Dr. Robert Kim-Farley

Robert Kim-Farley

TORGHELE: It is May 15, 2017. I am Karen Torghele, and I'm at the Los Angeles County Public Health Department with Dr. Robert Kim-Farley, who was an EIS [Epidemic Intelligence Service] officer in 1981. He is now the director of communicable disease control and prevention at the L.A. [Los Angeles] County Department of Public Health, and is also at the UCLA [University of California, Los Angeles] School of Public Health as a professor in the Department of Epidemiology, and is the associate editor of the American Journal of Public Health. Welcome, Dr. Kim-Farley.

KIM-FARLEY: A pleasure to be here.

TORGHELE: Yes, it's nice that you could talk with us today about your experiences. Would you start by telling us a little bit about your background before you came to CDC [Centers for Disease Control and Prevention]?

KIM-FARLEY: Yes. Actually, I started out kind of the backwards route. I started as an electronic engineer from UC [University of California] Santa Barbara, and then on graduation went to the Food and Drug Administration--the Bureau of 00:01:00Radiologic Health in the Washington area--in the area of protecting the population against the hazards of electronic production radiation, like x-rays from color TV sets, microwaves from microwave ovens. That kind of mixed, if you will, engineering and public health, which got me very excited and interested in public health. I then, actually, after two years with the Food and Drug Administration, went and did volunteer work for the Bahá'í Faith--went around the world for a year, mainly in Africa.

During that time, I think that's when I especially got interested in international health and public health, realizing the great needs in other countries besides in the United States. And I think that was my earliest intimation about being concerned about polio, too. Because I remember being very clearly in a village setting in Africa--this person had gotten off the bus. He had a coat and tie, but he had polio, and because, of course, in the village there were not any walkways or pathways for a wheelchair, he actually had to get down on his hands and knees and actually crawl along the road in the village. 00:02:00And to me that was such an impact that I still remember today, about the devastating effect that polio can have.

After that I decided to go then for a master's in public health at UCLA. And because I did not have the biomedical prerequisites for medical school, I ended up doing not only the master's in public health in population, family, and international health, but I went ahead and did the biochemistry and other biomedical courses that you needed to have for applying to medical school. I went on, then, to the University of California, San Francisco Medical School and it was very nice because they already knew I was interested in public health. So, for example, I was working with CDC at that time as a student to develop what they called a Peer Education and Prevention activity, where you brought in fellow students to orient them about prevention and public health majors. So it 00:03:00was kind of fun to do that in medical school.

I also--because of that international interest--ended up being chairperson of the American Medical Student Association International Health Committee. And we had the first all-medical student group go to China, so that was very exciting in 1978. I was used to traveling because my dad was in the Navy when we grew up. Every couple of years we moved. I was in Panama for a couple of years and the island of Kodiak in Alaska. In Guantanamo Bay, Cuba, I was evacuated during the Cuban Missile Crisis when I was 14. So anyway, there was a number of things that had gotten me excited about international work.

So between the third and fourth year of medical school--I had gotten married in second year--my wife and I also then took one year off and did some work for the Bahá'í Faith. And we went around the world again, this time the other direction from what I had done, mainly in the South Pacific and Asia. And during that time we spent one month at the National Hospital of Western Samoa, and for 00:04:00me this is really, again, suddenly another encounter with polio that I think was very formative for me. I happened to be there during a time when they had a group of visiting orthopedic surgeons, very senior in their field, training the Samoan doctors in some of the more current techniques.

So they were letting me in the operating room and I was sewing up here and there a few things, and one of the surgeons turned to me and he said, "Bob, what do you plan to go into?" And I said, "Well, actually, I plan to go into public health." He didn't say anything, went back to working on his patient, and I could just see, you know, this surgeon is going to downplay the role of public health. But in fact, what happened is he stopped again on the patient, turned to me, and he said, "You know something, you are going to have more impact in your career than I have ever had in mine." He said, "Here we are working on this child with polio, who should never have gotten polio to begin with," and for me, 00:05:00at that stage--again, as a formative stage of a medical student--to have someone who could have been easily, you know, very much putting down public health, to recognize the value of public health, was very reinforcing to me.

I realize, of course, in public health I'm never going to have the experience like when that child comes off the table to say, oh, Doc, thank you so much, I feel so much better now, or, I now can walk with this brace, et cetera. I'm never going to see a parent come up to me and say, gee Doc, I just want to tell you my child didn't get measles today, thank you so much. It's not going to happen. So you have to realize that the idea of the community being your patient as compared to individual--but that was, again, a formative period for me. So after that I came back to finish off medical school, did my rotating internship at the U.S. Public Health Service Hospital in San Francisco, and then went on to the Epidemic Intelligence Service at CDC, which of course, brings us to the CDC story part of it.

TORGHELE: So when you came to CDC you probably were interested in a number of 00:06:00different areas, so how did you settle on the one that you ended up in?

KIM-FARLEY: Well, when you come to CDC as an EIS officer, you may have ideas and thoughts of where you'd like to be, but that doesn't necessarily always be what you matched with. I was fairly flexible and open when I first came, and I matched with the National Immunization Program and it was a very, very good fit for me. Some of the other people, no doubt you'll be interviewing for the Chronicles, that had significant roles to play, things like--people like [Dr. Walter] Walt Orenstein or [Dr.] Alan Hinman. Walt Orenstein, at that time, was a section chief, my immediate supervisor as an EIS officer. I also remember talking with Alan Hinman too, who was the division director at the time, and I asked him, you know, do you think there is really a career in immunization? It seems like we've got all these vaccines now, the diseases are going down. He said, don't worry about it, there will be a career in immunizations. He certainly was right about that.

Walt Orenstein was very supportive and basically had me as the polio surveillance officer for the United States, including some other activities with vaccine-preventable diseases. I told him I was very interested in international health work and that I also wanted a variety of experience, and he certainly was able to provide that. So my first outbreak I ever went on was an outbreak of diphtheria in the Yemen Arab Republic. We were there for six weeks, virtually no communication. We had this--couldn't even use the phone--we had these teletype machines going back and forth with questions they might ask for us, because there were two of us that were on the assignment. And so it was a very illuminating experience about working in the developing world in an outbreak setting.

