TWO

Childhood Malnutrition in Vietnam

From Peril to Possibility

VIETNAM RECEIVED SUBSIDIZED RICE imports from its allies during the war. These shipments masked wartime disruptions and the low productivity of its collective farms. Following the war, a border dispute with China and deterioration of the Soviet economy brought an abrupt end to this source of relief. In the late eighties, by government decree, Vietnam’s collective farms were privatized, each family allocated a small parcel of land. Disruption to cereal production was staggering. The health care system also began to collapse under the weight of parallel shifts to privatization. By 1990, about 65 percent of all Vietnamese children under the age of five suffered from malnutrition.

Born in 1986, Kim-Mai had the rosy cheeks and cherubic face of a Vietnamese doll. She was the youngest of three siblings and the daughter of a very poor family. Precocious for her age, she chattered incessantly and delighted in the small discoveries of daily life that grown-ups find mundane. Grandparents on both sides had perished during the war. Her father suffered from chronic pain after a bicycle accident. When the government decided to distribute the land among the farmers, she could not comprehend the implications. But she was soon to experience them firsthand.

When the hard times began, her family could not keep up with the spirit-sapping toil of rice farming. Harvests were meager. She began to go hungry—always hungry. When occasional relief supplies arrived, family members would gorge themselves to the last calorie.

Undernutrition can manifest itself in two ways: acute (which arises from short-term inadequate food intake) and chronic (proceeding from the lack of adequate nutrients over a longer period of time). Both lower resistance to infection due to weakened immune systems and vitamin deficiencies. Both cause children to waste away. Chronic undernutrition causes irreparable stunting—survivors suffer from mental and physical impairment. One in five perish.

Kim-Mai was typical of many malnourished children in the Vietnamese countryside. Initially, access to calories kept her “full” but inadequately nourished. Lacking sufficient protein and vitamin intake, she became lethargic. As her digestive system slowed down, liquid collected in her stomach and her belly became distended. Her feet began to swell. Touching the tops of her feet left an imprint as if her skin were Play-Doh. Her black hair began to turn red.

Kim-Mai was unlucky. The following year’s harvest was even worse—insufficient to feed her brothers and parents. And she was a girl, which translates into getting the leftovers. Chronic malnutrition set in as the calories, protein, and carbohydrates available were simply insufficient to fuel her physiological engine. Her once attractive mane of shiny black hair thinned considerably. Kim-Mai’s body was husbanding its meager reserves to keep her heart pumping, lungs breathing, and other vital organs from shutting down.

As lethargy set in, Kim-Mai became inactive. A once curious child, she now followed moving objects with her eyes but not her head. Susceptibility to disease increased. Diarrhea, endemic in the villages, accelerated Kim-Mai’s dehydration and further impaired digestion. Urination dwindled. As flesh lost its elasticity and acquired the texture of dry parchment, she withered and appeared very old. Formerly endearing facial features were receding toward the foundational skull. Disproportionately large eyes peered out from cavernous sockets.

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In 1990, the U.S. NGO Save the Children (SC) received an unprecedented invitation from the government of Vietnam to create a program that would enable poor villages to solve the all-pervasive problem of childhood malnutrition. Ironically, the invitation was extended during the period of the U.S. government’s trade embargo against Vietnam, which sought to enforce the Paris Peace Accords through economic sanctions.

Save the Children asked me if I would leave my post as director of their Philippines program and go to Vietnam to open a program there. Although (or because!) the challenge was so formidable, I eagerly accepted, and in December 1990, Monique, our son Sam (who had just turned ten), and I left for Hanoi to become the thirteenth, fourteenth, and fifteenth Americans to take up residence in that city. We were met at the airport by our handler and translator, Ms. Hien—her severe face uncompromised by makeup, inquisitive brown eyes framed by large horn-rimmed glasses, thin lips, obsidian black hair cropped squarely above the shoulder, gray Mao suit with smartly creased slacks, and sturdy low-heeled oxfords. She introduced herself with few pleasantries. “You’re the Sternins? Follow me.” Bundling our belongings into a black Russian Volga, we threaded our way through the obstacle course of traffic along Hanoi’s main north/south artery: human-drawn carts, pedicabs, bicyclists balancing awkward loads on the ends of bamboo poles resting across padded shoulders—wire baskets stacked high with shimmering red tomatoes, cumbersome clusters of delicate yellow bananas, five-gallon jerry cans of gasoline, chickens squawking in protest at being transported upside down. One cyclist was shouldering a rattan sofa while maneuvering through the vehicular chaos. An hour later we were deposited at our tiny quarters in Hanoi.

The government knew that something needed to be done. While a traditional supplemental feeding program from local and international relief agencies provided temporary solutions, they were economically unsustainable. Although there were significant gains in children’s nutritional status during the period of program implementation, they were all but lost after the programs ended.

The reasons for the failure were not difficult to discern: villagers were passive program beneficiaries, neither encouraged nor required to change any of the underlying practices that had led to their children’s malnutrition, or even see that these practices could be playing a part. The nutritional gains realized during program implementation were completely based on external food resources. These were no longer accessible to villagers after the implementing agency departed. Further, the major focus of traditional nutrition programs was on providing additional food, with little or no attention paid to improving the all-important child care, hygiene, and health-seeking behaviors associated with good nutritional status. In short, “they came, they fed, they left,” and nothing changed.

The daunting challenges facing us, I quickly learned, were not just physical and programmatic; there were political hurdles as well. Many officials were not at all happy to have Save the Children, an American NGO, working in Vietnam at the very time the U.S. government was actively trying to bring the country into line through its economic embargo. The depths of those convictions were made clear when I was summoned to the Ministry of Foreign Affairs the week after our arrival. Mr. Nhu, a high-ranking official, greeted me in his spartan, hospital-green office and offered me the folding chair next to his desk. He was eager for me to know that he personally was very supportive of Save the Children and had been instrumental in inviting us to come to Vietnam. After a few perfunctory pleasantries, he got straight to the point. “Sternin, there are many officials who do not want you in this country,” he warned. “You have six months to demonstrate impact, or I’m afraid my ministry will be unable to extend your visa.”

Six months! An adrenalin rush. As a veteran in this line of work, I knew it usually takes a year just to begin to set up an office in a new country. Staff has to be identified and trained, office space secured, potential development partners identified, meetings held with potential program communities, and so forth. Here we were, being asked to actually demonstrate program impact within six months. I was stunned by the enormity of the challenge and only minimally reassured by my conviction that great opportunities are often accompanied by great risk. But there it was: a very real danger of failure given only six months to show impact. Juxtaposed to this was the extraordinary opportunity if we could somehow succeed.

