Bad News

January 19, 2008

You’re going to die.

I don’t know where and I don’t know when. I’ve never seen your medical record, but I can say with complete assurance, “You’re going to die.”

It doesn’t matter whether you’re eligible for Medicare or Medicaid. It doesn’t matter if your insurance premiums are paid up or not. It doesn’t even matter if you’ve never been sick a day in your life.

You’re still going to die.

Although mutual fund managers caution that: “Past performance is no guarantee of future results,” I’m going to side with history and science on this one--everybody eventually dies.

Given that health insurance and medical care will not prevent one’s eventual death, what are people thinking when they say, “I would love to quit my job and live out my dreams—but I can’t, because I would lose my health insurance?”

I think their real concern is: Who will take care of me if I cannot care for myself? And my answer is—it’s sure not going to be your health insurance company!

Medical care in the US today is set up and run according to conditions dictated by Medicare and big private medical insurance companies. It’s very, very difficult to actually get admitted to a hospital. Hospitals admit only a small percentage of the sick and injured people who pass through their emergency room doors. Most surgery these days is done on an outpatient basis. Reimbursement issues pressure hospitals to discharge patients as quickly as possible. So, the fact of the matter is that, even if you become seriously sick or injured, you may be spending most, if not all, of your recovery time in a hospital bed set up in your dining room as, chances are, you’ll be discharged from the hospital long before you’re able to climb the stairs to your bedroom. If you do pay an ambulance crew to carry you upstairs, you’ll be stuck up there while your spouse scuttles up and down the stairs with your meals. If you’re lucky, Medicare or your insurance will pay for a home health agency to send a nurse out a few times a week to teach your spouse how to change your surgical dressing, and perhaps a therapist to teach you to hobble over to the potty chair and to bathe yourself. It’s going to be hard on your spouse, because she’ll feel guilty about leaving you unattended when she slips out to the pharmacy or grocery store. Maybe this time you’ll have a complete recovery, but at some point, you will enter into a decline that will culminate in your death. Who will care for poor old you?

Will it be your spouse, who is aging, just as you are? Will it be your children? (That’s the bet that most people in Third World countries make.) Even the most well-intentioned adult American children find themselves in a terrible bind when their parents need care, because the kids themselves are tied down with their own financial and family obligations. You could pay out of pocket for a private duty nursing aide. How long would your finances allow that?

When my husband and I decided to quit our jobs, leave the US, and move to Vietnam in order to do volunteer work, one of the decisions we made was to forgo health insurance. This was not a decision we made lightly; we had never before voluntarily opted be uninsured.

Here’s our thinking on the situation: We can afford the same health care that any Vietnamese person can afford. It’s not “top notch”—but it’s not bad. We would rather contribute to the Vietnamese health care system by paying directly for our care than to give any more money to private health insurers.

We chose to move to Vietnam while we were in our fifties and still fit enough to be able to do meaningful work here. We hope that, when we do decline to where we can no longer do so much, that a reservoir of good will and savings will enable us to find and financially support someone to take care of us. It’s a vague notion—and we don’t spend a lot of time thinking about it—but it’s allowed us envision a life in which “keeping our health insurance” is not the ultimate goal.

There’s no doubt that you will die.

The question is: Will you live?

No Place to Run, No Place to Hide

January 17, 2008

Looking back now, I think it was around 3 AM on September 26, 1985, while lying on the floor of the Virginia Beach Convention Center, staring at the underside of a folding table, when my husband and I decided to move to higher ground. We had spent the previous day fastening plywood over windows, emptying shelves, closets and cabinets and then stacking our upholstered furniture, rugs, clothing, books and tools atop counters, tables and wooden chairs, trying to protect them from anticipated flood waters. Hurricane Gloria, described at one point as the “Storm of the Century,” was swirling off the coast, predicted to make a direct hit on Virginia Beach on the morning of the 26th. Our suburban lot, set two blocks back from the Atlantic Ocean, was low-lying. A long-time resident told us that, during the famous Ash Wednesday Storm of 1962, flood waters had reached our front door knob. We had flood insurance but, studying the fine print while hurricane warnings sounded over the radio, we realized that the policy only covered the “depreciated value” of the contents of the house. Depreciated value on a ten year old television, twenty year old books and a thirty year old sofa does not equal replacement value. Thus, the eight hour stacking, stashing and boarding up marathon.

