Public Health in Mongolia: Jenna Sandler Shares

Aside from working in the orphanage, I met with three different people to learn about Mongolia’s public health infrastructure. First, I met with the Women and Children’s hospital psychologist. Unfortunately, she and one social worker are the only mental health providers for the entire hospital. On top of that, they spend the majority of their time doing organizational psychology (i.e. counseling hospital staff to prevent burnout). She explained to me that there are very few mental health resources in Mongolia aside from a psychiatric hospital for the severely mentally ill.

I also met with a public health PhD student from the Mongolia University of Health and Sciences. She is a physician of traditional eastern medicine and now studies air pollution in Ulaanbaatar. According to her, the government of Mongolia is extremely corrupt so it makes it very difficult to effect change in the health policy field. As a result, most of her colleagues have moved to other countries- however, she has such deep roots in Mongolia and is determined to improve her homeland. She explained to me some of the major public health issues they face, including infectious diseases like TB and Hepatitis, poor oral health, alcoholism, car accidents especially in the countryside, and air pollution in the city.

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Degi (PhD student) and me

Lastly, the hospital social worker took Adam and me over to the university to meet with Sugarma, a professor of health social work. She was impressive in her approachability and knowledge. She is a physician by training but is very interested in the psychosocial determinants of health and she actually spent some time at Columbia University as a visiting scholar. Sugarma told us a little about the university, which houses the degree programs for medicine, dentistry, pharmacy, public health, social work, nursing, occupational therapy, physical therapy, and other allied health professions. She mentioned most of the same public health issues as listed above but we talked a little more about Hepatitis C in Mongolia. Prior to 1990, needles were sterilized and re-used – as a result, Hepatitis C became overwhelmingly common among a whole generation of Mongolians. Now, although all the hospitals use disposable syringes, Hep C is still seen in a significant number of the hem/onc patients who my dad saw this week. Presumably the blood bank tests all the blood before sending it to the hospital, however, the high prevalence among children who receive blood transfusions regularly seems concerning. Also, many of the chemotherapy drugs affect the liver so the hem/onc docs have to dose and titrate the medicines with extreme caution for patients exposed to Hep C.

Sugarma also explained a little about the health care system in Mongolia. Essentially, there are primary, secondary, and tertiary health centers. At the primary health care center, patients are not required to pay anything out of pocket. At the secondary health center, adult patients are required to pay 10% of the health care bills and at the tertiary health center, adult patients are required to pay 15% of the health care bills. Children and the elderly receive free health care. If a family cannot afford to pay out of pocket, there is no safety net nor social program to help them afford the doctor’s visits. The professor notes that this is a huge gap in access to health care. Also, each primary care doctor has about 2,000-3,000 patients each year so they are stretched beyond capacity.

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From left to right: Chimgay (hospital social worker), me, Professor Sugarma

Transportation is also a significant barrier to improving the health of the Mongolians. Only 3% of the roads in Mongolia are paved – a fact I can attest to after experiencing the countryside for the past few days. To travel from the countryside to a district hospital or a specialty hospital could take days and may be nearly impossible in the winter months. As the country progresses, its leaders will have to find a balance between preserving the unique nomadic way of life and incorporating westernized medicine to maximize the health and prosperity of its people.

-Jenna Sandler

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Dr. Gayle checking the depth of the water before fording the river in the Russian van

The Children’s Place: Jenna Sandler’s Experience

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As the non-clinical member of the team, I’ve gotten a slightly different perspective on Mongolia than the physicians. I’ve spent most mornings at the Children’s Place orphanage and then I’ve gone over to the hospital to hear the doctors’ lectures in the afternoons. The children at the orphanage were instantly affectionate and welcoming. Despite the language barrier, they somehow were able to communicate with me through pointing and gestures. We decorated t-shirts, played hide and seek, played outside, sang songs, did gymnastics, I braided hair, helped some children with math homework (luckily math is universal!) and we took lots of pictures.

