REMINISCING

Oh Hoian. Writing postcards in my living room, reading, admiring tiles. 

- Contemplating, bidding farewells, saying thank yous, making last-minute lists, going. This week has been a bit of a scramble: job application starts (not complaining though! I was sipping on a late night distilled coffee in a local cafe as I read through incomprehensible documents), finishing up the research, presented in the academic meeting, late afternoon ward round as the gentle afternoon glow fills the empty beds, trees turning golden and blooming voraciously, dinners (and ice cream parlours), more lake runs, wanderlust (imaginary bike tours around the country park, Huế, Saigon - they would have to wait). Happy to be going home while sad that I am leaving. Listening to CocoRosie.

xx

SPIRIT OF PLACE

In the early 1980s, Vietnam was at the beginning of a difficult period following the war end. Sir John Ramsden, arriving in Hanoi as part of the British Diplomatic Service’s mission, found himself in the middle of the poverty-stricken and chaotic society. Amidst the post-war living environment, however, one could feel a sense of hope and a relentless fighting spirit of the Vietnamese people.

Sir John went for long walks around the city of Hanoi, bicycled out to the surrounding villages and made trips during the weekends, always bringing along his camera. More than 1,800 photographs of Hanoi had been taken as a result between 1980 and 1983.

*

Sad to be missing the exhibition Hanoi Spirit of Places starting from 19th October, but always enchanted to hear old stories about a place you thought you knew well already - and how the storyteller felt, revisiting the city 30 years later, in his own words, in pictures.

TEA

Whereof one cannot speak, thereof one must be silent.

- Ludwig Wittgenstein 

*

I stumbled upon this beautiful tea house while wandering around old town - it is part of a local social enterprise and run by speech and hearing impaired persons. So to place your order you are provided with little wooden blocks that say 'hot water' or 'bill' or 'thank you', alongside with pencil and paper to scribble. It opens unto a street with only bicycles and pedestrians and on another side, a small rustic courtyard where a local gentleman teaches you to play his self-made pentatonic instrument. 'So you play the piano?' I smiled. My snow mountain jasmine tea arrived, and I drank slowly, pouring gently, as if it is ceremonial. Here every one, as if captivated by the extraordinary silence, stops speaking and starts devouring the sounds of the rain, leaves fluttering with the wind, book page turning. And there she stands, making tea, quiet and resolute.

Reaching Out Tea House | 131 Tran Phu, Hoi An | their story 

IATROGENIC

The term iatrogenesis - means brought forth by a healer from the Greek ἰατρός (iatros, "healer") and γένεσις (genesis, "origin") - is an inadvertent adverse effect or complication resulting from medical treatment or advice.

*

A 16-year-old girl lied on the bed in the ward. Her skin over her youthful face and body is all dry and peeling. She has had high fever with an itchy, extensive rash for the past few days - she is soft spoken, utters a few works occasionally, obviously distressed and in agony. Her rash and itching started a few weeks ago. It was suspected to be eczema and she was treated as an outpatient in the allergy/dermatology department in the teaching hospital nearby, but cortiosteroids, the mainstay of treatment, have not done her well. On the contrary, she started developing a fever that would not go away. A few transfers later, she came here from the provincial hospital. Blood culture shows actinomycetes. Heiman frowned. "There is no way she could have got this in the community. Do you know if she has any risk factor or possible exposure?" The doctor in ICU shook his head, looking puzzled. In the medical notes there is no record of previous medications either. We resolved to asking the girl directly with the doctor translating.

It turns out that she had received an injection from a private clinic before going to the teaching hospital when the rash first appeared, although she did not remember what the drug is, she remembered she did not have the fever then. Forming a microbiological story (i.e. always, always ask: Where is the source? What are risk factors?) it is suspected that she might have had an injection that is contaminated, and in fact this is not a rare occurrence in Vietnam. Children are often taken to receive treatment if they fall ill (be it flu or sore throat) and there is a belief that injection is a far more potent treatment than oral medication - and sometimes if the injection vial is contaminated either during manufacture, transport or storage, bacteria grow and the injection becomes unsafe to use. An iatrogenic outbreak accompanies the influenza season.

Iatrogenesis could sometimes have more lasting and serious consequences. There were cases where children, undergoing chemotherapy for leukaemia, have contracted the hepatitis C virus after receiving blood products. I have met one of them here (a 7-year-old girl, happily folding origami cranes for the end of her bed - does she know what might be in store for her?) and she would hopefully be started on treatment soon in the hope of eradicating the virus. The hospital and blood bank have been notified but no one is sure whether the responsible batch of blood products is destroyed yet. It still leaves me shudder with half-disbelief and half-anger that blood transfusion is not ensured to be 100% safe, especially for a population so young and vulnerable. Screening of blood donors and tracing contaminated blood products remain a mounting challenge as the prevalence of blood-born diseases is high in the region (for instance, with HCV prevalence at 6.1%, compared to a global prevalence of 2.8%) and the accountability system is unclear. Patient safety must be at the heart of all therapeutics and medical practice and "never" events like these really should never happen again. There might be difficulties but there should be no excuses.

