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ANNA KALBARCZYK: Hi
everyone, and welcome

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to our roundtable discussion.

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I'm Anna Kalbarczyk,
and today I'm

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joined by Svea Closser
and Kunle Alonge.

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And we're all faculty members
at the Bloomberg School

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of Public Health.

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The topic we're discussing
today was originally

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designed as a debate--

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eradication programs versus
routine immunization programs,

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and where we should be
putting our investments.

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But we know that
in global health,

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it's rarely just one
approach versus another.

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Things are rarely
that straightforward.

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So today, I'd like to ask
Svea and Kunle to discuss some

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of the ethical and
equity implications

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of these two approaches, and
describe their complexities.

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SVEA CLOSSER: Yeah.

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So maybe we can
start by describing

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what a polio
eradicator would say

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was great about their
program in terms of equity.

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So rather than actually
having the debate,

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I'll voice what that side
would say for a moment.

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So polio eradication, leadership
from the very beginning

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of the program, have
sold the program

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quite vocally as
what one of them

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called the ultimate in
equity in public health.

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And the reason they say this is
that eradication programs are

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forced, because they
have to eliminate

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every last case of the disease
to reach every last person

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on earth.

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So it's definitely true
that the polio program

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has reached populations
that were neglected

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for a variety of
reasons and were not

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getting health services
from any other program.

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Nomadic populations
very, very far away

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from population centers.

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Populations that were
marginalized politically.

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All kinds of groups
of people that

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were not being served
by any health system--

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of course, there were
indigenous health systems,

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but from any government
health system--

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were reached and vaccinated
by polio eradication.

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So that's one side
of what they would

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say is the equity
piece of eradication.

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That you really reach
people that are not

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reached by any other program.

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And the other piece
of why they say

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eradication is the
ultimate in equity

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is that everybody
receives the same benefits

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once the disease is eradicated.

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So once the disease
is eradicated,

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it doesn't matter whether
you're the richest

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person in the world
or the poorest,

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everybody now has a 0% chance
of getting this disease.

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So whereas most
infectious diseases

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tend to affect the poor the
most, in an eradication program

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the benefits, if
eradication is achieved--

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we'll talk more about
that in a moment.

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But if eradication is
achieved, the benefits

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flow to everyone equally.

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So that's the pro
eradication stance.

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OLAKUNLE ALONGE: And I
mean, very well said, Svea.

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And I would just like to
pick it up from there.

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Without any doubt,
there is a lot

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of equity benefits
for eradication--

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that is, easily able
to achieve eradication.

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And that's the point for me.

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And I think the other
side of the story

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is really the question
of can you actually

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achieve eradication?

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And what are the ethical
dilemmas to that?

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Because when we think
about eradication

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in this very strict
sense, we are

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saying that you
have the capacity

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to be able to surveil every
case of a particular disease

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in every part of the world.

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You have the ability, you have
an effective intervention,

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that is able to
eliminate-- that is

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to say make the incidence of the
disease to be completely zero.

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And that is to
say able to remove

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the organism from its
lateral reservoir and so on.

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So there are real
scientific criteria.

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You really want to
consider whether this

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is truly achievable
given the knowledge

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of the biology of the disease.

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The knowledge of the
natural history and the way

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it's transmitted
within a population.

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And it is in this that
we have some challenges.

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Because obviously
you're going to have

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to make some judgment call.

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So the question is, are
you making a judgment call

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based on the best science?

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Based on the best information?

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And are you being
completely transparent

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in the principles and how
you've adopted the principles,

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you know?

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Obviously the equity
benefit is really clear

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But the question is before you
get to the equitable future,

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you have to achieve
the eradication.

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And if the eradication-- if the
principal upon the eradication

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is based is faulty, then
there may be dilemma issues.

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SVEA CLOSSER: And I just want
to add to that, absolutely,

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that the decision making process
about taking up an eradication

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program also raises
questions about equity.

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Is it donors and
wealthy countries

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that don't want to spend
money on vaccination anymore?

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And people like, for
example, in the case

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of polio, Sabin, the developer
of the oral polio vaccine who

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wanted to leave a
legacy, are these people

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the ones whose voices
are getting heard

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and the ones that are driving
a decision to eradicate or not

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eradicate a disease?

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Or is it the people
who are actually

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affected by that disease?

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Are they the ones saying, yes.

