Steve Cochi - Session 3



CRAWFORD: OK. Today is Tuesday, August 6, 2019. This is Hana [S.] Crawford for the Global Polio Eradication Initiative [GPEI] History Project with [Stephen L.] Steve Cochi [MD] for session three. We're in Atlanta, Georgia in CDC [United States Centers for Disease Control and Prevention] studios. For the third session, [laughs] do we have your permission to conduct and record this interview?

COCHI: Yes, you do. Thanks for having me.

CRAWFORD: I'm glad you're here. Let's see. This is our third session. When we last spoke, we left off at 2014. We had covered, most recently, toward the end of the interview, the 2013-2018 Polio Eradication and Endgame Strategic Plan. We'd also talked a little bit about the switch, which is past 2014, but I thought, if you don't mind, you could set us up to move forward from 2014.

COCHI: Very good. Well, let me set the scene for where things stood in 2014 by going back several years. Most of the first decade, virtually all of the first decade of the twenty-first century, leading right up to 2014, the program was plagued by repeated importations from the few polio-endemic countries--and there were only three polio-endemic countries, as of 2014--into previously polio-free countries. To give the statistics on that, there were some ninety-one importations into forty-three countries. Some countries had repeated importations, which is why it was up to forty-three. This was a real diversion from completing the interruption of transmission from the three remaining polio-endemic countries. It was also very costly. It cost more than $1 billion to terminate those outbreaks in the previously polio-free countries.

In 2013, 2014, this was still a problem. In fact, there was a little bit of a resurgence of polio compared to 2012, from a little over two hundred cases in 2012 to more than four hundred cases in 2013, and almost four hundred cases in nine countries that were previously polio free in 2014. This is what led to the director-general of WHO [World Health Organization] declaring a public health emergency of international concern, because the program was strapped with these repeated importations, it needed more visibility, it needed more political commitment, not only from the three remaining polio-endemic countries but to attack the problem of insufficient population immunity in these previously polio-free countries.

Two thousand fourteen, we started with the polio public health emergency of international concern. That was right at the beginning of our latest five-year plan, strategic plan, the endgame strategy to complete the polio eradication effort, 2013 to 2018. It was actually a six-year plan, covering those years. These were times of uncertainty but a surge in political commitment and resources to address the needs of completing the job.

In the resources category, there was a tremendous resource mobilization effort to fund that six-year strategic plan, 2013 to 2018, with up-front fundraising for what was projected to be a $7.5 billion budget over six years. Majority of that budget was committed by the major partner organizations up front, in early 2013, which was very reassuring, in terms of the program being able to do what it needed to do.

CRAWFORD: Were there new features to the budget at that point?

COCHI: A good question. I think the one new feature was planning for the implementation of what's called the switch--we alluded to this at the end of our last discussion--the switch to occur by mid-2016. What that switch would consist of is, first of all, the introduction of the IPV, the inactivated polio vaccine, in all of the remaining countries--there were about 125 countries, I believe, that still hadn't introduced at least one dose of IPV into the routine childhood schedule--to provide immunity against [wild poliovirus] type 2 in advance of our removing the [oral polio vaccine] type 2 component of the trivalent [oral polio vaccine]--[oral polio vaccines] type 1, 2, 3--component of the trivalent OPV [oral polio vaccine] in 2016.

The switch had two separate parts of it, introducing IPV to provide population immunity against type 2, as well as 1 and 3, and then withdrawing a type 2 component in April/May of 2016, leaving a bivalent [OPV], type 1/3 vaccine to be used in the routine program, as well as in subsequent polio mass campaigns. That was a new feature, that really was a major feature that came into play for that strategic plan.

CRAWFORD: I'm trying to remember, for myself, when the Emergency Operations Centers [EOCs] came about. Was that part of the plan, as well?

COCHI: It was a major feature of the plan. If we look at the history, the first Emergency Operations Center for polio eradication came into existence in December of 2011 at CDC. Then it was in 2012 WHO headquarters created or opened its Emergency Operations Center. I think it wasn't until 2013, 2014 that Pakistan and Afghanistan and Nigeria opened national Emergency Operations Centers, as well as centers at the state or provincial level, in those three endemic countries where polio still continued to persist. It's a good point you raise. That really became one of the major features of the new strategic plan, as well as increasing efforts in program accountability, accountability for the resources, both human and financial, that each of those endemic countries--as well as the high-risk countries that were receiving resources.

