 Hello. So we're getting to the final section of our program, which is an address by Rajiv Shah, the administrator of the US Agency for International Development. We're thrilled and honored that the administrator has agreed to come and deliver the closing keynote address here. A few words of thanks. Several people at AID were very, very helpful and instrumental in helping us to make this happen today. Amy Batson, who's here with us today, Nicole Sheig, Cheney Bolton, all of them are here today. We've also, of late, had a terrific interaction with Ariel Pablos-Mendez, the assistant administrator on health who gave a major address at CSIS a week back. And we've had great fortune in interaction with the terrific team that Raj has put together at AID in many different ways, Nancy Lindbergh, Paige Alexander, Susan Reicheld on Steinberg. Today, we're going to hear from the administrator right near the two-year mark in which he joined AID about 10 days before the Haiti earthquake, which plunged him into a major crisis with a huge health component to it. We'll hear his vision around immunizations and vaccines, which under his leadership, AID has really brought this issue forward in a new and much more profound and visible way, which is a terribly important piece of U.S. leadership. And it was for that reason that we were so happy and so eager to ask him to come here today and lay out that vision. He's been in the period of the two years of leading AID. He's been at the forefront of the internal reforms, the USAID forward, the focus on procurement, getting the agency back into science and technology in a new way, putting forward a new monitoring and evaluation framework. It's been an exceedingly busy period as AID has gone through this process of strengthening and renewing itself. And we owe Raj a great deal of gratitude for taking that leadership on and carrying it forward. So please join me in welcoming Rajiv Shah here today. Thank you. Thank you, Stephen. Good afternoon. And thank you for that kind introduction, Stephen. I'm excited to be here and want to congratulate CSIS on the incredible work that you've done to raise visibility for global health for vaccination and not just amongst the community of us that believe in and have believed in and have worked in global health, but in a much broader community of leaders who think about our safety, our security, our prosperity, what drives that around the world and why health, vaccination, and basic progress against the milestones of human dignity are critical to that. So I'm very pleased to be here with you and with everybody here today. I want to thank Admiral Fallon in particular for your strong leadership and for being a visible symbol of how this has become a national security issue and a critical part of how we present ourselves around the world and I enjoyed catching the final words of the panel with Dr. Kochi and Eric and so many good friends and colleagues. I know you've heard a lot today about vaccines and immunizations, so I am not sure I'm going to have a lot new to add, but I am very excited that we at USAID under Ariel Pobles-Mendez and Amy Batson's great leadership are reinvigorating our own commitment to vaccines and immunization and I thought it would help to start by describing a little bit of the history of what brought us here. You know in 1862, this is a photograph of a Confederate hospital in Richmond. Admitted 250 soldiers with smallpox. Almost 45% would die. 110 would die per week. And by the end of World War II, of course, smallpox inside the United States had been almost eradicated, but even in the early 1950s, 150 years after the introduction of a vaccine, an estimated 50 million cases of smallpox occurred in the world each year. This is a photograph of smallpox vaccination in Ethiopia and we all know that under the leadership of many public health heroes like Bill Fahey and others, WHO, CDC, USAID all worked together for 13, 15 years, whatever it took to ensure global success and the world in fact first got the number of cases down significantly and then made that final push in India and other parts of the world going after the most difficult last cases and fully eradicating this disease. It's worth noting there have only been two diseases eradicated in human history. The second one was eradicated in the Horn of Africa over the past 18 months through a large scale livestock vaccination campaign and that was called Render Pest and I don't know how much, you've talked about livestock vaccination today, but I would argue that that also belongs in your thoughts as you consider these issues. This is of course a picture that I'm sure many of you are quite familiar with. Treatment for polio in the 1940s and 50s occupied entire wings of hospitals and as patients struggled inside of these cumbersome and mostly ineffective iron lungs. And you can just tell by the sheer magnitude of what's required on a treatment basis that this was not a sustainable way to eliminate the scourge of polio from the planet. This on the other hand has proven to be and today the focus is on prevention with easily administered vaccines in large contrast from the fears of even 60, 50 years ago where people worried about going to swimming pools and where they might get infected, what would happen to their children if they got infected. Today, global caseload is down to just those last few cases. Year on year, those cases go down or go up but in the grand scheme of history here we're well beyond third base and almost at home plate. It's been 11 months since we saw polio case in India and I know there's been an expansion