HEALTH IN VIETNAM
The overall quality of healthcare is regarded as good, as reflected by 2005 estimates of life expectancy (70.61 years) and infant mortality (25.95 per 1,000 live births). However, malnutrition is still common in the provinces, and the life expectancy and infant mortality rates are stagnating. In 2001 government spending on health care corresponded to just 0.9 percent of gross domestic product (GDP). Government subsidies covered only about 20 percent of health care expenses, with the remaining 80 percent coming out of individuals’ own pockets. [Source: Library of Congress, 2004 ]
In 1954 the government in the North established a public health system that reached down to the hamlet level. After reunification in 1976, this system was extended to the South. Beginning in the late 1980s, the quality of health care began to decline as a result of budgetary constraints, a shift of responsibility to the provinces, the reduced social role of agricultural cooperatives in 1988, and the introduction of fees in 1989. By 1996, the government was devoting only 1 percent of the gross domestic product to health spending, and 85 percent of all spending on health services came from private sources. Inadequate funding has led to delays in planned upgrades to water supply and sewerage systems. As a result, almost half the population has no access to clean water, a deficiency that promotes such infectious diseases as malaria, dengue fever, typhoid, and cholera. The quality of public health care and the level of medical technology remained inadequate and authorities were concerned about such problems as nutritional deficiency, mental health, and old-age illnesses. Cardiovascular diseases and cancers were reportedly not widespread but had increased "in recent years." Western medicine in Vietnam consisted of many things, mostly antibiotics, Vitamin B12 shots for "feeling bad," and IV fluids.
Life expectancy at birth: total population: 72.65 years, country comparison to the world: 130 male: 70.2 years; female: 75.4 years (2013 est.) "Life expectancy" is an abstract and complicated concept a complex formula that attempts to predict the lifespan of children born today by subjecting a hypothetical child born today to the current risk of dying in each bracket he or she mature through until, in effect, the accumulated risk of death is 100 percent.
Maternal mortality rate: 59 deaths/100,000 live births (2010), country comparison to the world: 101. Infant mortality rate: total: 19.61 deaths/1,000 live births, country comparison to the world: 95; male: 19.97 deaths/1,000 live births; female: 19.19 deaths/1,000 live births (2013 est.). Children under the age of 5 years underweight: 20.2 percent (2008), country comparison to the world: 35. [Source: CIA World Factbook **]
In rural areas dysentery is common, and malaria used be a problem. In the 1990s, by some estimates, half the children in the countryside suffered from malnutrition. Illnesses may be blamed on viruses or bacteria or they may be attributed to a hardship or problem, an imbalance of elements, or even a curse or spirit possession.
Hans Troedsson, WHO representative in Vietnam, told Reuters he links the battle to prevail over these diseases to the country's ambitions to develop the economy and lift people out of poverty. "My constant advice to the government is that if you don't have a healthy population you can't compete economically," said Troedsson. "You not only have the burden of diseases, but also they can't function in production." Malaria is far less prevalent in Vietnam than it used to be, partly due to a campaign to distribute mosquito nets and encourage their use. Trachoma, a leading cause of blindness among rural poor but treatable by surgery, has also been reduced by Vietnam's participation in a global program to fight the disease. [Source: Grant McCool, Reuters, October 5, 2006 *=*]
Life Expectancy Increases in Vietnam
In 2003, Xinhua reported: The average life expectancy of Vietnamese people was 67.8 years in 2001, up from 65.2 years in 1995, representing a rise of five months each year, according to a survey conducted by the General Statistics Office in 2001. The rise is attributed to an increase in per capita spending and better healthcare services, the Vietnam News reported.[Source: Xinhua, October 30, 2003]
Average monthly expenditure per person rose to 268,000 Vietnamese dong ($17) in the 2001-2002 period, up 28.1 percent from 1995. Meanwhile, healthcare services in all localities have been much improved. In 2001, Vietnam had 5.2 doctors per 10,000 people, up 60.7 percent from 1986 and higher than other regional countries such as Indonesia, Thailand and Malaysia.
