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The 25th of April

{Please visit http://www.hapsaglobe.org for more information and to find out how you can help. Thank you for reading!}

It’s April of 2015 and I’m a third-year medical student at UT Southwestern (UTSW) on a psychiatry rotation. It’s a warm Friday night in Texas and I’m in an Uber home after a lively night out with friends when I first receive the news. Being my usual chatty self, I’ve started a conversation with my driver and am soon trying to guess where he’s from. “You are from Nigeria!” I say. He doesn’t correct me and simply responds, “I’d say you are good, but you’re wrong,” and proceeds to ask me about my own roots. While I’ve been living in the U.S. for over a decade, Nepal had been home for the first 13 years of my life. Of course, I tell him, with no small amount of pride, that I’m from Nepal. Before I can finish my sentence, his entire expression changes and he asks me with a clear sense of urgency if my family is okay. I remember being momentarily confused, followed by an instinctive thought of a terrorist attack. The next second, my mind overrules that because Nepal doesn’t have a problem with terrorist attacks. Having no other ready explanation, I unlock my phone to look at the news. The Uber driver, by now recognizing my confusion says, “Did you not hear about the big earthquake?”

I sober up in the blink of an eye.

My heart starts to race and I break out in a sweat as I frantically confirm the news on my phone. There’s been a major earthquake reported in Nepal of 7.8 or 8.0 magnitude with “catastrophic” damage. I fail to find any other details on the news. I think back to the 2010 earthquake in Haiti. A 7.0 magnitude earthquake there had taken more than 100,000 lives and caused billions of dollars’ worth of damage. I panic thinking that an 8.0 magnitude earthquake would’ve destroyed my whole country. I incessantly refresh multiple webpages each minute to get the latest updates. Some websites have the death toll at 2500. I refresh again and the number increases to 2600. Another refresh and its risen to 3000. The death count and extent of damage would be more accurate later, but it was clear enough within the first few hours that it was bad. I panic, perhaps not unlike every other Nepali person I knew who was away from their motherland that day. I try frantically over and over again to reach my friends, cousins and relatives in Nepal. None of my calls go through. Every time the death toll rises, I can’t help but think that maybe my relatives and/or friends are among those numbers.

As an undergraduate student, I had studied Urdu poetry. A particularly memorable couplet speaks of how a fish feels out of the water. That day was the first time I ever experienced what that must feel like. It felt as if I was suffocating. Suffocating due to the lack of information and feeling utterly helpless as a distant bystander in this situation. I spent the rest of that early morning on the couch trying to connect with someone, anyone, in Nepal. As the sun rose, more information came through about the epicenter of the earthquake and the degree of damage. The death toll was still rising each time I refreshed a webpage. It was after noon when I was finally able to connect to my cousin in Kathmandu. T-Mobile and other phone companies had kindly made calls to Nepal free through their networks. My cousin, Pankaj Bhattarai, confirmed that everyone I knew was safe and that everyone in Kathmandu was staying outside their houses. Pankaj explained, “The house was like a swing when it happened first. We thought it was our end.” I was happy they were safe, but strong, continuous aftershocks continued to occur. Pankaj said that with every aftershock people feared losing their lives and houses. Though they were now physically safe, their continuing psychological stress worried me. During my psychiatry rotation, I was learning about the long term psychological impacts of such traumatic events.

GhumarChowk

As the day progressed, I received more information from multiple sources. Although initial news reports were dominated by the effects of the earthquake in Kathmandu, eventually we learnt about the extent of damage to the surrounding districts. Besides the death toll, the significant damage to schools, houses, roads, and livestock in almost half the districts in Nepal was bound to set the developing country back even more.

The news that was most devastating to me personally came on Saturday afternoon: Ghumarchowk was very severely affected. This community was dear to my heart since I had worked there in 2013 as a first-year medical student. Hem Sarita Pathak Foundation, a non-profit organization from Austin, had asked me to provide hand hygiene and health awareness education in the local school there. Ghumarchowk is a village located in the hills surrounding Kathmandu, and is about a 30 kilometers and a 1.5 hour drive from the city. It is a settlement of the Tamang community — one of the many communities in Nepal that has been marginalized due to the Kingdom’s nationalist, and often exclusionary, agendas. After experimentations with parliamentary democracy in the 1950s, a ban was implemented on party politics and power was centralized to the royal palace. Nationalist politics took a spotlight during this period with the royal kingdom pushing for a “Nepali” identity. In particular, a specific brand of Hinduism, a national dress, one Nepali language, and loyalty to state and dynasty were advocated by the state. The ruling elite inspired most of these nationalist agendas, and in the process, it alienated and oppressed many ethnic groups, including the Tamang people.

