Dr. Hamid Jafari

TORGHELE: It is July 5, 2016 and I'm here with Dr. Hamid Jafari who until recently was the Director of the Global Polio Eradication Initiative at the World Health Organization, and has just last week been appointed the Principal Deputy Director for the Center for Global Health at the Centers for Disease Control and Prevention [CDC] here in Atlanta. So welcome, Dr. Jafari. Thank you for agreeing to be interviewed today for the Global Health Chronicles. My name is Karen Torghele, and I'll be talking with Dr. Jafari about his polio-related work here and overseas. So to begin, Dr. Jafari, would you please tell us a little bit about your background? And how you came to be involved in polio work and came to be at CDC in the first place?

JAFARI: So I did most of my growing up in Karachi where I was born, Pakistan, but in fact, I did my first three grades in Tehran [Iran] where my father was in 00:01:00the Pakistan embassy as the Press and Cultural Attaché. I come from a family of mostly educators. My father started his career as an educator, but he then ended up being quite a celebrated poet, a satirist in Pakistan and India. And so I also went to medical school in Karachi, Sindh Medical College and graduated in 1983, did what in the British system is known as a house job which is sort of an internship and I came to the U.S. in 1984, and as they say, came off the boat in Boston. And it was a time when it was very difficult for foreign medical graduates to be accepted into a residency training program. I was interested in 00:02:00training in pediatrics, but it took some time. It actually took me two and a half years before I could get into a residency training program. But that sort of turned out to be good because for the first year I worked in a basic cell biology lab at St. Elizabeth's Hospital in Boston, where I learned to do basic science wet bench research, something I'd never done before. And that was very interesting, and I learned a number of new laboratory techniques, which enabled me then to get a research fellowship at Harvard Medical School at [Massachusetts] Mass General Hospital.

So I worked there for a year, and it was really, again, new techniques I was learning, like cell culture and protein biochemistry, and was working on a growth inhibiting factor from malignant 00:03:00effusions of patients with cancer. So after these two years doing basic science research in Boston, I got accepted in a residency training program at Dartmouth [College] and there--also what is called the national resident matching program. Somehow, that year, Dartmouth had a vacant position they were not able to match for. So I ended up interviewing the program director --in, actually, the librarian of Boston University --who was, I think, doing his MPH [Master of Public Health] at the University of Boston. So that's where I was interviewed. And I was offered the job, and I accepted that sight unseen. I hadn't even gone to Hanover to look at the hospital and the medical school, because I was quite desperate to get into residency training. So the lab that I was working at Mass 00:04:00General, they immediately threw a party. They knew that I was interested in really looking for a residency training program, so-- and there were all of these fellows and medical students going to Harvard [University], and for them it was obviously unimaginable that someone would accept a residency training program without having even looked at the hospital or the training program. So they said, "Look"-- a couple of them really expressed surprise that you haven't even gone up to Hanover and you've accepted the position. So my mentor at Mass General, he said, "Look, he comes from a culture where they get married without having seeing the bride first. This is only a residency training program." So it was kind of like an arranged marriage, and it really worked out well.

I learned a lot in that training program, and as I was training, I realized that I have a 00:05:00real interest in infectious diseases and so I was accepted in a pediatric infectious disease fellowship program at University of Texas Southwestern Medical School, which was one of the best pediatric infectious disease fellowship programs in the country. Lucky that way. So did some good research, learned a lot of good clinical pediatric infectious diseases. Then as I got into my third year -- senior year of the fellowship-- I wasn't really sure where I would go next. And [Dr. Gregory R.] Greg Istre, EIS [Epidemic Intelligence Service] 1980 was at that time the state epidemiologist for Oklahoma State. He was changing careers and wanted to leave the administrative work. He loved public health, but he said, "Look, I am doing less and less public health and more administration." So he decided to do a clinical infectious disease 00:06:00fellowship for a year. So as a senior fellow, I took him around, showed him the program. We had lunch at the faculty club, and he asked me what I was planning to do. And of course my plans were vague, other than to say I like infectious diseases, I like international work. And he said to me that, "You have an EIS officer written all over you, but you don't know it." So it was actually Greg who got the application forms for me from CDC, and I applied. And at that time, in sort of the confusion of the next move I was interviewing with the pharmaceutical industry -- and clearly I was very clear that I didn't want to go there, but the options were not very clear whether I wanted to stay in academia or try this CDC thing, you know, this EIS training program. And Greg said to me that those two years were the best of his career, and he assured me that I would 00:07:00find those two years the best in my career as well.

So I applied, was called for an interview. I interviewed in the immunization program and meningitis and special pathogens here at CDC, and at the end of the interview, everybody would ask me, "How do you know Greg?" So clearly, Greg had talked to all of the people I was going to interview. So anyway, I was very fortunate. I was offered a slot in the class of '92 EIS, and so I started my training in meningitis and special pathogens [Dr.] Anne Schuchat was my immediate supervisor and [Dr.] Jay [D.] Wenger was the branch chief. So we started off there. And after I finished my EIS, I joined the National Immunization Program [NIP] and Dr. Walter [A.] 00:08:00Orenstein was the director of that national program. And I started working on Haemophilus influenzae type b [Hib] surveillance. In fact, I had already started to work on that while I was in meningitis and special pathogens branch. But I very closely watched the debate at that time between the use of the inactivated polio vaccine [IPV] and the oral polio vaccine [OPV] in the U.S. An issue that had gone all the way up to the debate in ACIP [Advisory Committee on Immunization Practices], but also discussions at the Institute of Medicine. And finally, those discussions led to U.S. going to a full inactivated polio vaccine schedule from the oral polio vaccine, with a transition period of '96 to 2000 where both vaccines were being used in the infant schedule in the U.S.

So I worked in the NIP from '94 to '96, and I saw the small sort of activity begin to grow which was called the polio eradication activity led by Dr. Steve [Stephen L.] Cochi and his deputy Bob [Robert A.] Keegan. And at that time, I was learning that these CDC epidemiologists and Public Health Advisors were helping with establishing polio eradication programs in partnership with WHO [World Health Organization] and Rotary International. And UNICEF [United Nations Children's Fund] was also gradually getting on board, but these epidemiologists were really setting up the eradication effort in Africa, in the Southeast Asia region that included India. Many of them worked in key countries like China. And those two regions were considered particularly challenging. The eastern Mediterranean region of WHO that has all of the countries of the Middle East and northern Africa, but also Afghanistan and Pakistan and Iran. And in the Southeast Asia region that has India, Nepal, and Indonesia, some large countries, Bangladesh, many of these densely polio-endemic countries.