By 2001, the country had 836 state-owned hospitals and over 41, 000 private clinics, offering 24.4 beds to 10,000 people. According to healthcare experts, Vietnamese people' life expectancy will climb to 69.5 by 2007 if the same rate of progress is maintained. Along with the rise in life expectancy, the mortality rate among children dropped to 5.56 per 1,000 in 2001, down from 7.7 in the 1990-1994 period. The survey also showed a sharp decrease in the mortality rate among infants aged under one year, from more than 46 per 1,000 in 1984-1989 period to 36.7 in 2001.
Cancer, Obesity and Dental Problems in Vietnam
In January 2007, Xinhua reported: “Vietnam has annually detected some 200,000 cases of cancer infection, with 150,000 fatalities, the Vietnam Cancer Association said on Wednesday. The K Hospital in Hanoi capital alone, which specializes in cancer diagnosis and treatment, has annually treated 150,000 cancer patients. It has seen over 75,000 patients die from the disease in the past five years. Many of the patients are aged over 40. The most common cancers in Vietnam, with a population of 86 million, include lung cancer, gastric cancer, bronchial tube cancer, and liver cancer, the association said, noting that the country faces a severe shortage of specialized hospitals for cancer patients. The infection and fatality are attributed mainly to the polluted environment and the late diagnosis of the disease.” [Source: Xinhua, January 23, 2007]
Vietnamese American women have higher rates of cervical cancer than any other racial or ethnic group (including Hispanics), according to the Fred Hutchinson Cancer Research Center’s (FHCRC) cancer registry. According to a recent study at FHCRC, traditional health beliefs and risk-factor knowledge contribute to low cervical-cancer screening rates in Vietnamese-Americans (FHCRC, 2010).Chronic hepatitis B and hepatitis B associated liver cancer is a major health disparity among Vietnamese Americans, who have a chronic hepatitis B prevalence rate of 7–14 percent and an incidence rate for liver cancer six times that of non-Latino whites (Nguyen, McPhee, Stewart, Gildengorin, Zhang, Wong, Maxwell, Bastani, Taylor, & Chen, 2010). [Source: Pamela LaBorde, MD, Ethnomed ethnomed.org/culture/vietnamese <+> ]
In 2006, Grant McCool of Reuters wrote: “The transition from abject poverty to more prosperity has changed eating habits to more fatty foods, causing a shift to non-communicable diseases. They include cardio-vascular diseases, diabetes and those related to weight gain and lack of exercise. A study by the Vietnam Nutrition Institute released in September found obesity rates climbing to almost 30 percent in and around the southern commercial hub of Ho Chi Minh City. "These rates should set off some serious alarm bells," institute head Nguyen Cong Khan was quoted as saying by Thanh Nien (Young People) newspaper. [Source: Grant McCool, Reuters, October 5, 2006 *=*]
In August 2007, Xinhua reported: Up to 99.4 percent of Vietnam's population suffer dental diseases, local newspaper Pioneer reported Monday. Specifically, 87.5 percent of people aged under 18 have decayed teeth, while the rates of those in the age brackets of 33-44 and over 45 are 83.2 percent and 89.7 percent, respectively, the paper quoted the country's National Ophthalmology Institute as reporting. [Source: Xinhua, August 6, 2007>>>]
Dental diseases are mainly caused by lack of fluoride in drinking water, poor dental care, eating too much food with high sugar and starch content, and shortage of orthodontic doctors, especially in remote and mountainous areas. An estimated 50 percent of Vietnam's population and over 80 percent of those having decayed teeth have never undergone dental checkups. Now, there is one orthodontic doctor for every 25,000-30,000 Vietnamese people, only one-tenth of the world's average level, according to the Health Ministry.