of cases in certain parts of Pakistan and Afghanistan and they continue to deal with containment challenges in certain parts of Africa and West Africa but nevertheless, we are on the final pieces of this polio eradication struggle and we the United States government, USA, CDC and all of our partners are absolutely committed to seeing this through the way others were committed to see through smallpox and more recently render pest. This is a photograph that needs no introduction. This is in this audience, this is Jim Grant, a charismatic and compelling leader of UNICEF, a someone who carried in his pocket oral rehydration solution in vaccine vials so that he could show world leaders when he had the chance to meet them the simplicity and the ease of the concept he was promoting. A simple concept that with enough leadership and enough focus and a willingness to tackle bureaucracy, you could in fact pursue universal childhood immunization and we saw rates of coverage globally under his leadership increased significantly as a result of that energy and that leadership but we also saw a decline that occurred after the Jim Grant era of immunization in the 1990s. We know that global immunization progress slowed significantly. We know there was a divergence in the vaccine economies of the rich or more developed world and of the much, much, much more populous rest of the world. We chose IPV versus OPV. We chose MMR versus measles vaccines and those programmatic choices across all of these different products resulted in a situation where actually basic supply of vaccine for most of the world, 80 or so percent of the children born every year was pretty tenuous. It was dependent on an erratic and underfunded donor system that sometimes had the money to purchase the next few months of vaccine and sometimes didn't and it was at the verge of falling apart and into that context, the global community came together and created GAVI, the Global Alliance for Vaccines and Immunization and you can see here, if you look at around 2000 when GAVI was created and if you look just at the history of hemophilus influenza B vaccine, you can see this is a vaccine that we had and had rapidly introduced in high income countries from 1985 forward but 15 years later, barely any of this product, 15 years later, was reaching the bulk of the children who by the way, benefit from it much more greatly because we don't have as much child death from HIV here in this country but around the world it was a major cause of mortality for children and GAVI's funding support, the leadership of the global community, the desire once again of the international agencies to break through the bureaucracy and deliver a result did just that and inside of a decade you can just look at the progress of coverage with Hib vaccine. Now that wasn't the only part of the story. This Global Alliance unleashed a lot of creativity, new ways of financing incentives to create new vaccines, advanced purchase commitments and pooled procurement systems, a new way of thinking about global demand in countries that used to be the case that public health experts would estimate the need and then communicate that to manufacturers. Manufacturers would start planning based on that and then the money wouldn't show up because we all know that demand, market demand is not just need, I need a new Apple product every week. It's about having the resources and the will and in my case your wife's permission to purchase that product and moving from need to demand-based planning in countries was a big part of what Gavi had to offer. The result of all that of course is seen in this photograph, a child receiving pneumococcal conjugate vaccine and Orin Levine is here who led the NUMO ADIP, the Accelerated Development and Introduction Plan that had a lot to do with laying the groundwork for why we can today go to communities where children don't have the resources that they deserve and see them receive a vaccine product that we know is highly efficacious at saving their life, probably one of the most important interventions we've developed in decades. And we know that it should get to every kid but because it cost $54 a dose in this country for so long it was just assumed to be out of reach for poor children. Eric Schwartz and I had the chance to travel together to the Dadaab refugee camp at the Kenya-Somali border a few months ago and we walked through and we met these kids that were barely holding on to life after leaving war-torn Somalia suffering from excruciating famine and unbelievable human suffering. They were getting pneumobacs in that camp. That's incredible, you know, that's incredible. It just shows you the progress we can make if we put our mind to it and as the Admiral said, we just make decisions and we get the stuff done. Well, I tell all of that to point out that President Obama has made an absolute unwavering commitment to childhood immunization and to saving child lives around the world. The childhood immunization commitment was a $450 million multi-year pledge we made in London as part of a global effort that raised more than $4 billion to introduce pneumococcus and rotavirus vaccines along with accelerating the uptake of other vaccine products, along with continuing to invest in developing the new vaccines that Tony Fauci spoke to you about this morning, an AIDS vaccine and I know our IAVI colleagues are here today, a malaria vaccine and we're continuing to be proud of what the malaria vaccine initiative and its partners like GSK are accomplishing what they're going to accomplish in the coming months and years as those products