So I sort of became interested in this. And my wife and I we discussed that maybe it would be good to go out overseas and see what international work is like overseas. I was doing domestic immunization work here, and she agreed, and we said, "Let's try it for a couple of years and see where that leads." So I applied and was 00:09:00selected. And both Bob and Steve advised me that I should be located to --seconded to the Eastern Mediterranean region of WHO, and that office was located in Alexandria, Egypt, and it covers twenty-three countries. As I said, all of the Middle East, North Africa and Pakistan, Afghanistan, and Iran. And so I was selected in summer, but I volunteered for the summer Olympics in 1996. So they were very gracious. They allowed me time to work as an envoy in the Atlanta Olympics. So it was in September that we moved to, September '96 -- to Alexandria, Egypt. We didn't know anybody in that city. So my wife and I and our two and a half-year-old son, we landed in Alexandria, Egypt. I worked with that 00:10:00regional office for six years, and four years later, we moved to Cairo, and then a year later to Pakistan--Islamabad--for almost a year. And that was a very immense learning experience. Got to work with the government and partners in that region. Fascinating countries, very challenging countries, and got to really play a role in establishing polio eradication programs in some very, very difficult and challenging environments-- countries at war, countries with prolonged, complex emergencies, culturally challenging countries. But then we learned a lot about those countries and learned a lot about how to set up public health programs, surveillance programs, vaccine delivery programs in such settings. So that was a very good experience in that region. And we can talk about that more when we come to specifics of polio eradication and lessons we've learned.

Then I came back-- in fact, we were evacuated from Pakistan. We were posted to Islamabad three weeks before 9/11 happened. So our household goods had not even arrived in Islamabad, and 9/11 happened so we were evacuated. Then we're allowed back in December of 2001. And kids started going back to school, and we were starting to settle down in our house in Islamabad. There was a suicide bombing in a church in the diplomatic enclave in Islamabad, and we lost 00:11:00a staff from the U.S. Embassy and her child in that, and then Pakistan became a non-family duty station, so we were evacuated, and we came back to Atlanta in mid-2002. And I came back as polio eradication branch chief. And by that time, that small polio eradication activity had become the Global Immunization Division [GID]. And so within that, there were two branches, and I came back as the chief of the polio eradication branch. And then after two years, I was selected to be the director of the division of global immunization, and so did that for two years, and then another itch. My wife and I--we discussed, and then we said okay, let's go out again on an overseas assignment.

And a position was available in the Southeast Asia regional office of WHO, to support polio eradication in the region in New Delhi. So I stepped down as division director, and this is the interesting part. This is what I really like about CDC that you have these options that you could be on a leadership track or you can choose to switch that track and go into program work. And so that's what we sort of decided that I step down as director of Global Immunization Division to go and work closer to polio eradication in the Southeast Asia region. And so we arrived there in, again, August of 2006.

And by March of 2007, the regional director then asked me to basically go and lead the polio eradication program in India. 00:12:00And there were some significant uncertainties about that decision. While it was thought quite feasible that I could be posted to the regional office of WHO in New Delhi, India, there were some concerns that my origins being from Pakistan, how would I be accepted in India? But the regional office, since it covers about eleven countries, that was okay. But when I was asked to go and take up the polio eradication program in India, which was at a very intense phase-- there was a polio outbreak going on in Northern India--very visible, very public. The government was making funding decisions to put more and more of its own domestic 00:13:00resources into the eradication program.

I was concerned at how I will be accepted by the Indian government, by the large project-- more than 2,000 staff, more than 250 medical doctors from India, you know, what would that be like? And I think a couple of things were very interesting in that regard-- that I was first seen as an expert from CDC, and it didn't matter where I came from. I think it speaks to the credibility of the agency the scientific excellence, and that's what I think the government and the other technical experts in India. I suppose, looking at is that they knew that I was assigned to WHO from the CDC, 00:14:00and that's what I think brought a great deal of credibility to my assignment being there in the first place. And secondly, I think it really speaks to the I think the sense of diversity, plurality, in India, that we had all kinds of challenges during the eradication program, and some very tough periods of negotiation and discussion with the government-- both the central government and at the state level-- but never where I came from was an issue. It was always focused on the program issues, the challenges, and such.

So that turned out to be an absolutely fantastic assignment. One that I was extremely anxious and 00:15:00nervous about, and just had a fantastic team, fantastic partners, very strong collaboration with the government, and an outstanding public health workforce in the National Polio Surveillance Project that I led for five years in India. So then India was, as you know, successful in stopping transmission of wild poliovirus and the last case occurring in January of 2011. So in February of 2012, we had confidence that we might have stopped transmission, because all of the surveillance data, all the laboratory tests from cases of acute flaccid paralysis and environmental surveillance-- which is the sort of sewage surface 00:16:00water testing--had tested negative for a period of twelve months. So India was officially removed from the list of polio-endemic countries. And so one day, it was a Saturday evening, and I was at a dinner party with my wife, and there's some music playing, and my cell phone rang, and I saw it was a Geneva number. And I picked up, and, of course, I had over the years had many friends working in the polio program in WHO Geneva headquarters. So there was this lady on the line, and she said, "Hamid, this is DG calling." And I thought that one of my colleagues was playing a prank on me, that it's unimaginable, 10:30 Saturday night directly my phone rings. So I started saying, "Yes, yes, all my friends 00:17:00say that when they call me." So it actually did take Dr. Margaret Chan [Director-general of the World Health Organization] a couple of sentences to convince me that it was in fact her. So I said, "Okay, let me step out, the music is loud here." And basically, she said, "Look, I want you to come to Geneva as director of polio eradication next month," basically. And I tried to persuade her that, look, India is not out of the woods, we still have to consolidate on the gains we've made. And she said, "Look, others can do this-- you need to come to Geneva."

So that's how I moved to Geneva in March of 2012 and led that program there until end of January this year. So I hope that summary gives you a sense of how this has evolved.

TORGHELE: It does. That's very thorough and interesting how you got from 00:18:00starting out in Pakistan and ended up in Geneva at the World Health Organization. And in between, you were at CDC in different positions.

JAFARI: That's right I've been with CDC for now exactly twenty-four years, and of those twenty-four years, sixteen have been spent overseas on assignment to WHO. Seconded to WHO, which has been a totally fascinating experience--to have the benefit of the best of the two agencies and also manage the challenges of the two agencies, because I think all public health agencies have their strengths. So it's been a very, very good experience in this regard and to have 00:19:00worked in two regions that have two very different sets of concerns.

The Eastern Mediterranean region, in terms of population, is medium-sized, one would say 400 million population, but countries like Somalia and Sudan and South Sudan used to be part of that region until very recently. Afghanistan, Pakistan, Iran, Syria and Iraq and being able to help establish eradication programs in that region, and the lessons learned there, and innovations in that region were very interesting. On the other hand, Southeast Asia region only eleven countries but you have the diversity of Thailand, which is a middle income, good infrastructure, well-developed country and you have of course more than 25 00:20:00percent of the population live in these eleven countries. India 1.2 billion people, Indonesia more than 250 million, then you have Nepal--and then some of these small countries are tiny in terms of population size, like Bhutan and Timor-Leste and Maldives. And there again, unique challenges particularly in places like India, in particular, the population size and the density and the birthrates and the conditions, very favorable for poliovirus. The virus has been entrenched there for thousands of years, and the conditions were rife for its survival and propagation. So important experiences and learnings.

TORGHELE: So when you had your training, you had your cellular biology training, 00:21:00and you also had your residency, and you had your EIS training, all those things. Can you talk about how the training led to what you later did, and how different parts of your training led you to do the jobs you did?

