 Our panel is focused on overcoming strategic obstacles, I believe, to the delivery of immunization. And I really like that this panel is framed as a global issue because it's not a problem that's restricted to low and middle income countries because elimination of vaccine preventable diseases is a shared enterprise that demands a coordinated response. So there are two kinds of challenges or obstacles on the supply side. We have challenges related to financing. We have challenges related to priority setting. We have challenges related to supply and cold chain quality, among others. And we have ultimately challenges associated with the quality provision of services to people in need. And then we have challenges on the so-called demand side. So families and households themselves, their economic barriers to access for the poor. There's this tendency to wait to vaccinate your children until they're already sick. And there's also a lot of issues around trust and misinformation. So today we have three very prominent panelists who will discuss a selection of these issues, these challenges to immunization. First we'll start with Helen Evans of the Gavi Alliance who will talk about Gavi's approach to overcoming some of these challenges in their eligible countries. We have Oren Levine of Johns Hopkins University who will talk about these challenges in the context of the decade of vaccines. And finally Dr. Anne Sushat from the Centers for Disease Control who will talk about issues of public trust. Both here and abroad, I think. So I'll start with Helen. Thank you, Helen. Thanks, Amanda. I'm just working out how I... Seth, what do I do? Just do that. All right, good. Okay. Thank you very much, Amanda. And thanks to CSIS and especially to you, Steve, and to Seth Gannon and others who've organized this fantastic conference. It's very good to see so many familiar faces and I really wanted to convey Gavi's deep appreciation for CSIS's support over the years. And I also wanted to personally thank you, Amanda, because Amanda has shown enormous leadership in highlighting Gavi on her blogs on a regular basis. So thanks. And I'm pleased to be here on the panel with Anne, who's a Gavi board member, and with Oren, who's really right at the heart of our effort in his work on the Accelerated Vaccine Initiative. So as Amanda has said, I've been asked to speak about Gavi's strategic long-term thinking and within that about three very specific challenges to achieving success in immunization and all in 10 minutes. So I'm going to talk fast. The first is about delivery of vaccines to the poorest countries. The second is about financing and affordability of immunization and the third's about public trust. I'm actually going to leave the public trust part largely to Anne, but I did want to say that public trust really has multiple dimensions. For Gavi, I would say specifically it's trust amongst our donors that they're investing in the best buy in public health and that it's achieving results. Economic times are tough everywhere and it's incredibly important to donors that they can trust that we're going to deliver with the taxpayers money they're using. And there's trust around demand-based trust for the people in the poorest countries that when they immunize their children with a growing number of vaccines, and that in itself is a challenge, that this is the right thing to do. So let me start with a big strategic picture with Gavi. For those of you who don't know, Gavi, I'll just briefly say it's a public-private partnership. There's been a bit of a discussion about public-private partnerships already. It's the Global Alliance for Vaccines and Immunization. And its mission is to save children's lives and protect people's health by increasing access to immunization in the poorest countries in the world. We have an income cutoff for the countries that we fund. And in this country, the US government, through USAID and Amy Batson, I'm not sure whether Amy's here, but Amy is the USAID board member on the Gavi board. And from CDC, is there representing research and technology, as well as the Bill and Melinda Gates Foundation, who are enormously generous contributors. So this country is very well represented on the Gavi board. And the board is actually a truly global board. It has membership from developing countries, from donors, from civil society, vaccine companies, both North and South, and our multilateral partners UNICEF, WHO, and World Bank. And we have a small secretariat in Geneva and here in CDC, which is responsible to the board for managing and coordinating the alliance business. So since its launch in 2000, Gavi's support to countries contributed, we estimate, with solid data from WHO and UNICEF, not just Gavi, to averting more than 5.5 million future deaths and to contribute to immunization of 326 million children in the poorest countries. That's a pretty impressive track record, I think. However, great challenges still remain. I'm not very technologically competent, as you can see, so I seem to have lost my slides. They're not coming up there. They're not. I'm going to keep talking. I actually have a beautiful slide, which may come up at a later stage, which shows the challenges, because each year 130 million children are born, but 19 million of those children go unimmunized and 1.7 million of them will die each year of vaccine-preventable diseases. So these are deaths that could be prevented. And over 80% of them are in the poorest countries in the world, which Gavi supports. So the graph, if it was there, would show you that majority of those children live actually in two countries. They live in India and in Nigeria. So to tackle this, because that's our mission, we have what we think is a pretty clear, I'm going to hold up the document, a pretty clear five-year strategy, a comprehensive strategic plan with focused objectives