Cardiac Defects in Vietnamese Children
I have spent two days in the Mekong Delta province of Ben Tre with the Japanese charity Support of Vietnamese Children Association. They have been coming here since 1996 assessing congential cardiac defects and recommending surgery and treatment when appropriate and feasible. There have been some issues (about third-way down the page - search for "bentre") to do with implementing the costly treatment based on the diagnoses that have been made, but still, despite me getting a sense of some minor resistance or reluctance within the local hospital's administation, it goes on.
We had been able to introduce only few patients because the families didnít have enough money for operation, even if they could pay, open heart surgery was impossible under 20kg children.
We have been scanning for 2 days. The machine has been free in the afternoons only, but we've scanned over 40 children. I use the word "we" loosely. I've just been standing in the back helping the cardiologists press the right buttons on the machine - which is unfamiliar to one of them. I was thinking I would be stuck in this isolated community for an entire week but I've been travelling 6 hours a day from and back to Ho Chi Minh City instead. Which is why I been able blog and get my email.
Down below is a list of the type of abnormalities we have found. Some of them are quite rare, such as the Cor Triatrium. That's three atria. There should be only two. The cardiologists had only seen two or three of this anomaly in 12 years of pediatric scanning in Tokyo.
"Welcome to Vietnam," I said.
Luckily this problem is one of the most easly fixed, *merely* cutting away the unnecessary septum in open-heart surgery.
Most of the problems are less severe like small holes in the heart (septal defects - VSDs and ASDs) and some are more severe, such as narrowing of the artery and valves leading to the lungs (pulmonary stenosis - PS) which can have long-standing and eventually lethal effects, such as pulmonary hypertension.
Some of the other problems listed are quite horrendous to see on the screen, and equally unusual, like the two children with single ventricles, but they may not be acutely life threatening unless their PS progresses quickly. There was only what seems to be a morphologically left sided chamber in both these two kids, with both atrial valves draining into it and both arteries leading out of it. You'd think, like, how can someone survive with problems like this - in fact one of the kids was as chubby and healthy-looking as you'd imagine, sucking away on mum's breast all through the examination (see phota above)... The other needed surgery urgently as he was quite skinny - "failure to thrive" is the expression - due to the PS being extremely severe. (De-oxygenated blood was not getting to the lungs for growth bringing oxygen to be added.)
There were surprising similarities in the complicated lesions in these two children. Both had severe valvular regurgitation (the main valves were leaking badly), plus switching or transposition of the great vessels AND narrowing of the artery to the lungs, one worse than the other's as mentioned. Despite the amazingly severe mix-up of the heart tubes, a simple shunt operation to send some of the blood destined for the left arm back to the lung artery should see them both right. Not Olympic athletes mind you, but at least relatively productive. The switching of the great vessels could be ACUTELY life threatening in any new-born baby that did NOT have a hole in the heart or a patent ductus arteriosus, but in these kids, with what amounts to a completely absent septum, it was the least of their problems.
However, the poor boy with Down's syndrome who had the entire centre part of his heart missing - atrio-ventricular cushion or canal defect - is not going to fare so well. This one is too disruptive to ever correct surgically. Like most Down's kids, he was happy and smiling all the time. So what to do with this really bad problem in a Down's Syndrome child? (There is a strong association of this particular defect with Down's syndrome - if you see this in a fetus during a pregnancy ultrasound, something like 75% of them will have Down's.)
So. Are you going to make this child suffer enormously through a complicated surgery - maybe a heart transplant is about all you can do... And who is going to pay for this? The parents who are old and make probably less than $1 a day? And who is going to do it? And should this boy survive the operation (which itself is unlikely) what sort of life can he expect once his carers pass away, in a primitive prejudiced village, with a severe mental handicap?
Decisions have to be made.
The doctors told the parents they could do nothing for their child.
Yep. Some of these kids are going to die. Some are going to die real soon.
The "Suffering Of Children" argument has always been one of the most powerful logical confutations of the existence of God for me.
God by definition should be Perfect. If God is not omnipotent then He is not perfect. If He isn't perfect, He isn't God and therefore He doesn't exist. If He IS omnipotent then He would not allow children to suffer.
Children DO suffer, ergo there is no God.
Ventricular Septal Defect 17
VSD Multiple 1
Atrial Septal Defect 3
Patent Foramen Ovale 1
AV-Canal Defect 1
Tetralogy of Fallot 1 (VSD, ASD, Pulmonary Stenosis, PDA)
MonoVentricle 2 (also MR, TR, Transposition, PS)
Cor Triatrium 1
Patent Ductus Arteriosus 3
Pulmonary Stenosis 6
Pulmonary Incompetence 4
Aortic Incompetence 1
Mitral Regurgitation 1
Mitral Stenosis 1
Tricuspid Regurgitation 3
No Abnormality Detected 6
Yours, at the forefront of medicine and theology
OTHER MONKEYS SAID
What's happening? Is it something to do with the environment?
Nothing really specfic to Vietnam, that's how many heart defects there are out there. Maybe 3 to 4 in a 1000 children have a congenital heart defect.
In the modern West (and I vaguely include Singapore in definition) maybe 50% of these heart problems COULD be detectable duing the prenatal ultrasound scan. Treatment could be planned to commence early.
Also realize that health screening, something as simple as a doctor placing a stethoscope on a newborn's chest is not universal. I see the same in India. Heck, the same neglect occurs in some suburbs of Detroit, to say nothing of outback Australia. Too many people too far away and not enough doctors. Or not enough WILLING doctors. Only when their heart disease affects their growth or their fatigue levels or they go cyanotic blue easily does someone think to check up on these kids.
Doctors aren't going to go up country there if they can avoid it, they can't make enough money from these poor poeple, plus the hospitals are underfunded for treatment and equipment, even cleaning - you should have seen the toilets there! - and are generally unpleasant places to work.
You are smart, you study hard and you go through many hardships and deprivations to get a medical degree - you deserve that Mercedes. And the Beemer for the wife, or husband as the case may be.
One of the thoracic surgeons there, all he could talk about to me was getting to Australia to work, to make some real money, but he had failed the oral English comprehension test.
"What's a FRYND?" he asked me. I thought about it. Frynd? Then it clicked.
"It's the Australian way of saying FRIEND," I replied. He laughed but I think inside, he was crying.