TORGHELE: It is May 23rd, 2018. I am at the Centers for Disease Control and
Prevention [CDC] with Dr. Terence [L.] Chorba, who is the Branch Chief of
Tuberculosis Elimination at CDC. I'm Karen Torghele and I'll be interviewing Dr.
Chorba today. So first, I want to say welcome Dr. Chorba and thank you for
agreeing to participate in the Global Health Chronicles Oral History of Polio Project.
CHORBA: Thank you, Karen.
TORGHELE: So first, let us get started with a little bit about your background
and how you came to go into medicine maybe and how you wound up at the CDC in
the first place.
CHORBA: Well, my entry to medicine was a long walkabout. I was not a pre-med in
college. My dad was a surgeon who had had a full career, had me fairly late in
life, and he had--he was Hungarian, born in America. All his brothers and
1:00sisters were born back in Hungary. And he felt that medicine was becoming too
socialized and that the government would eventually tell doctors what they could
and couldn't do, so he discouraged both me and my brother from actually becoming
doctors. But since his practice, he had a family practice as well in the home,
it was hard not to grow up seeing and being part of a small part of the medical
machine. And so, to make a long story short, I was a psychology major in
college, wound up because it was the years of the Vietnam conflict, I wound up
being an enlisted man in the Navy for two years after graduating from college.
And then, wound up going off to Oxford [University] and got a degree there in
2:00physiology and turned around and came back to the States because I, by that
point in time, had got the medical bug and realized this is what I really should
be doing. I went to medical school up in Buffalo [New York] and became an
internist-- did my training at George Washington [University]. And then came to
CDC at the dawn of the AIDS [acquired immune deficiency syndrome] epidemic. I
came in 1983, at a time when we--the clinical entity of AIDS had been
recognized, but we still did not have our hands on what the causative agent was.
And I had actually done a year of a heme/onc [hematology-oncology] fellowship
and so I wound up working in what was then called the Division of Host Factors,
which was in the Center for Infectious Diseases. [Dr.] Bruce [L.] Evatt was the
3:00Director. In Host Factors was the interface between hematology and infectious
diseases, so I wound up working on hemophilia-associated AIDS for the couple of
years that I was an EIS [Epidemic Intelligence Service] Officer, but really
never let go for a long time after, because there were data that needed to be
analyzed and got back out to the hemophiliac community. So, I think that the
last paper that I wound up writing on hemophilia-associated AIDS in conjunction
with Bruce Evatt was probably in 2001. So, I had a probably an 18-year run in
hemophilia-associated AIDS, although by then I had gone on to do many other
things, including the topic that brought us here today, which is working on
polio issues in Soviet Central Asia.
TORGHELE: So how did you find out about CDC and that you wanted to work here?
CHORBA: I was an intern when I was at the University of Wisconsin, and I was
very depressed one morning after having been up all night the night before, and
I was sitting there in a funk in the cafeteria with [Dr.] Dennis [G.] Maki, who
had been trained up at CDC, but was one of the giants in the field of hospital
infections and of bacterial organisms, particularly gram negatives [bacteria].
5:00Dennis was one of the attendings [staff physician] in infectious diseases-- he
sat down there at the table with me and said, "you look under the weather.' And
I explained to him that I really was concerned that I didn't--that I felt that I
was--this was in the days before there were hospitalists-- had there been the
concept of a hospitalist, I would've been that at the time, but in those days,
people were expected to go and have a clinic practice and it just didn't grab my
soul. And he said, "well listen, what you really should do is you need to go to
CDC," and he told me all about CDC and that was an inspiration to me, so that
years later, I--probably three years later, wound up making my application to
CDC, to the EIS [Epidemic Intelligence Service] Program.
TORGHELE: Very serendipitous.
CHORBA: Yes, it was. It was, but life is like that. You sit down and have
breakfast with someone and your life takes a whole 'nother direction.
TORGHELE: What were your EIS years spent doing?
CHORBA: Well, I did hemophilia-associated AIDS and then, the Virology Division
got called several times by a hematologist up in Cleveland [Ohio]. His name was
[Dr.] Peter F. Coccia. Peter was Head of Hematology at Rainbow Babies and
Children's Hospital and he had--he was working on his 12th patient to come in
the door with acute aplastic crisis. The African American population in
Cleveland lived, in those days (and I have not followed the demographics of
7:00Cleveland since then but) in the main, East of the [Cuyahoga] river. So, on the
Eastside of the river, among the children who had sickle cell disease, this
once in a lifetime event was happening. It's a life-threatening event, and by
then, we knew that the cause of acute aplastic crisis was an infection of the
early red cell precursor by human parvovirus B19. West of the river where you
had the Italian, Irish and Polish populations, you didn't see aplastic crisis
happening because you didn't have children with hereditary hemolytic anemia.
There was one kid West of the river who did have an aplastic crisis who was a
8:00child with hereditary spherocytosis [hereditary hemolytic anemia]. But West of
the river, in the white population, you had a raging epidemic of erythema
infectiosum-- it's a benign childhood rash, fifth disease, slapped cheek rash.
And there was evidence that slapped cheek rash was probably caused by human
parvovirus B19 as well. And so, this was the first time though that we had
outbreaks of both [disease entities] identified in the same geographic region.
