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Medical Issues 2
By David Read Johnson, Ph.D., and Hadar Lubin, M.D.
NCP Clinical Quarterly 5(4): Fall 1995
In October, 1994, we led a delegation of 27 clinicians and scholars interested in post-traumatic stress disorder and the creative arts therapies on a mission to Vietnam.1 We met with physicians, psychiatrists, government officials, and Vietnamese combat veterans in Hanoi, Hue, Da Nang, and Ho Chi Minh City. We toured several medical/surgical and psychiatric hospitals, a rehabilitation center for disabled veterans, facilities of two medical schools, and met with American diplomats in the American POW/MIA office. Our movements were not constrained or controlled by the Vietnamese government, and we were able to examine numerous patients and speak with many people in the streets. In this article, we will briefly summarize what we learned about healthcare, psychiatric treatment, and concepts of post-traumatic stress disorder in Vietnam.
General Conditions Of The Country
Vietnam remains a profoundly third world, impoverished country. The population is 70 million, 80% of whom live in rural areas. The yearly income per capita is $132. The war with Cambodia and China during the 1980s strained an already ravaged country and economy. Most buildings are the unpainted remains of French structures from the 1930s, with families living in one room open to the street, where they eat and work. There are old unused street lights, no stop lights, and only a few telephones in Hanoi, a city of 500,000.
In 1986 economic reforms similar to those in Russia were instituted, allowing limited private enterprise. Over the next few years, the country improved its situation, so that by 1989, Vietnam exported rice for the first time, and is now ranked third in the world behind Thailand and the US in rice exports. While they have enough food to feed their people, 30% remain malnourished due to poor distribution systems. In 1989, they opened relations with the West, and have made normalizing diplomatic relations a high national priority. The transfer of Hong Kong to China in 1997 continues to motivate them to seek alliances with the US and other powers. The longstanding hatred of the Chinese is still palpable (so intense they adopted the Latin alphabet in 1920 to prevent the Chinese from being able to read their language!).
General Health Care System
The health care system is hierarchically organized into seven regions, 40 provinces, 537 districts, and 10,000 communal areas. At the commune level the health care team consists of four people: an assistant doctor, a nurse, a traditional medicine doctor, and a "hygienist," similar in function to a social worker. There is one hospital per district, one or two provincial hospitals, and one or two national hospitals linked with the major medical schools.
Most medical care is free (though unavailable), including abortions on demand. The health care budget per capita per year is 66 US cents. There are a total of 400 hospitals and 6000 medical beds in the country. The major priorities healthwise include sanitization of the water supply, immunization of children, family planning, and prevention of malaria, typhoid fever, dysentery, and other diseases. The immunization program has achieved 85% success. 1700 cases of HIV have been identified, mostly in the South. Other health problems include care for 4.4 million handicapped people and 300,000 orphaned children in the country. Needless to say, psychiatry is not a priority.
We visited the provincial hospital in Hanoi, Viet Duc, and were profoundly shocked at the terrible conditions of care: crowded open air wards with no glass in the windows, wooden beds without sheets or mattresses, unsanitary conditions (operating rooms open to the air and to visitors), and ill-equipped (one 30 year old X-ray machine, one EKG machine, and severe shortages of medicines, bandages, and books). Families huddled around patients (including children) recovering from major surgeries without the aid of pain medications, bandages, or vital monitoring.
There are seven medical schools in the country, training 300 students a year. The training is three years, followed by a three year internship. Students must pass certifying exams similar to our Boards. Classes are taught in English, Russian, and French. Until recently, many doctors were trained in Russia. There are 7,000 doctors and 48,000 assistant doctors in the country. There are only 360 psychiatrists and a handful of psychologists. Psychiatrists are just now beginning to open private offices in Saigon.
Traditional medicine is still a part of medical training - all doctors receive two months of classes in acupuncture and herbal treatment -- though these skills are still transmitted from father to son within certain families. In rural communities these doctors provide much of the primary care, while in the cities interest in traditional methods is waning. Doctors receive from $20 - $50 per month salary, far less than the salary of our tour guide, or anyone in direct contact with Western companies.
The University of Medicine in Ho Chi Minh City is divided into medicine, dentistry, and pharmacology schools, with a total of 500 faculty and 50 professors. There is a separate School of Nursing, which involves three years of training beyond high school, and separate schools for assistant doctors. The condition of the medical school is startling: they have almost no equipment (the Vice Dean of the Medical School asked us if we could send them some microscopes), pharmaceuticals, and medical textbooks, (other than outdated French or Russian ones from twenty years ago).