And so, we decided to “be safe” and move to higher—much higher—ground in the Shenandoah Valley, two hundred miles inland. Ironically, six weeks after Hurricane Gloria decided to give Virginia Beach a pass and strike Long Island instead, a storm spawned in the aftermath of Hurricane Juan devastated West Virginia and parts of western Virginia, including the Shenandoah Valley. When we arrived there the following spring, we were greeted by the sight of a two story house, still wedged high in an oak tree overhanging the Middle River, where flood waters had left it months earlier.

We found the home of our dreams--a hundred year old “fixer-upper”-- perched atop a hill surrounded by rolling countryside, framed to the east by the Blue Ridge Mountains and by the Appalachians to the west. No large bodies of water in sight. Safe at last, we thought.

We were taken aback, therefore, when a tornado struck the nearby town of Augusta Springs. It knocked a century-old wood frame church off its foundation, then skipped over a hill and reduced a trailer to a few scraps of aluminum and shreds of insulation. I commented to an elderly neighbor at what a freakish occurrence a tornado in these parts must be and he nodded, noting, however, that the last one he recalled had torn a path across his pasture before knocking the top off one of the massive oak trees that shaded our own house.

“Oh,” I said, swallowing, “I noticed that the tops of three of the oak trees were broken off. They all must have been damaged in that same storm.”

“Oh, no,” he replied. “The tornado only got one of them. Lightning strikes got the other two.”

One day we got word that my friend Lucy’s house had burned to the ground. My husband and I grabbed some crowbars and headed over to her place, thinking to help her shift the wreckage enough to recover some of her belongings.

“No”, she said, as we arrived to see the flat black ruins. “You don’t get it--there’s nothing left to move.”

Her big, solid house-- like our own--had been built of chestnut—a hard wood that had been seasoning for a hundred years. You just can’t get better firewood than that.

Twenty-one years after our run-in with Hurricane Gloria, we passed through the eye of Typhoon Xangsane in our present home in Da Nang, Vietnam, two blocks from the South China Sea. We survived unscathed, but the City of Da Nang appeared devastated. The typhoon ripped off part, if not all, of everyone’s roof. Great trees that formerly lined the avenues downtown were uprooted; tree limbs and downed electric lines blocked most roads.

Yet, even as the winds were dying down that Sunday evening, Da Nang residents were out salvaging corrugated metal panels and fixing their roofs. Enterprising people quickly began chopping up and hauling away downed trees, leaving only leaves and the smallest twigs for the city trash trucks. Electrical service was restored in a matter of days.

Less than two weeks later, another typhoon lurked off-shore. Da Nang residents bought empty feed sacks and headed resolutely down to the beach. They filled their sacks with sand and then hauled them up atop their houses to ensure that their newly repaired metal roofs stayed in place. The second storm by-passed Da Nang but the sandbags remained in place until the bags degraded and the sand sifted back down to earth many months later.

This year, in lieu of typhoons, central Vietnam was pummeled with a series of extremely heavy rain storms. I’m talking about days of continuous, horizontal, masonry-wall-penetrating rain! The storm drainage system of downtown Da Nang, for the most part, handled the run-off well—certainly much better than my old neighborhood in Virginia Beach. The Han River rose out of its banks, covering Bach Dang Street for one day. The nearby tourist town of Hoi An flooded, as it does every year. But, as soon as the flood waters receded, shops were mopped out, merchandize restocked and business resumed. Two days after river waters swept through a neighborhood on the outskirts of Da Nang, reaching a height of six feet within some houses, I traveled through to see freshly scrubbed houses, sleeping mats hung out to dry and people sipping coffee in the neighborhood shops.

