Steve Cochi - Session 1



CRAWFORD: Today is Tuesday, November 14, 2017. This is Hana Crawford for the Global Polio Eradication [Initiative] History Project [GPEI]. I'm interviewing Dr. Stephen [L.] Cochi [MD, MPH] in Atlanta, Georgia in the broadcast department at the [United States] Centers for Disease Control and Prevention [CDC] in Atlanta, Georgia. Todd Jordan is our studio engineer and videographer. We have had one pre-interview session so far.

Dr. Steve Cochi came to CDC in 1982 as an EIS [Epidemic Intelligence Service] officer, after working as a pediatrician for the U.S. Public Health Service in New Mexico. In 1987, he was at a PAHO [Pan American Health Organization] meeting in Washington, DC, which was his first contact with the GPEI. In 1993, Dr. Cochi became the first director of the newly-created Polio Eradication Activity [PEA]. He arrived with extensive experience in surveillance and immunization. He became the first Global Immunization Division [GID] director in 1997.

Today's interview will mainly focus on Dr. Cochi's direct experience working at the CDC and in polio eradication, from his early career until 2001, at which time polio had been eliminated from all but ten countries, globally.

This is the first of two or maybe three interviews.

Thanks for being here today. It's exciting to have a chance to speak with you. To begin, do we have your consent to conduct this interview and to record it?

COCHI: Yes, you do, and thanks for inviting me, Hana.

CRAWFORD: You're so welcome. Would you introduce yourself by name, say where and when you were born, and speak a little bit about your childhood? We have some information on your early career from a previous oral history, but we don't have information about your childhood.

COCHI: OK, very well. I'll try not to bore the audience.

My name is Steve Cochi. I was born August 19, 1951, in New York State and grew up in Rochester, New York, in a family of seven. There were five children, and I was the second oldest. I went off to college to MIT [Massachusetts Institute of Technology] in the Boston area. It was an eye-opener for me, because I spent my entire childhood without having left the state of New York. I think that it's very ironic that I am now involved and have been for decades in a public health adventure, if you will, that has taken me all over the world. I have traveled to sixty or seventy countries in the world. I was really very provincial as a child and had my first eye-opening experience when I went off to college.

CRAWFORD: Growing up, who were your influences? Who did you spend time with as a young child?

COCHI: Interestingly enough, there were no physicians in my extended family, so I was the very first. My role models really were people who I trusted, mainly my teachers. My father, who became my high school principal, if you could imagine that--that was somewhat difficult, but I think it points out that I was very steeped in the value of education. My mentors as I was growing up were teachers, people in the education field who I admired greatly.

CRAWFORD: Could you speak about a few of them, specifically?

COCHI: I was also an avid person involved in sports. I had a social studies teacher, Mr. [John J.] Soper, who also was a football coach and a lacrosse coach. I admired him greatly, because he was a very bright, talented person. He was very engaging, had very good interpersonal skills, and he also really showed me the way, in terms of how to respect people, how to interact with people in a positive way and how to not be selfish in the way you approach the world and life.

There were similar teachers and coaches, but I think he probably is the one that had the most influence on me at a very influential time of my life--of our lives when we're adolescents.

CRAWFORD: Do you remember any specific occasions when Mr. Soper modeled what it meant to be unselfish in the world or to treat people with dignity, treat people well?

COCHI: I think there were a number of occasions, like when we were playing a game of--I think a lacrosse game, when we were pretty desperately behind. It was half-time, but he had the right approach. He had the right attitude. It was an attitude not to criticize and humiliate, an authoritarian attitude of that sort, but to try to look on the positive side. What were the good things that happened in the first half of the game, and what do we need to do to do a better job? I thought it was a very humanistic and proactive and positive approach to try to get the best out of people, and so I've tried to emulate that in my personal life and in my professional life at CDC.

CRAWFORD: Moving forward in time--that would have been high school?

COCHI: That was high school, and then I became a biology major at MIT. Beginning as a freshman, I was very interested in pursuing medical school and was fortunately successful and got admitted to Duke University. I made quite a transition from the Northeast, from Boston, to Durham, North Carolina, which at that time was a small, sleepy southern town in a state--North Carolina. At that moment in time, most of the counties in North Carolina were dry counties: no liquor, no alcoholic beverages, and it was the Bible Belt. I found myself in an interesting situation where, particularly when I went around on the wards at Duke Hospital, I didn't have a Southern accent. I was a Yankee. Even more, when I did some chitchat with the patients and their families, and they found out I was Catholic, I was a "Catholic Yankee," so at that point in time, in the mid-1970s, that was almost like being an alien. Times have changed dramatically since that point in time.

CRAWFORD: How would people respond to you?

COCHI: I think you have to recognize that a lot of these folks came into the tertiary care hospital in Durham, North Carolina from rural parts of North Carolina, southern Virginia, all over the place. They probably never had seen or talked to or interacted with a person from up north, or maybe it was a rare event. I think I was kind of a curiosity at that point in time for the folks from the rural South. Of course, things have changed dramatically in the decades since, and there's been a lot more mixing of the U.S. population. But it did teach me a lesson about how important it is to stop and understand diversity and value diversity and not draw conclusions based on first impressions or the appearance that this person is different from me, and therefore, I shouldn't trust them--I should be very wary of that person. I've tried to implement that in my life and in my work.

The diversity and what it brings, in terms of different points of view--more collective knowledge--is key to the work I do, and in global immunization, [it] is key to a successful outcome. You're more likely to have success if you have more people with diverse opinions and views coming to the table to solve problems, and I think that's been one of the big successes of polio eradication.

CRAWFORD: When you enter into a room in a meeting and you're encountering people who you haven't met before, how do you draw on that experience to implement some of those lessons that you learned when you were at Duke in not making assumptions quickly? How do you enter with openness?

COCHI: I do my best to try to engage people that I don't know and try to understand who they are, where they are coming from, what their experience is, and how that experience is being brought to the situation, the issues and the problems that we're collectively trying to solve together, not preemptively prejudge or come to conclusions that may be totally inaccurate, totally false. I think it's helped me.

