January column

Claudio Schuftan

Vietnam (map, left) was first independent, from China, in 938 CE. Unified after the wars of recent memory (centre) the country is now booming (right)

Ho Chi Minh City, also known as Saigon. This column, like that last month, continues my account of the country where I have lived for many years – Vietnam. You may well still imagine Vietnam from the televised and still images of its wars of liberation against the French colonial power and then against the US and associated invaders. Photographs like those of Don McCullin, and of Philip Jones Griffiths (above) still remind us of the disasters of what in the West is known as the 'Vietnam war', which killed anything between 1 and 4 million civilians.

I have now lived 16 years in Vietnam, and I now may change your sense of my adopted country as it has developed in peacetime, and of how it has always been. My Vietnamese wife Aviva and I are planning to move to California in a year or two, so I am in pre-nostalgic mood. Here first are some vignettes, then some facts. Also, this month I briefly profile the person who for many, especially in Asia, can claim to be the most influential public health nutritionist in the second half of the 20th century.

My Vietnam
Culture: Opera, ballet, jazz

Paris? Vienna? No, here are opera houses of Hanoi and Ho Chi Minh City,
part of cultural life of Vietnam that continued during the wars of liberation

Vietnam has an active cultural life. This never stopped during last century's wars of national liberation. The first was against the French colonial powers; it began in 1946 and ended in 1954 as a result of the Vietnamese victory at Dien Bien Phu. The second was against the US, allied invaders and the US-supported South Vietnam regimes and armies; it began in the late 1950s and ended with the liberation of Saigon in April 1975.

In these times of war, the fine arts academy, the conservatoire, the symphony orchestra, the ballet and the opera all continued to function. The result can be seen today. We enjoy regular concert, ballet and opera seasons, and an explosion of art galleries with some Vietnamese artists having their works displayed in major museums and prestigious galleries the world over. The photos above depict the operas of both Hanoi and of Ho Chi Minh City. The opera house in Hanoi is a replica of the Opera de Paris. Both buildings are a couple of the (few) great legacies the colonial time left behind (other than French bread, which my friend Carlos Monteiro may object to).

Over sixteen years – seven in Hanoi and nine in Ho Chi Minh City, aka Saigon – I have been an avid consumer of this culture. Being a classical music aficionado and enthusiast, when I am in town I am at the opera at least twice a month. It is very affordable ($8-$10 gets you a very good seat) and of high quality with frequent visiting artists and conductors from all over the world. You want to hear about another advantage? I am such a frequent visitor to the opera house that the ushers that cut the tickets know me personally. When any programme is sold out, they try (and often succeed) to put an extra chair for me in the back. Unique here in Saigon, is the fact that they occasionally have a very special feature: an evening with a symphonic half programme and after the intermission a ballet programme. A two-in-one evening. Neat, hey? Ah, and for those of you who are jazz lovers, there are excellent jazz clubs both in Hanoi and Saigon as well.

My Vietnam
Food: Fish sauce and durian

Vietnamese fish sauce: factory in Phú Quôc; one of the hundreds of brands on sale; and the product mixed with water, sugar, lime, peppers, and garlic

In recent columns and in World Nutrition commentaries, Geoffrey Cannon and Enrique Jacoby have celebrated the food cultures of Brazil and of Peru. So, what about Vietnam? Here I will simply mention two items that are greatly loved by gourmets here.

First has to come 'nước mắm' or fish sauce. This is an amber-coloured liquid made by fermenting anchovies with sea salt. It is widely used in many dishes. It is intensely flavoured and those who have not been brought up with it, love it or hate it. Me, I love it. In addition to being added to dishes during the cooking process, nước mắm is also used as a base for a dipping sauce prepared in many different ways by cooks. As seen above (left) anchovies and salt are put in wooden tanks to ferment and are slowly pressed, yielding the salty, fishy liquid. Vietnamese nước mắm can be lightly sweet as well as salty to taste, and can even be sour or spicy if water, sugar, lime, garlic and hot peppers are added (right, above).

Nutritionally, the sauce provides some peptides and plenty of amino acids. But for us public health nutritionists, nước mắm is a big worry, because of its high sodium content and because the Vietnamese consume it constantly and will never give it up. Because it is virtually a staple item in Vietnamese diets, it is sometimes 'fortified' with iron, and the addition of iodine has also been tested.

The equally worrisome component of the traditional Vietnamese diet is a hidden ingredient – yes, you have guessed, it is the odourless, synthetic, flavour enhancer monosodium glutamate. Used everywhere, often in excess in street foods, particularly in the popular noodle soups consumed here for breakfast – it adds dangerous levels of sodium to all those susceptible to hypertension and ensuing atherosclerosis. No amount of the constantly consumed green tea, with its cholesterol cleansing properties, could undo the harm done by monosodium glutamate.

