Dr. Jay Wenger

Jay Wenger

TORGHELE: It is November 7, 2016. We are at the Bill & Melinda Gates Foundation to record an interview with Dr. Jay Wenger for the Global Health Chronicles Polio Oral History Project. I am Karen Torghele, and I will be interviewing Dr. Wenger for this project. Welcome, Dr. Wenger, and thank you for agreeing to talk to us today.

WENGER: Nice to meet you and glad to be here.

TORGHELE: Just to get started, would you tell us a little bit about your story, about your background, and how you became involved in public health and CDC specifically?

WENGER: And CDC specifically--okay, I can do that. You're right, one hardly knows where to start here, but I guess I started out as a child. My dad was a doctor, actually, so I had a little bit of a medical inclination. When I was in medical school, I became interested in not just treating patients, but also the 00:01:00public health aspects of things, how you could get the most bang for your healthcare dollar. When I was in medical school, I did a couple-of-months-long fellowship. It was actually done by Reader's Digest. Reader's Digest had a fellowship at that point, and the local guy who was the coordinator was [Dr.] C. Everett Koop, before he became Surgeon General of the United States. So I got selected for this thing, and I went off to Thailand and got to work in a mission hospital for a couple of months. There was probably my first real inkling that, yes, I could see how a little bit of healthcare dollar [going] into a population that wasn't very developed and needed a lot could actually go a long way and give you a lot of healthcare benefit. So that's where I got interested in it initially.

Then as I went through medical training, I got more and more interested in infectious diseases and how we could use that to deliver health in a 00:02:00cost-effective way. So then I became an infectious disease fellow and went through my fellowship and did some lab work for a while, but I didn't really think that was the direction I wanted to go. Out of my fellowship I had a friend who had been at CDC the year or two before in the EIS [Epidemic Intelligence Service] program. He said, oh no, you should try this, this is great, because then you can go out and do big things with big populations and prevent stuff. I thought, that sounds sort of neat, so I applied for that. I got into the EIS program and then went to work in a group that worked on bacterial meningitis. Just around that time a vaccine [became available] for Haemophilus influenzae type b [Hib], which at that time in history was the biggest cause of bacterial meningitis in kids in the United States, with ten to fifteen thousand cases of 00:03:00bad disease a year. So there were new vaccines coming out, and the group I went to, [Dr.] Claire Broome, who was the chief of the group, was in charge of that. I got assigned to do the national surveillance for the Haemophilus influenzae type b vaccine. Although initially I was a little disappointed because it was just a domestic thing and it wasn't overseas and all that jazz, it turned out to be a big deal. The Haemophilus influenzae vaccine was wildly successful and disease almost went to zero, and we got to monitor that and measure the impact of the different vaccines. So that was a lot of fun.

From that point, I then got loaned to WHO [World Health Organization] because WHO got interested in introducing Hib vaccines overseas, and they needed somebody to be the technical support for that. So I went over there with my family. We spent six years in Geneva working with the global immunization 00:04:00program there, the EPI [Expanded Programme on Immunization]. [The experience] was again very interesting, and I was really convinced that immunization in the third world was a great way to deliver a lot of health for really not that much money. So it looked like a great thing to do, and I was there for about six years, which if you know anything about the U.S. Public Health Service and donating people overseas, there's a bit of a limit there after four years. So I had to change my venue.

I knew at that point that they still needed some technical experts to work with the polio program, and so they sent me from Geneva to India. India was in the middle of--they were actually just having a polio outbreak that year. I think it was 2002, and I stayed there for five years as head of their polio surveillance unit. That was also the unit that provided technical advice on not only finding 00:05:00polio cases but also doing the immunization campaigns that you needed to get rid of disease there. So I did that for about five years, and we made a lot of progress and a lot of innovations. But after about 11 years overseas--and this is just totally how it goes--my kids were all growing up, and they were all going back to college in the United States. So it was long enough, I think, for me and my family. We decided we'd come back to the United States for a couple of years. I worked again with CDC in Alaska in the field station, working, again, on vaccine-preventable diseases. Then when the opportunity to come here to the Gates Foundation polio program arose, I thought that that would be--it seemed like a good slot for me at that point, given my experience in India and the need for increased activity on polio eradication in the last phase of the program. So 00:06:00I came back here, and I've been here for five years doing that.

