Margie Pollack

TORGHELE: It is April 26, 2018. I am Karen Torghele, and I'm here with Dr. Marjorie [P.] Pollack at the Centers for Disease and Control in Atlanta. Thank you for being here, Dr. Pollack, and agreeing to be interviewed for the Global Health Chronicles Oral History of Polio project.

POLLACK: Thank you. It's an honor to be here. Thank you. My pleasure.

TORGHELE: By way of introduction, I want to say that Marjorie has had a lot of interesting jobs. She has been most recently with ProMED [Program for Monitoring Emerging Diseases] for twenty years and is currently the Deputy Editor. She will explain a little bit more about ProMED later. She has been a consultant medical epidemiologist for thirty-eight years almost. She has been a consultant to the Centers for Disease Control Global 2000, United States Agency for International Development, World Health Organization, Pan American Health Organization, United 00:01:00Nations Children's Fund, the European Economic Community, the Asian Development Bank, and the World Bank.

POLLACK: Basically, she can't hold a job down.

TORGHELE: That's an impressive list. And you've worked in a number of different places that I will hear about later as we get into it. But where you got your start at CDC [Centers for Disease Control and Prevention] was an Epidemic Intelligence Officer in the class of 1977. You were with Enteric and Neurotropic Diseases, Viruses, is that correct?

POLLACK: Correct.

TORGHELE: You were in the Viral Disease Division. Then for a year, you were on the Immunization Division.

POLLACK: During my preventive medicine residency here.

TORGHELE: You have had a very interesting career, and we'll focus mostly on polio, but I hope you'll talk about some of the other things as we go along. Would you start by telling us where you came from and how you decided on medicine as a career at a time when it wasn't common for women to do, and where you got your inspiration to do the things you did later?

POLLACK: Okay. I came from--born in Manhattan, New York City, but my parents moved to Brooklyn when I was six months old, and I grew up in Brooklyn. My father was a doctor; my mother was a research developmental psychologist working in childhood schizophrenia. I had one brother, and it was a given that both of us would have doctor to our name whether it was Ph.D. [Doctor of Philosophy], M.D. [ Doctor of Medicine], D.V.M. [Doctor of Veterinary Medicine] -- that part 00:02:00wasn't as a given in the beginning, but it was just accepted we'd be going for higher education and that was the upbringing we had that was an important upbringing. I guess I went to public school in New York City, which in those days was excellent. In college, I majored in Psych [Psychology], minored in English and French Literature, and it wasn't until my senior year when I had courses that had me reading books I hadn't already read in high school. So, in those days--I know today things have changed, but in those days, you got a fairly good education-- actually, an excellent education. I went to New York University, the University of Arts and Sciences which was located, it was the 00:03:00uptown campus of NYU [New York University], and it was a fantastic education, very good education. I will interject that I was in college in the late '60s, so political activism was part of life in college, and I was in those days very active in the anti-war movement. I basically always remember wanting to go to medical school, and it was encouraged by my father and my mother, and my brother went to medical school as well. In fact, I have four first cousins, and all four of them went to medical school as well. So, there wasn't a shortage of doctors in the family. But I mention the activism because that played into the decision 00:04:00ultimately to go into public health in many ways.

TORGHELE: Your father was in private practice?

POLLACK: Yeah, internal medicine.

TORGHELE: So public health would've been veering from that track?

POLLACK: Yeah. My father was the type of Doc who made house calls in the middle of the night. He worked eight days a week. He was very dedicated to his profession and his family, too. We weren't totally ignored. He had the office in our house in the garden level of the house. There was just a lot of encouragement to go ahead.

TORGHELE: What was it that inspired you to go into public health?

POLLACK: There's been a wanderlust side to me with traveling, and it kind of explains what I ultimately did as a career, but in my trajectory when I was in medical school, I liked infectious diseases [ID] very much. That was a subject I enjoyed very much, and one of the ID attendings suggested why not go to CDC and join EIS [Epidemic Intelligence Service]? And he mentioned that, and this was my 3rd or 4th year of medical school -- my 3rd year. In my 4th year of medical school, my advisor in medical school was the chairman of the department but was also a well- known figure in infectious disease, Dr. Donald Kay. I went to him and asked him if he knew anyone in India that I could go study tropical medicine 00:05:00as part of the senior elective. And he said, no, I don't know anyone in India, but if you're interested in going to Brazil, I've been interested in setting up an exchange program in Brazil. At which point I went, squeak, squeak, when do I leave? And I spent four months studying tropical medicine in the northeast of Brazil which was a very formative and at that time relevant to the work in polio, I used to regularly go to a hospital in Bahia, called Coto Mayo where there was a polio room, there was a tetanus ward, a ward with only polio cases, a ward with only tetanus, a ward with diphtheria, etcetera., so there was exposure to seeing diseases that we really didn't see in the United States, and 00:06:00that made an impact on me. Fast forward, I did an internal medicine residency in New York at the Einstein Montefiore Hospital and one of the fellows when I was on ID, one of the ID fellows also was returning--I forgot to mention the names of the people. The ID attending who had been an EIS officer who suggested I do it was [Dr. Elias] Eli Abrutyn and the ID fellow during my residency who said why don't you apply for CDC for EIS, [Dr.] Marcus [A.] Horwitz. And it kind of seemed predetermined--now, I left out another instrumental thing that happened, and that was I did an elective in Australia for the summer after second year medical school, and I looked on the map where could I stop on the way there and on the way back, and I stopped in American Samoa on the way there, developed a photosensitive rash, so I went to the hospital there. It was called the Eisenhower Hospital, and there was an American Doc, and I basically said, you know, what's a nice guy like you doing in a place like this? And he said to me, well, they've been having an outbreak of dengue and I work with the Public Health Service with CDC and I was sent here to investigate this outbreak. I do not remember his name to give it. If you fast forward, one of my responsibilities during my EIS years in the Enteric and Neurotropic Viral Branch of Viral Diseases was dengue surveillance. So, what goes around, comes around. So that kind of all fit together. And as I said before, when I was finishing my 00:07:00residency and thinking what am I gonna do next, with the wanderlust I thought, how about if I hop freighters around the world for a year while I try to figure out what to do? And that's when it was suggested to me why don't you get paid to hop freighters around the world and do good while you're hopping freighters around the world. So that's how I--it's a long, convoluted set of anecdotes, but that's how I ended up in public health.

TORGHELE: It sounds like you were already interested in infectious diseases. So, did you know you wanted to go into viral diseases?

POLLACK: I was tossing between viral diseases and parasitic because of my interest in tropical medicine. I leaned a little bit more to viral diseases in those days because there were more outbreaks where it was more acute, and I was interested in doing acute management of trying to go out, solve a problem, and have a quick resolution. Famous last words. But it held its attraction.