 *

Further (but unrelated) reading | Genetic History of Hepatitis C Virus in East Asia (the common HCV found in East Asia is of a different genotype than its American/European counterpart, and is associated with higher viral load but more susceptible to a shorter course of interferon treatment)

ON THE CARPET

A somehow irrelevant thought (to my elective here/Vietnam) but as I stumbled upon this image, of a beautiful oriental rug, it reminded me of a story vaguely related to medicine. Hence I will write it down here.

I remember the first few weeks of starting clinical rotation, freshly landed into the busiest wards in a north London teaching hospital. Still learning how to take history properly within a certain time frame, I often found myself eventually diverging and chatting to patients who were longing for some company during their long stay in hospital. One day I was chatting to this lovely lady in her eighties (who is usually well until she tripped over at home and had a few bruises - the usual set of tests and scans were ordered ?mechanical fall. She was just waiting around and doing crosswords) when the occupation therapist came to tell her that they had a look around her house and recommended that she should add some railing to her toilet, (some other recommendations) and remove the carpet in her living room because it is a significant hazard. She mumbled and protested and was clearly upset. I forgot the rest of the story but I remembered her saying,

I might not be young and beautiful anymore but this is my living room and I will do anything to defend my rug!

We chuckled. Somehow I imagined her as a knight ferociously defending her rug against a torrent of army (which may be known as medical advice) - with the kind of grace and tenacity that only the wise and experienced possess. I don't even know if this counts as any kind of meaningful reflection or contemplation anymore but stories like these are the things that I really cherish about the vocation, of healing and caring for maladies and sufferings. Triumphant and humbling moment like this that lights up the journey, that consoles and reminds you that in front of illnesses all souls are equal, vulnerable but capable of even greater loving and feeling. 

I cannot help but feel extremely blessed and lucky that I have come this far, and just so close to having the responsibilities and being trusted as a doctor, and surrrounded by people who know how this feels too.

xx

OPULENCE

 

A LITTLE WANDER

The mind I love must have wild places, a tangled orchard where dark damsons drop in the heavy grass, an overgrown little wood, the chance of a snake or two, a pool that nobody’s fathomed the depth of, and paths threaded with flowers planted by the mind.

- Katherine Mansfield 

*

Battling Spearman's correlation in the day - travelling light in the weekends. This weekend I went to Sapa - a vast valley habituated by local tribes (H'mong, Red Dao and many others) and lined with rice paddy terraces. Joined by a couple also from Hong Kong we went trekking along the peddle stone paths and among the endless fields. It is now towards the end of september, when the rice plants turn golden and ready for harvest. Our lovely local guide Say (pronounced as Sai) is a 18-year-old H'mong girl who have just started to be a tour guide for a year for Sapa O'Chau, a social enterprise that helps locals learn English and sustain better jobs (Go with them if you are going to Sapa!). Led by her, we walked steadily on in the glorious sunshine - apparently it has been the best weather for weeks. The valley is lively with the sound of streams and waterfalls, children playing; the hues of wild flowers, lush trees bejeweled with the beautiful costumes wore by local people - and hours later we reached our homestay in a Red Dao village in the midst of the hills. Sat down in the hazy sunshine, a cold beer in hand, we chatted until dinner was ready by the open-fire. David is in fact a doctor two years above me at UCL (what a strange coincidence!) and Yaki works for a charity foundation funding environmental NGOs worldwide - so we had some interesting discussions regarding living in Hanoi/London, medicine and sustainable development (and also some fun stories re: school days in Hong Kong. It has been fun since I haven't spoken Cantonese for so long!). The Red Dao tribe is well-known for their knowledge in herbal medicine so after dinner we were keen to try the herbal bath - soaking in hot, fragrant water (prepared by boiling multitude of local herbs for hours) in a small wooden tub. It was not even 10 but we were ready for bed. The night was so serene you could almost hear the stars.

As promised we had a cosy sleep inside the bednet (I like to think of it as a dream-catching net) and got woken up by the resident rooster. Some delicious banana pancakes and coffee later we were off again. This time we took a different route even higher up, so we got some magnificent view across the valley. Walking is a good time for the mind to wander, while your body is so much in the moment of here and now (sometimes only the Cartesian model of mind-body dichotomy seems right) - I like running, swimming and biking too, but there is something special about walking that allows the tangles of the mind to unravel more slowly and freely. Back in Sapa sitting in a cafe I bumped into Joe who I went to college in Wales with - again, what chances! He happens to be doing a South-east Asia expedition as well and would be trekking in Sapa the next two days. We bidded farewell as I had to go back to Lao Cai town for the night train back to Hanoi - and back on the train I was in the same berth with the 3 French girls whom I met on the train a night ago. We had a little chanson-karaoke session before dozing off, as the train rocked us to sleep like a cradle.