CRAWFORD: I believe you returned to Massachusetts for residency after medical school. Is that correct?

COCHI: That's right. I returned to a pediatric residency at Massachusetts General Hospital in Boston.

Before I say any more about that, I should say that probably the most important experience I had at Duke Medical School was the opportunity to get to know Dr. Sam [Samuel L.] Katz [MD], who was one of the developers of the measles vaccine and a pediatrician. [He was] head of the Department of Pediatrics at Duke at the time and a staunch advocate of the value of vaccines in preventing serious vaccine-preventable disability, death, and suffering. He became one of my mentors--to this day, really. He just celebrated his ninetieth birthday. I was up at Duke University several months ago attending the celebration party for him, and he's still pretty sharp as a tack at ninety years old. I only wish that if I have the good fortune of reaching ninety years old, I'll be even half as sharp as he is.

Interestingly enough, not only did he help my career, because he had trained in the Harvard pediatric training programs [Massachusetts General Hospital/Harvard Pediatric Residency Program], but he helped me to get this residency. Then after I finished my pediatric training and spent two years on the Navajo Reservation in the U.S. Public Health Service serving as a pediatrician and then came to the CDC, lo and behold, there's Dr. Sam Katz as the chair of the U.S. Advisory Committee on Immunization Practices. We call it the "ACIP." This was in the 1980s, and he continued to serve both in the Academy--the American Academy of Pediatrics--and on the ACIP for the CDC. He was a chair twice for lengthy periods of time and in between served as a member of the ACIP. To this day, I've been able to enjoy both the personal friendship with him and the professional benefits and value that my relationship with him brought. He's definitely a giant--a giant in pediatrics, a giant in polio eradication, and in measles eradication, as well.

CRAWFORD: What is he like? What is his personality like?

COCHI: Despite his many accomplishments, he is somebody who engages with everyone he comes into contact with. He has an amazing memory about who you are, your family, asking how things are going, and just getting on the right page, virtually immediately. It's a skill that I wish I had. He makes you feel valued. He makes you feel like he knows you and has a relationship with you from the get-go. He does that to everybody. It's really amazing to watch, to observe.

CRAWFORD: Knowing him over time, has he given you advice? Would you say that he's influenced your leadership at all?

COCHI: I think in very subtle ways he has. He's been a guide for me. He's been a compass. He is totally the opposite of judgmental, so he's very soft and not strongly directive in that way. I'll use this metaphor: it may not be quite so appropriate, but the science of psychiatry is--when you're trying to deal with a patient, you want to combine support and insight. I think he had the perfect combination of supporting me and everyone else in his life: supporting our professional achievements, as well as giving some insight where needed, looking at our opinions or our strategies or where we want to go, our decisions, and just giving some insight about the pros and cons of those decisions. It's a wonderful combination. I was very fortunate to have mentors like him, but he really stands out, because his mentorship cut across several decades.

CRAWFORD: Is there anything else you'd like to include about Duke or your early training and education?

COCHI: I think the main thing is that getting into my career, I was searching. I was searching for, "What do I want to do when I grow up? What do I want to do with my life?" That brought me into the arena of pediatrics.

It's always nice, from my point of view as a pediatrician, to be able to take care of children and be an advocate for children. They are on the upslope of the curve, and they have so much promise. I venture to say that sometimes as a treating physician, the children get better in spite of what you do, compared with being a physician who deals with adults that are on the down slope of the curve and trying to stave off serious illness and death. I think it helped me. It's more my personality. It helped me to see the world optimistically, see the world as an idealist, because children have so much potential, and the objective was to help them realize their potential.

That was the first step that I took, and then I had to make a decision about whether I wanted to go into a subspecialty and be the best pediatric specialist with the knowledge of the right toe, or whether I wanted to do primary care pediatrics.

To help me get through medical school, I had signed up for a scholarship program with the U.S. Public Health Service that helped to pay for two years of my medical school education and provided a stipend, a living stipend, and in return, I had to pay back two years. It was something I was interested in doing, anyway.

When the time came at the end of my residency, I decided to go to the southwestern United States and work as a pediatrician in the Indian Health Service of the U.S. Public Health Service. I was assigned to Gallup, New Mexico, which is right on the edge of the Navajo Reservation. The Navajo is the largest Native American tribe in the United States. They're about 250,000 in numbers now. The Navajo Reservation spans the entire northern third of the state of Arizona, but it's in a very isolated, almost desolate part, high-altitude desert. Of course, treaties with the Indians being what they are, the U.S. government generally made a treaty that would confine the Native American population to the land that nobody else wanted, really.

Anyway, with that in mind, it was a totally different experience from growing up in the eastern United States, living in a high-altitude desert in a very rural location. In many ways it was fantastic, because it taught me so many new things. It enabled me to really apply the skills that I had learned as a pediatrician in training and also helped me to see the bigger world out there.

I grew up and never left the state of New York as a child until I went off to college and then ventured down to North Carolina to medical school. That was a very different cultural and geographic environment, and this was different still. I think these were like baby steps, which led to a career where I was flying all over the world and engaging with many different cultures in many different parts of the world.

The other thing about working in this environment is that we were responsible for taking care of the children on the Navajo Reservation, so it was very well defined. It was a defined population, and for better or for worse, we were it. We needed to tend to their curative care. We needed to tend to their preventive care, including their vaccinations. It helped me to start thinking in a public health framework, where in public health the patient is the community and not the individual patient.

When I decided, "Hey, I'm very interested in going to CDC to learn more about epidemiology and public health," it made that transition more obvious. It made that transition easier, because I had already started thinking in terms of [being] a public health preventive medicine person.

CRAWFORD: Could you speak about a couple of specific times when you were working in the Navajo Nation where that interest in public health was sparked, and where you made the connection between the individual--the health of the individual being the health of the community?

COCHI: Yes. I think one example is each one of the pediatricians--and we were six in number, and, oh, we had this big medical center, all of a 150-bed hospital in Gallup--we were young and energetic and idealistic. We each had responsibilities for a rural health clinic that we would go to one day a week. Mine was about sixty to eighty miles north of Gallup in a very small town called Tohatchi, New Mexico.

