Matters of Life or Death in Mongolia

For the moment, Dr. Robert Greenburg is a spectator. He stands at the feet of a patient--a nude, unconscious woman shaved for surgery--and watches as a nurse daubs the abdomen with an iodine-based sterilizing solution. The liquid glistens yellowish-orange under the intense lights, the smell mixing with ammonia disinfectants to fill the operating room with an acrid stench.

It is the same smell, Greenburg says, that filled American operating rooms in the 1960s.

But this is the capital of Mongolia. And it is 1997. The tools match the Mongolian doctors’ skills: Both are functional but out of date.

Greenburg’s job this week is to condense time, to bridge that gap between the way Mongolian doctors practice medicine--in this case, how they treat cervical cancer, which is curable with early detection--and the way medicine is practiced in Southern California.

Lives hang in the balance.

“There’s absolutely no reason for women to die of this disease,” says Greenburg, 52, a retired Newport Beach obstetrician-gynecologist. “It’s a matter of allocating resources, which are very dear in this part of the world. But we feel we can make an immediate impact by giving women hope that if they have this disease, they have the opportunity for a cure.

“I’m not saying that I’m Albert Schweitzer, but this is wonderful work, and I’m lucky to be able to do this.”

It’s a common sentiment among Greenburg’s colleagues this week.

Two teams of American doctors--13 in all, mostly pediatricians and oncologists from Southern California--have come here to watch and help Mongolian physicians work in three of Ulaanbaatar’s 15 hospitals, and in three villages in the countryside.

During the week, the doctors will stumble across diseases they’ve rarely seen, such as rickets and diphtheria. They will work with equipment that could double as medical artifacts. And they will see difficult surgeries pulled off despite limitations in training, supplies and basic operating tools.

But they will also witness the tragic consequences of misdiagnoses and limited access to equally limited health care.

By the time they leave, the doctors will have examined nearly 200 patients and consulted on dozens more cases. They will have directly saved the lives of several people, improved treatments for scores of others and passed along innovations that will help Mongolia’s doctors deal better with such ancient but curable killers of children as respiratory infection and diarrhea.

And the American doctors have only just begun.

Studying the Country to Learn of Its Needs

Back home, the two teams of doctors could open their own medical plaza.

The first team is a group of nine pediatric specialists assembled by Dr. Richard MacKenzie, director of the division of adolescent medicine at Childrens Hospital Los Angeles. The group includes an anesthesiologist, a medical equipment engineer from Oregon adept at jury-rigging balky machinery, and a public affairs specialist from Los Angeles with a knack for squeezing donations from American medical companies.

MacKenzie’s team arrives a week early to explore the area around Ulaanbaatar (pronounced OO-lahn-bah-TAR), which one doctor describes as putting the play before the work. Yet the play has a purpose. To understand the medical needs of Mongolia, the doctors must understand something of the country itself.

In some ways, Mongolia is defined by where the people aren’t. Just over half the nation’s population of about 2.5 million live in cities, some 650,000 in Ulaanbaatar alone. The rest lead traditional semi-nomadic lives, moving their gers--canvas-and-felt houses resembling quilted igloos--with their herds of cattle, horses, sheep and goats over an area of about 600,000 square miles, slightly larger than California, Nevada, Utah, Arizona and New Mexico combined.

Mongolia’s heyday was the 13th century, when Chinggis Khan--Genghis Khan to Westerners--united the Mongol tribes and, through brutal warfare, controlled Asia from the Pacific into Persia and to what is now Hungary. Even in the heart of Ulaanbaatar, the sense of that nomadic, conquering past pervades, with the name Chinggis on everything from vodka bottles to a new Western-style hotel for tourists the investors hope will come.

The core of the city has a generic industrialized look, its wide roadways lined with large, characterless buildings of stone and concrete. Grass and weeds sprout untended along the sidewalks and streets. Many residential lots have two main structures: a wood or plaster one-room house for the summer, and a stove-heated ger for the winter.

Outside the city, the landscape dominates with a mesmerizing starkness. Vast valleys stretch between sloping brown hills covered with a light green fuzz of grass. Stands of larch and birch meander along spring-fed creeks. Treed mountain steppes fill the west and north of the country; in the south and east the land flattens out into the Gobi Desert.

