 The closing segment of this program, which will run for a little over an hour, we have about an hour's time, is to think about the future. It's to think about some of the events that lie ahead as opportunities to reflect, particularly from the two senior personalities we have here from Merck and GSK respectively to reflect a bit on what has been accomplished over the last several years and what that means in terms of momentum and opportunity looking forward. So we have with us Julie Gerberding, who is in a new role, new to me, as Executive Vice President for Strategic Communications and Global Public Policy and Population Health at Merck, congratulations on that. Maybe you can tell us a few words about what that means. When I know, I'll tell you. But congratulations, it sounds like a very big job. Donna Alton-Pole was to be with us from GSK remotely by Videolink. We have changed our plans. We have with us today, fortunately we have Simon Gottfried, who's the Director of Public Market Development, special reference to HPV vaccine for GSK. So Simon, thank you so much for being with us. And we have Steven Resch, Dr. Steven Resch, Deputy Director, Center for Health Decision Science at Harvard School of Public Health, and he's the author of a very important recent costing analysis that we'll hear about from him. So what I'm going to do is we're going to kick this off by asking in sequence Julie, Simon and Steven to share with us six to eight minutes each their reflections on what's been accomplished since the HPV vaccine was first introduced in this rapid-evolving environment we've discussed today. And what does that mean in terms of the major opportunities and challenges going forward? It's really trying to hear from the three of them, where are we and what is that spell when you start thinking about the future? What does that really mean? And after that, we've had a chance to do that. We'll turn to two other questions that we put forward. One is, how do we translate that growing interest in cervical cancer in stronger political ownership, fully financed plans, and clear goals? And beyond that, thinking about 2015 and how is cervical cancer, prevention of NCDs, better use of vaccines, how are they going to figure in the World Health Assembly that's approaching in the Development and Financing Summit in the MDG? It's a sustainable development goal session of the UN General Assembly special session in New York in September. This is a huge year on goals, setting and on development and certainly cervical cancer is and will be and should be part of that. So we'll turn to those two questions. So Julie, if you could lead us off with your reflections on where are we right now? Thank you. It's a pleasure to be here and I really appreciate people's interest in this. This is a personal passion of mine and part of the reason why I joined the private sector because I really truly believe that HPV-related disease is a preventable disease and we have waited too long to get going and we have such a long way to go that we need to accelerate, consolidate and activate across a whole number of sectors to get the job done right. So I'm impatient, but I will start by talking a little bit about the glass being half full and then a little bit about the glass being half empty and then maybe together we can figure out how to get a bigger glass because I think that's ultimately what we need. The glass half full I believe is really in pipeline terms proof of concept. We have proof of concept that all three legs of the stool necessary to defeat HPV-related cancers, particularly cervical cancer, are feasible and work. We have preventive vaccine that we know can reduce the risk from the strains of virus that are contained in the vaccine. We have inexpensive screening that I know you heard about in many different frames this morning from the pink ribbon red ribbon perspective and we have cheap treatment for at least early disease that is affordable and accessible to more and more women around the world. To me that's proof of concept. We can simultaneously bring an affordable vaccine, an inexpensive screening and an inexpensive treatment to women in some of the most difficult to reach environments and if we can do it in those environments we ought to be able to do it everywhere. So that is a tremendous success. From a vaccine perspective and wearing my merc hat I think the fact that we utilize more than 185 million doses of vaccine around the world and that HPV vaccine is recommended in 65 countries so far is also a tremendous glass half full achievement. It's not easy to do, it's not easy to tear pricing, it's not easy to introduce and get started in immunization programs for a whole new population of children. But we've done it and we've learned a lot in the process. We've made a lot of mistakes but we're on our way to really continuing to improve that access. And I think the last thing that we've accomplished is to really mobilize awareness that this cancer is caused by a virus. That's not universally understood yet but I think in more and more countries it's just to at least my experience in the countries that have had to live with high prevalence of HIV, the notion that HPV causes a disease like cancer is not a far-fetched notion and we've actually paradoxically had the best luck at helping achieve that awareness and understanding in those countries. Countries that have limited experience with HIV have a harder time getting it that a virus can be associated with a cancer. So I think those are all really positive signs and actually they've happened pretty fast. It's been less than 10 years since the vaccines were launched and we're well on our way to expanding access in many of the most difficult to reach countries. The glass half empty part of it however is really what's top of my mind right now for two reasons. One is this past week American BMS and a number of other companies announced some really exciting immuno-oncology progress with new drugs that treat cancers by reactivating immune system and these are loudly touted as breakthroughs. It's creating great excitement in the oncology world and certainly great excitement for patients. But the frustration that I feel about that is we have cancer prevention products that are not being used and you know why are we getting such in the celebratory state about advanced complex and expensive treatments when we have something over here that's inexpensive should be universally available and would take a whole set of cancers off the table. So it is a glass half empty as far as I'm concerned. And the other very top of mind issue for me right now is the fact that HPV related cancers in women is really a poster child for health disparity. And this is a I really believe that if we were talking about a half a billion people getting penis cancer in a year we would have a very different outlook on what needs to be done and what steps