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.