Some issues were clear. The government of Vietnam simply didn’t have the resources to address the problem of ongoing malnutrition in ten thousand rural villages. A strategy had to be identified to enable the villagers to somehow solve the problem themselves. The focus clearly had to be preventive as well as curative. Given our six-month deadline, and my conviction that any solution must be sustainable, I knew that this couldn’t be “business as usual.” We would have to find a new approach based on something that was already working using resources already available. These defining criteria all pointed toward an obscure research construct: positive deviance (PD).

Although the PD concept had been around for many years, it had simply been used to describe those statistical outliers encountered in field-work who outperform the norm. In 1989 Marian Zeitlin and her colleagues at the Tufts University School of Nutrition published a collection of studies from around the world that identified well-nourished children from poor families (and labeled them positive deviants).¹ The children were somehow thriving in vulnerable populations with severe nutritional constraints. Zeitlin identified factors that led the positive deviants to better outcomes than others in their community. The findings ended there: case studies of field aberrations. She did not take the final step of suggesting an approach that might harness these positive deviant strategies to achieve nutritional gains. But the idea intrigued me. If some individuals in a community were better able to solve problems than others with access to exactly the same resources, could we use that provocative discrepancy? With five months left until our visa deadline, necessity became the mother of experimentation.

Monique and I turned to Ms. Hien, who had warmed to us over those first uncertain weeks. She would become a confidante and advisor on all matters of culture, politics, survival, and our closest friend in Vietnam. Born in 1959, Hien had lived through the horrors of the American war. She had a keen intellect (several years later she would attend the Kennedy School at Harvard on a full scholarship) and a whimsical sense of humor that magically crossed our cultural divide. Hien got my jokes and even laughed at them.

Hien set up a meeting for the three of us with Hanoi-based Health Ministry and People’s Committee officials to discuss potential pilot sites. They identified several possibilities. We finally chose Quang Xuong District in Thanh Hoa Province, a torturous four-hour ride south of Hanoi. It was a particularly poor area with extremely high malnutrition rates. We were eager to choose a location relatively close to the capital. If successful, the pilot site could be easily reached by government officials and other visitors, making it easier for us to scale up the demonstration program. (In retrospect, I reflect on how naively optimistic our concerns with “scaling up” were, given that we didn’t have a clue whether PD would even work.)

In late January 1991, with only twenty weeks left until the impact-or-no-visa deadline, our gang of three rented an oxidized black sedan of mixed Soviet parentage. A mechanic, perhaps thwarted by exigencies of the war and deprived of his true calling as a surgeon, had transplanted a tractor engine to power the beast—a loud, tireless, fume-spewing diesel. Shock absorbers designed for trucks reliably communicated every pothole to the spine. The vehicle’s interior made few concessions to creature comforts. The simple act of cranking the passenger window up and down exacted as much effort as operating the tire jack. We made the first of what would be hundreds of visits from Hanoi to Quang Xuong in this car. The seventy-five-mile, four-hour journey south on Highway 1 crossed three bridges, one a train trestle (shared alternately by the decrepit Hanoi-Saigon steam locomotive, all motorized traffic, and scores of market-bound bicycles).

Over the next week we met with members of the People’s Committee, Women’s Union, and Provincial Health Cadre to discuss the proposed project. We emphasized our commitment to collaborating with villagers to identify from within solutions to the problem of malnutrition. The independent and proud Vietnamese officials, all of whom had suffered greatly during the “American War,” warmed to the idea that solutions would be Vietnamese rather than foreign and that the project would not cause dependency. They were also clearly skeptical that it would work.

My most important and difficult meeting turned out to be with the deputy chairman of the People’s Committee of Thanh Hoa Province, Mr. Bhu. The meeting was set for early afternoon, and I spent all morning rehearsing my short introduction to our proposed PD program in Vietnamese. If I could dazzle my host on our first encounter with my command of the language, we would be off to a great start.

When I arrived at the People’s Committee provincial headquarters, Mr. Bhu invited me into his office, where he was still in chambers with several chain-smoking local cadres. I had expected a private meeting and was somewhat thrown by the smoke-filled room and all the quizzical faces around the table. I put aside my prepared speech for a moment to apologize for my interruption of their ongoing meeting. “I won’t spend too much time talking with you as I know you are all very busy,” I said. A look of utter disbelief and tentative outrage on every face in the room. A long moment of excruciating silence—then gales of laughter from Bhu and his fellow officers. Vietnamese is a tonal language. Choose the wrong tone and you are in deep trouble. Instead of saying bn (busy) with a level tone, I had used a falling tone (bn). The result: my opening salutation was, “I won’t spend too much time talking with you as I know you are all very dirty!” So much for my dazzling entry!

Mr. Bhu spent little time on the traditional Vietnamese formalities and got right to the point: “How much money and what kind of material inputs are you going to provide?” I explained that to create a sustainable model, most of the inputs would have to come from the villagers themselves. We would, of course, provide some material input, but would focus attention on training and developing the capacity of the villagers to address their own problems. Responsible for development of an extremely resource-poor province, he reluctantly gave the go-ahead. But it was clear to me that he wasn’t at all pleased with the rich American NGO that promised nothing more than “capacity building” and “self-reliance” instead of medical equipment and supplemental food—in his mind, the stuff of real assistance.

We began immediately to conduct a sample nutritional baseline survey of children in four villages proposed by Mr. Bhu as potential pilot sites. The good news was that the villages definitely needed help and provided a perfect opportunity for the first PD trial. The bad news was that 63 percent of the children under the age of three were malnourished. (The vast majority of the well nourished were members of comparatively well-to-do families or had access to special resources, such as a rich uncle in a neighboring hamlet.)

Immediately after the sample survey, we met with the village leaders and members of all the established community networks (the local People’s Committee, Women’s Union and Farmer’s Union, and community health cadres) to discuss the proposed project in each of the four villages or “communes.” It was the first time these stakeholders had met to discuss children’s health. Surprisingly, we found our work (there and elsewhere in the world) was often a catalyst for community collaboration. Villagers shared their beliefs about the causes of malnutrition and talked about their hopes for the future. We explained our desire to help the community permanently solve their malnutrition problem. Fortunately, the villages had previously had supplementary food programs initiated by the World Food Program, a UN agency. Their experience provided a great backdrop against which to explain and contrast the positive deviance approach:

Hien: Have you ever had a supplementary feeding program here before?

