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    Saturday, July 21, 2012

    Vietnamese Communal Street Culture

    A typical small street in Saigon with mom-and-pop shops
    One of the amazing parts of Vietnamese culture is the "night scene." As in many societies - perhaps because of a lack of air conditioning and lighting - people typically take to the streets in the evenings and then retire early. In Vietnam this daily routine is codified as arising one or two hours before sunrise, starting to work about 6 - 7 am (sunrise), taking a siesta in the middle of the day, returning home about 5 - 6 pm, and hitting the streets. Because of the now "stable" electricity (rolling blackouts are the subject of another day), people often stay out past dark, but in general, the country goes to sleep about 9 or 10 pm.

    Saigon stays out a little later than the rest, maybe due to the expatriate influence, greater electric stability, westernization - who knows. Anecdotally, the majority of people in the city still go to sleep at 9 or 10 pm like the rest of the country, but their are enough people in the city that a vibrant culture from 10 to midnight still exists.

    A "hẻm" (small alley) during the day where most people live 
    This street scene is enhanced by the communal nature of Vietnamese family culture and the living proximity of people in the country. Vietnamese society, like most Asian societies, live in large family structures. Typically three or four generations in a household. This creates a large network of closely related people to interact with on a nightly basis. Also, it manifests itself in gastronomical ways: family dinners are usually social affairs where many dishes are placed in the center of the table for people to share as they talk and joke.

    Vietnam has a population density of 280 people per square kilometer, according to the World Health Organization. Ho Chi Minh City has an even higher population density - 9450 in 2006 - and according to Vietnamese research, the inner city (old Saigon) has approximately 30,000 people per square meter!*

    The same alley alive around dusk as everyone comes home 
    *In comparison, the United States of America's density of 34 people/sq. km, and the two most dense cities - Washington D.C. and Los Angeles - have densities of 3886 and 2750, respectively.

    What all this close living does is create not only a "night scene" as thought of in America - clubs, bars, restaurants, etc. - but a small community "night scene" with local alleys (hẻm) alive with children running and playing, women gossiping, families and friends eating, and old men drinking coffee or beer and playing chess. These "micro-communities" are the true social structure of Saigon, and any visitor would be remiss to not experience it.

    Vince and Linh

    Travel blogs are nothing new, but I do enjoy perusing ones dealing with Vietnam to see other people's perspectives on my second (third?) home. In this case, the travel blog happens to include a good friend of mine, fellow white-boy-speaks-Vietnamese, adopter of Viet culture, Vince and his girlfriend Linh. So, if you want a fresh, biased-only-by-America, virgin view of Vietnam, this is for you. I'm too old and jaded now...

    Check out http://vinceandlinhinvietnam.wordpress.com/ and tell them hi from me!

    Monday, July 09, 2012

    Lang Co Clinic

    Three days of working in a rural clinic went by like a whirlwind. This is incredibly different than my previous medical experiences in Hanoi and Ho Chi Minh City (HCMC), but, it really is about what I expected. The disparity in care (and life) is amazing here. Some stats from a Vietnam News article I read yesterday:

    1. HCMC accounts from 21% of the nation's GDP (this is an improvement, I think, because it used to be 75%. Now Hanoi and Da Nang have grown tremendously, siphoning this off) including 44% of tourism dollars.
    2. Average income is 2.4 times higher in HCMC than the rest of the country.
    3. The city has an average economic growth rate of 11% over the last 25 years - 1.5 times the national average.

    What does all this mean? It means if you live outside of HCMC (and definitely outside of it plus Hanoi and Da Nang) you are markedly poorer than the rest of the country. It logically follows that your health care will also suffer, since all the major hospitals are in HCMC or Hanoi, and you will have little if any ability to travel for medical services.

    Consequently, clinic saw both run-of-the-mill malnutrition and parasites (probably 80-90% of cases) mixed with really interesting cases that had little to know previous medical follow-up.

    In the three days I was in Lang Co, I saw an average of 40 patients per day. One young boy, about 2 years old, came in with his mother who complained about a large lump behind his left knee. On examination, I noticed he had a rather large (7cm by 5cm), non-tender, immovable, solid mass behind the right knee. Nothing noticeable on the left. Mother stated that the mass had been there since at least 3 months of age, and had gotten bigger as he had grown. A local physician had seen the child early in the course, performed no tests, and said it was totally normal.*

    *(aside: this is common in Vietnam, where medical tools are scarce and money to pay for them more so - to do almost no tests, except an ultrasound of the abdomen which is done for everyone regardless of chief complaint because ultrasounds are so prevalent - and not explain to the patient anything. Although, in America we explain everything and the patient never hears or understands what we say, so perhaps that is just universal...)