TORGHELE: It sounds like another EIS officer recruited you.

WENGER: Well, yes, another EIS officer. That's how I found out about the program, I guess. This was a guy I actually had known in medical school, and we had stayed in contact over the residency years. He said basically he was convinced that the EIS program was good, and it was great for me. It was a great entry into public health, and it's been—I mean it's interesting to see how--I'm sure everybody says this, but in my iterations globally and all over the place, the impact that the EIS program has had in implementing public health programs, and especially immunization programs globally, has really been stunning.

TORGHELE: How did CDC work with WHO when you were there? CDC loaned you to the World Health Organization. How does that work?

WENGER: Well, loan is a bad word. What's the official word? Seconded. I was seconded to WHO. I don't know if this is politically correct, but I think WHO has a mandate to be representative of the world and actually operate throughout the world, so they have their own mechanisms for identifying folks to work there. I think [of] CDC as a reservoir of a lot of technical expertise. In a way CDC, I think, is an organization that is unique in the world in terms of bringing together the biggest mass of technical experts with a focus 00:08:00specifically on public health. So it's a logical source for a lot of technical input. I think that at that juncture there was--and there still is--a lot of good interaction between the immunization folks at WHO and the immunization teams and groups at CDC. So there was, I think, good back-and-forth. As the WHO folks identify a need for technical resource here or technical resource there, CDC is just one of the places that they know they can go to for people to potentially fill those needs. I think their relationship has been good, and it's been--I think a lot of folks have gone from CDC to provide specific technical support that's been pretty useful there.

TORGHELE: When you first went to the World Health Organization, what were the 00:09:00things you worked on the most?

WENGER: This wasn't polio, actually. When I went there at first, I went as an expert in Haemophilus influenzae type b vaccine, but then we branched out and that was a quote "new" vaccine. When I went there, WHO and the EPI program had been pushing, basically supporting the implementation of the EPI program, which was primarily DTP [diphtheria, tetanus, and pertussis vaccine], measles, BCG [bacille Calmette-Guérin] and polio vaccine as routine immunization. So, those six antigens. At that same time in the developed world, many new vaccines were being developed, and they were relatively expensive. But they were being developed for the developed world for diseases that were occurring there, like 00:10:00Hib disease and hepatitis B and pneumococcal disease. Those diseases all occur in the United States, and it was important to get vaccines for them. But actually, the biggest global burden of those diseases, of course, was in developing countries.

Those countries were not first on the list to get these vaccines, one reason being they were quite expensive. Of course, when you make vaccines initially, you don't make enough for the whole world, usually because that costs a lot of money. There was an issue about both awareness of the vaccines and then being able to make it clear how much vaccine was needed and who was going to pay for it. So part of my job for the Hib vaccine was to first make countries out there, developing countries, aware and provide knowledge and information about the availability of these vaccines; and then to work with them to figure out how, if they thought it was appropriate, to introduce them, how we would pay for it and 00:11:00how we would identify that funding. That was my job for about six years.

Initially I focused on Hib vaccine, but eventually we ended up organizing a group of not just me but one person in each of the WHO regions: one in the European office, one in the Southeast Asian office, one in the Western Pacific region, one in EMRO [Eastern Mediterranean Regional Office], and one in AFRO [African Regional Office]. They were specifically involved in assessing their countries for new vaccine introductions and helping them see what was appropriate for their country. Then [they] tried to work with donors and manufacturers and everybody to see how we could do that, and also develop the guidelines for introducing a new vaccine into developing countries. So that was what I was doing for about six years, but I was working very closely at that point with the routine immunization folks and also somewhat with polio folks in 00:12:00terms of what we were doing. I saw moving to polio eradication in India as just a distal end of the spectrum of what you could do with the vaccine. We weren't just trying to control the disease and drive cases down to almost nothing. We were actually trying to make it extinct and drive them to zero. That's a unique kind of goal, and also it could really highlight what you can do with vaccines and how you can permanently improve health. So I think those were the attractive parts of the polio program, at least initially to me.

