Source: The Lancet                         Date: 06 April, 2011

High rates of hepatitis C and B infection along with widespread alcohol use have left Mongolia with a burden of liver cancer that it is ill-equipped to handle. Mongolia has the world's highest rate of liver cancer mortality—six times the global average—and the number is increasing. By the time most Mongolians with hepatocellular carcinoma (HCC) are diagnosed, their disease is already inoperable.

According to WHO, one of every ten deaths in the country is due to HCC or its frequent precursor, cirrhosis. In turn, nearly all Mongolians with liver disease are carriers of hepatitis B or C viruses or both, and researchers agree that those infections are the main causes of liver disease in the country. More than a quarter of Mongolians are chronic carriers of at least one of the viruses, and almost none are aware of their status.

Asia has historically been burdened with a high prevalence of hepatitis B, so Mongolia is not an outlier in this respect. A national childhood vaccination campaign, initiated in 1991, has protected younger cohorts and holds the promise of eliminating the virus in the country's next generation. But what distinguishes Mongolia from the rest of Asia is the additional burden of hepatitis C, for which no vaccine currently exists. Although unsafe surgical procedures and dental practices are thought to play a part, much remains unclear about the origins of the virus in the country and the mechanisms of its continuing transmission. Alcohol use, which hastens progression to cirrhosis for those with concurrent viral infection, is also widespread in Mongolia, compounding the epidemic.

The global health community has given little attention to liver disease relative to other public health issues, and Mongolia's experience is no exception. “The utmost priority is given to HIV, TB, and infectious diseases such as avian influenza”, commented an officer in the ministry of health's division of international cooperation. “Viral hepatitis and liver disease are very much less targeted.”

Still poor by global standards, Mongolia is thus in the challenging position of dealing with a heavy burden of non-communicable disease that is more typical of the developed world, and which demands a rich country's resources and functioning health system. The Mongolian Government is making organizational and strategic changes to improve the early detection and control of non-communicable diseases, including liver disease, at the primary health-care level, according to a senior office, but such changes will be a challenge, and the extensiveness of the Mongolian countryside is daunting.

Even if diagnostics improve, it is not clear what treatments will be readily available. Neither antiviral treatment for hepatitis B nor interferon-based therapy for hepatitis C is presently covered by the national health system, and their high price puts them well out of the reach of most Mongolians. Even for services that the public system covers, much of the financial burden ultimately falls on patients.

By necessity, then, Mongolia has turned to palliative care as a final but valuable service for its terminal cancer patients, and with noteworthy success. But this is not yet widely available outside the capital, so patients often travel great distances for treatment. For the foreseeable future, dying in a peaceful place and free of pain might be the most that Mongolian patients with HCC can hope for.