I had spent a month during the summer of 2013 teaching hand hygiene to the children of the local Ghumarchowk school alongside my cousin, Pankaj. On the first day, we noticed a poorly maintained toilet. Pankaj and I cleaned the bathroom and figured out a way to bring water to the toilet while the teachers and students watched. Our actions, though unconventional, got the students and villagers interested in our project. The villagers welcomed Pankaj and I as we visited the school each day for the next month. Most of the villagers were farmers and lived in poverty. Most of them consumed alcohol every day and weren’t educated beyond the 5th grade. The broken health center in the village remained closed for the most part, and the government health post was too far for the villagers reach. Despite all this, they loved their village. It wasn’t long before we fell in love with the community.

When I got back to Dallas as a second-year medical student, three students in an Innovative Healthcare Solutions course I was facilitating became interested in the work I did in Nepal. They wanted to continue the project the following summer. For this visit, we set two goals: (1) assess and re-teach hand hygiene curriculum, and (2) understand and improve the health care available to the people of Ghumarchowk. Ryan, Michelle, and Charlotte went to Nepal in the summer of 2014 and enacted our plan. They carried out a comprehensive health assessment of Ghumarchowk using surveys and focus groups. During the process, they also fell in love with the people of the village. We shared the results of the health assessment with the Hem Sarita Pathak Foundation, and together we tried to address the needs identified. Later in December of that year, we partnered with a local Kathmandu hospital and conducted a medical and dental camp for more than 300 villagers. Although the villagers were happy with what we were doing, our team was dissatisfied with our temporary, one-off interventions. We wanted to strive to change the system and offer a permanent solution for the healthcare needs of these villagers.

Before we could make much progress, the 25th of April 2015 fell upon us. The harrowing news that close to 80% of the houses in GhumarChowk were destroyed felt like a physical blow. I remembered the kids who would happily sing the hand washing song with me; the old lady who had come to the health camp after having drunk “only 2 glasses” of homemade liquor; the mischievous kid who would skip class when I was not around; and the sweet young girl who wanted to become a doctor. I was anxious to know if they were all okay. I also felt it was morally imperative for me to respond and support this community within my capacity.

Acute Response 

With this in mind, I created a GoFundMe page like many others trying to raise money for their communities that day. I knew I wanted to focus on long-term solutions and not on the acute care that was already being provided by multilateral agencies and governments. I had no game plan beyond that on how I would spend the money raised. With the goal of few thousand dollars, I started a campaign titled “Medical Student for Nepal.”

Meanwhile, the rigors of medical education did not allow me to have time off. I reported for my clinical duty at Parkland Inpatient Psychiatry Service at 6am on Monday morning and was assigned to see a patient. As I interviewed the patient, a schizophrenic young man, my brain was preoccupied with what happened over the weekend and the continuing aftershocks in Nepal. Shortly after, I had to present the patient’s history to my attending and I was speechless. I had not even noted down the patient’s age, a vital component of the first sentence of a patient history presentation. My attending pulled me aside to ask me what had happened. Once I explained the situation to her, she connected me with an expert at UTSW who deals with psychological trauma in disaster settings and told me to explore resources that would help Nepali communities. She was also kind enough to offer me some time off to deal with things.

Back at home that evening, I saw for the first time that within a day I had exceeded my fundraising goal and, as a result, raised the goal to $10,000. To reach this target, I started emailing and messaging everyone I knew including faculty that I had worked with before, Facebook friends, and even people I only met in passing. I also called all of my friends. Since they were all students like me, I requested them to ask their parents to donate. Most of their parents had already donated to international organizations like the WHO and UNICEF. Thanks to several more donations the $10,000 goal was reached within 2 days. I increased the goal twice more to a final sum of $25,000. As the money started coming in, I asked Pankaj, back in Nepal, to explore areas around Kathmandu that had not received any help from the early responders. After a 2-day search, he found a community on the hill opposite of Ghumarchowk located in the Lalitpur district

Meanwhile, I reached out to the Nepalese Society of Texas (NST), a Dallas-based organization for Nepalis. Within a few days of the earthquake, NST had raised more than $100,000 and was planning on sending a team of medical professionals to Nepal with supplies. All my research had taught me that it was not a good idea to send non-essential supplies (like diapers and juices) and people untrained for care in disaster settings to the ground during the acute phase. During earlier earthquakes, we had a surge of generous people wanting to do that, but this approach, while well intentioned, overburdens the already busy government and NGOs that are trying to manage the situation. Although I tried to explain, I was unable to convince an emotional group of people wanting to help.