TORGHELE: I guess that would've been 1977 when you first came, so there were viruses then that not much was known about--or known at all.

POLLACK: Yeah. Well, dengue, for example, when I ran into the doc going back, I remembered when he said dengue fever I kind of scratched my head and went, hmm, that was about a paragraph this size in the Davis Microbiology textbook. So not much was known, and a lot of the viruses--my first outbreak that I went out to investigate was then referred to as a probable Norwalk-like virus. By the way, that outbreak was at Yellowstone National Park. And we now today refer to the organism as Norovirus. But we had a floating denominator of 35,000 every day to calculate.

TORGHELE: It must've been a challenge.

POLLACK: Yes, especially since it was looking like it was the pristine park water which wasn't so pristine, and we were the enemy in pointing this out.

TORGHELE: So that was a little difficult to have to--you had to be sensitive to what they were having to go through with the tourists.

POLLACK: Yeah.

TORGHELE: Did you also work with the State Health Departments?

POLLACK: Oh, yeah. That outbreak--because Yellowstone covered several states, we had participation from Montana, I believe we had Wyoming. We came in from CDC, and there were other state health EIS officers, state assignee that was the field service division and they came in to help because it really was a large outbreak.

TORGHELE: Was that your first outbreak that you worked on?

POLLACK: Yeah. I left two or three days after we finished the EIS course.

TORGHELE: So, you jumped right in.

POLLACK: Jumped, yes, but also thrown. I'm not sure which is the operative.

TORGHELE: Did you have more experienced people who also went with you?

POLLACK: Yes. The tradition in EIS is analogous to the tradition in medical training. See one, do one, teach one. So, when you certainly went out on your first outbreak, you had a senior--either a second and/or third year EIS officer accompany you. So, you didn't get to call the main shots, although you did offer your opinion.

TORGHELE: How did you feel the EIS course prepared you? Did you feel it was adequate for you?

POLLACK: It was very good. The case studies and outbreaks that we worked on were helpful, but you needed to get your feet wet. You needed to actually get out there and do it, and there were different settings and different situations. The outbreak in Yellowstone involved a huge population looking at--the outbreak involved a large population. It was with a floating denominator, and those really weren't the realities during the course, but these were the realities in the field. My second outbreak was a dengue outbreak in the Bahamas, so 35,000 was small when you're looking at a whole country. But the answer is yes, more senior level came.

TORGHELE: You mentioned you didn't know much about dengue. You probably didn't know much about polio or some of the other diseases from medical school either because presumably, polio cases were not that common in the United States.

POLLACK: No, they weren't at all. At that point, there were just the sporadic cases or the occasional--they were imported cases, or as I got involved doing polio surveillance, there were the vaccine-associated cases that were more of a problem. It was the background level of what was going on in the United States. But I had the comparative edge of having seen polio and having seen more than one case- having seen many cases in the northeast of Brazil during the time I 00:10:00was up there, so I had an understanding for the clinical diagnosis and the impact of the disease.

TORGHELE: That must've been very valuable to you and to the people you worked with.

POLLACK: I hope so. It was to me.

TORGHELE: So, when you got to the first two outbreaks, then somehow you honed in a little more to polio, is that right?

POLLACK: Mm-hmm.

TORGHELE: How did that happen?

POLLACK: Well, polio was on my list. I was interested in the disease because of my background in the studies in Brazil. I remember I went down, spent some time in the lab with [Dr.] Milford Pete Hatch to see the laboratory side of it and I just spent a lot of time trying to piece together and understand the history of where we were today--the today being 1977-78 with polio, but where we were, how we got to where we were and where we had been. And I saw the surveillance data, or the files were snippets of pieces of paper, sometimes a little tiny piece somebody took a note from a phone call, something like that. And this was early on in the computer era when it was back in the days of mainframes. We didn't have personal computers in those days. Your EIS equipment was a Texas Instrument calculator that you cherished and took with you. But we did have a statistical 00:11:00department that worked on computer programming. I, myself, in high school was in an experimental computer class in '65 and '66, and I had learned how to program using binary programing and also Fortran and the tapes where we'd punch holes in tapes. So, I believed in computers, and I decided what was needed was computerizing the data, and so I spent time--I really got into it spending time with [Dr.] Dennis [J.] Bregman from the division, a statistician, a wonderful person, and designing what the variables should be, kind of what kind of spreadsheet you should have transported onto the computer.

TORGHELE: You made all kinds of opportunities for yourself, and that were helpful to everyone.

POLLACK: I tried. So, time was spent, it was a challenge to try to do that and get it organized so that--try to eliminate one level of human error with calculations of when you do a late at night what-have-you, hopefully with data entry and doing double-entry verification which was something to try to ensure that we could at least reduce those errors.

TORGHELE: Could you talk a little bit about Epi-Aids [Epidemiologic Assistance], what those were like for you to do, what their purpose was, and how they were used over the years?

POLLACK: Epi-Aids are a means of when assistance is asked of CDC, whether it's a state, a health department, or a federal agency such as the Indian Health Service or the national park that falls under federal jurisdiction. It's a mechanism to get assistance from CDC, and EIS was now Epidemic Intelligence Service, where everyone refers to it as the disease detectives. We come out with our shoes with the hole in the soles and our magnifying glass to inspect. And the Epi-Aid was a means of getting people in to assist with investigations when there was a problem.

TORGHELE: So, you would get the request from presumably the state health department sometimes--

POLLACK: Yes.

TORGHELE: --and it would be as specific as it could be about what they wanted. But then, what was your next part in that?

POLLACK: Well, before you left you made recommendations based on the information you had. If you were bringing things back for laboratory testing, there would be a second round of recommendations once you had laboratory results, and then you had to write up a report documenting why the call was made, what the precursors were, what was going on, what went on, and what the findings were of the results and the recommendations.

TORGHELE: So those are records of all the work that's been done by EIS officers over the years.

POLLACK: Yes.

TORGHELE: And a lot of those were then printed or summarized in the MMWR [Morbidity and Mortality Weekly Report], and those would go out to where?

POLLACK: The MMWR was a vehicle for disseminating information on outbreaks. In the time we were there, I say we because of our association, Karen. Because the MMWR was in the pre-internet days, how did information get disseminated, and people who were interested in infectious disease and public health viewed their weekly report that came as the bible for what was going on? So, you wrote--your role as an EIS officer in addition to the Epi-Aid, your responsibility was writing the MMWR report and writing the discussion section, the editorial 00:14:00section of it, but also presenting the information for it. In today's day and age, reports come out faster on the internet. But go back forty years ago, and MMWR was the Holy Grail I guess of outbreak information.

