Mission to Vietnam
Two Beth Israel Deaconess Medical Center (BIDMC) cardiologists and a former Cardiology Division fellow recently went on an exciting volunteer mission to Choray Hospital in Ho Chi Minh City, Vietnam and blogged about their experience. The mission was sponsored by Hearts Around the World, a Connecticut-based non-profit.
Their goal was to bring CVI-style heart expertise to the needy and to train Vietnamese doctors. But
Dr. Duane S. Pinto and
Dr. Thomas D. O'Halloran and former BIDMC interventional cardiology fellow Dr. Tom Tu learned as much from the Vietnamese as the Vietnamese learned from them!
Mission to Vietnam
Posted by Duane Pinto on 10/20/2010
Heart surgery at Choray Hospital during 2009 mission
On October 22, a team of seven American doctors will travel to Ho Chi Minh City in Vietnam to perform heart procedures on patients and train Vietnamese heart doctors in the latest Medical and surgical techniques. The docs will be part of a volunteer medical mission put together by
Hearts Around the World, a non-profit based in Danbury, CT.
Three of the seven doctors have strong connections to the CardioVascular Institute at Beth Israel Deaconess Medical Center. I am one -- I'm a CVI interventional cardiologist. David O'Halloran, a non-interventional cardiologist, is another CVI doc. Our friend Tom Tu, who completed his interventional cardiology fellowship here in 2003, will also be part of the team. Tom is currently an interventional cardiologist in Louisville, KY. The trip should be of special interest to him because he is of Vietnamese descent.
I hooked up with Hearts Around the World through my roommate at Georgetown Medical School. My roommate was friends with Bob Jarrett, the Danbury cardiologist who founded Hearts Around the World with his wife, Menoo Afkari-Jarrett. Bob and Menoo have already lead a half-dozen trips to Choray Hospital in Ho Chi Minh City (formerly Saigon), and they plan to keep the relationship going for at least another five years and add new international partners.
Our job at Choray Hospital is to provide care that poor patients might otherwise be unable to get. We'll be doing heart catheterizations, cardiac surgery and transesophogeal echocardiograms. Even more importantly, we'll play an educational role with our medical colleagues. We hope to leave behind knowledge and technical expertise to help the hospital develop an integrated-systems approach to providing quality care.
The Vietnamese have cutting edge technology. For example, practically everyone seems to have not just a cell phone but an iPhone. The hospital also has good technology and talented physicians. What they need is a systems approach to managing patient throughput so they can efficiently maximize the amount of care they provide with their limited resources.
Choray Hospital, with 1,400 beds, is the tertiary hospital that serves all of the former South Vietnam with 40 million people. The need for cardiac care is huge. Rapid urbanization has resulted in unhealthy lifestyles; more than half of Vietnamese men smoke. The hospital has a heart surgery waiting list of 3,000 people who cannot afford to pay.
We are looking forward to helping our Vietnamese colleagues. But something tells me it's going to as educational for us as it is for them.
Posted by Duane Pinto on 10/23/2010
Our team has met up and we have completed our trip to Ho Chi Minh City (Saigon). What a trip! The journey began with a quick flight to JFK from Boston for David O'Halloran an me. There we met up with the leader of Hearts Around the World, Bob Jarrett, and the rest of the team that he has recruited, Leonard Lee, a cardiac surgeon, Manny Lopes, a cardiac anesthesiologist, Larry Fisher, a cardiologist and of course my friend Tom Tu, an interventional cardiologist.
We checked in the boxes of supplies to come with us and began the first and longest leg of the journey: the 15 1/2 hour trip to Hong Kong. The baby next to us seemed to be doing well with the flight, and I figured that if he and more importantly his parents could handle the trip, I shouldn't complain. All in all, the flight wasn't too bad. I passed the time doing some reading and watching 4 movies that I had already seen in the U.S.
After a couple of hours in Hong Kong, we took a 2 hour flight to our destination, Ho Chi Minh City. Everything moved like clockwork. We got through immigration in about 10 minutes, and by then our bags were coming out of the carousel. I was astounded at the efficiency since my expectations are set by Logan Airport.
All of us made connections with home reporting safe arrivals. Our hosts met us in the airport and we took a van to our hotel. Along the way, we caught our first glimpses of Vietnam. The streets were filled with lots of people, cars, scooters. The shops, restaurants and cafés were open and busy since it was dinner time here. We were struck with the number of scooters and routinely saw up to 4 people on a scooter (2 toddlers and parents).