JAFARI: I often wondered in the beginning, that this basic science work that I'm doing, how is that going to work later on? I was thinking of having a career in clinical infectious diseases, but that evolved, as I mentioned, into really more public health work and less and less clinical work. But in the end, it's all connected and interrelated. And so a very important part of the eradication program, of course, is laboratory surveillance and understanding laboratory methodologies and techniques. And as they evolve over time, you get a much 00:22:00better and clearer understanding of how the lab diagnostic methods and techniques, how do they work, how to interpret the data? And as the technology evolved, you are in a better position to keep up, because you have some laboratory background. So it really doesn't go to waste. In fact, it really helps you understand, even understand the problems labs are having because of that background.

Similarly, the clinical training for surveillance, and talking to your peers, pediatric associations, or convincing physicians or senior faculty to make sure that cases are reported from the institutions. It all comes in very, very handy to be able to have a conversation with clinicians, with 00:23:00experts in the field because you can speak their language and you can understand, and also to interpret the clinical data that comes out of surveillance and classification of cases. And being able to explain the merits of a vaccine--the adverse events of a vaccine-- to not only your peers, physicians, and doctors, but also to the community and to the public at large, to politicians, to policymakers. So all of this comes into great use actually.

TORGHELE: You had a unique set of qualifications and skills from all of your training.

JAFARI: Yeah, I mean, I think what I've learned is that it's so important to have--in public health. I think it's one of those in some ways almost like a 00:24:00unique career where you certainly need technical credibility of what you're doing--to have credibility to the training and the support of an agency like CDC where scientists are supporting your programmatic work. We've had fantastic support from scientists at CDC. Particularly we've had two giants here in enterovirus laboratories, [Dr.] Olen Kew and [Dr.] Mark Pallansch. I learned so much of polio virology from them and having their support which is directly on a critical pathway to setting up laboratory surveillance network, laboratories interpreting surveillance data, molecular epidemiology, sequencing of poliovirus 00:25:00genome. Tremendous work. So you need to establish that scientific credibility of yourself as a leader but also the credibility that's given to you by the institutions that support you in that work. So that's very important in public health.

The other, I think which is very important, is to have the cultural and diplomatic credibility. And that really comes from being able to understand cultures and have the ability to understand other people's perspectives, because that's the sort of art and diplomacy of public health, is to getting people onboard making political commitments, making financial commitments, putting in 00:26:00their technical resources into a program. And one has to have that credibility as well, where people can trust you, and you are accessible to them, and you can access them. And, you know, in many parts of the world, the real business gets done over a cup of tea or on the margins of a formal meeting. So I think for our emerging public health leaders, it's not all about technical leadership. I think it's also about the credibility that you establish in terms of understanding cultures, understanding people, being empathic, being able to see things from their eyes, understanding partnerships, and in the end having your personal integrity, that people can trust you, people from other cultures can trust you. 00:27:00So those are some of the important insights I've sort of gained in this journey.

TORGHELE: You got the technical training, and we know some about that. But how did you learn the diplomatic skills that you had to have had?

JAFARI: See, partly, I mean, as I said, I grew up mostly in Pakistan, but also part of my childhood in Tehran in the early '60s. And part of it, I think, comes from some of the watching your family first, but also some of the colleagues here at CDC, and understanding how they navigated some difficult meetings where you also can't sugarcoat things but also having the cultural sensitivity of 00:28:00communicating and conveying and thinking always win/win. Clearly I learned a lot from Bob Keegan, who recruited me, and also he was my deputy director when I was director of global immunization division, but I kept learning from him during that period. Certainly from Steve Cochi, who was the division director initially, in the initial period when I was in global immunization division--from him.

But also, I think having sort of a broad cultural background like the family I come from, and what was important in our family. I mean, in my 00:29:00extended family a person's worth is not measured by how much they make or what they own or what they have. It's always seen as, how many people can you help. That's the metric that's always used. So that kind of aligns with the public health training you get at CDC. How many lives are you saving? How many diseases are you preventing? It's a very bottom-line metric, and it sort of aligns well, that it's all about results, it's all about impact. So I think those things, sort of, I feel were important in my career development.

TORGHELE: When you came to CDC, smallpox had already been eradicated. Were there lessons learned from that effort that you took with you in your efforts with polio?

JAFARI: Absolutely. I think there were these eight points by Dr. [William H.] Foege that we were all given before we were put on that flight to overseas assignments, and those were absolutely jewels. The importance of expecting that it would be more difficult than you think, but can be done. Always maintaining the faith, not giving up in the face of adversity. The importance of local commitment, the government's commitment, and making sure how you get to that and deserving that. Some very important lessons were conveyed. Of course, Dr. Foege is not only a sort of mentor and hero for all of us in polio eradication, but 00:30:00also he was a hero for many of the people who were my mentors. So those were important lessons and, of course, no shortcut for hard work. It's just tough out there, and it's just not going to be easy, but just not giving up and just keeping at it. And polio eradication has lasted much longer than it was predicted to, and the program has had almost every possible difficulty that could have been imagined, either at the technical level or the programmatic level or political level. But its perseverance and the faith that it can be done that has kept this program going. And I think it was many of those important lessons that we learned from our predecessors who had worked in smallpox 00:31:00eradication that have motivated us to keep going.

TORGHELE: Just stepping back a little bit to clarify a little bit about what you did and when. During your EIS years, can you talk about some of the work you did? Those two years from '92 to '94?

JAFARI: So I would highlight in three or four specific areas that my EIS training was focused on. One area was, this was a period when the U.S. was having a number of outbreaks in various pockets, some based in college campuses of serogroup C meningococcal meningitis, and so I was involved with the 00:32:00investigation of one of those outbreaks right here in western Georgia, in Carroll County. But also I helped draft the guidelines for prevention and control of meningococcal disease-- that were finalized, of course, based on the recommendations of the ACIP, but I drafted those during my EIS training.

I also was very much involved with the surveillance and the disappearing of Haemophilus influenzae type b invasive disease because it was really sort of around 1990 that the new Hib vaccine, the conjugate vaccine was introduced in the infant 00:33:00immunization program and that led to precipitous decline in invasive Haemophilus influenzae type b disease. So I was involved in looking at that surveillance data and documenting that decline, and looking at the populations where the disease was still surviving, the sort of disadvantaged low socioeconomic populations where the visible disease was still persisting. So I was looking at analysis and publication of surveillance data for invasive Hib disease.

And then I was also involved in the development of guidelines for prophylaxis against neonatal group B streptococcal disease, group B strep. And so, Dr. Anne Schuchat 00:34:00was leading that work at the national level and she was my supervisor, so I learned a lot from her including--we did a survey of obstetricians about what sort of screening practices they use for screening for group B strep. So that survey helped with the final guidelines that were adopted across the country for screening of pregnant women for group B strep.

Then I also did a project in Kenya for three months in Western Kenya, based out of CDC's malaria's research station in Kisumu, where we were looking at the sick child assessment algorithms 00:35:00that could be used by clinical officers in the absence of a fully trained pediatrician. So we were comparing the performance of that evaluation algorithm with that of an expert pediatrician. And that work informed WHO's guidelines in what is called Integrated Management of Childhood Illnesses, IMCI. So I did some of that work there, and also shot some videos that were used for training of clinical officers in recognizing severe anemia, respiratory distress in children, signs of pneumonia, and such.

TORGHELE: You had an interesting two years.

JAFARI: Oh, very interesting, yes.

TORGHELE: And then tell us again where you went next.

