WEBVTT

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SVEA CLOSSER:
Eradication programs

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need to have surveillance
systems that cover

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every corner of the Earth.

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To achieve high-quality
surveillance

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over this wide area, incentives
can be extremely useful.

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We're going to talk about
the incentives used in polio

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eradication in Nigeria and DRC.

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But before we do that,
let's go back in time a bit

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to explore a classic
example of surveillance

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incentives, the
Smallpox Eradication

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Program in Bangladesh in 1975.

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As in our current examples
of Nigeria and DRC,

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reaching remote
parts of Bangladesh

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for smallpox surveillance was
very difficult in the 1970s.

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The image on the left
is a bamboo bridge

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being traversed by smallpox
eradication team members.

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The image on the right is
two local Bangladeshi women

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working as community smallpox
eradication volunteers.

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They were going house to house
in search of smallpox cases.

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In the early 1970s, teams
of surveillance officers

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traversed Bangladesh,
visiting markets and schools

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and asking about
cases of smallpox.

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Yet surveys showed that they
were recording only a fraction

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of the total smallpox cases.

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A new surveillance
strategy was needed.

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Faced with this problem, the
Smallpox Eradication Program

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began publicizing cash
rewards for community members

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who reported smallpox cases.

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The photo on the left shows
a local Bangladeshi smallpox

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eradication team volunteer
using a hand-held microphone

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to announce this reward.

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He's doing this in a marketplace
which drew large crowds.

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If from these efforts
someone reported a case,

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the Smallpox Eradication
Program investigated it.

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And if they found an actual
smallpox confirmed case,

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they paid a reward to
the informant, no matter

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the age of the informant.

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Children could get
these awards as well.

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As shown on the
right, children were

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a target of
surveillance efforts,

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because they went
a lot of places.

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And they were
motivated by money.

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So 500,000 leaflets were
printed and distributed.

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And on the right, they're
being distributed to children.

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The last known case
of naturally occurring

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smallpox, a young
girl named Rahima Banu

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was reported by
an 8-year-old who

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was paid her 250 Taka reward.

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All the rewards were handed
out in a public place

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so that more people
would know about them.

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So this graph here
shows the importance

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of these surveillance
incentives very clearly.

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So if you look at the bottom
of the graph, in 1974,

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the incentive was paid
to the first person

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to report the case.

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And the incentive was
$6.00 in 1974 money.

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So it was a
substantial incentive

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in the context of
rural Bangladesh.

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They did discover, however, that
there was an issue with this.

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Health workers were reluctant to
tell people about this reward,

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because the health workers
wanted to be the one to get it.

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So they would wait until they
heard about a smallpox case.

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They would be the
one to report it.

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And they would
collect the reward.

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This meant that a lot of
people in the community

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didn't know about
the reward and maybe

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weren't turning
in smallpox cases

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or reporting smallpox cases
in a way that one would hope.

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So what you can see where
the red arrow is, in 1975,

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they made a couple of changes.

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The first thing they did is
they more than doubled the size

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of the reward to about $15.

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And the second thing they
did is they gave two rewards.

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The first was to the
member of the public who

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reported the case.

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And the second was to the
health worker who confirmed it.

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When they made this
change, public knowledge

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of these rewards exploded,
because the health workers now

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wanted everybody
to know about this,

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because they would
also get a reward.

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So this is an example of
how important it is not just

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to have incentives, but to
get the incentives right

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so that health workers
and community members

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alike were rewarded for
reporting smallpox cases.

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And this reward increased
as smallpox cases declines.

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So it became very large when
there were very, very few cases

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left.

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The system was very
successful and, in fact,

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led to the elimination of
smallpox from Bangladesh.

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So given this model, this
really successful example

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of incentives and surveillance
in an eradication program,

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let's think about
why this hasn't

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been done in polio eradication.

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So the first question
to think about

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is, how is polio surveillance
different from the smallpox

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system?

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And why aren't direct rewards
of this type widely used

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within polio eradication?

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Take a minute and see if you
can think about some answers

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to this question.

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So there's a number of ways
that polio as a disease

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is different than smallpox
that makes surveillance harder.

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One thing is that
a lot of AFP cases

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that are picked up by the
polio surveillance system

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are not polio.

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The vast majority of them,
in fact, are not polio.