Somehow the power of wanderlust has brought all of us together, albeit transiently, from the different corners and walks of the earth - as if by some intrinsic drive for taxis towards the unfamiliar. The more I travel on my own, the more I realise it is really not about the destination, but the journey - outward or inward. The journey that is not focused on the clarity of structure, but rather, the clarity of thoughts and purpose. To meet others, to meet myself in a different environment once more. To flourish, to be wild and untamed. I cannot wait to be on the road again.

xx

ps. I am also happy to announce that my film camera is being loved and battered again. Just wait til I find a photo lab...

DIVE FOR DREAMS

"Happiness is a lasting state which does not seem to be made for man in this world. Everything here on earth is in a continual flux which allows nothing to assume any constant form. All things change round about us, we ourselves change, and no one can be sure of loving tomorrow what he loves today. All our plans of happiness in this life are therefore empty dreams. Let us make the most of peace of mind when it comes to us, taking care to do nothing to drive it away, but not making plans to hold it fast, since such plans are sheer folly. I have seen few if any happy people, but I have seen many who were contented, and of all the sights that have come my way this is the one that has left me most contented myself."

"...if my pleasures are brief and few in number, it is also true that when they come they give me an intenser enjoyment than if I were more used to them. I ruminate on them so to speak, turning them over frequently in my memory, and few as they are, if they were pure and unmixed, they would perhaps make me happier than in my days of prosperity. In extreme poverty a little is enough to make one rich; a beggar is gladder to find one gold coin than a rich man to find a purse full of money. People would laugh if they could see how my soul is affected by the slightest pleasures..."

"It is only when I am alone that I am my own master, at all other times I am the plaything of all who surround me."

- Jean-Jacques Rousseau, Reveries of the Solitary Walker

KHOA NHI

Tucked away from the main building is the paediatric department (Khoa - ward, Nhi - children) of the hospital, where sick children with different infectious diseases are being looked after. It has a certain different feel to the rest of the wards - with balloons and stickers on the wall, a room for parents/carers to rest in, and two rather vivaciously decorated wards for inpatients (with strings of origami cranes hanging by a young girl's bed, small desks for children to do their homework, always full of sounds of chattering, or the occasional lull when people doze off after lunch). Though nothing here is mere small matter - children are often referred here because they have contracted a serious infection, mostly from the countryside through close contact with animals, mosquito or water.

The range of differential diagnoses expands by manifolds. A parotid swelling - is in fact an abscess caused by Burkholderia pseudomallei which is found in paddy fields and still water (Could the young boy have caught it through swimming since he has otitis prior to having the abscess? - No, the bacteria is not found in running water - we had some interesting time trying to get the whole story from the father who is a farmer, with too many questions and answers lost in translation). Meningitis - here the major causative organism is in fact Streptococcus suis (as opposed to Streptococcus pneumoniae or Neisseria meningitdis in the UK) transmitted from pigs to human, and of course, one must not forget TB. A non-specific rash in children with fever - the probability of dengue is high when it is July to December each year.

In the past few weeks I have been going to see this 11-year-old girl elsewhere - who has Japanese encephalitis (JE) and is supported (fluids, feeding, ventilation - there is no specific treatment for the disease) in ITU. She lies there between two equally ill adults, quietly battling while drifting in and out of consciousness. The young ITU doctor explained to me how to differentiate between herpes encephalitis and JE (the former often affects the temporal while the latter affects the limbic region, as seen in MRI imaging; we had to hold the film up to the window in order to see more clearly. Things are mostly analogue here) - and also the range of possible outcomes. He has seen children fully recovered and going to back to school after a month, but there are more who will have long-term cognitive impairment.

Currently, there is a vaccination programme for JE in northern Vietnam when children are 1-5 years old but only in high-risk areas. With JE virus still widespread among swines, it is unlikely to be fully eradicated and unvaccinated children are still largely at risk of this debilitating disease.

*

Further reading | Effectiveness of the Viet Nam Produced, Mouse Brain-Derived, Inactivated Japanese Encephalitis Vaccine in Northern Viet Nam (PLOS Neglected Tropical Diseases)

Immunisation schedule in Vietnam 

TERRA INCOGNITA

The beauty of living here is that, even after weeks or months, when you turn into a small alleyway you are bound to see a space unknown to you before, a fleeting moment of charm and grace (be it a bird chirping in cage or children at play, old people sipping tea and playing chess, devouring the here and now) - something that will remain so close to the heart of living, of a quiet but resilient exuberance. And in years' time, people will come and go, places torn down and rebuilt; but within the myriad of lanes and backstreets, the urban oasis remains, the collective joie d'vivre indestructible - yet you will never know for certain what is in store behind the facade of the street. The beauty of the terra incognita is seen through diving into the unassuming unknown.

xx

NIGHTCALL

(Realise that I might lose some audience by not putting enough visuals in; so here we go)

People drinking coffee in cafes until late | Tadioto: a club/cafe/bar in an abandoned industrial complex | Moveable scenery on the road | Jazz by musicians from the Academy of Music at L'espace (very good!)