Treatment Of Veterans
Three and a half million Vietnamese served during the "American War", including Army of the Republic of Vietnam (ARVNs). During the war, 440,000 North Vietnamese and 220,000 ARVNs were known to be killed, and additionally a staggering 300,000 are missing, for a total of nearly a million dead. Hundreds of thousands of people are handicapped as a result of the war, or are suffering the effects of dioxin. Birth defects continue at a high rate in areas that were heavily defoliated. Veterans are treated in separate hospitals and clinics controlled by the Ministry of Defense. Currently there are about 15,000 war veterans permanently housed in treatment centers, and many more being cared for in brief inpatient treatment centers and outpatient clinics.
There are 80,000 Amerasian children (now young adults) most who have emigrated to the US. Some remain in the one "school" near Saigon, though officials reluctantly acknowledged that many are unemployed and homeless, or have turned to drug addiction or prostitution.
Many women served in combat-related roles during the war, however, the culture gives preference to the "war mother" as the container of the grief and loss associated with war. These mothers are highly honored and acknowledged. Each "war mother" who lost a child was given the equivalent of $4 as a pension from the government. In contrast, the young women who participated in the war were often unable to marry, and in their thirties found themselves unwanted due to the strongly held beliefs that they were too old to bear children. Many of these women subsequently suffer from depression and loneliness and are common among hospital patients. Rape is universally denied as a significant problem (as is homosexuality and domestic violence), and viewed solely as a crime, requiring only gynecological treatment.
Psychiatric care remains largely custodial and palliative. While there is greater awareness of modern trends in psychiatry in the medical school hospitals in Saigon, in general the psychiatric facilities we visited were deplorable. One of the only general psychiatric hospitals in the country near Da Nang, Hoa Khanh, had been transformed from a children's hospital built by the American Army to a psychiatric facility in 1976. The hospital has 150 inpatient beds, a 50 day length of stay, and serves approximately 4000 outpatients over a year. The doctors there estimate that 12% of the patients (men and women) have war related traumas. We viewed small rooms filled with beds without mattresses. Patients were heavily sedated on neuroleptics. Many were restrained in leathers, and a seclusion area (locked rooms with bars) was indistinguishable from a prison. The only treatments available include listening to music, watching movies, or physical therapy (massage). Psychotropic medications mentioned by the physicians include amitriptyline, Wellbutrin, and Valium. The doctors were aware of the diagnosis of PTSD, but had no treatment for it. When patients had dissociative episodes, flashbacks, or violent outbursts, they would be held down by 5-6 aides, and then restrained in their bed if necessary. We witnessed two such incidents while we were there: in one case a forty year old woman with PTSD had a flashback when she entered the room to be interviewed and saw the delegation. She fell to the floor with epileptoid movements, screaming out in Vietnamese, "Don't beat me! I'll do what you say!" She had been a POW of the ARVNs, and had been severely beaten, tortured with electric current, and had soap put in her mouth while being hung upside down from a ceiling. Her husband, with whom she still lives, had been an ARVN. The second incident was with a young psychotic patient who required physical restraint and a forcible return to seclusion. In both cases, the staff appeared remarkably calm and treated the patients with care, talking softly to them and holding them down. No sedatives were administered.
Ho Chi Minh City, with a population of over a million, has one 100 bed acute care psychiatric facility, a 200 bed hospital for chronic patients, one day hospital, one outpatient clinic, and one mobile team that visits the homebound. They are significantly more informed about Western psychiatry than their counterparts in the North: they use the DSM-III-R ,having just received the DSM-IV. Their treatments, however, were similar to those we had seen in the North, including physical therapy, relaxation, and diversional activities. Living conditions for patients were bare rooms filled wall to wall with beds with no amenities. We were able to sit in on a session of their new group therapy program. We witnessed a doctor leading six patients in a group discussion about their problems. He seemed knowledgeable about how to redirect the patients to speak to each other and develop the group interaction, though he had not been trained in any particular group therapy method.
Treatment Of PTSD
War veterans are classified by percent of disability and are treated in separate medical facilities under the Ministry of Defense. We learned that war veterans were housed in special clinics and hospitals on the outskirts of Hanoi, and our request to visit one was accepted. The Center for the Care of War Invalids covers about one acre of land with a dozen small buildings. The hospital takes care of 30-50 inpatients at a time for relatively brief stays of 20 days. They follow 500-600 patients in the community, 5% whom are women, providing what would be the equivalent of visiting nurse services. They seem to have a home-based health care orientation that recognized the need to provide support to the family of the veteran. The hospitalized patients receive food, rest, massage, reassurance, and medications, most commonly Ativan or amitriptyline, and then sent home. They are clearly honored as soldiers who fought for their country, and are provided marginally better living conditions than the civilian population.