Fast Food Brings Concerns About Diabetes to Vietnam
Reporting from Ho Chi Minh City, Jeremy Laurance wrote in The Independent, "As darkness falls, clusters of tiny plastic tables and stools spread across the pavements - improvised street-side restaurants to feed the armies of office workers. The acrid smell of pigs' trotters seared over charcoal braziers beside pans of meat bubbling on spirit burners fills the humid night air." In the old days "crisps, cola and ice-cream were novelties and fast-food restaurants featured only in Western magazines. Now they are part of the everyday scene.[Source: Jeremy Laurance, The Independent, February 27, 2006 /\]
"But progress has a price. Across the Far East, growing urbanisation, rapid industrialisation and increasing obesity associated with decreased physical activity is fuelling an epidemic that has killed as many as Aids but has received a fraction of the attention. The disease is diabetes. On the streets of Hanoi and Ho Chi Minh City, fast-food chains such as Kentucky Fried Chicken are starting to appear, alongside the snack bars, cake shops and mobile food carts catering for the worker on the move. Traditional dishes that have sustained people over generations are disappearing, to be replaced by Western-style cooking that uses more fat, salt, sugar, oil and meat. Ordinary restaurants now offer a special version of the standard Pho Ga - chicken noodle soup - aimed at more affluent office workers that contains 22 percent more calories than the basic dish. The casualties of the trend can be seen in hospitals around the country. Squatting on an iron bedstead covered with a thin straw mat, Le Quang Can, aged 58, is unaware of the threat the disease poses to his life. /\
"He arrived at the endocrinology clinic in Thanh Hoa province in northern Vietnam, 90 miles south of Hanoi, at 7 am for a routine test. He has unexpectedly been kept in for observation because his blood sugar level is sky high, and he could slip into a coma at any moment. A retired soldier with six children, Mr Can waits for the insulin with which he has been injected to bring his blood glucose level down. He wears a woolly hat and blue pyjamas against the cold - it is winter in north Vietnam and a chill wind is blowing down from China. He and his wife work in the rice fields and the doctor will later warn him that unless he controls his diet he could end up a blind amputee, dependent on his family. Outside, scores of patients wait patiently on the steps under the corrugated iron roof for the results of tests carried out in the morning. The clinic, funded by the WDF, sees 130 diabetes patients a day in this provincial town, one of the poorest in Vietnam, and the scale of the need it has uncovered has persuaded the government to set up similar clinics across the country. /\
"The most striking thing about the patients at the Thanh Hoa clinic is how few of them are fat. In the West, obesity is the chief driver of the epidemic - the Royal College of Paediatrics and Child Health has just released a new report showing that soaring levels of obesity among children in the UK are sparking a crisis of diabetes in under-16s. But Mr Can is lean and spry as are most of the other patients. Doctors do not know why Asians are more prone to the disease. One theory is that because of their slighter build, compared with Westerners, they have less muscle bulk and more fat, so do not need to gain much weight to put themselves at risk. Malnourishment in infancy or in the womb, which is known to increase the risk of diabetes, may also play a part. Seven out of 10 of the worst affected nations by the disease are in Asia. India already has a total of 31 million cases, the highest in the world, closely followed by China with 20 million. The Far East is expected to see the fastest growth by 2025, with a near doubling in the current total of 81 million cases to 156 million. /\
"The road to Thanh Hoa from Hanoi passes small village stores selling crisps, ice-cream and soft drinks, which are often cheaper than water. It is thronged with scooters but is free of the children - who once walked beside it to school - they now travel by bus. The disappearance of traditional diets and lifestyles and their replacement with junk foods and motor transport are believed to be behind the growth in the disease. "As the economy grows, lifestyle and eating patterns change," Dr Kapur said. /\
119 Rusty Nails in a Vietnamese Woman's Stomach
In June 2006, Associated Press reported: “Vietnamese doctors removed 119 rusty nails from a mentally ill woman's stomach after she apparently swallowed them months ago, a doctor said.The 43-year-old woman arrived Wednesday at Hospital No. 121 in the southern city of Can Tho City, complaining of a severe stomachache. "After having her stomach X-rayed and scanned, we found a stack of strange objects and decided to operate as soon as possible,'' said Dr. Tran Van Nam. [Source: AP, June 30, 2006]
During the surgery, doctors removed 119 7 to 8 centimeter (2.8 to 3.2-inch) nails. Many were rusty, indicating they could have been in her stomach for months, Nam said. The patient's stomach was scratched by the nails, but she did not suffer any major injuries, he said. "Her life is not at risk now, and she is recovering,'' Nam said, adding the patient was expected to be discharged soon.