need to be taken from a public health perspective. So why is it that this disease is still not talked about poorly understood disproportionately affecting the poorest women around the world but even in the United States disproportionately affecting African Americans and Hispanic people generally in the poorest communities in the U.S. That is absolutely embarrassing. It makes me angry and I think it's time that we stop accepting this in a complacent perspective but we get busy and say enough already. We know what we need to do now it's just activate and get the job done and I'm glad we'll have a chance to talk about that later on the panel. So I'll be quiet now but I hope I have infused a little energy into the room and that the passion that I think many of us feel on this issue can start to cascade into places where these kinds of decisions really have to be carried forward. Thank you very much. That was very powerful and eloquent. Thank you. Simon you get to file. Yeah. Thank you Stephen. You told me to speak up. I hope everyone can hear me OK. I speak softly so I'll try and project. I feel really humble to be here actually. I joined GSK only over a year and a half ago and I don't come from bioscience. I come from policy. I come from politics and I've learned a lot in that last year. So I'm going to touch on what I think some of the issues about getting to the future really are. I'm going to talk a little bit about political will that we've spoken about earlier today. I'm going to reflect on some lessons and one of the good things about going almost last at the end of the day is you get to sort of ad lib and you get to sort of reference other points. One of the bad things is a lot of things you want to say have already been said. So I'm going to try and just weave my way through an interesting set of conversations. I think for me first and foremost when I look around the room and I thought it's an allergy just earlier today that there are around about 45 people in the room here. There are many more online and for me this is a team effort. This is a team thing. OK. So when I think about and some of you in the room will really understand this. When I think about an American football team let's call them the Rock Washington Redskins. They put individual pools of great talent but they need to operate as a team to be truly truly successful. So I look around a little while since that. Well I'm a fan. Yes I'm a fan of the Redskins but it's been too long really. So my point here really is that we all have our individual talents and my call to action which I'll come back to at the end. I think we need to work much more smartly together. And I read a great book. I was at LAX for all of six hours just a few weeks ago and I popped into one of the book shops. I picked up a book by an astronaut ex-astronaut called Ron Garon called The Global Perspective and the theme of the book is about collaboration. He references it in terms of building the space station and how the Russians and the Americans came together and how many lessons they have been in that book that I think can translate to our industry because we are all part of the same team. And I want to recognize W.H.O. Gavi organizations like Pink Ribbon Red Ribbon there are many, many more in the room who are doing the hard yards on the ground. So it's easy for the industry to innovate and do what we think is right from a product perspective but actually where it really matters is getting the vaccine to the point of need in whichever country it is. One data point that I want to talk about is that we talked about 266,000 women dying last I think last Saturday was 2012 of cervical cancer. I then read that almost double that by the year 2035 are going to be dying from cervical cancer. And I did the math and instead of one woman dying every two minutes, that's one woman dying every, almost every minute. So, and that's if we don't act now. So I think, you know, the call to action from our whole day here is that we need to put our collective heads together and think about how we collaborate more smartly, put aside the egos, think about how we have a construct for success. But if the vaccine doesn't get introduced and we talked about access and there are two pillars for me. There's access and there's coverage. There are lots of different dimensions to that which I'm going to come on to in a minute. If the vaccine doesn't get introduced, if there's too much political apathy or too much political choice, then actually we will be doing the women of this world a bit of a disservice. So I want to talk about four things I think are barriers to future progress. One of those is political will. One of those we haven't talked a lot about today because the world is a complex and colorful place. It's about cultures. We mentioned at our dinner last night about the sexualization of the vaccine. I want to come back to that in a minute. I want to talk about infrastructural issues, things that are the hard yards, the difficult stuff, the refrigeration, getting it from point A to point B in the country where it matters. And I want to talk about finance as well. So I've spent at least two decades working closely with politicians and what I've learned in that time is politicians are generally quite fickle. Holding course for a long period of time is difficult because they are mostly, in most democratic countries, I'll be careful to choose my words, are elected. And they're very conscious of the time frames they have to do good work. This is not a short-term game. This is a long-term game. This is like a 19-minute Super Bowl, lasting three and a half hours. Extrapolate that out to the next 15 to 20 years. That's only when we'll see the results. So politicians are always faced with choices. And those choices are often made in the short term. And I want to talk specifically about the balance between screening and vaccination. You know, I would advocate you should always have a balanced approach. But where the needle sits really, really matters. So in the UK that David referred to earlier today, great screening program, great vaccination program, works really well, great stuff. Developed country, good news. I've just come back from a world tour where I visit a lot of different countries in Asia, some in Latam. And what I learned from a particular Asian country is they want to mirror the UK screening program. And I'm not sure whether that's the right choice. It's costly, it's time-consuming, there's a lot of infrastructure stuff they're going to have to build to make this work. And actually the results, they could get a better balance to focus perhaps on vaccination as a primary with screening and supporting that. So each country is different. Getting the balance right, therefore, is for me really critical. And I think if I look at where the tipping point is, how much money could we save by reinventing screening where vaccination takes