 the then Deputy Prime Minister Ahmad Zahid Hamidi accused Tun Dr. Mahathir of having used the Malays and UMNO on the pretext of championing the Malay agenda. He also said that Tun Dr. Mahathir had an Indian ancestry. He went on to accuse Tun Mahathir of just using the malays [6].

h. Pakatan Harapan Chairman, Tun Dr. Mahathir Mohamad remarks about the Bugis Community

On 26 October 2017 Tun Dr. Mahathir the Pakatan Harapan Chairman, made a racist remark about the then Prime Minister of Malaysia, Datuk Seri Najib Razak. He called Najib Razak a robber and a Bugis pirate and asked him to return to Bugis. The Bugis community created a furor and demanded an apology from Tun Mahathir. Tun Mahathir clarified that he did not say that all Bugis are pirates and that his remarks were aimed at Datuk Seri Najib Razak who claimed to a Bugis warrior [6].

i. Defence Minister Datuk Seri Hishammuddin Hussein Response to Patriot

National Patriot Association Brigadier-General (Rtd) Mohd Arshad Raji  said that the government's affirmative action policies of the 1980s had crept into the military administration and non-deserving Malay subordinates got promoted, and officers who were undeserving of promotion, were promoted over the years. This was the reason why non-malays shy away from joining the armed forces. The then defence minister Datuk Seri Hishammuddin Hussein responded to the Patriots statement by saying that the politics of hate and instigation of racial tension is normal when elections are around the corner. He blamed the opposition and parties that are not supportive of the government for playing up the racial divide and sensitivities. He also blamed the social media for spreading such sentiments [6].

j. PAS President Envisioning All-Malay Cabinet Members for Malaysia

PAS Party President Datuk Seri Abdul Hadi Awang called for a all Malay Malaysian Cabinet line-up since they are the majority race in the country. He believed that the national leader and his Cabinet members must profess the Islamic faith. Hadi went on to say that non-Muslims can be appointed as ministers but their role will be restricted to management duties and not policy making. According to Hadi Islam mandates that the main leaders be Muslims in order to safeguard islamic policies and concepts [6].

5. Entrenched Racism Among Malaysians

In the year 2017, social media was widely used to spread racially discriminatory statements which resulted in erosion of the social fabric of the country. Often racist statements were made in an anonymous guise on social media. These statements often criticised a particular race [6].

a. Preconceptions on Government’s Support for Athletes

On 28 May 2017 the Sun Daily reported that the loss of Agilan Thani, the Mixed Martial Arts (MMA) fighter in the ONE Welterweight World Championships showed the ugly side of Malaysians who made race an issue as far as the government’s support for athletes was concerned. Several quarters said that Government of Malaysia was reluctant to support him because he was an Indian and they made his loss a racial issue [6].

b. Racist Statements Against the Malays and the Melanaus by Papagomo on Facebook

In June 2017 controversial blogger Papagomo, Wan Muhammad Azri Wan Derus made a racially provocative remark on Facebook by telling the Malay-Melanau in Sarawak not to be arrogant since they the Malay-Melanau in Sarawak only formed 28% of the population in Sarawak while the Dayak and Chinese formed 72% of the population of Sarawak. He reminded them that the Malay Melanau are ruling Sarawak because of the strength of the Malays in Peninsular Malaysia. Following his post several police reports were made against Papagomo, who then removed the Facebook account [6].

c. Lecturer in a University Receiving a Message which has Racial Undertone

In August 2017 a university lecturer received a text message with racial undertones from her colleague. In the text message, the sender  questioned the actions of another individual who is of the Chinese race. The sender went on to say that the same person was also spiteful and rude to another lecturer. The sender was defending an elderly Malay and Islamic lecturer. The sender also said that the Malays are more patriotic than the Chinese race [6].

d. Racist Comments found in Social Media

As more and more individuals have started using the social media, more and more people are anonymously posting malicious and racially provocative statements which are meant to offend a particular ethnic group. In one incident, an individual going by the Facebook moniker name of Encik Jebat, commented on a post of PPIM and also on his homepage, that Indians and Chinese are the cause of the corruption in the police force because other religions except Islam lack punishment in the afterlife.
In another incident an individual using the name Olta Prayer shared an incident on his facebook about how he was apparently tricked to accept a personal loan online. He used a racist language and blamed the Chinese for tricking him. He gave an improper and incorrect impression of another ethnic race [6].