Nonetheless, since they were going to Nepal, I wanted to help them obtain supplies that would be necessary. I reached out to my colleagues who worked in Nepal and began to compile a list of medical supplies that they had found useful. My search for these supplies led me to Baylor Healthcare, which had a warehouse filled with medical supplies for NGOs. I will never forget the generosity they showed when I met with them. Once I told them that the supplies were for the Nepal earthquake, the Baylor folks invited me to take whatever we wanted from the warehouse. Together with volunteers from NST, we gathered about 23 boxes of medical supplies that included orthopedic casts and IV start kits. Some friends from medical school also took time off with me and helped sort through the supplies.

Once the NST team left, I focused on raising awareness about the earthquake with the UTSW community. Although my initial visit to Ghumarchowk in 2013 had been in coordination with the Global Health office at UTSW, the school was unable to help in this instance. Shortly after, Dr. Kavita Bhavan, my mentor, connected me with the CEO of Parkland Hospital, Dr. Fred Cerise. Dr. Cerise had been the Secretary of Health in Louisiana during Hurricane Katrina in 2005. He took time to meet with me and extended his help. Apart from his personal contribution, he provided a platform for me to speak with the Parkland community and the executive committee of the hospital regarding the earthquake and how they could contribute. Parkland employs and also takes care of many Nepali people as patients in Dallas. Alas, acts of great kindness like these do offer profound hope during moments of despair.

Strengthening the System

In July 2015, I went back to Nepal with the goal of assessing the two communities we identified. On my first day there, we (the local team and I) visited Ghumarchowk and walked through the village to assess the damage. In addition to all the houses, the already broken-down health center was severely damaged. The devastation in Ghumarchowk was unreal yet the whole village greeted us with smiles. People had already set up temporary tents and tins. They had seen an abundance of support during the acute phase, but complained that help had stopped coming to the village as the months passed. Later, we visited Lakuri Bhanjyang in Lamatar, the other village across the hill from Ghumarchowk. After extensive meetings with the villagers of both villages, volunteers in Nepal, and advisors in America, we decided to use the money to improve primary healthcare services in the villages.

In a way, disasters are opportunities to shake things from the core. This was our chance to change the way healthcare is provided in these villages. As an initial step, we committed to rebuild the health post (a district-level health center theoretically run by the state) for Lamatar, and made plans to turn a community building into a health center at Ghumarchowk. During my trip, I was also fortunate to meet Nick Abraham, a young man from Australia who wanted to help build sustainable buildings in Nepal. Nick and his team partnered with our team to help build the health center in Ghumarchowk.

Soon after the trip to Nepal, I began a Masters of Public Health degree at Harvard University. I used that opportunity away from clinical medicine to strengthen my core understanding of population health and health systems. As the year went by, I gained a better understanding of population health and health systems, and received invaluable advice about how we could further help these villages. In December 2015, I went back to Nepal working with Jhpiego, an INGO affiliated with Johns Hopkins University. Through them, I met with leaders at the Ministry of Health, Department of Health Services, as well as other NGOs and INGOs. It was a terrifically valuable experience interfacing with and seeing all the arms of the health system at work.

Long Term Goal

Today, it is the 25th of April again, two years after the earthquake. Although work from government and NGO fronts have started, a lot remains to be done.My team and I spent 2016 re-building the health centers, creating teams in the community, registering our organization in Nepal (HAPSA-Nepal), and creating partnerships with NGOs and the government. The members of HAPSA-Nepal come from business, medicine, public health, and pharmacy backgrounds, and share the same goal of strengthening the heath services in these villages. Our team is driven by the belief that the community must be at the center of healthcare decisions. More details of our mission, plans, and project model can be found here. On the 2nd anniversary, we have officially unveiled our projects and health centers — one in partnership with the local community, and the other with the community and the government. Our long-term goal at these places is to improve along two metrics: (1) lowering out-of-pocket payments, and (2) increasing utility of state-run primary health services. Out of pocket payments are healthcare expenditures that people spend from their savings and loans. These expenditures are credited with extending the cycle of poverty for thousands of Nepalis every year. The systems-based approach we are using will aid in ensuring long-term and sustainable benefits. Similarly, we hope to advise policy change and replicate these models at other community health posts around Nepal in the future. More information can be found at our website here.

