Beyond Biblical Days

Kuda Maloney, M.D/MPhil
Dermatology Resident
Trinidad and Tobago: A feasibility study on the utility of a standard set of Images as a screening tool for Hansen�s disease.

Two heavy barrels block the entrance to the street, communicating the wordless instruction to STAY OUT. But the man leaning against the fence recognizes the social worker, waves two youths over to move the barrels and we drive through. We are in a shanty town built along an old railway line in Southern Trinidad. The community is tight with low tolerance for outsiders, and the living space even tighter.
Despite this, the social worker has established a careful trust allowing the physical and social barriers into the community to be temporarily laid aside, as she visits our contacts. I marvel at her ability to impart vague detail, giving people the impression that they know what�s going on, enough so to allow us access, without imparting any information at all. � We are from the skin clinic� we smile.

We finally identify the house and climb the tenuous steps. She is lying spread across a mattress on the floor, the attraction of numerous flies. A nappied toddler crawls over her, patting her hopefully for attention. My heart stops for a second, fearing that she is dead, but returns to its usual cadence as I see her thin ribs rise and fall. She sleeps while we talk to her husband. We�ll have to wake her we explain, to look at her skin, as they were both listed as contacts for Hansen�s Disease. We explain what it is. � Haw, the one from the Bible?� He asks in awe and we affirm. Eventually we wake her and chat to her. She is spent beyond her 30 years. I�m glad that neither of them have skin lesions or sensory symptoms, glad to not have to add to their list of problems. The next family we screen, deep in a rural village, is a riot. The mother is indeed that biblical picture of the leper, with nose collapsed, drooping eyes, contractured joints, multiple amputations. She has managed to draw people to her, her house is bubbling with the activity and laughter of her children and her neighbors. Only her household contacts, her family, are on the list of people to be screened. It is sobering though when we find classic lesions for Hansen�s Disease in one of her friends who fortuitously dropped by that day. We suspect Hansen�s in one of her sons too, and refer them both for evaluation at the Hansen�s Disease Clinic. Our suspicions are later confirmed. We are again met with warmth at the next home we visit as well as a mixture of fascination and pride that a doctor would visit them at home. We also find a new case of Hansen�s Disease there. The numbers are telling...there is still work to be done.

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Thank you means no? Gia Dinh Hospital, Ho Chi Minh City, Vietnam

It's hard to live between culture, and I've found myself floundering a few times. Americans are so earnest, so honest, so straightforward at times, and I've grown to love this way of being. But I forget.

When my grandmother suffered a series of devastating strokes in Romania, we very sadly had to admit her to a nursing home, I'm sure with plenty of guilt of soul searching on the part of my parents. In addition in this country of transition we had to negotiate the usual channels of official and unofficial understandings. 

When my parents brought the gift for the director of the nursing home, she declined the gift so persistently they almost backed down. Then they remembered where they were, insisted, and the gift was accepted in the end. 

Observing this shifts in customs is familiar to anyone who has traveled across national borders, or even from one part of the US to another. 

In Vietnam I had to recalibrate my social compass. 

I don't fully understand how this works, and will need more experience, but the importance of "saving face," on a having a good outward interaction will often lead the Vietnamese to make promises and plans that will likely not pan out. They may have no intention of lying, and assume you have the experience to understand the situation. 

Several junior physicians had been cajoled into "inviting" me to various activities by my more senior host. They were clearly aware that I was foreign, and needed some guidance to settle in to the country. 

I was hesitant to accept the invitations, afraid of becoming indebted in some way I would not understand.  Not meaning to be rude, I accepted any persistent invitations, and sought out appropriate gifts. Once I replied to a text message asking what I would like to do with "thank you for thinking of me," and I'm thinking of these things.... There was no reply. The next week, in the hospital, I learned that "in Vietnam thank you means "no."" Or just thank you, of course.

Oh. OK. So I explained my own confusion, and we made plans, and carried a few out.

Since then there were a number of promises, plans, and many of them where carried out. Generally repeated confirmation and planning steps were a good sign of future activity. No reminders meant I could make other plans. 

One good friend is working for the CDC in Vietnam. Like many other Americans she was frustrated that agreed upon projects and goals were simply not pursued by their Vietnamese counterparts despite many promises and smiles. She was frustrated. I tried to work on her expectations a bit, understanding that "thank you" without any promises is a pretty clear no, while "yes" is very often maybe, and she'll have to take it easy and see when yes becomes real. 

She was only mildly relieved, but decided to reconsider her position.

Initial expressions of confusion or disbelief will not be very helpful. Anger is never helpful, and mutually embarrassing. Smiling always helps. East Europeans are not great smilers, and this may have been a problem even in Boston, but I'm learning, and Vietnam has been a good teacher. 