Villagers: Yes.

Hien: What was the result of the program?

Villagers: Our children got healthier and put on weight.

Hien: What happened after the program was over?

Villagers: Our children became malnourished again.

Hien: Why?

Villagers: Because when the project was over there was no one to give us those foods (oil, milk powder, high-protein biscuits) which made our children better.

Hien: Well then, what would you like to see different in the future?

Villagers: We want to see our children get better, and stay better.

Hien: Do you think it would be better if you could do that on your own, rather than be dependent on outside help?

Villagers: Of course, but how is that possible? We are a poor village.

Armed with faith rather than actual proof, I explained that the PD approach might help them address the problem of malnutrition through the identification of solutions that already existed within their community. They would require some initial help with those children who were already malnourished (we planned to supplement their diets with eggs or tofu), but the PD approach could show them how to independently sustain their children’s improved nutritional status once they had been rehabilitated. If this was going to work, however, the villagers would have to assume major responsibility for the initiative.

First Steps: Baseline and Common Practices

Is blue different? Silly question. Only by knowing the context—different from what—is it possible to differentiate PD practices from the norm. Until we determine what everybody is doing today, we can’t spot the exceptional and successful strategies. This turns out to be the most rigorous part of the PD process. The baseline establishes a base of facts from which progress can be assessed. This means collecting empirical data to document the current condition (e.g., weighing children), agreeing on criteria for inclusion (to ensure that potential positive deviants won’t be confused with individuals who aren’t at risk or have access to special resources—e.g., a very poor person subsidized by a relative), and then cataloging common practices.

The first step toward all this was the creation of Village Health Committees (VHCs), composed of volunteers from the Women’s Union, Farmer’s Union, People’s Committee, and the village health cadre. These volunteers from among the ranks would become the shepherds of the yet-to-be-determined process. Although we weren’t consciously trying to establish any PD guidelines at the time, we were discovering that the best people to manage a program aren’t those who are appointed by the powers that be, but those who are passionate enough about the mission to self-select.

The self-selected health volunteers were eager to get started. Assisted by local health staff and village leaders, they then began by weighing the children and charting their nutritional status by placing a dot on a simple card with two axes—one for age and the other for weight. The weighing device was a handheld fulcrum used for weighing rice, with a bucket for the child on one end of the weighing bar and weights on the other. Some children had previously been weighed during the sample nutritional baseline survey (the health volunteers conducted a community-wide growth-monitoring campaign in late February 1991). But this was the first universal weighing of all children under three in these communities. After the children had been weighed, we met with the health volunteers and the village leadership to review the findings. Consistent with the pattern of the earlier sample survey, 64 percent (rather than 63 percent) of the children suffered from some degree of malnutrition.

Because we sought solutions to the problem of malnutrition that would be accessible to everyone in the community, particularly to the most vulnerable, we asked the volunteers to do a socioeconomic ranking of all households in their hamlet. With no preset categories, the volunteers chose “poor,” “very poor,” and “very, very poor” as accurate descriptors of the economic status of almost all village families.

When they completed their rankings, we gathered the volunteers beneath the corrugated tin roof of the commune’s town hall. Stout timbers at each corner supported this modest unwalled structure. Makeshift benches were arranged on the earthen floor. A blackened panel of plywood served as a writing surface and soft stone as chalk. As expected, two-thirds of the children were malnourished.

Time for the Somersault

Simple idea, really. The “somersault question” draws on the concept of inversion. It turns circular logic on its head by looking at an issue the other way around. (Akin to the adage: “The chicken is the egg’s way of reproducing itself.”) All that was required was mirroring back the sweeping generalizations regarding village malnutrition. The common explanation of the cause of malnutrition was poverty. We asked the volunteers if any of the well-nourished children came from “very, very poor” families. They looked at the tally. Several literally rose in excitement: “Có, có vài ch´u rt nghèo nhung không b suy dinh durng!” (Yes, yes, there are some children from very, very poor families who are well nourished!) “Do you mean,” we asked, “that it’s possible today for a very, very poor child in this village to be well nourished?” “Có, có!” came the reply. “It is, it is!”

The “Có, có!” epiphany on that defining day in February represents an indelible milestone in a career devoted to community change. It was clear that the discovery of a possible way forward by those who needed to believe that one already existed quite literally triggered an attitudinal somersault. The “aha” moment broke the fundamental assumption of experts and residents alike that “villages are poor and have no solutions.” Allowing the villagers to discover there were exceptions among them created the context for investigating what was going on. As the positive deviance approach became refined over the following months and years, the Vietnamese “Có, có” equivalent of the “aha” moment took on ever-increasing importance. It has become a centerpiece of the PD design.

Having established the possibility of being well nourished despite extreme poverty, the volunteers explored the implications of the discovery. If some very poor families in the village had well-nourished children, it might be possible for their poor neighbors to have well-nourished children as well. This realization set the stage for what would become the inquiry phase of the approach: a process that identifies how some members of a community, faced with the same constraints as their neighbors and with access to no special resources, are uniquely able to avoid or overcome a pervasive problem.

Because positive deviants are deviant only within the context of their divergence from the norm (in this case, the traditional feeding, caring, and sanitation behaviors), we needed to identify common practices and behaviors before we could distinguish what the positive deviants were doing that was different. Over the next week, the trained volunteers conducted many focus group discussions in each of the villages. Meeting informally with mothers, grandmothers, fathers, older siblings, and community health providers, they discussed conventional practices regarding feeding, caring, and sanitation.

One of the insights that emerged was the importance of learning through contrast. For many, the first reaction to PD is often, “Oh yeah, we do that, I know that.” This dismissive acknowledgement overlooks important details and differences. What is most difficult to grasp when presented with a new idea is not what about the idea is similar, but what is different. Identifying PD behaviors without looking first at how they contrast with the norm would be a much less powerful provocation for change.

When Is “Enough”?

After the first eight conversations, the Vietnamese volunteers reported that they were hearing the same information over and over again and weren’t learning anything new or useful. We were about to call a halt to the effort when one of the volunteers registered a cautionary note. Tuyen, a mother of three and one of the most active volunteers, explained, “Although I’m not learning anything new either, there are still another three or four households in my hamlet that haven’t participated in these focus groups. Several of them are the poorest people in the hamlet. If I don’t go and listen to them, they will feel hurt, and conclude that I don’t think they have anything to contribute. If I’m going to need their cooperation later on when we begin our program, I better go and listen to their ideas.”