priority? How can we repurpose some of those funds? I'd like to talk about culture very briefly as well and society and the social issues. Hesitancy, we talked about Japan last night and again earlier today. For me, I think it's easy to sit in a room here in Washington and look out of a world and say, okay, we understand cultures are different. We understand the multiple different cultures, different ways of working. But actually, I think respect is a really important word as well because the English context is not the same as the Japanese context. The way the culture works, the way the culture thinks. It is very different. And we have to respect there is a different learning curve to go through. I sincerely hope that Japan comes through this because I, and I said to you last night and I know that this really is about setting an example, not just for Japanese women and girls, but for the whole Asian context. I really hope that comes to bear. So let's really keep our fingers crossed that we can resolve this. Infrastructural stuff. Okay, let's talk about some innovations. It isn't just enough to have a great vaccine. Gardasil, cervix, okay, on a part, absolutely. But actually it's about getting it to the point of need. So innovating from three doses down to two doses, the issue with that was really to get compliance up, to get coverage up, okay? So, and by the way, perhaps repurposing some of the money. So for me, the innovation gap in access has to be even more thoroughly thought of. But NCI referred earlier, Ted, I think you spoke about or at least asked a question around the one dose. And I think we're having conversations with you about how we can enable that to make that happen, which is great. I'm conscious of the time, so I'll speed up, Steve. And I've so much to say, this is largely unrehearsal and unprepared, so do forgive me. Affordability, okay. So we've done great work. We have driven along with the price of the vaccine down. So developed countries pay a great deal more than developing countries. That's a reason for that. We know that our supply and our cost and our price to Gavi are significantly below developed countries. We are interested in getting the vaccine to as many women as we possibly can. And I spoke to Steve last night, and I'm gonna throw this challenge out because we, governments think in monetary terms, because they have to. There's a public purse. They have to be accountable to the public. They've got to think about how much budget they've got to spend. Yet when we do the health economics and we look at the value of a life, we look at the value of life as a point on the spreadsheet. We run the numbers, we think about qualities, quality of adjusted life years, and out of it comes a number and either fits in a country context or it doesn't fit in a country context. Our point was raised earlier about the value of a woman in society. And I'm gonna say this because I'm proud to say it. I think, and Steve, we spoke about this last night, and I hope you'll reflect on it in a minute, that I think the value of a woman needs to be much more than a point on a spreadsheet. I think the value of a woman in terms of what she brings to the society, the family, the culture around it is much greater than we think. And I would really like to find a way to measure the value of a woman in society, in a context, to put forward a strong financial argument so that when this goes to an Asian country or a Latin American country, it is highly relevant for their decision making. It isn't just an abstract spreadsheet number. So my call for action, my policy, ask, if you will, is to start thinking really innovatively, get outside of just crunching the numbers to think about the impact of a life lost as such. So we talked about schools coverage. I made a note earlier. I'm not gonna harp on about it. I think actually what I want to really finish up with and the future for me is about innovation. Of course it is. It's not just about innovating with therapies and with good vaccines and good cancer therapies. This is about innovating with people. It's about innovating amongst ourselves. It's about innovating, putting an infrastructure together that actually works because it's a big, big issue. And we looked at this when we made our commitment to the 10 year price freeze for Gabby. How can you sustain the progress? It's easy to do year one. It's easy to do year two. But without a coalition of the willing in this room and the willing beyond this room, it's gonna be a really hard thing to do. So in three decades from now, I may still be here. Some of you will be, some of you won't be. I think I'd like to look back and think, okay, look, we played the game but we wouldn't play the game well because at this point in time, we made a decision to work much more smartly together, much more cleverly together and collaborate much more openly together. So that's really my sort of take on the future, Steve. And it's not just about the vaccine. It's not just about the site. It's about everybody in this room coming together and making it right for the good of women kind in 20, 30, and 40 years from now. Thank you very much. Steven. All right, I'm gonna speak a little bit about one of the barriers very narrowly around the idea of resource requirements for comprehensive cervical cancer prevention. And these remarks are really stemming almost directly from a paper that we did. So it will be a little more structured in that sense. The work was supported by the American Cancer Society and it leveraged existing validated computer models developed by Jane Kim and Sue Goldie at Harvard and also the CERVAVAC model which was developed by PAHO through the PROVAC initiative that we heard about earlier today. And just to be clear, I'm gonna give you a sense of the scope of what we costed but the idea here is that I'm gonna try and give you some numbers of essentially a price tag for taking action. And it has some limitations which I'll also try and mention. So we looked at a 10 year time horizon from 2015 to 2024 and we looked at about 100 low and middle income countries with over one million population and these countries we categorized by income tier and also to the extent that they had an existing psychology based screening program. We looked at both vaccination as well as screening. Vaccination was taking place in 10 year old girls with no catch up and the screening was in the target age of age 30 to 49 and also included lesion treatment but at the present time the costs that I'm gonna present to you don't include cancer care and we have not yet measured the associated health impacts or the social impacts in terms of orphanhood prevented and so forth yet. So and we also another issue that came up that people were talking about is the surveillance and the impact monitoring is an important piece and I would say that these estimates probably don't capture that fully either. The