CRAWFORD: What else was happening around 2014?

COCHI: Well, the [WHO designation of ] "Public Health Emergency of International Concern" [PHEIC] created a Polio Emergency Committee. I serve on that committee. The charge of that committee was to review the program every three months and report to the director-general on progress, on challenges, on whether the public health emergency should continue or not. We have had four meetings per year for the past five years to review the program. I think it's had its good points and it's had its bad points. I think we got a real boost, both on political commitment, attention, resources, in the early going, when the Polio Emergency Committee began its role. Now, five years into the effort, there's been a flagging and sort of a trailing off of the impact.

The other thing that came into the being is the creation--and this started back in 2012, really--the creation of the Independent Monitoring Board [IMB] for polio eradication, chaired by Sir Liam [J.] Donaldson [FRCS(Ed), FRCP, FRCA, MD]. This became a very good vehicle, an independent vehicle to review the program, generally on a biannual basis--twice a year--meeting with the Independent Monitoring Board and the endemic countries and the key partner organizations to review the program and give the program some tough love.

By that I mean Sir Liam and the Independent Monitoring Board was not shy about openly saying, "Here are the challenges. Here's what the program is doing wrong. You need to fix it, because you're not on track." Since we still haven't interrupted polio transmission, it's safe to say we're still not on track. It was very useful, I think, to get beyond the diplomatic niceties that all too often are a feature of the UN [United Nations] programs, WHO and UNICEF [United Nations Children's Fund], interacting with the country ministries of health, not saying the hard things that need to be said, for fear of offending or somehow damaging the relationship that those UN organizations have with the government.

CRAWFORD: The last couple of interviews, maybe within the last five or so, the topic of red-teaming has come up. Could you explain what red-teaming is and then tell me whether or not you've heard that as a suggestion around accountability and planning?

COCHI: I'm not sure I know that phrase, red-teaming, but I think, if I understand correctly, the accountability also led to the increase in the accountability-framework attention applied not only to the government and what it was doing in the field and at its headquarters but also to the major partner organizations, especially WHO and UNICEF, which had a lot of polio eradication-funded staff in the field. That related to, if people were not performing, they were not allowed to continue to non-perform. They had to be fired or removed from the program and replaced with people who were going to be able to perform the required tasks. That's been a chronic problem with the program, especially in low-performing countries and regions, where bad management was a feature of the failure to stop polio transmission. I believe that expression relates to this, but I may be totally wrong. You can correct me.

CRAWFORD: I don't know a lot about it either. I think that it's an approach to review that happens internally. I think it's a U.S. [United States] military approach to really scrutinizing, but by an internal body versus an external body like the IMB, I think.

COCHI: Yes. Anyway, what I just said about the accountability of the staffing may not apply to that expression, red-teaming, but it certainly has become, in the last several years, a feature, a new feature of the global effort.

CRAWFORD: Could you talk more about that and maybe--? I've wondered if the skill base that's needed from staff has changed over time also.

COCHI: Now that we're dealing with areas that are very difficult to operate in, both from the standpoint of infrastructure, or lack of infrastructure, as well as, in many instances, insecurity. I think it's hard to find the skill set--and the willingness of people who have that skill set--to operate in these difficult areas. Not surprisingly, where are the last few places where the polioviruses have been able to survive and to hide out, if you will? Well, they're in the most insecure parts of Pakistan, for the most part, Afghanistan, and northern Nigeria. How do you overcome that? It's a tremendous challenge.

Do you, in a sense, penalize the most highly performing people by sending them to the areas that are the most difficult not just to complete the task, but to get a good night's sleep, to feel secure, to have some adequate food, transportation, and so on? As the program drags out without achieving the interruption of polio transmission, this is a tremendous problem, because there's exhaustion. There's exhaustion on the part of the staff. There's exhaustion on the part of the communities whose children are receiving vaccine repeatedly. Overcoming this is a tremendous challenge for the program, going forward.

CRAWFORD: Thinking about Pakistan, Afghanistan, and northern Nigeria, I wondered could you think of 2014 and give a snapshot of what was happening in those places?

COCHI: Yes. OK. Well, let's take it country by country. First of all, Nigeria. Nigeria had in 2014, we thought, the last case of wild-type polio [wild poliovirus]--occurred in 2014. This was informally declared. Nigeria was actually taken off the endemic country list after 2014, but then we got a surprise with two cases of paralytic polio occurring in the summer of 2016, a little over two years after the last case--what we thought was the last case. This was in Borno state [Nigeria], the most insecure state, sort of the home state of Boko Haram and where, if you go back to 2013, close to 500,000--roughly--children less than five years of age were really inaccessible due to the insecurity.

