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Medicine in Viet Nam
Nicole Thanh-Cam Vecchi, M.D.
An infrastructure of medical facilities and personnel extends from the city to the village level. However, due to inadequate training and lack of supplies and equipment, the quality of care is rather poor except at some of the teaching hospitals.
The competence of doctors is highly variable. Most physicians working at major medical centers in both north and south represent a selective, better-trained and more dedicated group. A few have studied in Europe, and most speak at least one foreign language. Their experience abroad usually yields mixed results. Of course, it provides an opportunity to expand their medical knowledge; however, some of this knowledge cannot be applied to Viet Nam given existing working conditions. But most appear not to be discouraged by the disparity. As one doctor put it: "It's sad to realize our limitations. But we need to learn about all medical advances even though we can't put them all to use here. They show us what is possible and encourage us to try harder." In some cases, due consideration is not given to the level of doctors' competence. For example, there have been occasions where visiting surgeons with 10-15 years of clinical experience in Viet Nam were only allowed to participate in the most basic surgeries and thus did not benefit significantly from their experience abroad.
Upon returning home, doctors no longer have access to the medical information available to them while abroad. Most of the books and journals they have are at least 3-4 years old, and thus their knowledge quickly becomes outdated. The desire for professional information is evident from the doctors' eagerness to talk with visiting foreign doctors. Many attend French or English language classes in the evening because, as one commented, "Learning keeps my mind active."
Some physicians are less well trained or less motivated to learn or to care for patients. One often hears the comment, "How can we work hard on such a low salary. We have to try to make ends meet even after finishing our regular job in the hospital." With the change in policy allowing doctors to have private practices beside their regular jobs, it is sometimes difficult to find the doctors at their posts even during working hours.
While visiting hospitals in Viet Nam one is struck by the spartan conditions prevalent in the wards. The meager equipment that they do have is antiquated, and many machines have been repaired dozens of times. One of the major difficulties is lack of spare parts.
There is a marked lack of necessary equipment, but at the same time, some of what they have stands idle. Some of the machines were donated without knowing the needs or capability of the particular hospital. For example, many ventilators they have received require a certain oxygen pressure. But most hospitals don't have the oxygen system capable of using pressure limited ventilators. They require volume limited ventilators. A dialysis machine was given to a hospital without a nephrologist and the parts were subsequently used for other purposes.
Lack of medical supplies adversely affects patient care. During the past ten years, valve replacement surgery has been abandoned at the few hospitals endowed with the technical expertise and the bypass machine necessary to perform these operations, because other vital equipment is lacking. Cancer patients miss radiation therapy sessions, for instance, because the only machine in existence is out of order. In one hospital, it was touching to see the families of tetanus patients taking turns squeezing the ambu bag 10-15 times a minute for up to three weeks straight to provide mechanical ventilation. The lack of adequate laboratory equipment further hampers patient care. Old rusted machines used to produce intravenous fluids produce impurities which cause many patients to develop an adverse reaction.
Viet Nam does produce some needed products; for example, IV tubing, penicillin, etc., but their quality is often unacceptable. When asked why Viet Nam can't produce more and better low-technology medical materials such as sutures and transfusion sets, the answer was: "There is no profit in the medical industry so factories are unwilling to produce these products."
In the past, hospitals did not have their own source of income except for a very small budget allocated by the Ministry of Health. The gap between supply and demand depended on the amount of foreign aid the director or his staff could manage to obtain. However, Viet Nam is gradually switching to a fee-for- service system. The reaction to this change is mixed. On the one hand, hospitals now have a steady albeit small income with which to buy equipment and supplies. On the other hand, the new payment system creates problems for patients and their families. For those living far from a medical facility, payment for transportation usually requires tapping their meager savings, even before calculating the cost of the medical care itself. As many hospitals lack an adequate stock of medications, patients' families have to buy medications from abroad or from the local market as the need arises. Not infrequently, patients leave the hospital without further treatment for fear of incurring large debts. There are categories of patients exempt from paying their medical bills. However, it is difficult to meet the exemption criteria, and many do not. A significant amount of medical assistance has been given to Viet Nam. However, more aid is needed, and the aid needs to be better channeled; most importantly, medical assistance must be better tailored to meet their needs. The area in which western-trained physicians can be most helpful is through education. For instance, western medical journals help ensure a constant flow of information. But beside journals and books, significant benefit will come from foreign experts who teach in Viet Nam. As one frustrated doctor put it: "I learn a lot of new information from reading, but when questions arise there is no one to ask."
It is also of great importance to provide scholarships for Viet doctors and nurses to receive training in the west. However, their time and studies should be carefully tailored. They should relate to the environment to which they will return after their foreign experience. Otherwise, monies spent on visiting doctors will, to a great extent, be wasted. They should come with specific goals and their course of study should be programmed accordingly.
Frequently, one cannot rely on the lists of necessary equipment prepared by hospitals. The lists don't always correlate with the hospitals' most immediate needs. Sometimes foreign equipment is seen as a mark of status, and is desired for that reason. However, in fact, the equipment may be more efficiently used at another facility.
The difficulty is in identifying those institutions which need and can use specialized machines and equipment. It is helpful to visit the facilities or to determine needs with the help of visiting doctors with experience at the centers. Experienced persons at teaching hospitals can help to identify the needs and capabilities of staff and equipment at less sophisticated hospitals, and physician exchange programs and on-site consultations in the provinces will also be valuable.
While sending machines is essential, it is equally important to train technicians how to maintain equipment and to provide a supply of spare parts. These steps will ensure that valuable equipment will not remain idle.
Another area in which foreign experts can help is in the field of health care organization and management.
After decades of war Viet Nam is struggling to rebuild. Foreign assistance plays a vital role in this process and its success or failure will greatly affect the Vietnamese people. Health care is one field in which foreign aid can have a direct and significant impact, and there are various ways through which this can be achieved. Foreign experts can help by promoting better public health measures, by helping to provide better training to medical personnel, and by providing necessary equipment to the appropriate institution.