increasingly become real and ready for introduction. We know now that these questions that were asked 10 or 15 years ago about are these new vaccines too costly for poor kids are questions we can answer with innovations in financing and procurements and contracting and in management and how we think about global demand and global supply and we will be absolutely committed to making sure as these vaccines become real that we make them available to every child everywhere but our commitment to child mortality will go beyond vaccination because ultimately the goal is to save children's lives and we've had huge success and progress against that goal 70% reduction in child mortality over the last 50 years. In 1990, 12.4 million children died. In 2000, it was 10.8 million. In 2010, 7.6 million and it continues to and we believe will continue to come down so long as we stay focused on achieving great results in saving children's lives where they are preventable. In fact, if we could achieve the OECD average rate of child mortality all around the world we would basically have 1 million child deaths a year. We would be saving 6.5 million additional children's lives every year, everywhere. And so that led us to ask well is that achievable? And we now believe it is. We believe the state of technology, the knowledge of how to deliver these interventions, the data around the value of integrated community health in even very resource poor settings and the insights that have come from real progress in many, many countries make this goal possible. This photograph highlights 24 countries that represent 70% of total global child mortality. We believe in those countries alone we can achieve a 5 million lives saved over five years, over the next five years. And we can do that by focusing on a relatively straightforward package of interventions each of which like vaccination and including vaccination can be linked to very specific reductions in child mortality. It starts of course at birth and at that moment of birth we tend to lose a lot of kids, about a million children right before, during or immediately after birth because they don't have oxygen, birth aphyxia. We've entered a partnership with Lairdahl Corporation and with a number of other partners and have rapidly introduced some new technologies. If you look at this slide, you'll see a very low cost, $18 package of newborn resuscitation technologies. The same package by the way in a hospital in our country here would cost that hospital about $400. But for $18 and we're gonna keep driving this cost down we can provide that package. We can also provide a doll that you see Neo Natalie and train, I had one in the office and was gonna bring it and we said, no, we'll put it on the slide. And we can train a community health worker to help save a child's life from birth aphyxia. Studies have shown we've rolled this out in Bangladesh and actually now it's rapidly taken up in 33 countries as part of this public private partnership. We expect you can see a 30% reduction in birth aphyxia if we can roll this out at significant scale. And that will save hundreds of thousands of lives. But we know that the challenge doesn't stop there. That we have a long way to go to save those 1.7 million lost lives at the moment of birth. So we've instituted a challenge grant program at USAID together with partners, the Gates Foundation, Norway, the UK, others, the World Bank and Canada. And through that effort, we've issued a call for innovations and new ideas that can save lives at birth. The condition of course is the ideas have to be affordable, they have to be practical, they have to become the kind of low hanging fruit that we can actually reap and see real outcomes as they relate to it. And this is a photograph of one of our partners in this program that from William Marsh Rice University have invented a low cost bubble CPAP system, a continuous positive airway pressure system that again would replace a mechanism that costs thousands of dollars here in the United States, do it at far lower cost and then get it out to as many facilities, clinics, points of service, points of care as is possible. I'm so excited about this program because in addition to delivering specific results, it's helping us tap the innovative potential of partners all around the world. We had more than 600 program applicants present new ideas, 30% of them were from the private sector and all of them were winners in many ways. We were able to support 22 in the first round. But achieving 5 million lives saved over five years takes more than focusing exclusively at that point of birth. It also includes saving children's lives from HIV AIDS and in particular, eliminating pediatric AIDS. President Obama a few days ago made a powerful and important statement that we are at the beginning of the end of AIDS. And by doing a number of things together, we can actually begin the decline of that disease and rid ourselves of AIDS entirely. One of those things was a commitment to make sure we get antiretroviral drugs to pregnant women during their pregnancy and before birth. And we know that if we do this effectively, we can prevent the transmission of HIV from mothers to children. And if we hit global targets that the whole world has already agreed to, has already signed up to achieve, we will virtually eliminate pediatric AIDS and in doing so, by reaching 1.5 million pregnant women living with HIV AIDS will save 150,000 child lives a year. This is a photograph of a mother in a clinic, I believe in Kenya, who's come in for testing and for treatment. And we're now through the Global