I'll never forget going to Tohatchi and seeing twenty to thirty patients in the course of a day in this very rural environment. A third to forty percent of the Navajo in those days lived out on the reservation, in these six-sided hogans: houses, with no electricity, no running water. They had to carry their water in huge barrels from potable water sources.

I felt a sense--such a responsibility to try to take care of the health needs of this very rural community, and I was it. It really brought home to me the reach of public health and also the potential fragility of public health, if there weren't adequate resources available to meet the needs.

CRAWFORD: Did your mindset change a lot while you were in that position in the Public Health Service? When you entered, what did you expect of the community, of your role there?

COCHI: Yes, that's a good question, Hana.

Coming from a large urban pediatric training hospital, where one had exposure to the whole range of modern medicine, that was the mindset when I got on a plane and went to New Mexico. I began that two-year experience thinking like a pediatric clinician: "How can we apply--" and this is including my other young colleagues, who were mostly fresh out of training--"How can we apply what we learned in these state-of-the-art tertiary hospitals and medical centers?" We did have to apply it, because we had to take care of some very sick children.

I also had to confront that there was a lot more to health and medicine than taking care of children with life-threatening bacterial meningitis, that there were many primary health care needs that went way beyond those relatively unusual events: adequate nutrition, vaccination, good safe care of children by parents and extended family members, the basics of primary health care. So, yes, I was forced to confront that there was a lot more than intensive care units to delivering what the--to taking care of the health needs of children in the United States, including in this situation. Once again, I was struggling by the end of that [two-year period] and in the early days of my coming to CDC, [with the question of] "What do I want to be when I grow up?"

CRAWFORD: Could you talk us through the conversation that you had with yourself a little bit?

COCHI: To extend that a little bit: "OK, do I want to be a pediatrician who takes care of individual children on the curative side, or do I see my future more in public health, where I have to let go of being a real doctor, in terms of--"

Society in general, when they hear that you're a doctor they ask, "Where's your practice? What hospital do you admit to?" I had to make that transformation, just like everybody who ends up working in public health and has to, for the most part, give up seeing patients, because preventive health care is what you're focusing on.

I had that struggle at CDC, and I wasn't sure. "OK, is this for me? Or do I want to go back and do a pediatric infectious disease fellowship back up in Boston and become a pediatric infectious disease specialist?" Over time, the answer became clearer and clearer, because I really grew to love the approach at CDC, and I am one of the biggest fans of CDC. I think it's a fantastic institution, and it does so much for the American people and for the world. But it took me to the end of my two-year EIS program to let go of being a real doctor.

CRAWFORD: Were you thinking about public health as systemic change? How did you conceptualize the role of CDC and what you would be doing, and the scale on which it would operate at that point in time?

COCHI: That's a very good question, Hana. I think the way I was looking at it was, "Gee, you can do so much good for individual patients and see the results of your work within days." A child comes in very sick. Let's say the child has meningitis. You put the child on antibiotics, and they turn around within days, and you've saved them from serious complications like brain injury, like even death. You get the reward. It can come very quickly.

Making the transformation to a public health point of view, it's a lot more intangible. On the other hand, you have the potential to have so much more impact. It's not limited to the number of patients that you can see in a week, or in a month, or in a year; you can have an impact on an entire community, on an entire state, on the country, on the world.

Ultimately, that was the big attraction that drew me into the work that I do in polio eradication and in global immunization. It's amazing what impact those of us who work in prevention and in global immunization can have and have had. I'm so grateful that I had the opportunity to go through these different stages and end up landing where I have landed, because I would have never predicted it at the start of this journey.

CRAWFORD: You came to CDC in 1982 in EIS, and you worked--maybe we can skip EIS, because I believe that's in Karen Torghele's interview on Global Health Chronicles. Can we skip ahead to just before the Polio Eradication Activity came into being, so maybe 1989 or so, or even before that? I want to go ahead and move into polio. Could you find the beginning of your involvement?

COCHI: Sure, I came to know many of the players during the 1980s, in the evolving effort to move toward a Global Polio Eradication Initiative, which ultimately came into being in 1988 with the World Health Assembly resolution [WHA41.28] to eradicate polio from the world by the year 2000.

Going back earlier, there were some CDC folks and some other folks that were involved and instrumental in that coming into being. They included D.A. [Donald A.] Henderson [MD, MPH], who was the head of the Smallpox Eradication Initiative at WHO [World Health Organization], who many people don't know was actually a CDC person, going all the way back to 1955, when he came to CDC. He was seconded in 1966 to WHO to lead the smallpox--I think it was 1967, actually--to lead the smallpox eradication effort from CDC. He was a big player involved in the decision making about whether, following the eradication of smallpox, the declaration of this in 1980--whether or not polio or some other disease should be targeted for an eradication effort.

Dr. Bill [William H.] Foege [MD], who was also a major figure in smallpox eradication from CDC, became the CDC director in 1977 through 1983. He then went to Emory to found the Task Force for Child Survival, which created a multi-organization initiative, including WHO, UNICEF [United Nations Children's Fund], the World Bank, United Nations Development Program, and the Rockefeller Foundation, to dream big and to bring vaccines to the world's children, to the developing world's children and achieve eighty percent coverage with all of the routine vaccines that children in industrialized countries have available to them--and to do this by 1990. That target was reached by 1990. It was an enormous reach. It was an enormous example of thinking big, which is what polio eradication is all about. Dr. Foege was a major figure behind the scenes, working with these same organizations and with the director-general of WHO.

At that time [the director-general was] Halfdan [T.] Mahler [MD], who was Danish, who was from Denmark and was decidedly anti-eradication, decidedly anti-targeted disease. He was a proponent of systems--health systems--development, and he was almost dragged, kicking and screaming, into supporting polio eradication at the World Health Assembly in 1988. His opinion was changed at a key advocacy meeting in the French city of Talloires, which is very close to Geneva, in March of 1988, just a few months before the World Health Assembly. Dr. Foege and a few other notables, including Dr. Ciro [C. A.] de Quadros [MD, MPH] from the Pan American Health Organization, changed Dr. Mahler's mind, and lo and behold, polio eradication became an official target in 1988.

