I'll call him Mr. Trinh. He's a small but physically imposing man, sitting in the visitors' lounge of an intensive care unit at Cook County Hospital. Although he is past 55 his hair is still jet black, and this makes him appear no more than 40. As he speaks, his demeanor is impassive, even though he is waiting for his son to die. He pulls a set of rosary beads from his pocket, clutches them in his right hand, and begins his story with an air of dignified resignation.
"My wife and I were married in 1959 during the Diem regime. At that time there were many American advisers moving into Vietnam and many questions about currency and exchange rates, so I was able to get a job at the national bank in Saigon. My first son was born in 1960 and shortly after that I was drafted into the South Vietnamese army. About two years later my second son, Pham, was born. He is the one who is now sick in the hospital.
"While I was in the army the American advisers were very helpful. I spent much time with one American major who was very kind to me and my family and taught me how to speak English. I spent four years in the army and was discharged when the Americans began sending large numbers of troops to fight the Communists.
"When I left the army in 1966 I went to work for Esso oil company and helped to coordinate the distribution of fuel to American troops. The company stationed me at Tan Son Nhut Airport on the outskirts of Saigon, where I was responsible for making sure the American planes were supplied with enough gasoline. I was lucky to work at Tan Son Nhut because it meant I could live with my family. My wife and I were blessed with ten children. I went to law school at night but I was only able to finish two years before my family responsibilities and the war forced me to discontinue my studies.
"My duties increased when the Americans began moving out of Vietnam in the early 1970s. At that time I was involved in coordinating supplies for much of the country. But everything changed in 1975 when the Communists took control of Saigon. They renamed it Ho Chi Minh City, and with the occupation there were no longer jobs available in the city. I could not continue with my education and was forced to move with my family to the countryside, where we grew food that was sent to Ho Chi Minh City.
"My son Pham's illness began in 1979. Shortly after his 16th birthday, Pham showed me a small reddish blue bump on his wrist. At first I thought it was a bruise; perhaps he got it while playing football. But he told me it did not hurt like a bruise, and after several weeks it did not go away. I decided to bring Pham to a doctor in Ho Chi Minh City. The doctor who attended us was quite young, but he showed us that he had obtained his degree before 1975. This was very important because it meant he had been educated by the Americans and was well trained. He told us that Pham had a blood-vessel fistula [an abnormal connection between an artery and a vein]. He said that it might get bigger but that it was not serious and we should not worry.
"Sometime after this I was able to find work and our family moved back to Ho Chi Minh City. Pham and his older brother began attending the university. Pham had decided to study topography. In 1983 the bump on his hand had grown bigger, as the doctor said it might. We took him to the clinic at the university. A doctor looked at his hand and went to the bookshelf. He showed us a picture in an American medical textbook of a fistula and said this is what Pham has. He told us he would attempt to remove it surgically.
"I was present when the doctor cut into the bump. The expression on his face indicated that the surgery was not as simple as he expected. He decided to leave the bump alone, but he did try to redirect the artery feeding blood to it. Afterward, he was not sure the surgery was successful but he assured us there was no danger from the fistula.
"The next year Pham began having shortness of breath and we suspected he had a problem with his lungs. We went to a specialist in the city, who took a chest X ray. He called in some of his colleagues and they told us that Pham had 'mushrooms' in the upper parts of his lungs. They were not sure what was wrong but they strongly suspected he had tuberculosis, which is very common in Vietnam. None of the doctors thought the problem in his lungs had anything to do with the bump on his hand, which continued to grow larger. They took many specimens from his lungs but they never found tuberculosis. This surprised them because Pham was beginning to lose weight and appear ill just as tuberculosis patients do. They decided to treat him with medicine for tuberculosis anyway. They tried one medicine, then another, but none of these medicines seemed to improve his condition.
