Little Red Stool

I think most people consider the non la, the conical hat worn by everyone from rice farmers to trash collectors, the most easily recognized image associated with Vietnam. I disagree. If any object in Vietnam is iconic, by which I mean ubiquitous, irreplaceable and emblematic of the daily life of the vast majority of Vietnamese, it is the Little Red Stool. Oh how I love thee, let me count the ways.

Oh red stool, you are always an indicator of the best, and cheapest, food Vietnam has to offer. Any chair with a back and four walls to surround it is sure to increase the price and decrease the quality by a factor of four. It is you that shines like a crimson beacon on sidewalks across the length and breadth of Vietnam, pointing the way to delicious cauldrons of steaming pho or bun bo hue or bun thit nuong like a lighthouse to a wayward and starving sailor. Easily stacked and strapped to the back of moto, bike, or cart, you are whisked away at the end of every long day, free from the binds of taxation or permanant address or sanitation standards, only to return reassuringly with the dawn. Harbinger of streetfood, I salute you.


Oh red stool, you provide seating where there once was none, where many thought seating was never meant to be. In aisles and hallways of theaters, hospitals, nay! even "private" buses, you democratically and generously allow all the wretched comers to rest their weary haunches in numbers far exceeding pedestrian concerns of "safety." Some might consider the intrusion of an elbow into their back or a knee into their thigh for a 3 hr bus ride a burden too heavy to bear, but not I, red stool. Let the prols come, let them sit on your four flimsy pillars of communism, for they have been making French Fries all day for the gringos, and must dream fitfully of revolution.


Oh red stool, you are tool and toy, father, mother, secret lover. You allow us to reach objects five inches from our grasp and let us sit with our knees six inches away from our faces. You make tall white people look ridiculous. But soon the rains will come, and your sidewalk habitat will be made untenable by the vagaries of weather. But you will retreat, into the covered places, and you will bide your time. And in the spring, when the showers end and people emerge hungry and stiff from months of sitting in proper chairs, you will have your day in the sun.



Red stool, I [heart] you.

Put a leaf on it

After moving into the city proper for our second two weeks in Hue, we worked at Hue University Hospital, the teaching hospital for Hue Medical College. The work was similar to my daily life as a resident in the states: morning rounds followed by time spent teaching the medical students. I loved my time there - I got to focus on teaching and I learned so much about the similarities and differences between the way medicine is practiced in Vietnam and the US. And the fact that we only worked from 7am until noon, with a 30 minute break for coffee and pho, didn't hurt.

After practicing my Vietnamese over breakfast, we would adjourn upstairs to see the new admissions and the sickest patients. Dr Thuy, Chair of Internal Medicine, heart and soul of the department and my boss for the two weeks, would lead the students on bedside rounds. His breadth of knowledge and sense of humor were unparalleled. I served in a consultative role, weighing in on the differential diagnosis and how we would treat things back home. I also got to do lots of teaching of physical exam skills, much more important in Vietnam given the limited access to diagnostic tests but often less practiced given taboos around touching patients of older age or the opposite gender.


I saw some amazing things, from the medical management of an ST elevation myocardial infarction (that's a really big heart attack, for those of you who don't speak medicalize) to the diagnosis of depression based on a patient's hairstyle. I saw a patient rapidly deteriorate from presumed dengue fever in a matter of hours, followed by a futile attempt to rescuitate him when he went into an unstable cardiac rhythm. Interestingly, the doctors agreed to continue breathing for the patient until the family could transport him home, because otherwise the patient's soul would always be left wandering. One of the most interesting aspects of medical care in the hospital was the side by side use of Western and Eastern medicine. Unlike in the US where patients usually go to a second provider for their accupuncture or herbal remedies, those were prescribed right along side antihypertensives and aspirin. For a patient with an infected diabetic ulcer on his knee, in addition to broad spectrum antibiotics he was told to put a leaf on it. We also learned that patients have to pay by the day for their hospital stays, and that families bring in all their own food as well as do most of the basic nursing care (and hospital laundry).


I got particularly involved in the case of an 18 year old boy left paralyzed by a mysterious illness, most likely a viral encephalitis. I am still working with the Brigham neurologists back home to try to come up with anything to help him. He was actually transferred out of the University Hospital to the Tuberculosis Hospital on the chance that it might be tuberculosis (it wasn't). Because they do not have negative pressure rooms to isolate the tuberculosis patients, they are housed in a beautiful old French colonial building, which has its wide shuttered windows kept open so that a good cross-breeze can keep the tuberculosis at bay.