Once it was articulated, all grasped the importance of Tuyen’s insight. The value of the group conversations was not merely extracting useful information from a wide variety of stakeholders, but also listening to their ideas and beliefs and inviting them to be an integral part of the creation of the program. Ever since, one of the first steps in the PD process, whether applied in villages in the developing world or hospitals in the United States, has been for the local facilitators to listen to as many people in their community as possible, irrespective of the added value to the listener’s learning curve. This engenders the broadest ownership.

Within a few weeks, we completed the focus groups and had a firm grasp of the common practices that impacted kids’ nutritional status in the four villages. The health volunteers had held back visiting the very poor families with well-nourished children. Now the challenge was to see if we could actually identify some uncommon practices that would account for these kids’ superior nutritional status.

Hien, several health volunteers, and a few village leaders divided into teams and went out to see if our PD hypothesis would actually work. Over a two-day period we visited six households, asked questions, and most importantly, observed how moms and other family members fed and cared for their PD kids. We had arranged to visit the PD homes an hour or so before mealtime so that we could observe, rather than merely ask about, the actual food preparation and hygiene. In every case, our real-time presence during food preparation, cooking, and serving proved to be invaluable.

Uncommon Practices

What the PD caretakers reported doing and what they actually did was often at odds. This wasn’t the result of their being disingenuous, but rather of their not being conscious of all their actual practices (i.e., of the invisible not yet visible). One of the PD moms, for example, said that she only washed her daughter’s hands just before eating. But the team present during the mealtime noted that in addition to the initial washing, the mom washed the little girl’s hands again after she had petted a dog that had strayed into the house while she was eating, and then a third time when she started playing with her brother’s muddy flip-flops.

An interview without actual observation with this PD mom would have reported that she (like many others in the village) “washed her child’s hands before the meal”—not uncommon. On-site observation, however, allowed for the discovery that the mom washed her child’s hands every time they came in contact with anything unclean throughout the entire process of eating (an uncommon PD practice). Situational learning has become a core component of the PD inquiry in all settings and has captured many of the most useful hows, not just the whats.

After visiting the positive deviants’ homes, we reassembled at the community meeting hall. There was a palpable buzz in the air. Each team had discovered several uncommon behaviors among the PD families. First and foremost, in every instance where a poor family had a well-nourished child, the mother or father was collecting tiny shrimps or crabs (the size of one joint of one finger) from the rice paddies and adding these to the child’s diet along with the greens from sweet potato tops. Although readily available and free for the taking, conventional wisdom held these foods to be inappropriate, or even dangerous, for young children.

Along with the dietary addition of shrimps, crabs, and greens and the atypically strict hand hygiene in five of the six PD households, other positive deviant practices emerged. These involved frequency and method of feeding, quality of care, and sanitation. For example, most families fed their young children only twice a day, before parents headed to the rice fields early in the morning and in the late afternoon, after their return. Because children under three years of age have small stomachs, the youngest children could eat only a small percentage of the available rice at each sitting. PD families, however, instructed the caregiver (an older sibling, a grandparent, or a neighbor) to feed these children regularly. Their kids were fed four or even five times a day. Result: using exactly the same amount of rice spread out over an additional two or three meals, the PD kids were getting twice the calories as their neighbors who had access to exactly the same resource. This was the first of countless examples illustrating that PD practices often reflect not only what is being done differently, but how it is being done.

The Magic of Doing

Through the PD inquiries, community members had discovered for themselves what it took for a very poor family to have a well-nourished child. The challenge now was to get people to translate that knowledge into practice. We convened a meeting with the volunteers, local leaders, and health clinic staff to get their input. The aim was to design a process to “teach” villagers the special practices that had been discovered.

Lots of ideas for education sessions, hamlet meetings, and attention-getting posters were offered. Everyone was excited by what we had “learned” and the natural instinct was to “tell” others about it. Then, as the meeting came to a close and the crowd was dispersing, something occurred that might easily have been lost in the general distraction of the moment. One of the older volunteers observed loudly enough for others to hear: “Mt nghìn nghê không bng mt xêm, mt nghin xêm không bng mt làm” (a thousand hearings aren’t worth one seeing, and a thousand seeings aren’t worth one doing). Then, goodbyes all around. “Hn gp li!” “See you again next week.”

As we made our way back to the car (now sardonically referred to as “the beast”) for the long ride back to Hanoi, Hien, Monique, and I shared that eerie feeling that something subliminal had just flashed by and we needed to grasp it. “Seeing trumps hearing, but doing trumps seeing!” All the way back to Hanoi (which took seven rather than the usual four hours that evening because a train had broken down on the bridge), there was an elusive something that kept clawing for attention.

Perhaps because we were held captive by the trestle blockage, or perhaps because we sought distraction from the miserable conditions (too hot to keep the windows closed, too dusty to open them), we roused ourselves from our travel-weary stupor. Monique and I talked with Hien about our past development work failures. All had occurred exactly at the moment in which we now found ourselves—the moment at which the solution (aka the “truth”) is discovered. The next, almost reflexive step was to go out and spread the word: teach people, tell them, educate them. Bingo! Reflecting on those failures, we realized that they occurred because we were acting as though once people “know” something it results in their “doing” something. By the time we reached Hanoi this wide-ranging discussion was distilled into an epiphany, despite our fatigue and grittiness. What we needed to do was create an opportunity for people to practice, rather than merely know about, the successful PD behaviors the villagers had just discovered.

The objective, of course, was to rehabilitate the malnourished kids. Simple enough. That part required only the provision of sufficient additional nutritious food. The real challenge was to enable the parents to sustain their kids’ enhanced nutritional status at home after rehabilitation. To address the issue of sustainability, the program would have to avoid the pitfalls the villagers had previously experienced with the supplemental feeding programs. That meant they would have to acquire new habits and change their behavior. They would have to do something different from what they were currently doing.

The newly identified PD behaviors provided the “something different.” Addition of a small handful of shrimps or crabs and greens, in combination with increased frequency of feeding and other uncommon caring behaviors, had been shown to be sufficient to keep a child well nourished. We knew these foods and behaviors were accessible to even the poorest families in the village. Getting parents and caretakers of malnourished children to adopt these new foods and behaviors, however, was another matter. As noted earlier, these ingredients were not conventionally fed to children. The idea of doing so seemed as far-fetched to many as feeding garden snails (enjoyed by the French as escargots) and dandelion leaves (which garnish signature salads) to the children of Westerners. Delicacies? Maybe. But try selling that concept to your two-year-old and you have your work cut out for you!

