Le Van Nam still sees the soldiers who died while fighting alongside him in the 1960s.
Most nights he lies awake in bed, gripped by visions of his fallen comrades beckoning him to join them in heaven. He cries out, trembling with fear, until his wife wakes him and calms him down.
Nam, who fought for the North Vietnamese army, was partially paralysed after a mortar pierced his skull during a 1969 battle. The 76-year-old now has no function in his left arm or leg. And about once a month, he has a panic attack that requires hospitalisation in the mental ward of a local hospital. His doctors typically give him an anticonvulsant sedative that helps break his mood.
The 4.5 million Vietnamese dong, or $211, that Nam receives every month in government disability payments covers about 70 percent of his treatment and hospitalisation costs, according to his son Bach.
His four children pitch in the rest. “We’re lucky that we have the money,” says 33-year-old Bach, who is an accountant in Hanoi. But Nam’s treatment is entirely drug-based, and he receives no therapy or counselling.
Lack of understanding
There are at least 2.6 million war veterans in Vietnam, but mental health experts say it is impossible to know how many of them suffer from mental disorders because the country lacks comprehensive epidemiological data on mental illnesses.
But if the general population is any guide, the experts say, many veterans likely suffer from undiagnosed mood disorders that do not qualify as severe psychiatric problems. And the veterans, like millions of other civilians, would benefit from holistic treatment programmes that include therapy, counselling and community-based outreach.
Le Hong Loan, a mental health expert at UNICEF’s Hanoi office, says the absence of holistic mental health treatment in Vietnam is rooted in a lack of understanding on the part of doctors, health officials and the general public. “If you don’t know about depression and anxiety disorders – if you don’t see them as mental health – then you don’t have a system to respond,” she says. “Mental healthcare is not yet a priority.”
It is difficult to quantify Vietnam’s mental health burden.
The last official survey, completed in 2003 by the National Psychiatric Hospital, estimated that 12 million people, or 14.9 percent of Vietnam’s population, suffered from 10 common mental disorders – about the same rate as in other low- and middle-income countries, according to Professor Harry Minas of the Melbourne School of Population and Global Health in Australia.
But the survey omitted thousands of other disorders, and the results are now a decade old. That is a long time, researchers say, in a country in which economic growth and rural-to-urban migration have profound impacts on social customs and living standards.
Vietnam’s mental health infrastructure
The government has taken some steps in recent years to explore more holistic treatment programmes and to broaden the scope of mental disorders that are addressed.
For example, a national health programme includes a community-based scheme. The ministry of health has permitted a US nonprofit-making organisation, Vietnam Veterans of America Foundation (VVAF), to establish community-based mental health treatment programmes in two Vietnamese provinces. And in 2011, Prime Minister Nguyen Tan Dung launched a nine-year mental health project worth $400m aimed partly at integrating drug treatment with counselling, psychiatric counselling and other social services.
However, Vietnam’s mental health infrastructure is plagued by problems. One is a lack of adequate funding, especially for preventive care.
The government spent just over $3m in 2012 on mental health, but most of that was devoted to treatment of existing illnesses, Duong Quang Trung, the director of the Community Health and Development Institute, told the state-controlled newspaper Thanh Nien. And although social programmes are meant to help the poor and most vulnerable to afford treatment, many fall through the cracks.
For example, most mentally ill war veterans are entitled to some degree of free medical treatment, but some of them cannot afford to travel to hospitals or pay the extra charges linked to hospitalisation, according to Vietnamese health blogs and reports in the state-controlled news media.
Even if the government is serious about mental health reform, the current system is not designed to accommodate a comprehensive approach. There is no mental health law or comprehensive mental health strategy in Vietnam, says Dr Nguyen Mai Hien, the director of the mental health programme at VVAF.
Suffering in silence
Most mental healthcare services are administered either by the ministry of health or the ministry of labour, invalids and social affairs, she adds, and there is limited collaboration between them. The first ministry mainly provides care through 34 psychiatric hospitals, while the latter focuses on 17 social protection centres and a nationwide stipend programme for the poor or severely disabled who suffer from mental illnesses.
According to VVAF, Vietnam’s mental health programme focuses mainly on schizophrenia and epilepsy.
Researchers say one of the biggest obstacles to reform is a conspicuous lack of human resources. A 2006 World Health Organisation study found that there were just 50 trained psychologists and four occupational therapists in all of Vietnam.
There were 286 psychiatrists, but none of them worked outside mental hospitals. In 2009, another study found that Vietnam’s proportion of psychiatrists ranked below both Thailand’s and China’s. “The largest future challenge for the Vietnamese mental healthcare field is to attract mental health workers,” a team of international researchers wrote in a 2011 paper for the Journal of Asian Psychiatry.
Doctors and health analysts say the main deterrent for young doctors is low salaries. Vietnam’s official news agency reported in October 2013 that mental health doctors earn just $140 to $190 a month – about the same as the average national wage across all sectors.
A national decree that took effect in September 2013 includes incentives for students to pursue degrees in mental health. In the meantime, many Vietnamese with mental illnesses continue to suffer in silence.
War veterans are no exception. The government is typically eager to publicise the lasting health effects of dioxin, the chemical in the wartime defoliant Agent Orange that US planes sprayed across a large swath of central and south Vietnam during the war. But veterans’ quiet struggles with depression, anxiety and other mood disorders receive far less attention in the state-controlled press.
In October 2013, thousands of Vietnamese flooded the streets of the capital to pay their respects to General Vo Nguyen Giap, a military mastermind who played a key role in defeating both the French and American armies. Vietnam’s leaders used the occasion as a way to promote nationalism at a time when many blame the ruling Communist Party for corruption and economic mismanagement. Convoys of military trucks rolled through downtown, and state television showed documentaries glorifying Vietnam’s wartime victories.
Veteran Le Van Nam, however, said a few days after the parade that the military propaganda no longer interests him much.
In his modest, concrete home about 50km from Hanoi, the only framed pictures are of Nam’s grandchildren. “They are the happiest thing in my life,” he said.
He has hidden his war medals because thinking about the war only upsets him, and he is disappointed that the government does not provide more support for his ongoing mental health expenses. He recently went to the ministry of labour, invalids and social affairs to complain, he added. But he does not expect anything to come of it.
This article first appeared in the November 2013 issue of the Al Jazeera Magazine.