Up until then, the fifth disease outbreaks that had been described had been in
9:00London, in white populations in London. And the outbreaks of acute aplastic
crisis in sicklers [patients with sickle cell anemia] had been in Jamaica-- two
very different populations. And so here, the two diseases--the two clinical
presentations happening at the same time in the same geographic region-- was
stellar. I wound up getting on an airplane with Bruce Evatt giving me a bunch of
papers. I got on an airplane and was told when you get off the airplane, you're
one the world's experts on parvovirus. And I did. Of course, Bruce was very
interested in parvovirus because it was the--it's life-threatening--he was at
the interface of hematology and infectious diseases-- Bruce was a hematologist.
So I get off the airplane and realize that this was a once in a lifetime
opportunity. And I wound up coming back to CDC, I'm forgetting now, maybe 4
or 5, maybe 6 weeks later, some number of weeks later, with 840 blood specimens.
We wound up working up, not just the cases, but we developed--from the same
population of Peter Coccia's population, we had controls so we could demonstrate
the presence of the virus in the cases and not in the controls. And we did the
same for erythema infectiosum, that we could demonstrate the presence of the
antibodies in the cases and not in the controls. By the time you get fifth
11:00disease, a child with a normal hematologic compartment will not manifest the
same extreme symptoms that a child with an acute aplastic crisis will because
the red cell in a child with a normal hematologic compartment will last 120
days. And if you infect that red cell with--if you shut down the child's bone
marrow for ten days, the child will drop from a hematocrit, which is that percent
of blood that's occupied by red cells, will drop from a hematocrit of 45,
ten percent, let's say down to 41, and won't know the difference. But a child who's a
sickle cell child who's normally got a hematocrit of perhaps 24, and you turn
12:00off his bone marrow for ten days when his red cells only last for 20 days, you'll
drop from [a hematocrit of] 24 to 12. It's a life-threatening event and that
child will probably need to be transfused, very different clinical picture. And
so anyway, we wound up--I wound up spending the next year after that, of course,
working actually with your own husband, [Dr.] Larry [J.] Anderson, who was in
viral diseases in the laboratory, working with Larry and cobbling together, and
actually with a number of other people-- we got Yale University involved, [Dr.]
Peter Tattersall at Yale University, we got [Dr.] Neal [S.] Young at National
Institutes of Health involved, [Dr. Philip P.] Mortimer at the University of
London, and so we wound up having a lead article in Journal of Infectious
13:00Diseases, thirteen pages long with about probably as many as authors on the
paper as well. I had a fantastic run for my EIS two years.
TORGHELE: It sounds like it. And when did you start getting involved in polio?
CHORBA: Well, I didn't get started--I wound up then spending a couple of years
up in North Carolina at Chapel Hill as a preventive medicine resident for the
first year. And the second year I went to UNC [University of North Carolina]
Chapel Hill and got a Master's in Public Health and Epidemiology. I blundered
into the Highway Safety Research Center, wound up working on vehicular injury
then for the next several years at the dawn of when we went from being a
14:00Division of Injury Prevention to being the National Center for Injury Prevention
and Control at that interface. And then, wound up having a bit of a mid-life
crisis because I really, really wanted to get out--a young family and we wanted
to get them to have the opportunity to live overseas, and suddenly, [Dr. J.]
Lyle Conrad appears on the scene with an interagency agreement. It was called a
PASA and I forget what PASA [Participating Agency Service Agreement] stood for,
but it was an interagency agreement for me to be seconded to USAID [U.S. Agency
for International Development]. One of us was seconded to USAID in Georgia to
work in Georgia and Armenia, and one of us was seconded to Kazakhstan to work
15:00on, under USAID, to work in the five Soviet Central countries, Kazakhstan,
Kyrgyzstan, Uzbekistan, Turkmenistan, and Tajikistan.
Going out the door on that assignment, [Dr. Walter R.] Walt Dowdle cornered me,
and he and [Dr.] Olen [M.] Kew had identified a small pot of money that could be
used for helping to ascertain first of all, if there were cases of poliovirus
happening out in Soviet Central Asia--they were reporting some. And help to
16:00ascertain whether or not--if they were indeed bona fide cases of poliovirus or
not, and if not, then it could get the region declared poliovirus free so that
WHO's [World Health Organization] dollars could be--or Euros or whatever they
were then, could be spent more judiciously elsewhere, and efforts could then be
directed elsewhere because, in all of public health, it's an issue of opportunity
cost-- the choice to spend money on one thing is a choice not to have that money
to spend on something else.
TORGHELE: So, Lyle Conrad got you involved in this to start with?
CHORBA: He got me involved-- I said, "Lyle, what am I supposed to do out there?"
He said, "Do good things." What happened was the Soviet Union broke up in
17:00December of 1991 and when the break up came, these fifteen different republics
didn't have trade agreements with each other. And we, the Western world, had
always been kept out of Central Asia, but the United States Government was the
very first government to recognize Kazakhstan as being independent. Of course,
sure, there was a wedge that we wanted to stick in there because the concerns of
the Soviet Union. This was seen as a great opportunity for the Soviet Union to
be--to put an end to the concept of the Soviet Union. And so, [Ambassador
18:00William H.]Will Courtney, who was an economist working for the State Department,
became the first ambassador to Kazakhstan. Will Courtney did more for public
health than anyone I've ever known, although history probably won't remember him
that way. But he had, he was Bill Courtney, his son was Will Courtney. Bill
Courtney was the ambassador, what he did was he eventually denuclearized
Kazakhstan and that was huge. We're talking, they had something like 104 nuclear
warheads, and he not only got Kazakhstan to denuclearize itself, but the
19:00remaining fissionable nuclear material was in Fort Leonard Wood before the press
would even know--or in Fort Knox, Kentucky, before the press even knew that that
was planned. He was brilliant. But anyway, so Bill Courtney, I remember meeting
with Bill Courtney the first couple days, and I told him, well, I had some
infectious diseases background, I was an internist by training and I was out
there to work on good things. The people who worked on immunizations back in the
States said that we should be working, doing some work on poliovirus. We also
though, needed to do the very basics to figure out how they did infectious
This was a case of low-hanging fruit. The infectious diseases surveillance
systems throughout the former Soviet Union were made from a cookie-cutter.