April 25th is the most important date in Nepal’s recent history. Not only because the whole country was shaken, but also because such disasters are bound to happen again in the country. Nepal is located in one of the most seismically hazardous regions of the world, due to the ongoing collision of the Indian and Eurasian tectonic plates. As a Nepali, a future emergency medicine resident, and a student of public health, I will never forget this date. An earthquake, in medical terms, can be called an “acute on chronic” event. The chronic flaws and weaknesses of our systems become obvious in the acute phase of the earthquake. As vital as acute care is, as a community, we must work to strengthen our systems: health systems, disaster response and preparedness systems, telecommunication systems, etc.

I thank everyone who stepped up after April 25th, 2015 and donated their time and money to help, and those who prayed for the people of Nepal. While your acute response was invaluable, I implore us all not to forget what happened in Nepal on the 25th April 2015. Through our ongoing voluntary efforts, my team and I have pledged not to forget April 25th. I will be starting my residency in Emergency Medicine at Emory University this fall and plan to use my training to improve emergency services, as well as improve the health system in Nepal. In many of the meetings I attend now with Nepali organizations, the agenda for April includes much discussion of the Nepali New Year (April 14th), printing of calendars, celebrations, etc. These are important for any community group, but there is a lot more work needed to build earthquake awareness in our country. The Nepali groups that were very active during the earthquake need to continue being involved and work with the government to improve our systems. The slow, systemic response is not as flashy or exciting as the acute response, but it is absolutely necessary if we are to mitigate damage from subsequent earthquakes. It will be another winter and rainy season without permanent houses for many of those that were affected two years ago. Let us remember that it is not the earthquakes that kill. It is the weak houses, roads, buildings, bridges, hunger and disease that kill. We have a solution for all of these. Let us collectively work towards that solution.

In the words of Urdu poet Faiz Ahmed Faiz:

“Chale chalo ke woh manzil abhi nahi aaie”–Let’s keep moving, the destination is yet to come!

Sincerely yours,

 

Ramu Kharel,

Founder, HAPSA

One Year Since the Earth Shook-Nepal

One Year Since the Earth Shook-Nepal

Dear Friends, Family, and Donors,

I write to you on the 1st anniversary of the Nepal earthquake to extend my heartfelt thanks for your contribution last year. I also want to take a moment to remember the victims. Above, you can see the picture of Chini Maya Tamang. She is from Lakuri Bhanjyang and her home and most of her village was destroyed by the earthquake. When we visited her community, the resilience and commitment she showed to her village health post inspired  and encouraged our team to work with her. In this brief letter, I hope to provide you with an update of government activities in reconstruction and recovery. I also want update you on our activities with the funds that were raised and our plans going forward.

 Background

On Saturday April 25, 2015, at 11:56 am a 7.8 magnitude earthquake shook Nepal followed by major aftershocks including one of 7.3 magnitude on May 12, 2015. Almost 10,000 people died and more than 22,000 were injured. More than 800,000 houses, 50,000 classrooms, 1,000 health facilities were damaged, and 500,000 livestock were killed. After a year, it is estimated that 4 million people are still living in temporary shelters and almost a million are homeless. Major economic and political activities in Nepal came in the way of recovery in the last year. The Nepali government ratified a constitution in September 2015, but this was followed by unrest along the Nepal-India border. This led to a blockade of import and exports through the border, causing further economic damage and pushing hundreds of thousands towards the brink of poverty. It was not until 8 months after the earthquake that the National Reconstruction Authority (NRA, the government arm responsible for reconstruction and distribution of funds to the victims) was formed, and then another 3 months more for the first person to receive the promised $2,000 to rebuild homes. It has been a year, but the NRA has not helped many people. Many Nepalis spent rainy seasons and the winter homeless. There is some hope going forward now that the NRA is fully in place, but the lack of coordination impacted many lives.

After the earthquake, you poured in support for the post-earthquake health advancement of two villages: Lakuri Bhanjyang and GhumarChowk. These villages are predominantly settled by Tamangs: communities that have been marginalized and oppressed in Nepal for decades. I promised you that I would best utilize these funds to make a long-lasting impact in these villages. The following is what we have done so far.