The natural beauty of Mongolia, and the romance of nomadic life, hide some very real agonies.

In the nephrology department, Dr. Francine Kaufman finds that the supply of insulin is sporadic at best, which makes it nearly impossible for the young diabetic patients to maintain proper levels of blood sugar.

“They keep running out,” Kaufman says. “It’s incredible. We throw it away like water.”

Oddly, the Mongolian doctors say they have only 22 pediatric diabetes cases. Kaufman suspects many young diabetics die suddenly and misdiagnosed in the countryside.

After returning to Los Angeles, she will begin a program asking the families of her department’s 600 young diabetic patients to donate insulin, needles and old equipment for measuring blood-sugar levels.

The supplies are critical to the survival of the young Mongolian patients.

“They’re just not growing,” Kaufman says. “They’re not entering puberty. They’re developing cataracts, swollen livers and stiff joints and the early onset of kidney disease. If we can’t reverse that, it’s like a death sentence in 10 years.”

Cervical Cancer’s Eradication Is the Goal

Greenburg’s team of doctors, smaller than the pediatric crew, focuses on cervical cancer. In addition to Greenburg, the team includes Dr. Leo LaGasse of Cedars-Sinai Medical Center in Los Angeles; Dr. Klara Vogel, senior obstetric-gynecology resident at Cedars-Sinai; and Dr. Young Kim of Harvard Medical School and Beth Israel Hospital in Boston. The doctors are aided by Ginny Burns of Costa Mesa, a registered nurse who formerly worked with Greenburg at Hoag Memorial Hospital Presbyterian in Newport Beach, and Ann LaGasse, a registered nurse married to LaGasse.

The team is part of Medicine for Humanity, a Newport Beach-based organization that Greenburg and LaGasse, his mentor, formed two years ago in hopes of eradicating cervical cancer in developing countries. The group, whose 100 volunteers include doctors, nurses and counselors, has already worked in the Philippines, South Africa and Mexico. The week after the Mongolia project they will head to Malawi.

Greenburg sounds more like a missionary than a doctor as he talks about the vulnerability of cervical cancer to treatment.

The disease is caused by the human papalomavirus, he says, which is sexually transmitted and can cause small cancerous growths on the cervix. Pap smears are an early but unreliable diagnostic test. Regular gynecological exams can remove the doubt and give doctors the chance to excise the cancerous tissue as easily as if they were taking a biopsy.

But if the growth isn’t removed, the cancer will spread and the patient will die.

“This is a disease of poor people, of poor women, who have had barriers placed on health care,” says Greenburg, who lives in San Juan Capistrano. “Even in our country it is a disease of the underserved, the underprivileged. There are 6,000 [U.S.] deaths per year, primarily among the disenfranchised and the elderly.”

That translates into a mortality rate of about three per 100,000 women considered at risk, against a rate of those who develop the disease of 8.3 per 100,000.

In Mongolia, the reported mortality rate is about 33 per 100,000, which Greenburg suspects is low because of misdiagnosis.

More telling, lack of screening and treatment means the mortality rate mirrors the incidence rate. In other words, Mongolian women who contract cervical cancer usually die of it.

The problem, as in the U.S., ultimately comes down to access to medical care.

“The barriers are lack of awareness, lack of public education and lack of screening,” Greenburg says. “There just are not enough trained medical people [in cervical cancer] for the population.”

Even the few who are trained need refresher courses.

In the first-floor screening room of the National Oncology Center, Greenburg discovers that local doctors don’t use the colposcope--which helps detect cervical cancer at an easily cured stage--that they’ve had since 1992.

The machine works simply. Doctors swab the patient’s cervix with a vinegar solution, which dissolves the mucous membrane and reacts with the colposcope’s green light to make abnormal lesions glow white. The doctor can then remove the cancerous tissue easily and without invasive surgery.

But the Mongolian doctors weren’t using vinegar. They were using iodine, which doesn’t make the abnormal growths stand out.

So they gave up using the machine.

