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.

Exciting trip to Nam Giang

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.

Nam Giang district is among the poorest and least developed parts of the country.

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

Blog from our new volunteer

Around the hamlet of Tịch Yên on the Bình Nam commune, the topsoil is mostly white sand. Incongruously, for Central Vietnam, it looks a lot like a light dusting of snow! Summers here are arid, little will grow, and the sand gets so hot, I’m told, that chickens must wear shoes. The truth turns out to be a little more prosaic.

Nguyễn Thị Ngân is a 45 year old farmer. Two years ago she was thrown from the back of her husbands motorcycle when he swerved to avoid a child in the road. She fell heavily, severing a tendon in her leg. A six-inch scar across the bridge of her left foot indicates recent surgery.

While she was receiving treatment for this tendon injury, tests revealed evidence of stenotic mitral and aortic heart valves.

Mrs Nguyễn says she has no memory of a specific illness – but heart valve failure is a commonly diagnosed condition in Vietnam, and is often the result of childhood Rheumatic Fever. Untreated streptococcal infection, such as strep throat, is usually the cause. Although Rheumatic fever occurs most often in children aged 5 to 15, the symptoms of valve disease may not be seen for years.

Stenotic valve disease requires the heart to pump harder, which can strain the coronary system. Untreated, heart valve stenosis can cause chest pain, shortness of breath (due to heart failure), and fainting. In a small percentage of patients with heart valve stenosis, the first symptom is sudden death, usually during strenuous exertion.

Without treatment, the average life expectancy after the onset of heart failure due to heart valve stenosis is between 6 and 24 months.

The Nguyễn family is poor. Mr Nguyễn works as an occasional farmer and itinerant laborer, and, since his wife’s diagnosis, has become the sole provider for the family. In addition to maintaining the household of four, he must generate additional income to pay the interest on a 20 million VND bank loan, which finances the education of their two children.

With a combined income of less than 400,000 VND a month, the family qualifies for medical insurance funded by their Commune. Of the 80 million VND fee for the necessary heart valve operation, insurance will cover 30 million. The family has requested assistance from the VNHIP to cover the additional 50 million VND.

The living room of the family home is dominated by a shrine dedicated to ‘Cao Đài’ – topped by an image of the ‘All-Seeing Eye’. A relatively modern syncretistic, monotheistic religion, Cao Đài stresses ethical practices, including prayer, veneration of ancestors, non-violence, and vegetarianism. When I ask Mrs Nguyễn how she maintains a positive outlook in the face of her life-threatening condition, she cites the comfort of her religion – together with the kindness of neighbors and friends, and the care and support provided by her family.

The two children both attend Quảng Nam University in Tam Ky. Her daughter is studying for a career as a music teacher, and travels the 12 km to and from school by bicycle. Her brother, an Information Technology student, gets a ride on a friends motorcycle, and arrives home from school while we are visiting. He will graduate next year. In the meantime, he works as a laborer with his father on weekends to help support the family.Before I leave, I ask him about chicken shoes. Improbably, he knows all about them (gà mang dép su – literally: rubber chicken slippers) and can demonstrate their use. Rather than considerate footwear for the bird, though, they are an ingenious improvised shackle – a restraint to keep the poultry out of the vegetable patch. 

By Austin

Training at Nam Giang Hospital

Date Apr 10th, 2014

We came back to Nam Giang for the first training for doctors at district hospital after Dr Josh came and identified the need of the hospital.  We gave talks on cardiovascular disease management, hypertension and diabetes. Even though the incidence of these chronic diseases is increasing, the doctors at the hospital haven’t treated patients with diabetes and are referring patients to the far off provincial hospital. They all were very interested in the topics and asked a lot of questions and were very eager to see our treatment protocol – asking us to come next week to teach more but Dr Josh wont be here!

 So we will come back soon to introduce the protocol and provide them with advanced information on these diseases.

Thêm chú thích

We also brought them 4 pulse – oximeters and a nebulizer which they really appreciated. They said they only have one pulse – oximeter and one nebulizer that they have to move around from ER to OR to the internal medicine department.They hope to have more to bring to Chaval clinic that is bigger than a commune clinic and covers all the high land communes far away from the hospital. We are looking for more medical equipments to help these doctors care for the large amount of patients they have.

The silent warriors

silent warriors seeing a patient with stroke

We met with Dr Thanh, director of district Health Center after 4 years. We was busy with the pilot NCD (non-communicable disease) program in Phu Tho, northern Vietnam so we had to discontinue the program due to the shortage of staff.

