The life of a woman in Vietnam

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International Women’s Day, a day to celebrate the accomplishments of women both past and present, was celebrated earlier this month.  During my recent trip to Vietnam helping to care for women patients, I had the opportunity to hear many women’s stories, see their hard work both in the hospital and in the shops and visit the Women’s Museum in Hanoi.

Each day on my walk to the hospital I encountered women that had arisen before dawn to start food preparation at their street-side restaurant or had traveled to the wholesale market to purchase fruit for sale at their sidewalk stall during the day. Many of these women have husbands and children who live hours away in a rural location who they only have the opportunity to visit a few times each month. The income earned in the city makes it possible for their children to attend school, as public school carries fees of $25-30 each month.

Women who remain in rural locations closer to their families are responsible for all the domestic work in addition to working in the families rice plot. The rice plot is a source of not only food for the family, but also cash income as some of the rice is sold. While Communism has afforded women the opportunity to be employed outside of the home, it has not coerced men into assuming any of the household responsibilities. A Vietnamese meal is delicious, but time-consuming to prepare as it contains no processed components. Due to lack of refrigeration, prepared food is consumed immediately and there is not the availability of saving food for a future meal.  In the urban areas, many of the married men in their 30-40’s helped with some of the food prep and child care. This cooperative marriage model has not filtered out to the 65% of Vietnamese who live outside of the cities.

 

 

Similar to China, Vietnam has a 2 child policy that was implemented in the late 1980’s to control population growth. A patriarchal society that depends on a son to carry on the family name often comes into conflict with the reality of a family that consists of 2 daughters. This has led to utilizing abortion for sex selection and upsetting the gender balance of the society. Although contraception is free there is a lack of sex education and general taboo against pre-marital sex, resulting in many unplanned pregnancies outside of marriage. Young girls bear the brunt of these cultural beliefs, often visiting clinics or hospitals in secret to have an abortion.

Approximately 1/3 of the ob/gyn residents I worked with were women, most unmarried and living at home with their parents. Only a few of the attending physicians were women, a prevalence that was familiar from my early residency days. One of the attending physicians lamented the dual roles that Vietnamese culture places on professional women – achieving personal high educational performance and job status in addition to perfection in raising children and household responsibilities. Young women physicians worried that their “advanced age” of 25-27 years was making them less eligible for marriage. It seems that women in Vietnam and the US share many of the same concerns regarding careers and home.

Family is very important to Vietnamese, influenced by the Confucius culture of China. The most important job for a woman is to bear children and her worth within the community is influenced by this ability. Having sons is considered the highest praise. Adoption is only considered if a couple is unable to have children of their own. Each day as we saw many women in clinic, one of the first items discussed in their health history was whether or not they had children. It was assumed that all women wanted 2 children, without asking the woman. For this reason, there seems to be an unwritten taboo against birth control, as even health professionals falsely believe that it may influence a woman’s future ability to become pregnant. Unfortunately this mindset has resulted in Vietnam having the highest abortion rate in Asia. Abstinence only education doesn’t work in either America or Asia!

Walking the crowded hallways of the hospital on the obstetrical floor afforded me a brief glimpse into the world of women as they supported each other during the process of childbirth. Sisters, mothers and mother-in-laws often surrounded the pregnant women as she labored on a narrow cot or weaving her way down the packed hall. Food was cooked at home and brought in, urine buckets were taken away and emptied, arms were offered for support. Older women help new moms to breast feed and care for newborns. After a 7 day stay in the hospital (compared to 2 days in the US), moms are proudly escorted home by their husbands on the back of a scooter – the primary means of transportation in Vietnam. If employed, they are eligible for 6 months maternity leave.

Compare this family centered care to the medical care of women in labor or gynecology. Acquisition of technology to advance medical care has markedly improved in the past 10 years, but there has not been a similar interest in developing patient centered care. Women deliver their babies on a unpadded metal table with no family or friends nearby and nurses and doctors that are too busy to provide comfort. During gynecology clinic, patients are led into a room containing 10-15 students/residents/attending physicians that are all discussing her medical record. The nurse helps her climb up onto the exam table, again unpadded, so that she can undergo 4-5 pelvic exams while everyone continues to watch and discuss. Sometime after she leaves the room, a physician has a brief conversation with her and her family in the crowded hallway with a treatment plan. Most of these women feel privileged to be able to afford this care as it is only available to those who can pay the yearly fee for health insurance.  They have the opinion that “the doctor knows what is best for me” and don’t question recommendations. This is changing as patients in private hospitals are demanding more interaction with their physicians and lawsuits have started to climb.

