Steady Footsteps

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 café 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.

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

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.

I am not a saint, although from some folks’ reaction to my personal story, it seems that they see me as such. While it’s true that I do try to be a “clear channel for blessing” as befits my adopted Quaker tradition, that’s not the same thing as being a martyr in the Catholic tradition into which I was born.

Every decision that my husband and I have made in the course of our Vietnam adventure, unconventional though it may have been, can be argued for in pragmatic, or even economic, terms. Selling our home in 2006, for example, and putting the proceeds of the sale into foreign-denominated CDs turns out to have been a pretty shrewd move, in retrospect. Certainly, selling our gas-guzzling vehicles and our oil-heated house does not look too foolish now that oil has reached $100 per barrel!

The monthly rental for our four-story Da Nang townhouse is less than the amount we previously spent for taxes and insurance on our American home. While electricity rates are about the same here as in the States, it doesn’t take much to power our small fridge, lights and electric fans. Likewise, although gasoline prices parallel those in the States, it doesn’t take much fuel to propel our motorbike.

Gone is the perceived need to purchase a myriad of insurance products to protect our assets and our stream of income. Car insurance, life insurance, long- and short-term disability insurance, liability insurance, homeowners and flood insurance—all gone. We opted to relinquish our health insurance also—you can read my thoughts on that issue here.

My husband Dave and I had wrestled for years with the ethical issue of paying taxes to support a government engaged in an illegal war. That dilemma is resolved for us now, as we don’t have an income that reaches a taxable level. And our teen-aged son is beyond the reach of military recruiters and a possible future draft.

Our jobs are history, along with the stress that accompanied them. The cost of living is low enough here in Vietnam that we can and do live off the proceeds of the sale of our home. (We had neither a savings account nor pensions.) Other expatriates that we know live comfortably here on modest pensions. Still others get by on what they earn by teaching English for a few hours a week. Without that constant immersion in the American consumer culture, we find that there isn’t much that we really need to purchase. We got rid of most of our belongings when we moved to Vietnam and we still have an embarrassment of riches.

My volunteer work here consists of doing the kind of real-deal physical therapy that I dreamed of doing when I first entered physical therapy school back in the 1970s. I’m making a real difference in people’s lives here—without breaking my back and without spending any time at all doing meaningless paperwork! Does that sound like martyrdom to you?

Stepping out of the American rat-race and living a meaning-filled life in a third-world country is NOT impossibly quixotic. I’m here to tell you that it can be a personally gratifying and pretty darned comfortable way to go.

Mirror neurons, asserts neuroscientist V.S. Ramachandran, will be to psychology what DNA is to biology. These so-called “Dalai Lama” neurons, first identified in a lab in Parma, Italy, in 1995, are thought to be key to the human ability to learn skills and language from one another. These are the neurons that enable us to “read” each other’s facial expressions and body language. They’re what cause us to cringe when we watch our child receive an injection or to flush with embarrassment when we witness someone else “play the fool”. When our mirror neurons are in play, we “pick up” on subtle signs of distress from those around us and we are moved to alleviate the cause of that distress. They allow us to experience compassion. Mirror neurons teach us how to behave in community.

While the discovery of mirror neurons is recent, savvy forces have been making use of them for a long time. Totalitarian regimes have always known the importance of squelching demonstrations of dissent. Your mom warned you to stay away from “bad influences.” And there are real economic reasons behind the fact that advertisers pay big bucks to popular figures who model their latest fashions.

It turns out that the motivation behind our behavior is a lot less rational than we would like to believe. Studies show that we are more likely to act in accordance with the behavior that we see modeled around us than we are to act in accordance with our professed beliefs. If this is true, it’s time to examine what we have available to mirror. If you lead a stereo-typical American life, grabbing a pop-tart on the way out the door, driving your auto solo to work, spending the day in an office cubicle, grabbing some fried chicken at the take-out window before sitting down to face whatever the main-stream media has placed before you on the television screen in the evening, who is providing the template for your life?

