WEBVTT

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[MUSIC PLAYING]

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ADITI RAO: The next
course theme we'll explore

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is on reaching
special populations.

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As we mentioned at the
beginning of the lecture,

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the last 1% of the world's
communities affected by polio

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are socially, politically,
and/or economically

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marginalized.

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They may experience
conflict on migration,

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environmental hazards
such as poor transport

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networks and flooding, or
government persecution.

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These communities, already
underserved by a health system,

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may be skeptical of
disease-oriented programs,

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which deemphasize key health
and economic priorities

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and come from distrusted
state and non-state actors.

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This section will describe
how polio eradication has

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engaged with and been
affected by these forces

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and consider the intended
and unintended consequences

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on the community demand
for health services.

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Populations with ongoing
polio transmission

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are often the ones with
reasons to distrust

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their own governments.

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Polio eradication's
independent monitoring board

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has noted that in
Pakistan, polio cases often

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appear in isolated communities,
tribal populations,

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and environments with
extreme social and economic

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deprivation.

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These are people and places
where trust in government

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is low.

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The report further
notes one threat emerges

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from all the
individual community

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level voices heard in Pakistan--

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a sense of deprivation
and of disenfranchisement

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from rights and duties owed
by the state to its citizens.

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The concept of citizenship
may itself be in doubt here.

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Refusal of the polio vaccine
is not a mere gesture,

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rather it's a
distillation of the anger

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that communities feel when polio
workers knock on their doors

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over and over again,
in the absence

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of other governmental services.

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To better understand
some of these issues,

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let's look a bit at some
theoretical frameworks

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which might then
guide how we meet

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and address these
barriers in implementing

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program activities.

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So what is intersectionality?

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Intersectionality
recognizes that we're all

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made up of many facets.

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It does not presume that one
category of social identity

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is more important than another.

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When people meet or
interact with us,

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it's not just where the
one part of us, but with us

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as whole people.

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The theory assumes that
health outcomes are always

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caused by factors of
all of our intersections

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that are related to
multiple social identities.

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And finally, it relates to the
understanding of power dynamics

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among individuals,
which are the result

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of the interplay of
multiple social identities

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of these individuals.

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Having understood this, what
are the intersecting identities

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affecting communities refusing
polio vaccines in Pakistan?

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We can think about gender,
race, class, sexuality,

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disability status, et cetera.

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The communities most
at risk of polio

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were largely those
with limited access

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to fresh water, poor
sanitation, and the absence

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of public service
infrastructure.

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And why is understanding this
social position so relevant?

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Acknowledging this
sense of alienation

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in conjunction with the
deep practical challenges

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of simple survival
in contested contexts

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is crucial to understanding
how and why people behave

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the way they do, and it is
necessary to establishing

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how an extensive internationally
backed polio vaccination

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campaign fits into that world
and designs its policies

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and programs to align with it.

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I hope we're now beginning
to see how incredibly complex

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it can be to plan and
implement such a program.

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It's not as simple
as here's a solution,

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and here's a population
that needs the solution.

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Next, let's look at a slightly
more complicated framework

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by Diderichsen and Hallqvist.

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The relationship between the
social context and the way

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in which individuals are
sorted into social positions

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is central to the issue
of health inequities.

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What do we mean by these terms?

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Social context comprises
of the structure, culture,

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and functions of systems,
including education, economic,

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judicial, and political systems.

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Social position refers
to an individual's place

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within the society
in which they live,

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which is derived by
the social context

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and is linked to systems
that generate power, wealth,

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or risks.

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The model explores
how social contexts

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create social stratification
and assign individuals

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to different social positions.

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As we can see here, there
are multiple mechanisms

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that play a role in
stratified health outcomes,

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including the central
engines of society that

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generate and distribute
power, wealth, and risks

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and thereby
determine the pattern

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of social stratification.

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At the individual
level, this figure

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depicts the pathway
from social position

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to exposure to specific
contributing causal factors

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and onto health outcomes.

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As many different interacting
causes in the same pathway

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might be related
to social position,

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the effect of a single cause may
differ across social positions

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as it interacts with
some other goals related

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to one's social position.

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To dive into this further,
social stratification

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of individuals to
different social positions

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determine that
differential exposure

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to health-damaging
conditions and value

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in resources influencing
risks and outcomes.

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Influencing social
stratification-- that is,

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policies that influence gaps in
opportunities and resources--

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can be achieved via education;
family welfare policies,

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including parental leave,
subsidized childcare,

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early child care
provision, et cetera;

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social and economic
opportunities for women

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to address; economic
opportunities; equal wages; et

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cetera, which impact the trend
of social stratification.

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What is an example of this
in the Pakistan-Afghanistan

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context?

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As we saw earlier,
some people have

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access to clean water and
high-quality health services,

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while others do not, based on
how they have been stratified

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into a social position.

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Social stratification also
determines differential

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exposure to risks of ill health
for more and less advantaged

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groups.

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Decreasing exposure that
is reducing excess exposure

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to risk for those in
lower social positions

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can be achieved
via interventions

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such as HIV prevention
among high-risk groups

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and vulnerable populations.

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Again, how might this
work in the case of polio

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in Pakistan and Afghanistan?

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We can think about how
exposure to poliovirus

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is increased in areas
without good wash services

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due to poor
sanitation practices.

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In conjunction with
differential exposure,

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we might also consider a
differential vulnerability

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to risks of ill health, not only
how an individual's position

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affects what they are exposed
to but if and when exposed

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how vulnerable are they
to disease or injury?

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And what might enable them to
withstand such devastation?

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Thinking about polio in
Pakistan, Afghanistan,

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we know marginalized
people are less

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likely to be fully vaccinated.

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The final piece
of the model looks

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at differential
consequences of ill health.

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So when you was unwell, in
what ways and to what extent

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does it debilitate
an individual?

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Preventing unequal
consequences of ill health

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can be addressed by the
provision of universal access

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to care to prevent catastrophic
expenditure, social protection

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policies, rehabilitation
funds, et cetera.

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In the case of polio in
Pakistan in Afghanistan,

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poor kids who get
polio don't have access

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to education, health services,
et cetera that would help them

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become household providers
in their adulthood,

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resulting in further
debilitating conditions

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and perpetuating a cycle
of poverty and disease.

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The Diderichsen-Hallqvist
framework

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of the social
production of disease

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allows us to unpack
what we largely term

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as social determinants of
health across the individual

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and community levels.

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And while complex, it is key to
our understanding of challenges

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faced by marginalized
populations

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and how we can address
these issues in order

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to reach the vulnerable
communities for more than just

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achieving the goal
of polio eradication.

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I would encourage
you to take a pause

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and think about these questions.

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What are some inequalities
that lead to ongoing polio

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transmission, in particular
communities in Pakistan

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and Afghanistan?

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Can we explain how
these inequalities

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might lead populations to be
more or less likely to refuse

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the polio vaccines?

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And finally, what
can be done about it?

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Faced with the challenges
outlined in this section,

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recently the GPI
announced that they

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would begin an integrated
services initiative to mobilize

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urgent help for deprived and
polio vulnerable communities.

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UNICEF is proceeding by
supporting a convergent package

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of basic health services in
high-risk areas in Afghanistan

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and Pakistan.

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In addition to that, Rotary
International and the Gates

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Foundation are
supporting a number

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of important basic
services projects,

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also in high-risk polio areas in
Pakistan in the health and WASH

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sector.

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I'll end this section
leaving each of you

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with this question--

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do we think these
efforts are enough,

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and what goal or purpose
might it be serving?

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[MUSIC PLAYING]

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