PASSING THROUGH MONGOLIA
A Surprisingly Good Place To Die
What comes to mind when you
think of Mongolia? My answer, probably like many people's, was vast
empty space, those signature round white tents (which Mongolians call
gers, not 'yurts' – a word brought in during the country's period under
Russian and Soviet influence) and Genghis Khan.
One thing you might not think of is 'a
good place to die'. Yet Mongolia is punching above its weight in
palliative care, the branch of medicine that supports people with
terminal or complex illnesses. Palliative care takes a magpie approach,
borrowing from other medical disciplines and addressing a whole range of
issues at once, ranging from pain and other symptoms to spiritual,
social and psychological support.
In a 2015 survey of global palliative
care, the UK comes top, Australia second and the USA ninth. And while
the richest Western nations lead the pack, Mongolia appears notably high
up, especially considering that it's well down the economic rankings.
(It comes 28th in the palliative care survey but ranks 141st for gross
national income (GNI) per capita.)
In fact, when it comes to palliative care,
Mongolia is performing far better than any comparable economy, and is
ahead of several European states with much more developed healthcare
systems and greater spending power, including Greece, Hungary and
Lithuania. It also eclipses several big economies, including its two
giant neighbours, Russia and China.
In little more than a decade, Mongolia's
approach to palliative care has become a shining example of doing more
with less. But how?
A ribbon of snow marks the dark hilltops
from an overcast sky. The wind bites at the canvas folds of the Tumurbat
family ger, their dome-tented dwelling. A few lambs – almost fully
grown, too late to be sold – huddle together in a wooden pen nearby, the
remnants of a once 100-strong flock. As his aunt and two doctors come
into the yard, 18-year-old Dorj Tumurbat stands by the gate, foot up on a
kennel. The dog jumps for the visitors, held back by its chain. But
Dorj stays put, not even turning his head as they cross the yard and
then duck inside the ger. Inside, his father is dying.
Tumurbat Dashkhuu has late-stage liver
cancer. Although his illness is incurable, there is something the
physicians can do: grant him a death that's as peaceful as possible.
The materials for making a ger have
evolved – canvas is increasingly being used for the outer walls rather
than animal hides – but they are still constructed to the same basic
design. A typical family ger is built around two central wooden pillars
(larger ones have more), symbolising the man and woman of the household
in harmony. It is bad manners for any visitor to stand in this central,
sacred space.
But when Dr Odontuya Davaasuren and her
colleague enter the ger, everything is off balance. Enkhjargal,
Tumurbat's wife, is holding back tears, clutching a sheaf of
prescriptions and other medical papers. The stove is going out. A pool
of water is collecting on the linoleum floor, spilling from a washing
machine on one side of the tent.
Next to the washing machine is a large
fridge-freezer, and wires strung across the tent's wooden frame lead to a
television, DVD player and other electricals. The ger is situated in a
capacious fenced compound, with a platform built for a second tent.
The family had been doing well from its
livestock business, shifting between the pastures in spring and summer
and hunkering down during Mongolia's harsh winter here on the outskirts
of the capital, Ulaanbaatar. But with Tumurbat unable to work, they have
had to sell almost all their sheep. Enkhjargal has had to take a
part-time job in a local abattoir to make ends meet. Diagnosed late,
barely a year ago, Tumurbat's cancer has upended their lives. And he is
in agony.
The light from the doorway picks out his
face, which is stiff with pain. He sits back across a bed, leaning on a
stack of tightly folded blankets. He rests his hands delicately on the
source of his torment, a bloated, fluid-filled abdomen, a typical
symptom of late-stage liver cancer.
The comforting evidence of family
surrounds him. At one end of his bed there is a large wooden board
propped up on a table and tied to one of the ger's rafters. It's covered
with colour photos of big groups of adults and children. To the side
there's a small altar with a little figure of Buddha on top and several
brass water bowls below, part of a Buddhist ritual to ward off
negativity.
I fail to find any immediate positives in
this example of palliative care in action. Tumurbat struggles even to
answer questions from Odontuya and her colleague Dr Solongo Surinaa.
"All I want is to be without pain," he whispers.
Solongo is in charge of palliative care at
the nearest district hospital, looking after both in- and outpatients.
Odontuya asked her to make this home visit during my trip so I could see
how palliative care works for those without medical services on their
doorstep.
