Gaza's Looming Polio Threat—Gaza: The Human Toll

This transcript is from a CSIS event hosted on August 20, 2024. Watch the full video here.

J. Stephen Morrison: Welcome. Good morning. Good afternoon. Good evening. I’m J. Stephen Morrison, senior vice president here at the Center for Strategic and International Studies, CSIS, based in Washington, D.C., where I direct our global health work.

Today is the 16th episode of the CSIS video livestreamed series Gaza: The Human Toll. It’s a product of the CSIS Bipartisan Alliance for Global Health Security, co-chaired by former Senator Richard Burr and former CDC Director Julie Gerberding. We started this back in November, shortly after the October 7th massacre by Hamas of 1,200 Israelis and the taking of 251 hostages, and the onset of the war that followed that. This series is a collaboration with my colleagues Michelle Strucke, director of the CSIS Humanitarian Agenda; and Jon Alterman, senior vice president and head of the CSIS Middle Eastern Program.

Today’s focus is polio in Gaza. Before I delve into opening remarks there, I want to offer special thanks to my colleagues for putting this production together: Maclane Speer, Eric Ruditskiy, and Qi Yu.

Today’s focus is Gaza and features three leading figures in the accelerated response to the discovery on June 23rd of polio in Gaza, type two vaccine-derived polio, detected in wastewater in seven sites in Deir al-Balah and Khan Younis.

Our speakers include Hamid Jafari, director of polio eradication for the World Health Organization, based in Amman, Jordan; Rik Peeperkorn, the WHO representative for the Occupied Palestinian Territory; and Jean Gough, the special representative for UNICEF for the State of Palestine. Jean, Rik, and Hamid, thank you so much for making time to come back again at this very propitious moment to talk about what is happening in the response.

The first case of polio in Gaza has just been confirmed, a 10-month-old child. This is the first case in 25 years. The situation, as we’ll hear from our guests – our expert guests, it’s a very dangerous situation, and it’s very complicated and very, very difficult in trying to put together a micro plan on how to address this complicated threat. Polio is a particular threat to children under five and especially infants less than two years old. The virus attacks the nervous system, leading to spinal and respiratory paralysis, and can prove fatal.

There is awareness now that the population in Gaza is acutely vulnerable and action is urgently needed. The virus entered Gaza in September and has been likely circulating widely undetected. Surveillance systems and routine vaccination programs collapsed after the onset of war. There’s awareness that the vaccine coverage has declined from 95 percent to below 90 percent. There’s a risk of a major outbreak inside Gaza. There’s a risk of spillover into the surrounding region and beyond.

Circumstances inside Gaza many have explained, and we’ll hear more, are ideal for the spread of polio. The destruction of the health system, shortage of medical supplies, disrupted surveillance, constant displacement, overcrowding, breakdown of sewage and water treatment facilities, and widespread outbreaks of other diseases – diarrheal disease, hepatitis A – and the onset of extreme malnutrition bordering on famine. Action is urgently needed through repeated vaccination campaigns that require a large number of vaccinators, large number of local outreach coordinators, vaccines, and cold chains, and more that we’ll hear about.

And most daunting of all is security, and the active cooperation of both Hamas and the Israeli military and the Israeli government in bringing about the conditions in which these campaigns can be carried out. Last Friday, the U.N. Secretary-General Guterres called for seven day pauses in fighting to allow two rounds of vaccination of 640,000 children under ten. One-point-six million doses have been released from the WHO stockpiles. The secretary-general announced details of the micro plan, which we’ll hear today in our discussions. First campaign to start August 31st, hopefully with a seven-day pause in fighting.

That will be essential. The pause in fighting in the midst of this war is an essential step that’s not yet there. We’ll hear more about that. There is a hope, obviously, that an eventual ceasefire, return of hostages, and exchange of prisoners will be possible, and transition to a new form of governance. However, the companion assumption to that hope is that that may not happen for some time, that the war could – it will quite likely continue for the next period, the period when this urgent action is needed on polio. That urgent action cannot be delayed. This implies the need for intense, sustained diplomacy. We’ll be hearing, I hope, more about that today.

So thank you, Hamid, Rik, and Jean. We’re going to hear from each one of them in sequence, and then we’ll have a conversation. So I’m going to turn first to Hamid Jafari to kick things off. Hamid, great to have you back with us today. Thank you. Over to you.

Hamid Jafari: Thank you, Steve. And I think, just to – perhaps I would go over a little bit of what’s happening epidemiologically, and what’s the response of the Global Polio Education Initiative, the Polio Program, and how we are positioning to – how we are responding to this detection. So just maybe starting – and you’ve mentioned a number of things, Steve, already. The strains that have been detected in Gaza are type two variant polio viruses. And the samples were collected from seven different sites – three in Deir al-Balah governorate and four in Khan Younis, and six of the seven samples were positive from these sites that were in different parts of these governorates.

So, you can already tell that when you have multiple sites that are positive for a strain that is closely related that means that it has been circulating for some time. The genetic signature – we do genomic sequencing on polio viruses – all polio virus isolate, whether from the environment or cases of acute flaccid paralysis or other human samples. The genetics indicated that this virus was very closely related to the variant virus that was circulating in adjoining northern Sinai of Egypt in the second half of 2023. Egypt responded with mass vaccination response with the novel oral polio vaccine type two and this virus has not been seen in Egypt since December of 2023.

