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tv   Global Polio Eradication Efforts - Sen. Mc Connell Panel 1  CSPAN  July 13, 2018 1:00pm-2:29pm EDT

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good morning, everyone. welcome to csis on this beautiful morning. i'm steve morrison, senior vice president here at csis. global health policy center. we're delighted today to have this major conference on polio. and we're thrilled and honored to have center mcconnell here to kick things off. my boss, dr. john hamre will do the introductions in a moment. i want to offer special thanks and congratulations to my colleagues, particularly nellie bristol and izra hussein for
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pulling together the dinner last night and this complicated and impressive program of speakers over the course of the day, including videotaped communications from dr. tedros at w.h.o. and charisma lice from the bill and me linda gates foundation. we're in a period of end game on the global eradication effort. 30 years into this effort. a moment of pride and excitement and a certain amount of anxiety and uncertainty and debate. there's no question we've had truly remarkable progressed on this is a complicated and remarkable moment. the partners, rotary cdc, who, unicef, the gates foundation deserve enormous praise for the discipline and commitments made over these decades, the international vaccine alliance deserves enormous credit for the role it's assuming now. there are many fundamental questions in front of us.
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most importantly, this is a form of health security. this, we have to operate more effectively in disordered settings like afghanistan, pakistan, northeast nigeria. the investment in basic immunization infrastructure for polio in many low-income countries is the most basic capacity for surveillance and for immunization capacity. for those societies. we've learned a lot in the last 30 years about operating amidst conflict in doing multiple campaigns. against polio. there's debate over what is the end game, how do we define success, when do we define it, in what timeline. we have to complete the work while also thinking about the future. and and transitioning towards preserving those assets and repurposing them. for a broader and endurable benefits, that's not so easy to
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do. we began last night with many of our speakers that have come a distance to be here with us. gathered together with dr. redfield, director of cdc for a very animated discussion around many of these same issues. we'll continue that today. dr. redfield has a family emergency, unforeseen which skeeps him from being here today. he sends his greetings and fortunately, john bill out from the cdc is going to stand and deliver his speech and take questions and provide comments over the course of that. so with that, thank you all so much for joining us today. and to all of our speakers who have come a distance, thank you so much. and senator mcconnell. thank you. john? good morning, everybody, welcome i'm john hamre, the president of
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csis. we always have a little safety announcement and we're going to make sure you're safe. if you hear a voice that tells us we have to evacuate, the exits are right behind us here on the stage. there's a stair right closest to this one, we'll go down one flight down into the street and take two left-hand turns, go over to the national geographic and i'll buy tickets for everybody to see the "titanic" show. people don't know that was a cover story for secret operation, to try to recover the scorpion. a fascinating story. we're very fortunate to have senator mcconnell with us today. his world changed overnight because there was the announcement of a supreme court nomination and he's going to race up the hill to start the process with confirmation for the new supreme court justice nominee. i'm very grateful that senator mcconnell would join us, he has a personally very moving, personal story about polio.
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i can remember as a young kid, when vaccine was first made available, we would line up on sunday afternoon. go to the courthouse, the little sugar tablet, and it was quiet, orderly, almost like communion. you know. what stood out in my mind was how much people trusted the government to do the right thing. gosh, i wish we could get back to theira. unfortunately we do have government people with us today who are doing that for american every day. we're fortunate that senator mcconnell with, all of his astounding responsibilities, has championed polio eradication. he has held this up personally. assen emblem of what america can do. and he has been insistent that the government shoulder its responsibilities to help with the global eradication of polio. this is a unique contribution from a very busy man. would you please welcome him with your warm applause.
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>> thank you, john, good morning. i'm happy to be here. this is an extremely important and personal issue with me. dr. morrison, csis, our partners at usaid. the gates foundation, rotary, this has been an extraordinary collaborative effort. i wasn't invited to speak because you needed me to bring you up to speed on the latest particulars. in the fight to eradicate polio. quite the opposite. i'm sure i could learn a lot from each of you. all of you are the experts, you're manning the front lines of this fight. so i want to take this opportunity to offer a few big-picture observations for your consideration. and also express my personal gratitude. to all of you. because while it's an honor for me to stand here in my capacity
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as senate majority leader, it's a particular honor to thank you in a different capacity as a polio survivor myself. my first memory in life was the last visit to warm springs, georgia. i was two years old. my dad was in europe fighting the germens. we lived in athens, alabama, my mother decided while dad was overseas to go live with her sister in a different part of alabama. which was literally just a farm crossroads. it wasn't even a stop light. five points in alabama. and so the local doctor thought i had the flu. and when the flu went away, they
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noticed a paralysis in my left leg. the quadricep. the muscle between the knee and the thigh. and he suspected that it was polio. and didn't know what to do about it. but fortunately, we were 60 miles from warm springs, georgia. about an hour's drive. and he recommended we go over there. and we did. and at that particular point, remember this is ten years before the vaccine. at that particular point whatever experts there were on whatever rehabilitation you could achieve were at warm springs, georgia, so i was really lucky to be that close by. they took a look at me and they talked to my mother, a physical therapy regimen. and they said we need you to do this four times a day.
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the women in the room who have had children or even if you haven't, remember i'm two years old. we don't want him to try to walk. we think if he tries to walk prematurely, whatever comeback we might be able to get out of applying this physical therapy regimen may fail and he'll be in a brace the rest of his life. so my lower like a drill sergeant. literally watched me every waking moment. for two years. so i was never a patient at warm springs, but she would take me over there periodically and they would check on the progress. and she told me one time, while they were over there. she held me up to a window as president roosevelt drove by.
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and so after two years, my first memory in life was our last visit to warm springs, where the nurse told my mother i think he's going to be okay. looks like he'll be able to walk without a limp. and without a brace. and have a normal childhood. so that was my first memory in life. the hero of my story. obviously is my mother. how many mothers would have had the discipline to basically put everything else aside, and just watch a 2-year-old to 4-year-old all day every day. to make sure i didn't try to walk too soon. the so the story of my life is
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with the exception of going downstairs, i've had a normal, normal life. in those days, you could end up dying, you could end up in an iron lung, horribly disabled. some people even miraculously had a complete comeback. and ten years later, i could remember john, john mentioned earlier, that when the vaccine came out, that was palpable, audible sigh all across america, and all of us kids in school would be taking the vaccine. so -- in the late '80s when the
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global polio eradication issue was formed. it was estimated that the disease still paralyzed 350,000 people a year. since that time polio cases have fallen more than 99%. all of you are on the cusp of an extraordinary accomplishment here. i'm told we're sort of down to what, afghanistan and pakistan? it's also an important effort to keep it from coming back. this is a huge victory and it didn't happen by magic. it happened because of the people in this room. bei try to practice here in washington. one of them is is persistence. persistence, i think it's underappreciated outside the public health community just how much hard work and innovation has to continue once a disease has dropped off the front pages. if the enemies of polioey to thak their foot off the gas.