The psychiatrists at the center as well as the patients clearly view sequelae of the war as a physical condition similar to shell shock. They termed the patients' conditions as "serious brain problems, due to the noise from the war." Patients told us how their "brain" was affected, pointing to their heads, telling us they put bandages around their heads when there feel the "pressure" from their disorder. One veteran said, "Toxic substances like Agent Orange have made my heart beat fast." The focus on physical aspects of stress also include the use of hydrotherapy and Russian-style psychiatric treatments such as ultraviolet light exposure and radio-wave irradiation of the joints, consistent with the notions of PTSD as a somatic stress condition.
We were able to interview several of the patients through a translator and soon discovered the presence of all three symptom clusters of PTSD. The veterans reported intrusive imagery, flashbacks, avoidance, anxiety, sleep disturbance, startle, as well as drug and alcohol use, depression, and survivor guilt. Emotional numbing was less strongly endorsed. When we asked one veteran if he is visited by dead buddies, the translator/doctor refused to translate the question because he felt it was absurd. When we insisted, the veteran burst into tears and replied, "yes they come every day." The surprise on the doctor's face told us much about his lack of knowledge about the psychological dimensions of the disorder.
The physicians in general minimized the occurrence of war-related PTSD and reiterated the message of the larger culture that "we do not ask about the past," and "we look to the future - we understand that the past is filled with terrible things." Both patients and doctors uniformly told us that there is no point to dwell on the past but to look to the future with forgiveness and hope. Despite the supportive aspects of this approach, misdiagnosis was evident in many cases we examined. For example, in the facility in Da Nang, we interviewed a woman who was hospitalized for depression. She initially told us that her problems had nothing to do with the war, but upon inquiry we found that she had a major sleep disturbance due to nightmares about her father who was tortured and killed in the war. The doctors were completely unaware of this element of her condition.
Differences Between The North And South
Significant differences in culture, orientation, and relationships seem to exist between the North and South. The North is substantially poorer, more rural, traditional, suppressed, and patriotic. In contrast, the years of capitalism remain an influence in the South, despite the overlay of communist control since the war. More significantly, the South experienced most of the actual physical destruction of the war, and the conflict within families caused by the civil war. Many South Vietnamese told us how their families had been split into ARVN and Viet Cong factions. In addition, thousands of ARVNs had to abandon their families when they fled the country, were killed in the purge at the end of the war, or were put in re-education camps, creating ongoing disruption of family units. We were told that all the ARVNS were out of the camps by 1992 (17 years after the end of the war!), hardly a reassuring statistic. It is not surprising that we found more interpersonal tension among people we met in the South, and evasiveness in response to our questions regarding the war.
Culture And PTSD
Throughout our trip, we were impressed with the power of the broad cultural message to frame and contain potential distress in the populace. In Vietnam, not only revisionist propaganda, but also deeply held Buddhist beliefs and centuries of struggle as a small country, inform the people to move on and focus on survival. It is hard for Americans to fathom the extent of destruction caused by this war - perhaps only comparable to our own Civil War. There are graves everywhere, along the road, in the rice paddies, in numerous cemeteries that rival Arlington. Because the war took place on their land, the distinction between soldier and civilian in terms of trauma is not significant. The need to survive, economically as well as politically, given the proximity of their enemy China, propels everyone toward a convergent national goal and serves to suppress expressions of anger or pain. Our delegation members were highly skeptical when the leaders of the Vietnam Veterans Organization in Saigon proudly announced that they made no distinctions between NVA, VC, and ARVNs in their organization; that all had suffered and all could be members. Such levels of forgiveness are truly outside of our imagining. The openness and positive spirit we met everywhere were deeply disturbing to us, and we questioned it.
When we visited the History museum in Hanoi, one diagram was particularly instructive: a map of the world in 1328, showing the Empire of Genghis Khan including India, Europe, China, and all of Southeast Asia except for Vietnam. Three invasions over sixty years by the most ruthless warrior in history led to failure. A Vietnamese professor told us: "We have a long history of being invaded and governed by giants, though in the end we defeat them and they leave. Then, being such a small country, we must go back to these giants and apologize for our victory....now we must do this with America."
The Delegation was sponsored by the People to People Ambassador Program, created by Dwight Eisenhower in 1956 to further intercultural exchange. The members of the delegation included Lawrence Ashley, Mary Baures, Lois Carey, Nina Corwin, Marija Dixon, Brenda Doherty, Paul Frazer, Mildred Gustafson, Ron Hays, Robert Holmes, Mario Mercado, Margaret Mercado, Nancy Odell, Royal Randolph, Bonnie Riggenbach, William Root, Emily Rosenberg, Vernon Sackman, Niki Sepsas, Nancy Slater, Suzanne Sutherland, Richard Sword, John Uschuk, Candice Weigle-Spier, and Larry Winters.
David Read Johnson is Director, Outpatient