"By 1986 the bump on his hand was now quite large and ugly. We began to worry that perhaps this was more serious than the doctors had told us. We went back to the university, where the doctor agreed this was quite unusual. He attempted to do a special X ray by injecting something into Pham's arm above the elbow. I remember the pain in Pham's face when the doctor did the injection. The X ray was not successful and the doctor told us that perhaps it was time to go out of the country, possibly to America to have Pham's hand evaluated.
"There are very strict rules before one can be allowed to leave Vietnam for medical treatment. One way you are permitted to leave is if you have cancer and there is a special treatment available in another country. Although none of the doctors had mentioned it, we believed that that might be what the bump on Pham's hand was. We went to see one of the most important physicians at the university to get him to sign a consent stating that Pham had cancer. Although he was quite important, this doctor acted quite disagreeably and said he doubted that the bump was cancer. He refused to sign a consent.
"In 1987 Pham had become visibly ill. I made special arrangements to see an important functionary in Hanoi. We were finally granted an audience, and we traveled north to show him the bump on Pham's hand. Even though he was not a doctor, he took one look and was impressed that it was something bad. He said that when the paperwork was done our family could go to America so Pham could be treated.
"It turned out to be almost a year before we were allowed to leave Vietnam. While we waited, Pham continued to grow sicker. This was a very difficult time for my whole family because we felt so helpless. In March of 1988 my wife suffered a stroke which left her left side paralyzed. I believe that her stroke was a result of worrying about our son. The rest of the children cared for her and did extra work in our home. Finally at the end of August, with some assistance from people I worked for during the war, our family left Vietnam to come to the United States. We arrived on the first of September.
"In Chicago, we received help from the Vietnamese community on the north side of the city. We took Pham to a doctor at a clinic in the neighborhood. As soon as he saw the bump on Pham's hand he said he was fairly sure it was a tumor. Even though I suspected this, when I heard him say that my heart sank. I thought of how many doctors Pham had seen and how, if someone had diagnosed cancer, he might have received proper treatment earlier. The clinic doctor then advised us to go to Cook County Hospital as soon as possible.
"At Cook County Hospital the doctors did a biopsy of Pham's hand, which confirmed that he had cancer. They did more tests and found that the problem in his lungs was not tuberculosis but spread from the malignant tumor on his hand. They told us the prognosis was not good and that they would have to do surgery immediately. Before Christmas they amputated his right arm and administered chemotherapy.
"He was doing reasonably well until the beginning of May, when he became very short of breath. We brought him back to the hospital, and yesterday he was moved to intensive care. The doctors told us that the tumor now occupies most of his lungs. There is not sufficient oxygen in his blood and they have put a tube in his mouth to help him breathe. The doctors and nurses have all been very nice, but they told us there is nothing more they can do and they believe he will die in a matter of days. Now Pham's fate is with God."
Mr. Trinh did not know the technical medical term for his son's malignancy. Officially the tumor was listed as a soft-tissue sarcoma, a very rare form of cancer. It was late on a Friday afternoon when Pham Trinh was transferred to the intensive care unit at Cook County Hospital. As a senior attending physician was leaving his office for the weekend, a young resident mentioned that the new patient was a Vietnamese immigrant with a soft-tissue sarcoma and pulmonary metastases. This piqued the attending physician's interest, and rather than leave, he sought out Mr. Trinh in the visitors' area. It had been a decade since Pham Trinh, now dying, had shown his father the small bump on his wrist. Now, for the first time in that ten years, someone asked Nguyen Trinh about Agent Orange, which has been suspected of causing soft-tissue sarcomas in those exposed during the Vietnam war.