And then, a bit later on, another encounter with polio in 1982. There was a major outbreak of polio in Taiwan, which was very interesting because the government actually had very high levels of immunization coverage and was kind 00:08:00of scratching their heads as to, why would we be seeing polio? And so myself and another EIS officer, [Dr.] George Rutherford, I remember, went for six weeks again to Taiwan. And what we found as we did our epidemiologic investigations was that yes, on average the immunization coverage was very high, but there were pockets of unimmunized children, and that's what the polio virus was seeking out, was those pockets. That was enough to keep it going in different places. So we launched major national immunization efforts to be able to curtail this outbreak, which it responded to very quickly. But it was very interesting to see for myself polio in its worst forms, if you will, of an actual outbreak going on. And again, it caught the government by surprise. We were actually--very interesting there, because the sense--at that time even, Taiwan was not formally recognized by the United States as a separate national entity, but rather under 00:09:00the mainland Chinese. So basically, we actually had to go with our personal passports and not be able to go to an embassy. We actually had the U.S. Trade Mission that we were reporting to. So it was very interesting.

TORGHELE: So you wouldn't be a representative of the United States.

KIM-FARLEY: Exactly, so you're not formal representatives of the United States, exactly right. And so, when we also went to the Western Pacific Regional Office of WHO [World Health Organization], to be able to report out our findings that we had, again, they were just receiving us in an informal fashion. And it was very interesting, many years later when the Minister of Health of Taiwan came to CDC as a visitor, again, CDC was not able to actually formally have a reception for him. So they asked if I could have the reception in my home. So it was very interesting--we had the reception for the minister in our home in Atlanta.

TORGHELE: Interesting.

KIM-FARLEY: Yeah.

TORGHELE: How did you identify the pockets where there was still polio?

KIM-FARLEY: So what we did is we looked, again, those who were coming down with paralysis--which is kind of the marker of polio, obviously. It's not everybody 00:10:00gets it. You take one hundred people that are infected with polio, and only one will come down with paralysis, so it's kind of the tip of the iceberg phenomenon. But we went ahead and we found out where those cases were being reported. They actually had a very good surveillance system in Taiwan. And so then we could go and find out, well, what is the characteristics of these? And it turns out, they were mostly not immunized. We said, well, how can this be happening? So we learned that there were basically these pockets of unimmunized children.

So from that, I guess, in terms of the EIS experience, I then went on for advance training at CDC. They had a system at that time where you could apply in your first year of the EIS to do the preventive medicine residency, which would make me board certified in preventive medicine as a medical specialty. I already had the master's in public health, which is another requirement at that time, so I needed two years, then, of supervised experience. So they let the second year 00:11:00of the EIS count for that, and then I stayed for an additional year, but during that year is when I had the first assignment internationally.

TORGHELE: Did you have other roles within immunization?

KIM-FARLEY: Yes, I actually did a number of other diseases. I remember going on a mumps outbreak in Ashtabula County, Ohio. That was very interesting too, because we looked at the whole issue of vaccine efficacy. Again, this was with Walt Orenstein, who probably is the guru of vaccine efficacy. And what we did is kind of interesting. We looked at what the vaccine efficacy was by reported vaccination of the child, in terms of what the mother had reported, or the father. Then we looked at, well, what about the vaccine efficacy based upon the actual medical record that they had, the immunization card? And then, finally, we actually did a record review of the physician offices to see, was there documentation of the actual vaccine having been given? It turns out that as you 00:12:00progressively improved the actual definition of vaccination through these different--whether it was understanding, or record that they had in the home versus in a doctor's office--the vaccine efficacy continued to increase each time. So the more accurate you got, the better the vaccine efficacy.

I also was on an outbreak of measles at Indiana University, one of the first of the big outbreaks we'd had in a college campus. And that was kind of funny because typically, CDC--when we go into an outbreak--we kind of have a bit of a joke about it, that we always come in on the downswing of the epidemic. Because by the time it's gotten big enough at a local level that they've brought the state in--by the state time they'd say, hey, we need some additional resources here--by that time, the outbreak usually is kind of beginning to burn itself out. So as I came into Indiana University, it was going down. But it turns out, all of a sudden, while I was there, it started rearing back up again because of the fact you'd had your incubation period for measles. In fact, they had a 00:13:00bigger second wave than we had even on the first wave. So it was kind of an interesting experience, being on the ground, lots of media attention to this vaccine-preventable disease.

But during the time when I was there as the EIS officer, responsible for polio eradication, I worked with all of the lab staff. And you may also be interviewing people like [Dr.] Olen Kew and others as well--[Dr. Lawrence] Larry Schonberger. We actually put out a paper on the eradication of polio in the United States, because what happened was--although the last case had been in the '70s, with an Amish outbreak coming in from the Netherlands--no one actually said, "Well, I guess it's over." We still had about six cases a year, but that was due to the vaccine, because one in every three million doses administered, you get an adverse reaction of actual polio with oral polio vaccine, the live polio vaccine. But that was all the disease that was happening. There was no wild virus. So we actually wrote a paper specifically on that issue, of being 00:14:00able to declare that polio had been eradicated in the United States.

TORGHELE: And how long then was it until it was eradicated in the Western Hemisphere?

KIM-FARLEY: It was not until '90, as I recall. The Pan American Health Organization was the leading edge for polio eradication in the world. The regional elimination first occurred there, Dr. Ciro de Quadros was extremely instrumental in that, and many others, obviously, from the Pan American Health Organization. And so really that lead that they had done, I think, was what spurred the 1988 resolution of the World Health Organization for the eradication of polio by the year 2000.

TORGHELE: I've heard about Dr. Ciro de Quadros before. Can you talk about him a little bit? Did you know him?

KIM-FARLEY: Yes. A very passionate individual, very knowledgeable, and just recently unfortunately passed away a couple of years ago. But he is really 00:15:00credited, I think, not only for polio, but did visionary work for measles elimination too. So I think he had that vision of the reality of being able to eradicate disease like smallpox. He had been very active in the smallpox effort, and so I think he applied some of those principles to be able to move the world towards thinking of eradication of other diseases.

TORGHELE: You said earlier that you were interested in international work. When did that start for you, and how was that?

KIM-FARLEY: Yes, your question about international work is, I think, very interesting, because as you noted, I was very much wanting to get into this. And I told my boss, again--Walt Orenstein and Alan Hinman, again. They were very supportive. I think I've mentioned to you about the diphtheria outbreak in the Yemen Arab Republic, the polio outbreak in Taiwan. And then what happened was that the government of Indonesia asked CDC to send an expert in diphtheria for a consultation on the status of diphtheria and the impact of immunization programs 00:16:00in Indonesia on the disease. And so CDC looked around and says, well, who knows anything about diphtheria? And they said, well, Bob knows because he was on an outbreak, because we just didn't have any in the United States. So I suddenly became the resident expert on diphtheria, having been on an outbreak.

