Dr Poonam Khetrapal Singh likes to talk. And as the Regional Director of the World Health Organization (WHO) South-East Asia Region, there’s an awful lot to talk about. Understandably, she’s also very busy – way too busy to be quiet, in fact – which is why, from the minute she stops to chat with The CEO Magazine, she doesn’t draw breath.
It’s clear from the start, this interview will reveal very little about her, the first woman to take on the role. It will instead focus on the job at hand and that’s to get the word out that, despite impossible odds, health in Poonam’s corner of the world is getting a good shot in the arm.
The South-East Asia Region of WHO was created in 1948 and was the first of its six regions to be established. Poonam’s corner isn’t small. She spearheads a region comprising 11 countries, one quarter of the world’s population, around two billion people, and 30% of the world’s poor. Add to that a disproportionate share of disease, both non-communicable (NCDs) and communicable, with multiple and unique factors contributing to them, and you have a monumental hotspot of adversity.
The biggest killers in the South-East Asia Region are NCDs, which are responsible for 8.8 million deaths a year and 64% of all deaths. Half of those deaths are of people aged between 30 and 69, accounting for 29% of all premature deaths globally. Meanwhile, communicable diseases are attributed to 40% of annual deaths in the region, compared with the global proportion of 28%.
These infectious diseases are caused by pathogenic microorganisms – bacteria, viruses, parasites or fungi, spreading directly or indirectly from one person to another. Poverty, poor sanitation, rapid urbanisation, an ageing population and a tropical climate all contribute to contamination, while the simple geography of a land prone to natural disasters – earthquakes, floods, tsunamis, cyclones, typhoons and erupting volcanos – exacerbates it. All have devastating consequences leading to more disease and injuries.
Poonam has no time to be quiet. She was appointed to Regional Director on 1 February 2014, and in September this year, when member countries met in New Delhi, she was nominated unopposed for a second-year term. The WHO Executive Board is expected to confirm her nomination when it meets in Geneva next month.
“People just don’t go to some hospitals or health facilities because they’re not sure if they’ll even find a doctor there; let alone one willing to meet them with the right attitude.”
To date, under Poonam’s guidance, WHO South-East Asia Region has emerged as the top performer in the organisation worldwide. WHO Director General, Dr Tedros Adhanom Ghebreyesus, has described her leadership as dynamic, with her flagship programs bringing a strong focus to delivering results.
A glance at Poonam’s CV reveals she’s enjoyed more than 30 years of working in public health as a leader and manager, while a peek at her numerous formal qualifications, ranging from Public Health to Political Science and English Literature, leaves you reeling.
Poonam’s career in health began in 1987 when she worked with the Health, Populations and Nutrition Department of the World Bank, improving the conditions and status of women and children in India’s slums and developing training projects for the health workforce. Since then, her roles have seen her through two decades as a civil servant with the Indian Administrative Services: from Secretary of the Department of Health & Family Welfare in Punjab, responsible for 22 million people; to Executive Director of Sustainable Development and Healthy Environments at WHO headquarters in Geneva.
“UNICEF and WHO work as sisters within the family of the United Nations, to create results through the synergy between WHO’s normative role and UNICEF’s track record in implementation. Together, we work to save newborn babies and are bringing full immunisation to all children.” – Jean Gough, Regional Director, UNICEF South Asia
Poonam served as Deputy Regional Director of WHO South-East Asia Region for around a decade, so she embraced the transition to Regional Director.“South-East Asia is a huge mix of different countries, so let’s start with the three which have teeming populations,” she begins. “India is the largest of the region and the second largest in the world, Indonesia is the fourth largest in the world and Bangladesh, the eighth.
Then we have Sri Lanka, Myanmar, Thailand and DPR Korea effectively in the middle, and countries like the Maldives, Bhutan and Timor-Leste, with populations of just around a million. So, the disease, the problems and the extent of them vary from country to country.”
When Poonam took over as regional director, the first thing she did was what she does best. She left the office to get out and about, and she talked. “I made it a point to talk to everyone I could throughout the region,” she explains. “I talked to the health ministers, the various experts, the communities, just to see what they perceived as problems in all these different countries. It was the best thing to do and I was pleasantly surprised with what I discovered from all these discussions.
