As the furthest east of what are collectively called the Central Asian states, Mongolia has recently emerged from being a satellite state of the former USSR. Rich in mineral resources, the total land area is bigger than the combined territory of Britain, France, Germany and Italy. The relatively tiny population of only 2.5 million live mostly in the capital of UlaanBaatar (1.2 million) and in a few scattered small cities and isolated villages.

Life in rural Mongolia had begun to change under soviet guidance, with cultivation and industry encouraged across the country, but this abruptly declined after democratic reform in 1990. Today many rural people still live a traditional life based around their felt tents (or "Gers") and their flocks of sheep, goats, camels, cattle, Yak and of course the sturdy Mongolian horse. In fact, during the short summer, the urban centres appear empty when many people go to stay with relatives or in old home areas and reconnect with the old life in the steppe.

In the race to westernize and like many transition countries, Mongolia faces great challenges. One of these is meeting the health needs of its population. The Governments' efforts are hindered by: the country's geography and severe climate; the widely dispersed population; lack of infrastructure with little access to safe water and sanitation, electricity, communications, and other modern amenities. Growing health concerns now include tuberculosis, sexually transmitted infections and brucellosis. Cancers, cardiovascular disease, excessive alcohol consumption and other external causes associated with lifestyle changes are also important causes of morbidity and mortality.

With a view to assess what support was needed, Medecins Du Monde (MDM) initiated an exploratory mission in mid 2004. As a result of demand from health authorities, local politicians, and evidence on the ground, MDM launched a programme in Mongolia on 1 October 2005. Our main objective focuses on alcohol misuse and is to contribute to improving the process of managing patients and the information and awareness raising activities for health professionals and the public.

The issue of alcohol misuse has various cited origins, ranging from the unrestricted import of Russian Vodka in the early 1920 to the decline of soviet rationing in the 1990s. However, even the great Mongolian hero Ghengis Khan declared that he refused to allow entry to his home of anyone who was drunk and would not enter others homes if their occupants were drunk. He even had a law that stated if a man came to work drunk, the first time he would have his weapons confiscated, the second time his horse would be taken, the third he would lose an arm and on the fourth occasion he would be banished from the land.

While today's situation is a product of national and international history, it is now out of control, with over 13.6% (22% men and 5% women, WHO study 2006) of the total population dependent upon alcohol and up to 40% practicing harmful drinking. According to the UN Development Programme, 27,5% of mortality was attributed to alcohol in 2001, and it was also the 4th most significant problem facing the population. This is evident wherever you go in Mongolia, not just in the visible drunks passed out on the street, or the stories in every family of a relative, a brother or father who has succumbed to the disease of alcohol addiction. In another recent study by the Director of the National Centre for Mental Health, (L. Erdenebayer), he stated that: Alcohol-related traffic accidents were more than 1/3, 79% of people misusing alcohol had at least secondary school level education, over 80% of those in prison are there for a problem associated with alcohol and 60% of domestic violence is carried out by drunk persons.

Our programme in Mongolia tries to place the patients needs at the centre. We try to introduce new approaches and practices that could reinforce behavioural changes both for the health practitioners and the patients and to share information and raise awareness to eliminate the stigma attached to the disease of alcohol addiction.

Our main activities to date have included formal training for local health professionals with international experts and on-the-job training inside government medical and judicial organizations. Our programme introduced the techniques of Cognitive Behavioural Therapy, and Motivational Interview and our medical team has worked hard to establish a patients needs based focus to inpatients treatment and to develop the diversity of opportunity for follow-up support in the community. We have initiated horizontal communication between professionals through a monthly partners meeting and by accompanying partners to other structures so that they can share their experiences and understand mutual constraints. Our work is fully reported and we attempt to influence decisions within the structures where we work and also at the National level. Our information and awareness raising activities also now start to bear fruit, with the publication and distribution of leaflets and posters that we have developed with our partners.

In parallel, the programme transfers new techniques to wider related stakeholders in order that the lessons learnt in the pilot area may also be readily applied in other parts of the country. For example by providing training for Aimag (county) based doctors and sharing tools and materials to other structures requesting support, such as government centres.

In the immediate future, we expect to see the follow-up to some of the work we and others have started. We will consolidate the initial phase of the project, reinforcing the exchange of practice through both formal training courses and on-the-job support to those involved in alcohol misuse management. We will demonstrate the lessons learnt, particularly in one part of one District of UlaanBaatar. We hope to see the health professionals applying new ideas and international standards in screening, referral, treatment and follow-up. We hope that local groups and initiatives will ensure an increasing range of opportunities for patients and stakeholders to find support and information appropriate to them on the disease.

In the medium term we hope that all of the above will lead to decreasing levels of alcohol misuse and a high level of awareness on the dangers of misusing alcohol. We hope to participate in changing the attitude of the decision makers and practitioners, ultimately having a direct impact on the incidence new cases of alcohol misuse and better treatment of those suffering from alcohol dependence.

In the long term we would then expect to see a decrease in alcohol related deaths and a reduction in the cost to society related to the consequences of alcohol misuse.

This programme represents a rare opportunity to have a direct impact on a medical issue that affects almost all families across the country and can be seen as a catalyst to other medical and social problems. The full extent of associated problems such as the impact on the economy are still unclear, but if the experience and research in other parts of the world is an indication of its potential consequences, we must act now.

As should be evident from the above, there is still a great deal of work to be done and it is obvious that this will take time. We therefore hope that during the coming months we can identify funding and further support for these activities. At present, our small capable team has made a great deal of progress, but there is a need for their reinforcement and an increase in delivery resources for materials, prevention and training activities (both formal and informal).

If you would like further information on the programme, our activities or our partners, or have ideas or materials that we might find useful, please don't hesitate to contact us via mdmmongolie@hotmail.com.