Views About Health and Medicine in Vietnam
Many Vietnamese see suffering and illness as an unavoidable part of life. Some also feel (the Hmong in particular) that the length of one's life is predetermined, and life prolonging or life saving care is futile. Also within the community, stoicism, a masculine trait among mostly older gentlemen, is a highly respected personal trait which can prevent people from seeking care. [Source: Pamela LaBorde, MD, Ethnomed ethnomed.org/culture/vietnamese<+> ]
Illness may be attributed to organic or physical problems, an imbalance of yin and yang, an obstruction of chi (life energy), a failure to be in harmony with nature, punishment for immoral behavior (in this or past lives), or a curse placed by an offended spirit. Some traditional Vietnamese believe in organic causes of illness unless there is an obvious upset of supernatural forces, while most Hmong believe minor illness is organic but serious illness is supernaturally caused. Though immigrants may wish to use a shaman or spiritual healer, they can be expensive. Also, they are not easy to find in the U.S., and since many specialize in different types of disorders, one may not be able to find the right healer for their malady. <+>
It is said Vietnamese patients suffer in "quiet patience." According to the Vietnamese Cultural Profile by Diversicare, “Vietnam born people usually display stoicism towards pain and may suffer in silence. They may not try to disclose their feelings and pain to staff, doctors or other people in fear of losing face and honour. Older Vietnamese people may accept pain in a stoic manner; motivated by a strong desire to go home, they may hide their pain. Many Vietnam born older people may try to use traditional methods of healing exclusively, or in combination with Western medicine. In the United States and Australia there is, however, an increasing tendency for Vietnamese to attend a doctor before visiting a traditional practitioner such as a herbalist or acupuncture clinic. [Source: Vietnamese Cultural Profile, Diversicare, March 2009 <<<]
Buddhism has a great influence on the thinking and behaviour of Vietnamese people. For them it is not only a religion, but also a way of life that emphasizes disconnection to the present. People believe that "to the same degree, they reap today what they have sown in the past". In other words, they believe in rebirth and that their present life is a reflection of actions in a previous life. Thus pain and illness are often endured rather than immediately seeking remedies. People believe that all the pain which they suffer is caused by desire: desire for life, happiness, riches and power. If desire is suppressed, it is believed the cause of pain will be destroyed. Some Vietnamese Catholics believe pain comes from God, giving the person another chance to pay for/atone for previous bad behaviours. <<<
Health Customs in Vietnam
Vietnamese patients sometimes use both Western and Asian medicine concurrently. They often take large doses of several kinds of medicine and don't believe one kind will work. They often go to a pharmacist rather than a doctor. Many families bury the umbilical chords and placentas of their children in the courtyards of their homes so the children don’t forget where hail from.
Many believe that surgery upsets the soul or can actually cause one's spirit to leave the body. Some think injections may hurt the spirit, and therefore are hesitant to receive immunizations. Resistance to venapuncture is common for fear of upsetting the hot/cold balance. Also, during the war, peasants thought that when military doctors drew their blood, it was being given to the U.S. troops to strengthen them. Many less educated people do not realize that the body can make more blood, and believe venapuncture will weaken them. [Source: Pamela LaBorde, MD, Ethnomed ethnomed.org/culture/vietnamese<+> ]
Southeast Asian cultures value politeness, respect for authority, and avoidance of shame. Because of this, many will not ask questions, will not voice disagreement or concern, and will not reveal intentions or actions that seem in contrast to the physician’s wishes. If patients disagree or do not understand, they may simply listen and answer yes in respect, then not return for further care or comply with recommendations. <+>
Vietnamese patients may be reluctant to speak up about their illness. They often expect quick relief from symptoms They are cautious about Western medicines and sometimes initiate downward dosage adjustments to avoid even minor side effects. In their opinion, Western medication can be quick and effective in removing symptoms, but not a permanent cure. In effect, they rely on Chinese medicine for long term treatment. Going to health professionals is usual and Vietnamese people are used to the medical hierarchy (i.e. General Practitioners for overall health with referral to Specialists as needed for more in- depth treatment). Some older Vietnamese people would prefer go to the pharmacy and ask for medication, and can get frustrated if they need to visit the GP and ask for a prescription. For them going to a GP unless they want to see a specialist, is a waste of time. [Source: Vietnamese Cultural Profile, Diversicare, March 2009 <<<]
Ear Cleaners in Vietnam
Barber-ear-cleaners often set up shop on the streets in Vietnam. Lucinda Franks wrote in the New York Times: “In Haiphong, barbers in white coats set up shop along park fences. Wearing miner’s lights, they peer into ears and dig out dirt with gleaming steel skewers that have little spoons at the end. The victims sits back with blissful looks on their faces."
