Pressure , pressure ,pressure.........

The Homeless Adult Shelter (HAS) in Hoi An is home to about 100 residents , some of whom are profoundly disabled and bedridden. One of the nursing challenges that presents here is pressure area treatment. I have been volunteering as a nurse with VNHIP for the last couple of months and was asked to assess a few of the pressure areas and provide any treatment suggestions I thought may be helpful.

A pressure sore is any redness or skin break caused by prolonged pressure on the skin. The pressure causes blood flow restriction and eventually the skin breaks down. For the residents here who are unable to move about freely or even turn over in their beds , pressure areas can become a serious problem. 

There are no pressure -relieving mattresses here- beds are the standard Vietnamese slatted variety made of stainless steel and the “mattress” is a thin cypress mat with no pillow.

There is no regime in place for regular turning of those residents confined to their beds. 

There are no fancy wound dressings here- gauze , a solution resembling Betadine and Vaseline covering every wound are common place.

Pain relief is available but not necessarily dispensed readily. 

Simplicity is the key with regard to wound care here. A barrier cream for the incontinent residents was suggested and supplied and a simple homemade recipe for Saline solution to clean wounds  was discussed. The nurses on staff here have recently had a successful inservice on dressing technique .

 A trip to the pharmacy to buy the necessary creams and ointments was in order ,followed by Quynh explaining to the nurses the instructions regarding their applications and our visit was complete. I suggested we take photographs of some wounds before we left and reassess them weekly. This will enable all staff to keep abreast of the healing process.

Capacity building is the basis of the volunteer work here in Hoi An and up skilling in wound care is paramount in facilities such as HAS. The nursing staff are open to further education and VNHIP are happy to provide this where possible. 

Trần Thị Hòa

The biography of Etienne-Louis Arthur Fallot is intriguing. Born in Marseille in 1850, he began the study of medicine at age 17. His first publication, in 1876, was a dissertation on pneumothorax. By 1888 he had become professor of Hygiene and Legal Medicine at the University of Marseille, a position he held until his death in 1911.

Fallot’s interests seem to have been extraordinarily diverse. His published works include a treatise on a local epidemic of cholera, a study of a case of congenital pectoralis aplasia, and a report on an instance of hysterical hemiplegia. In another publication he detailed the incidence of encephalitis in Corsicans.

He was reported to have been a fine physician, known for his minute physical examinations, and to have been a compassionate and nurturing individual. He died a relatively young man – following a self-described period of ‘ascetic loneliness’. He stipulated that he should receive no obituary.

For the last two decades of his life, the only recorded work published by Fallot was a description of a Neolithic grotto in Reillanne, Provence-Beyond, in south-western France – however, his name endures in medical history because of his explication of the congenital heart condition eponymously known as ‘Tetralogy of Fallot’.

The condition had been identified as early as 1672, but it was not until Fallot’s detailed analysis that the mechanism was understood. The ‘tetralogy’ involves four heart malformations, which present together. All four are now thought to derive from one precipitating defect – a displacement of the septum that divides the right and left ventricles of the heart. This displacement results in a narrowing or restriction of the pulmonary valve (valvular stenosis), which inhibits the flow of deoxygenated blood to the pulmonary system. A hole is present between the two ventricles – the ‘ventricular septal defect’. The aortic valve, situated above the ventricular defect is itself displaced and ‘overrides’ the right and left ventricles, allowing deoxygenated blood to mix with oxygenated blood from the lungs – already reduced because of the restriction in the pulmonary valve. Finally, the right ventricle is typically hyper-developed as it works to overcome the narrowed (stenotic) pulmonary valve.

The primary symptom of Tetralogy of Fallot is low blood oxygen saturation, with or without ‘cyanosis’ (a blue appearance of the skin and mucous membranes). Apparent at birth, or appearing early in life, the condition results in symptoms including weakness, extreme shortness of breath, and retardation of growth and physical development.

In 1944, a technique was advanced to treat the condition that involved a shunt which directed a large portion of the partially oxygenated blood leaving the heart back into the lungs, increasing flow through the pulmonary circuit, which allowed for improved oxygenation and greatly relieved symptoms. Surgical procedures have since been developed that allow for total repair of Tetralogy of Fallot by correcting the pulmonary valve stenosis, and placing a patch or graft over the ventricular septal defect. Although the surgery initially resulted in high mortality, the risk has gone down steadily over the years, with surviving patients usually showing excellent cardiac function after the operation.