Some of us feel guilty that we don’t feel more compassion for the “unfortunates” of this world. Others don’t seem bothered and even make derogatory remarks about “rag-heads” and “welfare queens” and “wetbacks”. The plain fact is that it is impossible to feel compassion for an abstraction. What is there to mirror?

If you do feel led to lead a more engaged life, more in keeping with your Christian or Buddhist or Muslim or humanist beliefs, you’ve got to be present; you’ve got to turn your full attention to human beings who are now only abstractions to you.

For me, a big “ah ha!” moment regarding the “homeless situation” was driving up to a Catholic Worker “Breakfast on the Streets” site in Norfolk, Virginia, at seven AM one grey and blustery morning to see one hundred and twenty-five human beings standing quietly in line, each waiting for a cup of coffee, a bowl of boiled grits and two cold hard boiled eggs. Talking with them later, about the misfortunes and ways of thinking that had brought them to this point, I was overwhelmed with the sense that there, but for fortune, could be a child of my own.

For an even easier step, which only involves turning away from your television set and turning towards your computer monitor, I recommend taking a tour of the “Axis of Evil” through the eyes of Andy Chang, a young man who photographed his way across Northern Africa and into the Middle East. Andy’s artistry with a camera allows you to soak in the humanity of the people he met on his journey. Try to hold his images in your mind when next you hear calls to strengthen the American-Israeli position in the Middle East. Think about these faces when you hear terms like “military options” and “collateral damage” discussed.

Working in a Vietnamese rehabilitation hospital as I do, without the benefit of being fluent in Vietnamese, certainly comes with its share of difficulties. Yet many times I feel as if I better appreciate a bereft family member’s despair or a brain-injured man’s confusion when I focus on those individuals directly, rather than relying on my translator's account of their situation.

Your own personal set of mirror neurons can bring you clearly into another’s experience. What, for example, do I have to tell you about this man, in order for you to empathize with his situation?

You are already wired to be a compassionate human being. It’s up to you to “exercise” your compassion.

Last year, decades after dumping 20 million gallons of the toxic chemical Agent Orange all across the Vietnamese landscape, the US pledged to contribute $400,000 USD to partially fund a new study on the topic. What a relief! I’m sure that uncertainty regarding the outcome of this study is the only thing preventing the US from offering substantial assistance to people like May and Song, the articulate but impoverished parents of four disabled children, each conceived in the years following their father’s sojourn in an area which earlier had been heavily doused with Agent Orange.

Finally, almost forty years after another young man emerged from a defoliated jungle with a bizarre skin condition to father a son with strange, canoe-shaped feet before he, himself, succumbed to cancer, the US will know what should be done to make amends. Sixteen years after that man’s son produced a daughter of his own, afflicted with the same canoe-shaped feet, the wealthiest and most powerful nation in the world is finally getting down to the business of deciding whether or not it might have an obligation to help families like these. I have to wonder how the results of that million dollar study will ultimately benefit the generations of individuals and families afflicted with birth defects and early cancer deaths, who live in the poverty that still lingers following decades of US-imposed embargo, superimposed upon years and years of war. Will the proposed $14 million project to isolate a patch of dioxin-soaked ground at the Da Nang airport bring them any solace?

I’ve been tagging along recently with a group of American college students affiliated with the SUNY Brockport Vietnam Program as they make their Thursday morning home-visits to families of disabled children here in Da Nang. The students are studying to be social workers, so they do what they’ve been trained to do: they sit down with families and ask them questions. Then they listen.

Two weeks ago, we sat and listened to the diminutive mother of the canoe-footed girl tell us how sad she was that her daughter, a serious and dedicated student, could not attend high-school. The school, she said, was too far to walk to, and the mother was not able to balance her daughter safely on the back of her bicycle in order to take her there. (Her daughter’s canoe-shaped feet not only prevented her from walking without wooden crutches, but also made it impossible for her to pedal a bicycle herself.) A kind friend who lived next to the school, she said, had offered to let the daughter stay with her so that she could more easily attend school but, alas, that was impossible.

