Roberto Posada, MD, second from left, attends antibiotic stewardship rounds with Nepali colleagues at Dhulikhel Hospital.

At my first meeting with the staff at Dhulikhel Hospital in Nepal, Suman Shahukhala, a pharmacist, showed me bacteria growing from a urine sample of a patient who came in very ill. The bacteria was E. coli, and it was resistant to all antibiotics available in Nepal except colistin.

Discovered in the 1940s, colistin fell out of favor in the 1980s because it caused dangerous side effects in some people, and by the 1980s there were less risky alternatives available. However, in this case the pharmacist had no option but to advise the treating physicians to use colistin, despite its serious side effects.

The next bacteria he showed me, from a different patient, was even worse. In that case the organism was resistant to all antibiotics available; there was no drug at all that could be used. That patient had little hope of recovery from their serious infection.

Antimicrobial resistance is a growing global crisis, and Nepal is no exception. The misuse and overuse of antibiotics have led to drug-resistant bacteria, making common infections harder to treat. With limited health care infrastructure and increasing infection rates, Nepal faces a serious public health threat from antimicrobial resistance. Luckily, I am privileged to partner with a dedicated team at Dhulikhel Hospital, committed to reducing antibiotic resistance,  and to keeping their patients and communities safer.

Why Antimicrobial Resistance Is a Major Concern

When antibiotics don’t work, infections last longer and become more severe. Conditions like pneumonia and urinary tract infections, which were once easily treatable, are harder to manage, leading to higher mortality rates.

Patients with drug-resistant infections often need extended hospital care, additional tests, and more expensive medications. Many medical procedures rely on antibiotics to prevent infections. When antibiotics fail, the success of surgeries and treatments like chemotherapy is at risk.

These issues put a strain on both families and Nepal’s already overburdened health care system. In addition, drug-resistant bacteria can spread quickly in hospitals and communities, endangering vulnerable groups like newborns, the elderly, and those with weakened immune systems.

How Dhulikhel Hospital Is Combating Antimicrobial Resistance

To tackle this crisis, Dhulikhel Hospital, in collaboration with the Arnhold Institute for Global Health at Mount Sinai and the AMPATH Nepal Partnership, has launched an Antimicrobial Stewardship Program. This initiative ensures responsible antibiotic use to prevent resistance while providing the best possible treatment for patients. Key strategies of the program include providing more resources to clinicians to support their decision-making and creating systems to monitor antibiotic use. The program was created by the team from Dhulikhel Hospital, with Mount Sinai experts joining as advisors as they roll it out.

As a result of the program, one new resource available to Dhulikhel’s clinicians is an antibiogram—a report used at Mount Sinai’s hospitals and many others, that tracks local antibiotic resistance patterns—to help clinicians make informed treatment decisions and monitor changes in resistance over time. Dhulikhel Hospital is also developing guidelines for treating common infections like pneumonia and urinary tract infections. These guidelines help doctors select the most effective antibiotics while avoiding unnecessary use of drugs that we need to save for complex or very serious infections. Regular training sessions are also being held for doctors, nurses, and pharmacists to promote responsible antibiotic prescribing and use.

The hospital also has started an antibiotic stewardship committee that conducts weekly hospital rounds. This team of experts—including doctors, nurses, pharmacists, and microbiologists— helps physicians choose the right antibiotic, in the right dose, for the right duration, preventing unnecessary antibiotic use and slowing down resistance development.

To monitor and regulate antibiotic use, the hospital now classifies certain powerful antibiotics as “restricted,” meaning they require approval before use. This ensures these lifesaving drugs are only prescribed when absolutely necessary, reducing the risk of resistance.

The Team Behind the Initiative

The Antimicrobial Stewardship Program at Dhulikhel Hospital was established by Prakash Sapkota, MD, and is led by Nabin Simkhada, MD, both from the Department of Internal Medicine. The team includes specialists from anesthesiology, obstetrics and gynecology, pharmacy, microbiology, and nursing. Sujan Pathak, MD, serves as the research assistant for the project. Key collaborators from Mount Sinai include myself, Roberto Posada, MD, and my colleague Mary Boyle, MD, MPH. We are both pediatric infectious disease specialists.

