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April 12, 2016

World : In Countryside (Vietnam)

Dai Dong, Vietnam. Summer 2008

I waited to see Vietnam for the first time until I had a good length of time to spend there. The summer after my first year of medical school, I had the chance to do a public health project there. In addition to meeting my uncle for the first time and staying with him in the city of Hanoi, I was able to live in the countryside, which gave me a small sense of how different my parents' lives were before coming here. One of the things I like most about seeing patients is tracing back the sources of their paths and identities, which are so different from mine and from each other. Below is an email I sent during my time in Vietnam which takes me back to examining roots.


I remember reading a movie review of "In America," where the writer interpreted the title not as a grandiose notion that the film was an all-encompassing depiction of what America was.  Instead, he said, the title had a postcard quality, a glimpse of what America was like for the characters while they were there.  My short time in the rural commune of Dai Dong, a short but far distance from Hanoi, also leaves me with a kind of snapshot of the place.  I can't speak for the place itself, only for my limited experience with it.

For some context for why I was there, I'm working in Hanoi at the Institute for Social Development Studies in the social health department.  Some people are surprised to find that as a communist country, Vietnam's healthcare is neither public nor universal.  Along with other enterprises in the late 80s, healthcare became privatized. While the new market economy was beneficial in other sectors, it killed access to healthcare, as government subsidies plummeted and out of pocket payments now make for 80% of healthcare expenses, the highest percentage in the world.  So we wanted to look at how this affects people with high expenses and few resources, in terms of other aspects of their lives.  How do expenses affect resources for living conditions, basic needs, education.  How much poor households with illnesses can allocate for these things compared to poor households without illnesses and to non-poor households with illnesses.  We also want to get a sense of all the expenses and losses that come with sickness—fees for transportation and bribes, lost days of work and school for patients, lost income for people taking care of the patient, the debt that accumulates, and so on.

Because 70% of the population lives in the countryside, it made most sense to conduct the study in a rural commune.  We surveyed poor and near-poor households, and an equal number of non-poor households, regarding their household income and consumptions, health expenses and coping strategies.  In working on the survey I learned a little more about the system here, the different insurance schemes and the effects of lacking regulation in cost and services.  Thinking about the best ways to ask questions was more intellectually taxing than I'd thought, because you have to step outside of theory and think about how people actually live.  This became all the more clear when we started the interviews, and found many flaws, even making changes after a pre-test.  I learned more of the concrete, like how people often buy medicine haphazardly because you don't need prescriptions, how much people live off of borrowing money, how it's hard to know how much you make in a day when you farm or sell fruit that may or may not be in season during a particular time.  Always bored by the accuracies of statistics, I didn't expect to as interested in learning how to best measure all of this as I ended up being.  But imposing a structure on the nuances of human behavior, even when you "narrow" it to what people do when sick, made for an interesting challenge.

I think it was the juxtaposition of the study, which flounders without rigidity, with seeing a bit of rural life, which lives without thought to exactness.  I co-interviewed a few households (my health and rural life vocabulary being limited, couldn't have done it on my own), but after the first day my main responsibility was to oversee the interviewers, check their forms and explain the questions to them.  Because of the length and complications of the survey, we kept finding better ways to ask questions and record data, so informing the interviewers and checking their work was a constant job.  With ten interviewers we surveyed 700 households, and each one had to be checked, fixed, and checked again by four of us.  I found it to be hard work, literally working all day whenever we weren't eating or sleeping.

But falling in love with all the people involved made it all so enjoyable.  Firstly, my co-workers.  The laid-back work ethic here is such even when inundated with work, people take their time.  Things still get done (though with less organization, as I found with frustration), and you feel less stressed doing them.  People never get so focused that they won't lounge after a meal or converse with you or share some fruit.  They joke with you right away, so that camaraderie comes easily, naturally, and laughs aren't restricted to breaks but get mixed up in the work.