“Why is that?” asked a student.

“Because,” confided the mother, “my daughter cannot stand without her crutches and so cannot shower and attend to her ‘personal hygiene’ without my help.”

Being the only physical therapist in the room, it fell to me to suggest that, perhaps, the girl might sit down on a plastic chair when she showered and that, if a hole were cut in the seat of the chair, it might allow her to attend to her own hygiene when she used a typical “hole-in-the-floor” Vietnamese toilet.

The mother’s jaw dropped and the father beamed. As we departed, they each pumped my hand vigorously, smiling broadly. What had happened? Somebody sat down and listened to their story and made a simple suggestion. And, because of that, a sixteen-year old, third-generation victim of Agent Orange might go to high school.

We didn’t need a million dollar study. All it took was a few American college students and one middle-aged American PT, listening to one family’s story. Why is that so damned difficult? We didn’t even have to buy the plastic chair.

1 February 2008

Dear Katherine,

I realize that the recent submissions I’ve sent you may seem pretty bleak. In fact, I’m not sure you would consider me a “card-carrying progressive” anymore.

Well, here’s one more, and I can’t say that it’s any happier. I’m writing about what I’m feeling about America these days, but I’m doing it from my own unique point-of-view here in Da Nang. I’m writing for “my tribe”—despondent progressives (check out the comment section following any of Common Dreams’ recent articles). These people, like the family members I describe in the attached article, Going Home for Tet, have been engaged in heroic efforts against impossible odds—in our case, trying to right the ship of state.

It can’t be done. (Sorry, that’s my “unprogressive” conclusion.) I think we’re headed for a new stage in history, the one that will inevitably result from the end of cheap oil and the unraveling of the American economy. Building vibrant, functional, sustainable local communities will be essential. Many of us are in mourning for the loss of our idea of what American could/should be and we need to talk about that. But what are we to do after that? I want to write more and do more about building local food networks and compassionate communities to take the place of the corporate-dominated exchange economy and the professionalization and out-sourcing of every aspect of our lives. In order to build that new society, we will need every bit of energy and creativity that we can muster. We don’t need to piss it away tilting at windmills.

Sorry about that.

Best wishes,

Virginia

As the Lunar New Year countdown reaches its final week, everybody in Vietnam is heading home for the holidays. Northbound buses, trains and flights out of Ho Chi Minh City are completely booked as students, factory workers and businessmen alike stream homeward. Tet in Vietnam is like Thanksgiving, Christmas, New Year’s and Easter in America -- all wrapped up into one joyous celebration. And being home, with family, is the key element in this week-long event. There is no point in trying to embark on any business arrangement or to discuss any matter of importance these days because everything will be dealt with “after Tet”.

In America, hospital workers are accustomed to seeing empty beds around the Christmas holidays as doctors and patients alike do not “elect” to do elective surgery then. Likewise, patients and hospital staff often push towards getting the patient “home for the holidays”. That’s true in Vietnam, only more so. The rehabilitation hospital where I volunteer in Da Nang will be virtually closed over the week of Tet. Everyone who can physically get out the door has gone. The only two patients who remain on the “serious” ward are a young woman whose pelvis was crushed in a motor vehicle accident and a brain-injured girl whose family lives on a remote island in the South China Sea. Everybody else went home, including a quadriplegic riding sandwiched between two family members on a motorbike.

But the joy of the holidays and imminent family reunions was muted last week on the “serious” ward. This ward houses those with the most recent and severe brain-injuries.