and deliverables. And if you could also see the slides, you'd also see where the worldwide coverage is on the vaccines that Gavi funds. And you could see there clearly where the unfinished business is. Pentevalent vaccine, which covers the five areas, is reasonably covered now. We're heading towards the home stretch on that. But with rotavirus and pneumococcal vaccines, we still have a long way to go. So in the next four years, we aim to immunize an additional quarter of a million children and to contribute to preventing what we think will be four million deaths. And seeing not only reduction in deaths, but a reduction in morbidity. Because I think it's much harder to measure morbidity, but as someone was talking earlier about the meningococcal vaccine, morbidity is also a huge issue. But to do this, it's going to mean an unprecedented increase in the number of vaccine introductions, unprecedented in a rollout we've never seen before. And I'm sure that Oran's going to comment on this. So this is where we get to challenges in country. To be able to do this, we need a strong immunization system sitting at the heart of a well-functioning health system providing robust and timely data so that programs... Great, okay. So let me just quickly go back. That's where the unimmunized children are. This is how we're progressing on the vaccine and current Gavi-approved vaccines. Go back to that one. So we need a well-functioning health system with a strong immunization system sitting at the heart of it. And this requires clarity around roles and responsibilities for country ministries of health and finance. And I stress that in finance, Gavi Alliance members and partners and the secretariat. So we need to get this all working together. And country capacity to deliver is very variable, I would have to say. We've had comments this morning about issues around stock management and coal chain, and that's probably at the heart of the challenges we have. But country capacity is limited. We'd be less than honest if we didn't say that it's a challenge. And with Gavi to date, we've operated more on a wholesale model of one size fits all, but moving forward and given the variable capacity, we're going to move to a more customized approach with countries, giving a special priority to underperforming and fragile countries. In addition to vaccines, which is the bulk of our business, about 85% of our funding goes out in vaccines. We do provide cash grants to countries to strengthen the capacity of health systems to deliver immunization. And I would have to say, because I'm anticipating questions people might have, that we would describe this in the Gavi Alliance as a work in progress. We do have cash grants, but we're still working on how that's best done to get the best value for money. In a recent slide by Seth Berkley, who's our new CEO, he talked about achieving, putting Gavi within the center of the immunization landscape. Today, we've tended to move vaccine by vaccine, starting small with Hep B, but moving forward to maximize impact and efficiencies, we'll also be doing more horizon scanning across the global immunization landscape to ensure we benefit from the synergies with those working in other vaccine efforts. That's not to say, Gavi, it's talking about taking them over, but it's about better synergies. And I think polio and measles are probably the best example of where there are synergies, both in terms of experiences, in terms of structures on the ground, in terms of shared data, et cetera. And we also want to follow the developments in R&D, a lot of discussion about that, and to adjust our focus as new vaccines become available. So every time the Gavi board makes a decision, they've been clear to us, they want to know, first of all, about the decision rightly, is that specific decision justified in its own terms, in terms of impact and value for money? And secondly, what are the trade-offs by making that decision? Will taking that decision prevent future opportunities that might be a better investment? So we want to better understand moving forward where Gavi sits in the current vaccine landscape and where potentially we might be moving. So we want to be looking forward, saying, well, what's happening with the malaria vaccine? What's the sort of timeframe? Where would Gavi fit with that? What about Dengue? What about IPV when we eradicate polio? I'll say when, because everybody's wanting to be bullish. What about cholera? So we're going to be moving to a broader, more landscape scanning. To go back then to the specifics of the vaccines that we are focusing on, rolling out that are going to make a very major impact, the slide up there reflects our plan to introduce the powerful pneumococcal vaccine, which a number of speakers talked about this morning, to more than 50 countries by the year 2015. As I said, we're ramping up very rapidly. Pneumonia is the biggest killer of children before their fifth birthday and the pneumococcal vaccine can potentially prevent half of those deaths. This slide, yes, it's working, shows a similar plan for the rotavirus vaccine, which protects against the most deadly form of diarrhea. And three weeks ago, the Gavi board approved the rollout with some very clear caveats, I should say, of the HPV vaccine, which people have talked about this morning, and of rubella. And I'm not going to go into detail, but I'm happy to answer questions on that later. Now moving to financing and affordability of vaccine challenges. First of all, talking about financing. As many of you will know, thanks to the hard work of many people, including a lot of people in this room, Gavi had a very successful pledging conference in June, which we raised an additional $4.3 billion for the period to the end of 2015. And that brings our total resources for that period, this five-year period, to $7.6 billion. And