CRAWFORD: What did you hear about this meeting, and what did you hear about the resolution? You were at CDC at that time, correct?

COCHI: Yes. I heard that it had the promise to be an earth-shaking event. There were some other big players in this, not the least of which was the leadership of Rotary International. Back in 1985 [Rotary] had signed on to the regional polio eradication effort in the Americas, led by Dr. Ciro de Quadros, who headed the immunization department at Pan American Health Organization.

Rotary got into this game in 1985, because it was looking for a global target, a global initiative over the ensuing twenty years, a twenty-year commitment through the year 2005, which would be the hundredth anniversary of the creation of Rotary International. Rotary decided to jump in with both feet in 1985, and it began a fundraising effort to raise $120 million dollars. Over the next two years, they raised $247 million dollars.

What's interesting about this from a personality standpoint is that the president of Rotary International in 1985--and they serve for a one-year period of time--was Dr. Carlos Canseco [González, MD], who is a Mexican physician and who happened to be a good friend of Dr. Albert [B.] Sabin [MD], who was the developer of the oral polio vaccine [OPV]. Dr. Sabin had worked very hard to convince Dr. Canseco, the head of Rotary International, about how this would be a fantastic--"this," being polio eradication--would be a fantastic initiative for Rotary to sign on to. There was a collection of different personalities and figures that came together, first in 1985, and then in 1988, that spawned or gave birth to polio eradication.

In the wake of that, that resolution in 1988, I think everybody realized, "Hm, that's a very noble idealistic initiative, but how are we going to achieve this?"

There were no resources; there was no fundraising. Beyond Rotary, there was no fundraising mechanism. There were no staff at WHO or at the country level that could be directly devoted to this.

It took until the mid-1990s until most of the world and most of the countries in the world really got on board and started making any tangible efforts toward polio eradication. The only exception was that in the Americas, in the Western Hemisphere, there already was a polio eradication regional initiative that had begun in 1985 with a target for 1990. It was ultimately successful in 1991, when the last case occurred in Peru, so that was some forward motion.

Then in the Western Pacific region of WHO [Western Pacific Regional Office, WPRO], which includes Southeast Asia, China and the Pacific, the Western Pacific Islands, they passed a resolution to eradicate polio by 1995. Aside from those two efforts, the rest of the world--Africa, the Middle East, South Asia--was waiting around for something to happen.

CRAWFORD: From 1985 to 1989 you were an epidemiologist, correct? Working in surveillance?

COCHI: Yes, and in the [National] Immunization Program [NIP in the United States]. Polio was one of several vaccine-preventable diseases that I worked on, but primarily on the domestic side. Until 1991, CDC did not have a line-item budget from the U.S. Congress devoted to polio eradication, or for that matter, for any other global health activity.

CRAWFORD: How did that come about?

COCHI: I think that's a very complicated question, and the answer is not entirely clear.

Multiple people, the leadership at CDC, particularly in the immunization program and the past leadership from CDC, like Dr. Foege, worked to build advocacy for a budget line-item to be created. It was put forward to the Health and Human Services secretary [Louis W. Sullivan, MD] and then on to Congress for consideration. It was ultimately successful in 1991, but only after a period of years of advocacy. I think it definitely was helped by the fact that the polio eradication effort in the Americas was proceeding very successfully. By 1990, 1991, there was virtually no polio in the entire Western Hemisphere. I think, again, success breeds success. It enabled us to get, for the first time, earmarked resources to pursue polio eradication.

During the 1990s, as we had more and more success in the rest of the world, our budget, our polio budget, grew from $3.1 million dollars--which was the initial line item in 1991--to today, where we have a line item of $174 million dollars and well over two hundred staff that are working on polio and other global immunization activities at CDC and in the field.

CRAWFORD: In the late '80s, could you talk about the team of people, the group of people--yourself, Olen [M.] Kew [PhD], Mark [A.] Pallansch [PhD], [Robert A.] Bob Keegan, and I think [Walter R.] Walt Dowdle [PhD] was around at that point, but in a role--he did not become part of the Polio Eradication Activity. Could you talk about the group of people who would become the Polio Eradication Activity in 1993?

COCHI: Yes. You named most of the people who were involved. It was a very small group, very small, but a dedicated and idealistic group. I keep using that word, "idealism," because I think it's an essential element to be involved in an eradication effort. You have to have a positive attitude and an idealism, because it's such a big picture kind of thing. It's so far-reaching to try to eradicate a disease from the world. There are going to be so many setbacks and so many problems and issues that you have to grapple with along the way that in order to persevere, you have to have a positive attitude and idealistic view.

That's the way the group was and is. We were very much helped along the way by Walt Dowdle, who was then the deputy director of CDC--and actually became the acting director for a year in the early 1990s--who provided some very senior mentorship and guidance and direction.

After retiring from CDC in the mid '90s, he went over to the Task Force for Child Survival, now called the Task Force for Global Health. He became a tireless advocate for polio eradication and made many, many contributions from a scientific, technical, and advisory capacity, particularly in the realm of helping to build the Global Polio Laboratory Network [GPLN] that is the finest state-of-the-art network in the world for any infectious disease today.

In those early days, yes, there was so much to do and there were so few of us, we had to provide moral support for each other.

Just before I got into this game, or as I was beginning to get into this game, there were, I think mainly due to some personality issues, some tensions between the epidemiologists and the program people, on the one hand, and the laboratory people--the virologists--on the other hand. The latter group [was], on occasion or from time to time, being taken for granted too much for the fantastic work they were doing.

Just before I became the head of the--what was then brand-new--Polio Eradication Activity at CDC, Bob Keegan, who became my deputy, started what he called "beer diplomacy" as a way to bring the group together. This has been a tradition that has continued to the present day, every Friday, going to Mo's Pizza, which is on the corner of Clairmont [Road] and Briarcliff Road [Atlanta, Georgia].

