Elias Durry - Session 3



CRAWFORD: Today is Wednesday, February 28, 2018. This is Hana Crawford for the Global Polio Eradication Initiative [GPEI] History Project. I'm with Dr. Elias Durry [MD, MPH] in the broadcast studios of the U.S. [United States] Centers for Disease Control and Prevention [CDC] in Atlanta, Georgia. Todd [F.] Jordan is our videographer, and this is our third interview.

Dr. Durry is currently Africa team leader in the Polio Eradication Branch of the Global Immunization Division [GID] of the Center for Global Health at CDC. He's also chairperson to the Outbreak Preparedness and Response Task Team. The interview is going to focus on your roles since South Sudan and working in Nigeria, basically 2007 to present. Thanks for being here today. Do we have your consent to conduct the interview?

DURRY: Yes, you do.

CRAWFORD: Great. Thank you. Would you introduce yourself by name and then pick up where we left off, more or less?

DURRY: Yes. Thank you very much. I'm Elias Durry, working at CDC. Just to update your introduction, actually, currently I'm coordinating the CDC's outbreak response for polio.

CRAWFORD: Thank you.

DURRY: Yes. We talked in detail about while I was actually detailed overseas, meaning up to 2007. From then, I came back to Atlanta and took on to be the team lead for the EMRO [Eastern Mediterranean Regional Office of the World Health Organization, WHO], regional office. EMRO is Eastern Mediterranean Regional Office. At that time, it was just trying to still continue to support some really high-risk countries like Sudan, Somalia. Of course, Pakistan and Afghanistan. In between, I was also traveling to India for the last years to support the activity there.

Other than just sitting in Atlanta, I went back to WHO, to South Sudan for about a year. This is when they had reintroduction of the wild virus, the virus that came originally from Nigeria. South Sudan was also one of the countries that was afflicted at that time, in addition to Somalia, Yemen, and across the belt of Africa.

After I returned here, what was going on between 2007, '06, especially after the close to eradication of the virus in India, we felt like we were stuck: low level of cases, not a lot. Less than a thousand cases. Really, we just, especially after India was eradicated, the globe and all the partners really got very concerned that if we just continued going the way we were going, we would never reach there. It's like a slow death with no major or game-changing situation involving Pakistan, Afghanistan, and Nigeria. These countries were just stubborn. The activity was going on for years. It became like a day-to-day activity. The commitment from governments cannot be--there was nothing there to compare it to, so it's just a normal activity.

In 2011, the World Health Assembly took on the issue and really said that from now on, polio eradication cannot be just as any day activity. They have raised it to the level of calling it a "public [health] emergency of international concern."

CRAWFORD: Margaret Chan [Fung Fu-chun, MD, DSc, FFPHM, MScPH], right?

DURRY: Yes. They have demanded or asked each of these three countries for the polio program to be run at the level of presidents or prime ministers. We have demanded that each country will come up with an emergency action plan and so on

In 2012, I was asked to go and support Pakistan in this effort. It was clear that we could not do those things that had been--we could not eradicate polio--by the time I went there, there were about more than a 145 campaigns. Everybody was just doing the same thing.

What we did was as soon as we went there, we came up with the national emergency action plan [NEAP]. This action plan called for not only what to do, but especially accountability and responsibilities. The core issue was really to take the polio eradication out of the minister of health and bring it to the highest level of the government, meaning the prime minister's office. It called for a special prerogative [phonetic] to run the program who is answering to the prime minister himself. Our meetings and our activities were also managed in the prime minister's office. When you go further down, also, at the provincial level, they also were supposed to be run by the chief minister, which is the same level of the prime minister.

The second thing was that the overall polio activity in the field will not be just run by the ministry of health, or the ministers of health. The ministers of health would collaborate, but it would be run by the similar two mayors' level. They call them "deputy commissioners" or "commissioners." It meant that the deputy commissioner or commissioner will put everything that they had to put on the table to make sure that children are immunized, and especially to make sure that a lot of issues that were hindering from reaching through every children, to fix that. For example, the WHO gives money for the campaign to the ministry of health. The ministry of health will keep getting it through in ranks all the way down to the field. As you can imagine, this is cash money that used to go to them. As you can imagine, everybody is obviously looking for ways of getting more [money].

What you see in the field as vaccinators, either they are small kids, or even those ones who go out who really take this as part of their income, they will not do their work, so they will not really go everywhere that they need to go. Basically, you have a large chunk of population that are never reached or will not be reached. With that kind of thing, you cannot eradicate polio if you don't reach every child.

When we brought in the deputy commissioners, we raised the stake very high, and in a way that even the performance of a deputy commissioner in his other performance measures, what he did in polio or what she did in polio would be counted. It's a very serious impact in their own political career.

Although, the fact that it was just a quick, dramatic and a major change, it's helped the program to be really taken seriously. The deputy commissioners would resolve any issues that will come, whether let's say, if a certain group of people really continued to sabotage like they used to, this deputy commissioners have the power to even arrest them because they are--so that was one big change that we brought in.

The second one was just to make sure that the money that is given to the vaccinators will not be, again, misused. We came up with payment of the vaccinators, which are about 220,000 of them through a banking system.

CRAWFORD: Like hawala, but not.

DURRY: No. We received their names in advance. We submit their names to the bank with the amount of the days that they worked. They go to the bank and they show their ID card, and they receive their money. With this, we actually hit two birds at the same time because number one, we knew that the vaccinators would receive their money. No one can cut corners and hire less people than required or--so that's number one. The other one was also that, to have an ID card in Pakistan, you have to be eighteen or above. That way we also removed all of those like--in Karachi [Pakistan], for example, sixty percent of vaccinators used to be children eight years or nine years and maximum twelve. By motivating the vaccinators and also by making sure that children vaccinators were not [inaudible], by that we were able to kind of, again, give it a higher profile with some fairness in it.

CRAWFORD: Can I interrupt for a moment?

DURRY: Sure.

CRAWFORD: One of the questions that came up, I was reading a book called Chasing Polio in Pakistan by a scholar named Svea Closser. She's at Middlebury [College].

DURRY: Yes. I know her.

CRAWFORD: The focus of some of her research is this question of why, in a time when global health is receiving more funding than it has ever received, are we relying on volunteer efforts, and why are people in positions like polio health workers not being paid more? I wonder if you have any thoughts about that.

DURRY: Yes. It's really when we started, we started all this stuff as volunteers. We never told that we will go this far, that we have to pay people. Really, it's a volunteer spirit, it was. I think it's difficult to say whether the payment at that moment or--I think when I went, I know that I have doubled what they used to get when she was there. She was there before me. I know that's when she was there. Still, it may not be enough. What we want to do is just have people, also--not that they do it for the money, but they do it for a cause and they come out, and whatever they need for them to get that day over with, whether it's food or transportation, and plus something that they can take home. Although, eventually because it became such a continuous activity, it became a source of income for a lot of people because it became, you know. I can understand what she's saying. I think the volunteer part, I've seen a lot of them, even when we had difficult time in the later years, even at that time, they were just willing to come out and do what they had to do.

CRAWFORD: Did you see new kinds of impacts of when people started being paid? Like the change from volunteer to paid worker?

DURRY: Well, in all these countries that we have, as I said, a kind of long-lasting activity, I cannot tell you this one or that one, but I can tell you a lot of people made a lot of money out of it. This is obvious. That's why when we started working in Pakistan, one of the things that we really wanted to do was really bring in accountability at all levels, meaning that we can measure what people are doing based on what they planned to do. It's a resource. It's a lot of resources, for sure.