JAFARI: So next I went to the national immunization program, and there I continued with the--because since Haemophilus influenzae type b vaccine, conjugate vaccine, had become part of the infant schedule, then I continued to analyze and publish surveillance data on invasive Haemophilus influenzae type b disease, and worked with state and county health departments as to how they could further improve detection of invasive Haemophilus influenzae type b-- Hib disease basically. So I worked on that. I then also got involved with pertussis control in the U.S., and in fact investigated a pertussis outbreak in Yuma, Arizona, and also then ended up analyzing a lot of the data that was coming out of these several trials that were being conducted for acellular pertussis 00:36:00vaccines, because at that time the schedule around the world included whole-cell pertussis vaccines. So there were a number of studies done in Europe of various types of acellular pertussis vaccines, so I helped analyze those studies and data. That eventually then ended up informing the ACIP deliberations on making national recommendations on the introduction of acellular vaccines in the U.S., So I was one of the co-authors on the first set of ACIP recommendations on the acellular pertussis vaccines.

And it was at that time was my first brush with polio, because as I said, the polio debate had started at that time--of inactivated polio vaccine and the oral polio vaccine used in the U.S. And then I was invited for a couple of polio-related training activities for surveillance in Pakistan, and was --in fact in 1995 went and investigated a polio outbreak in Punjab Province of Pakistan. In fact, that was my entry into polio eradication really, while I was still with the domestic program. Then, having done this from '94 to mid-'96, that's when I moved to the polio eradication activity.

TORGHELE: I wondered how your past had gone, exactly, that led you to polio. But there must've been something, too, that really piqued your interest specifically about polio. Can you remember when that happened, or how?

JAFARI: I knew of this eradication effort ongoing, and I was hearing about challenges in setting up the program in India at the time but also challenges in 00:37:00Pakistan and Afghanistan. Egypt still had a lot of polio then, and Sudan, and many of these countries--Somalia--were sort of the tough challenges. So I was hearing about those. But I think what might have sort of at an emotional level pushed it was when I investigated the polio outbreak in Punjab. And this is in 1995.

So I was invited by WHO to go, and it was a pretty nasty outbreak. And as I started to go and see patients--you know, you hear about diseases and illnesses and you see them in clinical medicine, in a clinical setting--but as I went to the homes of these patients to talk to the families to understand the conditions, the environment in which this was happening, it was quite--it really made an impression on me. The one or two instances that a three-month-old baby girl and the mother knows that this doctor has come from America, and she's dressed her all up in her best clothes, and she feels that this doctor has come from America and maybe he'll heal her and maybe she'll be able to move her legs again. And there you are looking at a three-month-old girl and a lifetime of paralysis. And in many of these countries, and particularly for a young girl, that's a death sentence, right? I mean, how do you talk to a mother and explain this in a way that does not take away all hope, but it's realistic that there is 00:38:00no cure for this? And to think that this can be prevented by just a few drops of vaccine. Right? A few doses of vaccine, this could have been prevented. And we've had this vaccine for decades. So that's pretty powerful. And you go to some of the poorest areas, people in Shanties, they can hardly make their ends meet, and they offer you best hospitality. They'll offer you a bottle of Pepsi or Coke, saying that you've come from America and that you won't be able to cure their child, but they're still giving you their best hospitality. Part of their day's wage is going into that hospitality.

So it's sort of--you have to connect the dots that all of this training in medical school, all of this training in 00:39:00infectious diseases, all of this training in CDC, what does it translate to? What can you do with that? That it actually translates into making a difference to people. It's something that is not rocket science. It's making sure that children get vaccinated.

TORGHELE: So it sounds like you maximized all the parts of your training and your education to come to this effort of eradicating polio.

JAFARI: Yeah, I suppose it must be that sometimes all your energies and everything sort of gets focused on--like a convex lens focusing on a tight, and sort of it burns. And maybe that's probably what happened with polio, and that's why--a very deep sense that you can't give this up. It has to get done no matter what.

TORGHELE: I'm interested in, especially your time in India and how you got there in 2006. Five years later they were having their last of--wild poliovirus was gone you said. It was only five years. So what happened between 2006 and 2011 to make that happen?

JAFARI: You know, a number of things happened. I mean, I think first I should say that a lot of good work had already happened in India, because, you know, you stand on the shoulders of those before you. You don't start from a clean slate. So a lot of good work had already happened. My CDC colleagues and predecessors had done a fantastic job of setting up and running the surveillance program and what came to be known as the national polio surveillance project in India. They set up great partnerships with Indian Rotarians, a good working relationship with the central government, but also with the key state governments. By the time I arrived there, most of the indigenous virus from almost all the states of India had already gone.

There were only two states where polio had remained endemic, and it used to break out of there to other parts of the country, and these were Uttar Pradesh and Bihar. Of course, these were the two most challenging states in terms of development, their population size, and these were the most densely polio-endemic states. And Uttar Pradesh the size of 200 million population, and Bihar 100 million population. Just the birth rate of Uttar Pradesh was nearly 500,000 per month. So you have 500,000 00:40:00newborns every month, and in a condition where virus travels very fast, because it's fecal-oral transmission. The hygiene and sanitation conditions are very poor in these states, and the newborns are being born at that pace. And so it's a race with the wild virus, which is fitter, faster, and much better adjusted to that environment than the vaccine we were using. And we had to get to these children before the wild virus could get to them, and get to them with vaccines. So it required a number of elements to be in place for us to succeed.

In immunization, you generally have one or the other issue, which is either vaccine failure--the vaccine is not working, so you have to change your tool--or 00:41:00there's a failure to vaccinate, and you have to improve your program so that you get everybody. In India, we had both of those challenges in these states. The vaccine we were using was not performing as well, because it was under tremendous pressure-- and I'll explain that momentarily--but we were also missing critical populations, and we had to reach these children as well. So we had to optimize the tool as well, and also find ways to identify who we were missing, and then to find ways and innovations to reach them. So one important lesson we learned in India is that you have to really go back to the drawing board and establish a full research program.

Okay, so one important insight is that even you may think you know everything, and you're in advanced stages of an eradication program--never think that you 00:42:00don't need to do research again. So we had to actually establish a research platform in India, and in some of the most difficult areas, some of the most mistrustful populations to do research in those communities. And we were able to do that research to identify how different vaccines would work, how does polio immunity work in those communities, so that we could optimize our vaccination tool and strategy. On the other hand, we had to establish a very robust surveillance system to understand the epidemiology in detail at the micro level, but also a very intense program monitoring mechanism real-time data and capacity to analyze those data to know who we are missing, why we are missing them, and what's the solution that allows the front line to actually innovate and come up with solutions that are specific to the reasons we are missing children.

So there were a variety of reasons. For example, we went through a phase where there was a great deal of vaccine hesitancy, resistance, refusal to vaccinate because there was lack of trust, particularly in minority communities in India. And we had to establish--and UNICEF took the lead in that--but we had to establish a program of communications, community engagement, to build trust. And again at the micro level. Thousands of workers deployed in some of the key pockets of refusal and resistance. Then we learned through our data that we missed newborns because there is a custom that you don't bring out a newborn for the first forty days. When the vaccination team goes to the house and knocks on the door, they don't walk up to the door because they're too tiny to do that. So a whole newborn-tracking strategy was developed where they would register each 00:43:00time every house was visited in these states. So the scale of operation was enormous. More than 60, 70 million houses were visited several times in a year, and each time you visit you have to register a newborn and then make sure that in the next eight rounds that particular newborn gets vaccinated. So a specific tracking strategy for that.

