Terry Chorba



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 00:01:00sisters 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 00:02:00physiology 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 00:03:00Director. 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]. 00:05:00Dennis 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 00:07:00Cleveland 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 00:08:00child 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 00:09:00London, 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 00:11:00disease, 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 00:12:00off 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 00:13:00Diseases, 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 00:14:00Division 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 00:15:00on, 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 00:16:00ascertain 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 00:17:00December 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 00:18:00William 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 00:19:00remaining 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 diseases surveillance.

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 00:21:00the 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 00:22:00remember 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 00:23:00terms 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. 00:24:00At 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 00:26:00was 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 00:27:00cornerstones, 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 00:28:00from 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 00:29:00things 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 00:30:00vaccine 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 00:31:00into 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 00:32:00years 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 00:33:00to 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 00:34:00laboratory 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 00:35:00Tashkent 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 00:36:00world 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 00:37:00Kyrgyzstan 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 00:38:00in, 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 00:39:00anything 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 00:40:00the 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 00:41:00there. 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 00:42:00that 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 00:43:00the--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 00:44:00be 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 00:47:00at 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 00:48:00I 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, 00:49:00they'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 00:50:00American 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 00:51:00instance, bribery--

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 00:52:00had 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 00:53:00was 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 00:54:00state 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 00:55:00those 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 00:56:00approaches 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 00:57:00"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 00:58:00ask, "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 00:59:00if 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 01:00:00Karakalpakstan (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, 01:01:00which 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 get immunized.

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 01:03:00was 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 01:04:00Georgia 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 01:05:00people 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 01:06:00give 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 little awkward.

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 01:07:00a 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 01:08:00fruit. 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 01:09:00space 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 01:10:00I 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 was happening.

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 01:12:00English 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 01:13:00you 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 01:14:00system--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, 01:15:00but 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--

CHORBA: Yes.

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, 01:16:00people 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 01:17:00try 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. 01:18:00What 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 01:19:00when 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, 01:20:00Michael 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] 01:21:00Makhmud 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 01:22:00good 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 01:23:00we 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 01:24:00came 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 01:25:00surveillance 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 01:26:00realized 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 01:27:00in 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.