In the summer of 2015, my team in Nepal and I visited these two communities. The human and infrastructure damage in these communities was vast, and there was not much activity from aid agencies or the government there at the time. After conducting focus groups and interviews, we decided to build a temporary health center in Lakuri Bhanjyang. We also concluded that we must utilize this disaster as window of opportunity to improve long-term health service delivery in these villages. Since then, our team along with much needed guidance from friends, teachers, and advisors, has been thinking about how to best utilize the funds we raised to make a meaningful impact in these villages. Technical support was given to us by a Austin based NGO, Hem-Sarita Pathak Foundation (HSPF). HSPF has been working in Tamang community of GhumarChowk for a number of years and, it was through HSPF I was introduced to this community in the first place. The president of HSPF, Jeny Pathak, traveled with us to these communities and provided us invaluable inputs.

In December of 2015, I went back to Nepal. After a long thought process and advice from a wide range of people, we decided to pilot two different community-centred health models in these villages. Before getting into the details of these two models, it is important to understand the current structure of Nepal’s health system. Nepal has a centralized health system and a health post is the local level health facility. Each village has a health post. There are some services and medications that are supposed to be universally available in these health posts according to the law. This includes maternal services as well. Each health post also has a management committee that oversees the financial and operational management of the health post. But in marginalized villages like Lakuri, the management committees are not made up of people who know the village and the village’s health problems. Rather, people who don’t belong to the village and are from a different caste are appointed to these positions. For example, we checked the surnames of some of the people in the management committee for the Lakuri Bhanjyang health post, and most of them belonged to the Brahmin caste whereas no Brahmins live anywhere close to the area. Locals from Lakuri Bhanjyang did not know many members of the management committee and had never seen them.

Throughout Nepal’s poor, rural areas, there exists a major disconnect between what the government supplies and what is needed by the community, in terms of healthcare. For example, in these Tamang communities, chronic conditions due to long-term alcohol abuse are one of the major health problems. Unfortunately, this is not part of the mandate in the centralized structure and local health posts of these communities do nothing to manage these health issues. Furthermore, these communities don’t receive the already mandated services because of their rural and disenfranchised status. In these two villages, maternal and delivery services are either unavailable or so poor that the farmers who reside there use private hospitals in Kathmandu for healthcare and services during pregnancy. Health post workers’ timings are also not feasible for the farming communities. These health posts are open for 2-3 hours a day maximum. All these issues have led to a high out-of-pocket spending for health care that is supposed to be available for free. Our focus groups found that utilization and satisfaction of these communities with respect their health post is very low. When it was most needed during the earthquake, these facilities were not able to handle the burden. The need for strengthened health systems in these places is very apparent. We designed two models for these villages in hopes to synchronize the supply side with the demand side of health care. The goal is to increase utilization and satisfaction, while lowering out-of-pocket expenditures on health care. If proven successful, these models could pave way for many other rural villages in Nepal.

 A Three-way Partnership

 The model we have created is a partnership between three key partners. The below image shows the community-centric health model for the two communities. It is important that the community that is being served has a key stake in the decisions made around healthcare delivery and our model allows us to advance that notion.(Graphic representation of the model can be found in the images below.) 

Partner 1: First and foremost are the HACs (Health Advancement Committees). The HAC will consist of a group of representative from the specific village that will serve as the community arm of the model. The HAC would include women leaders, village teachers, local police, youth leaders, VDC secretary and other village activists interested in health advancement. The HAC will be the voice of the community and help everyone involved understand the community’s specific health problems. In effect, they are the representatives of the demand side of the model. (In the pictures below, HAC members from GhumarChowk and Lakuri Bhanjyang can be found.)

Partner 2: The second partner is the government health service entity in each village. These include the health post employees and the officers from the District Public Health Office (DPHO). These villages lie in 2 different districts, so we engaged with the DPHOs from both Kathmandu and Lalitpur district. This is the supply aspect of our model.

