Mandate for Change

January 27, 2008

I want to tell you a story, but first I have to paint you a picture.

Imagine, if you will, an upwardly country with a population of 86 million. 90% of the road traffic in this country consists of motorbikes. Every day in this country, 38 people die as a result of traffic accidents – mostly due to head trauma following motorbike accidents. Many more become permanently disabled — everyday -- because of motorbike accidents. Everyone is aware of the problem -- it’s hard to spend any time on the roads here without coming across the scene of an accident. If you ask folks, almost everyone knows someone who has died or has been disabled following a motorbike accident. Yet almost no one wears a helmet.

Over the years, the government, the World Health Organization, and various NGOs have weighed in on this on-going catastrophe. Studies were done. Inexpensive, light-weight helmets -- suitable for use in this country’s tropical climate -- were designed. One NGO even built a factory in order to produce helmets. An American president (Bill Clinton) was enlisted to kick off a program to provide free helmets for school children. Certain roads were designated as “helmet roads” and nominal fines were imposed on bare-headed riders.

Still, up until 15 December 2007, less than 5 percent of motorbike riders wore helmets.

OK, here comes the story:

My husband and I arrived in Vietnam in 2005 to serve as short-term volunteers at a rehabilitation center in Da Nang. Many of the patients that we saw in this rehab center were brain-injured -- mostly due to motorbike accidents. Every day, after work, we would go out to dinner and, often, we saw motorbike accidents. These were low-speed accidents, not the grisly sort of carnage that you might imagine. Often, in fact, the only injury was to the head, as the rider flipped over his handlebars or fell backwards off the bike. Unfortunately, that head injury was often sufficient to cause death or permanent disability due to intra-cranial bleeding. Had the rider been wearing a helmet, he would have walked away from the accident. Yet nobody, not even the Vietnamese physical therapists and physicians who worked with these head-injured patients every day, wore helmets.

It occurred to us that helmets, though inexpensive from an American point of view, were pricey by Vietnamese standards. Also, it was clear that nobody wanted to stand out by being the only one to wear a helmet. Towards the end of our volunteer stint, my husband and I decided to address both of those issues by providing free helmets for all the employees of the rehabilitation center. The employees appeared delighted and the director of the facility spontaneously announced that, hereafter, he would require all employees to wear helmets when travelling to and from the center. We handed out booklets that we’d assembled from internet articles and had had translated into Vietnamese in order to help these rehabilitation specialists better articulate to the general population “Why We Wear Helmets.” For the remainder of our stay, those employees wore their helmets. We thought that we had found the key to tipping the balance on helmet use in Vietnam: just give helmets, talking points and a little peer support to people who have first hand knowledge of the tragedy of head trauma.

We returned to that same facility in Da Nang one year later. Do you know how many of those sixty employees were wearing helmets? Zero. Absolutely zero – not even the director was wearing one. What happened, I asked? Where were the helmets? Back at home, they said – we only use them when we travel on Route 1, where helmet use is mandated.

Well, that was certainly disappointing.

By the beginning of 2007, we had established a working relationship with a different rehabilitation hospital -- this one under the auspices of the Da Nang Department of Health. Coincidentally, 2007 was also designated as the Year of Traffic Safety in Vietnam. Going about my work of mentoring Vietnamese physical therapists and physical therapy students in this second rehabilitation hospital, it was hard to overlook the fact that over half of the patients were there as a result of motorbike accidents, many of them having suffered severe traumatic brain injuries. I love the challenge of treating neurological patients, but it was overwhelmingly obvious that I and the fledgling corps of Vietnamese physical therapists were never going to catch up with the on-going deluge of new head trauma patients flooding Vietnamese hospitals every day. We decided to take another stab at the helmet situation.