6. Xenophobic Behavior

Xenophobia is defined as a dislike of or prejudice against people from other countries. Issues of xenophobia are quite evident in Malaysia.
Foreigners and migrant workers who have come to Malaysia are often
the subjects of xenophobic behavior by Malaysians. Some examples include:

a. Malaysians Warning Home Owners not to Rent their Property to Africans

Foreign workers usually find it difficult to rent property in Malaysia. In 2017 there was banner both in English and Mandarin, which was hung at a road junction at the entrance to a housing area in Cheras, which said that houses should not be rented to Africans. The banner obviously demonstrated xenophobic behavior of Malaysians towards foreigners [6].

b. Malaysians Chanting Derogatory Words during a Football Match in the SEA Games

Even sports have not been spared from xenophobic behaviour. Derogatory words were used during a football match between Malaysia and Singapore during the SEA Games. Malaysian fans called “Singapore anjing (dog)”, and one of the spectators was seen showing his middle finger to the singapore players on the pitch during the game. The group were members of Ultra Malaya, a band of hardcore Harimau Malaysia fans. They were heard  chanting words such as, “we come to Shah Alam, united in supporting Malaysia, Singapore dogs can be killed [6]

c. Malaysians Showing Xenophobic Behaviour to Colleagues from Different Countries

In 2017 a report was to Pusat KOMAS, about a foreign employee in a local business service provider who heard discriminatory statements about religion, gender and the accent made by a team leader against foreign employees and candidates in the company.
The employee reported the incident to the Human Resource Department and the CEO but no action was taken to address the issue. One of the incidents was about the foreign employee’s accent and another was about a  Thai candidate not being selected because he had an African Accent and the team leader was worried that there will be miscommunication. The team leader also refused to accept a girl wearing a Hijab as a team member. The team leaders actions were very discriminatory and xenophobic in nature [6].

Social Disparity in Sports and the Malaysian Experience

Malaysians claim to hold values such as multiracialism and multiculturalism close to their heart but there is a total lack of racial diversity even in sports. We need to just look at training fields, indoor halls and courts of popular sports here such as football, sepak takraw, basketball, table tennis and badminton to see that values of multiracialism and multiculturalism are totally lacking.

Politicians have penetrated into the sporting sphere at state and national levels. Politicians have racial preference with one race over the other and they tend to recruit individuals of one race more then others. Often the best do not get selected. Non Malay children are instructed by their parents to concentrate on education rather than sports to have a better future.

In the 1970s and 1980s there were a large number of Non-Malays in sports such as football and hockey which we don't see now. Those were the days when Malaysia was represented at the Olympics and World Cup in football and hockey. Sadly it no more so.

Favoritism and cronyism is the hallmark of sports in Malaysia nowadays. Selection into teams is race based to a large extent. Often players are selected because their parents are friends or family members of the scouting officials. The nature of sport should be “colour-blind” and it was in the 1960s, 1970s and 1980s and no more now. Selection is no more based  on the passion and flair for the sport.
Religion has also become an issue in sports. Islamist in Malaysia has objected to muslims wearing some customary sportswear, such leotards in Gymnastic and bikinis for Swimming. This has prevented many muslims from joining such sports.

Racial polarisation is obvious in all sections of our society even in schools. Language is also one of the factors which leads to racial polarisation. The malays majority teams speak in malay and the chinese majority teams speak in chinese.

Although schools are the best playgrounds to promote multiracialism, unfortunate nowadays schools are the breeding grounds for racism. Even at the workplace in most places interracial encounters are at the lowest possible level.

Racist and xenophobic behaviour is also rampant among football fans in Malaysian stadiums during league matches. Usually it is the Indian and African players who are at the receiving end of the racial slurs [6]..

Racial discrimination in education

Though the Malaysian federal constitution has provisions for special privileges for the Malays and Bumiputras, there is disproportionately excessive privileges for the Malays in the education system in the country.
 