Well, just looking at the relatedness of the genomics influence of these strains with what was in Egypt we estimate that the virus could have been imported into Gaza as early as September last year. We can’t be sure, but it could be as early as that, again, shows us that this virus has been circulating in Gaza, you know, for some time.

Why does WHO then assess? So as part of detection of polio virus transmission in any polio-free area the Global Polio Eradication Initiative has standard operating procedures. The GPEI partners work with local authorities. We have done similarly in Gaza. WHO and UNICEF have worked closely with the ministry of health of occupied Palestine territories and other partners like UNRWA that have larger operational presence on the ground to first do a detailed risk assessment as to what is the condition, what is the level of population immunity, what are the conditions for polio virus transmission, what is the status of our ability to track the virus in Gaza.

So as a result of that risk assessment on the surveillance side there are – several activities have been launched: training and sensitization of the health workers, community informants, hospitals, clinics, and such as well as attempts now to restore the – not only this acute flaccid paralysis surveillance but also to restore systematic environmental sampling, or sewage sampling that we call environmental surveillance, for polio virus.

So those efforts are ongoing, and as a result of the sensitization of care providers three cases of acute flaccid paralysis have been detected in a 10-year-old child, in a five-year-old child, and a 10-month-old child. And all of these children while they have been, you know, reported from central parts of Gaza are actually those that have been displaced from Rafah. They’re related – they’re coming from populations that have been displaced from Rafah into these areas.

You know, routine immunization coverage in Gaza was very, very high, around 99 percent, with the inactivated polio virus vaccine and the oral bivalent oral polio virus vaccine that does not include the type two component that would – the oral vaccine does not have type two represented in this, but the inactivated polio vaccine does.

So the coverage was very, very high in Gaza before the start of the war. It has now declined to around 86, 87 percent, and, obviously, the cohort that has been most affected, and this is the youngest cohort – children under one year of age – and given the duration of the disruption of immunization services, and so it is not surprising that amongst these three cases of acute flaccid paralysis that have been investigated there’s two samples tested in the Jordan national polio virus laboratory, which is also a WHO-accredited laboratory. A type two polio virus has been detected. We are still awaiting sequencing – genomic sequencing results of that virus.

But it is not surprising because the immunization of the youngest group is disrupted, and this is – in that 10-month-old – detection of virus in the 10-month-old.

On the immunization side, obviously, there are efforts to restore and improve routine immunization. But we know from our experience in so many places that we have to implement at least two large-scale vaccination campaigns with the novel oral polio vaccine type two that achieves high levels of coverage to stop transmission. That’s where things went wrong in Egypt, for example. They mounted a very good national response, but they missed some children in Sinai Peninsula, and this virus is very – is very unforgiving. It finds unimmunized and vulnerable children, and that’s what happened, that this virus emerged out of north Sinai in Egypt.

So the principles for stopping this outbreak are that we have to respond as quickly as possible; achieve, you know, a very high level of coverage, at least more than 90 percent or 95 percent ideally; and all children vaccinated, target children, in a short period of time. That’s very important.

And so because I think both for epidemiological and operational reasons it’s necessary to vaccinate this large proportion of children simultaneously, that’s why in many places it’s called pulse polio vaccination campaign. What the pulse does is that it induces mucosal immunity among all children in a short period of time. So suddenly a barrier – immunological barrier is created for further transmission in the country or in the – in the geography of interest. And that’s what we are looking at in Gaza, to try and implement a campaign over a seven-day period that covers all children under 10 years of age and that would start in 31st of August, and then to repeat that, you know, four weeks later in late September with the – with the second round. The more we compromise on the quality and gaps in implementation, the more likely that this outbreak will continue; it will cost more, both in terms of paralytic polio, financial cost; and all the efforts it takes to mobilize a campaign like this in such a setting of conflict and, of course, the coordination with the – making sure that the enabling environment is in place so that the vaccinators can move, vaccine and logistics can move, and most importantly families can bring their children for vaccination to the vaccination site.

My final comment is that ideally, we do campaigns house to house, which is, of course, not feasible in the setting of Gaza. So this will be a combination of fixed-site campaigns in health facilities, in pharmacies, in schools, in shelters; and then a community mobile-outreach element of mobile teams going and vaccinating children in communities. So the level of security and ease of movement that is necessary for a successful campaign is very, very important.

So I’ll stop here, and back to you, Steve.

Dr. Morrison: Thank you, Hamid.

I’m going to turn to Rik Peeperkorn to speak next. Rik, I hope you can also share with us some insights into this micro-planning process that’s been underway and what is in store in terms of the guts of this campaign. But you’ve come prepared to share some other thoughts, too.

Over to you.

Richard Peeperkorn: Thank you very much, Stephen, and good to see Hamid and Jean online.

So let me first focus a bit on polio, and then I also want to go back to the overall health situation in which this is – has developed and which we should pay attention to, too, as well.

