The roadsides are lined with freshly harvested peanuts drying in the early summer sunshine as our minibus climbs out of the central Vietnamese plain into the mountainous district of Nam Giang. Spread out on tarpaulins or wicker mats, the nuts are turned several times a day by farmers with wooden rakes.
Although our destination, the village of TaBhing, is barely 50 miles as the crow flies from the coastal city of Hội An, the route is along narrow provincial roads congested with motorcycle and commercial vehicle traffic. As we enter the remote Nam Giang district, our progress slows further as the road paving deteriorates.
Nam Giang is the largest – and western-most – district in Quang Nam province. It is mountainous, rugged, and poor. The ethnic homeland of the C’tu people, the district contains 11 semi-autonomous communes, each encompassing 8 to 14 villages of between 30 and 60 households. About half of the population - estimated to total around 50,000 - live in communes in the eastern ‘lowland’ areas, the remainder in the rugged highlands bordering Laos, where access can be difficult, and sometimes dangerous.
Although the Vietnamese government has provided considerable investment, infrastructure and essential community services are basic or non-existent. Community health (and health education) facilities are rudimentary; education, and education support, inadequate.
Medical services for the area are provided by one hospital, and additional outpost clinics – one in every commune - staffed by health care workers (physicians?) who have received only basic medical training. The hospital, located in the capital of Thạnh Mỹ, relies on a system of ‘village health workers’ to facilitate health education.
In 2002 Dr Joshua Solomon, having completed a residency in Internal Medicine at University of Texas, had taken a sabbatical. His vacation travel took him to Vietnam, where he met some Australian volunteers who had been providing medical services at an orphanage in Hoi An. What had been planned as a brief sojourn for Josh became a year of commitment, working individually, and collectively with other volunteers, to develop programs for the provision of high quality health care to the poor and disadvantaged in Vietnam.
As a result of this experience, and in recognition of the desperate need to improve medical knowledge and skills in rural central Vietnam, Dr. Soloman established the Vietnam Health Improvement Project (originally ‘The Hội An Foundation’) in 2004. The project has two related dimensions:
*To train local doctors in the management of chronic conditions, with a focus on pediatric HIV, heart disease, and hypertension and diabetes. The program provides specialized training and equipment to familiarize community physicians with current trends and methodologies.
*To facilitate the training of village health care workers - the ‘boots on the ground’ liaising between local communities, clinics, and physicians at the hospital in Thanh Mỹ.
A protracted negotiation with the district ‘People’s Committee’ has since resulted in the signing of a ‘Memorandum of Understanding’ (MOU) which permits the operation of the Vietnam Health Improvement Project on the Tà Bhing, Tà Pơ, and Cà Dy communes – encompassing 32 villages.
Our visit today is to be a training session for village health workers on the TaBhing commune. The schedule has been arranged by the director of the local ‘clinic’ – Ms Chien - whose responsibilities include contacting the workers and arranging for them to meet us at a local community center. Ms Chien joins our retinue in Thanh Mỹ and guides us to the village of PaSua, and to the meeting house – a traditional thatched building known as a Guol.
The Guol is an airy structure with a steeply pitched roof. The seating platform, enclosed by an abbreviated wooden wall, is raised a meter or so off the ground, and is surrounded by a bank of wooden steps. The exposed woodwork – beautiful clear boards harvested from the hardwood forests that surround us – is fancifully decorated with images of animals and bizarre humanoid creatures. Portraits of Ho Chi Minh are mounted on a ceiling beam, and certificates of merit issued to the village for various conformities are prominently displayed. Sited in the middle of dusty courtyard, the Guol is the epicenter of village life. Regular monthly meetings are scheduled by the village ‘head man’, to which residents are summoned by the sounding of a bell. Attendence is mandatory. Failure to participate in community affairs can result in a reprimand or other recriminations at the next village meeting.
We are here today to present a powerpoint presentation to a dozen or so village health care workers on the subject of infectious diseases. Our team includes Hayley Tristram (in-country Director), Lê Thị Hoang Yến (project manager), and Sagan Wilks, a nurse/volunteer. The presentation, assembled by Sagan, is based on the ‘Health Education Program for Developing Countries Handbook’, a document that presents the latest evidence based guidelines available through the World Health Organization (WHO) and its numerous collaborating partners.
The health care worker holds a position of considerable responsibility in village life. Their duties include the organization of vaccination programs, instruction of villagers in basic sanitation techniques, and the conduct of mosquito eradication drives. While health care workers play no part in treatment, their role is critical as liaison between the commune clinic and the village communities. The position is well compensated by local standards. Workers receive 500,000 VND/month ($25US) for their services.
The workers, an even mix of men and women, are seated on the woven bamboo floor of the Guol. A digital projector and portable screen are set up for the presentation. An initial series of slides follows up on earlier sessions covering basic hygiene methodologies, before moving on to a catalog of subjects of particular relevance to rural villagers:
*In Vietnam, there are 7 million cases of diarrhea a year, resulting in 46,000 deaths. Strategies for managing diarrhea, and techniques for treatment – particularly in infants – are discussed.
*Studies have consistently shown that upwards of 80% of sampled rural populations in Vietnam are infected with eggs or cysts of at least one parasitic worm species. The presentation identifies the different worm infection risks, modalities of transmission and prevention.
*Tuberculosis is still a major health risk in Vietnam, which ranks 12th in the world for most TB cases, with nearly 200,000 new infections and 30,000 deaths recorded every year. Symptoms of tuberculosis are discussed, and treatment protocols outlined.
*According to the Vietnamese Ministry of Health (MOH), as of October 2013 there were over 200,000 people in Vietnam living with HIV/AIDS, of whom more than 70,000 had developed AIDS. Approximately 66,000 people died of HIV/AIDS in the first nine months of 2013. Process of transmission, and treatment options are outlined.
*Dengue is endemic in Vietnam and although peak infections occur during the summer rainy season, dengue virus transmission occurs year-round. Vietnam’s hospitals see 50,000-100,000 cases a year, but the overall total may be five to ten times higher. The use of repellants and mosquito nets is discussed, together with the identification and elimination of mosquito breeding sites – issues common to the control of malaria. While the coastal and flat delta regions of Vietnam are almost malaria-free, there is still a risk of infection in remote, mountainous rural areas of the country.
Although the C’tu tribal residents of the Nam Giang highlands speak a unique dialect, our presentation today is made in Vietnamese. Ms. Yến reviews the slides and the information they contain. There is a high level of participation by the health care workers. Questions posed by the participants are translated into English for Sagan, and her responses are re-phrased in Vietnamese.
It is early afternoon, and hot, by the time our meeting ends. In the open area around the Guol, farmers have spread red and black beans on a tattered tarpaulin to dry in the sun. A child, wearing only a t-shirt, stands on the seat of a motorcycle and leans on the handlebars. The health care workers disperse to their villages, and we head back to Thanh Mỹ for lunch, and the long drive back to Hội An.
By Austin