TORGHELE: It would go to all the schools of public health, all the health departments, and internationally received--

POLLACK: Yes, and to individuals. I had started receiving MMWR while I was in medical school. I forgot to mention that, I guess, that also played into wanting to go into public health.

TORGHELE: That would pique your interest into what you could do.

POLLACK: Yeah, it definitely did.

TORGHELE: So, back to polio-- you were developing a computerized system to help analyze the surveillance and other activities that were related to polio, and you did some investigations into how the lab worked with the epidemiologists. How did that go?

POLLACK: Very well. We had a very good--Pete Hatch was just a wonderful collaborative individual, and there was a very good working relationship so that if Pete would get specimens, he would always check if we knew about it. And vice versa, if I heard about a possible case, I'd alert Pete had he gotten specimens and had work on it. So, it was a very close collaborative--my memory of it was it was a very good close collaborative working relationship with the laboratory 00:16:00aspect. TORGHELE: I think that was kind of unique in that setting. It didn't always work well for the lab and the epi people to collaborate. In some cases, they were a little more compartmentalized.

POLLACK: It could be. But I just decided early on when I was not traveling for outbreaks, I decided I need to go to the lab and learn and understand what the lab was doing, and Pete was welcoming, open arms, nice and was an excellent teacher. I didn't remember that other places within the center had more compartmentalization because we really did have very good communications between the lab and epi, for polio at least.

TORGHELE: You were probably a big reason for that.

POLLACK: No, Pete. It takes two to tango, and I think Pete was very willing and very welcoming.

TORGHELE: It sounds like you also went above and beyond because of your curiosity. Don't you think that probably has a lot to do with how you ended up doing the things you did, in how many places and different things you've done? So, speaking of which--when you were doing your work in polio, this would've been twenty years after the vaccine was introduced, the Salk vaccine, when you were doing your polio work. The Salk vaccine was introduced in 1955.

POLLACK: And this was '77, so it was twenty-two years.

TORGHELE: So, what was going on with polio in this country and in the Western Hemisphere, say?

POLLACK: I'll start with the Western Hemisphere, and then I'll go to this country. In the Western Hemisphere, polio was in cyclical epidemics in most of the countries; on the average, every three years-- two to three years, there'd be an increase. They'd have enough susceptibles--vaccination was just really starting in many of the countries. It had been available for private-sector people, but for general public sector initiatives, if my memory is correct, the 00:19:00Expanded Program on Immunization started as a segue from smallpox eradication in 1974. They started doing a transition and started working with countries to introduce the childhood vaccinations. The Expanded Program on Immunization, EPI, is what it was referred to. There were cyclical outbreaks going on in the countries in the region. It also evolved into a situation where a polio outbreak would cost a minister of health his or her job.

If the country had an outbreak, it would not be good for job security for the political level within health. And that was the baseline structure. For example, our neighbor to the south, Mexico, was having cyclical outbreaks. I remember in spring of '78 getting a call from Texas stating they had four cases of polio admitted in Brownsville, Texas, from Mexico. They had come across the border, thinking our medicine could cure polio. We had no information. I had met somebody working in the then Office of International Health Way. We had become friends after a dengue meeting, and she was liaising with PAHO [Pan American Health Association]. So, I called her on the phone. She had called me at times 00:20:00to find out information of things going on in the country. And I called her and said, do you have contacts in Mexico? Could you maybe find out what's going on there? And she called her contacts in Mexico City-- this was at the Ministry of Health. They didn't know about the outbreak up North. They called up North, they got the information, and they called her back, and she called me back, and within twenty-four hours basically had the information. And I wrote our famous Memo to the Record about the outbreak there. The state [Texas] was very concerned and said we should block people from coming in; we should be checking their vaccination status. And the response on the part of the division, and we 00:21:00discussed this thoroughly on the best way to respond, was basically to tell the state, well, if your population is vaccinated, you don't have anything to worry about. So, there isn't an indication to quarantine for polio, but just make sure your population is vaccinated. And there were no secondary cases in Texas, so that was--and the situation at that point in the states, we would have imported cases--in this case from Mexico and other cases, people who had been traveling overseas would come back. There was a population actually our age group that was in a gray zone for adequate vaccination history. Some had received the original 00:22:00inactivated vaccine [IPV], which had a lower efficacy. There wasn't consistent reliability in those days for potency and efficacy. Some had received some monovalent doses a mix, etc., so we had a population in the U.S. that had questionable immunity to polio. And we recognized that was one of our target--one of our challenging populations, so we would have imported cases that included the young adults because they fell into this group. One of the challenges that we were seeing, in addition to the imported cases, the majority of the cases we were having, and seeing were related to the vaccine itself. They 00:23:00were vaccine-associated cases, what's now called VAPP, Vaccine Associated Paralytic Polio, and these would be primarily you'd have two groups involved-- either the recipient of the vaccine, the child, the infant who was given the vaccine, or if an older person was given the vaccine but the older person, the young adult more frequently was a parent or a relative of a recently vaccinated child. In fact, until 1978-79, when we had our own small outbreak, the majority of cases were not associated with the wild poliovirus but in fact, were associated with the vaccine virus. So, we were dealing with the situation in the 00:24:00U.S. that are--to use the word cure isn't the right word, but our prevention was beginning to be worse--the risk-benefit assessment had one questioning whether we should still be using just the oral polio vaccine [OPV].

TORGHELE: How was it discovered? How was VAPP discovered? How did they differentiate that from the wild poliovirus?

POLLACK: Laboratory. It was in the laboratory. The vaccine virus was different, different markers than the wild poliovirus and there would be the history of exposure and in the case of a child, you know, you'd have a child where the parent would say that the child was vaccinated two weeks ago, three weeks ago or 00:25:00last week. And people started looking and the virus that was isolated, the laboratory was able to determine whether it was a vaccine-like virus versus a wild virus.

TORGHELE: It must've been a little bit of a surprise.

POLLACK: I wasn't there for discovering it. It was already a known entity when I came so that was part of my learning curve. I'm not sure I'd use surprise as much as disturbing. You know, with the Hippocratic Oath of, Do No Harm, you start questioning what's the risk in working in vaccine and making vaccine recommendations, you have to weigh the risk of the wild disease, the natural disease versus the risk of the vaccine. No vaccine is 100% safe, unfortunately, but there were different degrees of unsafety and different risks. And the question is, is the risk of the wild poliovirus greater than the risk of developing polio from the vaccine, or is it the other way around? And that was the part that was somewhat disturbing. I had problems with that personally.

