Khe Phung Thi vomits into a pink, plastic shopping bag.
A fit of coughing and wheezing shakes the 78-year-old’s frail frame. Lai, her daughter, closes the bag when the spell has passed. Dr. Eugene Etzkorn delicately peels the bright red, black and yellow plaid scarf from her head exposing her steel-wool hair. His fingers trace her leathery jaw line down to her neck and examine her glands. His hand brushes aside a bright orange coat and his stethoscope pauses in several places on her chest. Between a brow furrowed with concern and thin lips offering a comforting smile, Dr. Gene’s blue eyes remain focused. The prognosis looks grim.
Edema bloats her feet. Osteoporosis erodes her bones. Hypertension assaults her arterial walls. Atrial fibrillation denies her body oxygenated blood. Malfunctioning heart valves strain to keep pace with the spasmodic beat.
Congestive heart failure is killing Khe.
It’s the kind of case that Dr. Gene treats by the hundreds as a part of the Project Vietnam Foundation (PVNF), a medical non-profit that has been treating patients and training local providers in rural Vietnam since 1996. The 63 year-old infectious disease specialist, a former military doctor, joined the mission to provide medical care to poor minorities in the remote and destitute villages and provinces of Vietnam. It’s an effort that he says is all too often only a temporary bandage in cases like Khe’s.
Khe only weighs about 60 pounds, but it takes three people to carry her and an entire family to support her.
In May 2010 weakness began to eat away at Khe’s ability to contribute on the farm high in the mountains above Dong Dan village near the Chinese border. Her breaths grew shorter and took greater effort. Sleep eluded her as the constant battle for oxygen required conscious effort throughout the night. Thirteen family members – four generations – began to take turns sleeping next to her each night in the dirt-floor hut.
Her room – the only one partitioned from the rest of the living space, a sign of respect – contains her bed, adorned with brightly colored blankets and pillows. The rest of the hut wraps in an L shape around Khe’s room. On one end are the only two other beds. Lai’s is closest to her mother’s room. Her granddaughters share the next bed. On the opposite end of the hut is an old, wooden chair next to a small fire pit. Smoke and embers rise toward the thatched roof making the sunlight visible as it sifts through the holes in the log walls. In the dappled light, three conical hats rest on one of the wooden supports running overhead, parallel to the ground. A loft overhead stores their harvested corn and straw mats where Khe’s great-grandchildren sleep.
In the middle of the L is a faded green set of child-size table and chairs. A tea set rests on top. Just in front of the dining set against the outer wall of Khe’s room is a fading cherry-oak credenza containing the family’s few dishes, utensils and possessions. On top sits a large, rectangle picture frame. Behind the cloudy glass are old, faded, family photos taken long before Khe was sick. A shovel leans by the door next to a broom used to sweep the dirt floors. Everything is in immaculate order.
Outside the wooden walls, peeps scurry about in the dust, scattering at the sight of dogs roaming the grounds. Hens protect their eggs in wicker baskets set off the ground and covered by straw overhangs. Hogs grunt and root in bamboo cages. Down a path enclosed by bamboo fence approximately forty yards, in the shade of a small stand of palms, cows mill about in a small barn constructed of wooden planks. A blue tarp partially protects the western side from sun. Beyond, the narrow path leading from their home snakes through the fields before descending through corn fields, terraced rice paddies and into the dense forest.
It is a long way down to the dirt roads and villages below; over three miles of a narrow, steep, muddy trail. There are switchbacks and streams; rocks and logs.
Khe’s only way down is on the backs of her granddaughters.
From there, it is over three hours by motorbike to the closest hospital in Bac Kan, six hours north of Hanoi, the capital. Khe stayed there at the hospital in Bac Kan for a week recently after taking a turn for the worst. Her condition stabilized. They released her and prescribed medications.
The prescriptions were never filled.
They were too expensive, and after paying for a week in the hospital, the family’s resources had been exhausted. Khe can no longer work and with one person having to be by her side 24 hours a day, their productivity has dropped dramatically. Most of their profits go to the owners of the land where the small farm sits. They barely survive on what is left, most of which goes to Khe’s care.
When they heard about Project Vietnam – heard about the promise of western doctors and medicine so close, closer than the hospital in BacKan – they knew they had to find a way.
But only 10 vouchers would be hand delivered to each village. Only 10 vouchers would be distributed among the hundreds. The veritable golden tickets would have to find their way through the grasp of greedy officials, their passage propelled by “donations” in the form of scholarships and televisions, to those in most critical need; those young and old in need of care; those who couldn’t afford it otherwise; those like Khe.
Somehow one of those vouchers found its way to into Khe’s gnarled, leathery hands.
As she sits in the back of the crowd of impoverished children and decrepit elderly waiting to be seen, hunched over listlessly on a plastic child’s seat, a fly crawls on one of the filth encrusted, overgrown fingernails of those gnarled hands.
Khe doesn’t notice.
The medical team has worked all morning treating hundreds. The first batch of patients is nearly finished. The once crowded compound standing between Khe and the doctors is now mostly a sea of empty, red, plastic children’s chairs.
Khe doesn’t move.
Pain contorts her wrinkled face.
Several volunteers notice. With the help of a translator and the permission of a doctor, she is given permission to skip the remaining wait and intake process.
Two volunteers lift her to her feet.