Reporting from Ho Chi Minh City, John Boudreau wrote in San Jose Mercury News, "To most Westerners, the idea of paying someone to stick little scoops and tweezers into their ears is downright unnerving. To Vietnamese, it's an art. Though the procedure may sound like torture, men line up day in and day out to experience this unorthodox probing. It's part of the country's pampering culture and is offered in corner barbershops, the oases where Vietnamese while away hot afternoons with luxurious shampoos, relaxing shaves and facials. But it's the picking that elicits moans of ecstasy. [Source: John Boudreau, San Jose Mercury News, January 27, 2011 \+\]
"Many returning Vietnamese-Americans head straight to these barbershops, or "hot tocs," after disembarking from long United and EVA Air flights at Tan Son Nhat International Airport. "It brings a lot of happiness," said Silicon Valley, Calif., resident Nguyen Tuong Tam, who always heads to a hot toc upon arriving in this city, also known as Saigon. He likens a good ear picking to good sex. Indeed, fans of ear picking gleefully talk about "ear-gasms." There is a spot near the ear drum that, when touched the right way, "tingles," said 26-year-old ear picker Nguyen Thi Le Hang. "For one person, it may just be a tickle. For another person, it's a mind-blowing experience." \+\
"In fact, the ear has a G-spot, said Dr. Todd Dray, an ear, nose and throat surgeon at Kaiser Permanente Medical Center-Santa Clara. "The skin in your ear is super thin -- it's paper thin," he said. "It's very sensitive. And there are a lot of nerves that converge in the ear." That explains why some customers have been known to blurt out, "Will you marry me!" Ear pickers usually ignore such exclamations as they would words of endearment from a drunk. Just as a shampoo in Vietnam is more than washing hair -- it's also head massage, shoulder massage and a refreshing facial -- ear picking is more than cleaning the ear. It helps reduce the tensions of living in the bustling, horn-honking metropolis of 9 million people, fans say. \+\
"Though the practice is mostly popular among men, some Vietnamese women enjoy regular ear pickings, too. "Everybody is afraid the first time -- but after, it's, 'Oh my God!"' said Katie Dang, a 20-something singer who spends time in the United States and Ho Chi Minh City. "The men do a very good job. But the women are better. They have the magic hands." \+\
Ear Picking Procedure and Vietnamese Ear Pickers
John Boudreau wrote in San Jose Mercury News, "Ear picking has long been practiced in Vietnam and other Asian countries. And a few Vietnamese barbershops in San Jose, Calif., have quietly offered the service. But in recent years, practitioners in Vietnam have elevated it beyond simply removing ear wax to an experience on par with massage, said Hien Nhan, a former Californian who owns Lido's Spa in Ho Chi Minh City. Those offering the service range from a guy with a chair along a busy street to air-conditioned barbershops with several ear picking specialists and shops where the staff wear alluring uniforms. A picking and a shave can cost as little as $2, plus tip. [Source: John Boudreau, San Jose Mercury News, January 27, 2011 \+\]
"It's not uncommon for ear pickers to give a customer Vietnamese coffee or tea before he settles in. He then reclines in a barber chair, tilting his head to one side. The ear picker, frequently a young woman wearing a head lamp, begins to gently probe. "Some people like it really soft, others like it to hurt," ear picking proprietor Nhan said. "It's like a massage." \+\
"After scooping up some ear wax, she scrapes it onto the customer's hand as a way to show off her handiwork. The tools include a tiny razor to shave hairs, a miniature shovel-like device to scoop up wax, tweezer-like objects to scrape the inner ear and little cotton balls on sticks that are twirled inside the ear to tickle the skin. The overall effect is so soothing it's not uncommon for customers to doze off. \+\
"The procedure, ear pickers say, takes about a week to learn but months to perfect. Those who become highly skilled develop a following. Ear pickers ply their trade with a mix of intense concentration and flirtation -- one reason men often don't want girlfriends or wives to know about their ear experiences. Frisky ear pickers sometimes blow into customers' ears. There are stories of customers leaving wives for ear pickers and a life of in-home ear pleasure. \+\
"But all this ear fun can have unintended consequences. Ear specialist Dray cautions against unsafe ear picking. If implements are reused without being sterilized -- which is common in many shops -- customers can be exposed to a variety of viruses and even Hepatitis B, though that's relatively rare, he said. Too much ear picking can leave ears dry and itching. And if done improperly, ear picking can pack wax deeper into the ear, causing an infection called otitis externa, or swimmer's ear. "It's like smoking or drinking beer," said Truong Phung, a 44-year-old professional who visits a bare-bones barbershop every two or so weeks. "Some of my friends say it's not safe, but I still come here. They do it without any license or insurance. If something bad happens to you, I don't know what they could do." Dray, however, said the risks from ear picking can be greatly reduced by a few simple precautions. "If you bring your own instruments, and you have found someone who is good at it," he said, "go for it." \+\