TORGHELE: So you went from Geneva to India.

WENGER: Yes.

TORGHELE: Where in India?

WENGER: We lived in New Delhi for five years. New Delhi was where the National Polio Surveillance Project, NPSP, was headquartered and that was a phase that 00:13:00was a WHO/Government of India collaboration, so it was run as an adjunct of the WHO office in that country. But we also had links with the government, so we interacted daily basically with the government folks who were in charge of the immunization program. We worked very closely with them in terms of a whole range of activities. NPSP had about 300, around 300 offices. We had one big office in Delhi with about 50-70 people or so, and then we had 250 to 300--it changed, sort of oscillated a little bit--offices sprinkled throughout the entire country. The reason we had so many offices was that we had a system where we had 00:14:00a surveillance medical officer, who was an Indian doctor, and a driver and an office manager-administrative assistant person. So that three-person team was responsible, each team like that was responsible for monitoring surveillance data and looking over the immunization activity for polio in a given area, usually a district or maybe a couple of districts, with populations ranging from a couple hundred thousand to a million or two. But if you took a map of all those offices and all those areas of coverage, it totally covered India.

So we had an officer responsible essentially for everybody in India, and that system was--actually there was no other system like it in India. Their job was 00:15:00to make sure that their medical officer was in contact with every hospital in his or her given area. In every hospital they would have a contact person; it might be the doctor in charge of neurology or the nurse in charge of infection control or something like that. They would check with them every so often and say, did you have any cases of paralyzed kids that came in? Or, tell me when you get a case of a paralyzed kid. When they saw a paralyzed kid, then the surveillance medical officer would either go himself or herself, or contact the local public health person there to go get two stool samples from that kid and get a little bit of information. Then the stool samples were sent up the line to laboratories in India, and they got processed for polio. So that was the surveillance system. In a typical year they would identify forty or fifty thousand possible cases of polio and analyze the stool samples from everyone. 00:16:00That's how we figured out where the polio was and what was going on.

By the time I got there, the system was already there. I didn't make the system, but pretty much the system was there. It took a lot of work to keep it up. You had to make sure that people stayed doing their job and they really visited these hospitals, and the hospitals knew what they were supposed to do, and they didn't miss kids and all this kind of stuff. So there was a lot of work to keep it together. By the time I got there, polio had already been driven out of the south of India, where medical care is actually pretty good and people get the vaccinations they're supposed to get. But up in the north, where most of the people live and where it's the poorest and the least well served, there was still a lot of polio all over the place. So we worked for those five years to identify where the polio was, and then worked with the local folks there to make 00:17:00sure that every kid got vaccinated in these big campaigns.

Now, the way we did that was, theoretically every kid in India, just like every kid here, is supposed to get three doses of polio vaccine in their routine vaccinations. But in the north of India, there were states up there where essentially 10% of kids got three doses and 90% of kids didn't get anything, they got no vaccines. In order to make up for the gaps in kids who didn't get routinely vaccinated, and to top off the ones who did get routinely vaccinated, we ran these national immunization days. Generally, they're called supplementary immunization activities, meaning big campaigns where we would go out and try to vaccinate every kid in an area. About twice a year they would do a national immunization day. It wasn't really one day, it was like three to five days. Each 00:18:00area would identify vaccination teams whose job it was to march around to every house in their area and knock on the door and ask if there were any kids less than five who lived in that house. If there were, they would put two drops of the polio vaccine in their mouth and mark their finger with a little indelible ink marker, a little purple ink thing. They'd say thank you and go to the next house and the next house and the next house. A team could reach maybe a hundred, maybe a little more, houses a day, so it worked out. We worked on these micro plans, as they're called, where each team would have three or four days; they'd go to this area on day one, go to the next area on day two, go to the next area on day three, the next area on day four, and it would be finished.