It was a setback for the program, but the program has done tremendous things to reach those isolated towns and villages. In the past few years, there have been no reported cases of wild-type polio in Nigeria. We're about to reach the three-year mark on that. There's every reason to think, unless the circumstances change again--I will parenthetically say that the program has gotten that estimate of inaccessible children down to about sixty thousand, from nearly half a million--sixty thousand--with the help of the army and the improving security situation. There's every reason to think that this means that wild-virus polio [wild poliovirus] no longer exists on the African continent. It may be as soon as the first half of next year, 2020, when Africa can be certified as free of wild [polio]virus or naturally occurring polio, which will be a tremendous milestone.

The other side of the coin in Nigeria is that we're dealing with type 2 vaccine-derived poliovirus outbreaks because of the chronically weak routine immunization system, particularly in northern Nigeria, resulting in low coverage and low population immunity, particularly against the type 2 virus now that it has been removed from the trivalent vaccine. We're using bivalent vaccine now. That's the other side of the coin. We can get into vaccine-derived polioviruses a little more, in a few minutes.

Let me go on to Afghanistan. In Afghanistan, the problem there is--the overriding problem is insecurity and, in the past year, the Taliban clamping down and prohibiting, in many parts of the country, house-to-house vaccination, because of the alleged fear or concern that there's spying going on, that the vaccination teams are somehow identifying where Taliban--particularly Taliban leaders--are hiding out. This has been a real disruption to the overall program. Special vaccination teams and mosque-to-mosque vaccination and other ways of working around this ban on house-to-house vaccination with oral polio vaccine have been taking place. We're very concerned about--right now I think there are only about twelve reported polio cases in all of Afghanistan, during this year, but we're worried that there might be an explosion because of the probable decline in immunity against polio.

Then finally, we move to Pakistan, which I think is the biggest challenge and the biggest source of discouragement, where there's a change in government a year ago. This led to some disruption at all levels, including at the highest level, in the management of the program, the oversight of the program. Because the change in political parties in power--that disruption has led to a decline in political commitment and, unfortunately, a bit of a politicizing of polio eradication by the current party in power, which--the program has always been a nonpartisan program, but it's become more of a partisan program, which contributes, I think, to a fall-off in the vaccine acceptance in certain parts of the country.

Pakistan has a range of problems. There's the insecurity because of the Pakistani Taliban, there's the insufficient political commitment, and there's bad management in key areas, which leads to inflated budgets and insufficient quality of the polio mass campaigns, and, finally, a routine immunization system that is very weak in certain parts of the country. Those four areas, I think, have contributed to a resurgence in Pakistan. Now we've had nearly fifty cases in Pakistan. We're worried it might even top a hundred cases. That's a big resurgence.

[INTERRUPTION]

CRAWFORD: We're back from a water break. You mentioned bad management. I was wondering if you could talk a little bit about what approaches to management have been really effective in the polio eradication program and maybe, yes--maybe begin there.

COCHI: Well, it's not rocket science but I think the major ways to overcome bad management have to do with providing adequate training and rewards of various sorts for people who perform well, who are able to make good management decisions. Having good oversight at all levels, so in order to overcome bad management, there has to be, at all levels of the system, good, regular monitoring and supervision; the supervisors with the people that they supervise. The training needs to emphasize that, that there needs--providing positive reinforcement when people do something good. It takes more resources, I think, to be able to do that. It takes making sure that people are getting regular paychecks.

In Pakistan, all too often, the frontline workers are being asked to work month after month, often without receiving the very small amount of pay that they're entitled to, that they're supposed to receive. All too often, the supervision is very negative, it's very authoritarian, "Here are all the bad things you're doing," instead of providing some positive feedback when a person does something good or goes beyond the call of duty. Rewarding people as a meritocracy, rather than who they know and--this is part of the corruption that unfortunately seems to pervade the system, particularly in Pakistan and in Afghanistan and Nigeria, the three remaining endemic countries. These are very challenging things. There's no easy fix. The overriding fix has to do with having a proper political commitment, which brings with it the resources for training, for supervision, for hiring and recruiting and retaining the best people.

CRAWFORD: Do you have hope for Pakistan?