Every Friday at the end of the afternoon, we'd go and enjoy each other's company, have a little beer and pizza and talk through the issues of the week. It broke any ice that there was, and we became deep friends, as well as colleagues, and developed an enduring trust for what each other were doing that has continued to today. I'm a big fan of beer diplomacy.

Actually, later on at CDC, amazingly, people would ask me, would ask Bob Keegan, "What's the secret?" It became kind of a model of cooperation across different programs at CDC. People would come and ask us, how did we do it? It's not rocket science, but it worked and still works.

CRAWFORD: What were some of the big issues that were discussed at Mo's?

COCHI: Big issues: there were so many big issues. First of all, I think we did our best to make sure that any tensions or resentments didn't build up. We tried to, if there was any need to clear the air that week, then we did so.

Then moving beyond that, at that time, we were dealing with 125 countries on five continents at the start of this global initiative that were endemic for polio and an estimated 350,000 polio cases in the world. That was the starting point, and we had a budget at CDC of $3 million and half a dozen people on the program side and about the same, maybe a few more people, on the lab side. [There were] very few people at WHO or at other partners to deal with this, so it was daunting. We would talk about, "OK, what are the highest priorities? What do we do with the resources at our disposal, and how can we advocate to get more resources?"

We started having success. First of all, we could build on the success in the Americas. We were pretty deeply involved in the Americas' effort, especially on the lab side, since the CDC lab was the primary reference laboratory for the region of the Americas. As the success occurred, we were successful in getting more and more resources. The success builds on the success, in terms of being able to deploy those resources--people and financial resources--both within CDC and assigning people to the field, primarily to WHO on loan, on secondment.

We also provided resources to WHO and UNICEF through cooperative agreements that we began in the early to mid-1990s, so that they could--since they have country offices in virtually every country--expand their efforts and strengthen what they were doing. A partnership began to grow and mature and become stronger and able to do what seemed like an insurmountable task, but [it] became less and less insurmountable over the course of the 1990s.

Many of those 125 countries, which had endemic polio, but had--by and large--fairly strong immunization programs. With some additional effort, some selected polio mass campaigns could eliminate polio, interrupt polio transmission, in those countries. We focused on those that were the low-hanging fruit of the 125 countries, and we were knocking them off, one after another. Amazingly, with relatively few resources, by the turn of the century and by 2001, we had gotten down to ten endemic countries in the world from 125 countries. We sat back and said, "My God, that's amazing." Everybody was amazed, including ourselves.

CRAWFORD: It's amazing.

COCHI: Basically, it convinced the world--or most of the world--there were still many critics out there, that yes, this could be done. One of the major drivers of this, outside of the Americas, was China. China had a huge polio outbreak in 1989, 1990, in spite of having pretty high routine coverage with polio vaccine--ten thousand cases. It was devastating to China, and it wasn't the kind of situation, a face to the world, that they wanted to portray. The government got fully behind polio eradication after that experience and began doing National Immunization Days [NIDs], nationwide polio campaigns, beginning in 1993 with the president of China, chairman of the [Communist] party [Jiang Zemin], delivering the first doses.

I was in China, and this was in December of 1993. [It was] bitter cold in Beijing, but he was on television everywhere. Similar ceremonies were being held in all the provinces and prefectures of the country. Within four years from 1990--this was actually in 1993 when they went nationwide--but by the end of 1994, through multiple rounds of polio mass campaigns, China completely stopped poliovirus transmission in the country--another amazing feat. It was one of the big drivers that convinced people, along with the decline in the number of polio-endemic countries to only ten countries by 2001, that gave people confidence that, yes, this can be done.

CRAWFORD: To return to the beginning of the history of the program, in 1993, [William J.] Bill Clinton becomes president of the U.S., and he begins the National Immunization Program, which supports routine immunization in the United States--and also supports a case for supporting polio immunization at CDC. Would you say that's accurate?

COCHI: Yes. Yes, and just to expand on that a little bit, one of the precursors to this happening was in 1991, when the U.S. experienced--and this was when George [H.W.] Bush, Sr., was the president of the United States--the U.S. experienced an awful, horrific resurgence of measles, with a measles epidemic of 55,000 cases and more than 120 deaths due to measles. This is in the United States of America in 1990. It was a total embarrassment, and it uncovered weaknesses and shortcomings in the U.S. immunization program that ultimately led--after Bill Clinton took office and the President's Childhood Immunization Initiative--[to] a huge increase in the resources, priority, and attention given to the immunization program in the United States.

Our polio eradication efforts benefited from this, because we were the international arm--even though it was a tiny arm--of the new National Immunization Program, and we benefited by being able to take advantage of some of those resources. I think our budget increased along with the U.S. immunization, the domestic immunization program budget increases.

We were helped very much by Senator [Dale L.] Bumpers, who was the chair of the Appropriations Subcommittee that oversaw CDC's appropriations. He was a strong advocate for immunization, going back to the time when he was governor of Arkansas and had to deal with a large measles outbreak back in the 1980s in the secondary schools in Little Rock and other parts of Arkansas.

The other interesting thing about this is that an even bigger advocate was his wife, Betty [L. F.] Bumpers. She and [E.] Rosalynn Carter ultimately formed an organization called "Every Child By Two," which focused on getting immunizations to infants and young children on time, so that they are fully protected with all of the needed vaccinations by the age of two. It was "Every Child By Two," and this is an organization that survives to today. It has been a great advocate for children and for vaccines.

CRAWFORD: So, late '80s, early '90s--

COCHI: On through the mid-'90s.

CRAWFORD: On through the mid-'90s, OK.

COCHI: We were able to grow our budget and the number of people, both on the CDC side, as well as support through our cooperative agreements to UNICEF and WHO at the regional and country [levels]. It was an acceleration. It was an acceleration of effort, of energy, of resources, of optimism.

CRAWFORD: On a day-to-day [basis], what was your role? What were you doing?

COCHI: On the what?

CRAWFORD: Through this acceleration, in your daily work, what did this look like?

COCHI: I was running around crazy, trying to keep up with the acceleration, trying to manage it and trying to lead it, with the help of Bob Keegan. When you're leading and managing an organization that's growing so rapidly, there are so many things to attend to and falling through the cracks.

