After what was becoming a somewhat lonely couple weeks living solo in the guestrooms, I was pleasantly surprised when three new volunteers arrived at hospital. In true Vietnamese impromptu fashion, I had no idea they were coming until I ran into them in the hall, and while I was at first reluctant to have to split the internet connection four ways, the four of us quickly hit it off. One of the volunteers, Sara, is a Swiss physical therapist (PT) who just got her degree, and who is staying through the end of January. The other two are a Vietnamese-American couple from San Jose who stayed for about three weeks. The woman, Mai Huong, is a PT whose family left Vietnam when she was a young girl, and the husband, Minh, left Vietnam when he was about 18 and, as he would say, is still learning English in the US as an adult. He’s also an IT specialist, so he set up a wireless router for the guestrooms, solving that problem.
Since both Mai Huong and Minh are fluent in Vietnamese it has been really enlightening to get to learn so many things from them that I would be unlikely discover on my own. For instance they introduced me to a new dessert shop in town that sells a delicious concoction of all kinds of different flavored, sweet beans mixed with ice, coconut milk and a sweet paste. They also informed me of the Vietnamese custom of never praising the appearance of a child because the spirits may overhear you and decide to steal the child. Instead the proper etiquette is to compliment a child as being well behaved, to which the parent will then agree or disagree before lamenting how unfortunate it is that their child is so skinny and ugly. Additionally in Vietnamese culture, almost everyone gets a sort of official nick-name that is used informally as we would a person’s first name. And again to deter evil spirits, in some rural areas parents even go so far as to give their children nick-names like dirt, urine or feces in attempts to disguise them as something extremely unappealing to the spirits. Minh had a friend whose mother called him Fart until he was 18 years old.
I also learned that many of the hospital staff were members of the North Vietnamese army during the Vietnamese-American War. One of them even told Minh that they were about a month away from surrendering due to a lack of supplies and the incessant bombing when the war ended. I’ve also just recently seen the tragic and moving War Remnants Museum in Ho Chi Minh City, as well as the ingenious and impressive underground tunnel complexes about 70 km outside the city. Both are certainly worth seeing for their perspectives on the conflict. However, I must admit as a whole I haven’t been particularly impressed with HCMC. Someone mentioned it’s largely considered more of a business oriented city, rather than much of a destination, and I’d have to agree.
Much more interesting were the outings the four of us volunteers took to My Son and Hoi An, two world heritage sites near Da Nang. My Son is a secluded grouping of ancient Hindu ruins, impressively built without any form of mortar by the Champa dynasties between 300 and 1300 AD. Hoi An, in contrast, is best described as what you get when you give the invisible hand of economics a giant sewing machine and put it to work in a quaint, historic, Vietnamese coastal town. There is little doubt in my mind that it would win hands down in a worldwide tailors-per-square-kilometer contest. I would conservatively estimate 50-70 in the small area if you also include custom shoe shops. The custom clothing and other handcrafted items market makes Hoi An a huge destination for tourists. You can get a tailored suit for as little as $40, a very high quality suit for $150, and tailored silk dresses for as little as $15. It’s pretty much Adam Smith’s personal utopia set in French colonial Indochina.
I’ve also learned a lot from Minh and Mai Huong about the mindset of the people towards the government and vice versa. From their description, most people in Vietnam, especially within the younger generation, view participation within the communist political party simply as something you do to get a good job, rather than as a reflection of their personal ideological beliefs. More interestingly though is the government’s view of the people. The Vietnamese government is often criticized for the limitations it sets on citizen’s freedom of speech, for instance prosecuting those who publically denounce the government, and blocking access to networking websites like facebook (so don’t expect me to respond to my wall posts anytime soon). However, from what was described to me, the government itself even sees this as a less than ideal situation. Rather they view the restrictions as a stopgap measure to maintain what they currently see as the country’s top priority: peace.
