Vietnam War Report; Charles Karelis

This is Vietnam War report. A program presented each week at this time we have with us three doctors, Dr. Imre Toth, Dr. Michael Lewis, and Dr. John Constable all of whom have recently been in Vietnam. And we're going to discuss the war from a medical point of view just to get a little background I wonder if each of you could tell us what you do know and indicate briefly in what capacity you went to Vietnam Dr. Constable? [Constable] Thank you. I am a plastic surgeon at the Massachusetts General Hospital on the visiting staff there and I was asked to go for approximately a month to Vietnam in um late April early May. On behalf of a group called the Committee of Responsibility to try and evaluate the severity of the war injuries and particularly among children and with a specific object of seeing what how many or what type of children there might be who would benefit from transportation to the United States for definitive treatment. [Host] Dr. Lewis? [Lewis] I am presently a resident at the Massachusetts General

Hospital. I spent about one year in Vietnam with the United States Navy. Four months of this time was spent in a Marine field hospital in the whey food by area. The remainder was spent at the U.S. Navy hospital in Da Nang, primarily taking care of Marine casualties. [Host] Doctor Toth? [Toth] I was over in Vietnam for about for about a year with a uh military medical team that was working in a provincial hospital treating civilian casualties, civilian patients of all kinds in Vietnam. At present tense I'm a general medical officer with the navy. Why don't we begin with some general questions first on the side of military casualties. It's been said that each war has a distinctive medical tone to it including special problems and possibly new techniques in dealing with those problems. Dr. Lewis can you give us a medical thumbnail sketch of Vietnam do you think?

[Lewis] Well I can give you my experience at the hospitals I was placed at. A rough estimate is that about 60 percent of our actual hospital admissions were of a medical nature that is either a tropical viral disease parasites so forth they remain there were war casualties of some sort. [Host] Doctor Toth? [Toth] Well at the hospital I was at, a small provincial hospital approximately I would say one-third of the patients at any time were one form of war casualties or another. And this includes the accidental ones. Children playing with grenades and other than other than actual contacts with battles and so forth. The other two-thirds were medical patients with various tropical diseases, tuberculosis, plague, what have you and gynecological patients,

obstetric patients. [Host] Do you think you can say in what respects the Vietnamese War presents special medical problems, either to our soldiers, can anyone talk about that? [Toth] Well I can tell you in what respect it presents special medical problems to a team like ours. There is an astounding lack of medical facilities in Vietnam, Which means that patients who are injured somewhere have days of wait before they come-- before they come to medical attention, Which of course aggravates their injuries. That causes infection and the other, the other thing we have to fight is the fact that their medical knowledge is so much different from ours, what there is. In other words there's local Chinese healers who-- in [Tu Wum?] for example, would stuff the wound with herbs and dung and this sort of thing to prevent

bleeding. And by the time we finally saw the injuries they were hopelessly infected in many cases and minor injuries led to fatal causes. [Host] Well the delay you mention is then in sharp contrast with the reports of speedy transportation of our wounded to military field hospitals. [Toth] Absolutely. [Constable] I think you'll agree that this depends a little on the nature of the casualties and one of the great problems is evacuation. And I would have thought that from the point of view of what really was a little different in the war is that at least sometimes at Da Nang or the other major military hospitals you do have a chance to see casualties in an emergency ward situation with the best operative facilities available within a matter of minutes sometimes, of injuries. So patients with wide-open chest injuries, even cardiac injuries that would otherwise necessarily have died before evacuation [inaudible]. [Toth] This is absolutely true but there where we were, we were in a small province so far away from these facilities and even patients who were close enough to our town who

finally came to us, we sometimes were not able to provide the necessary care because of our lack of facilities and we could not sometimes get evacuation for these civilian patients. Although at other times we could. [Constable] Wouldn't you, you would agree that it's a superposition, imposition, really, of a lot of casualties over an already overburdened local medical set up which would be typical of many Southeast Asian countries and then becomes totally overwhelmed when you add these hundreds of major major casualties. [Toth] Well I would say that even without any war injuries and casualties at all, a team like ours coming into a small city that we came into, we were overburdened to begin with by just the tropical disease and malnutrition that was there. Of course all the war injuries on top of this, as you say, were even more an overburden. But there was [muffled word] to being to begin with-- there were absolutely no

