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The impact of social and economic transition on Mongolian elderly

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The impact of social and economic transition on Mongolian elderly
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Janchiv, Khulan
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English
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xi, 174 leaves : ; 28 cm

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Subjects / Keywords:
Older people -- Social conditions -- Mongolia ( lcsh )
Older people -- Economic conditions -- Mongolia ( lcsh )
Older people -- Government policy -- Mongolia ( lcsh )
Economic policy ( fast )
Older people -- Economic conditions ( fast )
Older people -- Government policy ( fast )
Older people -- Social conditions ( fast )
Social policy ( fast )
Social policy -- Mongolia ( lcsh )
Economic policy -- Mongolia ( lcsh )
Mongolia ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 169-174).
General Note:
Department of Anthropology
Statement of Responsibility:
by Khulan Janchiv.

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University of Colorado Denver
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Auraria Library
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ocm57507510
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Full Text
THE IMPACT OF SOCIAL AND ECONOMIC TRANSITION ON MONGOLIAN
ELDERLY
by
Janchiv Khulan
B.S., Mongolian Medical University, 1989
M.S., Mongolian Medical University, 1998
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Anthropology
2003


This thesis for the Master of Arts
degree by
Janchiv Khulan
has been approved
by
t Z / -oh
Date


Khulan, Janchiv (M.A., Anthropology)
The Impact of Social and Economic Transition on Mongolian Elderly
Thesis directed by Professor Craig R. Janes
ABSTRACT
In the early 1990s, Mongolia chose a new path of development. Mongolia
changed from the communist centrally planned economy to an open democratic
political system and a free market economy. Many reforms have been implemented,
including privatization of state owned enterprises, private livestock ownership, the
deregulation of price control, decentralization of political and economic systems,
increase of foreign relationships, and acceptance of foreign aid programs. These
socioeconomic changes brought poverty, inequality and unemployment. Alcoholism,
crime, social and economic stress, and poverty related diseases including
tuberculosis, malnutrition, STDs and AIDS have increased markedly. This transition
has had profoundly negative effects on the quality of life of Mongolians, particularly
the elderly.
The purpose of this study was to determine how the economic transition that
occurred in 1990s in Mongolia has affected the elderly. This research is the first study
of its kind that has sought to describe how the economic transition has affected
Mongolian elderly. This study examined elderlys opinions about the socioeconomic
changes and problems faced by the elderly. In addition, it provides a comparative
study of the experiences of urban and rural elderly. Analysis of the survey suggests
that the economic transition has had a negative impact on Mongolian elderly, and that
there are significant differences between urban and rural residents, and between men
and women, in their experiences of and responses to the economic transition.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
Signed
m
Craig R. Janes


DEDICATION
I dedicate this thesis to my dad Janchiv, 65 years old, and to my mom Geezav,
60 years old, who gave me opportunity to be educated and taught me the value of
hard work. I also wish to dedicate this study to my father-in-law, Khalzan, 82 years
old, and my mother-in-law, Tsend, 71 years old, who raised a wonderful and lovely
son, my husband, Jargalsaikhan. I also want to dedicate this thesis to the participants
who readily agreed to be a part of my study, and to all of the elderly around the
world, these honorable and exciting people from whom the younger generation has
the privilege to leam.


ACKNOWLEDGMENTS
I would like to express gratitude to all the members of my thesis committee. A
very special thanks and deep appreciation to my academic advisor, thesis committee
chairperson Dr. Craig Janes, for his invaluable advice and for all his assistance and
support in making this thesis. Grateful acknowledgment to Dr. Kitty Corbett and Dr.
Cindy Bryant for their patience, guidance and suggestions to the completion of this
thesis. My sincerest thanks to the staff of the Graduate School and to all other faculty
members of the Anthropology Department at the UCD for their warm understanding
and support during my academic study. This academic year was one of the most
important parts of my life with many memorable learning experiences. My thanks and
great appreciation to Dr. Ingrid Asmus, who spent considerable time assisting me
with the editing of this thesis. I am also deeply appreciative of the elderly people who
made this study possible.
Special thanks to my parents, brothers and sister for their continued love,
encouragement and support. Most of all I would like to acknowledge with many
thanks to my family the most special people for me: to my great husband,
Jargalsaikhan, to my wonderful children, son Ankhbayar and daughter Orkhon, who
never complained about my long hours of study and who have been a constant source
of love and support throughout my study. Without their support and encouragement
this study would not have been possible. Thank you very much to all of you!


CONTENTS
Tables.......................................................... x
CHAPTER
1. INTRODUCTION.................................................. 1
Goal of Study........................................... 1
Specific Aims........................................... 2
Significance of the Study............................... 2
Socio-economic Change and Globalization................. 3
. Population Aging...................................... 4
Aging in Asia.......................................... 8
Overview of the Study.................................. 10
2. AGING AND MODERNIZATION...................................... 12
Anthropology and Aging................................. 12
Demography and Demographic Transition.................. 15
Types of Aging.... .................................... 17
Biological Theories of Aging........................... 19
Psychological Theories of Aging........................ 23
Social Theories of Aging............................... 24
Social Change Theories................................. 27
vi


Effects on the Underdeveloped World..................... 29
Theories of the Effects of Social Change on the Elderly. 31
Effect of the Economic Transition on Asian Elderly...... 35
The Case of China....................................... 46
Conclusion.............................................. 50
3. THE MODERN HISTORY OF MONGOLIA................................. 54
Background.............................................. 54
Demography............................................... 54
Mongol Empire.......................................... 57
Independence............................................ 58
Socialism............................................... 60
Economic Systems..... ........................... 60
Social Systems.................................... 65
Mongolian Elderly................................. 66
Summary........................................... 67
Transition to Democracy..................................67
Current Political Structure....................... 68
Effects of the Economic Transition................ 70
Health System Reforms............................. 75
Social Welfare Services for the Elderly........... 83
Revival of Traditions............................. 87
vii


Summary.................................................... 88
4. METHODOLOGY....................................................... 91
Goal of Study.......................................... 91
Research Methods........................................... 92
Description of Interview Sample............................ 95
Data Analysis.............................................. 96
5. FINDINGS.......................................................... 97
Summary................................................... 101
Demographic and Socio-economic Characteristics
of Study Sample........................................... 102
Summary of Demographic and Socio-economic
Characteristics........................................... 108
Health Conditions of the Participants..................... 109
Elderly Opinions Concerning Health Services............... 119
Opinions and Issues about Family Doctor System............ 120
Participants Opinions and Their Concerning Issues
about Private Doctors..................................... 123
Elderly Opinions and Main Concerns about
Traditional Medicine...................................... 125
Elderly Opinions about the Economic Transition
and Their Concerns...................................... 129
Daily Activities...........................................136
Pension................................................... 137
viii


Discussion of Results
144
Limitations.......................................... 150
6. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS........... 151
Summary........................................ 151
Conclusions.................................... 152
Recommendations................................ 160
Future Research ............................... 161
APPENDIX
A. Human Subjects Research Committee at the
University of Colorado Denver Approval......... 163
B. Interview Questions............................ 164
GLOSSARY.................................................. 166
ABBREVIATIONS........................................... 168
BIBLIOGRAPHY.............................................. 169
IX


TABLES
Tables
1.1 World Population Aging 1950-2050....................................... 6
1.2 Population Aging 1950-2050 in Japan, China, and Mongolia.............. 9
3.1 Structure of the Mongolian Population, 1950-2050...................... 56
3.2 Private Health Care Institutions in Mongolia (2001).................... 80
5.1 Demographic Characteristic of Sample by Residence..................... 104
5.2 Demographic Characteristic of Sample by Sex........................... 105
5.3 Household Size and Number of Children by Residence.................... 107
5.4 Health Conditions by Residence and Sex................................ 109
5.5 Illness Symptoms by Residence......................................... 110
5.6 Illness Symptoms by Sex............................................... 112
5.7 Illness Symptoms by Age of Those Experiencing Symptoms................ 114
5.8 Hospitalization in Last Month by Residence and Sex.................... 115
5.9 Hospitalization in Last Year by Residence and Sex..................... 116
5.10 Issues Getting Care and Issues Care Regarding by Residence.......... 116
5.11 General Opinions about Family Doctors and
Private Doctors by Residence......................................... 120
5.12 Specific Opinions about Family Doctors and
Private Doctors by Residence.......................................... 121
5.13 General Opinions about Traditional
Medicine by Residence................................................ 126
5.14 Specific Opinions and Issues about
Traditional Medicine by Residence.................................... 126
5.15 General Opinions Given by the Effect
of the Economic Transition........................................... 130
x


5.16 Specific Opinions Given about the Effect of
the Economic Transition............................................ 133
5.17 Daily Activity and Residence.... ................................. 136
5.18 Age Began Pension and Residence................................... 138
5.19 Pension Amount by Residence....................................... 138
5.20 Pension Amount by Sex............................................. 139
5.21 Specific Opinions Given about the
Effects of the Economic Transition................................. 142
xi


CHAPTER 1
INTRODUCTION
Goal of Study
The main goal of this study is to describe how the social and economic
transition that occurred in the1990s in Mongolia affected the elderly. During the
summer of20021 carried out an ethnographic study designed to clarify Mongolian
elderlys perspectives on economic changes. For the purpose of this study I defined
elderly people as those who are no longer considered employable in Mongolian
society and are qualified to receive pensions from the government. This may be as
young as 50 years for women and 60 for men. In this survey I conducted interviews
with elderly and collected their opinions about the economic transition and how they
have been affected by this change, identified problems and needs faced by the
elderly, and compared urban and rural elderly.
Today, there have been just three previous studies of the economic and
living conditions of Mongolian elderly. None of these addressed the elderlys own
perspectives and opinions about the economic transition. The goal of this study was
thus, to ask opinions of the elderly regarding the socioeconomic transition and its
effects on their lives.
1


Specific Aims
The specific research questions: of this study are:
1. How did the sudden economic transition affect Mongolian elderly?
2. What did they think about the economic transition?
3. What differences exist between urban and rural elderly in terms of their
education, living conditions, daily activities, and the issue of getting
health care and a pension?
4. Do they have any particular problems, and if so, how do the elderly
respond to these problems? What sources of assistance are available to
them? What kind of issues and concerns do they have?
Significance of the Study
The findings of this study will contribute to better understanding of the needs
of the aged in Mongolia, with the goal of helping to improve their quality of life.
Because many ethnographic studies of socio-economic changes in China have
shown positive effects on the quality of life for the elderly, and because Chinas
political and economic background is similar to that of Mongolia, this thesis will use
data from China for comparative purposes. The intention is to discover public policy
guidelines that may benefit the aged in Mongolia.
2


Socio-economic Change and Globalization
Rapid socioeconomic changes associated with globalization are occurring
throughout the world, including Asia. Globalization refers to the democratization of
capital, technology, and information across national borders to create a global market,
which is integrated with international political and economic systems. With the
commercialization and globalization of the world, dominant countries benefited by
accumulating capital and speeding economic growth. In contrast, peripheral countries
have become poorer and more dependent on others. By the mid 1990s almost all
countries in Asia, South America, and Africa were integrated into a world market
economy led by the US. Andre Gunder Frank (1996) wrote that the capitalist world
economy is committed to production for sale of exchange; its goal is to make more
profit. While different countries have distinctive political organizations and economic
patterns, today these societies are related to each other by unequal exchanges of
material and capital between the periphery and the core.
Economic development is assumed to lead to improved social development.
However, in reality economic development may increase the vulnerability of a
society and cause deterioration in the quality of peoples lives. These changes with
globalization have increased the dependence of developing countries on foreign
investments. Structural adjustment policies of the International Monetary Fund and
3


the World Bank have resulted in cutbacks on social spending and especially on the
services most needed by the elderly, such as health, education and housing (Polivka
et al., 2002). Due to increased debt, governments of developing countries have lost
their power at the international level. Privatization of public services in these
countries has negatively affected the most vulnerable groups. Reduced fertility, along
with urbanization and industrialization has led to changes in family structure and
family care giving roles. Economic development has also led to rural- to- urban
migration, which also weakens family ties and traditional support for the aged
(Lechner et al., 1999, Phillips 2000, Bengtson et al., 2000).
Population Aging
Aging is an inevitable and universal process for all humans. Yet, the
physiological processes of age are modified considerably by culture. One of the key
factors in cultural evolution is population growth. As human societies have
developed, population has grown, as has the complexity of social structure and scale
of economic activity. This development has also propelled a demographic transition
in many countries. Until the 20th century few individuals lived to advanced age.
Today, however, population aging and the increasing needs of the elderly have
become major issues worldwide.
Population aging is a process characterized by an increase in the proportion of
the elderly in a population. It is a result of the demographic transition from high
4


levels to low levels of fertility, and is associated with increases in life expectancy,
and reduced mortality.
Aging has become a critical and central issue on every level local, national,
and international. Bengston et al. (2000) wrote that:
On the global level, the main force behind these
changes relating to old age has been the process of
modernization- encompassing industrialization;
economic growth; urbanization; and their attendant
changes in value orientations, social norms,
institutional arrangements, and behavioral
patterns.. .While basically a demographic trend,
population aging is in fact a revolutionary force that is
affecting the social, culture, political and economic
conditions of life in whole societies (p.3).
In the 21st century, all countries will face population aging. Population aging
is both a cause and consequence of changes in economy and social structure. Today
according to the United Nations World Population Ageing 1950-2050 (2002), the
worlds population is at 6.1 billion and expected to increase to 9.3 billion by 2050.
Worldwide population aging trends are shown in Table 1.1. The United
Nations (2002) noted:
The number of older persons has tripled over the last 50
years; it will more than triple again over the next 50
years (p. 11)... By the year 2050, more than one in
every 5 persons throughout the world is projected to be
aged 60 or over, while nearly 1 in every 6 is projected
to be at least 65 years old (p. 12).
World Population Ageing 1950-2050 (UN 2002) stated that the main predictor
of population aging is a decline in the total fertility rate, measured as the average
5


Indicator V ore developed Less develo ped Least developed
195 0 2000 2050 1950 2000 2050 1950 2000 2050
Total pop. (million) 0.8 1.2 1.2 1.7 4.9 8.1 0.2 0.7 1.8
Pop. of age 60+ % 11.7 19.4 33.5 6.4 7.7 19.3 5.4 4.9 9.5
Pop. of age 65+ 7.9 14.3 26.8 3.9 5.1 14.0 3.3 3.1 6.3
Pop. of age 80+ 1.0 3.1 9.6 0,3 0.7 3.3 0.3 0.4 1.0
Pop. of age 0-14 27.3 18.3 15.5 37.6 32.8 21.8 41.1 43.1 29.1
Pop. of age 15-59 60.9 62.3 51.0 56.0 59.5 59.0 53.5 52.0 61.4
Aging index 42.9 106.2 215.3 17.2 23.4 88.6 13.2 11.3 32.5
Total. depend ratio 54.4 48.3 73.4 71.0 61.1 55.7 79.7 86.0 54.9
Old age dep. ratios 12.2 21.2 46.5 6.7 8.2 21.8 5.9 5.8 9.8
Total life expect. 66.2 75.6 82.1 41.0 64.1 75.0 35.5 51.4 69.7
Total fert. rate 2.8 1.5 1.9 6:2 2.9 2.2 6.6 5.2 2.5
Table 1.1 World Population Aging 1950-2050.
number of children a woman would have during her reproductive age. Worldwide,
the total fertility rate has decreased from 5.0 children per woman in 1950 to 2.7 in
2000; it is expected to drop to 2.1 in 2050. Over this same period, life expectancy at
birth increased from 46.5 years to 66.0 in 2000 and is projected to reach 82 years in
the more developed countries and 75 years in the less developed countries by 2050.
6


In developed countries, due to very low fertility and high life expectancy and
improved access to health care and good living conditions, the number of the oldest-
old, those aged 80 and over, is projected to increase. Care of these individuals will
require more money, more social supports, and institutional care from government.
Even in these developed countries the aged are the most vulnerable group in the
population. Many states in the United States are currently reducing their subsidies of
social welfare programs for older and vulnerable people. In developing countries the
number of persons of age 60 and greater is expected to increase. Elderly in
developing countries live in much worse conditions because of generally weaker
economies and the unavailability of public services. In these societies, families take
care of their elders both because of tradition and necessity, and governments are
unable to provide social welfare programs due to fiscal constraints.
One aspect of world aging trends is the increase in the old age dependency
ratio the number of persons 65 years old and older per 100 persons 15 to 64 years
old. This old age dependency ratio will triple in the next 50 years. The aging index-
defined by the number of persons 60 years and over per 100 persons under age 15-
will also triple. The total dependency ratio- the number of persons under age 15 plus
persons aged 65 and above per 100 persons 15 to 64 years- is also expected to
increase. In short, the proportion of individuals of working age (15-59 years of age)
will decrease in more developed regions. In turn, this will put pressure on public
pension and health care systems.
7


Aging in Asia
The UN projects that, across Asia, populations will age rapidly.
Socioeconomic changes throughout Asia have had major impacts on population
aging, and the aging of populations in turn has had, or will have, a tremendous impact
on development processes in every country. Table 1.2 represents population aging
during the period of 1950-2050 in Japan, China, and Mongolia. Data of Japan
included to provide a broader comparison base because Japan is one of the developed
countries in the world. The United Nations projects that the population of Mongolia
will increase from 2 .5 million in 2000 to 4.1 million in 2050. The proportion of the
population age 60 and above will increase from 140,000 (5.6%) in 2000 to 958,000
(23.1%) in 2050. The old age dependency rate will increase from 6.1 to 25.4 over the
same period.
The aging of a population implies a greater increase in the number of elderly
women. World Population Ageing 1950-2050 (UN 2002) stated:
In the year of2000, the global sex ratio of the
population aged 60 or over was 81 males per 100
females. Thus, there were approximately 63 million
more women aged 60 years or older than there were
men of the same age. Since female mortality rates are
lower than male rates at older ages, the proportion of
women in the older population grows substantially with
advancing age. In 2000, women outnumbered men by
almost 4 to 3 at ages 65 or older, and by almost 2 to 1 at
ages 80 or above (25).
8


Indicator Japan China Mongolia
1950 2000 2050 1950 2000 2050 1950 2000 2050
Total pop. (million) 0.08 0.1 0.1 0.6 1.3 1.5 0.0008 0.003 0.004
Pop. of age 60+ (%) 7.7 23.2 42.3 7.5 10.1 29.9 5.5 5.6 23.1
pop. of age 65+ 4.9 17.2 36.4 4.5 6.9 22.7 3.3 3.8 16.3
pop. of age 80+ 0.4 3.8 15.4 0.3 0.9 6.8 0.2 0.6 3.4
pop. of age 0- 14 35.4 14.7 12.5 33.5 24.8 16.3 41.9 35.2 19.7
pop. of age 15-59 56.9 62.1 45.2 59.0 65.0 53.8 52.6 59.2 57.2
Aging index 21.7 157.9 338.2 22.3 40.7 183.3 13.1 15.8 117.6
Total.depen. ratio 67.8 46.8 95.8 61.3 46.4 63.9 82.5 63.9 56.0
Old age depend, ratio 8.3 25.2 71.3 7.2 10.0 37.2 6.1 6.2 25.4
Total life expectancy 63.9 81.5 88.0 40.8 71.2 79.0 42.2 63.9 77.5
Total fert. rate 2.7 1.3 1.8 6.2 1.8 1.9 6.0 2.3 2.1
Table 1.2 Population Aging 1950-2050 in Japan, China and Mongolia.
Everywhere, women are caregivers. Old women are more likely to be in a
disadvantageous position than men because they are more likely to be widowed. Also
they are more poorly educated, have less work experience, and less access to income
and services.
Many countries in the world are aware of the growing needs and problems of
the aged, and they provide health and welfare services for their aged citizens. Still,
particularly in Asia, many people do not have access to such services. The United
9


Nations, in cooperation with other international organizations, is considering the role
of economic change on the cultural roles and statuses of the aged in different
countries. The First World Assembly on Aging was held in 1982 in Vienna, the
second Assembly was organized by the United Nations and held in Madrid in 2002.
These assemblies emphasized the well being of the elderly, efforts to create more
supportive environments, and the increasing role of governments and international
agencies in improving living conditions, food, and economic resources for the
elderly. It also pointed out the need for research studies on elderly people in order to
define the situation of the aged and to guide the development of age-related policies
and programs. Asian government policies have emphasized the traditional role of the
family in caring for the aged. However, many studies show that with the increasing
numbers of the aged, the proportion of working adults will decrease, and it will be
more difficult for families to take care of their elderly. Therefore, the government
needs to assist families in taking care of the aged, and also needs to increase its own
role in providing direct help to the aged.
Overview of the Study
My discussion is divided into four parts. In this introductory chapter I have
discussed population aging, globalization, and socioeconomic change and its specific
features as they affect aging in developing countries, with special reference to
10


Mongolia. I have defined the problem and purpose of my study and presented my
research questions.
In the following chapter of my thesis, I consider aging and modernization. I
discuss the demographic transition and define population aging features as they differ
between developed and developing countries. I focus on how anthropology can
contribute to the study of elderly. I discuss theoretical frameworks for understanding
the aging process and consider different theories of how modernization and social
change affect the lives of the elderly. I consider differences between Western and
Asian family relationships and how they have been influenced by rapid
socioeconomic changes.
In the third chapter, I consider modem Mongolian history, with emphasis on
recent political and economic changes. This consideration emphasizes health care and
social welfare services of Mongolia both during the socialist period and during the
last decade. I emphasize the effects of recent economic and social reforms on
Mongolian elderly.
In the fourth chapter I present the methodology of my study, chapter five
gives the results of my research. The fifth and last chapter contains the summary and
conclusions, focused primarily on policy recommendations and suggestions for future
research.
11


CHAPTER 2
AGING AND MODERNIZATION
Anthropology and Aging
Anthropology plays an important role in the study of elderly because it
attempts to understand the bio-cultural process of aging in cross- cultural comparative
context. Anthropologists are interested in the process of aging in relation to human
biology, economics, politics, sociology, and psychology. Anthropology also plays an
important role in population studies, with interests in how economic and social
changes are related to, and affected by, population growth.
Today we live in a rapidly changing society where the numbers of older
people are growing fast, with effects on family, pension, and retirement policies,
health and social services, long-term care, and housing. All these changes are
growing concerns at every level- local, regional, and global. Of particular concern are
the increasing numbers of elderly in the world who lack access to basic social and
economic resources. Many chronic diseases are faced by elderly people, especially
elderly women, the oldest-old, and those living alone. It is important to understand
individual aging changes and how these changes are affected by social and physical
environments, and provide appropriate services to support older persons.
12


Anthropological studies are both scientific and humanistic. Scientific studies
are important to discover social relations and driving forces of change in a society or
in a culture, to understand the relationship of humans with nature, culture, and with
each other. Holmes et al. (1983) wrote that anthropologists investigate the value
systems, world views, and cultural norms of people in far- off lands because they
wish to test hypotheses about the nature of human beings in a world-wide laboratory
(p.4). Conversely, the humanistic approach considers subjective reality. Humanists
argue that in order to fully understand society we should take into account all factors.
Many anthropological studies are informed by the principle of cultural relativism.
Cultural relativism is based on objective and subjective reality, accepting cultural
diversity and understanding other cultures in their own terms. Anthropologists who
study the elderly have emphasized the different cultural contexts of the aged. Holmes
et al. (1995) wrote that:
cultural relativism is both a methodological tool that
ensures objective data collection and a philosophical
and theoretical principle that calls for open-mindedness
in accepting cultural diversity. It emphasizes the idea
that no single culture can claim to have a monopoly in
the right or natural way of doing things. From this
standpoint, anthropologists who study gerontology
believe that the meaning of old and the effectiveness of
solutions to the problems of old age can only be
understood and evaluated in terms of the cultural
context in which the aged reside. Although the common
biological heritage of human beings and the
inevitability of senescence create elements of common
experience, anthropologists are extremely cautious
about declaring that the customs in one society are
13


more acceptable or more honorable than those in other
societies (p.ll).
Anthropological studies of aging have contributed to the development of the
new fields of gerontology and geriatrics. These anthropological studies are very
important in the study of the health of the people, in providing good health care and
social support services to all human in the world.
Gerontology is the scientific study of older people and the normal and
pathological changes of aging. It examines human life from biological and cultural
perspectives, with the goal of improving the quality of life in the elderly. Infield
(2002) has noted that anthropological gerontologists believe that problems or
understandings relating to old age must be analyzed only in terms of the cultural
context in which they occur (p.16). The medical study of aging is provided by
geriatrics. It focuses on the biological, medical and social aspects of aging and
provides diagnosis, treatment, care and prevention. The field of geriatrics is interested
in the physical and psychological problems of the elderly.
Nowadays contemporary anthropologists study cultures in the context of
globalization, for example, research on how international trade, foreign investment,
and capital market flows affect extreme inequalities of class, gender and race. These
days, anthropologists focus on the challenges and opportunities presented by
biological variability, cultural diversity, ethnicity, race, gender, poverty, and class.
They emphasize in their writings the imbalance resources, human rights and power.
14


The feminist perspective is very important to anthropology. Women in most
societies occupy subordinate social positions. They are typically engaged in busy
domestic labors. In contrast, men have the authority and power. Womans role is to
fulfill the husbands and childrens practical necessities within the household.
Women are typically responsible for the health of children, their husbands and aging
parents. Ethnographic studies of old women provides good information about the
issues of gender, which allows us to include in our research voices from this
subordinate group.
Anthropological studies of aging help to assess the social, economic and
health conditions of the elderly, to predict what changes will occur in the future and
to identify implications for public policy. These policies should protect the rights,
interests and well being of the community, and provide safety and minimum living
standards for each individual, especially the most vulnerable groups such as children,
pregnant women, disabled people, the elderly. In general, aged women, the poor, and
the most deprived.
Demography and Demographic Transition
Population aging is defined by an increase in the number of older people (60
or above) in a population. Demographic analysis of aging helps us understand the
process of population aging and how it is related to other aspects of society. The
15


proportion of the population under age 15, over age 60 and overall life expectancy
vary widely between developed and developing countries.
Developing countries typically have high fertility and mortality rates. The age
structure of the population shows a characteristic pyramid shape: narrow at the top,
wide at the younger base with a steep slope. By contrast, in developed countries with
aging populations there are both low fertility and mortality rates. The population
structure shows a more rectangular shape: a narrow base relative to older ages and
greater proportions of the population in the upper age groups. The shift from high
fertility and mortality to low fertility and mortality is called the demographic
transition. Notestein was the first defined the demographic transition (Basch, 1999).
He identified 3 stages. The first stage is characterized by high mortality and fertility
rates and with low population size due to a high death rate. The main causes of death
are infectious diseases such as measles, diarrhea, cholera, malaria, respiratory
disease, tuberculosis and related acute disease. The second stage is characterized by a
decline in crude mortality rate and a decrease in fertility rate, which results in an
overall increase of the population. The third stage is characterized by low rates of
fertility and mortality with a steadily increasing population. This stage is
characterized by a shift from infectious to chronic diseases. Cardiovascular disease,
cerebrovascular diseases, cancer, rheumatoid arthritis and diabetes are the major
causes of death. Basch (1999) identified 5 stages of the demographic transition: high
mortality and fertility, declining of mortality followed by declining of fertility, then
16


fast decline of both mortality and fertility, followed by low levels of both and ending
up with very low mortality and fertility. According to him, these changes will lead to
increase on the median age and rising life expectancy of populations. The
demographic transition implies population aging: a decline in fertility and an increase
in the proportion of older people in the population.
Improved standards of living, coupled with
improvements in health and hygiene (especially at
childbirth), are seen as having contributed to increased
life expectancy, especially amongst infants and women.
Just so, like the industrial revolution itself, modem
population aging is regarded as having been an
invention of northern and western Europe, rather than
of the Roman Catholic south, let alone the Orthodox
Christian east. Nevertheless these are at most patterns
of association, rather than simple cause and effect
relationships (Finer, 2000, p. 23).
Thus, a decline in infant mortality rates and an increase in the life expectancy of
populations as a result of better sanitation, immunization, increased nutrition, and
improved health care. These are the driving forces of the demographic transition.
Types of Aping
Gerontologists have identified several forms of aging. Chronological aging is
defined as the number of years since birth. It is most useful in studies of age- related
mortality, fertility rates and population structure. In contrast, the biological aging
process is characterized by diminished physiological efficiencies in an individuals
17


organs and tissues in association with chronological age. Chronological age is not
necessarily closely related to a persons biological age. Infeld (2002) wrote:
It is likely that age changes begin in different parts of
the body at different times and that the rate of annual
change varies among various cells, tissues, and organs,
as well as from person to person.. .There is too much
individual variability in the potential markers of aging
(p.3).
Some people look and seem old at an early age, and some can look and seem
younger when they are quite old. Some elderly over 60 remain self-sufficient and
active, and some young individuals may require special care and services, especially
those with disabilities or chronic disease. In other words, persons with the same
chronological age differ in regard to biological aging.
The processes of aging are characterized by internal and external changes.
The aging process is gradual: organic changes begin at early age, and these changes
become more rapid in old age. The most visible physical aspects of aging are graying
hair, wrinkled skin, declines in sensory and motor function, and increased fatigue.
Internally, changes occur in the heart, lungs, kidney, central nervous system, and
stomach, urinary and endocrine systems. There are high mortality and morbidity rates
among elderly because aging is a process characterized by changes in internal
protective mechanisms, and these make older people more vulnerable to sickness.
Old age is not usually the main cause of death, instead death is caused by one or more
18


pathological processes that may or may not related to the biological consequences of
aging. Chen et al. (1989) wrote:
It is important to take a positive view of the increased
longevity of the population. If indeed, as bodies such as
the W.H.O. argue, the age of 85 is a possible outside
limit of disability- free old age, the importance of
promoting and maintaining health in an ageing
population can hardly be over- emphasized, because
during the twenty- five years of life from 60 to 85,
people can make a great contribution to society (p.75).
There are wide variations in the aging process across individuals because
people have different genetic make-up, habits, diet, exercise and variable living
conditions. They live in different cultural contexts, with exposure to different social
and ecological environments. Thorson (2000) identified differences between the
young old, elderly in the age range of 65 to 74 years, the middle-old with age
from 75-84 years, and the oldest-old, those 85 years or older. In different political,
economic and cultural settings, the number and proportion of elderly people in these
different categories vary considerably.
Biological Theories of Aging
Aging occurs through the complex interactions of biological, psychological
and sociological processes of change over time. There are many theories that attempt
to explain the process of aging. Identifying the biological changes occurring with
19


time is most basic to an understanding of the aging process. Aging occurs at all levels
of organization of the human body- the molecular, cellular, intercellular. These
changes influence die organs and lead to a gradual decline in the organism and the
persons health.
Fossel (2000) noted that cell senescence limits cell divisions in normal
somatic cells and may play a central role in age- related disease (p. 29), and
concluded that cell senescence theory is not only supported by and consistent with
all available experimental and clinical data in aging human organ systems, but it is
testable and has almost immediate clinical relevance to human aging and age related
disease(p. 33).
Some researchers believe that aging has a genetic base, directly programmed
in genes. Others believe that aging results from genetic damage in the cells by
external factors like radiation, ultraviolet rays and by internal factors that do not have
a genetic base. It is likely that there is an hereditary basis for aging and longevity,
which is modified by environmental factors such as climate, technology, emotional
stress and disease. Also human culture, behavior, life conditions, diet, stress, health,
social conditions, activity and positive attitudes toward old age all play a role in
aging. Mann (2002) stated:
The recent molecular revolution argues that aging and
the common diseases associated with age are
fundamentally determined by an individuals own
genetic make up, this being partly a function of the
inherited genome and the modifications to this that
20


occur over a lifetime. How well and how long a person
lives depends on the net balance- of this genetic
miasma- what the Victorians used to call
constitution. None the less, life style can have an
important role.
Clearly, diet and hygiene, excessive alcohol
consumption, cigarette smoking, drug misuse, sexual
promiscuity, and occupational hazards can damage
even the most perfect of cells and compromise life
expectancy. At greater risk are cells and tissues already
weakened by aging or diseases. Avoiding these risks
may increase an individuals likelihood of reaching old
age but not necessarily lead to high quality of life
(p.157).
Auto-immune theory postulates that the aging process is triggered by immune
system deficiency, limiting the bodys ability to respond adequately to stress factors.
The immune systems role in recognizing foreign antigens diminishes with age, and
the organism may produce antibodies against their own tissues, resulting in increased
physiological autoimmune reactions. With aging, control of homeostatic mechanisms
within the organism declines; this may increase susceptibility to stresses. Bessenyei et
al. (2002) pointed out:
Aging of the thymus plays an important role in the
etiology of autoimmunity.... Spontaneous genetic
instability produced by genetic mutations and related
changes of the body play a role in the physiological
autoimmunity and autoimmune diseases (183).
These researchers concluded that:
(1) age-related changes in the immune system are only
partly responsible for the senescence of an organism.
(2) Thymus involution seems to play a substantial role
in the senescence of the immune system. (3) The
21


elevated physiological autoimmunity is a result mainly
of the increase in apoptosis as well as cell death related
to general aging. (4) Several autoimmune diseases may
be a result of genetic alterations either caused by the
fluidity of the genome or by the overall genetic
alterations due to aging (p. 183).
Cellular Aging Theory asserts that each cell is programmed to a biological
clock that determines its maximum life span. A cell will stop replicating after a given
number of times, and cells become unable to repair damaged components. Each cell
has DNA that is depleted over time and reduces the production of RNA, which is
responsible for producing enzymes necessary for cellular functioning. That depletion
ultimately results in cell death.
Whitfield et al. (2002) wrote that knowing the sequence of the genome,
however, is only the beginning. Equally important will be our knowledge of how the
environment influences health, disease, and complex behaviors associated with
aging.. .Cultural differences among nations may also have an impact on quantitative
genetic studies(p.393). Beall (1984) argued for the necessity of analyzing
biological changes throughout the life span with reference to the appropriate cultural
context (p.88). According to Beall:
Adaptations to a stress like chronic disease, high
attitude, adaptation to cold, inadequate dietary
consumption and the level of physical activities
influence the human aging process. Human culture and
their habits play a role in biological changes. For
example smoking characterized by negative influence
on lungs and it can shorten human life, in contrast,
22


physical activity can have positive effects on body and
longevity (p.89).
For Beall, the events in previous stages of the life span play a role and noted
that there is an association between early growth patterns and the biological aging
process(p.88).
Psychological Theories of Aging
Some scholars emphasize the importance of psychological changes occurring
with normal and abnormal aging that influence older peoples social behavior and
dynamic relationships with their physical and social environments. Beside the
biological changes occurring in the aging organism, some changes in cognitive
functioning and personality may occur. Hooyman (1998) noted that older people
seem to experience more stress than younger people because they are at high risk for
depression, loss of income, jobs and ill- health.
Each individual and contemporary age cohort grows up in a different period
and experiences unique life events and social situations, and thus experiences
different psychological effects of aging. Many studies show that intellectual decline is
more closely related to diseases than to aging. Hooyman (1988) wrote that .some
changes in cognitive functioning and personality are a function of normal aging.
Other psychological changes may be due to the secondary effects of diseases(p.
23


190). Individuals continue to learn and respond to new things until death. The aged
may be little slower in learning and responding than the young, but the capacity to
leam does not necessarily diminish with age. There is not much change in memory
and recognition. Many elderly people continue to perform well on tests of
intelligence, learning and memory and they use their skills in the later years.
Whitfield et al. (2002) determined:
There are no age differences in heritability estimates of
the memory factor.. .there do appear to be some
differences in estimates of individual differences in
cognitive functioning across cultural groups. These
finding reflect differences in education and other
factors that influence the course of cognitive function
as we age (p. 398).
Social Theories of Aging
Decker (1980) wrote:
As humans we are biological creatures, and as
biological creatures we age. We are bom, and
immediately we begin moving toward death. We can
say that our biological nature sets the limits of our
existence, but it would be a mistake to say that the
biological process of aging is the whole of human
aging. There is another important dimension of aging,
the social dimension (134).
Every society has age norms that are created and diffused through
socialization. Older people become socialized to new roles and conditions that
accompany aging. Elderly people everywhere in the world face losses such as the
24


death of spouse, loss of employment, and many others, and they must learn to deal
with them. These changes have negative effects on the aged through decreasing their
self-esteem, increasing feelings of helplessness, and thus may result in physical,
emotional and behavioral disorders. These negative effects can be limited by social
practices and policies. With aging, old people may become increasingly dependent on
others and they may require some form of support, but this is not inevitable. Despite
their old age, the elderly can continue to support others. They can provide invaluable
wisdom, emotional, and economic support to their family and society. Thorson
(2000) noted:
For some individuals, of course, there is significant
disruption when they retire. But, for the broad groups
studied, it did not seem to be a crisis... .Many aging
people are masters of adaptation: they have seen many
changes in their lives, and the gradual changes
associated with aging are taken pretty much in stride
(59).
The qualities of social conditions are the most important factors for successful
aging. These factors include the economy, structure, cultural values, expectations and
social patterns. Kart (1985) wrote:
The World Health Organization (WHO) defines health
as a state of complete physical, mental, and social well
being- not merely the absense of disease. This
definition extends beyond biological considerations. To
the extent that modem medicine has been concerned
with what went wrong biologically, it has sacrificed
recognition of the broader social and emotional
elements that contribute to health (p.166).
25


In most pre-industrial societies and a high percentage of developing Third
World societies, kinship and family organization are much more important than in the
West, and peoples involvement with family determines everything they do, think,
and value(Holmes and Lowell, 1995, p. 113).
There are several theories that explain the social contexts of aging. Activity
theory attempts to explain how elderly people adjust to age-related changes.
According to this theory, more active older people tend to live to a greater age and
are adjusted in old age. Hooyman (1988) criticized this theory by noting that:
Activity theory tells us little about what happens to
people who cannot maintain the standards of middle
age. By failing to acknowledge a personality
dimension, it does not explain the fact that some older
persons are passive and happy while others are highly
active and unhappy... The value placed by older people
on being active probably varies with their lifelong
experiences, personality, and needs (p. 67).
Disengagement theory suggests that as people age, they withdraw gradually
from social roles and decrease their involvements and activities. This theory also is
criticized by many gerontologists. Disengagement theory has tended to ignore the
part that personality plays in the way a person adjusts to aging(Hooyman, 1988, p.
69). Some scholars argue that people may withdraw from some activities but they
may increase their involvement in others. In many countries the aged can play
important roles in family and society. Many scientific studies note that not all elderly
disengage, but remain healthy, employed, and socially and politically active.
26


