Franco - Vietnamese Hospital : FVH
The FVH is a modern 200 bed private hospital located in South Saigon, Ho Chi Minh City, developed by a group of French doctors with the support of the World Bank and inaugurated in 2003. The mission of the FVH is to provide international standard health care at a price adapted to the economic reality of Vietnam. There is as well a clear commitment of FVH to provide teaching for nurses, medical students and doctors through specialised courses and rounds in the premises of the hospital which have been granted with the necessary meeting rooms and a large auditorium. Moreover the association FVH Medicine Vietnam funded by private donors has been established in order to take care free of charge children who require surgery.
Economy and health care in Vietnam
Vietnam has population of over 80 million inhabitants a majority of which live in rural areas. A large majority of Vietnamese are under 30 years of age born after the terrible losses of life during the 25 years of war. Ho Chi Minh City still known as Saigon is the largest city in the south of Vietnam with more than 7 million people, one of the highest densities per km2. It is a booming economic hub growing at a very fast pace representing one third of the gross domestic product (GDP) of the country. While the mean national per capita income was $ 540 in 2004, Saigon boasted nearly $ 2000 with a GDP growth of 11.6 % per year.
Life expectancy in Vietnam is 68 years up from 45 years in 1960 but mortality under 5 years is still at a high of 39/1000 a better indicator of the health care system, in remarkable improvement from the dismal figure of 1960 with 219/1000 mortality. Despite the impressive economic growth health care still faces major challenges as the public infrastructures are not able to meet many of the standards of modern medicine despite an excellent background in basic training of doctors and medical professionals. For instance there are 39 hospitals with 17’000 beds and over 4600 doctors in HCMC however the available budget of the Ministry of Health is so restricted that many of these hospitals are totally out dated and salaries of health professionals are minimal.
In Vietnam the majority of the population does not have any type of medical insurance. Only public employees benefit from a kind of social security program which reimburses the official fees, which amount to about 30% of the real cost in public hospitals. As such almost all the medical expenses are charged to the patient whose family is more often than not in a very tight situation in order to pay if expensive treatment is to be considered. Therefore in public institutions these major financial constraints do not allow for the development of specialised educational programs nor do they permit recording reliable data on the epidemiology of many diseases let alone enforce guidelines for evidence-based medical practice.
Hepatology at FVH
The FVH is staffed with permanent French and Vietnamese doctors and has a specific structure of rotating specialists coming for short periods of time from France, Switzerland and Belgium. The Division of Gastroenterology and Hepatology benefits from the expertise of some 30 certified specialists in liver diseases, digestive diseases and endoscopy. These rotating gastroenterologists work in an outpatient clinic, a fully equipped endoscopy suite and take care of hospitalised cases in the inpatient wards. The FVH has a high standard quality Radiology Department and an up to date Medical Laboratory where many of the biological assays including a full liver panel can be done within the same day of consultation. Most of the patients come for consultation without appointment and over the first two years of practice the number of consultations specifically for liver disease and viral hepatitis has gradually increased to amount to about 30% of total. Patients come not only from HCM City but also from the heavily populated Mekong delta region, Cambodia and several regions north of Saigon. In this setting the large number of newly diagnosed cases of hepatitis B and hepatitis C has been awesome to consider by usual standards in Western Europe. The epidemic pattern of viral hepatitis in the country has been confirmed by our Vietnamese colleagues who are confronted with the difficult task to correctly identify those cases that would require expensive therapy that only a minute minority can afford. Only the cost of medicines for a six month treatment of hepatitis C can amount to 20 times the per capita income / year!
In this two year period of observation at FVH we have seen the shortcomings of poor work-up of many cases at other institutions, the lack of rationale behind decisions to treat, the loose follow-up of those who develop adverse events, and the erratic compliance of patients who are unable to understand the basics of a very complex therapy for which they engage in excessive expenses in view of their income, expecting unrealistic results of incomplete protocols. It must be stated that some information on hepatitis is given through the media and patients are actively seeking medical advice. While all the Interferons and antivirals used for treatment of hepatitis B and hepatitis C can presently be found in pharmacies in Ho Chi Mihn City there appears to be little or no control on quality of prescription.
Burden of liver disease in Vietnam
There is no single explanation for the large amount of cases of hepatitis B and hepatitis C in Vietnam the incidence of which is estimated to be at least 10 times higher than in the US or EU. Like in the rest of South East Asia and China hepatitis B is more frequent than in the Western World, a fact known for many years. There are a substantial number of cases due to mother-foetal transmission of VHB. A program of detection during pregnancy and vaccination at childbirth is theoretically in common practice. As well the Government of Vietnam has started a vaccination program of sero-negative young people.
There is no vaccination for hepatitis C and laboratory tests have only been available for about ten years for screening. With the slow recovery from war and the impact of economic embargo major delays in performing appropriate screening tests have been seen in Vietnam. Moreover lack of single-use medical material, needles and syringes for a prolonged period of time have all contributed to the spread of VHB and VHC during dental, medical and surgical procedures. It is unlikely that this critical issue has been solved except in major hospitals. Other forms of transmission cannot be excluded with the use of needles and other devices in traditional medicine practices. There appears to be a high prevalence of VHC genotypes 1 and 6 in Vietnam which are unfortunately more resistant to current therapies, with response rates under 50%.
The large number of cases of VHB and VHC leads to an increasing number of cases of liver cirrhosis as the population ages, this complication of liver disease developing after 20-30 years of evolution. In Asia the incidence of liver cirrhosis is 150/100’000, more than 15 times that of Europe. Cirrhosis is seen in young or middle aged men who may have a large intake of alcoholic beverages as a co-factor as well as in middle aged women who by rule have no alcohol consumption. Cirrhosis can lead to gastrointestinal hemorrhage through oesophageal varices due to portal hypertension, a complication requiring very costly hospital admissions and carrying a high mortality rate. Worldwide up to one million people die from liver disease secondary to viral hepatitis each year. As a further complication of cirrhosis the incidence of primary liver cancer (HCC) is among the highest in the world. For these patients surgical operations such as partial hepatectomy can be considered sometimes but for the most part this is an irreversible complication. Liver transplantation is not yet available in Vietnam.