We arrived to our beautiful hotel right across from the opera house. The French influence in the architecture is evident and the fact that the area caters to tourists is evident with our hotel bordering stores with brands like Louis Vuitton, Gucci and Cartier.
After a quick shower we took a walk to dinner with our hosts and had an incredible meal. Tasty plates of river fish with fish sauce and pomfret in mango sauge were my favorites.
We are all very excited with the anticipation of the new experiences this week and getting to know our hosts and one another. We are all anxious to get to work taking care of the patients at Cho Ray Hospital. One of the host doctors asked Dr. Lee (Lenny) how long he wants to operate since there are enough people waiting to keep him operating 24 hrs/day. I'm sure he reflects all of our sentiments when he said I'll operate as long as you want me to. I'm happiest in the operating room!
Medical Supplies in Bureaucratic Limbo
Posted by Thomas Tu on 10/24/2010
Duane did a nice job detailing our journey to Saigon. We jinxed ourselves by commenting on how smoothly everything was going. We had shipped 22 boxes full of donated medical supplies free of charge thanks to the generosity of the Cathay Pacific airline employees. They arrived undamaged on the baggage carousel in Vietnam and we loaded them onto 7 carts. They had to pass through an x-ray scanner on the way out of customs. We had made it to the airport curb when we were called back into customs to deal with some "paperwork".
After watching the customs agents discuss things back and forth, and move the boxes to three different locations in the airport over 2 hours, we eventually were told that we had to leave without our supplies. They would be held at airport until the next day until a supervisor could be summoned.
The next day, after four hours of negotiation and several more rounds of moving boxes to various places, we still don't have any of our donated supplies. We hope that it will be available on Monday, but our morning cases may have to be postponed.
I'll update tomorrow on our progress...
What's Low-Cost Heath Care Like?
Posted by Thomas Tu on 10/24/2010
I'm still getting used to the time change. Rather than sleeping, I've been thinking about the differences in health care between Vietnam and back home. It struck me right away when we arrived at Cho Ray Hospital. The building has been around since 1900 and was most recently rebuilt in the early 1970s using Japanese grant money. It is one of the largest hospitals in Southeast Asia. It is functional, but not at all luxurious by American standards. Most of the team commented that it reminds us of our training experiences in the VA hospitals back home.
The lobby is filled with people who just seem to be waiting...There are families sitting in chairs and sleeping on mats on the floor. I was told that many of these people traveled for at least 10 hours from outlying provinces just to sit in the hospital lobby. They will probably wait two days before being seen. The infrastructure doesn't seem able to deal with such a volume of patients. The hospital will care for at least 1,200 outpatients and 200 admissions each day.
The nature of the cardiovascular disease seems to be quite different than in the U.S. We saw at least 10 cases of extremely advanced cardiac pathology that easily would have made "Case of the Year" back home. I think a lot of this has more to do with socioeconomic status rather than the disease itself. Since advanced health care is so expensive for the average patient, most patients probably don't seek care until the disease has progressed to a critical state. One interesting observation, however, is that the patients seemed to be doing remarkably well despite having such critical coronary and valvular heart disease. Many patients with similar disease in the U.S. would be in the intensive care unit, possibly intubated and on intravenous medications. Our patients here were simply walking around the hospital ward without even an IV in place, taking occasional breaks outside to smoke.
I think that we are seeing a select group of patients who happen to be fit or lucky enough to tolerate their heart disease for so long. They probably represent the just tip of the iceberg of the real pathology in the population. I imagine that there may be 100 patients who never survive to make it to the hospital for every one that we see here.
David touched on another striking difference in his previous post. Since the cost of technology is so high compared to the human factor, the nature of care is quite different. Rather than having high-tech solutions to health management (computerized order entry and documentation, automated monitors and alarms), the approach is decidedly low-tech. The charts are hand-written and are about one-twentieth the size of those back home, but arguably contain just as much useful information. Nurses spend time with the patients rather than typing into a computer screen. Patients don't get twenty different tests (motivated by fear of litigation, desire for "completeness", or even curiosity), they get only the one or two essential tests to deal with the immediate problem.
Even the major clinical choices we make are affected by this lack of resources. Most patients with atrial septal defect here are treated surgically rather than percutaneously. In the U.S., it is quite the opposite. The procedure to patch a hole in the heart has moved away from a large chest incision and a five-day hospitalization to essentially an outpatient procedure done through an intravenous needle puncture. Back home my patients are walking within hours of their procedure and are back to full activities within two days. The doctors here are trained and able to do this procedure. Why then, do most patients end up having open heart surgery instead? It's because the cost of the patch is about $2,000, which is basically one year's salary for the average patient. This compares poorly with essentially $10 worth of suture material for the surgery. The surgeon's fees are minimal (their self-reported socioeconomic status is low here), so cost drives patients to a more invasive and higher risk solution.
