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First of all is the religious issue. Vietnam’s Catholic Church was established by missionaries in the 16th century and grew during French colonial rule (1787-1954) in Vietnam. After five centuries developing, Vietnamese Catholics are about 8% of more than ninety-one (91) million inhabitants in a predominantly Buddhist country.8 However, the Catholics represent a

7 _{Cf. Health Strategy and Policy Institute, Analysis of Factors Affecting the Ability to Attract and Retain Health} Human Resources in Mountainous Areas (Hanoi: HSPI, 2012).

8 _{The earliest established religions in Vietnam were Mahayana Buddhism, Confucianism and Daoism (called the}

‘triple religion’ or tam giáo). These religions have been co-existing in the country for centuries and mixed well with the Vietnamese tradition of ancestor worship. This special mix explains why the Vietnamese people find it hard to say exactly which religion they belong to. They usually classify themselves as non-religious, despite visiting religious temples several times every year. Cf. Queensland Partners in Culturally Appropriate Care (PICAC), Vietnam Cultural Profile: An Initiative of Queensland Partners in Culturally Appropriate Care

vital force for the culture, history and society of the nation, according to teachings of the Catholic Bishops’ Conference of Vietnam:

As the Church in the heart of Vietnam nation, we are determined to stick to the destiny of our homeland, following the national tradition and integrating in the current life of our country. The Council teaches that "the Church goes forward together with humanity and experiences the same earthly lot which the world does." (Gaudium et

Spes, n. 40) So we have to go forward together with our people, share the common life

with our nation, because this homeland is the place where we are called to live as God's children, this country is the womb carrying us in the process of implementing the vocation as children of God, this nation is the community that God gives us to serve as citizens and members of God's People.9

Nowadays, though many barriers still remain because of historical and political reasons, Vietnamese Catholics now are able to partake in all sectors of the country. For instance, the Catholic Church in Vietnam has recently been allowed to take a limited role in health care that the Communist government used to prevent or interfere with in the past. Moreover, when public hospitals are heavily subsidized, financial resources from the State budget are in shortage, private hospitals and foreign invested hospitals have more shares in the marketing of health care services in Vietnam. This also provides a chance for Catholics to pay their contribution. It is true that Catholic bishops of Vietnam continue to ask for more freedom and request Catholic involvement in health care, education and charity work as a contribution to social development.

The second challenge is about culture. As influenced by Buddhist theology and Confucian philosophy, most Vietnamese people are highly family oriented. Very often two or three generations reside in one household where elders are the leaders who have the strongest influence in decision making and are respected and sought after for advice. As parents grow older, children are expected to take care of them to compensate for the gift of birth and upbringing. Related to this culture, Vietnamese people may feel shame in their community if they accept outside help with caring for their ageing parents. It is, therefore, culturally very difficult for elderly Vietnamese to wish to be sent to residential facilities or nursing homes.10 Likewise, they seem to display stoicism towards pain and may suffer in silence. They may not

9 _{Catholic Bishops’ Conference of Vietnam, Pastoral Letter to All Priests, Religious and Lay People of the} Whole Country (Hanoi: CBCV, 1980), n. 9. This is the first national episcopal plenary assembly held in Vietnam after the Communist took over the whole country in 1975.

choose to disclose their feelings and pain to medical staff or other people in fear of losing face and honour, and a strong desire to go home or even die at home. This choice derives from a number of cultural beliefs that are likely to affect decisions at the end of life for Vietnamese patients and their families. These beliefs include: an aversion to dying in a hospital because of the belief that souls of those who die outside the home wander with no place to rest, the perception that consenting to end-of-life support for a terminally ill parent contributes to his or her death and is an insult to one’s ancestors and parent…11

This culture issue is really a big challenge for health workers in general and specifically for Vietnamese Catholic health carers in properly performing their work.

One more difficulty which should be noted here is that palliative care or the care for the patients at the end of life stage has a very short history in Vietnam. According to the statistics in 2007, there were an estimated 24,000 AIDS death, 150,000 new cancer diagnoses, 80% at an advanced stage, and at least 70,000 cancer deaths.12 Recognizing a very high level of unmet need for pain and symptom control, psychological support, and training for end-of-life care clinicians to help the cancer and HIV/AIDS patients, Vietnam’s Ministry of Health just began its palliative care initiative in 2005.13 The truth is that there is a lot of confusion for Vietnamese health care workers when they deal with some palliative care or end-of-life issues, such as: the ethics of pain management, advance directives, the morality of withholding and withdrawing medically administered nutrition and hydration, physician- assisted suicide, euthanasia. Vietnam as yet has no long-term strategy for palliative care. This country has only a small fraction of the number of trained palliative care staff and clinicians it needs. Also there is not yet a national palliative care organization that could provide a discussion forum for development plans and continuing education for its members, as well as promote palliative care research.14 Even when facing dilemmas in their work of caring for patients at their end of life, health carers of Vietnam do not have any ethics committees to guide or give them appropriate instructions. In short, despite rapid progress, many challenges must be overcome to meet Vietnam’s great need for palliative care.

11

Cf. PICAC, Vietnam Cultural Profile, 22-24.

12 _{The data is from Joint United Nations Program on HIV/AIDS (UNAIDS), “Epidemiological Fact Sheet on}

HIV/AIDS: Vietnam,”

http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008-VN.pdf/ [accessed 19 June, 2012]; cf. also Luong Ngoc Khue, HIV/AIDS and Cancer in Vietnam: Epidemiology, Treatment and Care (Hanoi, Vietnam: Bach Mai Hospital, 2009).

13 _{Cf. Ministry of Health of Vietnam, Palliative Care in Vietnam: Findings from a Rapid Situation Analysis in} Five Provinces (Hanoi: Ministry of Health, 2006); cf. also Krakauer, Cham and Khue, “Vietnam’s Palliative

Care Initiative,” 28.