data we use was largely, the epidemiological data is coming from IARC and ICO there's quite a bit of statistical work to impute HPV prevalence because the information we have on HPV prevalence across different countries the world is still very incomplete and the cost data came from systematic reviews the limit literature and we did quite a bit of extrapolating of costs using WHO choice estimates for healthcare delivery in different countries to do that extrapolation from countries where we had cost estimates to those where we didn't. The policy scenarios we looked at there were seven and I'm not gonna talk about them in detail of course but my point is here that they varied in terms of the technology for screening and the frequency and the scenarios came out of the broad and flexible guidelines of WHO and I suppose one of the bigger points here is that we do have a choice in terms of screening depending on the price point of what we wanna do and how ambitious we wanna be in terms of screening and we present in the paper a range of estimates of the cost of different levels of intensity of screening and they range from once in a lifetime screening to every five year screening in the target age and the technologies we examined were primarily visual inspection with acetic acid, VIA and HPV testing and some triage strategies and we looked a little bit at cytology for countries where they've already doing a lot of cytology but that's really almost a side point our focus was really on VIA and HPV and the basic idea of the scenarios were that you would have higher VIA in the lower income settings and HPV in the up middle income settings and we tinkered with who exactly gets HPV and who exactly gets VIA. For vaccination we did assume two doses and vaccination of 10 year old girls no catch up and we consider three different pricing structures so the key variable here, we did include service delivery costs as best we could but then the key variable that we tinkered with was what is the price of the vaccine gonna be in the countries that are not Gavi countries so that's where most of the variation in our analysis came from there. In the primary scenario we applied the Gavi price obviously to all the Gavi eligible countries and to all countries with income below about $2,600 per capita which is the midpoint of the low middle income tier of World Bank so it's the lower, lower middle income countries and then because our base case scenario was sort of an optimistic one from the point of the purchaser I suppose we assumed that the PAHO Revolving Fund price would be used in all other middle income countries and of course not all of those countries can actually access the revolving funds so how you get there is still something we would need to work out. In other scenarios the price for the non Gavi countries of the vaccine was basically higher prices as the countries got richer rising up to $40 a dose in the countries at the upper end of the middle income spectrum and finally the other major dimension we varied was the pace of scale up so this is something to think about too in terms of resources available in one scenario which is sort of as a slow rollout where we get to full coverage over 10 years it's a linear scale up 10 percentage points per year it's not saying every country would scale up at that rate but rather as a global average we would reach 100% coverage of women in 10 years from now and in 2015 this year it would be 10% the next year 20% and so on and then in the most extreme scenario we just said let's turn it on right now 2015 everybody gets coverage of vaccination and screening just as an upper bound and those are actually the numbers I'm gonna present to you because they're sort of the easiest intuitively so in terms of results for screening and lesion treatment the cost of making sure that for the next 10 years every woman of target age in all of these low and middle income countries in the world get at least one screening per lifetime and that's using VIA in the low and the lower middle income countries and mostly HPV testing in the upper middle income countries the cost would be about $9 billion we estimated so that's less than a billion dollars a year for this comprehensive screening program and about half to two thirds of that cost is for the initial screening and the rest of it is for the follow-up and the lesion treatment so LEAP or cryotherapy, some called POSCIPY for this cost we would reach about 440 million women of the target age group it's also important to note that only 3% of that cost actually falls in the lowest income tier and only 24% of the cost is in the low middle income countries so if you start thinking about who would pay the cost or which countries need the help the most because of the way the pricing structure is it gets much more expensive to do screening because of the cost of labor and so forth in the upper middle income countries so the price tag for the low income countries is actually not outrageous if you prefer a geographical perspective in Sub-Saharan Africa they only accounted for 8% of this nine billion dollars again for screening if you like to think about it from a per woman perspective once in a lifetime screening is about $20 per woman but in the low income settings it's as low as $3.50 per woman in our estimates if we want to think about a screening program that's more ambitious screening women every five years and using HPV testing in all but the lowest income countries that raises the total cost it basically triples the total cost to $29 billion over 10 years so it's about $3 billion a year at full scale about 45% of that cost or $13 billion is the need for the low and the low middle income countries so again if you want to think about where donors need to focus versus what might be the obligation of countries to raise themselves that split, that $29 billion over 10 years is about evenly split between the low, low middle income and the upper middle income countries for that, yeah. You need to wrap up, sure, okay so for vaccination, $16 billion over 10 years and that would vaccinate 500 million girls and three quarters of that cost is in non-Gavi countries and I'll just, I can stop there. Thank you. What is the baseline estimate of expenditure right now? Yeah, interesting so that was not in our scope of work for this project for certainly a number of Latin American countries are spending considerable money on cytology programs. There are cancer centers around the world cancer treatment costs are not yet is in our second phase of work so we haven't done that yet and then for vaccination, we heard 185 million doses of one of the vaccines has been delivered. I don't know how many of those through Gavi or to low and middle income countries but it's a small fraction compared to these numbers. I mean we did get some estimation of what between Ted's presentation and some of the subsequent discussions