What does this all mean? It's too much to discuss in one blog post, but it does lead me to wonder how cost concerns will affect health care back home.
First Day at Cho Ray Hospital
Posted by David O'Halloran on 10/25/2010
After a breakfast of champions (best buffet we have ever seen) our hosts picked us up for our first visit to Cho Ray Hospital. Our day started with a brief tour followed by a discussion of some of the current inpatients. Any one of these patients would be a "Case of the Month" at a U.S. teaching hospital but for the physicians and staff at Cho Ray, patients with extremely complex problems are a daily occurrence. This is partly because of the prevalence of untreated or poorly treated conditions such as smoking, hypertension and rheumatic fever and also because of the fact that Cho Ray is the main Cardiac Surgery center serving a population of over forty million people, some of whom come from more than 500 miles away. Compare this to the Boston area where there are more than 10 centers for cardiac surgery serving a population of about 4 million.
Here is a brief synopsis of some of the patients we saw and the decisions we made together with the Cho Ray cardiologists and surgeons:
- A 38 year old man with a three month history of back pain and weight loss who was found to have a chronic Type A aortic dissection and severe aortic regurgitation. His left ventricle is enlarged and poorly functioning. Unfortunately, his right ventricle is also dilated and with poor function, making survival through major cardiac surgery very unlikely. We plan to remove fluid with diuretics and hope that the right ventricle improves enough to make surgery less risky. However, we are all worried that we have missed the boat on this young man - he is very gaunt. You can see Larry Fisher examining this patient in the photo above.
- A 55 year old woman with severe mitral stenosis, moderate aortic stenosis and moderate aortic regurgitation. All are as a result of rheumatic fever she experienced as a child. The question was whether she should undergo high-risk surgery (with replacement of the aortic and mitral valves), whether she should have just medical management or whether she should have mitral balloon valvuloplasty (where the valve is cracked open by a balloon). We asked her to go for a brief walk and to climb some stairs. After two flights she was quite short of breath and tachycardic. This told us that medical management would not be enough. Dual valve replacement was thought to be not necessary at this time. So, tomorrow, she will have mitral balloon valvuloplasty. Duane Pinto and Tom Tu will assist the interventional cardiologists of Cho Ray.
- Another man in his 50s had presented with knee pain. However, a loud murmur was heard and his echo showed severe aortic regurgitation with a bicuspid valve. He may have had undiagnosed endocarditis in the past. Thankfully, his left and right ventricles function normally. Tomorrow, Lennie Lee will scrub in to surgery with Dr. Anh to replace this patient's aortic valve and ascending aorta. We decided that a bioprosthetic valve is best for this patient. If we used a metal valve he would need Coumadin for the rest of his life - which would be very difficult considering he would need to travel 200 miles for an INR check. What is needed are point-of-care INR machines that could be used in the rural clinics. If you know of any going cheap - let us know!!
Resources are limited here. This can lead to some situations that would be strange in the U.S. A coronary artery bypass graft operation is paid for by the state whereas a patient has to pay for their own stents or artificial valves. So some patients will undergo a CABG rather than a more straight-forward stenting procedure. A valve costs about $3000 - more than most Vietnamese people make in a year. Many patients will borrow money from friends and relatives to be able to have necessary surgery. On this trip, BIDMC has donated many different kinds of stents and other equipment and Lenny Lee has brought about 15 artificial valves. Hopefully, our supplies will be released by the authorities soon. Bob Jarrett has been dealing with the customs people and has learn way more about the intricacies of Vietnamese bureaucracy than he ever wanted to know!
So far, we have all been very affected by the dedication and skills of our hosts. They have each spent time training in surgical techniques abroad - in France, New Zealand, Korea, Australia and elsewhere. When these surgeons return home, their new skills are invaluable in caring for the many patients who desperately need help.
We hope to be able to help with teaching, support and donations of equipment. If you wish to donate to help with these challenges, please visit
We are looking forward to our first day of work in the wards, cath labs and operating rooms tomorrow and will keep you posted.
Posted by David O'Halloran on 10/26/2010
Even in the short time that we have been in Vietnam, we have realized that this country is on the rise. Although still part of the developing world, Vietnam is making huge strides towards becoming a developed nation.