So first of all, I think Hamid is quite really very well the background and how GPEI works, et cetera. And I think it’s important for us to realize when there is a polio event like that, like I guess what happened in Gaza, other mechanisms – global mechanisms kick in. And I think the polio program and the global program of polio eradication is probably one of the – one of the best programs, I mean, which we have – public-health programs, and the way it works and the way it assists any health authority and WHO and UNICEF at a country to help mitigate this.

Now, I want to say something about the roles. I mean, it’s within – so WHO and UNICEF are the two agencies which assist the health authorities with implementation support on the ground. And, yes, we do more or less everything together, hand in hand, but we have specific roles. I mean, Jean will – I’m sure she will discuss a little bit about the vaccines and the cold chain, et cetera. WHO is trying to convene and – convening and coordinating and leading on surveillance, on the monitoring, and in management of the campaigns, including any type of micro-planning. You do that, of course, with the Ministry of Health, with UNICEF, with UNRWA in this case, with all the key partners. Now, that’s – and it’s all about the micro-planning, as you rightly said. And in this case, it’s a special strategy. We talk about 392 big sites and outreach, a campaign setting – 295 mobile teams and 21 special teams, enormous. So total number of teams is 708.

We talk about flexible implementation, a special strategy based on access, geographic stratification, a five-day campaign plus two days what we call mobile. So there’s robust micro-planning done, exercised by municipality, et cetera. And there is a coordinated approach. There is an emergency operation already established – the WHO is in Deir al-Balah – for all the parties. We talk about human resources for this campaign; 2,700 people – health workers, volunteers, RIVO monitors needed for this vaccination campaign. We need to pay them incentives. I will get back to that as well. Vehicle hire – vehicles, motorbikes, et cetera, tuk-tuks. Social mobilization teams. And then, of course, the fuel and everything around that.

The social mobilization and risk communication, together with UNICEF, is incredibly important, and everything has to be linked to each other. I’m sure, Stephen and all of you, you have seen the joint WHO and UNICEF statements last Friday, and which was followed, I think, with a very clear statement from the secretary-general. And I want to actually focus a little bit about that, because what are now the key requirements for a potentially successful campaign in these incredibly complex circumstances?

Well, first, of course, that we have to ensure that the vaccine’s cold chain – (inaudible) – get into Gaza. Jean will tell more about that. But we also have to ensure that sufficient amount of cash enters Gaza to make sure that these volunteers, the health workers, et cetera, can do their work. We have to make sure that fuel is there in sufficient amounts; the entry of additional polio technical experts when it is needed. Critically important: A humanitarian pause – and I think the secretary-general also stressed that – for seven days over two rounds to allow these 2,700 health workers and volunteers to vaccinate the 640,000 children, each round. And the restored – we need telecommunication for effective communication, logistics, et cetera, and safe, sustained access within Gaza.

Now the issue is – and Hamid described that – we cannot compromise on these. These are what we call the needs and the requirements for a successful campaign. And why are we so focused on this? Because we need – we need to cover – we need to cover at least 90, preferably 95, percent of the children. Otherwise, we will not stop this transmission. The transmission will continue in Gaza, but there is also a high risk that this transmission will spread outside Gaza to neighboring countries. So we all want to make sure, I think, and all parties want to make sure that we prevent this.

I want to say also I’m mildly – I’m not optimistic; I’m mildly positive. First of all, Gaza used to have a very good EPI program, routine immunization. There’s high vaccination, et cetera. We, in our discussions with all parties, have said people seem to understand what the key needs are. We are ready, WHO and UNICEF. We need to get everything into Gaza, et cetera. We are ready to roll.

Now, my last point, I want to say something about the overall situation we are in. And I think the overall – and we should not – never forget that. The overall situation in health. We should talk about the hospital functionality, like 16 out of the 36 hospitals partly functional. Fifty-four of the 127 primary health-care centers partly functional. Eight out of the 10 field hospitals partly functional. And just to give you some examples, European Gaza Hospital, as you know, remains out of service since the 1st of July. Non-functional hospitals in Rafah for 10 consecutive weeks. Just yesterday, 19th of August, in the north of Gaza there’s currently a need for fuel for hospital. The director of Al-Awda Hospital, Dr. Mohamed Saleh, announced that all surgery operations had to be postponed because there was a lack of fuel. The same applies for Kamal Adwan Hospital, where there’s acute shortages.

We have not been able to reach the north since the 11th of August. And even PRCS is reaching out to us – that is, ambulances, emergency medical clinics, relief. It’s our risk to be housed in northern Gaza, due to the lack of fuel. This is in an environment where we also see a spread of diseases. We talk about more than almost one in 5,000 hepatitis A – reported hepatitis A cases, diarrheal diseases, et cetera. And those are underreported. Water and sanitation situation I’m sure Jean will address, et cetera. So we cannot – we have to – we need this focused polio campaign. We need it as quickly and planned as possible. And we may have to make sure that all the key needs are addressed.

Thank you. Over to you.

Dr. Morrison: Thank you very much, Rik. It’s quite impressive how much you’ve been able to rally the full support – fulsome support of the secretary-general around this proposition that there is no room for compromise and there needs to be this unified effort, in the way that you’ve described it.