around the country coverage. We got some idea of that. What I hear, what I hear coming out of this is a sense that there is momentum coming out of the last several years. There is a strong, as Julie has emphasized, there's a strong common sense argument, there's a strong moral and ethical argument but what is missing, there's not a visible, the problem is less visible and in a continuous and current way as a threat that preoccupies political leadership. It doesn't enter oftentimes into the calculations of overburdened political leaders and more over what has been missing is a kind of agreed and unifying vivid strategy that is costed out and where it's clear who the leadership will be to carry that forward. We have some evidence of things moving in that direction but we're at a point, it seems to me, we're at a kind of pivot point that's very ambiguous right now. Maybe this is another way of saying the half empty, half full and the question then is how do you mobilize political energy and finance in this current moment in order to propel things forward on a less incremental or gradualist basis. Julie, why don't you weigh in on what are your thoughts? What would you advise, if you were speaking to leaders around and trying to motivate and provide a vision of a way forward, what would your advice be at this time? I've thought about this a lot and I don't have a short answer. There are a few main lanes of action that have been used for other global health problems of this magnitude and I think it's worth considering all of them or some combination of them. One is to use the traditional public health route which is to define the problems that a WHO agenda mobilized the CDC and the various public health agencies around the world and begin the process of working through that approach. A second approach is sort of the government approach where you really do work within individual governments, have them own it, invest in it and mobilize the political will. A third approach is the people to use the grassroots engagement of the people who are affected by this, some of whom are angry about it, some who are becoming increasingly aware of the disparity, et cetera, sort of the Susan G. Coleman approach to mobilizing grassroots and really engaging people and I think the last lane which I have been thinking a lot about in my current role is the business lane. Employers around the world are really important, women are really important to these employers in terms of keeping their businesses operational and I think that employers have a responsibility just as some of them stepped up for HIV. There's an opportunity here for the business sector to really be a focus of action and to mobilize around this issue on behalf of the productivity and health of the women in the workplace in addition to the moral and ethical approach. So some combination of these, I think is where the conversation needs to occur. None of them are easy and none of them are fast. Have you been able to test that proposition in conversations with other business leaders? I have and I'm very interested in mobilizing women in business. I think that there is some energy around that. We had some conversations with international companies that are working in Japan to get a flavor of what would the appetite be for bringing this issue forward but so far we haven't really found the championship that we're looking for. But it's early days, I'm not done yet. Are there any logical fora? I mean, you've had conversations in the World Economic Forum. I'd love to see this much bigger at Davos. I think this is, as more women, let's hope a lot more women ascend to positions of political responsibility and visibility, I think we will be able to generate more focus and energy around this as well. That's my hope. Simon, did you have thoughts around the business, our angle, the business lane? The thought that strikes me, Stephen, is it's, and I think your points are excellent. I mean, really excellent. I think it's about multi-level leadership. And what I mean by that is we're all responsible to sort of take some ownership to make this happen. There are lots of different tools in the toolbox. I think from the business point of view, as employers of many thousands of people we're obligated to inform and educate, I'll hold my hand up. I came to the vaccination story personally late. So I was one of these, it's not gonna happen to me. I'm living in a pretty safe, secure country. But actually, as I entered this industry, it suddenly dawned on me that I can't afford to take those risks. So I think education through the business context is critically important. But we mentioned again at dinner last night around different sorts of leaders, cultural leaders, social leaders, pop leaders, people who the cohort that we're targeting actually look up to and can aspire to be like. So for me, it's using many different tools in the toolbox, Stephen. It's not one particular preference over another. There are plenty of vehicles in play at the moment. Are we doing enough? Probably not. Could we do more? I'm sure we could. But where are the gaps? What are we not doing? What could we do, which is totally out of left field? And this is a question I'd like to pose. I've had some thoughts about other parties, how they can come and be more involved in that dialogue. How would you navigate the, I mean, there's enough of a, there's an anti-vaccine movement that's out there that takes many different forms and that is alive. That is in the habit of trying to claim conspiracies or self-interested propositions. So yourselves, you're the source of the vaccine. And you're the global leaders, you're globalized. How do you navigate trying to use your special position of leadership in this environment to try to motivate galvanized folks and at the same time, fend off the inevitable tension with an anti-vaccine movement that is gonna tap into sympathetic media to try and turn the tables to make this into a different kind of conversation that avoids discussion of the real issues you're trying to put forward and turns it into something else. I mean, that, it would seem to me, is a complicated impediment to using the power and voice that you have and legitimacy here. And you have to have a pretty sophisticated strategy for dealing with it if you could just say a few words about that. I think though I speak for GSK, I think we're quite a shy business and I mean that in a typically British sort of way. We produce a great product and there's a lot of noise and David referred to this early in the anti-vaccine lobby groups and I looked at the wall behind me when David was talking and I just visualized a rock concert with this entire wall full of amplification and here is the noise from the anti-vaccine lobby and here are the three tables in front of us. This is the noise of the industry as a whole. It's not loud enough. It's being ground out by all the sophisticated