Once again, each of those plans linked in with the plan next to it, so that we would cover a whole state or actually a whole country in three or four days. This involved--when I was there--it would involve 1.5 million vaccinators, and 00:19:00most of these vaccinators were like moms and dads. They were just normal people, because it doesn't take--you don't actually have to have medical training to get this little tube and squeeze two drops into a kid's mouth. So they were just regular people who had their little plan. What our men and women did was make sure that these plans were right, that the plans really did touch every area and people went to every village and people went to every refugee camp and wherever. We had to get every kid, and 'every kid' was the mantra. You needed to reach every kid. That took a lot of work, because people, you know, near the end of the program when I was there, we were going from not just reaching people who were in houses but also setting up at transit stations. So at every train station we would have little booths where people would pull the kids out of 00:20:00trains and pull them out of their mom's arms and do them--didn't pull them out of mom's arms but, you know, identify them and vaccinate them at train stations and at big crossroads in towns.

Another big problem was that people in India, big groups of people actually, would tend to move. There would be migrant populations, so some people like the cattle herders up in Bihar or near Calcutta, they would move from one state to the next, depending on the season. So those people are people that would tend to get missed, at least at certain parts of the year, because they'd be there sometimes and then they wouldn't be there. Then they would be new, so they wouldn't be on these people's plans over here because they weren't there when they made the plans. The people over here were going to vaccinate them, maybe they were in their plans, but then the people had moved, so those kinds of people fell through the cracks. Then we had a big program to identify, well, who 00:21:00are the migrants, and where they are this time of year and where are they that time of year, you know, making sure that everybody was identified. So basically, [we were] going through the country and trying to figure out, are we getting everybody every time, and are the vaccination units actually going where we think they're going, and who's vaccinated and who isn't?

It was a big operation, and so it was that I was involved with it for like five years. We had the surveillance chunk of it, which was identifying paralyzed kids and getting the stool samples and seeing where the polio was. We had the immunization part of it, which was making sure these teams were organized and did go to the right place. Then we also had the monitoring of the immunization part, which is another end of the program. We had the immunization teams of the moms and dads who went out from house to house and did the thing, but then the day after they did that we would send monitors out. These were people that we usually hired, and they would go to some houses. They would take a random sample 00:22:00of houses, and they would knock on the door and say, could I see any kids less than five? And they would say, okay, could I see their little fingers? Then the kids would come out and then they would check and see all the kids' little fingers, were they all purple or were they not purple? Then we would get that data and say, oh no, here in this village only 39% of kids had purple fingers. Well, that's bad. They didn't do a very good job there, so send the team back. Then if you got a 98%, they said, that's great, they can go home and everybody's fine there. That monitoring thing and trying to get that data together and in time enough to correct it, at least correct it for the next round that they do, was another big component of the program. So it was a constant job to keep all those lines of work moving in order to get a better and better program and to drive the polio down and down and down. That was a job.

TORGHELE: When you got there and you saw what the situation was, what were your thoughts?

WENGER: It's funny, back in the 2000s the polio program had made a lot of progress. Since it was declared a global project in 1988, cases went from 350,000 a year to less than 5,000 within about 15 or 20 years. So it got down to almost like a plateau, a very low plateau, but it was in four countries. You've heard this probably 97 times. In Nigeria, in India, in Pakistan and Afghanistan we couldn't--the program was stuck. There was a long plateau where in those four countries polio just continued. We could drive it down. I mean, the number of cases had dropped precipitously, but it was still around in these areas, like I'm saying, in the poor areas of northern India.

What people would say--at that point in the 2000's what I would hear, and of course I was in India, maybe I was just hearing it louder there. People were saying, oh, you'll never get finished in India, there are just too many people, the routine immunization program misses too many, and there's no sanitation. That was another big thing, because up in northern India in UP (Uttar Pradesh) and Bihar, which are the two--well, UP is the most populous state in the country. When I was there, and I think it hasn't changed much, about 95% of the people did not have a toilet, which meant that they would just excrete either in the street or in the field or in their house, where it would just leak out into a little alleyway. So you could just go anywhere, any city in UP and walk down the street and see a little--you know, the gutter on the side would be sewage.