Ever mindful of the “no impact–no visa” challenge, our first inclination (given the previous epiphany on the road to Hanoi) was to design an action learning program to enable the caregivers of malnourished children to access and practice the desired behaviors. But recent insight that success would require doing (the how), not just knowing, restrained us from laying out our optimal design. We realized that if we designed it, it would be ours, not theirs.

The Tedious Work of Enrollment

Imagine spending two precious weeks “enrolling people” as the visa clock was ticking away. We met with local leaders, volunteers, clinic staff, and small groups of interested villagers. Over and over, we asked: “We have all learned many valuable secrets from the villagers over the past two months about how to have a well-nourished child despite poverty. But we don’t know the best way to help people to practice them. What should we do?” Although the repetition was tedious, for each new group of villagers the questions were new, and the invitation to create their own program revolutionary. (At one of the last meetings, I was barely able to repeat the same introduction yet again; to maintain my sanity, I joked in English—knowing that only the translator would get the joke—“We have come to steal your land and take your women!” Hien, without missing a beat, translated into Vietnamese, “We have learned many new valuable secrets about how to have a well-nourished child …”)

By the end of the second week, and scores of meetings later, a design emerged: for two weeks every month, mothers or other caretakers would bring their malnourished children to a neighbor’s house for a few hours every day. Together with the health volunteer, they prepared and fed a nutritious, supplemental meal to their children. (As noted earlier, tofu or egg was provided by Save the Children to help bring children up to normal weight for their sex and age.) The moms or caretakers (very often an older sibling or a grandmother was the secondary caretaker) practiced cooking new recipes with the health volunteers and also learned and applied basic sanitation and child care practices. These sessions provided an opportunity to practice successful behaviors identified during the positive deviance inquiry, such as active feeding and washing the caretakers’ and children’s hands with soap and water over the course of the meal whenever they touched an unclean object.

For the caretakers, the sessions provided a legitimate “productive” activity, but one that also happened to be fun. The Vietnamese are extremely hard-working people. With their Confucian heritage overlaid with decades of communist focus on sån xut (productivity), villagers rarely indulge in anything that is not productive. The little kids loved the party atmosphere of the sessions, and often “terrible eaters” astonished their moms by becoming “marathon eaters” as they competed with eight or nine other happily chewing kids.

Here was cause for celebration. We were getting caretakers to bring their kids to the monthly two-week sessions. They were being rehabilitated through the provision of additional food plus the PD practices. But we still faced the challenge of ensuring that they continue those practices at home after the sessions.

Price of Admission

It was the concern for the sustainability of behavioral change that led to the introduction of the mandatory “daily contribution” component of the nutrition sessions. Every day, each mother or caretaker was required to bring a handful of shrimps, crabs, or greens as the price of admission to the sessions. For two weeks every month, someone in the family (a spouse, an older sibling) had to go out to the rice paddy early in the morning and, ankle deep in mud, collect the required shrimps or crabs. By the time the two-week program was over for that month, the trip to the rice paddy with a small net and empty container had become routine.

It would be another dozen years before we found a succinct phrase that captured all this. But we had hit upon a pivotal insight: It’s easier to act your way into a new way of thinking, than to think your way into a new way of acting. The daily contribution was a beachhead in forming new habits. Once PD behaviors have been discovered, the design must provide those who seek to learn with both the opportunity and the means to practice the new behavior. A focus on practice rather than knowledge has proven to be a key element in bringing about lasting behavioral change across the range of issues addressed using the PD methodology.

One of the other great reinforcers of behavioral change is the ability of people to see results. All children were weighed on the first and last day of the two-week nutrition session. Typically, moms and health volunteers gathered around the scale, like a crowd at a lottery scratching the numbers on their card just before the drawing. All waited for the needle to come to rest. The result? Three-quarters of kids put on weight. Each weighing was greeted with applause and cheers. Seeing that new behaviors had actually resulted in their kids gaining weight and becoming “naughtier” (active and lively rather than apathetic and listless), caretakers returned home committed to practicing their newly acquired methods. Children who reached normal nutritional status during the first nutrition session “graduated.” Those who remained malnourished were signed up for the next session to be held the following month.

Community monitoring of the progress of each child’s nutritional status was a critical element of the overall success and sustainability of the program. Each health volunteer carried her own growth-monitoring book with fold-out pages, enabling her to record and track the weight and nutritional status of each child in her hamlet over time. Weights were also captured at village-wide child growth-monitoring sessions every two months. This enabled health volunteers and local leaders to review the overall trend lines of all the young children every sixty days. “Score cards” captured each child’s weight and were compiled into a village-wide tally.

With dramatic flourish, volunteers unlocked the green metal cabinet where precious scissors, tape, colored marking pens, and flip chart paper were stashed. They prepared their tallies of the latest “community children nutrition status” and updated their pie charts. These graphics were prominently posted in strategic places (such as near the meeting hall adjacent to the bust of Ho Chi Minh) and were one of the first things to greet villagers entering the clinic, Women’s Union, or People’s Committee offices. The charts enabled them to see nutritional gains in their hamlet as well as in the wider community over time. No Olympic scoring could have elicited more excitement than these postings.

By the fourth nutrition session in early June, five and a half months into the six-month pilot, the process seemed to have been incorporated into the village repertoire. Everyone had either a child, a relative, or a neighbor’s kid participating in the program. Invariably, Monique, Hien, and I were warmly greeted. Things just couldn’t have gone better.

Bliss of the Ignorant

It would be another two years before we discovered that under the façade of warmth and acceptance were serious doubts about our intentions. Earlier that spring of 1994, on the nineteenth anniversary of the “fall” or “liberation” of Saigon (depending on your point of view), a stringer for the Associated Press asked if she could visit our program to interview villagers for a story about memories of the “American War.” We assured her that because people knew and trusted us, they would give her straight, unedited responses. And, indeed, they did. The AP journalist stayed in Thanh Hoa for two days and interviewed scores of villagers about the war. People recounted how they had feared and hated the Americans, although they never saw them face to face as the South Vietnamese had. They knew them only from twenty thousand feet as planes dropped bomb after bomb on Thanh Hoa Province, a major artery of the Ho Chi Minh trail. A war veteran, hobbling around on his one remaining leg, took the journalist to the statue of the “boy hero” standing prominently in the primary school courtyard. This fourteen-year-old boy lost his life when he threw his body over a group of nursery school children, saving their lives as a bomb exploded nearby.