Untreated, Tetralogy of Fallot leads to heart failure and death. Although survival is relatively high for the first few years of life, only 5% of patients live to forty years of age.

Trần Thị Hòa is 38 years old.

Born into poverty, the second youngest of four siblings, her parents say she was diagnosed with Tetralogy of Fallot at age 12 – although it seems likely that she had had symptoms from birth. Her family has never had the financial resources to pay for the operation necessary to repair her heart, estimated to cost 45 million VND ($2250US). Her condition has now become so grave that her life is at imminent risk.

 

I am traveling with my colleague Lê Thị Hoàng Yến of the Vietnam Health Improvement Project (VNHIP) to follow up on an application made by the Trần family for financial assistance with the cost of surgery. Branching off highway 1 south from the city of Hôi An in central Vietnam, we head west into the mountains. Passing through the crossroads town of Đông Phú, we are soon climbing steadily over a steep pass, the Đèo Le. The area is known for its particularly tasty chickens. Halfway up the pass is the nationally acclaimed restaurant, ‘Gà Đèo Le’, whose specialty is the local fowl.

 

We descend into a beautiful valley ringed by high peaks, down the center of which, incongruously, a new four lane concrete highway is under construction. Although picturesque, the area is sparsely populated. Traffic is light, but a sprawling complex of buildings owned by the Nông Sơn coal and power company suggests that the new road construction is intended to spur the development of coal mining in the area.

 

At the crossroads town of Trung Phước we turn south and west, through the village of Trung Thượng and past a new bridge over the Thu Bồn river – the cầu Nông Sơn. On a dramatically narrowed single lane road, we approach our destination, the Trần home in the village of Khánh Bính.

From the back of the house the broad caramel colored sweep of the Thu Bồn can be seen through the trees. There is a pig pen in the yard, but no pig. There are no chickens. In the kitchen, a blackened pot sits on a hob above cold ashes. There is no sign of recent food preparation.

 

I sit at the living room table with my colleague Yến, Trần Thị Thuy, and her husband Nhan. In a voice husky from chain smoking, Mrs Trần tells us that her daughter’s condition has recently deteriorated, and that she has been admitted to the Danang General Hospital where she awaits surgery.

Mr and Mrs Trần are both 69 years old. Mr Trần has been a farmer all his life, his callused feet and blackened nails attest to a lifetime of barefoot work in the fields. Mrs Trần worked as a ferryboat operator on the Thu Bồn. In 2003, 18 local school children were drowned when a ferryboat overturned. The new Nông Sơn bridge, built with funds donated in a national outpouring of grief over this disaster, ended her career on the water. Now, with only occasional income from itinerant labor, and a small monthly contribution from their commune, the family lives in profound poverty.

Of the 45 million VND for the corrective heart operation, their commune’s health insurance will pay 7 million. A business group in the village has contributed an additional sum, although Mrs Trần tells us that some of that money has already been consumed by her daughter’s hospitalization. The family has applied to VNHIP for assistance with the balance.

A photograph accompanying her application to VNHIP shows a slim, pale, woman lying on a bed dressed in what may be her best pink pajamas. When we visit Trần Thị Hòa in her ward at the Danang Hospital, she is wearing hospital blue, and sharing a bed with another patient. She is tiny, listless, and appears much reduced from the figure shown in the earlier photograph. The tips of her fingers show the slight clubbing which is a common symptom of her disease.

Her youngest brother, Trần Văn Quế, has been with her since she was admitted. He sleeps on the floor beside her bed with his backpack and a thermos. The hospital is crowded, most beds have more than one occupant, and family members often live in the wards with the patients. Quế rarely leaves his sister’s side. He has resigned from his job in a shoe factory, and hopes to remain with her until she receives her potentially life-saving surgery.

Hòa has since been released from the Danang hospital, and has returned, with her brother, to the family home. The operation she requires is sufficiently complex that hospital staff have decided to defer the surgery until it can be performed by a visiting Hanoi specialist.

With our strong recommendation in favor of financial support, a decision has been made to contribute 15 million VND towards the cost of the operation. VNHIP will continue to monitor her progress.

Dũ Vản Lộc

If you squint and hold your mouth just so, the tattoo on the chest of Dũ Vản Lộc might almost resemble a seagull soaring over a coconut palm…. or perhaps a fishhook. The concept may have been more

literal. The design was intended to be a heart, but the decoration – self-inflicted – proved to be too painful, and remains incomplete.