That, compared with the other prominent issues, was that there were just so many people, and the population density in those areas was very high. High population density, no sanitation, not getting good vaccination; that's like a triple whammy against polio, because polio will travel very easily if you have open sewage running around and you have a million kids per couple of miles. So it was just a very tough place to get rid of polio. I think when I first went there, a lot of those things struck me as being indeed true. The population and the sanitation and the lack of routine immunization were just really daunting problems. But I think that one of the things that helped was that even though that was true, we were already seeing in big parts of India that they could do 00:26:00it. Like I said, in southern India they didn't have polio any more. It's the same kind of people but--I mean some things were a little better and they did a better job at some things. The idea was we just have to do a better job in these other places, and we can do it there, too.

So there was a lot of--I think my initial impressions were, this is going to be really tough. As I said, there were people globally who were saying that India is the toughest place in the world to get rid of polio, and you won't do it there. So there was a lot of that nay-saying, which continued while I was there. That was a little tough to deal with, but I think we could see that even though progress was slow, we were continuing to make progress. We could see how, for instance, just before I got there the last case of--you know, polio is in three serotypes, type 1, 2 and 3, and the last case of type 2 disease was seen a 00:27:00couple of years before. So we knew we had gotten rid of one of the three types, even in India. We could also see that of the other two types that were around, 1 and 3, you know, 3 was sort of on the ropes.

We could see we were crunching that, and we would look at the surveillance data and monitor where disease was. You couldn't really close it down to, well, it was in three states and then two states and then one state at that point, just because there's so much travel. You always get kids traveling out of that one place into other places and then pooping. Then other people would get disease, so it was constantly moving around a little bit. But you could decrease the number of cases, and you could slowly clean up this state and that state and another state and this one. So we were making progress in that.

We could also see from the genetic analysis of the polio that was out there, you 00:28:00could see that whereas there had been--and I'm just making these numbers up, but there had been 12 different families of polio viruses before. In a couple of years there were only eight, and now there were only four. We were actually chipping away at the large family of polio viruses and knocking off a number of these strains. So that was also positive, and we could see that happening, too. The other big thing during my years there, we started to do--for decades in the polio program we used the trivalent polio vaccine, tOPV, which has types 1, 2, and 3. When we were there, some studies were done along with some modelers; Nick Grassly, actually, at the Imperial College in London put this data together. We showed in India that if you used the trivalent vaccine, it looked like we weren't getting a good enough take for type 1 and type 3 in the north part of 00:29:00India. He did some studies which eventually got published, which showed that we would probably do better if we--well, basically that having types 1, 2 and 3 in the same vaccine was not so great if we were trying to get rid of types 1 and 3, because type 2, the virus that we had already gotten rid of, was actually the stronger component of the triple campaign, and it out-competed the other two. But if you took that one out of the vaccine and just used the bivalent vaccine, or if you used monovalent vaccine, just the type 1 or type 3 vaccine, kids would respond better to the type 1 and type 3 than they did if we threw the type 2 into the mix. So initially we started to use monovalent vaccines, and then we finally switched over to type 1 and 3 vaccine. Those had much better impact on the virus than just using the trivalent one. So we actually changed the vaccine 00:30:00while I was there, and we started to see good impact with that, so that even pushed the virus even further.

I actually left by 2007, and that's when we just had made some changes in the vaccine we were using, seeing how that worked out and continuing to make progress. But there was still virus there. I left in 2007, and then Hamid came in, Hamid Jafari, you've either talked to him or you will. He took the job that I was in and not doing that [noise]--it's automatic-- then for another four years of working at it and continuing to do these things and bringing in another vaccine, they finally switched it down far enough so the last case in India was in 2011, and they were polio free. It was great because you could see that something that people said would never be done was done. It was done through a lot of hard work and consistent hammering at the problem and consistently 00:31:00looking around and saying, how can we solve this problem, how can we solve that problem, where are the missing kids, why did this show up this late--continuing to innovate to try to get over those hurdles.

TORGHELE: Obviously, the people of India never gave up.