The journalist asked how the villagers felt when the American NGO first came to the village to start the nutrition program (given their previous preconceptions of Americans). The women looked uncomfortable. After an exchange of glances for several long seconds, one began: “When we first started the program,” she explained, “it was very difficult for us to get the caretakers to come. We had to constantly reassure the mothers and particularly the grandmothers that we were in charge of the food preparation and would oversee every step of the cooking.” Confused about the extraordinary caution, the journalist asked for clarification. Had there been a mistake in translation?

“No,” the volunteer continued, “your translator has it exactly right.” She went on to explain. “When Ba Monique and Bac Jerry first came to the village, the villagers thought they seemed very kind, but they were, after all, Americans. The villagers were certain that they were there to poison the children! During the first weeks of the feeding program, volunteers actually had to eat some of the food at the beginning of each session before the caretakers would feed it to their children.”

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The finale of the fourth two-week nutrition session was in June 1991, five and a half months after we had arrived in the country. The Thanh Hoa health staff were coming to the villages to see if we had met our impact goal. Just over six hundred children had participated in the first four nutrition sessions. The authorities were coming to weigh them.

While we knew the results from the bimonthly weighings and pie charts, our anxiety rose in proportion to all that was at stake. Hien, Monique, and I waited along with a group of the volunteers in the tiny health center for the district health officers to arrive. A few minutes after the appointed hour, two Jeeps arrived, carrying seven cán by t (health officers) dressed in white smock coats and rubber flip-flops, pads and pens in hand. Most (597 of the 600) of the children and their caretakers had been assembled by the volunteers and were all at the ready. (You don’t defeat the Americans, the Chinese, the French, and the Khmer Rouge without a strong talent for mobilization.)

We had tea, waited, had another cup of tea, looked at our watches, checked the time, and continued waiting as the weighing went on. An excruciatingly long four hours later, the district health staff approached us with smiles on their faces. Congratulations all the way around. Celebratory cups of tea. Then the highest ranking of the district health staff, Bc sĩ (Dr.) Hanh, shared the verdict: a total of 245 kids (more than 40 percent of those who had participated in the program to date) had been completely rehabilitated, and another 20 percent had moved from severe malnutrition to moderate malnutrition. “You have earned a six-month extension of your visa,” he concluded.

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Within two years more than a thousand children were enrolled in nutrition sessions, and 93 percent of them “graduated.”² As families witnessed firsthand the dramatic improvement in their children’s health status, the practices became the new conventional wisdom. An external evaluation of the program in 1994 by the Harvard School of Public Health found that “younger siblings, not yet born at the time of the nutrition program implementation, [were] benefiting from the same levels of enhanced nutritional status” as their older siblings.³ This made sense. As moms succeeded in rehabilitating their kids through the use of the new PD behaviors, they continued practicing them when their next child was born. The conventional wisdom about how to care for children had changed and was now internalized. Sustainability of the nutritional gains was assured, and there was no further need for assistance within the community.

By December 1991 it was decided that the model had proven its efficacy. It was time to demonstrate that success could be replicated elsewhere. We enlisted five junior staff members from the Vietnamese National Institute of Nutrition and had them deputized to Save the Children for a period of two years. With their help, we expanded to an additional ten villages, bringing the total to fourteen.

Although the new villages were adjacent to the original ones and the resource base almost identical, we insisted that a fresh inquiry be carried out in each new village. By now it was clear to us that the process of self-discovery was every bit as important as the actual behaviors uncovered. This focus on self-discovery, reinforced over the next decade, has proven to be a key element of the PD approach. It took the villagers in the ten new communities just over a year to realize the same dramatic results as in the original four.

Momentum was triggering a seismic shift underfoot. Unbeknownst to us, our Vietnamese hosts, from the ministerial level in Hanoi down to the leaders in the village, were becoming evangelists on behalf of what was happening. They spoke at the National Health Congress with thousands in attendance, disseminated white papers, appeared on panels. With characteristic Vietnamese attention to detail, they compared the PD outcomes to those of a resource-intensive United Nations World Food Program in a neighboring village. The PD program was determined to be more accessible, sustainable, and scalable. And the Vietnamese owned it—it was their success.

Because the program site was within a day’s drive from Hanoi, dozens of visitors came to call. Soon there were numerous requests from UN agencies and district and provincial health offices outside the program area for help in implementing the program in other parts of the country. Foreign delegations began to arrive—including staff from Save the Children headquarters in Connecticut, who left resolved to disseminate the idea to other regions. But as we had been so dramatically reminded during the pilot stage, people learn best by doing. We were exposed to the grave risk of being compromised by success, and struggled for a way to achieve scale given the flood of interest in learning about the PD approach.

One rainy day a Unicef representative paid a visit. We sat together inside a sky-darkened, corrugated roof hut with a group of local moms whose kids had participated in the nutrition program. The moms were animated, shouting to be heard above the hammering of the monsoon torrent on the roof. They explained how they had rehabilitated their children and how it was possible for any poor family to have a well-nourished child. They were absolutely intent on making sure that the foreign guest got it right. After an hour or so, we thanked the women and left the hut. Our drenched visitor stood transfixed, seemingly oblivious to the elements. “That was amazing!” he said. “I’ve never learned so much in so little time. It was a … a … a ‘living university.’” A concept was born.

The Living University was built around the fourteen program villages. They provided a social laboratory for exposure to the nutrition process at different phases of implementation. Participants could learn the conceptual framework but, more importantly, participate in fieldwork in the villages and spend twelve days directly experiencing the essential components of the program.

After graduation, Living University participants (for example, teams from the People’s Committee, the health services, and the Women’s Union from a given district) returned to their provinces and districts to implement the PD Nutrition Program in two new villages. They then became their own “Mini Living University” for further program expansion in adjacent areas. Over the next seven years, an estimated fifty thousand children were rehabilitated through the efforts of more than four hundred Living University graduate teams. Ultimately, the program was replicated in two hundred fifty communities encompassing a population of over 2.2 million.⁴

Reflections

PD is an approach, not a model. Malleability is an essential feature of the positive deviance process. The pervasive challenge of scaling up successful models, which more often than not fail, arises when rigid orthodoxies are transplanted on foreign soil. The PD process for nutrition, in contrast, has been successfully adopted and adapted in the last decade by ministries of health, UN organizations, and local and international NGOs in forty-one countries in Africa, Asia, Latin America, and the Middle East. PD is based on the sociocultural context of each program community. It must always be, by definition, “ours,” and is genetically, “culturally appropriate.” PD works like nature works. Like Darwin’s finches of the Galápagos Islands, each successful adaptation must be appropriate to the local ecology.