“Some countries put emphasis on non-communicable diseases. Others emphasised communicable diseases while others stressed maternal and child health. Then, when I looked at the problems of each country and put them together in the metrics, it was very easy for me to identify the priorities. From there I could establish my chief flagship concerns.”
Poonam’s eight priorities:
- Measles elimination and rubella control by 2020
- Prevention of non-communicable diseases through multisectoral policies and plans with a focus on “best buys”
- Ending preventable maternal, newborn and child deaths with a focus on neonatal deaths
- Scaling up capacity development in emergency risk management
- Universal health coverage with a focus on human resources for health and essential medicines
- Building national capacity for preventing and combating Antimicrobial Resistance
- Finishing the task of eliminating diseases on the verge of elimination (kala-azar, leprosy, lymphatic filariasis, schistosomiasis, yaws)
- Accelerating efforts to end tuberculosis (TB) by 2030
Substantial progress has been made in each of these flagship areas. Measles has been eliminated from the Maldives, Bhutan, DPR Korea and Timor-Leste; maternal and neonatal tetanus have been eliminated, only the second WHO region to do so; Thailand became the first Asian country to eliminate mother-to-child transmission of HIV; six countries have controlled rubella; maternal mortality rates have reduced by 69%; and various countries have reduced maternal and under-five mortality rates to levels below the Sustainable Development Goals (SDGs) – targets set by the United Nations Development Program to fight poverty and achieve sustainable development around the world by 2030.
In terms of neglected tropical diseases, India eliminated yaws; Nepal eliminated trachoma; the Maldives and Sri Lanka eliminated malaria; and the Maldives, Sri Lanka and Thailand all eliminated lymphatic filariasis. There is also improved preparation for outbreaks and emergencies to minimise deaths, while countries are increasing their health budgets, rolling out health-financing programs, strengthening their health workforces and making efforts to achieve universal health coverage.
While these achievements are monumental and are undoubtedly improving and saving millions of lives, there is no escaping the fact that so much more needs to be done. Always optimistic yet pragmatic, Poonam understands that the only way to approach what appears to be an insurmountable task is to tackle it head on, so she picked the battles she knew WHO had a chance of winning and, once again, started talking.
“Our region has maintained its polio-free status since 2014, freeing up a very huge and highly trained workforce which could then be deployed to eliminate other vaccine-preventable diseases, such as measles and rubella. That was something doable, so I focused on that,” she explains.“I’m happy to say the immunisation rate has gone up in the region since 2014, resulting in the elimination of measles from the Maldives, Bhutan, DPR Korea and Timor-Leste.
“The Stop TB Partnership is a United Nations-hosted body with the mission to serve every person vulnerable to TB, and ensure that high-quality diagnosis, treatment and care is available to all who need it. We leave no-one behind.” – Dr Lucica Ditiu, Executive Director, Stop TB Partnership
“We have a very elaborate process of certification,” she adds. “We have a committee that determines there has been no case for the last two years, then another committee determines whether that information is really authentic. So, after several visits to the country, the committee will recommend whether certification should be given or not.”
Putting the drive to eliminate measles from South-East Asia into perspective, more than 179 million children have been immunised in India and Indonesia alone in just over two years.
Poonam’s second priority, and a more complex one, is to prevent NCDs, which are responsible for 70% of deaths worldwide. Nearly nine million people die every year in the region from different causes including cardiovascular disease, chronic respiratory disease, tobacco, cancer, diabetes, and alcohol. More than four million of those are aged under 70.
“It’s very distressing that people die young,” says Poonam. “It varies from country to country, but the average rate of mortality reaches 60%, while in some countries it’s as high as 80%. Cancer is on the increase, high blood pressure often goes undiagnosed, and because people don’t get onto proper medicines, they experience strokes and heart attacks at age 40.
“To prevent NCDs, we have to deal with the obvious risk factors,” Poonam explains. “These are unhealthy diets, lack of physical activity, tobacco and alcohol. The problem is that people don’t really like to accept what is important for their health until some misfortune strikes them or someone they love. Only then do they start wondering that yes, maybe they should start on the prevention mode.
