The Status of Health Care in Reformed Mongolia:

Implications for Travelers Visiting the Nation

by Michael C. Walker

with contributing information from: Tressa A. Harlcorr, M.D., J.D., and Dalv Sairaan, M.D.

The nation of the Mongolian Peoples Republic may not be a travel destination which most American or Western European travelers are considering for their next vacation, but it is a country which offers great potential for those interested in "adventure travel" and is also becoming more and more important in the Asian trade arena, meaning that business people from the West may soon find themselves venturing to the exotic land of Genghis Khan. Like many "developing" countries, there are important conditions and complications that a traveler must consider when planning a trip to Mongolia, factors which would not be as crucial if the destination was a more familar, "developed" nation. Simply put, things which we take for granted at home are often not as easily obtained when in less developed countries. In the case of Mongolia, we could use the term "re-developing nation" to accurately describe the political and socio-economic status of this country. Mongolia was under Communist rule for the last half of the current century and during that time was very dependent on financial, administrative, and social aid from the former Soviet Union. When, in 1990, Mongolia reformed its government and went to a more democratic system of administration, it almost completely severed its ties to the U.S.S.R., which, of course, was also in the midst of political reform. Therefore, the infrastructure of the current Mongolian government is actually only about six years old and is embattled in the struggle to move from its old ways to a totally different type of society while maintaining a acceptable standard of living for its citizens. These changes and the state of transition also means that services in the areas of transportation, communication, and perhaps most importantly, health care are in the midst of transformation and should be approached with some advanced knowledge to ensure a safe and efficient trip to Mongolia for the foreign visitor.

The health care system in Mongolia is unique, and it was at one time a quality system which provided good (although not the most technically advanced) comprehensive care for the citizens of the nation and foreigners alike. However, since the system was basically designed, administered, staffed, and funded by the former Soviet Union it collapsed when Soviet aid was removed from Mongolia in 1990. Most of the health professionals who served in hospitals and clinics (being a Communist system, there was no private practice) were Russians who were brought in through either civil or military assistance programs. Consequently, when the aid was removed, not only did funding cease but the majority of the nation's health care professionals went back home to Russia. This was certainly a very serious situation which the Mongolian government had no easy means to deal with, thus to this day there is a shortage of qualified doctors, nurses, and other care-givers in all state hospitals and clinics.

Some Russian doctors did stay for various reasons, one being that the situation in the former Soviet states was not much more promising for them than the one in Mongolia, and nearly all of the physicians were educated either in Russia or the former East Germany. Their level of competence is not equal to the standard found in the United States and Western Europe, particularly in highly technical specialties, but they are mostly proficient and skilled in their discipline. Since the reform of 1990, the privatization of health care has been declared legal, -and even favored by the powers that be- but little progress has been made to make health care a commercial venture. Unlike the United States, nations which are emerging from a Communist system of rule do not generally see health care as a profitable field of business but as something which must be provided for yet is inherently a money-losing proposition. Any medical condition encountered that is more serious than a simple injury or bout with illness which would be normally treated on an outpatient basis will be enough cause for a doctor in any city other than the capital of Ulaanbaatar to refer his or her patient to Ulaanbaatar for treatment. The rural hospitals (this includes even those in the second and third largest cities in the nation) are not equipped to deal with life-threatening conditions in the manner that most visitors would expect them to be dealt with and evacuation to the capital (or outside the country, to Beijing or Tokyo) is the only viable option.

At this point, only two hospitals within Ulaanbaatar cater to foreign visitors. These are the Hospital Number Two and the Russian Policlinic. Both of these hospitals are still almost exclusively staffed with Russian doctors, who gravitated to the capital after the reformation from wherever they may have been stationed in the country. Few of the doctors and nearly none of the other medical staff speak English, so a patient not fluent in either Russian or Mongolian would be advised bring along an interpreter, who are easy to find on the streets of Ulaanbaatar and will often solicit their services to tourists. Note, however, that all interpreters are not truly professionals in their occupation and that nearly anyone -no matter their education- who speaks Mongolian and English (or another language) can make a better living as an interpreter than in most any other job. Some are certainly more skilled than others and most will not be very familar with medical terminology in either language. Hospital Number Two seems to be better equipped and therefore preferred over the Policlinic although they both probably offer about the same level of care. There is a Hospital Number One, which, in fact, was once considered to be the best in the nation but has since been surpassed by both of the aforementioned hospitals. Some Mongolians apparently are either not aware of this or do not believe it and advise ill visitors to go to this hospital but the reader can be assured that Hospital Number One is not anywhere near the level of care offered at the other two facilities.