TAKING SHAPE AS WE TRAVEL

"Touch is a reciprocal action, a gesture of exchange with the world. To make an impression is also to receive one, and the soles of our feet, shaped by the surfaces they press upon, are landscapes themselves with their own worn channels and roving lines. They perhaps most closely resemble the patterns of ridge and swirl revealed when a tide has ebbed over flat sand."

- Robert Macfarlane, The Old Ways: A Journey On Foot

C'EST CĄ! ESCHAR

I remember last March well. Every morning we turned up at the ID ward at University College Hospital (where the Hospital of Tropical Diseases in London keep their inpatients) to go through the "case of the day". Prof or the specialist registrar would go through the chronological order of the patient's story, and we asked questions in turn (always ask for travel history!), hoping to formulate some plausible and probable diagnoses as we go along. One of the old favourites would be travellers coming back with an eschar*. Again here we saw an old lady with an eschar just on her shoulder - she came in with a fever but otherwise not too unwell.

*a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but also seen in gangrene, ulcer, fungal infections, necrotizing spider bite wounds, and exposure to cutaneous anthrax

Usually in this case anthrax is not so likely; more often the eschar would have been caused by a tick bite, causing rickettsiosis (and then the disease will be rather confusingly named after the geographical location of where the tick was, see here)

In Asia, however, the rickettsiosis is caused by the intracellular parasite Orientia tsutsugamushi, a Gram-negative α-proteobacterium** of family Rickettsiaceae (so not exactly a rickettsia!). It is named after it was isolated in Japan in 1930 - The disease is thus called scrub typhus, as the mite (similar to tick, but smaller) lives in scrubs.

**Proteobacteria: In this group all are Gram negatives. The group contains many pathogens such as Escherichia, Salmonella, Vibrio and Helicobacter. Because of the great diversity of forms found in this group, the Proteobacteria are named after Proteus, a Greek god of the sea capable of assuming many different shapes

Below is the picture of the tsutsugamushi triangle where scrub typhus is endemic. The rule of thumb is: if you see an eschar on a patient in the triangle, think scrub typhus, give doxycycline for a week (as per most of the eschars). Typhus is a notifiable disease in the UK.

image source

STUCK IN THE MUD

A young man has always been working in the field, like many of his peers who are from the countryside near Hanoi. He was diagnosed with epilepsy when he was 11 years old, and is on regular anti epileptic medication. Two months ago he decided to stop the anti-epileptic as he hasn't had a seizure for a long while - and soon after that one day while he was walking he had a fit, lost consciousness and fell into a peat bog*. He fell head first into the mud and only after a long while was he discovered and pulled out from the swamp.

*wet spongy ground of decomposing vegetation; has poorer drainage than a swamp; soil is unfit for cultivation but can be cut and dried and used for fuel

Few days later he started having a high fever, and gradually it evoluted into a myriad of symptoms - cough, sputum, breathlessness and also a stiff neck and endophthalmitis in one eye. The provincial hospital transferred him here to NHTD. He had multiple imaging done - chest x-ray showed a diffuse shadowing in both lungs. Thus, he was suspected to have inhaled the mud while he was unconscious. Querying multiple infection and aspiration pneumonia he was started on multiple antibiotics. Nevertheless two weeks have passed and he is still doing rather poorly.

We went down to see him in the general infectious disease ward. After putting the pieces of the story together, Heiman and Baz (another ID consultant from London) figured out the key -

Normally, aspiration pneumonia may be caused by anaerobes and gut flora (the bacteria generally present in food and the digestive tract) - but if what you have aspirated is mud - one must consider the possibility of fungus and mould. 

Ah, an unifying diagnosis: mucormycosis. Turns out some fungi and mould can be so invasive that even someone with a healthy immune system can fall ill, very ill.

He is started on intravenous amphotericin B and ideally also posaconazole (another anti-fungal, although it is highly probable that it is not available here. One must make do). Meanwhile, I asked about the value of adding flucytosine because of his potential meningeal involvement, but flucytosine is only useful with cryptococcal infection especially, not all fungi. I hope he gets better real soon.

*

Mucormycosis: a rare infection caused by organisms that belong to a group of fungi called Mucoromycotina in the order Mucorales. The symptoms of mucormycosis depend on where in the body the fungus is growing. Mucormycosis most commonly affects the sinuses or lungs. If the infection is not treated quickly, the fungus can spread throughout the body, and the infection is often fatal.