The choice of graphic may have been romantic, perhaps a reference to the Vietnamese idiom ‘simple house, two golden hearts’………or it may have been intended to refer instead to Mr Dũ’s own heart, damaged by childhood rheumatic fever.

Rheumatic fever – often a complication of untreated strep throat – can cause a thickening and narrowing of heart valves, limiting their ability to open – stenosis – and may also scar the valves, preventing them from closing properly. A narrowed or stenotic valve requires the heart to pump harder, and can reduce blood flow to the body. A valve that fails to close properly is termed ‘regurgitant’, or ‘insufficient’ - and can allow blood to leak backwards through the valve.

While rheumatic fever occurs most often in children aged five to fifteen, the long term consequences may not be seen for years. Mr Dũ’s condition was diagnosed at age 11, but not before the disease had caused severe stenosis of the mitral, aortic, and tricuspid valves of his heart. Now aged 32, he has become increasingly weak and short of breath, cannot work, and is unable to support his wife, Võ Thị Luy and their two children. He has been advised that, without surgery to correct his stenotic heart valves, he is at great risk of a stroke or even sudden death.

We have traveled to Tiên Lãnh, one of fifteen communes in the Tiên Phước district of Quang Nam province in central Vietnam. An economically impoverished area of harsh topography, it offers a difficult terrain for the dominant activity of agriculture. Population is sparse, the main source of income the cultivation of pulp wood, pepper, and cinnamon. Ominously, the stretch of the Tiên river which circumscribes the district - and disgorges into the massive Thu Bồn river system – is known locally as the ‘river flowing backwards’.

Our passage has been arduous. From Tam Kỳ on the main north-south coastal highway we have traveled west into the remote mountainous territory of Tiên Phước. Our destination is the tiny hamlet ‘Thôn 6’. The road, narrow and rutted at best, has deteriorated into a rocky unsealed track, difficult to traverse even on a motorcycle. A sudden downpour overtakes us as we crest a hill to arrive at the Dũ homestead.

The family is ‘officially poor’ – their total income less than 400,000VND ($20US) a month. They have no savings. Until recently they lived with Mr Dũ’s elderly parents. Three years ago, with the assistance of a stipend from their commune, they were able to build a small house – one room for the family of four, with an attached partially enclosed shelter for cooking. They have no running water, and no bathroom. Their toilet is a hole scratched in the forest floor. Their only income, supplemented by a small contribution from the commune, derives from casual farming work that Luy is able to obtain. In her absence, Dũ cooks, and looks after the children.

‘Poor’ certification, in addition to entitling their children to free education at district schools, provides basic health insurance for the family. The cost of the operation required to correct Dũ’s heart defects is 80 million VND (approximately $4000US). Of this sum, health insurance will cover about 30 million. While the Dũ family hopes to raise some of the balance in the form of loans from relatives, they have appealed to the Vietnam Health Improvement Project (VNHIP) for financial assistance. We are visiting today to assess the needs of the family, and to consider a contribution to the cost of surgery.

It is VNHIP policy to arrive for home visits unannounced, and we are fortunate on this occasion to meet the whole family. Coincidentally, they have been joined by relatives who have come to offer support, and to help prepare a meal. Rain is pelting down, and water runs in sheets off the blue tarpaulin that covers the cooking shelter, where a duck is boiling in a pot over a wood fire.

The house is a ramshackle affair, with a concrete floor. The perimeter walls are made of rough sawn lumber, poorly fitted. There are large gaps between the planks and below the eaves - providing little protection from the elements. A tile roof is supplemented by plastic tarpaulins – but the combination offers little resistance to the weather. In the driving rain the inside of the house is already damp. There is one mattress for the family, a green string hammock hangs in a corner, the only other furniture, some red plastic stools.

The circumstances of the family are as desperate as any we have seen, but despite Dũ’s very serious heart condition, and the many challenges posed by their extreme poverty, they are gracious and cheerful hosts. 

My colleague, Lê Thị Hoàng Yến has had considerable experience with cardiac interventions, and is able to offer a number of recommendations that will help facilitate the medical process. We leave having arranged for the family to travel to Danang City where Dũ will undergo preoperative tests.

The decision to provide financial assistance is made jointly by VNHIP staff and director Josh Solomon based on our site assessment, but it seems highly likely that this needy family will receive our support.

