Good Morning Vietnam - Johanna Gibbs's vivid memories of southeast Asia

Language limitations and a lack of analgesia: just two of Johanna Gibbs's vivid memories of southeast Asia
The link between health and physical activity is crystal-clear in Vietnam. It's acted out in the open air every morning as young and old work out. From 5.30am the beaches and parks fill with people doing all kinds of exercise - from t'ai chi to badminton. It's an inspiring sight and even persuaded me to learn tae kwon do. The attitude to health through exercise carries through into hospital, where the idea that exercise can make you better is understood. Most Vietnamese know what a physiotherapist is. In addition, non-adherence to exercise programmes is not such a problem as in the west. Patients and relatives take advice eagerly and are good at adapting it to their own environment. This is a refreshing change and speeds up recovery.
Physios also have a highly respected position in multidisciplinary teams. Doctors often spend two years working as physiotherapists in order to become what are known as rehabilitation doctors. In addition, the doctor's practice of non-specific referrals allows the physiotherapist to act autonomously. Most physiotherapists treat private patients after work, bringing them much-needed extra income to supplement their low hospital salary (about 20 dollars a month).
I was in Vietnam to find out if I enjoyed working in a developing country, away from the comforts of the NHS. Before I started my training I had done a volunteer placement at a rehabilitation centre in Bangladesh, but found it rather frustrating because of my lack of experience. With two years of staff grade rotations at Leeds General Infirmary under my belt I was eager to try again.
A US charity, Vietnam Assisting the Handicapped, offered me a two-month post developing the physiotherapy service for amputees. I was based in a rehabilitation centre in the city of Qui Nhon, the capital of the Binh Dinh province on the country's south central coast. Qui Nhon is very much off the beaten track, and I was the only foreigner at the centre, although some westerners had visited before. The hospital director and the prosthetic director spoke some English, but the physiotherapists didn't speak any, and this turned out to be my greatest challenge, despite hiring translators.
Vietnamese patients have a high expectation of recovery, perhaps partly because of a recent upsurge in modern medicine. In fact, people tend to place a lot of trust in medicine generally, both traditional and modern. I once saw a physiotherapist inject herself with vitamin C rather than eat an orange, while the markets are full of old women selling brightly coloured pills. You mention any ailment and they point to a packet, but the pill seems to change every time you ask the question. Strangely, however, analgesia is not prescribed or encouraged.
On hearing a boy screaming with pain, I asked a physio about this and was told that the Vietnamese had a low pain tolerance. This attitude means that many patients endure a lot of pain during treatment - which is disconcerting for a soft westerner to watch. It is not always clear how much patients understand about their condition, prognosis and discharge plan. The educated patients ask questions, but they are in the minority. I am not sure exactly why doctors and physiotherapists don't give patients a full prognosis, but I think it is partly to do with giving the patient hope and partly about not losing face if nothing can be done. Unfortunately, the result is often the patient stays in the hospital far longer than necessary, paying for every day that they are there. Then, when they need wheelchairs and other equipment, patients have no money left.
When I planned my stint as a volunteer, I was keen to work with amputees, and the charity that sent me told me about the unexploded landmines, left over from the Vietnam war, that continue to disable farmers and children. But when I arrived at the centre, I found this specialty was one of the best funded and was staffed by some of the most skilled people.
Most of the new amputees were not landmine victims but had been injured in traffic accidents, due to the huge number of motorbikes. My patient load, therefore, turned out to include people with stroke, orthopaedic conditions, cerebral palsy and injuries from the so-called Agent Orange (the herbicide and defoliant, used by the US military in the Vietnam war), as well as new amputees.
Young and old were treated similarly in a gym, where six physios worked with about 10 patients a day, treating both in- and outpatients. Thanks to a charity, the equipment was fantastic compared to that of other hospitals in the area. We had separate gait re-education areas, hand therapy tables and a matted area for treating paediatric conditions.
However, the Vietnamese physios lacked confidence in using the equipment, which limited its success. They also tended to dismiss new techniques, although this attitude did not seem typical of the profession as a whole. I felt senior people were reluctant to learn new skills for fear of admitting they didn't already possess them. I decided the best way would be to teach through an 'exchange of information', where I could learn from them and, I hoped, they could learn from me.
The fact I was only 24, with just two years of postgraduate work, counted against me when I tried to encourage new practices. The Vietnamese, rightly, have great respect for older people. Although this means a huge amount of experience is handed down, the fact is treatment techniques are changing every day because of the impact of evidence-based practice. However, a lack of research funding means evidence-based practice is not so common in some developing countries. The older physios tend to stick with what they know, and new techniques are only introduced gradually as younger physios rise up the ranks. At the centre, this meant that contraindicated procedures were sometimes used. The most worrying was that patients, often children, with injuries such as supracondular and tibial plateau fractures, were pushed far beyond the pain threshold, while tied to a bed.
Strengthening exercises are not encouraged, so although transitory range is gained, there is increased inflammation and oedema, and active range is lost. I tried to change this, but the response was always that the patients were poor and couldn't afford to stay at the centre for long. Therefore, the most important goal was to regain the range of movement. The ability to squat is most important as this is the position most Vietnamese adopt to talk, wait and, of course, to go to the toilet. I did see some changes in practice while I was there, mostly involving strengthening exercises, but I will never know whether they went on to adopt any new techniques because changing practice immediately in front of a younger physio would have meant a huge loss of face. I can only hope there are fewer screams now I have gone.
The centre excelled in other ways. Patients could stay for as long as they felt they were benefiting. The environment was relaxed, with areas set aside for families to carry out most of the care. Just three nurses were responsible for 150 beds, but they only dealt with medical problems and, as most of the patients were medically stable, there wasn't a huge need for more.
The orthopaedic and prosthetic department was fantastic, producing 250 legs a month. The prosthetists were highly trained, and gave advice and recommended exercise as well as any physiotherapist could do. The most limiting factor to the patients' overall well-being was the lack of any discharge planning or follow-up care. Occupational therapists (OTs) are not recognised in Vietnam: no advice is given about how to cope at home, no adaptations are made to the patient's environment and no help offered on regaining a rewarding life. Patients are fully supported by their families, but the families often don't understand what the patient is capable of doing and so leave them lying in bed all day.
A government initiative to provide community-based rehabilitation throughout the country is now under way. This will go a long way to tackling a lot of the issues. However, the initiative needs proper teaching from experienced staff and, without OTs, skills are limited. My two months in Vietnam were fantastic but not without difficulties. Yet I gained a lot from the negative as well as the positive aspects. In particular, I learnt a huge amount about the sensitive issue of teaching new skills. You must understand the culture of the country if you are to be able to pass on your skills without causing offence.
One must have a huge respect for what is there already and accept cultures will determine the importance of certain goals - in Vietnam one example was the need to squat. Finally, we must not assume that, in the third world, people will instantly do everything we say.'
The Chartered Society of Physiotherapy - Issue: 19 April 2006