Continuity theory asserts that as people age, they maintain typical ways of
adapting to changing social conditions. Hooyman (1988) pointed out:
The complexity of continuity theory makes it difficult
to test empirically, since an individuals reaction to
aging is explained through the interrelationships among
biological and psychological changes, the continuation
of lifelong patterns, and so on. Because it focuses
primarily on the individual as the unit of analysis*
overlooking the role of external social factors in
modifying the aging process, policies based on
continuity theory could rationalize a laissez-faire or
live and let live approach to solving individual
problems facing the elderly (p. 72).
All human societies and individuals experience change. These changes may affect all
people in society, but it affects each person differently.
Social Change Theories
Economic development is traditionally termed modernization. It is in many
ways a term for describing the growth of capitalism or industrialization within
formerly traditional, non-western societies. Some societies have experienced socio-
economic changes earlier than others. These societies are categorized as developed
countries. Other societies experienced these changes later, and their economic
development has been slower. They are categorized as less-and least-developed
countries. Anthropologists who interested in the dynamics of the socio-economic
27


changes and in the study of the aged have examined how development or
modernization affects elderly life and health.
Within this broad concept of economic development, there are many theories
of social change. One relevant theory is called cybernetic or systems theory.
Cybernetics focuses on information communication and processing within a social
system. It was originally developed by Bateson (1987) to explain how social changes
occur. Cybernetics has several basic features. It assumes that under normal conditions
social systems are stability- seeking and inherently conservative. Social systems are
linked and open, and the different institutions of social system are integrated. Social
life has a dynamic equilibrium: a change in one sub- system leads to a change in
another sub- system. A change in a social system will occur for example, when there
is an intrusion of another foreign culture, and the local cultural system will respond
by changing in its attempts to maintain stability. When intrusion from outside is too
strong or disruptive, and when different parts of a social system disintegrate, then
there will be dramatic changes to whole a social system, or even a complete collapse
of the system. If such changes occur, local cultures may disappear or be completely
dominated by the intruding cultural system.
28


Effects on the Underdeveloped World
Existing economical, political, social and cultural institutions and relations in
the underdeveloped world are being overwhelmed by the development of the global
capitalist system. Globalization here refers to the electronic integration of societies,
internationalization of labor and of capital, and transnational commerce with hyper-
competition. It is also linked to variable sedentism/nomadism and characterized by
blurred borders. The integration of markets and technology may provide more
opportunities to people and nations for social and economic development. This is the
positive side of globalization (Greider, 1997). However, it also has many negative
consequences. It creates dependency of poor countries on richer ones, increases
poverty and inequality, leads to environmental degradation, and raises crime rates. In
this system the poor are more susceptible to diseases and they have higher mortality
rates, higher fertility rates, and reduced life expectancy rates.
Poverty is created by the inequality inherent in the social stratification of the
global system. Economic development, with its emphasis on progressive changes in
many aspects of individuals, communities and nations lives varies from country to
country. It has mostly brought about many negative changes in developing countries.
Elites at every level have benefited from development, while the number of poor
people has increased. Reflecting on this process, Garrett (1994) writes,
Thirdworldization had set in all over globe. Millions of abandoned children roamed
29


the streets of the largest cities, injecting drugs, practicing prostitution, and living on
the most dangerous margins of society(p.591).
An expanded program of technical assistance for the economic development
of underdeveloped countries was initiated by the UN, the World Bank, and the
International Monetary Fund in 1980s. Many poorer countries borrowed large
amounts of money. These countries are falling into a debt crisis, unable to repay these
loans. Polivka et al. (2002) concluded:
During the past decade the concentration of income,
resource, and wealth among people and corporations in
the countries of the North has steadily increased. The
neoliberal policies of structural adjustment have not
only reduced real wages in many developing countries,
but also contributed greatly to reductions in social
wages- public goods such as provisions for education
and health care. The forced reductions in public
expenditures for social, health and education services,
and the privatization of many of these services (the
minimalization of the state) has created a crisis of
care in many developing countries, even as the
populations in need of care, especially children and the
elderly, continue to grow at very high rates (p.201).
Development programs that cause ecological and economic deterioration in
rural areas also contribute to internal migration, which has resulted in increases in
STDs and HIV/AIDS rates in many Third World countries, especially in Africa and
Asia. All these diseases are exacerbated by poverty and a lack of aseptic conditions in
local medical centers. The lack of knowledge in the community, deficiency of
medical personal and equipment, civil war, and refugee migration are contributing
30


factors to diseases. Unstable conditions in a country tend to increase the economic
crisis and create new possibilities for poverty and disease.
Development has broadened the gap between rich and poor. This has negative
effects on society, including increased rates of morbidity, mortality, crime, violence,
and deterioration of living standards. Income inequalities also contribute to
inequalities of health, poor diets, and poor working conditions, which in turn have
negative consequences on health. All these changes have effects on the elderly.
Theories of the Effects of Social Change on the Elderly
There are many controversial theories about the effects of modernization on
the status of the elderly. Some suggest that the effects are all negative; others do not.
Aging and modernization theory was developed first by Cowgill and Holmes (1972).
They were concerned with how modernization processes affect the elderly in a cross-
cultural contexts. According to this theory, the role and status of the aged varies
systematically with the degree of modernization of society and that modernization
tends to decrease the relative status of the aged and to undermine their security within
the social system(1972: p.13). They noted that the elderly enjoy high status in pre-
industrial societies with intact traditional values but experience low status in
modernized societies.
31


An alternative theory has been advanced by Palmore and Manton (1974).
They postulate that the status of the aged will decrease in early stages of
modernization and will improve in more advanced stages. Some anthropologists also
argue that the negative influence of social change on elders is not an inevitable
process. According to them, the elderly may benefit form social change. Foner
(1984), for example, examined the relationship between age and social change, and
criticized modernization theory, arguing that it inappropriately emphasized the
negative impact of the modernization process on elderly in pre- industrial societies.
She wrote that:
Since the overall status of the elderly is
multidimensional, it is too simple to say that change
leads to improvements or declines in their status.
Rather, we must specify (as I have done in the .
preceding examples) which dimensions of the status of
the old we are talking about: which social rewards and
valued roles they lose or gain. With change, all
components of old peoples statuses rarely vary in
exactly the same way. In other words, the elderly may
lose some rewards and valued roles at the same time
that they keep or expand the scope of others (p.203).
Foner found that the elderly may benefit from economic development. Developed
societies maybe able to offer pensions and other social welfare services to the elderly,
though these may be insufficient. Foner emphasized what she calls age- stratification
theory, which focuses on the relationship between social change and specific age
cohorts. What is key here is that social changes do not, in general, affect all cohorts
the same way. This variation comes about, first of all, because as one cohort succeeds
32


another, each cohort has lived through different segment of history(p. 206). She also
pointed out that when we study the effects of social change on the old (or the
young) in a society, it is essential to know which cohort of old (or young) people are
being considered with all its unique characteristics^. 206).
Logue (1990) has argued that the low status of elderly, especially of the
oldest- old, is not related to modernization. She points out that, frail elders are those
who suffer major physical, mental, or social losses, and who require special care
(p.l 18). She concluded:
Over the course of human history there has been more
continuity than change for the frail elderly as assets, as
burden, and as low priority. But processes associated
with modernization, especially in the health care sector,
have exacerbated their plight as potential victims, by
expanding their numbers, enhancing their vulnerability,
increasing the duration of their dependence, and
making solutions more problematic; death hastening
and delayed death are the two major types of
victimization discussed (p.347).
Logue described many negative effects of long- term care institutions:
inadequate care and diet, the overuse of drugs, various forms of neglect, abuse, high
levels of isolations, and ageism. Logue wrote that, their greatest needs are not
medical, however, but primarily for help with the basic activities of daily living, such
as dressing, cooking, shopping and toileting(p.348).
Considering how anthropological studies about the aged and human culture
are important to the understanding the impacts of economic and social change,
33


Holmes et al. (1995) wrote that perhaps both the increase in number of elders and a
decline in the status of old people are merely correlated with modernization and its
many pervasive social, economic, and political manifestations (p.260). They
concluded,
It is well documented that change can greatly influence
societal attitudes toward senior status and role
assignment and can alter traditional practices in regard
to care and treatment. This is particularly true where
there have been contacts between pre-industrial and
modem societies. Newly acquired values and
institutional procedures often undermine age-old
support systems for the elderly (p. 284).
Jay Sokolovsky (1990) has criticized the modernization model and noted that
examination of ethnographic studies has suggested the need to consider variations
within given elderly populations based on such factors as class (Herlan, 1964), values
(Holmes 1987), gender (Roebuck 1983; Cool and Mc.Cabe 1987; Counts, in press),
kinship systems (Sokolovsky and Sokolovsky 1983b), and age cohorts (Foner
1984a), (p.140).
He emphasized the case study of Chinas elderly, in particular, describing
how socio-economic changes have affected them, and he concluded:
The theory of modernization predicts that the condition
of the elderly will deteriorate as the society reaches
more advanced industrialization and resources are
channeled into the younger generations and into
productive activities. This does not appear to be the
situation in China... it would appear that the elderly
will not suffer under modernization (p. 160).
34


Thus, rapid social and economic changes, which can influence the number or size and
sex composition of a population, can lead to other social changes.
Effect of the Economic Changes on Asian Elderly
The impact of socio-economic change on the status of the elderly can be seen
most clearly in an examination of the situation in Asia. Many Asian countries have
experienced massive socio-economic changes, and differ by their population size,
size of their aged populations, level of economic development, their customs, spoken
language, and their geographic conditions. The main feature common to all is the
fast- growing older population. The driving force of population aging is the process
of modernization, particularly the factors of economic growth, low fertility, low
mortality rates, and extended life expectancy. Increasing numbers of elderly will
likely play a significant role in the social, cultural, political and economic situations
of each country.
There are tremendous differences between Western and Eastern countries in
attitudes towards and care of the old. Most of the Western countries experienced
rapid economic development earlier than Asian countries. These developed countries,
which would include Japan, have mostly completed the demographic transition
(Bengtson et al. 2000). In contrast, many developing countries in Asia have either just
passed through or are in the transitional stage of the demographic transition. The
35


elderly in developed countries have better living conditions. The western countries
and Japan also have been able to engage in good planning of health and social
welfare services, including providing access to pension/social security funds. Health
policy in developing countries has tended to emphasize younger segments of the
population, like infants, mothers, and working age people. In Asian countries the
family, children and relatives are the main source of support of the aged. Lechner et
al. (1999) noted:
Developing countries have a limited capacity to
respond to the needs of employed caregivers and to
elders... One reason is that, in developing economies,
urbanization has resulted in less effective community-
based safety nets. Urbanization has left elders with
fewer support systems; they are more dependent than
ever on employed caregivers who are less able to care
for them. In transitional economies, state-owned
enterprises are being sold, and the new private sector
employers are cutting back pension and family focused
benefits in order to remain competitive (p. 230).
The governments of developing countries do not provide sufficient services
for the aged because of money constraints, but many Asian countries have become
aware of population aging issues and have begun to define national policy on the
elderly. Bengtson et al. (2002) wrote:
One of the potential advantages for newly economically
developing nations is that they can look to the more
developed nations for examples to emulate- or reject.
This vantage point contributes to the usefulness of
comparative studies, not only for rapidly developing
nations coming more recently to issues of population
36


aging, but for all nations facing the macro forces of
demographic and economic change (p. 7).
In Western society many elderly may live in nursing homes and have less
contact with their children. Western societies, for example, American culture, tend to
emphasize and reward individualism. The elderly thus often support themselves and
live independently from children. Self- reliance is seen not only as the key to mental
health but also as the prerequisite to personal success. Having rejected nearly all
forms of dependence on fellow human beings, the American finds that security,
must come from personal success, personal superiority, and personal triumph(Hsu,
1961, p. 228). Olson (1994) stated:
By 1989, there were over 16,000 nursing homes, mostly for- profit facilities,
providing for 1.5 million elderly (p. 31)... The pursuit of profits over human needs
has negatively affected the quality, accessibility, and affordability of care. ...In nearly
all nursing homes, the personal lives of residents are strictly organized; most are
denied their basic civil rights (p.33). Bengtson et al. (2000) wrote:
The global trend of population aging- in itself an
inescapable consequence of the modernization process-
has touched societies in the East such that they now
have to move away from exclusive reliance on the
family and expand the role of the state as the source of
support for the aged... On the other hand, Western
advanced societies- which long ago shed role reliance
on the family for care of its elderly members- are now
trying to reassert the importance of the family and
community for the care of its rapidly expanding aged
populations (p. 7).
37


In Asia the family is the main source of support for the aged (Bengtson et al.
2000). Respect toward ones elders- filial piety- is central to Confucian precepts, and
governs family relations throughout East Asia. This ideal demands that the young
recognize the support and care they received from their parents, and in turn demands
that they give reciprocal respect and care for the aged parents. In Asian countries
traditional values argue that elderly people should be recognized as the most skilled
and knowledgeable people from whom younger generations must leam. From ancient
times, the young have used respectful language in speaking with their elders, giving
them the best foods, most honorable seats, and special gifts. Children are obedient to
their parents by social norms. Young people are more likely to carry out the wishes of
their elders, not only their parents but also other elders in the community. Children
are given the responsibility to support their parents, have their own children, and in
this way, maintain the timeless continuity of family life. Sung (2000) wrote,
Filial piety is reflected in the practice of family-
centered care and support for parents. Family support is
characterized by cohesive ties between family
members, family responsibility, interdependence
between the members, family harmony, the individual
as a unit of the family, and the pooling of individual
members resources to promote the well-being of
parents and the family. This is in contrast to the
Western values of individualism, characterized by self-
determination, independence, autonomy, respect for the
dignity of an individual, the success and well-being of
an individual, and the strong emphasis on the nuclear
family (p. 45).
38


Bengtson et al. (2000) concluded that filial piety will remain a core value in
Asian societies, binding generations together, although its expression may change(p.
276). Today governments of many Asian countries attempt to keep the traditional
values of respect for elderly alive through formal education and policy. Bengtson et
al. (2000) observed that:
Other social patterns more unique to Asian societies- a
lower divorce rate, a smaller number of single parents,
a lower degree of family dispersion, a higher degree of
intergenerational solidarity, and a supportive family
network- will contribute to the improvement of family
support for elderly persons (p. 51).
Religion is one of the major components of culture, and has great influence on
the values ascribed to the elderly. Religion represents a powerful means to organize
societies, and it is a major form of social control. In Asia it plays an important role in
the life of the elderly. In East Asia the dominant religion is Buddhism, which focuses
on past and future lives, and includes high respect of the aged. The aged have a
special role in religious ceremonies, and they are respected for their age. In contrast,
Holmes et al. (1995) wrote:
The religious tradition observed in the United States
has little effect on attitudes toward the aged. While the
Bible urges believers to Honor thy father and mother
that thy days may be long, this commandment has
never had the impact on behavior that the filial piety
principle has had in oriental religions. It states an ideal
but does not represent a guarantee of respect and
responsibility (p.174).
39


Asian people focus on connectedness with others and have a close
relationship with family and community. Elderly people expect their children to listen
and to follow their advice, and they prefer live near them. There are many different
forms of financial support for the elderly, such as money, good, gifts, and help with
domestic work and personal care.
Increasingly the elderly in developed countries tend to live alone or with their
spouse (if alive). Haskey (1996) determined that, 33% of elderly men over 75 were
living alone in 1994, compared to 24% in 1973(Barlett and David, 2000, p. 177).
Albert et al. (1994) wrote:
In the more developed countries, sharing a household
with a child is the exception and is linked mainly to
health limitation in the elder or, less remarked, to the
economic dependency of the child... The vast majority
of elderly do not share households with adult children.
Excluding the 1.5 million elderly in nursing homes
(National Center for Health Statistics 1989), the most
recent U.S. census figures showed that 31 percent of
the elderly live alone. An additional 54 percent share
households with relatives, most with their own children
(p. 87). ...The proportion of elders living alone, for
example, ranges from 2 to 8 percent in Southeast Asia,
and from 5 to 11 percent in Latin America (p. 90).
Many ethnographic studies reveal that in most Asian countries families maintain
respectful relations with their elderly, though socio-economic changes may threaten
the capability of families to care for their elderly members. Yoon et al. (2000)
determined that:
40


Among the peripheral consequences of industrialization
and modernization are weakness in many sources of
material and normative support for the elderly
population and the negative social concept that elderly
persons are a burden both at the familial and social
levels (p.129).
Rapid economic change, which is often linked to educational levels attained
by the young, migration of young people to the big cities, and increased opportunities
for women to work outside the household, contributes to the erosion of the more
traditional roles of the elderly in family life. Sokolovsky wrote that increased
education of the young led many children and young adults to feel superior to their
parents. This has fostered a distinct negative change in generational relations-
sometimes involving high levels of abuse and even gericide- closer to the predictions
of the modernization theory(p. 11). Sung (2000) wrote that in recent decades,
industrialization and urbanization have been eroding the tradition of family centered
parent care in Korea and other East Asian nations such as Japan and China (p. 231).
Philips has focused on how to maintain family- based care for the aged in rapidly
changing societies. According to him, in Asian countries with a low level of
economic development, the elderly will face great difficulties in their daily lives due
increased poverty, lack of access to health and social services, increased migration,
decreased traditional values and very limited governmental support. Holmes et al.
(1995) pointed out:
Extended family units are weakened in the rural areas
while in the city the emphasis is increasingly toward
41


independent biological families. The rural areas have
always been strongholds of traditional culture, with
elders not only in control of property but of knowledge
and prestige as well. In the city the young escape the
control of the elders and begin to question their
authority and priorities (p. 272).
Financial support is a new phenomenon for elderly people. It is considered an
invention of Western societies. Retirement or social security is the monetary support
given by the government to the aged to meet their needs when they are no longer able
to work.
In pre- industrial societies elderly people worked until they are no longer able
to do so. Only serious illness or physical infirmity would lead them to withdraw from
their work. With economic development, the elderly often face compulsory
retirement, at an age defined by government policy. There are wide differences in the
age of retirement in many countries. It ranges from the age 50-60 in women and 55-
65 in men in China, Russia and in Mongolia. Retirement age may determined on
bases of hard working conditions, type of occupation, number of working years, and
number of children. According to Anderson (1972), retirement in America does
more than separate people from jobs and colloquies, it is actually a period of de-
culturation(Holmes and Lowell, 1995, p. 71). Many (not all) elderly in the more
developed countries have access to universal social security programs, and they live
in better conditions than the aged of developing countries. Even in developed nations
42


the aged are the most vulnerable people, especially older women. Kim (2000) pointed
out:
The Korean government introduced the compulsory
retirement system for government officers in 1963
(Yoo, 1999). Under the current system, most
government workers are to retire as early as 60 years,
with the exception of professional government workers
like teachers (62 years) and professors (65years). The
situation of the workers in the private sector is even
worse than the case of government workers. About 65
percent of the employees working in the private
industries retire at the age of 55 years (Yoo, 1999).
According to national survey (Rhee and others, 1994)
most of the Korean elderly (79.9%) want to remain in
the workplace as long as possible (p. 5).
Holmes et al. (1995) noted that the retirement forced by competition for jobs
is accompanied by a sense of dissatisfaction and depression(p. 271). The
compulsory retirement systems that exist in many Asian countries will produce larger
numbers of not-working people. According to U. N. projections, the proportion of the
elderly who work will decrease from 25% of the population 65 and above in 2000 to
22% in 2050.
Holmes et al.(1995) argued:
Modem economic technology also changes the work
situation. New technical processes result in the creation
of new jobs and changes in old ones. The younger
workers with their technologically oriented education
tend to be attracted to the new occupations, while older
workers make minimal adjustments to cope with the
new technology or attempt to carry on in the more
traditional roles as long as possible. The steady
43


reduction of traditional roles, however, represents still
another pressure for retirement (p.271).
Chang (1992) suggests:
Increasing education, urbanization and industrialization
have resulted in more women engaging in wage
employment outside the home. For example, the female
labor force participation rate in Singapore increased
from 44 per cent in 1980 to 50 per cent in 1990 (Lee
and Veloo, 1991:66). In Japan, the female laborer
forces participation rate rose from 55.2 per cent in 1965
to 58.2 per cent in 1984 for those aged 25-44 years and
from 58.4 per cent to 64.1 per cent for those aged 45-54
over the same period (Ogawa, 1987:63). Increased
female employment outside the home, however, means
that less labor is available to provide care for both the
young and old in the household (p. 4).
In Asia, elderly tend to live with their children but these rates are decreasing.
The Korean Institute of Gerontology pointed out that elderly living alone increased
from 7% in 1975 to 53% in 1996(Bengtson et al., 2000, p. 43). Yoon et al. (2000)
observed that 25% of the elderly parents lived apart from their children in 1988,
41% did not live together with their children or other relatives in 1994(p. 129).
Ethnographic studies by Sung et al. (2000) show that despite increased
migration and changes in family structure, the aged are still receiving effective help
and care from their children and relatives. Sung et al. (2000) write that, in Korea
about 90% of elderly live with their children and kids play an important role in caring
for their parents(p. 42). According to the 1995 survey of elderly who have not lived
with their children, 90% received gifts of food, clothes during previous years and the
44


same proportion received some money(Phillips, 2000, p. 257). Phillips notes that
families have undergone significant changes in the course of rapid industrialization
and urbanization in Asian society...family size decreasing, that based on Korean
National Statistics office in 1995 defined that 5.7 persons in 1955 and 3.3 persons in
1995(p. 41).
With technological development the educational level of the population is
increasing. In many developing countries a number of people remain illiterate,
especially women. Holmes et al. (1995) argue:
Traditional societies have a much greater proportion of
illiterates than modem ones, for traditional skills such-
hunting, herding and horticulture can be passed on from
generation to generation by word of mouth and through
informal teaching by example...In such societies the
people who exercise the greatest control and enjoy the
greatest respect are those who lived the longest and
have experienced the most... Modernization renders
experience in traditional life ways of little importance,
as it changes the rules, challenges values, and alters the
direction in which the society moves. Oral tradition and
learning by imitation are inadequate in communicating
knowledge that people must have to function in a world
of rapid change, urban life, and complex technology.
No longer can individual heads carry the information
requisite for a modem society. Modernization demands
literacy, libraries, and formal education. Not only is
more technical knowledge needed to function in a
modernizing society but it is needed in a hurry and in
large amounts (p. 273).
45


The Case of China
China has the largest population. China is a useful comparative case study,
because, like Mongolia, it is categorized as a developing country. At present, China is
a relatively young developing country compared to other industrialized countries but
the growth of aged people will be greater than other sectors of the population in
coming years (see Table 2).
Despite its status as a developing country, China has experienced the
demographic transition from high fertility and high population growth rates to a
situation of low death rates and low birth rates in a relatively short period of time.
The Chinese government has been concerned with population growth issues since the
latter part of the 20th century and established a one-child per family policy in 1979.
People who live in urban areas can have only one child, and in rural areas couples
may have two or more to help with agricultural work; The majority of people live in
rural areas. The Chinese government implemented a strong family planning program
in order to control population growth. They integrated this program with economic
development and efforts to increase peoples living conditions and to decrease
poverty, increase educational levels of citizens, improve womens status, and protect
the environment. As a result of family planning, today China is a country with
fertility rates, like many developed countries. Control of population growth
46


influenced their development positively; it increased the peoples living standards.
According to the Chinese State Statistical Bureau, per capita income in rural areas
increased from 133.6 yuan in 1978 to 395.5 yuan in 1985. However, China over the
next decade is projected to be one of the most rapidly aging populations in the world.
Economic reforms and increased employment opportunities allowed the
elderly to open small private businesses. It also decreased the status of the elderly
within the family. In pre- modem China the elderly were respected. Age was the main
determinant of prestige and authority, and children supported their parents.
Olson (1994) noted that economic development increased the educational
level of the population and enhanced public health. In China, the evidence is quite
clear that the family and local communal organization are expected to provide much
of the long- term care for frail elders to prevent otherwise costly institutionalization
(p.274). Most people in China have access to primary health care and reproductive
health services. As a result of the introduction of a new marriage law with emphasis
on the equality of men and women, womens status has been enhanced. Traditionally
in China, women had low status, and their status increased with old age, bearing sons,
and having daughters-in-law, who had to obey their mother-in-law. Womens rights
and economic independence are increasing, and the living standards of the total
population and the aged has been improving. Still, women everywhere are those
responsible for bearing and rearing children, doing heavy unpaid household work,
and also working outside of home. Doing all these is not easy, and governments need
47


to pay more attention to women and increase support from the family. Governments
need to reduce womens household responsibilities and help them take care of the
aged.
Ethnographic data (Olson 1990, Gu 2000 and Sokolovsky 1990) reveal that
the status of the elderly in China increased from the establishment and improvement
of a socialist market economy with fast and healthy development of national
economy.
The conditions of the elderly are better in urban areas than in rural. In rural
China the families mostly care for their elderly parents because of insufficient
pensions for older farmers. In 1956 China developed a new system, which is called
the Five Guarantees, for the childless and for those elderly who have only
daughters. The Five Guarantees system provides elderly with shelter, food, clothing,
medical, and educational services. Olson (1994) wrote:
During the last ten years, thousands of homes for the
aged have been built. The government reported that an
increase from 7825 homes in 1978 to 33,295 in 1986
(Shehui Baozhang Bao 1987). These homes serve as a
symbol to rural families that, should they have no one
to care for them in old age, the community will provide
that care (p.276).
According to Olson (1994), in rural China only 1% of the aged receive a
pension, compared to 75% of those in urban areas. The retirement age in China is 55
for females and 60 for males (Wu, 2000).
48


In 1978 China adopted a market economy. This shift emphasizes the
development of agriculture, military, industry, science, and technology through the
decentralization of enterprise management. Now the Chinese government is trying to
establish a pension for all people who are over 55.
In Chinese culture, old parents mostly stay with their oldest married son and
daughter-in-law, and other kids live near their parents. These parents play an
important role in their childrens lives, contributing labor for fanning work,
household chores, baby-sitting, and making food and meals. For the majority of
people, emotional and economic linkages between older parents and their children are
still well maintained(Bengston et al., 2000, p. 64). In China every family has a small
garden plot and it supports their daily livelihood. In this society the aged still are seen
as important members of the family, as an essential and integral part of the social
and economic, fabric of the society(01son, 1990, p.159). Ethnographic studies done
by Olson (1990) and Sokolovsky (1990) show that the economic and social changes
in China have had positive effects on the elderly.
In summary, many anthropological studies show that change to greater
economic development has had mostly negative effects oh the lives and living
conditions of the elderly. Urbanization, the increased educational level of the young,
migration, increased womens work outside of their home, compulsory retirement,
increased poverty, inequality, and unemployment all produce negative effects on the
lives of the elderly. In Asia, where the support of the aged is provided entirely by
49


families, particularly by children, changes that separate families, or limit these
interdependencies, will negatively affect the old. Anthropological studies reveal that
Asian countries maintain ideals of respect for their elderly, but the demands and
consequences of economic development have led to declining family care. In many
cases these changes have left the elderly behind. They have few social supports, and
become more dependent on minimal government supports.
Conclusion
Aging is both a biological and a social process characterized by external and
internal changes unique to each human body. Individuals vary in the aging process
due to their different genetic make- up, habits, diet, exercises, and living conditions.
Globally, rapid socio-economic changes are occurring, and these changes have had a
profound effect on elderly lives. Modernization is characterized by economic
development with high technology and improved medicine, which decreased human
mortality rates and expanded life expectancy. Today we live in a globalized world,
which as Sokolovsky (1990) noted,
is based on an international division of labor which
allows capital accumulation to take place in core
nations of a capitalist world system while these
countries control the developmental process in semi-
peripheral and peripheral areas. Overall, it is contended
that the tie of dependent nations to core industrial
powers through multinational corporations and foreign
50


aid has resulted in the enhanced position of favored
urban elites at the cost of growing rural
impoverishment and internal inequalities (p.140).
There are many anthropological theories that attempt to explain the effects of
socioeconomic change on the life of the elderly. Modernization theory, proposed by
Cowgill and Holmes (1972,1974), states that under the conditions of modernization
the status of the elderly and their prestige will decline. Palmore and Manton (1974)
argued that the status of the elderly will decline in early stages of modernization and
will increase in more advanced stages. Foner (1984) wrote that during modernization
process, elderly can loose some statuses and can gain some benefits from this
process. Some others, like Logue (1990), determined that elderly people are in
general viewed as low priority. According to her, modernization expanded the
elderlys life expectancy and increased their dependence, and she criticized negative
effects of long- term care institutions.
In this chapter I reviewed data from Asia, especially China. China is projected
to be one of the most rapidly aging populations in future. The Chinese experience has
shown a positive influence of economic and social change on the elderly. It can be a
good example for Mongolia. Many ethnographic studies show that the Chinese
government provides good and peaceful living conditions to the aged under the
conditions of socioeconomic changes. The Chinese people have access to medical
care, education, and pensions. There are some differences between urban and rural
residents, with better living conditions and pensions in urban areas. In rural areas
51


pensions are insufficient and children take care of their parents. Elderly without
children or who have only daughters are enrolled in the special program, Five
Guarantees, which provides the elderly with food, home, clothing, and medical and
educational services. In urban areas the elderly received increased state economic
support. Now the Chinese government is trying to establish pensions for all people
who are over 55. In China, nearly every family has a small garden plot that supports
their daily livelihood. Every person has access to primary health care, and the
Chinese government has provided support to the families and local communal
organizations that it is essential to providing care for the aged. In the future, if China
establishes a universal pension system, there will be good state and family care for
the frail elderly.
Mongolia is Chinas neighbor to the north, and having a similar political past,
may be able to learn a great deal from Chinas successes. The Chinese policy fits the
Mongolia context for several reasons: first, support of the elderly doesnt come
entirely from the government, but instead focuses on localized communal care and
families, which reduces economic burden to the state. Second, almost all Chinese
people have access to primary health care (PHC). The policy of PHC in China is to
provide low cost and effective traditional medicine for many chronic diseases, and
these in turn enhances care for the elderly.
The status of the aged depends on a countrys economic, political, and social
conditions, and on culturally- based family relations. The Chinese case study shows
52


that socio-economic changes can have positive effects on elderly as a result of
sufficient family support and good social programs from the state.
53


CHAPTER 3
THE MODERN HISTORY OF MONGOLIA
Background
Located between Russia and China, Mongolia is one of the largest countries
in central Asia. Mongolia is a land of natural contrasts: the Gobi desert to the south,
semi-desert, vast plains to the east and snow clad mountain to the west. The climate is
very hot in summer (+35 to +40 C) and very cold in winter (-40 C). The highest point
is 4,374 meters above sea level and has the highest atmospheric pressure. The lowest
areas are only 552 meters above sea level. Most Mongolians live at an altitude of
roughly 1600 meters, equivalent to the altitude of Denver.
Demography
After the socialist revolution in 1921, the population of Mongolia began to
grow. The population of Mongolia was 761,300 in 1950,2.5 million in 2000, and is
projected it to reach 4.1 million in 2050 (UN 2002). The 2000 census of Mongolia
estimated a population of 2.3 million people (NSO 2001). Despite its rapid population
growth, the population density of just 1.5 people per square km makes it one of the
most sparsely populated countries in the world. Just one half (56.6%) of the
54


populations lives in urban areas. Of the total urban population, 32.0% live in
Ulaanbaatar (UB), the capital city. There is some evidence for the acceleration of the
demographic transition in Mongolia. Total fertility rates dropped from 6.1 children
per woman in 1950 to 2.3 in 2000. Between 1989 and 1999 the crude birth rate per
thousand population fell from 37 to 21 (UNDP, 2000, p.19). Despite this, Mongolia
remains a young country: About 80.0% of its population is under the age of thirty-
five, though population growth has slowed (1.4%) a consequence of low fertility and
a high rate of migration.
Traditionally, Mongolia has been a nomadic society. Herders were mobile,
moving seasonally with their livestock over the vast lands of the country. Before the
socialist revolution population growth was very low due to the poor economic
situation. During this time a great number of the male population lived in monasteries
and practiced strict celibacy. After the socialist revolution that occurred in 1921, the
population began to grow. During the period of 1921-1990, Mongolia experienced
unprecedented rates of population growth due to the improved nutrition and
socioeconomic conditions of the population and increased life expectancy. During the
socialist period, a majority of the population had full access to health services.
In the beginning of the 1990s, Mongolia experienced changes to their
economic and political systems. Population growth decreased due to declining
fertility rates. The decline in fertility way is linked to changes in the social system,
such as introduction of the law allowing on abortion in 1989, deterioration of living
55


conditions of the population, and increasing use of contraception by women. The
declining growth rate during recent decades is also connected with high out-
migration. During the transitional period, thousands of Kazakh and other minority
ethnic Mongolian groups moved to Russia and many young people left their home
country to study and work abroad.
As a result of declining fertility there have been remarkable changes in the
population age structure. This table shows that although Mongolia is a young country,
this will change in the future with increasing numbers and proportions of older
people.
Table 3.1. Structure of the Mongolian Population, 1950- 2050.
1950 2000 2 050
Total population (thousands) 761 100.0% 2,533 100.0% 4,146 100.0%
0-14 (age) 319 41.9% 892 35.2% 815 19.0%
15-59 401 52.6% 1,500 59.2% 2,373 55.3%
60+ 42 5.5% 141 5.6% 1,099 25.6%
Aging index 13.1 15.8 117.6
Old age dependency ratio 6.1 6.2 25.4
Total fertility rate (children) 6.0 2.3 2.1
Life expectancy (years) 42.0 63.9 77.5
Source: United Nations, 2002
According to the statistics of the Office of State Social Welfare (Government
of Mongolia 2001), there were 180,180 retired elderly in Mongolia in the year 2000,
comprising 7.6% of the total population. Of these, 82,369 (45.7%) were male and
56


97,811 (54.3%) were female, with 95,758 (53.1%) elderly living in urban areas and
84,422 (46.9%) living in rural areas. There were 178,480 (99.1%) elderly (70,629
males and 107,851 females) who were receiving pensions; only 1422 (0.8%) people
of age 55 and above did not receive a pension. 4,546 veterans and 825 elderly receive
a special allowances in addition to pension. There are 55,516 (30.8%) elderly who are
engaged in income-producing activities to supplement pensions. According to these
data, about 32,739 (18.2%) of elderly are considered to be a high risk group who
are close to poverty, and of these 23,491 (71.8%) are considered to be very poor.
There are 2,612 (1.4%) people who live alone without any caregivers and 3,078
(1.7%) elderly are invalids. The Mongolian government provides special care with
free meals and clothing for those who live alone.
In the future, the number of the aged is projected to increase, and the aging of
the population will place demands on society at every level. This rapidly growing
population will need housing, jobs, health care, and social welfare services.
Mongol Empire
During the 11th and 12th"centuries Chinggis Khan established the first
Mongolian State (Baabar, 1999). The history of the Mongols before Chinggis Khan is
unknown, and there is little information about how the Mongols lived. Chinggis first
united Mongol tribes and then with a force of horse-mounted warriors conquered
57


most of Asia and many Eurasian countries. Chinggis Khan was a strong believer in
shamanistic power. He believed that the sky is the creator and sustainer of balance in
the world, and all human life is sustained through it. Chinggis developed unique
administrative organizational structures and established Mongol common law. He
organized the system of internal communication by horse riders. Chinggis understood
the power of literacy and he spread use of a Uighur script as the common
Mongolian alphabet. He died in 1227. After his death the Mongols rapidly went into
decline.
Later, Khubilai Khan (1215- 1294), one of the successors of Chinggis Khan,
conquered China, and changed the name of the Great Mongolian Empire to the Yuan
Dynasty. In 1260 he established the capital in Beijing, China, and transferred the
political center of the Mongol Empire to China, increasing Chinese influence. The
Yuan dynasty fell in 1368, and was succeeded by the Ming, then Qing, dynasties
Independence
The Qing rulers were patrons of Buddhism, and encouraged the growth of
Buddhism in Mongolia as a means to pacify the warlike nomads. At the end of the
19th century, the Qing rule weakened; the Manchus introduced new reforms in
Mongolia which were intended to impose Chinese culture on the Mongolians. The
Mongolians were prohibited from migrating from one place to another and from
58


working in gold mines. These reforms produced widespread protest and spawned an
independence movement. Many Mongolian elites and lamas decided to protect their
country from Manchu exploitation and to establish their State independence. When
the Qing dynasty fell in 1911, Mongolia was poised to assert its independence, and
proclaimed the supreme religious leader, the Bogd Khan as the head of government
in Mongolia. Baabar (1999) writes that:
The history of Mongolia in the twentieth century
officially began on the ninth of the mid- winter month
of the fifteenth sixty- year cycle of the White Pig Year.
On this day Outer Mongolia overthrew the 220- year
oppression of the Qing dynasty and officially
proclaimed her independence as a monarchy under the
Eighth Bogd Javzandamba Hutagt... .By the Roman
calendar, the decree was made on December 29,1911.
In this way, Mongolia, a country which had ceased to
exist as a nation after Ligden Khaan, re- emerged after
more than two centuries in oblivion and joined the
twentieth century (p.102).
The success of the revolution awakened the national consciousness, and
increased peoples political activities. At this time the first political party-the
Mongolian peoples Party was established. The Russian Revolution of October 1917
had a great impact on Mongolia. In the 1920s a fugitive of the Russian Revolution,
Baron Ungem, and Chinese troops from the south moved into Mongolia. To resist
these foreign intrusions, Mongolia sent a delegation to Russia to request assistance
from the Socialist Union. The Soviets provided the requested assistance, and a social
revolution occurred in July 1921, which established a Mongolian as a socialist state.
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By 1922 the entire territory of Mongolia was free from foreign occupation, and the
Mongolian Peoples government was established. Mongolia started to build a state-
guided economy supported by the Soviet Union. In August 1924, the 3rd Congress of
the Mongolian Peoples party adopted a Russian socialist type of political system.
Socialism
Economic Systems
During the period 1921-1990 Mongolian economic and social systems
were guided by the principles of socialist development. This system emphasized the
equality of all people, eliminated many forms of economic oppression as well as
those based on race, sex, and disability. Everything was owned by the state. The
governments main goal was to provide the population with the basic economic and
social necessities of life such as food, housing, education, health care and social
services. The socialist system had many positive impacts on peoples lives. However,
it restricted peoples freedom of speech and movement. Soviet style socialism also
created a huge bureaucracy, which controlled basically every aspect of social activity.
While following this path to socialism and communism, Mongolia achieved much
and made great progress, yet there were downsides as well. The Human Development
Report (2000) pointed out:
60


