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.
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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.
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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.
We began with
training sessions for the health care providers at all local clinics in the
district. We helped the staff to screen for hypertension and diabetes following
the protocol that had been developed by our founder Dr Josh Solomon. Bedside
training was conducted by our physicians. We equipped these clinics with
glucometers, strips, lancets, medication and other supplies. We have continued
to do regular follow up with these 3 clinics. We also conducted refresher training for medical staff to share about its effectiveness and the
different experiences they have encountered in controlling NCD disease.
Each clinic manages
about 30 patients with the medications provided by VNHIP. These patients live
in a remote small village accessed by
boat. Although they live in peace with picturesque green fields, river and
fresh air, they however lack medical knowledge because transport is too
difficult to access the center hospital. When they become unwell they are often
not aware of what they should do. They listen to the guidance of other people
to try many different ways instead of taking prescribed
medication. Some of them stop taking medication when they feel better and
suffer relapses of their illness.
After six months 3
clinics applied VNHIP’s NCD protocol, Doctors and
nurse now have confidence and a sound understanding of how to make NCD’s easy
to manage. They report their patients are now attending to their appointments
at the clinic on schedule without their reminder. The patients told us that
they are happy that they get more education on the diseases, diet, and
lifestyle that they were unaware of before.
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