WENGER: Yes, that's right. The other thing that was big that happened was when I started there, most of the Indian program was actually funded by outside donors--most of the Indian polio program: buying the vaccine and actually paying for the vaccines, which is the biggest part of the thing. While I was there, there was a real shift in that the Indian government began to take over bigger and bigger proportions of the cost of polio eradication, paying for the vaccines and paying for the vaccinators' costs and that kind of stuff. That was another huge shift, and I think that really helped. The Indian government's ownership of 00:32:00the program was also a big change that I began to see when I was there. I think that ultimately it was great because it was a success. I think that the Indian government could take a lot of pride in actually having done that, having accomplished that. It was really clear when they had the celebration--not the celebration, but the certification of freedom from polio in 2014. I was at the big meetings they had there where they had the official certification ceremonies, and they were very--I think the Indian government was quite proud of the achievement.

TORGHELE: How do they establish the fact that polio is gone, and how long do they have to wait after the last case?

WENGER: The plan is that you need to have surveillance going on. There are surveillance quality measures, but basically you have to have good surveillance 00:33:00going on for three years. If you don't see a wild poliovirus case in three years, then that is considered proof that it's gone. That was wild poliovirus in paralysis cases, so you still have to do that thing where you still have to find all the cases of paralysis and cultures.

The other thing we started in India while I was there, or maybe just before--anyway, we were doing it while I was there--was the environmental surveillance thing. [We were] not just trying to look for polio virus in people who were infected and had paralysis but also looking for it in the sewage. We started in Mumbai to do that, and then we spread that into multiple places across India. That gave us sort of a heads up on what was going on, because you don't actually need--before, we would actually need to find a paralyzed kid if we were going to identify polio. But the poliovirus only causes paralysis in 00:34:00about one in every 200 kids it infects, but there's another 199 kids who are getting the virus and they're excreting it and spreading it. So what environmental surveillance allowed us to do is identify the virus circulating in an area before it even caused a kid to get paralyzed. That gave us a little bit of a heads up on where we might need to do more work and focus on things. That was another innovation that happened earlier. Other people were doing it, too, but it was in India that it became a real part of the program pretty early.

TORGHELE: So if you identified wild poliovirus in the sewage, you would then, what, go to all the people who lived around that area and check the children or just vaccinate them?

WENGER: Well, we couldn't really track it that way. What we would do was, 00:35:00sometimes we would use that information to highlight that there's virus here. That must mean the population isn't well vaccinated. What are the vaccination characteristics of the people living in that area, and then how did the campaigns do last time, the last couple of times? Does it look like it was weak there? Are there areas that look like we should go back and do again? It highlighted that there was a problem, so we could go back and look at the data and make sure that--see if we thought the vaccination was poor in that area, and if it was, we might go back and do additional campaigns.

The other thing it helped us to learn was a little bit about this migration thing and how populations moved and how the virus actually might be moving and maybe avoiding us sometimes. [For example], in Mumbai we would find out that, oh, there's a virus there. But then when they did the sequencing, they would see 00:36:00that that virus actually was most recently seen in Bihar, like 2,000 kilometers away. They would say, hmmm, well, that probably came from Bihar, and it probably came in some people who were going back and forth from Bihar to Mumbai. Now, where are those people in Mumbai? Where did they go and where--because that might be how it got there, and then where did they go when they go back? And let's focus on that and try to see. So we find them in Mumbai, and then we try to figure out where they went back there. Then we notify the people back in Bihar, saying, okay look, these guys are coming back, and they're coming back at this time of the year; be sure that your programs get them when they come into your space. Similarly down there [in Mumbai], you be sure that your programs get them when they come into your space. So that was using some of that data to make sure that we didn't miss kids half the year. There were a number of ways we used 00:37:00it, but I think those were probably the most useful.

TORGHELE: It must have been amazing to hear that the last case had been found.

WENGER: Yes. I mean after the last case--of course, it's funny because you don't know the last case has been found until you wait until there's a case and another case and another case, and then you go two months and there's no more cases, and then you go six months. Hmm, no more cases. Then you start to get suspicious. Then you go a year. Aha! That's good. A year with no cases. That's a good tip-off that things might have really been stopped. Then it just goes on and you keep watching and watching. It's great.