Mongolia is the least densely populated
country in the world, and distance is one of the biggest challenges to
delivering any service there, including healthcare. It is just under an
hour-and-a-half's drive from the hospital to Tumurbat's home, which is
in a semi-rural hillside area – though it is still part of the
Ulaanbaatar capital city region. (The Ulaanbaatar region – treated as a
province in Mongolia – has a population of barely 1.4 million, but
covers an area nearly three times that of Greater London and five times
that of New York's five boroughs.)
Tumurbat is being hit by surges of what is
called 'breakthrough pain', which burst through the 60 mg/day of
morphine he has been prescribed. Two weeks earlier, I am told, he had
come home from hospital in a stable condition, his pain under control.
The oncologists said the best place for him was here with his family.
The local clinic would provide outpatient support, including his weekly
prescription of morphine tablets – all covered by Mongolia's national
health insurance scheme.
But Tumurbat's condition has worsened in
recent days and, as Odontuya and Solongo learn more, it is clear he and
his family have not been sure how to react. Enkhjargal has not bought an
additional drug, dexamethasone, that had been prescribed to reduce the
inflammation around her husband's liver and thereby temper the pain.
And crucially, Tumurbat was not aware that
he could take additional, so-called PRN doses (from the Latin pro re
nata, meaning 'as the circumstance arises') of morphine beyond his daily
prescription to deal with the surges of breakthrough pain. If he were
to go beyond four PRN doses in 24 hours, then his prescription would be
recalculated and updated.
On this visit, Odontuya – the more senior
doctor – acts as a trouble shooter, explaining how to respond to the
pain surges, gently soothing both Enkhjargal and her husband, and
providing an impromptu class in spiritual care, advising her how to
prepare for his impending death. Enkhjargal is distraught as the two
doctors make to leave. Outside she breaks into sobs and buries herself
in Odontuya's shoulder. It is a moment some doctors would struggle with,
but Odontuya lets her cry before gently pulling back, and then, holding
her arms, urges Enkhjargal to prepare for the end.
The doctor's most direct advice concerns
Enkhjargal's son Dorj, who was due to start his military service the
following week. The family has to talk to the relevant authorities to
delay his enlistment, Odontuya tells them. "It is so important that he
is there when his father dies," she tells me as we drive back, "to avoid
complicating his grief."
Odontuya is more than just a conscientious
doctor – she's also largely responsible for Mongolia's rapid progress
in palliative care. Spurred by her own father's traumatic death from
cancer, she's made it her life's work to campaign for better treatment
for people with incurable illnesses. And it's working.
The treatment Tumurbat and his family are
receiving is a long way from what Odontuya was taught when she trained
to be a doctor in the late 1970s. Growing up in Mongolia's socialist
years, when the country was a satellite state of the Soviet Union, she
studied in what was then Leningrad. She speaks fluent Russian. It was
excellent tuition, she says, "but we were told simply to treat patients,
not to treat them as people. There was no compassion."
The way her father died changed her
outlook forever. He was diagnosed with lung cancer the same year she
began her studies in Russia, and in Mongolia's health system at the time
he was effectively condemned to a painful death. Not only did
palliative care not exist, but it was impossible to get hold of morphine
or other opioid-based painkillers.
Less than a decade later, her
mother-in-law was struck down by liver cancer, and Odontuya says she too
died in extreme distress. What she calls the "psychological pain" of
witnessing a loved one in such a state affected everyone in her family,
she says.
It was a trauma that many more families
have gone through since, because of a steady increase in cancers
nationwide over the past two decades, especially liver cancer. The
underlying cause was Mongolia's already high incidence of hepatitis –
dubbed a "silent" hepatitis epidemic by the World Health Organization –
which was exacerbated by frequent needle sharing in the poorly resourced
socialist healthcare system.
Government policies made things worse,
according to Odontuya and other doctors I speak to, by handing out free
vodka. In the economic turmoil that followed Mongolia's independence
(after the collapse of the Soviet Union in 1991), the authorities were
forced to introduce food rationing. But one thing they had plenty of was
vodka, and they added it to every ration. "Each family got two bottles a
week," says Odontuya, shaking her head. "It was a very stupid policy."
Mongolia was already a country of heavy
drinkers, and alcoholism became even more common in those early years of
independence. Precisely how much impact this had is hard to determine,
but with already high rates of hepatitis infection, Mongolian doctors
believe the increase in drinking contributed to the rise in liver
cancer.