Khe can’t walk.
She is placed in another tiny, red, plastic child’s seat and is carried through the crowd and into the dingy, crowded, makeshift examination room.
Dr. Gene’s blue eyes remain focused.
Congestive heart failure is killing Khe.
Dr. Gene would normally prescribe Furosemide, a diuretic, to relieve her edema, relax her hypertensive state and allow her swollen heart to return to normal size, hopefully regaining its regular rhythm.
The team’s pharmacy has never actually stocked Furosemide – until now.
But the diuretic carries the risk of dehydrating Khe. The standard 40-milligram dose could easily be too much for her, but half that may be ineffective.
If it’s too much, Khe’s electrolyte and pH levels could spiral dangerously low.
She could lose what few precious nutrients she does take in as part of her impoverished diet.
Her kidneys could fail.
Khe could die.
Dr. Gene could try Atenolol, a drug used to treat hypertension by slowing the heart and reducing its workload.
It doesn’t carry the risk of dehydration, but won’t do anything to relieve her edema or reduce the size of her swollen heart, only slow it down.
It could slow it down too much.
It could stop her heart.
Khe could die.
Dr. Gene’s prescriptions would normally include follow-up visits and careful monitoring of dosages and reactions.
The PVNF team has received unexpected word from officials that this is to be their last day at this location. They are here to help, but there is concern that the team is creating a threat to security. Follow-ups are not an option.
If left untreated, Khe’s condition will only deteriorate.
Dr. Gene knows that she has a 90 percent chance of
dying within a year.
If her heart doesn’t give out or she doesn’t suffer a massive stroke, her shortness of breath will only worsen as her lungs fill with fluid.
Her respiratory system will fail.
Khe will drown.
Between a brow furrowed with indecision and thin lips offering a comforting smile, Dr. Gene’s blue eyes struggle for an
answer. The risk weighs
Volunteers carry Khe back out to the waiting area of the compound and sit her on a plastic child’s seat. This time it’s blue.
She rests momentarily before beginning the journey home. Her shaking hand raises a small, round, white pill to her cracked lips.
Sandwiched between the driver and her granddaughter on the back of a tiny motorbike, Khe winces as they bounce down the dirt road past a blur of ramshackle huts, lakes and rice paddies fertilized with human excrement.
The rest of the family walks.
Nearly half an hour later the bike reaches the base of the trail leading to their mountain home. Khe hunches on a log next the dirt road as the bike whirs away in a cloud of dust to pick up more passengers.
Her great-grandchildren laugh and play as another fit overtakes her. She leans over, hacking, and vomits behind the log. A withered hand grasps that of her granddaughter, Nhat, the only one wearing blue jeans. She stands and straightens up the best she can.
Lai’s gold teeth glint as she smiles. Together, she and Nhat help Khe onto the back of another granddaughter wearing pink sweats. Pink laughs. Straddling piggyback, two generations apart, they are bound together by long strands of blue cloth. The cloth wraps under Khe’s shoulders and criss-crosses around her waist and under her legs.
Pink puts one foot in front of the other on the narrow path that meanders up into the trees, cutting back and forth through weeds and ferns. Wearing only flip-flops, she carefully places her feet on stones and logs as she crosses streams carrying the weight of her mother’s mother. Khe’s bare, swollen feet dangle no more than a foot and a half over the obstacles her granddaughter traverses.
Khe’s great-grandchildren run ahead, laughing. They often swim here in the pools below cascading waterfalls. They hardly notice the steadily increasing grade.
The dense, green canopy provides shade from the sun but traps moisture.
Humidity pools with sweat on Pink’s brow and rolls off her nose. Her straight, black hair sticks to her forehead. Out of breath, she squats as Lai, gold teeth glinting, undoes the cloth.
It’s Nhat’s turn. As she stands, Khe cries out.
The straps between her legs are too tight and are hurting her.
They try again.
Nhat rounds a tight, steep, rocky switchback and with lunging steps drags her sandled feet up the leaf-covered slope. Vines hang here where the children swing and climb.
Nhat tires quickly.
Khe’s third granddaughter, wearing a red button-up, sleeves rolled, with blue, plaid pajama pants kneels. The mud turns the plaid of one knee brown as she is bound to her grandmother.
Her pink sandals scrape along the dirt path. Twigs and shrubs rip and scrape at the plaid pants.
Dense foliage gives way to fields and soon the path winds along terraced rice paddies.
They switch again. Nhat once again hoists her grandmother up and plods on.
The blue tarp of the cattle pen is visible among a refuge of palm trees in the distance. Dogs bark.
Soon the dirt path is littered with chips of wood, dead bamboo shoots and scraps of trash and paper.
Bamboo fences guide the way home.
Khe hunches on an old, wooden chair beside a crackling fire. She attempts to drink from an old, oxidized mug, but sputters and coughs. Water and spittle splatter the dirt floor between her bare, swollen, cracked feet.
Beneath a blue and white bandana with red flowers wrapped tightly around her head, Lai grins, gold teeth glinting. She examines the contents of a tiny brown paper bag. Inside are tiny, foil packs of precious medicine. It will keep her mother’s sickness at bay as long as she takes it, the doctors said.
Khe is supposed to take one of each every day.
There are 30 multivitamins in a plastic baggie.
The other foil pack reads, “Furosemide 40mg.”