BY: CARL E. BARTECCHI, MD, MACP
This issue of Health Progress, which focuses on services for our nation's veterans, brought many people to mind, including a doctor who is doing outstanding work to bring health care access to the people of Vietnam — a nation where he served as a flight surgeon during one of our country's most harrowing times.
When I contacted Carl E. Bartecchi, MD, to request an interview about the work he is doing in Vietnam in collaboration with Catholic Health Initiatives and the Bach Mai Hospital in Hanoi, he generously offered the manuscript to his latest book, The Bach Mai Hospital Project, published in April 2013 by Merriam Press. It is summarized in the pages that follow. May it inspire your work, and that of all of Catholic health care, as we strive to be of help and hope to all people in need.
— Bruce Compton, senior director, international outreach, CHA, St. Louis.
Humanitarian aid programs inevitably require a partnership; at the very least, they require a knowledgeable, capable donor and an organized, enlightened receiver. Programs maximizing those qualities have a good chance of succeeding, while others will waste the time, talent and treasures of the donor and further frustrate the hopes and ambitions of the receivers. The Bach Mai Hospital Project is a program that works, and I hope its story can help others develop a successful program too.
I am a physician and a Vietnam War veteran. I was drafted in November 1964 and served as a flight surgeon at a U.S. base in the Mekong Delta, where I worked closely with the civilian population. My military service left me with a very positive feeling for the country and its resilient, proud people. During my post-Vietnam days, I followed the war developments closely and began having the uncomfortable feeling that I owed something to Vietnam and the Vietnamese people. Making financial contributions to refugee organizations just didn't satisfy my desire to help.
My military service also provided me with a good understanding of the tremendous need for medical assistance in the rural areas of Vietnam, the vast medical problems of the Vietnamese, the public health and disease-countering needs of the region and the logistic difficulties involved in delivering any type of care. Vietnam's public health needs fit under the heading of global health, that is, the goal of improving health for all people in all nations by promoting wellness and eliminating avoidable diseases, disabilities and deaths. Divisions of the world into such categories as developed and developing countries, or in Vietnam's case, North and South, are less meaningful in this interconnected, globalized world of 2013. Today, not only are health problems global, but lessons, insights and fresh solutions regarding such problems flow in all directions.
Vietnam has been struggling to recover from the debts resulting from its wars of the past century, to repair its infrastructure (roads, bridges, water supplies and sewage systems) devastated during the Vietnam War and to overcome the results of some bad investments and corruption — as found throughout Asia — not to mention a depressed world economy and rates of inflation as high as 20 percent.
What's more, Vietnam might easily be considered a special place, deserving of aid and assistance from the United States. Americans dismayed at the loss of 58,000 soldiers during the Vietnam War and the return home of many more wounded veterans, often forget that North Vietnam lost over 1 million soldiers and probably twice as many civilians.
In 1996, I learned of an organization known as Friendship Bridge, based in Evergreen, Colo., not far from where I lived and practiced. Friendship Bridge was founded in 1988 with the goal of providing antibiotics and vitamins to a large, women's hospital in Hanoi. From that humble beginning, the organization became involved in projects to provide safe water supplies and sanitation to schools, community health projects, a women's loan project and a nurse education program.
What interested me most, however, was the organization's program that provided physicians and dentists for teaching and work projects in Vietnam. The director, Ted Ning, MD, was a faculty member of the University of Colorado School of Medicine, as I was, and we both had been medical officers during the Vietnam War. I contacted several physicians and teachers in my specialty, internal medicine, who had been to Vietnam through Friendship Bridge. I liked what they had to say; they reported generally positive teaching experiences during their visits to Vietnamese health centers. I was convinced that this was the opportunity I had been seeking.
I began making arrangements. Because my interests were in critical care medicine, it was clear that I should be involved with ongoing programs at Vietnam's large teaching hospitals — the Bach Mai Hospital in Hanoi and the Cho Ray Hospital in Ho Chi Minh City. At that point, my objectives appeared relatively easy. The internists who already had been to Vietnam gave me an idea of possible lecture subjects, and I had gathered my thoughts about some hot topics in U.S. intensive care medicine that would be appropriate for the Vietnamese physicians. The returning physicians gave me some good advice on travel, customs and do's and don't's while in Vietnam.