that's what's going to enable us to get on with our ambitious agenda. However, I want to stress to people that we're not resting on our laurels. We recognize that as the demand has grown and the complexity of our programs has expanded, we must be able to look and plan further into the future with regard to program financing. And this is to give predictability leading to sustainability. A number of people on the earlier panel said for vaccine manufacturers, for market shaping, that long-term visibility and predictability is extremely important. It's also extremely important for recipient countries to have the confidence that when they take on a vaccine, what it's going to be, what the likely price is, et cetera. So we're looking much further than we have in the past. We have expenditure and resource projections out to 2020, and we're working vigorously with our existing donors to improve predictability of the receipt of pledges and to seek new ones. And we're also going to continue to try and diversify our sources of funding by focusing on new champions and funders, including particularly focusing on the emerging economies. But it's also very important for us to have contact with a vibrant and successful private sector resource mobilization effort. And some of you may be aware of the newly created matching fund for private sector contributions, which is going to aims to bring in new corporates and foundation partners, not just as funders, but also champions. IFM, those of you who know what IFM is, IFM is the International Financing Facility for Immunization, where using sovereign donor underpinning, we buy bonds on the capital markets to bring forward money. That's going to continue to be a key part of our long-term strategy, because it gives confidence to countries and manufacturers that there is longer-term funding. And it also provides flexibility to move money through time as needed, because we can go out to the bond markets when we have a particular need or a gap where donor funding is delayed or is coming in at a later time. So moving then on to the affordability of vaccines and market challenges, and I think there's already been a lot of discussion about this, we have seen progress with vaccine prices. For example, the AMC, as a pull mechanism, has made it possible for us to fund pneumococcal vaccine. We have, this shows the pneumococcal, the pentavalent vaccine with the lower prices there, and that protects against five-layer diseases, and it offers significant price reductions over time. We've also seen a big drop in the price of rotavirus, which has made it possible, and the HPV vaccine, although we still need a lower price on that. The pentavalent price is important because it's a major cost driver for Gavi, and it'll allow Gavi to reunite more children over time, but it also sends an important message to countries about the prices they can expect to pay once they graduate from Gavi. I'm going to use, using the pentavalent example, the predictable aggregated demand that Gavi ensures has also attracted more manufacturers, so not just lowering prices, but more manufacturers, which increases competition, and most importantly, it's attracting in emerging market manufacturers, you can see from that slide. But we're now moving to a much more proactive effort, and we recently at the board, the board approved a strategy for supply and procurement, which entails a tailored approach for each vaccine to stimulate innovation, competition, and new quality manufacturers, and through this new strategy, we aim to, first of all, ensure sufficient and uninterrupted supply of high quality vaccines, secondly, to promote low and sustainable costs for developing countries, and thirdly, to foster an environment for innovation. While price is important, other essential factors include reliable supply of high quality vaccines, shortening the time it takes for products to become available to developing countries. I think that's one of the things we've really been able to achieve, and ensuring optimal product formulation to meet countries' needs and distribution systems, and that still continues to be a challenge and needs to be built in early in the development stage. Country financing is another key GAVI policy. All countries receiving GAVI vaccines must pay a co-payment, and this has been quite innovative, and that has a dual aim, the co-financing, it has the dual aim of ensuring country ownership of immunization and vaccines that GAVI funds, and to put countries on a trajectory towards financial sustainability by getting immunization funding as a budget line in order to prepare them to phase out GAVI funding, and we have 16 countries who are actually graduating out of GAVI funding, so the co-financing has a very important part to play, and that really brings me to my final part. GAVI and partners are beginning to explore ways which the specific challenges of GAVI graduating countries, and also low-middle income countries that may never have been GAVI eligible can be addressed. There's an increasing challenge about those countries being able to continue to supply vaccines at a price that's manageable for them. First and foremost, to be able to do this, there's a need to have a strong political will and commitment at the highest government level to sustain immunization programs, and we heard Julie talk about Zambia this morning. Political will cannot be underestimated for a commitment for immunization. Other elements include gaining commitment from manufacturers on pricing, the possibility of pooling procurement for low-middle income countries, increased transparency on prices and products also help countries to make informed decisions. Given the central importance of country commitment and ownership, my final slide is a picture of the President of Kenya, President Kibaki, at the launch of the pneumococcal vaccine that