My young friend Mieng confided that her grandmother’s house had washed away in the recent floods. Her grandmother lives in a bamboo hut by a river in Quang Ngai province.

“Oh, my God!” I said. “What will she do now?”

“The same thing she does every year,” said Mieng. “Stay at the community shelter until the flood waters recede and then rebuild her bamboo house with the help of her neighbors. My Dad wants her to move here, to Da Nang, and live with us, but she wants to stay in Quang Ngai with her friends and neighbors.”

My friend Tam tells me that, when she was a child in Da Nang, before the American War, all the houses in her neighborhood were made of bamboo. One day a fire swept through and burned them all down. I haven’t seen a fire engine in the year and a half that I’ve lived in Da Nang—but I haven’t seen a house on fire either. Da Nang houses now are made of brick and cement—impervious to both fire and flood. The walls are solid masonry; the floor is ceramic tile over concrete. There’s no carpet, no sheet rock, no insulation. If the roof blows off, they stick it back on. If the floor floods, they mop it. If the walls get wet . . . they get mildew.

Will we be able to avert the disastrous effects of global climate change? Maybe we will and maybe we won’t. But, even without that added complication, bad stuff happens. It always has and it always will. There is no safe place. Insurance policies and new technology are not the only possible responses to life in an unpredictable world. There’s a lot to be learned from cultures that have a history of weathering big storms and hard times.

A flexible reed may survive a storm that fells a mighty oak.

Living in the Material World

January 12, 2008

I came home from Vietnam in 1996 with two adopted children and a different point of view. My family and I lived on a little farm in the Shenandoah Valley of Virginia in those days and we were doing our best to move toward a sustainable lifestyle. Over the previous ten years, my husband and I had worked hard to transform a broken down farmhouse and 13 scruffy acres into our idea of a storybook farm. Our little farm had two big gardens, a small flock of chickens, sheep, goats, pigs, two dairy cows and a quarter horse that we were trying--with limited success--to train to harness work. We were certainly eating well but, due to our inability to circumvent the realities of the American food distribution system, our little farm required constant infusions of cash to enable us to purchase at retail those things we needed in order to be able to sell our farm products at wholesale prices. The situation struck us as difficult and unfair, but the sheer ridiculousness of our basic assumptions didn’t strike home until that first visit to Vietnam.

In the city of Nha Trang, where we stayed while awaiting the completion of the children’s paperwork, small herds of cattle meandered along the roadsides, munching on grass that grew at the edge of the pavement. The idea of building a fence so that cattle could have exclusive, unsupervised use of a field for foraging and toileting purposes began to seem a little eccentric in a country where old men scraped up cow pies from the pavement to sell for fertilizer and most of the city trees produced coconut crops for their respective owners. Back home, we had traded up to a larger pick-up truck to more readily haul livestock to the stock yard on sale days. But, in Vietnam, butcher-weight hogs rode in baskets affixed to human-pedaled carts and motorbikes.

Vietnamese homes, like ones built in America prior to 1900, rarely have closets. It took me awhile to realize that, if you only have two sets of clothing---one to wash and one to wear, you really don’t need a closet. I had labored long and hard to learn to spin and weave the wool from our sheep to make carpet runners to protect the polished wood floors in our refurbished American farmhouse. The Vietnamese damp-mop their locally produced ceramic tile floors and call it a day.

One day, a friend offered to take me to Nha Trang’s central market on the motorbike she shared with the eight members of her extended family. I was still a bit shaky following my initial encounter with Vietnamese traffic in Ho Chi Minh City, but I strapped on my bicycle helmet and climbed aboard. A few kilometers down the road-- just as I was starting to breathe a bit easier--the motor sputtered to a halt. Out of gas and not a gas station in sight! Without a word, my friend pushed the bike to the side of the road, where a lady sat behind a battered wooden table. Counting out a few thousand dong, my friend purchased the petrol contained in one Jim Beam bottle, upended it into the gas tank, and handed the bottle back to the lady. We were back on the road in less than two minutes.