According to the U.S. Department of State: The Vietnamese constitution provides for the protection of persons with physical disabilities. The law prohibits discrimination against or maltreatment of persons with disabilities; encourages their employment; and requires equality for them in accommodation, access to education, employment, health care, rehabilitation, transportation, and vocational training. [Source: 2011 Human Rights Reports: Vietnam, Bureau of Democracy, Human Rights, and Labor, U.S. Department of State; 2011 Country Reports on Human Rights Practices Report, May 24, 2012 ***]
The provision of services to persons with disabilities, although limited, improved during the year. The Ministry of Transportation implemented accessibility codes for public transportation facilities, trained transportation agency officials and students on the use of the codes, and developed training materials for bus drivers to assist individuals on and off buses. The government also put in place four accessible bus routes in Ho Chi Minh City and Danang with accessible buses and distributed free bus tickets (or reduced the fares for) 26,000 individuals in Hanoi and Ho Chi Minh City. ***
Construction and major renovations of new government and large public buildings are required to include access for persons with disabilities, but enforcement was sporadic. New buildings and facilities in larger urban cities were built with ramps and accessible entries. The Ministry of Construction maintained enforcement units in the cities of Hanoi, Ho Chi Minh, Danang, Quang Nam, and Ninh Binh to enforce barrier-free codes and provided training on construction codes for inspectors and architectural companies in more than 20 provinces during the year.
Access to education for children with disabilities, including blindness, deafness, and mobility restrictions, was extremely limited. The law provides for preferential treatment for firms that recruit persons with disabilities and for fines on firms that do not meet minimum quotas that reserve 2 to 3 percent of their workforce for workers with disabilities, but the government enforced these provisions unevenly. Firms that have 51 percent of their employees with disabilities may qualify for special government-subsidized loans.
In Ho Chi Minh City there is a special school where the blind teach the blind computer skills. According to the latest statistics of the Committee for Vietnamese Disabled People, 9.33 percent of the population is hearing impaired. The number of people who are able to make contact with hearing-impaired children is small. Meanwhile, the sign language lexicon is not unified among regions and teachers. The number of words for hearing-impaired people in Vietnam that are considered standard is only 2,000, and they are very simple, such as boy, girl. There are no words about generative organs, changes in psycho-physiology or pregnancy. Xa Dan School currently has 500 students, including 200 hearing-impaired children. Education for disabled children in Vietnam is very low. More than one-third of disabled children from 6-17 years old have never gone to school and one-sixth of them quit school. Two of the four major reasons are the lack of educational programmes for disabled children and those children’s lack of self-confidence in accessing information. [Source: Tien Phong, Viet Nam News, July 14, 2007 ***]
Mental Illness and Mental Health in Vietnam
A mentally ill man in Vietnam was discovered chained to a coconut tree for over one year by his parents, who gave him a mosquito netting and a rain coat for when it rained. The parents said they were forced to do this because their son had become two unruly and had destroyed the crops of their neighbors.
Traditionally, mental illness has been a shameful thing among most Vietnamese cultures. Because of this shame, mental illness is often feared or denied. The hill people think of mental illness as bad karma that has accumulated because of misdeeds done in past lives. Due to the stigma of mental illness, many Vietnamese refugees tend to avoid referrals to mental health clinics.
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Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, Lonely Planet Guides, Library of Congress, Vietnamtourism. com, Vietnam National Administration of Tourism, CIA World Factbook, Compton’s Encyclopedia, The Guardian, National Geographic, Smithsonian magazine, The New Yorker, Time, Newsweek, Reuters, AP, AFP, Wall Street Journal, The Atlantic Monthly, The Economist, Global Viewpoint (Christian Science Monitor), Foreign Policy, Wikipedia, BBC, CNN, Fox News and various websites, books and other publications identified in the text.
© 2008 Jeffrey Hays
Last updated May 2014