We also learned that at any given time, a proportion of children are on the move. So a very elaborate mobile and transit strategy was set up in place. At bus stations, train stations, in moving trains. In Uttar Pradesh and Bihar five million children were vaccinated during a vaccination campaign in moving trains and buses and children on the move, just five million, because the total target combined together was over 60 million children under 00:44:00five years of age that were vaccinated repeatedly in these mass vaccination campaigns. About 5 million of those were vaccinated when they were on the move, through this transit strategy.

We would also have periodic outbreaks of polio in other parts of the country, and what we found out towards these later stages, that there are certain types of migrant population--economic migrants--that were particularly at high risk of being missed during vaccination campaigns, who were vulnerable to getting polio. And then as they moved around, polio spread with them. So they became a very high priority population for us to cover. These are very underserved populations. They were construction site workers. India was in a construction boom in the Mumbai area, Delhi area, other parts of the country there was industrial construction, and many of these workers came from polio-endemic states of Uttar Pradesh and Bihar. So tracking them and then mapping them where they go, mapping their communities where they settle and then 00:45:00having special vaccination programs to reach them were very important. There was a certain parts of the year bricks are produced in parts of countries, and these workers move. Their children were being missed because they live in these very --sort of outside settled areas, where they make bricks so that we had a special strategy for brick kiln and agricultural workers. And so towards the late stages, before we interrupted transmission, we had mapped more than 400 migrant sites across India, so that each time we did a campaign in Uttar Pradesh and Bihar, those settlements were also vaccinated, those areas were also vaccinated. And there was special timing for them because they had different work hours, so that the vaccination teams, the monitoring, and even the hours of vaccination were tailored to this population.

So it was really identifying, again, through rigorous evaluation of data, assessment of data, why we were missing, who we 00:46:00were missing, what other characteristics of that population, and then what's the innovative solution to put in place to do this? So to summarize this, we had a system whereby what I call is a critical triad for success in an eradication program. We had motivated government officials right from the central government, to state government, and particularly at the district level, and these were district magistrates and chief medical officers. District magistrate in the Indian civil service is the chief executive officer for district. All line ministries, departments report to the district magistrate. So in these endemic states, the district magistrate was in charge of the quality of the polio program, so they were very motivated to take corrective action.

But corrective action cannot be taken in a vacuum. That corrective action was based on good-quality surveillance data--where the poliovirus is, how it's moving, 00:47:00who's affected, which is the vulnerable population and who we are missing--the program immunization monitoring data. So good monitoring evidence, right, that then linked to accountability. Who is not performing, who is not doing their bit. Roles and responsibilities are defined across the partnership. What WHO is to do, what UNICEF is to do, what government workers have to do, what are the responsibilities of Rotarians, local partners. And then making sure why children are missed, so they were tracked from round to round. Who is missed, why missed, what did not happen here, what needs to happen?

And this started to work really, really well. Accountability based on good objective evidence, so there is no argument. It's not a war in opinions, right, it's evidence-based, and committed officials who are empowered to take corrective action. And this circle of 00:48:00continuous optimization, and a pursuit for who's being missed, and then continuous optimization of vaccination. There was no magic bullet. It's about getting it right and making sure that you cover and you vaccinate everybody.

And there were times when it was really tough because polio is an epidemic-prone disease. As long as you have virus circulating, it will find vulnerable children, and over time susceptibles accumulate-- those that are missed or those who do not respond to the vaccine--and you will get an outbreak. And convincing the government who-- in the later years, the government of India was putting in more than $250 million a year into the immunization program, and it was a very visible program constantly in the media, constantly in the press. The cases were being reported in the press in the later years, and you would have these outbreaks, and the press would write about that, and there was always a risk 00:49:00that the state and the union would sort of argue about this. But we always had to explain why the outbreak is happening and what's the way forward. So that the political commitment and the financial commitment does not go away. Because it's not a straight road line down to eradication. It sort of goes like this, you have outbreaks, you have to explain those outbreaks, why they're happening, and still have a clear path as to what is the path to success here, still, so that everybody can see that and come along with you.

TORGHELE: So you were essentially trying to hit a moving target with multiple, multiple factors, but what you did it sounds like it went to where they were instead of having them come to you.

JAFARI: Well, that's exactly right. I mean this workforce, this project--national polio surveillance project--complemented by these district 00:50:00magistrates, the government commitment, and the work of Rotarians and the work of UNICEF in social mobilization and engagement of communities for us--I mean, it was constant optimization. And having the field workforce empowered to innovate is very important. You can't micromanage them. In fact, a lot of my effort was for them to focus strategically, collect less data, the more important data, take time to analyze the data, rather than-- what I used to say to them, "Don't work like robots. You're medical officers. Look at the data. Take one day of the week--just look at the situation you're in. Prioritize and put 80 percent of your time in 20 percent of the places which pose the greatest risk." They felt they were responsible for their entire district or entire state, and would lose focus. And I said, "I will take responsibility for what 00:51:00goes wrong in 80 percent of the low-risk areas. You're responsible for putting 80 percent of your time in the 20 percent of the areas that pose most of the risk." It's easy to say that, but it's very hard for managers on the ground to give up these other areas, where they feel, what if a case happens there? What will happen? And to sort of get them focused on that this is the source of the problem, the key blocks in your district that you know are under-performing where repeatedly polio circulates. That's where you have to stop it, and that's where your efforts have to be concentrated. Give them the tools. They have such rich data but teaching them how to analyze and how to apply it in prioritization and the innovation they did.

I mean, most of the innovations--the ones that survive and are meaningful--are all the ones that come from the ground. You 00:52:00can't innovate from outside. One of my early learnings were that when we first did trainings to set up acute flaccid paralysis surveillance so that all cases of acute flaccid paralysis are identified and reported, and stool specimens collected within two weeks of paralysis onset--for laboratory confirmation if the cause of paralysis is polio or not poliovirus. Setting that up in Afghanistan--and this is during the time when the Taliban were controlling one half of Afghanistan and the Northern Alliance, and we did trainings on both sides. In the areas controlled by Taliban in Jalalabad, we did trainings, and also in Mazar-e-Sharif, we trained the areas that were under control of the Northern Alliance at the time, in '97. And what we did was that we engaged our Afghan colleagues in designing the system. Our job was to give them the technical rationale, what we are trying to do, and then the programmatic objective. This is how we want cases to be-- these kinds of cases need to be detected and identified. Our objective is to collect stool specimens from them, and then the specimens have to be transported and then shipped through these UN [United Nations] flights from different parts of Afghanistan to the reference laboratory in Islamabad in Pakistan. So we had to give them the outlines of what our objectives were.

It was the Afghans who actually designed the operational part of the system, and it was beautiful. It's still working, and it continued to work through all wars in Afghanistan because it was designed locally. And in fact, that was such a strong surveillance operational design that we actually took it and then had a similar discussion with local health workers in Somalia 00:53:00and in South Sudan, and in other war-affected areas and other parts of Africa that were war affected and those principles were applied there. But again, the design work is done by the local health workers. They understand the conditions. They know what works. They know what the information systems are, both formal and informal. So that was very rewarding, to have that partnership. And once the innovation is at the local level, when the system is managed and handled at the local level, that's where a program is at peak performance.