At the market, we bought ten ceramic rice bowls for one US dollar—and yet the single dusty bottle of Scope mouthwash we found there was priced to reflect the length of its journey half-way around the world—and thus seemed unaffordable. There were no napkins at restaurant tables—yet there was bottled water. Why? Because, although there’s running water in most parts of Vietnam, it’s not purified to drinking standards. Thus the popularity of tea, bottled water and—yes—beer. This seems primitive to American sensibilities. And yet—how much sense does it make for Americans to wash their clothes, water their gardens and flush their toilets with purified drinking water? It rather depends upon your point of view, doesn’t it?

Urban Vietnamese now, twelve years later, enjoy greater access to consumer goods and have more income, on average, with which to acquire them. Thin and poor are virtually synonymous in Vietnam; some city dwellers are actually a bit chubby these days. Many families have more than one motorbike and a few of the ultra-rich even have a car. Factory-made blue jeans, knit tops and spike-heeled sandals have replaced the traditional hand-tailored ao dai for fashionable ladies. There’s an internet café on nearly every block. Yet you would still be hard-pressed to find a Vietnamese who would leave a light on in an empty room. You would never find a fan running without someone—often a guest—sitting before it. Half-empty glasses of water are poured onto potted plants, rather than down the sink. Coconuts may grow on trees here, but money does not—and people act accordingly.

An Early Christmas in Da Nang

December 20, 2007

Last Saturday, I woke early to the sound of motorbikes zipping past our Da Nang townhouse. What would I see when I looked out the window? The previous day, scarcely any riders had worn helmets in town, but this day--15 December 2007--was slated to be the first day of Vietnam’s mandatory universal helmet law. Both the Vietnamese government and international groups such as the World Health Organization have long been aware of the on-going tragedy of Vietnam's insanely high rate of traffic fatalities—among the highest in the world. The Vietnamese government and various NGOs (non-governmental organizations) have made repeated attempts to resolve this problem over the years. Back in 2000, Bill Clinton, during his final trip abroad as president, helped kick off the “Helmets for Kids” project, presenting Vietnamese school children with specially-designed motorbike helmets, produced by the Asia Injury Prevention Foundation-supported ProTec helmet factory of Hanoi. Over the years, various helmet laws, limited in both scope and enforcement, have come and gone. Public awareness projects have flared up briefly and then subsided. Seven years after Bill Clinton’s historic visit, motorbike helmets on city streets are still rare enough to attract notice and derision. And even though most Vietnamese are aware of the prevalence of deadly motorbike accidents, that awareness is not sufficient to convince them that they, personally, should be wearing a helmet as they travel the streets of the city. The excuses they offer are astonishingly varied—but it all boils down to the fact that they would never wear a helmet unless they were forced to do so.

So, finally, that’s what the Vietnamese government decided to do. For several months, short and poignant public awareness spots on TV have dramatized the often tragic aftermath of traffic accidents. Since the imposition two months ago of a new and stricter helmet law affecting the main roads outside of town, television news shows have highlighted the vigorous and effective work of the police in enforcing that law. Also featured on local and national news have been the helmeted workers of the Da Nang Health Department and interviews with yours truly at the Da Nang Rehabilitation Hospital along with video images of brain-injured patients at our hospital.

Local shops have offered heaps of brightly colored helmets for sale in recent weeks, yet they seemed to be worn primarily by travelers entering and exiting the city—rarely, if ever, by locals. It’s really hard to believe that everything could change overnight.

But it did.

I padded over to my window on Saturday morning, with all the anticipation I’d felt as a child on Christmas morning. (Would there be snow on the ground? Presents under the tree?) Gazing out my third floor window, through tears of joy, I saw that every single rider passing by was wearing a brand new, brightly colored protective helmet.