What happens is usually these resources also is managed by a central government. Like I mentioned last time, like for example in Nigeria, I remember the locals in the north, they felt that they had nothing coming to them from everything that is available. The aprons are made in the south. The papers are printed somewhere else. They had nothing to gain out of it. It's not only the payment of the volunteers, but there is so much other thing that--rental vehicles and all this, which usually ends up in the elite group of the country. Those ones who already have deficits, trust deficits, in the government can see these things, and it brings a lot of problems. "You're not working with us, so you're part of them, so we don't want--"

I think for Pakistan it was not only the money part that was changed. It was really the whole attitude. For us also to come up with a very solid technical advice because in 2011, I think they had 298 or something, a large number of cases almost everywhere. It was very good when 2012 came in with all these inputs from all different parts. We did a very good job. Two thousand twelve was very successful, enthusiastic. Everybody was in it. The media was in it. It was really good.

We were able also to at least cut the number of cases in places that did not have any major other issues, like social issues. One of the other problems with Pakistan, in addition to what I said earlier, is the issue of the tribe that is mostly affected by the virus is the Pashtun tribes. It's not just the tribe, but I think what it is, is that their area is also a tribal area where they can rule that place according to their tribal traditions. As you can imagine, sometimes there's difficulty in allowing people to get into their houses or allowing women to work. That always used to curtail the number of children we could reach because as a tradition, they don't allow a man to come into the house, and then they don't allow women to work. Where are you going to get these kids?

What they used to do and what they do is, in every village, there is a place like a guesthouse kind of place where guests could be put there until--since no one can go from house to house, or any house, they put you there. Sometimes they guided the children there and so on, but you don't have a chance of asking, "Is there any more child in this house or in that house?" You can't go house to house. That was an intrinsic problem that we had and we still have even now, both here in Pakistan and also in Afghanistan. That's a problem from a tradition, which is their tradition. You can't do much about it.

Because of these things, there were few places that we called "reservoirs" in Pakistan, few areas. Among them, the worst was Karachi. In Karachi, also areas where the Pashtun are still residing, the whole of Peshawar. That's in the north. It is close to FATA [Federally Administered Tribal Areas], the tribal area. The other one is Quetta, what we call "Quetta block" in the east. That's also heavily populated by Pashtuns.

In addition of that tradition, there was also problems with the acceptance of the vaccine by the public with similar rumors that were in Nigeria in these communities. You add to that the influence of Taliban, also. We had few places that we knew, that we called "reservoir," that we were really hoping that we'd be able to overcome the problems. Although in 2012, Karachi and Quetta did well, the area close to Peshawar and some other districts closer to Peshawar, they had some breakthroughs, and we had like fifty-six cases in those areas.

Then came December of 2011. Disaster. This is the day when they started to shoot volunteers, and the first day, I think we lost nine volunteers in three places at the same time. From then on, things just went--now, in 2013, things just started to go down the hill because these places that we really needed to be and work became really a war zone for us, for the polio program. We were specifically--or the vaccines were specifically targeted. Again, it was not in any other place, but this is the place where polio was flourishing. That took a lot of momentum from the initiative that started in 2012. Although it's much better, but I think the consequence is still, we are still paying for that.

CRAWFORD: In 2012, there was a leaflet circulating, right, that was communicating that vaccine would cause infertility, all kinds of rumors and misconceptions, but that wasn't the first time the Taliban had interfered in vaccine or communicated--

DURRY: No. The Taliban have [an] interesting, actually, engagement with the vaccination. When they used to be running Afghanistan, they were very supportive, but before the incident of starting killing--you could say before the incident of Osama [bin Mohammed bin Awad] bin Laden, also--there were these rumors all the time. These rumors were there all the time, but we were able to sometimes cheat the virus, also, but work with the community also with some of the religious leaders.

What I mean by "cheat" the virus is what we were doing was we were using what we call "short interval" additional doses. Rather than going and immunizing every four weeks, we were immunizing them every two weeks to quickly raise the immunity of the children, and also to cut the possibility of the virus to keep circulating for the next, you know. That helped us a lot, but that was really like trying to, like I say, cheat the virus and really get out of there as soon as we could.

It helped, but polio eradication is also not a whack-a-mole. If you do it like that, you will never--if you work very hard in one area, and then you have a problem in another area, once you're done with here, the problem from the other area will come, also. We had to do, and we still have to do, these good campaigns, reaching every child at the same time across the board.

All of those efforts that we brought in and the government brought in get really seriously challenged by the killings. Then we had to come up with different ways of doing, and basically it was two strategies: it was negotiated access or protected vaccination. With negotiated access, what we tried to do, like in Karachi and now it has expanded tremendously, is to give the community all of the necessary--like the way we were doing, like I was telling about with Somalia. But here, more, allow them to choose their own people, especially woman from their own--they have to decide who those persons are and give them an opportunity, where they don't have to come only for the campaign, but work throughout the month, and sitting and discussing with the parents.

That's what we called by "negotiated access." We don't go in, but they will do the work as much as they could. Currently, that strategy has been expanded to a lot of places, and it's fine.

The second one was protected campaign. Protected campaign is not something that we really wanted to [do], but we could not let out vaccinators in these places without police protection. Every vaccinator, either they are encompassed by a group of police, or they are escorted by the police. That is OK to some extent, but it's not sustainable to go back again and again, and there are not enough police in the world to come in and do this all the time. Then we could not do campaigns the days that we wanted to, or they extended for like, what? They used to be three days, like ten days. Two thousand fifteen was just lost like that because we could not do anything serious about it. Although there was a great commitment from the government to protect the vaccinators, but it was really difficult and almost--not impossible, but very, very challenging because with the media and everything, also, when any of the shooting happens, everybody hears about it across the country. All vaccinators started to really get panicked again and then they stopped it here, stopped it there. It could not do the job.

CRAWFORD: House to house, how were Pakistani police received by families?

DURRY: You see, the problem is where they are not already received well because in [inaudible] and in places that there's no problem, there's no problem. In these places where the killing happened, sometimes even the police doesn't go in. It's already a hostile community, so it could not be the final solution for this. What we did was in addition to really working with the community and with the religious leaders, that was a full-time job of us, just trying to figure out how to convince and come up with a way that there is--

Of course, the Taliban has kind of stated officially that they will not allow to vaccinate. It's not kind of whether they are in it or not, but they made official announcement that they will not allow [it]. In addition to what I said earlier about the community participation, we also started very heavily to be engaged with global religious leaders, including Mecca and Medina [Saudi Arabia], bringing scholars to the country, taking the scholars, the religious scholars from Pakistan to other countries, and so on.

There were two districts of administration in the tribal areas where the Taliban officially declared that there would not be any vaccination, which is North Waziristan and South Waziristan. Even when we were immunizing kids in Karachi with a lot of difficulties and all, these two places were absolutely not touched. It was where the Taliban had their stronghold. As we expected, then a big outbreak came out of the same place, North Waziristan and South Waziristan, if you look at the number of cases. While we are struggling to kind of manage the killing on the other side, in the other part of the country, we just could not do anything about two places where we see that more than a 140 kids were paralyzed. Viruses from those areas come out and infect other areas.

Then, I think 2014, something serious happened. No, OK. Before that, we started to also engage with the military, with the army because this, what we call "FATA," these tribal-administered areas, they may have what they call commissioners or whatever, but it's really run by the army because it is bordering Afghanistan, and movement and everything is--so we knew that to do anything there, we cannot do it without the help of the army and without the knowledge of the army.

CRAWFORD: What kind of knowledge did you need from the army?

DURRY: They just need to know where we are, where our people are going, when the campaign is because they don't like people just to move around in those areas. We established that relationship and we were telling them that--especially I was telling them that we cannot just leave this issue of the killing to the police and to the administration or others because I was not hearing any narrative from the government side. On the Taliban side, they tell them you are spies. You are this. "This vaccine is sterilizing our children," but nothing was coming from the other side to say--not to just answer those claims, but to come out saying, "Look, anybody who's attacking the vaccinators is like attacking the government itself. Don't dare do anything." In addition of doing all of the other thing that we tried to convince about the safety of the vaccine, but just the fact that anybody who could do that could get away with it again and again and again was not really a good way to eventually stop the killings.