If a traveler is seriously ill or has a pre-existing medical condition which will require continued treatment during his or her stay in Mongolia, the best option would be to contact his or her nation's embassy. The United States and United Kingdom and other countries have embassies in Mongolia and often a doctor is available at either embassy for consultation (this could always change -perhaps without any notice- as a doctor is re-assigned to another post so the traveler cannot be guaranteed to find a physician on duty at his or her embassy). If the condition is serious enough to merit surgery or another invasive procedure or requires advanced diagnostic technology, the embassy doctor will, in nearly all cases, recommend travel to a hospital outside of Mongolia for care. If the condition is not immediately life-threatening, a hospital in the traveler's home country may well be the best choice, but if the need for interventional or corrective care is imminent, air evacuation to Japan, Hong Kong, or the People's Republic of China will be recommended. Note that China (Beijing) is closer in distance to Mongolia but the traveler must already have a valid visa to be allowed into the country and that the Chinese government will not accept a medical emergency as enough reason to enter their country. There are various commercial services which provide medical evacuation via plane from Mongolia to areas where more advanced care is readily available, but keep in mind that such services are extremely expensive, are most often not covered by most health insurance policies, and cannot always get into Mongolia when they are needed.

As Mongolia is a nation with severe debts and is also geographically and politically isolated from much of the world, payment for medical services is almost always in cash (or possibly credit card or traveler's check) in U.S. dollars, British pounds, or the Japanese yen. Mongolian currency is frowned upon as it, like the ruble, is nearly worthless and suffers from skyrocketing rates of inflation. Most major health insurance policies, -even ones designed specially for travel purposes- are not honored by Mongolian hospitals or clinics. The infrastructure for normal health insurance to function for travelers simply is not in place within Mongolia as of yet. Sometimes a system of barter can be arranged between health care providers and the patient. Although this idea may seem absurd to those accustomed to Western standards of care, in a society where many goods are very scarce one cannot blame the physician or nurse who resorts to an equal and fair trade of services for a tangible product which they need. It is a good idea to carry some small gifts and useful, appealing, items to trade with Mongolians when the need arises (such bartering took place even during Communist times and is regarded by the Mongolians as the easiest and most successful means of obtaining needed goods and services as few people have enough money to buy the these items).

If a traveler does have cause to seek medical treatment at a Mongolian facility, it is important that he or she remembers the following information about the peculiarities of Mongolian health care. Fortunately, Mongolia has not yet (as of recent reports, at least) taken to the paranoid monitoring of foreigner for the HIV virus as is commonplace in many of the Independent States. Due to the shortages of basic medical supplies, the needles and lancets used for blood collection are often re-sterilized for multiple uses and there is the ironic possibility that a person could actually acquire the HIV virus through the drawing of blood to test for the presence of that very pathogen. Still, a traveler must be careful anytime that needles or other invasive instrumentation is made use of by Mongolian medical personnel as there is the chance that it has not been properly sterilized and could carry disease-causing organisms. This is a good reason to avoid any invasive procedures and surgery in Mongolian facilities unless there is absolutely no other choice. Also, it would be prudent to avoid having any diagnostic procedures done which make use of X-ray machines or other radiographic equipment. Much of the equipment being used in even the most technologically advanced of Mongolian hospitals is outdated and often in poor repair as parts are no longer available from Russia. There is the possibility of over-exposure to radiation and the more likely chance that the radiographs will not be of a high quality and could lead to a misdiagnosis. Drugs, especially antibiotics, pain relievers, and anesthetics, are very hard to come by and the latest information indicates that the scarcity of even what medical professionals in the West would consider essential drugs for routine treatment is so high that hospitals have only enough medication to treat half of their patients for half the time which the medication would normally be administered. Blood products should also be regarded with suspicion as no one really knows how safe the blood supply in Mongolia may be; some estimates consider it to be safer on the whole than that in some Western nations due to a lower incidence of AIDS but on the other hand, the screening of donated blood was never as proficient as it should have been and while AIDS is not a large public health problem, other blood-borne pathogens are.

As in any case of travel in developing nations, the best health care that can be advised is careful prevention. Mongolia is, generally speaking, not a dangerous country to travel in if a few precautions are taken and common sense is applied in all situations. Since Mongolia is not a tropical nation, many of the health risks which the American traveler associates with "Third World" countries are not present in Mongolia. The Soviet system of vaccination was largely successful, although it must be remembered that vaccination of young children has been suspended since the reformation of 1990 due to a lack of supplies and personnel. Likewise, public sanitation standards have slipped to some degree as the funding is no longer present to build and maintain such facilities as sewage treatment and water purification plants. Thus, giardia and brucellosis, among other diseases, are a recurrent problem. Brucellosis is transmitted from domesticated animals to humans through milk products or dung. Since milk products are a staple of the diet of Mongolians -especially in the rural areas of the nation- and these products are not purified in the same manner as they are in the West (nomadic herders sometimes do not even boil their milk before they consume it); the best advice is to avoid milk products when away from major cities.