Arun and I both attended earlier this year. Awareness and commitment at the highest level to health as a driver of development is critical. Then we can help realize the power of vaccines to save children's lives and protect people's health. Thank you. Thank you very much, Helen. Okay, after that, Keynote will turn to Arun Levine to talk a little bit about the decade of vaccines. Thanks, and thanks to Steve and CSIS for hosting this very important discussion. I'm gonna talk a little bit about the decade of vaccines, but before I do, I wanna actually start with just a couple of sort of personal reflections on what draws me to immunizations and what are sort of rehashing some of the themes that have come through today, which are woven into the work of the decade of vaccines coming through in the next few minutes. First of all, you almost always hear the words vaccines and success together. Vaccines are the part of global health where we apologize for 50% effectiveness. If we don't get 90% efficacy, we're disappointed. It's where we talk about big, hairy, audacious goals like making the germ go away from the world and people don't laugh. Vaccines have been successful and continue to be successful. They're successful in part because they're tools for social justice that when we apply vaccines and deliver them and develop them and all those things and get them out there, we essentially eliminate disparities and inequities. And you only need to look at the front page of any newspaper to know that inequities on many levels are really one of the challenges ahead in the next decade. And so vaccines are one of those tools. In addition, they help to break the cycle of poverty. When you vaccinate a child just two or three times, you reduce the likelihood that the kid's gonna get ill and that the parents are gonna have to dig into their savings and somehow pay for their child's treatment. In addition, research from David Bloom at Harvard and others have shown it's a great investment in the economy of a country, probably through multiple ways, but including direct benefits to the parent, to the child and the family, the household. Children who get vaccines are less likely to be disabled, more likely to have a better cognition, to become better educated and to be more productive in the future. And when we break that cycle of poverty, when we break that cycle of infant mortality, we lead to the demographic transition, fertility rates go down and economies grow. And so vaccines are one part of the whole development approach that we take to try and break that cycle of poverty and improve societies. They've been successful. We have seen really tremendous progress over the last 20, 30 years and especially in the last decade. But with the decade ahead, we will also have some new challenges. And I think that's part of the reason why Bill Gates challenged us in 2010 with this decade of vaccine. At the one hand, he said, I'm personally committed to it. Bill and Melinda pledged $10 billion over 10 years in order to spark this decade of vaccines. But I think he was also trying to challenge us to say, remain successful in the decade coming forward. Examine what you're doing well that needs to keep going, that needs to be amplified and expanded. Also examine the things that have worked but might need to change to stay successful in the decade ahead. And he's really challenged the community, I think, to think ambitiously about what kinds of transformative actions could be employed in the next decade that would really make a very big difference and might bring something very new to the field. So before I talk about the decade of vaccines action plan and the collaboration, I just wanna point out one of those trends, I think, that is on us, it's upon us. And we can predict it's gonna be an issue for the next decade that we need to anticipate now. And that is the expansion of emerging economies. So in 1990, when we set the benchmarks for the Millennium Development Goals and all those sorts of things, 90% of the world's poor people lived in poor countries. Remember debt relief, highly indebted poor countries? That's where the poor people lived. Now, the majority of poor people live in middle income countries. And middle income countries have somewhat more resources, not as few as the low income countries, not as many as the high income countries, but somewhat more resource to be able to make decisions about their own internal allocations for health and other investments in their population. And so the types of approaches that we've used successfully may need to continue for some countries. And for some countries, we may need to evolve and adapt. So the decade of vaccines collaboration, which kicked off last year, is fundamentally aiming at trying to develop a global vaccine action plan, a set of coordinated transformative and important actions or activities that will help to bring about the kinds of success at the end of this decade that we would all like to see success in trying to bring about improvements in research and development so that the vaccines that historically have vexed us for protection, things like HIV vaccines that have been talked about today might be legitimately vaccine preventable by the end of the decade. Drawing innovation throughout the enterprise of vaccines, not just in research and development, but in delivery and financing and in other areas. Trying to establish a much firmer country ownership of immunizations. We've seen so far today several pictures of presidents and first ladies and those types of things. And we're trying to establish that kind of leadership and commitment through the decade of vaccines that builds country ownership, but not just at the top, but also at the community level. We heard about the sort of community response to vaccines when we deliver the things that they want, that prevent the