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progress could erote rapidly. you kept it even. as the spotlight has moved on to other diseases. that my friends is persistence. another we quality has been patience, you've understood that all along this was a decades-long fight. not a short scramble. my mom reminded me that patience wasn't exactly my strong suit as a 4-year-old. in the treatments that i described to you. i was anxious to get up and go play. imagine how much it took to deter that. on the part of my mother. fortunately, that didn't last. i found that enduring success only comes to those who have the patience, to play the long game. i'm just lucky that my
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caregivers were willing to be patient and play the long game. researchers were willing to play the long game. today the polio eradication effort is proof to what it looks like to win the game or very close to winning the game. and along the way, the third big lesson i think you have shared some of the very best of america with the world. many of you know that prior to becoming republican leader, i was either the chairman or the ranking member of the state foreign operations subcommittee for many years. i've always believed that our national security is enhanced when we employ foreign assistance in pursuit a strategic objectives. and over the past decade, we can be proud that the state foreign operations subcommittee has appropriated more than half a billion dollars to polio eradication efforts alone. our nation should continue to reach out and engage the rest of the world. but success stories like the discovery and propagation of the
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polio vaccine show us how much good is done and has always been done. as part of our foreign policy. i've always been a big believer in the nondefense part of what we do overseas. you know everybody criticizes foreign assistance, and they assume we're wasting an enormous amount of money. the truth of the matter is you know it is a fraction, tiny fraction of what we spend every year. and you get a lot more bang for the buck, certainly, than having to send in the military. regretfully that's necessary from time to time. but we do an awful lot of good with a very small percentage. of with a we spend every year. all the researchers and experts and academics and nonprofits and
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entrepreneurs whose hard work and good efforts have spilled over our borders and have actually helped transform the world into a better place for everyone, so you should be proud. we all should this is america at its finest. think of the countries where polio remains, as we were saying, like afghanistan and pakistan, as well as a few other countries with circulating vaccine derived cases. and ponder the security environment in each of those countries. think of the progress that your efforts could achieve if we could reduce the revel of conflict in each place. think of the progress that could be made if we reduce the presence of insurgeoginsurgeanc. >> people of these countries have witnessed brutal conflict, and many of you have been in the fight to eradicate polio in those daunting places.
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more broadly. i want to ask you to keep up the persistence. keep up the patience. the same qualities that i was talking about with my mother. i've been in washington long enough to know when victory has been delayered prematurely. when you plan the victory party before you finish your homework and keep sharing best of our nation's and the world's values, our brain power, our innovation. and our heart with people. a vaccine is an amazing thing. it's better than even the best treatment or cure. because it proo serves the normal childhood and a normal life from the very beginning. how many stories like mine never had to be written because the
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international community took action? how many families never had to give a second thought to their children's first pair of walking shoes. weren't given any reason to market as a particularly special occasion. so on behalf, my by-words are, thank you all.
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good morning. i'm lori, the senior director for global health. can you hear me? is the mic on? okay. is that better? they assured me i didn't have to touch a button. is that better? okay. good morning, i'm lori sloat, the senior director for global health at the foundation in d.c. and i'm thrilled to be moderating our first panel. following on senator mcconnell's comments this morning you can see that the u.s. role involvement in polio eradication has been critical with he had mentioned that in the last decade, about half a billion dollars of appropriations, but it's also been about $3 billion overall. the largest government donor to the initiative. and you think of the global polio initiative itself, it's a phenomenal global public health movement, really.
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in terms of harnessing, it's massive harnessing governments, u.n. agencies, foundations, volunteers, partners worldwide. if you think of back in 1988, there's another statistics, i like to think of that i think is amazing as an advocate for this initiative. is that in 1988, there were 20 polio cases occurring worldwide every half an hour. and in 2017, enter were 22 cases for the whole year. we can't lose sight of the successes that the unique public partnership has brought us. at the same time we have to face and conquer the challenges that the polio end game brings, in terms of reaching the last mile. people in the hardest-to-reach places. what can we do to 0 insure that u.s. continued support, not only for global polio eradication but also how do we maximize the investments made to build public health, global public health capacity in terms of
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immunization and health security. the panel is going to focus on the u.s. role and the current and future role for eradication efforts. i'm joined by dr. will schrader. the director for the global up minization division within the center of global health at the center force disease control in atlanta and following his remarks, irene koek, the senior administrator for global health at us aid. >> we're going to hear from will and irene and also the challenges for completion and how the agency's role might evolve given a post-polio world. following the comments i'll ask a few questions. and then i'd love to open it up for questions and comments from you all and encourage a discussion and dialogue this morning. i'll turn it over to will to
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start us off. >> so lori had asked us to, to address about three questions and so i'll just go through those questions one by one. the first question was really is what is cdc's involvement in the global polio eradication initiative. cdc is a core partner of global pole he yoe eradication issue. the pill and melinda gates foundation. cdc has been involved with the global polio eradication initiative since its inception. as an implementing partner, cdc provides both financial support through u.s. government appropriations as well as scientific and technical expertise in polio eradication efforts worldwide. weigh work jointly with the global polio eradication initiative partners and
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ministries of health to monitor polio virus spread worldwide and to plan immunization activities, or response campaigns in multiple countries. maybe just to back up a little bit. so i think it's center mcconnell and others have mentioned that you know, the global polio eradication initiative was started and in 1988 when the world health assembly, the gompbing body for the world health organization declared they wanted to work towards global eradication. and a lot of progress was made in those first ten years. it was, you know, it was low-hanging fruit and a lot of countries moved rather quickly, in eradicating or interrupting circulation of polio virus. then in 1999, there was really a
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feeling that we needed more sort of boots on the ground and that was sort of the legacy or history of cdc. and so cdc started the stop transmission of polio program. which was where cadres of volunteers were deployed internationally and they would spend three months at a time supporting polio eradication efforts. either supporting immunization or strengthening surveillance. that program continues to this day. has changed several times. in the early days, the majority of volunteers were actually cdc staff. now more than about 95% of the volunteers that are trained are actually coming from african countries, and are mostly redeployed to other african countries, which helps build
