Conversations on COVID: Brown emergency medicine fellow in Nepal is fighting COVID-19 on multiple fronts

Dr. Ramu Kharel, a global emergency medicine fellow affiliated with Brown’s Center for Human Rights and Humanitarian Studies, went to Nepal to research emergency medicine and immediately immersed himself in the practice of it.

PROVIDENCE, R.I. [Brown University] — Almost as soon as Dr. Ramu Kharel arrived in Nepal as part of his Brown global fellowship to research emergency medicine programs there, he found himself in the middle of a national crisis. A second wave of the COVID-19 pandemic was crashing over Nepal, causing its already-weak health care infrastructure to collapse.

“While the international focus was on India, this country of nearly 30 million people was drowning in the pandemic,” Kharel said.

Kharel — who had treated COVID-19 patients as an emergency medicine doctor with the Miriam Hospital in Providence and is an affiliated fellow with Brown’s Center for Human Rights and Humanitarian Studies — immediately teamed with health care workers, government officials and NGOs to provide a multitude of creative and effective relief strategies. He has led training sessions for health care providers, advised local government leaders on COVID management protocol and consulted with health centers on treatment and resource management. Kharel, who just returned to the U.S. this week (a month later than he'd originally planned), responded to questions about efforts to address the pandemic abroad.

Q: What was the state of the COVID-19 situation when you arrived in Nepal on April 1?

Within the first 15 days of my arrival, COVID cases started to explode in India, and then not long after that, per capita cases in Nepal were even higher than in India. The border between Nepal and India is around 1,100 miles long, and it’s practically impossible to control all traffic from one country to the other. The rate of viral infections in Nepal was as high as 90% in some districts, especially those bordering India. There was a major lack of oxygen supply, testing was inadequate, very few people had received the vaccine and ICU beds were rapidly filling up.

Q: How did your experience in Rhode Island prepare you to help on the ground in Nepal?

Over the last year, I spent a lot of time treating COVID-19 patients and working at the field hospital at the Rhode Island Convention Center. Through Brown as well as Project HOPE, the global health and humanitarian organization, I’d also been participating in trainings with more than 55 countries on the principles of treating COVID-19. We’d done a three-day training on different concepts. Those experiences really put me in a prime position, when I got here, to help out.

Q: As part of a larger Center for Human Rights and Humanitarian Studies / Project Hope project to provide COVID-19 training for health workers, you’ve led training on clinical management and vaccines for health providers in Nepal. What impact do you think that training will have?

One 4-hour video training was attended by 300 doctors, nurses, health workers around the country, which was the maximum number allowed on my Zoom. The feedback has been tremendous. It is very clear that we do not have enough to equip health care workers working on the frontlines to fight this pandemic, and one of the gaps is basic clinical management knowledge. With my NGO, HAPSA Nepal, we also conducted a 2-hour training with a focus on isolation/surge center staff. This has also been well received. To help this reach more municipalities, we’re posting the videos online. When we put the 2-hour training video on YouTube, there were 4,000 views right away. There is a high need in Nepal to train and equip frontline health care workers with COVID-19 clinical knowledge.

Q: How else are you helping people affected by the virus?

Research shows that about 80% of patients with COVID-19 can stay at home to recover without requiring hospital care.  Nepal only has about 2,000 ICU beds and less than 700 ventilators, which is not nearly enough for all the people testing positive with COVID. Also, much of the population lives in rural areas without easy access to medical care. So we were trying to figure out the best way to keep infected people safe and comfortable at home. We came up with the idea of creating home isolation kits that contain items like paracetamol (also known as acetaminophen) to bring down a fever, cough syrup, rehydration fluid, surgical masks, sanitizer, soap, a thermometer, and instructions on what to expect when you’re sick with COVID and how to take care of yourself. The kit also contains a pulse oximeter that allows people to measure their own oxygen levels.

Q: How do people get the kits?

Through HAPSA Nepal, we have raised over $51,000 to fund the creation and distribution of the kits, and we’ve made them available to more than 2,000 families in 21 municipalities across the country. The pulse oximeter drives up the costs of the kits, but it’s such a key item to help people either feel reassured that they can stay at home or that they need professional help. Previously, many of Nepal’s health centers didn’t have any of their own. We are building the capacity for the local governments to be able to distribute the pulse oximeters to families in their area who need them. As part of this project, when the pandemic ends, the municipalities are supposed to collect the pulse oximeters and bring them to the health centers to build the institution’s stock. The other day, our volunteers made 600 home isolation kits. Our group, COVID Alliance Nepal, also runs a free hotline staffed by doctors who we trained to advise people who have questions about COVID. That was quite busy in the beginning of the pandemic and is still active. The home isolation kits program is fully donation-based through a GoFundMe campaign.

Q: How successful has the COVID-19 vaccine rollout been in Nepal?

Though available data varies, Nepal has vaccinated about 7% of its population with at least one dose. This is one of the lowest numbers in the world. Nepal has a really good vaccine delivery infrastructure from years of vaccine campaign experiences, but the country just has not gotten the vaccines. There's such a large inequity with global vaccine distribution. I don’t want Nepal to be in India’s shadow when it comes to receiving vaccines. We are working on advocacy through many fronts. In mid-April, a group of Nepali professionals inside and outside the country came together to form a group called COVID Alliance Nepal. We wrote a letter to the U.S. ambassador to Nepal asking for more assistance; we sent a letter with 50,000 signatures to President Biden; we organized a massive phone campaign to American government officials to increase vaccine aid for this country. We received word that two senators specifically mentioned in a hearing that they had received a lot of calls about Nepal. President Biden recently announced that the U.S. would be sending COVID-19 vaccines to Asian countries; we’re waiting to find out how many will be sent specifically to Nepal. So I’m happy that Nepal is now on the radar.

Q: What is the nature of the project that brought you to Nepal in the first place?

My primary research interest is advancing emergency care in Nepal. The field is in its infancy here — even in America, emergency medicine has only been around since the 1960s — and there’s a real need for it. My plan was to research emergency medicine at seven different hospitals and, using a tool from the World Health Organization, assess the current state of emergency care here. Fortunately, we’d been planning this for months, and we had local research assistants here who were able to do some of the advance work. I hit the ground running as soon as I arrived and we were able to study five of the hospitals right away, and then I finished the other two a few days ago. This work is partially funded through a grant from Center for Human Rights and Humanitarian Studies — I was only supposed to be in Nepal for two months, but the Brown global division was super supportive in terms of flexibility. I’m now supposed to resume my clinical work at Miriam Hospital in July.