In the minds of many Americans the term "Agent Orange" is inextricably linked to the Vietnam war. Far fewer Americans are aware of the program it was associated with, Operation Ranch Hand. Ranch Hand was the code name of the American military operation in which the Air Force sprayed 19 million gallons of herbicide on Vietnam between 1962 and 1970. Conceived by military strategists, it was a response to the fact that the jungle terrain provided a tactical advantage to guerrilla troops over a conventional land force. Michael Gough, in his 1986 book Dioxin, Agent Orange: The Facts, described the rationale behind Operation Ranch Hand:
"When America went to war in Vietnam, its conventional army fought infantry unencumbered by heavy weapons and independent of long supply lines. Since the American way of war relies on overwhelming fire power to devastate the enemy and hold down American casualties, the jungles of Vietnam hampered the American war machine. Heavy weapons, virtually immobilized in the jungles, were restricted to travel on highways and deployment in large base camps. Our infantry, which required large amounts of supplies, could not use the jungle as effectively as the enemy. In many respects, the battlefield favored the enemy, affording him cover and concealment. It takes only simple logic to figure out that if the battlefield conveys an advantage to the enemy, change the battlefield."
At the end of World War II, both the British and the U.S. armies began investigating ways to defoliate a battlefield using commercial herbicides. Early on in the Vietnam war, several different herbicides that had already undergone preliminary evaluation were tested on combat territory. Each chemical was shipped to Vietnam in a separately color-coded 55-gallon drum. The color of the drum made it easy to identify compounds with long, complex chemical names. Agent Pink, Agent Green, Agent Purple, and Agent Orange were all used for defoliating jungles and forests in the first years of Operation Ranch Hand. (Some years later, during the controversy over the toxicity of Agent Orange, the Air Force engaged in an unsuccessful campaign to have the name changed from Agent Orange to Herbicide Orange because of the malevolent connotations of the word "agent"). By 1965, Agent Orange emerged as the best herbicide for "changing the battlefield."
Agent Orange was not one chemical, but an equal mixture of two herbicides--2,4 dichlorophenoxyacetic acid (2,4 D) and 2,4,5 trichlorophenoxyacetic acid (2,4,5 T). There was a third, more important chemical present in Agent Orange, not an herbicide but an unavoidable contaminant that occurred in the production process of 2,4,5 T. Known scientifically as 2,3,7,8 tetrachlorodibenzo-p-dioxin, this by-product is more familiar by its abbreviated name--dioxin. Dioxin, regarded by science as one of the most toxic chemicals known to man, was present in varying concentrations in all the herbicides sprayed in Vietnam, including the 12 million gallons of Agent Orange dropped between 1965 and 1970.
In his book, Gough described in detail the day-to-day logistics of Operation Ranch Hand, which reached its peak from 1967 to 1969. In a typical mission as many as six specially tailored cargo planes would drop three gallons of Agent Orange per acre, primarily over jungle territory. The spraying itself might take no more than five minutes. To avoid hostile ground fire, the planes flew their missions early in the morning and were often provided with cover by F-4 Phantom fighter planes. So that chemical exposure to U.S. ground troops was minimized, the Air Force gave several days' notice to troop commanders and attempted flights only on days with light winds.
While most Agent Orange was sprayed in this manner, smaller amounts were sprayed by soldiers using backpack sprayers around the perimeter of military bases to deprive enemy troops of ground cover. To deter hit-and-run guerrilla attacks, helicopters and trucks were occasionally used to spray strategic fields of fire. The Navy also attempted to protect supplies transported by river from being ambushed by defoliating along the riverbanks.
After Ranch Hand was terminated, the National Academy of Sciences issued a paper on the short-term effects of Agent Orange on South Vietnam. The paper estimated that more than 36 percent of the mangrove forests, 10 percent of the inland forests, 3 percent of the cultivated land, and 5 percent of "other" land was sprayed one or more times. A 1978 Air Force report stated that 8 percent of the Agent Orange sprayed was used against enemy food crops--fruits, beans, peanuts, and potatoes. Vietnamese scientists noted profound changes in the pattern of bird life in herbicide-treated areas, specifically a marked decline in the peacock and pheasant populations.