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national capacity when they return to their home countries. and then between 2000 and 2010, there was some steady progress, but again there seemed to be some stagnation in progress by the end of 20010. and so cdc activated the emergency operations center. and declared polio eradication and emergency. and i think that that incentivized and led the way then for the world health assembly to make declaration in 2011. described polio eradication as a global public health emergency. so cdc's emergency operations center is still activated and has been for the last six and a half years. working on polio eradication efforts. so now whenever there's a polio
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yo outbreak or case it's set an example for local ministries of health to declare polio eradication a national public health emergency. then maybe one other innovation that cdc has been supporting is the national stock programs which is the national stop transmission of polio programs, sort of an extension of what we've done globally. but it's, it's an activity where we support countries to develop national staff who then can be redeployed. you know within the country to support polio eradication efforts. that provides lots of advantages, because they're already familiar with the language and culture and can work in locations where sometimes international staff can't work. maybe then, so cdc supports in a vit of other variety of other
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ways, we can determine where transmission is occurring or what kind of polio virus it is. we're promoting innovation, strengthening workforce capacity, supporting routine immunization and we also provide funding for vaccine purchase. to go to the second question, sort of the overview of the major challenges to completing polio eradication, let me just be brief to say that that as senator mcconnell said, polio virus now circulates only in the most remote or most difficult or conflicted countries or locations in the world. and so those major challenges are not new to you. or can be easily guessed that you know, it's really accessing those hard-to-reach populations in insecure areas, that are in emergency settings, with weak
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immunization systems, and difficult surveillance. and so then we also really focusing in afghanistan and pakistan in reaching mobile or migrant populations who are making long-distance travel between the two countries. i think that right now i can say that, i think we have the ability and the knowledge to do with the challenges. through recent innovations, we just have to make sure that the political will and funding holds out. maybe it's juggling the balls and trying to keep everything in the air at the same time. cdc's plan for moving into or
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easing into transition. i think that we understand that we need to focus on long-term planning and in a post-polio world to insure that the even after the last wild polio virus is detected. we have at least 10 or 12 years that we need to continue working to make sure we have adequate surveillance and we're continuing with ipv vaccination. we feel that that's best done by integrating polio vaccination with inactivated polio vaccine and surveillance activities into integrated vaccine preventible disease control efforts. so to protect the u.s.
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government investments and in order to secure the health of americans and the world in general, i think we need to think about polio integration as transition and so we integrate the assets and infrastructure into an integrated vaccine preventible disease platform if we strengthen routine immunization to provide ipv, as an injectable vaccine, we also build the country's capacity to provide other life-saving vaccines. if we think about strengthening the capacity for polio surveillance that provides a good platform for early detection and outbreak response for other vaccine preventible diseases or infectious diseases in general.
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the last component of transition in the post certification is that we need to make sure we contain all polio viruses. to protect against either accidental or intentional release of polio virus. and so at the time cdc is focusing on the polio affected or polio endemic countries as well as intensifying work in the few countries or geographic areas. where the most unvaccinated children or the most children die from vaccine preventible diseases. of course through this transition process it's important that we do it in a way not to jeopardize our major objective, which is to achieve polio eradfy indication. >> thanks for that and i want to thank csis and senator mcconnell, the support we've had from congress as you've been hearing has been a tremendously
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important that we all do, we want to thank the from the very beginning, rotary's advocacy for polio has made such a difference around the world. usaid has been formerly part of the global polio eradication effort since 19 6 when championed by the u.s. coalition for polio eradication led by rotary. congress established an earmark funding for usaid and cdc. our directive started at $20 million and has grown to $50 million in 2018. our work started before that. we had provided a grant to rotary in the 1980s and supported through the '80s and '90s, as an effort to eradicate polio three the western hemisphere. we all know by 1994 the region
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was certified polio free. so it's 1996 we've supported activities in 27 countries, primarily through grants to who and un kref. these are grants support the work that who and unicef do in surveillance, monitoring, mobilization, lab accreditation, containment and outbreak response. we funded surveillance medical officers who identify and investigate the majority of polio suspected cases in 27 countries. they've been essential to polio eradication. have been part of the first responder effort whether they be natural disaster or other things in a number of countries. we have also supported technical assistance through some of our partners such as jsi and the communication initiative. we have provided longstanding support for gabi, the vaccine
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alliance and bilateral alliance that core is what needs to happen now and in the future for polio. what we want to see is how these efforts do come together now and in the future. also a significant component of our support to polio eradication has been our extensive support, a lot of support through ngos, this has been primarily channeled through the core group, consortium of ngos led by world vision that works through local ngo and provides grants to ngos at the country level. this is in line with administrator mark green's vision for building local capacity. and certainly important part of what's happened with polio. the work of the ngos has been instrumental. border populations, marginalized groups. a critical opponent to polio eradication and success so far. this community through these ngos, we support community-based
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surveillance. >> rezeus vaccine refusals in the four hot districts, from 40% to less than 1%. using trusted well trained and supervised women from the communit community. ed world health assembly signed a resolution to eradicate polio. we main committed to achieving the goal and helping countries to smoothly transition to focused polio efforts once eradication is achieved. as will and lori mentioned,
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that's going to be a very complex task and much more work needs to be done. i want to touch on some of the challenges. first the challenges as we get close to eradication is that we're not yet interrupted while the numbers have come down significantly we're not yet there. and currently circulating afghanistan and pakistan. accessing all children with repeated vaccinations has been difficult due to active fighting, suspicion of health workers, variable quality of campaigns and reaching populationings on the move. health workers continued to be targeted and killed, but they continue to work regardless of that. nigeria wild virus had been silently circulating for more than four years. >> vaccine derived polio. how do we define the end game of polio. something that the global
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community is taking up now needs to be clear about what do we mean when we talk about the end of polio. our concern is that the vaccine derived polio virus is still circulating after polio is certified as being eradicated it will create a great deal of confusion at the country level. it looks and acts like undetected. it looks and acts like polio. it has a lot to do with our credibility of eradication. we need to have some clear guidance for countries on this. and clear definition as we go forward. whether it's wild or vaccine derived, it looks exactly the same. >> many of my asia bureau colleagues who are not health people are talking about the polio outbreak in ppapau new gu. >> routine immunization is a