Over the course of several months, the population of that ten-bed ward had evolved: as patients improved, either through therapy or the natural healing process, they moved to beds in smaller rooms where they stayed as they continued to work on re-establishing control over their bodies, or else they went home as family members either ran out of money or decided that they could continue therapy as an out-patient. Two patients, however, remained continuously on that “serious” ward—never waking up sufficiently to actively participate in therapy or even to sit unsupported in a chair. Their eyes opened, they swallowed food, and occasionally moved their limbs for no discernable purpose. As the other patients were learning to stand up and walk with assistance and saying their first few words, the mother of the tall, thin high-school student and the wife of the 29 year-old father of three worked diligently on feeding and bathing and passive exercises. As new patients transferred in, the young wife and the middle-aged mother taught the new families how to survive in this hospital setting. (Hospitals here in Vietnam are a family affair because it is the responsibility of the family to feed and care for their loved one while he or she is hospitalized.)

Other patients moved on, but those two young men remained in those beds. Yet, as long as they remained in the hospital, in the company of other head-injured patients and their families, the young wife and the middle-aged mother could cling to some nebulous hope of recovery, despite the increasingly obvious fact that things were not looking good.

Then came Tet. One morning I arrived at the ward to find the mother weeping silently as she bent over her son – stretching, stretching his ankle as I had taught her to do some months earlier in order to avoid muscle contractures that could prevent him from standing, flat on his feet. Her husband, the boy’s father, who had always been ready to lend a hand to anyone else on the ward, was hurriedly packing up the last of their belongings in preparation for the long trip home. The young wife of the other severely disabled man stood watching, with a tremulous smile on her face. She, too, was going home with her husband that day. Home at last, to be with their three young children and her “good neighbors” – and the husband who would never walk or work or talk to her again. Home at last, after months of “intensive caring” to the new normal—a life without hope.

Maybe that’s too harsh. How can we live without hope? Certainly these women, like many Americans nowadays, realize that the futures that they once dreamed of and worked towards have been dashed. The mother will not see her son enter university. He will not have children of his own and he will not be an aid and comfort to her in her old age. The young wife will care for her three young children and, now, one very large, eternal infant with no help from a loving spouse. How she will earn a living, I can’t begin to imagine.

But their epic struggle to reverse this huge catastrophic change in their lives has ended. What has happened cannot be undone. Yet they endure. And when they return home this Tet, they will be enfolded and supported by their families and their communities.

That is their only hope.

As it is ours.

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

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

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

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

OK, here comes the story:

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

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

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

Well, that was certainly disappointing.

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

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

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

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

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

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

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

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

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

You’re going to die.

I don’t know where and I don’t know when. I’ve never seen your medical record, but I can say with complete assurance, “You’re going to die.”

It doesn’t matter whether you’re eligible for Medicare or Medicaid. It doesn’t matter if your insurance premiums are paid up or not. It doesn’t even matter if you’ve never been sick a day in your life.

You’re still going to die.

Although mutual fund managers caution that: “Past performance is no guarantee of future results,” I’m going to side with history and science on this one--everybody eventually dies.

Given that health insurance and medical care will not prevent one’s eventual death, what are people thinking when they say, “I would love to quit my job and live out my dreams—but I can’t, because I would lose my health insurance?”

I think their real concern is: Who will take care of me if I cannot care for myself? And my answer is—it’s sure not going to be your health insurance company!

Medical care in the US today is set up and run according to conditions dictated by Medicare and big private medical insurance companies. It’s very, very difficult to actually get admitted to a hospital. Hospitals admit only a small percentage of the sick and injured people who pass through their emergency room doors. Most surgery these days is done on an outpatient basis. Reimbursement issues pressure hospitals to discharge patients as quickly as possible. So, the fact of the matter is that, even if you become seriously sick or injured, you may be spending most, if not all, of your recovery time in a hospital bed set up in your dining room as, chances are, you’ll be discharged from the hospital long before you’re able to climb the stairs to your bedroom. If you do pay an ambulance crew to carry you upstairs, you’ll be stuck up there while your spouse scuttles up and down the stairs with your meals. If you’re lucky, Medicare or your insurance will pay for a home health agency to send a nurse out a few times a week to teach your spouse how to change your surgical dressing, and perhaps a therapist to teach you to hobble over to the potty chair and to bathe yourself. It’s going to be hard on your spouse, because she’ll feel guilty about leaving you unattended when she slips out to the pharmacy or grocery store. Maybe this time you’ll have a complete recovery, but at some point, you will enter into a decline that will culminate in your death. Who will care for poor old you?

