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Building Sustainable Primary Care on Top of the World

Photo by Photos provided by Shreya Shrestha (MED'16)

Shreya Shresthra (Med'16), left, with villagers at one of the health camps she established to provide medical services in the aftermath of Nepal's 2015 earthquake.

By Susan Green

For many, Nepal is a country of monks and novices in brightly colored robes, sacred sites, the majestic Himalayas, children and adults dressed in the colorful and highly decorative traditional clothing, and the warmth and hospitality of the Nepalese people.

While these do exist, visitors who cling to this idealized vision of Nepal are unlikely to be aware of the rigid caste system or the injustices suffered by its socially marginalized, underprivileged, and medically underserved citizens.

Growing up in Nepal, Shreya Shrestha (Med'16), saw firsthand the scope of suffering from poverty, lack of health awareness, and lack of access to health care. "I've always felt the burden of that," she says, "and I wished to do something about it—it was a motivating factor for going to medical school."

Part of a new generation inspired to change access to health care, Shrestha began doing something about it during her undergraduate years in America—she established and ran innovative urban mobile medical clinics providing free primary care and medicine to those in underserved regions within the lush Kathmandu Valley. It was the beginning of what eventually became Aasha for Nepal—a nonprofit organization with the mission of making health care accessible to vulnerable and impoverished communities along with the broader mission of curtailing people's suffering.

When Shrestha arrived at Geisel as a first-year medical student, she became active in the school's Physicians for Human Rights (PHR) chapter where she met Daniel Albert, MD, a professor of medicine at Geisel and advisor to PHR. Albert had spent years trekking through Nepal where he observed children living in profound poverty—legions of orphans living on the streets because they had been either abandoned or trafficked into child prostitution and other forms of exploitation. Moved to help these children, Albert, along with his Geisel colleague Lauren Sanderson, decided to establish a foundation to provide shelter and medical care for this marginalized group.

When Shrestha first met Albert, she introduced herself and told him what she had been doing in Nepal—and how she envisioned moving "the mobile clinic project forward in a more permanent and organized manner that would have a sustainable and substantial presence in Nepal's landscape." Albert became her mentor, and she joined forces with him and Sanderson to co-found US-based Aasha for Nepal and Nepal Aasha in 2013. Aasha, an acronym for alliance for services and health access, also means hope in Nepali. Kathmandu-based Nepal Aasha is the implementing arm of the American organization and plays a key role in working with local humanitarian organizations.

Upset by the devastation in her homeland from Nepal's 2015 earthquake, Shrestha had a strong impulse to immediately help. "As tempting as it was to jump on a plane that day, she took time to learn from her Nepali network and on-the-ground contacts how she could be most effective once she got there," says Lisa Adams, (Med'90), associate dean for Global Health and director of the Center for Health Equity at Geisel. "This is a sign of a mature global health practitioner—I was very impressed with how she approached this difficult situation, and of course with how much she accomplished once in Nepal."

Though not a disaster relief organization, this was Aasha's first official mission.

It was a crazy time, Shrestha admits. "I was smack in the middle of my internal medicine rotation and about to start pediatrics, but thanks to the amazing professors at Geisel and the doctors at Dartmouth-Hitchcock, I was able to take time off and spend three weeks in Nepal," she says. "We created health camps, delivered supplies to those who were afflicted, and built shelters—we knew people needed health care, but there was also a massive need for shelter."

The health camps provided diagnostic and medical services and brought much needed reassurance and emotional support to Khokana residents who lost so much in the earthquake. Shrestha describes their transient clinics or health camps as "primary care in action." In addition, Aasha for Nepal worked with village youth to build corrugated tin shelters for the impoverished residents who had lost their homes.

Taking what they learned from that experience, Albert and Shrestha are now collaborating with their physician network in Kathmandu to implement a sustainable primary care clinic model. "It's tragic that people cannot afford care," she says. "We developed a plan to extend mobile clinic support to sister organizations, such as established NGOs, including an anti-trafficking NGO, and to bring clinics into poor rural villages," Albert adds.

The plan provides long-term health care in four villages on a three-month, loop back rotation—over the course of one year physicians and supplies will travel between the four sites looping back at the end of the year to the first clinic in Khokana, a farming community south of Kathmandu, which has a population of more than 4,200.

"We realize that in providing primary care, the follow up schedule in the model we are using is every six months," Shrestha explains. "But if there is massive need in Khokana we may stay there longer before moving on. As our resources grow and as we get a better idea of needs in each particular location, we'll be able to determine whether or not there is a need for a more permanent infrastructure."

Last April, Shrestha spent three weeks in Nepal working with Nepali board members fostering partnerships and strengthening relationships with new and potential partners for the clinic project. "Yulha Fund has been very receptive to a potential collaboration—we discussed starting a rotating health clinic in three villages in Mustang to cover the residents of rural Upper Mustang," Shrestha says. While there, she and Shannon Coy, MD, a US board member, together with Nepali physicians Dr. Abhusani Bhuju and Dr. Tony Pun Magar, conducted a health camp where they provided general medical care and screened patients who are among the poorest and the sickest in the village. "We are now working to start a health clinic in the village to provide long-term, continued care to these patients, and hope to expand both in this village and others like it in Kathmandu outskirts and in Upper Mustang," she says.

Shrestha credits the "phenomenal support" of her mentors at Geisel and Dartmouth-Hitchcock for being able to remain involved with Aasha for Nepal. "This has been a communal effort and I couldn't have done it without their support," she says. "I am grateful to Dartmouth and to Geisel School of Medicine because they really take care of their students."

For more information about Aasha for Nepal, please visit: aashafornepal.org.