With the recent suffering of such a terrible war still fresh in the minds of the government and the people, both groups see peace as the primary concern facing the country. Despite this, however, the government still perceives a threat from the country’s uneducated masses. It isn’t that they are a threat in and of themselves, but rather that they are a large group that could be easily taken advantage of by someone wishing to reignite a conflict. I hardly pretend to understand the situation well enough to have a well supported opinion on the matter one way or the other, but it definitely made me think when I first heard this rationale, and I would say it certainly seems a defensible position.
The most interesting insights though have been what I’ve learned through Minh and Mai Huong about the inner workings of the hospital. Before I understood in a general way that the communist government had a hand in the hospital’s affairs (they funded the new building for instance), but I didn’t know what all that exactly entailed. From Minh and Mai Huong, I learned that the most significant way the communist system affects the hospital is by creating an incentives system very different from our own in the US. Now before I go on, let me just preface this by saying that I don’t mean this at all to be a criticism of the hospital staff, or for this to detract from the great work that they are doing. As others have noted, Vietnam, as we know it today, is a country only about 40 years old and has been a world leader in its pace of development. As with all countries though, and especially the young, there are many ways to improve upon the current systems, and I think the current hospital system is one of those areas.
That said, the communist structure to the hospital seems to have created an internal operational system that doesn’t reward people for improvement. Promotions, for instance, seem to be based almost exclusively on political status within the communist party, rather than being based on professional merit. Due to the communist mindset of strict equity, there are also no financial incentives for the hospital staff to see more patients or improve their quality of care. The result is that the staff will get the same recognition from the hospital, and will receive the same compensation, regardless of their personal performance.
There is also a virtually complete absence of external pressures to improve the hospital’s performance. The Da Nang Orthopedics and Rehabilitation Hospital is the only public orthopedic center in the country, so there will always be a demand for their services, and there is currently no competition from other facilities to drive performance. Also due to the cultural mindset, and due to the lack of alternatives, patients are always completely trusting and deferential towards their physicians. The result is largely a lack of accountability to the patients beyond the doctor’s personal sense of obligation, which can be dangerous. Minh and Mai Huong related that in extreme cases they have heard of at other hospitals, parents have been known to even allow physicians to hit their children if the child is misbehaving. This is of course the result of far more factors than simply the Vietnamese hospital structure, but I do feel like it does help to illustrate the huge imbalance of power within the system that reduces accountability.
The manifestation of this lack of driving incentives and accountability was most evident in the conversation the four of us volunteers had with a few Swiss surgeons who came to the hospital as part of an ongoing program to teach arthroscopic surgery (http://en.wikipedia.org/wiki/Arthroscopy). They had come to the hospital several months prior to teach the surgeons here the basics of arthroscopy with the stated expectations that they would practice, and hopefully master the basic techniques, by the time the Swiss surgeons returned. Instead virtually no progress had been made at the hospital since their departure, and the surgeons never got a very clear answer on why this had happened. The rumors included a lack of confidence to continue without supervision, a lack of motivation to practice, and a rumor about it being some sort of administrative decision. Whatever the case though, it was clear the system had failed to meet the goals set out by the program, even when the program was explicitly for the benefit of the hospital.
The Swiss surgeons also had other complaints about the hospital’s operational structure, which can also be in part linked to its lack of accountability and incentives within the system. For instance after using a tourniquet in the operating room for two days, the Swiss surgeons found it missing on the third day. The explanation was that it had been borrowed from the general hospital next door, and they had not thought they would need it that day, despite the fact that they were performing the same types of surgeries. It is also not uncommon for patients’ family members to have go to the market to buy gauze, sutures and other supplies for them mid-surgery if the hospital runs out. If the hospital had a system concerned more about performance, these obstacles would likely be ironed out.
The nature of these problems of course goes beyond just the organization of the hospital. In general, Vietnamese culture is one that is very much focused on the present. Obstacles are confronted as they come, and people take life at a slow enough pace that you can usually count on someone being free next door when you need to borrow a tourniquet. The traffic system is largely the same way: people get by just fine with a fairly chaotic system as long as things are taken at a slow enough pace. In fact, when the traffic is light, these relatively unstructured systems even seem to run smoother than the more structured kinds. (No getting stuck alone at a red light.) However, the problem with both the traffic and the hospital arises when you start dealing with a high volume flowing through the system. The current hospital system with its semi-chaotic structure simply has too much inefficiency to see the number of patients a similar hospital could elsewhere.