diseases that they feel and see the kinds of ownership at a community level that bubbles up as a response. The decade of vaccines collaboration is at a very exciting time right now. It's at a point where it's very actively soliciting input and feedback on the actions that should be priorities that can be undertaken in this next decade. I think you heard about a team that is in Namibia this week soliciting input from immunization leaders and constituents all throughout Africa. There will be other interactions in other parts of the world throughout the year and some right here in Washington, DC. So I really encourage you if you've not already gotten engaged with the decade of vaccines collaboration. You can find out more on the website. You can find some of the people here. Laurie Werner, a colleague of mine from the decade of vaccines collaboration is here. And there are a lot of ways to get involved and participate and we need that if we're gonna build out a successful plan. I wanna quickly talk about just one or two of the sort of innovative ideas that are emerging out of the decade of vaccines collaboration and that are particularly one, just one, as I said, just one thing about the decade of vaccines collaboration. And that is around financing because it keeps coming up in the questions and the comments that we're in a tough financing time than we are. So one of the things that we're working on is actually an idea pioneered by Amanda Glassman, my colleague here, about it, the idea of a fair share financing pledge. And this is in many ways an extension of what the Gavi Alliance has been trying to do, which is to say, yes, we need external assistance from places like the US government to help countries build up systems and introduce new life-saving vaccines. But they do not need that assistance forever and we should not be obligated to provide it forever. We need a intentional and strategic approach to building out the increases in domestic funding and the shaping of the market to make it easier for developing country government financing and the needs of vaccine manufacturers to be met so that over a period of time, our investments, our responsibility goes down and theirs goes up. And I think these are the kinds of discussions that we are having through the decade of vaccines collaboration that are gonna be really, really important and they're really important here for people who are involved with the US government to know that in vaccines, they're successful, they're tools for social justice, they help break the cycle of poverty and we have a way of structuring our assistance so that over time, our responsibility goes down and country ownership goes up. Thank you, Orin. I just wanna add one footnote to that idea and that is that all countries need to contribute their fair share according to their contribution to the world economy and the benefits that they'll perceive from eliminating some of these vaccine-preventable diseases. But that also means that the US actually is a little bit below its fair share at the moment and could actually increase its funding to GAVI as well. So Dr. Shusat, it's timely that you get to sit on the hot seat at the end, but go ahead. So I'm gonna make a few comments about public trust and confidence and it's a huge area of personal interest and one that can really bring down all of the fabulous potential that the immunization program and vaccines of the future have. So I think people here have seen the headlines, HPV vaccine project halted in India, pentavalent introduction interrupted in Sri Lanka, WHO attacked for concerns about the role of pharma in pandemic vaccine and antiviral plans. Maybe you've seen the videos, so-called Red Skin Cheerleader who develops a very odd gait after she gets the H1N1 vaccine. Maybe you guys are too old for that, but when that video aired on YouTube during the 2009 pandemic, college student acceptance of the H1N1 vaccine stopped. Or maybe you've been following the blogs or Twitter or maybe some of you have personal experience taking your baby to the doctor and wondering, does he or she really need five injections today and how do I feel about that? It's pretty difficult to generalize about vaccine resistance and hesitancy and confidence because every particular episode investigated can lead to multiple narratives. But this is not a problem that we need to sit back and react to. It's something that we do have the ability to prepare for. So I think that public trust is difficult to earn, but it's very easy to lose. And preparedness for sustaining the incredible confidence and trust that immunization enjoys today is really important as we look to the next decade. I think this has been said a couple different ways, but there's no intervention that reaches more of the world's most vulnerable, youngest, marginalized people in the world on a regular basis than immunization does. So talk about trust. On the other hand, from one day to the next, a program can be shut down. And a lot of the international community and the US is ill-prepared for managing one of these episodes. So as I said, it's risky to generalize about what's going on in these events, but I think there are a few different factors that can occur. There can be questions about deception. Is this vaccine to protect me against this particular condition or is it actually a plot to sterilize the population? There can be questions about the program. Is this an immunization and health program or is this a program being run to change the religion of the community where it's located? There can be questions about the government itself. Frequent strikes can really erode the confidence that a community has in the people who are out there giving vaccines. It's easy to become tainted by a different part of the system and immunization really needs to protect against that. Sometimes it's a question