Just keep smiling. 

Dan-Victor Giurgiutiu

Partners Neurology

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Please bring food, water, and a caregiver Gia Dinh Hospital, Ho Chi Minh City, Vietnamskss

Since the decades of war ended in Vietnam seems to have always fostered large families (four or five siblings is common), until the recent introduction of a two child limit. The culture and even the language is built around a complex web of pronouns and deferential or authoritative addresses based on relative status drawn from age and kinship, then continuing out into relative social status outside the family.

While I can't cover how this shapes society, I'm particularly struck by the care provided in the hospital. The services that are offered in Boston, from orderlies taking care of bodily needs, to web of care from home visits to nursing homes takes in those who are no longer independent. In Vietnam this is rare, exceedingly rare, and often reserved for the well to do. Nursing homes are reserved for those abandoned by society, who have no one else to turn to.

Instead family steps in, with a rotation of caregivers across multiple generations allowing ailing family members to remain at home. When a hospitalization is required a family member is present throughout the day, and at times at night. Dutiful family members, often but not always a woman, sleep on reed mattresses below the fifty year old beds.

On hospitalization a large container of water, a supply of snacks and several forms of entertainment are arranged on the bedside table, and the patient is bathed and changed into the hospital's pajamas. From that point on feeding, bathing, changing is performed mainly by family. When there is money I understand that helpers can be hired. RNs administer medications, obtain tests, and orderlies help shuffle patients from crowded rooms and hallways to tests.

I wonder how this will change as the post war baby boom ages and the tasks of care shifts to the two children per couple. How will they be able to leave their jobs, or children to care for ailing parents or aunts or uncles? How could they possibly neglect their elder relatives to whom they owe so much? I wonder how the US system of care agencies and locations will be adapted in this country which places so much reverence on family support.

Dan-Victor Giurgiutiu

Partners Neurology

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Privacy and Personal Space, Gia Dinh Hospital, Ho Chi Minh City, Vietnam

Even in Boston I'm taken aback considering the experience of the sick, sharing rooms and experiences that are only making illness harder. The actively dying share rooms with the nearly well, and young, and I wonder if the thin curtain in the middle helps or hurts, if it would be better to just draw it back and share the spectacle of the illness.

In Vietnam this question has been in part answered for me.

When I'm told to see the patient in bed 42, I forget to ask a simple question: �Which one?�

Gia Dinh Hospital was build in the early 1950s, and has not been expanded since that time. A bed shortage forces patients to share beds, head to toe. This has been unfamiliar in the US since people stopped sleeping in the same bed in the 19th Century. However, I'm understanding more about the medical exam format note.

Most notes involved a general section, usually noted as NAD (no apparent distress), starting off the physical exam. 

However, the reason for this section dates back to when everyone worked in large open plan hospitals, where telling apart �a redheaded mustachioed man with a bandaged R arm� from the �redheaded mustachioed gentleman with glasses and a scar on the cheek,� would be your best bet to find the patient of interest among 30 other patients in a crowded ward with bed lined up against the wall.

So I've learned to ask for the bed and at least a few identifying features. At times this will include descriptions of a few family members who will volunteer extra information, and often spare the patient, no matter how well, the burden of telling the story, and will speak for them. 

We are surrounded by a gallery of spectators from the moment we walk in the ward, and they don't seem to want to disperse when we start the interview. Initially I asked if they were related to the patient. No, just passing the time. A family member may be down in the canteen, or having a smoke outside, but they'll be right back to help out.

So, two to a bed, every other patient and family member poking in, we start the interview. 

I'm surprised how much the bedmate, other patients, and other family members chime in when the patient has been interviewed many times before. They will describe if the patient was different yesterday, or what the last group of doctors has said. 

For a woman with likely bulbar ALS, her bedmate starts to share how the patient's husband has left her several months back, due to the illness. 

Once it comes time for the exam, and everyone crowds in to see as I push, pull, tap, prick, and walk with the patient, and much like the US, wonder what else I'll pull out my neurology bag.

Then, when we must speak with the family, and give the bad news, I'm left dancing, explaining that the damage is most likely in the brain and spinal cord, but shying away from the difficult discussion of prognosis. As you can see the subject of palliative care and end of life care is slowly being approached in Vietnam, and I am completely ignorant as to how to tell this woman that she will pass away soon. I promise to speak with the attending physician, to come back and check in. I take some small comfort in knowing she is not alone, that her children, and strangers sharing her bed and the hospital room will listen to her, and provide some of the comfort that we alway struggle to give as physicians.

Dan-Victor Giurgiutiu

Partners Neurology

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