Now, the problem is--I mean, if your surveillance is good, that works. If there was an area of the country where you weren't doing surveillance or where you don't know really what's going on and no cases are reported, that doesn't mean you're out of the woods. What happened more recently--but here I diverge: 00:38:00recently we almost thought we were on the same track in Nigeria, and it went two years, actually, without a case being reported. But then they reported just this August a number of cases up in Borno State, which is where these Boko Haram guys were. It turned out that in one area where they were in control, the government couldn't even do AFP [acute flaccid paralysis] surveillance. So we just didn't know. And actually there was still virus there. Now they're approaching it and finding ways to get into that place, and now that we know that it's there, we'll address it. But you can be tricked. You can't just think because you're finding zero cases that everything's cool. You have to be finding zero cases when you're also doing good surveillance.

TORGHELE: How did you get around them? How did you get around that in Nigeria?

WENGER: Around?

TORGHELE: The Boko Haram.

WENGER: I think the program, I think we're still working on it, obviously, 00:39:00because this thing, we didn't really get around it in the beginning. But there are many--the polio history is filled with examples of being able to see that as a problem. If there's an area that the government is not in control of and is controlled by anti-government elements, then that means there are a bunch of kids there that you have to figure out some way to get vaccinated. I think the earliest experience with this was in Latin America. This was before I was even involved in the polio program, and you can find other people to talk to more about this, but they instituted "days of tranquility." There were wars going on, civil wars, often with government and then often left-leaning revolutionaries, and they were fighting. In a couple of places they actually had negotiations 00:40:00between both sides and said, okay look, you guys are fighting, but we need to vaccinate these kids. We need to do two rounds of vaccination; we want to do them here and here. So for those weeks or those days we'll have a cease-fire, and then vaccinators went in and they did the work. Then they pulled out, and then they went on and had their war. So there was everything from that, which is a classic almost--a very nice solution to that, to other ways to deal with anti-government elements.

Sometimes it's a situation where the anti-government group, if they want to look like they're providing services to people in their area, they may be in favor of the vaccination program. They just might not be able to get the vaccine because they're in a war and people are shooting and no one wants to supply them. So it 00:41:00ranges: everything from possibly having an anti-government group that is amenable to the program, to in other places having an anti-government group where they're dead set against the program, maybe only because it's a program that the government that they're fighting against is in favor of. So there's that, and if that's the problem, that's obviously more difficult.

What we've done in a lot of places is, if there's an area that we can't get into, we make sure that anybody who comes out--and we do this by--we call them transit site or stations at the roads coming out of an area. We have a team, a vaccination team, in a little booth. So every car that comes out, we ask them if they have any kids less than five. If they do, they get two drops of vaccine. Similarly, any car going in we do the same thing, so that at least the people coming in and out of those places get vaccinated, the kids get vaccinated.

There are other things that have been done to try to just make sure that you're ready. If an area opens up, if there's active fighting and an area happens to open up, even for a week or two or three, you make sure you have teams that can go in there and do their job and then come out again. So those are rapid response kinds of vaccination programs. And then there's all other kinds of things in between. Within many places, even though it's government, they may be still pro kid and still want to have the vaccine. So sometimes you can have vaccines taken in and distributed inside the area of concern just by local village people who are interested in doing that. But those are many, many 00:43:00different ways-- how we deal with that is a very local kind of operation, and there are probably hundreds of different ways it's been done. You just have to have--I think the guiding light always is that you have to come up with some way to vaccinate these kids, through negotiations and through being quick on your feet and being intelligent about the way you do things. We've been able to get over that in a lot--essentially almost every place in the world except these last couple of places where we're working. We're still working on that, but places like Syria and Somalia and South Sudan and Angola have all gotten rid of polio in the middle of their messes.

TORGHELE: I read that you met in Afghanistan with President Karzai. What was that like?

WENGER: Yes. Again, I think that Afghanistan is an interesting example, because the government has been obviously in favor of the program. What we've had to do, because the country is split, is stress the neutrality of the polio program. So the government gives vaccines to people that they can reach, and the other folks give vaccine to people that they can reach, and we have to somehow reach some kind of arrangement where we facilitate that.

Afghanistan is a really tough place, and we don't have a lot of access there. Visiting and even doing business in Kabul is really a trip, just because of the 00:45:00security measures. To get into the presidential palace you have to go through a gauntlet of security checkpoints. It takes a very long time and everything has to be arranged days in advance, and it's a very tight situation. But I think that the support that we got from the Afghan government has been good and has been about as good as we could have expected. There's interest in President Karzai and President Ghani and who's the president now. They all know about the polio program.