medical facilities available in this town at all. When we came there was no doctor in this city, in this province of 300000 people who was-- [Constable] Who was [medicine chief?]? [Toth] That's right. Our [medicine chief?] was a medical technician. So that we were the first doctors there in years. [Constable] This is about the only problem to-- [Toth] This is, yes, this is the smallest and newest and most backwards province, I would say. [Constable] [inaudible] would run you a close second. [Toth] Maybe that's true, I don't know but it's newest province I think. [Constable] One thing you ask, you to mention about malnutrition. Did you really find that malnutrition was a very major problem? [Toth] No, I did not. There is, even in wartime I suppose you get enough rice but a big problem was well, it's hard to it's hard to say, they got enough calories, perhaps but there were many other patients were did not get the right sort of vitamins and there were many

vitamin deficiencies. [Constable] But on the whole if they can get the rice and the fish-- [Toth] They should be alright. [Constable] Straight malnutrition we didn't see a great deal in the entire countryside, even in refugee camps and things. Horrendously terrible conditions of living. But not straight starvation. [Toth] Not too many, only a few cases, yes. [Host] Dr. Constable can you give us, can you elaborate a little bit about the scope and the conclusions particularly of your own tour in Vietnam? [Constable] I didn't go in order to make a total evaluation of all the civilian medical facilities but, if you are going to decide what need there was to evacuate any patients, children or adults, to this country, one of the necessary criteria for evacuating them was that there be totally inadequate facilities for their care in Vietnam, because everyone would agree that if any one child or adult can be adequately treated there then we wouldn't export them. In order, therefore, to treat them to find out which ones, you

had to pretty fully evaluate what was available for them there. Both on the provincial hospital level, which Dr. Toth would know much better than I, even at the Da Nang Naval Hospital which is strictly a US military hospital. A large number of civilians have been treated off and on and even a fair number of elective cases, particularly if someone's interested. When I was there they had just had a plastic surgeon distinguished doctor now going to be head of the Bethesda Plastic Surgical Center, and as long as he was there a number of elective cleft clips, old burn contractions, etc. were being done in the military hospital. And completely mixed, with rather surprised me. I went there and there was this charming child of six whom he'd done an elaborate reconstruction of a torn-off ear, not well-connected. And in the very next bed they had the full colonel of Marines and no-one seemed to be objecting on either side. I think there's no question though that we did find an

enormous number of very severely injured civilians in hospitals, something like 1,500 we saw on a site survey in a month, this was 80 percent of all in the country, probably, for which for the most part care was structurally deficient in one respect or another. But the deficiencies, and I think Dr. Toth would say more about, basically in evacuation and in post-hospital care, there is no social service there. There is very little care for them when they leave. Nowadays thanks to [mill fair?] and other free-world teams, if any traumatic patient once reaches a provincial hospital I think it's very rare that they die or have really major additional morbidity because of grossly inadequate medicine. A minimally adequate standard is usually achieved, would you agree with that? [Toth] Yes I would agree, as a matter of fact what I-- I would also say that in many respects other than war casualties the

best medical care the Vietnamese people have ever known is now with these teams, because for before in this province which I was in, the plague and tuberculosis and so forth were totally hopeless diseases in most cases before we got there. But now that there was some sort of medical care, these patients were treated at least. [Constable] But on the whole, you'd agree, I think the teams, because they make up younger doctors with American training have tended to be more enthusiastic for the surgical aspect. I mean the progress in the care of the traumatic injuries has proportionately, I think, it seems me, been considerably greater than in some of the long standing diseases like tuberculosis. [Host] Can you just tell us what MILPHAP stands for? [Toth] MILPHAP stands for Military Provincial Hospital Augmentation Program, was the original meaning. But it has now changed to mean Assistance Program instead of Augmentation Program.