We were asking them to help us, number one, in places like Karachi, to bring in the army, to make sure that--because even with the police you see that the police get shot and then the people--just really have a major presence of the army with tanks, OK? At least to give kind of a circular protection, if something happens. Then nobody gets hurt.

The other one was we were asking them to help us to immunize children in the tribally administered areas where they have control. One good example is there is a place right by Peshawar where there has never been vaccination for years, and it is held by kind of fringe Taliban--not Taliban--but sometimes they go in and clear places. What we wanted to do is for them to actually go in and conduct the campaign, whatever way they feel is appropriate.

The third one was the major one, was the issue of North and South Waziristan, where the Taliban has declared no campaigns. I think it was 2014, early 2013, if you remember, there was a major attack by the Taliban, a school that the children of the military go. I think they killed about a 134 of them. I think when that happened, then the army, also, started to get really serious, and they started to implement what we always tell them: "There is no good Taliban and bad Taliban," because they had this management of things that, "This is a good Taliban. This is a bad Taliban." Eventually they went into North Waziristan and South Waziristan with big power and with big force. At that time, everybody in that place had to get out, in those two places. What we asked them, when they are clearing the area and asking people to evacuate, of course, they allow people to evacuate, only to go to certain roads.

What they did was, anybody who was coming out of that place, including if you are an eighty- or a ninety-year-old person, would be immunized when they get out. We immunized like--I don't remember--a million, including--and then what we did was, in addition to immunizing them when they come out, we were also continuing to immunize them because they were taken to unknown areas. Some of them used to go into the community, so we went and followed where they were and immunized the community and tried to really mitigate the fact that they are coming out of a very highly-infected--where circulation is very high. That was also very, very good. Then came Peshawar.

CRAWFORD: In 2012?

DURRY: No. This is 2014, '15--2014.

CRAWFORD: Are these the high-security, one-day [mop-up] campaigns?

DURRY: Yes.

CRAWFORD: --one-day campaigns?

DURRY: Yes. Yes.

CRAWFORD: OK.

DURRY: In Peshawar, we could not really do campaigns because either it takes twenty days or half of the place is not reached, and you know.

We keep going to the police station, to the police, and the police, army, and we keep presenting our case that we need to really do campaigns, but [in a] very short period. At that level, we just couldn't come up with a solution because they don't enough police. We don't have enough time. Somebody gets shot, and then the whole thing breaks apart again. The whole year went like that. Then, when we were able to bring in the political party that won in that area--

CRAWFORD: PTI [Pakistan Tehreek-e-Insaf]?

DURRY: Yes. We went there, and we told them, we went to Imran Khan, "Look, this is in your hands. If you want to, you really can make this thing happen." In addition of giving his own name to it, the first thing that we need is, number one, to try to change the image of polio of not being polio campaign, but we promised that we will do other immunization. Not house to house, but we will give coupons to families to go and tell them which health center they need to go and immunize. We were distributing things for sanitation and stuff like that. He had to take it as if it was his program.

CRAWFORD: Part of these campaigns are covered in Every Last Child, documentary, 2014.

DURRY: Yes.

CRAWFORD: Just for the record, the politician you're talking about is Imran Khan.

DURRY: Yes.

CRAWFORD: Correct? The PTI party, which translates as "Movement for Peace Party?"

DURRY: Yes. Yes.

CRAWFORD: I just wanted to record that.

DURRY: Yes. We were able to bring him in, but then the challenge was, "OK, how do we ensure security?"

CRAWFORD: Could you go back a little bit and talk about the need to rebrand polio? Workers were being targeted. The Taliban had said no more polio vaccination. One question I had watching the documentary was, was this approach geared toward people you would be visiting door to door, or was this to disguise--not disguise, but to rebrand polio to draw attention away from polio for the Taliban?

DURRY: Yes. I think probably what I would like to add to be up front with you is that somehow, not us, polio program, but somehow the polio team was utilized to hunt bin Laden--and to hunt bin Laden, that became an open secret. The Talibans were very pissed off at the fact that the program that they thought that is polio is also engaging itself in something else, including spying.

The reason that the Taliban banned campaigns in north and south Waziristan is specifically because of this reason, number one. Number two, they were also demanding that the drone attack stop before they allow campaigns. Number three, of course, the usual misconception that they give. Then, with this kind of news and with this kind of discussion, even for some non-Taliban, even for normal people, suspicion on polio was really very, very, very high. We had to find ways of--we keep telling people, "No, it's not the polio." It was a hepatitis B campaign that they were using because polio is drops. If you wanted to take a DNA, you can't get it. The only way they tried to take the DNA is by giving an injectable vaccine.

CRAWFORD: Dr. Shakil Afridi [MBBS]?

DURRY: Yes.

CRAWFORD: OK. It was hepatitis [B].

DURRY: But you can imagine what was the belief, everybody's belief, that these poor girls who come in, they come in, and they take information back with them to be attacked. They blame us sometimes. Drone attacks are, every time, are there. Vaccinations are also all the time there. It happens, but also, they used it as a political hostage. They knew polio eradication, globally, is an important issue for the west, and they really made sure that that does not happen, not because they don't like their children, but they believed so much [in] the fact that they have derail this western agenda.

I remember in Quetta [Pakistan] when a child was paralyzed, when the father was actually throwing a party. I think everybody [heard] him saying, "Look, God bless. My child is paralyzed." This is a man who [is], supposedly, a religious leader. Because of all of those previous Islamist mentality that they had--"It's made by the Jews"--

Because of that, and because of this connection with what happened with Osama bin Laden, the taste for polio was not good. People were leaving us. I remember I had to bring in a psychologist just to look after my staff, and more than sixty-five, almost eighty-five percent of them needed some kind of medication because it was so stressful and so difficult. Nobody wanted to work with us because it is like a death sentence for the person. It can be.

Not the issue with the safety, but the polio name was not a good name. We had to do two things: we had to take it off, the polio name by itself, from it--take the polio activity from it--and also make sure that the other part, the safety part, and the fact it's not something that is sterilized. Also, we had to attack that through religious groups who would explain that this is not what it is. Some of them say it is forbidden religiously to give vaccine because of this and this and that.

What we did in addition to what I told you about the religious leader, we also tried and succeed, worked very hard to make it look like it is supported fully by Islamic organizations. We immediately changed our source of money from other place, and we went and borrowed or got money from Islamic Development Bank. We brought in the UAE [United Arab Emirates] prince [His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi and Deputy Supreme Commander of the United Arab Emirates (UAE) Armed Forces] to at least lead an effort openly, at least to take away, and basically have to Islamacize the program.

Then, on the other side, we also had to take it away from being polio and call it something else. What we called it in Peshawar is in the south is "Unity for Health." We were saying, "This is really not polio," and we were giving other things, but of course, polio was in it.

CRAWFORD: Did anybody ever say, "Hey, but polio is part of this program"?

DURRY: Don't get mad at me, but my thinking was if people are so gullible that they that think polio can do all of these things, why can't you also--I'm not saying you say it in a wrong way, but yes, we say, "This is not only polio," because we made sure that families go and get their immunization. What we did was we made sure that the health centers are fully equipped to give all of the vaccines.

CRAWFORD: There are nine of them.

DURRY: Yes. All the necessary vaccines. We're not giving them house to house, but we made sure that all health centers, that each family will have a coupon with them. They do two things with the coupon: get vaccination and also hygiene kits. It was not a lie. We were not giving them vaccines all at the same time, or we were not saying that this vaccine cures nine diseases.