Fun and Frolics in the Ancient Capital: Annual Summer Trip to Huế for Children Living with HIV

It’s already warm at 7am as we wait in the minibus for our traveling companions – and the mid-summer day promises to be as hot as a firecracker. The occasion is the annual summer vacation for a group of children infected with the HIV virus, and their caregivers. This year, the trip, sponsored by the Viet Nam Health Improvement Project (VNHIP), will take us from Hội An to the ancient city of Huế - former capital of the Nguyến lords, a feudal dynasty which dominated much of Southern Vietnam
from the 17^th to the 19^th centuries. Our party includes VNHIP staff members Hayley Tristram, An Luu Phuoc, Nguyen Thi Thu Quynh, Le Thi Hoang Yen, Nurse Sagan Wilks, and marketing volunteer Gillian Eborn.

We are off to a slow start. There have been faulty bus connections, some of our family members have yet to arrive at the meeting point in the town of Vĩnh Đien – and our large vehicle is prohibited from entering the town precincts until 8am…..but finally, we are off. The children in our group range in age from 7 to 16. Most are accompanied by a parent, one in the care of her vivacious 80 year old grandmother. Most of the families are of very modest means, and for some, this trip represents a rare opportunity to travel beyond the boundaries of their home village.

Our path takes us North through the city of Da Nang and skirts the glorious sweep of Da Nang Bay before beginning a tortuous climb through the eastern extremity of Bach Ma national park. The highway, Đèo Hai Vân  (Ocean Cloud Pass) is a grueling series of switchbacks offering stunning views back across the bay, and, over the crest of the mountain, down into the beautiful beach landscape of the fishing and resort town of Lăng Cô. We pause at the summit for a rest stop and coffee break – 'the best coffee in Vietnam', and indeed, it is good coffee. Children and parents alike swarm the memorabilia stands, where the costume jewelry is a major attraction.

We roll in to Huế along a broad four-lane boulevard. It is close to noon, and everybody is hungry. In a tourist bus corral, promoters from a dozen small restaurants swarm the bus, but our driver has already made a recommendation – the Cóm Xuân Nhan, which advertises 'món ăn ngon' – 'delicious cuisine'. The restaurant is packed with customers, but within 10 minutes tables have been marshaled and set up on the sidewalk, and, amazingly, food begins to appear almost immediately, and is fresh and spicy. We supplement the meal with a sandwich confection made from crisp rice crackers filled with a sweet mixture containing nuts and ginger.

Our hotel is located 50 meters down a narrow alley, where we are soon installed in basic but clean rooms, and an hour is allotted for a rest before the afternoon schedule.

The party is divided into two groups for the first activity of the day: the children are to have a lesson on personal hygiene conducted by Quynh and Sagan, while the adults will have the opportunity to discuss the challenges associated with the special status of the HIV positive.

After an introductory chat with the children,and a quiz on hygiene issues, a demonstration of hand-washing technique is conducted by our nurse, Sagan. A glittery liquid soap is distributed – the glitter, transferred to any surface the children touch, is symbolic of germs. The point is quickly established, and the cleanup process in the bathroom a cheerful ruckus.

Predictably, the main topic of conversation among the adults relates to the isolation and widespread stigma resulting from fear of HIV and AIDS. Although the Vietnamese government has acted aggressively in issuing decrees prohibiting discrimination against those living with the virus, fear of casual infection stemming from a lack of understanding about the nature of the virus and modes of transmission is widespread. Often such fears combine with beliefs that all those with HIV acquired their infection through moral misconduct, and so should be avoided or excluded from society.

Lessons and discussions over, we board the bus for our first stop – The Citadel.

The history of the city of Huế for almost 400 years was virtually synonymous with the history of the Nguyễn family – one of the major families of Vietnam dating back to the end of the 14^th Century, and the days of the hero-emporer Lê Lợi. In 1558, Nguyễn Hoàng – the first of 9 'Nguyễn Lords' – prevailed in a dynastic struggle, and was given 'lordship' over the southern provinces of Vietnam. He ruled from the city of Huế, and established the dominion of the Nguyễn Lords in the southern part of the country.