[Host] And this is a military organization? [Toth] It's a military organization that's a joint service venture with Army, Navy, and Air Force teams. [Host] Is it military do you think for any particular reason, as opposed to it being a civilian organization? [Toth] I would suspect that in this way the Vietnamese identify the American military effort, the American military a little bit more with humanitarian actions and don't just think of them as bombs and napalm, perhaps this may be one one reason, but this may be one reason why the teams are military. [Constable] Out of necessity, I think. I think for a long time there have been individual doctors of one sort or another, volunteers, humanitarians who go out to provincial hospitals but it soon became clear that to really get anywhere you needed long-term continuity and a team of two or three doctors and six or seven technicians, which would be an average MILPHAP

team. And you really can't get this except on an assigned basis. [Toth] That's right. [Host] Dr. Lewis, one statistic with which Dr. John Knowles, the director of MGH, returned after his fact-finding tour was that 98 percent of those casualties to make it alive to the field hospitals survive. Does this seem to you from your experience a plausible kind of figure? [Lewis] Well I have no real statistics on this but I think of all our hospital admissions that 98 percent survive. Certainly that many survive. But as I mentioned earlier, about half of our admissions were medical and almost all of these survive and the other 50 percent being war casualties, I'm not sure of this figure. He may have some real basis for this but just from my observations I'd say

that might be just a little bit optimistic. [Host] Dr. Constable? [Constable] I think that again this will depend on the nature of the battles and exactly how quickly evacuation is going on. I think when evacuation is instantaneous it might be a little lower but I would've thought that it was pretty high figure. But I would say a word of warning about death reports from provincial or civilian hospitals because Vietnamese don't like to die in a hospital. And certainly it's true on the medical service, I think you'll agree. If a patient gets very ill, soon as hope's abandoned they disappear. And even surgeons have to be very cautious. If you go around the night before and tell a family that you're planning a great big wonderful operation for the next day, come looking for your patient in the morning, they have often disappeared in the night. [Toth] This happened very often. Also they will remove terminal patients sometimes to be treated by the Chinese doctor if it seems that he has not progressed under more modern care. [Constable] But I think in addition to the search for another possible method of care, there is the basic feeling that the reasonable, proper place to die, if the doctor can't help you,

is at home. [Toth] Exactly. [Host] Dr. Lewis, you mentioned to me in a conversation a couple of days ago that you've had some experience in training South Vietnamese medical personnel. [Lewis] Yes the first three months I spent in Vietnam was in the Hue Phu Bai area and at the time the Marine casualties were very light and we had plenty of opportunity to work with the medical students at the Hue Medical School. We probably spent two or three afternoons a week with them and I myself spent about two mornings a week in the surgical suites of their hospital. I think I might mention that I think their entire medical school numbered about 100. This was a five year program. About 20 each year. Every graduate was conscripted into the military service which left this real civilian problem that Dr. Toth and Dr. Constable were talking about.

It is almost impossible for a civilian to get treated in one of the ARVN hospitals, that's the Vietnamese Army's hospitals. So this a striking shortage of doctors was certainly felt by the civilian population. [Constable] I think as we toured and saw a great-- you both of you saw your institutions in much greater depth than I could see any, on the other hand we were able to see a vast number of institutions for a short time, and the relationship between the American or free-world doctors and the Vietnamese was very strikingly different depending on the individuals. And on the whole I'd quite agree with you that the vast majority it's been unsatisfactory and it's one of the great shames of the present scheme that all sorts of extra operations and extra medicine being done with its teaching effect being almost entirely lost. But there are lots of exceptions both in MILPHAP and the Project Vietnam doctors, the two month volunteers

who come through the-- an excellent relationship has been built up. Vietnamese doctors, they go on rounds together, and they really learn a tremendous amount. But it must be done with delicacy to a people that are both, you know, highly civilized and extremely proud. [Host] Dr. Knowles mentioned in his interview which I played for Dr. Constable, at least that the public health problem in our civilian relocation camps was rather severe. We've relocated about an eighth I think he said of the population presumably in the relocation camps they are also more accessible to treatment. Yes? [Constable] Yes, I must say I slightly object to the euphemism as a civilian relocation camp. Why not call them refugee camps? [Host] Refugee camp. [Constable] I think that yes this is true. On the other hand since here you have large groups of people willy nilly under central control many

of the public health measures have been rather better controlled than elsewhere. We visited three refugee camps, I think Dr. Knowles visited maybe a couple more. And here the wells were few, the water was regularly tested and the water supply was more or less ensured. I think a lot more public health was being done and it's true in many of the village areas. And these refugee camps are one place where I had a chance to observe at least grossly the nutrition of the children, where it seemed, you know, reasonably adequate. [Host] So you think-- it's all right to conclude that a civilian, a Vietnamese civilian would be from a medical point of view perhaps better off in his refugee camps than in his village, or not? [Constable] Oh no that would depend very much on exactly where he came from. I mean there would be certain [Martin IADs] who had been moved near [Pra Ku?] who it is true had never seen Western medicine of any sort before going into the camp. But this would be the rare exception. And if the implication is that this is a total benefit