During the Soviet era, the people of Mongolia took
rapid strides in many aspects of human development-
with particularly impressive gains in health and
education. Between 1960 and 1990, life expectancy
increased from 47 to 63 years and by 1990 almost
everyone had access to health services. Education
standards too were high- 96% of the population were
literate. Notably, women had shared fairly equally in
this progress- they made up more than 40% of higher
education graduates, for example, and around 85% of
women were working (UNDP 2000,p.l8).
In the beginning of the 1930 sherdsmen were organized into collectives.
During this collectivization period the government of Mongolia and its Stalinist
leader Choibalsan, engaged in a campaign to destroy religious institutions. Thousands
of ordinary monks were forced to leave the monasteries and to enter normal
economic activities. Monks of higher rank were killed during this period. After the
brutal collectivization of herdsmen under the leadership of Choibalsan, the party then
attacked other segments of the population such as the nobility, the intellectuals, and
the nationalists, and even purged its own ranks. Baabar (1999) found:
The hysteria was justified by the imperative of
strengthening the party to adhere to one class. The
campaign was launched right away and within half a
year 5,306 of the 18,000 party members were
dismissed, having been characterized as right- wingers
and exploiters. Being dismissed from the party were
suspect. Also, as a result of three turbulent years of
hysteria, Mongolias debt to the USSR reached
29,500,000 rubles (p.294). ... Out of the almost eight
hundred temples and monasteries almost none were
left. In 1934 there were 771 (according to Choibalsan,
the number was 797) temples and monasteries but 760
of them ceased to exist by 1938 (p.370).
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Between 1937 and 1957 many temples and monasteries were destroyed, the
property of religious and secular leaders was seized, and many thousands of monks
were executed. Mongolia lost its top writers, scientists and intellectuals.
By the late 1950s the vast majority of herders had been forced to join
collectives. The government imposed high taxes on the private sector and confiscated
private property. Many people became wage laborers, working for enterprises
controlled by the communist party. During the socialist period even herding activities
were centrally planned. Every herding household was a member of local herding
collective that was called a negdel. The government was responsible for production
and distribution of all goods and services. The main feature of socialism was
production for use, not for profit. All land and almost all livestock were owned by the
state. Households were provided free veterinary services, animal shelter and fodder,
and transportation services to delivery of meat, milk, wool and wheat. Herders
received a salary for herding. Because of good state support the number of livestock
increased rapidly. The collectivization of herds provided a stable source of raw
materials for the meat, camel wool, leather goods and cashmere needed to develop
national industrial sectors.
Agriculture was less developed than pastoralism because of the harsh
Mongolian environment, but it played, and continues to play an important role in the
economy. As a result of the expansion of crop production there were increases in the
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production of wheat, cereals, potatoes, vegetables and fruits. By 1980 Mongolia was
self-sufficient in grain (wheat) production.
Animal husbandry and agriculture are both heavily dependent on
environmental and climatic conditions. The weather is unpredictable and extreme.
Heavy snowstorms (dzud) which follow drought periods can kill many thousands of
animals and destroy crops, which seriously affects the economy.
With the assistance of the Soviet Union and other European countries, animal
related industries like camel, wool, carpet and coat factories were established in urban
areas. The Mongolian government also emphasized the development of mining and
heavy industry. This industrialization was accompanied by population growth in
urban centers and the construction of large numbers of new buildings and offices.
After WWH the Mongolian government adopted the five-year plan system
of economic development from the Soviet Union. The period of the WWII was
characterized by rapid industrial development that led to rapid increases in urban
populations. The first Two-Five Years Planning periods (1948-1957) focused on
moving the Mongolian economy from one based on livestock production into a more
diversified agrarian-industrial one. It emphasized the development of mining,
infrastructure, transport and communication. The main goal of the Third-Five Year
Plan (1966-1970) was the expansion of power-generating projects. The government
developed mechanized agriculture and increased the power supply to rural areas. The
Forth-Five Year Plan (1971-1975) emphasized the development of carpet, leather,
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timber, processing, and meat packing factories. In 1976, with the development of a
copper and molybdenum mining processing complex, the new city of Erdenet was
built. The main purpose of the Fifth-five Year Plan (1976-1980) was to increase
productive efficiency and product quantity in all areas of the economy. During the
period of 1981-1985 the major focus was on the agricultural sector, especially to
build new fodder farms, establish irrigation systems, and expand mechanized dairy
farms. Finally, during the last Five-Year Plan (1986-1990) the government
emphasized trade and foreign investment.
During the socialist period the Soviet Union provided 85% of all development
aid to Mongolia. Mongolia was integrated into the Council for Mutual Economic
Assistance (CMEA) international planning system. The CMEA was an international
organization of European, Asian and Central Asian economies, headed by the Soviet
Union. During the socialist period Mongolia exported raw materials, minerals and
metals to the Soviet Union and other European countries in exchange for machinery,
fuel, industrial equipment, and consumer goods. As a result of Mongolias integration
into the CMEA system, it became dependent on technological assistance from the
Soviet Union and other European countries.
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Social Systems
During the socialist period, the educational level and living conditions of the
population improved as a result of the establishment of universal free health care and
education. In 1989 public expenditures in the health sector were 5.1 % of GDP and on
education were 10.4% of GDP. The Mongolian health care system emphasized
providing care to the young and growing population. This socialist period was
characterized by a well-developed medical infrastructure, which followed the Soviet
model, with an emphasis on hospital-based curative care over preventive services.
Most of the medical care was provided through clinics and hospitals. The government
budget was the single source of health care financing. The government thus had
strong centralized control over all health services. It focused on increasing the
numbers of specialists in such areas as pediatrics, obstetrics, and infectious disease.
Despite limitations of access to health care services for the rural population
due to large distances and the poorly developed transportation infrastructure, health
care and other social welfare services were well developed in socialist Mongolia.
Partly as a result of such achievements, the total population of Mongolia increased.
Before the socialist revolution, the status of women was low. At that time
most decisions were made by men. Women were in subordinated positions and were
largely excluded from public life. The socialist era brought equal legal rights for
65


men and women, and it greatly increased womens access to education and health
care. The Mongolian socialist government encouraged high rates of population
growth by awarding National Hero medals and maternity allowances to mothers of
four or more children. The government supported women in child bearing and caring
through specific benefits. The government also provided jobs for everyone, and there
was no recorded poverty or unemployment.
Mongolian Elderly
As a result of improved education, living conditions, and good health care
with strong social support services, peoples life expectancy increased from 47 years
in 1960 to 63.0 years in 1990 (UNDP 2000, p.18). During the socialist period, older
people were not neglected. Health and transportation services were free for elderly
people. They received pension payments from the national budget. The aged spent
their later lives with their children and family. Pensions began at age 55 for women
and age 60 for men. Pensions were also based on years of working service, with at
least 20 years for women and 25 years for men. There were some exceptions on age
and length of service criteria for individuals who had worked under hazardous
conditions or who did heavy work. The pension amount was based on a persons
median monthly wages.
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Physician consultations for the aged were free, and prescriptions were
available at low cost. The elderly were able to receive free medical care not only in
hospitals or policlinics, but also in their homes. During socialism the elderly were
treated with great respect and they were valued for their age, experience and
knowledge. They also received free public services.
Summary
Thus the health and social welfare policy of Mongolia until 1990 was directed
toward the goal of improving in education and health care, as well as providing
support and protection for all, including older and disabled persons. This approach
had many benefits for people on one hand, but these policies may have weakened
their individual sense of responsibility on the other. Social development was
significant, yet it was achieved at the cost of some freedoms and, as in other socialist
countries, it resulted in an internationally uncompetitive economy which depended on
significant inputs from the Soviet Union.
Transition to Democracy
In the 1990s Mongolia chose the path of transition from a socialist command
economy to an open free market economy with the intention to improve the life of the
67


people. Mongolia was the first socialist country in Asia to abandon the socialist
model. As a result of the democratic movement, a multi-party parliamentary
democracy was established. The Mongolian government implemented many reforms,
such as the privatization of state property, decollectivization, decentralization of the
political and economic systems, liberalization of prices and markets, increased
foreign relationships, and acceptance of international aid. These socioeconomic
changes increased human rights and peoples rights to free speech, but at the same
time the privatization of public services negatively affected the livelihood of
vulnerable groups, particularly older people.
Current Political Structure
Mongolia is divided into 21 provinces (aimags) and the autonomous capital.
The population of these provinces ranges from 46,000 to 122,000, with the exception
of some Gobi provinces which have populations of as little as 13,000 people. Each
province is divided into several counties or (soum). The population of counties ranges
from 2000 to 6000 persons. Each county is divided into townships, (baghs), the
smallest administrative unit in rural areas. Each township has several hundred
residents. Ulaanbaatar is the capital of Mongolia. It contains 27% of the total
population and it is divided into 8 districts. These districts are further divided into
sub-districts, (khoroos). The governments power is vested in the people of
68


Mongolia; the people exercise it through their direct participation in state affairs, as
well as through representatives whom they elect. The Mongolian government
recognizes all forms of public and private property. The government does not engage
in religious activities, although Buddhism is considered to be the national religion. In
January 1992 the new Constitution of Mongolia was enacted. The Constitution of
Mongolia declared that all people have equal rights. No person should be
discriminated against on the basis of ethnic origin, language, race, age, sex,
occupation, religion, or education. The government is responsible to every citizen for
the creation and maintenance of economic, social, and legal standards, and it
guarantees defense of basic human rights and freedoms.
The Human Development Report (UNDP, 2000) pointed out:
Mongolia enters the new millennium as a dramatically
different country. Ten years of transition have
established Mongolia on a radically new path and
injected fresh energy and momentum. For many people
the changes of the 1990s have opened up vast new
economic opportunities, though for others they have
caused huge and painful upheavals. In some respects
the transition has thrust human development into
reverse.
The change from socialism to a market
economy was inevitably going to be confusing and
disruptive. Each transition country has had to find its
own way, testing new forms and innovative
approaches. Ten years on, however, it is appropriate to
pause for thought, to make a more realistic assessment
of what has worked and what has failed- and make the
best choices for the ten years ahead (p. 12).
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Effects of the Economic Transition
During the last 10 years, financial assistance from the Soviet Union and
CMEA countries has declined dramatically. Because about 90% of Mongolian
external trade was with the Soviet Union until the beginning of the 1990s, Mongolian
Gross Domestic Production decreased by 30% since 1990. The loss of this income
caused the failure of many national industries due to lack of technical resources from
the Soviet Union and the loss of CMEA markets. The same problems occurred in the
agricultural sector. Mongolia experienced a tremendous economic shock.
Consequently, these losses have led to Mongolias present problems, poverty and
human insecurity. According to the Human Development Report (2000):
Between 1990 and 1993, real wages in industry
dropped by one-fifth and in agriculture by nearly one-
third (p. 9). As a result of reduced GDP, the
government is faced with a budget deficit, and the
budget for public services was cut. Between 1993 and
1998 total government spending dropped from over
50% of GDP to 37% (UNDP 2000, p.30).
Mongolia, more so than other transition countries, chose the path of shock
therapy- removing many controls quickly and trying to pass as much activity as
possible into private hands. Over the period of 1990-1992 around 3,000 small and
large enterprises were privatized (Human Development Report, UNDP 2000:28).
Such quick and poorly prepared privatization of industries and farms produced large
70


numbers of unemployed. Unemployment figures are unreliable, registered
unemployed numbered 6.5% in 1991, and 8.7% in 1994. The Mongolian government
issued vouchers to individuals to purchase shares in previously state owned
enterprises, but the implementation of the privatization plan was mismanaged,
insufficient, and often corrupt. The process led to a rapid growth of poverty. During
privatization (1990- 1992), public service workers such as teachers, doctors and the
majority of the urban residents received little or nothing. Also during this period,
public sector construction, apartment building and improvement of housing in gers
(traditional dwellings) were left untouched. This rapid transition brought many
negative consequences such as poverty, inequality, increased crime, violence,
alcoholism, STDs, deforestration, and produced air pollution. It also increased the
number of female-headed households and street children.
During the early stages of the economic transition, Mongolia experienced the
most painful period of economic and social crisis. All national industries were closed
and many thousands of people lost their economic and social security. At that time
there were food shortages, and basic items like flour, meat, rice, and tea were
distributed by food stamps. The prices of basic food items increased but the salaries
and pensions were left unchanged. People who worked in state organizations were
unable to live on their monthly salaries, and many educated people started to do
various private sector jobs such as driving taxis and trading in the informal sector.
71


In rural areas decollectivization and privatization of livestock took place.
State farms were privatized and agricultural cooperatives were divided into small
companies. By 1992 about 70% of the national livestock herd had been privatized.
This process left many herders with too few livestock to support their households.
Previously the government exercised responsibility over all production. The
government had provided emergency help, veterinary, and transportation services for
seasonal moves. After transition these services were no longer available. After the
economic transition private herders were given greater opportunities to increase the
number of their livestock, They could sell milk, meat, dairy products, wool and
cashmere in order to buy needed basic consumer products. But they were also
required to survive natural hazards independently. The extremely harsh environment,
in combination with heavy snowstorms, preceded by drought in 1999-2001 killed
many thousands of livestock. It seriously undermined the countrys major economic
sector and forced many herders into severe poverty. Herders who lost livestock
during snowstorms moved to the cities to search for jobs. A Survey report of those
living in a ger areas of Ulaanbaatar, conducted by Japan International Cooperation
Agency (JICA) and Agency of Mongolia (2002), noted that the mechanic growth of
the urban population within the period of 1992-1999 is comprising 92%, and directly
connects to the changes in the structure of the society. If the share of the poor
families was 12% in 1993, it rocketed up to 28% in 2000(p.l4).
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After privatization of livestock, a hierarchy of informal social institutions that
are called hotail have reemerged. The hotail consists of several households,
mostly those of relatives or close friends, who live together and pool their resources.
They help each other in caring for livestock, trading animal products, and
collaborating during emergencies and disaster. The hotail is the modem equivalent
of the pre-socialist rural social unit.
Thus, the privatization of state property and decollectivization processes
produced huge unemployment and destroyed previously existing health care and
social welfare services. According to the UNDP (2000), about 35.6% of the
population are now poor. Female- headed families and families where the head is
unemployed are the poorest.
Poverty is a new phenomenon in Mongolia. Of these 35.6% of the population,
about 39.4% of the poor live in urban areas; of these in Ulaanbaatar about 34.1% of
population is below the poverty line. Poverty levels are defined by the monthly
income of households. The government has set the poverty line at $16 (17,600 tg) for
urban residents, $12.5 (13,800 tg) for rural residents. The Mongolian government has
recently developed different programs to reduce poverty, but unfortunately poverty
remains high, especially in urban areas.
Between 1992 and 1998 as a proportion of GDP, government spending on
health, education, and social security continued to drop-from 16.2% to 14.8%
(UNDP 2000, p. 9). Many schools and kindergartens have been closed and many
73


teachers have left their jobs due to insufficient school funds. According to the 2000
population housing census of Mongolia:
At the younger age group of 15-19, the proportion of
illiterate persons rises rapidly to above 3% (p. 75).
.. .By the year 2000,68.2 thousand children aged 8-15
were not attending school, out of which, 41.2 thousand
or 61.7% were boys and 26.1 thousand or 38.3% were
girls. The sharpest decline occurred between age groups
10-14 and 15-19 where school participation fell from
87.9% to 47.3% of the age group (NSO, 2001, p.76).
Ulaanbaatar is the main city where most people seek better education and
employment opportunities. During the transitional period, rural to urban migration
was high. The size of Ulaanbaatars population increased dramatically after 1992,
especially in sub-urban ger (traditional dwelling) areas, where poverty is also high.
According to the 2000 Population and Housing Census (2001), altogether 360,522
people migrated out of the other regions while 268,988 migrated into Ulaanbaatar(p.
57). During the economic transition the situation of the Mongolian family changed.
Families become more isolated as a result of increased rural- to-urban migration with
decreasing social support and community solidarity. Divorce rates, domestic
violence, and the number of street children also increased. Many children faced
I
poverty, violence, and hunger. The National Statistical Office (2002) determined:
Of the 541,149 household in the country, 83.7% are
headed by males and 16.3% by females. This percent of
female-headed households is much higher than the
10.2% estimated in 1998. ...In the country, 14,000
women live by themselves.... Among female heads,
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44.2% are 50 years and older... Nearly 10.0% of the
female heads are unemployed (UNDP, 2000, p. 43).
Health System Reforms
The socialist health system, with its centralized budget, focused on the
development of Western style technological medicine and restricted traditional
medicine. In 1990 this system was decentralized, with authority devolving to the local
province governors. The goals of the new health policy emphasize:
strengthening preventive and curative health care with more emphasis on
prevention
improving health institutions, particularly in rural areas
reducing maternal and child mortality
encouraging health promotional activities including family planning
introducing compulsory health insurance and private medical practice in health
care
improving access to health services for vulnerable groups
decentralizing the financial and budgeting systems and service deliveries
improving management and quality of health care services
better utilizating human resources
supporting research in Mongolian Traditional Medicine
75


developing medical science
There are four levels of health care services in Mongolia. Level 1 is the
smallest organizational unit, and it consists of the township (bagh) in rural areas and
the sub-district (khoroo) in urban areas. Primary health care services in townships are
provided by the community health worker (bagh feldsher) and in the sub-districts by
family doctors. Each county has 5 to 6 townships, each having 50-100 households.
The township centers are typically located 20 to 80 km from the county center. In
urban areas family doctor groups provide the primary health care services. The family
doctor groups consist of 4 to 6 doctors, 4 to 6 nurses and a few other maintenance
workers, depending on the size of the population served. One family doctor group
serves approximately 4- 6,000 people who live in particular sub-districts. A single
doctor is responsible for 1,200-1,500 officially registered residents, but at the same
time they must by law provide services to unregistered migrants. The main functions
of the community health workers and family doctors are to provide periodic home
visits, preventive services, and immunizations, and to identify and provide prenatal
care to pregnant women. They also provide simple curative care and help transport
sick people.
The second level of care in rural areas consists of a county soum hospital,
and in urban areas the public health centers. The typical county hospital has several
doctors: physicians for internal medicine, pediatrics and obstetrics, 2 to 4 community
health workers, 3 nurses, and one pharmacist. County hospitals have 10-30 beds, a
76


delivery room, and maternity waiting homes. Second level care provides emergency
curative services, obstetric care for normal pregnancies, health promotional activities,
family planning, and transportation patients to the next level if needed.
The third level of health services consists of general hospitals in the province
centers and district hospitals in urban areas. This level has relatively better diagnostic
equipment and better qualified specialists in surgery, gynecology and obstetrics,
pediatrics, and internal medicine, and it provides primary care services to the
province center population. Province hospitals have 200- 400 beds, act as referral
centers for county hospitals, and provide in-patient care and other specialized
services.
The fourth, highest level of care consists of general and specialized medical
and public health centers in Ulaanbaatar, with the most sophisticated equipment and
medical specialties.
Before the economic transition, health services emphasized curative, hospital-
based care, associated with high costs of goods, including medical equipment, drugs,
and trained specialized doctors. During the transitional period, all health care services
declined as a result of a lack of essential drugs, medical equipment, transportation,
and fuel. Access to health care was limited for rural populations as a result of
inadequate infrastructure, poorly developed transportation and communication
systems, sparse and low population density, and harsh environmental conditions.
Rural areas also lacked doctors, because many doctors did not wish to work in rural
77


areas due to harsh working conditions and low salaries. Many doctors left their jobs;
their numbers decreased from 45,600 in 1990 to 30,200 in 1997 (WHO, 1999, p. iii).
Currently the government now seeks the enrollment of medical students from the
countryside; these students will be required to return and practice medicine in their
home communities.
A compulsory national health insurance system was introduced in 1994 to
cover inpatient services. Initially the health insurance fund was under the control of
the Ministry of Health. In 1996 it shifted to the control State Social Insurance
Government Office. The health sector is now funded by the government budget and
the health insurance fund. The health insurance is compulsory for all employees and
employers and theoretically covers 98% of the population. The government pays half
of the contributions for employed people but provides full payment for children under
age of 16, students, elderly, pregnant women, and soldiers. Treatment of infectious
diseases such as tuberculosis, brucelosis, STDs, AIDS, and diabetes is financed
directly from government funds. The health insurance law was revised in 1997 and
some changes were made. For example, drugs were provided free to hospitalized
patients. In public hospitals patients are now required to pay 10% for inpatient
treatments. The system of payment is similar for private hospitals. According to this
law, half the price of the essential drugs prescribed by the family doctor or
community health workers are reimbursed by the health insurance fund.
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Health policy presently attempts, to reduce health expenditures by focusing on
the development of primary health care (PHC). PHC is community-based treatment
or basic curative services with an emphasis on the prevention of diseases through
health education, health promotion and immunization. It is now accepted as the most
cost-effective way to improve the health status of the population. WHO (1978) noted
that "Primary Health Care is essential health care made universally accessible to
individuals and families in the community by means acceptable to them, through their
full participation and at a cost that the community and country can afford(p.2).
Phillips (2000) wrote that:
A multi- pronged approach is probably needed,
involving proper development of primary care teams,
perhaps the instigation of patient list- based and
publicly supported general practitioners/family doctors;
incentives for health promotion rather than treatment;
and public education. Developing proper and integrated
primary care referral systems to secondary levels is
essential to minimize inappropriate use of hospitals
(P-31).
Family doctor services have been introduced in all districts of Ulaanbaatar
and a few provinces. The governments goal is to expand primary health care to rural
populations through providing additional specialized medical services. The new PHC
system is being supported through loans and grants from the Asian Development
Bank. Family group practices are small private units, working under contract with the
local government. Typically the family doctor has to have a broad medical
knowledge and works closely with patients. Family doctors provide needed and cheap
79


health care services to the community. In other words, family doctors are the
community health care providers or gatekeepers. If patients need a specialist, a
family doctor will refer patients to the appropriate level of care. The family group
practice is funded through a capitation based system. One family doctor serves 1200-
1600 people in urban areas. In this system patients can theoretically choose their
family doctor. Each resident of the sub-district has to be registered with a family
doctor and for all health problems an individual first has to go to the family doctor for
consultation and, if necessary, referral.
Some private clinic and hospitals have been founded since 1989 and mainly in
Ulaanbaatar. (See Table 3.2).
Table 3.2. Private Health Care Institutions in Mongolia (2001).
Type of service or Institution Number in all Mongolia Number in Ulaanbaatar
Private hospitals with beds 75 45
Private pharmacies 320 184
Drug wholesale agencies 42 42
Dental clinics 148 83
Gynecological clinics (abortions and STD treatment 60 43
Traditional Medical Clinics 59 45
Source: Government of Mongolia, Ministry of Health and Social Welfare.
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Self-employed private doctors rent offices, with equipment from previous
public facilities, and provide treatment with payment for service. Private services are
provided mostly in the areas of traditional medicine, gynecology, dentistry, and
ophtalmology. Many large hospitals in Ulaanbaatar have leased out hospital kitchens
and laundry facilities to small private clinics. Due to decreased living standards and
purchasing abilities of many Mongolians, the private sector has not been as rapid as
might have otherwise been the case.
With the end of socialism, Mongolia began to re-develop its traditional
medical heritage. Before socialist revolution, traditional medicine was the dominant
system of health care, practiced primarily by Buddhist monks. During the aggressive
Choibalsan purges of the 1930s, traditional medicine mostly disappeared in Mongolia
and was practiced in secret by just a few people. Also during this time, religion was
restricted and Buddhist rituals had to be performed in secret.
There are public and several private traditional medical clinics in Mongolia.
One of the biggest public traditional clinics is the Traditional Medical Science,
Technology and Production Corporation of Mongolia. It has 60 in-patient beds. Care
is covered by the national health insurance plan. As with other hospitals, insured
patients must provide a 10% co-pay. Retired people are hospitalized for free, but
there is often a long waiting list for admission. There are certain restrictions for
hospitalization in the traditional clinics. Patients with acute diseases, high blood
pressure or cancer, and patients with surgical conditions are excluded. At this clinic
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patients are treated for many different kinds of chronic diseases. Diseases are
diagnosed by pulse-taking and traditional analysis of urine by color, appearance, and
smell. The clinics use some biomedical drugs in emergency cases. Treatments such as
herbal therapy, bloodletting, acupuncture, massage, ionic treatment, cupping, mineral
baths, and mud treatments are provided at these clinics. Traditional medical clinics
require referrals from family doctors or province hospitals. The Traditional Medical
Science, Technology and Production Corporation has a small factory for making
herbal medicine. Over 160 doctors oriented to traditional medicine have graduated,
and nearly 300 doctors trained in western medicine have attended short term (2 to 10
months) training courses in traditional medicine(WHO, 1999, p. 56). Now each
province hospital has a department of traditional medicine, and many province
hospitals have inpatient beds for traditional care. In Ulaanbaatar, district hospitals
provide outpatient services such as massage, acupuncture, herbal and mineral
therapy. One popular private traditional medicine clinic is called Manba Datsan. This
clinic is more religious in its orientation, where training and clinical services are
integrated.
With the increasing number of elderly people, together with the burden of
chronic, degenerative diseases which require high cost therapy, it is important to
provide effective and inexpensive traditional medicine in health care. Also, with an
increase in the aged population, the incidence of poverty will increase, because
elderly people are more likely to be exposed to poverty than others. Therefore, it is
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important to integrate traditional medicine with modem medicine and into the
delivery of primary health care services, particularly to the elderly. Janes (1999)
wrote that:
.. .the experience of developed countries suggests that
dissatisfaction with biomedicine, dissatisfaction driven
by publicized iatrogenesis, perceptions of
ineffectivness, costliness, inappropriate medicalization
and so on, will drive an increased demand for
alternatives... Traditional medicine may be seen by
governments as an attractive supplement to
biomedically-based health services insofar as
traditional medicine is typically less expensive, often
more widely available and typically uses locally
available resources (p.1809).
Social Welfare Services for the Elderly
The Mongolian Constitution of 1992 states that all people have rights to rest,
social services for age, disability, or disease; to education; to health protection; and to
receive material assistance in old age. Currently, the Mongolian government is trying
to build a new system of social protection through the implementation of laws,
regulations, and programs concerning elderly issues. A law establishing social
insurance was established in 1995. According to this law, women who had paid
contributions to the pension insurance fund for a period of not less than 20 years and
who had reached the age of 55; and men who had not less than 25 years length of
service and reached the age 60 have a right to retire. Also women who have four or
83


more children have the right to retire at the age of 50. The social insurance funds are
accumulated from budget subsidies and the insureds employer. The Social Welfare
Fund is used for pensions, allowances, and care of invalids; it is distributed by social
welfare services. The majority of elderly in Mongolia receive a pension from these
funds.
According to the statistics of the office for State Social Welfare (2001),
nearly $ 182,000 (198 million tg) was given to the elderly by the state in 2001. Of the
180,180 elderly in Mongolia, 4492 (2.5%) elderly were sent to sanatoria, places for
short term therapy and relaxation, and 3649 (2.0%) elderly were sent to recreational
centers, where all payments were made by government. There are 125,093 (69.4%)
elderly who have contact with their previous workplaces, which provides support to
them, and 35,605 (19.8%) do not have any relations with previous work places due to
the privatization process. Each October first, is known as elderly day, and during
Tsagaan sar, the Asian traditional holiday, administrators of previous work place
invite retired elderly, and show them special respect, greetings, and give them special
meals and gifts. Each Asian New Year the president of Mongolia sends special gifts
to the elderly age 100 and older. In 2001, the Mongolian Elderly Federation helped
20,945 people contact their previous employers. In 2001, 886 (0.5%) elderly
participated in poverty reduction programs and about $87,300 (96 million tg) in loans
was distributed to them under this program.
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During the economic transition, the value of government payments to the
elderly and disabled were eroded significantly by inflation. This increased their
dependence on children and relatives. The Health Sector Review (WHO, 1999)
stated:
The Health Status of the Mongolian elderly population
is affected by a low standard of living as a consequence
of low pension level which equals to 12,000 MNT (14
U.S. $ in 1998) per month on average. This is
worsening their possibilities to ensure proper nutrition
and access to health services, (p. 57).
Today elderly people are among the most vulnerable groups in Mongolia.
Most of the elderly live on declining pensions, which is their main source of income.
There are some lower rates on payments for apartments, electricity, medicines for the
elderly and medical services for veterans, and flee transportation and health care, but
these are not sufficient. According to the health insurance law, drugs are free for all
hospitalized patients, but in reality, as a result of insufficient health care funds, many
people are forced to pay for treatment out-of- pocket. Hospitals in rural areas have
particular difficulties buying medicines or diagnostic equipment, and patients must
pay themselves or do without.
Many elderly in Mongolia are chronically ill. Their pensions are insufficient
to pay for expensive medicines and treatments. In most situations, children and
relatives help them purchase these things. However, due to the poor economic
conditions, children may be unable to help their elderly parents in need of care
85


because they are unemployed and lack money themselves. Ironically, instead of
receiving support and help from their children, today many elderly find themselves
supporting their children. Pensions have become a main source of income in many
families, especially in rural areas. These elderly pensions are equal to or even lower
than the minimum subsistence level needed for an individual. Thus, pensions are not
sufficient to meet the basic needs of normal life, especially for an entire family.
Elderly people who live in cities dont have enough money even for food. They
cannot afford meat, milk or vegetables, and they do not have money for medicines,
clothes, or other needs. Many retired people who worked for state organizations were
left without money or savings. Most of them cannot travel to receive treatment in
sanatoria. Privatization of state-owned enterprises and farms cut the support of
elderly, and they lost the social and economic support they would have received in
the past from their previous work places. In addition to financial stresses, loss of ties
to previous work places increased their loneliness and isolation.
In 2000, there were 30,128 women aged 50-54 receiving pensions. They were
retired at age 50 because of the large number of children they had borne. Most of
them would like to continue work, but they often have difficulty finding jobs. Even if
they wanted to have a small business, they dont have money to start it. The socialist
government offered special allowances to pregnant women and women taking care of
their children. In some cases, this provided a motivation for some women to have
babies, particularly in rural areas where cash was limited. However, subsequent to the
86


economic transition, women who have many children were hit hard by poverty, and
they were left with few state benefits, few opportunities to work, but many children to
support. The economic transition negatively affected women, with an increased
burden particularly on rural women. Womens roles as caregivers expanded and their
need to earn wages to provide for their family income also increased.
The five year period from 1999 to 2004 were declared as National Program on
Health and Social Protection of the Elderly with a goal to develop health and social
welfare services for the elderly.
The Human Development Report (UNDP 2000) determined that:
A survey of 1,000 people conducted in 1999 for this
report found dissatisfaction for most social services.
The following percentage of people surveyed found
them either mediocre or bad: 81% in health, 77% in
education, 77% in welfare services, and 74% in social
insurance services. When asked what were the main
problems with public services, the most common
responses were: high charges, poor management; the
wrong policies, and low quality. In the case of the
social welfare services they were understandably
unhappy with the level of benefits (p. 45).
Revival of Traditions
Today Mongolia is trying to revive old traditions and religious rituals. Gandan
Keid, the old center of Buddhist faith, has opened for worship, and some monks are
allowed to perform religious ceremonies in it. There Mongolian people created a 40
87


meter high statue of Aviloketeshvara (the Tibetan, Chen-re tsis). A college of
Buddhism has been opened in UB. The majority of Mongols, especially the elderly,
still follow the traditional life of their ancestors and maintain or recreate their old
religious rituals.
Summary
Mongolia is a large country with a small population. In the 20th century
Mongolia encountered many changes. It moved from being simple agrarian state with
little market or industrial development to a capitalist free market economy. In mid-
century Mongolia experimented with Soviet style development. During this period of
vast changes, Mongolia achieved many things, but at the same time made many
mistakes. The socialist state (1921-1990) emphasized equality for all people, and
provided the population with the basic economic and social necessities of life; it
provided security for all people as a result of universal free education, health care
services, and improved living conditions. The Mongolian population increased in
size, and peoples life expectancy increased. Elderly people, children, and women
benefited in many ways. But at the same time, the socialist command economy
stagnated as a result of insufficient or inefficient industries, producing few consumer
goods. Human rights were compromised. During the 1930s, many thousands of
innocent people were persecuted and purged by the single ruling communist party.
88


The socialist health system emphasized hospital based curative care, which produced
too many specialized doctors and resulted in a very limited number of general
practitioners. Primary care was undeveloped. The economic transition that occurred
in the 1990s terminated the previously existing economic assistance and trade
agreement with the Soviet Union. This, in turn, resulted in a vast economic crisis.
Rapid and mismanaged privatization of state properties produced unemployment and
undermined the living standards of thousands of Mongolians. Structural adjustment
programs initiated by the International Monetary Fund and the World Bank produced
cutbacks in social welfare services, which negatively affected the lives of the
community. Poverty became widespread in Mongolia, particularly among the elderly,
children, female-headed households, and unemployed. High migration, which
resulted from economic chaos, led to a breakdown of the family support system and
old age security.
Thus, elderly people were among the most adversely affected by the economic
transition. They were faced with poverty; compulsory retirement, especially women
with four of more children; unemployment of children; poor quality of health care;
few social welfare services; and a high degree of stress. It is projected that the
number of elderly people will increase in the future. Therefore, exploring the lives of
older people, defining their needs so as to improve their quality of life, health care,
and social services, is an important task.
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Full Text

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THE IMPACT OF SOCIAL AND ECONOMIC TRANSffiON ON MONGOLIAN ElDERLY by Janchiv Khulan B.S., Mongolian Medical University, 1989 MS., Mongolian Medical University, 1998 A thesis submitted to the University of Colorado at Denver in partial fulfillment of the requirements for the degree of Master of Arts Anthropology Z003

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This thesis for the Master of Arts degree by Janchiv Khulan has been approved by 2--1 -o"3. Date

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Khulan, Janchiv (M.A., Anthropology) The Impact of Social and Economic Transition on Mongolian Elderly Thesis directed by Professor Craig R. Janes ABSTRACT In the early 1990's, Mongolia chose a new path of development. Mongolia changed from the communist centrally planned economy to an open democratic political system and a free market economy. Many reforms have been implemented, including privatization of state owned enterprises, private livestock ownership, the deregulation of price control, decentralization of political and economic systems, increase of foreign relationships, and acceptance of foreign aid programs. These socioeconomic changes brought poverty, inequality and unemployment. Alcoholism, crime, social and economic stress, and poverty related diseases including tuberculosis, malnutrition, SID's and AIDS have increased markedly. This transition has had profoundly negative effects on the quality oflife of Mongolians, particularly the elderly. The purpose of this study was to determine how the economic transition that occurred in 1990s in Mongolia has affected the elderly. This research is the first study of its kind that has sought to describe how the economic transition has affected Mongolian elderly. This study examined elderly's opinions about the socioeconomic changes and problems faced by the elderly. In addition, it provides a comparative study of the experiences of urban and rural elderly. Analysis of the survey suggests that the economic transition has had a negative impact on Mongolian elderly, and that are significant differences between urban and rural residents, and between men and women, in their experiences of and responses to the economic transition. This abstract accurately represents the content of the candidate's thesis. I recommend its publication. iii

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DEDICATION I dedicate this thesis to my dad Janchiv, 65 years old, and to my mom Geezav, 60 years old, who gave me opportunity to be educated and taught me the value of hard work. I also wish to dedicate this study to my father-in-law, Khalzan, 82 years old, and my mother-in-law, Tsep.d, 71 years old, who raised a wonderful and lovely son, my husband, Jargalsaikhan. I also want to dedicate this thesis to the participants who readily agreed to be a part of my study, and to all of the elderly around the world, these honorable and exciting people from whom the younger generation has the privilege to learn.

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ACKNOWLEDGMENTS I would like to express gratitude to all the members of my thesis committee. A very special thanks and deep appreciation to my academic advisor, thesis committee chairperson Dr. Craig Janes, for his invaluable advice and for all his assistance and support in making this thesis. Grateful acknowledgment to Dr. Kitty Corbett and Dr. Cindy Bryant for their patience, guidance and suggestions to the completion of this thesis. My sincerest thanks to the staff of the Graduate School and to all other faculty members of the Anthropology Department at the UCD for their wann understanding and support during my academic study. This academic year was one of the most important parts of my life with many memorable learning experiences. My thanks and great appreciation to Dr. Ingrid Asmus, who spent considerable time assisting me with the editing of this thesis. I am also deeply appreciative of the elderly people who made this study possible. Special thanks to my parents, brothers and sister for their continued love, encouragement and support. Most of all I would like to acknowledge with many thanks to my family the most special people for me: to my great husband, J argalsaikhan, to my wonderful children, son Ankhbayar and daughter Orkhon, who never complained about my long hours of study and who have been a constant source of love and support throughout my study. Without their support and encouragement this study would not have been possible. Thank you very much to all of you!