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challenge. it's variable in many countries, particularly those that are at risk for polio. something that we need to work hard at improving and increasing. we talk about containment. a challenge with full eradication. one of the things we have to do is work with the global community to make sure that really is secure and then finally the number of countries have done transition plans. this is a good start to the effort. a number of those plans are weak and are only looking at a peace of the larger puzzle. it has to do with how are we defining, what do we mean when we're talking about eradication to make sure the transition plans take into account all the work that needs to be done now and over the next 10 or 12 years as well as into the future. the assets that have been developed for polio in systems and surveillance officers in the ngo networks and other things can be adapted to other needs
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for public health. there's an awful lot of working to done. these kind of discussions to help us think about what do we need to do now. building on what's happened so far. being clear about what's the what are the next stages and how does this effort really evolve going forward is critical. >> great. thanks. so i have two questions, to reflect a few comments i made. i like how you moved through how one of the things i think is so great about the initiative. how it adapts to the disease and the progress and the challenge, we don't know about. we didn't know a lot of things, 30 years ago when we started off. you had gone through hon cdc's response. low-hanging fruit. even that moved from volunteers at cdc to build capacity people from the countries themselves in 2000 and so on. my question is in terms of this tricky balance. we still need to focus our
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efforts. and that requires pay shins and concentration. so the second thing is how do you insure that we can leverage the investments that have been made towards benefitting people's health in other ways? what has been, can you be a little more specific, you both raised how your agencies adapted. can you be more specific of what that might look like? maybe it's not restructuring. you talk about integrating efforts within vaccine preventible diseases writ large. does that require cdc to sort of restructure itself? or is it technically in the countries? can you talk more specifically what it looks like to do both of those difficult tasks, eradicating and leveraging other benefits. >> think that's an important question, one that we've been thinking a lot at cdc in the global immunization sphere.
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since i've been in that position. as the director. you know, the they are big tasks. as i, as i talked to people around the world, you know, what's went right, what's gone wrong. the global eradication effort has been ongoing for 30 years. and you know are, there any lessons learned that we could take from that process? i think, i think one of the feedback, not as a criticism. you know it was pretty easy to get through the low-hanging fruit. we left the toughest places for last. the most densely populated, the most conflict-affected, most insecure. so if we really want to make progress, not only to achieve eradication, but then to help in our transition efforts. we're actually supporting an polio preventible platform.
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the solution is that the answer is the same to both of those questions. we have to make sure our immunizations are being provided in a timely way. i mean campaigns are great to reach you know a lot of children. quickly, but it would be even better if children were automatic caught as they were born. most high-risk countries. provide a zero dose. children are vaccinated at birth. despite our best efforts providing frequent campaigns, polio endemic or polio affected. that's never going to be as timely as if it was part of the culture that every mother you know at at the time of delivery, had her baby vaccinated with
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polio vaccine. either in a health care facility. or at home if she if she was chose to have a home delivery. go do you think the cdc, does it require a different response. is that different from say ten, 15 years ago. how it engages with the communities or governments writ large? >> i think, i think our focus now is we want to focus on the hardest places to develop really robust immunization systems. really have those characteristics where a lot of children are still dying of vaccine-preventible diseases so we can make good progress in those areas. >> supporting the surveillance officers and others if we can continue that platform. for early detection and response to not only polio, but for other
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vaccine-preventible diseases or communicable diseases. >> let me build on a couple of things that will said. the point about looking for ways to really put the investments into routine immunization systems is such a key piece. as i mentioned, we talked about such variation and high coverage of overall routine immunization, that that's an urgent issue that we all need to come together and move on. with building polio that that. 0 through the end stages as we shift to ipv vaccine. building that into systems is going to be important. one of the other pieces in the surveillance, we do have exactly as will said, surveillance officers in a number of countries who have in a number of cases done work beyond polio. beyond looking for afp. but making sure there are resources to continue the work of those surveillance officers who are built within the health
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system. to be looking for other disease issues. global health security and hugely important part of that how did we get resources to continue to support those kinds of officers, keep them in place and keep that network in place. part of that gets to be the money. it relates to the ngo networks. that are well-placed to take on any number of health conditions you can imagine. they're part of the community, they're there by making sure we have ways to get the resources to continue to support those networks. this is critical. it gets do how the money has come. the money has come for polio. we've been able to use that and build the platforms. how can we start to evolve those resources to pay for more broader health systems kinds of investments, whether for surveillance, laboratories, ngo surveillance. >> so that is really second
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question, that's on the investment side, right? there's a lot of advocates in this room and so with that in mind. why should we invest in obviously polio eradication, as we're talking here about say surveillance. i am a huge fan of the u.s. government's involvement in surveillance. came quite knew into the polio initiative to see how much is invested worldwide in surveillance. it's incredible and the radar detection for global health and lots of vaccine preventible diseases. how does the investment from polio transfer into that? some of it, some say it's subsidized. we're doing that otherwise. so how can we convince u.s. support for continued efforts for things like surveillance that go beyond polio. what would be your message to the group here to help advocate for support for that? >> i think that we're talking
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about polio transition and irene mentioned there were 16 countries that have the largest investment in polio investment in the polio resources or polio assets. one of those countries is south sudan. and you know when we were talking with representatives from the south sudan ministry of health. were describing how the polio surveillance infrastructure is, is the most comprehensive, the only existing surveillance system that has this global reach throughout the country. national reach throughout the country. that then could be used as a platform for other activities. and i, i think i had really the privilege to see firsthand when, when i was a cdc staff, who in three regions in africa,
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southeast asia and the western pacific. really how the polio infrastructure could, could be used. and is used to strengthen surveillance capacity for early detection. and the the early detection and response to the ebola importation in nigeria was a perfect example. it was the polio infrastructure surveillance system that made them capable of detecting early and mounting a response effort that prevented nigeria spread of ebola during the recent large outbreak in west africa. >> i would say two things. input on this question is one i love to hear from those in the room. >> talking about the surveillance and infrastructure at the health system is part of the end stage of polio.