COCHI: I have to have hope for Pakistan. I'm an eradication person. To be a person involved in disease eradication, you have to be an optimist. There have been ups and downs. Pakistan, not too long ago, got very close to stopping polio completely. I think we can get back there again. The main discouragement I have right now is that the past year has been a difficult year and a bad year for getting rid of polio from Pakistan. It needs to be turned around and turned around pretty quickly, I think, to get us back on the right track again.

CRAWFORD: There's a new target date, which is 2023.

COCHI: Yes.

CRAWFORD: Could you talk about the latest strategic plan?

COCHI: Well, target dates, [laughs] to some extent, in polio eradication, they've kind of lost their meaning. The original target date being the end of 2000--we've blown through one target date after another. I prefer to talk about it more as, we're now in a new framework or strategic plan. It's more of a framework than a plan, because it's only about a thirty-, thirty-five-page document, but it lays out, "Here are the major priorities and things that we're going to do differently during the five-year period 2019 to 2023."

If we do these things properly, then there's every reason to believe that, by no later than 2023, we'll be able to certify the absence of the wild or naturally occurring poliovirus. That requires interrupting transmission in Pakistan and Afghanistan by sometime in 2020. Right now, at least for Pakistan, that's not looking very encouraging, unless the government really takes better ownership and steps up its political commitment. I look at that 2023 as just a part of that framework and subject to change, because we can't predict the future right now very precisely on when the last case will occur and when certification, which has to be at least three years after the last case, will occur. Twenty twenty-three would be the ideal, still possible, date for certification. Twenty twenty would still be the ideal, but perhaps optimistic, date for interruption of transmission of the wild virus globally. I hope that answers your question.

CRAWFORD: Yes. That's wonderful. I was also thinking about making a transition from 2018 to 2019. Twenty eighteen was the last year of the six-year plan. Now there's the framework. I wanted to ask you about what has happened in that transition. Like the sunsetting of the Transition Management Group has been part of that transition. Could you talk about that aspect of the transition, as well as any others?

COCHI: Yes. Let me get into sort of the polio legacy, polio transition aspect of the program. Now, when we engineered the strategic plan, 2013 to 2018, we had the anticipation, if everything went right, that the last case of polio would occur in 2016 or, at the very latest, 2017, so that we could certify the world as polio free by 2019, 2020. Obviously, that hasn't happened.

We put into place, put into motion a polio transition planning process, both at the headquarters and WHO regional office level, as well as in the approximately sixteen to twenty highest-risk polio countries that had about ninety-five percent of all of the polio resources, including not only the financial resources but the human resources, the surveillance officers, the people who are doing communications, the people who are doing social mobilization. That polio transition plan was designed to, where appropriate, maintain those human and financial resources and redirect them to other global public health priorities, strengthening the routine immunization system in those countries that had weak systems, pursuing measles and rubella elimination, and the like.

That was our plan. With the delay in the program, I think it has stalled polio transition, not completely stopped it but--because that transition has happened in most of the countries that have become polio free. It is delayed primarily in the polio-endemic countries and the countries at the very highest risk of importations and getting reinfected with poliovirus. Unfortunately, the transition has sort of been put a bit on hold in those endemic countries and in those high-risk countries because of the delay in achieving interruption of polio transmission.

It's a real disappointment, especially for me, because I have been heavily involved in the work of the Transition Management Group, one of the working groups of the Polio Eradication Initiative, and in trying to support countries to develop transition plans, try to advocate with the partner organizations, donor organizations that they should not stop writing checks. They can stop writing checks for polio eradication over time, but they need to aware that those financial resources need to and should be redirected to these other priorities, or we're going to backwards in time with our routine immunization programs faltering, with measles resurging in the world. In the last year or two, it already has had some resurgence. Hopefully, we'll have a revival of the polio transition activities in the near future, but right now it is taking a lower priority, because of the preoccupation with stopping the remaining polio transmission.

CRAWFORD: This project is--do you consider it a transition activity, the lessons learned task team and--?

COCHI: This project, the GPEI History Project, the lessons learned activities, these are front and center, a central part of polio transition activities, because I think they've laid out what I was just saying a few minutes ago, how important it is that what we have learned from polio eradication, the human and financial resources that we have put in place and how they have had secondary benefits beyond polio eradication. The history project, where we are documenting the lessons learned from people who are heavily involved in the program so we can capture that history before it's lost--these are all aspects of polio legacy or polio transition that I'm pleased to say have been captured, have had time and energy devoted to them. They're going to be an enduring contribution to global health.