In 1802 Nguyến Phúc Ánh, a descendent of the Nguyến Lords, succeeded in unifying what is now modern Vietnam – founding the Nguyến dynasty, and taking the reign name Gia Long. Construction of a capital city – the current Citadel - began in 1805. The design included four fortified enclosures contained within a massive defensive wall. The main structures were the Kinh Thanh (Capital City), for administrative buildings; Hoang Thanh (Imperial City) for Royal palaces and shrines; Tu Cam Thanh (Forbidden Purple City) for the Royal residences; and Tran Binh Dai, a bastion designed to control movement on the Perfume river which flanks the fortress.

Our children are a colorful sight, clutching balloons as we pass through the spectacular Nga Môn gate in the perimeter wall. It is brutally hot - many of the Vietnamese women in our group are covered from head to toe, with thick stockings, long-sleeved jackets, face masks, and wide floppy hats, in many cases, with only their eyes exposed. 

It's hard to know how much attention our group is paying to the presentation of our guide. Several of our number seem more interested in capturing the popular Vietnamese snapshot with a 'V for victory' sign. Our children are, for the most part, cheerful and uncomplaining – although one stylish little girl in pink sunglasses has a spectacular meltdown, and refuses to budge until her mother picks her up and carries her piggy-back for the rest of the visit.

Although many elements of the Citadel have been diminished by time, careful restorations of many significant structures evoke the grandeur of its heyday.

Our tour completed, we trudge back wearily to the bus, and return to the hotel for a freshen-up before dinner.

We gather in the early evening at a lovely restaurant with a terrace overlooking the Huong (Perfume) river. Our table extends along the parapet with a grand view across the water. The food is tasty, the beer warm – although there is plenty of ice. Gillian has volunteered her digital camera to one of our young charges, who has become an instant convert. Her free-form pictures of her companions are great fun – and are complemented by endless 'selfies'.

Bún Bò Huế is rightly famous in Vietnam. After an early checkout from our hotel, we stop at a sidewalk café where, sitting at low plastic tables, we are served bowls of this spicy beef noodle soup, iced tea, and strong, sweet, Vietnamese iced coffee. 

There is considerable excitement when one of our children tosses a shoe in the air and loses it in a tree. Fortified, and having tracked down a new pair of shoes, we set off for the tomb of Khai Đinh.

Nguyen Phúc Buu Đao was the 12^themperor of the Nguyến dynasty, becoming the nominal ruler of French occupied 'Annam' in 1916. He took the name Khai Đinh (Auger of Peace and Stability) for his reign. Although his stated agenda was to restore the prestige of the empire, his policy of close collaboration with the French colonial rulers earned him the contempt of many Vietnamese. His popularity was further diminished when he authorized a dramatic increase in taxation on the Vietnamese population, in part to pay for the palatial tomb we are visiting today.

The structure is a muddle of Vietnamese and European architectural styles. The tomb interior, a wild reflecting chamber of glass and porcelain – contains a central life-sized bronze statue of the emperor wearing an expression that might be chagrin….or melancholia. Certainly he does not seem to have been a happy fellow. Reputedly of frail and sickly disposition, he died of tuberculosis at 40.

Our colorful troupe is in sharp visual contrast to the mildewed gray concrete of the stairs and terraces as we pause for a group photograph outside the main temple.

Back on the bus we head for our final destination of the day, the Thiên Mu Pagoda (Chùa Thiên Mu). The original structure was built in 1601 on the order of Hoang Nguyễn, the first Nguyễn lord, who at the time, was governor of the city now known as Huế. The original pagoda was a simple structure, but renovations and additions over the years have greatly increased the size and grandeur of the site. The brick 'Phuoc Duyên' tower was erected in 1844, stands 21m tall, and is of octagonal shape with seven stories, each dedicated to a different Buddha incarnation. The great tower, overlooking the Perfume river, has become the unofficial symbol of the city.

The inner courtyards of the pagoda are serene and un-crowded. In a dining hall monks are chanting before their mid-day meal. A garden of bonsai trees stretches to the rear perimeter wall. In a garage off the central courtyard, a pale blue Austin Winchester automobile is parked. Mounted on a wall behind it, the famous photograph of the self-immolation of  Thích Quang Đuc, a Buddhist monk who, driven to the site in this car, burned himself to death at a busy Saigon intersection in 1963. Quang Đuc was protesting the persecution of Buddhists by the American backed South Vietnamese government led by Ngô Đình Diem.