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Of course, with
smallpox surveillance,

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some of the cases picked
up were not smallpox.

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They could be measles, other
things that look like smallpox.

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But the proportion of
cases that were smallpox

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was actually higher.

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So it becomes just too
expensive to do it this way.

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If you think about
looking at AFP cases

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across the entire world, the
vast majority of which are not

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polio, it becomes rather
difficult to think about giving

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direct rewards to people.

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The second question is,
are there other diseases

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for which such a system
could be effective?

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Now, there's many possible
correct answers here.

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There's lots of cases
where giving people

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a reward for
reporting a disease is

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going to increase surveillance.

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But generally this isn't
used outside of eradication

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programs, because it's
just too expensive.

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And that answers question 3,
why isn't this standard practice

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in public health?

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For non-eradication programs,
this is too expensive and too

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labor intensive.

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Let's take a look at polio
surveillance systems.

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And as these charts show,
they're extremely complex

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and multilayered systems.

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So the two charts we
have here are probably

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a little overwhelming.

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And the point is not that you
remember each piece of them,

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but that you understand that
these surveillance systems are

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very complex systems.

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There's many layers and
many players involved.

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And all of these
people need to act

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in a timely and
appropriate manner in order

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to successfully detect cases.

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And this can be challenging.

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So the polio system
engages health workers

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at several levels.

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So if you look at the
complicated chart on the left,

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at the bottom is the
community, the place where

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polio cases may be occurring.

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One level up from that
is the health center.

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So health facilities
are asked to report

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any cases of paralysis
among children

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to a central focal
point in each district.

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So they may or may not do this.

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Some of them do a very good job.

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Some don't.

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So what you see on the
right is that the WHO also

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often in many areas has
surveillance staff whose

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whole job is to go
to health centers,

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look through the
records, and see

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if there have been any
acute flaccid paralysis

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cases that have shown up.

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So they often do this weekly.

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In some cases, they
may do it monthly

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in the case of less busy
health centers or maybe

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some private offices.

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They also follow up on
suspected polio cases

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by collecting stool samples.

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So ideally, this all happens
within the government system.

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But health officials being
what they are everywhere

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in the world, they don't
always report cases.

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So it's helpful to have
additional WHO staff following

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up.

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So if there's a
suspected polio case,

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stool samples are
collected from that kid.

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And they're sent to the lab
to test for polio virus.

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So the reason we go
through all of this

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is to think a lot about
incentives or disincentives

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of specific stakeholders.

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So let's start from
the community level.

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The community in
the case of polio

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doesn't have a huge amount
of incentive to report cases.

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However, when a
child is paralyzed,

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this is usually a pretty
traumatic incident

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for a family.

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They almost always
get care in that case.

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So when you have a case of
acute paralysis in a child,

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it's almost always the
case that that child

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is going to show up often
at multiple health centers.

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Certainly in the case of polio
where it's not getting better,

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the child is not going to show
up probably just at one place.

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They're going to show
up at multiple places

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as the parent searches for care.

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So although there's not a lot
of incentive for the community

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to report cases per se,
there is a lot of incentive

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for them to seek
care for the child.

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And so they're going to be
interfacing with the health

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center, probably
at multiple points.

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So let's look a level
up at the health center.

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So at the health center,
there may or may not

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be a lot of incentive to report.

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In fact, if the health
center is trying

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to show that they're doing a
great job in eradicating polio,

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there may be some
pressure or incentives

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to hide cases, which
is something that is

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very challenging to overcome.

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So that's part of
the reason that you

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may have separate surveillance
officers through the WHO who

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are incentivized to find cases.

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It's a way of trying to
deal with these conflicting

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incentives that people may have.

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So there's some advantages
and disadvantages

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of such a multilayered
surveillance cycle.

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So here's what a Nigerian
health worker told us.

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"They have an informant
in the community.

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Then we have focal persons
in the local government,

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each local government.

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We have focal persons in the
hospital and the community too.

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So the informants report
to the focal person.

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The focal person reports
to the local government,

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who reports to the
State, who reports

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to both the WHO and the
National government-- that's

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the hierarchy."