Diseases which most Americans rarely regard as a serious threat to human health due to aggressive public health efforts are still more commonplace in other nations, including Mongolia. Rabies cannot really be considered a major health problem in Mongolia, but nonetheless it is more prevelent than it is in most regions of the United States and the traveler should keep this in mind. If travel in remote areas is expected, a vaccination for rabies before entering Mongolia is recommended. Bubonic plague does appear in Mongolia's more isolated regions from time to time. While infection with this disease is not all that likely, precautions should be taken to avoid areas where rodents are obvious and it must be remembered that the drugs which are used to treat the plague are largely not available in Mongolia and if untreated, the plague is still very deadly. The Centers for Disease Control and Prevention offer information for travelers on matters of specific regional outbreaks of disease, recommended vaccinations, and general health and safety precautions and it would be advisable to check with their service before embarking on a trip to Mongolia, or any remote destination.

For those travelers who plan to hike and camp in the wilderness of Mongolia, natural hazards such as animals must be taken into account. Due to its climate and geography, Mongolia does not harbor the variety of "dangerous" animals that many other "adventure" travel locations do but it is still prudent to consider the possibility of running into animals and knowing how to best handle such situations if they do occur. Poisonous snakes are usually the first animal that a traveler will think of as being a potential threat and there are four types of venomous serpents native to Mongolia. These are the European adder, the Halys viper, the Orsini's viper, and a snake (which doesn't have one, standard, common name and is thus) known by its scientific name: Taphrometaphon lineolatum. All of these snakes are by classification viperids and carry a venom that attacks the blood (as opposed to a neurotoxic venom such as the poison of a cobra or coral snake). Avoidance is the best policy for dealing with snakes and other wild animals and the traveler should remember that snakes have no more desire to have close contact with humans than humans do to be bitten by a snake. In cold weather, snakes will not even be encountered as they will be in their burrows and dens. In warmer seasons, however, they may be found sunning themselves on rocks or wandering about little-traveled paths looking for rodents to eat. In all cases, treat them with respect and leave them alone. If the traveler is bitten by a snake, immediate medical attention is called for and evacuation to a hospital in China (which is more likely to have the needed antivenin than one in Ulaanbaatar) is the best idea. Knowing which one of the species of snakes was responsible for the bite is important, as an antivenin cannot be prescribed without this knowledge (although, in some cases antivenin is not prescribed at all, depending on the severity of the wound and the status of the patient). Scorpions, large spiders, and various types of wasps are also found in Mongolia, although they are rarely a problem for residents or visitors except when traveling far into the wild. Like snakes, they should be avoided and never provoked. Mongolia has, incidentally, very strict rules about the capture and exportation of native plants and animals and attempting to bring a "pet" home with you is certain to result in disaster somewhere in the process. Wolves are common in some areas of Mongolia, but like all wild animals are careful to avoid humans. The domesticated dogs owned by Mongolian herders are perhaps a greater danger as these animals are trained to protect their owners homes and flocks and can be very aggressive. Do not try to pet them or treat them like a typical American family dog but instead follow the cues from your host if you are visiting a nomadic family.

In conclusion, Mongolia can be a fascinating and amazing place to travel to, whether on business or as a tourist interested in seeing a part of the world very different from Western society. Like any nation which is struggling with political and economic reform, the standards of health care are not the same as those in a more developed country. Some diseases which are almost totally eradicated America and Western Europe are occasional problems in a country like Mongolia and the medical equipment available could use improvement. Still, this should not be a great deterrent from going to Mongolia as long as the traveler makes and effort to educate himself or herself and is not foolish in his actions while in the country. Being current on your vaccinations and having a complete physical exam before traveling to Mongolia is only good common sense. Seeing a physician who specializes in travel medicine and is therefore familar with the specific risks of traveling to remote nations is the best option, but a general practice physician should be able to offer sufficient care and advice if this is not possible. As stated before, checking with the Centers for Disease Control and Prevention is a prudent thing to do, as well.

Important Notice: This document was written due a to a lack of general information on health matters for the average traveler to Mongolia. Every effort has been made to ensure that all information in this document is up-to-date and accurate, but given the state of Mongolia's government and society, details may well change overtime. The reader can gain a great deal of knowledge from this document but should consult a physician or other health professional before planning a trip to Mongolia. Only such a consultation can provide personalized and current information. The authors do not take any burden of blame or liability for any injury, ailment, or annoyance which the reader incurs due to his reading this document. If the reader has questions beyond the scope of the coverage given here, he or she should seek out a professional who can answer such questions.