to be moved, this I certainly couldn't accept. [Host] What would you think of that? [Toth] I would agree. In our neighborhood the refugee camps were not very well cared for militarily and so forth. We had many more, not many more, but we probably had more diseases and contagious diseases there than in the rest of the population. Many times it would begin in these camps. [Constable] By percentages, you really think they were higher? I don't know the answer to that. [Toth] I can't tell you the answer to that. [Host] Dr. Lewis. [Lewis] Well I don't have the experience that these two doctors have had in the Vietnamese villages for any length of time but from my experience it's hard to me for me to imagine any worse public health conditions than in the average Vietnamese village. These people have absolutely no idea of sanitation. No idea of how diseases spread. And we could

treat them one day and they'd come back two days later with the same disease that they've picked up. They just, you just can't get through to them and I think that's one of the big teaching programs or one of the big things that has to be done in Vietnam. [Constable] I couldn't agree with you more. The public health has to be tremendously strengthened. But I think it's only fair to say that there is the rather ill-fleshed skeleton of an extensive system set up by the French with you know hamlet health workers in every hamlet who just distribute 13 fix drugs and nothing else after three and a half months' training and the district health workers who are much more educated, three and a half years post high school, national midwives, rural midwives, and these are the people rather than the after all, almost from the Vietnamese point of view, professorial US doctors who can do a lot in improving, and I think if you do visit a significant number of villages that are very striking differences. If you have a fairly powerful personality who is district

health worker there will be a lot of improvement. [Toth] I would agree with that, and I'd like to point out also that all these people who are in this skeletal medical framework, medical workers, they're are all very eager to learn and advance in their medical knowledge and we had very encouraging results working with these people. We developed malaria programs and immunization programs. I don't know how many thousands of plague vaccinations were given out, and not by us but by the Vietnamese field groups, perhaps on advice by us. [Constable] Obviously, the number of American doctors under any circumstances would never be sufficient for them themselves to give any significant number in an occupation. [Toth] That's right, of course. [Host] Do political considerations have any weight in who gets treated where For instance who treats the prisoners of war or wounded? [Lewis] We at the Navy Hospital treated a considerable number of Viet Cong,

North Vietnamese, what have you. [Constable] It is I think fairly generally agreed that the medical effort that the South Vietnamese government, backed up by the United States government, has made, has been one of the most valuable propaganda weapons that the South Vietnamese government has had and part of its value lies I'm sure in the fact that it is fairly widely used. They are the only hospitals and they do in fact treat both sides. Almost anyone can be treated in a provincial hospital. Now, when we toured we saw an occasional proved anti-Viet Cong chained to a bed or I think we saw perhaps two prison wards. But on the other hand we were told stories of countless civilian or para-civilian injuries of people who were young men who'd been shot at 4am outside a Vietnamese Army Depot in which it

was assumed they were Viet Cong and they do get treated and there are well-recorded cases of Viet Cong soldiers being actually referred with written records by Viet Cong medics to government hospitals. On the other side of this I think that at least on the whole as we traveled, and you again I'd like your opinion on this, was that the number of Viet Cong atrocities or terrorist activities specifically, deliberately aimed at medical personnel or hospitals have been extremely limited. [Toth] And I have, from my experience this is true, there were none, no cases in our district in our province. We in our hospital and all the other hospitals where MILPHAP teams were that I know of, the policy was to treat anyone who came to the hospital without asking questions except ARVN military who had to go to their own military hospitals. [Host] Could you make a guess at what percent of your people were Viet Cong sympathizers or Vietnam--? [Toth] Well, our hospital