I was fortunate to have Bob Keegan as my deputy. He was a consummate manager. He was a public health advisor at CDC. That's a nomenclature that describes a person who has a combination of management training and real-world operational management experience, working at the ground level and working up the system at CDC, whether it's in the sexually transmitted diseases [STD] program, the tuberculosis program, or the immunization program at the local, county, and state levels.

He had all of that training and then some. He had spent some time in Bangkok [Thailand] with the international efforts to screen refugees and had gotten five years of experience on the international front before coming back to become the deputy [of the Global Immunization Division].

So, yes, we were busy leading and managing this burgeoning effort. I was on the road all over the world, attending key regional and country WHO and other meetings, making sure that CDC had a presence, making sure that the face of CDC was there, making sure that the other partners and countries knew that we were totally committed to the eradication of polio. I wasn't the only one on the road, but I spent an enormous amount of my time, which is why I have more than four million Delta [Air Lines] miles now.

CRAWFORD: That's incredible. That's a lot of traveling. COCHI: Yes, it's kind of tiring to even contemplate that. Pretty much all of those [miles have been] since 1993.

CRAWFORD: What kinds of conversations were you hearing in meetings?

COCHI: In meetings, there was always this mixture of, "Did we really do that? Wow!" Combined with, "Is this insurmountable? How are we going to solve this problem? How is it even possible that we can eradicate polio from India, or from Vietnam, or from--" you know, fill-in-the-blank country?

There was a lot of problem solving that we had to face and address, talking about it at the meetings, but then after the meeting, "What's our implementation plan? Is it going to work? Are we monitoring the implementation adequately and making adjustments, henceforth?"

CRAWFORD: Would you say that you were drawing on your background in surveillance?

COCHI: Surveillance is the bread and butter of what CDC is all about. We are a scientific and technical agency, but also a program implementation agency. One of our biggest strengths, and I think the biggest strength that we bring to global immunization and to polio eradication, is our knowledge and capacity to do both the epidemiological surveillance--the investigation of cases and the diagnosis of individual cases--and our laboratory capacity, our reference laboratory--our ability to develop new diagnostic tests that make it easier to diagnose polio or any other infectious disease and to disseminate that technology and the diagnostic capability to many laboratories around the world and to manage that laboratory network through an accreditation process that tests laboratories, at least on an annual basis--are they capable of doing the appropriate testing to get the right answer?

Supplying those laboratories with the equipment and supplies that they need, that's been the story of CDC's laboratory network, and on the program and epidemiological side of what we do, one of the biggest strengths that we bring to the table to countries and to WHO as the lead organization, as the "world's health department," if you will.

CRAWFORD: As countries, and I'm assuming ministers of health, were in these meetings and you're communicating to ministers of health and medical staff--attending physicians, who else were you speaking with, and how would you address their concerns?

COCHI: At the country level, it usually wasn't the ministers of health, because these were annual meetings that were a review of polio and other immunization program aspects that were attended by the directors of the immunization programs of these countries. They were at a substantially lower level than the minister of health, but at the operational level, at the level where we can make change, if we can provide the knowledge and the resources and support to these country immunization program managers and their staff, then we can make a difference.

And we did. It became a very enormous capacity-building activity in each and every country--not in the industrialized countries, by and large, but each and every one of those 125 countries. Even some in addition to that, who may not have had polio, but were threatened by the prospect of polio being imported into their country, because they were geographically adjacent to a polio-endemic country.

CRAWFORD: And vaccination rates were likely to be low?

COCHI: --and may or may not have been low but needed attention to make sure that they had a high immunity against polio to protect them against an importation and spread within their countries. This applied to quite a number of the European countries, in fact. The European region did not certify--and this included the former Soviet Republics--did not certify itself as free of polio--and that's fifty-one countries--until the year 2002, because there still was endemic polio and the threat of polio, particularly in the Central Asian Republics of the former Soviet Union.

CRAWFORD: Kurdistan.

COCHI: Uzbekistan, Tajikistan, Kurdistan--the Kurds in southeastern Turkey were the last group of people who had polio in Turkey.

CRAWFORD: OK, thank you.

COCHI: Yeah, 1998, I think, were the last cases in Turkey, which is a fairly well-developed country. The Caucasus countries and the Kurdish people in southeastern Turkey were right next to Iraq and the Caucasian countries that still had a small number of polio cases, even until the late 1990s. I'm trying to portray a massive effort that cut across every WHO region except the Americas, which had successfully stopped polio in 1991, but had to sustain that effort against the risk of importation of polio for many years afterwards, right up to the present day.

There's still a risk of the poliovirus getting on an airplane and going almost anywhere in the world, undetected because most of the polio infections are silent infections. Only a small percentage get paralysis.

CRAWFORD: Could you trace the history of the outbreaks through the '90s, as the program is growing and accelerating? Where was your attention? Where was attention drawn, globally?

COCHI: Yes. Going back to what we were talking about a few minutes ago, since we had insufficient resources, we had to focus on, "OK, where do we have the greatest likelihood of making the most progress as soon as possible?"

After the Americas, the next region of the world, WHO region of the world, that had the most infrastructure and resources at its disposal was the Western Pacific Region. That was spurred on by China, which, with very few external resources, did the job it needed to do, because at every level of the Chinese government, being a hierarchical government and society, once the decision was made that this was a priority--boom, it happened. The Western Pacific Region was the next region that was prioritized. They had their last polio case in their region in 1997, and it occurred in Cambodia.

Interestingly, [it was] near the Cambodia-Vietnam border in the [Mekong] Delta region of southern Vietnam and Cambodia, and it was in the boat people. It was the boat people, who were basically migrants that rarely touched land. All of their commerce happened on boats. They were a population that wasn't being adequately accessed by your standard immunization activities. Even the polio campaigns had to be redesigned to not go house-to-house, but to go boat-to-boat to extinguish the last polioviruses. The last case [was] in 1997--and then there was a certification of eradication in their region in 2002.