In January 1997, my wife and I arrived in Hanoi and reached the Bach Mai Hospital at about 8 a.m. We made our way to the intensive care unit building where we were met by a surprised young physician. Excusing himself, he ran ahead, promising to return shortly. Within minutes, he was back with the surprised and somewhat embarrassed professor Vu Van Dinh, director of the Department of Intensive Care Medicine, and professor Nguyen Thi Du, deputy head of the department. They explained they had received no word that we had arrived in Hanoi, but professor Dinh immediately took over, saying, "We have much to do."
He knew I had planned on giving lectures and working with the young doctors in the intensive care unit. He asked me what lectures I would be willing to present, and I invited him to choose five topics from a list of 10 possibilities:
- Intravascular ultrasound
- Thrombolysis in the treatment of heart attacks
- Unstable angina pectoris
- Hyperkalemia
- Lipids and the development of coronary artery disease
- Cardiopulmonary resuscitation
- Management of diabetic ketoacidosis
- Management of hypertensive emergencies
- Temporary cardiac pacing
- Management of acute myocardial infarction
Professor Dinh looked at the list. "We would like all 10 lectures — two each day, beginning this afternoon," he said.
By his arrangement, each morning for five days, I made teaching rounds with the residents and the intensive care unit staff physicians; each afternoon I gave two lectures. He took my list to his office and by noon had a schedule all typed up and distributed to staff, residents, medical students and others in the hospital who might be interested in the lecture topics.
Professors Dinh and Du then gave me a quick tour of the ICU complex which included an intensive care unit, an emergency department and a poison control center. This complex was the backup facility for all the difficult and complex cases that came to the Bach Mai Hospital from all over Vietnam. It was a busy place, as was the Cho Ray Hospital in Ho Chi Minh City, where I followed a similar schedule. After two weeks of intensive involvement with the critical care medicine departments of these, the two largest teaching hospitals in Vietnam, it was apparent to me that they had a tremendous need for modern equipment: respirators, more and newer models; certain expensive, commonly used drugs; temporary pacemakers and pacing catheters; defibrillators; patient monitoring systems; medical beds, textbooks and medical journals.
I was determined to concentrate on one of the two hospitals. If my hosts approved, I wanted to revisit Bach Mai in Hanoi, and I wanted to seek formal recognition of a project to help it, outline its needs and describe how they might be met. I did that in the form of an editorial in Hospital Practice magazine entitled "Revisiting Vietnam." The article stimulated a lot of interest in the program and offers of help and money. It also put me on the road to realizing my aim: improving critical care medicine in, and on behalf of, Vietnam and its people.
FINDING FUNDING
Sometimes, things happen that are far beyond one's wildest expectation. For me, they centered on two individuals at Catholic Health Initiatives (CHI): the late Sr. Maryanna Coyle, SC, a nationally known and highly respected leader in Catholic health care, and Joseph V. "Jay" Maloney, then the president and CEO of CHI's Colorado Foundation. CHI Colorado Foundation is part of CHI's system-wide philanthropic partnership with local foundations to support the ministry by seeking funding for equipment, patient care services and capital improvements. Today, Maloney is president of the overall CHI Foundation.
A dedicated leader and visionary, Sr. Coyle founded CHI, headquartered in Englewood, Colo., in 1996. She was a past president of the Sisters of Charity of Cincinnati and past chairperson of the Catholic Health Association. Of great importance to our Vietnam project was the fact that she was president and executive director of the SC Ministry Foundation, in Cincinnati. That foundation grew out of the health care mission of the Sisters of Charity who, over many decades, have played a prominent role in Colorado health care, effectively managing several hospitals in that state.
I needed help in finding ways to approach foundations for money for the Vietnam project. Friends had pointed to Maloney as the best possible source for such information. I remembered my first telephone call to him — a lengthy description of what I saw in Vietnam and my vision for help for the Vietnamese. Like me, he was a Vietnam War veteran. He listened to my presentation and asked a few questions. Then, unexpectedly, he asked if he might visit Vietnam with me during my next mission. Surprised, but delighted, I said, "Of course." That was the beginning of a wonderful relationship between the CHI Colorado Foundation and our Vietnam project.