This time we approached the Da Nang Health Department with the proposition that our organization, Steady Footsteps, would provide every employee of the Da Nang Health Department with a free helmet if the Department of Health mandated their use. They agreed. With a great deal of fanfare, and three television crews filming, my translator and I addressed an assembly of 80 DOH administrators. We talked about the ongoing tragedy of head trauma in Vietnam. We told them that their leadership was essential to ensure the safety of their employees. And we talked about the potential for their helmet-wearing employees to serve as positive examples for the general population.

Well, it worked – up to a point. All 3401 employees received their pale green tropical motorbike helmets with the DOH logo emblazoned on the sides. Guards at the gates of each of the 26 DOH facilities in Da Nang prevented any employee from entering or leaving the facility without wearing their helmet. The employees wore their helmets—even to the market. And because of television coverage, including interviews with the workers themselves, and the identifiable logos on the helmets, they were a recognizable and respectable group of helmet wearers. However, helmet wearing still did not spread into the general population.

Later that same year, however, the prime minister issued an edict mandating helmet use throughout the country. (Groups like the Asia Injury Prevention Foundation had been promoting this idea for years, so I certainly claim no credit for this breakthrough.) Helmet wearing would be mandated on the main provincial roads as of the first day of November and implementation of a law requiring universal helmet usage -- city streets included -- was scheduled for 15 December 2007. Television stations aired public service announcements consisting of poignant stories and graphic footage, urging people to protect themselves by wearing helmets. As soon as the law took effect on the provincial roads, nightly news prominently featured footage of police road blocks and interviews with people who had just been caught and fined and – if they didn’t have their vehicle registration papers on them—had their motorbikes impounded. It caught people’s attention. Overnight, people started wearing helmets whenever they set off to travel out of town. Still, however, only the DOH workers and out-of-towners wore their helmets in the city. You had to respect the efficacy of the police in enforcing the helmet law on the few main out-lying roads, but it was still hard to imagine how they could convince city folks to comply with the law.

But they did. On 14 December 2007, less than 5% of motorbike riders in the city were wearing helmets. On the morning of 15 December 2007, over 95% were. Those who “forgot” to wear their helmets were readily caught up in the multiple traffic stops set up about town.

Now, over a month later, police are no longer working overtime and the news has turned to other things. But people are still wearing their helmets. Whereas helmet-wearing was previously seen as an aberration worthy of derision, it’s now “normal.” Someone without a helmet is now perceived as a “risk-taker”. New incidents of head trauma are less common, but out-patient clinics are gaining a new kind of customer—guys who fall off their bikes with their helmets in place. Instead of lying in the morgue or a head trauma unit, they are now being treated for “whiplash”—a diagnosis with an altogether more favorable prognosis.

What’s the point of this story? Simply this: large-scale behavioral changes require large-scale coordinated efforts, even if there is no organized opposition. There were no big corporations in Vietnam who stood to benefit either way from universal helmet use. There were no economic forces pushing the government either way. Medical care in Vietnam is pay as you go and the government provides no significant financial support for families affected by death or disability due to traffic accidents. The reality of head trauma was available for all to see, and yet people could not bring themselves to do something as simple as wearing a helmet. It took the combined forces of political leadership, police enforcement, the media, and earlier groundwork laid by an NGO willing to invest in designing and producing helmets when there was no market for them. It took all that to produce this “over-night” success. But the important thing to realize here is that there was NO organized resistance to helmet-wearing or to helmet laws – and it was still incredibly difficult to bring this change about.

What chance would we have had if there had been a powerful and well-connected opposition to our efforts?

In America, the large-scale option is not open to those who would have our society move in a more progressive direction. American media and government conspire to marginalize or even render invisible potential agents for change. So be it. Let’s be “sub-versive” in the truest sense: let’s turn society from underneath. Let’s begin the hard work of building caring friendships, supportive communities, local food networks and mutual aid societies that will protect and enfold us as our oil-powered, credit-dependent, imperialistic, corporate-run government becomes increasingly irrelevant to our lives.

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.