Moscow was the hub-- they had designed systems that evolved over the years from
the--there are three levels in Soviet countries and in Russia, it's the
Republican--well they call it Republican but it's the federated--level, the
equivalent to our national system, and that then dictates what happens at the
oblasts. The oblasts are the equivalent to states in a given republic, and then
21:00the next layer down was the raions. So, at the raion level, the oblast level,
and the federal level, the system was all very structured and that was repeated
in each and every republic, so that if you knew the system in Kazakhstan, you
knew how things were constructed with the least bit of change whatsoever, in
Uzbekistan. And if you knew it in Uzbekistan, you knew how things would be in
Turkmenistan, Tajikistan, and Kyrgyzstan. And the information flow was similar to
the information flow that we have in this country, of county level data going
to the state level, and the state level data then be transmitted to the federal
level, only it was all done with a pen and a piece of paper. And you will
22:00remember that historically, and it was totally true, if things looked bad
anywhere along the way, you could be punished or fired. So, the surveillance
data were doctored and for any organism, depending upon who was responsible. And
so we all would have liked to--in those days we were just--we had just evolved
ourselves to an electronic reporting system, National Notifiable Diseases
Surveillance System, back in the late '80s, remember working on it and going
up from CDC to Pennsylvania in 1988 working on it. So, they were dragging in
23:00terms of where they were in time, but they had had the same issues of having to
do things with a pen and a piece of paper. And so, I took that opportunity then
to--I said to the ambassador, there's a ton of computers back at CDC, as
computers were rapidly developing, that are--we were still operating in a DOS
[Disk Operating System] environment, that were in--that were lying fallow. And
so I got CDC to upgrade them, tons of computers back here and hundreds of
computers. We got them over the next two and half, three years, shipped out to
Central Asia and to help them adopt computerization of their reporting systems.
24:00At the time, realize I'm rambling here, but at the time, nothing worked. And
you had to look for efficiencies because there was no money-- they never had
budgets before. I remember sitting down with [Ambassador] Courtney and sorting
out that Kazakhstan's Ministry of Health had the equivalent to twenty-four
dollars per year, per person, for all of health care, soup to nuts. And
Kyrgyzstan had about nine dollars, and Tajikistan had less than three dollars.
And they had no idea how to do budgets, they had never had to do budgets before.
In the old days, if you had an immunization campaign, you said to Moscow,
"Moscow, I need 100,000 syringes," and that request would have passed up through
several levels of bureaucracy, and six months later, you'd get half the syringes
you asked for and everyone was happy. So, you always knew to ask for more than
you needed, but it wasn't--it was not a dollar-based or a ruble-based budgeting
system. Now with the break-up, people had a fixed number of rubles or zlotys or
tenge or whatever denomination of coinage to deal with, and that was it. And
they had no idea they had--so out there at the time there was a group from--it
26:00was Battelle Institute and it was--that group out there was headed up by a
physician economist, an American, named [Dr.] Michael Borowitz. And Borowitz
tried very hard with each of these republics to get them to understand the
concept of cost-effectiveness, which you know, in medicine, we have the ethics
of beneficence, justice, respect, and non-maleficence that grew out of the
Belmont Report that we think of as being the cardinal ethics. But in public
health there is a small family of other ethical principles and one of the
27:00cornerstones, I think one of the two cornerstones in public health, is
cost-effectiveness, and that is (again) the choice to spend money on one thing
is a choice not to have that money to spend on something else. So, as part of
trying to identify cost efficiencies, if you could computerize a system where
there are many people who are simply copying little numbers with their pens, you
could then free those people up to do other--engage in other activities in the
health care system. It was also a time, though, when they realized that there
were issues in the cold chain that out there in the steps of Central Asia, if
you needed to maintain something, either frozen or refrigerated and getting it
28:00from point A to point B was difficult. Gas was a dear commodity-- Kazakhstan is
oil-rich now, but that didn't happen until--that started around the end of 1996
when the Canadians started extracting oil. And today Kazakhstan is an oil-rich
country, but in Central Asia, there was nothing [at that time] that was
produced, there were no factories that the rest of the world depended upon for
anything. So, there was nothing that they could export for income, so the
situation was dire. So, I think that Walt Dowdle felt very strongly that, as
29:00things were as bad as they were, we should strive (insofar as immunizations had,
under the Soviet rule, happened systematically), that we should strive to take
advantage of the amount of herd immunity that was out there. We should strive to
do national immunization days to play catch-up. We worked out there to make sure
that things were refrigerated in a way that the product would be active, that
the immune response would be--that one would have an immune response to the
30:00vaccine as opposed to simply putting something in someone's arm that no longer
was of use-- and also, using the oral polio vaccine, same story, across Central Asia.