At Maloney's suggestion and with his help, I submitted an outline of our Vietnam project to the SC Ministry Foundation. Thanks to the personal help of Sr. Coyle, we received the grant money that we requested. This was the beginning of a wonderful relationship with the SC Ministry Foundation.
We determined Bach Mai Hospital's greatest immediate need to be new, state-of-the-art ventilators for the ICU. The SC Ministry Foundation had approved our grant request for $50,000, allowing us to purchase five ventilators that Jay Maloney, my wife and I hand-delivered to the Bach Mai Hospital, along with two temporary pacemakers donated by Parkview Medical Center in Pueblo, Colo. I never anticipated the problems of carrying pacemakers through airport security. Under X-ray examination, they looked like high-tech bombs. We caused quite a commotion at each checkpoint as we ventured toward Hanoi.
At the Bach Mai intensive care unit, the ventilators were greeted with great enthusiasm. One was quickly unpacked and rushed to the bedside of a young fellow who had just been admitted to the ICU with a king cobra bite on his right hand. It had been several hours from the time of the bite, and the poor fellow was just about to stop breathing. The ventilator saved his life.
I was careful to take some photographs, figuring a picture of a young person connected to a just-delivered ventilator would help affirm the value of such a life-saving gift. I was right, and I have learned that with all donated equipment, it is important to document for the donor that the gift has arrived and has been put into use. I have built up a large photo library of patients benefiting from equipment that was generously donated by supportive foundations, businesses and individuals.
That particular visit to Bach Mai brought benefits beyond ventilators and pacemakers. While we were there, Maloney accompanied me on teaching rounds, sat in on lectures and visited the intensive care units. He was able to see firsthand how a quality ICU team could have an impact on the future academic and clinical health care needs of the country. He also could see ICU staff needed up-to-date medical texts and journals, modern equipment, effective medications and the ability to access and learn from academic medical centers.
After our return to the States in March 2001, Maloney offered his services and the services of his staff at the CHI Colorado Foundation to perform critical administrative duties and maintain the financial records for what we were to call the Bach Mai Hospital Project. The value of this generous offer, which we only partially recognized in the beginning, became apparent as years passed. It has meant that donors could contribute to our project knowing that 100 percent of their gift would go to the project. We had already decided that we would pay all our own expenses incurred while on our visits to Vietnam, including the airfares, and we had no overhead. We thought that such a program would prove appealing to donors. The years that followed proved we were correct.
THE BACH MAI HOSPITAL PROJECT EXPANDS
On my return to the U.S., I quickly put together grant applications, with numerous pictures that clearly demonstrated the need, for hospital beds for the Bach Mai ICU. We were successful in finding generous donors for beds and other supplies, as well as the means to ship them. Our project continued to expand.
Education and training continued to be an important part of the project. My academic teaching visits were well received and especially enjoyed by the young Vietnamese physicians, but it was apparent to me that this wasn't enough to meet the academic needs of the practitioners. With that in mind, I began recruiting.
By 2007, we had gathered specialists to teach at Bach Mai in such areas as toxicology, a major department that also needed assistance in developing a poison control center. We added gifted teachers in critical care, emergency medicine and pre-hospital programs. The Mayo Clinic heard about the Bach Mai Hospital Project and offered help, launching a wonderful academic relationship with the physicians there.
The generosity of donors also allowed us to bring several young, talented Vietnamese physicians to the U.S. for intensive specialty training that they could then teach to colleagues back home, which turned out to be a highly successful undertaking. We were beginning to feel good about our progress with the Bach Mai ICU complex — which included the poison control center and the emergency department — where improved efficiencies made it possible to treat thousands more critically ill patients yearly, referred from all over the country. This resulted in a gratifying drop in the unit's annual mortality rate.
TRAIN THE TRAINER
I was quite pleased with the academic medical programs that we were providing for the Bach Mai Hospital. The hospital staff members, as well as physicians from all over Vietnam, were delighted with our academic medical offerings. But after several years, it was apparent to me that these teaching efforts were just not enough in light of the overwhelming needs of the hospital and the country.
With this in mind, I began talking with our funding organizations to bring more physicians to the United States for training, an effort that involved air transportation from Hanoi and back, room, board and other living expenses, telephone, educational meetings and health insurance, among other costs.