of the messenger, the wrong sex, nationality, religion of a person delivering a vaccine or talking about vaccines can be challenging. And maybe it's a question of the success. The vaccines in some communities have made the diseases disappear. The question of whether this is a priority, whether the threat is still there, how do you sustain demand and value? And a key answer there is sustaining immunizations as a social norm. In most of the world, parents think that immunizing their kids is the best thing they can do to keep them healthy. And that's a norm that we really wanna protect. Think about smoking and how long it took for people to stop asking, would you like a cigarette? And saying, do you mind if I smoke? Two generations, I think. But immunizations, we're already there, but we do have a lot to lose. So what can we, just a couple more points about the generalizations, there are a few kinds of vaccination efforts that are really lightning rods and that you have to take special effort to prepare for. One of them is mass campaigns. It might be a mass rubella introduction in the future. It might be a mass H1N1 vaccination response to a pandemic, but whenever you're vaccinating a large population over a short period of time, things happen. And those things can have nothing to do with the immunization program, or they may be causally related. You need to be ready to respond and you need spokespeople, investigation teams, and a strategy before you actually roll out your program. Another lightning rod is targeting. You can be targeting just women because that's who should be getting the HPV vaccine, or you can be targeting the police and military because they're special and they're supposed to get the product that no one else gets to. But people don't really like inequity and that's something that you have to be ready to explain and support and defend. Another issue is something new. And this was something I just learned fairly recently, but when you think about Apple products, new is really good. When you think about vaccines, new is really scary. In the US, we did not use adjuvants in the H1N1 flu vaccination effort because our population was not ready for them. We got letters, we did community engagement, there was this massive program of fear about what was in those adjuvants and what was gonna happen with them. And we felt even though they would be likely or theoretically dose-sparing or could get us more product upfront, the acceptance was going to be low here. They were used more successfully in other places. But new can be concerning. And so I think all of us want to reduce the gap between when vaccines are used in rich countries and poor countries, but we have to be careful with that and make sure that people are confident that this vaccine has been safe and tested. I think the meningitis A introduction in Africa was a great example where there was large-scale safety testing done before the launch and the vaccine was very highly valued. But another lightning rod is pharma. So I think Tony has gone big pharma may be family for Tony, but I think for some communities, there's suspicion. And we really need to reconcile that because we can't get vaccines without the pharmaceutical industry north and south. But so I think understanding what's the relationship between the program and the profit is very important. So what are we supposed to do about all these problems? I think there are really three areas that are very valuable. One is the idea of champions. It might be tempting to think of a president or a first lady as a champion and that might work really well in some places, but often it's the champion next door. It's the person who lives in your neighborhood who understands your values and your culture. I visited the DC Health Department earlier this week and they have a program here, I think funded by the city council, that's finding immunization champions that are doctors that visit other practices that help explain what really needs to happen. In on Nigeria, the Sultan of one of the northern states was a key champion who really learned about the program and explained it to his followers. I think champions are often most effective when they're closest to the community of interest. Another key strategy is communication. I have sort of this wonderful job where I'm promoting immunization in the US and helping us be more prepared and worrying about international vaccine initiatives. And there's a total relationship between all of these things because when you're worrying about a pandemic or dealing with a crisis, you use risk communication. When you're talking to a parent about their child and the five injections that you wanna give today, risk communication is also a good strategy. And the key principles of risk communication are being open and honest, being empathetic and caring. The line is people don't care what you know until they know that you care. And that's a critical way to talk about vaccines. You can't explain diseases are bad, here's how much money we're gonna save until somebody trusts you. So I think with our immunization efforts, we really need to learn those principles and really deploy that in terms of the international immunization community in every country. The third key point, I think, about public trust and confidence in immunization is to try to keep politics out of it. It's fantastic to have political will and country ownership, but it's not sustainable if that's identified with a single individual or leader who may have a certain tenure. It's really important for there to be a health and science sustainable defense for the program or support for the program and not just a temporary leader. So when there's an adverse event following an immunization, you really don't want the president on TV explaining why that is and what happened. You want Tony Fauci kind of explaining