Further reading | Centers for Disease Control and Prevention: Mucormycosis

THE UNKINDEST CUT

The intensive care unit has 15 beds, and every day at least 2-3 beds will be occupied by patients with tetanus. Tetanus is virtually unseen in the developed world because of well-established vaccination programme, but in Vietnam, elderly and the older generation with inadequate vaccination are still vulnerable to the potential lethal infection, often contracted via skin cuts and upon exposure to soil and rust. As patients often do not recognise the importance of receiving post-exposure prophylaxis (in this case, extra doses of vaccine, which contain the inactivated toxin), many did not go to emergency department to receive treatment and only presented to hospital when they are already experiencing "lockjaw", painful spasms and even respiratory difficulty caused by the neurotoxin produced by Clostridium tetani. They may often experience autonomic dysfunction (resulting in abnormally high or low blood pressure or body temperature) - Mortality can be up to 70% if untreated.

Here you would see patients (often farmers, or hawkers and rubbish collectors who spent hours on end treading on the streets) lying on the bed looking terrified and distressed, stiffed and twitching from muscle spasms caused by the tetanus toxins. They would have a tracheotomy (a breathing hole through the trachea via a cut in the neck) and be on mechanical ventilation for 3 to 4 weeks, followed by weaning off in a side room. Sedation is not a common practice in ICU here so you see patients obviously looking uncomfortable, being intubated wide-awake. There is also a general lack of knowledge of tetanus among the public - there was an instance where a female farmer stepped on a needle (probably discarded by intravenous drug users) in her allotment. She hurried to the local clinic to receive post-exposure prophylaxis for HIV (paid hundreds of dollars on end), only to be found to have tetanus days later and was in a critical condition for a long while.

I wonder if giving tetanus vaccine is a common practice here in A&E or in primary care setting if a patient present with open wound/injury/contact with soil or rust - that would be something to find out.

*

Tetanus: from Ancient Greek: τέτανος, tetanos "taut", and τείνειν teinein "to stretch"
Clostridium tetani: Gram-positive, rod-shaped, obligate anaerobic bacterium 

THE JOY OF SOLO

“I often think of the image only I can see now, and of which I’ve never spoken. It’s always there, in the same silence, amazing. It’s the only image of myself I like, the only one in which I recognise myself, in which I delight” 

- Marguerite Duras

THREE TIMES AT LEAST, EVERY SINGLE DAY

(Vietnamese person speaking Vietnamese to me - in the shop, in the street, in the park, there were even instances where a motorcyclist stopped to ask me for direction)

me: (pause for 5 seconds) Xin lỗi, tôi không nói tiếng Việt (with probable clumsy pronunciation and weird intonation: Sorry, I do not speak Vietnamese)

them: (look astonished) But you look Vietnamese! Where are you from?

me: Hong Kong.

them: You sure you're not Vietnamese?

...

COUNTRY STUDY

Well, I might as well not let the work go to waste right?

*


Epidemiology

Viet Nam has a population of 87,848,000. 86.2% of the population is Kinh (Viet) while local ethnic minorities such as Tay and Hmong make up the remaining population. The country is bordered by China, Laos, Cambodia and the South China Sea. The capital city is Hanoi since the reunification North and South Viet Nam in 1976. 30% of the population live in urban area (compared to a regional average of 50%) and Gross National Income per Capita is USD3,070 (compared to a regional average of USD10,218). Viet Nam was politically isolated and impoverished when it was first reunified under the Communist government, but since the Political and economic reforms (Doi Moi) launched in 1986 Viet Nam has transformed from one of the poorest countries in the world, with per capita income below USD100, to a lower-middle income country with per capita income of USD1,130 in 15 years time.

Life expectancy at birth for male and female is 70 and 74 respectively (compared to a regional average of 72 and 76).  6.8% of the total expenditure is spent on health.

There is a bigger disease burden, especially that of infectious diseases, in Viet Nam compared to neighbouring countries. The prevalence of HIV per 1000 adults aged 15 to 49 is 4 compared to the regional average of 1, while the prevalence of tuberculosis per 100,000 population is 334 compared to the regional average of 139. The prevalence of both diseases is rising steadily in the past decades.


Healthcare system

Viet Nam has been introducing social health insurance (SHI) since 1992. The country’s health insurance law was promulgated in 2008, with the goal of universal coverage by 2014. Viet Nam has introduced social health insurance (SHI) to gradually replace a tax-based health financing system since 1992, and currently population coverage for health expenses is 60%. The state subsidises premium payments, and the rest of payment is paid by citizens. Despite its decrease over the years, the share of household out-of-pocket payments for health still accounts for some 55% of total health expenditure.

Public healthcare is funded and governed by the Ministry of Health of Viet Nam - users pay a nominal fee for beds but would need to pay full price for clinical tests and medication.