Why This Matters

Antimicrobial resistance is a serious threat, but with immediate action, we can slow its spread and preserve the effectiveness of lifesaving antibiotics. The Antimicrobial Stewardship Program at Dhulikhel Hospital is a crucial step toward responsible antibiotic use, improving patient outcomes, and safeguarding future generations against untreatable infections.

Roberto Posada, MD, is Professor of Pediatrics, Medical Education, and Global Health at the Icahn School of Medicine at Mount Sinai.

A child receives a health screening in school in Guyana.

The Arnhold Institute for Global Health is proud to present Inside a National Healthcare Collaboration, a compelling documentary highlighting Mount Sinai’s groundbreaking partnership with the Government of Guyana and Hess Corporation to strengthen the health system across Guyana.

The film’s trailer premiered during a milestone signing ceremony in Georgetown, Guyana, where His Excellency Dr. Irfaan Ali, President of Guyana, announced a five-year extension of the National Healthcare Initiative. This renewed commitment aims to transform Guyana’s public health system with world-class health care services accessible to all citizens, especially those in vulnerable communities. Following the ceremony, President Ali officially launched the full documentary.

Inside a National Health Collaboration chronicles the first phase of this ambitious effort—from the rollout of school-based health screenings to the launch of a cutting-edge pathology lab that has significantly reduced the time it takes for patients to receive a diagnosis and begin lifesaving treatment. The film also highlights advancements in community-based diabetes care, improvements in the quality of care at the country’s largest hospital, and progress toward developing new digital health systems, including a national electronic health record system.

Produced by Mount Sinai, the documentary features interviews with President Ali, Mount Sinai experts—including from the Arnhold Institute for Global Health and Mount Sinai International—along with Guyanese partners. It tells the human stories behind this health transformation and offers a powerful look at how the collaboration is reshaping health care in Guyana and improving lives for generations to come.

Rachel Vreeman, MD, MS, with the leadership of the Rafiki Centre of Excellence in Adolescent Health in Eldoret, Kenya.

Today, I’m writing with a heavy heart. Several of you have encouraged me to share directly about how current events are impacting our global health work, and I want to explain what that looks like.

Who I Am and What I Do

While it is my privilege to lead the Department of Global Health at Mount Sinai, I’m also a pediatrician specializing in global HIV care. I’ve spent the last 20 years working to improve care for children living with HIV.

• I’ve had the difficult job of delivering the news to countless families that their children have HIV, and I’ve witnessed too many lives lost.
• Most of my work has centered in the AMPATH Kenya partnership, where Mount Sinai partners with a Kenyan medical school and hospital system and the Kenya Ministry of Health.
• Together, we built an HIV care system that serves over 200,000 people at 300 clinics across Kenya.
• This system was initially made possible through USAID funding.

Dr. Vreeman on the pediatric ward of Moi Teaching and Referral Hospital in Eldoret, Kenya, in 2004.

The Miracles We’ve Seen

Until January, this system allowed us to witness miracles every day. When I first started, I saw mostly babies in HIV clinics because children with HIV typically didn’t survive past age 3 or 4 without treatment.

• Today, our clinics are full of adolescents and young adults who have grown up with HIV treatment.
• These young people are now heading to college, starting careers, and building families of their own.

One of the girls I’ve cared for over 20 years is now a nurse in our largest HIV clinic. I could share thousands of success stories like these, all of which bring me immense joy and pride.

The Impact of the USAID Funding Freeze

However, since January, everything changed.

• The freeze on USAID funding has shut down most of the health care system.
• We cannot continue to give life-saving medication.
• My WhatsApp is flooded with messages from young adults in Kenya who are now asking, “How will we have a future without our medications? Where is our hope?”

These messages break my heart, and I’m struggling to provide answers.

The Urgent Need

We’ve been working closely with the Kenyan government to find ways to sustain care, but having this system dismantled overnight is a nightmare.