As in many parts of the world, the power and influence of women is changing age-old traditions. The overall rapid progress of change in Vietnam elevates the voice of women as they advocate for change that benefits their role as well as that of policies that benefit their families. Our role in the West is to provide educational support while allowing leaders within Vietnamese health care to create systems that work for their people.

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The American War in Vietnam

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I had trepidations when I planned this medical volunteer trip to Vietnam. As a teenager when the Vietnam war ended, all I remembered was watching the protests on TV  and the story of a local man who was held as a POW.  Those of us in the United States were protected from the reality of day to day warfare; the food scarcity, dropping of bombs and confiscation of property. The Vietnamese people not only witnessed all of this, but then saw the United States leave and were left to experience the reality of life under communism. I was apprehensive as to how I would be perceived by both Vietnamese hospital staff and the general public. My fears did not turn into reality – I have not experienced a single incidence of antagonism. In fact, the Vietnamese are happy to see the dollars that American tourists bring to their country and the jobs that tourism has helped to create. Those same rice fields that were targeted by American bombing missions are now  appearing in thousands of pictures taken by Americans (mine included).

As tourists are returning to this country, so are the Vietnamese who fled at the end of the war. They acquired the name of “Boat People” as they fled on boats headed for neighboring SE Asian countries, staying in refugee camps for months to years, before their applications for immigration were accepted in developed countries in the west. I had the great privilege of spending time with 4 of these friends during my trip, culminating in one great meal shared on stools at a street restaurant in Hanoi.

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Loi fought for the South Vietnamese Army and was wounded as he was guiding an American soldier. Following the end of the war and the victory of the North Vietnamese, his numerous rice fields and businesses were taken away and he was left with no way to support his wife and 2 small children. When a third child was born, his wife agreed to make the risky journey on a boat to a refugee camp in the Philippines,  with the hope of being accepted for immigration to America.  That 4 month old baby, born in 1979 as I was graduating from high school, is now a PA in our clinic, a former patient and a dear friend. She and her father accompanied me on this trip, providing invaluable insight into the Vietnamese culture and family structure, translated in the hospital and she assisted in surgical procedures. The trip was so much richer for their contributions. Loi lost all of his status as a landowner in Vietnam as well as  family connections and love of the food to move to the non-tropical climate of Minnesota and work initially as a dishwasher to support his family. With the support of a local church in Minnesota that sponsored the family, he went on to open a restaurant where his wife helped to prepare the food. Loi harbors no resentment for a war that was fought by the US against the communism of Russia – on Vietnamese soil.  A war that killed friends and family members and altered his family’s life forever. I don’t know as I could be as forgiving.

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Following the end of the war in 1975, Mai tried to leave Vietnam multiple times, once being caught and imprisoned for 3 moths. She was only 16 years old. Her father had been a high-ranking military officer in the South Vietnamese army and prior to the war their family had enjoyed many luxuries – chauffeured cars, private school, house servants. After the war, her father was imprisoned, her mother sent to work in a distant location and the servants gone. On the third escape attempt, Mai successfully made it to a refugee camp after a month long boat trip with her mother and 2 siblings, arriving soon thereafter in California. Her father remained imprisoned for another 10 years while her mother worked, obtained a college education and parented 3 teenagers.

The journey of Khanh’s  family was not so fortunate. Their boat was attacked by pirates and many people killed, including some of his relatives. Once in a refugee camp his large family was split up, with some being given asylum in America and others in Australia.

Sharing a meal of pho (Vietnamese soup) with these 4 people, who shared an instant connection, language and culture, was one of the best moments of this trip. America as a country of immigrants is fortunate to have their ingenuity, work ethic and laughter. And most importantly, their food!

 

 

 

 

Do I Make a Difference?

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During my many trips to Haiti since 2006, I always return with the same nagging questions. This time was no different, but at least I had one small answer. The question is this: “Do short-term medical mission trips really make a difference?” I always think I could help more by donating the costs of my trips to a local Haitian hospital that employs Haitian physicians. That is why this trip had a different purpose. For 2 weeks, I was teaching Haitian ob/gyn physicians how to improve their surgical skills, rather than leading an American surgical team. But even 2 weeks is not long enough for a teaching mission and the same question came to my mind. Until I encountered three patients.

