Interview with B Tsogtbaatar: Public Health and COVID-Response

By Julian Dierkes

Dr. TSOGTBAAYAR Byambaa earned his PhD from the Faculty of Health Sciences of Simon Fraser University in Vancouver in 2014. He received his MSc in Health Administration and International Health Policy from the University of Colorado in 2005. Tsogtbaatar is a family physician by background (HSUM, 2002) and public health professional/researcher by training who has worked for various health institutions at senior level positions such as lecturer at the National Medical University of Mongolia, officer at the GFATM supported HIV/AIDS projects, Director general at the National Center for Public Health as well as the Director general of Department of Public administration and Management of the Mongolian Ministry of Health. He has also worked as Project Coordinator for the CIHR funded Equity-Focused Health Impact Assessment Tools and Methodologies project. He was elected to the Executive Board of International Association of National Public Health Institutes (IANPHI) in 2017, representing Asia. Dr. Tsogtbaatar is now Senior Advisor for health at the UNICEF, Mongolia. He has previously written for this blog.

Q: You finished your PhD at Simon Fraser Univ in 2014, completing research about the utility of Health Impact Assessments in the Mongolian mining industry. What’s the current status of HIAs?

Although mining activities (except for coal export) in the economy and foreign direct investment has been declining for the past few years, the mining industry remains an important part of Mongolian economy. As for HIA, it still has not been converted well into practice due to relatively low number of foreign-invested mining operations. According to the 2012 Environmental Impact Assessment Law, HIA is required only for cumulative and strategic impact assessment. This needs to be expanded. Unless HIA is strictly mandated by law, local companies take it as just an unnecessary requirement. I am sure we are nearing another boom in the mining industry. When that happens, there is still unmet need for well-trained HIA practitioners in the country.

Q: Since completing the dissertation, you’ve been working in Mongolian public health before now taking on a role as Senior Health Advisor with UNICEF in Mongolia. What role(s) have you played in the meantime?

In line with my training abroad, my contribution in Mongolia focused on strengthening the public health system and informed decision-making practices. When I served in the role of DG at the Public Health Institute, both generating more evidence and applying that knowledge to diseases prevention practices were my main priorities. Eventually, PHI was transformed into the National Center for Public Health. My time and effort at the Ministry of Health was largely dedicated to improving post graduate training curricula, improving the salaries of health professionals, improving MOH visibility at the international level and the nation’s COVID-19 fight.

Q: A number of observers have commented on Mongolia’s response to the COVID19 pandemic as fairly successful, highlighting the lack of community transmission. Would you agree that the response has been successful overall?

So far so good. Timely public health interventions, including suspension of all classes as early as Jan 24th, swiftly shifting into regular news reporting by MOH, closing international borders exclusively, cancelling lunar new year celebrations, urging the public to wear mask at all times and cleaning hands, have helped to be where we are at today. However, we should always remind each other that we are one careless move away by a citizen or one sub-standard action away by a civil servant. That is what it will take to go from imported-cases-only status to local transmission.

Q: Thinking back to January/February, can you recall the context in which you heard about COVID19 for the first time?

First it came up during a weekly meeting at the ministry of health. Not many people knew about it or seemed to be interested. A couple of weeks later, the people who were supposed to inform the minister did just that. The minister asked for an urgent meeting of the State Emergency Commission and we held the first ever press conference at the MOH. This was on Jan 23rd of 2020.

Q: What does the Mongolian “warning system” for infectious diseases look like in non-pandemic times?

We had a decent warning system that calls for timely action and multisectoral collaboration when there is a public health emergency, coordinated by the deputy prime minister’s Regulation 8. Obviously, there were a number of flaws or gray areas that needed to be sorted out. The Mongolian parliament approved a “temporary” law back in April to mitigate against socio-economic impacts of COVID-19. Experts from all relevant sectors were included in the sub-working group that I was part of.

Q: Were there many alternative reactions in February or was it easy to convince decision-makers of need for the closing of borders/caution with Tsagaan Sar celebrations, etc.

Both, the public and decision-makers had a similar level of information and perception as COVID unfolded, rapidly. The classic public health approach of “expect the worst-case scenario” was in play and the government treated the evolving situation seriously, valuing health experts advice. Strong leadership and timely policy recommendations by the health sector were a key factor.

Q: Some observers have pointed to state socialist hygiene campaigns and relatively regular quarantining for diseases in animals as factors in high compliance with public health measures in Mongolian in the Spring. Important factors?

The so-called socialist hygiene approach is somewhat lost in the context of the current public health concept in the country. Yet, one cannot deny the impact of such roots in compliance with public health interventions. However, many contributing factors could have contributed, for example, previous experience of dealing with frequent seasonal flu epidemyic, hosting a WHO-supported “Pandemic Flu Readiness” workshop in 2019, having a relatively strong surveillance and lab system, the current speed of information sharing at the global level, the relatively small, manageable size of the population, role and pressure of social media and the leadership. Some people even jokingly linked the traditional high solidarity and adaptability of Mongolians during wartime situations.

Q: At UBC there has been some discussion of the Global Health Security Index in light of what we’ve observed with COVID response around the world. Any comments on how the index captures the Mongolian situation? For example, the index points to Mongolia’s strong ability to detect, but greater challenges to respond. Has this been a factor in COVID-response?

Although, I would not call the GHSI a flawless tool, this is the first comprehensive assessment of global health security capabilities in 195 countries. In the 2019 ranking, Mongolia was ranked relatively high at 46 out of 195 countries in the “more prepared” category. We were highly valued for detection capacity (20th) whereas response capacity was somewhere in the middle (90th) of the crowd. I would say, in reflecting on this ranking, numbers speak for themselves. As of Oct 9th of 2020, there are 315 registered cases (all imported), no fatality and no community transmission in Mongolia. We were ranked at 3rd among all LMICs.

Q: We tend to think that the policy response in Canada has been very strong, in particular in BC where there has been an emphasis on appealing to people’s solidarity rather than draconian measures. Have you/have Mongolian policy-makers been watching other jurisdictions at all?

Solely to speak to our own case, we have looked at WHO’s international health regulation and other countries’ experiences regarding the limiting international travel. For instance, the travel advisory system with 4 levels by USA was studied. In general, more emphasis was given to studying previous historic pandemic events and lessons learnt.

Q: Even for those of us in higher education administration, it was a spring of near-constant crisis management. I can only imagine that this was even more the case for decision-makers like yourself in public health. What have we learnt from this, so far?

Yes, we must admit that NO ONE was and still is ready for an event of such big magnitude. At times there were feelings of “wearing out” by working long hours repeatedly. So personal time management seemed to be crucial in the absence of a system that protects overall performance and wellbeing of civil servants. There should be contingency plans. Although we started talking about leading the “new normalcy” in our lives, we still do not know what that really means. I guess countries have bought some time for themselves to cope with such situations at different expenses. At least, now we know that we do not know many things and how commanding public health is.

About Julian Dierkes

Julian Dierkes is a sociologist by training (PhD Princeton Univ) and a Mongolist by choice and passion since around 2005. He teaches in the Master of Public Policy and Global Affairs at the University of British Columbia in Vancouver, Canada. He tweets @jdierkes
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