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i important piece, that it's not only about looking for afp, but it's also about building that infrastructure for other things. and i think that looking for ways to talk about polio and that longer stage i think is a really important piece. the other thing to do is continue to talk about it as part of your public health infrastructure at country level, and you know, increasingly, countries are taking on more and more of the share of those costs at countries. it's less and less coming from donors, right, and less and less coming from outside, but working with countries who can afford to start recognizing these staff who have been supported through the polio effort, but that is an integral part of what that country's public health system needs to be, and even as we do catalytic funding over the next couple of years to increasingly try to get domestic resources to pay for that is going to be really important. i think part of that message at country level is key, both for the ngos as well as surveillance officers who are there. but i do think it's going to be a tricky message, right, because it is certainly part of polio,
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and we've been saying that once you make these investments, you don't have to make the investments anymore, but how do you talk about that in a way that really does continue to resonate? and i do think there has been over the last several years increasing attention and interest in things like global health security, and surveillance is a core part of what needs to happen for global health security, so tying it there is another opportunity. >> i'm going to take you up on that idea of asking you all what works. and so, picking up on what you said, is it a tricky message? are we overcomplicating it in a way? you know, there's a lot of money that's going into the infrastructure. we need it for detecting the diseases worldwide. is that a good enough message, you know? shouldn't that be the case, you know? so, being a little bit provocative here, but think about that in your comments, if you'd like. i'd like to hear some reflect n reflections on that, but i also would like to open it up to the floor to ask your questions of what you'd like to hear from the
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panelists. so, any comments or questions? yes, please. >> hi. thanks very much for your presentations. steve robinson with world vision -- thanks very much for your kicking us off with your comments and observations. dave robinson with world vision. i worked in mauritania on child immunization programming with unicef, the ministry of health, rotary, and particularly focused on working with local faith leaders, imams, to get the message out with nomadic populations and marginalized groups. in getting to the last mile in places that you've mentioned, like afghanistan, pakistan, somalia, elsewhere, what is the investment, the catalytic investment that you mentioned, going into mobilizing faith leaders to sustain the acceptance to overcome the disinformation? senator mcconnell mentioned the
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resistance that are coming from some faith groups against immunization, particularly child immunization. could you comment on that and what is needed into the future in terms of sustaining the support of faith leaders, particularly in the muslim world? >> okay, why don't we take a few questions and then we can answer, or comments. yes, please. >> actually, it has to do with the -- first i will start with the campaign. i had worked in nigeria when there was in 2004-2008, when there was a problem, and then later in afghanistan. but what i saw in polio was there was a problem of ownership.
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the people, the community, families, even the government didn't own the problem, the solution, and what have you. what i heard from senator mitch mcconnell was very important, concerning the mother owning it and then making sure that they get the problem. but in those countries, the community, the people, and even the government didn't own it. it was us. i was working with unicef. it was us who are thinking, planning, implementing everything, and that was a problem. and i don't know how far you have gone. the same goes with afghanistan. all the problem is ownership first. and then the second problem is, i'm glad that usaid has mentioned it. the money that was paying for
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polio, all that money, if we had worked, implemented it for strengthening the routine immunization system, what would have the difference been? the routine immunization has been neglected. and then, i don't know, everybody's interested coming up in that, you know. when we have it, people are waiting for us because we bring money for them, and nobody cared. so, what i see is there are two things, ownership and a strengthening the routine immunization system. otherwise, we will not go anywhere, sorry to say. >> okay. >> that's my experience. >> thank you. let's take one more and then we'll do another round after. so we'll take three questions and have some answers. any other comments or questions? >> over here. >> go ahead, steve. i'll get you in the next round. steve, you want to go ahead?
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oh, sorry. i'll get to you in the next round, steve. >> i guess my question is, what have been the biggest challenges as to perhaps funding or investment or even attention towards polio as it is no longer a hot topic as it used to be? and how have you kind of seen that progression over time to still make it an important issue that needs attention still? >> okay, great, thanks. okay, so, let's take those questions. so, who wanted -- you can comment on all of them or -- irene looks like she's ready. >> i'll take the first one on faith-based, and thank you, david. i think that's a really important point, and where we see the work that we've done with world vision and the ngo community has been such an important component of all of this, because ngos and community-based ngos do, indeed, work with faith-based leaders at the community level, which are
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hugely important, you know. certainly, as you described in mauritania, but in afghanistan, in almost every country, engaging the faith-based leaders can make such a difference, and that's not only true for polio, it's true for every health intervention i can think of, right, is engaging those leaders as part and parcel of getting the message out and getting, and trying to get out the correct message, as opposed to fighting against some of the rumors and the incorrect messaging is really, really important. so, it has got to be a part of what we do going forward for polio, for immunization indeed, but also for anything in health. and that's where, you know, community and community groups as part of your broader public health infrastructure is such an important component, because they can do it to a degree that others, it's much easier to get at it through community groups has been our experience. >> if you could follow up with that, what do you think is needed in the future to sustain that? what are some tangible actions? what can we do to make sure that continues? >> i think two things.