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CONTENTS Tables ..................... .............................................................. x CHAPTER l. IN'I'ROOOCTION .............................................................. 1 Goal of Study ...... .................................................... I .Specific Aims ........................................................... 2 Significance of the Study ............................................... 2 Socio-economic Change and Globalization ......................... 3 Population Aging ....................................................... 4 Agin As" g m 1a .... ............... : ...................................... 8 Overview of the Study .......................... _. .................... 10 2. AGING AND ......................................... 12 Anthropology and Aging ............................................. 12 Demography and Demographic Transition ........................ 15 Types of Aging ........................................................ 17 Biological Theories of Aging ....................................... 19 Psychological Theories of Aging ................................... 23 Social Theories of Aging ............................................ 24 Social Change Theories.............................................. 27 vi

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Effects on the Underdeveloped World...... . . . . . . . . . . . . .. 29 Theories of the Effects of Social Change on the Elderly... . . . . 31 Effect of the Economic Transition on Asian Elderly... . . . . . . 35 The Case of China... . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Conclusion.:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 3. THEMODERNIHSTORYOFMONGOLIA ................................ 54 Background ............................................................... 54 Demography............................................................... 54 Mongol Empire... . . . . ... . . . . . . . . . . . . . . . . . . . . . . 57 Independence............................................................. 58 Socialism... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Economic Systems ..... : ....................................... : 60 Social Systems ...... ... . . . . . . . . . . . . . . . . . . . . . 65 Mongolian Elderly ........ ............................ . . . . .. 66 Summary ... : ...................................................... 67 Transition to Democracy ................................................. 67 Current Political Structure... . . . . . . . . . . . . . . . . . 68 Effects of the Economic Transition......... . . . . . . . . . 70 Health System Reforms.............................. . . . . .. 75 Social Welfare Services for the Elderly... . . . . . . . . . .. 83 Revival of Traditions... . . . . . . . . . . . . . . . . . . . . 87 vii

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Summary ................................................................... 88 4. METHODOLOGY ................................................................ 91 Goal of Study........................................... .. .. .. .. .. ...... 91 Research Methods...... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ... 92 Description of Interview Sample..................... . . . . . . . . . 95 Data Analysis............ . . . . . . . . . . . . . . . . . . . . . . . . 96 5. FINDIN"GS .. ,...................................................................... 97 Summary .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. ... 101 Demographic and. Socio-:-economic Characteristics of Study ............. ; . .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. . .. 102 Summary ofDemographic and Socio-economic Characteristics ... . . . .. . . . .. .. .. .. .. . . .. . . . .. . .. .. .. .. .. 108 Health Conditions of the Participants................................. 109 Elderly Opinions Concerning Health Services . . . . . . . . . . 119 Opinions and Issues about Family Doctor System . . . . . . . . 120 Participants' Opinions and Their Concerning Issues about Private Doctors .. . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. ... 123 Elderly Opinions and Main Concerns about Traditional Medicine .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. 125 Elderly Opinions about the Economic Transition and Their Concerns ....................... :. .. .. .. .. .. . .. .. .. .. .. ... 129 Dail A ... y .cttvrttes ........................................................... 136 Pension...................................................... .. .. .. .. ... 137 viii

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Discussion of Results ............................................................. 144 Limitations........................................................................ ISO 6. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS . .. ... lSI .Summary.................................................................. 151 Conclusioils ...... ........ ... ... ...... ... ... ... ... ... ...... ... ... ... ...... 152 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Future Research ... ... ... . . . . . . . . . . . . . . . . . . . . . . . . 161 APPENDIX A Human Subjects Research Committee at the University of Colorado Denver Approval ........................... 163 B. Interview Questions.................. . . . . . . . . . . . . . . . . . 164 GLOSSAR.Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 166 ABBREVIATIONS ........................................................................ 168 BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 ix

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TABLES Tables 1.1 World Population Aging 1950-2050...... . . . . . . . . . . . . . . . ... . . . . .. 6 1.2 Population Aging 1950-2050 in Japan, China, and Mongolia.................... 9 3.1 Structure of the Mongolian Population, 1950-2050.............................. 56 3.2 Private Health Care Institutions in Mongolia (2001)............................. 80 5.1 Demographic Characteristic of Sample by Residence .. . . . . . . . . . . . . 104 5.2 Demographic Characteristic of Sample by Sex.................................. 105 5.3 Household Size and Number of Children by Residence . . . . . . . . . . ... 107 5.4 Health Conditions by Residence and Sex........................................ 109 5.5 Dlness Symptoms by Residence . .. .. .. .. .. .. .. .. ... .. .. .. .. .. .. .. .. .. . .. 110 5.6 Dlness Symptoms by Sex........................................................... 112 5.1 Dlness Symptoms by Age of Those Experiencing Symptoms ... ...... ........ 114 5.8 Hospitalization in Last Month by Residence and Sex.......................... 115 5.9 Hospitalization in Last Year by Residence and Sex . . . . . . . . . . . . ..... 116 5.10 Issues Getting Care and Issues Care Regarding by Residence .. . . . . . . 116 5.11 General Opinions about Family Doctors and Private Doctors by Residence .. .. .. .. .. . .. . .. .. .. .. .. .. .. .. .. .. . .. . .. 120 5.12 Specific Opinions about Family Doctors and Private Doctors by Residence ... .. . . . .. .. ... .. ... . . .. .. . .. ... . . . .. 121 5.13 General Opinions about Traditional Medicine by Residence .. .. .. . .. .. .. .. .. . . .. .. .. .. .. .. .. .. .. .. .. 126 5.14 Specific Opinions and Issues about Traditional Medicine by Residence . . . . . . . . . . . . . . . . . . . . . . 126 5.15 General Opinions Given by the Effect of the Economic Transition .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. 130 X

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5.16 Specific Opinions Given about the Effect of the Economic Transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 5.17 Daily Activity and Residence . . . . . . . . . . . . . . . . . . . . . . . . . .. 136 5.18 Age Began Pension and Residence . . . . . . . . . . . . . . . .. . . . . . . . 138 5.19 Pension Amount by Residence . . . .. . . . . . . . . . . . . . . . . . . . . . . 138 5.20 Pension Amount by Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 139 5.21 Specific Opinions Given about the Effects of the Economic Transition . . . . . . . . .. . . . .. . . . . . . .. . .. 142 xi

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CHAPTER 1 INTRODUCTION _Goal of Study The main goal of this study is to describe how the social and economic transition that occurred in thel990s in Mongolia affected the elderly. During the summer of 2002 I carried out an ethnographic study designed to clarify Mongolian elderly's perspectives on economic changes. For the pwpose of this study I defmed elderly people as those who are no longer considered employable in Mongolian society and are qualified to receive pensions from the government. This may be as young as 50 years for women and 60 for men. In this survey I conducted interviews with elderly and collected their opinions about the economic tra.Tisition and how they have been affected by this change, identified problems and needs faced by the elderly, and compared urban and rural elderly. Today, there have been just three previous studies of the economic and living conditions of Mongolian elderly. None of these addressed the elderly's own perspectives and opinions about the economic transition. The goal of this study was thus, to ask opinions of the elderly regarding the socioeconomic transition and its effects on their lives. I

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Specific Aims The specific research questions: of this study are: 1. How did thesudden economic transition affect Mongolian elderly? 2. What did they think about the economic transition? 3. What differences exist between urban and rural elderly in terms of their education, living conditions, daily activities, and the issue of getting health care and a pension? Do they have any particular problems, and if so, how do the elderly respond to these problems? -What sources of assistance are available to them? What kind of issues and concerns do they have? Significance of the Study The findings of this study will contribute to better understanding of the needs of the aged in Mongolia, with the goal ofhelping to improve their quality of life. Because many ethnographic studies of socio-economic changes in China have shown positive effects on the quality oflife for the elderly, and because China's political and economic background is similar to that of Mongolia, this thesis will use data from China for comparative purposes. The intention is to discover public policy guidelines that may benefit the aged in Mongolia. 2

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Socio-economic Change and Globalization Rapid socioeconomic changes associated with globalization are occwTin.g throughout the world, iDcluding Asia. Globalization refers to the "democratization" of capital, technology, and information across national borders to create a global market, which is integrated with international political and economic systems. With the commercialization and globalization of the world, dominant countries benefited by accumulating capital and speeding economic growth. In contrast, peripheral countries have become poorer and more dependent on others. By the mid 1990s almost all countries in Asia, South America, and Africa were integrated into a world market economy led by the US. Andre Gunder Fr8.nk (1996) wrote that the capitalist world economy is committed to production for sale of exchange; its goal is to make more profit. While different countries have distinctive political organizations and economic patterns, today these societies are related to each other by unequal exchanges of material and capital between the periphery and the core. Economic development is assumed to lead to improved social development. However, in reality economic development may increase the vulnerability of a society and cause deterioration in the quality of people's lives. These changes with globalization have increased the dependence of developing countries on foreign investments. Structural adjustment policies of the futemational Monetary Fund and 3

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the World Bank have resulted in cutbacks on social spending and especially on the services most needed by the elderly, such as health, education and housing (Polivka et al., 2002). Due to increased debt, governments of developing countries have lost their power at the international level. Privatization of public services in these countries has negatively affected the most vulnerable groups. Reduced fertility, along with urbanization and industrialization has led to changes in family structure and family care giving roles. Economic development has also led to ruraltourban migration, which also weakens family ties and traditional support for the aged (Lechner et al., 1999, Phillips 2000, Bengtson et al., 2000). Population Aging Aging is an inevitable and universal process for all humans. Yet, the physiological processes of age are modified considerably by culture. One of the key factors in cultural evolution is population growth. As human societies have developed, population has grown, as has the complexity of social structure and scale of economic activity. This development has also propelled a demographic transition in many countries. Until the 20th century few individuals lived to advanced age. Today, however, population aging and the increasing needs of the elderly have become major issues worldwide. Population aging is a process characterized by an increase in the proportion of the elderly in a population. It is a result of the demographic transition from high 4

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levels to low levels of fertility, and is associated with increases in life expectancy, and reduced mortality .. Aging has become a critical and central issue on every level local, national, and international. Bengston et al. (2000) wrote that: On the global level, the main force behind these changes relating to old age has been the process of modernizationencompassing industrialization; economic growth; urbanization; and their attendant changes in value orientations, social norms, institutional arrangements, and behavioral patterns ... While basically a demographic trend, population aging is in fact a revolutionary force that is affecting the social, culture, political and economic conditions oflife in whole societies (p.3). In the 2151 century, all countries will face population aging. Population aging is both a cause and consequence of changes in economy and social structure. Today according to the United Nations World Population Ageing I950-2050 (2002), the world's population is at 6.1 billion and expected to increase to 9.3 billion by 2050. Worldwide population aging trends are shown in Table I.I. The United Nations (2002) noted: The number of older persons has tripled over the last 50 years; .it will more than triple again over the next 50 years (p. II) ... By the year 2050, more than one in every 5 persons throughout the world is projected to be aged 60 or over, while nearly I in every 6 is projected to be at least 65 years old (p. 12). World Population Ageing 1950-2050 (UN 2002) stated that the main predictor of population aging is a decline in the total fertility rate, measured as the average 5

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Indicator More developed Less develo Jed Least developed 195 2000 2050 1950 2000 2050 1950 2000 2050 0 Total pop. 0.8 1.2 1.2 1.7 4.9 8.1 0.2 0.7 1.8 (million) Pop. of 11.7 19.4 33.5 6.4 7.7 19.3 5.4 4.9 9.5 age60+% Pop. of 7.9 14.3 26.8 3.9 5.1 14.0 3.3 3.1 6.3 age 65+ Pop. of 1.0 3.1 9.6 0 .. 3 0.7 3.3 0.3 0.4 1.0 age 80+ Pop. of 27.3 18.3. 15.5 37.6 32.8 21.8 41.1 43.1 29.1 age 0-14 Pop. of 60.9 62.3 51.0 56.0 59.5 59.0 53.5 52.0 61.4 age 15-59 Aging 42.9 106.2 215.3 17.2 23.4 88.6 13.2 11.3 32.5 index Total. 54.4 48.3 73.4 71.0 61.1 55.7 79.7 86.0 54.9 depend ratio Old age 12.2 21.2 46.5 6.7 8.2 21.8 5.9 5.8 9.8 dep. ratios Total life 66.2 75.6 82.1 41.0 64.1 75.0 35.5 51.4 69.7 expect. Total fert. 2.8 1.5 1.9 62 2.9 2.2 6.6 5.2 2.5 rate Table 1.1 World Population Aging 1950-2050. number of children a woman would have during her reproductive age. Worldwide, the total fertility rate has decreased from 5.0 children per woman in 1950 to 2. 7 in 2000; it is expected to drop to 2.1 in 2050. Over this same period, life expectancy at birth increased from 46.5 years to 66.0 in 2000 and is projected to reach 82 years in the more developed countries and 75 years in the less developed countries by 2050. 6

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In developed countries, due to very low fertility and high life expectancy and improved access to health care and good living conditions, the number of the oldest old, those aged 80 and over, is projected to increase. Care of these individuals will require more money, more social supports, and institutional care from government. Even in these developed countries the aged are most vulnerable group in the population. Many states in the United States are currently reducing their subsidies of social welfare programs for older and vulnerable people. In developing countries the number of persons of age 60 and greater is expected to increase. Elderly in developing countries live in much worse conditions because of generally weaker economies and the unavailability of public services. In these societies, families take care of their both because of tradition and necessity, and governments are unable to social welfare programs due 'to fiscal constraints. One aspect of world aging trends is the increase in the old age dependency ratio the number of persons 65 ye3!8 old and older per I 00 persons IS to 64 years old. This old age dependency ratio will triple in the next 50 years. The aging index defined by the number of persons 60 years and over per I 00 persons under age IS will also triple. The total dependency ratiothe number of persons under age 15 plus persons aged 65 and above per I 00 persons IS to 64 yearsis also expected to increase. In short, the proportion ofindividuals ofworking age (15-59 years of age) will decrease in more developed regions. In tum, this will put pressure on public pension and health care systems. 7

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Aging in Asia The UN projects that, across Asia, populations will age rapidly. Socioeconomic changes throughout Asia have had major impacts on population aging, and the aging of populations in turn has had, or will have, a tremendous impact on development processes in every country. Table I.2 represents population aging during the period of 1950-2050 in Japan, China, and Mongolia. Data of Japan included to provide a broader comparison b,I1se because Japan is one of the developed countries in the world. The United Nations projeds that the population of Mongolia will increase from 2.5 million in 2000 to 4.1 million in 2050. The proportion of the population age 60 and above will increase from I40,000 (5.6%) in 2000 to 958,000 (23.I %) in 2050. The old age dependency rate will increase from 6.1 to 25.4 over the same period. The aging of a population implies a greater in the number of elderly women. World Population Ageing I950-2050 (UN 2002) stated: In the year of2000, the global sex ratio of the population aged 60 or over was 81 males per I 00 females. Thus, there were approximately 63 million more women aged 60 years or older than there were men of the same age. Since female mortality rates are lower than male rates at older ages, the proportion of women in the older population grows substantially with advancing age. In 2000, women outnumbered men by almost 4 to 3 at ages 65 or older, and by almost 2 to I at ages 80 or above (25). 8

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Indicator Japan China Mongolia 1950 2000 2050 1950 2000 2050 1950 2000 2050 Total pop. 0.08 0.1 0.1 0.6 1.3 1.5 0.0008 0.003 0.004 (million) Pop.ofage 7.7 23.2 42.3 7.5 10.1 29.9 5.5 5.6 23.1 60+(%) pop.ofage 4.9 17.2 36.4 4.5 6.9 22.7 3.3 3.8 16.3 65+ pop.ofage 0.4 3.8 15.4 0.3 0.9 6.8 0.2 0.6 3.4 80+ pop. of age 035.4 14.7 12.5 33.5 24.8 16.3 41.9 35.2 19.7 14 pop.ofage 56.9 62.1 45.2 59.0 65.0 53.8 52.6 59.2 57.2 15-59 Aging index 21.7 157.9 338.2 22.3 40.7 183.3 13.1 15.8 117.6 Total.depen. 67.8 46.8 95.8 61.3 46.4 63.9 82.5 63.9 56.0 ratio Old age 8.3 25.2 71.3 7.2 10.0 37.2 6.1 6.2 25.4 depend. ratio Total life 63.9 81.5 88.0 40.8 71.2 79.0 42.2 63.9 77.5 expectancy Total fert. 1.3 1.8 6.2 1.8 1.9 6.0 2.3 2.1 rate Table 1.2 Population Aging 1950-2050 in Japan, China and Mongolia. Everywhere, women are caregivers. Old women are more likely to be in a disadvantageous position than men because they are more likely to be widowed. Also they are more poorly educated, have less work experience, and less access to income and services. Many countries in the world are aware of the growing needs and problems of the aged, and they provide health and welfare services for their aged citizens. Still, particularly in Asia, many people do not have access to such services. The United 9

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Nations; in cooperation with other international organizations, is considering the role of economic change on the cultural roles and statuses of the aged in different countries. The First World Assembly on Aging was held in 1982 in Vienna, the second Assembly was organized by the United Nations and held in Madrid in 2002. TheSe assemblies emphasized the well being of the elderly, efforts to create more supportive environments, and the increasing role of governments and international agencies in improving living conditions, food, and economic resources fot the elderly. It also pointed out the need for research studies on elderly people in order to define the situation. of the aged and to guide the development of age-related policies and programs. Asian government policies have emphasized the traditional role of the family in caring for the aged. However, many studies show that with the increasing numbers of the aged, the proportion of working adults will decrease, and it will be more difficuh for families to take care of their elderly. Therefore, the government needs to assist families intaking care of the aged, and also needs to increase its own role in provjding direct help to the aged . Overview of the Study My discussion is divided into four parts. In this introductory chapter I have discussed population aging, globalization, and socioeconomic change and its specific features as they affect aging in developing countries, with special reference to 10

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Mongolia. I have defined the problem and purpose of my study and presented my research questions. In the following chapter of my thesis, I consider aging and modernization. I discuss the demographic transition and define population aging features as they differ between developed and developing countries. I focus on how anthropology can contribute to the study of elderly. I discuss theoretical frameworks for understanding the aging process and consider different theories of how modernization and social change affect the lives of the _elderly. I differences between Western and Asian relationships and how: they have been influenced by rapid socioeconomic changes. In the third chapter, I consider mqdem Mongolian history, with emphasis on recent political and economic changes. This consideration emphasizes health care and social welfare services of Mongolia both during the socialist period and during the last decade. I emphasize the effects of recent economic and social reforms on Mongolian elderly . In the fourth chapter I present the methodology of my study, chapter five gives the results of my research. The fifth and last chapter contains the summary and conclusions, focused primarily on policy recommendations and suggestions for future research. 11

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CHAPTER2 AGING AND MODERNIZATION Anthropology and Aging Anthropology plays an irilportant role in the study of elderly because it attempts to understai:J.d the process of aging in crosscultural comparative context. AnthropologistS are interested in the process of aging in relation to human ' biology, economics, politics, sociology, and psychology. Anthropology also plays an important role in population studies, with interests in how economic and social changes are related to, and affected by, population growth. Today we live in a rapidly changing society where the numbers of older people are growing fast, with effects on family, pension, and retirement policies, health and soCial services, long-term care, and housing. All these changes are growing concerns at .every levellocal, regional, and global. Of particular concern are the increasing numbers of elderly in the world who lack access to basic social and economic resources. Many chronic diseases are faced by elderly people, especially elderly women, the oldest-old, and those living alone. It is important to understand individual aging changes and how these changes are affected by social and physical environments, and provide appropriate services to support older persons. 12

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Anthropological studies are both scientific and humanistic. Scientific studies are important to discover social relations and driving forces of change in a society or in a culture, to understand the relationship of humans "with nature, culture, and with each other. Holmes et al. (1983) wrote that anthropologists "investigate the value systems, world views, and cultural norms of people in far-off lands because they wish to test hypotheses about the nature ofhuman beings in a world-wide laboratory" (p.4). Conversely, the humanistic approach considers subjective reality. Humanists argue that in order to fully understand society we should take into account all factors. Many anthropological studies are informed by the principle of cultural.relativism. Cultural relativism is based on objective and subjective reality, accepting cultural diversity and understanding other cultures in their own terms. Anthropologists who study the elderly have emphasized the different cultural contexts of the aged. Holmes et al. (1995) wrote that: cultural relativism is both a methodological tool that ensures objective data collection and a philosophical and theoretical principle that calls for open-mindedness in accepting cultural diversity. It emphasizes the idea that no single culture can claim to have a monopoly in the "right" or ''natural" way of doing things. From this standpoint, anthropologists who study gerontology believe that the meaning of old and the effectiveness of solutions to the problems of old age can only be understood and evaluated in terms of the cultural context in which the aged reside. _Although the common biological heritage ofhuman beings and the inevitability of senescence create elements of common experience, anthropologists are extremely cautious &bout declaring that the customs in one society are 13

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more acceptable or more honorable than those in other societies (p.ll ). Anthropological studies of aging have contributed to the development of the new fields of gerontology and geriatrics. These anthropological studies are very important in the study of the health of the people, in providing good health care and social support services to all human in the world. Gerontology is the scientific study of older people and the normal and pathological changes of aging. It examines human life from biological and cultural perspectives, with the goal of improving the quality of life in the elderly. Infield (2002) has noted that "anthropological gerontologists believe that problems or understandings relating to old age must be analyzed only in terms of the cultural context in which they occur (p.l6). The medical study of aging is provided by geriatrics. It focuses on the biological, medical and social aspects of aging and provides diagnosis, treatment, care and prevention. The field of geriatrics is interested in the physical and psychological problems of the elderly. Nowadays contemporary anthropologists study cultures in the context of globalization, for example, research on how international trade, foreign investment, and capital market flows affect extreme inequalities of class, gender and race. These days, anthropologists focus on the challenges and opportunities presented by biological variability, cultural diversity, ethnicity, race, gender, poverty, and class. They emphasize in their writings the imbalance resources, human rights and power. 14

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The feminist perspective is very important to anthropology. Women in most societies occupy subordinate social positions. They are typically engaged in busy domestic labors. In contrast, men have the authority and power. Woman's role is to fulfill the husband's and children's practical necessities within the household. Women are typically responsible for the health of children, their husbands and aging parents. Ethnographic studies of old women provides good information about the issues of gender, which allows us to include in our research voices from this subordinate group. Anthropological studies of aging help to assess the social, economic and health conditions of the elderly, to predict what changes will occur in the future and to identify implications for public policy. These policies should protect the rights, interests and well being of the community, and provide safety and minimum living standards for each individual, especially the most vulnerable groups such as children, pregnant women, disabled people,. the elderly. In general, aged women, the poor, and the most deprived. Demography and Demographic Transition Population aging is defined by an increase in the number of older people (60 or above) in a population. Demographic analysis of aging helps us understand the process of population aging and how it is related to other aspects of society. The 15

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proportion of the population under age 15, over age 60 and overall life expectancy vary widely between developed and developing countries. Developing countries typically have high fertility and mortality rates. The age structure of the population shows a characteristic pyramid shape: narrow at the top, wide at the younger base with a steep slope. By contrast, in developed countries with aging populations there are both low fertility and mortality rates. The population structure shows a more rectangular shape: a narrow base relative to older ages and greater proportions of the population in the upper age groups. The shift from high fertility and mortality to low fertility and mortality is called the "demographic transition.'' Notestein was the first defined the demographic transition (Basch, 1999). He identified 3 stages. The first stage is characterized by high mortality and fertility rates and with low population size due to a high death rate. The main causes of death are infectious diseases such as measles, diarrhea, cholera, malaria, respiratory disease, tuberculosis and related acute disease. The second stage is characterized by a decline in crude mortality rate and a decrease in fertility rate, which results in an overall increase of the population. The third stage is characterized by low rates of fertility and mortality with a steadily increasing population. This stage is characterized by a shift from infectious to chronic diseases. Cardiovascular disease, cerebrovascular diseases, cancer, rheumatoid arthritis and diabetes are the major causes of death. Basch (1999) identified 5 stages of the demographic transition: high mortality and fertility, declining of mortality followed by declining of fertility, then 16

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fast decline of both mortality and fertility, followed by low levels of both and ending up with very low mortality and fertility. According to him, these changes will lead to increase on the median age and rising life expectancy of populations. The demographic transition implies population aging: a decline in fertility and an increase in the proportion of older people in the population. Improved standards of living, coupled with improvements in health and hygiene (especially at childbirth), are seen as having contributed to increased life expectancy,.especially amongst infants and women. Just so, like the industrial revolution itself, modem population aging is regarded as having been an invention of northern and western Europe, rather than ofthe.Roman Catholic south, let alone the Orthodox Christian east. Nevertheless these are at most patterns of association, rather than simple cause and effect relationships (Finer, 2000, p. 23). Thus, a decline in infant mortality rates and an increase in the life expectancy of populations as a result of better sanitation, immunization, increased nutrition, and improved health care. These are the driving forces of the demographic transition. Types of Aging Gerontologists have identified several forms of aging. Chronological aging is defined as the number of years since birth. It is most useful in studies of agerelated mortality, fertility rates and population structure. In contrast, the biological aging process is characterized by diminished physiological efficiencies in an individual's 17

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organs and tissues in association with chronological age. Chronological age is not necessarily closely related to a person's biological age. Infeld (2002) wrote: It is likely that age changes begin in different parts of the body at different times and that the rate of annual change varies among various cells, tissues, and organs, as well as from person to person ... There is too much individual variability in the potential markers of aging (p.3). Some people look and seem old at an early age,' and some can look and seem younger when they are quite old: Some elderly over 60 remain self-sufficient and active, and some young individuals may require special care and services, especially those with disabilities or chronic disease. In other words, persons with the same chronological age differ in regard to biological aging. The processes of aging are characterized by internal and external changes. The aging process is gradual: organic changes begin at early age, and these changes become more rapid in old age. The most visible physical aspects of aging are graying hair, wrinkled declines in.sensory and motor function, and increased fatigue. Internally, changes occur in the heart, lungs, kidney, central nervous system, and stomach, urinary and endocrine systems. There are high mortality and morbidity rates among elderly because aging is a process characterized by changes in internal protective mechanisms, and these make older people more wlnerable to sickness. Old age is not usually the main cause of death, instead death is caused by one or more 18

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pathological processes that may or may not related to the biological consequences of aging. Chen et al. (1989) wrote: It is important to take a positive view of the increased longevity of the population. If indeed, as bodies such as the W.H.O. argue, the age of85 is a possible outside limit of disabilityfree old age, the importance of promoting .and maintaining health in an ageing population can hardly be overemphasized, because during the twentyfive years of life from 60 to 85, people can make a great contribution to society (p. 75). There are wide variations in the aging process across individuals because people have different genetic make-up, habits, diet, exercise and variable living conditions. They live in different cultural contexts, with exposure to different social and ecological environments. Thorson (2000) identified differences between the ''young old", elderly in the age range of 65 to 74 years, the "middle-old" with age from 75-84 years, and the "oldest-old," those 85 years or older. In different political, economic and cultural settings, the number and proportion of elderly people in these different categories vary considerably. Biological Theories of Aging Aging occurs through the complex interactions ofbiological, psychological and sociological processes of change over time. There are many theories that attempt to explain the process of aging. Identifying the biological changes occurring with 19

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time is most basic to an understanding of the aging process. Aging occurs at all levels of organization of the human bodythe molecular, cellular, intercellular. These changes influence the organs and lead to a gradual decline in the organism and the person's health .. Fossel (2000) noted that "cell senescence limits cell divisions in normal somatic cells and may play a central role in agerelated disease" (p. 29), and concluded that "cell senescence theory is not only supported by and consistent with all available experimental and clinical data in aging human organ systems, but it is testable and has almost immediate clinical relevance to human aging and age related disease"(p. 33). Some researchers believe that aging has a genetic base, directly programmed in genes. Others believe that aging results from genetic damage in the cells by external factors like radiation, ultraviolet rays and by internal factors that do not have a genetic base. It is likely that there is an hereditary basis. for aging and longevity, which is modified -by environmental factors such as climate, technology, emotional stress and disease. Also human culture, behavior, life conditions, diet, stress, health, social conditions, activity and positive attitudes toward old age all play a role in aging. Mann (2002) stated: The recent molecular revolution argues that aging and the common diseases associated with age are fundamentally determined by an individual's own genetic make up, this being partly a function of the inherited genome and the modifications to this that 20

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occur over a lifetime. How well and how long a person lives depends on the net balance-of this "genetic. miasma"what the Victorians used to call "constitution." None the less, life style can have an important role. Clearly, diet and hygiene, excessive alcohol consumption, cigarette smoking, drug misuse, sexual promiscuity, and occupational hazards can damage even the most perfect of cells and compromise life expectancy. At greater risk are cells and tissues already weakened by aging or diseases. Avoiding these risks may increase an individual's likelihood of reaching old age but not necessarily lead to high quality of life (p.157). Auto-immune theory postulates that aging process is .triggered by immune system deficiency, limiting the body's ability to respond adequately to stress factors. The immune system's role in recognizing foreign antigens diminishes with age, and the organism may produce antibodies against their own tissues, resulting in increased physiological autoimmune reactions. With aging, control ofhomeostatic mechanisms within the organism declines; this may increase susceptibility to stresses. Bessenyei et al. (2002) pointed out: Aging of the thymus plays an important role in the etiology of autoimmunity .... Spontaneous genetic instability produced by genetic mutations and related changes of the body play a role in the physiological autoimmunity and. autoimmune diseases (183). These researchers concluded that: (1) age-related changes in the immune system are only partly responsible for the senescence of an organism. (2) Thymus involution seems to play a substantial role in the senescence of the immune system. (3) The 21

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elevated physiological autoimmunity is a result mainly of the increase in apoptosis as well as cell death related to general aging. (4) Several autoimmune diseases may be a result of genetic alterations either caused by the fluidity of the genome or by the overall genetic alterations due to aging (p. 183). Cellular Aging Theory asserts that each cell is programmed to a biological clock that determines its maximum life span. A cell will stop replicating after a given number of times, and cells become unable to repair damaged components. Each cell has DNA that is depleted over time and reduces the production of RNA, which is responsible for producing enzymes necessary for cellular functioning. That depletion ultimately results in cell death. Whitfield et al. (2002) wrote that knowing the sequence of the genome, however, is only the beginning. Equally important will be our knowledge of how the environment influences health, disease, and complex behaviors associated with aging ... Cultural differences among nations may also have an impact on quantitative genetic studies"(p.393). Beall ( 1984) argued for ''the necessity of analyzing biological changes throughout the life span with reference to the appropriate cultural context" (p.88). According to Beall: Adaptations to a stress like chronic disease, high attitude, adaptation to cold, inadequate dietary consumption and the level of physical activities influence the human aging process. Human culture and their habits play a role in biological changes. For example smoking characterized by negative influence on lungs and it can shorten human life, in contrast, 22

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physical activity can have positive effects on body and longevity (p.89). For Beall, the events in previous stages of the life span play a role and noted _that ''there is an association between early growth patterns and the biological aging process"(p.88). Psychological Theories of Aging Some scholars emphasize the importance of psychological changes occurring with normal and abnormal aging that influence older people's social behavior and dynamic relationships with their physical and social environments. Beside the biological changes occurring in the aging organism, some changes in cognitive functioning and personality may occur. Hooyman(1998) noted that older people seem to experience more stress than younger people because they are at high risk for depression, loss of income, jobs and ill-health. Each individual and contemporary age cohort grows up in a different period and experiences unique life events and social situations, and thus experiences different psychological effects of aging. Many studies show that intellectual decline is more closely related to diseases than to aging. Hooyman (1988) wrote that" ... some changes in cognitive functioning and personality are a function of normal aging. Other psychological changes may be due to the secondary effects of diseases"(p. 23

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190). Individuals continue to learn and respond to new things until death. The aged may be little slower in learning and responding than the young, but the capacity to learn does not necessarily diminish with age. There is not much change in memory and recognition. Many elderly people continue to perform well on tests of intelligence; learning and memory and they use their skills in the later years. Whitfield et al. (2002) determined: There are no age differences in heritability estimates of the memory factor ... there do appear to be some differences in estimates of individual differences in cognitive functioning across cultural groups. These finding reflect differences in education and other factors that influence the course of cognitive function as we age (p. 398). Social Theories of AgingDecker (1980) wrote: As humans we are biological creatures, and as biological creatures we age. We are born, and immediately we begin moving toward death. We can say that our biological nature sets the limits of our existence, but it would be a mistake to say that the biological process of aging is the whole ofhuman aging. There is another important dimension of aging, the social dimension (134). Every society has age norms that are created and diffused through socialization. Older people become socialized to new roles and conditions that accompany aging. Elderly people everywhere in the world face losses such as the 24

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death of spouse, loss of employment, and many others, and they must learn to deal with them. These changes have negative effects on the aged through decreasing their self-esteem, increasing feelings of helplessness, and thus may result in physical, emotional and behavioral disorders. These negative effects can be limited by social practices and policies. With aging, old people may become increasingly dependent on others and they may require some fonn of support, but this is not inevitable. Despite their old age, the elderly can continue to support others. They can provide invaluable wisdom, emotional, and economic support to their family and society. Thorson (2000) noted: For some individuals, of course, there is significant disruption when they retire. But, for the broad groups studied, it did not seem to-be a crisis .... Many aging people are masters of adaptation: they have seen many changes in their lives, and the gradual changes associated with aging are taken pretty much in stride (59). The qualities of social conditions are the most important factors for successful aging. These factors include the economy, structure, cultural values, expectations and social patterns. Kart (1985) wrote: The World Health Organization (WHO) defines health as a state of complete physical, mental, and social well beingnot merely the absense of disease. This definition extends beyond biological considerations. To the extent that modem medicine has been concerned with ''what went wrong" biologically, it has sacrificed recognition of the broader social and emotional elements that contribute to health (p.l66). 25

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"In most pre-industrial societies and a high percentage of developing Third World societies, kinship and family organization are much more important than in the West, and people's involvement with family detennines everything they do, think, and value"(Holmes and Lowell, 1995, p. 113). There are several theories that explain the social contexts of aging. Activity theory attempts to explain how elderly people adjust to age-related changes. According to this theory, more active older people tend to live to a greater age and are adjusted in old. age. Hooyman (1988) criticized this theory by noting that: Activity theory tells us little about what happens to people who cannot maintain the standards of middle age. By failing to acknowledge a personality dimension, it does not explain the fact that some older persons are passive and happy while others are highly active and unhappy ... The value placed by older people on being active probably varies with their lifelong experiences, personality, and needs {p. 67). Disengagement theory suggests that as people age, they withdraw gradually from social roles and decrease their involvements and activities. This theory also is criticized by many gerontologists. "Disengagement theory has tended to ignore the part that personality plays in the way a person adjusts to aging"(Hooyman, 1988, p. 69). Some scholars argue that people may withdraw from some activities but they may increase their involvement in others. In many countries' the aged can play important roles in family and society. Many scientific studies note that not all elderly disengage, but remain healthy, employed, and socially and politically active. 26

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Continuity theory asserts that as people age, they maintain typical ways of adapting to changing social conditions. Hooyman (1988) pointed out: The complexity of continuity theory makes it difficult to test empirically, since an individual's reaction to aging is explained through the interrelationships among biological and psychological changes, the continuation of lifelong patterns, and so on. Because it focuses primarily on the individual as the unit of analysis, overlooking the role ofextemal social factors in modifying the aging process, policies based on continuity theory could rationalize a laissez-faire or "live and let live" approach to solving individual problems facing the elderly (p. 72). All human societies and individuals experience change. These changes may affect all people in society, but it affects each person differently. Social Change Theories Economic development is traditionally termed "modernization." It is in many ways a term for describing the growth of capitalism or industrialization within formerly ''traditional," non-western societies; Some societies have experienced socioeconomic changes earlier than others. These societies are categorized as "developed" countries. Other societies experienced these changes later, and their economic development has been slower. They are categorized as "less" -and "least" -developed countries. Anthropologists who interested in the dynamics of the socio-economic 27

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changes and in the study of the aged have examined how development or modernization affects elderly life and health. Within this broad concept of economic development, there are many theories of social change. One relevant theory is called cybernetic or systems theory. Cybernetics focuses on information communication and processing within a social system. It was originally developed by Bateson (1987) to explain how social changes occur. Cybernetics has several basic features. It assumes that under normal conditions social systems are stabilityseeking and inherently conservative. Social systems are linked and open, and the different institutions of social system are integrated. Social life has a dynamic equilibrium: a change in one subsystem leads to a change in another subsystem. A change in a social system will occur for example, when there is an intrusion of another "foreign" culture, and the local cultural system will respond by changing in its attempts to maintain stability. When intrusion from outside is too strong or disruptive, and when different parts of a social system disintegrate, then there will be dramatic changes to whole a social system, or even a complete collapse of the system. If such changes occur, local cultures may disappear or be completely dominated by the intruding cultural system. 28

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Effects on the Underdeveloped World Existing economical, political, social and cultural institutions and relations in the underdeveloped world are being overwhelmed by the development of the global capitalist system. Globalization here refers to the electronic integration of societies, . internationalization of labor and of capital, and transnational commerce with hypercompetition. It is also linked to variable sedentism/nomadism and characterized by blurred borders. The integration of markets and technology may provide more opportunities to people and nations for social and economic development. This is the positive side of glopalization (Greider, 1997). However, it also has many negative consequences. It creates dependency of poor couiltries on richer ones, increases poverty and inequality, leads to enviroru:Dental degradation, and raises crime rates. In this system the poor are more susceptible to .diseases and they have higher mortality rates, higher fertility rates, and reduced life expectancy rates. Poverty is created by the inequality inherent in the social stratification of the global system. Economic development, with its emphasis on progressive changes in many aspects of individuals', communities and nations' lives varies from country to country. It has mostly brought about many negative changes in developing countries. Elites at every level have benefited from development, while the number of poor people has increased. Reflecting on this process, Garrett (1994) writes, "Thirdworldization had set in all over globe. Millions of abandoned children roamed 29

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the streets of the largest cities, injecting drugs, practicing prostitution, and living on the most dangerous margins of society''(p.591 ). An expanded program of technical assistance for the economic development of underdeveloped countries was initiated by the :UN, the World Bank, and the International Monetary Fund in 1980s. Many poorer countries borrowed large amounts of money. These countries are falling into a debt crisis, unable to repay these D loans. Polivka et al. (2002) concluded: During the past decade the concentration of income, resource, and wealth among people and corporations in the countries of the North has steadily increased. The neoliberal policies of structural adjustment have not only reduced real wages in many developing coUntries, but also contributed greatly to reductions in social wages:.. public goods such as provisions for education and health care. The forced reductions in public expenditures for social, health and education services, and the privatization of many of these services (the minimalization of the state) has created a "crisis of care" in many developing countries, even as the populations in need of especially children and the elderly, continue to grow at very high rates (p.201). Development programs that cause ecological and economic deterioration in rural areas also contribute to internal migration, which has resulted in increases in STDs and HIV/AIDS rates in many Third World countries, especially in Africa and Asia. All these diseases are exacerbated by poverty and a lack of aseptic conditions in local medical centers. The lack oflmowledge in the community, deficiency of medical personal and equipment, civil war, and refugee migration are contributing 30

