WEBVTT

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[INSTRUMENTAL MUSIC]

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DANIELA C. RODRIGUEZ:
In this section,

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we're going to discuss
navigating politics.

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We're going to
talk about what it

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looks like to work with
country governments

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within national borders and
across country settings.

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Governments have
always been seen

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as the owners and beneficiaries
of the polio eradication

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initiative.

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In fact, this formal
GPEI policy states

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the polio-affected countries
take primary responsibility

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and ensure accountability
for the achievement

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of the objectives and
implementation of the plans.

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While this is the
rhetoric, reality

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has not always been this way.

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Polio eradication
really operated

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under a command-and-control
leadership for a long time.

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Before 2010, WHO had
a very directive role.

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They were telling
everybody what to do.

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But this has evolved over time.

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Earlier lecturers
have touched on some

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of the catalysts
for this evolution,

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such as changes to the
organizational structures

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and approach that came
about when the Gates

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Foundation joined the GPEI.

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Also, in practice,
not all governments

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have had the same commitment
to polio eradication

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and not all country
health systems

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have seen clear-cut benefits.

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Let's look at this
a bit more closely.

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OK, so let's start with this.

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Ask yourself, what
role do governments

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play in the global alliance
for polio eradication?

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Governments have many roles.

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They provide high level advocacy
in support of the program.

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They help finance the program.

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They help strengthen health
systems for program delivery,

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such as strengthening
surveillance, or the lab

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systems, or cold storage.

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They do resource allocation
to subnational areas.

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And they provide staffing,
supervision, and implementation

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of polio campaigns.

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As well as other
activities, one takeaway

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here is that a lot is
expected of governments

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in polio eradication.

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What you see here is an image
of the World Health Assembly

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declaration for
polio eradication.

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The World Health Assembly is
the governing body of the WHO.

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It is made up of representatives
from every country

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in the world, and each
country gets one vote.

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The World Health Assembly
Declaration to eradicate polio

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was unanimously
endorsed in 1988.

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This did not happen by accident.

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According to Bill Fahey,
who was a smallpox veteran,

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the World Health
Assembly resolution

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was the result of a lot
of work and education

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that was done with
health ministries

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outside of the
organization in order

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to encourage them to take
these responsibilities on.

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Fahey also pointed out the
critical role of Rotarians

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in advocating across
the world for this.

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Historian Bill
Muraskin has argued

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that work by international
actors like Fahey

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and Jim Graham of UNICEF
was less education and more,

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quote, "an exercise in backroom
power politics," end quote.

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Either way, achieving
adoption of this declaration

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required considerable
work and diplomacy.

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So moving to translating
this global alliance

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to local action, what have
been some of the challenges

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and strategies?

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Country buy-in has been
more complex in practice.

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The World Health
Assembly Declaration

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did not have substantive
buy-in from all countries

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that would be
required to undertake

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polio-eradication efforts.

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While many governments were
willing to give the declaration

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to eradicate polio a
verbal endorsement,

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they were concerned about
trade-offs on the ground.

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This was especially
true in settings

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where the
polio-eradication effort

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has diverted attention
and resources

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from local priorities.

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The important thing to
consider here are incentives.

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What were the potential risks
and benefits for countries?

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All countries, of course, would
be happy to be rid of polio.

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But in practice, many
were not ready to make

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eradication their
top priority when

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there were many other diseases
also affecting the populations.

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Not surprisingly, as
polio-eradication goals

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are missed and
deadlines are delayed,

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maintaining country
ownership and attention

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for polio has been
difficult. A question for you

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is, what is the
importance of engaging

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with national governments
and having their buy-in?

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What strategies
could you undertake

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to have that continued support?

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And yet, there's another
layer to this as well.

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Sustained buy-in for polio
at subnational levels

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has been uneven,
especially in countries

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that are decentralized.

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Even when polio
eradication has commitment

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at the national level,
consistent engagement

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is still required with
subnational actors.

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In the end, the
GPEI is implemented

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in door-to-door campaigns
by local governments,

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and local governments,
in some cases,

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have fewer reasons to buy
into an international goal.

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Why might this be the case?

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Take a minute to
think to yourself why

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local governments
may resist buying

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into these kinds of campaigns.

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So some answers can include
that local governments have

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competing health priorities.

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For example, polio may
cause much less morbidity

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and mortality than other
diseases in their area.

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Local governments
may have competing

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non-health priorities,
such as if there

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is an unrest or
violence, polio may not

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seem like a top priority.

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There also may be competing
political priorities.

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If a local government is led
by a different political party

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than the central
government, they

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may resist national directives
for reasons of party politics.

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Also, unlike
national governments,

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local governments may not have
been involved in the decision

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to take on polio eradication
in the first place.

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And we have examples of how
this has played out in practice.

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For example, in Nigeria,
the polio program

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is owned by the
national government.

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However, the government does
not have complete control

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over the country's
full territory,

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and it's contributed
to their struggle

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to achieve polio eradication.

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In Pakistan, there's
a division between

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federal and provincial
governments on priorities

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and strategies, which
has also contributed

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to their difficulties
controlling polio.

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The thing to remember is
that the polio program

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is existing within
a larger health

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system that has other
activities and priorities.

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So even if political
leaders are on board,

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this is not the same
as having all workers

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at all levels on board.

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Staff at various levels have,
in certain times and places,

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objected to being
asked to work on polio

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eradication for a wide
variety of reasons,

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including concerns over local
disease priorities being

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neglected or concerns
unrelated to polio,

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like delays and salary payments.

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Resistance to polio-eradication
efforts by health systems

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actors has been
overcome, at times,

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through activities offered
by the polio program

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itself, such as training
and quality assurance.

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Let me ask you this.

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How might weak
health systems impact

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governance and implementation
of the polio program?

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Countries with weak health
systems and weak management

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made operational management
for polio more difficult,

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such as managing
underperformance, which

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meant that you had to engage
other health systems' decision

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makers to be held
accountable for results.

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And resistance to polio
vaccination in many countries

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was driven by political
considerations and a lack

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of trust, primarily where
communities questioned

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why governments
were not providing

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a broader range of services or
supporting overall development.

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Engagement with high
level or local leaders

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played a crucial role in getting
buy-in and endorsing campaigns

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and then often required
repeated interventions

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and was affected by
turnover in key positions.

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Yet, level of engagement
of political leaders

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may still vary.

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As we discussed in the section
on the World Health Assembly

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Declaration, there
is a difference

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between agreeing to participate
in an eradication goal

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and being sufficiently
committed to see it

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through if the road gets tough.

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The last thing we'll
talk about here

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are cross-border considerations.

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Cross-border polio
efforts can be complicated

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by porous land borders,
such as between Pakistan

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and Afghanistan or
between Nigeria and Niger.

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These require cooperation
between governments

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for activities to be effective.

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Sometimes this can end up in
a blame game about whose fault

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a new recent polio case is.

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In the best cases, it can get
governments to work together.

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We would like to acknowledge the
contribution of these partners

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in mapping, synthesizing,
framing and preparing

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the content for the module.

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We would also like to
acknowledge the contribution

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of these partners in
providing information, data,

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and pictures to the module.

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We would like to acknowledge the
support of our funder as well.

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[INSTRUMENTAL MUSIC]

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