by Eve Jacobs
of the world knows nothing about. Fighting is centered in the South, around Ho Chi Minh City - or what many of us still call Saigon - but there is some activity in the central part of the country near Hue and a little in Hanoi and its surroundings. Although Americans are participating in very small numbers, they are driven to win this round. Their stratagem seems simple: to educate Vietnamese leaders who, in turn, will marshal and train select forces. The desired equipment is in short supply, but their goal may be feasible nonetheless: to minimize the projected onslaught of a relentless predator.
(far left) Children at the Hospital for Tropical Diseases in Ho Chi Minh City. Malaria, cholera and tetanus are not uncommon in Vietnam.
(left) One of many posters promoting AIDS awareness in Vietnam.
Many of the volunteers are over 40 - not generally the ideal age to whip the enemy. But these are fighters whose memories of another war stir in them an emotional response that is still strong, more than 20 years after the "fall" of Saigon. They were not the ones who fought in Southeast Asia in the '60s and early '70s, but they have such vivid mental images of the country, composed of a melange of remembered TV footage and the now archived magazine photos of dense jungles, beautiful landscapes and desperate mothers trying to protect children from the fallout of war.
But whether they supported the fighting, had brothers and neighbors in ROTC or marched in anti-war protests, these new warriors now seem to carry a placard advertising a mission of the heart: We've seen this enemy before and we're going to lick it early on this time. HIV maims white, brown and black, strong and weak, kills mothers and children, rips families to shreds, ruthlessly murders the burgeoning talents of artists and students and friends. Their newly proclaimed assault has already lit fires in a small number of other Americans with no memories of the prior war fought here, those who were babies or not even born when their fathers and uncles trooped through the jungles.
It seems like a bitter irony that when foreign investment gave a jump start to Vietnam's economy in 1989, followed by the U.S. lifting its 19-year trade embargo in 1994, HIV came sneaking in on the tail of better times. While Cambodia's and Thailand's HIV epidemics have been raging for years, Vietnam had remained relatively untouched by AIDS until very recently. Now no one is sure how bad it really is. Government figures put the number of infected at about 2,000, but health care workers think it is more like 20,000 and rising. The virus has gained a firm foothold in the South around Ho Chi Minh City - where drug use and prostitution are on the rise - with a far smaller number of cases north of what used to be called the DMZ.
(right) Duong Dinh Cong, a Vietnamese physician, and Dr. Bevanne Bean-Mayberry, a '96 graduate of NJMS, on a congested street in Ho Chi Minh City.
The journey from Newark to Hanoi is a long one, both geographically and philosophically. It took Pat Kloser, MD, a specialist in the care of HIV-infected women and an associate professor of clinical medicine at UMDNJ-New Jersey Medical School, three trips to the northern capital just to set the stage for her intended mission. She made her first to Hanoi in March 1992 - before the country was actually open to foreign travelers - to gain permission to set up AIDS training sessions for health care professionals in Ho Chi Minh City. Her welcome was warmer than she anticipated - by both politicians and the medical community.
"I'll never forget my first meeting with students at the medical school there, their meager supplies and educational tools, and their excitement at seeing someone from the West," she recalls. "They were so friendly, so welcoming, so hopeful."
For Kloser - who was a college student during the Vietnam War - it was an emotional journey. Like many Americans, she says the experiences of her brother - a medic in the Army who tended the wounded on the fields of Southeast Asia - and also the poignant stories of a young man from her hometown drew her to a ravaged country she had never seen. She wanted to go as a peacemaker and a healer.
What she had to offer this quickly modernizing country was never in question. With more than a decade of experience tending the HIV-infected of Newark and its environs, she homed in on the needs of a nation newly challenged with this infection. For while malaria, dengue fever, tuberculosis, tetanus and even leprosy are old but ever-present problems there, Kloser says that AIDS frightens Vietnamese doctors and nurses much as it did ours in the early '80s. "Fear of contracting the virus impedes the rendering of good care," she comments. "We are teaching the teachers at the medical school - who will then train their students - how to take care of HIV-infected patients."
"We want to spare the Vietnamese medical community a descent into paranoia," says Bartholomew Tortella, MD, trauma surgeon and director of UMDNJ-University Hospital's emergency medical services. "We want to teach them what we've learned - that with universal precautions and barrier protection they can do their jobs safely. Why should they have to repeat our mistakes?"
A veteran of seven prior international relief efforts, he accompanied Kloser on her third trip to Hanoi, as well as on her first trip to Ho Chi Minh City in March 1994.
"Time stopped in the South with the fall of Saigon, which was once the Paris of the Far East," he explains. "For us, it was like entering a time machine; everything was so perfectly preserved. In Hanoi time was frozen in 1953, when the French were expelled. We were surrounded by '50s music, style of dress, buildings, hospitals reminiscent of 'MASH' or 'China Beach.'"
He says the Vietnamese people are eager to speak English and hungry for information: "The great period of isolationism is over. Foreigners represent progress, good times."