Will it be your spouse, who is aging, just as you are? Will it be your children? (That’s the bet that most people in Third World countries make.) Even the most well-intentioned adult American children find themselves in a terrible bind when their parents need care, because the kids themselves are tied down with their own financial and family obligations. You could pay out of pocket for a private duty nursing aide. How long would your finances allow that?

When my husband and I decided to quit our jobs, leave the US, and move to Vietnam in order to do volunteer work, one of the decisions we made was to forgo health insurance. This was not a decision we made lightly; we had never before voluntarily opted be uninsured.

Here’s our thinking on the situation: We can afford the same health care that any Vietnamese person can afford. It’s not “top notch”—but it’s not bad. We would rather contribute to the Vietnamese health care system by paying directly for our care than to give any more money to private health insurers.

We chose to move to Vietnam while we were in our fifties and still fit enough to be able to do meaningful work here. We hope that, when we do decline to where we can no longer do so much, that a reservoir of good will and savings will enable us to find and financially support someone to take care of us. It’s a vague notion—and we don’t spend a lot of time thinking about it—but it’s allowed us envision a life in which “keeping our health insurance” is not the ultimate goal.

There’s no doubt that you will die.

The question is: Will you live?

Looking back now, I think it was around 3 AM on September 26, 1985, while lying on the floor of the Virginia Beach Convention Center, staring at the underside of a folding table, when my husband and I decided to move to higher ground. We had spent the previous day fastening plywood over windows, emptying shelves, closets and cabinets and then stacking our upholstered furniture, rugs, clothing, books and tools atop counters, tables and wooden chairs, trying to protect them from anticipated flood waters. Hurricane Gloria, described at one point as the “Storm of the Century,” was swirling off the coast, predicted to make a direct hit on Virginia Beach on the morning of the 26th. Our suburban lot, set two blocks back from the Atlantic Ocean, was low-lying. A long-time resident told us that, during the famous Ash Wednesday Storm of 1962, flood waters had reached our front door knob. We had flood insurance but, studying the fine print while hurricane warnings sounded over the radio, we realized that the policy only covered the “depreciated value” of the contents of the house. Depreciated value on a ten year old television, twenty year old books and a thirty year old sofa does not equal replacement value. Thus, the eight hour stacking, stashing and boarding up marathon.

And so, we decided to “be safe” and move to higher—much higher—ground in the Shenandoah Valley, two hundred miles inland. Ironically, six weeks after Hurricane Gloria decided to give Virginia Beach a pass and strike Long Island instead, a storm spawned in the aftermath of Hurricane Juan devastated West Virginia and parts of western Virginia, including the Shenandoah Valley. When we arrived there the following spring, we were greeted by the sight of a two story house, still wedged high in an oak tree overhanging the Middle River, where flood waters had left it months earlier.

We found the home of our dreams--a hundred year old “fixer-upper”-- perched atop a hill surrounded by rolling countryside, framed to the east by the Blue Ridge Mountains and by the Appalachians to the west. No large bodies of water in sight. Safe at last, we thought.

We were taken aback, therefore, when a tornado struck the nearby town of Augusta Springs. It knocked a century-old wood frame church off its foundation, then skipped over a hill and reduced a trailer to a few scraps of aluminum and shreds of insulation. I commented to an elderly neighbor at what a freakish occurrence a tornado in these parts must be and he nodded, noting, however, that the last one he recalled had torn a path across his pasture before knocking the top off one of the massive oak trees that shaded our own house.