But my primary responsibility was teaching the medical students. Each day I would prepare a talk on topics such as hypertension or diabetes, which are so familiar to my work in the States and of growing importance in Vietnam. One study found that the rates of these chronic diseases nearly doubled when people in Vietnam switched from bicycles to motorbikes! Doannie was a huge help since he has much more experience in pedagogy as well as much more Vietnamese. It was so much fun for us to work together in our respective careers - here he is explaining surface tension, of course using as his example the head on a freshly poured beer.

A Trip down the Perfume River

First, an apology to those of you following the blog. Our last 2 weeks in Hue were spent living in the city, carrying out a daily routine of work at the hospital in the morning, lounging by the pool after lunch, Vietnamese classes at the local University in the afternoon, and discovering a delicious new spot to eat each night. We thoroughly enjoyed our little attempt at becoming part of the fabric of everyday life in Hue, but it didn't make for dramatic blogging.


We finally hit up the main tourist attraction in Hue during our last week. The beautiful Perfume River runs through the center of Hue then meanders on past the royal tombs built by the emperors of the Nguyen dynasty in the 1800s. It is a relaxing and efficient way to the city sights, and despite its clearly touristy nature Doannie managed to have a good time. Here are a few of the highlights...

The Tomb of Khai Dinh: Known for his extreme vanity, his tomb is famous for its small army of mandarins. Can you pick Doannie out of the crowd?


The Tomb of Tu Duc: Known for his love of poetry and his dedication to building beautiful grounds, his complex also housed over 100 wives and thousands of concubines. Doannie hangs out in the ruins of the concubine palace.


The Monastary where Doannie's mother's cousin Cau Han waited out the American War:


Trying my hand at making incense at a shop alongside the river: This area is also famous for the construction of the most well-photographed symbol of Vietnam - the conical hat, or non la.

Pig of the Forest

There is no doubt that you can eat some really strange stuff in Vietnam. Congealed duck blood is served with ground beef, still-beating snake hearts can be procured in a shot glass filled with the blood of the unfortunate reptile, all with a vodka chaser. This doesn't even mention the oft-cited prime example of the unusual Vietnamese culinary tradition: the roasted dog, bane of every mercilessly teased Vietnamese immigrant child everywhere.

But it turns out that this list is far from exhaustive. Despite the lush productivity of their lands, the effortless fertility of their soil, the Vietnamese seem to have left literally nothing off the table in their quest for a good meal. Holly and I got to experience the smaller, furrier side of Vietnamese cuisine at a place called Huong Lua, far outside of Hue.

Of course, it would be uncle Han who took us to this place. For those of you who don't know, Vietnamese men's favorite past time is an activity known by a single word in Vietnamese with no precise translation in English. To ngo translates roughly as "drinking and eating prodigious amounts at a sub-glacial pace, typically while women form a human conveyor belt of food and alcohol and simultaneously mind the children, houses and businesses." I blame the particular talent and energy that Vietnamese men devote to ngo-ing for why Vietnam hasn't won an Olympic medal in.....well, forever. Uncle Han is a practitioner of the mildest form of ngo, a pleasant collection of overworked older men, gathering for some good natured toasts and friendly ribbing. At the ngo's worst however, spirits can be broken, pride obliterated beyond recognition, vast sums of money exchanged without thought or consideration of consequence. Insiders know that a prolonged ngo session between Ho Chi Minh and President Diem started the whole mess that the country has never really recovered from since, the ultimate day-after hangover.


So our particular ngo began with sight of this little fella. On the ride over to Huong Lua, Uncle Han was explaining to me what sort of foods were available at our destination. As I've described, some foods in Vietnam are odd because of composition, others are weird in translation, still others strange in circumstance. What Uncle Han described to me was sort of all three. I know the word for pork, which is heo. Okay then, something with pork. But he followed it with other words which were lost on me. We stumbled through a few more sentences of missed meanings when he was finally able to break out with a phrase in English: Pig of the Forest. As yes, the elusive Pig of the Forest, terror of woodland denizens everywhere, otherwise known as a wild boar. Arriving at the restaurant/petting zoo/slaughterhouse, we saw this decidedly un-fearsome looking little guy sitting in a cage next to a civit, a hedgehog, and several lizards. Luckily we were spared from having to choose which animal(s) would be served up to us, but we went inside to see what other surprises were to follow.