TORGHELE: There must've been differences of opinion on how to handle that situation, different camps of thought.

POLLACK: Yes, there were.

TORGHELE: Do you remember the arguments about--naming themes, but what were the arguments for and against?

POLLACK: The arguments for the use of the OPV was the very same trait of the vaccine, which was to infect people or immunize people more than the one you gave the vaccine to. It helped-- in addition to creating a natural herd immunity; you vaccinated more people than you actually gave the vaccine to. That very same trait that led to having contact-associated cases was a trait that was positive that if you had lower--and in the '70s, people were becoming complacent. They weren't seeing much of the diseases, so routine immunization levels were dropping, and there was a movement definitely with school entry vaccination mandated and then enforcement of the school, the laws for school 00:27:00attendance. It was kind of a double-edged sword to do that. But that was the side that was very strongly in favor of continuing to use that with lowering vaccination levels at that point and the ability to vaccinate more people and the still existence of the wild poliovirus in the world. The other side for which I leaned towards said, wait a moment, we have the introduction of the wild virus, we're not getting much spread, so we have a fairly reasonable herd immunity in the general population-- isn't it time to start rethinking what vaccine we're using? At the same time, the killed vaccine, the inactivated IPV, 00:28:00had been improved, and it was much more reliable. The studies that had been done--you could get well over 90% tritypic seroconversion after one dose administered after six months of age, which is pretty attractive. So, the side in favor of let's rethink our vaccination policy was Do No Harm, and the risk of wild disease is very low and that the risk from the vaccine was outweighing the risk from the wild virus.

TORGHELE: Were you involved at all with the Advisory Committee for Immunization Practices [ACIP]?

POLLACK: Yeah. We had to prepare--we tried putting forth that debate, getting the debate started with ACIP, the advisory committee, and we had to prepare background documentation to support what we were seeing. So yes. EIS officer was not exempt from working on that and getting the documents and putting together the information to present to the committee. I can divert. I think this is a good point, just an anecdote to give an example of what the situation was like. We had a report of a case; we had laboratory findings that it was 00:30:00vaccine-associated; it was a contact case-- I won't mention the state involved, but it was a case in a state--and I couldn't get the state epidemiologist to confirm the case. Now, CDC can't report, or in those days, could not report on something if the state didn't report on it. CDC could report on things under federal jurisdiction but not under state jurisdiction. And I was kind of beside myself. I would call every so often to ask are they ready to confirm it, what more is necessary, what information? And then I finally just said, why? I called the state, and I said, why? And I was told we want to be able if the press asks us have we ever had a problem with this vaccine, we want to be able to say no. 00:31:00There was a concern that releasing information on vaccine-associated cases in the state would decrease their vaccination acceptance rate. So, there was a lot going on, not just on the technical, scientific level but anthropologically as well in the community or the sociology involved with it.

TORGHELE: Made it very complex.

POLLACK: Yeah. It wasn't as black and white an issue as when you think you're looking at the pure science. There's more involved, and it was complex.

TORGHELE: Now, I imagine that Dr. Salk and Dr. Sabin had some say about these issues, am I right?

POLLACK: Yes.

TORGHELE: Do you have memories of the two of them?

POLLACK: Yes. Dr. Salk would call every week or two just to chat with me and tell me about some of the latest research and send on papers that had been published, to just discuss it. And just very, very nice. Very gentlemanly. It wasn't lobbying as we know lobbying. It just was scientific discussions. And as a first-year EIS officer, when you have a name like--I remember my secretary said, there's a Dr. Salk on the phone, is that the "real" Dr. Salk? And I went, uh, yeah. So, there was a lot, but he was very helpful. He would bring up discussions on what studies they were doing looking at anamnestic [secondary] 00:33:00response that even though you might not have detectible antibodies, you would, if challenged, would respond very rapidly to raise your antibody level. But the anecdote, I'm sure, with interviews with other people, it was not a secret that Dr. Salk and Dr. Sabin were not exactly best friends. I remember I think it was 1983 when PAHO was starting to develop the idea of doing polio eradication, and I was working as a consultant with PAHO. At that point, I was no longer with CDC. And I was at that meeting, kind of an overview on polio of where do we go next? And it was a call to action to put forth a plan for eradication. I put 00:34:00together all the data on polio in the Americas to present at that meeting, but Dr. Salk and Sabin did come, both of them, and that was a very unusual event. The two of them were not known for going--if one knew the other one was going, they wouldn't come. And they both were called on to talk, and they went alphabetically so Dr. Sabin went before Dr. Salk, and when Dr. Sabin got up, the first words he said were, well, I wanted to go down on record publicly that Dr. Salk and I are in complete agreement, there is no use for two vaccines. And it brought down the house. If I remember correctly, it was a standing ovation 00:35:00because it was quite on target.

TORGHELE: Very clever.

POLLACK: Yeah.

TORGHELE: So, did you also get to know Dr. Sabin?

POLLACK: No, I didn't. I just didn't. He didn't contact at least my level at CDC. I was not contacted by him. I did meet him at meetings, but I never really had any sort of interaction with him.

TORGHELE: So, you knew two of the real public health icons of the day.

POLLACK: Yeah.

TORGHELE: That's quite a treasure.

POLLACK: Yes, very much so.

TORGHELE: One of the things that distinguishes you--besides your self-direction--is being a woman at that time. I wonder if you would talk a little bit about what that was like for you-- if there were difficulties that you found and how you handled those things.

POLLACK: Let's just say the best way to put it was I felt as though I had a congenital anomaly, I had two X chromosomes, and it was a challenge. It institutionally reflected not just the institution CDC, but it reflected the greater field of medicine in the United States when I would do work 00:37:00internationally, whether I was seconded from CDC to PAHO or afterwards after I left CDC and was working internationally. Within the countries I think women were facing the same issues I faced back in the states, but I didn't face them because I was an international expert coming in, and it was quite nice not to have to be fighting to be heard, not to have to sit there and take a lot of abuse when you're in a meeting and you may raise a point and it is totally glossed over, nobody hears it, nobody listens to it, and then later on one of the men in the meeting will raise exactly what you raised and have everybody say what a wonderful idea it was. So, there were many issues, there really were, but 00:38:00it was institutional at CDC as well as institutional for the profession of medicine. My year nationwide--I remember the New York Times showed a graph, and there were seven percent women.

So, we were novelties; the general sense was more that in some schools of thought, well, you're taking paying jobs away from men who have to support their families. So, it was a challenge. You asked how I dealt with it. Not always in the best way, but one had to--it depended on where you were. There were some 00:39:00locations where there was a lot of support, and I personally tended to try to gravitate to work in those environments and try to avoid the necessity to fight for one's rights.