Jean Gough, UNICEF special rep. Jean, thank you for making time to be with us. Share with us your thoughts.

Jean Gough: Thank you, Steve. Thank you, Rik and Hamid, for these important elements. In my brief presentation, I will focus on UNICEF’s role and the efforts in this vaccination campaign. Namely, the procurement of supplies of the vaccine as well as risk communication and community engagement for vaccine acceptance.

As you heard before, the director-general of WHO has approved 1.6 million doses of vaccine. UNICEF’s role is to try to get them into Gaza. This has not been easy for the last two weeks because of the closure and disruption of the air traffic around Israel. So that has been a challenge that we have been facing. But we finally got them over. And we expect the international shipment of vaccines and other immunization supplies to be arriving in Tel Aviv. The first charter will arrive tomorrow, the 21st. And this will bring in the freezers that we need urgently to restore the cold chain. And they will also – on the 22nd we will get the vaccine and the vaccine carrier.

So, as you can see, this is a really push to get these things in as quick as possible. And we expect them to be in Gaza either the 25th or the 26th. So we are coordinating the efforts to make them in. Once they arrive in the Gaza Strip, we will take these vaccines to the cold storage that we have. And this is also managed by UNICEF. It’s also in Deir al-Balah, because the ones existing was not able to be operated. We have lost that cold chain. So we established a new cold chain to make sure that the vaccines for routine immunization and for the polio campaign could be safe and secure.

We also will use 11 health facilities that we will put these refrigerators that will come in, and make sure that we have capacity for the cold chain to be in – the vaccines will be distributed there to the vaccination centers. So we are going to push the vaccines out to the different centers that will be there. There are several challenges, that you heard from Rik. Sixteen out of 36 hospitals in the Gaza Strip are partially functioning. And 54 out of the 127 primary health cares are partially functioning. So the health system in general is not up to the level for this massive operation that needs to take place.

So we have – also there are security consequences of the conflict. I think the security will have a great impact on this campaign. The health workers needs to move around. We need to be able to move around the vaccines, the vaccine carriers, in this massive operation. And there are areas that we have limited access in the Gaza Strip. So all of this, and the continued displacement of population, are challenges for the – for this operation. The cold chain, currently we have less than 25 percent of the entire cold chain capacity still functioning in the Gaza Strip. So this is why it’s urgent that we bring in new cold chain to make possible this campaign and continue the routine immunization services.

Then, again, as we heard, there’s no reliable power supply. That means that we need to also get generators, and we need to get fuel to run these generators. All of this poses significant issues to maintain the continuity of the cold chain.

The objective of the risk communication and community engagement is twofold. One, to encourage the demand for polio vaccine by families in the Gaza Strip, which has been high in the past but maybe the de-mobility of the population with all the destruction could pose an issue. And number two, to raise awareness of the prevention and mitigation of the risk of infections and making sure the families knows where to go to get this service. This will be done through a series of social mobilization and interpersonal communication activities before the campaign – is ongoing now – during the campaign. And this will be supplemented by outreach to families done through a variety of mixed-media interventions such as digital. We’ll also do mass radio. We will try to get printed media. And I think the most important one is going house to house – or we call it tent to tent – to make sure that the families are really aware this is happening and the importance of this to each and every family. In order to do this, we are also doing a rapid assessment to identify what are the social and behavioral aspects of families, particularly to identify any barriers that will interfere with a successful polio vaccination.

I think we have many actors that helping us with all of this. UNICEF is only one of these partners. The Ministry of Health, UNRWA, WHO, the NGOs, I think they have all a big role to play. And the Palestinian NGOs are also playing a big role to mobilize the community and make sure that they’re all mobilized around this effort.

To conclude, I want to reiterate the critical importance that all parties are ensuring that this campaign can be rolled out in a safe, unimpeded manner; the absolute need to have safe access to distribute the vaccine to more than 640,000 children below the age of 10 wherever they are in Gaza. The best way to make this happen is to ensure the campaign is taking place during humanitarian ceasefires, or the so-called days of tranquility, or a temporary pause in fighting. If this is not implemented, it could have disastrous consequences for children not only in Gaza, but for the region.

So thank you, and back to you, Steve.

Dr. Morrison: Thank you. Thank you, Jean, Rik, Hamid.

I’m really struck by the level of ambition of what you’ve painted here and the urgency and shortage of time. And as I understand it, not yet agreement on the essential element around a pause – a cessation of fighting. I mean, you’re talking about reaching 640,000 under 10 of age children. You’re talking about deploying 2,700 health-care workers, 708 teams, 1.6 million – I mean, these numbers, these are – this is very, very impressive and ambitious, replacing a woefully damaged cold chain with new machinery and fuel and support, providing the power. In the meantime, we know that there’s a larger negotiation process that is underway and with conflicting accounts of what – where that – what its prospects are, and the war is raging in a pretty intense level which is oftentimes what happens as you get into the endgame of negotiations; you see a spike of violence. So it’s becoming more violent and insecure, not less, in this particular period. And of course, the threat looms of Iranian and Hezbollah response to the assassination of Haniyeh and the killing of the Hezbollah official in Beirut.