To Those in Mongolia, This Activist Is an Angel

The American doctors have come to this rugged and harshly beautiful country because of a man in a dress.

He is Arnold Springer, 58, a longtime Venice Beach political activist, professor of Russian studies at Cal State Long Beach and director of the private Ulan Bator Foundation. Springer wears dresses because they make him feel whole, he says, cloaking his androgynous, Freudian sense of dual masculinity and femininity in long robes, bracelets and fingerless lace gloves set off by a graying beard that explodes from his chin.

Springer began the Ulan Bator Foundation--reflecting the former Western spelling of Mongolia’s capital--seven years ago after accepting a controversial $200,000 settlement to drop his challenge to a housing development in Venice Beach. At the time, he pledged to use the money to bring Mongolia’s “concepts of space, light, air [and] horizons” to western Los Angeles, and conversely to bring a better understanding of the West to Mongolia.

“I thought they could inspire us because of the supreme and sublime nature of their country,” Springer says. “I wanted to encourage a people-to-people exchange, so we could learn from each other.”

In some quarters, Springer would be considered a mystical figure, melding the physical and metaphysical. In other quarters, he’d be considered a nut.

But in Mongolia, he’s an angel, delivering doctors with lessons in new techniques to a place where they are sorely needed.

With a Talent for Teaching and a Commitment to Help

Conditions at the Maternal and Children’s Health Center, a vast and dank 800-bed complex, are clean but rugged. Windows are sealed with tape against winter winds, and some of the panes of glass are cracked. The spigots on most of the sinks don’t work, so a nurse pours water over the doctors’ hands after each patient. Lightbulbs are scarce, and in some places bare wires dangle where light fixtures should be.

The American pediatricians are curious but quiet as they negotiate the warren of dark hallways and austere rooms of battered metal beds. Paint and plaster peel and sag from the ceiling, signs of old water leaks.

Each pediatrician was chosen primarily for expertise in areas in which the Mongolian doctors said they needed help. But there was an extra element that MacKenzie used to winnow the list.

“I picked people who had a commitment to international health, a commitment to teaching, who are effective teachers and clinicians,” he says.

Kaufman, an endocrinologist and director of Childrens Hospital Los Angeles’ Comprehensive Childhood Diabetes Center, will spend the week reviewing diabetes and other gland-related cases. Her husband, Dr. Neal Kaufman, is director of Cedars-Sinai’s Division of Academic Primary Care Pediatrics and a public health expert.

The list goes on. There’s Dr. Ken Geller, who runs the Division of Otolaryngology at Childrens Hospital Los Angeles; Dr. Stuart Siegal, director of the hospital’s Children’s Center for Hematology-Oncology; Dr. Larry Ross, associate professor of clinical pediatrics at USC and Childrens Hospital Los Angeles; Dr. Tristy Shaw and Dr. Pam Stein, pediatric residents at Childrens Hospital; and Dr. John Goldenring, trained as a pediatrician but now a hospital administrator from San Diego.

The physicians’ motives for making the trip are a mix of professional and personal. Geller, who speaks Russian, the unofficial second language of Mongolia, talks of the rewards of helping the sick in an environment not dominated by bureaucracy and insurance forms. Ross wonders at the implausibility of so many children dying, in essence, from chest colds that, untreated, develop into pneumonia.

But they also hold no illusions of effecting immediate change.

“I’m interested in bringing my knowledge to a place where it could truly make a difference,” Francine Kaufman says. “At home, you know you’re really making a difference. But if I wasn’t there, there are 20 other people who would be. But if I wasn’t here [on this trip], there might not be a pediatric endocrinologist. I’m not sure a few days will change a lot. This has to be the beginning. There has to be some sort of continuing relationship.”

The first links were made during the daily flow of watching the Mongolian doctors care for the ill.

One of the first patients Geller examines is Biambasuren, 16, who lives about 240 miles out in the countryside from Ulaanbaatar. In March, Biambasuren was chopping wood near his family’s ger when the ax bounced up and the blunt end struck him in the face, shattering bones.