TORGHELE: When you had other women who worked in public health at that time, was there a way for you to band together to share your experiences of things that worked and didn't work?

POLLACK: The answer is yes. In those days, I think we figured out there was only one career female at CDC in the scientific, technical staff. [Dr.] Mary [E.] Guinan put together a group of women. Mary was a few years ahead of me EIS, and 00:40:00she put together a group of women to try to figure out what could be done about it and how to approach leadership about what the problems were and how to resolve it. And one of the issues in raising that there weren't career women there was the response back was, well, why aren't women applying for career development? Which sounds logical. Only in those days, you got tapped for career development, and if you weren't tapped, you weren't getting career development. It really wasn't an open access. It was kind of known that they would suggest to people why don't you consider doing career development. And it was pointed out no woman had ever been tapped.

TORGHELE: Did that change then?

POLLACK: It did. It evolved. We did have one of the women in our group--my EIS class had the most, highest number of women for those days and there were five of us which meant that previously the women had been predominately assigned to family planning, that that was the nice safe place for women to be. But [Dr.] Claire [V.] Broome had a supervisor. Claire Broome, a super bright woman, excellent, and she was tapped. So, she was able to go through development and stayed on career.

TORGHELE: She was one of the first at CDC to make a career as a woman?

POLLACK: She was in the early batch. There had been the occasional woman who would stay for a little bit and then leave. I can think of a few names, but Claire was definitely a vanguard spearhead in doing that.

TORGHELE: When we were talking about your outbreaks, one of the ones that is of most interest was the Amish polio outbreak. I wonder if you would talk about that for us.

POLLACK: I'm sighing. It actually was a continuation of an outbreak in the Netherlands, and I think it's important to give that backstory that's part of it. There was an outbreak in the Netherlands among a religious group that didn't 00:43:00accept vaccinations, and if my memory is correct, their susceptible population were considered to be up through age twenty-seven. That's how long it had been presumably since the last outbreak had been in that community. They ended up having eighty cases in the Netherlands where an approximate risk group--I remember in those days the number of 80,000, so we were thinking of a paralytic to a non-paralytic ratio of one case per 1,000 infected if we assumed everyone was infected. I've reread some of the publications recently, and I'm seeing numbers of maybe 66,000. But the outbreak went on there. It also spread--there 00:44:00were communities of the same religious group in Canada and in the United States. They started having a few cases in Canada in the communities, so everybody started looking and checking on the vaccination status, and it was a very interesting--basically information that came out. The group in the Netherlands totally rejected the vaccinations. The communities in Canada, about 50% accepted vaccination, and were vaccinated-- 50% weren't. The groups in the U.S. were completely mainstream and accepted vaccination totally. So, we thought we were getting off easy on that at that point, and we followed it. I remember I was on 00:45:00the phone with the head of communicable disease in the Netherlands almost daily, or definitely multiple times a week, Dr. [Paul] Bijkerk, and I would get updates on what was going on in the Netherlands and the virus. And I can't remember the timing of when CDC did get a copy of the virus, and in those days, it was felt too, from the markers, the genetic testing--and I say genetic testing in quotes, it was definitely more primitive than we currently have today-- it was a virus that we were told resembled a virus more from Kuwait. In hearing further, I learned that, apparently with more sophisticated genetic testing, it was 00:46:00redefined as felt to be a virus that was seen in those times in Turkey. Anyhow, we were following that very carefully, including there was a family in London, Ontario that had ten children, and three of the ten children had paralytic polio. Well, there had been stuff in the literature about possible genetic predisposition for it, so I got permission to go up to Canada basically to use the vernacular, bleed the family, to take specimens from the family to do genetic testing and try to see--in those days we were using HLA [Human Leukocyte Antigen] typing, and we were starting a study working with the immunology group 00:47:00at CDC to do a study on it. And that was our level of involvement in that outbreak. That outbreak ended, and several months later, four months later, there was a case in Pennsylvania in the Amish. What we learned in delving into it was that a family--there was an Amish community fifteen kilometers from the Netherlands religious group in Canada, there was a community about fifteen kilometers away that obviously did have some interaction, and a family had moved down four months earlier.

We postulated--that was in the month of January--so we postulated late fall, early winter that there was slow transmission of this virus, and also as I alluded, we felt the range of paralytic to non-paralytic ran--nowadays we talk about it's an average of 1 in 200-- for every 200 infected individuals there's 1 case. In those days we discussed it more that we saw a range from a low of 1 in 1,000 to a high of 1 in 50, and we felt in this case we were dealing with a less neurotropic virus that was giving us 1 in 1,000 based on the Dutch experience so that we could see where it might've slowly been transmitted among the community 00:49:00until that case. And so, we had that single case, and the Amish community was not well vaccinated at all. They had not accepted vaccination, and there were communities not just in Pennsylvania where the first case was, and there were several cases in Pennsylvania; there was a community in Maryland, a community in Iowa, Michigan, Indiana, I believe. I'm not remembering all of the states, and I apologize even though I read up on it again. And one thing that the Amish did, they had been confronted--genetic studies had been done in the community because there was a high incidence of inherited disease in the community and when 00:50:00studies had been done, anthropologic studies had been done, what was learned was there was a lot of intermarriage going on. So, the community was educated on the risks of the intermarriage, and they changed their culture basically, and during the non-growing season, since it was mostly an agricultural community, the men of marriageable age would travel to communities far away to look for spouses. And then there were weddings that brought people together, and this kind of mixing of the communities helped the poliovirus spread among the communities. 00:51:00So, all told, we ended up with fifteen cases, a lot of infected people. The same debate that went on with Texas and the imported cases from Mexico of should we be doing mass campaigns in all of the communities, we debated and said, no, just make sure everybody's up to date with the exception of Lancaster, Pennsylvania where there was a large number of cases and a very large community with interaction because it was a tourist location. So, there was a lot of interaction with the general community, and it was felt, alright, that county we would have a vaccination program, mass campaign.

TORGHELE: When you worked with the Amish, because of the way their religion had them living, it was very--no modern appliances, no electricity, right? What about culturally communicating with them? How was that for you?

POLLACK: I personally was not involved in communicating. I was finishing my second year EIS, and I was moving over to immunization division, which in those days did not include polio, so the transition period when CDC was invited to go and assist was after I left the division. My communication was with the state health departments, and what they were doing, which I thought was fantastic, was working with medical anthropologists to understand some of the community and how to negotiate some of the discussions. And one of the things I remember walking 00:53:00away was one of the discussions they had was the response on the part of the Amish about vaccinations and why not taking it was it's God's will. The counter-response that was given from the side of the health department was, but if God wanted you to suffer from polio, would God have permitted the discovery of the vaccine? And from what I remember, that seemed to be a very effective discussion point. And my memory--the leaders in the community--each community had a religious leader--the way it finally evolved, and I hope my memory is 00:54:00correct, but the evolution was the leaders agreed to look the other way and let each community member make their own decision on whether to accept the vaccine or not but that there would not be castigation on the part of the community for those who chose to accept it, which I think related somewhat to the discussions and interchanges that went on for sure.