The remainder of the evening was filled with delights less grisly and more PETA-friendly. It turned out that we were there at the same time as huge group of driving instructors, all of whom were, bizarrely, drinking copiously without a designated driver in sight. Holly and I already know how to parallel park, so they became intent on teaching us other essential Vietnamese skills.

Vietnamese toast in the following ways, nearly all of which involve standing:

• "Tram phan Tram" -This essentially means, 100 parts of 100, or 100%. We would call this, Down in One, or Bottoms Up. In other words, drink your whole glass, or you suck.
  
• "Nam muoi phan Tram" - 50%, or drink half.
  
• "Di Saigon" - Literally, Go to Saigon. For people anywhere north of Saigon, the city Saigon represents the the bottom of the country, a proxy for the bottom of the glass, the view of which should be unobstructed by beer by the end of this drinking session.
• "Di Da Nang" - Da Nang is roughly in the middle between Hue and Saigon. Get the picture? People in Ha Noi will substitute this with Hue, which is the exact geographical center of Vietnam. No wonder the Vietnamese are so good with their geography.

So that's how we spent the better part of the evening, analyzing our spatial relationships in relation to other cities in Vietnam and practicing fractions through the soft, light amber haze of our favorite fermented beverage.

To all of those friendly gentlemen, may they always drive straight and use their horns liberally.

Di Saigon!

Like Costa Rica - without the crowds or the harness

Costa Rica has the canopy tour through the Cloud Forest of Monteverde. Switzerland has the sport of canyoning through the gorges of Interlaken. Both of them appeal to tourists seeking adventure-eco-travel, and both are wildly popular (and fun). You can do all of this and more for a fraction of the cost atop Vietnam's Bach Ma mountain without running into a single other tourist - if you are willing to go without the helmet and the harness.


We spent the past weekend at Bach Ma National Park, which rises 1450m above sea level but lies only 18km away from the sea itself. The number of tourists is limited by the few places to stay on the mountain - only a handful of charming old villas leftover from the French Colonial days. In fact, we were told there was only one room left on the whole mountain and we would have to share a triple with our friend Phuoc from Boston. Which was fine, but odd considering we saw only about 30 other tourists during our entire weekend there. The Vietnam tourism industry is totally missing out by not promoting Bach Ma as the eco-adventure experience it proved to be, but it sure was nice to have it all to ourselves.


We arrived at our villa after a harrowing half hour of careening up switchbacks on a single lane road - reminiscent of our friends Jesse and Theresa's recent post from their trek in India. We had left Hue in 90 degree heat but we emerged into 60 degree bliss. For much of the day the mountain was shrouded in a cool mist, making it one of the few true clout forests in the world (http://en.wikipedia.org/wiki/Cloud_forest). When the fog dissipated, the view was spectacular: ribbons of river winding through shimmering rice fields and spilling into the South China Sea.


After taking in the views and enjoying a light lunch, we set out for Bach Ma's most ambitious hike, which would take us by 5 lagoons before we reached a spectacular waterfall. The two people who ran our villa said it would take the whole afternoon, and they were right. But they somehow failed to mention the part about pulling yourself along wires wrapped around trees as your traversed through the gorge, or the 700 steps you had to go down to get to the base of the waterfall...and then the same 700 steps you had to go back up.


Doannie was made for this sort of thing, with his low center of gravity, freakishy long toes capable of grasping slick surfaces, and his general lack of fear. I on the other hand am pretty risk adverse. I may have bungee jumped 400 feet from a cable car in Switzerland and rappelled down waterfalls in Costa Rica, but both of those were before I turned 30 and both of those were with quality carabiners and ropes. It was all Phuoc and Doannie could do to keep me from turning back, and if the views were not as magnificent I probably would have! For the final test of the 1400 steps, I was huffing and puffing and seriously concerned that I might have a small troponin leak. We made it back just in time for dinner at the villa. I'm still recovering.

The Sound of Music

Odd things can happen to you at any time. You can find 20 dollars on the street, or you can get hit by pigeon poop walking across a public square. In this particular case, we got accosted and serenaded by a gaggle of nuns after running into a group of Microsoft employees from Seattle bringing 20 computers for the convent.

Those of you who are following this blog know that we have been staying at the clinic attached to my aunt's convent for the past two weeks. Still, the number of actual nuns that we have run into has been pretty small, and for the most part, they have been short interactions, full of deference, soft voices, soulful eyes.