TORGHELE: So you didn't ever go in and tell them how to do things and what to do. You listened to them and got their ideas.

JAFARI: Absolutely. And really it's really mentoring. Take the time to analyze, take the time to think. Thinking saves time. Don't react to everything. And again, highlighting what are the important parts of their job, but let them do 00:54:00the problem solving locally. I couldn't have solved problems from Delhi. My job was to mentor them and then ask the questions. That helped all of us to find the answers together.

TORGHELE: Can you think of some examples of some solutions that people came up with that maybe surprised you, or that you wouldn't have thought of yourself, that worked?

JAFARI: Two or three things really stand out. One of the other areas--we thought we were getting very high coverage in Bihar in the later stages, and still wild poliovirus type 1 kept sort of occurring and surviving in a part of Central Bihar. What we learned was that this is an area that gets annual flooding, And we had figured out how to vaccinate children during flooding, but what we had not realized that what happens after the floods are gone? These are the snows 00:55:00that melt in the Himalayas in Nepal. The rivers surge, and there is flooding of-- large parts of Central Bihar gets inundated. It's an annual phenomenon. People move to higher grounds--you vaccinate them there. But once the floods go away, this is very fertile land. And there's a land grab, and then there is very active cultivation in this basin. And what happens is that parents take their small babies and set up these small shanties called Basas. So when teams would go to vaccinate in villages, they would only find some of the children--but not the children that were living in these basas where their parents had found this temporary shelter while they were cultivating the land.

And this is a very difficult place to move. No roads, motorbikes could only go some distance, places--it took you like eight hours to walk to some of the villages in thick mud and such because it's all like a flood basin really. Very fertile land. So we actually had to completely change the planning paradigm for 00:56:00this area. And, again, it was the local staff that came up with a grid planning, rather than using administrative boundaries for planning vaccination. They came up with a grid planning approach with satellite mapping, and then established night shelters with water and food, because there's no electricity there, and so that medical officers and supervisors could actually go and spend the night. Because once you go, you can't come back in the same day to the main towns. So shelters were established, logistics were put in place in some villages so that work can continue without people having to come back to capitals or the major towns. So we found thousands of children that were being missed, and that's what explained the persistence of virus. A virus doesn't persist in vaccinated 00:57:00children. No matter what kind of innovative ideas you come up with--but that's what reinforced that lesson. So a lot of this grid planning was done by officers and workers in central Bihar.

Another innovation was the strategy in India--was house-to-house vaccination. And so the vaccination was fixed to a child living in the house. It was not how many children here? The focus was always, who's not there? So when you go to a house, the first job of the team was to establish how many children are in that house on that day. Whether those who live there, those who are visiting, or a newborn, somebody who's coming spending the night. How many children on that day? They have to write that, and then how many of those they actually were able to vaccinate. And if they were not able to vaccinate all 00:58:00those--so that by itself was a process of learning, as to how you ascertain how many children are in the house. It's not a simple process.

First of all, you find out how many households in a compound. A household is defined by a separate kitchen. You can have several kitchens in one large space. And then ascertaining how many households, how many children, how many newborns. You ask different ways the question--any guests visiting? daughter visiting her parents with a small child? All of those ways of asking questions. You do the micro-census and then see whether you were able to vaccinate all of them. If any child was missed, then you have to record that, and the reason why missed. Not there, or where the parents refused vaccination or was the house locked? And was the house locked because they had just gone to the market and will be back, or have been gone for weeks and won't be back during the days of the campaign?

And so the team started noting this for the reason why a child was missed and then would go 00:59:00back to that house with a strategy that would address the reason they were missed. So if the reason was that the family was reluctant to vaccinate--was refusing vaccination because they'd had enough or felt the vaccine was not safe--then that team already had names of local influencers who had influence in that community, who would go back to the house with the influencer to engage them in a discussion and persuade them to accept the vaccine. If the child, they said is sick and we feel is not well enough, a local doctor would go and talk to the family, assess the child and see if the child could be then vaccinated. Or go back and see if the child may be back at the house because they were just gone to the market and the house was locked. So it was according to the reason, and the conversion from non-vaccinated to vaccination was tracked by--

This is a local innovation. It's the local field volunteers, and the medical officers came up with this tracking strategy. And so the district magistrates were tracking this conversion from round to round. That's the level of detail that this was being done. As I mentioned for migrant workers, they figured out in Mumbai that we go--they leave very early for work, and they're gone all day, and they take their children with them. So they started vaccinating, and there were night vaccination teams. They would go at night to those neighborhoods and then find children and vaccinate them. And only local people know these issues and can solve them, as long as they know what you're monitoring. And they have to tell you why they are missing and who they are missing.

TORGHELE: How did you know which children had been vaccinated?

JAFARI: So this also was an innovation early in the program--was that there was 01:00:00finger marking done. So if a child was vaccinated, there was indelible ink that was put on the finger that was good for a few days. So it was through finger marking that it was checked. But even there was a check for that. That there would be monitors, who would go and check if there is false marking going on. That parents had said no to the vaccine but convinced the vaccinator to mark the finger. We had examples in countries, including in India and Nigeria. That was a big issue, where in Nigeria, they had to implement what is called directly observed OPV [oral polio vaccine] vaccination. So that they would be under the observation of a supervisor--that children in those particular compounds and communities would be vaccinated, where there was a history of where they had persuaded the vaccinator to just mark the finger but not give the vaccine. But that's how basically this was.

And then, validation. I talked about house marking, to see whether the house was marked appropriately, whether the child has been missed in this house or not. A supervisor would come and do a sampling of these houses behind the teams, to validate, is the house marking appropriate or not? In India, they used to call it a false P. If a house had a marking of P means that all eligible children had been vaccinated in this house. But if a supervisor found an unvaccinated child there, this would qualify as a false P, and false P's were tracked for the area by the supervisor, by the team. So this is the level of detail at which this program had to operate.

I've talked mostly about missed children. But we, in India had to go from trivalent vaccine oral polio vaccine, which wasn't working as well because the type 2 component in the vaccine was competing with the type 1 and type 3 attenuated vaccine virus. And 01:01:00type 2 had been eradicated and was last seen in India in 1999--last seen in the world anywhere in India in 1999. So we were vaccinating against the virus which had not been seen for several years. So then we shifted to the monovalent type 1 and monovalent type 3 vaccine. And there we ran into the problem where we were prioritizing eradication of type 1 virus because that was causing more outbreaks because that virus behaves differently from type 3 virus. Type 1 has a higher, or lower, rather, infection-to-paralysis ratio. So an average of 200 children would get infected, and one of them developed paralysis with type 1 wild poliovirus whereas type 3 could be at 1,000 to 1 ratio. So it was more dangerous 01:02:00that way and more virulent virus and it also had a tendency to spread further, so most of the outbreaks within India were spread from India to other countries was actually of type 1 wild poliovirus and not type 3. So we prioritized eradication of type 1 virus, so we used type 1 vaccine preferentially, monovalent vaccine. It was more effective than the traveling vaccine against type 1, which had all the three types of viruses that are presented in the vaccine.