Health Initiative using our HIV clinics around the world to provide this broader package of services and these broader interventions designed to help children and mothers survive. But we still have to do more and we have to help kids get a healthy start. And this is a photograph of a young child receiving a plumpy nut. And I know folks in this room are comfortable or familiar with plumpy nut as a product. One of the big scientific advances in this field over the last 10, 15 years has been recognizing that chronic malnutrition is a serious, serious problem. That children who are stunted or who are small for size and age they might be smiling and they might look vibrant but in fact they've suffered life long and debilitating changes to their brain development that their brains don't grow as much as they should. Their ventricles are larger, they have more fluid, less white and gray matter. That then leads to lower educational attainment and ultimately lower contributions to economic growth and for their societies. One of the solutions to that is to target feeding in the first, in the nine months of pregnancy in the first two years of life, those critical thousand days. And to target those thousand days specifically with high protein, high micronutrient foods that can rapidly improve their nutritional status and enable them to avoid chronic malnutrition at that very crucial period of growth. By refocusing our programs in nutrition in that area we're working in 15 countries where child malnutrition poses the highest risk and we believe this investment will help reduce chronic malnutrition by 30%. Another easy win to put it bluntly is malaria prevention. Perhaps the easiest win we have in the entire suite of tools that we deploy to save children's lives around the world. We've seen in the president's malaria initiative data coming out of more than 15 countries where we've scaled up our investment to provide insecticide treated bed nets for children to sleep under to make sure that when kids get malaria and get the symptoms that they have access to therapies that can actually work to save their lives, ACTs as opposed to older, less effective alternatives. And to conduct prevention activities, education, indoor residual spraying, a basic package of things that can be done easily that have in so many parts of the world including the Great American South helped virtually eliminate malaria in our country, eliminate malaria. I was thrilled to learn when I visited CDC that the reason CDC is in Atlanta is because it was part of our final push against malaria in this country. And that's where the burden of disease was. Well, today the burden of disease is in sub-Saharan Africa. And a few years ago, we noted that a million children under the age of five every year died of malaria. Today, that number is still too high. It's over 700,000. But we know with real validity because we've had rigorous studies that providing this basic package of interventions, country after country, at scale, can reduce all cause child mortality between 20 and 30%. We saw it in Tanzania, we saw it in Zambia, in Rwanda, in Senegal, country after country. And when I meet the leaders of these countries, President Kikwete, first thing he says, thank you for your partnership in malaria because I can go to our hospitals and they have room for patients for other things. I can go to our communities in rural parts of the country and children are surviving and it makes a difference and they value the leadership we've provided. In fact, a friend of mine, Dan Glickman, says he was in rural Tanzania recently. And he said he went into a village and talked to a gentleman there, a tribal elder. The elder came up and said, I have three favorite people in the whole world. He said, oh, who are they? I said, President Clinton, President Bush, President Obama. And Dan came back, called me and said, Raj, there isn't, I don't know if there's anyone in this country who would say those are their three favorite people. But this makes a difference, people value when they get those vaccines, when they get these improved nutrition products, when they sleep under bed nets, when you save children's lives, people value that partnership. And that brings me to my conclusion. That we know that this is the right thing to do. But we also know this is the smart thing to do. That when we save lives around the world, we're helping to usher in a different structure of population growth for economies that need to go through a demographic dividend in order to experience economic growth and development. We've seen that fewer births, we've seen that as child mortality improves, families have fewer births. And as they then have a lower number of dependents, they're able to build up more income and assets per dependent. We know that that then powers the kind of economic growth that we've seen make important contributions to the emergence of Southeast Asian tiger economies over the last 50 years. And we know precisely where those countries that we highlighted as high burden countries for child mortality, those are precisely the countries where we now need to see the demographic dividend take hold and the resulting investment in human capital and economic development take place there. And there's a reason why it's important that the growth and the stability of those countries remains in our national interest. Because when we have trading partners, instead of partners where we have to engage with our military, we are better off. We know that today in Southern Sudan, a young girl is more likely to die in childbirth than she is to complete a secondary education. In precisely an environment where we're engaged to slow the spread or reverse the spread of Islamic extremism and precisely the environment where we know that droughts and other more erratic weather conditions create instability, migration, tremendous suffering and where governments are increasingly democratic but are trying to move in that direction but need continued encouragement to get there successfully. We know in precisely those environments, making these investments now will be one of the keys that unlocks a future of stability and change. And in fact, I was in South Korea just last week where the global development community came together. 