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So in the case of
Nigeria, they've

00:09:29.303 --> 00:09:31.470 align:middle line:84%
got a huge network that
goes beyond even what I just

00:09:31.470 --> 00:09:35.340 align:middle line:84%
described to include focal
people in local areas who

00:09:35.340 --> 00:09:39.382 align:middle line:84%
are looking for cases and
then feed these cases up.

00:09:39.382 --> 00:09:41.340 align:middle line:84%
So think for a moment
about what the advantages

00:09:41.340 --> 00:09:44.310 align:middle line:84%
and disadvantages of a
system like this are.

00:09:44.310 --> 00:09:45.180 align:middle line:90%
So there's many.

00:09:45.180 --> 00:09:47.345 align:middle line:84%
I'm sure you can probably
think of more than me.

00:09:47.345 --> 00:09:48.720 align:middle line:84%
But one advantage
is that there's

00:09:48.720 --> 00:09:53.040 align:middle line:84%
lots of opportunity for cases
to get picked up and reported

00:09:53.040 --> 00:09:56.430 align:middle line:84%
at multiple levels wherever
parents may be seeking care

00:09:56.430 --> 00:09:58.368 align:middle line:90%
for their child with polio.

00:09:58.368 --> 00:10:00.660 align:middle line:84%
A disadvantage is that there's
a lot of people involved

00:10:00.660 --> 00:10:03.780 align:middle line:84%
who may have conflicting
incentives and a lot of ways

00:10:03.780 --> 00:10:06.770 align:middle line:84%
where politics can get involved
in the surveillance system.

00:10:06.770 --> 00:10:08.840 align:middle line:84%
"The challenges that
the polio program faces

00:10:08.840 --> 00:10:11.060 align:middle line:84%
is mostly in Northern
Nigeria, because most

00:10:11.060 --> 00:10:13.720 align:middle line:84%
of the high-risk states
are in Northern Nigeria.

00:10:13.720 --> 00:10:16.010 align:middle line:84%
And this is mainly due to
the Boko Haram insurgence,

00:10:16.010 --> 00:10:19.220 align:middle line:84%
because as you know, if you're
unable to access a community,

00:10:19.220 --> 00:10:21.770 align:middle line:84%
there's no way you can provide
vaccines to the children.

00:10:21.770 --> 00:10:23.690 align:middle line:84%
And there's no way
you can also carry out

00:10:23.690 --> 00:10:25.610 align:middle line:90%
surveillance activities.

00:10:25.610 --> 00:10:27.377 align:middle line:84%
And if you cannot
get these indicators,

00:10:27.377 --> 00:10:29.960 align:middle line:84%
then there's no way you can be
sure that there's no wild polio

00:10:29.960 --> 00:10:32.300 align:middle line:84%
virus circulating
in certain parts.

00:10:32.300 --> 00:10:34.310 align:middle line:84%
So the main challenge has
been in the Northeast,

00:10:34.310 --> 00:10:37.490 align:middle line:84%
that health workers still
cannot reach those areas.

00:10:37.490 --> 00:10:39.230 align:middle line:84%
And, of course, a
lot of innovations

00:10:39.230 --> 00:10:41.630 align:middle line:84%
have been developed to see
how people like community

00:10:41.630 --> 00:10:44.180 align:middle line:84%
informants from
inaccessible areas and then

00:10:44.180 --> 00:10:46.160 align:middle line:90%
the use of the military."

00:10:46.160 --> 00:10:47.660 align:middle line:84%
So in Nigeria,
they've had to use

00:10:47.660 --> 00:10:50.660 align:middle line:84%
a lot of other alternate
methods of trying to figure out

00:10:50.660 --> 00:10:53.900 align:middle line:84%
where polio cases are in
areas that are inaccessible,

00:10:53.900 --> 00:10:55.790 align:middle line:84%
like relying on
community informants,

00:10:55.790 --> 00:10:57.293 align:middle line:90%
trying to rely on the military.

00:10:57.293 --> 00:10:58.710 align:middle line:84%
And if you think
about incentives,

00:10:58.710 --> 00:11:01.190 align:middle line:84%
these people may not be as
incentivized to report cases

00:11:01.190 --> 00:11:03.490 align:middle line:90%
as a health worker might be.

00:11:03.490 --> 00:11:07.990 align:middle line:84%
So in Nigeria and DRC both,
conflict and insecurity

00:11:07.990 --> 00:11:08.735 align:middle line:90%
are issues.