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one is continue the investments through those ngos and through the networks, but also making sure that a ministry of health sees the value of working with the community groups and faith base, so it's a little bit of both. it's also from, not only from the donor's side, but from country side, that the public center in a country does see the value in this, and that certainly happens in a number of places, but looking for ways to facilitate those partnerships is really important. >> great. okay. and then, did you want to take the one on ownership? >> if i can combine the first two questions and sort of respond to them jointly, because i think they're closely related. i was in nigeria in 2004 as well, working on polio campaigns, and so, probably we were working together. you know, the -- i think that the two are closely related. i think that nigeria outbreak really taught us a lesson. for those in the room who are
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unfamiliar with that story, in 2003, in northern nigeria, because of unfounded rumors about vaccine safety, they stopped vaccinating against polio, and so there was a really sizable outbreak of wild polio virus in northern nigeria in 2003, and that really, then, affected so many surrounding countries. i was based in ethiopia at the time, and every week when the global update came out, the global update which shows polio cases on a map visually, we could see the polio cases coming ever closer to the ethiopia border, you know, marching from northern nigeria as they spread to the central african republic and then to chad and then sudan, and eventually, we had a polio outbreak in ethiopia as well. and i think that the lessons we learned from that were that we really had to engage faith-based and community leaders. and so, different countries have done that in different ways. in ethiopia, it was the orthodox
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church that really then promoted the message that vaccination is part of our culture, it's what we do in providing vaccination. in afghanistan and pakistan right now, there's huge efforts in engagement. in fact, the leadership in supporting polio eradication is largely from the religious community, where they've come out very strongly to support vaccination and made it very clear that it's now -- that there's no concern with vaccine safety, that the vaccines, there's no problem with religious or conscience for refusal of vaccine, and then really addressing the third question about vaccine, hesitancy is really related to that. and i think in all of those situations, you know, our success is our biggest risk. as we improve the quality of vaccine delivery so that the
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cases go down, fewer and fewer citizens or mothers recognize the risk from polio virus or any other vaccine-preventible diseases, but that's not only mothers, it's also health care workers, the majority of nurses and physicians in the united states probably have never seen a case of polio. they've probably never seen a case of measles, because our vaccine programs have been so effective. and so, they really don't understand the really important mortality that's associated with any of these vaccine-preventible diseases, and that's why we have to keep that message in the forefront to really, to emphasize the need of a robust vaccine-preventible disease program. >> comments from both of you on the question around the investment. so, what's been some of the challenges for the investments, the funding, as we, as polio, you know, drops off, so to speak, the high-level political
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agenda? although i think it still has some attention, but as we move forward, this patience factor, this persistence factor, and the investments it's going to take. so, how do we deal with that? >> so, i think at this moment in time, at least for the resources that we get, because we have not yet achieved eradication or have gotten there, the investments coming to us are still coming for polio, right? i think the difficulty comes as we get to this very complex period of when do you declare eradication, what does that look like, that's where i think the risk will come. you know, if it is, indeed, after while by risk there is no reason to continue to support polio, and i think that's where this complex conversation about what does certification mean and when do you certify as part of that question about resources and something we need to think about really, really carefully. i think at country level, it goes back to will's point about why do we need to continue to invest in polio, we haven't seen
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a case here in years and years, and making, continuing to do that advocacy at country level i think is really important, but also, it gets back to looking for ways to really build immunization into routine systems and build those routine immunization systems is quite key. >> okay, any comments or questions? okay. so, i had promised steve first, and then i'll come to both of you. >> one quick comment and then a question. the comment is, you know, you really do bring across very powerfully, each of you, the longevity and the centrality of american leadership, and that's terribly important. i mean, this is a disease that disappeared from america in the late '70s, and yet, we've been able to sustain that leadership abroad for decades now, and it's
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thankful, and i think we have congress to thank. i think we have administrations, i think we have the rotary foundation now, gates, there's an assembly of interests that have stayed the course and made that possible. my question is around the end game and the whole challenge of vaccine-derived virus. it's easy to understand the wild virus challenge, right? we're down to a handful of cases. we know the geography it's in, we know what it's going to take to disrupt the transmission. we know there are security and other logistical barriers, but there's been progress. what gets more confusing and more a.m. big is this other threat that's out there that we now appreciate in a much bigger way, which is these outbreaks, these cases that are appearing in various surprising places sometimes and not predicted
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places, different geographies that are vaccine-derived polio, and i don't have a very clear idea, like, what's -- how do you communicate to an interested public, okay, what's the game plan for arresting that form of transmission? because we're not going to declare victory until we've achieved that, but it's very unclear to me what the strategy is. so, maybe you could say just a couple key words on that. i know this is a topic that will be of discussion over the course of the day, but it's very fundamental, i think, to where we are today and how to communicate to a public that is confused. >> okay, great. okay, so, this gentleman here and then robert after. >> hi. jim tulch from george washington university. >> okay. >> i recognize the funding commitments are really, really important, but also really important is personal morale,
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institutional morale, and long-term commitment of your own staff. and this i think applies both to cdc and usaid but also to rotary international in terms of how do you maintain the kind of momentum and the commitment among your own staff that are involved in this over now decades of this effort and dealing with many of the frustrations where we've had some near misses and some retreats and some progress moving forward. >> great question. thanks. >> robert. >> thank you, robert steinglass with jsi. just echoing what senator mcconnell said about persistence and patience. i've always found that a strong and steady wins the race. and it is a challenge to develop health systems in countries. we get distracted a lot by the verticality of the disease approaches, which have their own sort of momentum and urgency to
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reduce incidence of disease, but health development requires a different sort of mind-set in many cases. i think usaid could take more credit in the role it's been playing in providing continuous support for routine immunization system strengthening. we hear about routine immunization increasingly now from the polio community because of the need to sustain eradication with inactivated polio vaccine, for example, but in fact, a.i.d. has been investing for the last 30 years in strengthening routine immunization systems, and i think a.i.d. could take more credit for that work, because that is the essential starting point for polio elimination, as some of the panelists have said. where immunization systems have been strong and operating through the health system, not as an end run around the health system, we saw polio incidents decline very quickly. i think routine immunization system strengthening could be recognized more as an essential function that a.i.d. has always
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been playing, just as cdc is recently starting to recognize it as an essential function as well. and i would just add one more point, which is i think there's a danger of prematurely, and perhaps in an imbalanced way, deciding what are the magic bullets moving forward. i've heard surveillance mentioned many times. it's essential, but it is not the only discipline. >> that's right. >> there's also behavioral scientists that are needed. there's information specialists, communication specialists, management and financial specialists as well. and again, that speaks to the health development of orientation of a.i.d., which is also so important. civil society i've heard many times, but it's more than civil society and more than epidemiology and disease surveillance. there's a need for supporting the health system as well in many of these countries, because the health workers oftentimes don't feel very supported, and they're not very well supported. they oftentimes don't have the resources and tools that they need and encouragement that they need to do their job at the
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peripheral level. thank you. >> okay. thank you. okay. so, we'll take this next round. so, irene, do you want to go first? >> yeah, let me start. and steve, thanks for your point. i think it is incredibly important that we look at, you know, the end of polio as the end of all polio, right? because it looks exactly the same, you know. as i mentioned the experience of papa, new guinea, people say, well, it's a polio outbreak. and yes, it was, but even if it was vaccine-derived, it still looks the same. but that means it's very complicated, and i don't know what the technical strategies, but i think that's got to be part and parcel of how we talk about moving toward the end and whether we talk about it in steps or phases or something that is clear about the end of wile but recognizing polio is still out there until we can get routine immunization up and ipv into levels much higher and whatever else we need to do, but i do think we have to be really careful and really clear about