2,500 people from around the world. In a country where in the 1960s, they had a lower per capita income than their counterparts in East Africa. And they had a lower per capita food consumption, a higher child malnutrition rate, a higher child death rate, a child mortality under five rate. Today, South Korea is a donor country themselves. We have more jobs in the United States trading with South Korea than we do trading with France and that number is gonna go up because of the president's free trade agreement. So we know that it's in our economic and it's in our national security interest to make the types of investments that keep us going here. But all of what we're talking about, health, food security, water, humanitarian response, diplomatic engagement, all of that is 1% of our federal budget. And today we're engaged in a very serious conversation about whether America can continue to maintain its six decades of leadership in vaccination, in health, in the alleviation of human suffering. And while we know that it's in our interest to do it, while we know that we can afford it, and in fact, we can't afford not to make these investments, I'll just close by saying, I think both Eric and I had this impression when we visited the Dadaab refugee camp, that when you look these children in the eyes and you meet mothers who have held onto their kids and walked for 60, 70, 80 kilometers to get into that camp, and you know that they get there and they get food from the United States of America, they get medical attention from partners we support, they get a NUMA vaccine because of Warren's great work, that's the right thing to do. And when we lead with our values, and when we demonstrate that that's who we are, that just trumps everything else. And that's how we should be engaging around the world. So I wanna thank you for being here today and for taking upon yourself to engage on vaccines and immunization. We will stand with you proudly and we hope you'll be loud and aggressive in trumpeting the need for America to continue with its leadership role as certainly President Obama, Secretary Clinton, and I intend for us to do. Thank you. Thank you so much. Administrator Shah has some time to share now for a further conversation. I'm gonna ask you just one question and then I'd like to open it up to comments and questions from our audience. My question really is about engagement with the Hill because I know that you have been intensively engaged for over a protracted period of time in making the case and understanding the perspectives in the midst of this budgetary difficulty in the midst of a polarized, increasingly polarized situation and one that's full of angst and fear and uncertainty around the future in making the case and finding your way forward and being very methodical and determined in carrying those dialogues forward. And I wanted you to reflect a little bit in this context of talking about the strategic value of vaccines, immunizations, child survival, advancing global health against that backdrop. What have been your reflections around what works in our current environment? Not that we're out of the woods or that there's clarity yet on what the outcomes are gonna look like, but you've spent the better part of this year intensively doing that and we're very grateful to you for having made that commitment because it's so valuable. But if you could just share with us a bit about that. In terms of the communication, in terms of what was that? In terms of the communication and how to make the case and looking at that at the state of our current political environment and the state of our current budgetary crisis, how do you navigate that and how do you make the case and how do you listen and advance an argument in this environment? Well, you know, I'd start by saying that I'm very impressed that on both sides of the aisle and frankly in almost all subsections of both major political parties, there's pretty much unwavering commitment and support to the range of issues that we've discussed. So I find that making the case that this work is important is relatively straightforward. The challenge, and it was best articulated to me by Prime Minister Harper, actually, when he chaired of commission that I had the opportunity to serve on with him and he said there's no other area of public policy that he has to engage on where there's a bigger difference in how the general public perceives the work and the implications for it. What he meant by that is if you can demonstrate that resources in generate real results and you can do that in a valid, transparent, open, business-like manner, the peoples of our countries will rush to support this work. If you don't do that, then they will just assume that the resources are spent poorly, ineffectively, not generating results. He said there's no other area where there's no middle ground and that's why we've launched USAID Forward. It's why I've actually