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factors to diseases. Unstable conditions in a country tend to increase the economic crisis and create new possibilities for poverty and disease. Development has broadened the gap between rich and poor. This has negative effects on society, including increased rates of morbidity, mortality, crime, violence, and deterioration of living standards. Income inequalities also contribute to inequalities of health, poor diets;,. and poor working conditions, which in tum have negative consequences on health. All these changes have effects on the elderly. Theories of the Effects of Social Change on the Elderly There are many controversial theories about the effects of modernization on the status of the elderly. Some suggest that the effects are all negative; others do not. Aging and modernization theory was developed first by Cowgill and Holmes (1972). They were concerned with how modernization.processes affect the elderly in a cross cultural contexts. According to. this theory, "the role and status of the aged varies systematicaily with the degree of modernization of society and that modernization tends to decrease the relative status of the aged and to undermine their security within the social system"( 1972: p.l3). They noted that the elderly enjoy high status in pre industrial societies with intact traditional values but experience low status in modernized societies. 31

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An alternative theory has been advanced by Palmore and Manton (1974). They postulate that the status of the aged will decrease in early stages of modernization and will improve in more advanced stages. Some anthropologists also argue that the negative influence of social change on elders is not an inevitable process. According to them, the elderly may benefit form social change. Foner (1984), for example, examined the relationship between age and social change, and criticized modernization theory, arguing that it inappropriately emphasized the negative impact of the modernization process on elderly in preindustrial societies. She wrote that: Since the overall status of the elderly is multidimensional, it is too simple to say that change leads to improvements .or declines in their status. Rather, we must specify (as I have done in the preceding examples) which dimensions of the status of the old we are talking about: which social rewards and valued roles they lose or gain. With change, all components of old people's statuses rarely vary in exactly the same way. In other words, the elderly may lose some rewards and valued roles at the same time that they keep or expand the scope of others (p.203). Foner found that the elderly may benefit from economic development. Developed societies maybe able to offer pensions and other social welfare services to the elderly, though these may be insufficient. Foner emphasized what she calls agestratification theory, which focuses on the relationship between social change and specific age cohorts. "What is key here is that social changes do not, in general, affect all cohorts the same way. This variation comes about, first of all, because as one cohort succeeds 32

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another, each cohort has lived through different segment ofhistory"(p. 206). She also pointed out that "when we study the effects of social change on 'the old' (or 'the young') in a society, it is essential to know which cohort of old (or young) people are being considered with all its unique characteristics"(p. 206). Logue (1990) has argued that the low status of elderly, especially of the oldestold, is not related to modernization. She points out that, "frail elders are those who suffer major physical, mental, or social losses, and who require special care" (p.ll8). She concluded: Over the course of human history there has been more continuity than change for the frail elderly as assets, as burden, and as low priority. But processes associated with modernization, especially in the health care sector, have exacerbated their plight as potential victims, by expanding their numbers, enhancing their vulnerability, increasing the duration of their dependence, and making solutions more problematic; death hastening and delayed death are the two major types of victimization discussed (p.347). Logue described many negative effects of longterm care institutions: inadequate care and diet, the overuse of drugs, various forms of neglect, abuse, high levels of isolations, and ageism. Logue wrote that, ''their greatest needs are not medical, however, but primarily for help with the basic activities of daily living, such as dressing, cooking, shopping and toileting"(p.348). Considering how anthropological studies about the aged and human culture are important to the understanding the impacts of economic and social change, 33

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Holmes et al. (1995) wrote that "perhaps both the increase in number of elders and a decline in the status of old people are merely correlated with modernization and its many pervasive social, economic, and political manifestations (p.260)." They concluded, It is well documented that change can greatly influence societal attitudes toward senior status and role assignment and can traditional practices in regard to care and treatment. This is particularly true where there have been contacts between pre-industrial and modern societies. Newly acquired values and institutional procedures often undermine age-old support systems for the elderly (p. 284). Jay Sokolovsky (1990) has criticized the modernization model and noted that "examination of ethnographic studies has suggested the need to consider variations within given elderly populations based on such factors as class (Herlan, 1964 ), values (Holmes 1987), gender (Roebuck 1983; Cool and Mc.Cabe 1987; Counts, in press), kinship systems (Sokolovsky and Sokolovsky 1983b), and age cohorts (Foner 1984a)," (p.140). He emphasized the case study of China's elderly, in particular, describing how socio-economic changes have affected them, and he concluded: The theory of modernization predicts that the condition ofthe elderly will deteriorate as the society reaches more advanced industrialization and resources are channeled into the younger generations and into productive activities. This does not appear to be the situation in China ... it would appear that the elderly will not suffer under modernization" (p. 160). 34

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Thus, rapid social and economic changes, which can influence the number or size and sex composition of a population, can lead to other social changes. Effect of the Economic Changes on Asian Elderly The impact of socio-economic change on the status of the elderly can be seen most clearly in an examination of the situation in Asia. Many Asian countries have experienced massive socio-economic changes, and differ by their population size, size of their aged populations, level of economic development, their customs, spoken language, and their geographic conditions. The main feature common to all is the fastgrowing older population. The driving force of population aging is the process of modernization, particularly the factors of economic growth, low fertility, low mortality rates, and extended life expectancy. Increasing_numbers of elderly will likely play a significant role in the social, cultural, political and economic situations of each country. There are tremendous differences between Western and Eastern countries in attitudes towards and care ofthe old. Most of the Western countries experienced rapid economic development earlier than Asian countries. These developed countries, which would include Japan, have mostly completed the demographic transition (Bengtson et al. 2000). In contrast, many developing countries in Asia ha.ve either just passed through or are in the transitional stage of the demographic transition. The 35

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elderly in developed countries have better living conditions. The western countries and Japan also have been able to engage in good planning ofhealth and social welfare services, including providing access to pension/social security funds. Health policy in developing countries has tended to emphasize younger segments of the population, like infants, mothers, and working age people. In Asian countries the family, children and relatives are the main source of support ofthe aged. Lechner et al. (1999) noted: Developing countries have a limited capacity to respond to the needs of employed caregivers and to elders ... One reason is that, in developing economies, urbanization has resulted in less effective community based safety nets. Urbanization has left elders with fewer support systems; they are more dependent than ever on employed caregivers who are less able to care for them. In transitional economies, enterprises are being sold, and the new private sector employers are cutting back pension and family focused benefits in order to remain competitive (p. 230). The governments of developing coU.ntries do not provide sufficient services for the aged because of money constraints, but many Asian countries have become aware of population aging issues and have begun to define national policy on the elderly. Bengtson et al. (2002) wrote: One of the potential advantages for newly economically developing nations is that they can look to the more developed nations for examples to emulate-or reject. This vantage point contributes to the usefulness of comparative studies, not only for rapidly developing nations coming more recently to issues of population 36

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. aging, but for all nations facing the macro forces of demographic and economic change {p. 7). In Western society many elderly may live in nursing homes and have less contact with their children. Western societies, for example, American culture, tend to emphasize and reward individualism. The elderly thus often support themselves and live independently from children. "Selfreliance is seen not only as the key to mental health but also as the prerequisite to personal success. Having rejected nearly all forms of dependence on fellow human beings, the American finds that "security," must come from personal success, personal superiority, and personal triumph"(Hsu, 1961, p. 228). Olson (1994) stated: By 1989, there were over 16,000 nursing homes, mostly forprofit facilities, providing for 1.5 million elderly {p. 31) ... The pursuit of profits over human needs has negatively affected the quality, accessibility, and affordability of care .... In nearly all nursing homes, the personal lives of residents are strictly organized; most are denied their basic civil rights {p.33). Bengtson et al. (2000) wrote: The global trend of population aging-in itself an inescapable consequence of the modernization process has touched societies in the East such that they now have to move away from exclusive reliance on the family and expand the role of the state as the source of support for the aged ... On the other hand, Western advanced societieswhich long ago shed role reliance on the family for care of its elderly members-are now trying to reassert the importance of the family and community for the care of its rapidly expanding aged populations {p. 7). 37

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In Asia the family is the main source of support for the aged (Bengtson et al. 2000). Respect toward one's eldersfilial pietyis central to Confucian precepts, and governs family relations throughout East Asia. This ideal demands that the young recognize the support and care they received from their parents, and in tum demands that they give reciprocal respect and care for the aged parents. In Asian countries traditional values argue that elderly people should be recognized as the most skilled and lmowledgeable people from whom younger generations must learn. From ancient times, the young have used respectful language in speaking with their elders, giving them the best foods, most honorable seats, and special gifts. Children are obedient to their parents by social norms. Young people are more likely to carry out the wishes of their elders, not only their parents but also other elders in the community. Children are given the responsibility to support their parents, have their own children, and in this way, maintain the timeless continuity of family life. Sung (2000) wrote, Filial piety is reflected in the practice of family centered care and support for parents. Family support is characterized by cohesive ties between family members, family responsibility, interdependence between the members, family l;larmony, the individual as a unit of the family, and the pooling of individual members' resources to promote the well-being of parents and the family. This is in contrast to the Western values of individualism, characterized by self determination, independence, autonomy, respect for the dignity of an individual, the success and well-being of an individual, and the strong emphasis on the nuclear family (p. 45). 38

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Bengtson et al. (2000) concluded that "filial piety will remain a core value in Asian societies, binding generations together, although its expression may change"(p. 276). Today governments of many Asian countries attempt to keep the traditional values of respect for elderly alive through formal education and policy. Bengtson et al. (2000) observed that: Other social patterns more unique to Asian societiesa lower divorce rate, a smaller number of single parents, a lower degree of family dispersion, a higher degree of intergenerational solidarity, and a supportive family networkwill contribute to the improvement of family support for elderly persons (p. 51). Religion is one of the major components of culture, and has great influence on the values ascribed.to theelderly. Religion represents a powerful means to organize societies, and it is a major form of social control. In Asia it plays an important role in the life of the elderly. In East Asia the dominant religion is Buddhism, which focuses on past and future lives, and includes high respect of the aged. The aged have a special role in religious ceremonies, and they ate respected for their age. In contrast, Hohnes et al. (1995) wrote: The religious tradition observed in the United States has little effect on attitudes toward the aged. While the Bible urges believers to 'Honor thy father and mother that thy days may be long,' this commandment has never had the impact on behavior that the filial piety principle has had in oriental religions. It states an ideal but does not represent a guarantee of respect and responsibility (p.l74). 39

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Asian people focus on connectedness with others and have a close relationship with family and community. Elderly people expect their children to listen and to follow their advice, and they prefer live near them. There are many different forms of financial support for the elderly, such as money, good, gifts, and help with domestic work and personal care. Increasingly the elderly in developed countries tend to live alone or with their spouse (if alive). Haskey (1996) determined that, "33% of elderly men over 75 were living alone in 1994, compared to 24% in 1973"(Barlett and David, 2000, p. 177). Albert et al. (1994) wrote: In the more developed countries, sharing a household with a child is the exception and is linked mainly to health limitation in the elder or, less remarked, to the economic dependency of the child ... ,The vast majority of elderly do not share households with adult children. Excluding the 1.5 million elderly in nursing homes (National Center for Health Statistics 1989), the most recent U.S. census figures showed that 31 percent of the elderly live alone. An additional 54 percent share households with relatives, most with tlleir own children (p. 87) .... The proportion of elders living alone, for example, ranges from 2 to 8 percent in Southeast Asia, and from 5 to 11 percent in Latin America (p. 90). Many ethnographic studies reveal that in most Asian countries families maintain respectful relations with their elderly, though socio-economic changes may threaten the capability of families to care for their elderly members. Y oon et al. (2000) determined that: 40

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Among the peripheral consequences of industrialization and modernization are weakness in many sources of material and normative support for the elderly population and the negative social concept that elderly persons are a burden both at the familial and social levels (p.129). Rapid economic change, which is often linked to educational levels attained by the young, migration of young people to the big cities, and increased opportunities for women to work outside the household, contributes to the erosion of the more traditional roles ofthe elderly in family life. Sokolovsky wrote that "increased education of the young led many children and young adults to feel superior to their parents. This has fostered a distinct negative change in generational relationssometimes involving high levels of abuse and even gericidecloser to the predictions ofthe modernization theory''(p. 11). Sung (2000) wrote that "in recent decades, industrialization and urbanization have been eroding the tradition of family centered parent care in Korea and other East Asian nations such as Japan and China" {p. 231). Philips has focused on how to maintain familybased care for the aged in rapidly changing societies. According to him, in Asian countries with a low level of economic development, the elderly will face great difficulties in their daily lives due increased poverty, lack of access to health and social services, increased migration, decreased traditional values and very limited governmental support. Holmes et al. (1995) pointed out: Extended family units are weakened in the rural areas while in the city the emphasis is increasingly toward 41

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independent biological families. The rural areas have always been strongholds of traditional culture, with elders not only in control of property but of knowledge and prestige as well. In the city the young escape the control ofthe elders and begin to question their authority and priorities (p. 272). Financial support is a new phenomenon for elderly people. It is considered an invention of Western societies. Retirement or social security is the monetary support given by the government to the aged to meet their needs when they are no longer able to work. In preindustrial societies elderly people worked until they are no longer able to do so. Only serious illness or physical infirmity would lead them to withdraw from their work. With economic development, the elderly often face compulsory retirement, at an age defined by government policy. There are wide differences in the age of retirement in many countries. It ranges from the age 50-60 in women and 55-65 in men in China, Russia and in Mongolia. Retirement age may determined on bases of hard working conditions, type of occupation, number of working years, and number of children. According to Anderson (1972), "retirement in America does more than separate people from jobs and colloquies, it is actually a period of deculturation"(Holmes and Lowell, 1995, p. 71). Many (not all) elderly in the more developed countries have access to universal social security programs, and they live in better conditions than the aged of developing countries. Even in developed nations 42

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the aged are the most vulnerable people, especially older women. Kim (2000) pointed out: The Korean government introduced the compulsory retirement system for government officers in 1963 (Y oo, 1999). Under the current system, most government workers are to retire as early as 60 years, with the exception of professional government workers like teachers (62 years) and professors (65years). The situation of the workers in the private sector is even worse than the case of government workers. About 65 percent of the employees working in the private industries retire at the age of 55 years (Y oo, 1999). According to national survey (Rhee and others, 1994) most of the Korean elderly (79.9%) want to remain in the workplace as long as possible (p. 5). Holmes et al. (1995) noted that "the retirement forced by competition for jobs is accompanied by a sense of dissatisfaction and depression"(p. 271 ). The compulsory retirement systems that exist in many Asian countries will produce larger numbers of not-working people. According to U.N. projections, the proportion of the elderly who work will decrease from 25% of the population 65 and above in 2000 to 22%in2050. Holmes et al.(1995) argued: Modern economic technology also changes the work situation. New technical processes result in the creation of new jobs and changes in old ones. The younger workers with their technologically oriented education tend to be attracted to the new occupations, while older workers make minimal adjustments to cope with the new technology or attempt to carry on in the more traditional roles as long as possible. The steady 43

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reduction of traditional roles, however, represents still another pressure for retirement (p.271). Chang (1992) suggests: Increasing education, urbanization and industrialization have resulted in more women engaging in wage employment outside the home. For example, the female labor force participation rate in Singapore increased from 44 per cent in 1980 to 50 per cent in 1990 (Lee and Veloo, 1991 :66). In Japan, the female laborer forces participation rate rose from 55.2 per cent in 1965 to 58.2 per cent in 1984 for those aged 2544 years and from 58.4 per cent to 64.1 per cent for those aged 45-54 over the same period (Ogawa, 1987:63). Increased female employment outside the home, however, means that less labor is available to provide care for both the :young and old in the household (p. 4). In Asia, elderly tend to live with their children but these rates are decreasing. The "Korean Institute of Gerontology pointed out that elderly living alone increased from 7% in 1975 to 53% in 1996"(Bengtson et al., 2000, p. 43). Yoon et al. (2000) observed that "25% of the elderly parents lived apart from their children in 1988, 41% did not live together with their children or other relatives in 1994"(p. 129). EthiJ.ographic studies by Sung et al. (2000) show that despite increased migration and changes in family structure, the aged are still receiving effective help and care from their children and relatives. Sung et al. (2000) write that, "in Korea about 90% of elderly live with their children and kids play an important role in caring for their parents"(p. 42). "According to the 1995 survey of elderly who have not lived with their children, 90% received gifts of food, clothes during previous years and the 44

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same proportion received some money"(Phillips, 2000, p. 257). Phillips notes that "families have undergone significant changes in the course of rapid industrialization and urbanization in Asian society ... family size decreasing, that based on Korean National Statistics office in 1995 defined that 5.7 persons in 1955 and 3.3 persons in 1995"(p. 41 ). With technological development the educational level of the population is increasing. In many developing countries a number of people remain illiterate, especially women. Holmes et al. (1995) argue: Traditional societies have a much greater proportion of illiterates than modem ones, for traditional skills such hunting, herding and horticulture can be passed on from generation to generation by word of mouth and through informal teaching by example ... In such societies the people who exercise the greatest control and enjoy the greatest respect are those who lived the longest and have experienced the most. .. Modernization renders experience in traditional life ways oflittle importance, as it changes the rules, challenges values, and alters the direction in which the society moves. Oral tradition and learning by imitation are inadequate in communicating knowledge_ that people must have to function in a world . of rapid change, urban life, and complex technology. No longer can individual heads carry the information requisite for a modem society. Modernization demands literacy, libraries, and formal education. Not only is more technical knowledge needed to function in a modernizing society but it is needed in a hurry and in large amounts (p. 273). 45

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The Case of China China has the largest population. China is a useful comparative case study, because, like Mongolia, it is categorized as a developing country. At present, China is a relatively young developing COUntry compared to other industrialized countries but . the growth of aged people will be greater than other sectors of the population in coming years (see Table 2). Despite its status as a developing country, China has experienced the demographic transition from high fertility and high population growth rates to a situation of low death rates and low birth rates in a relatively short period of time. The Chinese government has been concerned with population growth issues since the latter part of the 20th century and established a per family policy in 1979. People who live in urban areas can have only one child, and in rural areas couples may have two or more to help with agricultural work: The majority of people live in rural areas. The Chinese government implemented a strong family planning program in order to control population growth. They integrated this program with economic development and efforts to increase people's living conditions and to decrease poverty, increase educational levels of citizens, improve women's status, and protect the environment. As a result of family planning, today China is a country with fertility rates, like many developed countries. Control of population growth 46

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influenced their development positively; it increased the people's living standards. According to the Chinese State Statistical Bureau, per capita income in rural areas increased from 133.6 yuan in 1978 to 395.5 yuan in 1985. However, China over the next decade is projected to be one of the most rapidly aging populations in the world. Economic reforms and increased employment opportunities allowed the elderly to open small private businesses. It also decreased the status of the elderly within the family. In pre-modem China the elderly were respected. Age was the main determinant of prestige and authority, and children supported their parents. Olson (1994) noted that economic development increased the educational level of the population and enhanced public health. In China, ''the evidence is quite clear that the family and local communal organization are expected to provide much of the longterm care for frail elders to prevent otherwise costly institutionalization" (p.274). Most people in China have access to primary health care and reproductive health services. As a result of the introduction of a new marriage law with emphasis on the equality of men and women, women's status has been enhanced. Traditionally in China, women had low status, and their status increased with old age, bearing sons, and having daughters-in-law, who had obey their mother-in-law. Women's rights and economic. independence are increasing, and the living standards of the total population and the aged has been improving. Still, women everywhere are those responsible for bearing and rearing children, doing heavy unpaid household work, and also working outside of home. Doing all these is not easy, and governments need 47

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to pay more attention to women and increase support from the family. Governments need to reduce women's household responsibilities and help them take care of the aged. Ethnographic data (Olson 1990; Gu 2000 and Sokolovsky 1990) reveal that the status of the elderly in China increased from the establishment and improvement of a socialist market economy with fast and healthy development of national economy. The conditions of the elderly are better in urban areas than in rural. In rural China the 'families mostly-care for their elderly parents because of insufficient pensions for older fanners. In 1956 China developed a new system, which is called the "Five Guarantees," for the childless and for those elderly who have only daughters. The Five Guarantees system provides elderly with shelter, food, clothing, medical, and educational services. Olson (1994) wrote: During the last ten years, thousands of homes for the aged have been built. The government reported that an increase from 7825 homes in 1978 to 33,295 in 1986 (Shehui Baozhang Bao 1987). These homes serve as a symbol to rural families that, should they have no one to care for them in old age, the community will provide that care (p.276). According to Olson (1994), in rural China only 1% of the aged receive a pension, compared to 75% ofthose in urban areas. The retirement age in China is 55 for females and 60 for males (Wu, 2000). 48

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l:p. 1978 China adopted a market economy. This shift emphasizes the development of agriculture, military, industry, science, and technology through the decentralization of enterprise management. Now the Chinese government is trying to establish a pension for all people who are over 55. In Chinese culture, old parents mostly stay with their oldest married son and daughter-in-law, and other kids live near their parents. These parents play an important role in their children's lives, contributing labor for farming work, household chores, baby-sitting, and making food and meals. "For the majority of people, emotional and economic linkages between older parents and their children are still well maintained"(Bengston et al., 2000, p. 64). In China ,every family has a small garden plot and it supports their daily livelihood. In this society the aged still are seen as important members of the family, "as an essential and integral part of the social and economic. fabric ofthe society"(Olson, 1990, p.159). Ethnographic studies done by Olson (1990) and Sokolovsky (1990) show that. the economic and social changes in China have had positive effects on the elderly. In summary, many anthropological studies show that change to greater economic development has had mostly negative effects oil the lives and living conditions ofthe elderly. Urbanization, the increased educational level ofthe young, migration, increased women's work outside of their home, compulsory retirement, increased poverty, inequality, and unemployment all produce negative effects on the livesofthe elderly. In Asia, where the support of the aged is provided entirely by 49

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families, particularly by children; changes that separate families, or limit these interdependencies, will negatively affect the old. Anthropological studies reveal that Asian countries maintain ideals of respect for their elderly, but the demands and consequences of economic development have led to declining family care. fu many cases these changes have left the elderly behind. They have few social supports, and become more dependent on minimal government supports. Conclusion Aging is both a biological and a social process characterized by external and internal changes to each human body. Individuals vary in the aging process due to their different genetic makeup, habits, diet, exercises, and living conditions. Globally, rapid socio-economic changes are occurring, and these changes have had a profound effect on elderly lives. Moderhization is characterized by economic development with high technology and improved medicine, which decreased human mortality rates and expanded life expectancy. Today we live in a globalized world, which as Sokolovsky (1990) noted, is based on an international division of labor which allows capital accumulation to take place in core nations of a capitalist world system while these countries control the developmental process in semi peripheral and peripheral areas. Overall, it is contended that the tie of dependent nations to core industrial powers through multinational corporations and foreign 50

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aid has resulted in the enhanced position of favored urban elites at the cost of growing rural impoverishment and internal inequalities (p.140). There are many anthropological theoriesthat attempt to explain the effects of socioeconomic change on the life of the elderly. Modernization theory, proposed by Cowgill and Holmes (1972, 1974), states that under the conditions of modernization the status ofthe elderly and their prestige will decline. Palmore and Manton (1974) argued that the status ofthe elderly will decline in early stages of modernization and will increase in more advanced stages. Foner (1984) wrote that during modernization process, elderly can loose some statuses and can gain some benefits from this process. Some others, like Logue (I 990), determined that elderly people are in general viewed as low priority. According to her, modernization expanded the elderly's life expectancy and increased their dependence, and she criticized negative effects of long-tenn care institutions. In this chapter I reviewed data from Asia, especially China. China is projected to be one of the most rapidly aging populations in future. The Chinese experience has shown a positive influence of economic and social change on the elderly. It can be a good example for Mongolia. Many ethnographic studies show that the Chinese government provides good and peaceful living conditions to the aged under the conditions of socioeconomic changes. The Chinese people have access to medical care, education, and pensions. There are some differences between urban and rural residents, with better living conditions and pensions in urban areas. In rural areas 51

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pensions are insufficient and children take care of their parents. Elderly without children or who have only daughters are enrolled in the special program, "Five Guarantees," which provides the elderly with food, home, clothing, and medical and educational services. In urban areas the elderly received increased state economic support. Now the Chinese govenunent is trying to establish pensions for all people who are over 55. In China, nearly every family has a small garden plot that supports their daily livelihood. Every person has access to primary health care, and the Chinese govenunent has provided support to the families and local communal organizations that it is essential to providing care for the aged. In the future, if China establishes a universal pension system, there will be good state and family care for the frail elderly. Mongolia is China's neighbor to the north, and having a similar political past, may be able to learn a great deal from China's successes. The Chinese policy fits the Mongolia context for several reasons: first, support of the elderly doesn't come entirely from the govenunent, but instead focuses on localized communal care and families, which reduces economic burden to the state. Second, abnost all Chinese people have access to primary health care (PH C). The policy ofPHC in China Is to provide low cost and effective traditional medicine for many chronic diseases, and these in turn enhances care for the elderly. The status of the aged depends on a country's economic, political, and social conditions, and on culturallybased family relations. The Chinese case study shows 52

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that socio-economic changes can have positive effects on elderly as a result of sufficient family support and good social programs from the state. 53

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CHAPTER3 THE MODERN HISTORY OF MONGOLIA Background Located between Russia and China, Mongolia is one of the largest countries in central Asia. Mongolia is a land of natural contrasts: the Gobi desert to the south, semi-desert, vast plains to the east and snow clad mountain to the west. The climate is very hot in summer (+35 to +40 C) and very cold in winter (-40 C). The highest point is 4,374 meters above sea level and has the highest atmospheric pressure. The lowest areas are only 552 meters above sea level. Most Mongolians live at an altitude of roughly 1600 meters, equivalent to the altitude ofDenver. Demography After the socialist revolution in 1921, the population ofMongolia began to grow. The population of Mongolia was 761,300 in 1950, 2.5 million in 2000, and is projected it to reach 4.1 million in 2050 (UN 2002). The 2000 census ofMongolia estimated a population of2.3 million people (NSO 2001). Despite its rapid population growth, the population density of just 1.5 people per square km makes it one of the most sparsely populated countries in the world. Just one half(56.6%) ofthe 54

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populations lives in urban areas. Of the total urban population, 32.0% live in Ulaanbaatar (UB), the capital city. There is some evidence for the acceleration of the demographic transition in Mongolia. Total fertility rates dropped from 6.1 children per woman in 1950 to 2.3 in 2000. Between 1989 and 1999 the crude birth rate per thousand population fell from 37 to 21 (UNDP, 2000, p.19). Despite this, Mongolia remains a young country: About 80.0% of its population is under the age of thirty. five, though population growth has slowed (1.4%) a consequence oflow fertility and a high rate of migration. Traditionally, Mongolia has been a nomadic society. Herders were mobile, moving seasonally with their livestock over the vast lands of the country. Before the socialist revolution population growth was very low due to the poor economic situation. During this time a great number of the male population lived in monasteries and praCticed strict celibacy. After the socialist revolution that occurred in 1921, the population began to grow. During the period of 1921-1990, Mongolia experienced unprecedented rates of population growth due to the improved nutrition and socioeconomic conditions of the population and increased life expectancy. During the socialist period, a majority of the population had full access to health services. In the of the 1990s, Mongolia experienced changes to their economic and political systems. Population growth decreased due to declining fertility rates. The decline in fertility way is linked to changes in the social system, such as introduction of the law allowing ori. abortion in 1989, deterioration of living 55

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conditions of the population, and increasing use of contraception by women. The declining growth rate during recent decades is also connected with high outmigration. During the transitional period, thousands ofKazakh and other minority ethnic Mongolian groups moved to Russia and many young people left their home country to study and work abroad. As a resultof declining fertility there have been remarkable changes in the population age structure. This table shows that.although Mongolia is a young country, this will change in the future with increasing numbers and proportions of older people. Table 3.1. Structure of the Mongolian Population, 1950-2050. 1950 2000 2050 Total.population 761 100.0% 2,533 100.0% 4,146 100.0% (thousands) 0-14 (age) 319 41.9% 892 35.2% 815 19.0% 15-59 401 52.6% 1,500 59.2% 2,373 55.3% 60+ 42 5.5% 141 5.6% 1,099 25.6% Aging index 13.1 15.8 117.6 Old age 6.1 6.2 25.4 dependency ratio Total fertility rate 6.0 2.3 2.1 (children) Life expectancy 42.0 63.9 77.5 (years) Source: Umted Nations, 2002 According to the statistics of the Office of State Social Welfare (Government of Mongolia 2001), there were 180,180 retired elderly in Mongolia in the year 2000, comprising 7.6% ofthe total population. Of these, 82,369 (45.7%) were male and 56

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97,811 (54.3%) were female, with 95,758 (53.1 %) elderly living in urban areas and 84,422 (46.9%) living in rural areas. There were 178,480 (99.1 %) elderly (70,629 males and 107,851 females) who were receiving pensions; only 1422 (0.8%) people of age 55 and above did receive a pension. 4,546 veterans and 825 elderly receive a special allowances in addition to pension. There are 55,516 (30.8%) elderly who are engaged in income-producing activities to supplement pensions. According to these data, about 32,739 (18.2%) of elderly are considered to be a "high risk" group who are close to poverty, and of these 23,491 (71.8%) are considered to be very poor. There are 2,612 (1.4%) people who live alone without any caregivers and 3,078 (1.7%) elderly are invalids. The Mongolian government provides special care with free meals and clothing for those who live alone. In the future, the number ofthe aged is projected to increase, and the aging of the population will place demands on society at every level. This rapidly growing population will need housing, jobs, health care, and social welfare services. Mongol Empire During the 11th and 12th"centuries Chinggis Khan established the first Mongolian State (Baabar, The history of the Mongols before Chinggis Khan is unknown, and there is little information about how the Mongols lived. Chinggis first united Mongol tribes and then with a force of horse-mounted warriors conquered 57

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most of Asia and many Eurasian countries. Chinggis Khan was a strong believer in shamanistic power. He believed that the sky is the creator and sustainer of balance in the world, and all human life is sustained through it. Chinggis developed unique administrative orgS.nizational structures and established Mongol common law. He organized the system of internal communication by horse riders. Chinggis understood the power ofliteracy and he spread use of a "Uighur" script as the common Mongolian alphabet. He died in 1227. After his death the Mongols rapidly went into decline. Later, Khubilai Khan (12151294), one of the successors ofChinggis Khan, conquered China, and changed the name of the Great Mongolian Empire to the Yuan Dynasty. In 1260 he established the capital in Beijing, China, and transferred the political center of the Mongol Empire to China, increasing Chinese influence. The Yuan dynasty fell in 1368, and was succeeded by the Ming, then Qing, dynasties h1dependence The Qing rulers were patrons of Buddhism, and encouraged the growth of Buddhism in Mongolia as a means to pacify the warlike nomads. At the end of the 19th century, the Qing rule weakened; the Manchus introduced new reforms in Mongolia which were intended to impose Chinese culture on the Mongolians. The Mongolians were prohibited from migrating from one place to another and from 58

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working in gold mines. These reforms produced widespread protest and spawned an independence movement. Many Mongolian elites and lamas decided to protect their country from Manchu exploitation and to establish their State independence. When the Qing dynasty fell in 1911, Mongolia was poised to assert its independence, and proclaimed the supreme religious leader, the ''Bogd Khan, as the head of government in Mongolia. Baabar (1999) writes that: The history of Mongolia in the twentieth century officially began on the ninth of the midwinter month of the fifteenth sixtyyear cycle of the White Pig Year. On this day Outer Mongolia overthrew the 220year oppression of the Qing dynasty and officially proclaimed her independence as a monarchy under the Eighth Bogd Javzandamba Hutagt .... By the Roman calendar, the decree was made on December 29, 1911. In this way, Mongolia, a country which had ceased to exist as a nation after Ligden Khaan, reemerged after more than two centuries in oblivion and joined the twentieth century (p.1 02). The success of the revolution awakened the national consciousness, and increased people's political activities. At this time the first political party-the Mongolian people's Party was established. The Russian Revolution of October 1917 had a great impact on Mongolia. In the 1920s a fugitive of the Russian Revolution, Baron Ungem, and Chinese troops from the south moved into Mongolia. To resist these foreign intrusions, Mongolia sent a delegation to Russia to request assistance from the Socialist Union. The Soviets provided the requested assistance, and a social revolution occurred in July 1921, which established a Mongolian as a socialist state. 59

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By 1922 the entire territory ofMongolia was free from foreign occupation, and the Mongolian People's government was established. Mongolia started to build a state guided economy supported by the Soviet Union.In August 1924, the 3rd Congress of the Mongolian People's party adopted a Russian socialist type of political system. Socialism Economic Systems During the period 1921-1990 Mongolian economic and social systems were guided by the principles of socialist development. This system emphasized the equality of all people, eliminated many fonns of economic oppression as well as those based on race, sex, and disability. Everything was owned by the state. The government's main goal was to provide. the population with the basic economic and social necessities of life such as food, housing, education, health care and social services. The socialist system had many positive impacts on people's lives. However, it restricted people's freedom of speech and movement. Soviet style socialism also created a huge bureaucracy, which controlled basically every aspect of social activity. While following this path to socialism and communism, Mongolia achieved much and made great progress, yet there were downsides as well. The Human Development Report (2000) pointed out: 60

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During the Soviet era, the people of Mongolia took rapid strides in many aspects of human with particularly impressive gains in health and education. Between 1960 and 1990, life expectancy increased from 47 to 63 years and by 1990 almost everyone had access to health services. Education standards too were high96% of the population were literate. Notably, women had shared fairly equally in this progressthey made up more than 40% of higher education graduates, for example, and aroWid 85% of women were working (UNDP 2000,p.18). In the beginning of the 1930 sherdsmen were organized into collectives. During this collectivization period the government of Mongolia and its Stalinist leader Choibalsan, engaged in a campaign to destroy religious institutions. Thousands of ordinary monks were forced to leave the monasteries and to enter "normal" economic activities. Monks of higher rank were killed during this period. After the brutal collectivization of herdsmen Wider the leadership of Choibalsan, the party then attacked other segments of the population such as the nobility, the intellectuals, and the nationalists, and even purged its own ranks. Baabar (1999) foWid: The hysteria was justified by "the imperative of strengthening the party to adhere to one class". The campaign was laWiched right away and within half a year 5,306 ofthe 18,000 party members were dismissed, having been characterized as "rightwingers and exploiters." Being dismissed from the party were suspect. Also, as a result of three turbulent years of hysteria, Mongolia's debt to the USSR reached 29,500,000 rubles (p.294) .... Out ofthe almost eight hWidred temples and monasteries almost none were left. In 1934 there were (according to Choibalsan, the number was 797) temples and monasteries but 760 of them ceased to exist by 1938 (p.370). 61

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Between 1937 and 1957 many temples and monasteries were destroyed, the property of religious and secular leaders was seized, and many thousands of monks were executed. Mongolia lost its top writers, scientists and intellectuals. By the late 1950s the vast majority of herders had been forced to join collectives. The government imposed high taxes on the private sector and confiscated private property. Many people became wage laborers, working for enterprises controlled by the communist party. During the socialist period even herding activities were centrally planned. Every herding household was a member oflocal herding collective that was called a ''negdel." The government was responsible for production and distribution of all goods and services. The main feature of socialism was production for use, not for profit. All land and almost all livestock were owned by the state. Households were provided free veterinary services, animal shelter and fodder, and transportation services to delivery of meat, milk, wool and wheat. Herders received a salary for herding. Because of good state support the number oflivestock increased rapidly. The collectivization ofherds provided a stable source of raw materials for the meat, camel wool, leather goods and cashmere needed to develop national industrial sectors. Agriculture was less developed than pastoralism because of the harsh Mongolian environment, but it played, and continues to play an important role in the economy. As a result of the expansion of crop production there were increases in the 62

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production of wheat, cereals, potatoes, vegetables and fruits. By 1980 Mongolia was self-sufficient in grain (wheat) production. Animal husbandry and agricultUre are both heavily dependent on environmental and climatic conditions. The weather is unpredictable and extreme. Heavy snowstorms ( dzud) which follow drought periods can kill many thousands of animals and destroy crops, which seriously affects the economy. With the assistance of the Soviet Union and other European countries, animal related industries like camel, wool, carpet and coat factories were established in urban areas. The Mongolian government also emphasized the development of mining and heavy industry. This industrialization was accompanied by population growth in urban centers and the construction of large numbers of new buildings and offices. After WWll the Mongolian government adopted the "five-year plan" system of economic development from the Soviet Union .. The period of the WWII was characterized by rapid industrial development that led to rapid increases in urban populations. The first Two-Five Years Planning periods (1948-1957) focused on moving the Mongolian economy from one based on livestock production into a more diversified agrarian-industrial one. It emphasized the development of mining, infrastructure, transport and communication. The main goal ofthe Third-Five Year Plan (1966-1970) was the expansion of power-generating projects. The government developed mechanized agriculture and increased the power supply to rural areas. The Forth-Five Year Plan (1971-1975) emphasized the development of carpet, leather, 63

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timber, processing, and meat packing factories. In 1976, with the development of a copper and molybdenum miriing processing complex, the new city ofErdenet was built. The main pwpose Fifth-five Year Plan (1976-1980) was to increase productive efficiency and product quantity in all areas of the economy. During the period of 1981-1985 the major focus was on the agricultural sector, especially to build new fodder fanns, establish irrigation systems, and expand mechanized dairy Finally, during the last Five_-year Plan (1986-1990) the government emphasized trade and foreign investment. During the socialist period the Soviet Union provided 85% of all development aid to Mongolia. Mongolia was integrated into the Council for Mutual Economic Assistance (CMEA) international planning system. The CMEA was an international organization ofEuropean,_Asian and Central Asian economies, headed by the Soviet Union. During the socialist period Mongolia exported raw materials, minerals and metals to the Soviet Union and other European countries in exchange for machinery, fuel, industrial equipment, and consumer goods. As a result ofMongolia's integration into the CMEA system, it became dependent on technological assistance from the Soviet Union and other European countries. 64