CRAWFORD: One of the arguments that came up in the film: there's a scene where a family and men from a family are meeting and having a meal together with kids around. One of them said, "They're trying to just attack this one disease when there are so many diseases in the world," which echoes conversations that have been had at like the global health level.

DURRY: Yes, yes. No. That was very challenging.

We've done a lot of jobs. I didn't mention the moving trash and stuff like that. Especially Rotary International was very, very active in going into these places, remove trash that is like trucks after trucks after trucks. It forced us to really think about how we also do things, which is just always highlighting the polio part, and just not thinking about the other need of what the community requires. We tried to do that.

That's why I say, if we ever do it again, you have to start doing these things in the most difficult areas because as time goes by, you will never know that polio is the only thing that we "worry" about, in quotation. Unless we do this for a long time. If it is a short period of activity, OK. But if you do this for like years the way we are doing it, and the same person who would tell a mother at the health center that there is no Tylenol or aspirin, and goes to her house and says, "Take this," again, and again, and again. That's a challenge.

Then when we discussed with Imran [A.] Khan [Niazi, BA] and the police, we could not come up with ways of really ensuring security of the vaccinators. I remember that there is once a year a holiday called Ashura or Mu?arram. This is the one which you see when the Shias beat themselves. For that day, across Pakistan, every place is not locked down, but every place is safe. Not safe, but there is a tremendous attack on Shias during that day every year. The government knows that and for that reason, all places, they have a protocol how to maintain safety for that day, coming from the army, the police, all of them.

When we were discussing, we were saying, [campaigns in] "Two days, one day," I asked them, "How do you do Muharram or Ashura? Can you just go back and look at your Ashura protocol for one city?" Say, "Yes. We do that every year." I say, "OK. That's all I want. You do it for one day, but everything else is you don't have to come up with ways of doing it. Just do what you've been doing for Ashura." They say, "Oh, OK." Easy to explain.

I don't like to talk about it, but it was really an amazing thing. They started work like on Thursday. They go and whoever they feel like it is troublemakers, they held them until the campaign is finished. They put them in jail until the campaign is finished. During the day of the campaign, no motorcycles. In some areas, no phone. In some areas, complete quarantine, closing offices, shops. There's a very major activity, and you cannot do this for two days. It has to be one day. Then you cannot ask them to do this for the whole of the year. I asked them, "OK, give me three months. I just want twelve campaigns. Let's get [it over with]."

CRAWFORD: That's what you did.

DURRY: Yes.

CRAWFORD: There were twelve one-day vaccination campaigns, and you immunized I think 700,000 children or seven million?

DURRY: Million.

CRAWFORD: Million children.

DURRY: Yes.

CRAWFORD: They proved to be effective.

DURRY: Very effective.

CRAWFORD: Did you consider doing any more than twelve?

DURRY: No. Twelve was actually stretching it. It's not only the number, actually. It's also the timing at that time. We were doing like this time of the year when the circulation is the lowest. We call it the "low season." That [inaudible] by the program a bit, in a sense that at least it gave us a relief that it can be done.

We could not do the same way in Karachi, but Karachi also picked up a little bit. There were more police. Then, as time went by, also, I think it's clear that, as I said earlier, you can't just force these things with the army. After I left, I think what got more concentrated on is really bringing the community, so there are these community volunteers that almost cover most of these high-risk areas, whether it is up in Quetta or in Karachi, or in some other difficult areas.

There was major progress, but again, we still are missing some children that we cannot. Knock on wood, we don't have any case this year and we hope it will remain that way. Unfortunately, we did see a virus in the environmental sample, which we hope is just the tail end of the circulation.

CRAWFORD: It seems like one of the differences between work in Africa, or at least in South Sudan and Somalia--or Somalia, particularly--where you had advanced notice, you were pretty aware of what was going on politically between clans. It seems very unpredictable in Pakistan. How did you learn to navigate that?

DURRY: I think if anybody thinks that they can follow the politics of Pakistan would make a big mistake. I can say it here: I was actually suspicious if the army is not part of these things. It is just what they are going through and their politics, whether it's geopolitics, or their animosity with India, or what they want to do in Afghanistan and all, it's so complicated that anything outside of each of the units that they are working, outside of what they are thinking would be any value to them. Of course, people question all the time the engagement of the Pakistani government or the military, whether they are cahootzing with the Taliban sometimes.

That's why I said earlier, they have what they say the "good Taliban" and "bad Talibans," and the politics on the political level. For example, when I was doing this in Peshawar, I had been having a very difficult time with the central government. They thought we are giving a lot of credit and a lot of face time for Imran Khan. You don't know how the army thinks. Some of it is to fight for the little thing that they have. Here, it is way beyond what--this is their political, Pakistan's stance in the place. I don't want to get into where they want to go and what happens with their neighbors and all, but it is not a small place that you can say I understand these politics. I don't think anybody would.

CRAWFORD: Were you briefed before you went?

DURRY: No. Briefed. No.

CRAWFORD: You briefed yourself.

DURRY: I follow politics, country politics very closely, but--if anybody says that--it's the same thing in Afghanistan, the same thing. There are too much external interests and long-term interests, or national interests that you would not get into it. In Somalia, there was no national interest.

CRAWFORD: I had a chance to sit down with a Rotarian named Aziz Memon. Have you met him?

DURRY: Yes. He's a good friend of mine.

CRAWFORD: Oh, nice. Yes. Would you talk about him a little bit and his work? I'm looking at this point for connections between your work and partners with GPEI.

DURRY: He was, he is, and he will be a very, very useful ally in a place like Pakistan. He leads the Rotary International, and he's very knowledgeable about the program, but he's also very candid about telling people what are the problems and what it is. Not only in telling people, but he's also very willing to like establish this community-based activity. He's very helpful and like I said earlier, most of these sanitation things that we did in Karachi is because of him. He established a lot of activities around the border areas, between Afghanistan and Pakistan, providing all equipment, small equipment and things that the vaccinators require, like most of the transit vaccinators: he's the one who--they are the ones who--provide them with their uniforms and shades. Not only in doing these small things, his voice and his impact is really phenomenal.

CRAWFORD: It was striking to hear him describe even interpersonally his interactions with people, especially when a family, when parents would resist vaccine.

DURRY: Yes. He shoots it straightforward and says it the way it is. Yes.

CRAWFORD: Yes, yes. Would you talk a bit about--and I will probably mispronounce this name--Babar bin Atta?

DURRY: Yes.

CRAWFORD: Could you talk a bit about people that you worked with closely? He's an example of one person that you worked with in Pakistan.

DURRY: Yes. Well, let me say this. In the field, if I need a medical officer to be thrown into very difficult areas, I'll go look from MSF [Médecins Sans Frontières].

CRAWFORD: Doctors Without Borders.

DURRY: If I need a communication person, then I go look for someone who work for the [inaudible] industry. What I'm saying is they're aggressive, and they will make you believe what's not there. Babar was working for polio with UNICEF before I had arrived there, before me. He quit and then when I came back--

What happened was in the middle of that normal work, before this killing started, there was this TV [television] show, TV anchorman who just sat there for two days and just really trashed polio in all of these bad misconceptions. He just went on and on for two days. He's one of the most famous talk show hosts. This is not when the Taliban were doing it. He was just coming up with people who probably did not get paid or whatever, or did not get money, and they come and they say, "This vaccine is this--they give bad vaccine, this vaccine." Those two episodes really became a big headache for us, and we were not ready for it, to respond back. Basically, UNICEF [formerly, the United Nations International Children's Emergency Fund] was not ready. WHO was not ready with the communication people that we had. I had to bring in quickly to kind of work with the media on that. That's how we turned it. I can say that I really had a very good relationship with the media there.

CRAWFORD: As good as you did in Yemen?

DURRY: Oh, much better.