So we had National Immunization Days in Kazakhstan and in Kyrgyzstan and in
Uzbekistan. I wound up working with each of the respective persons equivalent to
the state epidemiologist, who was the person who would have then the say-so over
huge aspects of those National Immunization Days. And also, he [the state
epidemiologist] would have the say-so over our putting acute flaccid paralysis
31:00into the required national notifiable diseases surveillance system. So we got
acute flaccid paralysis made a reportable phenomenon in Kazakhstan and
Uzbekistan, and then in the other--the three lesser 'Stans. The other incredible
opportunity we had was that [Dr.] Galina Lipskaya from Moscow, Moscow--I can't
remember what number of hospital it was, Hospital 1 or Hospital 3, she for
32:00years had come here to CDC on sabbatical for 3 to 4 months a year working in the
poliovirus labs. And she was out there and would happily do work for WHO there.
For us, if there was work and if she felt it was worthwhile, and I assume the
first conversations were between Walt Dowdle and Olen Kew and Galina Lipskaya.
But then, when I was working with Bruce Ross, who was a Public Health Advisor
who was--we were a Mutt and Jeff team in terms of getting the CDC's office up
there up and running, that Bruce chased Galina down and we got Galina to agree
33:00to come down to Kazakhstan. She came down and evaluated things in Kazakhstan and
then we were able to describe to Walt Dowdle exactly what we would need in terms
of the equipment, and he figured it was all within budget. We came up with a
list of equipment including the refrigerators and the laminar flow hood, et
cetera, and all the plastic ware and the like, and the media that would be
needed to help beef up the laboratory in Kazakhstan. There was a poliovirus
34:00laboratory in Almaty. Almaty at the time was the capital of Kazakhstan. In
Almaty, there was a laboratory, and the laboratory had been the hub for work in
Central Asia back under Soviet rule, but things needed to be renovated and
improved on. We were able to get materials to Kazakhstan. Galina also then
identified someone in Uzbekistan who should come up and review things in
Kazakhstan, and then see to it that--and then I remember being with Galina in
35:00Tashkent and she evaluated their situation as well.
So, to make a long story short, we developed a laboratory in Kazakhstan, for
Kazakhstan and Kyrgyzstan. Bishkek, the capital of Kyrgyzstan, is about three
hours away from Almaty. Kyrgyzstan is a relatively small country. And then we
developed another laboratory in Uzbekistan to serve Uzbekistan, Turkmenistan,
and Tajikistan. Uzbekistan was a much more populous country-- Tajikistan and
Turkmenistan were more difficult environments in which to work. Tajikistan had a
civil war that happened at the end of the--when the break-up [of the Soviet
Union] came, and it was still very tense, and so, it made all the sense in the
36:00world to have a more centrally located, in between Tajikistan and Turkmenistan,
have Uzbekistan be the other laboratory that we would beef up. When I think back
on it, I'd love history to remember, [Dr.] Diloram Tursunova, who was the Deputy
State Epidemiologist in Uzbekistan, [Dr. Gulnur Kimbabanova] in Kazakhstan same
story, and Gulnur eventually became, I think, the epidemiologist for the
entirety of Kazakhstan. The third person was [Dr.] Ludmila Rozhkova in
37:00Kyrgyzstan and all three of them were incredibly helpful behind the scenes in
seeing to it that we, the CDC efforts, in Central Asia should succeed.
TORGHELE: That's quite a story. Now, your role was different from Galina's role.
CHORBA: Oh, very. So, Galina was a laboratorian. To tell you the truth, I was
flying by the seat of my pants. I knew scant little about polio -what I had
been taught in medical school, what I had heard in EIS presentations. But my job
was more, I saw it as being, a programmatic one, [it] was to see to it that
we got acute flaccid paralysis to be a reportable disease. That we got the
systems computerized. We didn't get all the way down to the raion level except
38:00in, I think, in Fergana Oblast in Uzbekistan and in Almaty Oblast in Kazakhstan;
we actually got computerization so that you would enter the data at the raion
level, it would pass up to the oblast level as individual patient data. So that
it wasn't just aggregate numbers that they would be getting. They would be
getting the entire record and then that would then pass to the federal level.
I'm sure that's what happens now, but back then it was--even paper itself, paper
was a fungible commodity. If you had a ream of paper that you had originally
gotten from Moscow, you held onto that because you knew you could trade that for
39:00anything else that you might need for your laboratory or for your offices. And
so, you would find these little stashes of paper, so even for the fact that
things were done with a pencil and a piece of paper, paper was a dear commodity.
TORGHELE: And what about other things that you ran up against? What were some of
the problems that affected your work?
CHORBA: Well, I think the overall-- the 900-pound gorilla in the room was the
fact that people didn't know how to deal with this American presence because up
until then, we had been this mean beast from the West. And here, we were there
standing there, you know, with our arms around people and they at once were
thrilled, but they were also very suspicious. How bad was it? Well, there was
40:00the other agency happening behind the scenes of their security systems. And so,
if Bruce Ross--Bruce actually demonstrated to me elegantly one day together we
had--[Story interrupted here for a remembrance of three more people; story
picked up again after a few lines below]. There were two people who also
were--no, three people who were employees of USAID, foreign service nationals of
USAID, who were wonderful in helping us out.
I'd like history to remember them as well. Gulbanu Altynbaeva, Gulbanu
helped--she's a Kazak lady now married to an American out there in Almaty,
Kazakhstan, but she helped us get that office up and running when we first got
41:00there. Gulshan Muratbaeva and Indira Aitmagambetova. Gulshan and Indira still
work for CDC out in Almaty, Kazakhstan. In a totally different incarnation, last
summer I went out there under my tuberculosis aegis to see what the panel
physicians who clear people to come to the United States on long-term visas,
what [it is that] they do--to help get an appreciation of how they work out
therefor clearing people to come to the United States. We're actually rewriting
now the TB [tuberculosis] Technical Instructions for panel physicians, and part
of my--my going out there was to understand what works and what doesn't work so
42:00that the technical instructions can--I can influence the writing of the
technical instructions. Actually, I went out there with the person who is
the chief author of the rewriting of the TB Technical Instructions, Joanna Regan.