technologies as such. So I think that we do need a voice. I think David used a phrase earlier about don't provide the oxygen. I think my fear is this, that if we don't say something, if we don't have a coordinated voice, then the oxygen is getting sucked out of the room and we haven't been to say. So I think we need to respond but we need to respond as an industry, as a group of well-intentioned professionals, not as one business or another business but we need to come together and organize a proper spot. Julie, did you have an answer? It's really a hard problem. It's hard for every vaccine and this one brings some special dimensions to it and we don't have the complete answer. I think what is necessary is the science. We need to demonstrate in a transparent way the benefit of the vaccine as well as the risk of the vaccine and that takes science and we need to use science to understand what is the source of people's concern and confusion in the culturally competent way, as you said earlier. That's necessary but it's not enough. It's not sufficient. The sufficiency is the hardest part and that is reconciling the fact that this isn't really a left brain problem. It's a right brain problem. It's about fear and people's emotions and we scientists and I think we manufacturers try to combat that with data and science and we need that but at the same time we've got to work in a different environment. We got to get our heads around the fact that this is about for an infant vaccine it's about holding your baby on your lap and recognizing that even though you know all the data someone's about to stick a needle in your child's arm and your friend or your neighbor has warned you that this might be dangerous for your child and the feelings that people have about that out of love for their child are completely operating in a different level than in their left brain and I think the same thing goes on across the board with adolescent vaccination as well and then when you add to that sex and cancer you're really raising the emotional content of the vaccination process. So we have to be more humane and more compassionate in our understanding of the source of the problem. We have to be more transparent in sharing what we know and I completely agree with you that we need to also stand strong. These are really good vaccines and they are doing a lot of good and would you rather have an HPV vaccine or cancer chemotherapy? I mean that's basically what this is boiling down to in terms of people's choices. So we need to be part of the positive aspects of the conversation and we are beginning to work on that collectively to the extent that we legally can work in that manner. Thank you. Stephen, you did us all a service in doing this costing exercise and creating a product that gives some very sophisticated I think estimates around these different scenarios and the American Cancer Society deserves a lot of credit for seeing the utility of that and investing in you to do this, but what happens? I mean, this is an important tool. This is a new tool that we have. How do you see it used in this point? Who uses it for what purpose? Yeah, there's a few different ways it could be used. One way to use it is for sort of resource mobilization in the way that the UNA's investment framework estimates for the cost of reaching their HIV strategy is used to mobilize resources for the global fund or for PEPFAR to some extent. I think where that's getting increasingly difficult and I work a little bit in the HIV space is that with the sustainable development goals and so forth, there's such a focus on universal healthcare and integration and so forth and there's less of an appetite, it seems in some circles, for very vertical disease focused priorities and separate funds for separate things and so forth. So I think that becomes a challenge in figuring out how to use this kind of information but the other way it could be used, especially as we move forward and we estimate the benefit side and we estimate the cancer treatment costs averted in certain places, particularly middle income countries where those may be significant in some places. There is a message that could be made to a minister of finance in terms of cost saving or return on investment and so forth. Maybe especially if we add in things, some of the costs to business or the costs related to orphan hoods and lost schooling and so forth. I was just gonna say when 2.6 billion women will die of cervical cancer over the next 10 years, what is that costing us? Yeah. That's another way of doing the math. Right. In this, I mean, 2015 is a very big year in terms of planning for the future and goal setting and mobilizing and focusing interest. You could argue that it creates some special opportunities to move this agenda forward. You could argue that things are gonna get awfully crowded and noisy and it could be more difficult. But how are you looking at this? When you look out over the WHA, the financing meeting in July and in Addis, the G7, which is in Berlin, going to have more health discussions than a normal year. The sustainable development goals coming forward in the fall than as you were referencing. Davos remains an opportunity. What's, how do you see this year? Is it not that much different? Is it a, from your standpoint, from an industry standpoint, is it, you know, are you excited or are you just seeing it as pretty much the same? I'm pretty excited. I am pretty excited. I mean, there is a business side to this conversation, of course, but from the passion and the possibility perspective, I'm excited that health is becoming such an important part of the agenda and that women's health is becoming a very, very important part of the political agenda. And I've been involved in some of the planning for the G7 and I've been kind of on the periphery of looking in some of these other domains. And the fact is that more and more attention is being placed on health and not just because of the cost of health but because of the possibility that good health brings to countries that are evolving and economies that are growing. So I think we're gaining in the opportunity space. That means that it's also going to be more competitive in any specific categorical problem, but we'll have to be innovative and clever about how we bring these things together in efficient ways so that in that we don't end up solving one problem but you can solve this problem but a person dies of HIV that this isn't really a solution. So we've got to integrate at the level of the individual. But I think we're now much better positioned to do that than we were even five years ago because health systems are developing and that gives us the opportunity. Thank you. Simon, did you have anything to add? Yeah, I'm gonna go to the audience. Yeah, I'm excited too, Julie. I think they present wonderful opportunities. I think the opportunity may go by very quickly if