In some ways, Operation Ranch Hand was symbolic of the entire American experience in Vietnam in that it was a military success and a failure in every other sense. The actual defoliation was quite successful in depriving the enemy of cover, and this undoubtedly saved the lives of many American soldiers. For their valor confronting ground fire in low-flying planes, Ranch Hand pilots composed the most highly decorated Air Force unit in Vietnam. Politically, the operation did not fare as well. While protocol dictated that the South Vietnamese government request all spraying missions, this was widely recognized as a sham. When the North Vietnamese seized on the potential health effects of herbicides as a propaganda tool, the U.S. forces were reduced to reassuring the Vietnamese populace by loudspeaker. Although the American Chemical Society defended the use of herbicides as a more humane form of warfare, a 1969 report by the U.S. Department of Health, Education, and Welfare detailing the teratogenic effects of Agent Orange in animals made the end of Operation Ranch Hand a fait accompli. In 1970 the Department of Defense ended the program. In a postscript, President Ford stated in 1976 that the United States would renounce the first use of herbicides in future wars.
Nguyen Trinh recalled his experience with herbicide spraying. "I remember the spraying from American planes very well. It was necessary at the time so that Communist troops would not be able to hide easily during their attacks. I don't know specifically about Agent Orange, but I do believe we came into contact with some of the chemicals that were sprayed. Some of the spraying east of Saigon was brought by the wind so that we may have eaten fruits and vegetables that had been sprayed. Some people in Vietnam believed that this was the cause of some birth defects.
"One incident, I think it may have been in 1967, stays in my mind. One morning I was driving with some Americans on the road that went from Saigon to Cu Chi. [Cu Chi was notorious as the sanctuary for Viet Cong troops who hid in an intricate system of underground tunnels. Because of the concentration of enemy troops hiding there and the fact that it was located less than 30 miles from Saigon, Cu Chi was a specially designated target of Operation Ranch Hand.] A storm must have been approaching because the wind shifted and the sky quickly turned cloudy. A few minutes later a light drizzle began to fall. As I looked up, my eyes began to sting and my lungs burned. For some minutes it was difficult for me to catch my breath. I thought to myself at that time that this must have been from the planes spraying somewhere close by."
The first association between Agent Orange and soft-tissue sarcomas was made in 1977. Swedish scientists observed that these tumors were five to six times more common in forestry workers using the herbicides that compose Agent Orange than in people with no exposure to the chemicals. This finding, along with several case reports of soft-tissue sarcomas in American workers involved in the manufacture of herbicides, created concern about the health of Vietnam veterans. Congress, which had already directed the Veterans Administration to compensate veterans who suffered from skin diseases attributed to dioxin, considered compensating those with soft-tissue sarcomas. Ultimately, no such compensation was forthcoming, for subsequent studies of forestry workers in New Zealand and Finland failed to confirm the Swedish findings. Congress did mandate, by law, that studies be done of Vietnam veterans who may have been exposed to Agent Orange.
A follow-up evaluation was done of the 1,300 pilots who flew missions for Operation Ranch Hand. None of those pilots studied had developed soft-tissue sarcomas in the intervening period of nearly 20 years. Any conclusions drawn from this finding were bound to be limited, because these tumors are extremely rare (occurring naturally in less than 0.1 percent of the population) and 1,300 patients is a small sample to study such a rare condition. Moreover, the pilots' exposure to Agent Orange, while indisputable, may have been far less than that of ground troops or Vietnamese civilians.
Despite its limitations, the Ranch Hand study might have put an end to the speculation about soft-tissue sarcomas and Agent Orange in light of two studies, one in New York State and one from 172 veterans' hospitals, that also failed to find an association. The question did not die because scientists in Massachusetts found a significant excess of soft-tissue sarcomas in their Vietnam veterans between 1972 and 1983. Two other state health departments, in West Virginia and Washington, have reported similar findings of elevated mortality due to soft-tissue sarcomas in Vietnam veterans. As the situation currently stands, the cause-and-effect relationship between Agent Orange and soft-tissue sarcomas is still uncertain. A recent article in the American Journal of Preventive Medicine stated that "the association of soft tissue sarcoma with dioxin exposure is questionable, but its potential for significant human illness and death makes additional epidemiologic investigation a matter of high priority."