There is extensive provision for bumiputra education in the country. There are at least 54 fully-residential elite Maktab Rendah Sains Mara (MRSM) (Mara Junior Science College) with more being built. In 2005 there were 32 Mara junior science colleges with 20,900 students. Now there are 54 MRSMs. These schools have been almost exclusively reserved for Malay Muslim students with perhaps a few token non-bumiputras.  Non-bumiputras are also largely excluded from other elite schools such as the Royal Military College, Aminuddin Baki Institution, Matriculation courses and the Malay College Kuala Kangsar. These elite schools and colleges are funded by Malaysian taxpayers.

Entry into public universities is via two streams. One is through a 12 month Matriculation programme and the other is through an 18 to 24 month stringent STPM programme. The matriculation programme is mainly reserved for Malays. In 2003 the government began offering 10% places for non-bumiputra students. The criteria for entrance into University is not  transparent and many believe that is based on arbitrary factors. There is also a lack of transparency when it comes to the eligibility criteria for the selection process for the choice of courses, award of scholarships and loans for study [7]. Bumiputras are given preference for admission into public universities. One university (UiTM) with a student population of 170,000 in 2011, is “For bumiputras only”. The other 19 public universities have an overwhelming large Malay population.

The number of seats available for non-malays in competitive courses in the universities is limited and apparently here too there is discrimination in the allocation seats. Only a limited number of seats in medical faculties in public universities are available to non-Malays. Of the 62,000 diploma places and 60,000 degree places at 27 polytechnics in Malaysia in 2010, the allocation for non-malays was small regardless of their qualifications [7].

Despite the presence of large numbers of malay students in public universities, the government has the increased enrolment of Malay students in private institutions of higher learning by sponsoring them to three private universities established by government corporations, namely Tenaga Nasional Berhad, Telekom  Malaysia and Petronas Malaysia [8].

The quota system in education

The quota system which exists in our education institutions was not part of the Independence Agreement of 1957. It came into existence in 1971 in the aftermath of the 1969 May riots. In 1971 Article 153 was amended when a new Clause 8A was added which states that: “... where in any university, college and other educational institution providing education after Malaysian Certificate of Education or its equivalent, the number of places offered by the authority responsible for the management of the university, college or such educational institution to candidates for any course or study is less than the number of candidates qualified for such places, it shall be lawful for the Yang di-Pertuan Agong by virtue of this Article to give such directions to the authority as may be required to ensure the reservation of such proportion of such places for Malays and natives of any of the States of Sabah and Sarawak as the yang di-Pertuan Agong may deem reasonable; and the authority shall duly comply with the directions.”

Some argue that Clause 8A does not give ‘a carte blanche for the blatant racial discrimination as is the case of enrolment at institutions such as UiTM. The 100% bumiputra enrolment policy at UiTM and the 90% bumiputra enrolment in matriculation courses make a mockery of the quota system itself and the justification of any affirmative action’ [7].

National progress and development can be hindered by such racial discriminatory policies in our education system. An inclusive society which is just and tolerant and which respects diversity and equal opportunity can only result from good education at our educational institutions [7].

Racial discrimination in the labour market

In Malaysia the problem of discrimination in hiring and promotion remains highly contentious, with claims of bias against the non-Malays in the Malay controlled public sector and against the Malays in the Chinese controlled private sector [9]. Unfortunately there has been little on discrimination in Malaysia and is largely due to restrictions on access to official labour force data as well as income data [9].

According to the Department of Statistics Malaysia, the labour force in 2018 stood at 15.3 million workers [10]. As of the fourth quarter of 2018 the private sector in Malaysia employed 8.48 million people which constitutes about 55.4% of the workforce [11].
The 2019 figures show that the civil service had 1.71 million personnel which constitutes about 11.17% of the workforce.  The racial distribution of the workforce in the public sector is not known. Some data however is available which cannot be verified. According to Lim Kit Siang of DAP party, the racial breakdown of the Malaysian civil service  comprising 1,247,894 employees as of 31st Dec 2009 was [12]:

• Malays                   78.2%
• Other Bumiputras 7.7%
• Chinese                    5.8%
• Indian                    4.0%
• Others                    4.2%

The figures for 2019 are not available but anecdotal evidence shows that the figures for the malays are much higher now. There has been a gradual increase in the percentage of malays in the civil service since 1971 when the NEP was introduced. The comparative figures from before 1971 to 2009 are as follows [12]:

                                    Malay       Chinese  Indian Others
Before NEP  1971    60.80%      20.2%       17.40% 1.6%
June 2005            77.04%       9.37% 5.12% 8.47%
Dec. 2009            78.2%       5.8%  4.0% 4.2%

As of March 2019 the number of civil servants stood at a whopping 1.71 million. The breakdown consisted of  [13]:

• Armed forces comprised 152,957 personnel
• Police had 128,536 personnel
• Civil servants of various schemes had 665,068 personnel
• Education had 523,226 personnel
• Health had 240,745 personnel

Besides the civil service the government controls other entities such as Government linked companies (GLCs). In Malaysia, GLCs are defined as companies with primary commercial objective in which the Government has a direct controlling stake. The GLCs control over 68,000 companies directly and indirectly with minority interest [14] and they account for 36% of market capitalization of Bursa Malaysia and 54% market capitalization of the Kuala Lumpur Composite [15].  The government estimates that GLCs employ around 5% of the national workforce which would constitute about 2.5 million people [15]. The racial breakdown of the labour force in GLCs is not available. It is highly likely that the percentage of malay employees will be high just as in the government service.
There is a disproportionately large number of malay employees as compared to other races in the civil service and the GLCs. This has prompted the non-malays to point out to the government that it practices  racial discrimination when hiring individuals.

It is common for Malays to decry racial discrimination in the private labour sector and the non-Malays retort by claiming that there is discrimination in the public labour sector.

Discrimination against malays in the private sector was fuelled by publication of an article by Lee and Muhammed in 2016 [9]. They carried out a field experiment to analyse differentials in callback for interview of Malay and Chinese job applicants by sending fictitious résumés of varying quality to job advertisements. They found that for every 1,000 Chinese job applicants, 221 were called for interview as compared to only 41 out of 1,000 Malay applicants. The Chinese were 5.3 times more likely to be called for an interview as compared to a Malay. They concluded that the private sector employers discriminate in favour of Chinese fresh graduate applicants and against their Malay counterparts.

One thing that the authors of this study overlooked is that racial discrimination in calling for interview does not amount to racial discrimination in  hiring in Malaysia‟s private sector. Calling for interview does not amount to hiring. The authors never studied discrimination in hiring in the private sector. To show that there is racial discrimination in hiring in the private sector, the authors should have studied the hiring patterns in the private sector.

A Chinese company may call 5 Chinese and 1 Malay for interview and hire the Malay if he is the most suitable candidate. Some Malay companies may call Chinese candidates for interview and not hire any of them. I believe that western foreign companies will have no racial preferences when hiring individuals. Their sole criteria would be the candidate's suitability and ability to carry out the job.

Many Malays will not be willing to work in the non-halal private sector and hence they will usually not be called for interview or hired in this sector. Companies from China doing business in Malaysia may want to hire Mandarin speaking candidates simply because they have lots of workers from China who only speak Mandrain and no other language. They will hire Indian, Malays or Chinese who speak Mandarin. Their intention is not to discriminate but their work can only be carried out when they hire Chinese speaking candidates.

Racial discrimination is ‘alive and kicking’ in Malaysia under the quise of affirmative action despite the existence of Article 153 of the Federal Constitution [17]:
Of the five major banks in Malaysia, one is multiracial and all others are GLCs controlled by Malays

• 99% of Petronas’s directors are Malays
• 3% of Petronas employees ar Chinese
• 100% of all contractors working under Petronas projects must be of Bumiputra status
• 5% all new intakes into civil service are non-malays3'3? of all new intakes in the civil service are non-Malays
• 100% of business licences are controlled by the malay government, for example, taxi  permits, approved permits etc

Conclusion

Racism in Malaysia is without doubt a reality. It is so deeply ingrained that
there is no chance that it will be eliminated in the future. It is there both in education and in the workforce. It is perpetuated by the politicians to obtain the support of the Malays and thereby stay in power.

A race-based criteria of assessment in society is now a norm in Malaysia.  A merit-based criteria of assessment is almost non-existent which has resulted a mentally weak workforce with low standards of performance. Praradoxly intellectuals who form the minority group are marginalized in favour of incompetent people who outnumber the intellectuals. As a result of these discriminatory practices in education, career opportunities and promotions, our society has developed a regressive negative culture where mediocrity is embraced leading to poor standards of competency. Racial polarization is so glaring in every sphere of our life both in schools, institutions of higher learning and in the workforce. To sum it all up racism is ‘alive and kicking’ in Malaysia.