Partner 3: Finally, the third partner is our team, HAPSA-Nepal (Health Advancement Programs in South Asia – Nepal). Founded in 2011, HAPSA started out as a student organization from UT Austin doing health awareness programs and fostering educational initiatives for a few children in the slums of Lucknow. While HAPSA is undergoing the process of being registered as a 501(c) non-profit entity in the US, HAPSA-Nepal has completed registration as an NGO in Nepal. To partner with the Nepali government, we were required to have a registered entity in Nepal. (You can see the picture of HAPSA-Nepal team below.) This team is primarily youth that belong to the medical, pharmaceutical and business fields. These are youth leaders eager to serve the health needs of these communities’ and have worked very hard to get the logistics set up in Nepal. HAPSA works with both the supply side and demand side to bring their interests together.

 Proposed plan for Lakuri Bhanjyang: Private-Public Partnership

After the earthquake, we used some of the funds to build a temporary health post in Lakuri Bhanjyang. Following my meeting with the District Public Health Officer (DPHO) of Lalitpur, the health post workers, and the HAC, we decided to create partnership there that would be unique. We verbally agreed to sign a memorandum of understanding (MOU) with the DPHO that will allow HAPSA to help the government strengthen its already existing services and add additional ones as well. For example, DPHO is unable to provide a birthing center in this village although this is mandated. HAPSA will provide some funds and help the government to establish this. In return, the DPHO will allow the HAC and the HAPSA team to oversee the management of the health post. Furthermore, we will also incentivize the health post workers to work more hours by increasing their salary by 20%. In partnership with Tribhuvan University – Teaching Hospital, we will also bring physicians to these villages for special care at least once a month. A formal MOU between the DPHO and HAPSA-Nepal has not been signed yet, and is currently a work in progress.

Proposed plan for GhumarChowk: Private Clinic Model

In GhumarChowk, the existing health post is too far for the villagers and utilization has been low because of this. Focus groups in this village strongly reflected the need of a closer health facility. The Rotary club had sponsored a clinic for a long time in this village, but stopped doing so because they ran out of funds. Furthermore, this facility was destroyed in the earthquake. The villagers and the HAC of this village proposed a plan of turning an existing community building into a HAPSA-run clinic. (A picture of this building can be seen below.) The municipality has also agreed to donate some of their funds for transforming this building into a clinic. We will be coordinating with the health post and will conduct a needs assessment with the villager to prioritize services. Our plans include hiring a Health Assistant and a nurse for the clinic. We hope to partner with the health post to provide basic lab services. Management of chronic illnesses and awareness surrounding alcohol use will be main focus of this center. We will be working closely with the HAC to conduct regular needs assessments and understand demand. We will also work closely with the health post to keep track of supply. The clinic will function independently. Our partners from Tribhuvan University – Teaching Hospital will help with healthcare delivery. The clinic construction process has begun and an agreement with the HAC has been reached.

Concluding Thoughts

As you can see, the HAPSA team has stayed busy this year. We are truly searching for a way our funds can have the biggest impact. Thus far, we feel like we have found a good model to work with in these villages. Ultimately, we hope that our pilot projects can lead to relevant, useful policy revisions at the Ministry of Health that make healthcare delivery more community-centric and more effective. Through our models, we are engaging with and hopefully empowering community members to fight both for the right to their health care as well as the decisions around it.

To use medical jargon, an earthquake might be considered an “acute on chronic” event. In this sense, the countries that have weak systems and are chronically ill will do worse in an acute crisis. The steps we have taken in these communities are steps to strengthen the health system of these villages. We believe resilience will be built through active community engagement. As donors, friends and well wishers, you have played a big part in inspiring us to take on this project. You generously answered the call when I requested of you to help us help Nepal, and I could not be more grateful. Similarly, none of this would be possible without the active participation of community members and the HACs. These are people who are volunteering a lot of their time in hopes that their neighbors will have better healthcare. I am grateful for them for welcoming us to their communities and allowing us to work together. I am also grateful to have a wonderful HAPSA team in Nepal, and especially to Pankaj Bhattarai for taking a leading role and spending numerous hours working on this project. I am also grateful to all the work HSPF does for these communities, and their support in our project. Further, I want to thank all my advisors in this designing this project. Many friends and professors at Harvard and outside have provided valuable insights.We hope to create something that will be long lasting and benefit the communities for years to come. Your continuous support and thoughts in this project are appreciated. As we become more formal, we will have a website and media presence through which you can follow HAPSA’s work. In the meantime, I can be reached at anytime at rak370@mail.harvard.edu.

Thank you,

Ramu Kharel,

Founder-HAPSA, MD/MPH Candidate 2017                                                                                 Harvard T.H.Chan School of Public Health                                                                                           UT Southwestern Medical Center