In Afghanistan we have--we call it the president's focal point on polio eradication. There's a guy who reports directly to the president about how it's going. The president in Afghanistan actually periodically holds a meeting with his key advisors on polio and what are they going to do about that. So it's a 00:46:00topic that's right at the top of the--not at the top--it's clearly visible at the highest levels in Afghanistan, and the same is true in Pakistan; the same arrangement. There's a person named Senator Ayesha [Senator Ayesha Raza Farooq], who's the prime minister's focal point on polio eradication. She reports, she follows the program very closely and reports to the prime minister.

That high-level ownership of the program and interest in the program is really important to get things to work on the ground and to get the governors to care and to get the people who work for them to care. Getting that kind of level of buy-in is really critical. That's where I think interactions with people like Bill Gates or like the head of CDC or having the President of the United States 00:47:00to say something about polio to a key leader is a big deal. You really need that. At some point that high-level approval is really critical in getting things done in these countries.

TORGHELE: But you were the guy in the room with President Karzai. So you sat down together, and then what happened? What did you say, and what did he say?

WENGER: Oh, boy. President Karzai is a very urbane guy. He's very sophisticated. But it's funny, he said--what did he say? [Laughing] You don't know what he told me, right? I don't know how much information you have. He opened with a joke. He 00:48:00said, so you work for Bill Gates? Because at that point-- Yes, I do. Oh, Bill. He said, you know, in Afghanistan we keep all of our money under our beds in big bags, because you never know when you're going to have to leave. Do you think that's what Bill does? I said, well, I don't really know, and Bill doesn't really tell me those things. But I mean he was a very, I would say, very personable guy, and he opened with that. We talked a little bit about the Gates Foundation and all that kind of stuff. But he actually knew what was going on with the polio eradication program, and we made some key points about how his role. It was his role primarily with the governors, because Afghanistan is all these provinces out there and each one has a governor. Usually I think they are 00:49:00appointed by the president, so they have a lot of clout there. Obviously, these governors in Afghanistan have a lot of things to worry about, and polio isn't right at the top of their list. So in order to get them to do anything, we have to make it be up there. That's the importance of making sure that people like Karzai and presidents and prime ministers are involved in it.

TORGHELE: I just have one more thing. I notice in your tweets that you gave tribute to the women vaccinators. That was very touching, and I wondered if there was something specific that prompted you to do that.

WENGER: Well, I think that especially in these countries, these last countries, women are essential to the program. In a lot of these countries you can't actually knock on the door and even ask for kids less than five, if you're not a 00:50:00woman. There are a lot of cultural barriers to having men enter a house, or if there's a man at the door even having a woman answer the door. So you can't actually get to the kids without women. I think that the women vaccinators in a lot of these countries are really one of the stalwarts of the campaigns. If you have respected women in these villages who actually take the polio vaccine and go house to house and show that they're behind it and work through their networks to say this is an important thing, that's really what you need to get the kids. Otherwise they'll just hide kids. I think that women have, you know, I 00:51:00guess--I shouldn't say that in the wrong way. I mean, women have their kids' health and well-being at the top of their list, and a lot of times it's not really at the top of other people's list. I think to get that energy and that sort of feeling behind the program is really what's made it move a lot farther forward in Pakistan.

You're aware in Pakistan over the last couple of years, they went through a rough period, when women were getting shot and vaccinators were getting shot. They happened a lot of times to be women for the reasons I just said, because women are the ones who often end up doing this. I think there are some great stories about somebody's daughter or sister getting shot, but they're just going to go ahead and still continue to deliver the vaccine. I think that's really 00:52:00impressive. That's really courage that you don't see with a lot of programs, or you don't see often, is what I should say. I think in many places in those countries that having that energy and love for your kids and love for your community that women actually can generate, that's been really key. So yes, I just think it is really important in the polio program to take advantage of that and to realize that without that, I don't think we'd actually be succeeding where we are.

TORGHELE: A wonderful acknowledgement of those people. Thank you so much. This has been wonderful.

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