- The people are hard-working and educated (95% of the population can read).
- Their economy is modernizing on a daily basis. High-rise buildings are going up all over the city and neon signs for Sharp, Sony, Canon and even KFC light up the night sky.
- The streets are clean. The hospital floors are scrubbed and cleaned several times a day.
The government is trying to guide the rapid transition towards a western-style democracy. Cars are heavily taxed in order to control traffic and pollution - a Toyota Camry costs about $60,000 which is WAY out of range for the vast majority of people. Hence, the scooters that swarm everywhere around the city. Education is a priority. The government has invested in medical care and seems to have a real commitment to the health of the people of Vietnam.
I talked with my sister Eavan who works in development economics in the World Bank. She told me that Vietnam is one of the world's great success stories in developing from a country that was devastated after the war into an up-and-coming regional and world powerhouse. A baby China maybe. An Asian Tiger, certainly.
The same sense of being on the crest of a wave of possibility is becoming apparent to us here at Cho Ray. In a hospital that sees 4,000 patients a day, has 1,700 beds with 3,500 in-patients (yes, that's more than 2 to a bed) and provides care to 40 million people there are many, many factors that need to be integrated in order to achieve the goals of care. Most of the systems in place are relatively modern and comprehensive. What is missing is the INTEGRATION of all of the services. Each component of cardiovascular care operates without significant interaction with the others. As the phrase goes - "one hand does not know what the other is doing".
Because the different disciplines at Cho Ray do not routinely discuss cases with each other, occasionally a patient will receive inappropriate care. For instance, a patient with mitral stenosis will be seen by a cardiac surgeon and as a result undergo mitral valve replacement when the most appropriate treatment would have been a balloon mitral valvuloplasty.
As a result, we have focused our efforts this week on teaching our hosts how to have the kinds of multi-disciplinary discussions that are a routine part of the U.S. health care system. On Tuesday we held a case conference with the cardiac surgeons, cardiologists, interventional cardiologists and electrophysiologists. Our hope and expectation is that our hosts will continue this kind of interaction in the future. That way, each patient who comes into the hospital needing cardiovascular care will receive the most appropriate investigation and intervention. Each discipline will need to learn that referring the patient to another discipline is not a sign of weakness but of truly integrated cardiovascular care.
We will continue to highlight this approach to our hosts. As their country moves boldly into the future, we hope that their medical care will continue to do the same.
Family Is Very Involved
Posted by Duane Pinto on 10/26/2010
We have a saying in the U.S. that "the family is very involved". This means that the family is often at the bedside of the patient and wants to know exactly what is going on. Yesterday, we really saw what it means for the "family to be very involved". I was asked to evaluate a 27-year-old patient with severe heart failure for a balloon pump. This is a routine thing to do in the U.S. but there are is only one pump here that hasn't been used in years. It can be used if needed but more importantly if the patient's family can pay the $800 needed for the catheter. I saw the patient in the CCU which was a big room with 12 patients in beds.
David O'Halloran was doing an ECHO on him and we ultimately decided not to do the balloon pump. What was amazing to me was that the patient was intubated (a breathing tube had been placed) but because there was not a ventilator, a machine to breath for the patient, the family was required to squeeze a bag to give breaths to the patient. The family needed to do this for days on end or the patient couldn't breathe. Unfortunately, not much about the patient was explained to the patient's brother who had been bagging the patient for many hours overnight.
We Do What We Can
Posted by David O'Halloran on 10/27/2010
Every time a person travels to a foreign country, there is always at least a mild degree of culture shock involved. When one works in the health care system of a developing country, the sense of shock is more severe - usually disconcerting and sometimes downright devastating. After working in the U.S. health care system we are all used to a situation where the basics are done well and, for complicated patients, resources are essentially unlimited. As a result, no matter what problem the patient presents with, we are prepared to provide the needed treatment.
Here at Cho Ray, the resources are pretty decent by western standards. They are much better than what would be available in most other parts of Asia and pretty much all of sub-Saharan Africa. And yet, every now and then the gap between care here and at home is keenly felt.
Today we saw an eight year old girl - you can see her photo on Tom's recent post. She presented with fatigue and poor growth. Tests have shown that she has severe regurgitation in her aortic valve and her aorta is massively dilated. (I have posted some images from her CT scan). The aorta is nearly 6 cm wide (more than three times the size it should be). The aorta is so large it can be felt as a pulsation in the base of her neck.