CHI, convinced of the value, funded this academic program with grants totaling more than $700,000. Diane Jones, CHI's vice president, healthy communities, oversaw most of the program and closely monitored the distribution of the funding. She was able to view the progress that the program was making by visiting Bach Mai Hospital and meeting with the Vietnamese physicians and nurses that had come to the U.S. for training.
In all, 29 Vietnamese health care workers were trained for 6 to 12 months in the U.S. and returned to work at the Bach Mai Hospital and other facilities as academic medical teachers. Though most of the trainees were physicians, there were also two nurses and one medical technician. Three of the physicians were trained as paramedics and were certified in that specialty. The trainees were required to write an essay describing their experience with the program and the value that they received from it. All said they were pleased with their experience and the opportunity to pursue a medical teaching career.
As a way to keep track of what happened after they returned home, we also asked each trainee to send us a list of their academic teaching efforts every six months following their return to Vietnam. The reports have been most impressive, delighting all of us who worked closely with them. Perhaps even more important, the Bach Mai Hospital and the Vietnamese government soon recognized the impressive teaching skills of these returning physicians. Each of the physician teachers was sent to province and district hospitals in rural Vietnam for one to three months each year. There they provided lectures, made teaching rounds, helped manage difficult patients, taught procedures and the use of certain instruments.
This was exactly what we had hoped might happen. By their teaching efforts, the trainees have been able to update the knowledge and skills of the doctors and nurses in the rural areas of their country where medical help is most needed. Not only has this improved the morale of the rural physicians and nurses; it also made them more effective and efficient in caring for those in need of medical assistance in the rural areas.
Best of all, the care for the people in those areas was coming from a Vietnamese physician who spoke their language, was aware of local health problems, of adverse health conditions and of cultural factors involved in providing medical assistance — and who would be there for follow-up care. The government and the ministry of health also recognized that improving the skills and knowledge of the practitioners in rural hospitals would relieve some of the burden placed on the large referral hospitals like Bach Mai.
Feedback from these rural hospitals suggests that health care quality has been improved in these rural areas. At the Bach Mai Hospital Project, we believe an effective "train the trainer" program will leave behind the medical message when we are gone.
ADDING SYMPOSIA
Our first symposium was in 2007 on the topic of emergency medicine. In 2009, we moved into pediatrics with our first international pediatric symposium — the first of three such symposia provided by outstanding physicians from the pediatric department of the Mayo Clinic and a pediatric emergency medicine specialist from Children's Hospital in Denver, among others. The pediatricians, besides being superb lecturers who provided interesting and captivating programs, were delightful people to work with. The pediatric programs attracted hundreds of attendees from all over Vietnam.
These symposia were followed by two more critical care medicine symposia, a pre-hospital medical care symposium, a second cardiology symposium, a trauma symposium and a pulmonary/critical care medicine symposium, each attracting 200 to 700 attendees.
We also added programs in fundamentals of critical care support and neurosurgery, including specialty training programs in the U.S. We have learned individuals inevitably emerge to offer extra-special contributions — among the national and international medical leaders in their specialties who have made numerous symposia visits to the Bach Mai Hospital, many also make return visits on their own and have been instrumental in training Vietnamese physicians in their own institutions.
NURSES TO VIETNAM
Much of what I have presented so far has had to do with physicians. Here in our United States ICU programs, we are strong believers in the value of teamwork in providing the best care for our patients. Today's well-trained nurses play a major role in the modern team approach to patient care.
I recognized at an early date the need to encourage development of such teams at Bach Mai Hospital. We were delayed in that goal because, unlike the doctors at Bach Mai Hospital, the nurses usually did not speak English. However, in 2007, we sent three specialty teaching nurses from the ICU at St. Anthony Hospital in Lakewood, Colo., a member of Centura Health, to the Bach Mai Hospital. These three highly skilled teaching nurses spent one month working side by side with their Vietnamese counterparts and provided them with lectures, protocols from their own special care units and assistance with managing many of the problems that they faced on a day-to-day basis. Their goal was to introduce the concept of specialty care nursing to the nurses at Bach Mai Hospital's ICU, emergency department and poison control center. The success of their effort was apparent from the many requests for a return visit for them to continue assisting those units.