spent more time on procurement reform within my agency and within our development enterprise than any other single issue and it's why we take so seriously the need to be operationally excellent at ensuring that we can take resources, invest them in a business-like manner and generate real results. And I think Gavi is a good example of that. Gavi has built a system that can make an honest case that it does that and it was able to raise in a tough global fiscal environment more than $4 billion to, for the first time, say to every child on the planet, you're gonna get the same vaccines that my son would get when he's born here at Sibley Hospital. And we can continue to have those successes but we have to make the case and we have to demonstrate effectiveness and results around everything we do. May I just look forward into 2012? We're going to have the secretary preside at a summit in early May at NIH on internal child health. We're gonna have the G8 summit in Chicago. We're gonna have AIDS 2012 in July here in Washington, D.C. for the first time on US soil in 22 years. Can you just talk a little bit about 2012 and what these opportunities mean for the agenda that we've been talking about here today in terms of engaging the American public? Well, each of these are important opportunities to raise the visibility of what we're doing. I would urge us all as we think about how to do that to really engage a broad set of partners in both executing this work and in sharing the message with the American people and people around the world. It's very powerful when Mutar Kent and I are able to do something together to demonstrate that our new water partnership with Coca-Cola, for example, is gonna reach hundreds of thousands of villages in Sub-Saharan Africa or it's powerful when Indra Nui of PepsiCo who has announced major investments with our Feed the Future food security program to help reach 30,000 chickpea farmers in Ethiopia to create products that, by the way, are like that plumpy nut product that will go to kids and be a high nutrition, hummus-like product. I think the American people, and we tend to listen, certainly to the experts that have spoken here today and to all of you that have been leading the fight, but we also tend to listen to corporate leaders and to a broad range of faith-based leaders, leaders at universities. This is an all-hands-on-deck effort. I think we have to do a better job of diversifying the voices we rely on to share the message. Thank you. I wanna welcome comments and questions from our audience. Just please put your hand up and we'll bring a microphone to you. There's a hand right there and there's one right here, Amanda. We'll cluster these comments and questions together and then come back to you, Roger, in a moment. Yes, sir. Thank you very much, Dr. Shah, and thank you, Steve, as well. My name is Steve Kuo. I'm the senior advisor of Taiwan to represent our office here in Washington, D.C. And I know Dr. Shah just visited Taiwan last week as part of your trip to Asia's and country like South Korea's. My question is that, could you comment or share with us a little bit about your view about the policy and the mechanism that you wish the USAID could use to sort of encourage countries like Taiwan and South Korea? Those in the past is the recipients of USAID and now is very much willing to feedback to the global communities but not really know how to do that and is there any policy or mechanism that you think that will be kind of useful and how to kind of encourage those countries to partnership with USAID and to do that kind of thing. Thank you. Thank you. Amanda, do you have a... There's a microphone right behind you. Are there other hands up? Yeah, come out here, thank you. So if there are cuts, those are anticipated, does AID have time of protocol for how to protect priorities like global health in the future? Great. Why don't we come back to you now? Okay. We'll see if there are other questions in a moment. Don't you have to take those two? Sure, well, let me start with the first one. You know, you're absolutely right to point out the donor landscape today is so much broader than it used to be and that's why I've been to China, I've been to South Korea, we've gone so many different parts around the world. Brazil, Taiwan to engage new partners to be active partners in taking on these global responsibilities and President Obama and Secretary Clinton in particular have pointed out that these are global challenges and it's in all of our collective interests to make the necessary investments and to share our experiences. Brazil has some amazing experiences at addressing hunger and malnutrition. South Korea has amazing experiences, many of which in a partnership with USAID over 30 years of deepening and expanding its health expertise and its health sector. So many countries today can join multilateral mechanisms like GAVI or the Global Fund or any of the other ones that are demonstrating real results in a way that's relatively efficient for them to do and frankly at the level at which they're able to give and so we've made a major priority out of broadening the global partnership to get this work done. In terms of US assistance and reductions, we of course continue to fight every single day for the President's budget and I would say to you that President Obama in a very difficult budget environment has every single year proposed the world's most robust global health and global development budgets in our country's history and he does it as he reminds me and my colleagues regularly because this is ultimately about who we are and this is