Without surgery, this little girl will very likely die in the next few weeks to months - from either rupture of the aorta or heart failure. All of us, U.S. and Vietnamese doctors alike, are aware of this reality. We also know that she cannot get the kind of first-grade operative and post-op care that would be available in the U.S. Her risk of dying as a result of surgery is therefore greater.
In an ideal world, the medical system in Vietnam would be equipped with the tools and expertise needed to maximize her chance of survival. It would also have enough funding to supply ventilators in the ICU so that patient's families don't have to "bag" the patient for hours on end. And enough money to provide needed vaccinations and public health interventions.
Choosing where to spend limited resources is an impossible task. Do we tell this little girl that her surgery is too expensive and the money would be better spent on vaccinating 100 of her school friends? Does the government here try to perfect the basics before moving on to the more complicated levels of care?
I don't know the answer to these questions. I don't think anyone does. All we know is she needs surgery, the doctors here can provide it and with their skill and some luck she will hopefully survive to enjoy a happy and healthy life.
Posted by Thomas Tu on 10/27/2010
It's not an exaggeration to say that the team has been on an emotional roller coaster. After working here several days, we've had our moments of joy and despair, triumph and failure. It reminds me of the Kubler-Ross five stages of grief: denial, anger, bargaining, depression, and acceptance.
In line with that thinking, I've come up with five stages of overseas medical work:
Excitement: Wow! I can't believe I'm getting to go to another country to save lives and teach! I can't wait to learn about another culture and to share something about America! I'm going to blog about it so everyone can share this adventure!
Unrealistic optimism: This hospital has so much potential. All we have to do is donate some supplies and teach them a few techniques and they'll be well on their way to a modern health care system. The local doctors seem so happy to have us here.
Shattered dreams: I just saw 3 people die in the CCU in one hour. Two heart attack patients were left to die because they could not afford to pay for a stent. We met three children aged 3 to 14 with severe congenital heart disease. They are looking at major open heart surgery without great chance for long-term survival. And we still don't have our supplies yet.
Therapeutic nihilism: What's the point of being here? All of the work we've done is just a single drop in an entire ocean of human misery. There are just too many people with too many problems and we don't have the ability to fix them. Nothing will change.
Acceptance: We can make a difference, but change happens slowly. We're planting seeds that we hope will bear fruit in the future. We are helping our patients one at a time, but we're also investing in relationships and systems that will help in unexpected and wonderful ways.
Right now I'm somewhere between 4 and 5.
Mind Moving Over A Bit?
Posted by Thomas Tu on 10/27/2010
One of the readers asked if there really could be two or three people to a bed. See for yourself.
Posted by Larry Fisher on 10/28/2010
Over the past week spent here at Cho Ray hospital, I am struck by the countless dichotomies noted in every day life.
- The cardiac surgery team performing complex congenital surgery in children, but not having a single pediatrician in the hospital.
- The cardiac cath lab team performing interventions in a state of the art facility, but using a 50 year old fluorosope ( with no C-arm) to implant a pacemaker.
- The residents in the CCU using advanced echocardiography to assess valve abnormalities but not knowing how to listen to the heart with a stethoscope.
- A French trained electophysiologist performing advanced arrhythmia ablations, but not having a room with a monitor to observe a patient with a life threatening rhythm disturbance (the patient has spent the last 2 weeks on a stretcher in the hallway).
- The provincial hospital outside of Saigon building a brand new 3 story hospital wing, but not having money for new beds or ventilators.
Even in Ho Chi Min city:
- The streets in district 1 are lined by upscale stores, like Gucci, Ferragamo, and Tag Heurer, but do not have sufficient drainage to prevent flooding during a brief thunderstorm.
- It seems like the zeal to acquire the best technologies has somehow become disconnected from the ability to provide the most basic of services.
Perhaps we have lost the "forest from the trees".
Just a thought.
United in Purpose
Posted by Duane Pinto on 10/28/2010
Friday will be our last day of working in Cho Ray Hospital and I am struck by the irony of what we will be doing today. We will be performing several mitral valvuloplasties. This procedure is done for those who have mitral valve stenosis from rheumatic fever. This disease has become uncommon in the United States but remains rampant here in Vietnam. As such, the physicians here are experts in the procedure, while physicians who trained recently in the United States like Tom and me, only see this procedure infrequently. As opposed to some of the procedures where both groups have substantial expertise, everyone knows that today we will be relying on the Vietnamese physicians to teach us the finer points of the procedure.