During my second day at Hospital Albert Schweitzer a young woman returned to the hospital hoping the American doctor (me) could cure her problem. She had arrived at the hospital in October after an obstructed and prolonged 2 day labor at home. Her baby had died sometime during those 2 days and she required a cesarean to deliver the baby. This was followed by a severe pelvic infection and the need for a hysterectomy a few weeks later. During the healing process after her second surgery, she developed a fistula between her bladder and vagina, causing her to leak urine uncontrollably.  Fistulas from childbirth are rare in the US and most ob/gyns have no experience in this repair, including myself. Urologists have experience in fistula repairs related to other causes, but there is no urologist at this hospital. Fortunately, I knew of a Minnesota urologist who would be working at the site of my previous short-term missions, 4 hours away. Phone calls were made and the patient was transported by private vehicle to Hospital Bon Samaritan where she had her fistula repair surgery and then returned home in less than 48 hours. She is only 18 years old and will never be able to have children, but she won’t be saddled with the need to carry a urine bag for the remainder of her life.

Severe pre-eclampsia is a tremendous problem in Haiti, necessitating the premature delivery of infants for the health of the mother. During my first week we delivered 4 infants weighing around 3 lbs. Each day that I visited the special care nursery checking on these babies, I noted other Haitian mothers caring for their growing premature infants. often feeding them formula via dropper or syringe. Formula is very expensive in Haiti, but because these women didn’t have access to a breast pump soon after delivery, their breast milk supply dried up before their infants were mature enough to swallow. Unfortunately, 2 out of the 4 premature infants had died within a few days of birth, but there will soon be 3 breast pumps at the hospital that I was able to order upon my return. Better nutrition and at a less expensive price.

During my second week of clinic, a mother brought in her quite shy 6-year-old daughter who had suffered thru numerous medical appointments in the past, both at this hospital and in Port-au-Prince. She was born healthy but with ambiguous genitalia, neither fully female or male. While being raised as a girl, she is likely genetically male with a enzymatic blockage of full testosterone production. It is important to know her genetics (XX or XY) as she is at great risk of testicular cancer if she is XY. After contacting a pediatric endocrinologist in Minnesota as well as friends who work in Haiti, we were able to determine that there was no possibility of chromosome testing in country but that we will have the chance to get a tube of her blood to a lab in Boston in March that is willing to perform the testing, which is very expensive, for a much reduced rate. We can’t change the girls chromosomes, but we can offer risk reducing surgery in the future and also give her mother some answers to the questions she has been asking.

These patients are a reminder to me that sometimes even short-term medical missions can provide aid. Passing on surgical skills as well as making connections that I have cultivated over the years has a benefit and can make a difference.

Where are all the Haitian doctors?

 

I had the opportunity to work closely with four Haitian physicians over the past two weeks at Hospital Albert Schweitzer, 90 miles north of Port-au-Prince. The hospital was founded in 1956 by an American doctor, Dr Larry Mellon (a member of the wealthy Pittsburgh Mellon family) who saw a great need in the rural, impoverished area. Initially the hospital was staffed by long-term American medical volunteers who learned the local language and provided care with the resources that they had available. This has gradually changed so that now all of the staff is Haitian and American/European volunteers only stay for short terms and work alongside staff to increase knowledge and skills.

Most of the Haitian doctors and nurses that I worked with are not from the local area and have family in other parts of Haiti. While they are working, they live in housing next to the hospital and visit their families on the weekends they have off. Each physician is “on call” for a week at a time, meaning that they are the provider called in the middle of the night for surgery or a complicated delivery. The average salary for a Haitian physician is $20,000 which certainly elevates them out of poverty, but does not make them wealthy. They often use their week off to work in an outpatient clinic near their family, where they can charge higher fees to urban patients.

Just as in the US, rural areas in Haiti have the most need and are less favorable locations for doctors to practice. The acuity of patient care is much higher as Haitians with few resources do not seek care until their condition is well advanced. Physical resources to provide care are often in short supply as they need to be transported from the larger urban areas. Due to the locals medical illiteracy, as well as illiteracy in general, it can take much longer to have a discussion with a patient about their illness. The volume of patients to care for is tremendous, with the hospital courtyard packed each morning with patients waiting all day to be seen in clinic.  Combine all of this with living away from your family and friends for weeks at a time and you can appreciate why these rural jobs are often seen as a stepping stone to a job closer to family in an urban area.