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what that longer-term game looks like. and when we declare polio done that it really is all of polio. that's got to be critically important. there's a lose of complications around that, including what the certification commission has currently had, and i know there's a whole number of policy issues, but it is something i think we have to be really clear about. otherwise, there will just be endless confusion, and quite frankly, threats to the credibility of the public health community of, well, you said it was over, but it's not kinds of things, and i think that's a huge problem. question on staff fatigue. i do think that's an issue, particularly at country level, and this is where this whole conversation we've been having about how do you make sure we continue doing what's right for polio, build it into the overall system is so, so important, right, so that you do continue, that it's not just one issue, but it's part and parcel of another. and just finally, thank you, robert, for your acknowledgement, but i would very much agree with you about the broader health system investments. you know, surveillance is
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critically an important part of that, but it is exactly as he described, a whole number of other things have got to be part of building polio and the end of polio into that broader system is really important. it's complicated, right, and we can say, yeah, let's just do that, but it is quite difficult, both for donors and for countries and ministries of health to figure out how do you take these investments and these external resources and build it into your current budget. and that's where the complication comes in, that it's something we've got to do. >> so, let me just reflect on the comments that were made and just say that, steve, you're absolutely correct that american leadership has been central the progress that we've made in polio eradication so far. and i really can't emphasize enough, and really, from the bottom of my heart, i sincerely believe it's because of rotary international that we've been able to make the progress we've
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made. the rotary international has been an unbelievable partner in helping to keep the focus not only through their fund-raising efforts that they do worldwide, not just in the united states, but really worldwide, but also the advocacy work they do with governments worldwide and their volunteer base that are really visible in countries around the wor world. just again and again emphasizing the need to sort of slow and steady until we're done with global eradication. the issue about vaccine-derived polio viruses is a complicated one, and some in the room may not really understand. and when you hear the word vaccin vaccine-derived, then you think if i avoid the vaccine, then i'm not at risk, which is just the opposite. vaccine-derived polio viruses only occur in pockets of low immunity, where the live, attenuated vaccine is circulate for a long enough period of time
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that it muteates and then develops neurosurvivorants and can cause paralysis. so they're prevented through vaccination, not the lack of vaccinati vaccination. so, i think that is a complicated message. it's one that we need to think about how we talk about, because it's a difficult concept. and when the public or the media hear vaccine-derived, then i've heard it often said, well, then if we're giving this vaccine, why is it causing this problem? and it's -- i mean, the beauty of a live, tenuated vaccine, is when you give it to a child, that child then secretes that live virus that gives a boost to household contacts as well, and so, you're really, you know, vaccinating not only the child but the community. so, the live attenuated oral polio vaccine has been central to achieving interruption of
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polio virus transmission in the majority of countries worldwide. there's been a handful that have achieved eradication by using only the inactivated vaccine. i think that the issue about maintaining commitment of staff is an interesting question. actually, as i talk to people worldwide or i mention that i am working on polio eradication, i get no lack of interest in people saying, oh, that's amazing that you have this opportunity to be involved in it. i actually, as a medical student in the late 1980s, when i hear about smallpox eradication, and they were starting polio eradication initiative, it was actually how i set out my career path to be involved in polio eradication, eventually, i took some detours along the way and actually then started working in africa around 2003, working on -- i actually went to africa
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as a measles officer because i thought i was too late, that i didn't have a chance to work on polio. as it turns out, i had an opportunity to work on polio, not only in ethiopia, but in nepal, which was my next duty station because we had an importation from india and a vaccine-derived polio virus in lao when i was in the western pacific. we're not done with polio. i think it shows that there are still challenges. with any -- with the two current eradication efforts that are endorsed by the world health assembly, with guinea worm and polio eradication, both have encountered obstacles at the end. we're sort of neck and neck. i think we've both had 22 cases in 2017, so we're fighting it out to see who will be first in this 30-year race to achieve eradication. and then just to address the comment that robert made, i think that working in the field, i think that we were really clear from the beginning that
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for tenants of polio eradication, one of those pillars was routine immunization, that that was part of the strategy all along to achieve an eruption of polio virus. and in the countries where i worked, i really saw that the benefits of those assets, not trying to accomplish at all the amazing contributions of the investments from usaid, because i benefited a lot working in w.h.o. and working with colleagues who were supported by the funding from usaid. >> so, i hope you don't mind me putting you on the spot, because i thought it was a great question about inspiration of staff and rotary has done an amazing job to keep that going. finding that the staffs of the motivations are motivated, inspired, that bleeds into the external-facing environment that we also face where we need
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inspiration. so, really, they're the best ambassadors for the initiative, when you have motivated staff working on the issue, but it is incredibly difficult every day, you know, sort of slogging through in this really challenging time. so, if you don't mind, i'd like to ask, how does rotary keep at it? what's the inspiration that keeps everybody going? >> yeah, thank you. mike mcgovern, the chair of rotary international's polio plus committee, and trying to lead our efforts with polio eradication. we're very happy to support this. we've been happy to support it for actually more than 30 years. the reason we do it is because of the kids. you know, i think that goes without saying, it's what motivates roe tarens. i think this week we've reached the point that through rotary sources alone, we have invested
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$1 billion. since this began. we also get matching funds from the gates foundation, the bill and melinda gates foundation. they have committed to us $985 million. we'd like to get this done, but we don't want to rush it for the purpose of getting it done. we want to make sure that we have a polio-free world and we sustain that polio-free world. just in the last year, between rotary's money and the money that gates gives us that we then reinvest in the system, we're committing over two years $300 million. so, you know, even though i've said very high numbers in my book, at the same time, the commitment is just as strong now as it was 30 years ago. rotarians out of their own pockets have given over $50 million this year to the eradication of polio. recently infected, will's suggestion, we went back to the board of rotary international and to our foundation board and
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said, you know, we're going to need to keep at this for ten years, we need to make sure we sustain a polio-free world, we want to make sure we have the integration that's necessary to strengthen health systems, to improve routine immunization, and the rotary board has committed to an additional ten years of advocacy. for us, that involves a million-dollar-a-year investment. it's hiring advocates on capitol hill, not only here in washington, but also in other governments around the world. it involves rotarians continuing to serve on committees, and we look forward to continuing to support usaid, to continuing to support the cdc, because they have excellent staffs. they're out there. they're on the front lines. and most of all, they believe, as we've heard in working with local communities, because without the support of the local communities, the community-based vaccinators, the leaders of
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governments and health councils in local areas, and the work of rotarians as well in those legal areas, we don't get this done. so, we're behind this. we're going to continue to be behind it. and we strongly believe that this isn't just about the elimination or stoppage of, circulation of the wild polio virus, it's also about what we call polio plus. it's helping out in all of these other areas as well. thank you. >> great, thank you. [ applause ] so, what i picked up out of that was actually, frankly, a tactic of keeping the inspiration moving, and as some of the discussions we had last night is, you know, given that we're in this difficult stage and polio isn't going to be eradicated with wild polio virus and that whole discussion and vaccine drive and all that, it gets complicated. so, technically, we sort of go down that roads and say it's complicated, it's complicated, but to the public, they don't necessarily want to hear that,
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right? so, is it as, i wouldn't say easy, this is certainly not easy, but is it as explicit as just being honest with our organizations and the public and saying, look, it's going to be at least another ten years, we need to have that commitment, and just set that as the frame, and then you have that commitment going forward. so you know, it's something to reflect on, rather than saying, you know, the press is going to pick up that it's not wild polio and all that, just saying it's going to take 10, 15 years. we need to sort of reassess commitment and to have that as an ask for all our organizations, and i think that's a great example of what rotary did. i mean, there is an example of how to inspire people to keep going in the long haul. we have about five minutes left, so i'm going to just ask for maybe one or two more questions and then we'll close. yes, please.