In 2000, in the European region there was regional certification. Those were the big--it was the European region and the Western Pacific region where the most progress was made over the course of the 1990s, leading up to this all-time low of only ten countries being endemic by the end of 2001.

CRAWFORD: When you get the news that polio has been eliminated from an entire WHO region, what happens to acknowledge that? This is a bigger question about how you maintain this optimism and the perseverance of GPEI or polio eradication, because this is a massive effort, and it's taken a very long time to come so far.

COCHI: We maintain it by publicizing the successes, by publicizing the progress, by making sure that that's publicized, not only to the public, but to the people working in the trenches in the countries that still are endemic for polio, to show them and to give them a sign that you can do it, as well.

CRAWFORD: What happened when polio ended in WPRO [Western Pacific Regional Office], the Western Pacific Region?

COCHI: There was some trumpeting from the highest mountains about this, and then there was a dissemination of that information and the know-how and the operation of how they did it to other regions of the world that still had polio. "Here's how operationally it was done, and let's consider doing it in a similar way." It may need to be adjusted for the cultural context of your particular country, but it gave people an understanding that, "Yes, this can be done, and we're getting help to get this done, and we can do it, too." It snowballed.

That's the way that I would characterize the 1990s, right up until the year 2001. It was a snowball effect. People who worked in the program were really riding high, because the slope of the curve was just going way down. It was a very exciting time.

Of course, although we were spending some time in the most difficult, challenging countries, they were not the countries that were stopping polio transmission. In the first decade of the twenty-first century, we had to confront that, which we can talk about in the next session.

CRAWFORD: Pakistan, Afghanistan, India and Nigeria? Those? The acronym was "PAIN [Pakistan, Afghanistan, India, Nigeria]?" The "PAIN" countries?

COCHI: The PAIN countries, yes. I think that's probably the most appropriate acronym that we can use for what we had to confront in the first decade of this century. CRAWFORD: Leading up to 2001, what happened from 1995--actually, let's go with 1997, because you changed positions in 1997, correct?

COCHI: I actually didn't change positions. Going back to what I was saying before, we started as the Polio Eradication Activity in 1993. We had a budget of $3 million dollars, and we had six people. Plus, we had the lab, the lab folks, but they were few in number. I described a few minutes ago how our budget increased dramatically over the course of the 1990s and the number of staff that we had increased. I had the same job, but with many more people and a much larger budget, and so by 1997, we officially became a division instead of a minuscule activity of half a dozen people with a tiny budget.

In 1997, we actually had our name changed to the "Vaccine-Preventable Disease Eradication Division," because Congress had begun to give us a second line item to address measles, to focus on measles elimination. We were not only polio eradication, but also beginning to dabble in measles eradication. By the end of the decade, since we were beginning to work in all different areas of global immunization, not just polio and measles, we changed our name to be more generic, as the "Global Immunization Division" [GID]. We were involved not only in disease eradication, but also in other aspects of vaccines and global immunization, although our number-one priority was polio eradication.

CRAWFORD: Let me just see if you would talk about countries in which there was less infrastructure than in other countries. I'm thinking of [southern] Sudan and Somalia, in particular. A few minutes ago, you also mentioned that there were some countries that have been more challenging than others. I'm wondering, through the '90s leading up to 2001, where the number of endemic countries is markedly, incredibly reduced. Where did you meet challenges along that way, through the '90s?

COCHI: Good question, Hana. Yes, when we're looking at that, that downslope of that curve, as I said, most of the countries where we were successful over the course of the 1990s, although they were low-income countries, lower middle-income countries and didn't have the ideal amount of resources. They still basically had reasonably well-functioning immunization programs and systems. They may not have had optimally high routine vaccination coverage, but they had the capacity to do what was needed in localized areas where they were still experiencing some polio cases to strengthen the surveillance and do some additional effort, both through the routine program and through polio mass campaigns, to get rid of poliovirus.

That was a fairly large group of countries that enabled that downslope of a decreasing number of polio-endemic countries to occur.

As time went on--there's another set of countries, and you mentioned South Sudan, which at the time was still united with Sudan. It only became a separate country a few years ago--but South Sudan. Another example, Somalia, which since the early 1990s has had no national government that really has a reach throughout the country, was split up into warring factions--warlords and different jurisdictions. Other countries in conflict [were] Democratic Republic of the Congo, Afghanistan, Pakistan, and so on.

As the number of the low-hanging fruit countries decreased through our successes in the '90s, we had this totally separate group of countries, where war, civil unrest--breakdown of civilization, if you will--breakdown of any functioning health system, had to be addressed in a very different way. It was in those countries--and I think South Sudan and Somalia are excellent examples of this--there had to be a very big build-up of replacement for nonfunctioning domestic immunization systems. There had to be additional resources provided to the WHO country office, the UNICEF country office, and non-government organizations that were actively working in that country to deliver health services, to build them up as a replacement for a nonfunctioning domestic immunization system, until such time as that could be restored. That still hasn't been restored in many parts of Somalia or South Sudan.

It existed in Iraq, but then got largely destroyed with the war. Same thing with Syria, which had a very high-performing immunization program for many, many years. It's sad to see how the destruction of war has lowered vaccination coverage to fifty to seventy percent--depending on the part of the country--and caused the reemergence of polio.

Over time, the program had to deal, in an unprecedented way, with how to address these challenges and find new ways of operating--be very creative, be innovative. I think that's been the story of this polio eradication odyssey: facing challenges, finding new ways to creatively and innovatively operate to get results to make it happen. It's provided lessons learned that I think are applicable to other global health programs: how to go about addressing these issues.

Afghanistan is an example where making the program work required engaging the Taliban, including the local commanders and making them see that good health is good politics for their local communities and allowing them to be in charge of creating the vaccination teams in the communities that they controlled and providing the vaccine to them, so that they could implement the program and show the community that they are doing something useful for the community. That's, I think, just one of the many examples of innovation that have had to take place.

CRAWFORD: Would you talk about some of the staff people: individuals who have worked in-country, and then innovators who would come to mind immediately?