00:11:08.735 --> 00:11:10.360 align:middle line:84%
And the health system
has been weakened

00:11:10.360 --> 00:11:12.640 align:middle line:90%
due to this insecurity.

00:11:12.640 --> 00:11:14.580 align:middle line:84%
So they've come up with
a number of strategies

00:11:14.580 --> 00:11:17.910 align:middle line:84%
for conducting surveillance
in hard to reach areas.

00:11:17.910 --> 00:11:20.040 align:middle line:84%
For example, they've
built new networks

00:11:20.040 --> 00:11:23.220 align:middle line:84%
in camps for internally
displaced families.

00:11:23.220 --> 00:11:25.050 align:middle line:84%
They've recruited
surveillance volunteers

00:11:25.050 --> 00:11:27.060 align:middle line:84%
at the key points
of entry and exit

00:11:27.060 --> 00:11:29.520 align:middle line:84%
into the worst of
the conflict zones.

00:11:29.520 --> 00:11:33.030 align:middle line:84%
And in one case in Nigeria,
they trained medical corps

00:11:33.030 --> 00:11:36.030 align:middle line:84%
to reach conflict afflicted
populations to spot

00:11:36.030 --> 00:11:37.952 align:middle line:90%
signs of polio.

00:11:37.952 --> 00:11:39.910 align:middle line:84%
So let's talk a little
bit more about this idea

00:11:39.910 --> 00:11:42.640 align:middle line:84%
of incentivizing
community volunteers.

00:11:42.640 --> 00:11:44.980 align:middle line:84%
This is a little different
than the smallpox example.

00:11:44.980 --> 00:11:48.070 align:middle line:84%
In smallpox, community
members were incentivized

00:11:48.070 --> 00:11:49.990 align:middle line:90%
for reporting a case at all.

00:11:49.990 --> 00:11:51.820 align:middle line:84%
For polio, it's a
little more complicated,

00:11:51.820 --> 00:11:53.830 align:middle line:84%
because community
volunteers are actually

00:11:53.830 --> 00:11:56.290 align:middle line:84%
working on collecting
stool samples,

00:11:56.290 --> 00:11:58.730 align:middle line:84%
tagging them and
sending them to the lab.

00:11:58.730 --> 00:12:01.600 align:middle line:84%
So this is a more
professionalized and complex

00:12:01.600 --> 00:12:03.475 align:middle line:90%
role for a community member.

00:12:03.475 --> 00:12:06.550 align:middle line:84%
A Nigerian health official
explained, "Now it

00:12:06.550 --> 00:12:09.590 align:middle line:84%
is reaching every community
strategy that we have in place.

00:12:09.590 --> 00:12:11.080 align:middle line:90%
So they're quite different.

00:12:11.080 --> 00:12:12.670 align:middle line:84%
Now we're taking it
to the grassroots,

00:12:12.670 --> 00:12:14.230 align:middle line:90%
to the community level.

00:12:14.230 --> 00:12:18.400 align:middle line:84%
Unlike before, surveillance now
involves an active case search

00:12:18.400 --> 00:12:21.290 align:middle line:84%
in the health facility
and also the community."

00:12:21.290 --> 00:12:23.670 align:middle line:84%
So in many cases,
this worked well.

00:12:23.670 --> 00:12:26.600 align:middle line:84%
You got more people
involved in surveillance,

00:12:26.600 --> 00:12:28.240 align:middle line:90%
which is usually a good thing.

00:12:28.240 --> 00:12:31.900 align:middle line:84%
But these incentives could
also have perverse impacts.

00:12:31.900 --> 00:12:34.738 align:middle line:84%
So some volunteers were
over-tagging stool samples.

00:12:34.738 --> 00:12:36.280 align:middle line:84%
So they were collecting
stool samples

00:12:36.280 --> 00:12:39.520 align:middle line:84%
from all kinds of kids who
didn't have polio in an attempt

00:12:39.520 --> 00:12:42.400 align:middle line:84%
to receive more money for
reporting more potential polio

00:12:42.400 --> 00:12:43.300 align:middle line:90%
cases.

00:12:43.300 --> 00:12:45.790 align:middle line:84%
This overburdened the labs
and slowed down the process

00:12:45.790 --> 00:12:47.660 align:middle line:90%
of identifying true cases.