what happened and what we're doing about it. And I think those are concepts that we use very aggressively during the pandemic flu response here and that I think many countries around the world are learning to deploy themselves. I think the last thing to just say is that as much as the internet and other sources make us nervous about the future of confidence in vaccines, how easy it is to bring things down, we're working with such a strong base. We have such a successful program in every country of the world that we really can sustain that if we pay attention. Thank you so much. I think that was a really, really interesting perspective also on how the institutions that exist in a country like the United States help promote the public trust and immunization and that it's not really a political, it's related to politics, but it's not only about politics. So now we have about four minutes for questions from the audience. So I would ask you to be very concise, introduce yourself, we'll take two questions. And that there's two here. Peter Hale, I'm with the Foundation for Vaccine Research. There's an anti-vaccine movement out there whooping up frenzy, and we know that people have doubts in rich countries and in poor countries. My own foundation, we have a raging continuing debate. Should we take the anti-vaccine movement on directly? We know they're a minority, or do we ignore them and focus on the 20% or 30% of the population who have some kind of doubts? Yeah, I think that's a great question, or do you want to take lots of questions? Why don't you answer and then we'll go to the second question. I mean, I think that there are actually several different movements and groups and I do think it's difficult to generalize. But I actually think we need to be careful about giving more attention to some groups. In the US, some of the attacks and concerns are actually diminishing and losing a voice. Some of the science really has, for instance, in the US, the vaccines and autism issue was a big question for parents, rightly a question for many years. There's been so much science completed now. Scientific community has made conclusions. Many leaders within the autism community have moved on from that to other more promising areas. And going back to the old arguments and the old attacks just keeps that concern alive. So I think there are really decisions that need to be made locally, nationally for a foundation. I do personally think that reaching that 20% we're not reaching and getting to the hardest-hit places and figuring out strategies for conflict settings and fragile states is the biggest challenge for immunization right now and that's where I'm putting my attention. But I wouldn't say any EPI manager around the globe can live in 2011 and not learn how to do risk communication and think about their safety tracking system and have a system of local voices that can talk about things that's separate from them themselves. Okay, one more question. There is a woman towards the back, on the left side. Go ahead. Hi, thank you. My name's Kelly Cappalier and I work with JSI in the USA Immership Project. And I just had a question about, we've talked a lot about new vaccines and the future of vaccines, but I'm wondering how the strengthening of routine immunization systems fits into this conversation and sustaining the benefits and introduction of new vaccines in the future. Do you wanna say something about that, Helen? Yes, I mean, the Gavi Alliance was set up to look at and to introduce new and underused vaccines. So that's our primary focus, but there's a whole merging continuum. And as I said, we want to look at Gavi in the center of it. The fact that we fund the pentavalent vaccine actually picks up the three DTP, which are the core of it. We're now taking on Rubella, which is actually gonna be a Rubella mesomes. And from the Gavi perspective, one of the other aspects we've had in terms of trying to reinforce the importance of the basic immunization is that we've had a filter for eligibility for Gavi vaccines. So it started off at a 50% coverage for DTP-3. And that was for two reasons. One was to ensure, because people were concerned that the focus would go away from the core routine vaccinations, to ensure that countries maintain that focus. So you had to have at least 50% coverage, but also because it's an indicator of the health system's capacity. And we've now actually increased that to 70% as routine immunization has gone up over the last decade and it averages in Gavi countries at about 79%. So yes, it's absolutely core, but I think it goes to the point I was making about whatever aspect of immunization we're in, we really need to look at the synergies and the full landscape. To Orrin? Just one quick follow on. This is an issue that's come up for a long time. And our group has just recently completed analysis of DTP-3 coverage over the last 20 years in all countries. It tried to relate it to new vaccine introduction. In other words, does new vaccine introduction either increase your coverage with routine vaccines or decrease it? And the answer is neither. There are huge fluctuations in immunization coverage, but they're not associated with the introduction of new vaccines. And what that points out is we need to stay focused on the key drivers of immunization coverage, strengthening the systems, both supply and demand side that helped to do that and recognizing that and recognizing the need for immunizations to be part of primary healthcare and a package of services. The decade of vaccines collaboration has a whole delivery working group that is just dedicated to trying to figure out how are we gonna strengthen those systems and increase our coverage and sustainable coverage of vaccines in the years ahead. Okay, well thank you very much to our panelists for a great talking to the people who ask questions. Thank you.