But anyway, I'm getting sidetracked here. So those three ladies were incredibly
helpful to us in getting the office up and running. But Gulbanu was sitting
there one day with Bruce Ross and Bruce demonstrated to me that if you said the
word, if we were on the phone with Tajikistan (and at the time they were having
the world's all-time largest ever outbreak of typhoid in Dushanbe because of
43:00the--that's a whole other story--of issues to do with their sewage and their
water system). But Bruce demonstrated that if you said the word "typhoid" or
"cholera" while on the phone with Tajikistan, the phone would go dead. So you
knew that you were being watched. And frankly, inside the Embassy, we all knew
that if we walked out the door of the Embassy, we knew which window we were
being watched from. And so we were being monitored by an invisible security
force out there. And at times, when we would have specimens that we felt would
44:00be merited to be shipped somewhere, there were a lot of hoops that we would have
to jump through to make sure that the right signatures and stamps were achieved
ahead of time, permissions and people talked to, so that--it was not like
walking into your local FedEx office or your local DHL [Dalsey Hillblom Lynn
Worldwide express] and having something shipped or UPS [United Parcel Service].
It was a very--it made for--sometimes we would actually, we would just have to
be very creative about how to try to achieve getting things to the correct
laboratory in order to push on with the work.
Or, just getting the materials, the way that the materials came out there to
Central Asia that Bruce and I and Galina wound up assembling in the laboratory
in Almaty and in Tashkent, if I recall correctly, we actually had them come
through the diplomatic pouch. That is, that they got shipped from here [CDC] to
the Embassy under the diplomatic aegis so that in a timely fashion we could then
have them in our hands to then turn over to the respective countries to
assemble. Well, we would help in the assembly as well.
TORGHELE: How did you deal with the language problem?
CHORBA: I wound up, well, we all took Russian lessons and both Bruce and I were
able to survive in the marketplace in Russian. But Gulbanu and Gulshan would
serve as, at once, our coworkers and our interpreters. I did get to the point
where when we would give presentations, we could present things in English and
they would be translated into Russian. And if something was obviously being left
out or were said or the sentence was not given completely, I would be able to
catch what was missing and fill in the dots. And so, it was fun. It was strange
47:00at times because, in Central Asia, Russian is spoken by--almost everyone knew
Russian. In the Soviet Union, 80 plus percent of people, despite the fact there
were 15 different republics, learned Russian. But our comrades there, our
country partners, they would quickly devolve, when meeting each other to talk,
either into Kazak or Kyrgyz or Uzbek. And the Kazaks, Kyrgyz, and Uzbeks all
understand each other because they are really speaking Turkic languages from the
days when this was part of the Ottoman Empire. So, I would think that, although
48:00I don't speak either Kazakh or Uzbek, it's my impression that the difference
between Kazakh and Uzbek is probably how the differences between my speaking
here and someone who is from London would sound.
TORGHELE: Probably just an accent.
CHORBA: Accent and then I'm sure there's some idioms and word terms that are
different. And when we would go out, I would, I remember begging them to please
stay in Russian when we would be having a social setting, and that would happen
for about two minutes and they'd be back into their speaking [in a Turkic
language]. Even if there was a Kazakh, a Kyrgyz, and an Uzbek at the table,
49:00they'd be speaking in their respective tongues and understanding each other.
TORGHELE: And Galina helped with their interpretation, too, didn't she?
CHORBA: Well Galina certainly helped at a much higher level because she was
coming with the authority of Moscow and there was still a tremendous respect
given to what Moscow said. The term in Russian is так и будет [tak y
budet]," thus it is and thus it shall be". They looked to Moscow for guidance for
approval, and so Galina coming down from Moscow I think had, even if we had an
50:00American who was fluent in Russian show up on the scene saying this is the way
you do it, it wasn't the right time. Moscow was still very much the authority
so, Galina put us way downfield in terms of getting to our goal by just showing
up with all the respect and knowledge, the way to put things in the right
parlance that would be accepted as the way to go.
TORGHELE: I wondered too about some of the other cultural things you must have
run into when you were trying to get projects done and work done there. For
CHORBA: Well actually, that was huge--bribery was--I gave you that figure of
twenty-four dollars per year, per person, for all of healthcare, soup to nuts in
Kazakhstan. People, nonetheless, would have their appendixes taken out and their
babies delivered and the like. And the way the system supported itself was
physicians were paid scant little, and if you needed a procedure, there would be
a cash transaction that would happen, and you could call it a bribe or you could
call fee-for-service. But, in every sector, in every level of the economy, it
was like that. So when we showed up, there was an expectation that many people
52:00had that there would somehow be financial rewards for engaging in whatever,
whether it was immunizations we were dealing with, or trying to get something
turned into a reportable disease, or we were trying to--we actually did other
work besides poliovirus-- we worked on tuberculosis issues, we worked on
childhood diarrheal disease and acute respiratory illness in children, changing
the definition of a live birth so that they would really get an appreciation of
where they stood relative to the rest of the world. And when we worked on those
issues, we worked on malaria in Tajikistan, and typhoid, as I mentioned. There
53:00was this expectation that money would follow. The only money that we had to
follow was-- we could provide them with-- we could improve upon their
laboratories, their work situation. We, I think, eleven times here [at CDC] got
people from Russia and from the other republics to the United States, sat them
here in a classroom at CDC, probably about twenty-five people at a clip. Lyle
Conrad was the grandmaster of this and we would get them here to then talk to
them about what we do. We'd do a week here, and then they'd go off to a state or
a local health department or do two weeks here, and then they'd go off to a
54:00state or a local health department, and then they'd come back for a week. They'd
go back so that they would have had a month of a per diem that was a huge bit.