00:12:47.660 --> 00:12:50.860 align:middle line:84%
So getting these incentives
right is very tricky.

00:12:50.860 --> 00:12:52.990 align:middle line:84%
In DRC, they also
tried incentivizing

00:12:52.990 --> 00:12:55.060 align:middle line:90%
community volunteers.

00:12:55.060 --> 00:12:57.230 align:middle line:84%
In this case, they weren't
collecting stool samples.

00:12:57.230 --> 00:13:00.400 align:middle line:84%
But they were incentivized
for reporting AFP cases

00:13:00.400 --> 00:13:03.460 align:middle line:84%
and also for engaging in social
mobilization and advocacy

00:13:03.460 --> 00:13:05.440 align:middle line:90%
activities during outbreaks.

00:13:05.440 --> 00:13:10.627 align:middle line:84%
Sometimes they were given mobile
phones to report AFP cases.

00:13:10.627 --> 00:13:12.460 align:middle line:84%
A DRC health official
said, the surveillance

00:13:12.460 --> 00:13:14.200 align:middle line:84%
has been further
strengthened, including

00:13:14.200 --> 00:13:15.850 align:middle line:90%
community-based surveillance.

00:13:15.850 --> 00:13:17.350 align:middle line:84%
They make home
visits a little more.

00:13:17.350 --> 00:13:18.940 align:middle line:84%
And then they also
see cases and then

00:13:18.940 --> 00:13:21.250 align:middle line:90%
also sensitize communities.

00:13:21.250 --> 00:13:25.270 align:middle line:84%
Some people in DRC said that
just like Nigeria, this worked

00:13:25.270 --> 00:13:26.440 align:middle line:90%
really well in many ways.

00:13:26.440 --> 00:13:27.880 align:middle line:84%
But these incentives
didn't always

00:13:27.880 --> 00:13:30.430 align:middle line:84%
work exactly the way
people were hoping.

00:13:30.430 --> 00:13:33.448 align:middle line:84%
For example, some volunteers
used the money they were given.

00:13:33.448 --> 00:13:34.990 align:middle line:84%
So I want to pause
here for a moment.

00:13:34.990 --> 00:13:37.032 align:middle line:84%
They're called volunteers,
but they were actually

00:13:37.032 --> 00:13:38.860 align:middle line:84%
paid to go
door-to-door advocating

00:13:38.860 --> 00:13:40.780 align:middle line:84%
for their own religious
beliefs and teachings

00:13:40.780 --> 00:13:42.700 align:middle line:84%
instead of raising
polio awareness.

00:13:42.700 --> 00:13:46.210 align:middle line:84%
So it's not just engaging a
community that's important.

00:13:46.210 --> 00:13:50.500 align:middle line:84%
Thinking carefully about what
their needs and desires are

00:13:50.500 --> 00:13:52.030 align:middle line:84%
is also really
important in thinking

00:13:52.030 --> 00:13:55.270 align:middle line:84%
about how to engage them
in a surveillance system.

00:13:55.270 --> 00:13:57.240 align:middle line:84%
So the takeaway here is
that community members

00:13:57.240 --> 00:13:59.070 align:middle line:84%
can be great partners
in surveillance,

00:13:59.070 --> 00:14:02.370 align:middle line:84%
as shown by the smallpox
example and also the polio

00:14:02.370 --> 00:14:04.870 align:middle line:90%
examples in Nigeria and DRC.

00:14:04.870 --> 00:14:07.650 align:middle line:84%
But incentives must be
considered very carefully,

00:14:07.650 --> 00:14:09.360 align:middle line:84%
should never assume
that a community

00:14:09.360 --> 00:14:11.280 align:middle line:84%
member is going
to naturally want

00:14:11.280 --> 00:14:13.350 align:middle line:90%
to report cases of a disease.

00:14:13.350 --> 00:14:15.720 align:middle line:84%
It's important to think
both at the community level

00:14:15.720 --> 00:14:18.720 align:middle line:84%
and at the health system level
about what people's incentives

00:14:18.720 --> 00:14:20.520 align:middle line:84%
may be, what their
motivations may

00:14:20.520 --> 00:14:24.590 align:middle line:84%
be, and try to design a
system that aligns with those.

00:14:24.590 --> 00:14:31.000 align:middle line:90%