CRAWFORD: Could you explain?

DURRY: Of course, journalists are journalists, but also it's not in my nature to hold things back or whatever. You can explain everything. There's nothing that [can't be] explained. I worked with them regularly if they want to write something. Sometimes I can have also things and say, "OK. Listen, if you say this, this is what happens. Can you just not say it?" It's not because I give them and they do it, but the way I was discussing with them is really, is openly and with science. Sometimes I know what they were writing the next day, in advance. You have things that--I also call it, there is a way of working for me was, I call it "special memo," meaning if things don't go right, you just talk about it on the news media. In the afternoon, probably the president will call and say, "OK. How come we don't have vaccine?" It was a good relationship. He [Babar bin Atta] was managing all of those things.

Going back and thinking about it, maybe a little bit too much of media, but I think in places like Pakistan, if you want to keep everybody on their feet--it's not shaming, but it is really important that we all are on the same page on where we are going. For example, in Quetta, the vaccinators, they used to have a union. A union. They organized a union. They would not allow anything to be changed. Like when we brought in the issue of direct dispersement through the bank, they would not accept it. What I was saying was, then we came up with criteria for the campaigns, which we called "deferment criteria." If things don't happen, whether in planning or whether in preparation, then that campaign has to be deferred for a week to fix that, for a few days. If second deferment comes, then we need to think. I said we need to think about outsourcing the campaign.

That Quetta place, it's just such a difficult place, especially because of this. What I'm trying to tell you, then I sit and I talk with a journalist and say, "If campaigns are not done well, we are going to outsource the campaign." That becomes an agenda of--and probably tomorrow, the next time when we go and we start discussing, it is if you with something. There were a lot of things like this that we were using it for.

CRAWFORD: Any other uses of mass communications or media?

DURRY: Well, a lot of people didn't like it, but I used to put out the cases, the number of cases on prime time.

CRAWFORD: What were their objections to that?

DURRY: Because we were not supposed to have any case. Whatever it is, it is just to ring the bell that we need to move on. I don't know how much you know about the media of Pakistan. They try to replicate or duplicate what the Indians did. There are so many channels and they just--some of them work with the government. There's just so many of them and there is so much of breaking news mentality and stuff like that.

CRAWFORD: I've seen images of news teams in India, and they look very strong and ready to move.

DURRY: Yes. Anyway, eventually the thing that we did not want, meaning the issue of whenever somebody gets killed, then the whole TV is just on that. That one I did not really--but I think if you look at some of the write-ups in Pakistan especially in some of the newspapers, they all have some message behind them. For example, the first year I was there, Sania Nishtar [phonetic], she was a lady who was running for DG [director-general of the WHO]. She had an article there arguing the only way to eradicate polio in Pakistan is by using the army. She is a professor, and she knows--the reason she was saying [that]--when there is anything that has any monetary issues in it, whether it is polio or other things, she thinks that the country is not ready enough or transparent enough to do things properly and finish it. She was advocating, for example, the army taking over the polio eradication program. This is way before all of the problems that we have [now].

The way they [journalists] are holding them [the government] responsible for what happens in the field, like when they see children vaccinating and stuff like that, that's also very important. There are two or three writers there, which really bring out very--at the end, they all go back and they blame the government of not doing what needs to be done. Holding the government like that, also, responsible also was good.

CRAWFORD: Hamid [S.] Jafari talked about accountability and transparency. Those themes came up in our conversation. I'm hearing accountability come up with you today.

DURRY: Yes. The issue is, let's say, OK, for me as a WHO team leader, if there is one district that I have an issue with, I have to have someone who I go to and say, "OK. What happened?" Someone who I would say, "OK. You are responsible for this," although that person may not be responsible for everything because he has to work for the government--at least for my side, I have someone whom I have given specific activities and asked what happened to these activities. The same thing: somebody could come to me directly and say, "Why is the Pakistan program not moving?" I have to be the one who has to answer it.]

Nobody in the [Pakistani] government structure or in any other places there is that you can go to someone and say, "OK. You are responsible. How come there are twenty cases in your town?" You see, to overcome those ones, there are activities that need to be done: bringing in people for a meeting, chairing meetings, and all of these things that we put as part of our performance indicators. For example, we follow religiously how many meetings do these mayors or DCs [district commissioners] are holding. Not any meetings. For polio. Then we say, "Where is the minutes?"

These are the kind of things that we like--remember the story I told you last time when a friend of mine told the chief minister that, "It's you." Each of them, if they take that responsibility that is on their shoulder and make sure that things happen, there's no problem; there won't be any problem. But if the guy does not care--like we have a big problem, most of the time in deputy commissioners who are working in Islamabad and--especially Islamabad because they are so busy with other things because they're in a capital city. These things [polio] for them is nothing, and no, he also has to be responsible for those. Those accountabilities is very critical to really overcome. These are big challenges. If someone does not own them, they won't go anywhere.

Then to be clear of what you are asking for--[asking for] what you want. You don't come up with new rules every time and say, "OK, last time I've asked you for it," but that's where the transparency also comes in.

We started a dashboard where we looked into different things. Then we, on our side, have also to kind of verify what those dashboards say, whether it is just kind of a quick way of getting everybody agreeing, or it's really that's how it is. The problem is also you cannot keep emergency situation for a long time. This has started in 2012. I'm not there now, but I bet you that it will not--the enthusiasm of everybody after how many years now--six years or seven years--cannot be as high as it was before. We need to also come up with new ways of restarting that momentum. If you do one thing for three times and everybody knows what are the main things, then you don't have to work very hard on them because you just know what do you need to write in the report.

CRAWFORD: Because you brought it up: reinvigoration. Would you talk about some of your roles after 2014? Did you return to Atlanta? You were in Jordan.

DURRY: I was in Jordan.

CRAWFORD: OK.

DURRY: I came back in 2016.

CRAWFORD: In 2016, would you say that part of your activities included reinvigorating polio activities?

DURRY: Yes. Then, by 2016, we were still stuck with the three countries, which they were all in high alert. Each of them had EOC, emergency operation centers.

CRAWFORD: Tom [Thomas R. Frieden, MD, MPH] had activated?

DURRY: [Yes.] In the countries, too. There is an EOC in Pakistan, in Nigeria, and somehow in Afghanistan, but not really national, but also provincial EOCs. That can continue to keep the engagement of the governments and the partners.

But we have to finish it. We said 2018, '17 would be the last. We already have three cases from Afghanistan this year [2018], part of the early January. We are not working only for polio. We are also working for overall public health. I think we cannot keep going like this, number one because we cannot afford lose. Losing and not finishing means the virus coming back roaring because we are not immunizing as we used to immunize before. There is definitely low immunity across the globe. If this virus gets out--OK, if this virus is not eradicated and it keeps lingering, and it gets out and goes to places where there was no vaccination, it will be a disaster. I don't know if you remember, but the cases that we had that came from Nigeria--in Somalia alone, I think there were more than four hundred cases. You can imagine what the world [phonetic] would look like.

We owe [it to] the world that we must finish this. We also have to prove that these eradication initiatives are not just something that somebody cooks up and says, "OK. I want to be famous, and I'm going to do it." It has to be based on scientific information, which would allow us to think whether we can spend so much money on one disease and do it or not. If we are not successful, no one will ever come close to anything that has anything with elimination or eradication. The malaria eradication program that was in the '70s actually kind of held back a lot of people from thinking of eradication until we saw what happened with polio in South America. We can't afford to lose. I think what we have to do now and what everybody is doing now is really concentrate on these two countries and do whatever is necessary to at least finish it by this year, and then get ready for the outbreaks, which is not from the wild virus, but from vaccine-derived virus. That's what I'm spending most of my time on now.