Then came our "teach the teacher" undertaking. We sought and found a candidate among the Bach Mai critical care unit nursing staff who had good English skills and a desire to become a teacher like the three U.S. nurses she had encountered. She came to the St. Anthony Hospital ICU for six months of training supervised by our three nurses. A delightful young lady and a quick learner, she easily fitted into the ICU team, and not long after her return to the Bach Mai Hospital ICU, she became a respected teaching nurse for their program. Building on the success of her visit, we brought another nurse to St. Anthony's for training as a teaching emergency department nurse. It has been a joy for us to return to the Bach Mai Hospital and see that the two young teaching nurses have fulfilled all our expectations.
Bach Mai Hospital also needed nurses skilled in assisting with neurosurgical procedures and managing the neurosurgical patients that are so plentiful at that hospital. Thanks to funding from CHI, we were able to send a neurosurgery nurse and an emergency medicine nurse, both from the University of Colorado Medical Center program, to the Bach Mai Hospital to work with the nurses who were managing neurosurgical patients. Our two nurses spent a month lecturing and working closely with their Vietnamese counterparts and brought with them some CDs, nursing protocols and procedure manuals.
Recently, I came upon an online article by Greg Crow, RN, Ed.D., director of the Vietnam nurse project of the University of San Francisco School of Nursing. From the article, it was apparent that, unknown to us, his program had been working with the Bach Mai and the Thanh Nhan hospitals in Hanoi for a couple of years. This is not really so surprising, as Bach Mai is so large that many foreign programs operate there, completely unknown to other program providers. I contacted Crow, who was also unaware of our program at Bach Mai — and he was delighted to learn of our interest in nursing education. We agreed that there is room for future collaboration between our two programs.
The generous organizations and individuals involved with medical humanitarian aid programs readily acknowledge that such programs, to be effective, require more than just providing money or medications, supplies or equipment. Programs destined to last require trained individuals, on site, who can effectively utilize and manage all the above for the good of the population being served.
Teachers training teachers, who in turn will train more teachers, all of whom would have the capability of making the best use of the medicines, supplies and equipment, have the best potential to achieve the goals of a medical humanitarian aid program.
Medicines are most effective when used by someone skilled in their use and who know when not to use them. Equipment is most useful when employed by a user skilled in its use and who is supported by someone who can calibrate, maintain and repair the item.
An effective program requires good, committed individuals in the team providing the aid, as well as involved, enthusiastic individuals in the organization that is the recipient of the aid. I have been fortunate to be a part of a program that has experienced such a desirable relationship, and I feel that the success of the Bach Mai Hospital Project could be a model for other medical humanitarian aid programs.
CARL E. BARTECCHI, MD, MACP, is a distinguished clinical professor of medicine at the University of Colorado School of Medicine and author of A Doctor's Vietnam Journal and The Bach Mai Hospital Project. He also is a professor (honorary) at the Hanoi Medical University and has been awarded a government of Vietnam, Ministry of Health medal. For the past 16 years, he has been director of the Bach Mai Hospital Project. His book about the project was published in April 2013 by Merriam Press.
HISTORY OF THE BACH MAI HOSPITAL
The Bach Mai Hospital, Hanoi, was founded during Vietnam's French colonial period. From its beginnings in 1911 as the small Cong Vong Infectious Hospital, it has become the largest comprehensive general hospital in Vietnam.
As one enters the multi-storied foyer just beyond the entrance of the hospital, one can view the earliest photos that nicely show the historical development of this massive hospital complex, now housing 2,000 beds and 3,000 patients and a staff of more than 2,000 doctors and nurses. It provides care and treatment for over 100,000 inpatients and more than 1 million outpatients each year.
In 1965, following the beginnings of the Vietnam-American War, the Bach Mai Hospital began providing doctors and nurses along with mobile surgical teams for that conflict. In the early 1970s, the Swedish government assisted the Bach Mai Hospital by providing large quantities of much-needed equipment. In December 1972, a section of Bach Mai was hit during the massive "Christmas bombing" campaign targeting Hanoi and the port city of Haiphong. A memorial monument now stands in the area of a destroyed section of the hospital.
The 1973 Paris Peace Accord ended the U.S. involvement in Vietnam, and starting in 1974, the Bach Mai Hospital has been rebuilt and upgraded, assuming its prior role of patient care and medical education and dispatching trained staff members to medical stations throughout the country.