In Hanoi, Tortella explains, physicians often do open-heart surgery by candlelight, or may have to hand-crank the generator. He says there are wards of people waiting for donated heart valves - rheumatic fever is the most common cause of heart failure - and that as soon as these patients are cared for and released, the wards immediately fill up again.
A bed constructed specifically for cholera patients who become too weak to get up to use a toilet
He was also struck by the complete lack of ambulance services in Vietnam. "You have to get used to people dying who would easily survive in the U.S.," he comments. "A little girl was hit by a car 100 miles from Hanoi. Although she was badly injured and in shock, her family had to scrounge up 100 American dollars from neighbors and friends for a cab to take her to the hospital. The bottom line is, if you have no money and are badly injured, you will die."
(right) A team from the Hospital for Tropical Diseases with Drs. Pat Kloser (center), Vernon Sackman and Cheryl Kennedy
(left) A Vietnamese woman with traditional hat and black pajamas pulls a cart packed with firewood.
"I felt inspired when I left Vietnam. Any sense of burnout I'd been feeling about my work here had evaporated."
- Cheryl Kennedy
Tortella calls his relief work "an important and focusing reality check." Age 40 in rural Vietnam is old, he says. In the cities, you might expect to live until 50.
Labor is cheap, he observes, but supplies are unavailable. Stapling devices, forceps, scissors, clamps, metal instruments - what we use once and throw away, our "disposables" - can be cleaned, autoclaved and sent over, he says, along with antibiotics and unused suturing material. That is what he has done and will continue to do.
"We have no conception of how blessed we are," he states. "When April 15th rolls around and I write out my tax check, I know exactly what I'm paying for."
Working with the Sex Workers
For Cheryl Kennedy, MD, a specialist in the psychosocial aspects of HIV infection, the March 1995 NJMS-Vietnamese AIDS Conference was a rare professional and travel opportunity. A seasoned voyager, she says the guidebooks and her prior international treks did not prepare her for the experience of Ho Chi Minh City, "the press of humanity, being truly a minority - no blending in with the Asian populace - and the striking level of openness, acceptance and courtesy.
"There is a huge, booming economy that knocks you out - there is a lot of money flowing," she says. "The level of enterprise - the willingness to work hard at making a living - is astounding. People sell everything and anything and they do it in a very portable fashion."
But more important to her than "revisiting" a war-torn nation she had heard so much about during college was the question: "How can I be helpful?" In a country with an antiquated health care system, what could an American psychiatrist do to stop the spread of the virus?
"They think Americans have all the answers," comments Kennedy, an assistant professor of psychiatry and preventive medicine and community health. "We look very rich and very successful."
Street scene in Ho Chi Minh City
One source of the Vietnamese HIV problem is the sex trade, which had a resurgence in 1992 when foreign businessmen - first from other Asian countries, then from Europe and Australia - began visiting Ho Chi Minh City. The shared needles of heroin addicts - who go to shooting galleries where they inject the drug into the femoral vein - are also a major means of transmission.
The psychiatrist says commercial sex workers and drug users who have been jailed are sometimes enlisted as peer educators - after their "re-education" by the government - but that they frequently have problems getting the job done. She worked with two "extraordinary women, both with master's degrees - one in social work, the other in public policy," to conduct two days of workshops for nine former sex workers, five former injecting drug users and two teenage youth workers now employed by the government to teach.
The major problems, she says, are related to cultural resistance and lack of resources. "It's a Catch-22," Kennedy explains, "because the government employs the peer educators, but they are afraid of the police, who often hassle them when they're working. The police and government are very powerful here. They also often have only one condom to give each sex worker - who may see five to seven clients in a day."
The psychiatrist helped the peer educators to develop practical strategies: a support group for the sex workers - who do not feel valued; a system of going out in pairs for safety and support; and ways to build alliances with small businesses - such as hotels and cafes - that can have condoms available for purchase and also place them in rooms.
"These people are so dedicated and courageous," she says. "They work at their teaching six days a week in a country where it's unacceptable to talk about sex, even professionally, and they are very vulnerable politically. No one is clear right now where the boundaries are."
Kennedy says the legacy of the war is very visible in Ho Chi Minh City: Amputees - who lost their limbs to land mines during and after the fighting - are everywhere. "But I felt inspired when I left Vietnam," she says. "Any sense of burnout I'd been feeling about my work here had evaporated."
She continued on to Thailand alone after the conference to meet with an international relief group focusing on AIDS. "I am trying to help the Vietnamese find funding for their battle against HIV," she says.
"This was just seed work."
Behind Every Successful Venture, There's a Manager
With advanced degrees in nursing administration and adult family health, and years of experience in what she calls "the administrative side of HIV disease," Pat Correll, RN, MSN, a clinical nurse specialist at University Hospital, was invited to the March 1995 conference to share her expertise in management. "Politicians control health care in Vietnam," she explains, "and physicians are not as esteemed as they are in the U.S."