Political and Socio-economic factors

Modern Viet Nam is a one-party socialist country, but it is no doubt undergoing a transition from a planned to a market economy. Although the GDP per capita is increasing, what accompanies is also a widening income gap and weakened safety net – compared to in the past there was universal coverage of essential health services at little or no direct cost to households. Viet Nam has a developed health service with extensive rural coverage by communes and village health workers, but these rural health services are under threat with the loss of cooperative finances. With the income of poor households not catching up with the ever-increasing cost of healthcare in Viet Nam, study has shown that poor households delayed and minimised healthcare seeking, especially of expensive hospital services. They also had to reduce essential consumption, sell assets and incur debt in order to pay for hospital care. Such inequity may increases their vulnerability to illnesses and in turn their inability to afford healthcare that was previously available, contributing to the downward spiral of health of the poor.

Ethnicity, culture and religion

Vietnamese may attribute illness to biological causes (as defined by Western medicine), spiritual causes or the disruption of balance and harmony. For illnesses that are thought to have a spiritual or supernatural cause, Vietnamese may seek assistance from traditional practitioners or Buddhist monks (Buddhism being the predominant religion of the nation). They generally regard Western medicine as more effective than traditional medicine, but they may discontinue medications or self-adjust to smaller dosages because Western medications are believed to be extremely potent. This might cause problems especially with infectious diseases as they may stop taking antibiotics prematurely and encourage the evolution of multi-drug resistant infections.

Also, despite improving literacy rate and education level, many Vietnamese demonstrate limited knowledge as in how infectious diseases are spread and have little recognition for the concept of preventive medicine. Using tuberculosis as an illustrative example, a sample of Vietnamese people has identified TB causation as malnutrition, excess stress, heredity, sharing eating utensils, and the supernatural. Most people also believe in two forms of TB, namely “psychological TB” (lao tâm) and “physical TB” (lao løc), and often consider themselves as low risk for TB. This may in turn contribute to delayed care seeking and increased risk of transmission because of prolonged period of infective illness.

Geographical factors

Viet Nam is a country vulnerable to climate change, with the majority of the country’s poor dependent natural resource exploitation for their living. The problem of poverty is especially high in rural, costal, mountainous, islands and areas prone to climate change – the reason is multifold. First of all, these areas are difficult to access. Local people would find it more difficult to reach points providing healthcare service and equally it is more difficult for healthcare professionals to reach these areas. They are thus more likely to escape health surveillance and early intervention.

Secondly, Viet Nam is one of the world’s most severely flood-prone developing countries with frequent flooding caused by monsoons, typhoons and coastal storms as the major natural disaster. Climate change brings forth more dramatic and adverse weather conditions to the vulnerable areas, resulting in more rife spread of infectious diseases which in turn impact on health. An example would be that floods favour transmission of dengue fever and more frequent and prolonged floods have increased the disease burden on the population living in low areas.

Research has shown that, however, environmental factors can possibly be counteracted by local adaptations. In North Viet Nam for instance, low land housing types, which were transplanted without modification to the highlands, were responsible for the higher rates of malaria among lowland-to-highland migrant populations, whose ground-level dwellings exposed them to low-flying mosquito vectors. Native hill peoples, on the other hand, had adjusted to the malaria threat by constructing stilted houses with living quarters above the mosquito’s 10-foot flight ceiling. People in Viet Nam are aware of their particular vulnerability to infectious diseases because of their geographical location and are constantly working on adapting to adverse conditions and promoting village healthcare to improve access.

*

Further reading (if you must) |
Centers for Disease Control and Prevention (2008a) Chapter 2. Overview of Vietnamese Culture. Promoting Cultural Sensitivity: A Practical Guide for Tuberculosis Programs That Provide Services to Persons from Viet Nam – US CDC Ethographic Guide to Viet Nam. U.S. Department of Health and Human Services Centers for Disease Control and Prevention

Centers for Disease Control and Prevention (2008b) Chapter 4. Common Perceptions, Attitude and Beliefs About Tuberculosis Among Viet Namese. Promoting Cultural Sensitivity: A Practical Guide for Tuberculosis Programs That Provide Services to Persons from Viet Nam – US CDC Ethographic Guide to Viet Nam. U.S. Department of Health and Human Services Centers for Disease Control and Prevention

Few R, Tran PG and Hong BTT (2004) Living with Floods: Health Risks and Coping Strategies of the Urban Poor in Viet Nam. British Academy (Committee for South East Asian Studies)

Inborn MC and Brown PJ (1990) The Anthropology of Infectious Disease. Annual Reviews of Anthropology 19:89-117

McMichael AJ and Lindgren E (2011) Climate change: present and future risks to health, and necessary responses. Journal of Internal Medicine 270:401-413

Ministry of Planning and Investment, Socialist Republic of Viet Nam (2010) Millennium Development Goals 2010 National Report. Hanoi, Viet Nam

Segall M, Tipping G, Lucas H, Dung TV, Tam NT, Vinh DX, Huong DL (2002) Economic transition should come with a health warning: the case of Viet Nam. Journal of the Epidemiology of Community Health 56:497-505

Tran VT, Hoang TP, Inke M and TKP Nguyen (2011) Health Financing Review of Viet Nam with a Focus on Social health Insurance. World Health Organisation

ONLY IN VIETNAM

1.