So I went there for six weeks as well, and we were able to show the impact of a vaccination program on diphtheria. And then what happened was that the World Health Organization requested that CDC station a medical officer in the Southeast Asia Regional Office of WHO, which covers about ten countries in Southeast Asia, located in New Delhi. And so they had a little mini-competition within CDC for this position, because always the international positions are somewhat plums. And it turns out that--a couple of things, because oftentimes, at that time, they had a very strong international health program office that technically they might draw from for a person to be selected for that. But I 00:17:00remember Don [Hopkins], who was heading up that, was very open to the idea of others being able to be considered for this position. And because I was already working with immunization programs, and this medical officer position was for the expanded program of immunization--the immunization program--that that was a good match.

And then the other thing that was interesting--and I sometimes tell this to students that I'm mentoring or advising about who have international health interests, because typically, how do you get international health positions unless you've had international health experience? But how do you get international health experience unless you've been hired for those positions? So that kind of catch-22 exists, and I think sometimes personal travel can make a difference. So the fact that I had actually travelled with my wife to seven countries of the region--we actually spent one month at the National Institute of Nutrition in Hyderabad in India and we made our own WHO study tour, so I had 00:18:00actually been at the regional office for about a week, meeting with the different people in several of the country offices. So I could show on my resume and my interviewing for this position, Southeast Asia Regional Office, that I've actually been to many of the countries of the region. You can definitely count on me to able to go there and not run back, because I've lived in India itself for over a month. And so I think that all helped to be able to be assigned to that.

So that was in 1983. We went for basically five years--my wife and my daughter, who was at that time two years of age. So we went off to Delhi. And it was a very exciting time for me because we were at the stages, in the immunization program, to be able to start expanding on measles. For example, in India, vaccine--they had just recently introduced this into their program on a national scale. The efforts of working with a very highly international group--this was a 00:19:00great opportunity for me to learn that experience with WHO and how to handle that.

Also, it was very interesting to me--it was right away a good lesson for me in terms of, how does CDC operate within a United Nations framework? And the issue came up very early on, because about three or four months into the assignment, CDC asked me, well, where is your quarterly report? And I said, quarterly report? We hadn't actually talked about a quarterly report back to CDC. And I said, but you know, that's fine, I'll be glad to go talk to the regional director and say that, you know, I'd like to have a quarterly report. And I remember it's Dr. U. Ko Ko from Myanmar, Burma, at that time--very nice guy. I really considered him a mentor in terms of helping me learn about United Nations. And he turned to me and said, "Bob, you're going to have to make a 00:20:00decision, are you working for WHO or are you working for CDC?" He says, "If you're working and sending quarterly reports to CDC, then that's not acceptable." So it was very interesting. So I went back to CDC. I said to them, well, you know, this is what the regional director says, you know, if you loan me to WHO, then really I'm in WHO's hands now. And so CDC said, well, great, okay, we accept that and everything was fine. And then about six months into this they said, well, you know, it's time for your personnel evaluation, but we don't really know that much of what you're doing because you're not sending quarterly reports. So I could see this little dilemma was going to be an interesting one. And so what I did is I discussed again with the regional director and we decided this: I would write the regional director a quarterly report of my activities, and he had no objection for me to share that with CDC. 00:21:00So, problem solved. But it's very interesting sometimes how these come up.

There's another one, if you'd like me to share, too. I remember another subtle point of working internationally from CDC was in Indonesia--we'll come to Indonesia a bit later in the interview. But we had a situation where the President [Muhammad] Suharto, the collapse of that regime--the United Nations was evacuating all nonessential personnel, women and children, but they were requiring that heads of mission--which I was at that time, their country director for Indonesia--to stay. On the other hand, in parallel, the United States government, the ambassador to Indonesia, was doing a parallel activity. He was having all nonessential American staff return back to United States, and 00:22:00he had listed me as being nonessential--which I was to the American government at that stage, to the embassy--but I was essential.

So here we had a situation. And I brought it up with WHO, and I had the situation of, I'm liable to a court martial, because I'm a commissioned officer, if I don't obey the ambassador. And I'm liable to dereliction of duty to WHO if I left the post. So we got WHO and lawyers talking to the State Department back in Washington about, what do we do about Kim-Farley here, because we both have claims to him? It turns out then there was released a memo from the State Department to WHO that no one had ever seen before. And basically it was an internal memo at that stage, saying that any U.S. government staff assigned to the United Nations was under the United Nations authority in purview during that 00:23:00assignment, except for the situation of an evacuation. And under that exception, the person must follow the ambassador. So then they started--and this was news to WHO and the United Nations, because they said, well, look, we can't put your people at high levels in our organization if we have that concern that they suddenly might abandon the post right at the time when we need them the most. So what happened was lots of conferring going on, together with the ambassador, and they finally decide, okay, that the U.S. ambassador would declare me an essential personnel. And so we resolved that little bit of crisis. However, it got to where they had a million people in the street. They were going to try to overthrow the government. And the aircraft carrier was standing off the coast. They were about ready to even evacuate the ambassador. Luckily the situation got diffused. But we never got to that point where it turns out that all Americans--I think by that time, all United Nations staff had probably been 00:24:00evacuated too. But anyway, it was an interesting situation, a study in diplomacy, shall I say.

So that was--going back now to the issue of in my course of duties in Southeast Asia Regional Office--working as a medical officer, working in different countries of the region during immunization coverage surveys and looking at how we could improve immunization programs in the different ministries of health. And also, we were able to have a very good collaboration among the different countries working together--I was very pleased with that. We'd have WHO meetings with immunization programs so the immunization program directors would come together. And we'd try to make policies and strategies for the region that would make sense and have collaboration.

We tried to work on surveillance issues. For example, in the past it used to be that there was this border town in India that had a case of polio. Well, they 00:25:00had to report that to their provincial level, and the provincial level had to report it to state central level in Delhi, and then that would go over to the WHO, and it would then go over to the other WHO office on the other side, and down again through this to finally the border town in the other side in Nepal, but it could be weeks before that happened. So we then were able to work on cross-border communications, so that someone in a local health department in the border town could actually communicate to their fellow border town in the other country next to them. So you wouldn't have a problem with delays because, again, we know these diseases know no boundaries and, you know, don't need visas to cross over countries. So that was an exciting part of it as well.