So it’s a very sort of bare-knuckle situation that you’re describing here, and the we-can’t-compromise line, I think, is a very powerful one. Maybe I could ask you: What is the status of discussions with both Hamas and Israel? How far onboard are they? And what is the status of those negotiations around the security provisions, the pause in fighting in particular? I expect you’ve already won agreement from the Israelis to move material – various materials in but maybe you could clarify where the negotiations stand with both parties and then what needs to happen in the 11 days between today and the first campaign. You can’t move those 2,700 in on August 30th. You’ve got to move immediately in terms of winning a commitment on this pause in fighting.

Maybe, Jean, you could share with us a little bit, and then Rik and Hamid.

Ms. Gough: Well, this is one of our tasks now. I think we are all trying to work around the clock to make sure that these people – that we continue the discussion. Yesterday, we were having discussions with COGAT and different levels with the minister of health in Ramallah, the minister of health of Israel, the local on the ground, to make sure that we all try to understand the complexity, and I think getting all of us at the same level of discussion.

And I think yesterday we had a good discussion in terms of sharing what has been shared before with the – with the Israelis, with the COGAT. And I think we have – this discussion needs to continue, and we need to have a decision when is the closing date so we can move forward. And I think this one, making sure once we get the vaccine in, the campaign is on, because we are already moving with these investments.

So I think we have some levels of agreement. This level of discussion needs to continue. We are also requesting the member states to come to the table and support this big effort. It is not only seen as the U.N., but also the member states have a stake into all of these things that is happening.

So I think the discussion is ongoing and we still – as Rik said, we have hope that we will reach good agreements and be able to take this massive – because the consequences of not doing is too high. So I think this is what takes us to make – to move forward, is the consequences of not doing nothing.

Dr. Morrison: So, Jean, what I hear you –

Ms. Gough: And I think the consequences would be high.

Dr. Morrison: You know, Jean, what I hear you saying is the 25th and 26th when the vaccines are moving across into Israel along with the cold chain equipment that’s sort of the drop-dead date by which you need to have. If you’re going to stick to the August 31st campaign start time you’ve got to have resolution on the pause by then.

So you’ve got a few days left until early next week in order to get the pieces in place. Is that accurate?

Ms. Gough: Here the colleagues, we need to have a timeline. And I think – I see Hamid wants to come in –

Dr. Morrison: Yes.

Ms. Gough: But I think that’s where we are moving, because the vaccine is coming. And once you have the vaccine, there’s no turning back. So I think this is part of all of this negotiation that we need to put on the table and push the machinery and see how we also adjust the work.

Over.

Dr. Morrison: Thank you. Thank you.

Hamid?

Dr. Jafari: Yeah, just a couple of points, I think, first, to say that it appears from all the indications and discussions we’ve had at multiple levels that there is a lot of interest all over to getting this done. Nobody wants this outbreak to continue and to get out of hand and then spread into Israel, into West Bank, and into surrounding countries.

Nobody is interested in that from happening and I think one detects that, you know, a number of member states – you know, governments are interested in promoting that this should happen and I think the authorities – all authorities at the local level are also interested in finding solutions and ways to make this happen, to which I also find encouraging, as Rik mentioned.

The second point I want to make is that I think the discussion is at a point, and Rik will probably expand on this, is that as a program we have very clearly defined what needs to happen for this outbreak to stop, both technically, epidemiologically, operationally what would it look like and what actually, even given the level of destruction and loss of health workers and others, what could still be done to stop this outbreak and then what are the prerequisites in terms of cessation of hostilities and all of that.

So that has been very clearly laid out and so I think that’s where we are right now. Now I think it is up to the various, you know, parties to kind of look at that and then say what of it can be met, what of it cannot be met, what are the flexibilities and all of that, will there be further negotiations.

But I think this has been very clearly laid out. In order to stop the outbreak one, two, three, four needs to happen, right, and so – and I think in terms of timeline I think we have the timeline that Jean described. It may be that the other parties say, we need more – we need some more time to put that enabling environment into place, and just as we had to wait for the logistics to get in we may have to wait, perhaps, for all the other planning to happen so that the campaign can go forward when there is trust and confidence all around for it to move forward because we have to give the health workers and the communities the trust and the confidence that they can come out and get their children vaccinated.

Thanks.

Dr. Morrison: Hamid, is it true that – I mean, when I’m listening to all of you underlying your arguments is, I think, the belief that there’s something exceptional about polio as a threat, as a global problem, and as – I think, as Rik pointed out, the GPEI has been in force since 1988. It’s showed dramatic progress in the last 15 years. It’s close to the finish line and this is a – this would represent a massive setback and a dangerous phenomenon for the entire region if not more.

So maybe you could say something about this exceptionalism. Is that –

Dr. Jafari: Public health emergency of international concern under the IHR. And it is a very big deal for a country that is polio free and detects poliovirus circulation in their borders.

They have to declare a public health emergency, they have to start vaccinating their travelers, and then the whole thing you talked about that – you know, remember 2022 when a similar strain of polio virus was detected in New York and a case of paralytic polio happened in New York and in the London sewage.

So I think this clearly gets a lot of attention of all countries, given the stage of polio eradication and how it sets back country at a stage of polio eradication, and how it sets back countries and regions when the polio virus outbreak gets out of – out of control.