For me, it was Christmas.

 

A View From Outside the Box

October 2, 2007
 
Here’s a confession: the person who most captured my imagination during the 2004 American presidential campaign was Teresa Heinz Kerry. She was attractive, out-spoken, and very, very rich. And her job was to distribute the assets of the Heinz Family Foundation in ways most calculated to benefit humanity. How cool was that? Wow, I thought, I wish I could be a billionaire--I wish being a philanthropist was my job! It didn’t seem like a reasonable goal at the time, but it was heartfelt.

That wish came true.

To be completely honest, I’m a billionaire in terms of Vietnamese currency (at an exchange rate of 16,000 Vietnamese dong to one US dollar), and I don’t draw a salary in my new role as “professional philanthropist”—but I do run a US-registered non-profit organization from my new home in Vietnam. I am certainly rich by Vietnamese standards and my family lives quite comfortably here, while I am free to do the work of my new organization: Steady Footsteps. How cool is that?

What would you do if you realized that, compared to most of the world’s population, you were very rich indeed? What would you do if you decided that the things that you were clinging to –job security, rising home equity, readily available health care, and a democratic government—were illusory? Would you hold fast to your present lifestyle—or would you consider doing something “radical”?

This Cracks Me Up!

 September 25, 2007

American Physical Therapist Runs Amok

September 15, 2007

Well, here’s something I didn’t see coming: I’m now doing speech therapy for Vietnamese patients. How strange is that?

I’m not an Occupational Therapist, but I play one in Vietnam. Now, it appears that, by default, I’m playing Speech Therapist as well. Weird, when you think about it, especially since I can barely pull together enough Vietnamese to order banana pancakes and tea in the morning! More prosperous countries have highly trained, experienced physical, occupational and speech therapists. Here, in Central Vietnam, minimally qualified PTs are the only therapists patients will ever see. There just aren’t any OTs or speech therapists here.

Lately, I’ve been luring therapists and patients away from the high, narrow treatment tables of the crowded “PT” area of the hospital and into the newly provided “OT” room in order to get them to try more functional upper extremity activities. There, we work on hand-eye coordination, trunk stability, combination hand-and-arm movements, and bilateral upper extremity function. Having a cabinet full of donated wooden puzzles has allowed us to see that some of the non-verbal patients have pretty sophisticated problem-solving abilities. We’ve also uncovered previously undetected visual and perceptual deficits in this setting. We check patients’ ability to follow verbal commands versus visual demonstrations. Today we experimented with one-step and two-step commands to look into memory issues. And we asked some patients to verbalize about their activities--what color is this?—and so forth. I couldn’t do any of this, of course, without Mieng, my trusty translator. This weekend, Mieng is stocking up on large-print and picture books, markers and notepaper. We’re going to see what we can do with a post-meningitis patient who, we now realize, has double vision and a stroke patient with right-sided paralysis who has word-finding issues and difficulty reading.

I always urge my student therapists to take a functional approach when evaluating and treating their patients. But “activities of daily living” in Vietnam do not necessarily equate with ADLs in my former home country of America. Today, for example, I learned I’ve been operating under a mistaken assumption. I didn’t realize that most families in Vietnam sit and eat their meals on the floor. Many of our patients have difficulty feeding themselves in the hospital when they sit perched on the edge of their bed, without a table in front of them. I thought that issue would be resolved once they returned home, as long as the family ensured that they sat in a chair at the family table. Not necessarily true, if there’s no table or chair at home, eh?

Earlier, I was stunned when a right-handed woman with a paralyzed left arm told me that she could not eat rice.

“Why not?” I asked.

“Obviously,” she told me, “because I can’t hold my rice bowl in my left hand!”

I thought, at the time, that I’d resolved that issue by instructing her to set the bowl on a table with a little piece of rubber mesh under it to prevent it from sliding around while she scooped up rice using a spoon in her good right hand. Now I realize that she probably never eats at a table at all.

Live and learn.