Why We're Here (The Long Version)

The seed of the idea that eventually became “Steady Footsteps” was planted in a little house in Nha Trang, Vietnam, in 1995. My husband Dave and I had come to Vietnam to adopt two children and, while we were treading bureaucratic water, a man asked me what my job was. As his English was rudimentary (and he was an English teacher!) and my Vietnamese was non-existent, I explained that my job consisted of helping sick and injured people walk again. “Oh,” replied the teacher, “Here in Vietnam, EVERYBODY does that!” Eventually, however, he invited me to come to his home to meet his father.

His father, who was perhaps 65 years old, was lying in bed, as he had been for five years. His story was this: several years previously, he had been struck by a vehicle which broke his hip. As there was no orthopedic surgery, his hip did not heal, but he was able to hop about on crutches – until, that is, he had a minor stroke which left him unable to use the crutches. Ever since, he had lain in the bed. On special occasions, his son would pick him up in his arms like a baby and carry him to an armchair where the man would sit with tears streaming down his face. Just prior to this medical disaster, the son’s family had been approved to immigrate to Canada. Once the old man became disabled, however, those plans were dashed and the family stayed in Vietnam to care for him.

As I sat on the floor and tried to absorb this information, several thoughts occurred to me. First, although I was an experienced Home Health therapist and considered myself able to “make do” with virtually no specialized equipment and minimal contact with other professionals, there wasn’t much I could do about an old, unhealed hip fracture without access to an orthopedic surgeon. Had this man had his injury in the US or Canada, his hip would have been surgically repaired within 24 hours and, after about six weeks, he would probably have been walking without an assistive device. Then, when he had his stroke, he might have been slowed down a bit but, with a little more therapy, he would most likely have been walking again, perhaps with a cane. Instead, he was bedbound -- without wheelchair, walker or therapist.

Secondly, I was adrift without my most valuable tool: my voice. How to explain to this well-intentioned and guilt-ridden son that his father’s tears most likely resulted from the emotional instability often associated with strokes that affect the left side of the body--not from pain the son was inflicting on that poor old hip? Pantomime can only go so far with abstract concepts.

And, finally, I realized that there must be thousands and thousands of disabled Vietnamese people, spending their lives on floors and in beds, simply because they lack the medical and rehabilitative care that we take for granted in the west.

I didn’t know what I could do about it – but it haunted me.

Fast forward 10 years: an e-mail message from a North American NGO pops up on my computer screen, calling for a volunteer physical therapist to serve as a clinical instructor at the Da Nang Orthopedic and Rehabilitation Center. Whoa! They’ve got orthopedic surgery and physical therapists in Vietnam now! And – crucial for me – they were asking for a clinical instructor, not a stand-up lecturer.

Even with those key elements in place, however, I knew that adaptive aids were still unlikely to be available and affordable in Vietnam. So, as we prepared to return to Vietnam, that was the task allotted to my husband: design and fabricate prototypes of appropriate adaptive devices from inexpensive, locally available materials. AFOs (plastic leg braces) were the one essential item that I thought necessary to import because I had been led to believe none could be fabricated locally. When I queried volunteer therapists returning from Da Nang, they said that, not only were AFOs unavailable, but that they couldn’t be used in Vietnam because everybody wore rubber flip-flops! Likewise they noted that modified forks and spoons were not appropriate because people in Vietnam eat with chopsticks. Really. I don’t think that it’s culturally insensitive to note that sometimes shoes, spoons and forks can be adaptive devices.

 So we loaded up our suitcases with coping saws, brace-and-bits, riveter, reachers, sippy cups, flexible straws and 40 off-the-shelf AFOs. My friend, Barbara Coverdale, an American occupational therapist, devised a wrist splint from chopsticks, fabric, and elastic for Vietnamese tailors to copy. Once we were in Vietnam, Dave spent his time on scavenger hunts in the markets and making prototypes of equipment that we brain-stormed together in our hotel room.  Our best “out-of-the box” idea from that trip was a lap table for quadriplegics fashioned from a plastic sidewalk cafĂ© table. We merely shortened the legs and cut a semi-circle in one long side. This provided a steadying support and a useful working surface so that the quadriplegics and the non-ambulatory head-injured patients who, at that time, were being discharged home without a wheelchair, could sit up safely and feed themselves in bed or on the floor.

I found it disconcerting to note how ineffective the activities of the Vietnamese therapists were in that facility – especially when I considered that the NGO that I was volunteering with had been sending American and Canadian PTs and OTs there for five years already. Most of the treatments seemed to consist of hot packs (in Vietnam, in July!) and very simple passive exercises performed by the therapist on the patient. Nobody was teaching the patients how to get out of bed and into a chair safely or even how to walk correctly. And because there were only 2 or 3 decrepit wheelchairs in the whole rehab center, families were literally dragging or carrying the patients across an open courtyard to the official “therapy room,” where the physical therapists waited. While I was there, I resolved to focus on functional activities and to clearly articulate my rationale for everything I did. Unfortunately, the promised translator was only intermittently available (and you can’t fake Vietnamese!) and the therapists tended to wander off and leave me to treat the patient alone.