“Oh,” I said, swallowing, “I noticed that the tops of three of the oak trees were broken off. They all must have been damaged in that same storm.”

“Oh, no,” he replied. “The tornado only got one of them. Lightning strikes got the other two.”

One day we got word that my friend Lucy’s house had burned to the ground. My husband and I grabbed some crowbars and headed over to her place, thinking to help her shift the wreckage enough to recover some of her belongings.

“No”, she said, as we arrived to see the flat black ruins. “You don’t get it--there’s nothing left to move.”

Her big, solid house-- like our own--had been built of chestnut—a hard wood that had been seasoning for a hundred years. You just can’t get better firewood than that.

Twenty-one years after our run-in with Hurricane Gloria, we passed through the eye of Typhoon Xangsane in our present home in Da Nang, Vietnam, two blocks from the South China Sea. We survived unscathed, but the City of Da Nang appeared devastated. The typhoon ripped off part, if not all, of everyone’s roof. Great trees that formerly lined the avenues downtown were uprooted; tree limbs and downed electric lines blocked most roads.

Yet, even as the winds were dying down that Sunday evening, Da Nang residents were out salvaging corrugated metal panels and fixing their roofs. Enterprising people quickly began chopping up and hauling away downed trees, leaving only leaves and the smallest twigs for the city trash trucks. Electrical service was restored in a matter of days.

Less than two weeks later, another typhoon lurked off-shore. Da Nang residents bought empty feed sacks and headed resolutely down to the beach. They filled their sacks with sand and then hauled them up atop their houses to ensure that their newly repaired metal roofs stayed in place. The second storm by-passed Da Nang but the sandbags remained in place until the bags degraded and the sand sifted back down to earth many months later.

This year, in lieu of typhoons, central Vietnam was pummeled with a series of extremely heavy rain storms. I’m talking about days of continuous, horizontal, masonry-wall-penetrating rain! The storm drainage system of downtown Da Nang, for the most part, handled the run-off well—certainly much better than my old neighborhood in Virginia Beach. The Han River rose out of its banks, covering Bach Dang Street for one day. The nearby tourist town of Hoi An flooded, as it does every year. But, as soon as the flood waters receded, shops were mopped out, merchandize restocked and business resumed. Two days after river waters swept through a neighborhood on the outskirts of Da Nang, reaching a height of six feet within some houses, I traveled through to see freshly scrubbed houses, sleeping mats hung out to dry and people sipping coffee in the neighborhood shops.

My young friend Mieng confided that her grandmother’s house had washed away in the recent floods. Her grandmother lives in a bamboo hut by a river in Quang Ngai province.

“Oh, my God!” I said. “What will she do now?”

“The same thing she does every year,” said Mieng. “Stay at the community shelter until the flood waters recede and then rebuild her bamboo house with the help of her neighbors. My Dad wants her to move here, to Da Nang, and live with us, but she wants to stay in Quang Ngai with her friends and neighbors.”

My friend Tam tells me that, when she was a child in Da Nang, before the American War, all the houses in her neighborhood were made of bamboo. One day a fire swept through and burned them all down. I haven’t seen a fire engine in the year and a half that I’ve lived in Da Nang—but I haven’t seen a house on fire either. Da Nang houses now are made of brick and cement—impervious to both fire and flood. The walls are solid masonry; the floor is ceramic tile over concrete. There’s no carpet, no sheet rock, no insulation. If the roof blows off, they stick it back on. If the floor floods, they mop it. If the walls get wet . . . they get mildew.

Will we be able to avert the disastrous effects of global climate change? Maybe we will and maybe we won’t. But, even without that added complication, bad stuff happens. It always has and it always will. There is no safe place. Insurance policies and new technology are not the only possible responses to life in an unpredictable world. There’s a lot to be learned from cultures that have a history of weathering big storms and hard times.

A flexible reed may survive a storm that fells a mighty oak.