He called us to ask if we can help him with the NCD management in the district. Even now, these diseases have become national program but the staff is not trained to treat the diseases. Dr Thanh said “There is higher awareness in the community through the media so the health staff and patients know the importance of managing the diseases and it is easier to implement the project, not like back at the time you started it, you were THE SILENT WARRIORS”

That reminded us the time we first started the program on managing hypertension and diabetes at commune level clinics in rural area of Quang Nam in 2008 with 2 staff, 1 physician and 1 health educator. We provided a training session to talk about these chronic diseases for the doctors and nurses with a simple algorithm. We convinced the director to make changes to the available medications and we helped to train the staff by seeing the patients with them. Although it was difficult, we were happy because we could show Ministry of Health and World Health Organization the model and results.  We then got involved in developing a model for national pilot program.

The first exciting trip for children with HIV

Last month we organized a trip to Ba Na for the kids with HIV living in Quang Nam province and Đa Năng city. were 11 children and their relatives participated in this trip with every child or 2 children accompanied by an adult. So in total there were 23 people in total including An Hayley, who volunteers for us, and I. Ba Na is a famous mountain tourist resort in Da Nang with cable systems and a spectacular amusement park that everyone had heard about through the media daily. But is is also pretty expensive for most Vietnamese people with low incomes and most are unable to afford to go there. The children with HIV and their relatives who are living in difficult circumstances, told us this was a place where they dreamed of coming to. So when they knew we were organizing a trip there, everyone was excited. One grandmother of a little girl who was sick in the hospital gained permission for her to be discharged from the hospital to join us. Our group also had a 70-year-old grandmother of a little girl with us. To save costs and provide better care for the children, we prepared some nutritious food and some essential items: milk, bread, fruit, drinks, and even some medical devices as needed. We also hired a bus and made hotel reservations...

At 6:30 am, the bus picked us and our things up at the office. Then we went to Vinh Dien and Da Năng to pick up the children and their relatives. After I checked the number of participants, we went to Ba Na. While sitting on the bus, they talked and exchanged information with each other. Everyone was very excited. Although it was Monday, there were so many tourist there. An, Hayley and I had much trouble organizing 20 people who had never been there before! After we got the tickets for the cables, we had to wait for a long time as the long queue moved very slowly to get to the cables. I can not describe the excitement and pleasure of even touching of them while they sit on the cable car.

Especially the children, they were so excited. They were also slightly worried when sitting up there hundreds of meters high. We walked to the sightseeing mountain pagodas. The children were very excited to get photographed together. Then we went to the big amusement park on the mountain. It was a paradise for children. There are many exciting games and most are free. So the kids were excited and played, appearing virtually tireless. The adults had to follow them to wait their turn to participate in all the games that they have never been part of before. There are also many games for the adult that relatives of children eagerly to participate, even grandmother of a little girl played the adventure game. She seemed very interested. We laughed when she told us that. The elderly grandmother of a little girl, who was carrying a plastic basket (something that housewives used to go to the market) for clothes and other things, was too tired to go follow her niece.

So Hayley had to help her bring the plastic basket, took the little girl to attend the games. She loved Hayley and just wanted to go with Hayley throughout the trip. At night we stayed on the mountain hotel. We booked 7 rooms for 23 people. As each room has 2 beds. But many kids just wanted to stay together. It was the first time they had stayed in a hotel. So everything was new to them. They did not know how to use hot water, showers and other things. Even a grandma and her granddaughter felt afraid to be in separate rooms. So I had to stay with them. 

We had a really delicious dinner after a day of fun. After dinner, people lingered at the restaurant and the kids were singing and dancing together. The atmosphere was very cozy and happy. Morning on the mountain is great, with people enjoying a shroud of mist and the cold air of winter. Very different with the hot weather below. After breakfast, while I, An and Hayley walked, the kids to ask their relatives led to the amusement park. They almost never get tired of playing. After lunch, we got into the bus to back home. On the way home, the kids still regretted not being able to stay there longer. They also asked that next time, where we will go? We discussed the places they want to see as Hue, Da Lat...if we have a budget for next time. 

Any way, we had a meaningful trip that is not only a trip, but it also helps everyone closer, loving each other. It was wonderful to watch the children and their carers form friendships over the two days. That is a beautiful memory that everyone can not forget. We took group photos that we will be sending to all the people who came on the trip with us.