• We estimate there is a $5 million gap to sustain the most critical health care services over the next year.

How You Can Help

I know this is a lot to ask, but if you are able to contribute anything at all to our emergency fund, it would mean the world to me – and to the thousands of lives we are trying to save.

• Donations can be made through the emergency fund set up at the Arnhold Institute for Global Health at Mount Sinai here.

Thank you so much for considering this urgent request. Your support can make a tremendous difference.

Rachel Vreeman, MD, MS, is a pediatrician, Chair of the Department of Global Health, and Director of the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai.

Physicians at Dhulikhel Hospital in Nepal receive simulation training in newborn resuscitation.

The Arnhold Institute for Global Health at Mount Sinai has announced that the Laerdal Foundation has awarded $49,800 to support the launch of INSPIRE-Nepal. This initiative, which stands for Increasing Neonatal Survival Program Incorporating Reinforced Education and Distance-learning, will enhance neonatal resuscitation training for health care providers in Nepal, with a focus on rural and remote areas.

With the support of the Laerdal Foundation, the INSPIRE-Nepal initiative represents a vital step toward reducing neonatal deaths and improving outcomes in Nepal.

A Global Health Challenge

Neonatal mortality rates (newborn deaths) remain alarmingly high in Nepal, especially in remote regions. The Helping Babies Breathe program, an evidence-based training that teaches skills in resuscitating newborns who don’t breathe on their own after birth, has proven to decrease neonatal deaths globally. However, a critical challenge remains: Health care providers’ skills in neonatal resuscitation begin to decline within seven months after their initial training. This skills loss poses a significant barrier to sustaining improvements in neonatal outcomes, particularly in areas with limited access to continuing education.

Dhulikhel Hospital in Nepal and its 18 outreach centers handle more than 3,500 deliveries every year. However, there is no regular training program for neonatal resuscitation. This gap leaves providers without the support they need to retain their life-saving skills.

A Collaborative Solution

Our INSPIRE-Nepal project seeks to address this gap by combining in-person training, system strengthening, and distance-learning to create a sustainable solution that will continually reinforce neonatal resuscitation skills. Our project has three goals:

• Enhance Provider Knowledge, Skills, and Attitudes: INSPIRE-Nepal will provide health care workers with neonatal resuscitation training, systemize post-resuscitation screening and referrals, and assess facility readiness at Dhulikhel Hospital and its outreach centers.
• Provide Virtual Training to Sustain Learning Through Project ECHO: Using the Extension for Community Healthcare Outcomes model (Project ECHO), a telementoring and education program, health care providers will receive monthly, case-based sessions to reinforce their neonatal resuscitation skills. This approach will evaluate the retention of provider knowledge, skills, and attitudes 12 months post-training.
• Reduce Neonatal Mortality and Stillbirth Rates: By combining education with ongoing support, we aim to reduce stillbirths and the rates of newborn deaths on the first day of life, creating a model that can be used in other low-resource settings.

Why It Matters

Remote areas often face both high neonatal death rates and limited access to training and resources. We offer a practical solution by providing continuous training through Project ECHO to maintain skills and improve neonatal care. Our project offers a scalable and sustainable solution to mitigate loss of skills, ensuring providers are equipped to deliver high-quality neonatal care when it matters most. With the support of the Laerdal Foundation, we can transform care for the most vulnerable newborns.

Led by Rose House, MD, the INSPIRE-Nepal team includes John Kulesa, MD, Neha Limaye, MD, Diana Lee, MD, and Katherine Anderson, MD, from Mount Sinai; and Srijana Dongol, MD, and Anamika Mahato, MD, from Dhulikhel Hospital.

Established in 2022, AMPATH Nepal is a global health partnership led by Mount Sinai, Dhulikhel Hospital, and Kathmandu University School of Medical Sciences in Nepal.

Rose House, MD, MS
AMPATH Nepal Partnership Director
Associate Professor, Arnhold Institute for Global Health
Department of Global Health and Health System Design
Icahn School of Medicine at Mount Sinai