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International Child Health Section: Articles
Mongolia
Submitted by Catherine Grenier Cliche
My elective in Mongolia in the fall of 2006 took part in two phases, which allowed me to visit different areas and get a better grasp of the health conditions existing in the country. As a former Soviet republic, Mongolia used to be able to boast of international-level medical infrastructure as well as solid medical training. However, like most of its public institutions, its health care system has been in serious decline since the fall of the USSR. Poverty has also increased, in large part due to the transition to a market economy and the exodus of people from rural areas into the cities. In addition to these difficulties, the country is vast, at high altitude, and covered in snow six months of the year. It is also a country where tuberculosis and hepatitis B and C are endemic and where every year inevitably sees a few cases of plague occur.
The first phase of my elective took place in Dashbalbar, the capital of a township of a few thousand inhabitants whose hospital serves both the village and the surrounding nomadic population. The facility consisted of two “wings,” with the first wing containing three consultation rooms and a birthing room, and the second containing three hospital rooms and a “plaster room” (which morphed into a TV room in the evening). There was no electricity or running water, and it goes without saying that no paraclinical examinations were available. The people we treated there had few major health problems; most were attracted by the novelty of a foreign presence and of an oto-ophthalmoscope (even the village paediatrician did not have one—I saw dozens of pairs of eardrums, most of which were perforated). Others came for reassurance: No, their occasional cough and twice-yearly diarrhea were not signs of more serious conditions. With hygiene measures minimal to non-existent, I was surprised to see that chronic diarrhea and other major gastro-intestinal problems were not more prevalent. The children were tall, active and heavy, although their outward appearance hid invisible malnutrition. Their diet, composed almost exclusively of dairy products and meat (with no fruit or vegetables), causes major health problems, especially among adults, many of whom are hypertensive. In addition to the people who came to see us for consultations, we performed home visits and took part in a healthy lifestyles awareness campaign delivered in the local school.
I faced several challenges while in Dashbalbar. The first was the total, permanent lack of confidentiality. The room to which I was assigned was also used by one to three other local physicians and a vaccination nurse (UNICEF had provided a vaccine refrigerator powered by a generator placed in the same room). The vaccination nurse would come in at any point during consultations, and mothers/cousins/neighbours would go down the hall opening doors while looking for someone (and listen in on the consultations underway at the same time). Coming from North America, it was difficult for me to remain focused through such pandemonium and accept this lack of confidentiality, especially in a village where everybody knows each other. That said, I encountered an even greater challenge during my stay, namely that of working with interpreters. This difficulty made me realize how important direct patient contact is to me and how key it is to diagnosis. A single word can often clearly differentiate between two potential diagnoses, but I found it difficult to obtain such accuracy through interpreters.
The second phase of my elective took place in Tolgoit, a suburb of Ulaan Baator, the country’s capital. This neighbourhood is home to animal herders who have abandoned the countryside in search of a better life in the city. These people are often unemployed, have no medical coverage, and live in crowded yurts or small wooden shacks. The problems encountered in this environment, in addition to an epidemic of alcoholism, were incredibly varied, with orthopaedic problems being the most frequent. Because babies are wrapped “in the Russian fashion” (laid out and tightly bound), I saw a great many cases of development dysplasia of the hip that were often quite serious (some school-aged children have a several centimetre difference in the length of their legs). I have no information on Mongolia’s periodic screening program for this malformation but I now see the relevance of our own program. I also observed many cases of children with cerebral motor dysfunction. Their development was surprisingly good, given their living conditions and the total lack of support they received from their families. In most cases, children were brought in simply to confirm their diagnosis, with the hope that the “foreign doctor” could do something. Questions such as, “What if I went to China?” and, “Do you treat it like this in your country?” often came up. People show little confidence in their system.
In
short, my stay in
Mongolia
was an incredible experience that
bolstered my confidence in my clinical
skills. I also observed the limits that
having no budget imposes on a
system—occupational therapy and
physiotherapy for LGMD, speech-language
pathology for stuttering or language
difficulties, or psychology
follow-up—none of this is available. I
advised a few patients to go to hospital
for more advanced tests (such as for a
child who appeared to have muscular
dystrophy), but I remained doubtful about
the possible follow-up. Would the
physicians have the necessary training and
resources, and would the parents, who must
pay for all the care, have the means to do
so? I found such a short stay somewhat
frustrating and came away from it with the
desire to be involved on a longer-term
basis in a single location during my next
international experience. I still have
many questions and feel a certain sense of
powerlessness, but I above all hope that
this country is able to gradually find its
way and rebuild itself, for the sake of
its people.
The
food yurt—national campaign for healthy
eating
Dashbalbar
Hospital
- with
outhouses in the back and parking for
horses in front
Home visit in the countryside surrounding
Dashbalbar
The Mongolian countryside
Dashbalbar ambulance—and me in front
watching that the children’s horse race
did not
create serious injuries
Tolgoit
Seeing patients in our clinic yurt in
Tolgoit
Baby wrapped up in Russian fashion
Last
updated: May 2007
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