“One way to combat it is to encourage more physical activities. That is very important,” she continues. “A lot of people in these modern times are spending too much time indoors on electronic devices. That is a problem around the world, including South-East Asia. We need to get outside and exercise.
“It’s vital that people understand that prevention is the way to go, because once you have the disease, then it’s a question of committing to life-long drugs. People say we don’t have the time; we are so rushed. But that’s because we don’t make it a priority. If we gave it priority, we’d find the time. We don’t think it’s important until the disease strikes and then it’s too late.”
The Sustainable Development Goals (SDGs) are a collection of 17 goals set in January 2016 by the United Nations Development Program to fight poverty and achieve sustainable development around the world by 2030.
- No poverty
- Zero hunger
- Good health and wellbeing
- Quality education
- Gender equality
- Clean water and sanitation
- Affordable and clean energy
- Decent work and economic growth
- Industry, innovation and infrastructure
- Reduced inequalities
- Sustainable cities and communities
- Responsible production and consumption
- Climate action
- Life below water
- Life on land
- Peace, justice and strong institutions
- Partnerships for the goals
Quitting tobacco is another no-brainer solution for Poonam to push in her fight to prevent NCDs, but she’s also concerned by another, just as deadly recreational pursuit, spreading around the world in homes, cafes and bars. “There’s a big trend, particularly among young people, for smoking hookah,” she reveals. “There’s a mistaken belief that hookah is safer than tobacco. But it’s not. It has many of the same health risks as smoking cigarettes. Water pipe smoking delivers nicotine, just as cigarettes do. In fact, those using a hookah to smoke may be exposed to the toxins in the smoke longer than if they smoked cigarettes.”
Working her way down her list, it’s easy to see Poonam is particularly passionate about preventing maternal newborn and child death. An estimated 6.3 million children under 15 died worldwide in 2017. That’s one child every five seconds and most died from preventable causes such as not having access to clean water, nutrition, sanitation and basic health services. The vast majority died aged under five, with newborns accounting for around half of the deaths.
More than a quarter of these children – 1.5 million – died in Poonam’s region. Despite the devastating figures, mortality among children has decreased in the region, with a reduction of 67% between 1990–2017, from 119 to 36 deaths per 1,000 live births on average. Worldwide, child mortality rates have decreased by half over the past two decades.
India, notably, has made remarkable progress. A UNICEF report released in September revealed that, for the first time, the under-five mortality rate was estimated at 39 deaths per 1,000 live births, equalling the global average. Also for the first time, the number crept in at under one million – an admirable achievement; however, still a chilling 9,890,000 deaths.
“That’s really very impressive in India,” Poonam observes. “There are also some countries in the region that have already achieved the SDGs of aiming for deaths under five to be as low as 25 deaths per 1,000 live births.” Universal health coverage, which would provide adequate human and medicinal resources to the South-East Asia Region, is also vital. As Poonam explains, the provision of a health facility means little if there are not professionals available to man them, or no medicine ready to be administered.
“People just don’t go to some hospitals or health facilities because they’re not sure if they’ll even find a doctor there, let alone one willing to meet them with the right attitude. Then there is the problem of people becoming poor because of their own bad health, or someone else suffering in their family. They borrow money to pay for medicines, or diagnostics, which impoverishes them even further. Each country needs to think of ways for procurement, like bulk buying, or buying generics, instead of brand names.”
The ending of TB is another target Poonam is determined to achieve by the 2030 SDGs. More than 1.3 million TB-related deaths are recorded annually worldwide, with almost 630,000 of those registered in WHO’s South-East Asia region. “It is unacceptable,” Poonam says. “It was a flagship I only added last year because it is so high in this part of the world. TB is so infectious, it takes no time to infect people and is the number one killer in the 15 to 45 age group. The Maldives and Sri Lanka think they can end it by 2022, while India says by 2025.”
Poonam will officially start her next five-year term as WHO’s South-East Asia Regional Director in February next year. Meanwhile, she continues to talk. Not only to let the world know how much her region is improving, but to make it understand how much more help is needed. This is no time to be quiet.