Researchers are all fighting for a piece of the limited resources pie, she remarks, just like here. How to fund HIV research was the primary concern voiced at her workshops, which were attended mainly by politicians. "I did my best to explain our system's intricacies," she says, "how government agencies work and also how private physicians can conduct research."
When she returned to Vietnam for the January 1996 conference, she went as a nursing consultant.
"The nurses were hung up on the fact that they do not have the necessary supplies to practice universal precautions," she says. "They reuse gloves after bleaching them and hanging them out to dry. And gowns, masks, caps, booties and surgical-strength gloves are only found in the O.R. suites of city hospitals - provincial sites get nothing."
Correll explained to them that proper hand washing should be combined with meticulous preparations for such procedures as inserting catheters and IVs. "I found that the more experienced a nurse is, the more comfortable she is in providing HIV care - with or without all of the recommended equipment," she says.
It's not so different from the U.S. in the early days of AIDS, Correll observes. There are no medicines for treating HIV, and the average life expectancy after diagnosis is just three years. Donated blood is screened for the virus, and HIV testing is available.
"The concept of anonymous testing is foreign to them," she says. "The point of HIV testing in Vietnam is to identify those who are infected, segregate them and control their actions."
This, she explains, is distinctly different from our approach: "We counsel first about risky behaviors, what positive results mean and that one negative test does not mean no HIV. Then we draw blood for testing. If the patient doesn't come back for results, that's not so bad. We've accomplished our task.
"We bring in more people for testing because we don't penalize them. In the U.S., we also offer incentives such as food and condoms in testing centers. The Vietnamese nurses and social workers liked that idea."
Change will take time, Correll concludes. The health care workers are ready; the politicians will take a bit longer.
The Future Is Just an E-mail Away
Ho Chi Minh City has not been untouched by the computer age, but technological know-how and equipment lag far behind the U.S.
Vietnamese participants in the March 1995 conference requested that an expert in database design and computer networking accompany the American team on their next visit. Matthew Sarrel - the "computer whiz kid" of the medical school's National TB Center - fit the bill, and he joined the group when they went back in January 1996.
Sarrel - carrying 25 NJMS hats for Vietnamese conference participants, as well as gifts of computer software and books - traveled without emotional baggage. He was 5 years old when Saigon fell.
He was struck by the pace of life in Ho Chi Minh City where bicycle and motor scooter traffic can challenge even the most adept walkers. "Crossing the street was a trip," he says.
He was also impressed by the eagerness of the workshop participants to learn everything he could teach them. "We worked from right after breakfast until 7 p.m.," he says. "After three days we were exhausted, but we had accomplished a lot."
Right now, there is no way to monitor the spread of AIDS in Vietnam, says Sarrel: "Hospitals need computer systems to maintain accurate patient data, and systems at each health care facility should be able to feed their information into a larger database. Collecting reliable statistics to send to Hanoi for reporting to the World Health Organization is difficult - if not impossible - now."
Another major problem, Sarrel points out, is that the telecommunications infrastructure is inferior and, therefore, modem connections are very slow. "This conference was just the beginning," he explains. "The people are industrious and intelligent, but there is no funding now to continue the work."
Sarrel would like to help Vietnamese health care workers access the Internet. He says e-mail could be used to answer medical or computer questions, and also as a tool for further collaboration between the UMDNJ team members and their Vietnamese counterparts.
A newsletter - prepared at the medical school in Ho Chi Minh City with information retrieved from the Internet - could be a valuable resource for those working in this field.
He has also developed a World Wide Web page on the Vietnamese HIV problem and on this project (http://www.umdnj.edu/~sarrel/vnhome.htm).
"I would like to attract funding for computer equipment to take on my next trip back," he says."We take computerized support for medical research for granted. You need accurate surveillance databases in place to assess the severity of any epidemic."
It's been eight months since the group's last visit to Ho Chi Minh City. But when they take a break from their pressing responsibilities in Newark, the future of Vietnam is high on their list of conversation topics. They talk about the many public health issues facing the rapidly modernizing country: massive automobile pollution and serious crowding in the cities, poor sanitation and the many infectious diseases other than HIV that are rampant everywhere.
They also wonder if they will ever see their Vietnamese friends again, and if, maybe, they will be victorious in their battle to save some precious lives from a cruel fate.
"I think we were provocative - we encouraged people to think," concludes Kloser. "It was also very healing for us to be an early part of bringing Vietnam back into the world community after so much suffering."
The two conferences in Ho Chi Minh City were funded by a grant from the World AIDS Foundation. Other members of the NJMS group were: Bevanne Bean-Mayberry, then a fourth-year NJMS student; Maureen Fitzpatrick, a judge who spoke on the legal and political implications of HIV, and who is the wife of Dr. Tortella; and Dr. Vernon Sackman, a specialist in the dermatological manifestations of HIV, who practices at the Cleveland Clinic. Dr. Kloser would like to continue this work in Vietnam. She is asking that those with time, skills and/or money, and students interested in this mission call her at 201-982-7115 or send a fax to 212-877-1072.
Doris Cortes contributed to this article.