we don't see it. I think these events happen, the stars are aligning, whatever phrase we want to use. I'm fearful, fearful because we're talking about HPV in this room. There are other diseases competing for the tax dollar, for the tax power, for the tax euro, whichever currency you wish to choose. So I think the time for action is absolutely now. I think the appetite is now but I'm fearful a week is a long time, as they say in politics. A year can go past very quickly in politics too. So we need to be very cognizant of how we have that conversation and how we mobilize our conversation and our arguments. That's my concern, but I'm optimistic. Why don't we open up to David, we'll start with David and then we'll move over to the central table here and we'll take three or four comments and questions and then we'll come back to our panelists. Yes, David. Thank you. Two brief comments. There was a mention about the science. The science is hugely exciting to the scientists, but if we think that we can communicate about vaccines based on the science, we will not win the communication issue. We lose as soon as we talk about the science. We have to use other, and I think Julia enunciated some of those sorts of considerations that we have to be using to get the moral high ground and the effective high ground. The second point is that we talked earlier today about parallels with polio. And, you know, the first decade at least, following the 1988 World Health Assembly resolution about polio eradication, I used to go around saying, this is the world's best kept secret. And there were no champions apart from Rotary and all credit to Rotary for what they did, but there were no champions. And actually, throughout the polio eradication process, there have been very few champions. And I think that if you want to achieve the sort of impact that we've been talking about, about HPV and preventing cancer, not just cervical cancer, but all the other cancers, we're gonna have to have champions. And somebody has got to step up and be identified, or some people, to be identified with why this needs the investment and what will be achieved. And they've got to be seen to be making those noises. And we have to identify who the champions are if we want to get this running. Thank you. Yeah, I just, I just wanna add something. You joined me, I've mentioned this earlier this morning, but, you know, one person can change the picture. Agnes, the health minister in Rwanda, changed the picture in Rwanda by championing vaccination of those girls. And the fact that that country has 97% coverage is not because, you know, we Americans went in and did it. It's because Agnes championed it and got the political environment to go in that direction and mobilized and, you know, practiced and set the thing up and they were successful. So it's just a power at one person can really make a difference. Yes, good afternoon again. I just wanted to comment on Simon, on collaboration. Collaboration is the most important thing, looking at the big players, the government, the civil society and everybody has to be part of this, like I was at the World Bank IMF Summit last week where we talked about Ebola. It was all about Ebola, it has been about Ebola and so many women have been infected, as he said, if there were men infected in their private, but it would be a news all over the world every day and night that men are infected. But because of the women, we need to get this out there, work with the civil society, the victims themselves to raise their voice on economic forum, on G8, G summit, G20 and all, including the UN. So if we collaborate and work together as a team, I think this can happen. How much money was given for Ebola? That was billions of dollars for Ebola, only awareness. What about the civic or cancer? What about the other cancers and other diseases? So we should look at it and everybody should be a voice of this. For those who are voiceless, the women of victims in refugee camps and everywhere, women needs help and if we don't do it, they'll die and Ebola will end and the cancer is going on because this is a continuation sickness and Ebola, the treatment is there, is gone. What about the cancer is on and going? So that collaboration is assignment, it's very, very important. We need to collaborate to be on the table with the lawmakers, the government and talk about this. Thank you. Can I just respond to that? So I have a phrase that's going around in my mind, why waste a good crisis? And I think the visibility of Ebola was a very visible crisis, clearly in the media everywhere. Cervical cancer is a crisis, but it's not a visible crisis. It's not in the news every day. So I think we need to change our frame of reference that this is a crisis and it's a crisis that will not go away anytime soon. We need to act now, so thank you for your comments. Thank you. Again, I'm Sarah Goldsmith with Cervical Cancer Action. Sally asked me to make a comment because she had to scram. Many of us in the room, I'm looking around Rob, Julie, Dr. Salisbury, we were all involved in a 2006 meeting, which was the first meeting to talk about global access to the HPV vaccine. And we worked together over the last number of years, many of us here, to be the civil society voice. And the next thing that we are gonna tackle is this issue of financing for cervical cancer. And as much as I'm optimistic about the social development goals and the D7 and the World Health Assembly and the ATIS meeting, that's inserting a little flavor of what we need to do. Maybe getting a mention of HPV vaccine access or cervical cancer prevention into those larger documents. But we're organizing a meeting on November 4th in London and we welcome participation of those who are in the room to roll up our sleeves into the community to really create a bigger pie, to invite the Bilaterals, the Gates Foundation, Gavi, everyone together to really talk about how we're gonna finance global prevention for cervical cancer. And Steven's research is the basis for that work. So I just wanted to mention that, Sally asked me to mention that and welcome your engagement in that work as we move forward in the next couple of months. Thank you. Thank you. Thank you. We have a couple of hands over on this side of the room, Ira and... The situation in Japan is terrible. We've been talking about what Asia and others around the world would learn from that. So what's the worst case scenario that other Asian countries and others are going to learn from Japan, assuming Japan can't fix this situation in the next year, two years, three years? Next to you. Yeah, there seems to be some evidence out there that many of the anti-vaccine groups are anti-science or they don't believe in science. They're suspicious of government and they're pretty anti-big business. That's, so that's pretty much this room here, right? And so I'd like to go back to the two people before that