CRAWFORD: Could you talk about the genesis of the GPEI History Project?

COCHI: Genesis. It came out of the Transition Management Group, which is one of the major working groups of the GPEI governance structure. It actually started when Dr. [Thomas R.] Tom Frieden [MD, MPH], who is our previous CDC director, was the chair of the Polio Oversight Board. Membership of that board was the agency heads of the five core partners, WHO, UNICEF, CDC, Rotary [International], and Bill & Melinda Gates Foundation.

As the chair, this idea had been brought to his attention of starting a history project in the here and now rather than delaying to the point where many of the people who were involved in polio eradication, particularly in the early days, were no longer available, because they had passed on. There are a lot of people in a thirty-year Global Polio Eradication Initiative who were getting up in their years or had already passed away. Dr. Frieden recognized that this was a priority. Thankfully, it became a priority. It was endorsed by the Polio Oversight Board.

Then CDC, on behalf of the five partners, created a steering committee and took the lead to hire an oral historian by the name of Hana Crawford, and also an archivist who would help in the collection of materials that otherwise might be lost to history. We're living the history. Polio eradication is a living history and we are doing the documentation of it right now. I have to thank Hana Crawford for taking a tremendous role in the oral history part of this history project.

CRAWFORD: Wow! [Laughs]

COCHI: Is that a good time to end?

CRAWFORD: [Laughter] It can be. Thank you. That's very kind of you, very generous. It's been absolutely life-changing for me to be part of it.

COCHI: You're not out of it yet.

CRAWFORD: No.

COCHI: We're going to--

CRAWFORD: We're still--

COCHI: --be pulling you back from time to time.

CRAWFORD: --working, still working. I'm looking at my list. We've talked about the remaining--Pakistan, Afghanistan, and northern Nigeria. Changes in leadership. I wanted to ask you too about Gavi [the Vaccine Alliance] as part of the framework now. They're being considered as a sixth, potentially, core partner?

COCHI: That's right. One of the things that has really led to increasing interest and attention on the part of the five core partners to have Gavi, the Vaccine Alliance, join the core partnership--because their role, I think, over the longer-term, is going to be increasingly important as we spend more time in those three remaining endemic countries, focusing on, how do we strengthen the routine immunization coverage in those most difficult localities where routine immunization coverage is low and where the poliovirus continues to exist?

We have two ways to increase population immunity. We can do polio mass campaigns and we can give doses through the routine program. In these most difficult areas, mainly in insecure parts of Pakistan, Afghanistan, northern Nigeria, particularly where repeated acceptance of oral polio vaccine, again and again, without delivering other health interventions, has led to many of these local communities pushing back. Let's give these communities something else. Let's give their children other vaccines. Let's give them clean water and sanitation.

This is one of the fundamental, central parts of the most recent strategic framework, 2019 to 2023, [Polio Endgame Strategy 2019-2023]--not all over Pakistan or all over Afghanistan or all over northern Nigeria, but in those most isolated, poorest communities where the virus continues to hang out. Let's give them something more, so that they will be able to thrive better as a community, their children will be able to thrive better, so that they will be more willing to accept repeated doses of oral polio vaccine. I think that's the prescription for success. Going back to Pakistan, I think the government needs to ratchet up its political commitment and its ownership of the polio eradication program, but it also needs to expand its efforts more broadly related to the health and well-being in these communities where the poliovirus continues to exist.

CRAWFORD: This is the second human disease to be the target for eradication. I'm thinking about smallpox. What has changed in the world and in disease eradication as a tool since smallpox?

COCHI: It's a much more complicated world [laughs]. That's nothing highly academic or intelligent to say. All you have to do is turn on the television. You see that the world has changed. We're living in, in many ways, a darker world, a much more complicated world. There's a lot more inequity in the world. There's a lot more violence and strife. The displaced populations have--there's tens of millions of displaced people in the world now. It's gone way up. There's conflict.

Solving those problems is a lot more complicated now than it was back in the smallpox days. Smallpox also had the advantage of having a vaccine that was highly effective after one dose and a disease that was recognizable in everyone who is infected with the disease, as compared to polio where most of the infections are silent--can't be detected. There are other things that have--not changed, but are differences between what it took to accomplish smallpox eradication. I think a world where the Taliban still operates in Afghanistan and in parts of Pakistan is a world that's--for years and years--and is killing frontline vaccinators; that's a very different world than the days of smallpox eradication.