TORGHELE: The best possible outcome.

POLLACK: Yeah. The outbreak was over--the first case was in January. Sequentially I think we started seeing more cases in March. There was a wedding that brought a lot of people together that helped amplify both geographically as well as numerically, and the last case had date of onset in the end of June. So, 00:55:00it was a fairly well circumscribed--and there were a total of fifteen cases which is a lot but not a lot if you looked at, in those days, worldwide there were over I think the estimates were 350,000 cases a year. So, fifteen worldwide was a drop in the bucket. For the U.S., it was huge.

TORGHELE: Was this the last outbreak in the United States?

POLLACK: Yes. It was a pleasure. It was nice to feel as though we all worked ourselves out of a job, between quotes, in the U.S., in a sense.

TORGHELE: You also had some involvement with the Pan American Health Organization in eradication efforts for the Western Hemisphere. Do you want to talk a little bit about that?

POLLACK: Yeah. I left CDC; I had been working in immunization division. I had been interested in globally in doing international health. As I mentioned earlier, I did have that chromosomal anomaly that was somewhat of a challenge and barrier, and I was seconded to PAHO several times while at CDC, both for dengue fever, for a meeting, also for polio. There was an outbreak of polio in the Dominican Republic that I was seconded to PAHO for, and when I came back 00:57:00from that trip, I had another request from PAHO to go to Brazil to work on polio, and I had a request from SEARO, Southeast Asian Regional Office, to go to India working on doing baseline surveys on neonatal tetanus and polio. Well, if you remember historically, I went to my advisor asking if he knew anyone in India, so I clearly had an interest in going to India, and Brazil having studied there, I had a love the word in Portuguese is saudade and I had saudade for it. I love the country.

So I clearly wanted to go, and I went to my indirect supervisor, [Dr.] Alan [R.] Hinman, at that time, and I told Alan about the offers I had and asked could I be seconded, and he said I would love to be able to second you but you do have a domestic FTE, full-time equivalent, you have a position domestically and we kind of need a little bit of stuff domestically. And he looked at me and said, go for it, do it, that's what you want to do, go! And it wasn't said in a means of I want to get rid of you. It was said as really a mentor saying this is what your love is, go do it.

And I did, and I went to Brazil, and I worked on developing their polio control program. They were just starting to do campaigns. This was 1980, and I remember 00:59:00working on developing a manual. I will preface, I did speak Portuguese because of when I had studied in Brazil I learned Portuguese and I did travel around the country a bit but not that much that time, and I spent the next I guess four or five years really working with PAHO a lot, working with [Dr.] Ciro [Carlos Araujo] de Quadros, who really was an amazing person, the driving force really behind polio eradication and deserves a lot of credit. He's no longer with us, but his memory is definitely with us, and I had the good luck and pleasure of working with him. And I would do polio outbreaks. I remember I went to Colombia-- I had been working in the Dominican Republic and I got a call from 01:00:00Ciro saying there's an outbreak of Guillain-Barré Syndrome in Colombia. And I flew down there and traveled around the country including a helicopter going to a casario in the mountain in Antioquia which is where Medellin is and having to negotiate with the then epidemiologist who kept saying we're expecting seventy-five cases. They were having cases in the Medellin bases and we expect to have them, and here's our data. And they had wonderful data, historical data, and after about two days of this and my being flown out to a casario that took two days by horseback to get to, but you had 90% of the population living in the Medellin bases, and I finally turned around and said, well, you know, you 01:01:00probably will have the seventy-five cases, but if you'd like to discuss how you can have fewer than seventy-five cases, that's why I'm here. And we sat down and spoke about what they could do for interrupting--well, (the) first thing we did document that it was not Guillain-Barré Syndrome, but it was polio--I left that out. But that was one of the things, and that's what I did, and then Ciro was very strong on doing polio eradication, feeling it would be ideal. He had been very involved in smallpox eradication. His primary supporter of that decision who he had worked with and spoken with about was [Dr. William H.] Bill Foege, who definitely believed in eradication, and then it shifted into a mode of what 01:02:00was gonna be necessary for eradication. There was the meeting of getting (the) scientific group that worked in polio behind it, and then it was preparing a plan of action which I helped to write for polio eradication in the Americas. And in '85 I remember I went down--we were preparing that to be passed at the annual meeting of Ministers of Health in June but went down, and I may be off, date-wise it was afterwards I went down to Brazil to look at basically doing an assessment of the polio control program that I had worked with them. I really was just a helper. The Brazilians did all the work. But I went back to look at 01:03:00that and look at it with a focus on what were important issues for disease surveillance for polio eradication. And when I arrived in Brazil, they had had e suspected cases of which only four were confirmed. So, I asked to go through the files, and I went through the files, and I said, uh, Houston, I think we've got a problem here. And I went out with teams to investigate, and within a few months' time, we had identified over 400 cases. There was a huge epidemic ongoing in northern Brazil in the northeast, including where I had studied years earlier. And the way we did it, I would go from state to state. I think I ended 01:04:00up covering about--all totaled, I've been to about seventeen states in Brazil. On that trip, I think easily ten or twelve. And people would come from (the) central level, we'd work with the state health department, and we would go, and we would investigate, and we would do active surveillance, and that's when we discovered all of these cases. An unusual diagnoses because what we uncovered was the fact that the doctors in Brazil, because they had been doing all the campaigns, hadn't been seeing polio and therefore when they would see something, well, it couldn't be polio because we've taken care of polio, everybody's vaccinated. So, I remember reviewing charts in the hospital, going in the 01:05:00records rooms and looking at possible--from the suspected cases that were ruled out and then just reviewing ones that weren't even reported, and one of them had a diagnosis of trauma. Okay, trauma to the lower limb. Well, the reason there was trauma was he was paralyzed, and he fell, and that's when he hurt himself. But he had acute polio. And this is what we were uncovering were some of the creative alternative explanations for acute flaccid paralysis that we were finding. I mean, I'm smiling at it now. I was not smiling at the time. And it was just the Brazilians were amazing to work with in public health. They were fantastic, and we really traveled around, we had our traveling roadshow of 01:06:00investigating with the state health department people so that everybody was being trained, and we were learning. I mean, would I have thought of looking for trauma as--I wouldn't have thought of that in the beginning. What I do remember is by the time I was ending and I was going to be going back to the states, one of the comments from the under secretary of health who I was working with, Dr. Hezi (unclear) made, we had over 400 cases and Dr. Hezi (unclear) said to me, well, the first step we're gonna have to do to eradicate polio in Brazil is to get you out of here because you just keep finding cases.