In 2011, the Bach Mai Hospital celebrated its 100th anniversary. It has become Vietnam's leading hospital, with two research institutes, seven medical centers, 38 departments and a staff of more than 2,600. It has established itself as the referral hospital for a myriad of difficult and complex cases from all parts of the country. It is a major teaching hospital for the Hanoi Medical University, assisting in the daily training of hundreds of medical students and interns as well as postgraduate students and medical specialists. The Bach Mai nursing school trains over 100 students annually, with specialized programs for head nurses and nursing specialties.
Hundreds of research projects are ongoing at the Bach Mai Hospital and result in significant contributions to the medical literature. Each year, the hospital receives hundreds of foreign delegations who go there for training, for sharing medical knowledge or to cooperate in the development of research projects.
FINANCING THE BACH MAI HOSPITAL PROJECT
Few programs that provide humanitarian aid to developing countries could ever expect to survive without financial assistance. The degree of such assistance will ultimately influence the size and scope of the program. Most do not start out with enough money to accomplish all their stated goals as well as cover the unexpected costs that burden all such programs. Programs generally expect to start out small, with some start-up funding to achieve some measure of success, which could possibly lead to more funding, broader recognition, more diverse sources of funding, and then to further successes.
The need for broad-based funding is critical, as a single funder might be less dependable over the long haul. Having multiple strong financial supporters lends a degree of confidence to those who might be considering support for your program. Each funder would be expected to evaluate the program according to standards that they employ to justify their support for your organization.
Multiple supporters also help in another way. Supporting organizations, be they foundations, service clubs, religious groups, businesses or other charitable groups, all have board members, executives, staff members and other contacts who might have a personal interest in helping, or may belong to another organization, church group or service club that they might be able to influence in your behalf. In my case, I have often benefited by having contacted an organization that had a Vietnam veteran who took a special interest in our program because of a desire to help the Vietnamese people in the manner that we were proposing: medical assistance.
The Bach Mai Hospital Project was fortunate to have a number of financial supporters whose generosity made our program possible and successful. Our major source of funding and all around support came from Catholic Health Initiatives (CHI), the nation's second-largest faith based health system, with 78 hospitals throughout the United States and $715 million in annual contributions to charity and community benefits. Since the early 2000s, CHI has provided the Bach Mai Hospital Project with almost $1 million for a wide range of programs. The grants were overseen and supported by Diane Jones, CHI's vice president, healthy communities, with the assistance of St. Anthony Health Foundation's Beth Elland, director of grants and communications, and Leslie Strate, president and chief development officer, who skillfully manages the finances and the budgetary processes of the Bach Mai Hospital Project. Their ongoing efforts on behalf of the project have contributed greatly to any success that we might have achieved.
We also were fortunate, in our very early years, to have received significant financial assistance from the Sisters of St. Francis, Rochester, Minn., and The Vincentian Congregation of the Mission, Earth City, Mo. St. Anthony Hospital has made major financial and educational contributions to our program. The Star Foundation, Bethlehem, Pa., and the Star Foundation Fund of the Lehigh Valley Community Foundation, and the Bruce and Jolene McCaw Family Foundation, Belleview, Wash., have made major contributions to the Bach Mai Hospital project.
The Evergreen, Colo., Rotary Club, the Pueblo, Colo., Rotary Club and Pueblo Aerie No. 145 of the Fraternal Order of Eagles have given substantial monies to the Bach Mai Hospital Project.
Physicians who have volunteered as lecturers and teachers for the Bach Mai Hospital Project have contributed over $160,000 in cash over the years of the project's existence. That figure does not include their purchases for the Vietnamese physicians of books, entertainment venues while in Colorado, meeting fees, and other items.
Over 30 private individuals have contributed significant funds to the project. Many have been repeated contributors, supporting our program since the early days and coming forth with funds at times of special needs. Often, their support has been more than just financial, going out of their way to help the program be successful.
In the spirit of openness and today's need for financial disclosures for individuals working for foundations or managing public funds, I need to report that as director of the Bach Mai Hospital Project, I receive no salary and in no way profit from my position with the organization. One of my books — A Doctor's Vietnam Journal, published by Merriam Press, in part covers the development of the Bach Mai Hospital project, has been favorably reviewed in the New England Journal of Medicine. All royalties from that book have gone to the Bach Mai Hospital Project.
— Carl E. Bartecchi, MD