[chef?] estimated about 25 percent of our daily census was probably Viet Cong sympathizer. We had a few cases of known Viet Cong, there was one fellow who was thought to have been in a group that [murdered?] our camp. And he ended up somewhat later in our hospital with a brain injury and various other injuries, and strangely enough he lived and turned out to be rather pleasant fellow. [Constable] And near the border for instance, it's well known that large numbers of Cambodians are treated and no, deliberately, no effort I think is made to restrict this. Now, it is true that if a young male is treated who turns out later to have no identity card, and he's got well enough that he would be fit for military service, he is as I understand it likely to end up in the South Vietnamese army. [Toth] He's always checked by various intelligence sources. [Constable] But he gets treated nonetheless and he treated well, and generally in the same mixed ward, wouldn't you say that's true? [Toth] In our case perhaps

sometimes he got treated better because he was treated in our hospital, whereas the soldiers were treated in the ARVN hospital. [Constable] I know, once they were in a provincial hospital the treatment they got was-- [Toth] There was no discrimination at all. [Constable] You had no prison ward. [Toth] We was no prison ward, no. [Host] To get back to some more general things. The story in The Wall Street Journal for August 30th expressed concern that some Vietnamese veterans are bringing back infectious diseases to the United States. Malaria was mentioned as one whose incidence has increased five times since 1962, any reactions? [Constable] Incidents where, in the United States? [Host] Yes. [Constable] I think it's always a threat in any war that's being waged in a new climate with new diseases, certainly not particularly new, I think there's a lot of concern about certain new strains of malaria that are meant to be resistant to treatment. I think this is a legitimate concern. [Host] Whose responsibility is it to see that people who are leaving the country don't have any infectious diseases, or are these undetectable until appearing? [Constable] I think many of them would

be undetectable certainly for myself, no such check was made other than the standard one that's made by anyone coming back to the country after being in a cholera or other area, they just stamp your yellow card when you come back because you know that if you develop cholera within two weeks they want to be informed of it. [Toth] As far as malaria, all military personnel at least are required to continue anti-malaria pills, prophylaxis, after they have returned to the states, eight to 10 weeks. [Lewis] Right, and I think the malaria that they bring back they are not going to spread anywhere to other people. This is their own problem and once it makes itself evident, they seek the proper treatment and I'm sure come out all right so I don't think that our people are bringing back diseases that they're going to spread throughout this country, I don't think that's a problem at all. [Toth] Well I think the medical profession in most areas where malaria would be dangerous are aware of this problem and looking out for it at present. [Constable] It certainly doesn't frighten me very much.

[Host] Not facetiously. Is there any possibility that we Americans have brought anything to Vietnam that they hadn't seen before? [Constable] Well certainly. Well I won't say they haven't seen before because the French had been there before us but the rate of venereal disease for instance has skyrocketed since the Americans have been there. [Toth] So has the rate of plague for example which I'm sure Americans haven't brought in. It's simply a matter of recording incidents which has not been done before. I mean there were five cases of plague recorded, I'm not sure now, but approximately '51 whereas there were many thousands recorded in '65 and this does not mean that the incidence of plague has increased. It simply means that the incidence of plague has been recognized more frequently. [Constable] The plague is endemic, at least in the northern parts. [Toth] So is venereal disease. [Lewis] I think most of the disease was there already, don't you think, when we got there? [Constable] Well-- [Lewis] Perhaps we helped spread it around but-- [Constable] I don't think that any new diseases, it's not like the early measles being brought to the South Seas and

decimating them. After all with they've been Westernized to the extent of having a French administration and lots of visitors for a long time. And it certainly wouldn't be anything brand new. I quite agree with that. I think the very rapid movement about the country, all the troops and everything, does tend to make the spread of an endemic disease such as plague specifically, which is meant to be only in the coastal area around the mountains in the northern part of the country. The risk of this being spread in the delta where it has never been known before is very much greater and has I think caused certain problems. [Host] Battle psychosis or war-connected psychoses are always I suppose a problem in war. Can we characterize the Vietnamese conflict in this regard as being different from other wars? [Lewis] Yes, real improvement. I think the fact that you have one year to serve-- [Constable] Absolutely. [Lewis] and you know at the end of that year you're coming home, and if you can get through that year-- [Constable] Only one Christmas, only one birthday, only one wedding anniversary to get

through. [Lewis] That's right. You have a specific date to look forward to-- [Toth] You can count the days, everybody did. [Lewis] That's right, everyone does. [Host] Fine, thank you very much. We've been talking tonight to Dr. Imre Toth, Dr. Michael Lewis, and Dr. John Constable about the medical situation in Vietnam. This has been Vietnam War report. This is Charles Karelis.