Social history

What animals does the patient have at home, since the whole family is ill?
A buffalo, three pigs and a few chickens.
Hmm could it be zoonotic influenza?
No, it seems like it's just a bad bout of food poisoning.

... nevertheless, never forget to ask about pets!


2.

Eating dogs, not a great idea.

Furious Rabies after an Atypical Exposure


3.

Harm reduction policy

The hospital/pharmacy organised free needle exchange programme for intravenous drug users (IVDU) to prevent HIV/hepatitis B and C transmission but very few people went; turns out as intravenous drug use is illegal as Vietnam, police officers dressed up as social workers and lurked in the centre to arrest IVDUs (they need to arrest a certain number to reach monthly target). What antagonism!

LE PREMIER JOUR

I was sitting in the living room with my landlord (him teaching me basic Vietnamese phrases, me playing with his 2-year-old son) when my supervisor came on his motorcycle to pick me up. Heiman is a medical microbiologist from the Netherlands and has worked in Vietnam for several years and during my time here I would be working on the data analysis of his Vinares project. Doing the Vietnamese way he non-chalently signalled me to sit on the back of his motorcycle and off we went navigating the most packed street of Phuong Mai - You can only appreciate the somewhat orderly chaos from the back of a motorcycle, there is barely any space in between cars and bicycles (a relative rarity) and motorcycles but everyone just keeps moving, moving steadily. Slowly moving forward amidst the motorcycle jam we made a right turn into the hospital complex. Comprised of the French Hospital, Bach Mai Hospital (teaching hospital of Hanoi Medical University), Hospital of Dermatology, National ENT and Hospital for Tropical Medicine, the complex is like a small city of its own. There is even a barber by the side of the pharmacy!

While Heiman is parking his motorcycle in the car park I met Binh, who is a lab scientist working just below our unit. She studied in South Korea for 2 years and afterwards she felt paralysed by the sight of Hanoi's traffic, but now she is off on the road again. We walked up 7 stories and on the way I was introduced to the different divisions of the hospital. Triage and outpatient clinics on the ground floor, emergency department on the first floor (for more ill patients, akin to the acute medical unit in a general hospital), wards for hepatitis, virology and parasitology (currently overflowing with patients with dengue fever or influenza) and HIV. Sandwiched between the floors there are also the intensive care unit - which I would be going next week onwards and the children's department ("Mostly fever, meningitis or diarrhoea").

Our unit is nestled on the top two floors of the seven-stories hospital, which run multiple projects at the National for the past seven years on various subjects such as dengue, influenza, antibiotic resistance and CNS infection. Heiman described it as a happy long-term marriage, where the research unit works alongside with the hospital collaborating but also not interfering with what each other is doing.

In the morning I was teaching myself how to use the WHONet for data analysis on antibiotic resistance (now finally all that microbiology reports make sense! Studying the resistance profile of bacteria is almost akin to zoology/ecology, where you can see the usual 'wild type' who is susceptible to the usual antibiotics but also the emergence of the resistant type where the bacteria develop several mechanisms to counteract the effects of their nemesis, I have found this even more interesting than before and have been thinking about its implication also in antibiotic stewardship in hospital and also primary care setting. More thoughts later)

For lunch (Vietnamese lunch hour is 11:30-13:30, what a treat) four of us headed over to the local market opposite to have noodles. Heiman has the best command of Vietnamese and ordered a bowl of soup noodles with everything in it (tofu, snails and beef - it looks delicious), Annette helped me order a mien (golden vermicelli with soup served on the side) while Sophie got iced tea from the stall opposite. Annette is an immunologist who has done much research in dengue and influenza and she is due to move to Melbourne to take up another post later in the year, and Sophie is a specialist registrar in Infectious Disease/General Medicine working at Imperial and also University College Hospital before moving to Hanoi to carry out dengue research for her Academic Clinical Fellowship. It is refreshing to be able to discuss scientific ideas during lunch but also a bit about buying piano, children and expat life here in Hanoi.

In the afternoon I went with Sophie to recruit newly admitted patients for her dengue study and also see how automated vascular analysis were performed, with the lovely research nurse Lien - by looking at the blood flow into vasculature underneath the tongue plus how occlusion of the arm alters pulse pressure during the course of dengue in different patients, the extent of endothelial dysfunction caused by dengue fever can be recorded. Her project aims to look at whether the extent of endothelial dysfunction in the early phase of the disease can predict patient's course of disease (either gradual, spontaneous recovery or in some cases developing bleeding or capillary leak - dengue shock syndrome or haemorrhagic fever) and therefore may facilitate early intervention and closer surveillance for vulnerable patients. Dengue fever is a fascinating disease not only because it manifests in many ways but also of its feature of antibody-dependent enhancement: if you are infected with one type of dengue (there are four types) you develop life-long immunity for that one type, but if you are infected with another type of dengue then it would significantly increase your risk of developing a more serious disease. They are still looking into explanations into this and it has posed additional challenge for vaccine development, because a vaccine must target all four types in order to prevent this phenomenon. (Again, more later! This is becoming a never-ending medical rant)