But it was this same cancer crisis that
helped make the case for developing palliative care in Mongolia.
Odontuya started lobbying for the introduction of palliative care in
earnest from 2000 onwards. But first she had to come up with the right
words. "[In Mongolia] we didn't have any terminology for palliative
care," she tells me as she gives me a tour of the country's first
palliative care ward, established in 2004 at Mongolia's National Cancer
Center. Pointing out the sign on the door, she laughs: "If you pronounce
it wrong, it can sound like our word for 'castration'."
But even with the words fixed, the initial
reaction from officials was scorn, she says, as they dismissed
palliative care as an "activity for charities". "They asked how they
could justify spending money on 'dying' patients, when we don't have
enough money for 'living' patients." She answered with her own question:
"Would you say this to your own mother, if she gets cancer or some
other incurable condition? And I told them, these are still 'living'
patients." Even at the end of life, she says, people have human rights.
None of the former health officials I
contacted responded. That Odontuya encountered resistance is hardly
unique. Palliative care advocates elsewhere have also faced scepticism
regarding its value – as much from medical professionals as from
bureaucrats. For instance, one US study reported oncologists being
reluctant to refer patients for palliative care because it "will mean
the end of cancer treatment and a loss of patients' hope".
And for many doctors, palliative care
chafes against their default philosophy. As Simon Chapman, Director of
Policy and External Affairs for the National Council for Palliative
Care, a UK-based umbrella charity for people involved in palliative and
end-of-life care, puts it: "There is still a view among many clinicians
that [a patient] dying is a professional failure."
Today, Mongolia still has the highest
incidence of liver cancer in the world. Many people are diagnosed late,
when the disease is advanced and doctors can do little to stop it
spreading.
The Songino Khairkhan district hospital on
the west side of Ulaanbaatar has a solidly Soviet feel. Built in
Mongolia's socialist period, its walls are so thick they look like they
would stop a tank. And the signs around the building add to the
atmosphere, written in the Cyrillic script the Russians bequeathed the
Mongolians.
Behind the locked door of the hospital's
main dispensary for morphine and other opioid painkillers, I am firmly
back in the present. There is an air of efficient calm as two staff
members work at computers, updating the database on recent
prescriptions, while their boss Dr Khandsuren Gongchigav gives me a
short tour of their workspace. The security is necessary to meet local
and international laws aimed at combating drug abuse, and here they
distribute only opioids. There is another pharmacy in the hospital for
everything else.
Against one wall is a bulky metal security
cabinet, its shelves filled with neat stacks of boxes of tablets. Some
contain morphine, the strongest of the opioid family of drugs. It's used
for severe pain, including breakthrough cancer pain, because of its
fast and powerful effects. There are other stacks – of tramadol, a less
potent opioid for what specialists call moderate to severe pain.
There is a lot more to palliative care
than pain relief, but experts agree you can't have a successful
palliative care programme without it. That means having an effective
system for distributing opioids, which both meets patients' needs and
satisfies concerns about addiction and abuse. Reforming Mongolia's
approach to morphine was an early priority of Odontuya's campaign.
Before the government agreed to reforms in
the early 2000s, the rules were highly restrictive and
counterproductive. Only oncologists were allowed to prescribe opioids
and at a maximum of 10 tablets per patient – enough for just two or
three days in most cases. As a result, people with cancer often died of
"pain shock" when their dose ran out, says Odontuya, leading to a
widespread myth that the drugs were killing people. Making morphine more
readily available has helped educate patients and doctors about its
benefits and reduced what she calls "morphine-phobia".
Opioid medications still require a special
form, as in most countries worldwide. But a much wider range of
professionals can now prescribe them, including oncologists and family
and palliative care doctors. This has led to a 14-fold increase in their
use in the country from 2000 to 2014, according to Mongolian health
ministry figures. Khandsuren is an oncologist by training, and now
oversees opioid prescriptions for all the hospital's outpatients. The
majority are still people with cancer, but non-cancer patients have
become more common.
Every district hospital in the country now
has a pharmacy like this one, allowing patients to visit weekly and get
all the medication their doctor has prescribed. Nonetheless, in a
country so large and so sparsely populated, that still means long
journeys for patients in areas beyond Ulaanbaatar or other towns and
cities.