TORGHELE: It was your fault.

POLLACK: It was my fault. And I looked at him and said, I'm sorry, I'm leaving-- start work, I'm leaving. And they did an amazing job, they really did, and 01:07:00eradication in the Americas was declared--it was announced, the goal for eradiation was announced in 1985, and the last case of polio in the Americas was in Peru in 1991 and in fact they were declared having eradicated polio in the Americas in 1994.

TORGHELE: Sounds like a miracle.

POLLACK: It was an amazing experience.

TORGHELE: Now, going back a little bit to the CDC days again, you still probably worked with some of the people from CDC after you left. For instance, when doing 01:08:00this PAHO work, did you also work with some CDC people?

POLLACK: Not really directly. I definitely interfaced a lot, but not really directly, but I was constantly speaking with Pete Hatch. If there were questions from the laboratory side in the early days, Pete was working on setting up a laboratory network around the region, and I would--I kept in touch with people but direct--not really. My liaising with CDC after leaving it, I worked a lot also with what's now the field epidemiology training programs in helping broker and set up and develop new areas so that when I would do a project design with 01:09:00AID funding, I suggested this would be a great place to strengthen epidemiologic capabilities to put in what we called in the early days a global EIS, and some programs were started that way.

TORGHELE: So, your input helped to shape those programs?

POLLACK: A little bit.

TORGHELE: As they should! How many countries have you worked in?

POLLACK: Well, over fifty. I think my count may be up in the sixty or seventy range. I don't know; I haven't done a count in a while. But I've worked in a lot of Latin America, a lot of the Americas because I did go back for PAHO and do a similar exercise that I had done for polio for measles to work on the measles 01:10:00elimination plan for the Americas as well with Ciro de Quadros. That was 1989. But I worked in the Americas region; I worked in Africa, a lot in francophone Africa. I speak French and Spanish, and I've worked now in the Middle East a bit, and I've worked in Southeast Asia quite a bit. So, I've been around. I've worked in a lot of countries. I've had a side interest through the years in anthropology and linguistics, and this work has allowed me to indulge in those interests.

TORGHELE: And you've been able to maximize that experience.

POLLACK: I've tried.

TORGHELE: When we were talking about your work these days and you're being a deputy editor; would you say more about that publication?

POLLACK: Okay, ProMED mail stands for the Program for Monitoring Emerging Diseases. It is a program activity of the International Society for Infectious Diseases, ISID. It was started back in 1994 as an offshoot of the 1991 IOM, Institute of Medicine review on emerging diseases and the recognition that our disease surveillance had weaknesses. And this was in the early days of the 01:12:00internet, and the concept was how about using the internet as a source for information exchange on it? And it began as a moderated listserv, what we used to call moderated listserv, but it's an electronic discussion group moderated with cadres of expert moderators so it's not a blog where people can post directly. And we really worked on developing the use of nontraditional information sources as a source of information, so you have a network of people. It's almost like a social network of people who are interested in emerging diseases.

ProMED covers plant, animal, and human diseases, very much on the zoonotic diseases, also because of food security so animal and plant, and also acute toxic exposures. And we've grown and developed. It was started--the father of ProMED or grandfather now was [Dr. John Payne] Jack Woodall, who I worked with on my first dengue outbreak when he was in charge of the dengue lab in Puerto Rico, so Jack was a former CDC-er who then went over to WHO [World Health Organization] and he started ProMED. Basically, at ProMED we use nontraditional sources rather than--we use traditional sources when we can, but we quickly learned that the media was a very good source and the media--you pick up the 01:14:00paper--I remember when I was at CDC, we dreaded if we got a call from the media. If a journalist called, we were in fear. But as it turns out, there are some very reliable journalists who think the same way we do and they're great for investigating and finding out when there are problems.

I've put together in a talk explaining why it's not the fault of the public health system for not being able to find these outbreaks because the realities are that a lot of cases don't come to the attention of the official sector. I have a series of slides that I put together kind of showing a cluster of cases and showing how only one out of five would come to the attention, and a severe 01:15:00respiratory illness during the febrile respiratory illness season won't ring an alarm bell. But if you know, there are five like it, that will ring an alarm bell. That's where using alternative sources--and I've through the years and especially also with polio, it was always looking for alternative ways of getting the information and I gave that anecdote about the outbreak in Mexico how I went around the official channels to get the information in twenty-four hours as opposed if I had gone through official channels, average would've been six to eight weeks, if even, and that was kind of a mantra I had through my consulting career. With neonatal tetanus, I remember doing an assessment of 01:16:00using a methodology to determine that there weren't more cases, and it cost to do it, lot quality. But it was $20,000 to do it, and I was doing the study in Bangladesh, and I discovered that the family planning folks on the other side of town had data on pregnancies, pregnancy outcomes, all of the above. So, I took a rickshaw over to the other side, had meetings there, got all of the data, and in fact, I got basically pretty much the same information that the lot quality assessment had done. So when I presented it at a TED meeting, I presented comparative cost, and it cost--I think my rickshaw cost $1.50, then there was 25 01:17:00cents for the cup of tea I was given when I arrived, 10 cents for the biscuit, another 25 cents for the 2nd cup of tea and another $1.50 for the rickshaw to go back to the health office as opposed to the family planning group, compared with $20,000 and here's the--and I just presented that. But what it was looking at alternative sources of information, and that's what ProMED is all about, looking at alternative sources. We, for many years, were considered the enemies, I guess because we got information before other people got it and now event-based surveillance has become a household word in epidemiology, and it is basically 01:18:00using alternative sources and accepting them as getting information on outbreaks sooner.

TORGHELE: So, it sounds like what you do is you present these ideas and let people come to their own methods, too, that are similar and work for them. So, you present a situation in which you used that kind of alternative thinking, and it helps them to think outside of the box as well.