a smart down payment on building a safer and more secure future and so we're gonna keep doing everything we can as Stephen points out to get there. Of course, if we're unsuccessful or if there are significant reductions we have a plan to address that and the level of reduction we're talking about is so significant that really everything would unfortunately be on the table. We'll make tough priorities. We've proven that we can make tough choices. We've shut down under my leadership 14 missions, a number of program dozens of programs around the world repositioned our health portfolio and to those places where you get the best results in the highest mortality, the child mortality it's these 24 countries in maternal mortality it's 28 of the highest maternal mortality countries. We're gonna keep making those tough reallocation decisions because that's how you get better results but at some point when you're looking at 20, 30% reductions that it will touch everyone. There are other comments. I wanted to add that over the course of last night and today Pakistan surfaced at many different points, right? At the discussion last night we had around polio it brings us back to the difficulty and the intractability it seems at times of managing polio in Pakistan. We've heard during our discussion around operating in unstable and conflicted settings I know from the strategic US Pakistan strategic dialogue and you've been very involved along with a secretary on that whole prospect of trying to really engineer a different approach on immunizations but we're in a point of crisis right now obviously in the internal condition of Pakistan but in the difficulty of understanding that but also in the bilateral relationships. Can you comment a little bit about how you think about all of these challenges right now because they do keep surfacing as terribly important challenges in front of us from a number of different angles. I know you've been very involved. You're in Pakistan in particular. Yes. Well, Pakistan is, we obviously have a very complex, important and difficult but durable relationship and the challenge from the perspective of those of us in this room that have worked on child mortality and vaccination is that the birth cohort in Pakistan is about 5.4 million children. It's significantly larger in the birth cohort of our country here in the United States. So anytime you think about global child mortality statistics, Pakistan becomes an immediate priority. The backtracking in progress on polio is, as you know, very significant. I think you had the conversation yesterday and it has to do with the ability of effective vaccinators to get access to communities in a trust-based way in some very difficult to access parts of the country near the Afghan border. There are, they also are dealing with a structural change in their government. They've chosen to devolve a lot of administrative authorities from a central government to the states, their provinces. That's the right thing for them to do over time because it is part of their larger constitution and politics and trend towards democratic governance and accountable local governance. But health, it's more challenging in health because they had a very technically capable central ministry of health with some very capable partners and so the state, the provincial departments of health have more variability in their capacity to take these programs forward and we're working through that programmatically in a number of different areas. We've supported 18,000 lady health workers that have had a huge impact at reducing maternal mortality, improving birth spacing, helping to reduce the total fertility rate but all of these things are gonna go through this difficult transition. Well, I think we've got one more hand, Peg. Peg? Thank you. Peg Willingham with United Nations Foundation. Dr. Shah, I wanted to ask you about HPV vaccines. It's something where my understanding is health ministers in developing countries regard that as a high priority. I know you know it's a leading cause of cancer death and yet here in the political environment in Washington advocates sort of quake at the idea of talking about HPV and I wonder how you bridge and send the message that this is what countries want and need versus very different political considerations here. Thank you. Sure. Well, thanks for the question. In the global system, especially through GAVI, the countries have the ability to construct their own priorities to set market demand as I used the term earlier based on their kind of actual plans. The introduction of HPV of course is very different than the introduction of a basic childhood vaccination. So they need a public health and a health system delivery strategy that can support their aspiration to use that product if they have that aspiration. And my, I was pleased that GAVI has begun a very serious process to help countries with the planning and the demand development and then supporting the distribution in an appropriate way as they do that. So there are a lot of questions that have to be asked because it's not gonna be delivered through a traditional childhood immunization system. So you can't just say, okay, we cover 70% of the kids and so here's how much we need and we're ready to roll. It has to be done thoughtfully and methodologically and ultimately countries themselves taking into consideration data and what's best for their populations need to be the ones accountable for making the decisions. I think we've reached the conclusion of our program, Raj. Please join me in thanking the administrator. Thank you. You too, you too.