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This disease is the
one we want eradicated.

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This is our priority.

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And you know, to what extent
are marginalized voices

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foregrounded in this decision
making process versus very

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wealthy powerful voices?

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That's an important
consideration.

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OLAKUNLE ALONGE: Yeah.

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And I think the other
side to it is also--

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so we took the body biological
criteria for eradication.

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The economic criteria--
and this also

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creates another ethical dilemma.

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So if you have--

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if the decision has been
made need to eradicate,

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are you going to be
committing huge resources?

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There's an opportunity
cost to that.

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So the money that is being
invested into eradication you

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could easily argue
that they could

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go into routine management of
diseases, routine immunization,

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and so on and so forth.

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But because of the
decision that you

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made to pursue an
eradication goal,

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there is an
opportunity cost that

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is lost in terms of
what other things

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those resources could go to.

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And that's why the
decision is something that

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should not be taken lightly.

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And I think one
[INAUDIBLE] in my mind,

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I think being true
to the science.

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Since eradication is a
scientific endeavour,

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rooted in science, to the
science and the biology

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of the disease, to the
science of the transmission

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of the disease, it's really key.

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It's really key.

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And of course the
politics will influence

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the science in the long run.

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But for the fundamental decision
on whether to eradicate or not,

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I think the science
and the facts

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should really play
a significant role.

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SVEA CLOSSER: But I
would also add to that

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that just because something
is eradicable in theory, when

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we talk about the
scientific facts,

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it also include the facts
about things like conflicts,

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about things like
inaccessible areas.

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We can't just think of
the science as something

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that exists outside of on the
ground political realities.

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Because those are part of an
eradication program, as well.

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OLAKUNLE ALONGE: Absolutely.

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Absolutely.

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I couldn't agree more.

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And I think really
thinking through all

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of this consideration
is really key.

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So it's not just about--

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I mean, we don't
question the benefits.

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We don't question the equity.

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We don't question-- and we've
seen the polio program has

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done that in a tremendous way.

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The polio program has
been to places where

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no other program has ever been.

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You know, the polio program
is the health system

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in a lot of places.

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It's actually the health
system in a lot of places.

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So we have that equity gain.

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But we've also seen that
in the last 10 or 20 years,

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or there about, it has been
so difficult to achieve

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the goal of eradication,
because of the [INAUDIBLE],,

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and for some of the reasons
Svea was mentioning--

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thinking through the
politics, thinking

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through the political and
the social cultural context,

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and whether eradication is
feasible in this setting.

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Again, visiting the sites.

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Making sure that we are
really using our best

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scientific information.

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And obviously we're
dealing with people,

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so engaging with people
on a continuous basis

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is also important.

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So again, I don't think that
there's like a clear cut

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yes or no answer.

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But obviously there are clear
advantages, clear equity

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benefits.

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And there are also
ethical issues

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that need to be reviewed.

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And I think being open and
having open conversation

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around some of these
challenges means

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a more collaborating together
with different actors

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is really key.

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SVEA CLOSSER: Yeah.

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And I just want
to add something--

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I couldn't agree more, again.

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I think one of the
things you mentioned

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was that in certain areas
the polio program has

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become the health system.

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And that raises particular
ethical equity issues

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if all that's being provided
is just oral polio vaccine.

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So when you have a
health system that's

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been created to serve you, and
yet only provides you with one

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vaccine, is that equity?

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And the answer to
that question depends

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on who you ask, for sure.

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OLAKUNLE ALONGE: Exactly.

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SVEA CLOSSER: So that comes back
to Kunle's concluding point,

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I think, about the importance
of thinking collaboratively,

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working with communities.

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And even if you're focused
on an eradication goal,

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perhaps thinking
a bit more broadly

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than just that narrow goal
can help it serve equity

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maybe a little better.

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ANNA KALBARCZYK: I
think not only does that

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tie back to Kunle's
point, but also one

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of your original points
about prioritization.

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And who is setting some
of those priorities?

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And so what does that
look like if you've

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got the polio program
as your health system

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if it's not your priority?

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So I'll stop us there.

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Thank you for a
lively not debate,

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but discussion, on this
very interesting topic.

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Thanks, everyone,
for joining us.

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OLAKUNLE ALONGE: Thank you.

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SVEA CLOSSER: Thanks.

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[MUSIC PLAYING]

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