Rebuilding health care in Nepal

Following last year’s devastating earthquake, a student commits to improving health care in his native country

June 1, 2016 — When Ramu Kharel, MPH ’16, was seven years old, his father won the lottery for an immigrant visa to become a permanent resident of the United States. That serendipity ultimately brought Kharel from a small village in Nepal to America, to medical school in Texas, and ultimately to the Harvard T.H. Chan School of Public Health to learn the skills he is now using to improve health care delivery back in his native Nepal.

Kharel vividly remembers the day he learned of the family’s change in fortune. “My sister and I were heading to our school in the village and the postman was running toward our house, followed by lots of people. He was waving a letter and calling, ‘Your father is going to America!’ And my sister and I looked at each other. We were like, ‘What is America?’ So we kept on walking.”

Kharel was 13 when he—along with his mother, sister, and brother—was finally able to join his father in Houston, Texas. Keeping in touch during the years they were apart required a certain amount of planning. “For the first phone call from America,” said Kharel, “the person from the phone center in our village came to our house and told us, ‘Your dad is going to call you at this time tomorrow, so come to the phone.’ The next day, we went to the phone center and waited for my dad to call.” It was a conversation that would define the shape of Kharel’s life.

“One of the first things he said to me was, ‘I’m in the process of bringing you all to America. I want you to take advantage of this opportunity, and I want you to be a doctor,’” Kharel remembered. “It’s not like he forced me to become a doctor, but from that day it was engraved in me that I should be a doctor. And then I slowly realized that being a doctor really was my calling.”

Currently enrolled at University of Texas Southwestern Medical School, Kharel took a break after his third year to study global health at Harvard Chan School. His awakening to issues of public health came during the year he spent in India as an undergraduate, when he worked in impoverished neighborhoods with a Muslim women’s rights organization. Among other health issues, Kharel witnessed a lack of basic hygiene and heavy smoking among the residents and realized there was more to being a doctor than just treating individuals; some of these problems needed to be addressed at the population level.

When it came time to choose his medical specialty, he decided on obstetrics and gynecology, because he had enjoyed that rotation in medical school and because of his work with women in India. But in 2015, two things led him reconsider his choice. In the spring, Nepal suffered a devastating earthquake. And that fall, Kharel came to the Harvard Chan School. He now plans to specialize in emergency medicine, with a focus on disaster preparedness and disaster management. One particular course at the School—Societal Response to Disasters and War—solidified this choice. The course, taught by Jennifer Leaning, François-Xavier Bagnoud Professor of the Practice of Health and Human Rights and director of FXB Center for Health and Human Rights, helped him decide that this field was indeed where he wanted to be. “Natural disasters are increasing; climate change is happening; war is a reality,” he said. “There is a need for people focusing on disaster preparedness and management, and emergency medicine is at the center of it.”

Life through a liberal arts lens

Growing into adolescence in Texas, Kharel had become immersed in American life. His time in India served as a pointed reminder that his roots were in South Asia. It also drove home to him just how fortunate he was. “Some of my relatives, some of the friends I grew up with in Nepal—they are now working very hard in India as dishwashers,” he said. “Their families did not win the lottery, and their lives are so difficult and so very different from mine.”

Kharel attributes his understanding of these inequalities to the perspective he gained from his undergraduate liberal arts education. Knowing that he would be going to medical school and would therefore receive a deep education in science, he pursued liberal arts courses rather than going the “biology route” at the University of Texas, Austin. He was recruited to the fledgling Hindi Urdu Flagship Program, through which he studied South Asian literature and poetry and majored in Asian cultures and languages. These studies, including learning how difficult the conditions were for Muslim women in India, gave him a more profound understanding of the lives of the women he would meet when he spent his junior year in that country.

Realizing that he wished to continue health-related efforts in India, he started a student group called Health Awareness Programs in South Asia, or HAPSA, after returning to University of Texas, Austin. Among other activities, HAPSA members created workshops on smoking, alcohol abuse, and basic hygiene that they would present, in coordination with the Hindi Urdu Flagship Program, to residents of slums in Lucknow, India. After the 2015 earthquake, Kharel decided that HAPSA, which had been a student organization, should become an official nonprofit. So he registered the group—now called Health Advancement Programs in South Asia—as a nonprofit organization in Nepal and is working to register it in the U.S.

Long-term commitment

During medical school, Kharel had spent time in Nepal conducting studies on knowledge, attitudes, and practice around hand hygiene. So he knew many of the communities that had suffered devastating losses of life and of buildings in the earthquake. He raised nearly $22,000 in a matter of days and helped gather medical supplies for earthquake survivors. But he also realized that he wanted to work in these communities long term, not just zip in, provide post-earthquake aid, and leave. He wanted to rebuild the health systems in a sustainable way. So he dedicated the $22,000 to improving health in two villages in which he had already established ties through work he conducted there in the summer of 2014 to gather basic information about residents’ health, access to water, and hygiene practices.

After completing his medical school rotations in 2015, he went to Nepal and formed a team. Eager to involve the communities in health system planning, the team conducted focus groups among the residents. What did they see as their primary health care needs, for example, apart from rebuilding the health centers? How had health care changed, if at all, after the earthquake? What were the communities’ biggest health problems? What aid had they received after the earthquake, and how had physical trauma been managed? With support from the communities, the team decided to implement a different model in each village to sync the supply of health care with the demand. In one village, the team is developing a completely private model, in which HAPSA is building its own clinic. In the other, they are creating a public-private partnership, working with the local government and involving residents in health center decisions. “Working with the government is very difficult in Nepal,” said Kharel, “but it’s also important for our long-term efforts.

Being the focus of attention does not come easily to Kharel. He is quick to give credit to the many others who are working to create sustainable health care in Nepal. “I may be the one in the spotlight in this interview,” he noted, “but there is an amazing team in Nepal meeting with the government, with people in the villages, with health workers. I’m so thankful to all the people doing such hard work on the ground in Nepal. My mentors and friends in the U.S., too, advise me—sometimes we talk on the phone about these issues all night. It’s truly a team effort.”

Kharel’s vision for the future is simple: that every single village in Nepal have access to quality facilities that can provide proper health care. “I know that will require a lot of logistics—including first completing medical school and then my residency,” he said. “But that’s the ultimate goal. That’s why I came to study public health.”

Source: Harvard. Date: June 1, 2016

Rebuilding health care in Nepal