But then we started having resurgence of type 3 polio outbreaks. And then how do you explain that to parents, to the policymakers and decision makers, that this is a cost we are incurring? For a parent, it is polio. And then we had to optimize the type 3 vaccine campaigns and type 1 campaigns. And then we moved to the use of the bivalent vaccine, which we also first studied in 01:03:00India, as I said when we established the research platform. And we studied the performance of the bivalent vaccine compared with trivalent and compared it with monovalent 3 and monovalent type 1, and it was non-inferior to those. So then we went with bivalent vaccine that addressed both the type 1 and type 3 remaining wild polioviruses in India. And then that was the optimization of the vaccine tool.

So this all came together, that vaccine alone would not have done it if you were still missing children. You have to vaccinate children for the transmission to stop. But then we were able to optimize our vaccine delivery so that we're missing very, very few children. And then we were also in parallel optimized the vaccine itself.

TORGHELE: It almost sounds impossible.

JAFARI: Many people actually said that the conditions on the population size, as I said--birth rate, the environmental and climatic conditions in India were such that there is such efficient transmission of poliovirus in those conditions that this will overwhelm the capacity of polio vaccine to interrupt transmission, so it can't be done in India. And that's why the success in India was such an important turning point in the global polio eradication because it removed sort of this--a lot of experts questioned the biological and technical feasibility of polio eradication because of what we were faced with in India. But once India interrupted transmission, I think these arguments of technical and biological feasibility was removed. And the strategies are solid-- that you have to have good surveillance, you have to vaccinate all children, and transmission will stop. So any place where transmission is persisting, it's because children are 01:04:00being missed. And they're being missed either because there isn't enough political commitment, not enough financial commitment, not enough accountability, the quality of micro-plans for local planning is not good, they don't understand fully who they are missing, and that's why they can't find those children and such. And that's how this was a major push, then, in the remaining endemic countries of Nigeria, Pakistan, and Afghanistan to optimize those programs.

And so a lot of lessons learned from the India program were actually adapted by the program in Nigeria, Pakistan, and Afghanistan. And in fact, waves of the medical officers from the national polio surveillance project of India--the project I was heading in India-- actually spent months in Nigeria, and sort of transferring those lessons learned and helping with the adaptation of those lessons by the local workers and local officers in Nigeria itself. And so many 01:05:00of these best practices around accountability and corrective action and micro-planning and tracking of migrant and mobile groups were applied in these countries based on the lessons we learned in India.

So Nigeria succeeded. They had their last case of wild poliovirus in July of 2014. So this is getting to be now two years with no wild polio in Nigeria. In fact, in the last wild polio case in North Africa, in fact, was in Somalia, which was following an importation from Nigeria for wild poliovirus type 1. So the last case in Somalia--all of Africa--was in August of 2014. So all of Africa, in a month or so, would be without any case of wild poliovirus for two years. And now Pakistan and Afghanistan are making very, very good progress, and there is likelihood that they will succeed this year in stopping transmission of wild poliovirus.

Of course, we had very unique challenges in both Nigeria and particularly in Pakistan, where in Nigeria many of the polio vaccinators died as a sort of collateral damage to attacks on health centers and such as part of the armed activities of Boko Haram. And in Pakistan, this is sort of a truly unprecedented challenge in public health, where the polio vaccinators were killed and assassinated in cold blood because they were, for political reasons, in the country. So tremendous lessons have been learned in Afghanistan, Pakistan, Nigeria and many countries, and Somalia also, when we faced these outbreaks where there was some extremist elements in Somalia also that were not allowing 01:06:00and have not allowed vaccination of children in areas that they were controlling--the al Shabaab in Somalia. But program has learned very important lessons as to how there could be, again, operational innovation to vaccinate children in areas of conflict or areas where the program has no physical access, okay, and in some of the most insecure areas, how you can still maintain surveillance--as well as strategies with cooperation of appropriate security planning, and vaccination of mobile populations that are moving in and out of such areas, so that you get to them and provide vaccination as they're on the move.

Very important lessons for public health in general--how to reach 01:07:00populations that up to this point, I think, in public health were considered, "Let's wait for the conflicts to get over." We were entering a global situation where there are so many active areas of conflict and extremism and insurgency that you can't just wait and leave women and children non-combatants in areas that are affected by such conflict and say, "Okay, we're not going to give them any services, because let's just wait for this to get over." Don't know when that's going to happen." But we've learned enough that we can now think of providing essential services to women and children, non-combatants in these areas, largely through the lessons we've learned. Some very hard way-- by losing a lot of our workers on the ground--but important lessons have been learned on how to vaccinate children from such communities. TORGHELE: How do you get workers in when there's a war situation?

JAFARI: The first and foremost is building trust and engagement of communities, 01:08:00the non-combatants in these communities because what often you find is that they also are held hostage by the extremist elements in those areas. Okay, everybody wants to protect their children. So what if this is in areas controlled by a Taliban faction or some other militant faction. You know, those women and children, you know those parents still want their children to be protected and so one has to find the local leaders, religious leaders, community leaders, engage them, build bridges with them. Get them to implement the program, empower them, empower communities, empower community leaders, give them the resources to protect their own children. And once you build that bridge, then the communities become the biggest protectors of the program.

And in parts of Pakistan, for example, we've had enough leverage to take young women from those communities, 01:09:00get the endorsement of community leaders and religious leaders for them to be trained so that they can go and vaccinate children in their communities and in their neighborhood and that obviates a lot elaborate security arrangements and apparatus. In other areas, you create corridors or zones of security so areas are cordoned off in a way that with careful security, planning and coordination of security and vaccination campaign operational planning that you can create these safe zones where vaccination teams can move and these are vaccination teams largely made up of local people. So there's not outsiders coming in-- they have the language skills, they understand the community leaders so that there is acceptance of these teams when they're moving in these areas.

The third area, as I mentioned, is to set up vaccination posts in critical transit points where --people move. So as they move, you can engage these communities and vaccinate their children as they're moving in and out of these areas. And then fourthly, political situations change. Leaders change. Different leaders take different positions. You can actually negotiate access to some of the leaders because there's not one opaque body. Afghan Taliban have always been supportive of polio vaccination when they were in government and even when they've been out of government. So in areas that they're largely controlling Afghanistan, they still support the polio eradication program. The program has to engage intermediaries, neutral parties to negotiate the program. But they identify workers in their areas, and they get trained, and they provide vaccination to their children. They're not philosophically against vaccination of children.

So this can't be painted with one brush. As I said, even in Afghanistan, there are different factions who deal with it differently. Different in the south, different in the eastern region next to Pakistan. So it all has to be tailored and customized to what the local challenges are and who are the people on the ground. Where there are problems, the solutions are always there.

TORGHELE: If you empowered the people to help and promote their solutions along with you.