Then about three years into the assignment in SEARO [South-East Asia Regional Office], my boss was actually from the Soviet Union at that time, [Dr] Rafi Aslanian. He was very nice. I remember we had a good collaboration together. And 00:26:00at that time, the Soviet Union would not allow their employees to stay longer than five years in United Nations at any one time. So they recalled him, and I was able then to become the regional advisor for immunization programs for southeast Asia region. So that's how I ended the situation in program. Then what happened is that CDC, at that time, kind of had a limit on amount of time overseas, about five years at that time. So they said, well, we'd kind of like you to come back to the mothership. But at that stage, the person who was actually Walt Orenstein's boss, which was [Dr. Kenneth] Ken Bart, he had gone and was in charge of the Bureau for Child Survival activities for USAID [United States Agency for International Development] in Washington. And so when he heard 00:27:00that I was coming back to the United States he said, well, why don't you come to work with us? So he was able to get permission, since it was still coming back now into the United States, for CDC to loan me to USAID for that year. I was expecting to be there for a long time, but what happened actually is that the director general then called the very next year and asked if I might come and head up the global immunization program in Geneva.

So while I was at USAID, I was a child survival specialist. So I dealt with things like immunization programs including polio, control of diarrheal diseases, acute respiratory infections, that sort of work. And then what happened was [Dr. Ralph] Rafe Henderson, another name that's certainly well connected with immunizations and polio, was promoted to the assistant director 00:28:00general in WHO. And so the director general, he asked if I could come then and lead the global program. And although it had only been a short time back in the United States, I think the CDC realized the importance of that position and what the prestige for the United States would be to have someone that was from the CDC and U.S. there, so they agreed to that loan. And so that started another five-year period approximately, until 1999, and so I was basically in charge of the global program.

We were majorly involved with polio eradication by that time. And so we worked on things like improving the surveillance system--the Acute Flaccid Paralysis Surveillance System, for example--for polio, and the policies and strategies to promote polio eradication. So at that time we had what was called the Global Advisory Group, or GAG for short--we now have the Scientific Advisory Group of 00:29:00Experts, SAGE, was taken over for that now--and we would convene this group once a year to establish policies for both polio as well as other vaccine-preventable diseases. A number of CDC people were involved with that. You had also [Dr. Donald Ainslie] D.A. Henderson was involved, Alan Hinman at one time the secretary for it, and also Walt Orenstein served as the secretary for the Global Advisory Group as well. And in that we prepared things like, for example, we were able to introduce the first new vaccine into the expanded program immunization since its creation after the smallpox eradication. And so that was hepatitis B vaccine.

It was a big step because at that time, the hepatitis B vaccine cost was the sum of all the other components of the vaccine program, so it was a big step forward. It was requiring a lot of new efforts too. How do we promote more 00:30:00indigenous manufacturers of the vaccine, too, in addition to just being able to have the vaccine manufacturers in Europe and UNICEF [United Nations Children's Fund], which were great partners in terms of being able to get vaccines into children? But we also saw India come up and Indonesia come up to do vaccine development during that time. It was also in 1993--another major polio resolution brought to the World Health Assemblies, World Health Assembly Resolution 46.33. And it was, again, reiterating the priority to the global community for polio eradication. And I remember, just kind of as an effort that I did on my part was to go to as many country delegations as I could, to actually have them become cosponsors of this resolution. I think it's had the greatest number of cosponsors that they had had. I'd have to go back and take a look at the total number, but it was really--I mean, it was going to pass, but 00:31:00it was nice to have all these countries signing in as actual cosponsors to the resolution. And I think that gave, again, another impetus to the work of polio, reframing it, again, as a global priority. We also, at that time, used the opportunity to present the director general's Health-for-All gold medal to Rotary International, that had been a major instigator and player and partner in the polio eradication effort. And so that was very exciting, to have that opportunity to have the director general give that award at that stage, in recognition, again, of the work towards polio eradication. So that kind of puts us through to the time in Geneva, at least, and the headquarters.

TORGHELE: Your role expanded into a global role, and there are also, at the same time, issues around OPV [oral polio vaccine] versus IPV [inactivated polio vaccine], and decisions that were made around those and which to use. Can you 00:32:00talk a little bit about that?

KIM-FARLEY: Yeah, I think the whole issue of oral polio vaccine and inactivated polio vaccine is a good one. Obviously, the first vaccine developed was by Salk, the IPV--had tremendous efficacy. We saw tremendous drops in the United States on its use. And then was subsequently developing with the OPV, with oral polio vaccine, with Sabin, and there was a transition then over to oral polio vaccine in the United States. I think there was a number of reasons why that I would say for early phases in an eradication effort, oral polio vaccine has some benefits. So for example, inactivated polio vaccine, its administration requires the injection, which means a licensed professional. Whereas oral polio vaccine, because it's given by drops--or as you probably may have heard about in the United States, we called Sabin Oral Sundays, SOS, when they give it on a sugar 00:33:00cube to children--It makes the administration much easier to get large numbers of people.

Secondly, the fact of the type of immunity that you get from these vaccines. So primarily the inactivated polio vaccine, being given by injection, gives you antibodies or protection in the bloodstream. Oral polio vaccine, when it's given by mouth, gives not only the immunity in the bloodstream but also gives an immunity in the gut, in the intestines, because there's an infection going on there, and you get this other type of antibody, called secretory antibodies, in the gut. So what this means, again, for the eradication is very important. Because if, for example, someone who has been vaccinated with inactivated polio vaccine gets exposed to the wild poliovirus that's caused by disease, they're protected, because, again, they have the antibody in the bloodstream. But that 00:34:00virus can grow in their gut and they can excrete it. Fecal-oral spread is how the disease spreads out. And that then means that they will not be a barrier to transmission from wild disease. Wild disease can come to that person. They won't get the disease, but they can be a transmitter of disease. So again, the benefit of oral polio vaccine under that setting. So, basically, this ease of administration, the type of immunity being developed by oral polio vaccine were all really important for the eradication effort.