At the foot of the pagoda, we board a brightly decorated 'Dragon' boat for a brief cruise down the Perfume River which bisects the city of Huế. According to local lore the river derives its name from the fact that it passes through forests of aromatic plants before reaching the city, bringing with it a pure and fresh aroma. In this central part of Huế, development has been restricted on the riverside, most of which is devoted to an attractive pedestrian park. We are a large group for the relatively small boat, but, reassuringly, there are sufficient life jackets for all. Our host has a captive audience in mid-river, where she presents us with a range of memorabilia for sale.

We stop for one final meal before boarding the bus for the return journey. Rather than the long haul back over the mountains, our route is through the new Hai Vân Tunnel linking Huế and Da Nang.  Opened in 2005, it is the longest tunnel in Southeast Asia.

There are high-fives and smiles as our companions disembark in Vĩnh Đien. It has been a privilege and an education to share a vacation with this lovely group of children and their parents. 

Austin Trevett

An is leaving VNHIP

It has been nearly seven years since I started to work with the Hoi An Foundation (VNHIP). Time has passed really quickly, and I will be leaving soon to study in the US.

I have really enjoyed working for the organization. Dr Josh, Dr Brian, Carol and Hayley trained me to be a medical translator, then a health educator and project manager. I have had many opportunities to work with the doctors and nurses from the US and Australia, who volunteer with us and have gained so much knowledge and experience.

I still remember when we first started the Non Communicable Diseases (NCD) project in Dien Ban and Duy Xuyen, there was so much work to do, and I had very little experience. We would ride to the local clinics by motorbike very early in the morning carrying medicines, medical equipment and patients' charts. Sometimes we went to a clinic very far to the West and Dr Brian kept asking if we were in Cambodia yet.

Counseling a patient at a clinic in Duy Xuyen

I am inspired by the way Dr Josh, Dr Brian and all the other volunteers are so devoted to the community. I am proud of VNHIP; it is a small organization that achieves such a lot. VNHIP is very lucky to have Quynh and Yen; they manage their projects efficiently, and I am confident that they will manage the foundation well after I leave.

Josh, Carol, Quynh and I at a clinic in Phu Tho (WHO project)

I was encouraged by many of you to believe more in myself and move forward in my career. Thank you for being so supportive, it was because of you that I was awarded the Fulbright Scholarship. Thank you Quynh and Yen, for taking on extra work so that I could prepare for the interview and exams.

I feel so lucky to work with you all, and I hope to work with you again when I come back. I have so many pleasant memories of my time with VNHIP, and will continue to support your work when you need me.

beautiful scenery when doing patient home visit that I will miss

I would also like to thank the volunteer teachers at CHIA who have helped me to improve my English and my friends at CHIA, PIC who shared their experience with me during my time with VNHIP.

The good, the bad, and the inspiring

I had been working as marketing and communications volunteer with VNHIP for three months when I was asked to accompany Yến (Nam Giang Project Manager) and Hayley (In-country Director) to Nam Giang. I had seen photos from previous trips: the stunning scenery, the ornate meetinghouses, the beautiful smiling children and stately women in traditional dress, so I didn’t need much persuading.

The health worker at Pa Ting was an unexpected
star presenter.

This was VNHIP’s third visit to Nam Giang and it was going to be very different. Instead of VNHIP delivering health education to the ethic minority villages, this time the village health workers and village leaders would be delivering the sessions themselves. VNHIP’s Primary Health in Nam Giang Project started in December 2013 with VNHIP delivering hand washing training to seven ethnic minority villages in the remote Central Vietnam province of Nam Giang. The purpose was twofold; to promote the importance of hand washing for the prevention of infectious diseases, and to show the village health workers and village leaders the type of training VNHIP hoped they would one day deliver themselves.

A warm welcome awaited VNHIP in Pa Ting

The Village health workers and village leaders from seven villages came together in April to learn about common infectious diseases, and how to present the information to their villages. (See Austin’s Exciting trip to Nam Giangblog). VNHIP’s original intention was to co-deliver the training, but the village leaders and health workers felt it would be better if they delivered the training in their local dialect. This may not sound like a big deal to you or I, but it meant that each presenter would have to make a formal presentation, their first, to their village.

Glossophobia, the fear of public speaking, is common the world over. In the hills of Nam Giang, we are a world away from the nearest Toastmasters in Hanoi. Nerves set in as we set up the equipment, some of our presenters jokingly try to get out of it, others plead with Yến for her to deliver the training instead. This is capacity building in action and Yến firmly but gently reminds each of them that if we are to effect lasting change in their village they need to deliver the training.