JAFARI: That's correct. That's exactly right. You can't parachute programs, and you can't parachute ideas and such. I mean I think this is becoming an important learning, right? I mean we would have an important lesson learned in the Ebola outbreak also is that we didn't have good bridges with communities. We were not talking to them well enough, right. And this was a surprise, but now I think in 01:10:00polio we learned this lesson that when there's a polio outbreak, you don't just send an epidemiologist. You send in a logistician. You send people who can plan administrative and operational aspects, the logistics, movement, communication, data, you know, the whole multidisciplinary team. That must include a communications expert--how to engage the affected community, get people engaged from those communities. Are we listening to them? How are they processing this polio outbreak? What does it mean for them, and how are they perceiving the threat of this outbreak, and how do they perceive people who've sort of come to help them? So that's now a part of the package of the outbreak response that it's just not a uni-dimensional outbreak response.

TORGHELE: So what's your prediction about polio eradication? When and --

JAFARI: My first prediction is that it will happen because I think that maybe some people who still think that maybe it can't be done but I think after India and Nigeria we should--you know, there's just no way this can be given away at this time and so it will happen. It's really a matter of are we getting to these final pockets of under-vaccinated populations. Are we getting there or not? And if we are, it can go like this. An indication in Pakistan and Afghanistan we are getting there. All the data seem to suggest that but there are also complex places with complex security, you know, conflict situation and there could always be a setback. But these programs, as I said, have learned very important 01:11:00lessons. They've come a long way from where they were even two years ago, and those learnings are not lost. So if there are any pockets left this year, I mean I think that they are pretty close of getting done this year.

But even if they don't get done this year, I think they're on their way. They're on their way, and I don't think we should hold people's feet to a calendar year. Polio has its own seasonality, and if not this year maybe the next low transmission season which will be the early part of 2017. But I'm hoping. I'm keeping my fingers crossed and really rooting for the team to do this year, to interrupt transmission in Pakistan and Afghanistan. These are the only two countries left, and it's not even--in other words, these countries are tiny pockets in Afghanistan and pockets in very well circumscribed pockets in Pakistan as well. I mean more than 95 percent of the population lives and has lived in areas that 01:12:00have been without wild virus transmission for years. It's, again, who is it that we're missing and how to get to them.

TORGHELE: Before we go, can you just say a little bit more about how Rotary International and UNICEF and CDC and WHO, World Health Organization, all worked together and what that was like?

JAFARI: Fantastic partnership. I think the Global Polio Eradication Initiative [GPEI] is one of the most enduring. We didn't plan it that way-- it's lasted longer than we thought, but in some ways, it's been a kind of exemplary partnership that many other programs have tried to emulate. And it's worked really well, and it's not formal. There's no legal entity like GPEI, but it's a very effective partnership. It works well together. WHO, UNICEF, Rotary 01:13:00International, Bill and Melinda Gates Foundation and, of course, U.S. Centers for Disease Control and Prevention. The roles and responsibilities are clearly defined, which is very important in a partnership. Understanding each other's priorities and strengths and weaknesses is important, and everybody brings unique strengths to this partnership.

And Rotarians, in particular, have been absolutely outstanding and I've had the privilege of working with the Rotarians both at the local level and National level particularly in India and Egypt and in Pakistan and other countries, and they are just tremendous partners. I mean you come to a block, whether it's a financial block or a political block, there is lack of commitment or even outside health sector, if you need the help of another ministry, Rotarians will engage, and they'll open the doors for you and 01:14:00very effective. Clearly, Rotary volunteers bring a lot of passion to eradication, and they are the voice of the people, the civil society in this partnership.

CDC is a scientific organization. The CDC experts work in this organization. We get paid to do this work. So is WHO, so is UNICEF, similarly Gates Foundation, although with some important differences. The leadership Mr. Gates brings to the partnership, giving away, and tremendously effective leader, but Rotarians are the voice of civil society. They give their time, and they give their money to this all on a volunteer basis, and they bring tremendous leadership in their countries and at the global and international level. And so 01:15:00they are in a unique position to hold all of us accountable because they're putting in their time, their money and they have the voice of civil society, so they can hold the GPEI partners accountable, and they can hold their own governments accountable for what they're doing for polio eradication. Among all of us partners, they are the most uniquely positioned to ask their governments the questions. Whether they're a government that is polio-endemic or polio infected or if it's a donor government. So I've worked with Rotarians in Europe and accompanied them, advocating with their parliamentarians, with their ministers of development, going in with Rotarians who, German Rotarians and Swiss Rotarians, talking to their leadership and saying we need your funding support to finish global eradication. It's a global public good. So they're enormously effective.

And I think clearly the scientific and technical credibility and excellence of CDC is enormous. The work of the CDC virologists, I mean they're the ones that have set up more than 145 labs around the world which are the poliovirus laboratory network on which other vaccine-preventable disease laboratory networks have been set up. The measles labs and measles and rubella labs and yellow fever labs in Africa have been built on this poliovirus network, and our scientists here have been instrumental in building those networks and CDC leaders, of course, public health leaders and our scientists have been key. As I said, in four of the six WHO regions the CDC experts were instrumental in establishing polio eradication programs in those regions-- the Southeast Asia region, the European region, the Eastern Mediterranean region and the African region. And then in other region also CDC has been very engaged, CDC had a very close working relationship with China when China was polio-endemic, and so we had a lot of Chinese scientists here. A lot of exchange programs. So there's enormous scientific exchange between CDC China and CDC US.

So the role of CDC in polio eradication evolved over time as WHO built more capacity and more leadership in polio eradication. The sort of gap-filling work and the early 01:16:00program establishing work that CDC had to do was called on less and less as the global program expanded and more and more staff were recruited by WHO and deployed for this work. But without that bridging and the early foundational work and program establishment work of CDC, we would have never made that kind of progress. And where we go from here, CDC will have to stay engaged and provide that leadership of transition planning how global public health, the world of immunization, the next set of eradication programs, global public health security--programs benefit from all we have learned and all we have built for polio eradication. So I think CDC is engaged in that and will remain engaged in that sort of the next set of benefits because I think most donors and the 01:17:00public health world looks at the global public good of polio in two ways. One is, of course, the eradication of wild poliovirus and poliovirus altogether forever as a cause of paralysis of children. They'll be gone forever. So benefits accrue forever just like they do for smallpox.

But the other benefit is that what can we build on this tremendous workforce, this lessons we've learned of reaching the unreached populations and putting populations on the map that were not on anybody's maps and being able to deliver services to those populations. Amazing surveillance system, field surveillance system that has ability to detect cases of acute flaccid paralysis is almost every district around the world. And being able to collect stool specimens and have them tested 01:18:00in a WHO accredited laboratory. What more can we build on that? I mean a lot has already been built but what more can we build onto that? So the many donors look at that as a return on their investment as well in this eradication program so there are direct benefits and then there are enormous indirect benefits of polio eradication. And CDC is also involved with and must stay involved with this kind of transition of work because it involves other parts of CDC as well. Global Health Security Agenda is an important U.S. government and an agency priority, and there are links between polio transition and how global health security can build on top of the assets built for polio eradication.

TORGHELE: Well, this has been an amazing discussion. And when you talk about 01:19:00lessons learned, you've communicated the lessons learned in polio eradication so well. I can't imagine them being communicated any better. So it's been an education, and it'll be very valuable to have your input for these oral histories.

JAFARI: Thank you.

TORGHELE: So I really want to thank you so much, Dr. Jafari, for coming and sharing your experience and your skills and your knowledge and your insight.

JAFARI: It's been a pleasure. Thank you for the opportunity.

TORGHELE: Okay. Thanks very much.