Beyond the store cupboard, Khandsuren
shows me into a room where they keep garbage sacks filled with empty
blister packs. Patients have to hand over the used strips before they
can get their next dose. "We do everything here according to guidelines
from the United Nations," says Khandsuren, referring to rules drawn up
by its specialist drugs control agency, the International Narcotics
Control Board (INCB).
Mongolia's achievements have turned it
into an example for many middle-income countries struggling with similar
health problems but which, for a variety of reasons, maintain much
stricter rules on opioid use. Doctors from former socialist states in
particular have been coming to Mongolia to learn from its experience,
their mutual past ties to Russia giving them a common language and
training background.
The National Cancer Center recently hosted
some doctors from Kyrgyzstan, one of the former Soviet states of
Central Asia. They remarked on how "peaceful" the palliative care
department was, says Dr Munguntsetseg Lamjav, one of the centre's senior
staff. In Kyrgyzstan, she was told, it's much harder to prescribe
morphine and patients are always crying in pain.
One of the most striking contrasts with
Mongolia is its giant neighbour Russia. So tight are the rules there on
prescribing morphine and other opioids, I learn, that consumption has
actually declined in recent years, according to INCB figures.
There is also a tendency among Russian
doctors, many still influenced by their Soviet-era training, to see pain
as a problem to be endured rather than treated. It is hardly surprising
then that palliative care there remains very limited. But one result is
frequent horror stories of people with cancer or chronic pain dying by
suicide because it is so hard to get effective medication.
In fact, many governments around the world
remain nervous about making morphine more available – and with good
reason. Take a look at the USA, which has an endemic problem with abuse
and addiction to legally prescribed opioid painkillers. But there are
far more Americans suffering chronic pain (at least 30 per cent of the
population according to one study) than there are drug addicts. It is
all about balancing priorities, Odontuya argues. And so far at least,
Mongolia's controls seem to have worked well – its health ministry says
there are few reports of people abusing opioid drugs. You hear far more
concern about alcohol abuse.
§
You don't have to spend long with Odontuya
Davaasuren to realise that she's not someone who gives up easily. I
have rarely met someone as committed to a cause – except perhaps in a
warzone. And there is an element of underground insurgency to her
campaign, which she has pursued while also holding down a full-time
medical teaching job, working as a doctor and juggling family
responsibilities.
Her flip-top mobile phone rings
constantly, until she switches it off. Sometimes she sees patients in
her own home after work. "My husband has got used to me using our front
room for consultations," she says, smiling.
The advocacy and training organisation she
established, the Mongolian Palliative Care Society, turns out to be
little more than a few filing cabinets and certificates at the back of a
basement room in the clinic where she works as a family doctor. The
society is an umbrella group of charities and palliative care
specialists, including all the country's hospices. Odontuya is the glue
holding it all together. "Sometimes I get very tired," she tells me one
day. "But I don't think anyone else has the same heart for this."
It has been a quest of relentless
government lobbying, made more complicated by frequent political
upheavals. There have been nine different health ministers in the last
decade, and for each she says that they have had to go and "convince
them about palliative care".
It is in the cramped basement room that I
first meet Odontuya, on a day when she is using the space as a
classroom. She is a professor at the country's premier medical
institute, the Mongolian National University of Medical Sciences, and
her fourth-year students are here for a session on geriatrics. And she
is teaching in English, her third language after Mongolian and Russian.
I feel some pity for the students because
the class lasts over three hours, and it is well past the halfway point
before Odontuya remembers to give them a short break. Slackers at the
back, I note, have no escape. "Why don't you have any questions?" she
demands of a young man who thought he had managed to avoid her gaze. But
she is an excellent teacher, and by the end of the class I have learned
a lot about diagnosing elderly patients.
Her university work complements her
campaigning, because she has also set up a palliative medicine course
there. Hundreds of doctors and nurses have now been through the training
programme, according to Odontuya – helping to build a nationwide
network and reservoir of skills.
She has also built the foundations of a
similar international community through her own efforts to educate
herself in palliative care. It began in 2001, when she studied
palliative medicine in Poland, which was ahead of Mongolia in developing
its own hospice network. Today, she is increasingly in demand to
provide her own palliative care training, particularly in
Russian-speaking former Soviet states. She has recently returned from
running a course for doctors in Kyrgyzstan.