So we became an attractive group to cooperate with. The republican (the federal)
state epidemiologist and then his or her lieutenants would wind up coming here.
And the state epidemiologist, the people from laboratory, people who were chief
pediatricians and the like, they would wind up coming here and being trained up
and have that week that they'd go off to state health departments; Lyle put all
55:00those pieces in place.
So, they'd go to North Carolina, they'd go to South Carolina, they'd go to
Virginia and then they'd wind up coming back to here [CDC] and then exchanging
their ideas and seeing just how, getting an appreciation for efficiencies,
getting an appreciation for the fact that it made no sense to hospitalize people
who had syphilis or gonorrhea or hepatitis A, which in the former Soviet Union,
those were hospitalizable disease entities. And the result was just a much
better understanding that they needed to join the rest of the world in their
56:00approaches to diagnosis, treatment, and prevention of disease and surveillance.
So, the other issue though, while you're on the topic, so we never paid bribes
for government work there. I personally, in order to get my youngest into a
daycare center, did that sort of thing. There was no getting in otherwise. It
was just, it was an odd existence to be living. The other issue though that we
dealt with was the issue of показухa [pokazuha] in Russian. It's
57:00"dissemblance". It's making believe that things look good when they actually are
quite bad. I remember talking to you about this on the phone. The concept of the
Potemkin Village, Grigory [A.] Potemkin was Chief of State back under Catherine
the Great and he would--when Catherine the Great, when he would have her see how
things were in her kingdom, he would send word ahead as to what the routes would
be and how things should look, so that she would always get the impression that
the peasants were happy, they were well-attired, they were well-fed. We would
58:00ask, "how are things functioning in your laboratory or in your corner here of
the world?" And we'd first get this picture that everything was rosy, but they
didn't anticipate that we'd sit there and then ask the right questions because remember, I said the systems were similar, not just similar, the systems were
carbon copies, cookie-cutter copies. If you had been through the system in one
raion [county], then you'd know how all the other raions functioned, and you
[then] knew the right questions to ask about what was the time from this action
taken until that action being taken. And then people realized that they really
needed to-- it made sense to then just go ahead and tell the truth, because then
59:00if you told them the truth the potential was there that you might get assistance
that would help make the work environment work more smoothly.
TORGHELE: How did they report their polio cases and how did they start asking
for help for polio work?
CHORBA: That I don't know. That probably--that predated me, because at the time,
I know that they still had some cases. I remember in Karakalpakstan, which is
the autonomous region of the far west of Uzbekistan-- Karakalpakstan had its own
parliament-- it was treated relatively independently. I remember that in
60:00Karakalpakstan (and it's in the far West of Uzbekistan) that they had a polio
case in 1998.
So, whereas they had thought the region was free by late '97, I know that
Galina Lipskaya ascertained that indeed there were still--there still were wild
type virus cases occurring out there that needed to be addressed. To tell you
the truth, after '98, I had come back and I really didn't follow it, but I know
that soon thereafter, we were able to get Central Asia declared poliovirus free,
61:00which then freed up the funding, WHO's funding, to go give attentions elsewhere.
And by then, the National Immunization Days concept was up and running and that
the--we had changed the immunization calendar from about twenty contacts with
the health care system to get a child fully immunized to about twelve contacts
with the health care system, which made for incredible money-saving and
efficiencies and it just made it much easier to see to it that every child did
TORGHELE: What were their participation rates like? How did they get people to participate?
CHORBA: I remember sitting in a meeting with President [Nursultan] Nazarbayev
who was the President of Kazakhstan at the time. He's still the President of
Kazakhstan, but [we sat with ] his wife, talking with her about issues of
National Immunization Days. And she got very excited and here was an
opportunity. This was a win-win-win situation to get her face-time and to get
National Immunization Days face-time out there in the public press. And she went
out there on national television to talk to people about the importance of
National Immunization Days. And so, that aspect of things was grassroots. There
63:00was a respect for people that--in public health, we think of proportionality,
that your actions should be proportional to the issue at hand. So, to get a
child immunized you wouldn't be coercive, you would cajole and give whatever
incentives it took. And there was a value then placed in the respective
communities on participating. A little bit like wearing your "I voted today" in
64:00Georgia button on your shirt. Well, I can't remember at the time, but we may
have had something similar to that, like "I have participated in National
Immunization Days" (in Russian), that you'd have--have some sort of sticker you
could then show your friends.
TORGHELE: Was there anything in the culture that affected your work that
surprised you? Were there things that happened that you could see were
counterproductive, but it had just always been there?