The uncertainty over the long-term health effects of Agent Orange continues even in view of the spate of studies being performed with Vietnam veterans. This uncertainty is well expressed in the book My Father, My Son by Admiral Elmo Zumwalt Jr., the former U.S. chief of naval operations, and his son, Elmo III. The book, written in 1986, is a moving account of Elmo III's experience in Vietnam with Agent Orange and his subsequent gallant, losing battle against Hodgkin's disease (Elmo III died in 1988). His son, Admiral Zumwalt's grandson, suffers from a severe learning disability, which the authors also attributed to his father's exposure to Agent Orange. What makes the story even more tragic is that Admiral Zumwalt was the officer who gave the order to spray Agent Orange in the areas his son patrolled.
"I, too, am convinced based on what I have read, and conversations with people, that Agent Orange can cause cancer and birth defects, and in the case of many Vietnam veterans has done precisely that. I realize the final scientific word is not in yet, but I think that because of all the veterans Elmo and I contacted, and all the illness and medical problems they told us about, we are ahead of the scientific evidence."
"I think over the next several years the full story of Agent Orange's health hazards will emerge. It may be too early for definitive answers, since the latency period for a disease like cancer can be twenty to thirty years. This may be one case where the layman is ahead of the scientist. Perhaps the Agent Orange issue was best expressed by Paul Reutersham, who formed an organization called Agent Orange Victims International in 1978. Paul was only twenty-eight at the time he learned he had terminal stomach cancer. He had been a helicopter pilot in Vietnam and often flew through Agent Orange mists sprayed by the C-123s. Paul said (in a television interview on the Today show in 1978), "I got killed in Vietnam. I just didn't know it at the time."'
In the decade since Paul Reutersham spoke on Today, the impact of Agent Orange on the health of Vietnam veterans has been both an issue in a private lawsuit and a concern of the federal government. The class-action lawsuit filed by veterans against several chemical manufacturers was settled out of court for $180 million, with no firm conclusions being drawn about the health effects of Agent Orange. Two agencies of the government, the Veterans Administration and the Centers for Disease Control, have been intimately involved in the studies mandated by Congress on the health of veterans who may have been in contact with Agent Orange. If the case of Pham Trinh is any indication, the health of exposed Vietnamese now living in the United States does not appear to be a high priority with these agencies. This seems to be so even though the data that might be provided could help answer questions that concern everyone involved with the issue.
While Pham was at Cook County, it occurred to the doctors that if he had developed cancer as a result of dioxin exposure, then the Trinh family might also be at risk. It would be important for Pham's father, mother, and nine brothers and sisters to receive physical examinations and counseling about symptoms that might be related to dioxin exposure. Since all veterans' hospitals have Agent Orange contact personnel who examine and counsel veterans, the local VA hospital was the logical place to go. The Cook County doctors did so, and realized that the question of Agent Orange exposure in Vietnamese citizens now residing in the U.S. was a new one. They were told by a VA official, "You've raised an interesting question about who should screen Vietnamese immigrants for exposure to Agent Orange. We're not legally responsible for them. Let me put you in touch with someone in Washington."
The Cook County doctors were referred to a highly placed Veterans Administration physician in Washington who offered his own perspective on the scientific uncertainties surrounding Agent Orange. "Let me say at the outset that I don't believe there is any firm connection between dioxin and soft-tissue sarcomas. You know these things are hard to document, you have to follow these people for 10 or 15 years or more. The North Vietnamese have done some studies but they were badly done." The Cook County doctors pointed out that if Pham Trinh had been a U.S. veteran with a soft-tissue sarcoma, the VA would be very interested in talking to him and his family. The physician in Washington acknowledged that this was true; but then he resorted to language that echoed the VA official back in Chicago:
"Well, this is strictly out of our province. We have no legal responsibility to investigate this. I don't really know who you could talk to about examining and counseling this family, maybe someone in Congress or at Health and Human Services. Anyway, this family's chances of exposure to dioxin are low. They're probably no greater than yours or mine if we were here in the States."