Here is where the irony comes in. A current member of the BIDMC interventional section, Dr. Sam Shubrooks, performed these procedures in Vietnam about 10 years ago. He taught some of these very same physicians (who still remember him) the technique, thus laying the groundwork for today where a refined version of this technique will be brought to another generation of interventional cardiologists.
My more loquacious friends have detailed the trials and tribulations of the week. I'm not one to be exceptionally cheesy, but after an emotional roller coaster that Tom and Dave have detailed, I have found a small amount of solace in the common ground that I have discovered with the cardiac specialists here. Though all of the chaos and misery, I have decided that the Vietnamese and US doctors are basically the same. We are united in our love and understanding of the disease processes of the heart and a desire to share our knowledge so that patients get better care. It is my hope that those common threads can transcend many of the hurdles we have encountered here and frankly many of the ones we have at home.
Posted by David O'Halloran on 10/29/2010
Some numbers to consider:
75 million - population of Vietnam.
40 million - numbers of people in the referral base for cardiac surgery program at Cho Ray hospital.
10,000 - number of people in Cho Ray hospital at any one time: in-patients, out-patients, family members, staff.
750,000 - our estimate of the number of people on a motor scooter at any one time. The majority of them seem to be buzzing around us when we travel to the hospital!
120 - number of head trauma cases seen at Cho Ray hospital EVERY DAY. Of these 20 need urgent neurosurgery, 5 will die. Almost all are as a result of motor scooter accidents.
2 - marks out of ten for safety of the helmets the bikers wear.
$800 - average yearly wage of a Vietnamese person.
$200 - monthly wage for a newly graduated cardiologist. The head of Cardiology gets paid about $500 a month.
$4,000 - amount a patient has to pay for a new heart valve. If they don't have this money, they don't get the surgery. If the doctors show compassion and do the surgery anyway, the doctors get the bill!
$1,000 - amount a patient has to pay for one cardiac stent. It's another $1,000 each for every additional stent needed.
150 - number of patients on the cardiology service at any one time.
25 - average number of new admissions seen by one doctor on a call night.
500 - estimated number of Code Blue events in the 10-bed CCU in one year. Very few of these patients survive.
250,000 - estimated dollar amount of the supplies we brought with us from the U.S. We have asked that these be used for patients who would not otherwise be able to pay.
? - incidence of congenital heart disease in Vietnam. Nobody knows this statistic but, from what we have seen, it must be far higher than in the US. and Europe. Long-term effect of dioxin, DDT, Agent Orange? Or some other unknown environmental factor? There are many unanswered questions.
2 - number of children "allowed" per family in Vietnam. If a doctor or government worker has more than this number of children, their contract is not renewed.
2 - number of children my wife Catharina and I have. Ella and Hugo will be joined by a new brother or sister in about two weeks, God willing. Hopefully this does not mean I will get the sack from BIDMC...
100 - percentage likelihood that we will return next year.
Not the End, Only the Beginning
Posted by Thomas Yu on 10/31/2010
Our week in Vietnam has come to an end. In some ways it seems as if we've been here for months. I've seen more patients with complex heart disease in five days than I have in all of my medical training. In other ways the week was but a fleeting moment. Our work here, though exhausting, has only touched a tiny fraction of the enormous population of patients in need. Sure, Vietnam can use some talented physician volunteers and donated medical supplies. But what it also needs is an economic and physical infrastructure that can raise the living standards of its people. They say a rising tide floats all boats, and that ocean comes in the form of sustainable and environmentally-responsible economic development. These are topics beyond the scope of our mission here, but need to be addressed for Vietnam to provide modern medical care to its people.
In our brief visit, we hope we have made some lifelong friends with our Vietnamese colleagues. Our time outside of the hospital has been spent talking about our lives and our families. It turns out that we are very similar despite the economic and cultural differences. We both enjoy good food and the camaraderie of our coworkers. We get calls from our spouses when we've been at work too long. We worry about the future of our profession, of the economy, and of our countries. We each sacrifice so that our children may have more opportunities than did we. And we put the needs of our patients above those of our own.
Despite the shock of seeing so much hardship and suffering in the hospital, outside it's a different story. Walking down the French-designed boulevards and avenues of Saigon, seeing young local professionals sip coffee while chatting on their iPhones, and haggling over prices for Vietnamese-made shirts in Ben Thanh market, I can't help but to be optimistic about Vietnam's future. The principal strength of Vietnam is its people. They have endured the ravages of war and poverty, yet continue to face daily challenges with dignity and a hope for a brighter tomorrow. My colleagues and I are committed to play a role in that future.