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It’s quite amazing to watch the older children take care of the younger ones. There is one girl with Autism and the older children also act as caregivers to her. There are 27 children at the orphanage ranging from ages 1-13. This little boy around 2 years old held onto my hand the whole time I was there:

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Aside from my mornings at the orphanage, I spent the afternoons listening to the lectures by my dad, Dr. Gayle, and Dr. Abram. I also spent some of my time sitting in on patient encounters with my dad and Dr. Abram. One morning, I went with Dr. Abram to the developmental center (which is attached to the orphanage) where they provide therapy to children with developmental delays or conditions such as cerebral palsy and kernicterus.  The center treats children from the countryside who would never otherwise have access to such services. The families travel very long distances to bring their children to the center and they often stay in Ulaanbaatar for the 2 week initial assessment and treatment. In addition to providing therapy (physical therapy, speech therapy, occupational therapy, etc), the providers teach the parents how to nurture their children’s development at home and sometimes actually provide equipment such as braces for children with cerebral palsy for the family to take home.

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At the center, I spoke to a mother who has a child with Autism. The therapists at the Developmental Center are teaching him to communicate simple choices such as which food he would like to eat through the use of picture cards (he is completely non-verbal). His mother was very frustrated by the lack of services here in Mongolia and desperately wants to move to another country to find the best care for her son. I told her about Autism services in the United States and about other parents’ experiences with having a child diagnosed with Autism. She seemed very hopeful about her son’s future, saying that she read stories on the Internet about Autistic children becoming writers and doctors.

So far, my impression of medicine in Mongolia is that they are working diligently to improve their care but they are still a few decades behind. Very few of the physicians speak English and, as a result of language barriers and time, very few of them stay up to date with the latest research and recommendations. Many of their practices are outdated and ineffective, and many of the patients’ conditions are preventable. On the flip side, as I sat in on the patient encounters, I noticed that the parents knew every detail about their children’s medical history, including the dosage of all the medications. They asked a lot of questions and seemed very engaged during the visit. It’s also very apparent how much they respect and trust physicians. In this respect, Mongolia has far surpassed the United States.

-Jenna Sandler

The Journey Begins: Jenna Sandler Shares

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After all the anticipation, we are finally en route to Ulaanbaatar. In fact, I’m writing this on the airplane – we are 8 hours into the flight, about 6.5 to go. The flight attendants on Korean Air are impeccably dressed in their light blue uniforms and matching hairpieces. They have been kind and hospitable, welcoming each of us individually by name. There was a blanket, package of slippers, water bottle, and headphones on each of our seats when we boarded the plane (and that’s just economy class!). Needless to say, my dad switched from sneakers to slippers almost immediately.

As we were sitting in Atlanta waiting to the board the plane, Michael, Harry, Adam, and my dad were exchanging stories about responding to medical emergencies on airplanes. Ironically enough, a few hours ago, the flight crew made an announcement asking for physicians to volunteer to help a passenger with a medical emergency. Luckily, there were about 20 doctors on the plane who responded and the passenger is doing fine.  Now, we are flying over the North Pole and I can see the iced-over Arctic Ocean below me. Just the beginning of our adventures.

As the trip preparations were playing out, I wasn’t sure exactly what my role would be on the team since I am not a clinician. We thought about setting up some time at the Ministry of Health but a week is really too little time to learn or contribute much of anything, especially since I don’t speak the language.  Instead, I am looking forward to spending most of my time at the Children’s Place orphanage while my dad and colleagues are at the hospital. I checked an entire suitcase full of arts and crafts, M&M’s (which Justin told me were a hit last year), puzzles, coloring books, etc. It’s been a long time since I’ve gotten to really just enjoy time with kiddos and I am really excited about it.  My only concern is that I will want to bring all of them home with me to Boston.

There is something so liberating about leaving everything behind for a few weeks to learn about a completely foreign place and culture, especially knowing it is in memory of Jonathan.  Surely we will have some mishaps (like when John put the pile of milk curds in his coffee last year) and we will share them on the blog as they happen. Something that my dad has always taught me is that traveling is where the best learning happens – I am looking forward to soaking up new experiences and also happy to have some quality time with my dad. I am sad not to have met Jonathan Soud but am so grateful to his family for helping to create this partnership with Mongolia. I could not think of a better way to honor the legacy of a very special young man. His memory is a blessing. 

-Jenna Sandler

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