Brain drain is a common problem in many developing world countries, but particularly a problem in Haiti where 80% of Haitian trained physicians often travel to surrounding islands in the Caribbean or Mexico to practice. The reality is that they are better able to support their families back in Haiti with their increased salary than if they worked a Haitian job.

Rwanda has recently addressed this issue with their new medical school (partially sponsored by Partners in Health which has it origins in Haiti) and are seeking out students from the local rural area where the hospital is located. 70% of the first class are women as it is felt that they will more likely stay in a job near their families. The school will also focus on the use of basic technology (x-ray, a limited panel of blood tests) and careful physical exam to make a diagnosis as well as public health measures that can prevent disease or treat in earlier stages.

Americans like to develop a long-term relationship with a physician they trust. There are 280 physicians for every 100,000 Americans, compared to Haiti with 25 physicians for every 100,000 people (almost a ten fold difference). Haitians just hope that there is a physician in the house when they are in need and are not concerned if they have ever met that provider in the past.

I am grateful that these physicians have allowed me into their lives for the past two weeks and to tell their stories. Taking the extra time on rounds each morning to explain what they are discussing (I still don’t understand Creole, the local language) as well as trying to learn new skills can make life stressful for both of us. They handled it with the usual Haitian humor and perseverance. We both benefitted from this experience as I have a new appreciation for work-life balance and they have improved surgical skills and some new clinical knowledge.

Privacy, Privilege and Practicality

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The hospital where I have been working for the past few weeks, Hospital Albert Schweitzer, has a policy requesting volunteers to refrain from taking pictures while they work in the hospital. This is to protect the privacy of the patients as well as their families. For fundraising purposes, the hospital has taken professional pictures of patients, but only after a written consent is obtained (these are the pics that I have posted).  Contrast this to other Haiti mission trips that you have seen. Pictures are posted on social media of volunteers surrounded by cute, smiling kids or of a patient undergoing an interview/exam. I was guilty of this in my first few trips to this country as well until someone much smarter than I reminded me of what an American would experience if a stranger took a picture of them in the hospital as they were nursing their newborn, only to show that picture to all of their friends back home.

Contrast this with the practical side of privacy in the hospital.  The hallways are lined with patient gurneys, an extension of the hospital wards that each house 6-7 patients. When we make hospital rounds, there is very little privacy as you remove a dressing and examine a patient that had surgery the previous day.  Charts are distributed in the maternity ward by the nurse asking a patient their name over the din of another patient screaming in labor. As you discuss a patient’s medical condition, the surrounding patients are listening as well as their families. In clinic, there is one ultrasound machine for 3 exam rooms. I can be interviewing a patient as another patient is having an ultrasound only 6 feet away. It is quite difficult to ask questions about sexual health and maintain a semblance of privacy as well as get an honest answer from a patient. I have heard of 2 immaculate conceptions this week alone.

A presentation earlier this week by one of the physicians concerned respecting patients and providing “bad” news in a private setting. A heated discussion followed the lecture that was translated to me as “Great idea but impossible to implement in our circumstances. Even if we are able to give the patient the info without others hearing, the patients often ask their families, friends and others in the hospital what they think.”  This must be the Haitian version of Google!

In the developed world, we have the privilege of privacy. We can get our test results via secure email, be confident that a conversation with a provider in a room with a closed door will not be heard by others in the waiting room and expect a private room with a shower in the hospital. Providing patients here with a small vestige of privacy by skipping the medical voyeurism is a worthy request.

Dear Anti-Abortion/Pro-life Protester, Come to Haiti

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You would love it here. Abortion in Haiti has always been illegal and always will be. 90%+ of Haitians are Christian with the 2 predominant religions, Baptist and Catholic, conservative and anti-abortion. Most of you probably identify as conservative Christian also. You certainly don’t need to worry about equal rights for women or the #Metoo movement , as male dominance is very prevalent in both church and home. Abstinence outside of marriage is the preferred method of birth control for young people and for married people “children are a woman’s duty and gift from God”.

But if you decide to visit, please don’t dig any deeper than the surface, as the reality is much different from what you will hear. In speaking with one health care worker who has been here for many years, they estimate that 70% of Haitian women have attempted to end an unwanted pregnancy at some time in their life. This may only be an estimate but was based on a 6 month survey of women. Read that again … 3 out of 4 women have tried to end a pregnancy, most without success. A “didn’t want” pregnancy can be ended thru misoprostal (this is one of the drugs that is used in the US for medical abortions) bought from a street vendor, Pitocin from a bootleg pharmacy, a surgical abortion from a doctor who has a clinic to make extra income, drinking some type of poison and on and on. The doctors here think that things have improved for women since they have been able to obtain misoprostal as there are less women trying to end a pregnancy with sharp objects stuck in their vagina, perforating tissue and the uterus.