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Social Systems During the socialist period, the educational level and living conditions of the population improved as a result of the establishment of universal free health care and education. In 1989 public expenditures in the health sector were 5.1% ofGDP and on education were 10.4% ofGDP.The Mongolian health care system emphasized providing care to the young and growing population. This socialist period was characterized by a well-developed medical infrastructure, which followed the Soviet model, with an emphasis on hospital-based curative care over preventive services. Most ofthe medical care was provided through clinics and hospitals. The government budget was the single source ofhealth care fmancing. The governinent thus had strong centralized control over all health services. It focused on increasing the numbers of specialists in such areas as pediatrics, obstetrics, and infectious disease. Despite limitations of access to health care services for the rural population due to large distances and the poorly developed transportation infraStructure, health care and other social welfare servic.es were well developed in socialist Mongolia. Partly as a result of such achievements, the total population of Mongolia increased. Before the socialist revolution, the status of women was low. At that time most decisions were made by men. Women were in subordinated positions and were largely excluded from public life. The socialist era brought equal legal rights for 65

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men and women, and it greatly increased women's access to education and health care. The Mongolian socialist government encouraged high rates of population growth by awarding "National Hero" medals and maternity allowances to mothers of four or more children. The government supported women in child bearing and caring through specific benefits. The government also provided jobs for everyone, and there was no recorded poverty or unemployment. Mongolian Elderly As a result of improved education, living conditions, and good health care with strong social support services, people's life expectancy increased from 47 years in 1960 to 63.0 years in 1990 (UNDP 2000, p.l8). During the socialist period, older people were not neglected. Health and transportation services were free for elderly people. They received pension payments from the national budget. The aged spent their later lives with their children and family. Pensions began at age 55 for women and age 60 for men. Pensions were also based on years of working service, with at least 20 years for women and 25 years for men. There were some exceptions on age and length of service criteria for individuals who had worked under hazardous conditions or who did heavy work. The pension amount was based on a person's median monthly wages. 66

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Physician consultations for the aged were free, and prescriptions were available at low cost. The elderly were able to receive free inedical care not only in hospitals or policlinics, but also in their homes. During socialism the elderly were treated with great respect and they were valued for their age, experience and knowledge. They also received free public services. Summary Thus the health and social welfare policy of Mongolia until 1990 was directed toward the goal of improving in education and health care, as well as providing support and protection for all, including older and disabled persons. This approach had many benefits for people on one hand, but these policies may have weakened their individual sense of responsibility on the other. Social development was significant, yet it was achieved at the cost of some freedoms and, as in other socialist countries, it resulted in an intematiomilly uncompetitive economy which depended on significant inputs from the Soviet Union. Transition to Democracy In the 1990s Mongolia chose the path of transition from a socialist command economy to an open free market economy with the intention to improve the life of the 67

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people. Mongolia was the first socialist country in Asia to abandon the socialist model. As a result of the democratic movement, a multi-party parliamentary democracy was established. The Mongolian government implemented many reforms, suc;h as the privatization of state property, decollectivization, decentralization of the political and economic systems, liberalization of prices and markets, increased foreign relationships, and acceptance of international aid. These socioeconomic changes.increased human rights and people's rights to free speech, but at the same time the privatization of public services negatively affected the livelihood of vulnerable groups, particularly older Current Political Structure Mongolia is divided into 21 provinces (aimags) and the autonomous capital. The population ofthese provinces ranges from 46,000 to 122,000, with the exception of some Gobi provinces which have populations of as little as 13,000 people. Each province is divided into several counties or (soum). The population of counties ranges from 2000 to 6000 persons. Each county is divided into townships, (baghs ), the smallest administrative unit in rural areas. Each township has several hundred residents. Ulaanbaatar is the capital of Mongolia It contains 27% of the total population and it is divided into 8 districts. These districts are further divided into sub-districts, (khoroos). The government's power is vested in the people of 68

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Mongolia; the people exercise it through their direct participation in state affairs, as well as through representatives whom they elect. The Mongolian government recognizes all forms of public and private property. The government does not engage in religious activities, although Buddhism is considered to be the national religion. In January 1992 the new Constitution of Mongolia was enacted. The Constitution of Mongolia declared that all people have equal rights. No person should be discriminated against on the basis of ethnic origin, language, race, age, sex, occupation, religion, or education. The government is responsible to every citizen for the creation and maintenance of econoniic, social, and legal standards, and it guarantees defense of basic human rights and freedoms. The.Hurnan Development Report (UNDP, 2000) pointed out: .Mongolia enters the new millennium as a dramatically different country. Ten years of transition have established Mongolia on a radically new path and inj fresh energy and For many people the changes of the 1990s have opened up va8t new economic opportunities, though for others they have caused huge and painful upheavals. In some respects the transition has thrust human development into reverse. The change from soCialism to a market economy was inevitably going to be confusing and disruptive. Each transition country has had to find its own way, testing new forms and innovative approaches. Ten years on, however, it is appropriate to pause for thought, to make a more realistic assessment of what has worked and what has failedand make the best choices for the ten years ahead (p. 12). 69

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Effects of the Economic Transition During the last I 0 years, financial assistance from the Soviet Union and CMEA countries has declined dramatically. Because about 90% ofMongolian external trade was with the Soviet Umon until the beginning of the 1990s, Mongolian Gross Domestic Production decreased by 30% since 1990. The loss ofthis income caused the failure of many national industries due to lack of technical resources from the Soviet Union and the loss of CMEA markets. The same problems occurred in the agricultural sector. Mongolia experienced a tremendous economic shock. Consequently, these losses have led to Mongolia's present problems, poverty and human insecurity. According to the Human Development Report (2000): Between 1990 and 1993, real wages in industry dropped by one-fifth and in agriculture by nearly one third (p. 9). As a result of reduced GDP, the government is faced 'Yith a budget deficit, and the budget for public services was cut. Between 1993 and 1998 total government spending dropped from over 50% of GDP to 37% (UNDP 2000, p.30). Mongolia, more so than other transition coUntries, chose the path of 'shock therapy'removing many controls quickly and trying to pass as much activity as possible into private hands. Over the period of 1990-1992 around 3,000 small and large enterprises were privatized (Human Development Report, UNDP 2000:28)". Such quick and poorly prepared privatization of industries and farms produced large 70

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numbers of unemployed. Unemployment figures are unreliable, "registered" unemployed. numbered 6.5% in 1991, and 8.7% in 1994. The Mongolian government issued vouchers to individuals to purchase shares in previously state owned. enterprises, but the implementation of the privatization plan was mismanaged, insufficient, and often corrupt. The process led to a rapid growth of poverty. During privatization (19901992), public service workers such as teachers, doctors and the majority of the urban residents received little or nothing. Also during this period, public sector construction, apartment building and tmprovement of housing in "gers" (traditional dwellings) were left untouched.This rapid transition brought many negative consequences such as poverty, inequality, increased crime, violence, alcoholism,. STDs, deforestration, and produced air pollution. It also increased the number of female-headed households and street children. During the early stages of the economic transition, Mongolia experienced the most painful period of economic and social crisis. All national industries were closed and many thousands of people lost their economic and social security. At that time there were food shortages, and basic items like flour, meat, rice, and tea were -distributed by food stamps.The prices ofbasic food items increased but the salaries and pensions were left unchanged. People who worked in state organizations were unable to live on their monthly salaries; and many educated people started to do various private sector jobs such as driving taxis and trading in the informal sector. 71

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., In rural areas decollectivization and privatization of livestock took place. State farms were privatized and agricultural cooperatives were divided into small companies. By 1992 about 70% ofthe national livestock herd had been privatized. This process left many herders with too few livestock to support their households. Previously the government exercised responsibility over all production. The government had provided help, veterinary, and transportation services for seasonal moves. After transition these services were no longer available. After the economic transition private herders were given greater opportunities to increase the number of their livestock. They could sell milk, meat, dairy products, wool and cashmere in order to buy needed basic consumer products. But they were also required to survive natural hazards independently. The extremely harsh environment, in combination with heavy snowstorms, preceded by drought in 1999-2001 killed many thousands of livestock. It seriously undermined the country's major economic sector and forced many herders into severe poverty. Herders who lost livestock during snowstorms moved to the cities to search for jobs. A Survey report of those living in a ger areas ofUlaanbaatar,.conducted by Japan International Cooperation Agency (JICA) and Agency ofMongolia (2002), noted that "the mechanic growth of the urban population within the period of 1992-1999 is comprising 92%, and directly connects to the changes in the structure of the society. If the share of the poor families was 12% in 1993, it rocketed up to 28% in 2000"(p.14). 72

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After privatization of livestock, a hierarchy of informal social institutions that are called "hotail" have reemerged. The "hotail" consists of several households, mostly those of relatives or close friends, who live together and pool their resources. They help each other in caring for livestock, trading animal products, and collaborating during emergencies and disaster. The "hotail" is the modem equivalent of the pre-socialist rural social unit. Thus, the privatization of state property and decollectivization processes produced huge unemployment and destroyed previously existing health care and social welfare services. According to the UNDP (2000), about 35.6% of the population are now poor. Femaleheaded families and families where the head is unemployed are the poorest. Poverty is a new phenomenon in Mongolia. Of these 35.6% of the population, about 39.4% of the poor live in urban areas; of these in illaanbaatar about 34.1% of population is below the poverty line. Poverty levels are defined by the monthly income of households. The government has set the poverty line at $16 (17,600 tg) for urban residents, $12.5 (13,800 tg) for rural residents. The Mongolian government has recently developed different programs to reduce poverty, but unfortunately poverty remains high, especially in urban areas. "Between 1992 and 1998 as a proportion ofGDP, government spending on health, education, and social security continued to drop-from 16.2% to 14.8%" (UNDP 2000, p. 9). Many schools and kindergartens have been closed and many 73

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teachers have left their jobs due to insufficient school funds. According to the 2000 population housing census ofMongolia: At the younger age group of 15-19, the proportion of illiterate persons rises rapidly to above 3% (p. 75) . . By the year 2000, 68.2 thousand children aged 8-15 were not attending school, out ofwhich, 41.2 thousand or 61.7% were boys and 26.1 thousand or 38.3% were girls. The sharpest decline occurred between age groups 10-14 and 15-19 where school participation fell from 87.9.% to 47.3% of the age group (NSO, 2001, p.76). illaanbaatar is the main city where most people seek better education and employment opportunities. During the transitional period; rural to urban migration was high. The size.ofUlaanbaatar's population increased dramatically after 1992, especially in sub-urban "ger" (traditional dwelling) areas, where poverty is also high. According to the 2000 Population and Housing Census (2001), "altogether 360,522 people migrated out of the other regions while 268,988 migrated into tnaanbaatar"(p . 57). During the economic transition the situation of the Mongolian family changed. Families become isolated as a result of increased ruralto:-urban migration with decreasing social support and community solidarity. Divorce rates, domestic violence, and the number of street childrel) also increased. Many children faced I poverty, violence, and hunger. The National Statistical Office (2002) determined: Of the 541,149 household in the country, 83.7% are headed by males and 16.3% by femaies. This percent of female-headed households is much higher than the 10.2% estimated in 1998 .... In the country, 14,000 women live by themselves .... Among female heads, 74

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44.2% are 50 years and older ... Nearly 10.0% ofthe female heads are unemployed (UNDP, 2000, p. 43). Health System Reforms The socialist health system, with its centralized budget, focused on the development of Western style technological medicine and restricted traditional medicine. In 1990 this system was decentralized, with authority devolving to the local province governors. The goals of the new health policy emphasize: strengthening preventive and curative health care with more emphasis on prevention improving health institutions, particularly in rural areas reducing maternal and child mortality encouraging health promotional activities including family planning introducing compulsory health insurance and private medical practice in health care improving access to health services for vulnerable groups decentralizing the financial and budgeting systems and service deliveries improving management and quality of health care services better utilizating human resources supporting research in Mongolian Traditional Medicine 75.

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developing medical science There are four levels of health care services in Mongolia. Levell is the smallest organizational unit, and it consists of the township (bagh) in rural areas and the sub-district (khoroo) in urban areas. Primary health care services in townships are provided by the community health worker (bagh feldsher) and in the sub-districts by family doctors. Each county has 5 to 6 townships, each having 50-100 households. The township centers are typically located 20 to 80 km from the county center. In urban ateas family doctor groups provide the primary health care services. The family doctor groups consist of 4 to 6 doctors, 4 to 6 nurses and a few other maintenance workers, depending on the size of the population served. One family doctor group serves approximately 46,000 people who live in particular sub-districts. A single doctor is responsible for 1,200-1,500 officially registered residents, but at the same time they must by law provide services to unregistered migrants. The main functions of the community health workers and family doctors are to provide periodic home visits, preventive services, and immunizations, and to identify and provide prenatal care to pregnant women. They also provide simple curative care and help transport sick people. The second level of care in rural areas consists of a county "so urn" hospital, and in urban areas the public health centers. The typical county hospital has several doctors: physicians for internal medicine, pediatrics and obstetrics, 2 to 4 community health workers, 3 nurses, and one pharmacist. County hospitals have 10-30 beds, a 76

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delivery room, and maternity waiting homes. Second level care provides emergency curative services, obstetric care for normal pregnancies, health promotional activities, family planning, and transportation patients to the next level if needed. The third level of health services consists of general hospitals in the province. centers and district hospitals in urban areas. This level has relatively better diagnostic equipment and better qualified specialists in surgery, gynecology and obstetrics, pediatrics, and internal medicine,.and it provides primary care services to the province center population. Province hospitals have 200400 beds, act as referral centers for county hospitals, and provide in-patient care and other specialized services. The fourth, highest level of care consists of general and specialized medical and public health centers in illaanbaatar, with the most sophisticated equipment and medical specialties. Before the economic transition, health services emphasized curative, hospital. based care, .associated with high costs of goods, including medical equipment, drugs, and trained specialized doctors .. During the transitional period, all health care services declined as a result ofa lack of essential drugs, medical equipment, transportation, and fuel. Access to health care was limited for rural populations as a result of inadequate infrastructure, poorly developed transportation and communication systems, sparse and low population density, and harsh environmental conditions. Rural areas also lacked doctors, because many doctors did not wish to work in rural 77

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areas due to harsh working conditions and low salaries. Many doctors left their jobs; their numbers decreased from 45,600 in 1990 to 30,200 in 1997 (WHO, 1999, p. iii). Currently the government now seeks the enrolhnent of medical students from the countryside; these students will be required to return and practice medicine in their home communities. A compulsory national health insurance system was introduced in to cover inpatient services. Initially the health insurance fund was under the control of the Ministry ofHealth;In 1996 it shifted to the control State Social Insurance Government Office. The health sector is now funded by the government budget and the health insurance fund. The health insurance is compulsory for all employees and employers and theoretically covers 98% of the population. The government pays half ofthe contributions for employed people but provides full payment for children under age of 16, students, elderly, pregnant women, and soldiers. Treatment of infectious diseases such as tuberculosis, brucelosis, STDs, AIDS, and diabetes is financed directly from government funds. The health insurance law was revised in 1997 and some changes were made. For example, drugs were provided free to hospitalized patients. In public hospitals patients are now required to pay 10% for inpatient treatments. The system of payment is similar for private hospitals. According to this law, half the price of the essential drugs prescribed by the family doctor or community health workers are reimbursed by the health insurance fund. 78

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Health policy presently attempts. to reduce health expenditures by focusing on the development of primary health care (PHC). PHC is community-based treatment or basic curative services with an emphasis on the prevention ofdiseases through health education, health promotion and immunization. It is now accepted as the most cost-effective way to improve the health status of the population. WHO (1978) noted that "Primary Health Care is essential health care made universally accessible to individuals and families in the community by means acceptable to them; through their full participation and at a cost that the community and country can afford"(p.2). Phillips (2000) wrote that: A multipronged approach is probably needed, involving proper development of primary care teams, perhaps the instigation of patient listbased and publicly supported general practitioners/family doctors; incentives for health promotion rather than treatment; and public education. Developing proper and integrated primary care referral systems to secondary levels is essential to minimize inappropriate use of hospitals (p.31). Family doctor services have been introduced in all districts ofUlaanbaatar and a few provinces. The government's goal is to expand primary health care to rural populations through providing additional specialized medical services. The new PHC system is being supported through loans and grants from the Asian Development Bank. Family group practices are small private units, working under contract with the local government. Typically the family doctor has to have a broad medical knowledge and works closely with patients. Family doctors provide needed and cheap 79

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health care services to the community. In other words, family doctors are the community health care providers or "gatekeepers". If patients need a specialist, a family doctor Will refer patients to. the appropriate level of care. The family group practice is funded through a capitation based system. One family doctor serves 12001600 people in urban areas. In this system patients can theoretically choose their family doctor. Each resident of the sub-district has to be registered with a family doctor and for all health problems an individual first has to go to the family doctor for consultation and, -if necessary, referral. Some private clinic and hospitals have been founded since 1989 and mainly in Ulaanbaatar. (See Table 3.2). Table 3.2. Private Health Care Institutions in Mongolia (2001). Type of service or Number in all Number in Institution Mongolia Ulaanbaatar Private hospitals with 75 45 beds Privatepharnnacies 320 184 Drug wholesale 42 42 agencies Dental clinics 148 83 Gynecological clinics 60 43 (abortions and STD treatment Traditional Medical 59 45 Clinics Source: Government ofMongolia, Ministry ofHealth and Social Welfare. 80

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Self-employed private doctors rent offices, with equipment from previous public facilities, and provide treatment with payment for service. Private services are provided mostly in the areas of traditional medicine, gynecology, dentistry, and ophtalmology. Many large hospitals in Ulaanbaatar have leased out hospital kitchens and laundry facilities to small private clinics. Due to decreased living standards and purchasing abilities of many Mongolians, the private sector has not been as rapid as might have otherwise been the case. With the end of socialism, Mongolia began to re-develop its traditional medical heritage. Before socialist revolution, traditional medicine was the dominant system of health care, practiced primarily by Buddhist monks. During the aggressive Choibalsan purges of the 1930s, traditional medicine mostly disappeared in Mongolia and was practiced in secret by just a few people. Also during this time, religion was restricted and Buddhist rituals had to be performed in secret. There are public and several private traditional medical clinics in Mongolia. One ofthe biggest-public traditional clinics is the"Traditional Medical Science, Technology and Production Corporation ofMongolia." It has 60 in-patient beds. Care is covered by the national health insurance plan. As with other hospitals, insured patients must provide a 10% co-pay. Retired people are hospitalized for free, but there is often a long waiting list for admission. There are certain restrictions for hospitalization in the traditional clinics. Patients with acute diseases, high blood pressure or cancer, and patients with surgical conditions are excluded. At this clinic 81

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patients are treated for many different kinds of chronic _diseases. Diseases are diagnosed by pulse-taking and traditional analysis of urine by color, appearance, and smell. The clinics use some biomedical drugs in emergency cases. Treatments such as herbal therapy, bloodletting, acupuncture, massage, ionic treatment, cupping, mineral baths, and mud treatments are provided at these clinics. Traditional medical clinics require referrals from family doctors or province hospitals. The Traditional Medical Science, Technology and Production Corporation has a small factory for making herbal medicine. "Over 160 doctors oriented to traditional medicine have graduated, and nearly 300 doctors trained in western medicine have attended short term (2 to 10 months) training courses in traditional medicine"(WHO, 1999, p. 56). Now each province hospital has a department of traditional medicine, and many province hospitals have inpatient beds for traditional care. In Ulaanbaatar, district hospitals provide outpatient services such as massage, acupuncture, herbal and mineral therapy. One popular private traditional medicine clinic is called Manba Datsan. lbis clinic is more religious in its orientation, where training and clinical services are integrated. With the increasing number of elderly people, together with the burden of chronic, degenerative diseases which require high cost therapy, it is important to provide effective and inexpensive traditional medicine in health care. Also, with an increase in the aged population, the incidence of poverty will increase, because elderly people are more likely to be exposed to poverty than others. Therefore, it is 82

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important to integrate traditional medicine with. modem medicine and into the delivery of primary health care services, particularly to the elderly. Janes (1999) wrote that: ... the experience of developed countries suggests that dissatisfaction with biomedicine, dissatisfaction driven by publicized iatrogenesis, perceptions of ineffectivness, costliness, inappropriate medicalization and so on, will drive an increased demand for alternatives. .. Traditional medicine may be seen by governments as an attractive supplement to biomedically-based health services insofar as traditional medicine is typically less expensive, often more widely available and typically uses locally available resources (p.l809). Social Welfare Services for the Elderly The Mongolian Constitution of 1992 states that all people have rights to rest, social services for age, disability, or disease; to education; to health protection; and to receive material assistance in old age. Currently, the Mongolian government is trying to build a new system of social protection through the implementation of laws, regulations, arid programs concerning elderly issues. A law establishing social insurance was established in 1995. According to this law, women who had paid contributions to the pension insurance fund for a period of not less than 20 years and who had reached the age of 55; and men who had not less than 25 years length of service and reached the age 60 have a right to retire. Also women who have four or 83

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more children have the right to retire at the age of 50. The social insurance funds are accumulated from budget subsidies and the insured's employer. The Social Welfare Fund is used for pensions, allowances, and care of invalids; it is distributed by social welfare services. The majority of elderly in Mongolia receive a pension from these funds. According to the statistics ofthe office for State Social Welfare (2001), nearly $182,000 (198 million tg) was given to the elderly by the state in 2001. Of the 180,180 elderly in Mongolia, 4492 (2.5%) elderly were sent to sanatoria, places for short term therapy and relaxation, and 3649 (2.0%) elderly were sent to recreational centers, where all payments were made by government. There are 125,093 (69.4%) elderly who have contact with their previous workplaces, which provides support to them, and 35,605 (19.8%) do not have any relations with previous work places due to the privatization process. Each October first, is lmown as "elderly day," and during "Tsagaan sar," the Asian traditional holiday, administrators of previous work place invite retired elderly, and show them special respect, greetings, and give them special meals and gifts. Each Asian New Year the president ofMongolia sends special gifts to the elderly age 100 and older. In 2001, the Mongolian Elderly Federation helped 20,945 people contact their previous employers. In 2001, 886 (0.5%) elderly participated in poverty reduction programs and about $87,300 (96 million tg) in loans was distributed to them under this program. 84

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During the economic transition, the value of government payments to the elderly and disabled were .eroded significantly by inflation. This increased their dependence on children and relatives. The Health Sector Review (WHO, 1999) stated: The Health Status of the Mongolian elderly population is affected by a low standard of living as a consequence of low pension level; which equals to 12,000 MNT (14 U.S.$ in 1998) per month on average. This is worsening their possibilities to ensure proper nutrition and access to health services. (p. 57). Today elderly people are among the most vulnerable groups in Mongolia. Most of the elderly live on declining pensions, which is their main source of income. There are some lower rates on payments for apartments, electricity, medicines for the elderly and medical services for veterans, and free transportation and health care, but these are not sufficient. According to the health insurance law, drugs are free for all hospitalized patients, but in reality, as a result of insufficient health care funds, many people are forced to pay for treatment out-ofpocket. Hospitals in rural areas have particular difficulties buying medicines or diagnostic equipment, and patients must pay themselves or do without. Many elderly in Mongolia are chronically ill. Their pensions are insufficient to pay for expensive medicines and treatments. In most situations, children and relatives help them purchase these things. However, due to the poor economic conditions, children may be unable to help their elderly parents in need of care 85

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because they are unemployed and lack money themselves.-Ironically, instead of reeeiving support and help from their children, today many elderly find themselves supporting their children. Pensions have become a main source of income in many families, especially in rural areas. These elderly pensions are equal to or even lower than the minimum subsistence level needed for an individual. Thus, pensions are not sufficient to meet the basic needs of normal life, especially for an entire family. Elderly people who live in cities don't have enough money even for food. They cannot afford meat,milk or vegetables, and they do not have money for medicines, clothes, or other needs. Many retired people who worked for state organizations were left without money or savings. Most of them cannot travel to receive treatment in sanatoria. Privatization of state-owned enterprisesand fanns cut the support of elderly, and-they lost the social and economic support they would have received in the past from their previous work places. In addition to financial stresses, loss of ties to previous work places increased their loneliness and isolation. In 2000, there were 30,128 women aged 50-54 receiving pensions. They were retired at age 50 because of the large number of children they had borne. Most of them would like to continue work, but they often have difficulty finding jobs. Even if they wanted to have a small business, they don't have money to start it. The socialist government offered special allowances to pregnant women and women taking care of their children. In some cases, this provided a motivation for some women to have babies, particularly in rural areas where cash was limited. However, subsequent to the 86

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economic transition, women who have many children were hit hard by poverty, and they were left with few state benefits, few opportunities to work, but many .children to support. The economic transition negatively affected women, with an increased burden particularly on rural women. Women's roles as caregivers expanded and their need to earn wages to provide for their family income also increased. The five year period from 1999 to 2004 were declared as National Program on "Health and Social Protection of the Elderly'' with a goal to develop health and social welfare services for the elderly. The Human Development Report (UNDP determined that: A survey of 1,000 people conducted in 1999 for this report found dissatisfaction for most social services. The following percentage of people surveyed found them either mediocre or bad: 81% in health, 77% in education, 77% in welfare services, and 74% in social insurance services. When asked what were the main problems with public services, the most common responses were: high charges, poor management; the wrong policies, and low quality. In the case of the social welfare services they were understandably unhappy with the level of benefits (p. 45). Revival ofTraditions Today Mongolia is trying to revive old traditions and religious rituals. Gandan Keid, the old center of Buddhist faith, has opened for worship, and some monks are allowed to perform religious ceremonies in it. There Mongolian people created a 40 87

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meter high statue of Aviloketeshvara (the Tibetan, Chen-re tsis). A college of Buddhism has been opened in UB. The majority of Mongols, especially the elderly, still follow the traditional life of their ancestors and maintain or recreate their old religious rituals. Summary Mongolia is a large country with a small population. In the 20th century Mongolia encountered many changes. It moved from being simple agrarian state with little market or industrial development to a capitalist free market economy. In mid century Mongolia experimented with Soviet style development. During this period of vast changes, Mongolia achieved many things, but at the same time made many mistakes. The socialist state (1921-1990) emphasized equality for all people, and provided the population with the basic economic and social necessities of life; it provided security for all people as a result of universal free education, health care services, and improved living conditions. The Mongolian population increased in size, and people's life expectancy increased. Elderly people, children, and women benefited in many ways. But at the same time, the socialist command economy stagnated as a result of insufficient or inefficient industries, producing few consumer goods. Human rights were compromised. During the 1930s, many thousands of innocent people were persecuted and purged by the single ruling communist party. 88

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The socialist health system emphasized hospital based curative care, which produced too many specialized doctors and resulted in a very limited number of general practitioners. Primary care was undeveloped. The economic transition that occurred in the 1990s terminated the previously existing economic assistance and trade agreement with the Soviet Union. This, in tum, resulted in a economic crisis. Rapid and mismanaged privatization of state properties produced unemployment and undermined the living standards of thousands of Mongolians. Structural adjustment programs initiated by the International Monetary Fund and the World Bank produced cutbacks in social welfare services, which negatively affected the lives ofthe community. Poverty became widespread in Mongolia, particularly among the elderly, children, female-headed households, and unemployed. High migration, which resulted from economic chaos, led to a breakdown of the family support system and old age security. Thus, elderly people were among the most adversely affected by the economic transition. They were faced with poverty; compulsory retirement, especially women with four of more children; unemployment of children; poor quality of health care; few social welfare services; and a high degree of stress. It is projected that the number of elderly people will increase in the future. Therefore, exploring the lives of older people, defining their needs so as to improve their quality oflife, health care, and social services, is an important task. 89

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There are few studies done which examine the living conditions of elderly in Mongolia. None of them asked elderly's opinions about the economic transition and its effects on their lives. Thus, this study provides the first examination of elderly's perspectives on the economic transition and its effect on their lives. 90

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CHAPTER4 METHODOLOGY Goal of Study The primary goal of this study is to describe how the economic transition that occurred in the 1990s in Mongolia has affected the social life and the health status of the elderly. In order to achieve this goal, interviews were conducted with the elderly regarding their experiences with the economic transition. Interview questions were designed to identify problems and needs faced by the elderly and to make it possible to compare needs and resources between urban and rural areas. The specific research questions of this study are: I. How did the sudden economic transition affect Mongolian elderly? 2. What did they think about the economic transition? 3. What differences exist between urban and rural elderly in terms of their education; living conditions, daily activities and the issues of getting health care and pensions? 4. Do they have any problems and how do the elderly respond to their problems? What sources.ofassistance are available to them? What kind of issues and concerns do they have? 91

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The findings of this study will contribute to the better understandjng of the needs of the aged in Mongolia, with the goal ofhelping to improve their quality of life. Research Methods This study was part of a larger study of health reform in Mongolia. Funds were provided by a grant to Craig R. Janes from the U.S. Fulbright program. Other investigators includecl Oyuntsetseg Chuluundorj,Casey Hillard, and Kim Rak. Each of us developed our own specific research projects in addition to helping Dr. Janes complete his study. This study used both quantitative and qualitative methods of research. All research was conducted in the Mongolian language and translated to English during data analysis. Methods used in this research study were ethnographic interviews with open-ended questions directly related to the specific aims. The ethnographic survey was conducted in Mongolia during the four month period of May through September, 2002. Ethnography is the primary method in cultural anthropology, which anthropologists do field studies seeking to generate practical and theoretical "truths" based on the realities of daily existence in a particular culture. Anthropologists study other cultures from both outside and inside. Geertz (1973) defined culture as a set of 92

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shared meanings and defined the proper method of ethnography as a process of interpretation. According to him, to understand other cultures we need to feel the same ways as cultural members do. The task of the ethnographer is the ''thick description" of other cultures. Ethnographic data collection for this study included participant observation, which is a study of culture from the inside. It is an active interaction of researcher with participants. It helps a researcher to be less of a stranger and is characterized by increased trust and tolerance. The participant observation method is unique because it allows anthropologists to look, listen, question, record, and interpret other cultures from within. Ethnography helps to define what people do and what they say. Ethnography includes both quantitative and qualitative methods. Its findings can produce different questions and solutions that would be useful for the future well being oflives within a community. The quantitative method for this study included statistical-analysis of data that provided descriptive nwnbers and percentages of different characteristics of the study sample. Qualitative methods are important in anthropology and it is a particularly useful approach for the understanding the lives of the elderly. Qualitative ethnographic methods help define particular problems faced by the aged, and reveal how the rapid economic transition influences elderly lives and health. In doing this ethnographic study, I conducted household and individual interviews. From household interviews, major elderly demographic information like 93

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age, sex, residence, number in family, number of children, years of school, occupation, and illness symptoms were obtained. Individual interviews attempted to reveal the elderly life situation before the economic transition, and their opinions about economic changes and how these affected them. It also elicited infonnation on the elderly daily activities and on issues such as getting help and accessing health care services. I interviewed as well elderly persons receiving care in various health care settings, including public and private traditional and elderly hospitals, and illaanbaatar countryside homes. Interviews with rural and urban residents were conducted in order to permit comparative analysis. I carried out three focus group studies with a total of 13 elderly people from the countryside. The first focus group was conducted with three elderly people at a family doctor's clinic in the Huvsgul provincial center. The next two focus groups were in the Tarialan and Gault county clinics ofHuvsgul province respectively; each group consisted of five elderly. This descriptive, exploratory survey used face-to-face interviews. Interviews were non-structured and open-ended to allow participants to describe their life experiences and to listen and learn more from participants. Interviews varied in length, lasting approximately 20-30 minutes each. Handwritten field notes were taken during each interview process. Doing this descriptive survey I used both quantitative (demographic) and qualitative methods. The combination ofboth 94

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methods provides a more efficient way to develop a fuller understanding of the effects of the economic transition on the elderly. Description of Interview Sample For the purpose of this study I defined elderly people as those who are no longer employable and are qualified to receive retirement pensions from the government. All participants were Mongolian elderly from urban and rural areas. Participants were selected from various places, at their homes, public and private traditional hospitals, elderly hospitals and UB suburban homes. The total sample consisted of79 participants. Of these, 58 (74.4%) were from urban areas and 20 (25.6%) were from rural areas. Participants were interviewed at a time and place that was convenient for them. Twenty-four (30.4%) elderly were. interviewed in their own homes in Ulaanbaatar city, 11 (13.9%) at the Mongolian Traditional Medicine hospital, 12 (15.2%) at the private traditional hospital, 14 (17. 7%) at the elderly hospital, and 2 (2.5%) in UB suburban areas at their summer homes. In Huvsgol province, two people (2.5%) were interviewed in Moron county, 7 (8.9%) in the county center, and 7 (8.9%) in rural townships. The age range of the sample was 50 to 92 years with a mean age of 67.4 years. Verbal consent was obtained from each participant prior to the interview verbally. Before conducting this study, the research proposal was submitted to the 95

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Human Subjects Research Committee at the University of Colorado at Denver (Appendix A). The participation in this research study was strictly voluntary. All participants were informed that they could stop their interviews or participation in the study _at any time. Questions asked of participants are presented in Appendix B. Data Analysis Data analysis was carried out through coding and categorizing of the interview data. The first step in the analysis was coding data. The next step was . categorizing. Ultimately, several themes emerged from the categories. I used the Statistical Package for the Social Sciences (SPSS) program for all quantitative data analyses. Numbers, frequencies, and percentages are reported to describe the characteristics of the sample. Descriptive analysis of different variables is presented. The main findings of these analyses are described in the next chapter. 96

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CHAPTERS FINDINGS In this chapter, I first provide an overview of sample characteristics of the study population and basic descriptive findings. My survey findings are compared with the statistical data provided in the 2000 Population and Housing Census of Mongolia and with other studies of the elderly. These studies include: "Selected Studies of Daily Life on Elderly"conducted by the WHO and the Ministry of Labor and Social Welfare in 1999; the survey, "Assessment of the Health of the Elderly," provided by M. Shagdarsuren and L. Shimen in 1998 and ''The structure of elderly population of Mongolia and social problems," conducted by M.Shagdarsuren and I. BatErdene in 1999. The first is a study conducted by the WHO and the Ministry of Labor and Social Welfare on elderly in 1999. I will call this study as WHO study. The main goals of these studies were to understand the living conditions of elderly in Mongolia in order to define their needs with the intention to increase their quality of life, health care and social welfare services. This study included elderly from different parts of Mongolia. Samples were collected randomly from five provinces .. West zone-Khovd, East-Sukhbaatart, Central-Selenge, Khangai zone-Uvurkhangai, and Govi-Umungobi provincesand from the capital city Ulaanbaatar. From each province two counties 97

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and two townships were selected, including the _province centers. In total, there were 100 people interviewed from each aimag, for a total of 500 people from rural areas. In Ulaanbaatar, the sample was collected from five different districts: Songinokhairkhan, Chingeltei, Khan-Uul, Bayanzurkh, and Bayangol. From each district two sub-districts were chosen; 40 people from each sub-district and, from one district, for a total of 80 people each. The Ulaanbaatar sample totaled 400 people, for an overall sample_ size of 902. Interviews were conducted during 8 months from October 1998 to June 1999. This study consisted of two parts: ho1,1sehold interviews, which defined the structl.J.re of families with member, the age, gender educational level, marriage, living conditions of the elderly; and individual interviews, which considered health conditions, daily activities, employment, pension, material or other sources of help. It also examined elderly opinions about health care and social welfare services. WHO study found that the elderly in mostly live in extended families with their-children, .grandchildren, and relatives. According to this survey, 75.3% of elderly were educated and 24.7% were not educated. Ofthese, females were more likely to be less educated and illiterate, particularly rural elderly. Most elderly were unemployed (72.8%) and they were more interested to have ajob. Men were more likely to be employed than women, and males' salaries are higher than females'. Rural elderly were more engaged in economic activities, mostly in animal 98

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husbandry, than those in urban areas. Almost all elderly in this survey received pensions, but 84.9% said their pension was not sufficient fot living. Rural residents receive less than urban ones. In rural areas, the elderly ate often faced with pensions received late. WHO study showed that elderly in Mongolia have poor health. Urban elderly (70.3%) have poorer health than rural elderly. The study shows that 77.7% of elderly receive help from their children. Of the 902 respondents, only 44 elderly receive help from the Mongolian Elderly Federation and only those urban residents age 70 and above had received this help. The WHO study concluded that social support for elderly is not sufficient in Mongolia, particularly in rural areas. The second study to which. I refer as AHS, is entitled "Assessment of the Health of the Elderly'' (1998). This study \\(as designed to evaluate elderly health conditions. This survey included 1564 elderly, age 60 and over, from 8 sub-districts in tWo districts of.Ulaanbaatar, and in 9 counties in Khentei, Uvurkhangai and Umimgobi provinces. The survey examined blood pressure, skin elasticity, pulse rate, hand strength and determined the health index of the elderly. The AHE study (N=1534) found that 85.5% of the participants had one or more diseases based on participants' responses to the health evaluation. In other words, 24% elderly had one disease per every 100 persons, 6% people had two diseases and 1% person had three or more diseases. The most common Symptoms were hypertension (20.3%) and musculo-skeletal symptoms (14.0%); 8.7% of the participants reported headaches, 99

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8.0% reported urinary problems, and 7.8% reported cardiac symptoms, and 7.6% complained of liver pain. ARE (1999) found that leading causes of death were diseases of circulatory system (47.1 %), cancer (28.5%), diseases of the respiratory system (8.3%), gastrointestinal disease (6.8%), and infectious disease (1.5%). Of the total1534 participants, 70.3% received ambulatory services and 49.1% had been hospitalized. The investigators were interested in smoking and alcohol consumption patterns of the elderly. They found that one in two men smoke and one in three men use alcohol. One in five women smoke and two in five women said they use alcohol. The study found that about 17.9% ofthe men and 27,5% ofthe women stated that they often use medication. AHE study (1999) concluded that the health status ofthe Mongolian elderly is poor. They also wrote that there is a high incidence of diseases among the less educated and illiterate elderly. Thus, it is important to ensure access by all to. educational programs and job training. They found that less than 15% of the elderly reported themselves to be healthy. Thus, high incidence of diseases exists in older ages. The third study, conducted by M. Shagdarsuren and I. Bat-Erdene (1999), was titled "The structure of elderly population of Mongolia and social problems" I will refer to it as SEP. This study used the same sample as described in the preceding paragraph. The SEP study (2000) also found that educational level and income rate 100