However, what happened is also the recognition of vaccine-associated polio, and this was noted in the United States, about one case for every three million doses distributed. You'd get about six cases or so a year in the United States where you give the vaccine to the individual--and two-thirds of the cases of vaccine-associated disease were not in the individual who received it, but in 00:35:00family members or others surrounding them. Because--and what's happened is that typically, when the polio vaccine is taken orally and it grows in the gut, it can mutate a little bit. So what's being excreted by that person is not the same as what they took, and it can revert to being more neurovirulent, we call it, which can affect the nervous system. So the fact that we were, in the late '70s, '80s, recognizing that the only polio really occurring in the United States was the vaccine-associated polio, that the risk was not there really for wild disease, so that we switched then from oral polio vaccine to inactivated polio vaccine. So we continued to keep the immunization guard up, but we didn't have to have that concern about that side effect of the rare case of actual vaccine-associated polio. Again, when you have lots of numbers of polios going 00:36:00on, that is just a miniscule risk compared to what the wild disease risk is. But when you have no wild disease going on, then that comes out.

So I think that that's really one of the things that happened in the Global Advisory Group, the discussion between oral polio vaccine and inactivated polio vaccine that was going on. There was some concern about, what happens at the late stages of the eradication effort, will we need to use inactivated polio vaccine? And so some wanted to have more research being done in its use. Others felt that, well, we know all the research that we need to have, but if we start emphasizing at all inactivated polio vaccine, of having any role, that it could distract from the emphasis we're trying to place on oral polio vaccine. So there were some tensions surrounding that. But I think now we're seeing that, in fact--again, when we're down to just forty-two cases, I think, last year in 2016 in the world and Afghanistan and Nigeria and Pakistan--that the 00:37:00vaccine-associated disease becomes more of a concern. And the idea is, how would you know when you really wiped out polio--perhaps then to switch over at the end stages to inactivated polio so that there's no circulating virus of any type, wild or vaccine-associated. So that was one thing that I think was the driving factor for oral polio vaccine, which I think was the right choice for the major tool for eradication. But when you're talking about the endgame strategy, there may be roles here for the inactivated vaccine to come into play.

There was also another tension that I think existed in what I would call the eradicationists versus the integrationists. The eradicationists, the hard line, would say, don't bother me with any other vaccines or any other things, let me get this done as fast and expeditiously as I can, because ultimately, we can 00:38:00stop vaccinating for polio and save billions of dollars. The opposite extreme is what I would call the integrationist, and would say, well, you know, this is our whole portfolio of vaccines that we have, and we shouldn't do anything more for polio than we would do for BCG [bacillus Calmette-Guerin] vaccine. And you know, we need to be doing all of these at the same pace and the same route. What I think we ultimately have done, and I think was the right course, is to say, yes, we recognize both of those polarities exist, but let's recognize that polio has a priority, but let that priority help drive the other vaccine antigens that we use. So for example, if we're going to build, to reach out to the periphery of cold chain, to be able to deliver the polio vaccine, let's make sure that the cold chain is big enough to handle the other vaccines that also need to be in that cold chain. If we're going to go ahead and develop a surveillance system to detect acute flaccid paralysis for potential polio cases, let's make sure that 00:39:00that surveillance system can be used for other things of high public health priority. For example, it was used in the Americas for cholera surveillance. If we're going to develop what we call a reverse cold chain--that is, to be able to take stool specimens from children who have paralysis and be able to keep that under cold conditions, then bring it back to a laboratory to be able to check, is this paralysis due to actual poliovirus--let that reverse cold chain, let that reverse mechanism for getting specimens back from the periphery to central laboratories, be used again for other diseases of high public health priority. So I think that that balance we finally were able to get was an important one, but there's always those who had felt were doing too much for this disease or not enough for the other diseases. But I think that ultimately got resolved, and I think we're moving forward in a balanced way, but recognizing that polio has a priority from it.

I remember that supposedly Salk and Sabin, they said they agreed on one thing; that is, that their vaccine was the best. So anyway, they both had difficulties with each other to be able to accept those roles. And it would have been nice, I think, for them to see, again, this phase where we realize, gee, there's a role for both to play, and both have important contributions to make to public health. And let's make sure that we all recognize we're on the same team and making it happen.

I would think it would be appropriate at this time to talk about the use of acute flaccid paralysis--I've mentioned a couple of times is an indicator for the surveillance systems. Actually, we're fortunate, in a sense, with polio, because we had one difficult problem. And that is, again, mentioning that if you had a hundred people infected with polio and maybe only one would come down with actual paralysis. So as compared to smallpox, where virtually everybody who came 00:41:00down with smallpox had visible pox that you could see and you could ask people about, again, ninety-nine of your cases in polio for every hundred are going without anyone knowing about it.

So what happens is, it turns out that if you look at a population, that there are other things that can cause paralysis. They can be Guillain-Barré syndrome, there can be other Coxsackie viruses or enteroviruses that can cause paralysis, usually more transient in nature. But on average, at least one per hundred thousand population will have some paralysis. And so if you can start looking at your surveillance system as you're trying to improve it for the polio surveillance, if you choose--rather than just polio as your surveilling activity, you actually choose acute flaccid paralysis, of which polio is one of the types of flaccid paralysis you can have--you know that, if you can get a surveillance system capable of giving you over one per hundred thousand cases of 00:42:00acute flaccid paralysis, that if there were polio there, you should be able to find it. And so that's one of the success stories that we use. We look for acute flaccid paralysis. We do stool samples on them to be able to see whether or not this was actually due to poliovirus. And if we had that level of surveillance going on, we knew we should be able to detect it.

So these are the types of things that this Global Advisory Group dealt with, trying to understand and promote surveillance practices, immunization practices, the issue of having national immunization days and also having the ability of doing what we call mop-up operations. And maybe I'll discuss that a little bit as we move to a next chapter that happened in my life.

It was then, after about five years of being in the global program, the director general asked if I would like to go and be the country director--or WHO representative, as it's called--to the government of Indonesia, which is our 00:43:00second-largest country program in WHO. And so, my whole family decided that this would be something very nice for us to do. I remember our daughter was in the eighth grade at the time, and so we decided we'd make this a family decision. And so we sat down, writing pluses and minuses and kind of expecting her--you know, it's Geneva, nice school, et cetera--to say, well, Mom, Dad, I'd just as soon stay here. But she actually said, "I know I remember being in India a little bit." And she said, "I'd like to maybe have one more experience in a developing country before I go on to college." And so she was all in favor. And I think because the fact that she was in international schools all her life, with students coming and going, it wasn't quite the same thing as what you might see in the United States, where, you know, you're suddenly the only one going and everybody else is staying. So she had friends that were going and coming all the time, so it was not that much of a problem from that point of view.