And the administrator of the hospital, Mr. Cuc, is aware of this. Having just returned from a trip to Seattle to study US hospital administration, he wants to see dramatic improvements in efficiency in the hospital. However, the impression Minh and Mai Huong got from the staff was that he was largely out of touch with lower levels of operation within the hospital. He is after all an engineer by education, not a doctor, who was appointed largely through his status within the party. I am not trying to imply that he is incompetent. He is an intelligent man who works earnestly to improve his hospital. However, it is clear that his placement was chosen for reasons beyond solely the performance of the hospital. And, in a nut shell, that is essentially the greater problem: the system doesn’t have performance improvement built in as a goal.
Minh and Mai Huong’s also noted that another serious impediment to the hospital’s improvement is the fact that the staff has largely developed the mentality that someone is always going to come help them. This is something that I have also noted myself to a certain extent. When volunteers come to give lectures or teach new techniques, instead of being seen by the staff as a great opportunity to learn, it has gotten to the point where they clearly see it as routine. Even the Swiss surgeons who came at great expense to teach a highly desired new surgical method were met with a high level of absenteeism from the surgeons, and to some extent a dismissive attitude from the administration. The Swiss surgeons also noted that when something would break, no one seemed to think it was their responsibility to fix or replace the piece of equipment. The prevailing attitude seemed to be that someone else will replace it, which of course has cast no small amount of doubt on how much my efforts are really helping in the long term.
And while this mentality is unfortunate, I think the staff can hardly be blamed for it. I would estimate they see over a couple dozen volunteers a year, and when it is so hard for much of what the volunteers teach to actually stick due to the lack of resources, coordination and follow up, it is easy to see how for the staff attending the lectures could become as much a polite gesture as a genuine opportunity to improve their skills.
As for my own project, four months has gone from being a significant chunk of time to the blink of an eye. I’m halfway done, and yet in many ways I feel like I’m just getting started. So far it looks like things are on track for the hospital’s equipment, though the going is slow with all the government bureaucracy. What I fear may be a missed opportunity though is the chance to help get resources to the other charities I’ve gotten in contact with. In true spontaneous Vietnamese fashion, one morning over coffee with our local shipping agent, he decided to invite a friend of his over who works with the Da Nang Charity Association. That afternoon I’m meeting with their executive director who gives me a run down on the whole organization, and we discuss one of their program branches’ need for ultrasounds and other medical equipment.
The same shipping agent even went so far as to set up a meeting for me with the program director of Giving it Back to Kids, another local NGO, to learn how to set up a Vietnamese regional NGO office, all because she was a friend of his who was single, and he thought we might hit it off. It turned out to be a great meeting, however, where I gained new contacts and potential resources. And of course I now know how to set up a Vietnamese regional non-profit office, which, for most, is probably the world’s most obscure and mundane piece of trivia.
I’ve also enjoyed a few more of the developing world’s bountiful surprises. A couple weeks ago I noticed that a few of the flecks of dirt on the floor of my bathroom were moving, which upon closer inspection turned out to be tiny worms a couple millimeters in length. Having just taken a class entitled “Parasites and Pestilence” last winter quarter, I eagerly collected a few samples in the lid of a peanut can and rushed to the CDC website to find out what kind of nematode was now likely trekking its way through my interstitial fluid. You can of course imagine my disappointment when they turned out to be too large to be any of the parasitic candidates. After Giardia in Peru this summer, I was really looking for the next notch in my belt.
The new volunteers have also had their first run-ins with the guestrooms’ deteriorating plumbing. I was annoyed at the time when I found the laundry machine full, but it turned out my neighbors had actually taken a bullet for me after we discovered their clothes had all been stained yellow by the rust in the water. I think it’s pretty safe to say the building will not be missed when it gets torn down—which the hospital administration assured me before I left for the holidays, will almost certainly not happen before I get back. I guess I’ll find out shortly.
