The Practice of Neurology in Mongolia

Training has been cut from 2 years to 1 year; residents are unsalaried; exams are not standardized.

I am glad to have the great opportunity to write about the practice of neurology in my country, Mongolia. Let's begin with its interesting history. The practice of neurology got its start in Mongolia in 1939 with the establishment of 10 neurologic beds in the Central Hospital by the Russian neurologist Dr. N.Ya. Semyonova.

In 1947, a neurologist who was a faculty member of Leningrad Medical High School, Dr. G.Ya. Liberson, founded the neurology department in the medical faculty of Mongolian State University. Dr. G. Ya. Liberson's work was taken over by the first Mongolian neurologists, Dr. G. Lodon and Dr. L. Dagzmaa.

In the 1950s and 1960s, the first scientific research works were done in the field of neuroinfections (neurolues, epidemic encephalitis, polymyelitis) according to the social and ecological requirements of the country at that time (G. Lodon, D. Rawdandorj). At this time, the second adult neurology ward and the first one for children were launched, the first department of neurosurgery was founded, and the use of new diagnostic methods such as EEG and pneumoencephalography (PEG) was adopted (Tsagaankhuu G et al. 2007).

In the 1970s and 1980s, the neurologic service in the country expanded to become an independent medical branch and improved the quality of neurologic care by increasing the number of neurologists (about 100) and founding neurologic wards in all province hospitals (each with about 20 beds and two neurologists). At that time, the Mongolian neurologists were supported mostly from Ukrainian neurologists (E.P. Zagorowsky), and inherited their methods (Tsagaankhuu G et al. 2007).

The political changes in the late 1980s and early 1990s with the end of the Cold War smashed completely the old socialist social system in the country. While the loss of contact with Russian neurologists was keenly felt, one benefit was that Mongolian neurology was offered new chances to develop professional relationships with neurologists from other countries. In 2002, the Mongolian neurologic association "Monneurology" was founded, and it became a member of the WFN. Also in 2002 the first international epilepsy seminarworkshop was held with the support of the ASEAN Epilepsy Society.

In 2006, the first international neurologic INFOSeminar was held in Ulaanbaatar, with the initiation of WFN and international participation opening new opportunities in foreign relations. Today, the neurologic service in Mongolia consists of more than 20 medical doctors with PhDs and about 200 neurologists. The number of neurologists in Mongolia is 7.8 per 100,000 people, which is a very high proportion compared to most other countries of the world. About 60% of all Mongolian neurologists are working in the capital Ulaanbaatar, where more than a half of the population is concentrated (1.5 million of Mongolia's entire population of 2.5 million people live in the capital city). The number of neurologic beds is about 900 in the whole country, about 3.7 per 10,000 (Baasanjaw D et al, 2006).

In recent years, neurologic research has focused on the epidemiology of most common neurologic disorders such as stroke, epilepsy, neurodegenerative and neuroinflammatory diseases. The stroke epidemiology study revealed that there is a high percentage of the hemorrhagic type (about 50% vs. about 40% ischemic stroke and 10% subarachnoid hemorrhage), which requires special attention to prevention (Baasanjaw D et al, 1999). Also, several research studies were done on epilepsy, which is a significant cause of disability in Mongolia. But because of flaws in the design of these studies, their findings do not distinguish various exact types of epilepsy, limiting the studies' usefulness.

From 1997 to 2000, the neurogenetic group from the U.S. National Institutes of Health, which was led by Dr. Lev Goldfarb, collaborated with the Mongolian Medical Research Institute to undertake research on neurohereditary diseases in Mongolia. The investigators found a high prevalence of certain neurogenetic disorders associated with certain regions of the country. For example, Charcot Marie Tooth [CMT] type 2 disease was prevalent in Arkhangai province, where there were about 100 cases in the population of 97,000. Other disorders with a geographic prevalence included the observations of CMT type 1 disease in Khulunbuir, Dornod province; hereditary spastic spinal paralysis in the Khowd and Uws provinces; and familial oligophrenia in Dornod province. Cases of myotonic dystrophy were registered in nearly all provinces. Not all provinces were involved in the epidemiologic research, but the fact that hereditary neurologic disorders occur in high prevalence within a country that has small population deserves special clinical attention.

Despite the high number of specialists and neurology beds in Mongolia, there are many problems resulting from the difficult current socioeconomic situation in the country. There is insufficient medical and social insurance, both of which were newly founded in Mongolia only 10 years ago. 

The low level of knowledge and outdated training methods of some neurologists are leading to misdiagnosis and treatment failures in many cases. Neurologic residency training lasted for 2 years during the period from 1997 to 2001 and included psychiatry training. Since 2002, the training program has been shortened to 1 year. The quality of clinical training is limited by numerous problems: Neurology residents must often pay for part or all of their training costs; they lack proper workplaces; and they are unsalaried. In most respects, neurology residency training in Mongolia lacks standards, adequate supervision, and standardized examinations.

Established neurologists require but usually do not receive training in order to bring them up to date with the massive increase in new diagnostic methods in recent years. Without such training they risk misinterpreting test results. Pharmaceutical companies are not inclined to introduce their new drugs in Mongolia because our small population means fewer sales for them. Some important medical branches in neurology, such as neurorehabilitation, are still nonexistent in the country. Instead, this type of treatment has been replaced by minimally effective traditional treatment methods.

To become familiar with the latest versions of diagnostic and treatment research, the neurologic consultant of the Ministry of Health began to implement a CME program for neurologists. The younger generation of neurologists eagerly participates in these CME opportunities. All recent information must be translated into Mongolian because knowledge of the English language is not widespread. We are also working on setting and renewing the special standards and guidelines for neurologic diseases which can be generally diagnosed and treated. Mongolia is located in the center of the Asian continent, is bordered by Russia and China, and, belongs neither among the Southeast, Pacific, nor Middle East countries.

The climate is dry and cold. Mongolia has its own culture and language, and a population with a nomadic style of life that has existed for thousands of years. We hope our geographical, cultural, and climatic conditions will not be a barrier for expanding our foreign relationships, and we continue to makes strides to improve our neurologic services in Mongolia. ■

At time of print, SARANGEREL JAMBAL, M.D., known to her friends as Saraa, is a neurologist at the "Reflex" Neurological Clinic in Ulaanbaatar, Mongolia.