POLLACK: Yeah. I have a bunch of slides about outside the box, thinking outside the box. But yeah, but with ProMED, I'm also while I'm Deputy Editor and I serve as what we call top moderator where everything goes through that individual 24/7 for a week at a time, I also serve as the epidemiology and surveillance 01:19:00moderator and because of my interest in polio, I write the reports on polio and follow polio as one of the things and also some of the unknown that were initially unknown new organisms. So, I still follow the MERS, the Mid East Respiratory Syndrome outbreak in the Middle East, and I did do the reporting on SARS [Severe Acute Respiratory Syndrome] when the SARS outbreak was back in 2002-03. But ProMED is a terrific initiative, and one of the initiatives we're working with is crowd sourcing now to help get validation on the ground for some 01:20:00of the rumors we hear. We have volunteers that we send requests for information to, so we're trying to help ultimately ministries find out more, get confirmation of things going on in the country.

TORGHELE: So, you have a network of people that you work with.

POLLACK: Yeah.

TORGHELE: That's really a great use of resources.

POLLACK: Yeah. We have our subscriber base, and the first case of MERS reported the physician virologist who identified the virus sent us the report, and we posted it on ProMED. And for SARS, the first report we posted which was the first going public on it, one of our subscribers had heard rumors of stuff, he knew someone who had a friend who belonged to a teachers' chatroom in Guangdong, 01:21:00China and they heard that there was an epidemic and people were dying, hospitals were closing, and asked us did we hear anything about it? We hadn't, and we tossed, is this a rumor, so we kept searching, looking, we found one sentence in the Chinese language on the Hong Kong website saying there doesn't seem to be any threat to Hong Kong right now, we're keeping an eye on it, but we'll keep everybody posted. And when we saw that as a completely separate source as valid, we went, and we posted it. Twenty-four hours later, there was the confirmation from the Chinese Ministry of Health that there was an outbreak in Guangdong. So, networking and using backchannels in addition to using media reports and other things.

TORGHELE: You're maximizing the resources available--

POLLACK: Yeah.

TORGHELE: --and tying them together.

POLLACK: Yeah.

TORGHELE: One of the things I wanted to ask you about was you had written for your publication an article to the Anti-vaxxers, and I wondered if you would talk about that a little bit.

POLLACK: I guess backtracking, during my PMR [Preventive Medicine Residency] year in immunizations I worked with people on developing what was the precursor to the Vaccine Reaction Monitoring system, we called it ARMS in those days, Adverse Reaction Monitoring System, and so I was very--during that time we had a computerized system, we were trying to get people to report in and it was 01:23:00voluntary reporting, it wasn't mandatory reporting, and we tried to get people to report in and we were testing limits on the computer what would flag if there was a problem with a Lot with the vaccine. And I remember the first threshold series we used was ten reports of any sort of reaction to a Lot-- three reports of serious neurologic seizures or something else and one death, and that would flag our investigating a Lot. And at that time we did have Lots come up for investigation, and we had one Lot show up as very hot, it was hot in Denver, Colorado, and we investigated, we got the distribution information for the 01:24:00vaccine and it had been distributed to about six different states, the particular Lot, but the only state where it was hot was Colorado because we tried active surveillance as best as we could in the other states. Then we realized that several months earlier we had the National Immunization Conference in Denver, Colorado and I gave a talk on the Vaccine Reaction Monitoring System and wherever a conference is held, you get a lot of local people there including I have family members who live there, doctors, and brought their friends and colleagues. And we realized that what we had done was creative, active surveillance in that state and that we really couldn't find a problem with the 01:25:00Lot. Well, the anti-vaccine movement weren't happy campers about that, and there was a book written in I guess the early '80s I think it was, and it was called "A Shot in the Dark" written by the Anti-vaxxer Movement. And I'm proud to say that I'm named in it as being part of the government coverup for that particular investigation. So fast forward, needless to say I've kept an eye on the Anti-vaxxer Movement and I was asked--I periodically write and coauthor with Dr. Donald Kay, my advisor from medical school days who is also a ProMED colleague now, and I coauthor articles for the IDN, Infectious Disease Newsletter that 01:26:00goes out and one of the topics we chose to write on was the Anti-vax Movement, specifically with respect to measles and the damage that's gone on. There are preventable deaths and serious diseases that are happening due to the Anti-vaxxer Movement, and that's painful to see.

TORGHELE: We've been talking for a while now, and it's been so interesting. I know we could talk for a lot longer, but I wondered if you had thought of things you would like to include that we didn't cover.

POLLACK: What you didn't ask me about is the state, I guess, of polio eradication and thoughts about it and challenges. And one of the pieces I wrote for IDN was on End Game, and I think if I remember, the title was "End Game Hiccups." And there have been surprise packages that the virus and the vaccine virus have provided that leaves a big question mark of how to overcome it, but I guess I would make myself unpopular if I elaborated more on that. I might make myself very unpopular and unwelcome in certain venues.

TORGHELE: Doesn't seem like it's ever stopped you before, Margie, in a very good way. You've accomplished a lot of good with your direct approach.

POLLACK: Like a bull in a china shop. I raised the questions of are we going to be in a vicious circle now with what's happened with the vaccine virus, with the circulating vaccine-derived polioviruses, the fact that it's predominately type 2. The fact that type 2 has been removed from the oral, although the oral is now being supplemented or being predated now with the killed vaccine, the inactivated, the IPV, but there are outbreaks. This last year 2017, there were 01:29:0094 cases associated with circulating vaccine-derived poliovirus type 2. Seventy-four of those cases were in Syria, and twenty were in Congo-- DRC, (the) Democratic Republic of the Congo, in three different locations in the Congo. The question are we going to be in a vicious circle, you get the circulating--I'm sure other people you've spoken with have discussed it in greater depth-- it's an indicator of pockets of susceptibles where there's low vaccination coverage, the vaccine virus is out there, it keeps getting transmitted with each cycle 01:30:00through humans. There are mutations, and it reverts in its neurovirulence and behaves really very similar to how the wild poliovirus behaves. Well, we've now got a situation of outbreaks due to it. Outbreak control measures are used monovalent type 2 oral polio vaccine, so are we still seeding the environment with vaccine virus that will still come back to haunt us? And I think that's some of what we're beginning to see. There's a report this month of the vaccine virus, vaccine-derived poliovirus, circulating vaccine-derived poliovirus type 2 in Kenya. There was a report last month in Somalia. I wonder, and I raise that 01:31:00as not a definitive it can't be done, but I think unfortunately through the years what I've always said is the best bioterrorist out is Mother Nature, and I think she's proving it. So, I just wanted to get that in, and will you escort me to my car so I can go safely?

TORGHELE: I think you're in good hands here. Those are good discussion points that I know people need to be aware of if they're not. And you have a very logical way of looking at it that has to be good. I just want to say thank you so much for your perspective. It certainly has been interesting to hear from a woman because there weren't many of you in those days. There are more now, but your approach reflects that, too. Your career and your perseverance and made a big difference to a lot of people.

POLLACK: Thank you for thinking of me.