But I think the flip side of the coin is that it shines a light on what is happening in health and what is happening to communities in the setting of a polio outbreak, that it is much, much larger than a polio outbreak.

So I think if we can get to a point where there are corridors of peace, if there could be negotiated sort of cessation of hostilities, then it does create, you know, platforms for delivery of essential humanitarian because if people can stop fighting for polio they can stop fighting for many very, very important things also in health and humanitarian needs.

Dr. Morrison: Thank you, Hamid.

Rik, your thoughts?

Dr. Peeperkorn: Yeah. I want to add a little bit on what Jean and I think Hamid rightly described.

I think there is an exception and a lesson about it, and that is – as you rightly described, that’s not because of me or Hamid or Jean or something; it’s about the world. There’s a World Health Assembly. There’s a WHO. There’s a World Health Assembly. And this is a public health event of international concern.

So all member states, territories, et cetera, will adhere to that, and they will all do their level best to ensure that this polio virus will not – well, that we stop the transmission within Gaza, but also that we prevent a transmission outside Gaza to neighboring countries and areas. And I think that makes the need exceptional.

Now, secondly, you asked, like, so how far, then, are you. And I think the key partners – WHO, UNICEF, Ministry of Health, and key health partners – they have been busy with this and focused the moment this environmental sample was reported. We focused on that with all. So all partners are very much informed and onboard. We constantly also inform member states, et cetera, and all parties. And we have, as Jean described – only last Saturday, Jean and myself had a very good meeting with the minister of health in Ramallah, where we – you know. So we are very clear about what is needed and – what is needed, which we described today with you as well.

We had a very good meeting yesterday, again. I mean, that’s one of the many meetings with COGAT, CLA, Ministry of Health Israel. And we want more meetings with them. But what we – and I think you asked, so what can we then do in this crisis and in everything around? So, yeah, we have to remain full and whole access, and we have to act and react as evidence informed as possible. And that’s what we are doing. That’s what we are – when we mentioned key needs, key requirements, key asks, whatever you call it, they’re based on experience from the GPEI since 1988. There’s many, unfortunately, outbreaks still for cVDPV. And we have two outbreaks from the wild poliovirus in Afghanistan and Pakistan. We know how to deal with that. We also know how to deal with that in conflict settings. This is what we described. This is the key needs. And I would expect and hope that all parties are saying, like, hey, yeah, we have to work accordingly.

And that is, I think, one of the most important things, is that – we always discuss, can you do this differently, can you do this staggered, et cetera. No. You want to make sure that you reach 90-plus percent of the children, so you want to do it in the best way possible. And that comes to two times five-plus-two days at all these places we describe very precisely in the – in the micro-planning. So, yeah, I have good hope that this will happen.

And I might say – add something other maybe even more ambitious than this. So, you know, they always – Hamid said in another meeting, we should not let this crisis within a crisis go to waste. So it shows not only attention, again, on health and everything else, but also, we are already working – WHO and partners – to strengthen surveillance. That was why these three samples were quickly brought to Jordan. But also, together with UNICEF and all parties, how do we strengthen routine immunization in this – in this chaos, in this – in this crisis? And we will do that. If this works well, this campaign, what can we do about micronutrients and everything related to that, and have a focused approach?

And then, of course, last one please, how can we really then also work on strengthening in a much more substantial way primary health care, referral, and referral care? And as Hamid says, not just health, many other key areas and key sectors will come into play as well. If we can do this for polio, we can do this for other areas as well. But, yes, there is sort of an exceptionalism on polio. That is not because of us here discussing this topic; this is because member states demanded this as part of the Health Assembly. It’s a – it’s a global agreement, and we should, indeed, continue to focus on that.

Over to you.

Dr. Morrison: Thank you. I expect – I get your point that this crisis may create opportunity to have a broader understanding and a broader strategy with respect to the very challenging set of health problems that are in front of Gaza. I also would expect that as – if your campaign goes forward, like many other campaigns, the public expectations are going to rise. In other words, you have an urgent mission to get out there and get to 95 percent vaccination of those 640,000 under 10. But simply going into the community with someone, people are going to say that’s great but we also have this, this, this, and this urgent requirement, and you can’t just walk in the door and turn away and then we return to war in a few days. It’s going to be a difficult predicament, it seems to me, morally and operationally in managing expectations in this – in this crisis setting. Maybe you could say a few words about how to manage that, because it’s inevitable. I’m sure you’re already facing that.

Jean, your thoughts?

Ms. Gough: Yeah. Just wanted to come in here because I think this has been something that UNICEF has been trying to push. As you know, water and sanitation, hygiene products – having soap and stuff – on the ground is something that we want to push.

I think in this first round we all agree that maybe it’s not the best interest because we are testing the waters, but for the next round we will definitely have additional things to provide, especially so cleaning materials that are very essential and a high – a scarce commodity in Gaza. So I think that’s something that we have under procurement. We’ve taken it to Gaza now. And that would be ready to go for the next round that will be at the end of September if everything goes well.