But still, I got hooked. The “gotcha” moment for me came about this way: I had been watching a thin man with dry, cracked skin and his despondent wife out of the corner of my eye for several days. Sometime earlier, a falling wall had broken this man's neck and rendered him paralyzed. Some of his muscles had started to wake up, yet--to my eyes--there was something about him that did not look right. His hands appeared useless, but were not held in a familiar pattern. The big muscles in his legs were barely functioning--but his toes wiggled. This is not how a patient recovering from quadriplegia typically presents. Every day, his therapist would strap boards to the man's knees to hold them straight. Then she and the wife would hoist him onto his feet, and then suspend him by his armpits from some weird, welded-together rolling walking frame. Once standing, he could shuffle along. Finally, it occurred to me that this guy had crutch palsy—paralysis of the arms caused by the pressure of crutches under armpits--a condition I had read about in textbooks, but had never seen in thirty years of practice. Looking closely at this man, it also dawned on me that he was dehydrated and starving.

In Vietnam, it's the responsibility of the family to feed and provide all personal care for hospitalized patients, but his wife was penniless. His spontaneous recovery from his neck injury was being masked by starvation, dehydration and a new case of crutch palsy. Here’s the cool part: I instructed the therapist to discontinue the “walking exercises” and to work on knee strengthening exercises with him. My husband went out and bought him some bottled water (tap water is not potable in Vietnam), Ensure and canned beans. Two days later, the patient was standing up and walking with minimal assist of the therapist and wife—with no boards or walking frame. Whoa. That’s when I knew I had to come back to Vietnam.

But my husband and I could not figure out how we could afford to travel back and forth between America and Vietnam. Our trip to adopt our children back in 1995 had been funded by money bequeathed to me by my father. The second trip, including the purchase of the AFOs, had been paid for with money left me by my recently deceased aunt. We had run out of elderly relatives, so that funding source was no longer an option. Our only asset was our home. It finally occurred to us that, if we were to sell our home and purchase one-way tickets to Vietnam, we would have enough money to live there modestly, with some left over to fund small projects.

So that’s what we did.

The details are a bit more complicated than that, of course, involving establishing a non-profit organization in the States and finding a suitable Vietnamese governmental entity with which to work--but that's another story.

Here’s the essence of what we’ve learned thus far. Poorly conceived, hit-and-run missions generally miss the mark in Vietnam. The fact that the seats in most rehab clinics in Vietnam are rickety old tub benches sent to a country where bathtubs are rare is one clue.

Orientation literature provided for prospective volunteers at that first rehab center where we worked urges volunteer therapists to prepare a Power Point presentation on an area of their particular expertise. Still, however, that NGO neglects to mention the fact that Vietnamese physical therapists have only two years of the most basic vocational training following high school graduation and that half of that consists of internships under the cursory supervision of therapists who have had that same minimal training. Evaluation and treatment planning are not part of their curriculum. With that sort of introduction and a frequently missing-in action translator, how can a well-meaning short-term volunteer teach effectively?

The fact that an American-based NGO received a $400,000 USD grant from USAID to build a rehabilitation wing onto a private hospital in Da Nang for the express purpose of “demonstrating modern rehabilitation equipment” and that, only as an after-thought, did the director think to contact me to ask if I would care to “volunteer” to be their physical therapist says a lot, too.

 Because we’re here continuously, the veils are gradually lifting from our eyes. And because we’re committed to doing small things that will make a big difference, we do things that you would never see a big NGO do. For example, we buy plastic armchairs for the patient wards and also for families to take home. We buy good quality, Vietnamese-made sport sandals for all the potentially ambulatory patients in our rehab hospital.  We collaborated on the design for, and fund the fitting and production of, a new hinged-ankle AFO, designed to be worn with a sport sandal for neurological patients unable to walk safely due to ankle instablity. We buy rattan canes in order to give patients the confidence they need in order for them to ambulate as well as possible.

What is the point of lecturing about the importance of getting patients out of bed early and often if there are no chairs available? How can you teach someone to pick up their feet if their flip-flops fall off when they do? A rattan cane (complete with tip) costs $2.50 USD, sport sandals are $6.25 and a plastic armchair costs $7. The AFOs are more--but still far, far below what they would be back in the States.