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>> good morning, lee losy with the polio project. first, i was really heartened by senator mcconnell's commitment, not only to polio, but to international aid. that's great to hear from somebody in his position, and many thanks to usaid for their longstanding support to polio and in particular to the core group of ngos, about 50 different ngos supporting that. more of a comment maybe than a question on that side is, one piece of that that i think is so important as we have so many critical partners -- cdc, rotary international, gates foundation, u.n. agencies working on polio -- there are people at a lot of different levels, and we need all of those partners. and what the ngos bring, i think, critically, in many cases, is that connection to the community level. they get right down to the community level and they know what's going on, so they're actually with the mothers, with the children, so they know
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what's happening and they're able to both communicate and find cases. so, i think that's so critical. will, a question, as i keep thinking about this communications conundrum. could we put our heads around changing the name from circulated to mutated polio virus or something else? it seems to me that that is a really communications challenge, and i wonder if we couldn't figure out another name for that, because i think it's a misnomer. as you explained it, it's not strictly speaking just vaccine-derived. it's a mutated thing, so maybe we could change the name. thank you. >> okay. yes, back here? >> henry perry from johns hopkins university. one of the important lessons from the polio eradication experience so far, and irene alluded to this, and i guess to a certain extent. but the lessons we've learned in
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reaching out to communities where persistent polio transmission has continued, and the methodology for doing that in a collaborative way that is engaging and gives community ownership, as we've mentioned, the lessons learned in doing this are critically important, not only for polio, but for many other important global health priorities. and so, one of my questions -- i have two questions, they're related -- but one of my questions is how can we build on the experience that the ngo community has had, unicef has had, in reaching out in these very difficult places where polio transmission was not interrupted, but how can we learn from that and apply that to other global health priorities, not only for immunizations, but for other critical issues where we know that with simple technologies and low-cost interventions, we can save a lot of lives. we're moving towards the ending preventible child and maternal deaths campaign, and these
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lessons i think are terribly important for that, that go far beyond immunizations. the other related comment and question i have is one of the lessons from the polio eradication experience and was also true in the smallpox eradication experience was the feeling that people and communities had who had been neglected where transmission was continuing, of resistance, because why are people coming to us for this problem, which is not a priority for us, when all of our other problems have been totally neglected by the government and the rest of civil society. there has been experience that gates has built through the portfolio project of bringing in other theories for the marginalized high-risk communities, and how can we build on that to extend our experience in the very high-risk, marginalized
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communities that should be our priorities in global health? >> okay, great, thanks. so, those will be the final two questions. and so, if you want to close out with those comments. >> okay, so, maybe just taking the questions. i think that we do have a couple communication challenges. i think that circulating vaccine-derived polio virus is not only a mouthful, but it's also a communication challenge. i like your suggestion. i think that we should think about how we communicate that affluently. we need to think about how we communicate polio transition. and it was suggested at the regional technical advisory group last week in rwanda that maybe we should talk about polio transition, but also polio integration, how we're integr e integrating polio surveillance into broader disease prevention activities. i think the second questions actually are closely related to that. i think that those immunization activities, i think that we've tried to do it, and up to now,
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using the opportunity of immunization activities to provide broader services like vitamin "a" distribute or bed net distribution or deworming. through those disease control efforts, but i think that really, you know, all of those efforts that we're talking about polio integration, if we're strengthening a robust, sustainable immunization program, we're going to provide so many services that are going to prevent child and maternal mortality, because it encourages health facility-based delivery, where we can give not only a birth dose of polio, but of bcg and of hepatitis b and then throughout the life span that we're providing life-saving vaccines at every point along that continuum. so, i do think that there's lots of opportunities, and that's exactly where we're focusing on now. and when we're talking about moving our efforts to, you know, big, most difficult countries where we want to start first is
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cdc, and we're working with partners and we've identified six countries where we're really focusing on, and those six countries include pakistan and nigeria, but along with that, four other countries -- india, indonesia, the democratic republic of congo, and ethiopia -- that represent 50% of unvaccinated children and 75% of measles mortality. so we really want to put our efforts in those areas where a lot of children are dying, where it can make a big difference in child and maternal mortality. >> one more question. >> and getting to your point and will, lessons learned. i think that's a good point, doing more documentation, getting out the stories, getting out the experience particularly of all of the elements of polio is important. i think forums like these is really important to do that, but getting it out into the literature and publications would also be a really important thing to do. >> okay, great. thanks. so, it's hard to sum up. this has been a great
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discussion. it's obvious that it's been really, forums like this are great to move this along. ideas are generated. we know that there's communication challenges. this idea of rotary calling out, like you know, it's going to take ten years, being realistic about it. so, i think in this whole effort of the polio eradication and ensuring that the assets are used towards bettering people's health in other areas, if we can think of it in terms of what i've heard is two themes today, which is, we need to be vigilant in our actions and inspirational in our efforts to get it done, but also to ensure a polio-free world, and that would be a great gift for the future generations and the billions who will come after us on this planet. so, i want to take the time to say thank you very much for our panelists, and if we can give them a round of applause. [ applause ]


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