So we all went to Indonesia. We took intensive language training together. I got to where I could speak Bahasa Indonesia, which is the language, pretty fluently. 00:44:00I was actually giving television interviews in Indonesian, because basically--as compared to India, where most of the senior folks could speak English, or certainly in the United Nations people were speaking English--in Indonesia, really, mostly people spoke Indonesian, and so you really needed to have that language facility. And they were always so kind, you know, they were saying, "Oh you're so fluent," and I said, "I know I'm not that fluent," but at least they really appreciated people making an effort to it.

So it was a very fascinating story in Indonesia, because when I arrived, I was met by the UNICEF representative and the Rotary International representative. And they had talked about how, over the last year, they had been really striving to work with the Ministry of Health--Professor [Achmad] Sujudi, who was the minister at the time--to be able to embark on the major polio eradication initiative for Indonesia, but it wasn't happening. So they asked, you know, well, maybe I, as the new representative on the block, could be able to help on 00:45:00this. So I went and talked to Professor Sujudi, who was a microbiologist by training, and so he was very knowledgeable of polio. And he just basically had very much concern, scientifically, about the issue. Was polio really eradicable in the sense that he knew about, that only one per hundred cases showed? And, you know, is this really possible? So what I did was go ahead and we convened an international meeting in Bali, in Indonesia--brought actually Ciro de Quadros over to be able to share his experiences in the Americas. And by the time that that meeting was finished, Professor Sujudi was very convinced, yes, actually, this is doable. And he was very supportive of that.

And so, I said, "Okay, well then, are we ready to go?" And he said, "Well, no." He says, "You know, we have to get the president, President Suharto, to be able to agree to this." I said, "Okay, well, that's good." He said, "I will go and talk to President Suharto and let you know the outcome." So after a week or two, 00:46:00he came back to me and he said, "You know, Bob, I am so sorry, but the president has not agreed to go forward with polio eradication, with national immunization days and things in Indonesia." I said, "Well, why, what did you say?" He said, "Well, I talked to him about the fact that I'm now convinced that it can be done technically, and, you know, that we could do these efforts in Indonesia and reduce the cases and ultimately eradicate. And the President asked me, 'Do you think we should do it?'" And of course, if I was there I would have been saying, yes, of course you should do it, you don't want to be exporting the polio out of the country and things like this. But in Indonesian culture, for those who may be familiar with it, they never say no. And so the fact that the president just asked the question, "Do you think we should do this?" was, to the minister, a statement that he was not in favor of it.

So I said to him, "Well, what do we do now?" And I said, "Well, how about this?" 00:47:00I said, "What if I had the director general"--it was Dr. [Hiroshi] Nakajima at that time--"come to Indonesia, and he will meet with the head of state," because that's the usual protocol for the head of the WHO to do when they visit a country. "And then we could ask the same question, but maybe we could say something more." He said, "Well, you're foreigners, you could do that, there's no problem with it." He said, "I can't go back at this stage." So we did that. After about three or four months, the director general came. And we're meeting with President Suharto, Professor Sujudi was there too, and we brought up the same issue. I said, gee, we're embarked in a global program of polio eradication, it would be wonderful for Indonesia to be a part of this. And the president said exactly the same words that Professor Sujudi had mentioned, you know, well, "Do you think we should do this?" But we were able, at that stage, to say, "Yes, we think it's a very good thing to do, because you don't want to have your polio going to Malaysia. You don't want to be the last country in the world still having polio. Think of, again, the burden to your country and the 00:48:00citizens," et cetera. And so, it didn't take any convincing, really, in my mind. President Suharto said, "Well, yes, then. We should do it."

And in Indonesia, which was such a command and control country at that stage, very centralized in its functioning, when the president said something, everything cleared away and it happened. So he had the army and the navy and the air force all at Professor Sujudi's disposal. And with six thousand inhabited islands in Indonesia, you needed all of those things to get to remote places. The only thing Professor Sujudi asked me was, "I know that they call this National Immunization Day," he said, "but look, with all of these territories, again, the six thousand inhabited islands, I just don't think it can be done in a day. So can we call this Pekan Imunisasi Nasional, which means National Immunization Week?" I said, "Sure, you can call it anything you want to call it, as long as we're moving and doing it." And so we did all this. They prepared the 00:49:00day--they had all the instructions going down to even just village level, because, again, the command, the central command, just everything was at their disposal. And later, the minister of health and I laughed because we probably could have called it National Immunization Hour, because that first day, all the children--even before the immunization thing opened up--were all lined up in the village to get their vaccine. And so within about an hour, I think probably 70% of all the children had been immunized. It was just incredible. But the amount of--and I would go with them on helicopters to places, we went on navy ships to places, and things like this.

So everything was opened, and it was a very exciting time to actually see us go to zero cases of polio. And I remember back then about that incident we talked about back in medical school, when the orthopedic surgeon was saying, "You're going to have more impact in your career than I ever had in mine, because here 00:50:00we are working with this child with polio who should never have gotten it." And here I was thinking, oh my goodness, we've gone to zero cases of polio, this is what this surgeon was prophesizing twenty years earlier. So it was very exciting to see that come to fruition. But I think that again, that issue that no one was in charge, in the sense of being solely responsible for the eradication--it was really a team effort, from village levels up to UNICEF and Rotary and WHO and UNDP [United Nations Development Programme] and World Bank, all working together with ministries of health to make this possible. And this was happening all over the world. And so I think that it was a very exciting time to be able to see that effort being able to get to actually zero cases of polio.

After six years in Indonesia, the director general asked if I could go to head up the country program in India, so we went back to New Delhi. This time, as 00:51:00compared to being in the regional office, I was actually in the minister of health's offices--Nirman Bhavan, it's called--and heading up the country program, which is our largest country program of WHO. And in it we had people, again, working with the polio eradication area out of the regional office also. Jon Andrus is another person that is a CDC, U.S.-trained, very involved with PAHO most recently--but he was there, and he was working with a team that we had of 750 staff in India, three hundred of which were professionals, and others being drivers and things like this. They were actually working with the different provincial ministries of health and the central government in terms of being able to do the acute flaccid paralysis. The national immunization days--we had a big launch in 2001 with Prime Minister Vajpayee himself delivering the 00:52:00vaccine. I've got a picture that I can show you on that. And the efforts were such that it really mobilized the country with over a billion people. It was really something to see, all the zero to fives [ages].