COCHI: In the early days, in the Western Pacific region, we had assignees to China--Mac [W.] Otten [MD, MPH]--who we assigned there back in 1992 before the first polio National Immunization Days in China. He is an imposing figure at six [feet], seven inches and a staunch advocate and proponent of disease surveillance, of polio surveillance, and of mapping polio cases. He brought both that energy and that knowledge to that program in China to the point where they became the model for the world on how to do polio surveillance, only exceeded later on by India. He was so interested and engaged in the surveillance system and in mapping that I used to call him "Map Otten," instead of Mac Otten. He was one of the driving forces in the early days.

We also had a person assigned to Vietnam, another highly polio-endemic country at the time, Bernard [J.] Moriniere [MD], who was a CDC EIS officer who then moved into the Global Immunization Division, subsequently.

We had a person in the regional office, which was in Manila, the Philippines, [Rudolph H.] Rudi Tangermann [MD], who is a German national who had also completed EIS and then moved into polio eradication after a short interlude.

In the Americas, we had Dr. Jon [K.] Andrus [MD], who was the deputy to Dr. Ciro de Quadros late in the polio eradication game in the Americas. He then moved to India, to Delhi, to lead the regional effort in the Southeast Asia region of WHO [South-East Asian Regional Office, SEARO] and became a very important figure during the 1990s and early 2000s in reducing the polio burden in India. Those are a few of many people.

Hamid [S.] Jafari [MD], who we assigned to the regional office, the Eastern Mediterranean regional office [EMRO, WHO], which at that time was in Alexandria, Egypt, later moved to Cairo, Egypt. Then his counterpart in the European regional office was [Steven G.] Steve Wassilak [MD]. Those folks are still around and are still working on polio eradication aspects. We had the good fortune of having an unending stream of talent flow into the program and really bolster what it was that we needed to do.

CRAWFORD: The GPEI History Project Archivist Laura [L.] Frizzell [MSIS] and I were in conversation about different periods of time in which there are tons and tons and tons of documents. Also, with the staffing increase, there's this expansion for her in her role, as well, of items to collect. My question is, how cohesive was the staff through the '90s, through this giant expansion at CDC and more broadly?

COCHI: One of the very fortunate things, which I think made it work: there was a chemistry. There was a cohesiveness; there was a camaraderie, and that still exists today. It was really intense, very intense in the early days, because there were fewer people, and we were drawn together by adversity, if you will, by the monumental challenges that lay ahead. I would describe it as highly cohesive, like a family, and we took care of each other and looked out for each other. I think the Friday Mo's events--it wasn't just a symbol that was narrowly defined or superficial. People really went there to unwind, to enjoy each other's company. It wasn't a requirement that people socialize, but that's just the way it evolved. We were a very close and tight-knit group. I think that contributed greatly to the success we had, because the work required perseverance and the work required hanging in there, despite adversity and despite setbacks. For whatever reason, it attracted people that were crazy enough to just hang in there and work very hard for a common goal.

CRAWFORD: Could you describe an occasion or two when you saw people really needing to go to Mo's?

COCHI: When we would have a setback. I think of a setback that we had in the year 2000, in Hispaniola, the island that includes Dominican Republic and Haiti, where we had our first well-documented outbreak of vaccine-derived polioviruses [VDPVs]. We had to confront the fact that looking forward, there was a world where the vaccine virus in the oral polio vaccine, the Sabin vaccine, rarely--and usually under conditions where there was low vaccination coverage, so [there were] a lot of susceptible children around in the communities--the vaccine virus could rarely mutate sufficiently to where it could take on the characteristics of the wild or naturally-occurring poliovirus.

We had this outbreak happen. It was almost entirely in Haiti, rather than Dominican Republic. I think it was twenty-one cases, ultimately. The outbreak could be controlled, terminated the same way as we approached the wild and naturally-occurring polioviruses by doing multiple rounds of polio mass campaigns. It was terminated, but we had to confront the fact that we're probably going to be seeing more of these [outbreaks] and the realization that--I think we had to share our disappointment over beer and pizza at Mo's and try to make sense of what had happened, what this means: how do we have to prepare going forward for the future? That was one prominent event, I think, that got played out in Mo's, not just one week, but on a regular basis.

CRAWFORD: I have some follow-up questions, but I'm also noticing that we are at time, with just a few minutes before time. Where do you think we should end for today, from 1980--and the follow-up questions. We'll do another interview, so I can address the follow-up questions I have at the beginning of the next session.

COCHI: I think we should end by just stating the fact that entering the twenty-first century there was a lot of optimism, and well-deserved optimism, that we had made so much progress. It had really helped to support people and organizations who are very heavily involved in the program to move ahead, in spite of the fact that we had not eradicated polio by the year 2000, which was the original goal from the World Health Assembly resolution. Of course, when you're eradicating a disease, it's all about zero. Getting close is still a failure, but nobody would have imagined in 1988 or even in the early 1990s, when the program was moving along at a glacial pace, that we would have gotten as close as we had achieved by the year 2001. In a way, that was a major milestone--that was a major victory, that we were down to ten countries--and reenergized everybody to be able to move forward.

CRAWFORD: Would you say a bit about where you were when you heard that you were down to ten countries, that moment?

COCHI: It wasn't a single moment, to be honest with you. We had to watch the weekly surveillance data and the statistics in every country, and even after the end of the calendar year, since there's some lag in reporting of cases and in the laboratory results. We didn't know as an absolute fact until a few months into 2002 that we could declare that there were only ten polio-endemic countries.

But where was I? Where we celebrated this the most was we were continuing to have annual global meetings, and beginning in 1996, these were hosted by WHO in Geneva. I can remember very well in the 2001 meeting, where we were anticipating that there were only ten remaining endemic countries, that that was something that was made very clear in the presentations and in the summary of the annual meeting. [It was] something that brought a pride and optimism and a "let's roll up our sleeves and get the last ten" kind of attitude, kind of behavior. It was a great way to end the annual meeting in 2001, to be able to realize that milestone.

CRAWFORD: Is there anything else that you want to add for today?

COCHI: I think I'm pretty talked out for today.

CRAWFORD: Thank you so much. We'll pick up, and we will schedule session two.

COCHI: OK, thanks.