Despite what must have been agonizing pain, the family didn’t seek medical help until mid-June, when infected sores wouldn’t heal. As Geller squeezes pus from the open wound and feels for the knit of the shattered bones, Biambasuren sits immobile, trickles of tears the only sign of pain.

“The bones have set abnormally, and there’s chronic bone infection,” Geller explains as he works. “The sinuses are all filled and the skin is open. He needs reconstructive surgery.”

Then, turning to the Mongolian doctors, he asks in Russian, “Did you take blood for a bacterial check? No? You should do that first.”

Later, away from the doctors, the frustration seeps out.

“It’s all very romantic when you’re out there in the countryside with the gers and the horses, but then you see what goes on,” Geller says in a level but intense voice. “People joke about, ‘What did you doctors ever do before antibiotics?’ Well, this is what we did. Kids went deaf.

“People died from ear infections, from injuries like this.”

With Turmoil Comes a Chance to Reorganize

The American doctors follow an agenda devised with Dr. B. Enkhjargal. (Mongolians traditionally are identified only by their given name and, occasionally, the family initial, which makes looking up telephone numbers an exasperating exercise.)

Dr. Enkhe, as she is called, is an English-speaking pediatrician in Ulaanbaatar who also serves as volunteer director of the foundation’s Mongolian Medical Program. Sponsored by the Ulan Bator Foundation, she spent the 1996-97 academic year as an observer at Childrens Hospital Los Angeles and Cedars-Sinai, and is enrolled in a master’s program in public health at UCLA this fall.

The Ulan Bator program created immediate benefits in the capital, she says, ranging from sparking discussions among the Mongolian doctors on how to improve their skills, to grabbing the attention of other aid organizations--such as UNICEF--that might play a role in future medical visits.

“Every Tuesday since the doctors left, the departments are having meetings where the [Mongolian] doctors are sharing their knowledge,” Enkhe says, summing up the visit in a recent telephone interview. “More patients are getting the right diagnosis.”

Mongolia offers an unusual opportunity for the program to succeed. Until the advent of democratic reforms in 1990, Mongolia was Communist-run under the tutelage of the Soviet Union.

Communism’s central planning meant a 70-year national investment in health care, which ended abruptly seven years ago when Russia, which accounted for about a third of the Mongolian economy, withdrew its financial support. The country has since embarked on a campaign to convert to a market-driven economy.

But the changes haven’t been limited to economics.

“If we would have thought of Americans a few years ago, we would have thought of enemies,” Dr. J. Radnaabazar, a top Mongolian medical researcher, says as the doctors begin the week’s work. “Today, we see you sitting here and preparing to share your knowledge with us.”

MacKenzie sees in this time of economic and political turmoil a rare chance to reorganize the way medical care is delivered.

“The best time to change a system is when the system has been disrupted,” MacKenzie says. “If they had a strong government, a strong political system, a strong economy, it would be difficult because they would be satisfied.”

Although economics and remoteness over the years limited the Mongolian doctors’ training, they have attained basic Western skills, a foundation upon which Springer hopes to build over the next four years. The Mongolian doctors themselves are eager to learn. Among adults, literacy is high--between 85% and 95%, according to varying sources--which makes public-awareness health programs more likely to be effective.

Yet there is only one CAT scan machine for the entire nation. Orange County alone has 64.

The new economics have caused some of their own problems. Under the market economy, the Mongolian government pays for inpatient care, but individuals cover outpatient treatments. So marginally sick patients hospitalize themselves for free treatments and access to otherwise hard-to-get drugs.

The medical condition of the country has worsened in even more profound ways, according to a June report by staff at the Mongolian Medical University in Ulaanbaatar. The report warns that the health of Mongolian children particularly has deteriorated, and will continue to do so unless the new government can make health care more widely available and improve nutrition for the one-third of the population now living in poverty.

Specifically, infant mortality rates jumped from around 40 per 1,000 to around 70, according to United Nations statistics. In the U.S., the infant mortality rate is about 7.

However, lack of centralized record-keeping in Mongolia renders such statistics unreliable. Even doctors must rely on patients’ families to tell them medical histories during diagnostic visits.