References

1. The English Oxford living dictionaries at https://en.oxforddictionaries.com/definition/racism accessed on 27/5/2019.
2. The Cambridge dictionary at https://dictionary.cambridge.org/dictionary/english/racism accessed on 27/5/2019.
3. Article 1, International Convention on the Elimination of All Forms of Racial Discrimination (ICERD).
4. Department of Statistics Malaysia at https://www.dosm.gov.my/v1/index.php?r=column/ctwoByCat&parent_id=115&menu_id=L0pheU43NWJwRWVSZklWdzQ4TlhUUT09 accessed on 28/5/2019.
5. The Federal Constitution of Malaysia as at 1 November 2010 at http://www.agc.gov.my/agcportal/uploads/files/Publications/FC/Federal%20Consti%20(BI%20text).pdf accessed on 10/6/2019.
6. MALAYSIA RACIAL DISCRIMINATION REPORT 2017 at https://komas.org/v2/wp-content/uploads/2016/03/Malaysia-Racial-Discrimination-Report-2017.pdf accessed on 3/62019.
7. Kua Kia Soong. Regressive matriculation policy perpetuates discrimination. 25 April 2019 at https://www.thesundaily.my/opinion/regressive-matriculation-policy-perpetuates-discrimination-AJ821637 accessed on 11/6/2019.
8. Lee, “Public Policies on Private Education in Malaysia,” 81–82.
9. Lee HA and Khalid MA. Degrees of discrimination: Race and graduate hiring in Malaysia at http://repository.um.edu.my/91447/1/Lee%26Muhammed2013_Degrees%20of%20discrimination_grad%20hiring%20in%20Malaysia.pdf accessed on 20/6/2019.
10. Department of Statistics Malaysia Official Portal at https://www.dosm.gov.my/v1/index.php?r=column/cthemeByCat&cat=126&bul_id=ekU0SG1yQk1wcExKUDhvN2RHTlhjZz09&menu_id=U3VPMldoYUxzVzFaYmNkWXZteGduZz09 accessed on 22/6/2019.
11. Department of Statistics Malaysia Official Portal at https://www.dosm.gov.my/v1/index.php?r=column/cthemeByCat&cat=439&bul_id=NDFQVGJBU2RhNjFiaUhnaEMzekx5dz09&menu_id=Tm8zcnRjdVRNWWlpWjRlbmtlaDk1UT09 accessed on 22/6/2019. 
12. Lim Kit Siang. Lowest Chinese and Indian representation in the civil service in the 53-year history of Malaysia – 5.8% Chinese and 4% Indians as at end of 2009 at https://blog.limkitsiang.com/2010/04/07/lowest-chinese-and-indian-representation-in-the-civil-service-in-the-53-year-history-of-malaysia-%E2%80%93-5-8-chinese-and-4-indians-as-at-end-of-2009/ accessed on 21/6/2019.
13. Azura Abas. 1.71 million civil servants on govt payroll as of March 2019 at https://www.nst.com.my/news/government-public-policy/2019/04/484308/171-million-civil-servants-govt-payroll-march-2019 accessed on 21/6/2019.
14. GLICs control 68,000 companies and 42% of Bursa Malaysia at https://www.freemalaysiatoday.com/category/nation/2017/07/25/glics-control-68000-companies-and-42-of-bursa-malaysia/ accessed on 21/6/2019.
15. Razaka NH , Ahmad A ,  Aliahmed HJ. Government ownership and performance: An analysis of listed companies in Malaysia at http://unpan1.un.org/intradoc/groups/public/documents/apcity/unpan050510.pdf accessed on 21/6/2019.
16. Menon J. Government-Linked Companies: Impacts on the Malaysian Economy at http://www.ideas.org.my/wp-content/uploads/2017/12/PI45-Government-Linked-comapnies-and-its-Impacts-on-the-Malaysian-Economy-V4.pdf accessed on 21/6/2019.
17. Sumithra. The Blatant Unsettling Reality of Racial Discrimination in the Malaysian Workforce at https://www.academia.edu/5045042/The_Blatant_Unsettling_Reality_of_Racial_Discrimination_in_the_Malaysian_Workforce accessed on 24/6/2019.