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decreases by age. This means the elderly people are the poorest and least educated segments of the population. According to this study 75.2% of the elderly received pensions of $13 (15,000tg.) per month. They concluded that it is essential for the government to increase economic and social welfare services for the aged. Summary These three elderly studies tell tis that current living conditions of Mongolian elderly is not adequate. Elderly persdns' monthly pensions are not sufficient to meet their basic needs. All these three paper reports also reveal high incidence of diseases in older ages and many elderly in Mongolia are chronically ill. The most common symptoms were cardiovascular, and urinary symptoms. The leading causes of death were diseases of circulatory systems, cancer, respiratory, and gastrointestinal diseases. These studies concluded that current health care services and social supports for the elderly are not sufficient in Mongolia, particularly in remote rural areas. Further, they note that it is important for the government to increase economic conditions, health care, and social welfare services for the elderly. My study findings are close to the reports of these previous studies, which I will discuss next in findings section of my study. 101

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Demographic and SoCio-economic Characteristics of Study Sample In this section I provide summaries of data on elderly individuals' age, residence, sex, educational and occupational backgrounds, number of family members, and health conditions of participants. It includes information regarding participants' opinions about the effects of economic changes in their lives and about current health care services. In Ulaanbaatar, household interviews were conducted in two sub-districts ofChingeltei and one sub-district ofBayanzurkh districts. These sites were part oflarger stUdy of poor neighborhoods. In rural areas, interviews were provided in Huvsgul province because several years ago family doctor services had been introduced. This survey included 79 Mongolian elderly from urban and rural areas. Participants' ages ranged from 50 to 92 years, with a mean age of67.4 years. Table 5.1 shows the demographic characteristics of the sample. Elderly aged 55-64 and 64,..74 constituted the largest proportion ofthe interviewed sample. From urban areas 58 (74.4%) elderly were interviewed, whereas 20 (25.6%) elderly were from rural areas. This reflects the approximate portions of elderly living in urban and rural areas. According to the 2000 Population and Housing census of Mongolia, "about 57% of the total population of 1,345,000 persons were living in urban areas, defined as the capital, Ulaanbaatar, the 21 aimag centers and 22 counties"(NSO, 200 I :31 ). 102

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Of the 79 elderly, 28 (35.4) were male and '51 (64.6%) were female. Again, this reflects the gender distribution in the country as a whole(NSO 2001). The AilE study (1998) found 1247.9 women per 1000 men. Most ofthe participants lived in traditional housing, called a "ger". The living conditions in ger areas are very poor. Ofthe 78 elderly participants, in urban areas 70.7% of the respondents lived in gers and only 29.3% lived in aparbnents. In rural areas only 10.8% lived in aparbnents and 90.0% elderly lived in a ger. The 2000 Population andHousing Census (2001) noted that: About 49.1 and 50.9 percent total households of Mongolia lived in conventional housing artd gers respectively. In the urban areas almost 72 percent of the households lived in conventional housing while in the rural areas the corresponding figure was only 22 percent (NSO, 2001, p. 112). The study SEP (1999) observed that about 61.8% elderly lived in ger area, 37.4% lived in apartments and 0.8% elderly do not have their own house. Information on marital status was not collected during the interview. However, marital status was reported by study SEP 2000. Of the 1534 participants 56.2% lived with their spouse, 41.2% were widowed, and 1.6% of the elderly had never been married. Table 5.1 also shows that 58.7% of the elderly had 8 or fewer years schooling. In urban areas 20.0% of the participants reported fewer than 5 years of schooling, and in rural areas 30.0%. The illiteracy rate was high among elderly, in urban area 18.2%, 103

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and in rural areas 20.0% were illiterate. Five ( 6. 7%) elderly had 9-10 years of schooling, 7.3% in urban area and 5.0% in rural area. Schooling 10+ years was high Urban Rural Total N. % N. % N. % Age 45-54 1 1.7 3 15.0 4 5.1 55-64 23 39.7 8 40.0 31 39.7 65-74 19 32.8 8 40.0 27 34.6 75+ 15 25.9 1 5.0 16 20.5 Total 58 100.0 20 100.0 78 100.0 Schooling 0 10 18.2 4 20.0 14 18.7 1-4 11 20.0 6 30.0 22.7 5-8 18 32.7 9 45.0 27 36.0 9-10 4 7.3 1 5.0 5 6.7 10+ 12 21.8 0 .0 12 1.6.0 Total 55 100.0 20 100.0 75 100.0 Occupation Herder 5 8.8 11 55.0 16 20.8 Prof. Job 18 31.6 5 25.0 23 29.9 14 24.6 1 5.0 15 19.5 Skill/lab/w. 7 12.3 1 5.0 8 10.4 Unskill/1./w. 6 10.5 2 10.0 8 10.4 Driver 4 7.0 0 0 4 5.0 57 100.0 20 100.0 77 100.0 Salesperson Total Table 5.1 Demographic Characteristics ofSample by Residence. Note: Totals do not always sum to 79 because of missing data. among urban elderly 21.8%, but not reported among rural elderly. According to the Population and Housing Census (200 1) reported that 19.7% people were not educated and 80.0% people were educated. From these, not educated elderly of age 50+ were 104

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9.7% and educated elderly constituted 12.2%. Thus, this is a low level of schooling among elderly population. Male Female Total N. % N. % N. Age 45-54 0 0 4 7.8 4 55-64 10 35.7 22 43.1 32 65-74 10 35.7 17 33.3 27 75+ 8 28.6 8 15.7 16 Total 28 100.0 51 100.0 79 Schooling 0 1 15.4 10 20.4 14 1-4 2 7.7 15 30.6 17 5-8 11 42.3 16 32.7 27 9-10 2 7:7. 3 6.1 5 10+ 7 26.9 5 10.2 12 Total 26 100.0 49 100.0 75 Occupation Herder 1 3.6 15 30.0 16 Prof. Job 8 28.6 15 30.0 23 Skill/lab/w. 7 25.0 8 16.0 15 Unskill/1./w .. 2 7.1 6 12.0 8 Driver 7 25.0 2 4.0 9 Salesperson 1 3.6 3 .0 4 Total 28 100.0 50 100.0 78 Table 5.2 Demographic Characteristics of Sample by Sex. Note: Total do not always sum to 79 because of missing data. % 5.1 40.5 34.2 20.3 100.0 18.7 22.7 36.0 6.7 16.0 100.0 20.5 29.5 19.2 10.5 11.5 5.1 100.0 Educational level among females was comparatively low (Table 5.2). Higher rate of illiteracy are among females (20.4%) than males (15.4%), whereas 10+ years of schooling were higher among male (26.9%) than female (10.2%). Shagdarsuren and Shirnen also found the higher educational levels among males 71.1% than 105

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females 28.9%.llliteracy rate was 31.0% among male and 69.0% among female. Thus, educational level was higher ammig males and illiteracy rate was higher among females. The participants were asked about their occupation before retirement. In the urban area 31.6% elderly had professional jobs, 24.6%.did skilled labor, 12.3% did unskilled labor, I 0.5% worked as drivers, 7.0% worked as sales persons and 8.8% were herders. In rural areas a majority of participants were herders 55.0%. The others had professional jobs 25%, or were drivers or labors 20%. Thus, urban elderly were more likely have been professional than rural elderly. If we consider sex in relation to occupation, herders constituted females 30.0% and male 3.6%. About 30.0% of the female elderly and 28.6% of male had had a professionaljoh. Males were more likely to have been skilled laborers 25% than females %, whereas fem3les were more likely to have been unskilled laborers 12% than males 7.1 %. More males 25.0% worked as drivers than females 4.0%. According to the 2000 Population and Housing Census, "in the professional and technical occupations, females were in the majority. Almost 38,000 more men than women were classified in the agriculture occupational group"(UNDP, 2001, p.86). 106

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Urban Rural Total N. % N. % N. % House/size 1-2 9 15.5 5 26.3 14 18.2 3-4 23 39.6 8 42.1 31 40.2 5-6 14 24.1 2 10.5 16 20.8 7-8 7 12.1 2 10.5 9 11.7 9+ 5 8.6 2 10.5 7 9.1 Total 58 100.0 19 100.0 77 100.0 #of children 6 12.8 3 15.0 9 13.4 0-2 10 21.3 3 15.0 13 19.4 3-4 16 34.0 5 25.0 21 31.4 5-6 6 12.8 6 30.0 12 17.9 7-8 9 19.1 3 15.0 12 17.9 9+ 47 100.0 20 100.0 67 100.0 Total Table 5.3 Household Size and Number of Children by Residence. This analysis shows that big or extended households are more prevalent in urban area, whereas small households are more prevalent in rural areas. This likely reflects the greater poverty of the urban respondents, and the tendency for individuals to Iirigrate from rural to urban areas. Conversely, the results of this study indicate that Mongolian families in rural areas tend to have more children. Average number of household size of the sample was 4.6 and number of children was 5. In the SEA study (1999) observed that 33.0%ofelderly lived with unmarried children and 61.5% with grandchildren. 3.1% of elderly who lived with the third generation and 8.4% elderly who lived alone. The survey SEA showed that the number of persons in one family is approximately 3.9 people and the number of children is 4.6. 107

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Summary of Demographic and Socioeconomic Characteristics A majority of the participants in the survey were (74.4%) from urban areas and most ofthe participants (74.3%) were between age 55-74. In this survey, 35.4% were male and 64.6% were female. Elderly, particularly rural residents, were the least educated segments of the population. Among elderly the educational level was higher among males and the illiteracy rate was higher among females. Most of the urban sample lived in the "ger'' areas of cities, which have the poorest living conditions and lowest access to services. However, more of the urban elderly report having had professional jobs than rural ones. Elderly in rural sample were mainly herders mostly female. Mongolian families tend to be large, especially in rural areas. Big families (with 5or more members) were more prevalent in urban areas, while small families (with 1-2 members) were more prevalent in rural areas. This is related to economic and social factors. which have pushed rural residents, particularly elderly, out of the rural areas to move into the poorer, urban ger districts. 108

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Health Conditions of the Participants This section includes discussion of the participants' perceptions of their health and opinions about health care services. I provide here an analysis of illness symptoms by residence, sex and age. The elderly in the survey were asked to evaluate their health. Relatively healthy Poor N. % N. % Residence Urban 15 60.0 41 80.4 Rural 10 40.0 10 19.6 Total 25 100.0 51 100.0 Gender Male 8 30.8 19 37.3 Female 18 69.2 32 62.7 Total 26 100.0 51 100.0 Table 5.4 Health Conditions by Residence and Sex. This table represents responses to this question according to location by residence and sex. Analysis of the data show that 60.0% of the elderly who lived in the urban area were relatively healthy, while 40.0% of those in rural areas consider themselves healthy. Conversely, 80.4% of urban elderly claim to be in poor health, whereas 19.6% of rural elderly believed they were in poor health. This would suggest that rural elderly are healthier than urban ones. This may be related to the needs for high physical activity in rural areas where most people are engaged in animal husbandry. It 109

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is also related to Rural elderly who become ill move to counties, urban areas, where they are close to health care. About 30.8% of the men feel_they are relatively healthy and37.3% said they have poor health. In contrast 69.2% female said they are relatively healthy and 62.7% claimed they have poor health. then, the majority of participants felt they were in poor health 66.2%, and females _perceived themselves to be more healthy 36.0% than males 29.6%. There was a wide range of symptoms associated with individuals' health problems. Urban (58) Rural (20) Total (78) N. % N. % N. % Gastroin. 19 32.8 8 40.0 27 34.6 symp. Respirat. 3 5.2 1 5.0 4 5.1 symp. Cardiac symp. 27 46.6 15 75.0 42 53.8 Dermatologica 2 3.4 0 0.0 2 2.6 1 symp. ENTsymp. 7 -12.1 3 '15.0 10 12.8 Urinary symp. 20 34.5 9 .0 29 37.2 Neurological 40 69.0 4 20.0 44 56.4 symp. Psychological 13 22.4 1 5.0 14 17.9 symp. Muse-skeletal 28 48.3 11 55.0 39 50.0 symp. Table 5.5 lllness Symptoms by Residence. Note: Total do not sum to 79 because of missing data. Participants could give more than one response. Therefore percentages do not total to 100%. 110

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For urban elderly the most common symptoms were neurological1 (69.0%), followed by musculo-skeletal (48.3%) (46.6%), urinacy? (34.5%), gastrointestinal4 (32.8%) and psychological5 (22.4%). For rural elderly the most prevalent symptoms were cardiovascular (75.0%), followed by musculo-skeletal (55.0%), urinary (45.0%), gastrointestinal (40.0%), neurological (20.0%) and endocrinological6 (15.0%). An elderly person from UB, 60 years old, said that "I have poor health. Last year I was hospitalized twice in the district hospital and one time in Chingeltei district hospital. Now my complaints are tiredness, chest pain, abdominal pain, unstable blood pressure, abnormal rhythm, dizziness,. blurring vision and nose in ears." A man, 82 years old, Ulaanbaatar complained that: I have pain in my knee joints, back pain, increase of pain during motion, difficulty in walking, tiredness. Last year twice hospitalized Chingeltei District hospitals. Man, 56 years old, Huvsgul province, Gault County: 1 Neurological symptomsheadache, emotional stress, fatigue, anorexia, loss of vision, anxiety, contralateral motor and sensory deficit, difficulty in talking or disarthria. 2 Cardiovascular symptomspain in heart that radiates in the shoulder, upper abdomen or back, chest pain, anxiety, sensation of tightness or pressure in chest, abnormal rhythm, unstable blood pressure, dizziness, blurring vision, noise in ears. 3 Urinaryrenal pain, sometimes fever, urethral pain, dysuria, cloud urine, fatigue, difficulty in carrying heavy things and physical labor. 4 Gastrointestinalmild abdominal pain, arthralgia, decrease in appetite, easy fatiguability, anorexia, tenderness. 5 Psychologicalheadache, weakness, tingling, unstable blood pressure, stress, increased worriness, anxiety, fearful. 6 Endocrinologicalthirst, polyuria or increased urination, dryness of skin. Ill

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I have cardiac and chest pain, anxiety, abnormal rhythm, contraction of limb muscles, tiredness, dizziness, noise in ears and blur in vision.Since 1972, I was on disability pension of cardiac problems. Last year I was hospitalized twice in province and county hospitals. Table 5.6 reveals that 67.9%ofthe males have neurological symptoms, followed by cardiovascular 39.3%, and musculo-skeletaf and urinary both 32.1 %. Further analysis of the data show that cardiovascular symptoms 60.8% were more prevalent among females, followed by musculo-skeletal59.8%, neurological and gastrointestinal symptoms each 41.2%. Male (28) Female (51) Total (79) N. % N. % .N. % Gastroin. symp. 6 21.4 21 41.2 27 34.2 Ftespir.at. symp. 1 3.6 3 5.9 4 5.1 Cardiac symp. 11 39.3 31 60.8 42 53.2 I>ermatological 1 3.6 1 1.9 2 2.5 symp. ENTsymp. 4 14.6 6 11.8 10 12.7 Urinary symp. 9 32.1 20 39.2. 29 36.7 Neurologicw symp. 19 67:9 21 41.2 40 50.6 Psychologicalsymp. 7 25.0 7 13.7 14 17.7 Muse-skeletal s}imp. 9 30 58.8 39 49.4 Table 5.6 Illness Symptoms by Sex. Note: Total do not sum to 79 because of missing data. Participants could give more than one response. Therefore, percentages do not total to 1 00% . If we look to the illness symptoms by age of those symptoms, the results of the analysis show that as people age, their susceptibility to different 7 Musculo-skeletalpain in joints of the pain on motion, spinal pain, nocturnal pain in knees, decrease of functions oflegs, difficulty in walking. 112

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disease changes. Table 5.7 shows that elderly aged 50-54 were more likely to report .cardiovascular symptoms 100.0%, gastrointestinal 75.0%, and urinary 75.0%. Elderly aged 55-64 have high rates ofneurological65.6%, cardiovascular symptoms 56.3%, and muscular-skeletal symptoms 40.6%. Elderly aged 65-74 have more muscular skeletal 59 .2%, and cardiovascular symptoms 48.1 %, followed by urinary and neurological each 37 .0%. The disease patterns of elderly of age 75+ were different. For them neurological symptoms 81.2% were more prevalent followed by musculo skeletal68.8% and cardiovascular symptoms 43.8%. In short, as people age they are more susceptible to chronic disease. Young elderly are more likely to have cardiovascular symptoms, followed by gastrointestinal and urinary symptoms, while elderly above 65+ and 75+ years are more likely to have high rates of musculo skeletal and neurological symptoms. These findings are close to other studies. The AHS (1998) reported that the most frequently reported diseases were circulatory diseases, which constituted (50.6%), followed by gastrointestinal (16.0%), musculo skeletal (10.1%), respiratory (6.2%) and urinary diseases (7.9%). They found that males are more susceptible to respiratory diseases (58.0%), and the rest were more prevalent in females, This study determined elderly mortality rates. The leading causes of death were circulatory diseases (47.1 %), followed by cancer (28.5%), respiratory (8.3%) and gastrointestinal diseases (6.8%). The most common types of cancer that leading to death were liver cancer (10.8%) and cancer of the stomach (5.3%). 113

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Participants were asked whether they had been hospitalized in the last month or last year. Table 5.8 and 5.9 show that 23.2%urban and 20.0% rural elderly were hospitalized in the last month; while 39.3% urban and 35.0% rural elderly were hospitalized in the last year. Thus, the hospitalization rate was slightly higher among urban elderly than rural ones. This is may be related to the fact that rural elderly appeared to be more healthy than urban ones, or because urban elderly live close to the hospitals and have easier access to health care services. It could be also related to problems accessing health care in remote rural areas where transportation, fuel and money are scarce. Disease Age Total symptoms 45-54 (4) 55-64 (321 65-74 (27) 75+ (16) N. % N. % N. % N. % N. % Gastroint. 3 75.0 12 37.5 9 33.3 3 18.8 27 34.2 Symptoms Respirat. 0 0 0 0 1 3.7 3 18.8 4 5.1 symptoms Cardiac 4 100.0 18 56.3 13 48.1 7 43.8 42 53.2 symptoms Derma to I. 0 0 0 0 2 7.4 0 0 '2 2.5 symptoms ENT 0 0 2 6.3 4 14.8 4 25.0 10 12.7 symptoms Urinary 3 75.0 12 37.5 10 37.0 4 25.0 29 36.7 symptoms Neurolog. 0 0 21 65.6 10 37.0 13 81.2 44 55.7 symptoms Psycho I. 1 25.0 4 12.5 4 14.8 5 31.3 14 17.7 sym_ptoms Musculo1 25.0 13 40.6 16 59.2 11 68.8 41 51.9 skeletal Table 5.7 fllness Symptoms by Age ofThose Experiencing Symptoms. 114

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It is possible that elderly with cardiovascular symptoms do not reach greater ages. Hospitalization in the last month and in last year were slightly lower among females, (20.4% and 36.7% respectively) than in males (25.9% and 40.1% respectively). This may be related to greater number of females than males who participated in this survey. Participants were asked, "do they have difficulty getting health care? If yes, what the major problems do.they have?" From bible 5.10 we can see the majority of the participants answered "yes" to the first question, in urban areas 84.5% and in rural areas 85.0%respectively. About 81.0% urban elderly and 80.0% rural elderly defined money as the major problem in receiving health care, 22.4% urban and 40.0% rural elderly reported that transportation was a problem, and 5.2% of urban participants complained about the long waiting list to get in to hospitals. Yes No Total N. % N. % N. Residence Urban 13 23.2 43 76.8 56 Rural 4 20.0 16 80.0 20 Sex Male 7 25.9 20 74.1 21 10 20.4 39 79.6 49 Female Table 5.8 Hospitalization in Last Month by Residence and Sex. Note: Totals do not always sum to 79 because of missing data. 115 % 73.7 26.3 35.5 64.5.

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Yes No Total N. % N. % N. Residence .Urban 22 39.3 34 60.7 56 Rural 7 35.0 13 65.0 20 Gender Male 11 40.1 16 59.3 27 18 36.7 31 63.3 49 Female Table 5.9 Hospitalization in Last Year by Residence and Sex. Note: Total do not always sum to 79 because of missing data. Urban (58) Rural (20) N. % N. % Yes 49 84.5 17 85.0 No 9 15.5 3 15.0 Total 58 100.0 20 100.0 Money 47 81.0 16 80.0 Transportation 13 22.4 8 40.0 Waiting 3 5.2 0 0 Others 1 1.7 1 5.0 % 73.7 26.3 35.5 64.5 Table 5.10 Issues Getting Care and Issues Care Regarding by Residence. Note: Participants could give more than one response. Therefore, percenta,ges do not total to 100%. 116

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One participant argued that: Yes, I have problems in getting health care, because of the lack of money. I can't even purchase all the drugs the doctor prescribed. My family doctor sometimes loans me drugs which must be repaid when I can, but it is hard to pay back because my daughter spent my pension (which I got in advance for the treatment up through October). Another elderly stated that: It is very difficult to get health care because 1 am not registered as a resident ofUlaanbaatar. I can't get service from family doctors, and private doctor services are too expensive. If I had a serious illness, I would die easily. I think the insurance system doesn't work, even for the elderly. There are many people/migrants who are struggling to get health care in UB. It is difficult to figure out how insurance can be transferred, people at the sub-district and districts are unhelpful, and I think it is just a lot of bureaucracy. There should be special programs to help elderly get access to health services. One woman stated that "public hospitals don't like to hospitalize elderly people because we don't pay them, except for the 10% co-pay. They are more interested in hospitalizing young people who have money, particularly patients from other districts because they usually have to pay for treatment." Another man thinks that: Public hospitals treat only current complaints and they don't consider and treat chronic diseases. I think these kinds of services are bad. They need to provide more complex treatments including psychological therapy. Most of the time, we patients bring our medications from outside because hospitals don't have the medication we need. Our kids help us to buy these 117

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expensive medications. Hospital service is poor, also their meals are insufficient and most of patients get meals from outside, sometimes two or three times a day. We also bring all other things like towels, sheets, and supplies. Many elderly share the opinion of one person, who said that "doctors' lmowledge in public services are very poor and their ethical standards are low. Some doctors are ignoring the elders. When we give our complaints, they tell us these complaints are because of our old age and they do not provide needed treatment." One ofthe positive opinions is that"I don't have difficulties getting health care because I worked in the health care system and I have many friends who can help me." Table 5.10 shows that there are two people says "other" category, who believe that medical referrals are major obstacles to health care, especially for those elderly who live in rural areas. Access to services in Ulaanbaatar and in province center hospitals depends upon proper referral from the county or family doctor. To the question, "is there somebody to help you when you are sick or need to get to the hospital?" 74 of the elderly answered that their children help them when they need help, 7 get help from a spouse, 1 from other family or relatives, 2 from friends and 3 from others, or from family doctors. Shagdarsuren and Shimen's (1999) study showed that 89.0% of elderly reported their children help them, and 8.8% of elderly complained that children do not help them. 118

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In summary, a large majority of the participants have difficulties in accessing health care. Most identified money and transportation as the main obstacles and some of them complained about difficulties getting referrals from rural areas to go to the Ulaanbaatar for treatment. Analysis of the data reveals that children are the most common source of help for Mongolian elderly. Elderly Opinions Concerning Health Services Participants of this study were asked several questions regarding current health care services in Mongolia. This section includes discussions of the respondents' opinions about family doctors, public hospital services, private doctors and traditional medicine services. It also includes a summary of the elderly's thoughts concerning why health care services do not satisfy their needs, the main cause of poor quality services, and what needs to be done to improve it. 119

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Opinions and Issues About Family Doctor System Urban (58) Rural (20) Number Percent Number Percent Family doctors Positive 20 34.5 8 40.0 Negative 25 43.1 5 25.0 No opin. 3 5.2 1 5.0 Mixed 10 17.2 6 30.0 Total 58 100.0 20 100.0 Private doctors Positive 6 10.3 5 25.0 Negative 19 32.8 5 25.0 No opin. 13 22.4 5 25.0 Mixed 20 34.5 5 25.0 Total 58 100.0 20 100.0 Table 5.11 General Opinions About Family Doctors and Private Doctors by Residence. Note: Totals do not sum to 79 because of missing data. Table 5.11 and 5.12 show responses to question ''what do you think about the family doctor system? How about the district hospital?" Of the 78 respondents, 34.5% urban, 40.0% rural elderly had positive, and 43.1% urban elderly, 25.0% rural had negative opinions about family doctor services. Respondents who said poor services were constituted 28.2%, followed by insufficient medical supplies 14.1 %, doctor's knowledge 8.9%, poor budget 7.7%, to poor salaries 3.8%, and 3.8% corruption in health system. About 47.4% elderly said family doctors services are good and 1.3% mentioned enhanced doctor and patient relationships. Urban elderly 120

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were concerned more about the poor quality of family doctor services. On the contrary, rural elderly were more concerned about lack of medical supplies. Urban (58) Rural (20) Total (78) N. % N. % N. % Family doctors Budget 4 2 10.0 6 7.7 impact Poor supplies 5 8.6 6 30.0 11 14.1 Close to 1 1.7 0 0 1 1.3 patient Poor 5 8:6 10.0 7 8.9 knowledge Poor service "19 32.8 3 15.0 22 28.2 Poor salaries 3 52 0 0 3 3.8 Good service 25 43.1" 12 60.0 37 47.4 Corruption 1 1.7 2 10.0 3 3.8 Private doctors Good service 24 41.4 9 45.0 33 42.3 Too 39 67.2 9 45.0 48 61.5 exp_ensive Don't use 28 48.3 7 35.0 35 44.9 Other 2 3.4 l 5.0 3 3.8 Table 5.12 Specific Opinions About Family Doctors and Private Doctors by Residence. Note: Participants could give more than 1 response. Therefore, percentages do not total to 1 00%. Positive opinions given by participants were similar to a comment offered by the person who said "family doctors' services are good because they are close to the people and helpful to kids and elderly." Another person stated "family doctor service is good, they do regular home visits, respond to our calls. The community health worker regularly visits and checks blood pressure." 121

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Several elderly gave mixed opinions. One person said: Family doctors and hospital services are good because they don't ask for money from retired people, but if you want to get good services, you need to have money for treatment due to poor budget. Public rehabilitation resorts (sanatoria) are free for the elderly, but there is a very long waiting list. If people pay-money, they can get in without having to go on the waiting list. Private resorts don't have a waiting list but they are very expensive; it costs 4000 ($4.00) tg a day. Most of the participants gave negative opinions; for example: Family doctor services are not sufficient because when we call them to come to our homes, some of them come very late. My friend said that some family doctors don't come to their homes and they require us to come to their clinics. I don't trust the family doctors, but I do the private doctors. I suspect corruption. I think that public doctors' knowledge isn't as good as those in the private sector, and their service is poor in comparison. For ordinary people to get health care is hard. I went with my daughter who wanted prenatal care and there was long line. It was hard for us to get service, even through we had friends who work there. In regard to health care services, some participants in focus groups were of the opinion that doctor's knowledge is good, but the supply of medications, equipment, and transportation are insufficient. Others complained about the doctors' poor knowledge; they are always referring patients to the province hospitals and some nurses are only trained to give injections. They were mostly concerned with an unavailability of drug or car and inadequacy of doctors in counties. Several of them 122

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criticized the existing bureaucracy and corruption in health services. One man stated that: I have a friend who lost his right arm many years ago, and he got disability pension. Last year doctors cut his pension. The main reason of that was he didn't receive treatment during last year. We live in remote areas and for us it is hard to go to the county, then province for extension of disability pension. Why so many bureaucracy? I think the cut of his pension is wrong, instead he has to be on permanent and there is no need to extend each year. Another man from Gault count said: Community health worker or bagh feldsher" has 60,000 tg drug revolving funds and that is not sufficient in rural areas." He criticized high cost of drugs, and recommended increasing drug funds and supplying in county. One woman noted that because of poor supply of drugs, we usually buy it with high price from people's hand, and use it without any inspection. Participants' Opinions and Their Concerning Issues About Private Doctors From Table 5.11 and 5.12 we can see urban residents 34.5% had more mixed opinions followed by negative 32.8%, no opinion/don't know 22.4% and positive 1 0.3%. Rural residents responded equally to the 4 different options. The respondents who gave mixed opinions reported that private services were good but too expensive. Many of them mentioned that if they had enough money, they would like to go to a private doctor because the quality of health care was perceived to be better than that 123

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available at public hospitals. Those who responded no opinion/don't know stated that they never used private doctors due to the high cost of their services. Some of them reported that they are not interested in private doctors because they know they cannot afford the services. The elderly who had positive opinions pointed out that the care provided by private doctors is very good. Person who had positive opinions said that: Private doctors' services are better than the public because the doctor's knowledge is better. They have good relationships with patients but it is very expensive. Here in private clinics patients do not need to bring medications, towels, or sheet from outside, which is good, but before hospitalization patients have to finish with lab tests, which requires money too. Another person stated that "private hospitals are much more convenient because everything is included in the price, but it is too expensive for us." Most of participants noted that private doctors diagnose diseases well and that their treatment is more effective. Some elderly gave negative responses largely because private care is too expensive. Table 5.12 also presents participants' responses regarding private health services. About 61.5% of the respondents said private services are too expensive. One person said "it is too expensive. Most knowledgeable doctors are more likely to work in the private sector and have their own private clinics. I think some of them use only their names and do not provide sufficient service." Another person stated that "private dental clinics are too expensive, and they don't accept health insurance, and they ask patients to pay them a lot of money." Nearly half 44.9% said they don't use private doctors because of the expense; and 42.3% elderly 124

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said private doctor services are good. "Other" responses, from3.8% of the respondents, included comments that there are no waiting lists or long lines to get in to the private hospitals, which is good, but on the other hand it is very expensive. One of the respondents complained that private doctors do not respect the elderly community, particularly patients with chronic diseases. Private doctors appeared to be more interested in hospitalizing young people and those who have money. Thus, the majority of the elderly had negative opinions about private doctors and claimed that their services were too expensive. Elderly Opinions and Main Concerns About Traditional Medicine From Table 5.13 and 5.14, about 67.9% elderly had positive opinions, 15.4% had no opinions/didn't know, 11.5% gave negative responses and 5.1% mixed opinions about traditional medicine. Negative opinions were higher among urban elderly 13.8% than rural5.0%. No opinion/don't know responses were higher among rural elderly 20.0% than urban 13.8%. Positive responses were same in both areas. About 43,6% elderly described traditional medicine as effective and 28.2% respondents claimed it is good for treatment of chronic disease. 26.9% said that-they didn't use traditional medicine because they prefer European medicine. For these respondents traditional medicine seems new, they though do not know what it is good 125

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for. 19.2% defined it as an inexpensive treatment,.and 2.6% said it gave a quick result. Urban Rural Total N. % N % N % Positive 39 67.2 14 70.0 53 67.9 Negative 8 13.8 1 5.0 9 11.5 No opinion 8 13.8 4 20.0 12 15.4 don't know Mixed 3 5.2 1 5.0 4 5.1 Total 58 100.0 20 100.0 78 100.0 Table 5.13 General Opinions About Traditional Medicine by Residence. Urban (58) Rural (20) Totalt 78) N. % N. % N. % Effective 26 44:8 8 40.0 34 43.6 Cheap 14 24.1 1 5.0 15 19.2 Quick 2 3.4 0 0 2 2.6 result Good for 15 25.9 7 35.0 22 28.2 chronic disease Don't use 13 22.4 8 40.0 21 26.9 Others 19 32.8 6 30.0 25 32.1 Table 5.14 Specific Opinions and Issues About Traditional Medicine by Residence. Elderly who gave positive opinions stated that "traditional medicine is effective especially if it is used alongside biomedicine. It is well suited to the human 126

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body and not hannful if dose if the dose is correct. It just needs to be further developed." Another person argued that, "it is effective and the doctors see every patient daily and do all the treatment by themselves, which is nice. However, private services are too expensive." One person.whohad no opinion stated that: I am not interested in traditional medicine. Doctors often prescribe many different kinds of herbal medicines that have special requirements. It is difficult to use it properly because we don't have enough money. I think if you don't follow the elaborate instructions properly, you can damage your body. One respondent who had a negative opinion said that: In ancient times, traditional medicine was practical by high level monks who learned this knowledge from a young age .. Now many doctors have emerged in a relatively short time. I think these people are more interested in making money than treating people. The quality of their medications are insufficient because herbal medications are now collected not by doctors but mostly by people who are not trained. In other words, they produce poor quality medications for :the community. "Other'' opinions were expressed by 32.1 %. Some participants argued that traditional medicine might be useful for cancer. Others stated that traditional medicine has no side effects. Some of the elderly complained about long waiting list for hospitalization in traditional hospitals. In Mongolia, rural elderly especially have knowledge about traditional medicine. Many of them undertake self-treatment with basic herbal medicines; e.g., fruits for diarrhea, coughs etc. Different kinds of herbal medicines have special 127

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requirements for how, when and with what they are to be taken. Some herbal medicine is used with milk, tea, soup, or water and proper use. Some elderly believe that if a patient doesn't follow the elaborate instructions properly, the outcome will be bad. Others complained that use of traditional medicine was too much trouble. Some participants complained about the high cost of private traditional services. A few elderly were concerned about the decreasing quality of traditional treatment and said that is why they no longer use it. According to these people, traditional medical knowledge requires a long period of training. They argue that the efficient use of herbal medicine requires a careful mixture of different ingredients with strong doses, and requires thorough knowledge. They believe that many new traditional doctors are poorly trained and only are interested in making money. They also complained that herbal medicine is ineffective due to its poor quality. In general, though, most elderly prefer and use traditional medicine. They believe that it is effective, cheap, good for chronic diseases, and that it is well suited to the human body .. Rural elderly have more positive opinions oftraditional medicine and they use it more than do urban elderly. This may be related to the fact that the elderly in rural areas have more knowledge about homebased herbal treatments, and they have kept alive more old traditions and customs than have the urban elderly. In addition rural elderly use traditional medicine more because they know about, and live close to, locally available medical resources. 128

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. . Elderly Opinions About the Economic Transition and Their Concerns This section of the thesis summarizes data on the life situation of elderly participants before and after the economic transition. It provides general and specific opinions about the effects of the economic transition, their daily activities, their pensions and issues ofhow to gain access to other aid beside the pension. It also considers primary concerns of participants about what needs to be done to improve the quality of health and social services for the elderly. The participants in the survey were asked describe their life before the economic transition. Sixty-five (83.3%) of the elderly interviewed reported that their life was good, nine (11.5%) that was a5 mixed, two (2.6%) had no opinion, and two (2.6%) said their life was poor. There was no difference in opinions between urban and rural respondents. Thus, for most elderly, living conditions before the economic change was generally considered to have been good. One person stated that, "before 1990s life was good and not stressful. Health care services were good and the doctors used to come to our houses regularly for the care." Another person said that "life was good, it was easy to find jobs, we all had jobs and we had our own apartments." To the question ''what do you think about the economic transition? How has it affected your life, personally?" a majority of the respondents 42.3% indicated that the 129

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economic transition was bad and gave negative opinion. About 33.3% had mixed responses, followed by 17.9% had positive, 3.8% who didn't know and 2. 7% who said there was no change. 45.0% of rural elderly had positive opinions compared to only 8.6% of the urban elderly, while 43.1 %of the urban elderly had negative opinions compared to rural ones 40.0% (see Table 5.15). Urban Rural Total N. % N. % N. % Positive 5 8.6 9 45.0 14 17.9 Negative 25 43.1 8 40.0 33 42.3 No change 2 3.4 0 0 2 2.7 Don't know 3 5.2 0 0 3 3.8 Mixed 23 39.7 3 15.0 26 33.3 Total 58 100.0 20 100.0 78 100.0 Table 5.15 General Opinion Given About the Effect ofthe Economic Transition. One elderly who gave positive opinion said, "the economic transition is not bad. Now we have opportunities to do anything. I think if people are poor, particularly the yol.mg, it is because they are lazy. I am a religious person. Before the economic transition, religion was restricted, and after that I experienced my religion, that is good for me." Another person said that "the economic transition allowed us to buy animals, which was allowed us to be more selfsufficient." One participant who had mixed opinions argued that "people's lives depend on themselves. If a person is a hard worker, the transition can have very good influence, if a person is lazy, then they 130

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will find their lives much Everything about being "free" is good, but the life of most people has deteriorated." Another person said: It brought freedom but also increased alcoholism, unemployment and crime. My life situation has worsened. Now basic products and services are very expensive. I really want there to be less crime, unemployment, and alcoholism. We need to develop our industries and increase job opportunities for people. Also, I am against age restrictions in jobs. I think the government should make their laws stronger against crime. There is a need to increase hygiene and sanitation in ger districts, decrease the number of bars, alcoholism, corruption, infectious diseases and increase the quality of foods. I want the government to increase pensions before October, before wintertime, so I can afford firewood and coal. One elderly who had a negative opinion told me that: It is difficult because everything now revolves around money. For an elderly person trying to survive on less than 20,000 tg (U.S. $20) a month, our lives are not easy. In addition; there are not enough employment opportunities for young people, especially in the countryside, so they migrate to UB where everything is very expensive. It is a difficult situation. Another person said, "privatization of state owned enterprises was wrong. The new government destroyed many previously existing good things such as kindergartens, schools, hospitals, social services and produced too many unemployed people. It increased poverty and number of street children." Elderly woman argued: 131

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I think the Mongolian government established a wrong law on elderly pensions. According to this law, too many young people, who have four or more kids, can be retired. I retired at age 3 7 because I had four children. I think this is wrong because many employable people are retiring and these places more burden on pension funds. Another person said, "the economic transition widened the gap between rich and poor. The most concerning changes have been environmental: many 'dzud' events, a drying out of the weather with less water and lower quality of grasses, which has a negative effects on herding families." Table 5.16 presents specific opinions about the effects ofthe econori:ric transition. There are no significant differences in opinions between urban and rural residents. Negative effects included increased poverty and inequality 62.8%, and unemployment 44.9%, it increased crime and corruption 28.2%, increased alcoholism 20.5%, a loss of traditions 14.1 %, wrongful privatization 8.9%, increased prostitution 7.7%, homelessness 5.1 %, environmental degradation 3.8% and stated increased costs of basic commodities 1.3%. Iri contrast, 38.5% ofthe elderly said that it brought more opportunities to people's lives, 30.8% said it increased freedom and people's ability to speak freely, and 7.7% said it broadened international relations. The response category "other" was selected by 20.5% respondents, who argued that it was a necessary process but it was too sudden a change. They stated that the country's economic conditions and people's ideology provided a poor foundation for this change, particularly to the fast 132