Durian: the whole 'king of fruits' (left) and cut and showing the flesh (right).
Often banned in public places because of its odour, the Vietnamese love it

And, of course, I have a dessert for you: durian! Regarded by many people in Southeast Asia as the 'king of fruits', the durian is distinctive for its stomach-churning odour and formidable thorn-covered husk. The edible flesh emits a distinctive strong and penetrating odour. Some people regard the durian as pleasantly fragrant; others find the aroma overpowering and revolting. The smell evokes reactions from deep appreciation to intense disgust, and the fruit is banned in some hotels and on public transportation. I have a deep appreciation for durian. When I get the right type, for me it is the nectar of the Gods.

Box 1

Tu Giay

There is a nutritional aspect to the Vietnamese victories over the US troops. Tu Giay, who died at a great age in 2009, was an agronomist and biological scientist whose greatest achievement was to compile 'a little green book' given to every regular North Vietnamese army and Viet Cong soldier. This explained what plants in the jungle were safe to eat, how to cook with fire, but without smoke, and many other food and nutrition survival principles and advice. The soldiers also carried packed rations he had formulated in the most cost-effective yet nutritionally sound manner. His account of some of this work can be accessed here.

Tu Giay at right, and at centre being greeted in the field of battle by Vietnamese
president Ho Chi Minh (shown on the cover of Time magazine in 1975, left above).

I had the privilege to know Tu Giay personally, and met him several times during my Hanoi years. His second claim to fame came after national unification in the long period of peace and prosperity this country has now enjoyed. He is the father of the Vietnamese agricultural system and programme that integrates the tending of ponds, small animals and fruit trees. In rural areas here, where most people are rice farmers, many households have a small fishpond. Tu Giay started a big national movement to put a piggery and chicken coop next to the pond in a way that their faeces are washed into the pond to feed the fish. On the edge of the pond, people were taught to plant fruit trees, thus completing the scheme of a sustainable household level food system. The system continues to be very popular nationwide.

Tu Giay once took me personally out on a field trip to show me the achievements of his system. I was impressed to say the least. You can perhaps guess what his biggest uphill battle was in this endeavour. This was convincing people that they should not build their own latrines on top of the pond…. In times of peace Tu Giay founded the Vietnamese National Institute of Nutrition and remained its director for twelve years. He is a nationally revered person.

My Vietnam
Peacetime advances and changes

Vietnam economically is a star 'Asian tiger'. I can hardly remember how so much less developed it was when I first visited in 1991, and then in 1995 to stay to work as a senior primary health care advisor in the Ministry of Health under a Swedish International Development Agency project. The differences are like those between night and day.

Almost three years of immersion in the health bureaucracy here, allowed me to get to know the country, including its fascinating remote districts where 53 different minorities reside. To my disappointment, I found out that a bureaucracy is a bureaucracy, even in a socialist country. I have also witnessed how the opening of the market under a socialist regime has brought much progress to the country. Since 1990, poverty has fallen from 54 per cent to levels in the low teens; malnutrition from around 39 per cent also to the low teens. It has also brought us a motorbike explosion (3.1 million in Saigon alone in 2008 and about 400 now sold every day).

There are rosy and not so rosy aspects in this accelerated development. With a population just over 80 million, the country has around 10,000 health centres and 600 district hospitals. But health is now more 'market' oriented. There are many poorly controlled and often under-qualified private providers and drug sellers. Just about anything can be had without a prescription, and you may be offered an ultrasound when complaining to the doctor of fatigue.

In 2003, a National Health Care Fund for the Poor was established. Intended to cover the needs of ethnic minorities (16 per cent of the population), in principle it provides free health care, but has reached only 60 per cent coverage. This is because of low usage often caused by failure to exempt patients from paying fees – and also charging of 'informal' fees. Plus long distances often have to be travelled. Plus the Ministry has few health workers of the respective minorities, so there are language barriers, including lack of printed educational materials. Poor people and ethnic minorities also have lower inpatient admission rates and higher rates of use of traditional medicine. The bottom line is that maternal mortality is three times higher in minorities, as is infant mortality. Antenatal care use in impoverished districts is lower with much higher rates of home deliveries. Oral health remains a big largely unattended problem. There is a programme of subsidised latrines, but it reaches minorities to a lesser degree. In recent years, catastrophic health care spending seems to have somewhat decreased for poor families. In Vietnam, ethnic status affects health and health care rather more than economic status.


Acknowledgement and request

Conflicting or competing interests: I am a member of the Council of the People's Health Movement. I do not regard this as a competing interest. This commentary has been reviewed by Geoffrey Cannon.

Readers may make use of the material in this commentary if acknowledgement is given to the Association, and WN is cited. Please cite as: Schuftan C. My Vietnam. [Column]. Website of the World Public Health Nutrition Association, January 2013. Obtainable at www.wphna.org

All contributions to this website are the responsibility of their authors. They should not be taken to be the view or policy of the World Public Health Nutrition Association (the Association) or of any of its affiliated or associated bodies, unless this is explicitly stated.

2013 January column. Claudio Schuftan

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