Secondly, the interviewers.  They were college students, most of whom grew up in the commune.  They were only a few years younger but felt much more so, in part due to the culture here of politeness extended to anyone older than you, and to a kind of innocence that seems to endure longer in Dai Dong.  In working with them, I felt a slight sense of what must be fulfilling about teaching—feeling proud as they learned and their surveys became more polished and they found their groove, and having a soft spot for the ones who are especially bright or diligent, and the cute ones, and the quiet ones, which pretty much makes for everyone.  They were so sweet, and curious, and extended their affection so automatically and simply.  People here in general are very affectionate; girlfriends hold hands and each other when napping.  For that reason also they seemed younger.  Getting to know them was also endearing in the way it is when you get to know kids--because they're still visibly growing up, you see small things in them that will grow into their character.  One of the things I liked most was that despite all being so dutiful and polite, the students' individual personalities are always present, always strong. They don't need to rebel or actively be different to assert themselves.

These are some of my favorite photos of the trip. I had very few opportunities to take pictures because we were working all the time, and I didn't want to look conspicuous in the town.  But when I asked for a picture of the group on our last day, they turned my request into an hour-long photo expedition.  The girl looking up is my favorite (everyone has one, no?).  She's looking at a kite.  When I asked her how to say "kite" in Vietnamese, she told me and then explained that it flew in the sky after you ran with it in the wind.  Then she patted my arm excitedly and said, "Look, look he's running.  See it go up in the sky?"  Later she pointed to a cow and said I should take a picture to show my American friends what a cow looks like.  Instead, I am showing you her.

The other group of people who made the work worthwhile was of course the interviewees.  I was a little surprised by how many came, and how long they waited, all for less than two US dollars compensation.  One reason they sometimes had to wait was that they seemed to have little sense of time and schedule.  One morning we arrived at 7:30 to find three women who'd been waiting since 6, even though they'd been invited to interview at 8.  Rarely did anyone complain.  They arrived smiling, smiled as they waited, and smiled throughout the interview, which could take up to an hour.  They rarely gave only the answer when asked a question, often taking more time to elaborate or tell an unrelated story. I admired especially the easy way so many are both tough and warm.  They will be loud, brutally honest and adamant about something they don't like, and then they will pour your tea so gently it barely stirs in the cup.

I might guess that the people absorb some of their hardiness from the environment.  So much of life there is dictated by the elements, which are extreme, so people have a wide range of adaptability.  I adapted to the new things, like sleeping on pure bare wood (after a couple of nights of waking up every hour with a different part of my body aching or numb, I was shocked to find that it feels no different from a mattress) and very unsanitary food preparations (just look away, it won't actually kill you).  But I couldn't adapt to mosquitoes.  I actively hate that immediate post-bite feeling of sudden itch everywhere, hate watching the bite appear, hate how each one swells and reddens in a different and equally gross manner.  These are the most vicious I've encountered and at times, there's more of them than air.  20% deet is useless in fighting them off and hydrocortisone does nothing to soothe the bites.  The Vietnamese word for "bite" in context of mosquitoes is the same you'd use to say light a fire, and I'd say that's apt. I got huge clusters of them, one on my forehead (what the hell?) and another on my knee; the latter consisted of dozens of bright bright red, tiny bumps that would periodically re-swell.  I currently have over fifty bites (I count to distract myself from scratching; I can't not pay attention in some form).

While I can find no positive in mosquitoes, I was constantly amazed by the beauty that comes from the unpleasant extremes of the town.  The electricity is cut from 8 AM to 8 PM, sometimes later, which means no fans in 90-degree 90% humid weather.  The moisture builds up and comes back down in heavy rain, one of the things I love about this kind of weather.  As a result I saw two rainbows in a week, the most beautiful I've ever seen, a long half of one setting over rice paddies and a near-full arch in the backyard of the clinic where we worked.  Most rainbows are shrouded in post-rain gray, but the light in Dai Dong can return so quickly that you can see the rainbow in sunlight, and the purple and orange in addition to the usual red and green.  Sometimes a thunderstorm comes so heavy and long it extends from dusk into night.

We barricaded ourselves in a restaurant one night waiting for one to pass.  The lightning occurred every second for two hours, lighting everything up like it was day before going back to dark.  The storm kept us inside, unable to walk the seven minutes to our destination. This must be a nuisance while living there but as a visitor I found myself savoring it.  Because so often our lives are driven by ways to control our environment, so that nothing hinders us.  Sometimes it's nice to be reminded that other things have their way and we have to wait for them to take their course, or clear our way to let them pass. It reminds me why I like places, because of how much life exists in small spaces.

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