CRAWFORD: I spoke with Dr. [William H. "Bill"] Foege [MD], Dr. Bill Foege, and one phrase that we mentioned, certainly after our interview, was "missed opportunities." Looking back, are there any missed opportunities that stick with you?

DURRY: I think today I could say two things that we should have known before. The number one thing is recognizing and understanding the country's relationship in the countries. Like minorities and so on--those who are neglected. I think probably we did not think that it will take us this long, but for a program that has to go into every house and work with every community, to come strictly through the central government and just only work with the central government, and impose things on others, that we should not do. We should be able to really figure it out from the very beginning. We have to open our arms and work with the community from the very beginning. That's number one. We did not do that.

Number two is we should have started at the toughest places. The reason I'm saying is, of course, it may be easy to start with places that have--but we should have started at the toughest places, not in neglecting others, but making sure that we understand all of the issues that may come up in these places, like war zones or places like big countries like India to really think and come up with the strategy in advance. Make sure that the funding and everything is available. Not to go into it like a frog in the warm water. That's what I would do.

I think this is a missed opportunity, but I think that we have learned from this also is really amazing. The ability to even manage such a huge program, the ability to bring in social mobilizers. What I mean by that, social mobilizers, I mean to places that have never, ever been known before, places that could not have been on the map. Not the logistic part of reaching there but reaching there so that you can talk with people.

During the Ebola crisis, if you see what the polio team did in Nigeria, it's really exactly what it is now. They should have done the same thing in the other countries because for some reason we knew--and we know--at the community level every community. Even when you have issues like that which require the consensus from the community, you can use this system. The surveillance activity that we have for people. Now surveillance is known by villagers: what are they looking for? Not only that we have reduced the number of mortality and morbidity from the virus, but we really have changed and brought in a lot of things [to communities], the thing we have learned from is also phenomenal. We don't want that name to be tarnished by not being able to finish it.

CRAWFORD: Last time [during Session 2] you talked about work in Somalia and South Sudan as having an impact on the ways that WHO and UNICEF work. Could you explain some of the evidence that you see of the experiences, in-country, impacting that work?

DURRY: Yes. Like I said, UNICEF may have already had some operation in the field, but WHO, as it is, everything was expert-based support to countries. WHO never engaged itself in operations, meaning implementing activities, direct implementation. If you remember, during the Ebola outbreak, there was a lot of questions that WHO was asked. "How did it allow it to go this far?," and this, this. "How come you cannot hire people on time?" All of these kinds of stuff, WHO was never part of it. Never. All they used to do is send one person. With polio, polio was the first one that really entered into mass implementation activities where you have to have our own HR [human resources], our own budget, and our own everything. It was our own because the other part did not have it, did not need it.

Even now when people talk about emergency protocols for emergencies, what they try to do is they see, they take the country activities as if a country does not have any emergency. Like let's say you take a small country which has one representative, one epidemiologist, and two or three drivers, which is the majority of countries. Somebody who's expert in that cannot tell you what to do if there is a major outbreak in some country where you have to bring in fifty people in one day, work on millions of dollars, and write reports.

Not everybody, but most of our [polio] people who are working in management and HR were taken for the Ebola [outbreak] because we were the only ones who had that experience. That is on the WHO part, but also on the country side. These are places where they could not have afforded or were capable to train those many people in their own countries. You will see them taking a lot of really high positions once the country settles or is liberated, like what happened in South Sudan. Really, our footprint is in every district of every country.

CRAWFORD: Having laid that footprint, I wonder how that's changed your kind of mindset, or opinion, or perspective on global health systems.

DURRY: Yes. Systems, systems. I think global systems, and I don't want to say this is something, but I think we should start with really helping countries to be able to plan: comprehensive planning. That is where you start to kind of use the strength of different programs. Once you plan and you know where you want to go, and then you start asking what do I have to put in place?

A lot of countries are just caught in between each and everybody. I go for polio. Tomorrow the other one comes and says health system strengthening. If the country does not have a plan, all of these noises that come in would just be another annoyance because that official doesn't have a document that he goes back for himself and say, "OK, where does your input fit in?"

We're not doing enough of that. We really need to help countries to be just able to plan and see what is, based on the situation that is in their own hand, see what is required. Not just us coming in and saying, "OK, I am this today. I'm that tomorrow." It's a long process.

It's a long process, and yes, there's always this fight between vertical and horizontal line of thought. I think people will not change, people from our side because it becomes like a religious discussion. Everybody's holding his own belief and then trying to argue, but it is never one or the other. There has to be some horizontal kind of mindset. It will be very useful if the countries can lead that because all of us come from our own viewpoint and what we want to do. What we want to do is another thing, but the one eventually that we serve is the country. That country has to help us, or they have to force us to kind of follow their plan and their thinking.

If they allow the polio program just to work by itself, and not force it to kind of help other programs, it will be the country's fault. I always tell them that. "You take advantage of this. We will bring this." We need this, these outputs, but see what else we can do with this activity, with this support that we give to strengthening the other health system, the other health activities.

Few countries do that because, again, programs are run by people, individuals, who each one also wants to have his own legacy and his own palace and everything.

CRAWFORD: I feel like we're kind of starting to wrap up a little bit.

DURRY: That's very good.

CRAWFORD: It's just before three o'clock right now, so we still have some time. I have a list of some kinds of loose ends a little bit.

We didn't talk really at all about Djibouti. I wanted to see if you wanted to say anything about your work there.

DURRY: I call it "a drop in an ocean." No, Djibouti is a very small country. It is a very difficult country. One time I went to India. I went to India, arguing up in Moradabad, a country with millions of kids to be immunized, millions live there. I went straight to Djibouti from there. I can tell you I had the same problem, going and arguing with the ministry.

It is a country that is somehow neglected sometimes. It is at risk of getting a virus from either Somalia or Ethiopia because it sits right in the middle, but the good thing is it's a very small country. You can do it [eradicate polio] in a very short period of time, whatever you want to do. That's what we used to do. We used to go and not only immunize with polio, but we immunized with all vaccines three times a year. Yes. We had to establish a surveillance, which was very difficult. We may need only one or two cases. It's a country that is only one city, but it was in our area, and we were going there pretty often.

CRAWFORD: You brought an item with you, so I thought I would ask you to describe it today for the archivist, Laura [L.] Frizzell [MLIS].

DURRY: Yes. That is during the killing for the campaigns.

CRAWFORD: Just to describe it, it's a red paddle--

DURRY: Yes. It looks like a--

CRAWFORD: --made out of wood, painted.

DURRY: Yes. It looks like a tennis thing, and we were distributing it to the police, that they can use it because in Islamabad [Pakistan] there are a lot of check points when you travel. You would have a stop sign, the stop sign. We were giving them this and agreed to give them this so that the public also knows that the police is also part of the whole thing. It's just building confidence of the vaccinators that the police was also with them. It reminds me of those tough times.

CRAWFORD: Thank you. I just remembered a scene from Every Last Child. It prompted a question for me. There's a scene where there's a vaccinator team who's been working at a check point maybe, three men in yellow.

DURRY: Yes. With yellow, yes.

CRAWFORD: Yes. They're working together and this is right after--

DURRY: The Karachi killing?

CRAWFORD: Yes. Suddenly, there were no police to work with them. There was no security with them. My question is what was the impact of the killings on vaccinators?

DURRY: Oh, usually it's devastating. It's devastating. The other thing, and I don't know if I said it loudly, after the police starting escorting them, they were the ones who also started to be attacked. Even the police were attacked. It's just impossible. For them, for example, they were outside by bus stops where they immunized children who were on the move. You can't have one police for each of all of those people who are working in the street. It really frustrates and demoralizes the vaccinators. Not the fact that they don't have a police, but the fact that another incident had happened.