And I think this is something that we want to do more of, because we have access to children. As you know, malnutrition is a big issue, and we want to strengthen that in more micronutrients, vitamin A, and see if we could put that into this. So this first round will be a learning for all of us, and I think this is a good opportunity for us to strengthen.

I also wanted to add that we have a good concentration – this is what gives me hope – concentration of people living in a very small area. So you have 1.9 million people that are maybe more accessible than others, and that gives us hope that around those areas ceasefire, some days of tranquility, I think reaching people is not so difficult. I worked in Nigeria in reaching people when they were in the last end of polio eradication. It was not easy because they were very remote. I think here we have the issue of a big group and area that gives us our strengths and gives us challenges. So I have hope because of that. And the areas that we have high risk, we’ll have to control that as well and be alert to make sure that we reach each and every child, as I said. So that’s another thing that we need to look at and make sure that – if a ceasefire comes, I also know we will – that will also bring its own challenge, because if a ceasefire comes before the campaign the expectation is that people will move. What we are planning for today will be not as useful when we have mobility of people. So I think everything has its challenge and advantage, and so we are keeping all those open to make sure that we are all prepared.

Over.

Dr. Morrison: I assume that you are – you have to be thinking and planning for different scenarios, and there’s a probability – you know, there is a significant risk here that things get delayed or you can’t get resolution on the cessation – the temporary cessation of fighting. What is your message to the decision-makers in Gaza and in Israel about how much time there really is to continue to delay and negotiate? And what is your – what picture do you paint of if there is an indefinite stall in getting to campaign, when do we begin to see a major outbreak in this – in these circumstances? Are we able to paint that sort of picture of if we don’t get A, B, and C, this is what you’re going to face? And how can you – can you lay that out in simple terms here?

Hamid?

Dr. Jafari: Yes. I mean, I think this is what we have been – we are saying, that this transmission in the absence of immunization will continue to intensify over this – you know, we are in the middle of our high – summer months of high transmission season, and we’ve already now had the first case of paralytic polio detected and reported. And if we don’t start vaccinating, I am afraid we will see more children paralyzed in Gaza.

And then, of course, the risk of spread to Israel, to West Bank, back into Egypt, in Lebanon and Syria, where immunization systems – I mean, in Lebanon they’re in a decline. In Syria, they’re in a post-conflict situation. So this risk is truly beyond Gaza, and it will spread. And I again mentioned about, you know, the detection of this virus in New York and in London in 2022. So it – this virus travels if it is not – if it is not – if it is not controlled.

So in some ways, we are already late, Steve. I mean, we have already failed a child. I mean, this child is paralyzed. And so we should have started – I mean, we should have, first of all, detected this much sooner, but the surveillance system was disrupted. But then when we have detected, we are now, you know, getting ready to – we are basically almost there to start vaccinating. So I don’t think we can delay any further. The risks will continue to increase for further spread and further cases of paralytic polio.

Dr. Morrison: Rik, your thoughts?

Dr. Peeperkorn: Well, I think in addition to Hamid and Jean, I want to react a little bit – add something on what Jean said and what you said about expectation.

First of all, Stephen, we – you know, now also very much nothing is easy in Gaza, and that’s probably the understatement of the year. I mean, like, so, of course, we constantly think about other scenarios, and what to do, and how to do it. We don’t do that only for polio; we do have a need for the most simplest mission to bring medical supplies, fuel, emergency medical teams, et cetera, and how to organize that. I mean, we constantly are there.

I would say that if any – if any group has been – shown enormous resilience, it’s the Gaza health workers. I mean, like – and also in adapting and adapting under incredibly difficult circumstances, which we would do the planning of this campaign with them, including the humanitarian teams from WHO, UNICEF, UNRWA, and the whole lot. So will we have other hurdles? Will we have other obstructions? Yes, of course we will have that. It will not be smooth ride. We will constantly have to adapt and reorder, et cetera. We can only do this. We have to make clear to everyone what we say, evidence-informed, what are our key requirements for this. And we hope people will listen and listen carefully to that, and will address and will help to facilitate that process. If that’s not happening, of course, we will do everything to protect and to move forward and see how we then can manage.

On the community and the community expectations, I completely agree with you. So that makes polio always difficult – it's exceptionalism, as you rightly described. I mean, put down by the world, and rightly so, that we are on track of eradication. So we can’t afford nowhere that suddenly the viruses pop up again and spread. And as Hamid knows much better than me, that goes much more rapid than we – than we think. So all of us have an obligation – member states, states have an obligation, territories – everyone has an obligation to that.

Now, we have to communicate this in very simple terms and clear. Jean relayed to risk communication, the communication. We do this together. And we have to be very – everything is aligned. We have to be very clear how we communicate that to the population – the families, the mothers, the fathers, et cetera – in Gaza and elsewhere. Positive part of it in Gaza and West Bank, vaccination acceptance has been always very high, et cetera, so people get that.

Now, will there be more expectations? There are already enormous expectations, but there’s mainly an enormous sense of disappointment among Gazans in the – in the international world. I mean, like, they feel incredibly let down, and for many, many reasons, and understandably so. And somehow all of this we have to get, how can we improve not only health, but also many other of the – of the key humanitarian services – within food security, within wash, within shelter, et cetera, et cetera. And we will continue to focus that.