CRAWFORD: Does that change the legacy of polio eradication? Could you compare the legacies of smallpox to legacies of polio eradication?

COCHI: Well, it was different times. The legacy was somewhat different, but I think the one major thing that's different about the polio legacy compared with smallpox is that with smallpox you didn't have to reach everyone--or virtually every child. With smallpox, it's a virus that was much less transmissible than polio. When an outbreak occurred, you could vaccinate around the outbreak--called "ring vaccination"--because smallpox spread a lot more slowly. When it did spread, you knew exactly where it spread to, compared to polio. In polio, we've had to learn how to reach the unreached--we call it--how to overcome the tremendous challenges of working in insecure areas, of negotiating days of tranquility so that both sides in a conflict are cooperating to vaccinate the children. That is a totally different legacy that we have learned and hopefully can be carried forward after the end of polio to tackle other global health priorities.

CRAWFORD: When you say global health priorities, do you have a third disease eradication program in mind? Or what are some examples for the other global health priorities?

COCHI: Well, currently there's a Guinea worm eradication project [Guinea Worm Eradication Program]. It is very close to being finished, but it has faced some of these same barriers. I'm a very big advocate of measles and rubella eradication. Those two diseases, along with Guinea worm, are among the five or six top candidates for disease eradication as deliberated by the International Task Force for Disease Eradication, which is based at The Carter Center here in Atlanta, and has had a committee to review candidates for disease eradication that's been in existence since 1993. They meet regularly, at least on an annual basis, to review the prospects.

Measles and rubella would be the next two candidates for disease eradication. They can be prevented easily by a vaccine, a combined vaccine, a two-for-one, that will provide protection with one vaccine. It has most of the same strategies that are being pursued for polio eradication--a laboratory network, a surveillance system that is being used. The polio surveillance system is being used to also track measles and rubella throughout the world.

You touched on one of my hopes, that we can finish the job of stopping polio in the very near future and then we can use the knowledge and experience and resources that have been gained through the polio eradication effort to go out and eradicate measles and rubella, rubella being the number one infectious disease causing birth defects in the world and measles a major killer of children. Without measles vaccination, we would have one and a half to two million measles deaths per year. In developing countries primarily, because poor nutrition is a factor that tremendously increases the risk of dying of measles. There you have it. That's my wish for the future.

CRAWFORD: [Laughs] That's great. I have a couple more. Do you think that polio has impacted the way that we consider global health priorities outside of Western countries and more developed countries? Do you think polio has advanced developing countries being prioritized?

COCHI: I think it has in the health sphere, but I say that as a caveat because, in terms of global inequity, it's growing all over the world. It's been growing in the United States for the past thirty or forty years. The same phenomenon is happening all over the world. I hope a lesson of polio is that we should prioritize health activities--any activity in a way that's a humanitarian way, that allows everyone, regardless of their socioeconomic status, the benefits that that initiative has--in this case, polio vaccine, or you pick another vaccine. Every child in the world should have the opportunity to benefit from polio vaccine and other vaccines. There should be health equity. That's the humanitarian thing to do. I hope the world learns from the polio eradication experience to move toward a more equitable world.

CRAWFORD: Does polio leave a legacy in terms of vaccine manufacturing and supply?

COCHI: Yes. You've touched on something. I think, over time, the volumes of polio vaccine that have been required to carry out the Polio Eradication Initiative are very large volumes and have challenged countries, WHO, UNICEF, partner organizations, and manufacturers to make sure that there's an adequate supply--and, I think, indirectly has--as new vaccines have been introduced, I think there have been some lessons learned about how to anticipate the huge increase in vaccine supply that is required to make these new vaccines available to the world's children.

Haven't done as good a job [laughs] as polio has. Most of these vaccines are injectable vaccines. They're more complicated to manufacture than oral polio vaccine in terms of the preparation of the vaccine, the bottling of it, and so on--the licensing in different countries, by different manufacturers. I think the sheer magnitude of polio eradication has allowed people to dare to dream. The creation of the Global Alliance for Vaccines and Immunizations in 2000--it's nearly twenty years old now--and with the goal of making all new vaccines that are routinely given to children in the developed world available to children in the developing world. That is a statement of equity that I think carries on the tradition of polio eradication.