With two decades of experience and the ongoing application of the PD process to scores of issues other than nutrition, we find ourselves constantly adding to the list of lessons learned. The first application of PD in Vietnam was very much a work in progress. We learned as we stumbled, recovered, and eventually succeeded. Many of the principles highlighted in this chapter became principles only after the fact, upon reflection of what worked and what didn’t. Two important insights came from the people themselves. From an exhausted volunteer, we got the importance of hearing every voice, at every stage of the process, so that people felt included in the problem definition, inquiry, discovery, findings, and implementation. From an old woman at the end of a long day, we got the importance of doing, as opposed to just seeing or hearing.

Measuring Progress

With malnutrition, we had stumbled upon the easiest of all possible problems. This facilitated an “early win,” as contrasted to the more murky challenges since encountered. Everyone wants a healthy, well-nourished child. Eliminating malnutrition is culturally and politically acceptable and universally compelling. It is an issue around which everyone can rally. Not so easy are the many other intractable problems on the planet.

Measuring the impact of a nutrition program is as simple as putting a child on a scale and waiting for the measuring needle to come to rest. Ability to measure is a powerful reinforcer of behavioral change. Not only is measurement simple and easily understandable to caregivers, but change is rapid. In two weeks a child can gain a few hundred grams. A caretaker witnesses not only the progress on a weight chart, but the change in the behavior of her child. One of our favorite “complaints” from participating moms, especially grandmothers, was, “Our little one is ‘naughty’ now.” (One ruefully observed she needed a fitness program to carry the heavier child.) The listless two-year-old who had begun the program a short month or two earlier was transformed into an active, happy kid who had to be stopped from romping through the rice paddies and squashing newly planted seedlings.

Many of the subsequent issues for which the PD process has been used have been much more daunting, the constellation of potential factors impacting the problem less clear, and proof of success more diffuse. What motivates poor parents in a developing country to sell their daughter to the sex trade? Is it not Allah’s will that decides the fate of infants in Pakistan? What stakeholders need to be involved to challenge the conventional wisdom? What social, economic, and cultural factors need to be explored? Determinants are a lot more complicated to spot than quantifiable factors like adding shrimps and crabs to rice in Vietnam or ladling soup from the bottom of a kettle in Bolivia. It’s much more difficult to prove an event averted, as contrasted to alleviating one that occurs. Clear-cut correlations between new practices and results are more elusive. A death avoided is much more difficult to link to newly practiced behaviors than a gain in body weight.

Acting Your Way into a New Way of Thinking

“A thousand seeings aren’t worth one doing.” The Vietnamese proverb uttered by a humble village volunteer has become a mantra that has spawned a thousand applications around the world. It triggered our epiphany on the long drive back to Hanoi; it led to volunteer-designed workshops. It gave rise to the Living University.

Peel the onion and, not surprisingly, the concept harnesses incontrovertible principles of social psychology: Enactment (behaving differently in front of your peers is the shortest distance to thinking differently) and consistency (having staked out a position, we strive to behave accordingly).⁵

Enactment means putting skin in the game. Doing so breeds commitment—and with commitment comes a shift in attitude. The power of commitment to transform beliefs and behavior is starkly evident in experiences such as Marine boot camp, college hell week, and tribal initiation rites.⁶ When people go through a lot of pain or effort to attain something, they tend to value it more highly than when it is provided with minimum effort. (Perhaps that’s why expert advice and “best practices” often don’t stick—no pain, no gain.) The arduous first steps of a PD process—weighing children, conducting multiple group discussions to establish common practices, and ferreting out potential PD behavior through follow-up sessions—invisibly serve to extract commitment.

The feeding workshops were based on practice—both collecting shrimps, crabs, and greens and getting one child to eat them. Practice sneaks up on you, providing a circuitous path to deep insight. For a while it’s all disjointed fragments (as in the movie Karate Kid—“waxing on and waxing off”). Then one day, everything falls into place. Previous self-conscious activities become sublimated into your repertoire in ways that cannot be precisely explained. This is the real nature of learning.

Enactment is most effective in shifting a person’s attitudes, self-image, and behavior if involvement is active, public, and effortful. A PD process fires on all three cylinders. Participants own their choice to be involved. The kickoff meeting and subsequent PD workshops entail small investments of individual time and attention. Slowly and gradually participants morph from observer to activist. The process also catalyzes the energies of the collective, subtly shifting group norms and assumptions from fatalism to curiosity, and the social political structures from more formal hierarchies to open systems in which the least empowered participants can offer the most important findings.

Consistency exploits another potent mechanism for attitude change. We desire to see ourselves as internally coherent and outwardly dependable. Abundant evidence shows that once we have made a choice or taken a stand, we incur both internal and interpersonal pressures to behave consistently with that commitment. Most of us look closely at our own actions and decide on that basis who we are. Consistency is a valued personality trait. Inconsistency engenders distrust.

One perverse but compelling illustration of the power of consistency derives from the experience of POWs (prisoners of war) during the Korean War. Robert Cialdini, author of Influence: The Psychology of Persuasion, documents the experience of captured American soldiers in POW camps run by the Chinese. “The Chinese were very effective in getting Americans to inform on one another,” states Cialdini, “in striking contrast to the behavior of American POWs in World War II. For this reason, among others, escape plans were quickly uncovered and the escape attempts themselves were almost always unsuccessful. Nearly all American prisoners in the Chinese camps collaborated with the enemy in one form or another.”⁷

The Chinese treated captives quite differently from their allies, the North Koreans, who employed deprivation and harsh punishment to gain compliance. Cialdini observes that by avoiding the appearance of brutality, the Chinese “lenient policy” was a sophisticated psychological assault on individual identity. The Chinese methods subtly harnessed the human quest for psychological consistency. They’d ask prisoners to make statements that seemed inconsequential (“the U.S. is not perfect; Communism may be a good form of government for some societies”). If a soldier agreed, he might be asked to give examples. The next step was to get the POW to write these concessions down or verbalize these admissions with other POWs in a group. (Those who refused were asked to copy the statements of others.) Then, to the POW’s surprise, written statements might be read to the whole camp on the PA system or used on an anti-American radio show (overheard by U.S. intelligence agencies along with the POW’s name, rank, and serial number).⁸