CHORBA: Well frankly, at the time, there was a lot of alcohol that would
be--there was an obligation that you had to engage socially, you wanted to get
65:00people on board. But, I guess in old Soviet times there was a tremendous amount
of alcohol consumed and certainly around the time of the break-up things became
a huge issue, alcoholism. But we would have gatherings and with the gatherings, of course, would be food, and you know, there would be--in Kazakhstan, they
would serve the sheep's head and someone would have to then get up and give a
toast and then carve the sheep's head. Well, they would always look--because I
went gray very early, they would look to me as being this--as being the patron
who has shown up from the United States and anticipate that I should get up and
66:00give a toast and then the carve sheep's head. And you carve it and you give, you
know, an ear to the youngest one to teach him to be attentive. But they would
laugh about it because they would know that other people would find this a
But nonetheless, there was a lot of negotiation-- I would try to save some of
the harder negotiations that needed to be done to those moments of levity
because people would be a little more relaxed then about having to deal with a
Westerner in that setting. And there would be more humor and it was easier to
get people to say yes in that sort of setting. It's an understatement, there was
67:00a lot of that and it was also, if we, we Westerners, if we picked up--if we paid
for dinner, then it made it easier for people to say yes to and come to the
negotiation table because nobody had anything then. The poor people were out
there begging in the streets. In the old days, you had, under the Soviet system,
you had a right to an education, you had a right to a job, you had a right to
housing, you had a right to health care and you had a right to a retirement. And
after the dissolution came, all of that went down the drain if you didn't have
money, and nobody had any money. As again I said this, this was low hanging
68:00fruit. If we knew what to do or we could identify what needed to be done, people
were willing to, either to be dragged into the 20th Century, into the 21st
Century there. They welcomed the concept of a computer. It was alien to them, it
was new and it was wonderful. Sort of a side comment here, it was at the dawn of
the internet and the space agency for Kazakhstan was in Almaty. Remember, the
69:00space agency for Russia, Baikonur [Cosmodrome], the space platform is in
Kazakhstan and so the Kazak Space Agency was very sophisticated. And I remember
going into this space agency, I made a friend there and seeing this--he asked me
where I lived, and then he tip-tip-tip went over to his computer. There was a
huge wall and he was able to show me on it the grain on the wood in the child's
swing in the courtyard where I lived, from out there in space, in real-time. And
70:00I realized, good grief, they could do that probably for your play-structure here
in Atlanta. I mean, because they had their satellites, they had an incredible
sophistication. But when we came along with the internet, they were just
absolutely wowed and fascinated. And so I brought the same guy over to work in
our offices. To make a long story short, he wound up identifying a job for
himself in Queens, New York and then one for his wife and then one for his son.
They were out of there to--onto the States because of their incredible knowledge
of computers. But people were really, really wowed by the fact that the internet
So we realized that this was a great opportunity for us then as well, to
make--if they had computers and if they had internet capability, that they
would--and so there were some places that were just starting out in the private
sector, to get that sort of capability, that they would be able to just go out
there and download MMWRs [Morbidity and Mortality Weekly Report], download URLs
[Uniform Resource Locator] from CDC, you know, little films of how to do
something. So then, of course, everyone also wanted to learn English. By the end
of '97, there was a real push for people wanting to learn English, because
72:00English was the language of the internet.
TORGHELE: And science.
CHORBA: And science.
TORGHELE: You mentioned earlier that there were losses of electricity and water sometimes.
CHORBA: Yeah, well, in Kazakhstan we didn't have losses of water where we were.
There were losses of water in Tajikistan, certainly, because in the old days,
under the Soviet system, you didn't have the metering of water. And so, if
something broke and it was now your toilet flushing unit if you had the luxury
of a toilet, if you didn't have the money to fix it, it didn't matter because
73:00you weren't paying for the water. And so in 1996, [Dr. Jonathan H.] Jono Mermin,
who is now the Center Director for the National Center for HIV/AIDS, Viral
Hepatitis, STD [Sexually Transmitted Diseases] and TB Prevention, Jono came out
as an EIS Officer and we bundled him up and sent him down to Tajikistan to work
on the typhoid epidemic that was roaring in Dushanbe. And the bottom line was
that people needed really to have water metered because of the amount of chlorine
that they were using, given the population, was a staggering quantity and you
realized that it was because there were so many breaks in the system, that the
74:00system--that they needed to develop efficiencies. But we cooked--my wife was the
Peace Corps Medical Officer in Kazakhstan, we cooked Thanksgiving dinner for the
Peace Corps and the gas went off because Kazakhstan stopped paying its money to
Uzbekistan for gas and the gas did not turn on again until March. So
fortunately, we had--my wife was able to get a hotplate from the Peace Corps,
and we wound up cooking our way through the winter on a hotplate. So that we
would have electric brownouts--we would have brownouts and we would lose power,
75:00but when power was on, then we knew to go ahead and cook up whatever we could to
get us through the winter.
TORGHELE: So, you had a lot of adapting to do.
CHORBA: We did a lot of adapting. We did a lot of adapting, yes.
TORGHELE: And a lot of this was because the Soviet Union had broken up--
TORGHELE: --and the countries weren't used to being independent.
CHORBA: No and if you had a car, it was a Soviet car, Zhiguli, from Moscow. The
parts came from 15 different republics, and the republics were no longer trading
with each other and so supply lines just didn't exist. But I assume that a bit
of that had happened as things were going downhill back in the 1980s anyway. So,
76:00people were very--were homemade engineers, were very good at figuring out or
knowing who to go to get a jimmy-rigged part to get their car to keep on moving.
But I remember having two Army trucks abandoned right there in our courtyard and
the kids took over the Army trucks as play structures because they just didn't
have the parts to replace them.
