By Michelle Borok
Earlier this month, the Ministry of Health announced that 2014 would be the Year of Maternal and Children’s Health. While, undoubtedly, this was good news for nurses, doctors, administrators and advocates in the health sector, the challenges to making tangible improvements to the nation’s health care industry are tremendous.
The issues facing public health are many. Increased attention to the harmful effects of growing air pollution on residents in the capital (home to the majority of Mongolia’s population) will hopefully be a driving force in the changes that need to made on a large scale, but the issues of infrastructure (access to clean water and heat), health education, nutritional education, and simple access to medical resources all need to be addressed.
Few people look forward to having to engage the health care system here. The costs at private clinics are feasible for only the privileged few, and the majority are left with the long lines, limited information, and slapdash diagnoses offered at public hospitals. With rapidly growing populations in the nation’s cities and province centers, the systems in place are under serious strain.
I had no plans to truly put the Mongolian public health care system to the test, but last week I was taken to a Darkhan emergency room for surgery. Living in a small town has benefits, one of which is being able to call your OBGYN for an emergency house call when you are six months pregnant and experiencing severe abdominal pains. She wasn’t able to make a diagnosis, and neither was the doctor who arrived with the ambulance, but the general consensus was to head straight to the hospital.
We opted for the front seat of a friend’s car parked in front of the apartment instead of the Russian Jeep-made-ambulance parked in a neighboring parking lot, and ended up beating the ambulance to the hospital. Somehow, I also luckily beat the emergency room rush, and was able to receive the attention of two of the doctors on staff. Without MRI machines or an ultrasound, as my described symptoms were translated to the doctors conducting an external physical examination, it was determined that I was most likely experiencing appendicitis. Immediate surgery would be required.
While it’s never easy to face the reality of required and complex medical procedures, I’ve come to find it even more challenging to face when communication with your health care practitioners is stunted by language barriers. As I did when I first encountered the Mongolian health care system for the birth of my first child, I resolved to trust in my doctors, family and support network, and to remember that everyone wanted the best possible outcome for me.
Darkhan’s general hospital was built in the early 1960s, and like most major public service centers in Mongolia, its seen piecemeal improvements over the decades, but never a full blown restoration. It is mostly equipped with second-hand and donated resources from South Korea, Russia and the U.S. Although the hospital’s cleaning staff is fastidious, the non-restricted areas of the hospital are fairly open to everyone and show the wear and tear of heavy use by Darkhan residents and residents of neighboring soums. Shoe covers and paper capes are given to people accompanying patients onto surgical floors, but few other measures are taken to maintain a sterile environment.
I tried to forget all of these things as I lay on the operating table. Two of the hospital’s top surgeons had been called in to perform the operation, and my OBGYN was on hand to monitor (by sight and intuition honed over nearly 30 years in practice) my unborn child. I set aside any last psychic grasps for control, and trusted in trained professionals who had no doubt saved countless lives before mine.
The surgeons asked curious questions about their foreign patient, and my OBGYN did her best to fill them in and translate their inquiries. It was the perfect distraction. About a third of the way through, my OBGYN leaned over to join a discussion with the surgeons. It turned out that the possible ruptured appendix was actually an ovarian cyst. Without missing a beat, it was carefully removed, and I was sewn back up and sent off to recovery.
I spent my first night in the general hospital. While I was in surgery my husband raced home to collect bed sheets, toiletries, clothes and other supplies for what would end up being a five day hospital stay. The public hospitals provide limited bedding to patients, and when they are overcrowded, sometimes they aren’t even able to provide beds. The nurses laid out the sheets from home, and stashed the rest of my belongings in the wooden bedside table next to elevated, hand-cranked Korean hospital bed I was transferred to from the surgical room’s gurney. I had a fitful night’s sleep, but I spent a lot of time reflecting on how lucky I was to have the attention and care of my doctors, something that small town life allows. But I spent as much time imagining how different the experience would have been in a modern hospital in Los Angeles.
The next morning, after paying our emergency room bill in full (just a little over 135,000 MNT) a nurse helped my husband and I pack up and I crept down three flights of stairs to be driven to the maternity hospital located behind the general hospital. I spent the rest of my recovery there for monitoring of my baby.
There’s an efficiency to Mongolian character that I, personally, have always appreciated. It comes from a practicality and sense of purpose that I sometimes feel is lacking in other cultures. My maternity hospital nurses all displayed this trait with varying degrees of softer bedside manner. They were a bit thrown off by the wounded foreigner on their floor, but news spread quickly that I could understand a little bit of Mongolian, but not much. They were all incredibly organized, informed and prepared to care for me during the recovery process, and the least shy of them would strike up conversation. My favorite nurse, learning that I was also an English teacher, had me chat on the phone with her fourteen year old daughter as she listened on speakerphone.
There’s a sense of community that’s created on hospital room floors. Thankfully, there was no overcrowding in the maternity hospital. All patients had their own beds, but no one had a private room. According to a head doctor at the adjoining children’s hospital, the rooms were completely full. The children’s hospital has 40 beds, but during the winter, gurneys, thin mattresses and bedrolls line the hallways to treat the tidal wave of children brought in with severe flu and pneumonia. During my stay, there were over 80 in-patient children being looked after by the children’s hospital staff.
Only the smallest of meals are offered by the hospital. Milk tea and rice porridge were brought down the halls each day, but patients rely on family or friends to deliver food to the hospital throughout the day. There’s a steady stream of full and empty food storage containers that move up and down the hallway, as visitors are seldom allowed to go directly to rooms. Men are even less welcome beyond the waiting room of the maternity hospital, but exceptions are sometimes made. When a new hot meal arrives, patients share and serve their hospital roommates before eating, and many set aside food to share with the nurses. Roommates share mobile phone minutes, power strips, toilet paper, electric kettles, and whatever else other women might be without. It’s a beautiful thing.
Of course, it’s also a reminder that all of these things are only available to those who can provide for themselves. The hospitals can’t feed, clothe, provide clean blankets and pillows, or even a steady supply of painkillers to patients. I’m eternally grateful for the resourcefulness of Mongolians, and for their innate need to take care of one another, but I’d still rather see the health sector receive the attention and resources it needs to take more holistic care of its patients.
Back at home, and still on the mend, I checked in with Andy Mayer, an Australian childbirth educator who has spent her time in Mongolia working hands-on with maternity hospitals and staff through the Maternal Health Training Project. When asked for her thoughts on the Ministry of Health’s start of the year pronouncement, Mayer said, “It is a great thing that the ministry is focused on improving maternal and infant health. It would be beneficial to invest heavily in antenatal education and post natal education at hospitals to enable more mothers to learn skills that prevent poor outcomes. Now there are over 100 maternal healthcare workers trained in antenatal education practices the implementation of patient education classes should be easy to facilitate.” The work of the Maternal Health Training Project will continue because the Mongolian health care providers who participated in the program are eager for change, whether or not the “Year of Maternal and Children’s Health” ever gets off the ground.
I can’t vote in this country, but I’m going to raise children who were born into the Mongolian health care system, and will someday – hopefully – motivate their elected officials to make good on their public promises. Improved maternal and children’s health in Mongolia will take more than a year to treat thoroughly, but now is as good a time as any to take a close look at the changes that need to be made.