Finding Solutions Is Central to Mission

Reflecting the agrarian remoteness of most of the country, accidents are the leading cause of deaths among children. They range from car crashes to farm injuries that can occur hours from Mongolia’s main medical center.

Little trauma care is available outside the capital. During this week, the doctors will see several accident survivors, including one voiceless boy whose larynx was crushed when a horse kicked him, and the boy whose face was shattered by an ax. In both cases, the families sought medical help only when the injuries didn’t heal after several months.

After accidents, the leading causes of death are respiratory infections, diarrhea and parasitic infections. Those illnesses have common roots in chronic poor nutrition, limited access in the countryside to medical help and supplies--including key medicines--and unhealthful living conditions exacerbated by winter temperatures that drop to 40 below zero.

Yet, the doctors suspect those numbers might be misleading. They suspect untold numbers of children die in the countryside of illnesses misdiagnosed as flu or diarrhea.

Other maladies, rare in the U.S., crop up with regularity, such as iron and iodine deficiencies and brucellosis--a bacterial infection caused by drinking unpasteurized milk and characterized by recurring fevers, sweats and joint pain. For reasons that are unclear, chronic hepatitis is rampant, as are kidney and bladder stones among children. One of the Mongolian doctors, Dr. G. Erdenetsetseg, will spend the next year in Dallas studying the underlying causes of the stones.

In the U.S., kidney stones are removed or pulverized with sonic equipment; in Mongolia, if they don’t dissolve with dietary treatment, the kidney often is removed.

Finding solutions to some of these problems has become the American doctors’ mission. During the week, the two teams will watch and advise, and later begin sketching out a report from which Springer and the doctors hope to draw a blueprint for a four-year plan to rejuvenate Mongolia’s health care system.

Springer hopes to make the medical exchange program--endorsed by the Mongolian Health Ministry and directors of the oncology and pediatric hospitals--long term and self-sustaining, financed by Western companies investing in Mongolia’s nascent oil industry.

International medicine can be expensive. Springer’s foundation long ago went through the $200,000 settlement and now gets by on sporadic donations and about $20,000 in each of the last two years from Springer’s teaching salary.

The $42,000 budget for the Mongolia trip was partially underwritten by a $16,000 grant from the U.S. Mongolia Business Council. Another $15,000 grant failed to materialize, forcing Springer to scramble to cover the bills in Mongolia.

As the trip ended, the foundation was between $6,000 and $9,000 in debt, which Springer describes as “manageable.”

Now he’s focusing on financing trips under the four-year plan that’s still being devised.

“I want to have a significant exchange of medical people between both countries,” Springer says. “I want the Mongolian doctors and support staff put through our rotations to see what it’s like in Southern California medical institutions.

“Then, I want them to come back here and apply what they’ve learned and work with us to transform the hospitals.”

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Local Comparison

Population

Mongolia: 2.496 million (1996 est.)

Orange County: 2.659 million (1997 est.)

*

Population density

Mongolia: 4 per square mile

Orange County: 3,332 per square mile

*

Area

Mongolia: 604,800 square miles

Orange County: 798 square miles

*

GDP*, 1996

Mongolia: $4.4 billion

Orange County: $87.8 billion

*

GDP* per capita

Mongolia: $1,762

Orange County: $33,020

*

Registered automobiles,1996

Mongolia: 21,000

Orange County: 1.57 million

*

Engineer’s monthly wage

Mongolia: $100 (est.)

Orange County: $4,344

*

CAT scan machines

Mongolia: 1

Orange County: 64

*

Infant mortality

Mongolia: 70 per 1,000 births (1996 est.)

Orange County: 5.9 per 1,000 (1994)

* Gross domestic product

Gail Fisher, photo editor/special projects, has worked for The Times Orange County for 14 years. She previously has filed photo stories from Bosnia and Chechnya, and most recently covered the transfer of Hong Kong from Great Britain to China. She can be reached at (714) 966-7455, or e-mail: gail.fisher@latimes.com

Staff writer Scott Martelle joined The Times Orange County at the beginning of the year. He lives with his family in Irvine. He can be reached at (714) 966-5974, or e-mail: scott.martelle@latimes.com