Henry Segal and Edgar Schein, who headed the psychological evaluation team that examined returning POWs at the war’s end, noted how self-image is squeezed from both sides by consistency pressures. From the inside, there is a pressure to bring self-image into line with action. From the outside, there is a social pressure—a tendency to adjust this image according to the way others perceive us. And because others see us as believing what we have written or said (even when we’ve had little choice in the matter), we experience a pull to bring self-image into line with the written statement.⁹

The pilot PD process in Vietnam surely drew on the consistency principle—although not with manipulative intentions. Villagers took public stands in volunteering for the initiative, demonstrating further investment through weighing kids and facilitating group discussions on common practices and prospective PDs. Unsurprisingly, when the need arose for sponsors and activists for the feeding workshops, consistency pressures guided their ongoing involvement as surely as a gyroscope on a Mars-bound spacecraft holds to its trajectory. Unlike in Korea, where consistency was manipulated to an adversary’s advantage, in the PD process we seek to avoid manipulation by insisting that the community, and only the community, decides whether and what it will pursue.

As noted in chapter 1, PD makes sense when a problem is “adaptive” as contrasted to “technical.” What distinguishes one from the other is social complexity and the need for behavioral change. In Vietnam, had the solution been the introduction of high-yield or drought-resistant rice, social and behavioral change by the villagers would have been unnecessary. But we learned to be alert to the way in which “logical” technical solutions can inflict a kind of cognitive blindness. The elegance and efficiency of technical solutions seduces us—preventing the change advocate from spotting the behavioral and social land mines along the way. The Salk vaccine eliminated polio. Seems straightforward. But recent outbreaks in India and Nigeria underscore that superstitions regarding vaccine use by some rural communities have allowed a disease largely eliminated from the planet to stage a comeback. Problems embedded in social and behavioral patterns resist technical fixes. Valid technical solutions pass without impact through a resistant social system like neutrons through a concrete building.

The “Expert” Trap

The villagers’ prior experience with nutritional and agricultural experts had not been good. We noted how expert status, in and of itself, can shift the ownership from the community to dependence on the expert’s authority. We witnessed what was possible when villagers engaged in the learning process and discovered the solutions for themselves. The outsider’s “expertise” spares the community from the essential trial and error of learning.

The larger point here: too often those in sponsorship, expert, or authority roles can generate unconstructive dependency among their followers. This dependency can absolve the community from owning the solutions it must adopt for change to succeed. When the group becomes the guru, members “credientialize” themselves as change agents. We learned in Vietnam that problem identification, ownership, and action must begin in and remain with the community. Community members are the opportunity and the source. When the villagers stepped up and became accountable for the design of the feeding workshops, they introduced nuances that would have been hard to grasp from afar—let alone implement top-down. Disbelief and resistance dissipated like morning mist over the rice fields.

The Problem of Scaling

A “product warning” is in order here. PD successes scale far better “vertically” (i.e., within the community involved) than they do horizontally (i.e., replicating successes across communities). The reason is self evident: each community must opt in to the process and discover its unique wisdom for the discoveries to gain traction.¹⁰ The future is created one community at a time. Each defines its own future, and pilots its own destiny.

The conundrum arises when trying to apply “shrimps, crabs, and greens” from one Vietnamese village to the next. Without careful attention to the setup (beginning with a group decision to opt in to the process and invest sweat equity in determining their own common practices and discovering uncommon ones), the unfolding pattern quickly defaults to a “best practices” drill. Ownership is absent or insufficient to sustain interest, immune responses are activated, and fleeting curiosity ebbs away.

Each community’s stakeholders, group dynamics, and solutions are exquisitely idiosyncratic. The good news: once people have tasted self-generated success and flourished from their own wisdom, the foundation for learning is laid. Throughout the world, villages and organizations that have been the beneficiaries of PD continue to evolve as they apply the process to other intractable problems.

Finale

In June 1996 Monique and I left Hanoi for Cairo. Hanoi had not been a comfortable place to live. Our tiny, eight-hundred-square-foot concrete apartment, unheated in winter and stifling in summer, would not be missed. Nor would the constant government surveillance of our activities, the parade of visitors to our home, telephone calls at all hours of the night, and incoming and outgoing telegrams. And yet, the thought of leaving our friends, our work, and the villagers with whom we had shared so much during our weekly visits, of relinquishing our current life, was wrenching.

We had come to cherish Hien as our younger sister and guardian angel. We would sorely miss our hot-chili-for-breakfast-lunch-and-dinner driver Dinh; our former library-archivist-turned-housekeeper Huong; our officemates and friends; Lang, the English Department chairwoman at the Hanoi College (now working with us as trainer and head of the Living University); and Tuan, a nuclear physicist (who joined us as a secretary to earn a decent living but was swiftly promoted to senior staff member).

We somehow made it through the final few weeks of formal and informal parties and farewells. On our very last evening in Hanoi, we had a gathering of our closest Vietnamese and expatriate friends. Those goodbyes were the hardest, and we couldn’t bear the thought of having to go through them yet again. We pleaded with our friends not to come to the airport the next morning. Our expatriate friends understood and complied. But it was just too much to ask of our Vietnamese friends, for whom an uncelebrated departure would have been a grievous, unthinkable act of disrespect.

As we arrived at the airport the next morning, two vans full of our Vietnamese friends showed up bearing enormous bouquets of roses, flower leis, and kilos of our favorite dried shiitake mushrooms to say their final “final goodbyes.” Long hugs, and tears. Then, without turning back, we made our way through passport control and customs, and onto Thai Airways for the first leg of our journey to our next destination, Cairo.

Waiting on the runway, sealed within our “smooth as silk” cabin, we already seemed worlds removed from the bustling contradictions of Hanoi on the other side of the window: its entrepreneurship checked by Marxist orthodoxy, passion and sensuality stirring within prudish restraint, an irrepressible spirit infecting the somber rectitude, transitioning forward yet holding back. Monique and I sat in silence while the pilot intoned, “Cabin crew, be seated for takeoff.” Six years of our lives had been spent in Vietnam. We had learned more there than anywhere else in our professional lives. Vietnam had given us the opportunity to embark on the PD journey, which has shaped our lives ever since. Takeoff; wheels up, in the air, and off into the unknown.