    So, I ordered some xrays of the bilateral knees and femurs and told the mother to return the next day. Early the next morning, in she walks with xrays in hand, showing growths on both femurs (left markedly greater than right). Luckily, one of the other physicians on the team, Mark, is an orthopedic surgeon, so I walked next door to get a specialist consult. He had the child walk, looked at the xrays, then declared it was most likely an osteochondroma - a benign tumor of the bone. It's monitored through periodic xrays and removed if it impacts function (walking in his case) or grows rapidly (small chance of becoming malignant).

    Mother went away happily knowing a diagnosis, and knowing what to look for, and I moved on to the next patient - more worms.

    In all, I saw probably three or four cyanotic heart lesions, a previously undiagnosed brain mass, juvenile idiopathic arthritis, hodgkins lymphoma not receiving treatment because of no money, cleft lip, and - jewel of the diagnosis crown - Russell-Silver Syndrome (stories for another day). Sleep was welcome each night. It's amazing how much good you can do with so little.

    Wednesday, July 04, 2012

    My First Clinic

    Lang Co is a small hamlet between Da Nang and Hue.
    This month I have two different medical experiences designed to let me see the disparities of care between rural and urban Vietnam. For four days at the beginning of the rotation,i will work in a small rural clinic in Lang Co, Vietnam with an organization called Vets With A Mission. They are a nonprofit organization that provides medical missions to Vietnam with a Christian background.

    Today was my first day in the clinic. VWAM had their in country representative contact local leaders who sent flyers ands invitations out ahead of time to residents advertising them that we would be providing free medical care over four days. Of course the prospect of American physicians and free care is incredibly popular, and we saw 153 patients between four doctors: family practice, orthopedic surgery, chiropractor, and myself ( pediatrics).

    A typical house in rural Vietnam near Lang Co
    A clinic like this provides unique challenges. Many parents being their children just because we are American, even though their children have already seen doctors and received medications. Usually the normal Vietnamese doctor takes the week of because we make crowded and siphon patients. We also see children incredibly sick, who have not received care because their families cannot afford it.

    The rural clinic where we practiced
    Today was a "get the hang of it day," so I only saw 29 patients. Most children came for two reasons: inadequate weight gain and horribly rotten teeth. The chief complaint was " my child is a lazy eater." I am very good now at explaining that milk is not healthy in Vietnam when they mix sugar with it. This causes cavities, which cause pain, which leads to decreased eating and poor weight gain.

    The communist government provides free care "in theory," but in practice those doctors are not respected, wait times are so long, that people don't see them. They go instead to private physicians, but often do not have the money to buy the medicines prescribed. So, in practice the Vietnamese have a very capitalistic health care system with two tiers, similar to the USA system, and very low access for the poor.

    The waiting area on the morning of day 1

    Monday, July 02, 2012

    The flight over

    Korean airlines is the best airline in the world. I hear that Singapore Airlines is wonderful also, but Korean Air is top dog. My wife says I love them because the stewardesses are hot. She is correct ( they employ incredibly good looking people), but that is not all. What sets them apart from the rest is their customer service.

    Flying over this time was as enjoyable an experience as 37 hours of travel can be. I had an aisle seat near the rear of the plane and received prompt service for all my needs. More to the point, a few rows ahead sat two families with small children about the ages of my two. One family was just a mother and the kids, and I couldn't help remember my wife's ordeal with bringing our two to Vietnam just two sort months earlier, and how it was made light by the helpful staff.

    Many times I saw a steward or stewardess sit with the children while mother stretched her legs or use the restroom. Nobody complained when the toddler got tired and cried. Instead, they immediately brought games, things to help the child sleep, and offered in any way possible to help the young mother in her defensive efforts.

    Consequently, thirteen hours later, an entire plane unloaded happily, and with sanity and hearing intact.

    Years ago, when taking my son as a baby, Korean Airlines helped us with formula after an idiotic Vietnamese official read a poorly translated copy of international flight requirements. Then, when his bad parents let him fall out of the bassinet, they helped us get to see a physician in the airport to make sure he was OK and not have to worry about flight arrangements.

    So yes, Korean Airlines is the best airline in the world ... and it doesn't hurt that they're pretty too.