I think, what I really want to finish with is how much in debt we are to these vaccinators. Not only in Pakistan. I said this before, also. If there is any way of thanking them, I don't know why they are not being put as Nobel Prize winners because what they have done is absolutely fantastic. Not fantastic. It's not the work that they do, but the enthusiasm that comes out of them. Like those ladies that you saw, one of her relatives is shot, but she still goes out and then she still brings her little daughter, and then standing up and saying, "This is what we do."

I mean, imagine. I don't know. One day I will sit down and count all of the number of doses that we have given, where each place--from Indonesia, all the way to Senegal--each house has been visited by these people, whether it is up in the mountains, river line [phonetic] areas. The final result for polio is that we don't see much, or we hopefully will not see a single child who is paralyzed. I think that could not happen without these vaccinators. They are the most important component of this initiative. We all are just enablers, but they are the ones who have done it.

CRAWFORD: There's a question that's kind of forming for me right now. I was talking with a friend of mine, and this friend of mine does environmental justice work in New Mexico. He said something that made me ask him how and when do you offer congratulations and praise to your staff and the people who carry out the work on the ground and how does that translate? He was involved in fundraising. How does that translate when you're working with donors, I guess, too? I wonder, for you as a manager of large staff over many years, what you think about that, how and when to acknowledge people.

DURRY: I think there are different kinds--like the vaccinators, day and night. The rest of us? I'm not sure. One day we were sitting in a meeting in Pakistan. It was a big consultative meeting. Everybody came from everywhere. As a joke, we started to count the years that we worked in polio. There were about six hundred years or something. But anyway, it was a very big meeting, a very expensive meeting.

At the end, now, we've spent this much money. Now I started looking for what is the output here, now. You got so many people here. What is exactly? Forget what the nationals would do, but what are you guys doing here? Everybody was thanking them for coming here. "Congratul--"

I said, "No, wait, wait, wait, wait. No, no. There is no congratulation. I know you're all paid per diem, are paid like almost a half a million dollars. You're not going to come out of this house until you give me your last report, and what are the action points? No." You know what I mean? I just don't like just to go [to] a place or to have a position and not perform as we are asking people to do.

Congratulating vaccinators? Yes. The rest of us, we are always trying to hedge around and figure out how to, we just have to show what you say. We are paid well by the way, huh?

Yes. There are times when you see people go out of their way and do things, but for the normal work? Last time you asked me a question, and I remembered, I was first in Nigeria. I had international state coordinators in each of the states and also a national coordinator. I was driving around from one state to another state, just to get a quick update, and I do this very frequently. I reached Kano with my other staff.

Before we arrived, we tell them, "Look, we are coming." Not in a fresh way, but just we need some of these and conclusions and whatever. The two guys were sitting there: one national state coordinator, another one, international state coordinator. For every question I ask, it is the national one who is answering. I say, "Look, really. Can you tell me?" They say, "Oh, let me." All the data is there with the other guy, with the national. Then I just take the phone, and I called Abuja [Nigeria], and I say, "OK. I'm changing the state coordinator. From now on, he is the state coordinator and you--" [Laughs]

Right there. That's how we work. I'm appreciating the other one, the one who is doing his work, but the other one who just sits there, then takes the name [job title] and does not follow based on the position that he's holding--

CRAWFORD: Make that adjustment, which is one example of where you had the authority and the ability to make fast change.

DURRY: Yes.

CRAWFORD: I'm going back to wondering--the question of, if you are able to set up these systems yourself, based on what you observe in-country and what you see in what needs to happen based on polio--you said there's a third way, right, which is--

DURRY: It's the polio way.

CRAWFORD: --the polio way. What does the role of these other orgs [organizations and countries] become?

DURRY: No. You cannot do it by yourself because I didn't have anything. I don't have money. I don't have any, but all of the authority and everything is given to me. It's given to me, not because I was working for WHO. It was given to me by WHO, by UNICEF, by CDC, by everybody. That's really a very fantastic accomplishment, but I think the reason that I would also be able to be like that is because the management--all management: the [Robert A.] Bob Keegans, the Bruce Aylwards, UNICEF--they were all so cohesive and spoke the same language and had the same vision, which really opened the platform to do that. Now, you cannot do one-third of that. You cannot do any of that.

Nowadays, OK, it is much more organized in a way that everybody knows what's happening, and it's not run by a few people, but the bureaucracy has become too much now. Of course, and when you are still in the country, you still have that power to decide what to do. That doesn't mean it's taken away from you. If your work has really a clear goal, a clear strategy, a clear way of, modus operandi, that's how things need to be done. Most of the time we don't know why we are here, why we are wherever we are. What is the system that will take us? We just take a job. A job is a job, but if you go with the way, with something that you believe in--not only believe because it is something that you want to believe in, but well tested, evidence-based, clear strategy, clear objective--it makes it so much different in being able to do what you need to do.

CRAWFORD: Another list question: tough questions that you've responded to. Are there certain conversations or certain questions that you have memories of responding to that have been particularly challenging?

DURRY: Hmm. I think the question about, "Why are you coming to us all the time?" from the community, and just trying to convince them with the smallest little things, which is not being, telling them the truth. That is the toughest question. "Why do you come all the time, while we have so many other problems that you can't listen to us?"

In working with my peers, I don't think there is a tough question.

CRAWFORD: I think that has covered at least this interviewing guide.

DURRY: Thank you very much.

CRAWFORD: Thank you. Is there anything we haven't covered?

DURRY: No. I just want to repeat the few things.

I think polio, the other thing that it did was it has demonstrated how you can bring together so many different partners in a way that's not only smooth to work, but really very, very synchronized work. The issue of the vaccinators who are still--remain--the hero for us, and the fact that our success is not measured by how many millions of children we reached. It's measured by what did we do to fix those who we did not reach?

For example, in Pakistan, we immunized forty million children. The number doesn't do anything for me, but it is how many did we miss and what are doing to correct that? It's not just how many we missed, but also it has to be measured: how do we overcome the challenge that led us to miss these children?

CRAWFORD: Which kind of multiplies if you're considering imported cases, other places or exported cases, I guess.

DURRY: Yes. It's not how many children we reached. It's who we are missing and what are we doing to correct that?

CRAWFORD: Do you consider polio eradication a movement? There have been several people who have used that language.

DURRY: I think it's a public health intervention. "Movement" is too much of--we haven't reached there, and we don't want to reach there. It's very challenging. I think it looked very easy, and it is not easy. It was not easy because of what I mentioned to you earlier. The deficit of confidence in some of the population in countries is the cause that has brought us where we are.

CRAWFORD: In the case of Pakistan--

DURRY: Every country that has lingered behind, that's the problem. That's the common denominator that we have.

CRAWFORD: It seems in Pakistan, specifically, that thinking of it and describing it as a movement could be a disservice.

DURRY: Of course, it would be a disservice, but it is something that should have gone long ago, like back in 2005, 2006. Now these days we are talking about 2020, there won't be any more GPEI. A movement will last forever, but this is a very--how can I say it?--a public health intervention that really touched a lot of population, almost every child.

Yes. I wish you good luck, and I hope you will finish it, and not only you finish your project, but also we finish the eradication process. In addition to others that I mentioned, including like the vaccinators, and the partnership, and lessons learned and all.

I think we cannot really say that we are where we are without the engagement of the Rotarians for different reasons. Number one, they are the ones, actually, who started this initiative from the very first when nobody was there. They have given it such a safety net that others who are brought in, based on the science, could take it further.

Number two, it's just like the volunteers that we discussed earlier with the vaccinators. These are groups of people everywhere across the country, across the world who had nothing to do with this activity, but they spent so much energy and time on it. A lot of them are not physicians. They don't even know what is going on, but they believe in this initiative so much.