And not only that--then, of course, we still had cases of polio occurring in India, and we would do what we call the mop-up operations. This is where, when you actually detect cases of polio going on--in addition to the national immunization days, which were happening three times a year--you actually then go in and what do what we call mop-up operations, where you go door-to-door making sure that all children under five were receiving oral polio vaccine in those areas we actually had cases. And these were the strategies that were being used, not only national immunization days, but mop-up operations and the routine immunization program. Those three things together--like three legs of a stool, so to speak--was really the platform of which the polio eradication effort was 00:53:00founded on, including, then, of course, the surveillance to be able to detect and then be able to focus our program operations to those areas of greatest need.

We also had to do sophisticated epidemiologic work too; for example, to make sure that our vaccine was still a potent and strong and working well for us. And in fact, it turns out it was a very interesting experience--we started to notice that the vaccine efficacy for type III vaccine--the vaccine has three types in it because there are three types of polio--was not at the levels we would have anticipated. And so we were looking at different things that this might be due to. Do we have breaks in the cold chain? Do we have breaks in the way in which the vaccine is being administered in the field? What could possibly be causing this? And we were scratching our heads about it, and finally we said, well, why don't we also bring in some experts from Geneva to talk about--to go over to the vaccine manufacturer here in India and look at what they're doing. And it was 00:54:00very interesting because they knew the WHO standards, and it required a certain amount of titer of each of the components of type I, II, and III in the vaccine. And in the vial, as it was going out the door, it was meeting those standards. But kind of unbeknownst to them, it was the fact that the standard actually goes beyond just what is it like as it goes out your door, but it's also supposed to be able to meet those same minimum standards two years in storage.

The vaccine manufacturers in Europe recognized that this type degraded over time, so what they did is that when it goes out the door of their plant, it's at a much higher titer, so that after two years, it's still above the standard. But what was happening in India was that it was going out the door at the standard and over time it was degrading. So it was a simple fix. The vaccine manufacturers went ahead and upped the titer in the vaccine, and we didn't have 00:55:00that problem again. But it was kind of, again, showing where the role of epidemiology, the role of looking and testing and seeing--how is your vaccine doing in the field, where are you seeing disease, why could these people be having this level of vaccination but still coming down with disease--how that works. It's a very exciting part of sleuthing, if you will, in the epidemiology world about vaccines.

And so I think, also--I might digress on one thing that you might find of interest--is that I also had the concept that looked at, as the WHO, as the Ministry of Health, we should be practicing what we preach. And I don't know if some of the folks that are listening to this and hearing this and seeing this have seen sometimes government buildings in India, but oftentimes they are not so well kept up--abandoned furniture in the stairwells, things like this, 00:56:00unclean bathrooms, et cetera. And the Ministry of Health is no different. So because my offices, though, were in the Ministry of Health, not in the regional office, I said to the minister, I said, "Look, how about if we had a project? We'll call it the Healthy Public Building Project, and we'll start here. And a healthy public building should be at least safe and reasonably clean." And he agreed, he said, "Okay, that sounds good." And so what we did, we started having a group of us go around once a month--and we had people from the general services and from the Department of Public Works and from the electricians, et cetera--and we said we'd start by identifying things.

So the first thing we identified was just these abandoned file cabinets and furniture that were in the stairwells and the hallways. A safety hazard for fire, but they said, "No, we can't take it out, because we tried that once and people would come out and say, 'Oh no, that was my valuable file cabinet you're taking away. You can't take that.'" So we said, "Okay, we'll write all five 00:57:00thousand people in the building"--it was a big building--"and tell them that in two weeks' time, if there's something important to them that's in the hallways or the stairwells, put it into a room." So then after two weeks, we just took it all out, and no one could complain, because they had been given a warning about it. So that was kind of nice. You saw a little bit of space now to walk. Then we handled the bathrooms because it smelled. The building smelled the minute you go in. So it was a matter of communication, that the general services people thought the Department of Public Works is supposed to take care of that. Public Works said, "No, no, we'll take care of something broken, but the general hygiene and maintenance has to be done by general services in your building." And so with the two of them together, the fact is that half the fans weren't working. So that was Public Works, so they got the fans working in the bathrooms. And then, at least, a modicum of cleaning going on by general services. And within about four or five months, there was no longer any smells in the building.

So now people were being kind of interested about this. So we said, what are we 00:58:00going to tackle next? And then--it was a major problem, and it happens in some buildings in India, is we had these small monkeys that come in at night and they're really vicious. And I had one of my staff members bitten, in fact, by one of these. They'll just have monkey doo all over the place, and anything that's in the hallway they'll just rip up and tear apart. And so one of the people in the group that we had going around once a month said he had heard about hiring an animal trainer with a langur, which is a big monkey, that this guy could walk around and that the little monkeys are the--their natural predator--the big one is the natural predator of the small ones, and that they are scared. So I said, "You know, it's worth a try." Incredibly, in one day's time, with this guy walking this monkey around, there were no monkeys to be seen in the building, and not even the parking lot, because they used to tear off people's mirrors in the cars and all that sort of stuff. And although we had to have him go by once every day, but it completely solved the problem. So it's 00:59:00kind of an interesting situation where again, by just slowly and methodically being able to address it, we actually came up with a clean and healthy building.

So I think again, in India, one of the things that we learned is, again, the importance of being able to communicate about vaccination and the vaccination program and the polio eradication program. We had some setbacks--and remember, this has happened in other countries, Nigeria as well, where sometimes rumors start to spread that the vaccine is somehow sterilizing children or something like this. And I know this happened in a few of the Muslim villages--it was happening in India. And so how we best dealt with that was to be able to, again, reach out to the influencers, the imams and the mosques, and be able to talk with them. And they understood then, and then they were able to preach in the mosques about the importance of the polio program, or they themselves would give the polio vaccine, or their children would come and receive the polio vaccine, 01:00:00so you could see that that trust and nature of it. And I think that 2000 National Immunization Day launch with Prime Minister [Atal Bihari] Vajpayee also himself giving the vaccine was another powerful message for people to see that was widely circulated in the country. I think those are some of the things that we were trying to do.