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privatization of state property. According to them the rapid and poorly managed privatization process destroyed many previously nice things, such as preschools, colleges, hospitals, animal barns, and sanatoria. Urban (58) Rural (20) Total (78) N. % N. % N. Freedom/voice 16 27.6 8 40.0 24 Increased inter. 2 3.4 4 20.0 6 relations Opportunities 20 34.4 10 50.0 30 ,. Increased 15 25.9 7 35.0 22 crime/corru_p. Increased 12 20.7 4 20.0 16 alcoholism Increased 37 63.8 12 60.0 49 poverty/ineq. Contradiction 4 6.9 1 5.0 5 Envir.degradation 3 5.2 0 0 3 Homelessness 4 6.9 0 0 4 UnemploYm-ent. 26 44.8 9 45.0 35 Prostitution 6 10.3 0 0 6 Negative privatiz. 5 8.6 2 10.0 7 Loss of traditions 11 18.9 0 0 11 Expens. commod. 0 0 1 5.0 1 Medication Other 12 20.7 4 20.0 16 Table 5.16 Specific Oplnlons Given About the Effect ofthe Economic Transition. % 30.8 7.7 38.5 28.2 20.5 62.8 6.4 3.8 5.1 44.9 7.7 8.7 14.1 1.3 20.5 Note: Participants could give more than 1 response. Therefore, percentages do not total to 100%. 133

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Several respondents noted that while the government passed many laws, it has no way to enforce them. A majority of people pointed out that if a person was a hard worker the transition brought. good opportunities, but if the person was lazy, then they found their life much worse. Elderly participants mentioned .that everything being "free"in speech, economy, personal decisionsis a good thing, but at the same time this change diminished quality oflife. Those who had positive opinions about the economic change felt that it brought freedom and a newfound voice to communities. It was considered to be a necessary way to develop the country. The change is good because it encouraged private property, improved international relations, and it created more opportunities for young people to be educated abroad. In contrast, many of the elderly said that the economic transition worsened their lives, only a few people benefited from the transition, and most of the community was left at the bottom of society. They felt that the government had made a big mistake in privatization, that it was not the way to go, that state property was lost, and this was a serious loss. The most negative side of the economic change as they saw it was unemployment. They argued that it is very difficult to find jobs not only for elderly people but also for young people. They were mostly concerned about the age restrictions in jobs. In Mongolia, people of age 30 and above were considered to be too old for many jobs. According to them, their children really wanted to have jobs, but they couldn't find jobs because of their age. All newspaper ads say they will 134

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hire "young, tall and pretty ones, mostly girls." One woman noted that "I have nine children and none have found a permanent job." As a result, she spends her pension to support her children. Another participant stated that "I don't support this change because I'm a communist party member and I don't like this change." In the survey, several elderly commented that after the economic transition different political parties emerged. Now there is so much contradiction and competition between them that it has decreased community These conflicts and the resulting unfriendly atmosphere have affected their lives. Some of the elderly participants criticized the government and the way that upper leaders spend a lot of money on election campaigns. They argued that this money should instead go for community health and social services. In a focus group one person said, "I don't think the economic transition was the right way. It brought much poverty and corruption. It has benefited only the administrators:" The majority of urban respondents complained they were left without anything during privatization. Rural eldetly were mostly concerned with the issue of environmental degradation. They said that during the last three winters they had lost many livestock and this forced many ofthem into poverty. Families who lost most of their livestock during a 'dzud,' or blizzard, moved to the cities where they hoped to find work. Many thousands of families moved to the ger areas ofiDaanbaatart without authorization. Without such authorization residents are basic services, including health care. One of the respondents stated that it is very difficult to get health care because she 135

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does not have an official Ulaanbaatar registration. She claimed that if she had a serious illness she would die. In Mongolia, she is not the only person with this problem; there are many migrants facing the same difficulty in getting health care. Daily Activities Chores Urban Rural Total N. % N. % N. % No regular 21 36.2 8 40.0 29 37.2 activity Babysit 33 56.9 7 35.0 40 51.3 Animal 6 10.3 9 45.0 15 19.2 chores House 46 79.3 12 60.0 58 74.4 chores Income 2 3.4 2 10.0 4 5.1 activity Gardening 1 1.7 1 5.0 .2 2.6 Others 1 1.7 1 5.0 2 2.6 Table 5.17.Daily Activity and Residence. Note: Participants could give more than 1 response. Therefore, percentages do not total to 100%. Totals do not sum to 79 because of missing data. The analysis of data shows that 74.4% of the elderly were engaged in household chores, 51.3% were baby-sitting, 37.2% did not note any regular activity, 19.2% did chores related to animal herding, 5.1% worked for income, 2.6% did gardening and 2.6% were unable to work. There were differences in activities between urban and rural elderly. As seen in the table, 56.9% urban and 35.0% rural 136

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elderly were engaged in baby-sitting, while 10.3% urban and 45.0% rural residents were engaged in animal related chores. One rural participant said that "I have my own animals, for me days go so fast because I'm always busy with domestic chores. I make dairy products like milk, go to the spring for water, collect wood, dung, cook food, and take care of my animals and grandchildren." Another person stated, "there are no opportunities for older people to have a job." These results are similar to SEP study (1999) which observed that 79.7% of elderly do basic household work and 20.1% did not participate in household work because oftheir age. According to this study, ofthe totall534 elderly surveyed, only 36.0% were engaged in economic activities: 4.4% had jobs, 18.6% were involved in animal husbandry, and 12.9% worked in agriculture. The population census of 2000 stated that "for persons aged 60 years and above, only 12% remain in the labor force" (p. 84). Pension Ofthe total79 participants, 78 (99.9%) were receiving old age pensions. One response is missing. These findings are close to the findings ofShagdarsuren's survey (1999), who determined that ofthe 1534 elderly, 94.7% of the respondents received pensions. As seen in table 5.18 age at which pension payments began is as follows: 10.3% were aged 45 years or less, 24.4% were between the ages of 46-50, 19.2% 137

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were in the range of 51-55 years, 26.9% were aged 56-60, and 14.1% were aged 6165 years. Urban (58) Rural (20) Total (78) N. % N. % N. % -1,45 5 8.6 3 15.0 8 10.3 46-50 12 20.7 7 35.0 19 24.4 51-55 11 .18.9 4 20.0 15 19.2 56-60 15 25.9 6 30.0 21 26.9 61-65 11 18.9 0 0 11 14.1 Table 5.18 Age Began Pension and Residence. Note: Totals do not sum to 79 because of missing data. Participants could give more than 1. response. Therefore percentages do no total to 100%. In Urban Rural Total Mongolian N. % N. % N. % Tugrics (tg) 10,00043 74.2 18 90.0 61 78.3 20,000 21,0008 13.8 2 10.0 10 12.8 30,000 31,0006 10.3 0 0 6 7.6 40,000 41,000+ 1 1.7 0 0 1 1.3 Total 58 100.0 20 100.0 78 100.0 Table 5.19 Pension Amount by Residence. Note: Approx. US $1=1,100 tg. Totals do not sum to 79 because of missing data. This table reveals that there is a big difference between urban and rural elderly. A monthly pension income of 10,000-20,000 tg was more common among rural elderly 90.0% than among urban ones 74.2%. Monthly pension incomes of 21,000-30,000 tg were more common among the urban elderly 13.8% than rural ones 138

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1 0.0%. Only urban elderly received pensions above 31,000 tg. One elderly said, "the pension amount is not sufficient. We buy wood for winter, and I have difficulties in buying food which we need. Our food consists mostly of flour, rice and meat." In Male Mongolian N. % Tugrics (tg) 10,00013 46.4 20,000 21,000.. 8 28.7 30,000. 31,0006 21.4 40,000 41,000+ 1 3.5 Total 28 100.0 Table 5.20 Pension Amount by Sex. Note: Approx. US $1=1,100 tg Female N. % N. 49 96.0 62 2 4.0 10 0 0 6 0 0 1 51 100.0 79 Note: Totals do not sum to 79 because of missing data. Total % 78.5 12.6 7.6 1.3 100.0 Another person argued that "my pension is not sufficient to live but I can't complain because it comes free." One woman in a focus group stated that she received compulsory retirement because of the number of children she had. She pointed out that not only she, but all people who retired at young working ages were victims left without any jobs and with very low pensions. Several elderly noted that it was possible to receive three month loans against their pensions. This money mostly goes for their children's tuition, and they are concerned about the high interest rate changed by the banks. They reported payments 5000 tg (US $5) for a three month loan that was 600 tg before. Several of them stated that it is difficult to send kids to Ulaanbaatar for schooling, because besides the high school costs, the cost for room is 139

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very expensive. Now they pay 75,000 tg per two semesters, and if the state increases the cost of electricity this cost will also increase. They argued that the state should provide free education for the young, especially for the most talented children. Another woman complained that: It is difficult for us after the economic transition, because now everything is based on and measured by money, and for us an elderly pension is not sufficient to live. In rural areas three are not enough employment opportunities for young people and they are migrating into the cities leaving us behind without support. One young pensioner from the province center in Huvsgol said, "I could work until age 55 but there were no jobs." A majority of the participants pointed out the lack of social services in rural areas, and they stated they wanted to have social support and services from the local government. Some of them recommended free sanatoria the aged and improved communication and roads in rural areas. All people from two rural counties were concerned about the loss of many livestock during snowstorms. They noted that after snowstorms and that is an increased number of animal robberies. Urban elderly appeared to have higher pensions than rural elderly. If pension amounts are considered with respect to sex, there are huge differences between males and females. As seen from Table 5.20 about 46.4% males and 96.0% females had monthly pension of 10,000-20,000 tg, 28.7% males and 4.0% females had pensions of 21,000-30,000 tg. No females reported pensions of greater than 30,000 tg, but 140

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21.4% males received 31,000-40,000 tg, and one male received more than 41,000 tg. Thus, males have a higher monthly income than females. These findings are similar to those from studies conducted by WHO study (1999). According to these studies, 27.2% of males received 18,000 tg pension per month, whereas only 2.5% of females have monthly pensions. The SEP study (1999) calculated that elderly pensions average 14,368+3820 tg per month. This report noted that 88.5% ofwieducated elderly and 75.2% ofless educated elderly received pensions of no more than 15,000 tg per month. When asked 'is your pension sufficient to live on?" about 94.9% answered ''no." These findings are also similar to previously cited studies. The study of daily life carried out by the WHO noted that ofthe 902 elderly iri.terviewed, 776 (84.9%) said that their pension was not sufficient to live: on. Shagdarsuren (1999) observed that 41.6% of the eldedy claimed that basic needs could not be satisfied, and of these, 90.0% of the elderly said they worry about their future. Thus, these studies suggest that there is a need to increase pensions and social services for the elderly. Table 5.21 shows responses to the question, "What do you think are the most important issues facing older people in Mongolia today?" Eighty-six percent ofthe participants defined money as the major issue in elderly life. All elderly stated that pensions should be increased. There is also a reported need to improve access to health care as well as the quality of health services, as asserted by 55.1% of the participants. About 35.9% of the elderly said there is a need to lower medication 141

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Urban(58) Rural (20) Total (78) N. % N. % N. % Money 53 99.4 14 70.0 67 85.9 lncr. access/ 32 55.1 11 55.0 43 55.1 qual. health/s Increase 17 29.3 7 35.0 24 30.8 welfare/serv. Decrease 10 17.2 7 35.0 17 21.8 crim.e/corrup. Decrease 20 34.5 6 30.0 26 33.3 poverty/ineq. Deer. alcohol 5 8.6 3 15.0 8 10.3 Increase job 18 31.0 8 40.0 26 33.3 Support old 6 10.3 0 0 6 7.7 employment Incr. Transls 3 5.2 o 0 3 3.8 Deer. cost of 10 17.2 0 0 10 1.8 electricity Deer. prostit. 4 6.9 0 0 4 5.1 Decrease cost 22 37.9 6 30.0 28 35.9 of medication Decrease cost 21 36.2 4 20.0 25 32.1 of food Maintain 3 5.2 0 0 3 3.8 traditions Freeeduc. 5 8.6 2 10.0 7 8.9 Dec. 2 3.4 1 5.0 3 3.8 envir.deg. Others 27 46.6 10 50.0 37 47.4 Table 5.21 Specific Opinions Given About the Effects of the Economic Transition. Note: Participant could give more than 1 response. Therefore, percentages do not total to 1 OOOA.. costs; 33.3% wanted to lesser poverty and inequality; 33.3% hoped to increase job opportunities, 32.1% wanted to reduce the cost of food; 30.8% increase welfare 142

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services; 21.8% reduce crime and corruption. Other responses included about 12.8% of the elderly wanted to reduce the cost of electricity; 10.3% said do something about alcoholism; 8.9% wished to provide free education; 7.7% wanted increased support for elderly from their previous work place, 3.8% to improve transportation service for the aged, and 3.8% wanted to reduce environmental degradation. Thirty-seven out of seventy-nine (47.4%) participants commented on "other" issues. These responses included a very diverse variety of concerns. Some felt a need to decrease the cost of m.edical services. They argued that there is a need to increase the number of elderly hospitals, pharmacies and sanatoria Several respondents claimed that elderly patients should have access to hospitalization without being on a waiting list. They also wanted family doctors to be able to give them medications on credit, to be paid for when they can. Some of them pointed out a need to create employment opportunities for the elderly, and more support for people who recently migrated from rural areas, giving them some sort of loan at low rates. They stated that there is a need for more attention to the young pensioners because only elderly of age 70+ receive financial support from the state and the others are forgotten. A few ofthe respondents felt that there should be subsidized markets for the elderly where the prices were lower. One commented that it would be good to have apartments paid by the state for elderly people. Reducing the cost of coal and wood, providing transportation in private buses, and decreasing the number of bars and liquor stores were mentioned by some elderly. A few of them mentioned that there is a need to 143

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increase the managerial skills of administrators and reduce bureaucracy and corruption, particularly at the middle and lower levels. Several of them wanted to have lessons about gardening vegetables and fruits. One person claimed that, "to help the elderly, medications should be free, sub district activities for the poor should be increased, psychological support for the aged should be promoted and free coal and wood for the elderly should be provided in wintertime." Another person argued that "there is a need to increase elderly pensions and their accessibility to the public health and welfare services, create job opportunities for younger people, so they can support their parents, and provide small loans where they can engage in productive work." One woman complained that: Retired people should be able to continue working, perhaps through community organizations. After retirement, these old people have nothing to do, they are bored and thus, through different organizations, elderly would welcome the opportunity to talk, share opinions, and earn some additional income. I heard in some places, for example in Bayanzurkh district, there is a program that is initiated by foreigners. These things would be wonderfuL We also need to develop child care, pre-schools for children, elderly day care centers, gardening, and sewing. Discussion ofResults The central problem of this study was to determine how the economic transition that occurred in Mongolia had influenced the lives of Mongolian elderly. 144

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To address this problem, 79 Mongolian elderly who participated in the study gave their opinions about the economic transition and how they have been affected by this change. These participants also identified problems faced by the elderly and their needs and resources. This information was used to clarify the effects of the economic transition on the elderly, and to allow a comparative study of the differences between urban and rural elderly. Findings of the survey show that the sudden economic and social changes that occurred as a result of the economic transition had in most cases negatively affected the lives of the elderly. The majority of the participants 42.2% had negative opinions about the economic change. The survey found that the most prevalent problems of older people in Mongolia were health and financialconcems. Before the economic transition, living conditions for the people of Mongolia were good as a result of well-developed health care and social protection services. Sixty-five (83.3%) participants reported that their life was good before the transition. During the socialist period, every member of the community had a job, and the government took care of everyone. During that period there was no reported unemployment or poverty. The educational level was high as a result of free education for all individuals. Socialism tried to create equality between men and women; women had access to education and health care, though they did not receive the same services as men. 145

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Many changes have occurred and are still occurring since the economic transition. Few positive opinions about this change were given by participants. The economic transition produced job insecurity and reduced employment opportunities. Most of those interviewed stated that the hurried and poorly organized privatization of state property created huge unemployment problems and removed the social "safety net" for many people. The most basic problem related to this change is the increase in poverty. During the economic transition school dropouts increased, birth rates declined, and mortality rates increased. Many studies show a high level of poverty in Mongolia, and one that is higher in the city and peri-urban "ger" or slum areas. The economic transition diminished women's previous high status, increased women's economic insecurity and decreased their participation in public life. It created increased workloads for rural women. Herder women are often busy with heavy unpaid household labor, 24 hours a day and seven days week. Rural women milk livestock, process milk, go to get water from local the springs, collect firewood and dung, as well as taking care of young livestock and their own children. The elderly participants of this study said that high unemployment causes an increase in alcoholism, which leads to increases in domestic violence, divorce, and single mother families. It has also increased the number of street children, and homeless, and has weakened social cohesion. 146

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This study and other studies indicate that elderly people have become the most disadvantaged segment of the population in the past decade. Financial problems were reported by virtually everyone who participated in this study. One elderly person complained that: The economic transition affected my life negatively. Before the 1990s everything was free and there was no stress about how to find money or jobs. All people had equal access to health care services. After this change, everything has changed and now money controls everything. I am 70 years old and though I worked in state organizations my pension is only 18,850 tg, which is not sufficient for a normal life. I have ten children, nine of them married and they live separate fromme. I think during the economic transition, most of the people who worked in state organizations were left without anything during the privatization process. I don't have any savings. My children help me when I am sick or need care. This study indicated that the elderly were the least educated people in the population, especially rural women. It also showed that elderly people tend to live in extended families and that they have many children. These days, due to high rates of unemployment, any family with many children is faced with poverty. Large numbers of these vulnerable elders live in "ger" or slum areas without piped water and with poor sanitary conditions. This survey indicated that there are few jobs around the house for elderly, mostly just baby-sitting and basic household chores. Comparative analyses of data from urban and rural elderly reveal that there are tremendous differences between them. The surveys showed that there were 147

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differences in education, employment, pension amounts, retirement ages, and health conditions between rural and urban elderly, higher in urban areas. There were also significant differences between men and women in both areas. Urban elderly have better education and higher pensions than rural elderly. Men were more likely to be better educated than women and their pensions were higher. This survey indicated that many women were legally required to retire at a young age because of law and they were out oflabor force. Many of them mentioned that they want to continue work but it is difficult for them to find jobs. Health problems were experienced more frequently by those age 55 or above. Rural residents tend to have better health than urban residents, and women tend to have better health than men. Almost all elderly participants in this survey had negative opinions about family doctors and private doctor services, and more positive opinions about traditional medicine. The hospitalization rate was high among the elderly and the majority of respondents indicated that they have difficulty gaining access to health care. Participants said that local health care services suffer as a result of insufficient funding, poor communication, lack of transportation, and insufficient access to drugs and medications. During the economic transition social services were destroyed. This study indicates that, due to poor roads and inadequate funds, there are now no social services in rural areas. One person said: 148

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The economic transition had mostly negative effects on the community. Under the privatization process, many previously existing health care and social services were destroyed. Now there is almost no social services in rural areas. We are isolated from the province center. In rural areas there are no telephones, no newspapers or radios. Before the economic transition almost all rural families had Russian transistor radios, these were the main source of information. Now they can't buy batteries for the radios because they have no money. The economic transition separated nomadic rural people from previously available consumer goods, and they are now dependent on small business traders. Elderly pensions are the main source of income, but these pensions are too small to support large families. The Mongolian government is currently introducing primary health care services in rural areas. Some participants in this study noted the family doctor system is good, but that the implementation of this new service is hampered because of shortages of medical personal, doctors and medications. Pensions are the main source of income for the elderly in both rural and urban areas. This study reveals these pensions are not sufficient to sustain a normal life. Many elderly reported that they don't have money even for basic foods, especially in urban areas, where nearly all the pension is spent to pay electricity or other bills. The majority of respondents complained that they are unable to afford the health care and medicines they needed. They don't have money to go to the sanatoria or even to visit their relatives. Many of them stated that before the economic transition "our kids 149

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supported us in old age, now we are supporting our kids due to lack of jobs and money." Most of the elderly had negative attitudes towards the current high costs of health care and education. They complained about the poor quality of heath care services, and they said that patients not only have to pay for treatment but also have to bring food from their homes. Some of them complained about the bureaucracy that has developed in health care. In short, the economic transition negatively affected elderly and it destroyed many P!eviously existing valuable programs. Limitations The limitations of this study were the sample size. Due to the small size, 79 surveyed elderly are not representative of the general elderly population in Mongolia. However, despite these limitations, this study collected valuable and informative data. Further studies should include a large sample size. 150

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CHAPTER6 SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS Summary The review ofliterature provided in chapter two indicated that the aged population in Mongolia and worldwide has increased in the past decade and will continue to increase rapidly in coming decades. The world is facing population aging. Many countries are aware of the growing needs and problems of the aged, and they provide health and social welfare services for their aged citizens, but still a lot of people do not have access to such services. Many Asian countries have experienced demographic changes parallel to the socio-economic changes related to global economic development. These changes have tended to weaken family ties and old age support. Throughout the world, the elderly are faced increasingly with social and economic difficulties like limitations of access to health care services, lack of social welfare programs, inadequate living conditions, and poor education. Providing services to meet the needs oftoday's elderly requires development of good policies based on examination of the lives of the elderly, their health conditions, and characteristics of the health care and social services that are or should be available to them. Anthropological studies are an important tool in determining the 151

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needs, concerns and resources of the elderly, a prerequisite to developing solutions that will contribute to the well being of the aged. Many demographic studies show that the proportion of the aged will increase in the future and there will be increasing difficulties for families attempting to take care of their elderly relatives as the proportion of people qfworking age decreases. Thus, the role ofthe state needs to expand to assist families in taking care of their aged. Conclusion Mongolia, in geographic terms, is one of the largest countries in the world. It is maintaining its nomadic heritage in combination with contemporary socio economic developments. Today Mongolia exists under the influence of an active, global network of world multinational corporations and multinational organizations. Globalization is an irreversible process, which is driven by its own internal dynamics and by powerful technologies. The global system seeks to find the lowest possible cost in terms of production and the highest profits, not just in one country but any and all countries, regardless _of boundaries. The economic transition that is occurring in Mongolia has brought few positive changes and many negative consequences. The findings of this study show clearly that during the economic transition community lives declined and the poor and elderly were marginalized. The transition was expected to improve the 152

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community but has instead fostered and deepened poverty. Today in Mongolia, poverty and unemployment are major concerns not only in rural areas but also in the city. The increase in costs of food, shelter, electricity and medication detract from urban people's quality oflife. Often even people who are employed are unable to live within their monthly salaries. Elderly people are in the most difficult situation; those who have worked hard all their lives now find themselves sinking in poverty. At the present time, the Mongolian economy and social services are too weak and unable to meet the needs of Mongolian citizens. Current health care funds are no longer able to cover the costs of free medicine for elderly, and they are forced to pay for treatment out of their own pockets. The government of Mongolia has been implementing a new social welfare system. There is the central office of State Social Welfare in each district ofUB, the center of Social Welfare in each province, andan officer-for social welfare in each county. However, their services are insufficient, especially in rural areas. The year 1999 was named "the Year of Elderly." Throughout 1999, activities were provided for the elderly in urban areas, but there was no action in rural areas. In 1998, the Mongolian government approved a 4-year program called "Health and Social Protection of the Elderly." This program focuses on the development and improvement of health and social services for the elderly. The survey described in this study and the other three elderly studies cited insufficient implementation of this program either in urban or rural areas. Today, both the Mongolian economy and the 153

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public health and social sector depend heavily on foreign assistance. The donor states provide millions of dollars that never seem to benefit the poor. The majority of study respondents mentioned that during the economic transition only people who worked in the upper administrative levels benefited from the transition, while rest of the elderly were left at the bottom and are struggling with poverty. The transition has also resulted in increased migration that has caused a breakdown of traditional family support systems. Health care and social services that existed previously have also declined, and the government's ability to help the vulnerable segments of the population has been eroded. People at the upper administrative level benefited from this change, and the elderlyand poor are at the bottom of hierarchy of social life, surviving on inadequate wages and pensions. Grieder (1997) noted that developing countries always have no choice in global decisions and processes because these countries are too weak; they do not have money, technology and knowledge, and they are deeply in debt. Hessler (2001) wrote that: Representatives of the World Bank and the I.M.F. told me that a period of economic pain was an inevitable part of the process, and they assured me that the essential pillars for sustained development were now in place. Even so, in the past two years there has been a slight increase in foreign aid, and none of the niajor donors has established a clear timetable for ending their support. At times, I had the disquieting thought that Mongolia had simply traded one form of dependence for another (p. 64). 154

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The government took huge international loans, and so lost its power to protect its own vulnerable people. As a result of structural adjustment programs of the International Monetary Fund and World Bank, the government had to reduce public funds for education, health and social services. The Mongolian government is implementing several poverty alleviation programs, which were initiated over the past few years financed by international donors. Yet poor planning, high costs of service delivery and inadequate government involvement have resulted in little improvement. Certainly the poorest segments of the population were unaffected and perhaps not even touch,ed by these programs. This study reveals that today' s crisis in health and social service sectors, which is due to the government's lack of financial resources, has resulted in poor supply of medicine and medical equipment and an absolute lack of social services, particularly in rural areas. The elderly are surviving on incomes below the poverty line. This survey showed that women were forced to retire at young ages because of the number of their children. This actually will produce more burdens on the pension fund because the life expectancy of women is longer than that of men. A solution would be for women to retire at the same age as men or even later. It would improve fiscal condition of the government to extend the retirement age for all elderly and create job opportunities, particularly for women. The participating elderly expressed the need for an increased number of doctors in rural areas. Improving working conditions in rural areas and increasing doctor's salaries might accomplish this. 155

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The study of disease patterns indicates that in recent years mortality and morbidity from non-communicable diseases'are increasing. These diseases require more 'resources and as a consequence they increase the burden to the country's economy. Rather than expensive biomedical care whenever possible, cheap and effective traditional treatment may in some cases provide more economical care for these chronic diseases. High levels of migration and increased poverty have caused a reemergence of infectious diseases such as tuberculosis as well as STD and HIV I AIDS. During the economic transition, mamutrition among children and maternal mortality due to inadequate prenatal care also increased as a result of financial problems. WHO, UNICEF, UNFPA, the World Bank and the Asian Developmental Bank have provided many different health projects to prevent, diagnose and treat diseases. These international organizations provide technical and financial assistance for the implementation of health sector reform programs, but so far these programs have had little effect. The economic change brought inequality and corruption. Hessler (2001) quoted a Mongolian source who said, "And why does our government always ask for money for power plailt development? Because many corrupt officials will have an opportunity to make money off it" (p; 64). This suggests that poverty reduction programs and health sector reforms have not worked well due in part to corruption. 156

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Thus, this study generally supports modernization theory, defined by Cowgill et al. (1972) proposed thatmodernization tends to decrease the status of the elderly people. This study show that the economic transition that occurred in Mongolia in 1990s has negatively affected elderly people. Study participants said, "I don't believe that the economic transition was right way. It brought much poverty and corruption. It has benefited only the rich and it supports people at the top. The rest of us are forgotten." It is likely that privatization of public services such as health and social welfare services and the burden of debt payments to the IMF and the World Bank either created or exacerbated these problems. However, it is important to know that Mongolia went through socialist system of development during the period of 19211990 that had many positive impacts on elderly lives. Therefore, this study also supports Foner's theory, which suggested that during modernization process, elderly can lose some status and at the same time can gain some other benefits. In other words, modernization can have mixed impacts on the lives of the aged. Grieder's (1997) comments that there is "no place to hide" from globalization, and I thus think that the Mongolian government must make an effort to transform Mongolian civilization in directions that will help to bring it into harmony with globalism. To achieve this purpose, it will be necessary to build and provide a program of sustainable development, intensify its industry, decrease poverty and unemployment, improve animal husbandry, increase the energy supply in or to the countryside, and disseminate infomiation and modem technology to rural areas. 157

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Governments need to emphasize civic education, to protect human rights, to help people find jobs, and to protect people from the negative effects of globalization. Also there is a need to decrease bureaucracy and corruption, and provide social services to vulnerable groups, particularly in rural areas. This study shows that there is a need to reform the pension system so that it will sustain a healthy and productive elderly life, and to establish an environment that enhances the wellbeing of older people. Human well-being depends on the quality of the surrounding environment, the availability of and access to health care services, economic conditions, educational level, family and state support. The WHO has defined health as "complete physical, mental and social well-being, not merely the absence -of disease or infirmity"(Breslow, 1990, p.9). Bryant (1998) defined healthy aging in this way: "older people with something meaningful to do and a combination of abilities, support, and the will to do it feel healthier than those who do not"(p.l36). Human behavior and personal lifestyles are important determinants of health. Many diseases and negative illnesses can be avoided by health promotion and disease prevention programs, in combination with improved nutrition, better housing, clean water and air, and immunization, assisted by health education and good quality primary health care. During the socialist period of free health care services, most people believed that they were not responsible for their own health and that only doctors were capable of being responsible for the health of people. Now, high medical costs require everyone to be responsible for their own health because, in 158

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many ways, they are the only ones who can make decisions and control their lives. Community members must understand and take more responsibility for their own health, using resources provided by active health promotion and health education. Health promotion is new in Mongolia, and there is a need for further development. There are increasing health problems associated with alcohol and drug abuse, eating disorders, smoking, stress and lack of exercise. These problems can be prevented. Woo et al. (2002) examined the impact of physical activity, dietary habits, smoking and alcohol consumption on health of Chinese elderly aged 70 years and over. They identified positive influences on healthy lifestyle in older people. Alcohol consumption and smoking contributed to poor health. Increased physical activity contributed to a healthy life style and diets rich in fruits, vegetables, fish, and olive oil contributed to the health and extended the life expectancy of elders. I think that the Mongolian government to learn from other countries, their positive attitudes and services toward aging and the aged, particularly from China. The inherent problem of globalization and rapid economic development is poverty. The Mongolian government needs to emphasize the reduction of inequality and poverty. The government needs to create more opportunities to strengthen family systems by giving them education and sufficient resources such as small loans to enable and encourage them to earn for themselves. For elderly, provision of social services and programs that fill food, clothing, housing, and medical care needs should be part of governmental assistance. 159

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Recommendations As a result of the findings of this study it is recommended that: 1. More emphasis needs to be given to the improvement ofhealth and living conditions of the elderly in Mongolia. 2. In order to decrease differences in health care, access to education and social services between urban and :tural areas, and between men and women, the government should do the following: To increase pensions for the aged to a level where elderly can afford basic human needs. hnprove the quality of health care services and provide adequate social welfare support for the aged, particularly in rural areas. Produce more jobs for the young people so they can take care for their aged parents. Also needed are employment opportunities for retired people. hnprove the quality oflife of the community and the lives of the elderly, decrease poverty and inequality. Encourage the development of the private sector and give the aged loans with low interest for business activities. Increase the government's role and encourage the private sector, non160

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governmental organization and different community agencies to provide services for .the .aged. Create a pleasant environment to maintain active life styles for the elderly such as home help service, elderly day care, nursing homes, senior clubs, high quality of primary care services, and counseling. Integrate Western and Traditional medicine in primary health care. Consider future population aging trends in order to develop appropriate public policies, programs and services. Develop and strengthen the gerontology sector in Mongolia, design specialized training and prepare professional health care and social workers in the field of gerontology and geriatrics. Develop and strengthen health promotion and health education programs in the community, especially in rural areas. Future Research Other than the few studies cited here, there is no other research on the study of effects of economic and social changes on the elderly lives and health in Mongolia. I think there is need to continue studies of the elderly, to determine special needs and health problems of older people throughout the country, and additional studies could be done with a larger sample size. It may be valuable to further explore these 161

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questions with a larger sample and with additional statistical and qualitative ethnographic analysis, including examination of psycho-emotional and physical conditions of elderly from different places in Mongolia. 162

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Appendix AHuman Subjects Research Committee at the University of Colorado at Denver Approval University of Colorado at Denver HUMAN SUBJECTS RESEARCH COMMITTEE University of Colorado at Denver Campus Box 129 P.O. Box 173364 Denver, CO 80217-3364 DATE: TO: FROM: SUBJECT: March 21, 2002 Craig Janes MEMORANDUM Oyuntsetseg Chuluundorj Khulan Janchiv Casey Hilliard Kimberly Rak Deborah Kellogg, HSRC Chair Human Subjects Research Protocol #800Globalization, Medical Pluralism and Community Health: The Case of PostTransition Mongolia The HSRC has approved your protocol as non-exempt. The committee waives the requirement for signed informed consent, but does require you to obtain verbal consent and provide participants with the text of the consent document included in your protocol. You are responsible for obtaining local permission to conduct this research and must follow local laws. Ifthere is conflict between U.S. requirements and local requirements, the more strict will apply. This approval will apply for one calendar year after which time you should contact the HSRC for an extension. Should you encounter any adverse human subject issues, please contact the committee immediately. If you change your any of your procedures, sample group or questions, contact the HSRC for procedures to amend protocol. Good Luck with your research. 163

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Appendix B-Interview Questions 1. What is your name? 2. How old are you? 3. Gender? 4. Where do you live? City? District? Countryside? Aimag? Soum? Baagh? 5. Do you live in apartment or ger? 6. How many people are there in your family? 7. How many children do you have? 8. How many years of school do you have? 9. What is your occupation? 10. How is your health? 11. What health complaints and disease do you have? 12. Have you been hospitalized in the last month? 164

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13. Have you been hospitalized in the last year? 14. Is it difficult to get health care? If yes, what are the main problems? 15. Is there somebody to help you when you are sick or need to get to the hospital? 16. What do you think about the family doctor systerri? 17. Have you ever used any private doctors or clinics? What do you think about them? 18. How about Traditional Medicine, do you use it? What do you think about it? 19. If you are retired or are now receiving a pension, when did this begin (year)? 20. How much money do you get from your pension? 21. Is your pension sufficient to live? 22. Do you have any other aid from the government besides your pension? 23. Can you tell me a little bit about your life before the economic transition? 24. What do you think about the economic transition? How did it affect your life, personally? 25. Can you tell me what kind of jobs you do around the house during the day? 26. What do you think are the most important issues facing older people in Mongolia today? (use reverse). 27. Is there anything else you would like to tell me? 165

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GLOSSARY Aimag or province is an administrative unit. There are 21 aimags in Mongolia and illaanbaatar. Soum or county is an administrative unit in rural areas. Each aimag is divided into so urns. Bagh or township is the lowest administrative unit in rural areas. Each soum is divided into baghs. Khoroo is the lowest administrative unit in Ulaanbaatar. There are 9 districts in Ulaanbaatar and each district is divided into khoroos. . Ger is a traditional Mongolian housing in the fonn of a round felt tent. Household is one or more members of family, who share their income for food and other essentials; and these members can be relatives or non-relatives. Negdel is a cooperative that existed during socialist period. It controlled by the government and members of cooperatives work together. Hotail is several households consisting ofmostly relatives or friends who live as a neighbor. They help each other caring for livestock, trading animal products, and during disasters. Dzud is heavy snow-storms or blizzard.' Feldshers are the community health workers who are the primary health care providers in baghs. Tugrug (tg) or MNT is the Mongolian national currency, $1=1100tg CMEA is an international organization of industrial production and cooporation for economic development. This organization existed during 1949-1991 and was comprised several socialist coutries. Population aging is an increase in the proportion of persons of age 60 and above in a population. 166

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The aging index is the number of persons 60 years old or over per I 00 persons under age 15. The old age dependency ratio is the number of persons 65 years and over per I 00 persons of age 15-64. The total dependency ratio is the number of persons under age 15 and persons aged 65 or older per 100 persons of age 15-64. Total fertility rate is the average number of children that be born alive by the woman in her reproductive age (15-49). Maternal Mortality rate the annual number of deaths of women from pregnancy and delivery related causes per I 00 thousand live births. Life expectancy is the length of time that a person is expected to live. . 167

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UB IMF WB UN WHO UNICEF ADB UNDP CMEA STD's HIV/AIDS PHC ABBREVATIONS Ulaanbaatar, capital city International Monetary Fund World Bank United Nations World Health Organization United Nations Children's Fund Asian Development Bank United Nations Development Programme Council for Mutual Economic Assistance Sexually Transmitted Diseases Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome Primary Health Care 168

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BffiLIOGRAPHY Albert, S.M., &Cattell, M.G. (1994). Old Age in Global Perspective: Cross cultural and Crossnational Views. New York: Human Relations Area Files, Inc. Baabar, B. (1990). History of Mongolia. Uhianbaatar: Monsudar Publishing. Bash, F. (1999). Textbook of international Health. Second Edition, 235-295. New York: Oxford University Press. Bateson, Gregory ( 1987). Steps to an Ecology of Mind. Collected Essays in Anthropology, Psychiatry, Evolution, and 61-72. Northvale, New Jersey: Jason Aranson Inc. Beall, C. M. (1984). Theoretical Dimentions of a Focus on Age in Physical Anthropology. In Kertzer, D. I. (Ed.), Age and Anthropological Theory, 65-82. Ithaca/London: Cornell UniverSity Press .. Bengtson, V. Z., Kim, Myers, G. C. & Eun, K. (2000). Ageing in East and West: Families, States and the Elderly. New York: Springer Publishing Company, Inc. . Bessenyei, L U. & Semsei, M. M. (2002). On the Role of Aging in the Etiology of Autoimmunity. Gerontology, 48, 179-184. Bruun, 0. & Odgaard, 0. (1996). Mongolia in Transition. Old Patterns New Challenges. Nordic Institute Qf Asian Studies, CURZON. Bryant, L. L. (1998). Healthy Aging: Factors that Contribute to Positive Received Health an Older Population. Dissertation. University of Colorado at Denver. Health and Behavioral Science. Chang, T. P. (1992). Implications of Changing Gamily Structure on OldAge Support in the ESCAP Region. AsiaPacific Population Journal, vol. 7, No. 2, 4966. 169

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