Childrens Hospital 'Team International' in Mongolia

by Dr. Richard MacKenzie

"There is no way that I am going to get on the MIAT flight with my baggage full of medicines and equipment. They are weighing each bag and I am, for sure, grossly overweight." Andreas Reiff MD, rheumatologist reflected the anxieties of all the CHLA team as they stood in line to board the final leg of their flight from Beijing to Ulanbator, Mongolia. But, this was just another test of determination of CHLA's TEAM INTERNATIONAL. Planning had begun months before, collecting donations of equipment and medicines to take on their teaching mission to the Maternal and Child Health Research Center (MCHRC) in the country's capital city. A research center that epitomized the best that Mongolia has to offer its sick children and adolescents. But by western standards was indeed primitive in resource and technology. Perhaps kindly akin to what existed at a county hospital in LA in the 1940's and 50's. And that was what this team of dedicated volunteers from the faculty and staff at CHLA were out to change, by doing what they do best - educate the Mongolian doctors, nurses and administrators in the logical next steps into the 21st Century. The dilemma they were now faced with was indeed a metaphor for the dilemma that many developing countries face - old thinking, policies and rules were obstructing change and advancement. Here the team had packed in its luggage and carry-ons, tools for change. And yet it was the nation's government-run airline that posed the challenge to change.

"A good warm up to problem solving," I quipped. I had been through this many times. "You'll find many situations similar to this once we get down to our work in Mongolia, but somehow they seem to solve themselves. Maybe it is the power that is generated by the spirituality of the country - they worship the sky and the earth, against a shattered history of Buddhism. Their philosophy is often, 'what is meant to be, is meant to be'". At that moment, I spotted Otgonbat, Vice Chairman for the Mongolian Foreign Investment and Trade Agency, standing in another line waiting on the same flight. Otgonbat's 3 year-old son had been a patient at CHLA a month before, a consultation arranged by the now visiting team. After a brief conversation between myself and Otgonbat and then Otgonbat and the flight manager at the desk, all luggage was safely stowed and CHLA's TEAM INTERNATIONAL was on its way. Larry Ross MD, Infectious Diseases, David Skaggs MD, Orthopedic Surgery, Jeff Koempels MD, ENT, Charles Krozek MSN, Nursing Research, Diane Wingert MSW, Social Work, Steve Stumpf PhD, USC Telemedicine and Communication Technology and the support team Holly Engelman and Lauren Karp from the Ulanbator Foundation, settled into the 3 hour flight to Mongolia.

This was the third visit for Team International to Ulanbator. But this visit epitomized the creative thinking of the Team's vision. The Team's primary goal is to change the way Mongolian doctors think about disease and treat their young patients. The main focus of this activity is the faculty at the MCHRC and the Medical University. Direct teaching through patient care, surgical demonstrations, consultations and seminars form the backbone of the Ulanbator Foundation's California-Mongolia Medical Project (CaMMP). Special consultation is also provided to the curriculum committee at the medical school to introduce pediatric problem-based learning into an educational system which has its origins in the inductive approach of Russian medical teaching. In fact, the socialist system of the Russian revolution and occupation had left the new democracy of Mongolia, itself in a state of infancy, with very few friends in the world and no family ties.

But this visit was also to explore the feasibility of telemedicine and teleconsultation in a country of extremes punctuated by primitive lifestyles and vast, roadless, open spaces. Of approximately 2.6 million Mongolian residents, over 1 million (almost 50%) live in the capital. The remaining live in small clusters or villages (soums) or towns (aimags) spread over a sometimes geographically hostile landmass the size of Texas. Children under 15 represent 41% of the population, and those under 30 represent nearly 70%. Team International was proposing a plan that was bold and imaginative. It proposed that Mongolian pediatrics- stuck in the technology and thinking of the mid 20th century- skip the 'experiments' of the latter part of this last century and jump into the thinking and technology of the third millennium. Telecommunications, using existing commercial infrastructure, documented by Steve Stumpf from the ABBC Group at USC, with modification and integration into the public holdings, would make this possible. Distance no longer would be the enemy and Team International's impact could be felt countrywide and year-round. And Mongolians, once the proud rulers of Asia and Eastern Europe, would again lead the way into the future through a quantum leap in its pediatric medical practices.

"Cutest little girl" claimed the embroidery on the dress of the little patient from the countryside. The 2 day trip into the MCHRC had not been too arduous says the mother, because "we are going to see the American doctors. We want the best for our children and you are the best". In many ways this was echoed by patients and professionals alike. And 'the best' did their best with what was available - outdated equipment and medications, in the hands of minds eager to learn. They were challenged with babies with RDS creatively intubated with a Foley catheter; a five year old 'in extremis' on life support without the appropriate medications to make the difference between life and death; a 7 year-old undergoing major hip surgery - awake - frightened by the banging of the surgeon's hammer and bone chisel; a 14 year-old holding a basin to catch the blood during her tonsillectomy under local anaesthetic. The end of each day brought stories of successes, failures, frustrations and appreciation for why it is so important that TEAM INTERNATIONAL continue to do what it is doing. New bonds of friendship and respect are cemented among the team members, bonds that will serve the project's mission well. Under adversity and in the absence of family, team support and experience often become the life-blood of professional and personal sustenance. "And we are making a difference, in a country defined by its differences in history and culture, but alike in its need to provide the best in medical care to its future - the children," I assured them.

Charles Krozek, MSN, was surrounded by nurses envious and eager to learn. This was the first time that a member of CHLA's nursing team had been included in a delegation. Previous visits had demonstrated a clear need for nursing, and Charlie was the one to do it. It quickly became clear that this was the first time the nursing staff had received any 'special attention' by foreign visitors. They were also fascinated that a male would choose to be a nurse.

Charlie was there to learn. His goal was to develop a nursing needs assessment- one that would document the specific areas for professional development that would be congruent with what was happening at the level of the physicians and surgeons. Clearly there was a lot of work to be done. But like the doctors, the nurses were ambitious and committed, despite their meager $25-a-month salary. Again it was the dilemma of the children that made the difference.

The children of Southern California and Mongolia are also playing an important role. Each visit by CHLA's Team International brings along the products of the previous year's Child-to-Child Art Project activities of the Foundation. This program is designed to enhance cultural understanding, and to celebrate physical and mental health among children of the two participating nations. Various groups of children and adolescents, both in the hospitals and community create art and other means of cultural expression to visually enhance the healing environment. They are working for their own well-being - an important part of the philosophy of the Program.

The Ca-MMP project of the Ulanbator Foundation of Venice, California and the faculty of CHLA is a volunteer, five-year project committed to making the difference through providing education, technology consultation and implementation. Each delegation is chosen on the experience and recommendation of the faculty's annual needs assessment. The width of the gap between what needs to be done and what can be done is dependent on the generosity of the project's supporters. Another visit by CHLA's Team International will be made in late summer 2003 with a special focus on both the Research Center and the Medical School.