For a country that had no palliative care
to speak of barely a decade ago, the change has been dramatic. All
Mongolia's 21 provincial hospitals as well as the nine district
hospitals in Ulaanbaatar have at least five palliative care beds, as
well as individual morphine dispensaries. There is also a network of
private and charity-run hospices that provide palliative care around the
capital city region. Even Ulaanbaatar's prison hospital has four beds
reserved for terminally ill patients. The national health service now
has to provide palliative care by law.
"It is the government that has made the
policy," Odontuya says. "All I have done is advocate." But I am not
surprised to hear from colleagues of hers that I speak to during my
visit that she has been dubbed the 'Mother of Palliative Care in
Mongolia'. At the country's Ministry of Health they agree. "We have
learned a lot from her," says the Director of Medical Services, Dr
Amarjargal Yadam.
"In the past, many hospitals turned people
away because they were incurable," Yadam says, speaking for the
minister, who was away during my visit. "We still need to make a lot of
reforms," she adds, "but we are listening to the people." Health is now
such a priority, she says, that it is ring-fenced from likely future
budget cuts forced by a recent economic downturn.
As Odontuya's students grab their books
and rush gratefully out of the tiny classroom, she switches back into
her role as evangelist, showing me the many training manuals from
Western medical institutes and international health bodies that she has
had translated into Mongolian.
And at a time when she was already a
grandmother, that meant learning English from scratch – not just to
understand the texts, but also to apply for grants to get them printed.
She remembers getting the first email from one of her funders, the Open
Society Foundations, and then spending the next day going through it
with her English-to-Mongolian dictionary. "There was no Google Translate
then," she says. "This is how I learned English."
§
"I have less pain now" says Batzandan, a
57-year-old film and stage actor with advanced cancer. "But I know I am
not getting better." We are talking at his bedside in the palliative
care ward of Mongolia's National Cancer Center. In the past, he may not
have been given the whole picture, but Munguntsetseg, the senior doctor
on duty, says Batzandan has been told to prepare for the end. "Our
policy now is to give patients the full diagnosis," she says.
But 'breaking bad news', as it is often
called, is one of the hardest tasks for any doctor – even more so in a
country like Mongolia, where any mention of death has long been a taboo
subject. There are also particular beliefs about dying on certain days
of the week, I learn. "Tuesdays and Saturdays are bad luck," Odontuya
says, "so if someone is close to death on those days, families put a lot
of pressure on doctors to make sure they die the next day."
As much as possible, they try to work
within local traditions and beliefs, not against them, using them to
their advantage to put a local face on palliative care. Odontuya often
uses a Mongolian proverb in her conversations with patients who are
close to the end. It is hard to translate directly, but in essence it
speaks of the inevitability of death, and she says it helps "patients to
accept the real situation, accept a poor prognosis easily, because it
is true that everyone will die someday".
Traditions from Buddhism – the country's
dominant faith – have also been a help. When someone dies, a lama, or
priest, reads from special scriptures, which is known as "the opening of
the Golden Box". The priest can also tell if this person had lived
longer or shorter than God intended, explains Odontuya, and "sometimes
the lama says [living longer] is because of good medical treatment".
Back on the palliative care ward,
Munguntsetseg says she has seen attitudes to death change since the ward
was established. "More patients write a will now," she says. "They
would never have done that in the past because it would be seen as a bad
omen."
The hospital also offers patients what the
doctor calls a "reputation treatment service", encouraging them to tell
their life story before they pass away. It began as a way of dealing
with patients suffering severe depression, she says, but then they found
that other people wanted to tell their stories, to set the record
straight. "We had a patient recently who asked his ex-wife to visit, so
he could apologise for his past behaviour, and he gave her money too."
Some palliative care patients have
responded by drawing up 'bucket lists'. During my visit, I met a woman
with terminal cancer who had recently returned from a visit to Lake
Baikal (the world's deepest lake) in Siberia, just the other side of
Mongolia's border with Russia. With her week's prescription of morphine
tablets, she had been able to make a journey that had been "a lifetime
ambition".
Before she studied palliative care,
Odontuya says she was a "very closed, quiet person", adding that if
anyone had mentioned spirituality in the past, "I would have thought it
was religion". But a visit to a Polish hospice sparked a "revolution in
[her] brain". Then she understood that palliative care is total care,
she says, something that covers "all physical, psychological, spiritual
and social pain".