The reaction to Pham Trinh's case at the Centers for Disease Control was not much different. The CDC has been performing large-scale evaluations of U.S. Army veterans, using a specially developed test that measures dioxin levels in blood and tissue. The CDC has also been doing detailed studies that attempt to ascertain the relationship, if any, between dioxin exposure and soft-tissue sarcomas in veterans. The major stumbling block has always been the uncertainty as to which veterans actually experienced significant exposure to Agent Orange in Vietnam. The toxicologists at Cook County, in an attempt to determine whether Pham Trinh had been exposed to dioxin, obtained samples of his blood and tissue. They were aware that the CDC operates under tight budget constraints, and that the test for dioxin was expensive and generally reserved for the VA's Agent Orange program. Even so, the toxicologists were optimistic that the CDC would be anxious to measure samples of a patient from Vietnam who had lived near an area that the Americans sprayed and had developed a soft-tissue sarcoma. Perhaps, they thought, the CDC might even request samples from the rest of the Trinh family to trace potential dioxin exposure in an epidemiologic fashion.
As it happened, the officials at the CDC turned out to be less than enthusiastic. A Cook County toxicologist spoke directly to one of the CDC physicians in charge of dioxin research. After listening to the story of the Trinh family, the physician said he would call back. Several days went by before a secretary from the CDC called the toxicology office at Cook County Hospital with a message she had been instructed to deliver. It stated tersely, "We [at the Centers for Disease Control] decline the opportunity to analyze the Vietnamese for dioxin."
Nguyen Trinh glanced at the clock in the visitors' lounge as he finished his story. "Soon I will have to bring my wife to a clinic in our neighborhood where she can get physical therapy for her stroke. We will need help paying for this but I have hope that she will be able to use her left arm again. My children are at home now, taking care of her, and they take turns coming out here to visit Pham. At present we are receiving money from the government but I hope to have a job soon. I will have to take a course to improve my English and then I will take a course in computers. It seems that everybody here in the United States works with computers."
Then his voice trailed off and he looked down at the floor. "But all that will have to wait until everything here has ended." He placed his rosary beads back in his pocket and stood up. "I hope you will excuse me. We are only allowed several minutes at his bedside every hour. I must go now and pray for my son."
He walked out of the visitors' lounge and joined Pham's older brother and two younger sisters. They spoke briefly in Vietnamese and then went through the double doors into the intensive care unit. The nurse taking care of Pham left his bedside so his family could be alone with him, although the young man was in coma and unaware of his family's presence. Mr. Trinh grasped his son's hand briefly and knelt by his bed to pray.
Did Agent Orange cause Pham Trinh's cancer? There is currently no way to answer that question with confidence. The results of studies by the Centers for Disease Control and the National Cancer Institute into the relationship between dioxin and soft-tissue sarcoma will soon be available. It is impossible to say in advance whether those results will be conclusive.
Hundreds of millions, possibly even billions of dollars have been spent addressing the issue of dioxin exposure as it has affected American veterans. Where the Vietnamese are concerned, the sums aren't even remotely close to that, even though many of the Vietnamese are now U.S. citizens, even though dioxin may have entered Vietnam's food chain, leading to exposure different in form and possibly far greater in degree than that experienced by American troops.
The final irony is that those persons exposed to the greatest long-term risk from Agent Orange, those who were children during the war, may least appreciate the problem. While Nguyen Trinh distinctly remembers his eyes and lungs burning when it rained and the wind shifted, his oldest son does not remember this and doubts it ever happened. He mistakenly believes that significant spraying did not occur before 1970 and was mainly confined to areas hundreds of miles from Saigon. At the height of Operation Ranch Hand, whose planes his father may have helped supply with fuel, he was six years old. His younger brother Pham, who has since died, was four.
Art accompanying story in printed newspaper (not available in this archive): illustration/John Figler.