Number three, really the dollar amount is not what we count, but I think the advocacy that they bring in, not only in countries like Nigeria, or India, or Pakistan, but also here within the United States and everywhere else. They are something that any program would be jealous not to have them because we see a lot of other programs which are trying to also achieve eradication. For example, measles, to be frank with you. It never had some friend like the Rotarians for polio that could really push and carry the activities to the end.

CRAWFORD: I'm considering the dates. The Bill & Melinda Gates Foundation became involved in 2007. Just because Todd [F. Jordan, videographer] brought up Rotary, I'll go ahead and bring them up because you worked closely with WHO and UNICEF, so they came up anyway.

DURRY: The one thing that happened some years back is, I think overall what I can see, what the Bill & Melinda Gates Foundation brought for us is, in addition to the money, is really to look into the way we do things differently--differently, whether it is technologically or even thinking about it and trying to come up with new ways of doing things and things that could have never happened.

For example, in Borno [State], in Nigeria, you could follow vaccinators where they are entering based on the GIS [geographic information system] system that we have. Bringing these new technologies, bringing in--of course, the funding is fantastic, but in addition to that, forcing us to think more in how we do things right and be able to really finish the job. They're coming in. Then funding-wise, also--in a lot of places, I think it's better if billionaires talk to billionaires. Not a leader talk to a billionaire. His role in that fundraising really helped us tremendously because what I said earlier about the Islamic Development Bank loan, the Japanese loan, the UAE [United Arab Emirates] loan: all of these things would never have been even close to us if he was not there. It's really been a very, very timely addition to the partnership.

CRAWFORD: The GPEI actual architecture started--I think our archivist has traced it back and it's consistent with what I've found, too--to around 2010 when there was a POB, Polio Oversight Board in that structure.

DURRY: Exactly.

CRAWFORD: Did that structure, that organization impact your work?

DURRY: Yes.

CRAWFORD: How?

DURRY: It put too many structures into play. That what I was hinting to earlier. It is good. Like as you know very well, it brings everybody together. But it's also become very bureaucratic. You can do this for any activity, for any kind of thing. Let's say you have a big factory, and you can have this kind of setup. Or you can be--how can I say--an NGO [non-governmental organization] that is trying to--or a group of people that tries to reduce or eliminate homelessness or whatever. You know what I mean? The structure, it should work for everything, but all I know is I'm eradicating polio. If I sit down and listen to the talks--I hear a lot of talks--and very rarely I hear polio there because we're talking about systems and the structures, and budgets, and this and that and that. I'm always attracted to that polio word.

CRAWFORD: Would you say that that organizational structure introduced barriers or impediments to your work?

DURRY: Barriers, but not impediments, although you have to have a benevolent leader. There was only one person who decides all of these things. That's why I'm [saying] it has to be a benevolent leader. For a decision-making process, it was that difficult--just one person or a few people decide, and we move forward. But now this consultation is good, but it's taking a long time to move things in the field.

CRAWFORD: Which is particularly difficult with a disease like polio.

DURRY: Yes. Although to be frank with you, the thing that is done in endemic countries has not been impacted very much by the structure because still, the structure that was put in the endemic countries both--not both, but by everybody, whether it was government, WHO, UNICEF--it's so strong that it can sustain and maintain themselves. All they need is the money. Remember, with the EOC, this is a consultation process that the government is leading. Once that decision is made, none of us has anything to do with deciding to go ahead with that or not. You know what I mean? For the endemic countries, it may have helped it more actually.

CRAWFORD: Along that line, do you think that the structure boosted accountability? What do you think the impact was?

DURRY: Where?

CRAWFORD: Of the GPEI architecture coming in, being established. Part of that, like the IMB [Independent Monitoring Board] is intended to support accountability.

DURRY: Yes. Absolutely. Overall, accountability is not so different than it used to be before. At one point, all of us were just happy folks, running around and doing what we need to do, and we were doing good. When things start to stagnate, and we wanted to know why this is stagnating and who is responsible for it--and today also we have those questions. If there is a response that is planned and some group says yes and the other group says no, and then each of them, they say, "Look. You'll be responsible if this outbreak goes out of hand." The other one says, "You'll be responsible if the vaccine gives us circulating vaccine-derived--" You know what I mean? It's no more, just let's go ahead and do it and be happy with [it].

CRAWFORD: Any other thoughts on any of the individual partners or GPEI in general?

DURRY: I think at the end of the day, for us also--and I'm talking about for CDC. I don't know if we talked enough about really the culture of our team here in CDC from the get-go. It was really wonderful. It was like a family affair. It was not as big as that, but it was really a family affair, and we all credit this to Bob Keegan, who was the deputy chief [of the Polio Eradication Branch] here. It was a wonderful time. It was a special team where everybody wanted to join, not only because of the achievement and the work that we were doing, but also that sense of being together.

We can stand in front of the Congress and say that we really have done our job very well. We would like to continue to be the vanguard of eradication, not just to somehow lose the--sometimes I know there is some politics and other things, how you see things, how we move forward. For us, it's not done until it's done, and we will keep supporting the partners. A few things, we feel like it is our forte: surveillance, laboratory, data management. We're working very hard with the digital division how to translate this to supporting overall immunization. I hope they're all doing that.

CRAWFORD: Because you brought up the culture of CDC, and maybe this is where we close, could you tell a few stories about that culture of CDC when Bob Keegan was deputy because I think that that's really important. The Polio Eradication Activity [PEA] was the beginning at CDC, and it was a six-person staff. The time that you're remembering, was that after?

DURRY: Yes. Yes. We were so close. So close, not because we were just kind of thinking alike or we were friends or anything like that. I think the enthusiasm that we had for the polio eradication based on the strategy and the objective it had and being able to go out and really just implement it, and the support that we had for each other from here to that, that is what brought us much, much closer to the extent that my kids have been advised, and even now by my colleague, whom I know through polio, just as an example.

When we were overseas, we used to come back every now and then. When I come, for example, with my family, I have to rent a car. Then I say, "Now, why do I rent cars?" I went and bought a car, and then I leave the key in the office. Then when Anne-Renée [Heningburg] travels, she leaves the key in the office. Anybody who comes from anywhere has the opportunity to have a car and a house. We were doing this for--if my kids give me headaches and I call Anne-Renée or Bob Keegan, one of them, they're the ones who--all of them, really, they're with us together. This cannot happen if our communication is only work-related and dry. Of course, we always talk about work, but in a different way. It was a fantastic team.

CRAWFORD: Do you have any particular or specific Bob Keegan stories, stories that are specific to Bob Keegan? Because we're trying to represent him because I won't have a chance to meet him.

DURRY: Well, the first time I went to Yemen, so I looked at it, and then I saw, and I say, "OK. Now we can do campaigns." I called him and I said, "Bob, I need $375,000 dollars." He says, "Where am I going to get it from?" I say, "You have friends at Rotary. You will figure it out, how to get me that $375,000. I want my vaccines." This is the first interaction that we really had in getting to do things.

In two days, he got me the money. In seven days, we got the vaccine. In seven to fifteen days, we got the vaccine in Yemen. This is for activity that has never been planned by anybody before. I think one of the things that you will keep hearing if you didn't hear--that you would have heard from him--is his adventure in Ethiopia. Him and Tim Petersen.

They went to supervise some activity up north, northwest of Ethiopia. They had to take a boat to go there. The boat driver was someone from a tribe that had animosity with a tribe that they went to, and they killed him. Tim and Bob had to run and escape by running like a day-and-a-half at night. Bob loved to talk about that all the time. Actually, he even wrote it in his book. Bob was always--you're never bored with him. He helped me a lot when I was in Nigeria, also. Stood up with me when I was challenging the Minister of Health. Yes.

CRAWFORD: Do you feel like we've talked enough about Nigeria?

DURRY: Yes. I think we've talked enough.

CRAWFORD: OK. [Laughs] Thank you.

DURRY: Thank you.