The idea of palliative care being holistic
can be traced back to Cicely Saunders, the British nurse and doctor who
established the first hospice in the UK in the 1960s. She came up with
the concept of 'total pain', arguing that it was as important to address
the mental, emotional, spiritual and social aspects of patients'
suffering as it was to treat their physical symptoms.
Odontuya worries that spiritual matters
could still be sidelined by the modernising pull of more clinical
approaches. "The Ministry of Health and our university do not understand
what spirituality, spiritual pain and spiritual care mean," she says.
Still, Saunders's focus on the spiritual side has been an inspiration
for Odontuya.
"She lived in modern society, but she
thought like a postmodern person," Odontuya says. Saunders was also a
charismatic campaigner, and Odontuya seems to be taking on her mantle –
you can already see the impact she has had in Mongolia. But she modestly
ducks the comparison, saying: "I am just her little finger."
It is a bright, freezing day in the
Mongolian capital. Shards of winter sun reflect off of the nearby crop
of glass towers, which sprung up in the city centre during the country's
recent minerals boom.
A small crowd is heading towards a giant
statue of Genghis Khan on the far side of a square that is named after
him. Some people carry placards in Mongolian exhorting the virtues of
palliative care, hunching into their coats as the wind stiffens. These
doctors, nurses and hospice staff, as well as their friends and family,
have come from across the country to hold a rally to raise awareness,
part of World Hospice and Palliative Care Day.
In the midst of the crowd is Odontuya,
alternating between greeting friends and making phone calls to check the
journalists she has invited are on their way. "Always I am doing
advocacy, advocacy," she says.
I wouldn't associate Genghis Khan with
palliative care, I think to myself, as I follow them towards the statue
of Mongolia's famously pitiless founding father. But time is a great
cleanser of reputations, and now the man Mongolians call Chinggis Khaan
is everywhere – even the main airport is named after him. And his is the
square in Mongolia you choose if you want your gathering to have
maximum impact.
The municipality had turned down her
request for a rally, Odontuya says, apparently claiming it was closed
for an event. She decided to show up anyway. Apart from a wedding party
posing for a photographer, there is no sign of anything else going on.
As they approach the statue, a guard sees the placards and TV crew
waiting nearby, and holds up a uniformed arm to halt the impromptu
collective. "This is not allowed," he barks.
Odontuya and two colleagues persuade him
to compromise. Workers from each hospice take it in turns to line up
beneath the statues, laughing and chatting as they hold up their
placards for the cameras. Genghis glowers from above.
Photos done, it's time to head off for a
picnic in the hills. We drive up through one of the new suburbs creeping
up the hills around Ulaanbaatar, past unfinished developments with
names like English Garden and Forbes Mongolia.
The mood is very happy. The care workers
laugh at the pretentious names. They laugh at everything. The jokes
continue as they unload picnic baskets from the cars and carry on up the
hill, past a park filled with concrete gers for tourists.
After lunch, there is music, dancing and
games – and then an awards ceremony, with Odontuya handing out prizes
for the best hospice and palliative care workers of the year. And then
there is a prize and a cake for her too. "We love her," says one young
hospice worker, nodding her head towards Odontuya behind us.
Another hospice worker brings out his
guitar and starts up a group song. Odontuya peels away to do a couple of
television interviews. That evening all of Mongolia's main TV channels
run a story about palliative care.
Odontuya says that they get together like
this every year because the hospices are spread so widely across
Ulaanbaatar she may not see some staff for months. "I remember going to
visit hospices in China and Singapore," she says. "They have far more
resources than us, but they don't have this atmosphere. We are poor by
comparison, but we love each other. We are a family."
It is, I realise, a theme that permeates
all that Odontuya does. From the personal experiences that put her on
the path to becoming Mongolia's 'Mother of Palliative Care', to the way
she practises it, 'family', in every sense of the word, is a guiding
spirit.
After I return from Mongolia, I ask
my translator to call Tumurbat Dashkhuu's family and find out what had
happened. He died at home a few weeks after my visit, in his ger, with
his family around him. And, after following Odontuya's advice to
postpone his military service, his son Dorj was there too.
This article was first published by Wellcome on Mosaic and is republished here under a Creative Commons license.
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