CRAWFORD: What has polio eradication's impact been on CDC?

COCHI: I think the impact on CDC is that it carries on CDC's tradition as an organization that is committed to health and safety and well-being, not only domestically but globally. I think polio eradication has increased the visibility of CDC worldwide. We had visibility before polio eradication, but I think it has heightened that visibility. Over time, it has allowed CDC to move into other areas of global health, HIV/AIDS [human immunodeficiency virus/acquired immunodeficiency syndrome] prevention, malaria, tuberculosis, global health security, and global disease surveillance. I think it's really participated in improving the visibility of CDC as a major player in global health. We're very proud of that. That's a legacy that we hope and trust CDC will carry on. I'm confident that CDC will continue to be a major global health player. We can't take all the credit for that, but I think we've been a part of that growth.

CRAWFORD: Trying to think of other innovations or new ways of doing things, new paths that polio eradication has carved.

COCHI: I may have covered everything that's in my head right now.

CRAWFORD: What about partnerships, working in partnership? Have there been new avenues forged?

COCHI: Good point. Partnerships--I think we have demonstrated in the Polio Eradication Initiative the value of partnerships. We didn't invent it, but I think it is one of the largest global public health partnerships in existence and has been since the late '80s, early '90s. It preceded the global partnership for HIV/AIDS, tuberculosis, malaria. I think these are also global partnerships that--if I daresay--learned from the partnership experience in polio eradication and have, to some extent, emulated that.

I say that because my colleagues who work on those other diseases, if you go back in time, they regularly would contact us to talk over, how did we do it? "What are you doing now? Why are you doing it that way?" It's a learning experience. Yes, we feel proud that we have been able to, to some extent, show the way for how to structure and implement a successful partnership, because in global health, you can't get anything done successfully as a single organization. You have to enter into partnerships and take advantage of the various comparative advantages and strengths of the different partners. That's been a very successful part of polio.

CRAWFORD: This is--

COCHI: I think--

CRAWFORD: --a different kind of question--last--

COCHI: Oh! You still have more! OK.

CRAWFORD: Yes. [Laughter] There are always more. I wonder, do you have lingering questions about polio eradication for yourself, lingering questions about certain periods of time or areas of the program?

COCHI: I have some lingering questions. I'll bring up the biggest question, that I wish was a do-over for the program--was, in the most difficult countries, the most challenging countries, I think Polio Eradication Initiative separated too much from the rest of the immunization program. I think we're suffering the consequences of that now. I think there should have been and could have been more of a balance instead of having to stovepipe operations in these selected countries.

Pakistan and Afghanistan and, to a lesser extent, Nigeria are prime examples of this, where, if we had spent more time and energy and some resources--but not to jeopardize the primary goal of achieving polio eradication--I think we'd have stronger immunization programs in Pakistan, even Afghanistan, and in northern Nigeria, and we'd have better population immunity and we wouldn't have had to do so many repeated mass campaigns, polio mass campaigns, in those countries. I think we'd have better population immunity and wouldn't have the pushback from communities that aren't getting any other health services and have to suffer repeated knocks at the door to have their child receive the twentieth does of oral polio vaccine. I think we could have done it differently.

That haunts me a little bit. I was always a proponent of--I'm an immunization person who's also a polio eradicationist. I have not appreciated the separation that began to occur and that accelerated in the first decade of this century. I've wondered, "Gee, could I have done something different? Could I have been more outspoken to try to prevent it from happening?" But there you have it.

CRAWFORD: What were some of the early signs that that was happening, I guess? What do you remember?

COCHI: By 2001, we were down to--the end of 2001--only ten endemic countries, but they were the most difficult, challenging countries, including Pakistan, Afghanistan, Nigeria, India, and others. That was a point in time where I think the separation began to accelerate. Some of it was personalities. Some of it was a rightful desire by polio eradication people to have a laser focus on eradicating polio. "We can't be distracted by other things."

I'll use Pakistan and Afghanistan as an example and the WHO staffing. The regional office of WHO in the eastern Mediterranean region [WHO Regional Office for the Eastern Mediterranean], basically, they completely subdivided. The number of polio eradication staff grew and grew and grew, particularly in Pakistan and Afghanistan. The staff who were working on immunization or EPI [Expanded Programme on Immunization] remained very much the same in number or didn't increase very much. They were working in completely separate domains with separate lines of supervision and leadership. I think it exacerbated the problem with Pakistan and Afghanistan governments taking ownership of polio eradication, because polio was no longer nested within the broader immunization program. There was infighting between--on the WHO side, and particularly--the polio eradication people and the immunization people. There was jealousy. There was anger on the immunization side of the house at all of the resources that the polio program was getting.