I think that this whole issue about concerns about the side effects of vaccines, we often see it less, actually, in developing countries, because parents see the difficulties of the wild disease occurring. They see children dying of measles. They see children becoming paralyzed from polio. So usually it's not such a hard sell, if you will, to say, hey, we've got vaccine here. There's usually a clamor for it. They want to have that vaccine. And I think, actually, it's been more of a situation that occurs in the developed countries, like back here now in the United States, where what's happened is that there's a complacency that's set 01:01:00in. That parents look around and they don't see these diseases, and so they hear about side effects, some of which is false, some of which is exaggerated. Of course, we always try to recognize that vaccines are safe and effective, they're not perfectly safe and they're not perfectly effective. But they're a lot better than the wild disease. And I used that. Recently there was an editorial I put in the American Journal of Public Health, and I called it "The Dangerous Curve and the Guardrail: Disease and Vaccination," in the sense that you have a situation that occurs if you look over a dangerous curve in a road--so over the last year a hundred people died going over this dangerous curve. That's like having the disease, okay? Now what do we do? Well, we put up a guardrail. Well, that's like having the vaccine as a safety feature. Now the next year, the statistics show that nobody was killed going over this dangerous curve. However, three people 01:02:00were hurt hitting this guardrail. And some people would say, oh my goodness, we've got to take down the guardrail because it's injuring three people a year--just like the side effects, you know, very rare, but it happens on vaccines. So some people would say, oh my goodness, we've got to take down this guardrail, we've got to stop vaccinating, when of course what will happen is that you'll go back to the pre-guardrail era of a hundred people dying going over the curve, or pre-vaccine era where we had--like in polio, you know, fifty thousand cases a year occurring in the '50s. So people have to understand that problem that we face. So sometimes that analogy helps groups to understand that I can't compare side effects of vaccine against current levels of disease, which are low because of the very success of our vaccination programs. I have to compare of what would happen in the absence of vaccination.

So I think that in India also, we again recognize the importance of lots of people working together in a partnership. Again, it was with UNICEF, Rotary 01:03:00International, WHO, UNDP, Asian Development Bank--all of us working together with the Ministry of Health in a partnership. And that's really the only way you can achieve these sorts of goals and strategies. It was in 2002, actually, that I left India after a little over three years. My wife, unfortunately, had developed breast cancer. Fortunately, she's done well, but at the time the U.S. government wouldn't let us stay in India if she was on chemotherapy--concerns about decreased immune status, susceptibility to infection. And I'll always be grateful to CDC, they were able to accommodate me as a career field epidemiology officer, stationed here in Los Angeles. My wife was able to go to the Revlon UCLA Breast Center. And I was then stationed at the--half-time at UCLA and half-time here in the Department of Public Health in the area of bioterrorism preparedness, because that's of course where the funds are. I had to develop a smallpox plan for Los Angeles County at that time. I also prepared a course on 01:04:00preparing for a smallpox at a bioterrorist event at UCLA.

And then this position of director of communicable disease control prevention opened up. And it was just the right timing in my career to be able to leave, at that time, government service, because I had up to thirty years' retirement as a commissioned officer, and so a second career here in this capacity. And I've been able--because one of the five programs that I had administered overseas, the immunization program--I've been able to keep involved with immunization-related activities. And so again, this issue of looking at vaccine concerns and relationships to community groups, to be able to develop stronger vaccination for new vaccines, like our human papilloma vaccine, things like this. It's been a very nice, opportune time to be able to stay very much involved with immunization programs while looking at an even wider portfolio of communicable disease programs as well.

I think, in reflecting back on lessons learned in polio eradication, I think a number of things in my mind. Firstly, for CDC itself, the recognition it is a global leader and a global player in this field, that it gives prestige to the United States government as well as to just CDC itself. To have its staff involved in these activities providing expert guidance, providing reference laboratory--the CDC that really developed some of these techniques of what we call oligonucleotide mapping, which is like fingerprinting of the poliovirus to be able to detect, where did this actual polio virus come from? As you get more and more polioviruses typed and oligonucleotides mapped, you can actually have a geographic map and figure out where these things have come from, and will help you then in your detection of how to stop the spread of disease. I think that being able to provide epidemiologists--and for persons involved with the 01:06:00immunization program at high levels in the organization--has been able to provide CDC with a visibility that even though, yes, I had a UN hat on or a WHO hat on, everybody realized I was CDC. In reality--which is that we didn't try to promote this--we were trying to promote the fact that we were now under a United Nations flag at this stage and all of us were partners in this. And with now the Gates Foundation and others that have become involved with private sector even more, I think that again, it's important that we understand CDC is often one of those drivers, together with WHO, for the research that's necessary to help develop the strategies, and to fine-tune the strategies that are necessary for the eradication effort like we're doing now with this role of IPV and OPV at the end role. The ability to detect this vaccine-associated polio and what is its contribution to the remaining polio in the world and how to be able to 01:07:00ultimately use, perhaps, IPV to be able to stem that problem as we move to a polio-free world.

I think that the CDC has been very generous with its time and expertise, and I think, again, it just has been to the betterment of CDC and the United States and its perception in the world. And I think that all of us who have been involved at one time or another in the polio eradication effort, it's like the next generation that came after the smallpox, which was, again, a cadre of people that were very much involved with a global worldwide effort that resulted in success of the eradication of smallpox. And we're right in the middle of the end stages, now, of those who were involved with the polio eradication to see that goal finally coming to fruition. And that again, will be, I think, probably one of humanity's greatest achievements in the twenty-first century, is going to be the eradication of polio. I know we have kind of a friendly rivalry with those that are working in Guinea-worm or dracunculiasis eradication, which is 01:08:00another great story to be told. Each side was saying, okay, we're going to reach it first, and then each side had just a little bit more to go. So it's still a little bit up in my mind which one is going to actually get to eradication first, but obviously the polio is a much wider-spread problem. But it is a healthy competition. And again, CDC, [Dr. Donald] Don Hopkins and others have been very, very influential in that effort. And it's been kind of nice to see the cross-fertilizations occur that way in a safe, healthy competition as well.

So I think, in summary, certainly the polio eradication initiative has been one of the defining aspects of my own career, something that I take great pleasure in having been a part of. And again, I emphasize being a part of it. I don't think anyone can ever say, you know, they own it. But I think all of us working together--we're much stronger than any of us as an individual. And I think that is really, perhaps, the real lesson learned in this, is that partnerships, 01:09:00collaborations, and cooperation can achieve things that no individual could ever expect to.

TORGHELE: That is a perfect way to end. Thank you so much. You gave such good examples of using creative ways to overcome problems that were effective. And you were able to maximize use of all your resources that other people will be able to then use in the future.

KIM-FARLEY: Yeah. I'm glad it served what you needed.

TORGHELE: Thank you so much.

KIM-FARLEY: My pleasure.