Villagers leaving the meetinghouse in Pa Sua

The presenters at our first village, Pa Ting, completely blew us away. Both the village health worker and village leader have studied the resources we provided in advance and even added extra information themselves. Their presentations were professional and enthusiastic, and we were surprised and impressed by their level of commitment. We could have happily gone back to Hoi An after this one village, proud of their accomplishment and thrilled to have our expectations exceeded to such an extent.

Pa Ting was a tough act to follow for the remaining six villages. Most of our other presenters were not as committed, skilled, or enthusiastic, and the blistering heat made it difficult to hold their audience’s attention. I couldn’t help admiring our presenters, as it must have taken a great deal of courage to speak in front of their whole village for the first time.

Creative play Nam Giang style, Pa Va

The infectious diseases training proved that this model of village led training works. VNHIP will be returning to Nam Giang in late June to help the village health workers and village leaders deliver training sessions on nutrition. We will continue to support them by providing additional presentation skills training and will evaluate the program’s success by surveying the villagers to assess information retention and changes in behaviour. With limited access to power and proper sanitation, the information our presenters shared with their villages has the potential to save lives. It was an honour to catch a brief glimpse of their way of life and pleasure to be able to add many new photos to VNHIP’s growing Nam Giang photo library. 

By Gillian Eborn

Another success for VNHIP protocol

It's a brilliant late spring morning as we pull in to the Social Center for homeless and disabled people in Hoi An – a State run facility for elderly Vietnamese, where The Viet Nam Health Improvement Project (VNHIP) under the direction of it's founder, Dr Josh Solomon, has been conducting a program for the identification and management of risk factors for cardiovascular disease (CVD) since 2011. Of the 50 residents, a high percentage had previously been identified as ‘at risk’ for CVD – many already diagnosed as hypertensive.

Statistics provided by the Vietnamese Ministry of Health suggest that 60-80% of deaths in Vietnam are attributable to chronic disease – those long-lasting medical conditions that can be controlled, but not cured. The lives of many patients with these conditions can be extended using relatively simple protocols.

In Vietnam, the implementation of this kind of regimen is minimal or non-existent. They require a relatively labor-intensive continuity of care, which is uncommon – particularly in low-resource areas of the country, where patients are rarely seen more than once by a physician, and there is virtually no follow-up care.

One of the most common causes of death from chronic disease in Vietnam is cardiovascular disease. Dr Solomon and the staff of VNHIP have spent years working in clinics in central Vietnam studying prevailing models of care, and attempting to develop a treatment protocol for the control of CVD risk factors, and the management of hypertension and diabetes, using international guidelines.

In 2011 the foundation signed an agreement with the World Health Organization (WHO) to implement the protocol, and to develop a teaching procedure for the training of health care providers in commune health care facilities.

Hypertension (high blood pressure) and diabetes are major risk factors for CVD

The protocol identifies a set of basic interventions to integrate management of hypertension and type 2 diabetes into primary health care. Blood pressure is tested using a standard inflatable cuff, and ‘point-of-care’ devices (glucose meters) are used to measure blood glucose in the diagnosis of diabetes. 

Our visit today is enthusiastically supported by the center’s director, Ms Nguyện, and her associate Trung. Project manager, Ms Yen, interprets for Dr Solomon.

The patients – all women on this occasion – provide a brief review of their medical histories, and receive a blood pressure test. A ‘Fasting Plasma Glucose’ test is conducted to identify diabetes risk – the glucose strips analyzed in a machine provided by VNHIP. A majority of the patients tested today have readings that fall outside target blood pressure, and a small percentage have blood glucose readings that are consistent with ‘prediabetes’. For those at risk, Dr Solomon stresses the need for lifestyle changes for both conditions. Obesity has been closely associated with both hypertension and risk for diabetes. Dietary changes to include more whole grains, fruits, and vegetables are recommended for weight loss, together with regular exercise.

With information provided by Josh, Ms Nguyễn and Mr Trung will provide follow-up on the dietary and exercise recommendations. Type 2 diabetes is a relatively slow developing disease, and will be monitored on subsequent visits by our team.

The warm reception we receive at the Adult Center is gratifying, and confirms that the simple, low-cost model implemented by VNHIP for increasing awareness of hypertension and diabetes as risk factors for cardiovascular disease is already paying dividends.