If there had just been more cooperation, I think there would have been more ownership on the part of--particularly the government of Pakistan, taking ownership of the polio eradication effort from WHO, as well as the immunization program. We'd have higher coverage. We'd have higher population immunity. We might have no polio any longer. Who knows whether it would have worked out that way? I think that's a major legacy that's on the negative side of polio eradication. That's kind of a down way to [laughs]--

CRAWFORD: We can turn it!

COCHI: [Laughs]

CRAWFORD: We can turn it. I think that's actually a fine way to conclude, also. Is there anything that we've--?

COCHI: Well, that's a lesson to learn. It's not too late. In fact, the 2019 to 2023 strategic framework, that is one of the themes, that we need to pay more attention, including some resources, at bringing polio and the rest of the immunization program activities back together again. The word integration is used. Some people don't like that word. I like the word synergy, because integration can be a good thing, it can be a bad thing, but synergy means, when you put two things together, one plus one equals three. You get more by combining than you have the two separate parts individually.

CRAWFORD: I know that we've talked, maybe not in interviews but other times, about the diagonal that has emerged. Back in 1988, there was a horizontal approach versus a vertical approach. I wonder if the synergy--do you consider that diagonal?

COCHI: You're exactly right. Yes. Diagonal means we're paying attention to both the system-oriented activities--the horizontal, system-oriented activities, and the laser-focused vertical, repeated polio mass campaigns approach. Diagonal gives a balance between those two. That's exactly what I'm trying to convey, that we need to achieve a greater balance. In the end, this is the key, in my opinion, to being successful in Pakistan and Afghanistan, a greater balance--and greater ownership, particularly by the government of Pakistan, to achieving that balance--and the resources, human and financial, that will be needed for that.

CRAWFORD: How would you describe the legacy of polio eradicationists?

COCHI: [Laughs] Well--

CRAWFORD: Well, what is a polio eradicationist? Could you describe the polio--? Someone called it, I think it was Carl Tinstman [MPA, MBA], the polio eradicationist mindset.

COCHI: Well, I think the polio eradicationist mindset, in general terms, is somebody who dares to dream, somebody who's willing to say, "I want to see a world as it should be, rather than as it is." The "should be" is we should be able to get rid of poliovirus from the world--forever.

Now, there are various versions of polio eradicationists. I won't dwell on this, except to say that, at one extreme, there are the real true zealots. The legacy of those will be they're satisfied when polio is eradicated, "We did it," declare victory, go on and do something else, or they may just retire completely. Those are the zealots.

There are other people, who are more middle-of-the-road, where they want to--they like the diagonal. They want to see polio eradication as a means to an end. They like to declare victory. "This is a tremendous accomplishment." Then they want to use the lessons learned to transition to achieving other priorities that need to be achieved. They're not satisfied. They're not satisfied with just that one victory, even though it's a tremendous victory. They want to carry it forward into other areas. I don't know if that makes sense, but it's not a single animal.

CRAWFORD: That's great.

COCHI: There are different types.

CRAWFORD: That is fantastic. Any final thoughts for today? What haven't we covered?

COCHI: I think that covers the waterfront. I'm starting to feel like maybe I'm repeating myself a little bit, but you've given me the opportunity to lay out what's been on my mind and what's in my heart. Yes, I think you emptied it.

CRAWFORD: Could you say one more thing about what it's been like for you to participate in the GPEI History Project as both an interviewee and someone who's donated artifacts to the collection?

COCHI: It's been a fabulous opportunity for me to participate in a history project, because it has given me a chance to go back and review and reflect on a very long history--it's almost an epic--of polio and the many people, the many activities, and many milestones, how it changed over time. It's nice that the history project has given me a chance to put in context the various things that have happened, the various people I've worked with, the remembrances. It's just very satisfying to be able to reflect, and to be very thankful that I was in the right place at the right time and had the chance to participate--and still have the chance to participate in various ways. It's been a fantastic life experience. Yes. I appreciate it more than ever because of what the history project has brought out for me, individually. Yes.

CRAWFORD: Thank you. Thank you for three sessions with us.

COCHI: [Laughs] Thank you, for listening to me. Appreciate it.