Now you have to picture, so I'm talking about this in the side of the home
sector, the domestic environment, it was worse in the environments of the
workplace because they didn't have budgets before. It was a very strange time to
77:00try to arrange things from a central aspect and get things to happen out in the
periphery. But the beauty was that in the old system, as Moscow said, so as
would the republics do, as the republics said, so would the oblasts do, as the
oblasts said, so would the raion do. And they all had the equivalent to, well,
we call them guidelines, and they [guidelines] don't have in this country, in
the United States, the force of law. In Kazakhstan, they had
something--throughout the former Soviet Union they had prikazi-- я
приказываю(ya prikazyvaio) means I order you to do something-- a
приказ (prikaz) is an order and so прикази (prikazi) were orders.
78:00What we use for clinical guidelines, they had "clinical orders," and if you
deviated from doing what was said in the prikaz, you potentially could be fired
or punished. And so, those [the prikazi] actually became a target for us because
we realized we had to get them rewritten to achieve what we would hope in some
arenas. A friend of Galina Lipskaya was [Dr.] Michael Favorov-- Michael
similarly had--was head of all of hepatitis for the former Soviet Union, but he
would come here--he was here working in [Dr. Harold] Hal Margolis's lab back
79:00when the break-up came in December of '91- January of '92, and he looked at his
passport and realized that that no longer described a country he was from. And
so, he decided he was going to do everything he could to stay, and he eventually
became an American citizen and has done great work for CDC. He just has left
CDC, we're talking--last week, but he became my right hand back here. I can't
remember whether Hal had the FTE [Full-Time Equivalent] and didn't have the
money, or he had the money and he didn't have the FTE, but we cut a deal with
each other so Michael was half time doing hepatitis for Hal and halftime working
on our issues from back here for Soviet Central Asia. And eventually, in 1999,
80:00Michael replaced me out there in Kazakhstan as Head and he spent the next 7 or 8
years as Head of the CDC offices in Soviet Central Asia. I think he finally left
in 2008 from there-- achieving, running downfield, helping achieve getting the
Ministries of Health to do the right thing in many different aspects of
epidemiology, not just Kazakhstan. He wound up putting a CDC extension in
Uzbekistan and in Kyrgyzstan, and you'll find that out there, [Dr. Makhmudkhan]
81:00Makhmud Sharapov works for CDC in Uzbekistan, a pediatrician-- Makhmud's son,
[Dr.] Umid [M. Sharapov], works on immunizations for CDC, came through EIS. So
we've had two generations out there. But Umid originally had been working for
the CDC office in Kazakhstan when Michael said, "Umid, you need to go to EIS"
and Umid has done brilliant work. I think he works in measles-- he might even
work in polio for all I know, now, here in immunizations.
TORGHELE: It sounds like you have had quite the adventures and done a lot of
82:00good in your work.
CHORBA: It's been a lot of fun.
TORGHELE: And I wondered if there are things that you would like to say that we
didn't touch on or other things that came to mind while we were talking that you
would like to say.
CHORBA: Yeah, I realized that another person for whom I have a world of thanks,
and I haven't seen him in 20 years, was Sergei Deshevoi. Sergei is a Russian
from Saint Petersburg, who I know has worked for WHO, and I've lost track of
him, but he did a wealth of helping us achieve work in diphtheria. There was a
raging diphtheria epidemic in Tajikistan and throughout Central Asia back when
83:00we first showed up there, which told us then that the cold chain was not--there
must have been great dysfunctioning or lack of proper immunization, the fact
that you had a raging diphtheria epidemic. I first met Sergei working on that,
but then Sergei worked with us on getting acute flaccid paralysis made a
notifiable disease. Another one, Roman Gvetadze! Roman Gvetadze is from Georgia
and he came out [to Kazakhstan]. I forget how we first identified Roman, but he
84:00came out and helped us teach Epi Info when we got--when we got to the point
where we could have Epi Info on our computers, so we must have come out of a DOS
[Disc Operating System] environment and into a Windows environment. We were at
the dawn of the Windows environment and Roman helped us teach the Epi Info
to--he came from Georgia. I remember him giving presentations in Almaty,
Kazakhstan for us. Roman has since then had a full career working for CDC-- I
think he has an FTE [full-time equivalent position] for CDC in HIV doing
85:00surveillance in HIV. Those are the ones who immediately come to mind of people
I'd, you know, certainly like to say my "thank-yous" to.
TORGHELE: That's great. It's a good way to end and I want to thank you so much
for sharing your unique experiences. This really is very unique-- we haven't
heard this perspective before. And your stories will flesh it out for a lot of
people and help us imagine what it was like for you.
CHORBA: Well, I'm just so grateful to CDC because it just provided an incredible
opportunity. I had no idea what I was doing. I had no idea where I was headed.
But I realized that it was a little bit like being an astronaut, that you
86:00realized that this was important stuff and that you could do good things and I
did have the power of the U.S. government and its financial resources behind me
and it just worked out far better than I ever dreamed. Louis Pasteur said that
fortune favors the prepared mind and I had a lot of fortune in my run out there.
And just great people to work with and this was not the doing of any one person
or any three persons or any five persons, this was many people with their oars
87:00in the water. Of course, special, special thank you's to Walt Dowdle, Olen Kew
, and Lyle Conrad, Bruce Ross, Larissa Vakhmistrova, the CDCers who made sure that
it all happened. But it was just also a lot of wonderful people from the
respective republics who worked on getting it right.
TORGHELE: And you served a lot of people in the process. Wonderful, it's a great
story. Thank you so much for sharing it with us.
CHORBA: Sure, my pleasure. Thank you.