I think we have to be honest with communities. And we will be in our risk communication, as good as possible how we address that. And whenever we see an opportunity, a lesson learned, or we hope to plan to carry out, we will take that and we will – we will – as Jean said, we will – if the first round goes relatively smooth, maybe we can adapt something for the second round, or already start doing different things differently, et cetera, with the communities, with the health workers on the ground in Gaza, with the humanitarian partners present. And I think this is how we have to – how we have to approach it.

I think it’s different, of course, in countries where UNICEF campaigns already for years and years and years. This is exceptional. We plan two campaigns. And we want to do – we want to do well. We all know what it – what it takes to stop the transmission: 90 to 95 percent of these children vaccinated as soon as possible. So that’s what we should focus on.

Over to you.

Dr. Morrison: Thank you.

We’re getting towards the end of our hour. This has been a remarkable – a remarkable conversation. And it’s so impressive what you have put together – the scope, and the complexity, and the ambition, and the urgency of what you’re trying to do. You really have done a remarkable job in a very short period of time of pulling this together. And I think everyone who’s watching this is going to watch very carefully with hope that this – that the pieces are put in place, and there’s not massive delays, and that you’re able to get that first campaign completed safely and effectively and prove that, even with war raging, that the parties are willing to come around to this vision that you’ve laid down.

Maybe I could ask you to close, and start with Jean and work our way – Jean, Rik, and Hamid. Just what – I mean, you’ve delivered some very strong messages, I think, to our audience about what needs to happen, and why, and what the plan is. Is there a bigger message you want to leave to a Washington audience about thinking about this particular moment in the – in the war and then the response? Jean.

Ms. Gough: I think just in Palestine they have been free – polio free 25 years. We cannot afford to get polio back in. And I think our commitment is to how do we continue to strengthen routine immunization, focus on those newborns. And I think it’s not only about water – is not only about vaccine, but it’s also about water. It’s about sanitation. It is improving the wellbeing of all kids. And I think it’s not one thing, it’s a combination of all of this coming together that will make a big difference.

So we count on your support to really advocate at the highest level with member states to let’s get this campaign done, and get it done well. So count on us that we will put all our energy and planning behind this. We are going into Gaza. I go tomorrow and will stay there until the campaign is over to make sure that we are all supporting the efforts that’s done locally. So we will continue this struggle, because it cannot – we cannot fail. And I think this what gives me the strength every day. Thank you.

Dr. Morrison: Thank you, Jean.

Rik, your thoughts? What message do you want to leave with our audience here?

Dr. Peeperkorn: Well, I think – I think Jean worded it very well. I mean, let me say it in my words. If this polio response can lead and can help to create an environment, a humanitarian pause – whatever you call – and we’ll be leading – I mean, leading, hopefully, or part of a of a wider ceasefire arrangement, and finally leading to a sustained ceasefire and peace, I would be more than happy. And I think if we all can focus on what we have to complete in this task, of course we have to look at the broader aspects. And we, of course, are rightfully obsessed with health, but there’s much more, as we know and we discussed. I mean, all the other areas – wash, food security, economic development, et cetera, and education. So when this leads to something bigger – I think it can lead to something bigger. That’s my hope.

And maybe my second point is Jean said – so I also plan to go to Gaza. So maybe the next show, Steve, or the next discussion we could both have from Gaza, and hopefully then with you and Jean and Hamid, and hopefully with some – well, some positive news that we are actually in the middle of a campaign which is really focused, and which really works. And of course, first see, then believe. This will not be easy, right, et cetera. But we are ready to take a challenge, and we expect that we will be supported all by all partners.

That’s it for me.

Dr. Morrison: Thank you, Rik.

Hamid, I’m turning to you for the – for the last word here today.

Dr. Jafari: So, Steve, as you know, that I’ve been in polio eradication for 30 years now. And for me, polio eradication is a metaphor. It’s the polio virus is actually a yardstick for us as to how we behave as human beings. When eradication is all about equity, you have to reach everybody. If you miss some people, you will fail. It’s about absolute zero. Secondly, eradication has also taught us that when human beings come together with a collective resolve, they can do impossible things. And we have demonstrated that in so many other areas of the world, to be able to stop polio through everybody coming together and doing that. And thirdly, the reverse is true. When we bicker and disagree, this virus is very smart. It comes and measures us, and puts us in our place, and embarrasses us.

So for me, this is where we are. This virus is again asking us these questions. What kind of people are we? Are we able to come together? Can we do this, or we can’t do it? This virus is measuring us again as human beings. Thanks, Steve.

Dr. Morrison: Thank you.

We will be posting the video of our conversation today on the CSIS homepage, CSIS.org. In a couple of hours we’ll post a transcript of that, that you can access. And we will be continuing to follow this topic closely. And we will take up Rik, Jean, and Hamid’s suggestions that we stay with this as the first campaign begins. And I just want to thank the three of you for your courage and for your commitment, and the remarkable effort that we’re seeing emerge at this moment. It’s rather inspiring. And I just want to thank you on behalf of those who are watching this closely and concerned to see that these humanitarian and health crises get reversed somehow in this period. So thank you. And we’re adjourned.

 (END.)