In the evening I got home quickly and got changed to go for a much needed run. The local park has the third biggest lake in central Hanoi (the Ho Bay Mau) and there were many locals running, playing badminton, fishing or dancing aerobic which is a lovely sight. To cool down I walked around the lake as the night falls and the lake glows quietly with a blue hue. There was also an interesting choice of background music: first some Mandarin classic love song followed by Shostakovich's Jazz Suite, which were both surprising fitting - although it really did make me chuckle.

xx

FIRST IMPRESSION

     

A WEEK OF PRELUDE

The raindrops form the rhythm and birdsong sings the tune. Getting lost in unmarked alleyways, casually sitting by the lake or on the sidewalk drinking bia hoi (locally brewed beer by a Czech recipe as a token of Communist solidarity, apparently), walking through a very wet wet market, sipping on Vietnamese distilled coffee with condensed milk while sitting on a balcony overlooking the busy leafy street, good cheap hearty amazing food every day while hanging out as fours or twos or one (interlaced with green rice flake ice-cream breaks), pleasantly surprised by a long boat trip around the glorious Halong Bay, kayaking among fishing villages, sitting at the back of the motorcycle for the first time and through the jungle and cave and along the coastline we go; swimming all day, swimming together, or alone to the furthest floating platform and watched the ships sail by, in a big beach, or in a small secluded beach that belongs only to us; a half-failed midnight dip later we looked up to a skyful of stars, the sea lit up by fluorescent planktons. To be tanned and to be drenched. To remember the breeze in my hair, the blue hour as blue as your eyes, the lazy morning light, the glow of the afternoon sun, distant thunderstorm, the fragrance of jasmine and incense suffusing the air.

Independence, freedom, happiness.

This is the end of the beginning.

xx

PREFACE

aka an idiosyncratic journey on planning my elective

The more years I spent in medical school the less I know what I really wanted to specialise in - perhaps because I am a generalist at heart - The big picture interests me and everyone (young or old, the alive or the deceased) does too. At the same time I am also intrigued by the small details and the origin of things  - so naturally Infectious Diseases (ID) becomes a speciality of choice that encompasses most if not all the above qualities. Another speciality that I am interested in would be primary care/population health, so I am still trying to decide on which; but of course there are always ways to reconcile both.

I started thinking about where to go for elective in summer 2012, after I got back from a week of medical expedition in southern Yunnan, China with the charity Operation Smile. Working in a rural hospital alongside with doctors around the world has become something that I would like to continue during my much longer medical elective. I would also like to go and live somewhere more unusual but safe enough on my own - and since I have always been interested in South East Asia, it has become my naturally inclined option (instead of South America or Africa). I sent out a few emails here and there with some favourable replies, but being back in London I got carried away by things and the matter of elective sat back on the shelf for a while.

... Until one day I stumbled upon a Chinese blog by a journalist in Hong Kong who was in Hanoi on her own just to chill and write; the way she described Hanoi alongside with pictures of old streets lined with trees, the locals, the laid-back atmosphere, the neighbouring scenic and untamed countryside - I was completely sold and since then have an irresistible desire to live in this old city that has yet lost its lustre and charm.

Meanwhile, through people I've met and a few activities I was involved with during the past year of medical school has got me interested in the prospect of learning more about medical and translational research. Having both the destination and activity in mind I trolled the internet (the Elective Network and also the Lonely Planet, strangely enough, has been rather useful) and several email exchanges and lots of finger-crossing later, I am where I am now.

For the next six weeks I am at the Oxford University Clinical Research Unit (OUCRU) at the National Hospital of Tropical Diseases (NHTD), Hanoi. My main project here would be analysing data for the Vinares project - a 3-year study looking at the correlation of antibiotics use and varying pattern of antibiotics resistance in 16 hospitals in Vietnam - and preparing for its intermediate report for a national meeting in late October. I would also be helping out with other projects that happen in the centre, attending academic and project meetings, seeing patients (in A&E, wards and ITU) recruited in the projects and also venturing out to different places with various people who work here. Prior to the start of the elective I came out a week early to meet Chris, Martin and Bessie who are fellow medics travelling in Vietnam at the same time. We had a truly fantastic week and I could not have hoped for a better start to my time here.

Accomodation-wise I used the Hanoi's version of gumtree/craigslist - the New Hanonian - to have found a nice airy room (with my own balcony in which I am sitting now) located in a quiet alley and just five minutes walk to the hospital. My landlord is a young family living just next door and there are several expats living in the house as well (a French girl and Finnish guy downstairs, a paediatric cardiologist from the Philippines just opposite me)

And in eight weeks time I would have to be back at UCL to finish my final year of medical school. This all seems rather unreal right now...

xx