Not this time. This time, we met up with about 10-15 Aspirants, or young women who are just beginning the 13-14 year long journey to full nun status. We proceeded to go through long meandering conversations in English/Vietnamese hodge podge with some of the most spirited and boisterous people I have ever met. It was as if every single one of them was like Maria from the Sound of Music. It wasn't clear to me how the metamorphosis from chatterbox to serene vessel of God's grace was supposed to occur, but I suspect that it has something to do with the two year VOW OF SILENCE that each of these Aspirants was about to undertake. If I was about to not talk for two years, I would probably be yakking my head off, too.

But clearly, the most surreal, Sound-of-Music-like moment was about to come. For what would be more Rodgers and Hammersteinesque than a full-on musical moment? One nun would start, and then all the rest would join in with perfectly blended, multi-part harmonies. Somehow, we got shamed into our own choked version of America the Beautiful, only to later learn that these nuns have choir practice three times a week. Basically, we got vocally hustled.

They invited us to join them for a ride on the famous Dragon Boat tour of Hue's Perfume River, but we declined. I won't say that we didn't feel like getting schooled again as they sang up a storm while floating down the river, but I'm sure if factored into our decision.

Here's your moment of Zen: We were there with our friend Phuoc, who also has a caucasian wife and he was showing them a picture of her. She is also blond and fair skinned, and one of the nuns asked if she and Holly were related. To see her response when we said no, you'll have to watch the video of the singing shown below:

Oh how, the tables have turned. Please see www.alllooksame.com

HIV Home Visits

Today we set out early in the morning for the countryside of Quang Tri province to call upon 3 of the HIV patients under Di Dien's watch. On the way there we learned that she has 95 HIV/AIDS patients assigned to her and that about 1/3 are on anti-retroviral treatment (ARVs). As a primary care provider of sorts she does not dispense ARVs; the patients must make the trek into Hue once a month to the dispensary at the main hospital. Rather she serves more as a case manager for the patients and their families, periodically checking in on them to ensure that they have the food and water and shelter necessary to comply with their ARV regimen. The standard ARV regimen in Vietnam consists of three medications which must be taken twice a day with food and water; if a patient misses doses the virus can rapidly develop resistance to the medications, rendering them useless. The same is true of anti-tuberculosis regimens (a four drug combination), and about 10% of patients with tuberculosis in Vietnam also have HIV.

Patients are referred to her from the Infectious Disease Unit of Hue Central Hospital after they have been diagnosed with HIV. She and her staff of volunteers conduct an initial home visit to assess the living situation upon discharge. They look for things such as whether there is running water, a clean cooking area, and a separate latrine from the house, or whether the patient even has a house at all. If the living situation is deemed unsafe or unsanitary they argue the case before their board of donors and try to relocate the patient. They also assess the health of the family members, who may or may not have contracted HIV themselves, but are disadvantaged by having a relative with this still stigmitized and often debilitating disease. They check to see whether the children of the family are in school. They provide financial and emotional support for the family, even after the person with HIV dies. All in a day's work for Di Dien.

Of course if she finds a person too sick to stay out in the province, she brings them back with her and admits them to the hospital. Fortunately this did not happen today, although we did visit one young one man with HIV and TB who was recently discharged after she had found him very sick on her last visit. We met him on the side of the road, because his father is currently not allowing him in the house. He showed us his ARV and TB medications, kept in a small baggy in his pocket. Di Dien was very concerned about his situtation and will be working to secure stable housing for him. We also visited a woman widowed after her husband died of AIDS. She and their 3 children (thankfully uninfected) and the grandmother all sleep together on one bed in the simple 2 room structure, although they do have a mosquito net. The cook over an open fire but they do have running water and a proper latrine 20 feet from the house. Much better off than many I met in Tanzania all those years ago. They even have their own local drugstore of sorts - check out this guy on his bike selling an aray of sundries to the tunes of his boombox. He just rolled right on by while we were standing on the path in the middle of the rice fields!

In addition to getting to see the patients in their homes (or lack thereof), today was also an amazing opportunity to see more of the rural countryside. The guidebooks talk about how difficult it can be to get away from the coastline and visit the rural villages nestled in the mountains and foothills of Vietnam. In some cases tourists simply are not allowed by the government. The lack of good roads or anything in the way of a restaurant or hotel is also prohibitive. Standing in the shadows of the rolling green hills which separate Vietnam from Laos today was yet another privledge we were afforded in our roles as part tourist, part family.