How cool, and how very, very wonderful to be a philanthropist at such budget prices! People are overwhelmingly grateful for these small gifts and – they make a difference! Brain-injured people walk. Stroke patients sit up and look around. I have enormous credibility with family members. And I will tell you, here in Vietnam at least, it is the family members of one patient who teach the next patient’s family how to care for their loved one. Nurses administer IV’s and treat wounds. Therapists “do” exercises and modalities. But it’s the experienced family members who teach the new-comers on the ward how to move and feed and bathe their own disabled son or husband. They’re the ones who are teaching each other how to transfer and position their patients. They’re the ones that are trading feeding tips and helping each other when another set of hands is needed. Winning over these dedicated family members and establishing, through them, new practice on the ward bears fruit. Not only will they be better able to care for their own family members, but they will teach the next group of families. We are establishing what could be called “institutional memory”.

The truth is, my most enthusiastic students are the family members of the patients. In second place are the affiliating physical therapy students from the Da Nang Medical School who, by now, have heard of me from the previous graduating class. Least enthusiastic are some of the physical therapists themselves. It’s not easy, changing old habits. It’s slow going but, with administrative support, persistence and a few “miracle cures,” we are starting to help Vietnamese PTs realize how rewarding and how FUN it can be to be an engaged and effective physical therapist.

The Dark Side of the Mirror

An excerpt from a comment by Usha, made in response to my post of 16 February 2008, Exercising Compassion:

One further thought, regarding the mirror neurons, which I've been reading about quite a bit, lately. It's interesting to me that they're referred to as "Dalai Lama" neurons. I guess that's because they must enable our empathy and compassion. But I've also thought that there is a flip-side to this, for it would seem that mirror neurons must also enable the ignoble "mob mentality," which is not something we'd readily associate with His Holiness.

The raw material of our humanity seems to provide ample potential for the development of both our higher and lower natures. I think it matters a great deal how we cultivate it.

Dear Usha,

You are entirely right, of course, about the “flip-side” of mirror neurons. I’ve been thinking about this a lot recently, especially with the approach of the 40th anniversary of the My Lai massacre, which occurred in nearby Quang Ngai province.

It’s important to realize that each of us does have the capacity to express both the dark side of human nature, as well as something more closely approximating the Divine. And it’s instructive to examine our own lives in order to understand what conditions bring out the best in us and what brings out the worst. For my own part, I note that I am at my best when I feel relaxed and appreciated. When I feel stressed and unloved, I am hard-pressed to put my ideals into practice.

Larry Colburn was an 18 year-old gunner on the helicopter crew that intervened to stop the massacre of unarmed civilians by American troops in My Lai in 1968. In a 2002 interview, he took pains to note the difference in stress levels between his job and that of the troops on the ground. His job, which consisted of drawing enemy fire in order to locate hidden enemy troops was a dangerous one, he noted, but he and his crew slept in relative safety back at base every night. On the other hand, troops in the field remained in harm’s way continuously. It doesn’t excuse the mayhem that those troops exacted on the unfortunate villagers of My Lai, but it is, perhaps, a cautionary note: a combination of unrelenting fear and stress, along with the kind of solidarity fostered by the military can and does trigger the dark side of mirror neurons—the “pack mentality”.

Forty years ago, the American government tried its best to cover up the atrocities committed at My Lai, just as the early reports of prisoner mistreatment by Americans assigned to Iraq’s Abu Ghraib prison were dismissed as “pranks” committed by a few “bad apples”. We’re getting into murky waters these days, when the highest officials of our land condone “enhanced interrogation” techniques and deny any responsibility for the literally uncounted civilian lives destroyed by the reign of destruction in Iraq and Afghanistan. American soldiers are subjected to the unremitting stress of repeated deployments under extremely hostile conditions, while knowing that their often heroic efforts are making no one’s life better. Their superiors consider the Geneva conventions to be “quaint”. Could we design more perfect conditions to bring out the worst in both the Iraqis and the American soldiers? What kind of world is being created here?

While military culture and conditioning is relatively easy to see, at least to those of us standing on the outside, the everyday conditioning to which all Americans are subjected is harder to perceive, at least when you’re sitting in the middle of it. The uncertainty that ordinary Americans experience, living far from any war zone, is in no way comparable to life in Baghdad or Fallujah. It is, nevertheless, unrelenting. Fear-mongering by the Bush administration in the aftermath of September 11th is, perhaps, the most obvious source of that anxiety. Other elements, however, combine to make us feel insecure and thus indisposed to be the best human beings that we can be. Corporate America finds it extremely profitable to conjure up boogeymen for us. Whether your perceived issue is bad breath, financial insecurity, or lack of sex appeal: Corporate America has the cure -- for a price. The backbone of their business plan is the creation of insecurity, which can only be mitigated through the frequent purchase of their products.

We can’t, as individuals, change the way that corporate America and the American government promote their twin messages of insecurity and compulsive consumption. But we can elect to tune those messages out. We can turn off the television and choose to focus instead on creating nurturing communities to replace those that American corporate culture has worked for decades to dismantle. We can work to help those around us feel secure and appreciated. And we can, each of us, strive to model behavior that will make this world one in which we would choose to live.