If you come, please bring health education and particularly sex education materials. Although contraception is provided free by the government in family planning clinics, many women have misperceptions about the benefits of contraception and don’t use it. This is also likely due to the perceived sin of using artificial means of contraception within the Catholic church. In only 1 week here, I have heard from patients that they will lose weight, not be able to have future children, develop mysterious aches and pain and build up too much blood in their system. The best excuse – Their partners don’t like them to use anything.

Don’t bring your thoughts and prayers. They don’t feed your 2 young children when you are too sick from pregnancy to go to work. They don’t protect you from a husband that beats you. They don’t make your married boyfriend answer his phone after you have told him that you are pregnant. They don’t prevent your parents from making you stay home from school when they find out you are pregnant age 16. They don’t stop the boy next door from raping you one night on your way home. These are the circumstances that many Haitian women find themselves in and why they choose to end a pregnancy. They take the risk of bleeding, poisoning or bodily damage because the alternative of continuing the pregnancy is much worse.

If the United States overturns Roe v Wade, some states will make abortion illegal. They will also limit access to contraception and education for women.  Women will still get pregnant with a “didn’t want” pregnancy and become desperate to change their situation. Parts of the US will look like Haiti. Be careful what you protest for.

 

Life as a woman in Haiti

 

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Patient dripping urine from fistula

Haiti can be a difficult world, both for visitors and for its citizens, especially woman. The unique smell of the country hits you as you deplane; an odor of slightly rotten fruit mixed with burning garbage and body odor. By the next day the odor has faded into the background and you don’t recognize it again until you visit once more. Your feet hurt at the end of a long day on concrete floors in the hospital and your sleep is interrupted by the incessant crowing of roosters, no matter the time of day.

Women in this country live with all this and so much more. As I was told by a Haitian doctor today, “When the choice is between the life of the mother or the baby, we choose the mother because she is needed to keep the rest of the family together”.  Woman are expected to get married and have children but pregnancy comes with unique problems.

Although freely available, birth control has many misperceptions and is not frequently used outside of marriage. Thus, women become pregnant and try to terminate unwanted pregnancies with the use of misoprostol that can be bought from street vendors.  They are often only partially successful due to inadequate dosing or unknown gestational age of the pregnancy. A young woman I met yesterday was one of the unlucky ones – her membranes ruptured and she started bleeding but has not yet miscarried her 4 month fetus that still has a heartbeat. Because abortion is illegal in this country, no intervention can be considered unless she has a life threatening infection or the baby dies.

Severe pre-eclampsia is very common in this part of the world, due to genetics and underlying hypertension that is not well controlled. We rounded on three patients today who are all around 7.5 months pregnant with very high blood pressure. Babies have a good chance of survival here after 33-34 weeks. Delivering these babies now will save the mom but almost certainly result in the infant dying. Each day we have to reconsider the risk of continuing the pregnancy, especially if the woman has other children at home to care for.

Women who live in the mountains many hours walk from any health care center often labor at home with the assistance of their female relatives or a lay midwife (Matrones). When labor doesn’t go as expected, they are carried for hours to the hospital. In November, a slight 18-year-old arrived after 2 days of labor and no progress. Her baby was dead and a cesarean was needed to deliver the infant. A week later she returned with a serious infection that required removal of her uterus to save her life. Now she has a fistula(opening) between her bladder and vagina where she is constantly leaking urine, even with a catheter in place. The surgery to repair this is very difficult and often not successful. She can no longer have children and will probably carry a urine bag for the rest of her life.

As I have written about before, cervical cancer is very prevalent in Haiti due to a lack of screening or knowledge about the disease. We have already had to inform 2 women, ages 31 and 41, that their constant vaginal bleeding is due to large cervical tumors that are too advanced to remove. One woman has a hemoglobin of only 4 (normal is 12-14). Both will leave young children orphaned.

I am only a visitor in this country that I have grown to love for its tenacity.  The physicians, nurses and midwives that are here full time caring for these women are my heros.  I can learn as much from them as they may learn from me.