commented on civil society. I mean, I don't know if there are any faith groups here, any civil society groups. In the Ebola crisis, the faith groups were extremely helpful in community response to Ebola. So I'd just like to say, are we thinking out of the box in terms of how we're going to win hearts and minds in various places? Shall we take another question or comment over here? Going back to how this is a team effort, I was wondering if thoughts on including boys in promoting the HPV vaccine as in Australia would help de-stigmatize the burden, reduce the burden of stigma on promoting the vaccine. Okay, that's great. Why don't we start with the Iris question around if the Japan case remains unresolved? I think I'm recounting your question correctly. What will the ramifications be if under a worst case scenario in terms of Asia wide implications? Do you have any? I mean, I think the worst case scenario is even more women will die of cervical cancer and even more women will be infertile because they have to have procedures that render them unable to have babies. That's the worst case scenario. And that's already a concern in a country like Japan where there's such low screening rates for cervical cancer, so diagnosis is late. But in many of the other Asian countries, there's a similar, it's not just the lack of immunization coverage, it's also lack of screening and lack of awareness of the high prevalence of the disease. So to me, that would be the worst outcome is that a lot of even more women will die. Do you expect to see if it remains unresolved on the trajectory that the situation is right now in Japan, do you see it having contagion effects increasingly in other marketplaces, other societies within Asia? You're already seeing some of that, but do you see that as galloping forward? That's not, you know, there are pockets of this that pop up from time to time all over the world and we're beginning to understand what are the kind of antecedents that make that sort of more public reaction more common. But we've also seen the pendulum move in the other direction and recently in the US because of the measles outbreak at Disneyland and a few other outbreaks around the country, all of a sudden we're seeing, wait a second, I think maybe we better get our public health hat back on here and really take some effective action. So it's going to probably remain in that state of flux forever. What would your advice be to the leaders in Japan? Maybe you'd like to take that question. No, I'll take it. Well, we have the brain minister here early next week for a state visit in a joint address to joint chambers of Congress. I think the beauty of our Asia is it's not one thing. It's a multiplicity of different cultures, societies, people. So Japan is really important, but is it pivotally important? Perhaps, okay. What I think could happen if a decision isn't reached sooner rather than later, it will delay the positive uptake within the context of Asia. Will it stop countries like Malaysia? Will it stop countries like the Philippines? Will it stop countries like Cambodia? Applying for Gary, no, it won't. I think they're going to continue to do what they need to do. Will a signal from Japan accelerate things? Yes, I think it will. So I think strange bedfellows is the expression that I come up with, but I think that Prime Minister Abe's arrival next week, I think that I was to give in the message was, look, you need now to show some global leadership on a global stage. This is one tool to do that. All the science, all the data, all the evidence points to other issues, not vaccine related. And I think it's time to step up, make the decision, and be very clear about re-recommending the vaccine in Japan. Julie, I'm not sure if you agree with that sort of fourth-party opinion. I would really love it if that would be helpful and would be effective. I think it is really important for all government leaders, particularly the UK and the US leaders, to signal that we're very concerned about the status of the health of the women and that this is from a medical and public health perspective a very unfortunate situation. I'd like to offer our help, et cetera, et cetera. You know, all the diplomatic approaches, but I think that, you know, at the moment, the political leaders have got themselves in a really difficult trap, and they're really not clear at all how to find their way out. I agree. I mean, it's becoming more exceptional, and it's becoming more dangerous in terms of the longevity and the degree of complexity and difficulty in unwinding it. And I don't think a year ago, people were thinking with quite the same level of alarm that you would think today, when you look at a split scientific community, you look at the proliferation of the numbers and the degree to which the situation remains quite stuck. So let's hope that there is some reconsideration at a very senior level of the leadership. There were two very good points made in this last round. One about where's the faith community and is the faith community engaged and how to build in boys as part of this as a strategy for getting to success in terms of higher political investment and commitment and the like. Julie, do you wanna add any thoughts on those two? Those are great interventions. I think that on a global basis, we have not been as inclusive as we should have been in the faith-based community. So that's an area where I just learned something important here, so I really appreciate your question. In the US, I was at the CDC when guardstone serverics were launched. And I remember being impressed with how the faith-based community at the beginning of the launch actually helped a lot as a cancer vaccine. So I think that was overall a successful engagement and something that maybe we need to think more about globally. Thank you. Yeah, so I had the pleasure of working in the Middle East and I recognize the power of the Imam, the spiritual and the faith-based leaders to make an effect real change. We should not ignore those individuals, those type of people. All politics are local. I think all politics is local. It's a very famous phrase. Religion too is local. People look up to their religious leaders, their faith leaders. I think we would be doing our cause a real disservice if we weren't to be inclusive. The conversations are tough. They're really hard. They go on, they go on, and then they go on again. Some you will win and some you won't win, but if you don't have them, you won't win them. So I think from my point of view, being inclusive in the faith community is absolutely critical for this success. We've gotten to the end of a long and rich, and I think a very worthwhile day of discussions. So please join me in thanking our three speakers here today for this closing session, which has given us quite a bit to take away in thinking about where we need to move the agenda next. Thank you so much. Thank you.